Safety of nicotine: the smoke causes the harm

A study was published in the journal, Nicotine and Tobacco Research by Dr Stephanie Smith of the Robert Wood Johnson Foundation and Princeton University, showing that the public still has major misunderstandings about the harmfulness of nicotine and tobacco products. She asked over 400 students from John Hopkins University to compare the harmfulness of 11 nicotine delivery products (ranging from a “light” cigarette to a nicotine patch) with the harmfulness of a regular cigarette.

20% perceived the nicotine patch to be as harmful as a regular cigarette, as did 24% for nicotine gum and 53% for the nicotine inhaler! Of course in reality all of these products are far less harmful than smoking cigarettes as they each deliver only medicinal nicotine, without the 4000 other chemicals delivered by a cigarette.

On the other side, over 35% believed that “light” cigarettes are less harmful, and of course they are not. Perhaps the biggest misperception was that 89% incorrectly perceived “dip” or chewing tobacco to be as harmful or more harmful than regular cigarettes. In reality smokeless tobacco is much less harmful than smoking (it doesn’t cause lung cancer or respiratory disease and has lower risks of oral cancer than smoking).

Its important for people to understand that most of the harm from tobacco is caused by inhaling smoke into the lungs. This causes thousands of toxic chemicals to be deposited into the lungs – one of the most important and sensitive organs in the body. Almost anything that doesn’t involve inhaling smoke is bound to be less harmful. In the case of nicotine replacement medications, the only drug involved is medicinal nicotine. Now nicotine itself doesn’t cause lung cancer or respiratory diseases, and when taken by an ex-smoker for a relatively short period really doesn’t do any harm at all. For a smoker using NRT as a smoking cessation aid it has the simple advantage that it doesn’t require taking a new drug – just taking the same one the smoker has taken every day for years – without the 4000 other toxic chemicals. Taken in this way, nicotine has a good safety profile, and an excellent record of helping smokers to successfully quit smoking. (Main exception here is effects on the unborn child if used by a pregnant woman).

One of the big problems caused by people mistakenly believing that nicotine is very harmful is that even if they try NRT they tend to take as little as possible for as a brief a time as possible. In fact the evidence shows that the more you take and the longer the duration, the more likely you are to succeed in stopping smoking. So for a typical pack-a-day smoker combining the nicotine patch with 10 pieces of 4mg nicotine gum for over 12 weeks would likely be much better than just taking the patch for a few weeks. This is partly because these NRT medications deliver lower blood nicotine levels than cigarettes.

So the main message here is that if you are a smoker, it’s the smoke that will kill you, not the nicotine.

Labels: cigarette smoking, Nicotine Replacement

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New smoking cessation medicines being evaluated: selegiline patch

We’ve recently seen the launch of one new smoking cessation medication – Chantix (also called Champix outside the USA) and so you may be interested to know if there may be new medicines in the pipeline and how these are being evaluated.

One that is currently in clinical trials is a medicine called Selegiline transdermal system (STS) or skin patch. Selegiline is a drug that was developed to help treat Parkinson’s disease. Parkinson’s disease is at least partly caused by loss of cells in the brain that stimulate activity of the neurotransmitter called dopamine. This neurotransmitter is important for movement and for brain reward or reinforcement functions. Selegiline increases dopamine activity by inhibiting another substance (called MAO-B) that clears dopamine in the brain. By inhibiting MAO-B, selegiline is believed to increase brain dopamine activity. More recently the Selegiline patch was approved by the US FDA as a treatment for depression (marketed as Emsam) http://www.fda.gov/bbs/topics/NEWS/2006/NEW01326.html

When one considers that nicotine is thought to be addictive partly because it stimulates brain dopamine reward systems, that Parkinson’s disease is one of the few illnesses that is actually less common in smokers, that smokers have a higher frequency of depression, and that depression is a nicotine withdrawal symptom, its not hard to see a rationale for trying Selegiline for smoking cessation. In addition, some preliminary studies with the drug produced some promising results. For example, after 8 weeks of treatment, Professor Tony George and colleagues at Yale University found that 45% of smokers treated with Selegiline had quit, compared with 15% of those treated with placebo.

Now that the more user-friendly skin-patch formulation of the medicine has been used in depression, a clinical trial is underway of the Selegiline patch for smoking cessation. This trial is taking place at a number of sites around the country, including one here in New Brunswick, New Jersey. If you are a New Jersey smoker who wants to quit and are interested in participating in that trial, you can find out more at:
http://rwjms.umdnj.edu/addiction/seligeline.htm

But remember that in addition to experimental treatments, that we already have effective treatments for tobacco addiction, including group, individual and telephone counseling and 7 different medicines approved as safe and effective. So why wait when you can get effective help now?

Labels: dopamine, selegiline, smoking cessation, trial

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Immediate and delayed quitting

Last week I attended the 4th annual meeting of the Society for Research on Nicotine and Tobacco (Europe) in Madrid. This is a conference where the top researchers present their latest research findings. As you can imagine a lot of fascinating stuff was presented. One that I particularly liked was presented by David Gonzales of the Health and Sciences University in Portland. He presented data on immediate quitting (i.e. those who succeeded in quitting on their target quit date with no lapses) and delayed quitting (i.e. those who had some lapses after the initial target quit date but then managed to get quit and stay quit) among patients treated with either varenicline (Chantix), bupropion (Zyban), or placebo.

For me the interesting thing was that Chantix and Zyban each improved the proportion who initially quit (over placebo), but Chantix also increased the proportion who managed to achieve abstinence after their initial target quit date. Dr Gonzalez presented a nice diagram showing that the number of patients achieving abstinence continued to increase across the first 12 weeks among those on Chantix or Zyban (although it increased faster among those on Chantix).

Colleagues have remarked that patients taking Chantix are less focused on the target quit day (typically day 8 of taking Chantix) than we are used to. We think that’s because almost all of the patients we treated before Chantix were also using nicotine replacement therapy (sometimes combined with Zyban/bupropion). The NRT (patch, gum etc) is typically started on the target quit day and so patients are very aware of the importance of that day. We don’t typically combine Chantix with NRT (as the Chantix is supposed to block the nicotine receptors in the brain) and so on Chantix its easier to see the target quit date as less distinct from any other day and just continue reducing cigarette consumption rather than quitting completely.

The take-home message for patients is that it still makes sense to select a target quit-date (day 8) and to try to quit smoking completely on that day. However, if you don’t immediately get quit, don’t give up on yourself or on the medicines. The evidence suggests that if you keep trying you will likely achieve abstinence, and that Chantix improves your chances, so long as you keep trying and keep taking the medicine. On the other hand, its important to be clear that the aim of the game is to quit completely, and its better in the long run to throw away the cigarettes and get on with it.

Labels: bupropion, Chantix, cigarette smoking, quit, varenicline, Zyban

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Report on Tobacco Harm Reduction by Royal College of Physicians

The Royal College of Physicians of London (established in 1518) has a long history of producing influential, cutting edge reports on topics of critical importance to public health. For example, the RCP’s 1962 report “Smoking and Health” was the first major report to conclude that smoking causes lung cancer. The RCP has 12,500 fellows in over 90 countries and their reports have a similar status to the Surgeon General’s reports in the United States.

On Friday (October 5th) the Royal College of Physicians (London) released their latest report on tobacco and health, entitled, “Harm Reduction in Nicotine Addiction: Helping People Who Can’t Quit”. In the preface to the report, Professor John Britton, Chair of the RCP’s Tobacco Advisory Group, stated,

“Harm reduction is a fundamental component of many aspects of medicine and, indeed, everyday life, yet for some reason effective harm reduction principles have not been applied to tobacco smoking. This report makes the case for radical reform of the way nicotine products are regulated and used in society. The ideas we present are controversial, and challenge many current and entrenched views in medicine and public health. They also have the potential to save millions of lives. They deserve serious consideration.”

The 242-page report was written by a group of leading experts on tobacco from the UK, New Zealand, Canada and the United States. It reviews the history of tobacco use, the neurobiology of nicotine addiction, the health risks of various nicotine products and current regulation of nicotine delivery products, before making recommendations on future nicotine product regulation. Among the key conclusions and recommendations are the following:

- Most of the deaths and disease caused by smoking in the near and medium term future will occur in people who are smoking now.
- Current preventive approaches will be ineffective for the millions of smokers who, despite best efforts to persuade and help them to quit, will carry on smoking.
- Harm reduction in smoking can be achieved by providing smokers with safer sources of nicotine that are acceptable and effective nicotine substitutes.
- There is a moral and ethical duty to provide these products to addicted smokers.
- Current systems of regulation of nicotine products inhibit the development of innovative medicinal nicotine substitutes for cigarettes and perpetuate the use of the most dangerous nicotine products (cigarettes). This is unjust, irrational and immoral.
- The unprecedented and unjustifiable market freedoms enjoyed by manufacturers of cigarettes and other smoked tobacco products must end.
- Low nitrosamine smokeless tobacco products may have a positive role to play in a coordinated and regulated harm reduction strategy which maximizes public health benefit and protects against market exploitation.

The report provides numerous examples of the kinds of irrational regulation currently in place around the world and the effects it has on cigarette smoking for health. In the European Union, for example, Swedish snuff (snus) which has health risks around 90% lower than cigarettes, is banned in every country except Sweden, while cigarettes are available everywhere. Why restrict the public’s choice of tobacco products to only the most harmful ones? In the United States (and many other countries), medicinal nicotine products (e.g. nicotine gum) are sold in packs covered in lengthy warnings and contraindications, while cigarette packs have a very small, brief health warning on the side of the pack. The net result is that many smokers mistakenly believe that the medicinal nicotine products are about as harmful as smoking and so are less inclined to use them.

The new Royal College of Physicians report contains a wealth of information about tobacco, nicotine and health, as well as radical new proposals to reduce the number of smoking-caused deaths. The pdf of the report is available online at no cost at:
http://www.rcplondon.ac.uk/pubs/brochure.aspx?e=234

Labels: harm reduction, nicotine addiction cigarette smoking tobacco, nicotine regulation reduction smoking, quit smoking cessation tobacco advice cigarettes, smokeless

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Finding out about smoking and health

I’ve now been writing this blog for over six months and have noticed that some questions keep coming up that have been covered on a previous post. The site allows you to search for things and has a listing by month of topics, but I thought it might be helpful to post a full up-to-date list, with links attached. Most of these posts also have links to additional sources of information on the internet.

Jonathan Foulds’ posts on: www.healthline.com/blogs/smoking_cessation/

Introducing Dr Jonathan Foulds, 2/16/07
http://www.healthline.com/blogs/smoking_cessation/2007/02/introducing-dr-jonathan-foulds.html

How bad is smoking for your health? 2/18/07
http://www.healthline.com/blogs/smoking_cessation/2007/02/how-bad-is-smoking-for-health.html

3. Do women find it harder to quit smoking? 2/24/07
http://www.healthline.com/blogs/smoking_cessation/2007/02/do-women-find-it-harder-to-quit.html

Tobacco industry found guilty of racketeering. 2/25/07
http://www.healthline.com/blogs/smoking_cessation/2007/02/tobacco-industry-found-guilty-of.html

Why “lights” are just as deadly. 2/28/07
http://www.healthline.com/blogs/smoking_cessation/2007/02/why-lights-are-just-as-deadly.html

What is nicotine withdrawal syndrome? 3/6/07
http://www.healthline.com/blogs/smoking_cessation/2007/03/what-is-nicotine-withdrawal-syndrome.html

Ten tips for coping with nicotine withdrawal. 3/7/07
http://www.healthline.com/blogs/smoking_cessation/2007/03/ten-tips-on-coping-with-tobacco.html

Cold Turkey – 1. 3/18/07
http://www.healthline.com/blogs/smoking_cessation/2007/03/cold-turkey-1.html

Cold Turkey – 2. 3/18/07
http://www.healthline.com/blogs/smoking_cessation/2007/03/cold-turkey-2.html

“Lost” and FDA regulation of tobacco. 3/22/07
http://www.healthline.com/blogs/smoking_cessation/2007/03/lost-and-fda-regulation-of-tobacco.html

Quitting smoking while living with a smoker. 3/25/07
http://www.healthline.com/blogs/smoking_cessation/2007/03/quitting-smoking-while-living-with.html



Nicotine addiction: how it can trick you into “absent-minded” smoking. 4/13/07
http://www.healthline.com/blogs/smoking_cessation/2007/04/nicotine-addiction-how-it-can-trick.html

Chantix: how does this new stop smoking medicine work? 4/15/07
http://www.healthline.com/blogs/smoking_cessation/2007/04/chantix-how-does-this-new-quit-smoking.html

How about quitting smoking with someone else? 4/15/07
http://www.healthline.com/blogs/smoking_cessation/2007/04/what-about-quitting-smoking-with.html

Telephone quitlines: do they help smokers to quit? 4/19/07
http://www.healthline.com/blogs/smoking_cessation/2007/04/telephone-quitlines-do-they-help.html

Can smoking cessation internet sites help you to quit? 4/21/07
http://www.healthline.com/blogs/smoking_cessation/2007/04/can-smoking-cessation-internet-sites.html

17. How to tell if a smoking cessation aid works. 4/29/07
http://www.healthline.com/blogs/smoking_cessation/2007_04_01_smoking_cessation_archive.html

18. Facing the tobacco industry. 5/12/07
http://www.healthline.com/blogs/smoking_cessation/2007/05/facing-tobacco-industry.html

19. Facing the tobacco industry -2. 5/18/07
http://www.healthline.com/blogs/smoking_cessation/2007/05/facing-tobacco-industry-2.html

20. How addicted are you to cigarettes? (1) 5/19/07
http://www.healthline.com/blogs/smoking_cessation/2007/05/how-addicted-are-you-to-cigarettes-1.html

21. How addicted are you? (2) 5/19/07
http://www.healthline.com/blogs/smoking_cessation/2007/05/how-addicted-are-you-2.html

22. Is there such a thing as a safer cigarette? 5/23/07
http://www.healthline.com/blogs/smoking_cessation/2007/05/is-there-such-thing-as-safer-cigarette.html



23. Institute of Medicine Report: Ending The Tobacco Problem -1. 5/26/07
http://www.healthline.com/blogs/smoking_cessation/2007/05/is-there-such-thing-as-safer-cigarette.html

24. Institute of Medicine Report: Ending The Tobacco Problem -2. 5/27/07
http://www.healthline.com/blogs/smoking_cessation/2007/05/institute-of-medicine-report-ending_27.html

25. The nicotine reduction strategy. 5/28/07
http://www.healthline.com/blogs/smoking_cessation/2007/05/nicotine-reduction-strategy.html

26. Effects of alcohol on smoking cessation – 1. 5/29/07
http://www.healthline.com/blogs/smoking_cessation/2007/05/effects-of-alcohol-on-smoking-cessation.html

27. Effects of alcohol on smoking cessation – 2. 5/29/07
http://www.healthline.com/blogs/smoking_cessation/2007/05/effects-of-alcohol-on-smoking-cessation_29.html

28. Think you don’t really smoke for nicotine? 6/2/07
http://www.healthline.com/blogs/smoking_cessation/2007/06/think-you-dont-really-smoke-for.html

29. Marlboro Snus: what is it? 6/10/07
http://www.healthline.com/blogs/smoking_cessation/2007/06/marlboro-snus-what-is-it.html

30. Why did Philip Morris’s new smokeless tobacco product (“Taboka”) deliver almost no nicotine? 6/12/07
http://www.healthline.com/blogs/smoking_cessation/2007/06/why-did-philip-morriss-new-smokeless.html

31. Get rid of all your tobacco. 6/16/07
http://www.healthline.com/blogs/smoking_cessation/2007/06/get-rid-of-all-your-tobacco.html

32. Nicotrol Nasal Spray: an effective treatment for the heavy smoker. 6/16/07
http://www.healthline.com/blogs/smoking_cessation/2007/06/nicotrol-nasal-spray-effective.html

33. Can quitting smoking trigger depression? 6/16/07
http://www.healthline.com/blogs/smoking_cessation/2007/06/can-quitting-smoking-trigger-depression.html


34. Its time for pictorial warnings on cigarette packs. 6/18/07
http://www.healthline.com/blogs/smoking_cessation/2007/06/its-time-for-pictorial-warnings-on.html

35. Which nicotine replacement therapy? 6/19/07
http://www.healthline.com/blogs/smoking_cessation/2007/06/which-nicotine-replacement-therapy.html

36. Whats the problem with Accomplia/rimonabant (Zimulti), the weight-loss drug that helps you quit smoking? 6/20/07
http://www.healthline.com/blogs/smoking_cessation/2007/06/whats-problem-with-accompliarimonabant.html

37. Is nicotine replacement therapy effective in the “real world”? 6/21/07
http://www.healthline.com/blogs/smoking_cessation/2007/06/is-nicotine-replacement-therapy.html

38. Higher nicotine intake per cigarette among African American smokers: is it a menthol effect? 6/26/07
http://www.healthline.com/blogs/smoking_cessation/2007/06/higher-nicotine-intake-per-cigarette-by.html

39. Cigarette brand preferences: start young and focus on 3 brands. 6/26/07
http://www.healthline.com/blogs/smoking_cessation/2007/06/cigarette-brand-preferences-start-young.html

40. Reductions in teen smoking. 6/26/07
http://www.healthline.com/blogs/smoking_cessation/2007/06/reductions-in-teen-smoking.html

41. Tobacco use around the world. 6/27/07
http://www.healthline.com/blogs/smoking_cessation/2007/06/tobacco-use-around-world.html

42. When is the best time to quit smoking? 6/29/07
http://www.healthline.com/blogs/smoking_cessation/2007/06/when-is-best-time-to-quit-smoking.html

43. Advice on using over-the-counter nicotine replacement therapy. 6/30/07
http://www.healthline.com/blogs/smoking_cessation/2007/06/advice-on-using-over-counter-nicotine.html

44. Wearing the patch prior to quitting may help. 7/1/07
http://www.healthline.com/blogs/smoking_cessation/2007/07/wearing-patch-prior-to-quitting-may.html

45. Celebrate your independence from tobacco. 7/4/07
http://www.healthline.com/blogs/smoking_cessation/2007/07/celebrate-your-independence-from.html

46. Tobacco and global warning. 7/7/07
http://www.healthline.com/blogs/smoking_cessation/2007/07/tobacco-and-global-warming.html

47. A year of smoking takes 3 months off your life. 7/9/07
http://www.healthline.com/blogs/smoking_cessation/2007/07/last-friday-july-6th-new-paper-was.html

48. Thanks to grand rounds 3.42. 7/13/07
http://www.healthline.com/blogs/smoking_cessation/2007_07_01_smoking_cessation_archive.html

49. 17th Surgeon General, Dr Richard Carmona, joins Healthline. 7/13/07
http://www.healthline.com/blogs/smoking_cessation/2007/07/17th-surgeon-general-dr-richard-carmona.html

50. How many cigarettes does it take to become addicted? 7/20/07
http://www.healthline.com/blogs/smoking_cessation/2007/07/how-many-cigarettes-does-it-take-to.html

51. How many medical doctors smoke? 7/22/07
http://www.healthline.com/blogs/smoking_cessation/2007/07/how-many-medical-doctors-smoke.html

52. Health insurance coverage for nicotine dependence treatment. 7/22/07
http://www.healthline.com/blogs/smoking_cessation/2007/07/health-insurance-coverage-for-nicotine.html

53. Increase cigarette tax to pay for children’s healthcare. 7/27/07
http://www.healthline.com/blogs/smoking_cessation/2007/07/increase-cigarette-tax-to-pay-for.html

54. Could smoking reduction improve your health? 7/27/07
http://www.healthline.com/blogs/smoking_cessation/2007/07/could-smoking-reduction-improve-your.html

55. Is cannabis smoking more harmful than cigarette smoking? 7/31/07
http://www.healthline.com/blogs/smoking_cessation/2007/07/is-cannabis-smoking-more-harmful-than.html



56. Thank you Health Business Blog for grand rounds 3:45. 8/2/07
http://www.healthline.com/blogs/smoking_cessation/2007/08/thank-you-health-business-blog-for.html

57. Menthol smokers inhale more toxins. 8/3/07
http://www.healthline.com/blogs/smoking_cessation/2007/08/menthol-smokers-inhale-more-toxins.html

58. Health effects of Tobacco Smoke Pollution. 8/6/07
http://www.healthline.com/blogs/smoking_cessation/2007/08/health-effects-of-tobacco-smoke.html

59. Sidestream cigarette smoke more toxic than mainstream smoke. 8/8/07
http://www.healthline.com/blogs/smoking_cessation/2007/08/sidestream-cigarette-smoke-more-toxic.html

60. Make yours a smoke-free home. 08/10/07
http://www.healthline.com/blogs/smoking_cessation/2007/08/make-yours-smoke-free-home.html

61. Chantix and mental illness. 08/12/07
http://www.healthline.com/blogs/smoking_cessation/2007/08/chantix-and-mental-illness.html

62. Two new studies of Chantix (varenicline). 08/19/07
http://www.healthline.com/blogs/smoking_cessation/2007/08/two-new-studies-of-chantix-varenicline.html

63. Thanks to Grand Rounds 3:47. 08/20/07
http://www.healthline.com/blogs/smoking_cessation/2007/08/thanks-to-grand-rounds-347.html

64. Getting through the first few weeks. 08/20/07
http://www.healthline.com/blogs/smoking_cessation/2007/08/getting-through-first-few-weeks.html

65. Carcinogens from smoking and smokeless tobacco use (1). 8/27/07
http://www.healthline.com/blogs/smoking_cessation/2007/08/carcinogens-from-smoking-and-smokeless.html

66. Smoking, smokeless tobacco and cancer (2). 8/28/07
http://www.healthline.com/blogs/smoking_cessation/2007/08/smoking-smokeless-tobacco-and-cancer-2.html



67. Do you (or your kids) hookah? 9/13/07
http://www.healthline.com/blogs/smoking_cessation/2007/09/do-you-or-your-kids-hookah.html

68. Stopping smoking effects on drug metabolism. 9/16/07
http://www.healthline.com/blogs/smoking_cessation/2007/09/stopping-smoking-effects-on-drug.html

69. Does Chantix cause mental health problems? 9/20/07
http://www.healthline.com/blogs/smoking_cessation/2007/09/does-chantix-cause-mental-health.html

70. Does it help to add nicotine gum to bupropion? 9/24/07
http://www.healthline.com/blogs/smoking_cessation/2007/09/does-it-help-to-add-nicotine-gum-to.html

71. Tobacco tax to renew insurance for poor kids. 9/24/07
http://www.healthline.com/blogs/smoking_cessation/2007/09/tobacco-tax-to-renew-insurance-for-poor.html

72. Effects of smoking during pregnancy. 9/28/07
http://www.healthline.com/blogs/smoking_cessation/2007/09/effects-of-smoking-during-pregnancy.html

73. State-specific prevalence of cigarette smoking. 9/30/07
http://www.healthline.com/blogs/smoking_cessation/2007/09/state-specific-prevalence-of-cigarette.html

Labels: cessation, cigarette smoking, health

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