Could FDA reduce nicotine levels in cigarettes?

In the previous posting I discussed the possibility of FDA requiring that no tobacco products be allowed to emit Carbon Monoxide. While appealing in its simplicity, such a strategy may have problems in that it could be interpreted as a ban on a whole class (or classes) of tobacco products, which the legislation does not allow.

Another strategy might be to reduce the harm from tobacco by lowering the nicotine content/delivery of cigarettes down to the level at which they are no longer addictive. A form of this strategy was proposed in the 1990’s by leading tobacco researchers Professor Neal Benowitz, and Professor Jack Henningfield. The FDA legislation singles out nicotine as the only chemical that cannot be reduced to zero, but this allows FDA the right to reduce the nicotine delivery of tobacco products down to a level just above zero at which they would no longer be addictive.

Although people could debate and study precisely what level of nicotine delivery is non-addictive, in reality it would not be at all difficult to define a level that would be so lacking in reinforcement as to be insufficient to perpetuate addictive use. For example, one could require that no cigarettes are capable of providing the user with a venous blood nicotine level higher than 4 ng/ml, whether from chain-smoking a number of cigarettes, or from smoking a whole pack throughout the day. For cigarettes to meet this criterion would not require them to be nicotine-free, but it would require them to deliver a per-cigarette boost in venous blood nicotine of less than 2 ng/ml (as compared to a typical boost of 10-20 ng/ml from a typical cigarette). This low level of nicotine delivery would not be sufficiently reinforcing for the vast majority of users. If alternative nicotine delivery products such as nicotine replacement therapy, smokeless tobacco products and possibly e-cigarettes were allowed to remain on the market with their normal (or possibly even increased) nicotine delivery then highly addicted smokers would transition onto these products as the nicotine delivery of their cigarettes is cut.

One of the primary aims of this strategy is to get to the point where young people will no longer become addicted to cigarettes.

So long as very low nicotine delivery cigarettes remain available, this strategy should be consistent with the legislation, and so long as plenty of smoke-free nicotine delivery products remain available it should not cause major problems of nicotine withdrawal, even if it is implemented relatively swiftly.

Of course, although in these days of FDA regulation there is talk that now tobacco policy can be driven by science rather than politics. While there is now a much more direct role for science than we had before the legislation, that does not mean that politics do not play a part. In the end, money counts, and right now the federal government and the states have become somewhat reliant on revenue from tobacco (primarily cigarette) taxes to come close to balancing budgets. If that revenue source was suddenly taken away (or even gradually) then there is a risk that the political world may interfere with the science-based public health strategy. For that reason I would recommend that the same nicotine reduction strategy not be applied to smokeless tobacco products. Rather, these should be regulated with a toxin reduction strategy to ensure they are minimally harmful, while maintaining the ability to deliver adequate amounts of nicotine to satisfy smokers’ addiction. These products would continue to be taxed at a relatively high rate and would take on the tax burden vacated by smoked products (which would no longer deliver adequate amounts of nicotine to be the lead product). In this way, the financial consequences for the states need not be so severe that the cigarette nicotine reduction strategy would be called to a halt. This dual track strategy also allows the tobacco industry to stay in business. There will be a greatly increased demand for low-toxin medium-high nicotine-delivery smokeless tobacco products, along with a greatly reduced demand for very-low-nicotine cigarettes and cigars. The companies will have to change fairly drastically to producing products that no longer cause hundreds of thousands of cases of lung cancer and COPD each year. But this is precisely the purpose of the FDA legislation: to regulate tobacco in a manner that prioritizes public health.

Labels: cigarette, comprehensice tobacco control, FDA, Jack Henningfield, jonathan foulds, Neal Benowitz, nicotine addiction, nicotine reduction, nicotine regulation, smokeless

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Could FDA require tobacco companies to cease selling products emitting carbon monoxide?

Carbon monoxide (CO) is a clear, odorless gas that is produced by burning any carbon-based substance. So when tobacco is burned and inhaled, one of the 4,000 or more chemicals that enters the body is CO. When the smoke is inhaled into the lungs, CO is rapidly absorbed into the blood stream. CO binds to the hemoglobin in the red blood cells 200 times more effectively than oxygen does. The result is that many of these blood cells that were designed to carry oxygen to different parts of the body, instead bind to the CO, forming carboxyhemoglobin (COHb). This means that the heart has to do more work to supply the necessary amount of oxygen to the body. There is good evidence that high levels of carbon monoxide in the blood of smokers is one of the main factors causing smokers to have increased rates of cardiovascular diseases (such as angina and heart attacks). Other factors include platelet aggregation increasing the “stickiness” in the blood, stimulated by oxidant gases in cigarette smoke, and increased myocardial oxygen demand caused by nicotine. But it is clear that the reduced oxygen supply caused by carbon monoxide is a major factor. For example, increasing blood CO levels (either by smoking non-nicotine cigarettes or inhaling CO) has been shown to reduce the amount of exercize required to cause angina (chest pain) in patients with a history of angina.
(see: http://circ.ahajournals.org/cgi/content/abstract/61/2/262 )

Tobacco smoking is by far the largest determinant of CO levels in the blood, with smokers typically having blood COHb levels around ten times higher than non-smokers. So the idea that you might as well smoke because there is so much pollution in the air anyway is just nonsense. See this link for a study of this in a population sample:
http://www.biomedcentral.com/1471-2458/6/189

The legislation that was passed 8 months ago giving the US Food and Drug Administration the right to regulate tobacco products, allows FDA to require tobacco product manufacturers to take out any chemical (except nicotine) that appears to be harmful to public health. This can include not only chemicals IN the product, but also chemicals emitted by the product and absorbed by the user during normal use. Given the kind of evidence described above, it would seem highly likely that if it were to be reviewed by the FDA scientific advisory committee, it would conclude that CO is a chemical emitted by cigarettes that is harmful to the individual consumer, and also that limiting the industry to selling products that do not emit carbon-monoxide would be very likely to improve public health. I don’t believe there would be any controversy over the scientific evidence on CO from cigarettes and cigars, or the benefits of banning CO-emitting products.

However, the controversy would arise over whether or not the FDA legislation really empowers FDA to do this. It is highly likely that such a move would immediately result in tobacco company lawyers claiming that such a requirement is in effect a ban on at least 2 classes of products (cigarettes and cigars), and that the legislation does not give FDA the right to ban whole classes of products. This is something that would be decided by lawyers and possibly ultimately by politicians. But here is another view of the possibilities:

The legal definition of a cigarette in the United States is as follows:

“Any roll of tobacco wrapped in paper or in any substance not containing tobacco; and any roll of tobacco wrapped in any substance containing tobacco which, because of its appearance, the type of tobacco used in the filler, or its packaging and labeling, is likely to be offered to, or purchased by, consumers as a cigarette.”

By this definition, electronic cigarettes (e-cigarettes) could be classified as cigarettes. In fact just last month a U.S. judge ruled that e-cigarettes were cigarettes and not drug delivery devices (actually over-ruling the claims of FDA). For more details on this, cut and paste the following link:

http://www.e-cig.org/2010/01/19/what-does-judge-leons-ruling-against-the-fda-mean-for-electronic-cigarettes/

So if e-cigarettes are judged to be cigarettes, and they don’t emit carbon-monoxide (which they don’t), then FDA requiring tobacco companies to cease selling CO-emitting products would NOT in fact be a ban on a class of products. It would simply be a sensible way of reducing the harm to health from certain tobacco products, just as the legislation was intended to do. Of the big smoked tobacco manufacturers want to stay in business they could (and should) switch to focus exclusively on making and selling products that deliver nicotine without simultaneously delivering carbon-monoxide, such as e-cigarettes and smokeless tobacco.

At that point FDA could require the companies to minimize the amount of harmful chemicals being emitted by these products, even although over 90% of the harms from tobacco would already have been eliminated by taking out the burning part of the process. Some people reading this may think it sounds naïve or even crazy. But maybe its not. The federal government and the states would likely ramp up the taxes on e-cigarettes and smokeless tobacco to make sure their revenue is not affected too much, and cigarette and cigar manufacturers would focus on exports and on sales to sources they know will smuggle them back into the country. So in reality, traditional cigarettes would still exist, but they just wouldn’t be used nearly as widely in the United States, just as marijuana is still smoked, but not as regularly as cigarettes.

Labels: carbon monoxide, cigarette, e-cigarette, FDA, jonathan foulds

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More adolescent smokers becoming addicted to menthol cigarettes

I have previously written about the increasing evidence that smokers of menthol cigarettes find it harder to quit. (You can find previous posts on menthol by typing “menthol” in the “Search health experts” box on the right). Today I want to highlight the growing evidence that a higher proportion of adolescent smokers are smoking menthols and that those who so, get addicted quicker.

Some of the best evidence for this phenomenon was contained in a paper published by colleagues here at UMFNJ-School of Public health, Drs Olivia Wackowski and Cristine Delnevo. They analyzed the results from the 2004 National Youth Tobacco Survey, which contained data from a nationally representative sample of over 13,000 U.S. high school students. They found that 46% of all HS smokers smoked menthols, but that percentage was higher for 9th graders (59%) than for 12th graders (46%). 88% of African American teen smokers smoked menthols. The menthol smoking teens were also significantly more likely to say that they felt a need for another smoke within an hour of their last cigarette and that they experience cravings for cigarettes, even when controlling for other differences between the groups. For example, while a quarter of non-menthol smoking teens reported experiencing cravings, over a third of menthol smoking teens experienced cravings.

Another similar study by James Hersey and colleagues found very similar results and suggested that menthol cigarettes are becoming a starter product for youth. A resent paper by Kreslake and colleagues analyzed tobacco industry documents and found evidence that the tobacco industry has learned that young smokers prefer a medium menthol taste, which helps mask the harshness of nicotine but doesn’t contain too strong a menthol flavor. Brands that have followed this strategy have become dominant in the young menthol smoker segment, leading to long term growth in market share. When this evidence is combined with the evidence that many menthol smokers find it harder to quit smoking (discussed previously), it provides even stronger reason for the FDA to consider regulating menthol as an additive in cigarettes.

References.
Hersey JC, Ng SW, Nonnemaker JM, Mowery P, Thomas KY, Vilsaint MC, Allen JA,
Haviland ML. Are menthol cigarettes a starter product for youth? Nicotine Tob
Res. 2006 Jun;8(3):403-13. PubMed PMID: 16801298.

Kreslake JM, Wayne GF, Alpert HR, Koh HK, Connolly GN. Tobacco industry
control of menthol in cigarettes and targeting of adolescents and young adults.
Am J Public Health. 2008 Sep;98(9):1685-92. Epub 2008 Jul 16. PubMed PMID:
18633084.

Wackowski O, Delnevo CD. Menthol cigarettes and indicators of tobacco
dependence among adolescents. Addict Behav. 2007 Sep;32(9):1964-9. Epub 2006 Dec
22. PubMed PMID: 17229528.

Labels: addiction, adolescent, cigarette, cigarette smoking, jonathan foulds, menthol, Olivia Wackowski, youth

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Menthol: it helps the poison go down easier

I’m writing from the second conference on menthol and cigarettes, in Washington DC. This conference was organized to review the evidence on the effects of menthol in cigarettes and to discuss what further research is necessary and what actions should be taken.

To me, the presentations appeared to suggest that right now the evidence that menthol cigarettes are more harmful to health is weak. However, the evidence that menthol cigarettes are a starter product for youth and that menthol cigarettes can (under certain circumstances) be more addictive and harder to quit, is quite strong and getting stronger all the time.

My own presentation focused on data we have previously published (and that I’ve already discussed on this blog) showing that menthol cigarettes are harder to quit for African Americans, Latinos and for people on a low income. It was very fortunate that just yesterday a new study by colleagues at UMDNJ-School of Public Health came into the public domain and so I was able to discuss its findings.

I think that study, by Drs Dan Gundersen, Cris Delnevo and Olivia Wackowski, is a very important one. The paper, which will be published in the journal “Preventive Medicine” and appeared online yesterday, was based on the 2005 National Health Interview Survey. It focused on a representative sample of U.S. adult ever exclusive cigarette smokers who had ever tried to quit (n=7,815). It aimed to assess whether people who were primarily menthol smokers had a lower quit rate than people who were regular cigarette smokers (after adjusting for other characteristics of those groups). The study found that among African American and Hispanic smokers, those who smoke menthols have a significantly lower rate of quitting. Interestingly it found that among whites, there was an opposite effect, with white menthol smokers having a slightly higher quit rate than white regular cigarette smokers.

One of the pleasing parts for me about this study was that the results, in a representative sample of smokers who had tried to quit, were almost perfectly consistent with the results we had previously published based on people trying to quit at our smokers clinic (Gandhi et al, 2009). Like our clinic study, this new paper found that the effect of menthol on inhibiting smoking cessation is a sizeable one. For example, among African Americans, while 62% of regular cigarette smokers successfully quit, only 44% of menthol smokers were able to quit. Also like our clinic study, the effect remained significant after controlling for differences in the relevant characteristics of those who smoke regulars and menthols. Also like our clinic study, the menthol effect differed between white (non-Hispanic) smokers and minority smokers. But one thing that was different was that Dr Gundersen’s study found that white menthol smokers were actually MORE likely to quit than white non-menthol smokers. So the question remains, why the difference of effect of menthol on quitting smoking between whites and minorities?

I remain convinced that the underlying mechanism of action of menthol is to enable smokers to inhale more nicotine (and smoke) under circumstances that require it. The main circumstance requiring the smoker to inhale more nicotine per cigarette is a situation forcing the smoker to reduce their daily cigarette consumption. There are various forces requiring smokers to reduce their cigarette consumption, but a major one is money. In recent times as cigarettes have become more expensive across the United States, many smokers can no longer afford to smoke a pack a day. So they have to reduce to 5 or 10 cigarettes per day or try to quit. Of course we know that as smokers reduce, they rend to inhale more nicotine per cigarette (an effect often referred to as “nicotine compensation”). But inhaling more smoke per cigarette can cause harsh sensations in the throat. Menthol cools that effect, making it easier for larger doses of the poison to go down (Williams et al, 2007). But one of the effects of inhaling a higher dose of nicotine per cigarette is that each cigarette becomes more reinforcing and addictive. Although there is always more than one explanation for any effect, I believe that facilitation of increased nicotine inhalation is one of the main effects of menthol. But people who have plenty of money don’t need to smoke fewer each day, and inhale more from each one. So there is a socioeconomic difference in the effect. This is part of the reason for the difference of effect of menthol in whites and minorities. In our clinic study we found a similar menthol effect in unemployed whites that we did in employed African Americans (with no effect of menthol on quitting at all in employed whites).

I suspect that if national data is analyzed focusing on unemployed white smokers living in the north east of the U.S. (the highest cigarette cost area), who tried to quit in recent times (when high cigarette taxes kicked in), we would find a lower quit rate among the menthol than the non-menthol smokers in that group.

In terms of harms to health, we’d more easily find these in the short term by looking, for example, at pregnancy outcomes in menthol versus non-menthol smokers. I’m suggesting greater study of the effects of menthol in pregnancy because it’s a situation when many smokers try to cut down or quit, but many remain smoking, and in which the health impact can be measured in the short term (e.g. birth weight and complications).

I’m leaving this conference with a greater clarity that menthol added to cigarettes make it easier for young people to start smoking and harder for smokers to quit, because menthol helps the poison go down easier.


References

Gundersen D, Delnevo C, Wackowski O. Exploring the relationship between race/ethnicity, menthol smoking, and cessation, in a nationally representative sample of adults. Preventive Medicine (2009), doi:10.1016/j.ypmed.2009.10.003

Gandhi KK, Foulds J, Steinberg MB, Lou SE, Williams J. Lower quit rates among menthol cigarette smokers at a tobacco treatment clinic. International Journal of Clinical Practice 2009 Mar;63(3):360-7.

Williams JM, Gandhi KK, Steinberg ML, Foulds J, Ziedonis DM, Benowitz NL. Higher nicotine and carbon monoxide levels in menthol cigarette smokers with and without schizophrenia. Nicotine Tob Res. 2007 Aug;9(8):873-81.

Labels: African American, cessation, cigarette, ethnicity, Gundersen, Hispanic, jonathan foulds, latino, menthol, NHIS, race, Smoking, white

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Smoking after cancer diagnosis: Comment by Patrick Swayze’s doctor on CNN’s Larry King

Many people were saddened to hear of the recent death of the actor Patrick Swayze, after an almost two year battle with pancreatic cancer. Patrick Swayze was a very successful actor, most noted for his leading roles in the hit movies, Ghost and Dirty Dancing.

Within the past week, one of Patrick Swayze’s oncologists, Dr George Fisher, was interviewed on the CNN “Larry King Live” show and made the following comments:

LARRY KING: “He continued to smoke. Was that a bad idea?”

DR. GEORGE A. FISHER, ONCOLOGIST, STANFORD HOSPITAL & CLINICS: “I think at the point that one is already diagnosed with cancer, there's little additional harm in it. And if it -- it seems to provide him some comfort or partly identity of who he is, I certainly have no objections to that. But he would be the first to say that if you don't smoke, don't start. And if you do smoke, quit before you develop cancer.”

I suspect that Dr Fisher’s comments were referring to the specific context of someone suffering from a severe type of terminal cancer where the estimated life expectancy is in months rather than years, and not referring to all cancer diagnoses. So I think it is important that people, and particularly those people with a recent cancer diagnosis who are still smoking or recently quit, don’t take this comment out of context. Nowadays many types of cancer can be cured or effectively managed over a period of many years, and it is very clear that for many of these cancer diagnoses, the prognosis is much better if the patient quits smoking.

Below is a quote from a published review by an expert on this subject, Professor Ellen Gritz, of MD Anderson Cancer Center:
“The detrimental effect of smoking on cancer survival rates has been consistently demonstrated. Continued smoking after diagnosis has been found to negatively affect overall survival in patients with lung, head and neck, prostate, and cervical cancers. However, stopping smoking before diagnosis and treatment can have a positive influence on survival rates. Studies have generally indicated that the longer the interval between smoking cessation and initiation of cancer treatment, the better the prognosis.“

(Gritz ER, Fingeret MC, Vidrine DJ, Lazev AB, Mehta NV, Reece GP. Successes and failures of the teachable moment: smoking cessation in cancer patients. Cancer. 2006;106:17–27.)

Just last month the results of a very large study were published showing better outcomes for smokers who quit sooner after lung cancer diagnosis. I’ve copied the study summary below. Just to be clear, the research evidence shows that in the vast majority of cancer diagnoses, health outcomes will be improved by quitting smoking.


Impact of smoking cessation before resection of lung cancer: a Society of
Thoracic Surgeons General Thoracic Surgery Database study.
Mason DP, Subramanian S, Nowicki ER, Grab JD, Murthy SC, Rice TW, Blackstone EH. Ann Thorac Surg. 2009 Aug;88(2):362-70; discussion 370-1.

Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute,
Cleveland Clinic, Cleveland, Ohio 44195, USA. masond2@ccf.org

BACKGROUND: Smoking cessation is presumed to be beneficial before resection of
lung cancer. The effect of smoking cessation on outcome was investigated.
METHODS: From January 1999 to July 2007, in-hospital outcomes for 7990 primary
resections for lung cancer in adults were reported to the Society of Thoracic
Surgeons General Thoracic Surgery Database. Risk of hospital death and
respiratory complications was assessed according to timing of smoking cessation,
adjusted for clinical confounders. RESULTS: Hospital mortality was 1.4% (n =
109), but 1.5% in patients who had smoked (105 of 6965) vs 0.39% in those who had
not (4 of 1025). Compared with the latter, risk-adjusted odds ratios were 3.5 (p
= 0.03), 4.6 (p = 0.03), 2.6 (p = 0.7), and 2.5 (p = 0.11) for those whose timing
of smoking cessation was categorized as current smoker, quit from 14 days to 1
month, 1 to 12 months, or more than 12 months preoperatively, respectively.
Prevalence of major pulmonary complications was 5.7% (456 of 7965) overall, but
6.2% in patients who had smoked (429 of 6941) vs 2.5%% in those who had not (27
of 1024). Compared with the latter, risk-adjusted odds ratios were 1.80 (p =
0.03), 1.62 (p = 0.14), 1.51 (p = 0.20), and 1.29 (p = 0.3) for those whose
timing of smoking cessation was categorized as above. CONCLUSIONS: Risks of
hospital death and pulmonary complications after lung cancer resection were
increased by smoking and mitigated slowly by preoperative cessation. No optimal
interval of smoking cessation was identifiable. Patients should be counseled to
stop smoking irrespective of surgical timing.

The CNN interview transcript is at:
http://transcripts.cnn.com/TRANSCRIPTS/0909/19/lkl.01.html

Labels: cancer, cessation, cigarette, CNN, diagnosis, George Fisher, jonathan foulds, Larry King, Patrick Swayze, Smoking, survival

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Does the e-cigarette deliver nicotine?

I’m currently attending the annual conference of the Society for Research on Nicotine and Tobacco. This is the main organization for nicotine researchers and this conference is often the first place that exciting new research findings are presented, prior to being published in more detail in scientific journals. So this week my posts will be based on some of the most interesting things I have come across at this conference, including new developments in helping smokers quit.

There is currently considerable interest (hype?) in the e-cigarette, and I have written about it before. Last weekend I was walking through our local shopping mall in New Jersey with my 8-year old daughter when she tugged at my arm and said “dad, dad, theres a man smoking over there.” I told her that couldn’t be true because people arnt allowed to smoke inside the mall, but she insisted. On looking over I was surprised to see that sure enough, someone was standing next to a booth and appeared to be puffing away on a cigarette. So we walked over to investigate, and found out that in fact it was an e-cigarette and he was selling the product at the booth. We chatted and he showed me the product which actually looks very impressive. I had already purchased an earlier version a couple of years ago, which was more stogie cigar-sized, but this one looked and puffed very much like a cigarette and was also considerably less expensive than the earlier model.

But whenever discussing this product, to me the first and most critical question (after …”whats in the vapor and might it harm my health?”) is, “does it deliver enough nicotine to satisfy nicotine cravings? “ Until I came to this conference, I hadn’t met anyone who had completed a study that included measurement of blood nicotine levels in people using the e-cigarette. This question is critical because cigarette smokers are used to receiving a boost in blood nicotine levels of at least 10 ng/ml from each cigarette, and for a product to have any chance of effectively reducing craving for or replacing cigarettes it needs to come close to that level of nicotine delivery.

But I was lucky enough to bump into Dr Murray Laugesen, a tobacco control expert from New Zealand who has been one of the foremost proponents of the product. He showed me a preliminary report on the e-cigarette which was being presented at the conference. Full details of the study will be presented in a formal publication sometime in the future, but for right now the main conclusion is that although the e-cigarette CONTAINS a reasonable amount of nicotine it actually DELIVERS very little nicotine to the user, and certainly much much less that can be obtained from smoking. To my mind this relegates the status of this product to that of a very nice and cleverly designed theatre prop, and unfortunately not a product that is likely to be highly effective in helping smokers to quit smoking.

As always, if you are interested in using a product to assist you in quitting smoking, your best bet is to use a product that has been approved by the medicines licensing agency in your country as safe and effective for that purpose (e.g. in the U.S. that would be the FDA).

For more information about Dr Laugesen’s work on the e-cigarette, visit:
http://www.healthnz.co.nz/ecigarette.htm

Labels: cigarette, e-cigarette, jonathan foulds, nicotine

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Do menthol smokers inhale more nicotine and toxins?

I have previously discussed some studies conducted at UMDNJ suggesting that under certain conditions menthol smokers inhale more nicotine and carbon-monoxide from their cigarettes and have a lower quit rate when attending our tobacco dependence treatment clinic.

The pattern of results we have observed suggest that it may not be a simple effect of menthol causing smokers to inhale more smoke. Rather, we have proposed that in circumstances requiring the smoker to reduce their cigarette consumption (e.g. when price increases affect affordability in a low-income smokers) menthol enables the smoker to increase the amount of smoke and nicotine they inhale per cigarette, by reducing the harshness.

Now clearly manufacturers of menthol cigarettes have an interest in this issue. In particular, the Lorrilard Tobacco Company, who depend on sales of Newport cigarettes for most of their profits, have an interest. So I was interested to read a paper by Dr Daniel Heck of Lorrilard Tobacco Company, on biomarkers of smoke exposure on menthol and nonmenthol smokers.

The study recruited 54 monthol smokers and 58 non-menthol smokers, provided them with preference-matched standard menthol or nonmenthol for a 1-week study period and menthol smokers were also given free menthol cigarettes for 2 weeks prior to the study period to allow them to acclimatize to the study menthol cigarettes.

For one day at the start of the one week study period and another day at the end, participants were allowed to smoke normally but blood and urine was taken in order to measure a variety of indicators of smoke exposure. The main result was that there were no consistent differences in markers of smoke exposure between menthol and nonmenthol smokers.

I am not writing to dispute the findings or even the measures used in the study (although Id have preferred if blood nicotine concentration had been measured). Rather I want to point out some characteristics of the study population and study procedures that make it unsurprising that they didn’t find any differences.

First of all, the study sample smoked an average of 27 cigarettes per day (both menthol and nonmenthol smokers). This a very high cigarette consumption, and extremely unusual for current African American menthol cigarette smokers. Just for comparison, among smokers attending our clinic (who are heavier than average smokers), AA menthol smokers smoked under 16 cigarettes per day.

Secondly, providing the sample of menthol smokers with free access to the study menthol cigarettes for 3 weeks, including the study week, detracts from the financial reality facing many smokers just now, and could have altered the way they smoked the cigarettes.

It is a pity this study did not recruit a more representative sample of US smokers and allow them to smoke their own, paid-for cigarettes.


Heck JD. Smokers of menthol and nonmenthol cigarettes exhibit similar levels of biomarkers of smoke exposure. Cancer Epidemiol Biomarkers Prev. 2009 Feb;18(2):622-9.

Labels: biomarkers, cancer, cigarette, cigarette smoking, jonathan foulds, menthol, toxins

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Walmart sells smoking cessation medicine for $9.

Last month Walmart announced that it has started selling the prescription-only smoking cessation medicine, bupropion (same drug as brand version, Zyban) at a lower price than any other effective smoking cessation medicine.

The starter pack, consisting of 17 bupropion 150mg extended-release tablets (a 10-day supply), sells for $9, and subsequent 30-day supplies (60 tablets) will cost $27 (less than $7 per week). Bupropion is typically taken as a single 150mg tablet per day for the first 3 days, then two tablets a day for the next 4 days. The smoker is advised to quit smoking completely on day 8, and continue on two tablets a day for approximately 8 weeks thereafter .

Currently smokers who don’t have health insurance coverage that includes smoking cessation medicines have to pay prices ranging from around $20 for a small box of generic nicotine gum intended to last a few days, up to around $55 for a 2-week supply of nicotine patches or around $130 for a month supply of varenicline (Chantix).

So the chance to get started on bupropion for an initial outlay of only $9, is much less expensive than other options, as is the continuing cost of around $27 per month. Not everyone can tolerate bupropion’s slightly stimulant initial side effect (including agitation and insomnia), but the initial 10-day supply is designed to take people to 3-days after their target quit date. So the smoker can find out if bupropion is helpful to them without a large initial financial outlay.
Bupropion also has the advantage that it can be combined with nicotine replacement therapy (e.g. nicotine gum) to obtain better results, as discussed in a prior blog posting: http://www.healthline.com/blogs/smoking_cessation/2007/09/does-it-help-to-add-nicotine-gum-to.html

You can find full details of the outcomes of smoking cessation treatment with bupropionas described in the New England Journal of Medicine at: http://content.nejm.org/cgi/content/abstract/340/9/685

You can find details of the Walmart announcement at: http://walmartstores.com/FactsNews/NewsRoom/8904.aspx

Labels: bupropion, Chantix, cigarette, jonathan foulds, nicotine gum, NRT, smoking cessation, varenicline

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Cigarette taxes to increase across USA

On February 4th President Obama signed legislation designed to provide health insurance to uninsured children in low-income families, which will be funded by a 62 cent increase in the federal cigarette tax per pack . This will increase the federal cigarette tax from 39 cents to just over a dollar per pack. The federal tax per packet of “little cigars” is also increasing to the same level ($1.01 per pack).This is the first time there has been a national increase in cigarette taxes for over a decade. Although the tobacco companies typically try to reduce the initial impact of such increases by offering temporary discounts, it will inevitably lead to an overall increase in the cost to the smoker per pack of cigarettes. This increase in federal cigarette taxes is in addition to increases in state and city cigarette taxes that are also sweeping the country. Although the cost per pack across the country will be around $5, in places such as New York City a packet of cigarettes will soon be well over $7. If you needed another reason to quit smoking, having to spend over $2000 a year on cigarettes, in tough financial times, might be the one. I hope you can find some helpful tips on other blog posts on this site that might help you succeed.Try some of the links on this post:http://www.healthline.com/blogs/smoking_cessation/2008/12/get-ready-for-smoke-free-2009.html

Labels: cigarette, cigarette tax, jonathan foulds, little cigar, smoking cessation

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What proportion of smokers become addicted?

Most people who become smokers initiate smoking before the age of 18. They generally try smoking as part of experimentation, after observing their peers and family smoking and viewing tobacco advertising. It is fairly natural, when cigarette smoking can be observed so widely, for a child to think, “I wonder what that is like?”. Most kids who try smoking are not considering or expecting that they may become addicted. But it may be worth educating young people on their risks of becoming addicted. To do so we have to be clear about what we mean by “addiction”.

Nowadays the words “dependence” and “addiction” are generally used interchangeably with the same meaning. When used in relation to substance or drug use, these words refer to a situation in which the drug has come to unreasonably control a person’s behavior. The central characteristic of most definitions of drug addiction is that the individual experiences an impaired ability to reduce or end their use of the drug. In the case of cigarette smoking that characteristic is most commonly expressed as long term daily smoking despite awareness of the likelihood of serious health effects, a desire to reduce or quit, and failed attempts to reduce or quit.

In order to more clearly define, diagnose and study nicotine dependence, various diagnostic criteria have been developed, such as those of the American Psychiatric Association (DSM-IV) or the World Health Organization (ICD-10). These typically describe a list of criteria and require individuals to meet a certain number of these to meet the diagnostic threshold for “nicotine dependence”. There are 7 main DSM-IV criteria, (including things like difficulty cutting down, continued use despite it causing problems, experience of withdrawal symptoms when reducing etc) and if a smoker meets at least 3 of these they are considered to be “nicotine dependent”. Of course there is a certain artificiality about this because most people consider that nicotine addiction exists on a continuum of severity, rather than being a categorical disorder that a person either does or does not have. But these diagnostic frameworks at least give us a way of identifying those who are clearly addicted.

Last year, Drs Eric Donny and Lisa Dierker published a paper (in the journal, “Drug and Alcohol Dependence”) that aimed to identify what proportion of smokers in the general population met strict DSM-IV criteria for nicotine dependence. Their study was based on direct interviews with a large, representative sample of non-institutionalized adults in the United States in 2001-2. From that sample they focused on the 8,213 who were daily smokers in the past year. This sample included people who smoked anything from 1 to over 40 cigarettes per day, and people who had smoked for less than one to over 50 years.

The study found, not surprisingly, that the greater the number of cigarettes per day the person smoked, the greater the chance that they would meet strict diagnostic criteria for having become nicotine dependent. Whereas under 50% of those who smoked 1-5 cigarettes per day met the criteria, over 80% of those who smoked over 30 cigarettes per day met the criteria.

Unexpectedly, however, the longer the person had smoked, the less likely they were to have become dependent, particularly if the person had started smoking over 50 years ago. This finding seems very odd, and may have more to do with memory for quit attempts or attitudes to smoking among older age cohorts.

Overall, over 60% of ever daily smokers met strict diagnostic criteria for having become nicotine dependent. But almost all smokers had experienced at least one symptom of nicotine dependence. For example, 97% of “dependent” smokers had experienced difficulty cutting down their cigarette consumption, as had 72% of “non-dependent” smokers. The authors acknowledged that the differences in dependence between these two groups may be more quantitative rather than qualitative. The authors also acknowledged that certain co-occurring factors appear to make it more likely that a smoker will bcome dependent. An example they provided was a history of major depression, which is associated with approximately 100% nicotine dependence among heavy smokers.

So we can tell young people that if they take up smoking, there is an over 90% chance that they will experience some symptoms of nicotine addiction, and over a 60% chance that they will go on to meet strict diagnostic criteria for becoming addicted to nicotine.

A pdf copy of the full paper by Drs Donny and Dierner can be accessed (near the bottom of the page) at:
http://www.tern.org/Publications.htm

Labels: addiction, cigarette, cigarette smoking, dependence, jonathan foulds, nicotine

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Can cigarettes be made less deadly?

Since it became clear in the 1950s and 60s that cigarettes are deadly when used as intended, there have been various attempts to make them less harmful. These have included the addition of and modifications to filters, and changes in the type of tobacco used. But none of these changes has made a great deal of difference. Part of the problem is that changes that reduce the amount of one toxin often have an opposite effect on the amounts of other toxins in the smoke. Another problem is that changes to the product can affect the way it is used by consumers. The most obvious example here is that as the amount of nicotine in the tobacco decreases, so the smoker takes larger puff volumes in order to get their usual dose. The main lesson from all this is that when humans take any product, burn it, and inhale the smoke into their lungs, it is inevitably going to be very harmful to that individual’s health. Our bodies did not evolve to inhale smoke.

It is partly for this reason that I take the view that the tobacco industry should be given the strongest encouragement to move out of the smoking business entirely, and focus on smokeless tobacco as a way of making money out of nicotine addiction.

However, it’s a reality that cigarettes will be around for the foreseeable future and therefore it makes sense to try to make them less harmful. This month an influential report was published on this topic in the journal, “Tobacco Control” by a World Health Organization study group. The group (called TobReg) proposed a mandated lowering of of permissible toxicants in cigarette smoke. They took the 9 main toxicants, examined the range of levels of these toxicants emitted by international cigarette brands (and there are very wide ranges) and recommended that all cigarettes must emit an amount less than approximately the current median level found in a range of brands. This is analogous to measuring the amount of pollutants emitted by all of the new cars in the world today, and then saying that from some future point in time, all new cars must emit an amount of pollution less than the car that ranks in the middle of the current range. Clearly the standard can be tightened again in the future.

This would mean that for each toxicant, about half of the existing brands would require modification in order to comply with the standard. It means that for 9 toxicants, a far larger proportion of current brands would need to be modified in order to be fully compliant for all 9 toxicants. It should be noted that the toxicant concentrations are expressed in units per milligram of nicotine. This is a wise way to do it, which recognizes that smokers smoke for nicotine, and that it is the ratio of toxins to nicotine that is therefore important. The rationale and many complex details of the proposal are described in the report, which can be accessed for free at:
http://tobaccocontrol.bmj.com/cgi/content/full/17/2/132
A commentary can also be viewed at:
http://tobaccocontrol.bmj.com/cgi/content/full/17/2/73

These proposals are a sensible first step at making cigarettes a bit less harmful. Surprisingly there is even a chance they could be accepted by a major tobacco company. Philip Morris (now split into a separate US and a separate “international” company) may consider that despite all the hassle in complying with such regulations, they may come out smelling of roses (i.e. smelling of money) because they are in a stronger position to make the required technical changes than many smaller companies. They therefore may consider that the regulations present an opportunity for them to gain market share via more efficient regulatory compliance.

It is interesting that the approach taken in this report is almost the opposite of that which has been proposed in the United States, which involves leaving all the toxicant levels as they are, but reducing the nicotine delivery down to levels that will no longer be addictive.

I continue to believe that while both of these approaches have merit, the most direct route for the tobacco industry to stay in business but causing much less harm to health, is for it to be required to focus exclusively on smokeless tobacco products. These have already been shown to be consumer-acceptable, deliver adequate doses of nicotine, but cause far lower levels if ill-health (e.g. no lung cancer or COPD). This approach also avoids the challenging task of enforcing at the individual level. If I’m a policeman walking down the street and I see someone smoking, it is impossible to tell if that cigarette complies with the reduced nicotine or reduced toxicant regulation. If cigarettes are outlawed and only smokeless products are allowed, then enforcement is much simpler.

For smokers, it is important not to sit back and wait for these less harmful cigarettes to come along. This is a long-term project that has only just been proposed. It is highly likely that you will have died of a serious smoking-caused disease long before these proposals result in meaningfully less harmful cigarettes. So the main message remains the same:

The single best thing you can do for your health is to stop smoking completely. There are now a range of effective methods (e.g. quitlines, internet sites, etc) and medicines available that can help you to successfully quit smoking, and you should talk to your healthcare professional about which ones would suit you.

Labels: cigarette, cigarette smoking, jonathan foulds, nicotine addiction, tobacco

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What is in cigarette smoke?

More than 4000 different chemicals have been identified in cigarette smoke. Most of us have a very basic idea that these chemicals can be harmful to health and that the mechanisms whereby this complex mixture of toxins contained in tobacco smoke leads to specific diseases are complex. However, I thought it might be helpful to some readers to provide a very basic description of the ways in which some of these components of cigarette smoke cause ill-health.

The simplest categorization of the components if cigarette smoking identifies 3 major components: tar, nicotine, and cabon-monoxide (CO).

Tar is the black sticky mass that coats the lungs and the airways. There are many hundreds of different chemicals within the tar, some of which have been shown to be carcinogenic in animals and/or humans. The deposition of particles of tar in the lungs and upper airways leads to the blocking of airways and to serious breathing problems, including Chronic Obstructive Pulmonary Disease (COPD). The toxic chemicals also cause inflammation and reduce the elasticity of the lungs and hence the ability to inhale and exhale normally.

The carbon-monoxide in smoke replaces oxygen in the hemoglobin (a component of blood), adversely affecting oxygen transport and energy supply, and requiring the heart to do more work to supply the same amount of oxygen to the body. A large number of smoke constituents, and particularly components of the gaseous phase of the tobacco smoke, cause immunologic responses and inflammation in the cells. This causes increased stickiness of the blood which increases the risk of clots. These processes increase the likelihood of a heart attack, stroke or other problems with the cardiovascular system.

Irritants such as nitric oxide cause hypersecretion of mucus and substances such as acrolein, acetone and acetaldehyde cause damage to the small hair-like strands that line the airways (cilia). This damage to the cilia impairs the ability of the cilia to clear mucus, causing breathi9ng difficulties. Years of smoking and daily coating of the lungs and airways in tar leads to irreversible lung damage and ultimately death from COPD .

Acute nicotine (critical for the development of addiction), increases heart rate, blood pressure and causes peripheral vasoconstriction (i.e. impairs peripheral circulation and thus exacerbates Reynauds’ Disease and erectile dysfunction). However, studies of smokeless tobacco users (who have high nicotine exposure like smokers, but without the smoke) compared with smokers, suggest that most of the cardiovascular problems are not caused by nicotine. It therefore appears that it is the thrombogenic effects of tobacco smoke exposure (primarily oxidant gases), combined with reduced oxygen supply (carbon monoxide) and increased myocardial oxygen demand (nicotine) that cause the cardiovascular harms from smoking.

Some of the chemicals found in cigarette smoke are listed below.

Carbonyls
Formaldehyde, Acetaldehyde, Acetone, Acrolein, Propionaldehyde, Crotonaldehyde, Methyl-Ethyl-Ketone, Butyraldehyde
Phenolics
Hydroquinone, Resorcinol, Catechol, Phenol, Cresol (m+p and o)
Aromatic Amines
3- and 4-aminobiphenyl, 1- and 2- aminonapthlene, o-toluidine, o-anisidine
Oxides of Nitrogen NO,
Hydrogen Cyanide
Ammonia
Volatiles
Benzene, Toluene, 1,3-butadiene, Isoprene, Acrylonitrile
Semi-Volatiles
Pyridine, Quinoline, Styrene
Trace Metals
Nickel (Ni), Cadmium (Cd) Lead (Pb) Chromium (Cr) Arsenic (As) Selenium (Se), Mercury (Hg)
Tobacco Specific Nitrosamines
N-Nitrosonornicotine (NNN)N-Nitrosoanabasine (NAB) Nitrosoanatabine (NAT)4-(N-nitrosomethylamino)-1-(3-pyridyl)-1-butanone (NNK)
Volatile Nitrosamines
N,N-Nitrosodimethylamine (NDMA)N-Nitrosopyrrolidine (NPYR), N,N-Nitrosodiethylamine (NDEA)N,N-Nitrosoethylmethylamine (NEMA), N,N-Nitrosodipropylamine (NDPA)N,N-Nitrosodibuthylamine (NDBA), N-Nitrosopiperidine (NPIP)
Polycyclic Aromatic Hydrocarbons
Naphthalene, 1-Methylnaphthalene, 2-methylnaphthalene, AcenaphthyleneAcenaphthene, Fluorene, Phenanthrene, Anthracene, FluoranthenePyrene, Benzo(a)anthracene, Chrysene, Benzo(b)fluorantheneBenzo(k)fluoranthene, Benzo(j)fluoranthene, Benzo(g,h,l)peryleneBenzo(e)pyrene, Benzo(a)pyrene, PeryleneIndeno(1,2,3,-cd)pyrene, Dibenzo(a,h)anthraceneDibenz(a,j)acridine, Dibenz(a,h)acridine, Dibenz(a,e)pyreneDibenz(a,h)pyrene, Dibenz(a,i)pyrene, Dibenz(a,l)pyrene7H-Dibenzo(c,g)carbazole,
Heterocyclic Aromatic Amines
2-Amino-3-methylimidaszo(4,5-f)quinoline (IQ)2-Amino-3,4-dimethylimidazo(4,5-f)quinoline (MeIQ)2-Amino-3-methyl-9H-pyrido(2,3-b)indole (MeAaC)2-Amino-9H-pyrido(2,3-b)indole (AaC)1-Methyl-9H-pyridol(3,4-b)indole (Harman)9H-Pyrido(3,4-b)indole (Norharman)

Labels: cancer, chemicals, cigarette, jonathan foulds, nicotine, smoke, tar, toxins

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One Cigarette Wouldn’t Do Any Harm – Would It?

Just over half of the “ever-smokers” (those who ever became regular smokers) in the United States are now “ex-smokers”. Of course for all ex-smokers, the possibility of relapse is real, and the shorter the time since your last smoke the greater the risk of going back. As many as 40% of those who go a whole year without a smoke will lapse and have another cigarette or more in the next few years, while for those who havn’t smoked for five years or more the chances of going back to smoking are much lower.

I suspect that most visitors to the Healthline.com website are not current smokers, but that a sizeable proportion will be ex-smokers, many of whom gave up long ago (5 years or more). Most long-term ex-smokers are very happy and relieved to have successfully quit, but many will admit to getting occasional urges to smoke. Being in situations where you previously smoked (e.g. a bar) or doing an activity that was associated with smoking (e.g. walking the dog) or even just being in a certain mood state can trigger thoughts about smoking, even if you hadn’t thought about it at all for weeks or months. On many of these occasions you won’t have any tobacco available and the thought will pass in a matter of a few seconds. But certain things seem to be associated with stronger cravings and relapse risks. Some of these things are very obvious practical factors, such as the availability of cigarettes. Some are factors that serve to lower our inhibitions or lead us to believe that we “deserve” a smoke (e.g. drinking alcohol, being at a celebration or being on vacation). Even though alcohol can trigger cravings directly, sometimes I suspect that consuming alcohol also causes an indirect effect whereby the ex-smoker believes that being intoxicated somehow gives them an acceptable excuse.

One other psychological factor that increases relapse risk is the thought that, “one cigarette won’t do any harm.” This type of thought is very seductive because on the surface it may seem like a very reasonable point. One cigarette on its own is very unlikely to trigger a serious illness. Ex-smokers entertaining this train of thought often find themselves thinking further rationalizing thoughts such as, “and if I hang out in that smoky bar all evening I’ll probably breath in a whole cigarette’s worth of smoke just from other people’s smoke…so whats the difference?”. But the important thing to remember is that the biggest risk from smoking a single cigarette, is that it greatly increases the risks that you will smoke another and then another and so on. We don’t fully understand the mechanism for this type of relapse but some of it likely occurs at a neurobiological level. Even laboratory rats that have learned to press a lever for nicotine may get a sudden reinstatement of bar pressing if they are given a single injection of nicotine. But there is also a cognitive component to it, that is referred to as the “abstinence violation effect”. This is the process whereby an ex- smoker who has a lapse cigarette then finds him/herself thinking, “oh well, I’ve broken my good record now…I may as well finish the pack” (something that the lab. rat probably doesn’t think).

So it is far better to be very clear in your mind that one cigarette could do a great deal of harm, (by prompting a return to pack-a-day smoking) and that “not-a-puff” abstinence is the way to go.

Labels: cigarette, relapse, smoking cessation

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State-specific prevalence of cigarette smoking.

In previous posts I’ve discussed international differences in tobacco use, which showed that by international standards, male cigarette smoking prevalence is relatively low in the United States, but female smoking prevalence is higher in the US than most other parts of the world. The clearest contrast is with a countries like China, where almost two-thirds of men smoke, but only a few percent of women smoke.

On Friday (Sept 28th, 2007) the US Centers for Disease Control published the latest (2006) figures for adult cigarette smoking prevalence within each U.S. state. The median prevalence was 20.2%, but consistent with recent years, there were some large between-state differences. The highest smoking rates were in tobacco-growing states such as Kentucky (28.6%), or West Virginia (25.7%). The lowest smoking rates were in places with strong cultural prohibitions against tobacco such as Utah (9.8%) and California (14.9%).

Overall, the median smoking rates were higher for men (22.2%) than for women (18.5%). Although it is probably unwise to make too much of single-year prevalence estimates for relatively small geographic regions, such as individual states, I like to look at these to see if anything potentially interesting pops out. The California figures are always of interest as a guide to how low we can go in the rest of the United States. Although the low smoking rates in California are partly related to the high number of non-smoking immigrants to that state, they are largely due to California’s comprehensive tobacco control program that was the first to be reasonably well funded, to increase cigarette taxes, and to pass legislation requiring smoke-free indoor public places. The California program also used a hard hitting media campaign to publicize the harmfulness of tobacco smoke (including to non-smokers), and to encourage smokers to try to quit.

Kentucky provides us with a good example of what happens in a state where the tobacco industry dominates the political agenda – you get very weak tobacco control and very high smoking rates. One thing that stood out was the low smoking rate in Idaho (16.8%). I must say I have no idea why Idaho’s smoking rates are so low, but would be grateful if someone could tell me! The other odd thing I noticed was that despite the fact that men generally smoke more than women, in two states that wasn’t the case. In West Virginia 25.4% of men smoke cigarettes and 26% of women smoke them, and in Montana 18.5% of men smoke as do 19.6% of women. The very high female smoking rate in W.V. may just be a blip in the data, (?) but the Montana difference looks to be related to unusually low male smoking rates in that state. The only other part of the world where the proportion of men who smoke is consistently lower than women is Sweden, and in that case it is because many men have switched from smoking to snuff (smokeless) tobacco. If anyone out there has an explanation for the male/female smoking pattern in Montana and West Virginia I’d be interested to hear it.

If you would like to find out the latest figures for your own state, check them out via this link: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5638a2.htm

Labels: cigarette, cigarette smoking, prevalence

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Menthol smokers inhale more toxins

A new study published this month in the journal, Nicotine & Tobacco Research, has found that people who smoke menthol cigarettes have higher levels of blood nicotine, cotinine (main nicotine metabolite) and higher levels of exhaled carbon-monoxide.

The original study, led by Dr Jill Williams of the University of Medicine and Dentistry of New Jersey, was actually designed to assess whether people who suffer from schizophrenia inhale more nicotine from their cigarettes than people not suffering from schizophrenia. Dr Williams, one of the nation’s top experts on smoking and mental health, found that people with schizophrenia inhale about 30% more nicotine from their cigarettes (as indicated by biochemical measures). After we noticed that quit rates were significantly lower among smokers of mentholated cigarettes at the Tobacco Dependence Clinic at UMDNJ-School of Public Health, Dr Williams and colleagues re-analyzed the data from the schizophrenia study, which included data on the type of cigarettes smoked by participants. The finding of higher nicotine and cotinine levels among smokers of menthol cigarettes is not entirely new. But previous research was unclear on whether this reflected different metabolism of nicotine by menthol smokers, or increased inhalation of smoke by menthol smokers (or both). The finding of increased levels of carbon-monoxide points to increased smoke inhalation by menthol smokers.

So why would menthol smokers inhale more smoke? Note that this study took place in New Jersey, the state with the highest cigarette taxes ($2.58 state tax plus 39c federal tax per pack). So smokers on low incomes have been forced to reduce their cigarettes per day as a financial necessity. The natural reaction of the nicotine addict to smoking fewer cigarettes per day is to inhale more nicotine (and smoke) per cigarette to try to get the usual dose. However, with regular cigarettes the attempt to inhale larger puffs is limited by harsh sensations on the throat. However, with menthol cigarettes, larger puffs deliver larger doses of menthol which cools the harshness by stimulating cold receptors, and facilitates increased inhalation.

At first thought this could sound like a good thing to the heavy smoker. But it appears to lead to increased addictiveness (lower quit rates) and also may be a part explanation for the much higher death rates from lung cancer among smokers from racial groups that predominantly smoke menthols (e.g. African Americans and Native Hawaiians). It is noticeable that the tobacco industry targets its marketing of menthol brands towards groups who typically have less cash to spend (e.g. young people and ethnic/racial minorities). Perhaps the industry has figured that the menthol brands can get those groups “hooked” on a lower daily cigarette consumption?

To view a TV news item that includes coverage of this issue, visit:
www.tobaccoprogram.org

To view the full text/pdf of a study reporting lower initial quit rates among menthol smokers (Foulds et al, 2006. Factors associated with quitting smoking…) and a number of other studies, visit: http://www.tobaccoprogram.org/staffarticles.htm

To learn more about quitting smoking while coping with a mental illness, visit:
http://www.njchoices.org/index.htm

Labels: carbon monoxide, cigarette, lung cancer, menthol, nicotine, schizophrenia

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Could smoking reduction improve your health?

Although around 70% of smokers say they would like to quit smoking, many are not planning to try to quit within the next six months. A sizeable minority are more attracted to the idea of reducing smoking rather than quitting altogether. It is also true that with increases in the cost of cigarettes and restrictions on smoking in public places, many smokers are having to reduce their smoking, whether they like it or not.

However, is there a health benefit from reducing the number of cigarettes smoked? Now this may sound like a silly question. Most of us are aware that there is a clear “dose-response” relationship between the number of cigarettes smoked and the risk of suffering from a disease such as lung cancer. But we must remember that most of the people in these studies were smokers smoking at their natural rate. A person who has always smoked 10 cigarettes per day may not be like someone who smoked 20 per day and then reduced to 10 per day. One of the effects we know about is that people who cut down their daily consumption tend to increase the amount they inhale from each cigarette. In fact it is not difficult to suck two or three times as much smoke out of a cigarette by simply inhaling more deeply and taking more puffs per cigarette. Clearly if someone inhaled twice as much smoke out of each cigarette we would not expect any health benefit from cutting the number of cigarettes per day in half.

Last month, Professors Charlotta Pisinger and Nina Godtfredsen from Denmark published a comprehensive review of the medical literature on the health effects of reduced smoking (in the journal, “Nicotine & Tobacco Research”). They defined smoking reduction as reducing the number of cigarettes per day by at least 50%. Overall, they found that such a reduction may improve some respiratory symptoms, and may reduce lung cancer risks. However, on some of the “harder” outcome measures, such as performance on lung function tests, there was no improvement from reduced smoking. Perhaps most importantly, in the largest study that looked at effects on mortality, people who cut down by 50% and maintained it over 15 years were just as likely to die early as those who didn’t cut down, and of course both groups had much higher death rates than those who quit smoking.

So overall, the data suggests that the health benefits of reduced smoking are much smaller than one might expect or hope for. It is also important to recognize that most smokers find it very difficult to reduce by much more than 50% and then maintain the lower level for a long period. When stressful life events occur, there’s a strong tendency to return to the old level of smoking. It suggests to me that it makes much more sense to make a firm plan to quit smoking altogether. If something is causing you to hesitate about quitting completely on one day, then by all means make a plan to reduce prior to quitting. But its important that your reduction has a plan (i.e. a date) by which you will reach zero cigarettes per day and keep it at that. The evidence is absolutely clear that quitting smoking results in substantial health benefits, as summarized in previous posts.
http://www.healthline.com/blogs/smoking_cessation/2007/02/how-bad-is-smoking-for-health.html

Labels: cigarette, health, nicotine addiction cigarette smoking tobacco, nicotine regulation reduction smoking smokeless

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Tobacco Use Around The World

A reader from Australia requested some comparative information on tobacco use around the world. By far the best source of such information is a superb book called, “The Tobacco Atlas” (2nd Edition) written by Dr. Judith Mackay, Dr. Michael Eriksen, and Dr. Omar Shafey. Large parts of the book are available online via the link below, but I’ll try to summarize the parts I found most interesting.

The most striking thing is the enormity of it. Taking cigarettes alone, global cigarette production continues to increase dramatically, from 1,686 billion cigarettes in 1950 to 5,604 billion in 2002. The magnitude of tobacco consumption in Asia generally and China in particular is mind-boggling. More than 300 million men smoke in China (70% of men) – more than the entire population of the United States, and they consume 30% of the world’s cigarettes each year. The other striking factor is that in many countries in the world (particularly Asia, Africa and the Middle East) smoking is largely a male past-time, with male smoking rates about 10 times those in women.

Because of these marked sex differences in smoking in some countries, around a billion men smoke and around 250 million smoke around the world. It is largely the high smoking rates among women in North America and Europe that causes the overall smoking rates in these countries to be relatively high – in most other countries male smoking is higher but female smoking is much less common. In fact the only country in the world that has had consistently higher female than male cigarette smoking rates over the past 10 years is Sweden. Sweden has the lowest male smoking rates in Europe, and is the only member of the European Union that allows the sale of smokeless tobacco. More men now use smokeless tobacco than smoke in Sweden.

In countries like the UK, USA and Australia there is a clear linear relationship between smoking rates and education/socioeconomic status, with smoking rates being much higher in the poorest, least educated sections of society. However, it is not like that across the globe. For example, in southern European countries such as Greece, female university students are more likely to smoke than young women not attending university. Amazingly in some countries (e.g. Turkey and Bulgaria) the smoking rates are higher among health professionals than in the general population. In China 57% of male doctors smoke!

The China National Tobacco Corporation is the biggest tobacco company in the world, having a monopoly in China as part of the Chinese government, and therefore having about a third of the global tobacco market. Then there are 5 major multinational tobacco companies with significant global market shares: Altria (Philip Morris): 17.6%, British American Tobacco (15.1%), Japan Tobacco Inc (9.5% including recent take-over of Gallaher Group PLC), Imperial Tobacco Group (3.6%) and Altadis (2%). In 2004, Philip Morris sold $57 billion worth of cigarettes in over 160 countries. Interestingly, in 2003, 851 billion cigarettes were reported as being exported around the world but only 664 billion were reported as being imported. Unless we are exporting to aliens on another planet, almost 200 billion cigarettes went “missing” in the process!

And to return to our Australian colleague, in fact Australia is one of the world leaders in tobacco control, with an adult smoking prevalence of around 17.6% (as compared with around 26% in UK and around 22% in USA). I often hear Americans return from vacation in Europe commenting on how “everyone” smokes over there. However, it depends which part of the USA one lives in whether smoking rates are much lower. In Utah and California smoking rates are much lower than most countries in Europe, but in Nevada and Kentucky smoking rates are higher than in many European countries.

For those of you with an interest in global tobacco, I’d strongly recommend taking a look at The Tobacco Atlas.
http://www.cancer.org/docroot/AA/content/AA_2_5_9x_Tobacco_Atlas.asp

Labels: cigarette, consumption, global, international, nicotine, smoking tobacco

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Cigarette Brand Preferences: start young and focus on 3 brands.

When you look at the cigarette counter at a supermarket or even a chain pharmacy you will typically see a wall of cigarettes and advertising placards touting dozens of types of cigarettes. However, although there are actually hundreds of different brands, and at least 25 different brands that are widely available, sales of cigarettes focus very much on just a few brands.

This is particularly noticeable in children, for whom almost all the sales focus on just 3 brands (can you guess what they are?). The other thing that is very noticeable is how brand preferences vary dramatically by ethnic/racial groupings. A massive ongoing study run by University of Michigan called, “Monitoring the Future” has been tracking youth smoking and other substance use over many years and has produced some fascinating data. For example, it has found that 65% of white youth smokers smoke Marlboro (as do 60% of Latino and only 8% of African American youth smokers), whereas 75% of African American kids who smoke prefer Newport (a mentholated brand), which is smoked by only 12% of whites and 20% of Latino youth smokers. The only other brand with any recognition in 1998 was Camel, which was smoked by 9% of white youth smokers. The full breakdown as of 1998 can be seen at:
http://www.monitoringthefuture.org/data/tables/cigbrands/table1.html

These patterns persist in smokers aged 12 or over (including adults) in a national survey carried out in 2005, with whites and Latinos preferring Marlboro, and African Americans preferring Newport. The main (fairly small) differences in that study were increased market penetration among African Americans for the “Kool” brand (11%, also a menthol), and increased market share for “discount” brands (eg Doral and Basic). The most recent data can be found at: http://www.oas.samhsa.gov/2k7/cigBrands/cigBrands.htm

If you would like to know why brand preferences are concentrated in this way, then visiting the website: www.trinketsandtrash.org may give you a clue. This site contains a collection of tobacco advertising and memorabilia and is a good tool for tracking the activities of vector in this epidemic: the tobacco industry.

I’d be interested in hearing your reasons for your brand preferences and if any ads influenced you.

Labels: brand, Camel, cigarette, Marlboro, Newport, preferences, race

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Higher nicotine intake per cigarette by African American smokers: is it a menthol effect?.

There are some quite large differences in tobacco use between the different racial and ethnic groups in the United States. One of the most consistent findings is that African American and Latino smokers smoke fewer cigarettes per day than non-Latino whites. For example, in a large study reported by Dr Richard O’Connor and colleagues in the American Journal of Epidemiology, in daily smokers aged over 24 years, African American smokers averaged around 12 cigarettes per day, whereas non-Latino whites smoked an average of around 18 cigarettes per day. Mexican-Americans smoked only 8 or 9 cigarettes per day on average.

However, this study also included a measure of blood cotinine – the main metabolite of nicotine and a good index of total nicotine intake. African American smokers had much higher cotinine concentrations (253 ng/ml) than white/non Latino smokers (208 ng/ml) and Mexican American smokers (94 ng/ml). So the estimated cotinine per cigarette was much higher (33) for African Americans, than both non-Latino whites (15) or Mexican American smokers (17). While there is some evidence that these differences in cotinine levels may relate to metabolic differences, they also appear to be due to real differences in nicotine intake per cigarette, as indicated by higher levels of exhaled carbon-monoxide.

A similar pattern was recently reported among 900 young adult smokers (aged 18-26), among whom whites averaged over 15 cigarettes per day but African Americans, Latinos and Asian smokers averaged 10-11 cigarettes per day. However, African American smokers had blood cotinine levels that were much higher than other groups, and an average cotinine level per cigarette that was more than twice that of non-Latino whites.

Part of these differences in nicotine intake per cigarette may relate to differences in the types of cigarettes smoked by different subgroups. Around 80% of African American smokers smoke a mentholated brand of cigarettes, compared to 25% for non-Latino whites. Menthol stimulates cold receptors and so cools the harshness of cigarette smoke on the throat, enabling a larger inhalation per puff.

If African Americans are inhaling more nicotine per cigarette, this would suggest that they may have increased absorption of other toxic chemicals. The habitual intake of more nicotine from fewer cigarettes may also produce a stronger addiction to cigarettes. Further evidence that is consistent with this idea emerged last year in a paper published in the New England Journal of Medicine which reported a higher rate of lung cancer, and lower rate of “ex-smokers” among African American and Native Hawaiian smokers. Interestingly, Native Hawaiians also have a strong preference for mentholated brands (65-80%). Putting together all of the evidence on this leads me to believe that people who smoke menthol cigarettes are likely to inhale more smoke per cigarette, be more addicted, and be at greater risk of smoking-caused diseases (all other things being equal). These effects are likely to be more marked in people who have had to restrict their cigarette consumption due to the expense of cigarettes, restrictions on smoking in public places or other factors (e.g. those affecting young people, or pregnant smokers). It also seems likely that the tobacco industry has targeted their marketing of menthol brands at groups they perceive as having less disposable income, because the industry knows that menthol cigarettes can get the customer addicted on fewer cigarettes per day.

Labels: African American, cigarette, cotinine, menthol, nicotine, smoker

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Which nicotine replacement therapy?

Nicotine replacement therapy (NRT) is the name given to FDA-approved medicines containing nicotine that are used to reduce nicotine withdrawal symptoms and cravings and to help smokers quit. Currently there are 5 main types: patch, gum, lozenge, nasal spray and inhaler. These latter two (nasal spray and inhaler) are only available via prescription in the United States, although they are available over-the-counter in many other countries (e.g. UK).

Each type of NRT has its own advantages and disadvantages. The patch is by far the most commonly used NRT, largely because it is the easiest to use, requiring only a single patch application per day. Another advantage of the patch is that its side effects are usually mild – primarily mild skin irritation and itching. The main disadvantage is that there is nothing one can do with the patch to increase the dose when you feel the need for more nicotine.

The gum and the lozenge are broadly similar in terms of dose (each available in 2mg and 4mg formats) and route of administration. The main challenge facing the gum chewer is to adopt a “chew and park” style, such that you chew the gum a few times to release a peppery taste (nicotine) and then park it in the side of your mouth for a few minutes before chewing again. The labeling on the gum suggests that people who smoke less than 25 cigarettes per day should use 2mg (rather than 4mg) and the labeling on the lozenge states that those who don’t smoke within 30 minutes of waking in the morning should use the 2mg lozenge. In practice many clinicians have learned that this labeling (especially the gum) is a recipe for under-dosing and advise all but the lightest smokers to use the 4mg formulation of each product. To get a real benefit from these products you need to use enough. Most users only take 3 or 4 per day in response to cravings. You can get a far greater benefit by taking one per hour (to prevent cravings and withdrawal symptoms) plus another whenever you have a breakthrough craving.

I described the nicotine nasal spray in some detail a few days ago. It appears to be particularly helpful for heavy addicted smokers who are willing to persevere despite the initial nasal irritation. Make sure you have some Kleenex handy when you first try the spray. The initial doses sting and will make you sneeze. But, just as with smoking, you will get used to it within a few days, and within a week will probably like it!

The inhaler‘s main advantage is that it enables the smoker to continue with a similar hand/mouth habit, but it helps to gradually wean them off nicotine. The main thing to note is that one puff on a cigarette delivers a similar amount of nicotine to ten puffs on the inhaler. This means that in order to obtain a therapeutic dose, the ex-smoker has to be puffing on the nicotine inhaler almost all the time. We recommend puffing on the inhaler for 20 minutes out of ever waking hour. Again, people who get into that regular use habit early on tend to do very well with the inhaler.

Some years ago Professor Peter Hajek and colleagues at the University of London conducted a randomized trial comparing the nicotine patch, gum, nasal spray and inhaler. In practice they all had similar quit rates (around 20-25% complete abstinence 3 months later), although women did better on the inhaler than the gum and men were the opposite. Prior to their quit attempt, participants were shown videos describing each NRT and were then allowed to rate their preferences. They were each then randomly allocated to one product. This meant that some people were allocated the product that was their first preference, whereas most were not. However, at the end of the study the smoking cessation outcomes were similar for those receiving their preferred NRT versus those being randomly allocated to a less preferred NRT. Also, people came to prefer the product they were given after they had used it for a week.

One final thing to consider is that the products differ in the risk of inducing dependence. It is extremely rare for someone to have any difficulty coming off the patch (which typically have a built-in reduction plan, involving using smaller sized patches over 4 weeks). However, some people (about 5-10%) find themselves using the gum, inhaler or lozenge long term (i.e. over 3 months and possibly continuing for years). The nicotine nasal spray has the highest dependence potential, with around 10-15% of those who use it continuing use after 3 months. The risk of becoming dependent is related to the speed of nicotine delivery from the product (spray fastest, but still slower and lower dose than a cigarette, whereas the patch delivers nicotine very slowly). It also seems to be related to how addicted the person was to their cigarettes. Thus people who smoked over a pack a day and smoke within 30 minutes of waking in the morning (or wake at night to smoke) are more likely to become a long term user of their NRT product. However, in the placebo-controlled trials these were precisely the people who were much less likely to succeed in quitting if they received the placebo. The thing to remember here is that it is much better to be a long term user of an NRT product delivering only nicotine, than a continuing user of a product that delivers a higher dose of nicotine plus 4000 other toxic chemicals (i.e. a cigarette).

Recently a group of experts in the treatment of tobacco addiction got together to produce a consensus statement guiding consumers on the most effective ways to use NRT to help them quit smoking. You can find a copy of the paper and the summary (in both English and Spanish) at: http://proyectovidanofume.org/publication.htm

Labels: addiction, cigarette, nicotine, NRT, replacement, Smoking, therapy, tobacco

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Its time for pictorial warnings on cigarette packs.

Virtually everyone knows that smoking is bad for health. But smokers typically don’t give much thought to the effects on their own health until they have been smoking for years. They also tend to be less aware of effects other than lung cancer (e.g. cardiovascular effects, effects on reproductive health etc). Health warnings first appeared on the side of US cigarette packs in 1965, stating that, “Cigarette smoking may be hazardous to your health.” The labels on U.S. cigarettes have not changed since 1984 and appear in small black and white print on the side of cigarette packs. Can you remember what they say? (most people can’t).

Messages given in small print on the side of the pack clearly lack salience and persuasive power compared with more colorful, larger messaging placed on the front of the packs. An expert panel commissioned by the National Academy of Sciences described the current warnings as “woefully deficient.” In an effort to help smokers be more clear about the health effects of cigarettes, many other countries around the world (including Australia, Belgium, Brazil and Canada) have introduced larger pictorial health warnings on cigarette packs.

You can view the pictorial health warnings from other countries around the world at:
http://www.smoke-free.ca/warnings/default.htm . These warnings provide quite a contrast to those in use in the United States, and may even help increase a smoker’s motivation to quit simply by viewing them online.

Some recent studies indicate that current U.S. warnings are woefully ineffective at getting the attention of smokers, communicating health risks or motivating smokers to quit, whereas the type of pictorial warnings used in Canada are much better. David Hammond and colleagues at University of Waterloo in Canada examined Canadian smokers’ reactions to the pictorial warnings in Canada. Over 90% of smokers had read the new warnings and those who read them, thought about and discussed the new Canadian warnings were more likely to have quit, made a quit attempt, or reduced their smoking three months later. Dr Ellen Peters and colleagues from University of Oregon recently compared US warnings with those in Canada. A majority of both smokers and non-smokers endorsed the use of Canadian-style warnings in the United States.

A bill currently pending in Congress would give the U.S. Food and Drug Administration (FDA) authority to require major changes in U.S. cigarette pack health warnings and require that they cover at least the top 30 percent of the front and back of cigarette packs. The legislation would also allow the FDA to increase the warning size to 50 percent of the front and back panels and adopt graphic or pictorial warnings, as Canada and several other countries have already done. Some countries also include the toll-free number for the national Smokers Quitline next to the warning. Its time to upgrade the health warnings on cigarette packs in the United States to include pictorial warnings and the national quitline number (1-800 QUIT NOW).

Labels: cigarette, pack, warnings

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