Are tobacco manufacturers secretly controlling nicotine levels?

This morning I noticed a news article in the online version of the Swedish/English newspaper, “The Local’ discussing claims that the Swedish tobacco Company “Swedish Match” had added a secret substance to some of their snus (Swedish moist snuff) products to make them more addictive. The article went on to document that the company acknowledges that it has introduced some new brands with higher nicotine levels, in response to “consumer demand”.

The article mentions that Swedish match deny adding a secret ingredient to make their products more addictive and quotes a Swedish Match official as saying that,

”We use it to stabilise the pH value in snus and have done so for 200 years,” (SM information director Henrik Brehmer).

Whenever I see articles like this I have to scratch my head a little bit and wonder what is new here? It is surely not a new idea that tobacco companies are designing their products to ensure that users will become or remain addicted to them. That is pretty much the entire basis for their whole industry! On the one hand news media try to sensationalize this from time to time by referring to “secret additives” and "spiking “ the product with nicotine, and on the other hand the tobacco industry representatives try to avoid use of words like “addictive’ and make it all sound like some natural or traditional production process that has nothing to do with nicotine levels or addiction. So let’s decode the quote from the SM representative. He pretty much admitted using an additive to control the pH of the product. It’s a widely known fact that the pH of the product is one of the main determinants of how much “free nicotine” is available in the product…..this being the form of nicotine that can easily be absorbed in the human body. Even fairly small adjustments to the pH of a smokeless tobacco product can cause a tenfold difference in the amount of nicotine the typical user will absorb. He referred to it as “stabilizing” the pH, but that means nothing as manufacturers always want to “stabilize” their products as a matter of quality control. It’s not a denial that they want to stabilize the pH at a level high enough to cause the user to get addicted to the high nicotine delivery.

But the issue of whether they are using a “secret” substance to control the pH or not doesn’t seem particularly important unless that substance is harmful in some other way. There’s really no surprise that they use additives to control pH and hence nicotine delivery. In fact I am much more surprised when a tobacco company fails to increase the pH of its product sufficiently to deliver an adequate dose of nicotine (as in the recent case of Marlboro Snus being test marketed in the USA).

So let’s get real. Tobacco companies are in the nicotine addiction business. They have known it for over 40 years and we have known it for over 20. They will typically develop products designed to deliver a dose of nicotine that consumers demand (i.e. get addicted to). Not everyone is the same, and so their products will vary in their nicotine delivery. I would expect any successful tobacco product to be able to deliver enough nicotine to sustain addiction. What I’m not so sure about is whether enabling a product to deliver much more nicotine than that will necessarily result in it being more addictive. It may just mean that the user ends up taking fewer “doses” because they can get more from each one (which may or may not cause it to be more addictive). The main thing we can be confident about is that so long as a product is capable of delivering a sufficient dose of nicotine to sustain addiction (at minimum an increase in blood nicotine concentration of around 8 ng/ml within 10-15 minutes of a standard unit dose), then each consumer will be able to use that product flexibly to meet their nicotine needs (i.e. to maintain their addiction). The nicotine patch delivers a higher “dose” of nicotine but the speed of delivery is too slow to produce reinforcing psychoactive effects and so is not addictive. For most users, 2mg nicotine gum doesn’t deliver enough nicotine fast enough to be satisfying/addictive (it gets a boost of 4-5 ng/ml in 20-30 minutes). Of course some users will use a lot of 2mg gum and put up with the taste for long enough to get addicted, but most do not. Incidentally, nicotine gum also has an alkaline additive to “stabilize” its pH and hence nicotine delivery.

Everyone considering using a nicotine delivery product, whether it be snuff, cigarettes or nicotine gum, should be aware that nicotine can be addictive and that the rate and amount of nicotine delivered will determine how satisfying (addictive) the product will be once you are used to it. Generally, smoked tobacco products are in a different league both in terms of speed of nicotine delivery and amount of harm done to the body, because the nicotine is delivered in smoke (along with 4000 other chemicals) directly into the lungs. Smoked tobacco is more addicting and MUCH more harmful. Generally the pharmaceutical nicotine replacement products are less addictive (satisfying) as they are designed to be used for a temporary period to help get you off cigarettes. Part of that design includes lower and slower nicotine delivery. Many researchers and clinicians feel that current nicotine replacement medications deliver too little nicotine too slowly to satisfy more highly addicted smokers. We are concerned that those smokers will either continue to smoke (and to die from it) or will switch to higher delivery smokeless tobacco products, rather than quitting tobacco altogether.

Tobacco companies definitely control the nicotine in their products and (via pH control) the nicotine delivered by their products. Its critical to their business.

Here is a link to the news article:
http://www.thelocal.se/22864/20091025/

Here is a link to a Journal article on nicotine delivery from Marlboro Snus.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2288606/

Labels: addiction, jonathan foulds, marlboro snus, nicotine, Nicotine Replacement, snus, spiking, Swedish Match

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New study shows how nicotine stimulates drug-associated memories.

Researchers at the laboratory of Professor John Dani, at Baylor College of Medicine in Texas have published new research that helps explain how nicotine creates memories of drug-related cues. In a series of studies of laboratory mice they found that mice would learn to go to a place where they received nicotine (a paradigm called “conditioned place preference”). In addition to reinforcing preference for places where nicotine is received it seems that the neurotransmitter, dopamine, which is released by nicotine, signals that the environment at that place is particularly salient and should be remembered. It is as if nicotine takes over the brain’s natural mechanism for helping us learn that elements in an environment are particularly relevant for survival (e.g. have food, water, shelter etc), and instead leads the brain to expect something rewarding to happen in that situation. The result is that when either a mouse or a human returns to an environment with stimuli that were thereon previous occasions they had nicotine, they will have a cued desire for the drug, that likely leads to cravings and increased drug-seeking behavior.

This animal research may explain why ex-smokers sometimes experience a sudden strong urge to smoke when they go to a place, or are in a situaution in which they formerly smoked. Professor Dani’s research shows that dopamine is not simply a “reward” neurotransmitter but also plays a role in stimulating the connections between neurons that underlie learning and memory. In the research, Dani’s team found that when the dopamine release was prevented, the animals did not learn half as well as when nicotine was allowed to stimulate dopamine release in a normal manner.
It has been obvious for a long time that cravings to smoke are triggered in places or situations in which the person usually smokes. What this new research adds is a more detailed explanation of the mechanism, and the role of the neurotransmitter, dopamine.

This finding may help explain why taking some smoking cessation medicines for a few weeks prior to quitting may be helpful. Wearing the nicotine patch for a couple of weeks before quitting may prevent cues being attached to specific situations (because the smoker also receives nicotine between cigarettes). Taking varenicline (which partially blocks nicotine-induced dopamine release) may similarly similarly reduce the extent to which nicotine-related situations cause later cravings.

Reference:
Tang J, Dani JA. Dopamine enables in vivo synaptic plasticity associated with the addictive drug nicotine. Neuron. 2009 Sep 10;63(5):673-82.

Labels: dopamine, J Teng, John Dani, jonathan foulds, laboratory, nicotine, smoking cessation

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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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Does nicotine cause cancer?

Every now and again we see a new newspaper headline claiming that nicotine causes some serious health problem, whether it be heart attacks or cancer. Usually the headline is based on a very small study in humans, or a laboratory study of cells in a petri dish or test tube. In the past week we saw the latest example. A study by Gemenetzidis and colleagues in London examined the effect of nicotine on a protein transcription factor named FOX-1 in tissue cells in the laboratory. Fox-1 expression has been associated with onset of tumor growth in prior studies. The study found that nicotine application to cells in the lab resulted in an increase in Fox-1 expression (in the laboratory, not in humans). The authors therefore concluded that nicotine , by stimulating FOX-1 expression, may promote cell instability and tumor growth.

The thing that is relatively new about this finding is that many prior studies and reviews have concluded that nicotine does not play a part in stimulating tumor development or growth. So for this study to claim that nicotine causes cancer is contrary to previous expert opinion.

I am not a cell biologist and cannot claim to fully understand the science contained in this recent publication by Gemenetzidis and colleagues. However, I can think of some ways of assessing whether the laboratory finding really does translate into health effects in the real world. In many countries around the world people use smokeless oral tobacco for most of their adult life. Oral smokeless tobacco delivers high quantities of nicotine (in addition to other proven carcinogens), but without delivering any smoke. In Sweden there is a tradition of men using a form of smokeless tobacco, called snus, that is relatively low in other toxins. So if nicotine really does have a role in increasing oral cancer risk, we would assume that people using this nicotine delivery product throughout their whole life would have an increased oral cancer risk. However, numerous long term epidemiological studies of Swedish men who use this oral tobacco product have found that they do not have an increased rate of oral cancer, as compared with men who never used any tobacco products.

Gemenetzidis and colleagues, on the basis of their lab study of cells in the lab, have cautioned against the use of nicotine replacement therapy in case it causes cancer. Now nicotine replacement therapy is typically used for up to 12 weeks, but occasionally for longer. But NRT typically delivers lower levels of nicotine than snus smokeless tobacco and is almost never used in a lifelong fashion ….daily from teenage years for life, as is common for smokeless tobacco. So to my way of reading the epidemiological evidence, if lifelong use of high nicotine oral tobacco does not increase the risk of oral cancer, then the risk that a few months of NRT use will cause oral cancer are non-existent. So no, I don’t believe that this study provides convincing evidence that nicotine causes cancer.

Sometimes I wish that lab scientists would check out the epidemiological evidence before announcing to the press that effective therapies may cause cancer.


Example article last week in the London Times:
http://www.timesonline.co.uk/tol/life_and_style/health/article6143744.ece

The full study report can be viewed at:
http://dx.plos.org/10.1371/journal.pone.0004849

For a very thorough review of the health effects of nicotine, and of smokeless tobacco, check out the relevant chapters of the recent Royal College of Physicians report on tobacco harm reduction at:
http://www.rcplondon.ac.uk/pubs/brochure.aspx?e=234

Labels: cancer, jonathan foulds, nicotine, NRT

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47 posts in 2008

This link contains a list of my posts in 2007:
http://www.healthline.com/blogs/smoking_cessation/2007/12/ninety-five-posts-in-2007.html

and here are the ones from 2008….

Time to quit….now. 1/1/08
http://www.healthline.com/blogs/smoking_cessation/2008/01/time-to-quitnow.html

Not a puff. 1/6/08
http://www.healthline.com/blogs/smoking_cessation/2008/01/not-puff.html

How does your state or country tackle tobacco? 1/12/08
http://www.healthline.com/blogs/smoking_cessation/2008/01/how-does-your-state-or-country-tackle.html

100. Do you wake at night to smoke? 1/16/08
http://www.healthline.com/blogs/smoking_cessation/2008/01/do-you-wake-at-night-to-smoke.html

101.Swedish Snus: A Reply to Professor Tomar. 1/22/08
http://www.healthline.com/blogs/smoking_cessation/2008/01/swedish-snus-reply-to-professor-tomar.html

102.What does a tobacco treatment clinic do? 2/6/08
http://www.healthline.com/blogs/smoking_cessation/2008/02/what-does-tobacco-treatment-clinic-do.html

103.New study compares Chantix to the nicotine patch. 2/11/08
http://www.healthline.com/blogs/smoking_cessation/2008/02/new-study-compares-chantix-to-nicotine.html

104.What is in cigarette smoke? 2/17/08
http://www.healthline.com/blogs/smoking_cessation/2008/02/what-is-in-cigarette-smoke.html

105.Snus use in Sweden: another reply to Tomar. 2/19/08
http://www.healthline.com/blogs/smoking_cessation/2008/02/snus-use-in-sweden-another-reply-to.html

106.Chantix and depression on stopping smoking. 2/26/08
http://www.healthline.com/blogs/smoking_cessation/2008/02/chantix-and-depression-on-stopping.html

107. Marlboro Snus Isn’t Really Snus 3/4/2008
http://www.healthline.com/blogs/smoking_cessation/2008/03/marlboro-snus-isnt-really-snus.html

108. Smoking and lung function 3/7/08
http://www.healthline.com/blogs/smoking_cessation/2008/03/smoking-and-lung-function.html

109. Wearing the patch prior to quitting 3/21/2008
http://www.healthline.com/blogs/smoking_cessation/2008/03/wearing-patch-prior-to-quitting.html

110. Why Chantix may reduce alcohol consumption. 3/22/2008
http://www.healthline.com/blogs/smoking_cessation/2008/03/why-chantix-may-reduce-alcohol.html

111. How have New York and New Jersey reduced smoking? 3/24/2008
http://www.healthline.com/blogs/smoking_cessation/2008/03/how-have-new-york-and-new-jersey.html

112. Buy cigarettes on the internet? Expect a large invoice. 3/26/2008
http://www.healthline.com/blogs/smoking_cessation/2008/03/buy-cigarettes-on-internet-expect-large.html

113. Lung Cancer, Spiral CT and Tobacco Industry Funding 3/26/2008
http://www.healthline.com/blogs/smoking_cessation/2008/03/lung-cancer-spiral-ct-and-tobacco.html

114. Smoking and Lung Cancer 3/29/2008
http://www.healthline.com/blogs/smoking_cessation/2008/03/smoking-and-lung-cancer.html

115. Can cigarettes be made less deadly? 4/20/2008
http://www.healthline.com/blogs/smoking_cessation/2008/04/can-cigarettes-be-made-less-deadly.html

116. Vote for Healthline for Webby Award 4/20/2008
http://www.healthline.com/blogs/smoking_cessation/2008/04/vote-for-healthline-for-webby-award.html

117. Which U.S. states smoke most and least? 4/21/2008
http://www.healthline.com/blogs/smoking_cessation/2008/04/which-us-states-smoke-most-and-least.html

118. Smoking and suicide. 4/22/08
http://www.healthline.com/blogs/smoking_cessation/2008/04/smoking-and-suicide.html

119. Tobacco harm reduction. 4/25/08
http://www.healthline.com/blogs/smoking_cessation/2008/04/tobacco-harm-reduction.html

120. Become an ex. 4/30/08
http://www.healthline.com/blogs/smoking_cessation/2008/04/become-ex.html

121. Which kids in the US are most likely to use tobacco? 5/6/08
http://www.healthline.com/blogs/smoking_cessation/2008/05/which-kids-in-us-are-most-likely-to-use.html

122. Unwise to cut tobacco control funding in tough times. 5/9/08
http://www.healthline.com/blogs/smoking_cessation/2008/05/unwise-to-cut-tobacco-control-funding.html

123. Thanks to grand rounds 4.34 at Health Business Blog. 5/17/08
http://www.healthline.com/blogs/smoking_cessation/2008/05/thanks-to-grand-rounds-434-at-health.html

124. Why comprehensive tobacco control? 5/18/08
http://www.healthline.com/blogs/smoking_cessation/2008/05/why-comprehensive-tobacco-control.html


125. Thanks to the Dinosaur for grand rounds. 5/28/08
http://www.healthline.com/blogs/smoking_cessation/2008/05/thanks-to-dinosaur-for-grand-rounds.html

126. Chantix (varenicline) safety. 5/28/08
http://www.healthline.com/blogs/smoking_cessation/2008/05/chantix-varenicline-safety.html

127. Chantix safety at the US Veterans Affairs health service. 5/31/08
http://www.healthline.com/blogs/smoking_cessation/2008/05/chantix-safety-at-us-veterans-affairs.html

128. Are Americans switching to smokeless tobacco? 6/09/08
http://www.healthline.com/blogs/smoking_cessation/2008/06/are-americans-switching-to-smokeless.html

129. Doctors under the influence: the real story. 6/30/2008
http://www.healthline.com/blogs/smoking_cessation/2008/06/doctors-under-influence-real-story.html

130. Happy Independence Day. 7/5/08
http://www.healthline.com/blogs/smoking_cessation/2008/07/happy-independence-day.html

131. Extended treatment for some addicted smokers. 7/06/08
http://www.healthline.com/blogs/smoking_cessation/2008/07/extended-treatment-for-some-addicted.html

132. What proportion of smokers become addicted? 7/13/08
http://www.healthline.com/blogs/smoking_cessation/2008/07/what-proportion-of-smokers-become.html

133. Parental use and restrictions influence teen smoking. 7/19/08
http://www.healthline.com/blogs/smoking_cessation/2008/07/parental-tobacco-use-and-restrictions.html

134. MPOWER: Bloomberg and gates pledge millions to tobacco control. 7/27/08
http://www.healthline.com/blogs/smoking_cessation/2008/07/mpower-bloomberg-and-gates-pledge.html

135. Congress votes for FDA tobacco regulation. 7/30/08
http://www.healthline.com/blogs/smoking_cessation/2008/07/congress-votes-for-fda-tobacco.html



136. UK National Smoking Cessation Conference. 8/1/08
http://www.healthline.com/blogs/smoking_cessation/2008/08/uk-national-smoking-cessation.html

137. Carbon-monoxide in cigarette smoke. 8/0208
http://www.healthline.com/blogs/smoking_cessation/2008/08/carbon-monoxide-in-cigarette-smoke.html

138. Effect of extended counseling on smoking cessation. 8/10/08
http://www.healthline.com/blogs/smoking_cessation/2008/08/effect-of-extended-counseling-on.html

139. Cigarette health warnings and bogus buy-ology. 12/16/08
http://www.healthline.com/blogs/smoking_cessation/2008/12/cigarette-health-warnings-and-bogus-buy.html

140. Facts and fiction on stopping smoking. 12/20/08
http://www.healthline.com/blogs/smoking_cessation/2008/12/facts-and-fiction-on-stopping-smoking.html

141. How to stop smoking with varenicline (Chantix). 12/20/08
http://www.healthline.com/blogs/smoking_cessation/2008/12/how-to-quit-smoking-with-varenicline.html

142. Happy holidays. 12/25/08
http://www.healthline.com/blogs/smoking_cessation/2008/12/happy-holidays.html

143. Get ready for smoke-free 2009. 12/28/08
http://www.healthline.com/blogs/smoking_cessation/2008/12/get-ready-for-smoke-free-2009.html

Labels: blog, cessation, cigarette smoking, freedom from smoking, healthline, jonathan foulds, nicotine

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Celebrities killed by tobacco-caused illness

Many of us watched the Oscar award ceremony over the past weekend, which is always very entertaining and includes a good deal of reminiscing about past great actors. As I watched some of the great old faces flash across the screen I was reminded how many of them had their life and career brought to a premature end by smoking-caused disease.
In the United States, many people are aware of the fact that great stars such as Yul Bryner , Michael Landon and John Wayne were killed by tobacco, but in fact many more stars have been killed by their smoking than we are generally aware of. Part of it is an understandable desire to preserve some privacy for the person at the end of their life. But in the case of smoking-caused illnesses, it seems that the media sometimes goes out of its way not to mention the ultimate cause of death in a way that they don’t do when it comes to drug or AIDS related deaths. It is not uncommon for newspaper reports also to simply refer to the cause of death as “cancer” rather than to specify it as lung cancer, even when the diagnosis was clear and obtainable in the public domain.

Here is how Professor Simon Chapman (University of Sydney) referred to this phenomenon with regard to the death of George Harrison, in his excellent book on public health:
"His death on 29 November 2001 from smoking caused lung cancer was noted in some reports as if he had died from any other cause, despite losing more than 20 years off the average life expectancy of a 58 year old man. Indeed the ABC network in the USA went so far as to note that unlike many other rock stars of his generation (Jimi Hendrix, Janis Joplin, Jim Morrison) Harrison had died of "natural causes"44. If we assume Harrison took up smoking at the age of 15, and on average smoked 20 cigarettes a day, he therefore smoked for around 43 years, smoking 314,115 cigarettes in that time. Observations of smoking show that a cigarette takes about 5.6 minutes to smoke45. We can therefore calculate that Harrison had a cigarette alight for a cumulative total of 1221.6 days or 3.34 years of his 58 years. Recalling that he lost about 20 years off normal life expectancy for an Englishman, we can calculate that each of the 314,115 cigarettes he smoked took 33.5 minutes off his life – about 6 times longer than the time it took him to smoke each one."

I’m not writing this article to argue that celebrities shouldn’t smoke because of their role model status. Celebrities have the same right to smoke as anyone else, and the same human tendency to become addicted to the nicotine in tobacco and to be killed by it. Rather I think it is worth recognizing how much poorer the world is for having lost so many talented people too early. I suspect that George C Scott had a few more good movies in him, George Harrison a few more songs, and Peter Jennings a few more news stories. So rather than berate our current smoking celebrities, I think we should make sure they can get access to effective treatment and succeed in quitting.

If you are in the entertainment business and would like help to quit smoking, contact : http://www.picturequitting.org/

You can see a long list of just some of the celebrities killed by smoking-caused diseases at: http://roswell.tobaccodocuments.org/hall_of_shame.htm

You can find more information on Simon Chapman’s book: Public Health Advocacy and Tobacco Control: Making Smoking History at:
http://www.wiley.com/WileyCDA/WileyTitle/productCd-1405161639.html

Labels: celebrity, cigarette smoking, jonathan foulds, nicotine, picture quitting, premature death, simon chapman

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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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Snus use in Sweden: another reply to Tomar.

I have previously discussed the role of snus in reducing smoking in Sweden, and criticized the IARC report’s coverage of this issue. Professor Scott Tomar (a member of the IARC committee) stated (as a comment to a posting criticising the new IARC monograph on smokeless tobacco):
“Using official Swedish data for smoking for 2004 (from the ULF survey conducted by Statistics Sweden), smoking quit rates (or what some call smoking quit ratios, defined as the proportion of ever smokers who are now former smokers), by age group and sex are:Age 16–24Men 13.2%Women 14.6%Age 25–44Men 37.8%Women 38.3%Age 45–64Men 54.5%Women 51.7% “

However, a colleague of mine based in Sweden (Lars Ramstrom), who is very familiar with Swedish surveys on tobacco use, has informed me that these figures on Swedish tobacco statistics are inaccurate in two ways:
1. They provide inaccurate numerical values for “the proportion of ever smokers who are now former smokers”
2. They inaccurately claim that the figures come from “the ULF survey conducted by Statistics Sweden”.

Statistics Sweden generally does not publish any figures on “the proportion of ever smokers who are now former smokers”. The main reason is that their ULF survey uses a questionnaire that does not include enough items to identify the subgroup “former occasional but never daily smokers who are now former smokers”. Since this subgroup must be part of both numerator and denominator of the calculation of such proportions, the ULF data are just unable to provide a basis for such calculations.

For this reason, we believe that the figures provided by Professor Tomar are likely to be inaccurate. However, the proportions in question can be calculated from other surveys that are performed by the Swedish research institute FSI, Research Group for Information and Societal Studies. These surveys are described in the literature (Ramström LM, Foulds J. Role of snus in initiation and cessation of tobacco smoking in Sweden. Tob. Control 2006;15;210-214). Using the same data base as the just mentioned article we get the following data:

Proportion of ever smokers (daily plus non-daily)
who are now former smokers
Age span Men Women
16-79 61% 54%
16-24 49% 42%
25-44 54% 53%
45-64 63% 55%
65-79 75% 68%

Professor Tomar made a point about the “similarity” between males and females quitting based on his original figures.
“Please explain why the quit rates in Sweden are so similar for men and women within each age stratum if snus had such a dramatic effect on cessation?”

In these figures we can see similarity in one age group only, 25-44. In this very age group a large proportion of women are planning or going through pregnancy and are thereby met the very forceful encouragement and treatment for quitting smoking that is very well established in the Swedish maternal health care system. This is a gender-specific condition that explains why this age group shows a different men/women comparison than the others.

The relevant question is rather opposite to the one asked by Professor Tomar:

Why are overall quit rates generally higher in men than in women in Sweden?

The answer is given by the following data picked up from the above mentioned article:
(These data refer to quit rate for daily smoking, while the data above refer to quit rate for all smoking. Therefore the numerical values differ a little)

Proportion of ever daily smokers
who are now former smokers
Men Women
Overall 59% 49%
With a history of daily snus use 72% 71%
Without history of daily snus use 51% 48%

These data illustrate that gender comparisons have to be made between truly comparable subgroups in order to yield meaningful conclusions.

In each one of the two lower lines there are comparisons between men and women who are comparable with respect to snus use. In each case there is no difference.

In each one of the gender columns the two lower lines give gender-specific comparisons indicating the influence of snus use. Both for men and women there are large differences in quit rate according to presence or absence of a history of snus use.

The above observations demonstrates that the overall difference between men and women does not stem from factors related to gender itself but to the fact that snus use, as a cessation promoting factor, is more prevalent among men than among women.

In summary, contrary to Professor Tomar’s thesis, the Swedish statistics on smoking cessation suggest that snus use is having a substantial effect in promoting cessation of smoking among men. Of course this is self evident from the simple fact that 24-30% of male Swedish ex-smokers used snus to quit smoking. My thanks to Lars Ramstrom for providing clarification on the pattern of tobacco use in Sweden.

Incidentally, the issue of snus for smoking cessation was recently debated in the British Medical Journal, at:
http://www.bmj.com/cgi/content/full/336/7640/358

For the record (again), I don’t believe that health professionals should recommend snus to their patients. I believe that we have medicines and counseling that can be effective treatments for addiction to cigarettes (or at least as efficacious as snus) and that these are what we should be recommending to patients. However, I do believe that the public should have accurate information about the relative risks of snus and cigarettes. Currently the public underestimates the risks from cigarettes, relative to snus or nicotine replacement therapy.

Labels: jonathan foulds, nicotine, nicotine nasal spray smoking cessation, smokeless, snus, 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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New study of Chantix in comparison with NRT

Recently there has been some concern over side-effects experienced by a minority of people using Chantix (varenicline). Although Chantix had a remarkably good safety and efficacy record in the clinical trials conducted prior to its launch, those trials excluded patients with complex medical or psychiatric problems (normal practice in pre-approval clinical trials). So when a number of patients (albeit a tiny proportion of the millions who have used Chantix) have reported unpleasant and serious mood disturbances or even suicidal thoughts and acts while taking Chantix since it was launched, this has led to a concern that perhaps Chantix may have more serious side-effects in regular patients with complex medical and psychiatric problems.

A new study by John Stapleton and colleagues was published this week in the journal, Addiction, that addressed this issue. The study reports on the clinical outcomes of 412 patients being treated at a tobacco dependence clinic in London, UK. 204 patients were treated with nicotine replacement therapy (NRT) between May and November, 2006 (prior to Chantix being launched in the UK), and 208 patients were treated with Chantix from January to April 2007. Although the two groups were not randomly allocated to treatments, they were very similar on a number of baseline measures - for example 47% of those treated with NRT were men and 50% of those treated with varenicline were men. The daily cigarette consumption of the two groups was 21 and 22 cigarettes per day respectively. The only signs of baseline differences between the groups were that 69% of those treated with NRT were white, compared with 79% of those treated with Chantix. Those treated with Chantix also rated themselves as being slightly more “determined to quit” at baseline. All of the patients were treated in weekly stop-smoking groups for 7 weeks, with the target quit date coming at the third group meeting. Some of the patients using NRT used “combination” NRT (typically the patch plus either nicotine gum, lozenge, nasal spray or inhaler). At the end of group treatment (i.e. four weeks after the target quit date), 66% of those using a single NRT, 75% of those using combination NRT and 80% of those using Chantix were no longer smoking (not a puff in the previous two weeks). So Chantix produced higher quit rates than a single NRT product, but similar to combination NRT.

111 of these patients were receiving treatment for a mental illness, and the pattern of results for those patients was similar to that of the group as whole, with higher quit rates for those using Chantix. In the whole sample, those using Chantix reported significantly lower craving scores, with no differences on ratings of withdrawal symptoms (e.g. irritability, poor concentration, etc).

An analysis of adverse drug reactions found only one that was more commonly reported with NRT than with Chantix (skin irritation related to patch use). However, 12 symptoms were reported more frequently among those using Chantix. Those symptoms were, nausea (38%), disturbed sleep (30%), vivid dreams (13%), drowsiness (12%), constipation (11%), headache (10%), dyspepsia (8%), dry mouth (7%), bad taste (7%), depression/low mood (5%), diarrhoea (5%), and disorientation/confusion (5%). 7 patients reported moderate/severe anxiety/panic while on Chantix, compared with only one on NRT. Two patient had adverse reactions while using Chantix that were of sufficient severity to be reported to the Medicine’s Regulatory Authority in the UK. One of these was for a “severe psychological reaction likened to a bad LSD trip, including anxiety, paranoia, and confusion.”

It should be noted that around 80% of the patients in this study had previous experience trying to quit smoking using NRT. It is possible that those taking the new drug (Chantix) would have a stronger tendency to note side effects than those using an NRT that they were familiar with.

Overall, these results are broadly consistent with the evidence from clinical trials and post-launch clinical experience with Chantix. They are consistent with the ideas that (a) Chantix may result in slightly higher chances of success in quitting smoking than another single medicine/NRT (b) Quitting success rates on Chantix are broadly similar to those with combination NRT, (c) Chantix results in more side effects than NRT, of which some are common (e.g. nausea, disturbed sleep and vivid dreams) and some less common (<5%) – including depressed mood, disorientation and anxiety. The single patient experiencing a severe psychological reaction while using Chantix may be an indication that such reactions can occur but are rare (<1%).

It should be noted that all of the patients in this study were being treated in a specialist tobacco treatment clinic, within the context of support groups facilitated by experienced clinicians. In that context adverse effects of medications can be monitored, and if necessary patients promptly switched to different medications. Many of the psychological side effects were 3-5 times more common among patients using Chantix than among patients using NRT.

The research continues to show that Chantix is an effective drug for smoking cessation, that offers renewed hope for those who have tried and failed with other treatments. However, I think patients who are not planning on maintaining regular contact with an experienced clinician during their quit attempt (i.e. a clinician who can monitor side effects and provide supportive advice on a regular basis) should give serious consideration to using combination NRT (patch plus one other NRT) as a first choice. This treatment has the advantage that the patient is not taking a “new drug” – just the same one (nicotine) they have been taking, but without the 4000 other toxic chemicals.

Labels: Chantix, cigarette smoking, foulds, nicotine, NRT

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Snus use in Norway.

Snus is a form of smokeless tobacco that is widely used – primarily by men – in Sweden. It is characterized by being relatively low in toxins but delivers about as much nicotine as a cigarette. It is not harmless (causes gum erosion, and pancreatic cancer) but has been estimated to be about 90% less harmful than smoking cigarettes (no lung cancer, oral cancer, or chest diseases).

In Sweden more men now use snus on a daily basis than smoke, and about a quarter of Swedish men who quit smoking did so by switching to snus. Consequently Sweden is just about the only country in the world in which it is consistent that fewer men smoke than women. As I’ve previously discussed, multinational tobacco companies are now test-marketing their own snus products, including in then US. However, some doubt remains as to whether this product (which is banned in the European Union, Australia and New Zealand) could become popular in another country.

A report has just been published on tobacco use in Norway (which is not a member of the EU), which shows a fairly dramatic increase in snus use among young men.
http://www.shdir.no/publikasjoner/faktahefter/tall_om_tobakk_1973_2006_13509

This report found that in the period 2004-6 10% of men used snus on a daily basis and 7% on an occasional basis (compared to 7% and 6% in 2001-3). However, the proportion of users is much higher in young men, with 17% using daily and 17% occasionally in the 16-24 age group. Overall the proportion of daily snus users among men aged 16-44 has more than quadrupled from 1985 to 2006. It remains to be seen what the effects of this expansion of snus use is on smoking rates and health effects. Figure 24 in the report shows that of 631 men who successfully quit smoking during the period 1990-2006 and were surveyed in 2004-6, 17% quit smoking by using snus – a proportion equal to the number who quit by using the nicotine gum (10%), patch (4%) and Zyban (3%) added together. Most Norwegan male ex-smokers quit without any assistance, and 1% used the national telephone helpline. This suggests that a meaningful proportion of men are quitting smoking by switching to snus in Norway. Clearly no tobacco use is preferable to use of smokeless tobacco, and approved medicines are preferable as smoking cessation aids. But anything that gets people to quit smoking has the potential to reduce the harm to health in then population.

If you are interested in learning more about snus, and the effects it has had on smoking in Sweden, click on this link: http://www.tobaccoprogram.org/staffarticles.htm, scroll down to the papers by Foulds and colleages (2003) on “The Effect of smokeless tobacco (snus) on smoking and public health in Sweden” and the paper by Ramstrom & Foulds (2006). These are both available as pdfs for free from this site.

Labels: nicotine, smokeless, snus, tobacco

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Getting through the first few weeks

When people quit smoking it is very common for them to experience a temporary increase in certain unpleasant symptoms. The most common nicotine withdrawal symptoms are:
1. Irritability
2. Restlessness
3. Poor concentration
4. Depression
5. Increased appetite
6. Anxiety
7. Insomnia

I discussed these symptoms in previous posts:
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

However, I’m bringing this topic up again because I’m noticing a number of people trying to quit smoking by using Chantix who are still experiencing some of the symptoms mentioned above but are concluding that these symptoms are caused by the medicine. Of course with any individual person the best way to figure out the cause of a new or worsening symptom is to discuss the problem in detail with your health professional. But in general, if someone has just quit smoking and they experience one of the symptoms mentioned above, the first explanation to consider is that it is a temporary nicotine withdrawal symptom caused by stopping smoking, rather than a symptom caused by a smoking cessation medicine.

Sometimes similar symptoms can be caused by smoking cessation medicines. For example, insomnia and vivid dreams can also be caused by the 24 hour nicotine patch and by bupropion (Zyban or Welbutrin). Chantix has also been known to cause vivid dreams. Generally, the heavier a smoker the person is, the more likely they will be to experience strong withdrawal symptoms, and the less likely their symptoms are caused by their medication. The opposite is also true. So if a 40-a day smoker experiences insomnia 2 days after quitting smoking while taking the standard dose of a smoking cessation medicine it is more likely to be due to nicotine withdrawal. If a 10 cigarettes per day smoker who never wakes at night to smoke and doesn’t smoke within half an hour of waking in the morning experienced the same insomnia it is might be caused by the medicine. In the case of the patch, they might want to try taking it off a few hours before going to bed, and in the case of Zyban or Chantix they might want to make sure they don’t take the second pill just before going to bed.

My main point here, however, is to caution against blaming the medicine for symptoms that it may actually be helping with, and then stopping using the medicine too soon. Any change in timing or dosage of a medicine should be discussed with your doctor first.

Similarly, it is tempting when a medicine is not giving complete relief of unpleasant symptoms like insomnia, anxiety or cravings to want to try another medicine as well. As always, a decision on what medicines are most likely to help you in any specific situation is best made after a full discussion between you and your doctor. However, when one of the symptoms mentioned above is the problem, and particularly if you were a heavy smoker and have recently quit, then the symptom is likely caused by nicotine withdrawal and will resolve by itself gradually over a couple of weeks. Medicines that have not been approved by the FDA or a similar medicines regulatory authority for smoking cessation will be unlikely to help much.

To tell if you are a “heavy smoker” check out my previous posts on that topic:
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

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

If you are a heavy smoker and are having a rough time quitting I’d strongly encourage you to get as much support as you possibly can. As well as speaking to your own personal health professional, I’d recommend a specialist face-to-face tobacco treatment service if there is one near you (they will have experts in smoking cessation counseling and medicines), as well as use of smoking cessation telephone helplines and internet sites, that were also discussed in previous posts:

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

Key things to remember during the rough times are:
A. Nicotine withdrawal symptoms are worst during the first couple of weeks after you completely quit tobacco and gradually calm down to be almost gone by the 4th week.
B. Each individual episode of craving for a cigarette typically lasts a few seconds, and rarely longer than a couple of minutes. Keeping yourself busy and actively switching your mind onto other things will help get rid of cravings more quickly.
C. Cravings are stimulated by being around tobacco and other people smoking. If you have any in the house, get rid of it. If you are hanging out in a place where people are smoking, hang out somewhere else!

You have probably put in quite alot of effort by the time you found this web-site. Don't throw it away by having a smoke. Keep going. It is tough but you can succeed.

Labels: Chantix, cigarette smoking, nicotine, patch, quitting, side-effects, symptoms, withdrawal, Zyban

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Two new studies of Chantix (varenicline)

Two new trials of the smoking cessation medicine varenicline (Chantix) were published this past weekend. One reported the results in 515 nicotine-dependent Japanese smokers (mainly men) and the other reported the results in 250 Korean and Taiwanese smokers.

The Japanese study compared the outcomes across various doses of varenicline, with participants taking the pills for 12 weeks, and then being followed up for a further 40 weeks off drug. As in previous studies, the 1mg dose (twice daily) achieved slightly higher quit rates than lower doses, albeit with higher reported side-effects. The 1mg dose achieved abstinence rates of 65% at 12 weeks, as compared with 40% among those using placebo pills. At one year follow up, 35% of those who were given 1mg pills for the first 12 weeks remained abstinent, compared with 23% of those who had taken placebo pills. So this study in Japan confirmed the safety and efficacy of Chantix, but the “effect size” – the degree to which the drug performed better than placebo, was not quite as impressive as previous studies. This was partly because a relatively large proportion of Japanese smokers in this study succeeded in quitting while using placebo pills.

Another study based in Korea and Taiwan directly compared 12 weeks of 1mg varenicline with 12 weeks of placebo in 250 smokers (mainly men). After 12 weeks, 60% of those using varenicline were not smoking, compared with 32% of those using placebo pills. After 24 weeks (i.e. another 12 weeks “off drug”) the quit rate was 47% among those who had used varenicline, versus 22% among those who had used placebo. As in previous studies, those taking varenicline were more likely to report some nausea, constipation and abnormal dreams, but these were generally mild in nature. Also like prior studies, those on Chantix were not less likely to report an increased appetite. This is noteworthy as most previous smoking cessation medicines (such as nicotine replacement therapy or bupropion) tend to reduce appetite compared with placebo, and suggests that Chantix works via a slightly different mechanism.

So far, the placebo-controlled trials of varenicline have been remarkably consistent in finding that it approximately doubles quit rates compared with placebo, and that this increased quit rate is maintained even after up to 40 weeks off drug. The early studies suggested that Chantix may result in higher quit rates than other pharmacological treatments for smoking. Whether this ultimately turns out to be the case will require additional studies directly comparing different treatments.

The take-home message for smokers interested in trying to quit is that this new medicine continues to demonstrate that it is safe and effective in increasing smokers’ chances of successfully quitting, with the most frequent side-effect being mild nausea (16-42% of users). The nausea is less marked at lower doses, and also appears less when taking the pill along with food and water. Most people using Chantix are able to continue using it and the initial nausea subsides. Those continuing to take Chantix for the full course (up to 24 weeks) tend to have higher quit rates than those discontinuing early.

Labels: addiction, cessation, Chantix, cigarette smoking, nicotine, tobacco, varenicline

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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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Wearing the patch prior to quitting may help

If you buy a box of nicotine patches, you will notice that the instructions for use and warnings advise against wearing the patch while taking nicotine from any other source. Many smokers interpret this as implying that something terrible will happen if they kept the patch on while smoking, and consequently when they have a lapse cigarette then often decide to take the patch off (and so obey the instructions on the box).

However, numerous studies have shown that nothing terrible happens when you smoke while wearing the patch. 15 years ago I published a study in which 30 smokers smoked normally for 2 weeks, and wore full strength nicotine patches for one of those weeks and placebo patches for the other. The smokers generally couldn’t tell which week was the week with the nicotine patches and the single participant who vomited did so while wearing placebo patches! So it appears to be very unlikely for smokers to experience adverse events caused by wearing the patch while smoking.

However, some recent studies have actually suggested that wearing the patch for a few weeks prior to the target quit date may actually increase the chances of a successful quit. One such study was carried out by Dr Schuurmans and colleagues in South Africa. They found that people who wore nicotine patches for two weeks prior to their quit day had better long term quit rates than smokers who wore placebo patches for two weeks prior to their quit date (22% vs 12% quit, 6 months later).

Interestingly, studies of the use of other forms of nicotine replacement therapy by smokers not intending to quit have also found that not only does the NRT help them to reduce their cigarette consumption, but that a significant proportion of them go on and quit completely. One such study was carried out by Dr Batra and colleagues in Germany. They recruited over 300 smokers who were interested in cutting down but not quitting. They were provided with either 4mg nicotine gum or placebo gum for a year. As well as helping with smoking reduction, the group receiving the nicotine gum had significantly more people who were quit 13 months later (12% versus 5%).

We are not clear on the mechanism whereby combining NRT with smoking prior to quitting may help subsequent cessation. It may simply be that it loosens the associations between smoking and reinforcement (by providing nicotine separately from smoking). Just to be clear, the use of NRT prior to the quit date is not yet normal practice, and may never become so. My current practice is to advise patients using the patch to put their first patch on the morning of their quit day and not before (as suggested on the box). However, as more evidence is gathered on the safety and effectiveness of NRT pre-treatment, I may have to reconsider.

Labels: cessation, nicotine, pre-treatment, replacement, Smoking

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Advice on using over-the-counter nicotine replacement therapy.

Surveys have shown that many smokers (incorrectly) do not believe that nicotine replacement therapy helps smokers to quit. Many also believe NRT can cause cancer (again incorrectly). Unfortunately the labeling on the NRT product packaging also uses very cautious language that reinforces the idea that NRT can be dangerous. For examples, the long list of precautions regarding co-occurring medical problems, the advice to use low doses unless you are a heavy smoker, and the advice against using the NRT if you smoke or use another NRT, all feed the perception that NRT is dangerous and should be avoided if at all possible.

Partly because of these miscommunications to the public, only a fraction of those trying to quit smoking use an effective smoking cessation aid and even fewer use it in an optimal manner for smoking cessation. In order to help improve this situation, Professor Lynn Kozlowski (University of Buffalo) and a group of experts in smoking cessation have produced a paper discussing these issues, and (importantly) providing a consensus statement on the most effective way to use NRT. The summarized version of the agreed-upon advice to consumers is provided below:



1. NRT is one good tool to help you quit smoking. But NRT can’t do all the work for you—you have to help—and it is not the only tool to help you stop smoking.


2. Don’t worry about the safety of using NRT to stop smoking: NRT is a safe alternative to cigarettes for smokers.


3. Do be cautious about using NRT while pregnant.


4. NRT is less addictive than cigarettes and it is not creating a new addiction


5. Stop using NRT only when you feel very sure you can stay off cigarettes.


6. If the amounts of NRT you are taking do not help you stop smoking, talk with your health care provider about using (1) more NRT, (2) more than one type of NRT at the same time, (3) other smoking cessation medicines at the same time, or (4) telephone or in person advice on quitting tips.


7. If NRT helps you stop smoking, but you go back to smoking when you stop using NRT, you should seriously think about using NRT again the next time you try to stop smoking.


8. Make sure you are using the gum or lozenge in the best way:
o Chew the gum slowly – fast chewing doesn’t allow the nicotine to be absorbed from the lining of the mouth and can cause nausea.
o Don’t drink anything for 15 minutes before and nothing while you are using nicotine gum or the lozenge so your mouth can absorb the nicotine.
o Make sure you get the right amount of nicotine – people who smoke more than 10 cigarettes per day should use a 4mg piece of gum or lozenge.


9. Make sure you are using the patch in the best way:
o If you can’t stop having a few cigarettes while using the patch, it is best to keep the patch on. Don’t let a few slips with cigarettes stop you from using the patch to quit smoking.
o You may need to add nicotine gum or lozenges to help get over the hump or you may need to use more than one patch at a time. Talk to your healthcare provider about this.


10. If the price of NRT is a concern, try to find “store brand” (generic) NRT products which are often cheaper than the brand name products.

11. Do whatever it takes to get the job done—it is not a weakness to use medicine to stop smoking.

Adapted from: Kozlowski LT, .Giovino GA, Edwards B, DiFranza J, Foulds J, Hurt R, Niaura R, Sachs DPL., Selby P, Dollar KM., Bowen D Cummings KM, Counts M, Fox B, Sweanor D, Ahern F. Advice on using over-the-counter nicotine replacement therapy- patch, gum, or lozenge- to quit smoking. Addictive Behaviors (in press).

Some of these pieces of advice contradict some of the advice given on the product packaging (e.g. suggestion to combine NRTs and to continue use until confident of quitting). However, this advice is based on the latest research evidence and the clinical expertise of 16 experts on tobacco treatment.

You can read the full paper and a Spanish translation of the key points at:
http://proyectovidanofume.org/publication.htm

Labels: aid, cessation, nicotine, nicotine addiction cigarette smoking tobacco, replacement, therapy

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When is the best time to quit smoking?

Most of us are familiar with the statistic that in countries like the USA, UK, Canada and Australia (and many other developed countries) approximately 70% of current smokers say that they would like to quit smoking. An even greater proportion typically state that if they had their time again, they would choose never to start smoking.

However, if you ask them when they plan to quit, most give a time frame over 6 months in advance, but expect to have quit within 2 years. So we see a lack of urgency combined with an understanding that it would be a big mistake to let it drag on for much longer. The big problem, however, that the average smoker who stated 10 years ago, “I want to quit, but its not a good time right now, - I’ll definitely do it within the next 2 years” is still smoking today. What this means is that smokers tend to put off quitting for much longer than they plan to, and if they try to wait for “the right time” there is a very large chance that they end up waiting until the worst time – after the diagnosis of a serious illness caused by smoking.

A report by Professor Martin Jarvis and colleagues at University of London commented on the “delusion gap” between smokers’ expectations (53% expecting to be quit in 2 years) and reality (only 6% actually quitting in that time frame).

One of the reasons people often give for putting off a quit attempt is that they have too much stress in their life. Unfortunately, people who have stress now are fairly likely to continue having stress in the future. Cigarettes add to many of the most common stresses (financial problems, health problems etc) and the evidence is very clear that people who smoke are not less stressed than people who don’t. In fact, if you follow a group of smokers who successfully quit for 6 months the typical finding is that they report being less stressed as an ex-smoker than they did as a smoker. So stress is probably not a great reason for delaying quitting.

Another reason people sometimes have for delaying (often supported by psychologists like myself) is the belief that you need to do a lot of planning and preparation before trying to quit. Professor Robert West (University of London) recently published an interesting study that seemed to argue against that idea. Based on a survey of almost 2000 smokers and ex-smokers he found that almost half of the most recent quit attempts were made rather spontaneously (i.e. they made up their mind to try to quit on a day without prior planning on previous days), and perhaps more surprisingly, those who claimed to have made a quit attempt without any prior planning were twice as likely to still be quit at least 6 months later, compared with those planning ahead!

Now the tricky bit here is in interpreting what this means. No-one (or at least not the authors of the article, nor most of the commentators including myself) think this means that it is detrimental to plan your quit attempt. But what it does suggest that if you find yourself suddenly convinced by some thought, experience, or something you saw on TV, that now is the time to quit, then don’t talk yourself out of it by reasoning that you need to take time to plan. Go with the flow, get rid of your cigarettes and follow your instincts there and then.

So (perhaps predictably), the best answer to the question posed in the title is “right now”!


The paper by Professor Jarvis and colleagues can be found at: http://www.bmj.com/cgi/content/full/324/7337/608

The paper by Professor West and colleague can be found at:
http://www.bmj.com/cgi/content/full/332/7539/458

Labels: cessation, nicotine, nicotine addiction cigarette smoking tobacco, quit

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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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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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Is nicotine replacement therapy effective in the “real world”?

Over a hundred double-blind randomized placebo-controlled trials have evaluated the efficacy of nicotine replacement therapy for smoking cessation, and the results are very clear: use of NRT almost doubles the smokers’ chances of successfully quitting. Five years ago, a paper published in the Journal of the American Medical Association by Professor John Pierce and colleagues claimed that since becoming available over-the-counter, NRT was no longer effective. This study was based on retrospective recall of quit attempts by respondents to a large survey in California. Many researchers questioned the validity of the findings, partly based on evidence that smokers are more likely to forget unaided failed quit attempts, and partly because smokers who choose to use NRT tend to be more addicted than those choosing to quit on their own, and the Pierce study was not able to adequately measure this.

Since then, a number of studies have been published that shed more light on this issue. A more recent study by the same research group found that use of a pharmacological aid (NRT or bupropion) is more effective than no aid in households with either no other smokers or a smoke-free policy. This result was an interesting demonstration of the interaction between effects of a medication and the environment in which it is used. It also suggests that effectiveness of NRT has little to do with whether it is prescribed by a doctor or purchased over the counter. However, this study still relied on retrospective recall and so some doubts about recall accuracy remain.

Further light was shed on this issue in a study by Miller and colleagues published in the Lancet in 2005. They reported on a large scale distribution of free nicotine patches (via a telephone quitline) to over 34,000 people in New York City. Six months later they followed up a randomly selected sample of participants, and also a sample of people who called the quitline but did not receive patches due to mailing errors. They found that 33% of those receiving patches had quit 6 months later, as compared with only 6% among those not receiving them. This suggests that nicotine patches are effective when used along with very low intensity support.

Very recently, Professor Robert West and Xiaolei Zhou have reported in the journal, Thorax, the results of a multinational prospective study of over 3,605 smokers attempting to quit. This study found that those using NRT were about twice as likely (8% vs 4%) to remain continuously abstinent six months later. This study, like the New York City patch study, supports the findings from randomized clinical trials and demonstrates that smokers making a self-initiated quit attempt without additional behavioral support are twice as likely to remain abstinent for at least six months if they use NRT as compared with trying without NRT. Nicotine replacement therapy is therefore an effective aid to smoking cessation in the “real world”.

Labels: cessation, nicotine, nicotine addiction cigarette smoking tobacco, replacement, therapy

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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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