Tobacco Harm Reduction

There are a bunch of policy options designed to reduce the harm to health caused by tobacco.

Right now, those option focus on reducing exposure to second-hand tobacco smoke pollution, reducing initiation of smoking among young people, and encouraging existing smokers to quit. In many developed countries these policies have had some success, with significant reductions in the proportion of the population who smoke. In some other countries there has been little progress or smoking has actually increased. At the end of the 20th century almost half of all men on the planet were smokers. Perhaps the main hope for improving this situation is via implementation of the World Health organization’s Framework Convention on Tobacco Control (FCTC). Details on the FCTC can be found at;
http://www.who.int/tobacco/framework/en/

There have also been moves to reduce the harm to health via increased regulation of the tobacco industry and the products it sells. For example, in the European Union, there are fairly tight regulations governing the advertising of tobacco, the emissions from cigarettes, the warnings on packs and also an almost complete ban on oral snuff tobacco.

In the United States, there is currently a piece of legislation that has cleared a number of initial hurdles, (but with a few more to be crossed) that would, for the first time, give the US Food and Drug Administration (FDA) the right to regulate tobacco products. Though most people agree that it is only right that the tobacco industry should be more tightly regulated, there are differences of opinion as to the way to do it that would be most likely to lead to reduced harm to health.

One model (on which the current FDA legislation appears to be based), involves reducing the potential nicotine delivery from tobacco products gradually down to the level at which they would no longer be addictive. The existing smokers would hopefully gradually switch over to nicotine replacement products or give up nicotine altogether.

Another model involves gradually reducing the permissible toxins levels that can be emitted by tobacco products, while keeping the nicotine delivery at a level that users can still be addicted. In the end this policy might end up at a similar place to the previous one, with users using clean nicotine products, without any tobacco.

Both of these models have merits. However, there may be problems with the time delay before reaching the point where there is significantly less harm being caused. There may also be challenges for enforcement, as it may be difficult for enforcement authorities to tell if a cigarette is reduced toxin/nicotine or a regular cigarette that has been smuggled in from another country. Another potential problem with both these strategies is that they pretty much put the tobacco industry out of business. Now it’s a fair bet that the tobacco industry would not want to go out of business, and would use its considerable resources and influence to prevent these policies from being implemented to their fullest extent.

This is where a similar but slightly different policy, may have some merit. With this model, the tobacco industry is given notice by regulators that smoked products can no longer be sold in this country 10 years from now. They are told that they should plan for this, by switching their consumers to products that do not involve combustion, i.e. any form of smokeless tobacco.

Now the companies won’t love this idea either. But it at least gives them a way to stay in business and also gets them out of the lung cancer and emphysema business, which has always been a slight PR negative for the tobacco industry. I believe that this policy stands the best chance of being sustainable and acceptable to all stakeholders.

If you would like to view a full slide show and talk I presented to a meeting of tobacco industry representatives that laid out this approach, it can be viewed on the supercourse (a free health teaching website) at: http://www.pitt.edu/~super1/lecture/lec31261/index.htm

Labels: cigarette smoking, FCTC, FDA, harm reduction, jonathan foulds, nicotine addiction, tobacco

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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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Marlboro Snus Isn’t Really Snus

In some prior posts I’ve talked about the type of smokeless snuff tobacco that is very popular in Sweden, called “snus”. This product has captured considerable attention because in that country more men now use it than smoke cigarettes, and because it is lower in toxins and carcinogens than other forms of smokeless tobacco (such that it doesn’t cause oral or lung cancer, but probably does cause pancreatic cancer, though less than smoking). It has also captured the attention of multinational tobacco companies, and is currently being test marketed in many countries, including the US.

Swedish snus is a moist snuff product (50% water) that delivers a comparable amount of nicotine to a cigarette. However, it appears that most of the versions being test-marketed in the US have very low nicotine delivery. Marlboro snus, in particular, appears to be a quite different product from Swedish snus. It is relatively dry (12% water), has a low pH, and therefore delivers an amount of nicotine to the blood that is less than 20% of that delivered by leading brands of Swedish snus (e.g. General) or US smokeless (e.g. Copenhagen) or cigarettes. On analyzing some of the data on Marlboro snus, and trying to understand why Philip Morris have produced a product with such low nicotine delivery, Dr Helena Furberg (from University of North Carolina) and I suspect that the product may be designed to fail. If you have tried any of the new smokeless tobacco products being test-marketed in the US or other countries (e.g Taboka, Camel snus, Marlboro snus, Ariva, Exalt, Skoal Dry, Revel, etc) I’d be interested to hear what you thought of them and their marketing.

If you are thinking of switching from smoking to a safer form of nicotine delivery, then far better to miss out the tobacco products altogether and move onto a product with reasonable nicotine delivery but no carcinogens, like 4mg nicotine gum. Some of the NRT products are now being sold in much better flavors than the original. They are not intended for long-term use, but if you feel you want to keep taking nicotine in a form that won’t kill you, this is a better choice than some unregulated tobacco product with unknown ingredients and nicotine delivery.

If you’d like to read the full article on Marlboro snus, with links to other data, it can be accessed at:
http://www.harmreductionjournal.com/content/5/1/9

Labels: jonathan foulds, marlboro snus, nicotine regulation reduction smoking smokeless, tobacco

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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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Why do some doctors not treat tobacco dependence?

Although the US Public Health Service Clinical Practice Guideline for the Treatment of Tobacco Use and Dependence recommends that all patients should be asked about their tobacco use, and all smokers offered an approved medication to help them quit, it is clear that this is not happening (1). An analysis of the 2001-2 national Ambulatory Care Survey (2) found that tobacco counseling occurred in 22.5% of visits by tobacco users, and cessation medications were prescribed on only 2.4% of occasions (with the odds being 15 times higher if the patient requested it). These rates are no higher than were found in this survey in 1991. A study involving direct observation of physician encounters with patients (3) found that of 244 smokers identified, physicians provided assistance with smoking cessation for 38% (range among practices = 0%-100%). Bupropion and nicotine-replacement therapy were discussed with smokers in 31% and 17% of encounters, respectively. Numerous other studies have documented poor adherence of physicians to the basic recommendations in the 1996 and 2000 Tobacco Treatment Guidlines (1) regarding the “5 As” (Ask, Advise, Assess, Assist, Arrange), with particularly low rates of “assisting” on use of medications and “arranging” follow-ups (4,5,6). This partly relates to lack of familiarity with the Guideline (7), but time constraints and the perception that smokers are unreceptive to counseling were the two most common barriers cited by both physicians and office managers in one study (8). Thorndike et al (9) reported that there has been a small increase in physicians' rates of patients' smoking status identification and a small decrease in rates of counseling smokers over the decade 1993-2003. This lack of progress may reflect barriers in the US health care environment, including limited physician time to provide counseling.

A National Commission on Prevention Priorities, led by dormer US Surgeon General Dr David Satcher ranked 25 preventive healthcare interventions for their population impact and cost-effectiveness (10). 3 interventions achieved the top ranking on both of these measures (total score=10): Daily aspirin for people over 40, childhood immunizations, and brief counseling and pharmacotherapy for tobacco use. Of all the interventions evaluated, the tobacco intervention was estimated to have by far the biggest impact on Quality-Adjusted Life Years saved if widely implemented (1.3 million annually). Undertreatment of tobacco dependence therefore represents a major failure in the US healthcare system. So what are the causes and potential remedies? Here are my thoughts:

Causes
1. Although very thorough evidence-based reviews and clinical practice guidelines are available, most clinicians are unaware of them and few healthcare systems require that they be followed in the same way that guidelines on the treatment of other comparable disorders (e.g. hypertension) are followed. If the healthcare system (whether that be the hospital system or the health plan) does not explicitly value tobacco treatment one should not be surprised that busy clinicians are not going out of their way to find and follow clinical guidelines on this issue.

2. Clinicians have found that it is not simple to get paid for tobacco treatment interventions. Where these are covered by health plans there may be high copays or deductibles, and frequently payments are low and certain effective treatment components are not covered (e.g. OTC NRT or group treatment). So for both clinicians and patients there is uncertainty about what (if any) treatment components are covered and this itself is a barrier to treatment provision.

3. Clinicians are unsure about the effectiveness of tobacco treatment. Their experience is that of 50 patients counseled and offered a medication, 40 will still be smoking when they are seen a year later. This can seem unrewarding compared to some other clinical interventions.

Solutions
1. We need to make all the effective components of tobacco treatment covered benefits of all health plans. Model benefit designs have already been described and widespread adoption of these would take away that doubt/barrier. http://www.tobaccoprogram.org/cftfkinsurance.htm
This will require patients and employers to ask for it, as well as insurance companies to offer and provide it.

2. We need to ensure that a new tier of healthcare provider can be trained and eligible for reimbursement for tobacco treatment. MDs and other prescribers’ time is valuable and the counseling component is best provided by counselors who have been trained to specialize in that work. In large hospitals or high population densities this tobacco counseling can be provided face-to-face in specialist clinics, but in more rural areas this can best be provided via telephone quitlines and interactive websites. This will require that more tobacco treatment counselors be trained, and approved for reimbursement by health plans. Standards for Practice for Tobacco Treatment Specialists have been developed by the Association for the Treatment of Tobacco Use and Dependence (ATTUD):
http://www.attud.org/public/survey.php

3. Steps 1 and 2 above will enable MDs to move to a model where they routinely ask patients about tobacco use, advise them to quit and offer to prescribe a med but then refer on to a local counselor or quitline (ideally via an electronic or “fax-to-quit” service). The MD intervention needn’t require more than one or two 15 minute appointments, and the counselor’s intervention would consist of 4-8 30-minute sessions.

I’d be interested to hear from clinicians regarding what they think could be done to improve tobacco treatment provision. For the patients, I think the advice has to be to ask your clinicians for help. Most clinicians see it as part of their role (even without adequate reimbursement) and are happy to help, but are currently working in a reactive rather than proactive mode.

1. Fiore MC, Bailey WC, Cohen SJ, Dorfman SF, Goldstein MG, Gritz ER et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: U.S. Public Health Service, 2000.
http://www.surgeongeneral.gov/tobacco/tobaqrg.htm
2. Steinberg MB, Akinciquil A, Delnevo C, et al. Gender and age disparities for smoking cessation treatment. Am J Prevent. Med. 2006 May;30(5):405-12. http://www.tobaccoprogram.org/staffarticles.htm
3. Ellerbeck EF, Ahluwalia JS, Jolicoeur DG, Gladden J, Mosier MC. Direct observation of smoking cessation activities in primary care practice.J Fam Pract. 2001 Aug;50(8):688-93.
4.Thorndike AN, Rigotti NA, Stafford RS, Singer DE. National patterns in the treatment of smokers by physicians. JAMA. 1998 Feb 25;279(8):604-8.
5. Longo DR, Stone TT, Phillips RL, Everett KD, Kruse RL, Jaen CR, Hewett JE. Characteristics of smoking cessation guideline use by primary care physicians.Mo Med. 2006 Mar-Apr;103(2):180-4.
6. Cokkinides VE, Ward E, Jemal A, Thun MJ. Under-use of smoking cessation treatments: results from the National Health Interview Survey, 2000. Am J Prev Med 2005;28:119--22.
7. Ward MM, Vaughn TE, Uden-Holman T, Doebbeling BN, Clarke WR, Woolson RF. Physician knowledge, attitudes and practices regarding a widely implemented guideline. J Eval Clin Pract. 2002 May;8(2):155-62.
8. Marcy TW, Skelly J, Shiffman RN, Flynn BS. Facilitating adherence to the tobacco use treatment guideline with computer-mediated decision support systems: physician and clinic office manager perspectives. Prev Med. 2005 Aug;41(2):479-87.
9. Thorndike AN, Regan S, Rigotti NA. The treatment of smoking by US physicians during ambulatory visits: 1994 2003. Am J Public Health. 2007 Oct;97(10):1878-83.
10. Maciosek MV, Edwards NM, Coffield AB, Flottemesch TJ, Nelson WW, Goodman MJ, Solberg LI. Priorities among effective clinical preventive services: methods. Am J Prev Med. 2006 Jul;31(1):90-6. Review
http://www.prevent.org/content/view/130/163/

Labels: counseling, pharmacotherapy, tobacco

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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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Do you (or your kids) hookah?

A hookah—also known as hubbly bubbly, shisha, or narghile—is an elaborate glass based waterpipe used for smoking tobacco. You have probably seen it in movies based in Arab countries, but may not be aware that its use has become very widespread among college students in the US and other western countries. Special tobacco (usually moist with added sweeteners and flavors) is placed in the bowl at the top of the apparatus and heated with burning charcoal. During inhalation the smoke from the charcoal is pulled through the tobacco down the pipe and towards the water. After bubbling through the water, the cooled smoke surfaces and is drawn through the hose and inhaled.

The smoke delivered by a waterpipe contains similar concentrations of carbon-monoxide to the smoke inhaled from a cigarette. It also contains the usual other toxins (nicotine, tar heavy metals etc) delivered by cigarette smoke. There may be some differences resulting from the different types of tobacco and additives used with waterpipe smoking, and from the different temperature to which the tobacco is heated (about half the temperature that cigarette tobacco reaches).

However, overall we have no good data supporting the commonly held belief that waterpipe smoking is less harmful than cigarette smoking. This belief appears to be partly based on the idea that the passing of the smoke through the water somehow “cleans” the smoke. This is false. This process simply cools the smoke, making it easier to inhale, but basically the same smoke with all its toxic constituents comes out the other end via the mouthpiece and is inhaled.

Even in countries where waterpipe use is very common (some Arabic, eastern Mediteranean, and Asian countries), many users also smoke cigarettes, making it difficult to clearly identify the health risks specific to waterpipe use.

In Syria, where waterpipe use is widespread, many men acknowledge that they are addicted to the hookah. Until more is known about waterpipe use and its effects, it would be reasonable to assume that waterpipe use is about as addictive and harmful as cigarette smoking.

Over recent years, waterpipe use has increased in frequency in the United States – primarily in connection with the increased numbers of “hookah bars” which have been developed. Hookah bars are commonly found on or near college campuses, and the increase in use appears to be primarily in this age-group (16-28). These bars provide the waterpipes and tobacco for a fee, and are perceived as a novel and pleasant social experience by young people. When a group of young people find they are enjoying waterpipe smoking but perhaps spending more money or time at the hookah bar than they would like, then some start to purchase their own waterpipe and materials and smoke at their apartment. As many as 20-33% of students on some campuses have at least tried a waterpipe. In one survey, 37% of college freshmen believed that waterpipe use was less harmful than cigarette smoking. It is therefore important to make clear to young people that waterpipe smoke is just as harmful and addictive as cigarette smoke.

Labels: cigarette smoking, hookah, tobacco, waterpipe

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Smoking, smokeless tobacco and cancer (2)

My previous post discussed toxin delivery from different tobacco products. Now what is the evidence relating use of these products to health problems? Unfortunately most studies don’t collect data on different brands or even categories of smokeless tobacco being used, and few compare directly the risks from smokeless with those from smoking. However, we can get a sense of the risks by examining studies based in different parts of the world where different types of tobacco are used. When we look at it this way we can find very clear evidence that the types of smokeless tobacco used in Sudan and India increase the risk of oral cancer. There is also toxicological evidence showing that Sudanese smokeless tobacco has very high concentrations of TSNAs (carcinogenic toxins), as do some forms of smokeless tobacco used in India. In Asia the picture is complicated by the tradition of adding other ingredients, especially areca nut which is highly carcinogenic on its own.

Then when we look at studies of smokeless tobacco use from the U.S. we see mixed results. One particular study published in the 1980s found very high risks of oral cancer. That study by Professor Deborah Winn and colleagues focused on women in southern United States and found that white never-smoking women (who tend to use oral dry snuff powder) had a relative risk of over 4.2 (2.6-6.7), for developing oral and pharyngeal cancer. Women who had used smokeless tobacco for 50 years had a 50-fold increase in risk for some oral cancers. It should be noted that only a tiny minority of smokeless users use the type of dry snuff tobacco that is commonly used by women in these rural parts of North Carolina. It should also be noted that the type of smokeless tobacco with the extremely high concentration of toxins mentioned in my previous post was also a type of dry snuff. So it begins to look like it’s the smokeless tobacco with very high toxin levels that has evidence of a causal effect on oral cancer. In fact, one of the largest studies on the effects of smokeless tobacco use in the United States (by the American Cancer Society) found no significant increase in the risk for oral cancer among smokeless tobacco users. One of these studies examined a population of 2488 smokeless tobacco users with a median age of 57 at enrolment (i.e. they'd used smokeless for decades) and followed them up 18 years later (i.e. mean age 75). This study found only one death from oral cancer in exclusive smokeless tobacco users, and none in former users, which was a slightly lower rate than occurred in people who had never used any tobacco in their life. These findings from the American Cancer Society suggest that any effect of commonly used brands of smokeless tobacco in the United States on oral cancer, if present, is relatively small.

Finally, we can examine the studies conducted in Sweden where the use of a form of low-toxin moist snuff (called snus) is more common than smoking in men. These studies consistently find no increased risk of oral cancer for snus users. One of the best of these studies was published in the Lancet recently and found that snus users have no increased risk of oral or lung cancer, but they have twice the risk of pancreatic cancer of never tobacco users. That same study found higher risks of all these cancers in smokers (e.g. smokers were about 10 times more likely to get lung cancer than either snus users or never tobacco users, who both had similar risks).

So now lets come back the recent report by Hecht and colleagues. It found similar concentrations of a specific carcinogen in smokeless users and smokers. But we have excellent data showing that smokers have much higher risks of lung cancer than smokeless users, and also higher risks of oral cancer than users of some forms of smokeless tobacco. The lung cancer pattern suggests that deposition of carcinogens directly into the lungs is relevant to the causal mechanism as smokeless tobacco has generally not been found to cause lung cancer in humans. But then we also have a higher risk of oral cancer for smokers. This causes one to consider whether the biomarker being measured in the urine in Hecht and colleague's study is very closely linked to the mechanism wherbye tobacco causes cancer in humans. Perhaps there are other toxins (e.g. benzo(a)pyrene) that are important in triggering cancer in smokers, but are found in lower levels in smokeless users? Whatever, the explanation, it seems that urine NNAL levels do not relate very closely to cancer risks in tobacco users.

But when discussing health risks from tobacco we need to be clear that these involve much more than lung or oral cancer, but also other cancers, and also other serious respiratory and cardiovascular diseases. For most of these, the health risks from smoking greatly outweigh the risks from smokeless tobacco. Chronic respiratory diseases are extremely common among smokers but there is neither good evidence nor a plausible rationale linking use of smokeless tobacco to these respiratory diseases.

So although it is clear that smokeless tobacco contains carcinogens and is not harmless, it is significantly less harmful than smoking cigarettes. I agree with Hecht and colleagues that we should not encourage anyone to use smokeless tobacco, when we have safe and effective medicines to help them quit smoking. However, I think we need to be able to give an honest answer to the question, “Are there forms of smokeless tobacco that are much less likely to kill me than smoking cigarettes?”. The honest answer is,”yes”. Similarly, of we are asked whether some types of smokeless tobacco may be less harmful than others, it seems prudent to suggest that some types of tobacco that have higher concentrations of toxins than others, and that the type of smokeless tobacco used in Sweden (snus) appears to be lower in toxins and health risks than much of the tobacco used in the rest of the world. It is far from risk-free (as are many things that people choose to do on a regular basis, like driving a car, eating donuts, drinking beer, mountain-climbing, or having sex), but experts agree that it is about 90% less harmful than smoking:
http://cebp.aacrjournals.org/cgi/content/full/13/12/2035
Similarly, given the relationship between toxin delivery and health effects from smokeless tobacco, it would seem to be sensible to regulate tobacco products in a manner that requires manufacturers to minimize the concentrations of toxins delivered as much as is technically possible.

In the mean time (and also after regulation is in place), manufacturers who produce and market products containing and delivering unnecessarily high quantities of toxins should be legally liable for the effects of their defective products.

Labels: cancer, smokeless, Smoking, tobacco

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Carcinogens from smoking and smokeless tobacco use (1)

This month an interesting study by Professor Stephen Hecht and colleagues at University of Minnesota was published in the journal, Cancer Epidemiology, Biomarkers & Prevention. The study compared cigarette smokers with smokeless tobacco users on their urine concentration of a biomarker of nicotine intake (cotinine, the main metabolite of nicotine), and a biomarker of exposure to a known carcinogen (NNAL, a biomarker of NNK exposure). The study found that the smokeless tobacco users had higher concentrations of the nicotine metabolite and higher concentrations of the carcinogen biomarker than smokers. The authors concluded that smokeless tobacco is not a safe substitute for smoking.

The authors are correct in this conclusion, as some forms of smokeless tobacco have been shown to be associated with oral cancer, other oral lesions, and may also increase some cardiovascular risks. The idea that smokeless tobacco is not safe is unlikely to be surprising to many people. But given that many of the major cigarette manufacturers are currently test-marketing smokeless tobacco products it may be worth examining the types and risks from smokeless tobacco in more detail, and also looking at how the epidemiological data relates to the recent findings from Hecht and colleagues.

The first thing that needs to be said about smokeless tobacco is that it is not just one thing. The extremely wide variety of different types of smokeless tobacco can be viewed on an excellent website produced by the U.S. National Cancer Institute and Centers for Disease Control, online at: www.cancercontrol.cancer.gov/tcrb/stfact_sheet_combined10-23-02.pdf.

Secondly, smokeless tobaccos vary enormously in the amount of toxins (including carcinogens) they deliver, and (not surprisingly) the ones containing higher concentrations of toxins (like carcinogenic tobacco-specific nitrosamines, or benzo(a)pyrene), appear to be more likely to have adverse health effects. To give an idea of the range of concentrations of toxins, Professor Brad Rodu at University of Louisville published data on the concentration of carcinogenic Tobacco-Specific Nitrosamines (TSNAs) in various smokeless tobacco products. Some examples are as follows (the units of measurement are parts per million based on dry weight):

Ariva (new powdered tobacco lozenge): <0.1 ppms
Ettan (Swedish snus): 2.0 ppms
Red Man (US chewing tobacco): 1.8 ppms
Copenhagen (leading US moist snuff): 12.1 ppms
Red Seal (US dry snuff): 1096 ppms

So we have here over a thousand-fold difference in the concentration of certain toxins in different types of smokeless tobacco! There are a few additional problems. Most of the smokeless tobacco products sold in the United States use fermentation in their production. This facilitates the development of carcinogenic compounds in the tobacco. In fact there is evidence to show that in these fermented products, they continue to ferment in the can, such that the concentration of carcinogens may increase in the can as it sits on the shelf. The method of production used for Swedish snus does not include fermentation, but rather uses a pasteurization-like process that treats the product with steam and appears to kill the microbes required for fermentation. This is thought to be the reason why Swedish snus has lower levels of carcinogens than US Smokeless tobacco. It may also be the reason that Swedish snus does not appear to cause oral cancer. However, the problem remains in the United States that the tobacco manufacturers can adjust the way they produce their products and the ingredients included in them without telling anyone. That is part of the reason why many experts support the pending legislation that would give the FDA the power to regulate tobacco products. This legislation appears to enable the FDA to require maximum permissible levels of harmful toxins in both smoked and smokeless tobacco products. With cigarettes the problem of what happens when you burn the product and inhale the smoke remains, but for smokeless there is a real prospect of offering a product that contains and delivers a known maximum level of toxins – and potentially a level that would be extremely unlikely to cause cancer. But for now, as demonstrated in Hecht and colleagues study, US smokeless tobacco delivers more toxins than necessary and there is little we can do about it.

In my next post I’ll discuss the relationship between the concentration of toxins in smokeless tobacco products and their harmfulness to health.

If you are interested in the views of tobacco and cancer experts on this topic you can learn more by reading the article linked below:
http://cebp.aacrjournals.org/cgi/content/full/13/12/2035

Labels: cancer, cigarette smoking, smokeless, tobacco

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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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Chantix and mental illness - what are the facts?

The August issue of the American Journal of Psychiatry included two letters reporting single cases of worsening of symptoms of schizophrenia and mania, while they were taking the new smoking cessation medication, Chantix (varenicline). Links to those case reports can be found below. It was also noticeable that some readers of my previous article on Chantix who were also taking medications for psychiatric problems wrote online comments about unpleasant side effects.
http://www.healthline.com/blogs/smoking_cessation/2007/04/chantix-how-does-this-new-quit-smoking.html

People suffering from major mental illnesses were excluded from the initial placebo-controlled trials of varenicline (Chantix), which showed that it is both safe and effective in helping smokers to quit. It is normal practice to exclude certain categories of patient from trials of new medicines, prior to the drug being approved for sale to the public. Often the reason is that patients with certain diagnoses are more likely to be taking medications that may affect the condition being treated (e.g. antidepressants could theoretically affect smoking cessation, as at least 2 antidepressants are effective for smoking cessation). Sometimes it is partly to protect those considered “at risk”, from taking an unlicensed experimental medicine. What we end up with is that many new medicines have mainly been studied in people who are relatively healthy, apart from having the condition the new medicine is designed to treat. Chantix is like many new drugs in this respect. It is also very common, especially for new medicines that are very widely used, for reports to appear of unusual side-effects occurring in some patients. I’ve published a few such reports myself.

However, it is not until fairly thorough additional placebo-controlled studies have been published in more patient groups, that we can tell with any confidence whether the new drug really does cause problematic side effects in certain patient groups or not. Sometimes such studies are never carried out and in that case we need to rely on the reported experiences of clinicians treating those patient groups over a period of time.

One thing we have to bear in mind is that when a person starts using Chantix, that’s not the only thing that’s changing. That person will also be trying to quit smoking. Quitting smoking itself causes a number of changes, including the increases in nicotine withdrawal symptoms I’ve talked about before (see link below), and also a slowing in metabolism of some medications, that could cause an increase in the blood levels of the drugs contained in those medicines (I’ll discuss this in a future post). So some symptoms may be related to quitting smoking, rather than Chantix per se.

So if I had a relative who smoked and suffered from a mental illness (like schizophrenia, bipolar disorder or depression) and was taking medicine for that illness but wanted help to quit smoking, what would I suggest?

As with all the people I see who want to quit smoking, I’d describe all the available forms of help, including counseling, internet support and medicines. I’d recommend that they use these. With regards to medicines, I’d point out one advantage of nicotine replacement therapy, which is that it does not involve taking a “new” drug, - as they have been taking nicotine in a much more harmful form every day, for years. When discussing Chantix I’d point out that it had not been studied in many people with a serious mental health problem, and so it would be particularly important to discuss that option with their doctor and to allow the doctor to monitor their progress on that medicine fairly closely if the doctor decided to prescribe it. But if my family member had already tried nicotine replacement therapy and wanted to try something different, I wouldn’t discourage it. I’ve heard from many clinicians who have treated patients with mental health problems successfully with Chantix, and so I am not convinced yet that there is a markedly increased risk of adverse events caused by Chantix in such patients.

It would be helpful to hear peoples’ experiences of using Chantix, particularly if you have also had a mental health problem. If you feel that any medicine has caused a harmful effect, then you should tell your doctor, and particularly in the case of a new medicine, it may be appropriate to report this to the FDA. For further information on that procedure, visit: http://www.fda.gov/medwatch/

Here are the links to the recent case reports:
http://ajp.psychiatryonline.org/cgi/content/full/164/8/1269
http://ajp.psychiatryonline.org/cgi/content/full/164/8/1269-a

Here is the link to my previous article on nicotine withdrawal:http://www.healthline.com/blogs/smoking_cessation/2007/03/what-is-nicotine-withdrawal-syndrome.html

Labels: Chantix, mental illness, quit smoking cessation tobacco advice cigarettes, Smoking, tobacco, varenicline

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How many medical doctors smoke?

In many countries medical doctors have been at the forefront of attempts to reduce the number of people who smoke. The medical doctor is one of the most highly respected professionals and patients place a large amount of faith in their doctor’s advice. However, concerns have been expressed about the willingness of doctors who smoke themselves to advise their patients to quit, and about the likelihood of patients taking such advice seriously if they are aware that the doctor is a smoker him/herself. So what proportion of medical doctors smoke?

In the past month Drs Derek Smith and Peter Leggat published a comprehensive international review of tobacco smoking in the medical profession from 1974-2004. The study showed that in countries like the United States, UK, Canada, Australia and New Zealand, smoking rates have dropped dramatically among doctors, from 15-20% in the 1970’s to around 5% at the end of the 20th century. However, such low smoking rates are not uniform among doctors across the world. In China, 32% of male doctors smoke (but 0% of females doctors smoke), in Italy 28% of doctors smoke (32% among men), and in Turkey or Bosnia & Herzegovina around 40% of doctors smoke.

Some may be surprised to hear that as many as 5% of US doctors smoke. But remember that doctors are human beings like the rest of us, and not immune to either infections or addictions. Many smoking doctors report that they (like most smokers) started in their teen years and so were likely addicted even prior to the decision to study medicine at college. I prefer to look at the low (and still falling) smoking rates among doctors in some countries as a very positive sign. It provides an indication of how low it is possible for smoking prevalence to go in a population that is well informed of the health risks, has relatively good access to treatment, and generally works in a smoke-free environment where smoking is not considered to be socially acceptable. It suggests that 5% may be a reasonable target for the rest of the population as well.

The full report on smoking among doctors can be found at:
http://www.biomedcentral.com/1471-2458/7/115

Labels: doctors, medical, profession, Smoking, tobacco

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Tobacco and Global Warming

Having spent most of my professional career focused on activities that ultimately aim to reduce the harm to health caused by tobacco, you won’t be surprised to hear that I believe its one of the most important issues affecting human health. But every now and again even I have to admit that there are a few things that are going to have an even greater impact on the health of people on planet earth. One of those is clearly the increased pollution of our planet and the consequent climate change.

Last summer, I took my eldest daughter (Georgia) to see the Al Gore movie, “An Inconvenient Truth”. We found it very convincing and whether you like Al Gore or not, I’d recommend that you get it out on DVD and watch it with your family if you havn’t seen it already. Even if you don’t like the statistical stuff, its hard to argue with photographs of massive lakes that have dried up, glaciers that have melted and polar bears that have all but run out of ice. Of course in the United States some people can’t get past the politics (i.e the fact that Gore is a Democrat) and so think this global warming stuff is probably just some liberal, left-wing, tree-hugging, anti-business, mumbo-jumbo propaganda. It would be great if that’s all it is. Unfortunately the evidence is crystal clear. 22 of the hottest years ever recorded on the planet have occurred since 1980 and 2005 was THE hottest ever. This website provides some of the evidence:
http://www.pewclimate.org/global-warming-basics/basic_science/

In the last few years the world’s top scientists have reviewed the evidence and have come to the conclusion that not only is the planet heating up but that human activities (primarily burning fossil fuels and other activities emitting greenhouse gases) are the cause (rather than just some random fluctuation). I’m no expert so I wouldn’t want you to take my word for it, but feel free to check out what the experts think:
http://en.wikipedia.org/wiki/Scientific_opinion_on_climate_change

So what can we do? Again I’m no expert, but this site has useful suggestions and information: http://www.climatecrisis.net/takeaction/

My own personal opinion is that suggestions that we all drive less, take the bike/bus etc are too inconvenient to follow and so people just won’t. Just like with tobacco, it’s really all about money and power. So I think the most important thing we can do as individuals is find out more about this threat to our families and our world, do our best to consider the environmental impact of the products we buy, but most importantly, only vote for politicians who are taking this thing seriously and are willing to implement policies that move us towards a solution. This goes all the way from your local township (can kids and adults walk or safely ride their bike around the neighborhood, or do the sidewalks stop and the end of the development so we all need to drive wherever we go?) all the way up to the presidential elections (who took the most funding from the oil companies and hired former oil company folks as “advisers”?).

So what does all this have to do with tobacco? To be honest, not a lot. I just thought that on this day (07/07/07) when the issue is being raised via the Live Earth concerts it deserved a mention on its own merits. There are, however, a couple of links to tobacco. One is of course the similarity between big tobacco and big oil. We can be certain that the big oil companies will be using all their (considerable) influence to prevent proper steps being taken on this issue, while simultaneously trying to do a good PR job of seeming warm and fuzzy. The other relevance is the fact that tobacco is itself a major cause of environmental pollution, both from the cigarette smoke itself and even more so from the industrial processes involved in bringing cigarettes to market.

For more information on tobacco’s environmental effects check out this site:
http://www.ash.org.uk/html/factsheets/html/fact22.html
If you needed another reason to quit smoking, this should give you one.

Labels: Global warming, tobacco

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Reductions in teen smoking.

One of the most fascinating and unexplained changes in smoking habits that has taken place in the United States was the dramatic reduction of cigarette smoking among African American youth since the 1970s. The “Monitoring the Future” study has documented clearly that in 1975, smoking prevalence was very similar across ethnic/racial groups of teenagers, with 38% of white teens smoking, 37% of African American teens smoking and 36% of Latino youth smoking cigarettes in 1977. However, by 1985, smoking prevalence had halved among African American teens (18%) but remained high in whites (31%) and Latino youth (26%). By 1992 the differences had become even more marked, with only 9% of African American youth smoking, compared with 32% of white youth and 25% of Latino youth. Although smoking declined in young people of all backgrounds since 1998, these ethnic/racial differences largely persist. So the proportion of African American teens who smoke was cut by more than three quarters over 15 years, and yet no-one appears to know how it happened. Suggestions have ranged from increased price-responsiveness among African American teens (during a period involving increases in price of cigarettes), the possibility that African American youth could be using other substances instead. However, this last idea is based more on stereotypes than data: illegal drug use has also fallen in African American youth over the same time frame, and in 2006 a smaller proportion of African American high school seniors had used an illicit substance in the past year, as compared with whites or Latinos.

So this rather dramatic reduction in smoking by African American youth occurred prior to the major funded campaigns that followed the master Settlement Agreement in 1998, and is largely unexplained. If you think you have an explanation, please tell me!

Labels: ethnicity, nicotine addiction cigarette, race, Smoking, teen, tobacco, youth

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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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