Association between exclusive pipe smoking and mortality from cancer and other diseases

Impact of smoking cessation duration on lung cancer mortality: A systematic review and meta-analysis

BACKGROUND

Smoking history is a heterogeneous situation for different populations, and numerous studies suggest that smoking cessation is conducive to reduce the mortality of lung cancer. However, no quantitative meta-analysis regarding smoking cessation duration based on different populations has demonstrated it clearly.

METHODS

We systematically searched four electronic databases (PubMed, Embase, the Cochrane Central Register of Controlled Trials, and Scoups) till February 2023. Eligible studies reported the association between lung cancer survival and duration of smoking cessation. Additionally, we stratified the study population according to whether they had lung cancer at the time they quit smoking. Studies were pooled with the random-effects model.

RESULTS

Out of the 11,361 potential studies initially identified, we included 24 studies involving 969,560 individuals in our analysis. Lung cancer mortality varied across two groups: general quitters and peri-diagnosis quitters. For general quitters, those who had quit smoking for less than 10 years exhibited an RR of 0.64 (95% CI [0.55-0.76]), while those who quit for 10-20 years had an RR of 0.33 (0.25-0.43), over 20 years had an RR of 0.16 (0.11-0.24), and never-smokers had an RR at 0.11 (0.07-0.15). Among peri-diagnosis quitters, the 1-year Overall Survival (OS) showed an RR of 0.80 (0.67-0.96), the 2-year OS had an RR of 0.89 (0.80-0.98), the 3-year OS had an RR of 0.93 (0.84-1.03), and the 5-year OS had an RR of 0.85 (0.76-0.96).

CONCLUSIONS

Earlier and longer smoking cessation is associated with reduced lung cancer mortality, no matter in which cessation stage for two different populations.

Updates on Larynx Cancer: Risk Factors and Oncogenesis

Laryngeal cancer is a very common tumor in the upper aero-digestive tract. Understanding its biological mechanisms has garnered significant interest in recent years. The development of laryngeal squamous cell carcinoma (LSCC) follows a multistep process starting from precursor lesions in the epithelium. Various risk factors have been associated with laryngeal tumors, including smoking, alcohol consumption, opium use, as well as infections with HPV and EBV viruses, among others. Cancer development involves multiple steps, and genetic alterations play a crucial role. Tumor suppressor genes can be inactivated, and proto-oncogenes may become activated through mechanisms like deletions, point mutations, promoter methylation, and gene amplification. Epigenetic modifications, driven by miRNAs, have been proven to contribute to LSCC development. Despite advances in molecular medicine, there are still aspects of laryngeal cancer that remain poorly understood, and the underlying biological mechanisms have not been fully elucidated. In this narrative review, we examined the literature to analyze and summarize the main steps of carcinogenesis and the risk factors associated with laryngeal cancer.

Evidence relating cigarette, cigar and pipe smoking to lung cancer and chronic obstructive pulmonary disease: Meta-analysis of recent data from three regions

BACKGROUND

There is a need to have up-to-date information for various diseases on the risk related to the use of different smoked products and the use of other nicotine-containing products. Here, we contribute to the information pool by presenting up-to-date quantitative evidence for North America, Europe and Japan and for both lung cancer and chronic obstructive pulmonary disease (COPD) on the relative risk (RR) relating to current vs never product use for each of the three smoked tobacco products, cigarettes, cigars and pipes.

AIM

To estimate lung cancer and COPD current smoking RRs for the three products using recent data for the three regions.

METHODS

Publications in English from 2010 to 2020 were considered that, based on epidemiological studies in the three regions, estimated the current smoking RR of lung cancer and/or COPD for one or more of the three products. The studies should involve at least 100 cases of the disease considered, not be restricted to specific lung cancer types or populations with specific medical conditions, and should be of cohort or nested case-control study design or randomized controlled trials. Literature searches were conducted on MEDLINE separately for lung cancer and for COPD, examining titles and abstracts initially, and then full texts. Additional papers were sought from reference lists of selected papers, reviews and meta-analyses. For each study identified, the most recent available data on each product were entered on current smoking, as well as on characteristics of the study and the RR estimates. Combined RR estimates were derived using random-effects meta-analysis. For cigarette smoking, where far more data were available, heterogeneity was studied by a wide range of factors. For cigar and pipe smoking, a more limited heterogeneity analysis was carried out. Results were compared with those from previous meta-analyses published since 2000.

RESULTS

Current cigarette smoking: For lung cancer, 44 studies (26 North American, 14 European, three Japanese, and one in multiple continents), gave an overall estimate of 12.14 [95% confidence interval (CI) 10.30-14.30]. The estimates were higher (heterogeneity P < 0.001) for North American (15.15, CI 12.77-17.96) and European studies (12.30, CI 9.77-15.49) than for Japanese studies (3.61, CI 2.87-4.55), consistent with previous evidence of lower RRs for Asia. RRs were higher (P < 0.05) for death (14.85, CI 11.99-18.38) than diagnosis (10.82, CI 8.61-13.60). There was some variation (P < 0.05) by study population, with higher RRs for international and regional studies than for national studies and studies of specific populations. RRs were higher in males, as previously reported, the within-study male/female ratio of RRs being 1.52 (CI 1.20-1.92). RRs did not vary significantly (P ≥ 0.05) by other factors. For COPD, RR estimates were provided by 18 studies (10 North American, seven European, and one Japanese). The overall estimate of 9.19 (CI 6.97-12.13), was based on heterogeneous data (P < 0.001), and higher than reported earlier. There was no (P > 0.1) variation by sex, region or exclusive use, but limited evidence (0.05 < P < 0.1) that RR estimates were greater where cases occurring shortly after baseline were ignored; where bronchiectasis was excluded from the COPD definition; and with greater confounder adjustment. Within-study comparisons showed adjusted RRs exceeded unadjusted RRs. Current cigar smoking: Three studies gave an overall lung cancer RR of 2.73 (CI 2.36-3.15), with no heterogeneity, lower than the 4.67 (CI 3.49-6.25) reported in an earlier review. Only one study gave COPD results, the RR (2.44, CI 0.98-6.05) being imprecise. Current pipe smoking: Four studies gave an overall lung cancer RR of 4.93 (CI 1.97-12.32), close to the 5.20 (CI 3.50-7.73) given earlier. However, the estimates were heterogeneous, with two above 10, and two below 3. Only one study gave COPD results, the RR (1.12, CI 0.29-4.40), being imprecise. For both diseases, the lower RR estimates for cigars and for pipes than for current smoking of cigarettes aligns with earlier published evidence.

CONCLUSION

Current cigarette smoking substantially increases lung cancer and COPD risk, more so in North America and Europe than Japan. Limited evidence confirms lower risks for cigars and pipes than cigarettes.

Novel hazards of waterpipe tobacco and the benefits of stop smoking in men, a prospective cohort study

Waterpipe smoking is an emerging epidemic and a severe public health problem worldwide. Observational studies on the hazards of a specific new waterpipe tobacco product are timely needed. The objectives were to analyze how dangerous waterpipe tobacco smoking is on the causes of all mortality, including cancer, and how effective smoking cessation is for improving health. We analyzed the hazards of exclusive waterpipe smoking through a prospective cohort study in Northern Vietnam. We obtained exposure data on the smoking status of specific cigarette and waterpipe and smoking cessation histories from each study participant. The outcome includes deaths due to all causes. The cause of death for each case is determined based on medical records. HR (95%CI) was estimated using a Cox proportional-hazards-regression analysis for overall mortality and all cancers. The ever-cigarette smoking group as the reference group, the exclusive waterpipe smoking group had a statistical increase in the risk for overall mortality HR (95% CI): 1.63 (1.32, 2.00), and all cancers HR (95%CI): 1.67 (1.18, 2.38). The risk of death increased statistically in the group of waterpipe smoking over 20 years for overall mortality HR (95%CI): 1.82 (1.45, 2.29), and all cancers HR (95%CI): 1.91 (1.27, 2.88). After stopping smoking, the risk of death decreased steadily. The risk of death was reduced by 41% for overall mortality HR (95%CI): 0.59 (0.39, 0.89), and 74% for death from cancers HR (95%CI): 0.26 (0.08, 0.83) after ten years or longer of cessation. Life expectancy was shortened by more than six years for the group of exclusive waterpipe smokers compared to non-smokers. This study found new novel hazards of exclusive waterpipe tobacco smoking. The findings are scientific evidence for developing strategies, policies, and budget allocations to control this novel tobacco product and promote cessation to improve life expectancy.

Assessing the association between smoking and hypertension: Smoking status, type of tobacco products, and interaction with alcohol consumption

Background

The association between tobacco use and hypertension risk has been extensively researched but remains controversial, and few existing studies have considered the role of tobacco type and dosage response in this association. In this context, this study aims to provide epidemiological evidence for the possible relationship between tobacco smoking and future hypertension risk, with the tobacco type and consumption dose into consideration.

Methods

This study was based on 10-year follow-up data from the Guizhou Population Health Cohort conducted in southwest China. Multivariate Cox proportional hazards regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals [95% confidence intervals (CIs)], and restricted cubic spline analyses were performed to visualize the dose-response association.

Results

A total of 5,625 participants (2,563 males and 3,062 females) were included in the final analysis. Heavy smokers of machine-rolled cigarettes had an elevated hypertension risk compared with non-smokers (HR: 1.50, 95% CI: 1.05-2.16). The interaction effects of heavy smoking-heavy drinking patterns increased the future hypertension risk, with an adjusted HR of 2.58 (95% CI: 1.06-6.33).

Conclusion

This study did not find a significant association between overall tobacco use status and the risk of hypertension. However, heavy machine-rolled cigarette smokers had a statistically significant increased risk of hypertension compared with non-smokers, and a J-shape association has been found between the average daily consumption of machine-rolled cigarettes and the risk of hypertension. Besides, tobacco and alcohol consumption jointly increased the long-term hypertension risk.

Sexual Orientation Discrimination and Exclusive, Dual, and Polytobacco Use among Sexual Minority Adults in the United States

Research on whether sexual orientation discrimination is associated with multiple tobacco product use among sexual minority (SM) adults is limited. Thus, we explored the associations between sexual orientation discrimination and exclusive, dual, and polyuse among a subset of SM adults (18+) (n = 3453) using the 2012–2013 National Epidemiologic Survey on Alcohol and Related Conditions-III. We evaluated six indicators of prior-to-past-year sexual orientation discrimination separately and as a summary scale and defined past-year exclusive, dual, and polyuse based on cigarette, electronic nicotine delivery systems, other combustible (cigars and traditional pipe), and smokeless tobacco products. Using multinomial logistic regression, we estimated adjusted associations between sexual orientation discrimination and exclusive, dual, and polyuse. Experiencing discrimination in public places, being called names, and being bullied, assaulted, or threatened were associated with dual use, while experiencing discrimination when obtaining health care or insurance and when receiving health care were associated with polyuse. Each one-unit increase in the sexual orientation discrimination summary scale was associated with 5% and 10% higher odds of dual (95% CI: 1.01–1.10) and polyuse (95% CI: 1.02–1.18), respectively. To conclude, we advise health professionals to consider the salience of discrimination against SM adults and how these experiences lead to dual/polyuse.

Factors Associated With Quitting Smoking in Indonesia

Objectives:

The aim of this study was to identify factors associated with quitting smoking in Indonesia

Methods:

Data on 11 115 individuals from the fifth wave of the Indonesia Family Life Survey were analyzed. Quitting smoking was the main outcome, defined as smoking status based on the answer to the question “do you still habitually (smoke cigarettes/smoke a pipe/use chewing tobacco) or have you totally quit?” Logistic regression was performed to identify factors associated with successful attempts to quit smoking.

Results:

The prevalence of quitting smoking was 12.3%. The odds of successfully quitting smoking were higher among smokers who were female (adjusted odds ratio [aOR], 2.69; 95% confidence interval [CI], 2.08 to 3.33), were divorced (aOR, 2.45; 95% CI, 1.82 to 3.29), did not chew tobacco (aOR, 3.01; 95% CI, 1.79 to 5.08), found it difficult to sacrifice smoking at other times than in the morning (aOR, 1.29; 95% CI, 1.14 to 1.46), and not smoke when sick (aOR, 1.32; 95% CI, 1.14 to 1.54). About 59% of variance in successful attempts to quit smoking could be explained using a model consisting of those variables.

Conclusions:

Female sex, being divorced, not chewing tobacco, and nicotine dependence increased the odds of quitting smoking and were associated with quitting smoking successfully. Regular and integrated attempts to quit smoking based on individuals’ internal characteristics, tobacco use activity, and smoking behavior are needed to quit smoking.

Tobacco Smoking and Smokeless Tobacco Use among Domestic and International Medical Students in Hungary

Medical students as future physicians will have an important role in tobacco control; therefore, their tobacco use behavior is of particular interest. Consumption of combustible tobacco (cigarettes, waterpipes, cigars, and pipes) is prevalent throughout Europe, whereas smokeless tobacco use is common mainly in the Nordic countries. Objectives: Aim of our study is to assess tobacco use among medical students from different countries studying in Hungary with special focus on students from Norway where smokeless tobacco is widely used. A self-administered questionnaire survey was carried out to measure current tobacco use. Results: The survey included 1337 students from Hungary, Norway, Germany, and from other countries (Multinational group). The lowest prevalence of cigarette smoking was found among students from Norway (13.0%) when compared with students from Hungary (21.5%), Germany (34.2%), or with students in the Multinational group (29.5%). Conversely, prevalence of smokeless tobacco use was the highest among students from Norway (40.9%) when compared with students from Hungary (1.4%), Germany (2.6%), or with students in the Multinational group (6.2%). Waterpipes, cigars, and pipes were rarely used, mostly only 1-3 times a month in all groups. More than half of Norwegian students used some form of tobacco (smokeless and/or combustible tobacco). Conclusions: Considering the impending role of medical students in tobacco control, faculties of medicine should sensitize their students on the topic of possible health risks associated with combustible and smokeless tobacco products. Culturally tailored tobacco cessation programs need to be offered to medical students coming from different cultural backgrounds.

Smokeless Tobacco and Cigar and/or Pipe Are Risk Factors for Barrett Esophagus in Male Patients With Gastroesophageal Reflux Disease

OBJECTIVE

To investigate the effect of smokeless tobacco (ST), cigar and/or pipe smoking (CP) on the development of Barrett esophagus (BE) in white male patients with gastroesophageal reflux disease (GERD).

PATIENTS AND METHODS

A total of 1015 records of white male adults with BE (cases; n=508) or GERD (controls, n=507) were reviewed for lifestyle factors. Logistic regression analyses were performed after adjusting for lifestyle factors to assess the effects of ST and CP on the risk of developing BE. Differences between patients with BE and those with GERD were compared using chi-square and t tests.

RESULTS

Patients with BE were significantly older than patients with GERD (mean age, 66±12 years for patients with BE and 55±15 years for patients with GERD; P<.001). The odds of developing BE in patients who used CS were 1.7 times higher than that in patients who never smoked cigarettes (odds ratio [OR], 1.7; 95% CI, 1.3-2.2). It was observed that when CS use was combined with either ST or CP use, the odds of having BE significantly increased (OR, 2.5; 95% CI, 1.2-5.2; P=.01 and OR, 1.9; 95% CI, 1.03-3.58; P=.04) in comparison to CS alone. There were no significant differences in body mass index and alcohol consumption between BE and GERD groups.

CONCLUSION

This study suggests that there is indeed an association between CS and BE. We believe that this is the first time that ST and CP were associated with an even higher odds of developing BE. Further studies are needed to investigate whether the use of ST and CP is also associated with an increased risk of developing BE-associated adenocarcinoma.

[Old and new tobacco products]

Tobacco use is not just about manufactured cigarettes. Rolling tobacco, highly prized in the wake of price increases, is estimated to carry more toxic agents than its counterpart. This study shows that the use of cigar, pipe, cigarillos and narghile also leads to a cohort of pathologies similar to or more than what is known for smoking single cigarettes. Exotic, liquid or heated forms do just as much. The non-smoked tobacco, often fallen into disuse in France is very used in the United States and especially in Scandinavia. Denuded of inhaled products, it is often pointed as a form of reduction of smoking risks. Its use by athletes in all countries as a doping attitude, especially in ski disciplines, required a campaign of prevention within the federations concerned.

Association of Cigarette, Cigar, and Pipe Use With Mortality Risk in the US Population

IMPORTANCE

Tobacco products have changed in recent years. Contemporary mortality risk estimates of combustible tobacco product use are needed.

OBJECTIVE

To investigate the mortality risks associated with current and former use of cigars, pipes, and cigarettes.

DESIGN, SETTING, AND PARTICIPANTS

The National Longitudinal Mortality Study is a longitudinal population-based, nationally representative health survey with mortality follow-up that includes demographic and other information from the Current Population Survey, tobacco product use information from the Tobacco Use Supplement, and mortality data from the National Death Index. In this study, participants provided tobacco use information at baseline in surveys starting from 1985 and were followed for mortality through the end of 2011. The study includes 357 420 participants who reported exclusively using cigar, pipes, or cigarettes or reported never using any type of tobacco product.

EXPOSURES

Current or former exclusive use of any cigar (little cigar, cigarillos, large cigar), traditional pipe, or cigarette and never tobacco use. Information on current daily and nondaily use was also collected. Estimates adjusted for age, sex, race/ethnicity, education, and survey year.

MAIN OUTCOMES AND MEASURES

All-cause and cause-specific mortality as identified as the primary cause of death from death certificate information.

RESULTS

Of the 357 420 persons included in the analysis, the majority of current and former cigar and pipe smokers were male (79.3%-98.0%), and smokers were more evenly divided by sex (46% of current daily smokers were male). There were 51 150 recorded deaths during follow-up. Exclusive current cigarette smokers (hazard ratio [HR], 1.98; 95% CI, 1.93-2.02) and exclusive current cigar smokers (HR, 1.20; 95% CI, 1.03-1.38) had higher all-cause mortality risks than never tobacco users. Exclusive current cigarette smokers (HR, 4.06; 95% CI, 3.84-4.29), exclusive current cigar smokers (HR, 1.61; 95% CI, 1.11-2.32), and exclusive current pipe smokers (HR, 1.58; 95% CI, 1.05-2.38) had an elevated risk of dying from a tobacco-related cancer (including bladder, esophagus, larynx, lung, oral cavity, and pancreas). Among current nondaily cigarette users, statistically significant associations were observed with deaths from lung cancer (HR, 6.24; 95% CI, 5.17-7.54), oral cancer (HR, 4.62; 95% CI, 1.84-11.58), circulatory death (HR, 1.43; 95% CI, 1.30-1.57), cardiovascular death (HR, 1.24; 95% CI, 1.11-1.39), cerebrovascular death (stroke) (HR, 1.39; 95% CI, 1.12-1.74), and chronic obstructive pulmonary disease (HR, 7.66; 95% CI, 6.09-9.64) as well as for daily smokers.

CONCLUSIONS AND RELEVANCE

This study provides further evidence that exclusive use of cigar, pipes, and cigarettes each confers significant mortality risks.

Association between Cigar or Pipe Smoking and Cancer Risk in Men: A Pooled Analysis of Five Cohort Studies

Introduction: Use of non-cigarette tobacco products such as cigars and pipe has been increasing, even though these products entail exposure to similar carcinogens to those in cigarettes. More research is needed to explore the risk of these products to guide cancer prevention efforts.Methods: To measure the association between cigars and/or pipe smoking, and cancer incidence in men, we performed meta-analyses of data from five prospective cohorts. Cox regression was used to evaluate the association between different aspects of cigars and pipe smoking and risk of each smoking-related cancer (head and neck, esophagus, lung, stomach, liver, pancreas, kidney, and bladder) for each study. Adjusted HRs were combined using random-effects models.Results: Cigars and/or pipe smokers were at increased risk for head and neck [HR, 1.51; 95% confidence interval (CI), 1.22-1.87], lung (HR, 2.04; 95% CI, 1.68-2.47), and liver cancers (HR, 1.56; 95% CI, 1.08-2.26). Ever-smokers of cigars and/or pipe had an increased risk of developing a smoking-related cancer when compared with never smokers of any tobacco product (overall HR, 1.07; 95% CI, 1.03-1.12). The risk for smoking-related cancers was also increased in mixed smokers who smoked cigars or pipe as well as cigarettes, even when they were smoking predominantly pipe or cigars.Discussion: This pooled analysis highlights the increased risk for smoking-related cancers, particularly for lung and head and neck cancers in exclusive and predominant smokers (former and current) of cigars and pipe. Tobacco prevention efforts should include these products in addition to cigarettes. Cancer Prev Res; 10(12); 704-9. ©2017 AACR.

Smoking cessation affects the natural history of COPD

Background

Cigarette smoking is the most commonly encountered and readily identifiable risk factor for COPD. However, it is not clear which quantitative factors related to smoking influence the prognosis of COPD patients.

Methods

A total of 204 patients with a long-term history of smoking were enrolled into this study and followed up for 5 years. Patients were divided into “death” or “survival” groups based on follow-up results and “quitting-smoking” or “continuing-smoking” groups based on whether they gave up smoking.

Results

Patients in the death group had a longer smoking time, lower prevalence of quitting smoking, later onset of COPD symptoms, older age at quitting smoking, lower forced expiratory volume in one second (FEV₁) % predicted, and lower ratio of FEV₁/forced vital capacity. Age, age at quitting smoking, and FEV₁% predicted were independently associated with mortality from COPD. Compared to the continuing-smoking group, the quitting-smoking group had a lower mortality rate, longer course of COPD, earlier onset of COPD symptoms, and lower residual volume percent predicted. During the 5-year follow-up, 113 deaths were recorded (quitting-smoking group: n=92; 40 deaths; continuing-smoking group: n=112; 73 deaths). The mortality risk remained significantly higher in the continuing-smoking group than the quitting-smoking group (log-rank test, 13.59; P=0.0002).

Conclusion

Smoking time may be related to the mortality rate from COPD. Smoking cessation has the greatest capacity to influence the natural history of COPD.

US adult tobacco users' absolute harm perceptions of traditional and alternative tobacco products, information-seeking behaviors, and (mis)beliefs about chemicals in tobacco products

INTRODUCTION

Harm perceptions about tobacco products may influence initiation, continued use, and cessation efforts. We assessed associations between adult traditional tobacco product use and absolute harm perceptions of traditional and alternative tobacco products. We also described the topics individuals looked for during their last search for information, their beliefs about chemicals in cigarettes/cigarette smoke, and how both relate to harm perceptions.

METHODS

We ran multivariable models with jackknife replicate weights to analyze data from the 2015 administration of the National Cancer Institute's Health Information National Trends Survey (N=3376).

RESULTS

Compared to never users, individuals reported lower perceived levels of harm for products they use. Among current tobacco users, ethnicity, thinking about chemicals in tobacco, and information-seeking were all factors associated with tobacco product harm perceptions. In the full sample, some respondents reported searching for information about health effects and cessation and held misperceptions about the source of chemicals in tobacco.

CONCLUSIONS

This study fills a gap in the literature by assessing the absolute harm perceptions of a variety of traditional and alternative tobacco products. Harm perceptions vary among tobacco products, and the relationship among tobacco use, information seeking, thoughts about chemicals in tobacco products, and harm perceptions is complex. Data suggest that some individuals search for information about health effects and cessation and hold misperceptions about chemicals in tobacco products. Future inquiry could seek to understand the mechanisms that contribute to forming harm perceptions and beliefs about chemicals in tobacco products.

Pattern of tobacco use and its correlates among older adults in India

PURPOSE

We examined tobacco use pattern and its correlates among older adults.

MATERIALS AND METHODS

We used data of 9,852 older adults (>=60 years) (men 47% mean age 68 years) collected by the United Nations Population Fund on Ageing from seven Indian states. Logistic regression analysis was used to assess the correlates of tobacco use.

RESULTS

Current use of any form of tobacco was reported by 27.8% (men 37.9%, women 18.8%); 9.2% reported only smoking tobacco, 16.9% smokeless tobacco only and 1.7% used both forms. Alcohol users (OR:5.20, 95% CI:4.06-6.66), men (OR:2.92, CI :2.71-3.47), those reporting lower income (OR:2.74, CI:2.16- 3.46), rural residents (OR 1.34, CI 1.17-1.54) and lower castes (OR:1.29, CI:1.13-1.47) were more likely to use any form of tobacco compared to their counterparts.

CONCLUSIONS

Tobacco cessation interventions are warranted in this population focusing on alcohol users, men, those from lower income, rural residents and those belonging to a lower caste.

Do CDK4/6 inhibitors have potential as targeted therapeutics for squamous cell cancers?

Introduction Dysregulation of cell cycle progression has an established link to neoplasia and cancer progression. Components of the cyclin D-CDK4/6-INK4-Rb pathway are frequently altered in squamous cell carcinomas (SCCs) by diverse mechanisms, including viral oncogene-induced degradation, mutation, deletion, and amplification. Activation of the CDK4/6 pathway may predict response to CDK4/6 inhibitors and provide clinical biomarkers. Recently, the CDK4/6 inhibitor palbociclib showed clinical efficacy in combination with cetuximab in HNSCC patients. Areas covered This review focuses on the current research on the use of CDK4/6 inhibitors, comprising preclinical animal studies through phase II clinical trials across all SCCs. Expert opinion CDK4/6 inhibitors have a proven clinical benefit in breast cancer, but data on SCCs are sparse. Although frequent dysregulation of the cyclin D-CDK4/6-INK4-Rb pathway in SCCs suggests that targeting CDK4/6 may hold promise for improved clinical outcomes, single-agent activity has been modest in preclinical studies and absent in clinical studies. Combinations with immunotherapy or inhibitors of the PI3 K/mTOR or EGFR pathway may be effective. Given that SCCs caused by human papillomavirus have high levels of p16 and low levels of Rb, the CDK4/6 inhibitors are predicted to be ineffective in these cancers.

Smoking intensity (pack/day) is a better measure than pack-years or smoking status for modeling cardiovascular disease outcomes

OBJECTIVES

Smoking as an epidemiological exposure can be quantified in many ways including duration, intensity, pack-years, recency, and age at initiation. However, it is not clear which of these are most important for cardiovascular disease (CVD) and how they should be modeled.

STUDY DESIGN AND SETTING

Using the Multi-Ethnic Study of Atherosclerosis, Cox models for time to incident CVD adjusted for age, sex, race/ethnicity, education category, and income category were compared which included various characterizations of smoking history.

RESULTS

Duration, age at starting, time since quitting, and noncigarette forms of smoking were not independently associated with CVD, whereas baseline current intensity was associated with CVD [e.g., hard CVD hazard ratio 1 pack/d of 1.85 95% confidence interval (1.33, 2.57)]. Former smokers, regardless of duration, intensity, or recency, were not at increased risk, suggesting that risk may risk may drop precipitously from the time of quitting. For CVD events, representing smoking exposure as baseline smoking intensity produced better model fit as measured by Akaike information criterion than models using smoking status or pack-years.

CONCLUSION

The association of smoking with incident CVD events was well captured by including a simple term for baseline smoking intensity.

Tar yield and risk of acute myocardial infarction: pooled analysis from three case-control studies

BACKGROUND

Controversial information is available with reference to the role of type or yield of cigarettes on the risk of cardiovascular disease.

DESIGN

We considered the issue in a combined dataset of three case-control studies of acute myocardial infarction conducted in Italy between 1983 and 2003.

METHODS

Cases were 1990 subjects with a first episode of non-fatal acute myocardial infarction, and controls were 2521 patients in hospital for acute diseases unrelated to smoking or other recognized risk factors for myocardial infarction. The odds ratio and the corresponding 95% confidence interval (CI) were derived by unconditional multiple logistic regression models, including terms for age, sex, and several major risk factors for myocardial infarction.

RESULTS

As compared to never smokers, the multivariate odds ratio was 2.70 (95% CI 2.01-3.63) for smokers of low tar cigarettes (<10 mg), 3.06 (95% CI 2.53-3.70) for intermediate (10-19 mg) and 3.14 (95% CI 2.12-4.64) for high tar yield (> or =20 mg). After further allowance for duration of smoking and number of cigarettes per day, as compared to low tar yield cigarettes, the odds ratio was 1.14 (95% CI 0.85-1.53) for intermediate, and 1.28 (95% CI 0.81-2.02) for high tar yield.

CONCLUSION

Our study confirms that no substantial reduction in acute myocardial infarction risk resulted from the decrease of cigarette tar yield.

Epidemiology of Lung Cancer

Lung cancer continues to be one of the most common causes of cancer death despite understanding the major cause of the disease: cigarette smoking. Smoking increases lung cancer risk 5- to 10-fold with a clear dose-response relationship. Exposure to environmental tobacco smoke among nonsmokers increases lung cancer risk about 20%. Risks for marijuana and hookah use, and the new e-cigarettes, are yet to be consistently defined and will be important areas for continued research as use of these products increases. Other known environmental risk factors include exposures to radon, asbestos, diesel, and ionizing radiation. Host factors have also been associated with lung cancer risk, including family history of lung cancer, history of chronic obstructive pulmonary disease and infections. Studies to identify genes associated with lung cancer susceptibility have consistently identified chromosomal regions on 15q25, 6p21 and 5p15 associated with lung cancer risk. Risk prediction models for lung cancer typically include age, sex, cigarette smoking intensity and/or duration, medical history, and occupational exposures, however there is not yet a risk prediction model currently recommended for general use. As lung cancer screening becomes more widespread, a validated model will be needed to better define risk groups to inform screening guidelines.

Evaluation of the knowledge and perceptions with regards to pictorial health warnings on tobacco products among tobacco users diagnosed with head and neck carcinoma: a study from the Kumaon Hills of India

BACKGROUND

Tobacco products continue to be used in large quantities in India despite the mandatory inclusion of pictorial health warnings (PHWs) on all tobacco packaging. The circumstances as to how people could continue the use of tobacco to the point of developing head and neck cancer despite enhanced awareness about the ill effects of tobacco is the main focus of this study.

MATERIALS AND METHODS

This study concerned patients with least 5-years history of tobacco use, having been diagnosed with histopathologically proven malignancies of the hypopharynx, larynx, oropharynx and oral cavity presenting at the Government Medical College-Haldwani, Nainital, India. A total of 183 patients were eligible for inclusion during July 1 2013- June 30 2014. Of these, 59 patients used smoked tobacco exclusively, 22 patients used smokeless tobacco exclusively, and 102 patients used both forms of tobacco. Among users of smoked forms, 75.2% (n=121) were beedi users, and 24.8% (n=40) were cigarette users. Patients were asked direct questions as to whether they had noticed the presence of PHWs upon tobacco products. The reasons as to why PHWs were not effective in stopping the patients from tobacco use were investigated.

RESULTS

Of the 183 patients, 146 reported being aware about the presence of PHWs, and when they were asked reasons as to why they continued tobacco despite being aware of ill-effects, the commonest reason chosen (by 53.4%) was that patients had not regarded themselves as using tobacco heavy enough to cause cancer. Among the 36 patients who reported as being oblivious to the presence of PHWs on tobacco products, 63.9% reported that the products they used never displayed any PHWs, and 36.1% reported never having paid attention to the packaging. The awareness about PHWs was higher among cigarette smokers in comparison to beedi smokers (100% vs 76.1%, p=0.0002).

CONCLUSIONS

Locally produced and marketed tobacco products such as beedis and oral tobacco often fail to display PHWs. The presence of PHWs without doubt enhances awareness about the carcinogenic risks of tobacco. However, enhanced awareness alone may not be enough, and as elucidated by this study, some persons continue to use tobacco to the point of developing malignancies. The need of the hour is the implementation of legal and economic sanctions discouraging the use of tobacco products.

Estimating the decline in excess risk of cerebrovascular disease following quitting smoking--a systematic review based on the negative exponential model

We attempted to quantify the decline in stroke risk following quitting using the negative exponential model, with methodology previously employed for IHD. We identified 22 blocks of RRs (from 13 studies) comparing current smokers, former smokers (by time quit) and never smokers. Corresponding pseudo-numbers of cases and controls/at risk formed the data for model-fitting. We tried to estimate the half-life (H, time since quit when the excess risk becomes half that for a continuing smoker) for each block. The method failed to converge or produced very variable estimates of H in nine blocks with a current smoker RR <1.40. Rejecting these, and combining blocks by amount smoked in one study where problems arose in model-fitting, the final analyses used 11 blocks. Goodness-of-fit was adequate for each block, the combined estimate of H being 4.78(95%CI 2.17-10.50) years. However, considerable heterogeneity existed, unexplained by any factor studied, with the random-effects estimate 3.08(1.32-7.16). Sensitivity analyses allowing for reverse causation or differing assumed times for the final quitting period gave similar results. The estimates of H are similar for stroke and IHD, and the individual estimates similarly heterogeneous. Fitting the model is harder for stroke, due to its weaker association with smoking.

Could a scheme for licensing smokers work in Australia?

In this article, we evaluate the possible advantages and disadvantages of a licensing scheme that would require adult smokers to verify their right to purchase tobacco products at point of sale using a smart-card licence. A survey of Australian secondary school students conducted in 2011 found that half of 17-2013-old smokers and one-fifth of 12-2013-old smokers believed it was "easy" or "very easy" to purchase cigarettes themselves. Reducing tobacco use by adolescents now is central to the future course of the current epidemic of tobacco-caused disease, since most current adult smokers began to smoke as adolescents--at a time when they were unable to purchase tobacco lawfully. The requirement for cigarette retailers to reconcile all stock purchased from wholesalers against a digital record of retail sales to licensed smokers would create a robust incentive for retailers to comply with laws that prohibit tobacco sales to children. Foreseeable objections to introducing a smokers licence need to be taken into account, but once we move beyond the "shock of the new", it is difficult to identify anything about a smokers licence that is particularly offensive or demeaning. A smoker licensing scheme deserves serious consideration for its potential to dramatically curtail retailers' violation of the law against selling tobacco to minors, to impose stricter accountability for sale of a uniquely harmful drug and to allow intelligent use of information about smokers' purchases to help smokers quit.

Tobacco use in older adults in Ghana: sociodemographic characteristics, health risks and subjective wellbeing

BACKGROUND

Tobacco use over the life-course threatens to increase disease burden in older adulthood, including lower income countries like Ghana. This paper describes demographic, socioeconomic, health risks and life satisfaction indices related to tobacco use among older adults in Ghana.

METHODS

This work was based on the World Health Organization's multi-country Study on global AGEing and adult health (SAGE), conducted in six countries including Ghana. Wave one of SAGE in Ghana was conducted in 2007-2008 as collaboration between WHO and the University of Ghana Medical School through the Department of Community Health. A nationally representative sample of 4305 older adults aged 50 years and above were interviewed. Associations between tobacco consumption and sociodemographic, socioeconomic, health risk and life satisfaction were evaluated using chi-square and odds ratio (OR). Logistic regression analyses, adjusted for age, sex and other variables, were conducted to determine predictors of tobacco consumption in older persons.

RESULTS

Overall prevalence of current daily smokers among older adults in Ghana was 7.6%. Tobacco use (i.e. ever used tobacco) was associated with older males, (AOR = 1.10, CI 1.05-1.15), older adults residing in rural locations (AOR = 1.37, CI 1.083-1.724), and older adults who used alcohol (AOR = 1.13, CI 0.230-2.418). Tobacco use was also associated (although not statistically significant per p-values) with increased self-reporting of angina, arthritis, asthma, chronic lung disease, depression, diabetes, hypertension, and stroke. Older adults who used tobacco and with increased health risks, tended to be without health insurance (AOR = 1.41, CI 1.111-1.787). Satisfaction with life and daily living was much lower for those who use tobacco. Regional differences existed in tobacco use; the three northern regions (Upper East, Northern and Upper West) had higher proportions of tobacco use among older adults in the country. Quitting tobacco use was higher in the 70+ years age group, in women, among urban residents and in those with at least secondary education. Quitting tobacco use also increased with increasing income levels.

CONCLUSIONS

Tobacco use among older adults in Ghana was associated with older men living in rural locations, chronic ill-health and reduced life satisfaction. A high proportion of older adults have stopped using tobacco, demonstrating the possibilities for effective public health interventions. Health risk reduction strategies through targeted anti-smoking health campaigns, improvement in access to health and social protection (such as health insurance) will reduce health risks among older persons who use tobacco.

Cigarette, cigar, and pipe smoking and the risk of head and neck cancers: pooled analysis in the International Head and Neck Cancer Epidemiology Consortium

Cigar and pipe smoking are considered risk factors for head and neck cancers, but the magnitude of effect estimates for these products has been imprecisely estimated. By using pooled data from the International Head and Neck Cancer Epidemiology (INHANCE) Consortium (comprising 13,935 cases and 18,691 controls in 19 studies from 1981 to 2007), we applied hierarchical logistic regression to more precisely estimate odds ratios and 95% confidence intervals for cigarette, cigar, and pipe smoking separately, compared with reference groups of those who had never smoked each single product. Odds ratios for cigar and pipe smoking were stratified by ever cigarette smoking. We also considered effect estimates of smoking a single product exclusively versus never having smoked any product (reference group). Among never cigarette smokers, the odds ratio for ever cigar smoking was 2.54 (95% confidence interval (CI): 1.93, 3.34), and the odds ratio for ever pipe smoking was 2.08 (95% CI: 1.55, 2.81). These odds ratios increased with increasing frequency and duration of smoking (Ptrend ≤ 0.0001). Odds ratios for cigar and pipe smoking were not elevated among ever cigarette smokers. Head and neck cancer risk was elevated for those who reported exclusive cigar smoking (odds ratio = 3.49, 95% CI: 2.58, 4.73) or exclusive pipe smoking (odds ratio = 3.71, 95% CI: 2.59, 5.33). These results suggest that cigar and pipe smoking are independently associated with increased risk of head and neck cancers.

Non-cigarette tobacco products: what have we learnt and where are we headed?

A wide variety of non-cigarette forms of tobacco and nicotine exist, and their use varies regionally and globally. Smoked forms of tobacco such as cigars, bidis, kreteks and waterpipes have high popularity and are often perceived erroneously as less hazardous than cigarettes, when in fact their health burden is similar. Smokeless tobacco products vary widely around the world in form and the health hazards they present, with some clearly toxic forms (eg, in South Asia) and some forms with far fewer hazards (eg, in Sweden). Nicotine delivery systems not directly reliant on tobacco are also emerging (eg, electronic nicotine delivery systems). The presence of such products presents challenges and opportunities for public health. Future regulatory actions such as expansion of smoke-free environments, product health warnings and taxation may serve to increase or decrease the use of non-cigarette forms of tobacco. These regulations may also bring about changes in non-cigarette tobacco products themselves that could impact public health by affecting attractiveness and/or toxicity.

Adolescent cigarette smokers' and non-cigarette smokers' use of alternative tobacco products

INTRODUCTION

This study uses the most recent data from the nationally representative National Youth Tobacco Survey (NYTS) to examine the use of alternative tobacco products among U.S. cigarette smokers and non-cigarette smokers aged 14-17. Alternative tobacco product use is defined as use of one or more of the following products: smokeless tobacco, cigars, pipes, bidis, or kreteks.

METHODS

Using the results from the 2004, 2006, and 2009 NYTS, multivariate logistic regressions were used to investigate separately the extent of alternative tobacco product use in current cigarette smokers and in those who reported not smoking cigarettes controlling for demographic and other independent influences.

RESULTS

The results indicate that for adolescent smokers and nonsmokers, the use of one type of alternative tobacco product made it much more likely the individual would use one or more of the other alternative tobacco products. Non-cigarette smokers using these tobacco products appeared to exhibit symptoms of nicotine dependence comparable to those of cigarette smokers.

CONCLUSIONS

More information on adolescent use of alternative tobacco products is needed. Current cigarette use declined 3.4% annually over 2004-2009 for the NYTS 14- to 17-year-old population, but this cohort's use of alternative tobacco products was unchanged. The number of adolescents aged 14-17 who did not smoke cigarettes but used alternative tobacco products increased 5.9% per year over the same period. Current surveillance measures need to be expanded in order to gain a more comprehensive understanding of adolescent alternative tobacco use.

Patterns of tobacco use and tobacco-related psychiatric morbidity and substance use among middle-aged and older adults in the United States

OBJECTIVES

To examine prevalence of tobacco use and identify psychiatric symptoms and substance use correlates of tobacco use comparing adults 50-64 years of age with those 65+ years of age (N = 10,891).

METHODS

Data were from the 2008-2009 US National Surveys on Drug Use and Health.

RESULTS

Past-year tobacco use was one-half as frequent among adults aged 65+ years (14.1%) compared to adults aged 50-64 years (30.2%); the latter group surpassed the former in rates of cigarette smoking (24.8% vs. 10.6%), daily cigarette smoking (16.5% vs. 7.1%), cigar smoking (7.4% vs. 2.3%), and smokeless tobacco use (2.5% vs. 1.7%). Increased odds of cigarette smoking were noted among men, whites, African Americans, and those who had less education, had lower income, were not currently married, or were binge drinkers or illicit/non-medical drug users. In controlled analyses, odds ratio in those 65+ years of age who had smoked during the past year was 2.2 for binge drinking and 3.5 for illicit or non-medical drug use. Odds ratio of binge drinking among those 65+ years of age for cigar smokers during the past year was 3.1. Past-year cigarette smoking was not associated with reports of symptoms of depression or anxiety in the 65+ age group.

CONCLUSIONS

Tobacco use is less prevalent among adults 65+ years of age yet continues to be strongly associated with binge drinking and illicit or non-medical drug use. Preventive efforts to decrease these substance use problems should include programs to decrease tobacco use.

The effects of cigarette smoke on airway inflammation in asthma and COPD: therapeutic implications

Asthma and COPD are two chronic inflammatory disorders of the airway characterized by airflow limitation. While many similarities exist between these two diseases, they are pathologically distinct due to the involvement of different inflammatory cells; predominantly neutrophils, CD8 lymphocytes in COPD and eosinophils and CD4 lymphocytes in asthma. Cigarette smoking is associated with accelerated decline of lung function, increased mortality, and worsening of symptoms in both asthma and COPD. Furthermore, exposure to cigarette smoke can alter the inflammatory mechanisms in asthma to become similar to that seen in COPD with increasing CD8 cells and neutrophils and may therefore alter the response to therapy. Cigarette smoke exposure has been associated with a poor response to inhaled corticosteroids which are recommended as first line anti-inflammatory medications in asthma and as an add-on therapy in patients with severe COPD with history of exacerbations. While the main proposed mechanism for this altered response is the reduction of the histone deacetylase 2 (HDAC2) enzyme system, other possible mechanisms include the overexpression of GR-β, activation of p38 MAPK pathway and increased production of inflammatory cytokines such as IL-2, 4, 8, TNF-α and NF-Kß. Few clinical trials suggest that leukotriene modifiers may be an alternative to corticosteroids in smokers with asthma but there are currently no drugs which effectively reduce the progression of inflammation in smokers with COPD. However, several HDAC2 enhancers including low dose theophylline and other potential anti-inflammatory therapies including PDE4 inhibitors and p38 MAPK inhibitors are being evaluated.

Lung cancer: epidemiology, etiology, and prevention

Lung cancer is the leading cause of cancer death in the United States and around the world. A vast majority of lung cancer deaths are attributable to cigarette smoking, and curbing the rates of cigarette smoking is imperative. Understanding the epidemiology and causal factors of lung cancer can provide additional foundation for disease prevention. This article focuses on modifiable risk factors, including tobacco smoking, occupational carcinogens, diet, and ionizing radiation. It also discusses briefly the molecular and genetic aspects of lung carcinogenesis.

Lung cancer: epidemiology, etiology, and prevention

Lung cancer is the leading cause of cancer death in the United States and around the world. A vast majority of lung cancer deaths are attributable to cigarette smoking, and curbing the rates of cigarette smoking is imperative. Understanding the epidemiology and causal factors of lung cancer can provide additional foundation for disease prevention. This article focuses on modifiable risk factors, including tobacco smoking, occupational carcinogens, diet, and ionizing radiation. It also discusses briefly the molecular and genetic aspects of lung carcinogenesis.

Systematic review with meta-analysis of the epidemiological evidence relating smoking to COPD, chronic bronchitis and emphysema

BACKGROUND

Smoking is a known cause of the outcomes COPD, chronic bronchitis (CB) and emphysema, but no previous systematic review exists. We summarize evidence for various smoking indices.

METHODS

Based on MEDLINE searches and other sources we obtained papers published to 2006 describing epidemiological studies relating incidence or prevalence of these outcomes to smoking. Studies in children or adolescents, or in populations at high respiratory disease risk or with co-existing diseases were excluded. Study-specific data were extracted on design, exposures and outcomes considered, and confounder adjustment. For each outcome RRs/ORs and 95% CIs were extracted for ever, current and ex smoking and various dose response indices, and meta-analyses and meta-regressions conducted to determine how relationships were modified by various study and RR characteristics.

RESULTS

Of 218 studies identified, 133 provide data for COPD, 101 for CB and 28 for emphysema. RR estimates are markedly heterogeneous. Based on random-effects meta-analyses of most-adjusted RR/ORs, estimates are elevated for ever smoking (COPD 2.89, CI 2.63-3.17, n = 129 RRs; CB 2.69, 2.50-2.90, n = 114; emphysema 4.51, 3.38-6.02, n = 28), current smoking (COPD 3.51, 3.08-3.99; CB 3.41, 3.13-3.72; emphysema 4.87, 2.83-8.41) and ex smoking (COPD 2.35, 2.11-2.63; CB 1.63, 1.50-1.78; emphysema 3.52, 2.51-4.94). For COPD, RRs are higher for males, for studies conducted in North America, for cigarette smoking rather than any product smoking, and where the unexposed base is never smoking any product, and are markedly lower when asthma is included in the COPD definition. Variations by sex, continent, smoking product and unexposed group are in the same direction for CB, but less clearly demonstrated. For all outcomes RRs are higher when based on mortality, and for COPD are markedly lower when based on lung function. For all outcomes, risk increases with amount smoked and pack-years. Limited data show risk decreases with increasing starting age for COPD and CB and with increasing quitting duration for COPD. No clear relationship is seen with duration of smoking.

CONCLUSIONS

The results confirm and quantify the causal relationships with smoking.

Smoking is related to pancreatic fibrosis in humans

OBJECTIVES

Smokers are at risk for pancreatic cancer (PC) and other pancreatic diseases. Cigarette smoking also aggravates the risk of PC in patients with hereditary and chronic pancreatitis (CP) and results in a higher incidence of acute pancreatitis and relapses in CP. Both PC and CP are characterized by a progressive fibrosis. Recently, two studies on rats reported that tobacco smoking is associated with chronic pancreatic inflammation with fibrosis and scarring of pancreatic acinar structures. In this study, we aimed to confirm a relationship between cigarette smoking and pancreatic fibrosis (PF) in humans.

METHODS

In this retrospective study, pancreatic and liver tissue acquired during autopsy was collected and analyzed. PF was scored by assessing severity of intralobular, extralobular, and total PF: grade 0 (normal or mild; 0-25% PF), grade 1 (moderate; 25-50% PF), and grade 2 (severe; >50%). Information on smoking habits was extracted from (electronic) medical records.

RESULTS

Of 900 autopsies performed from January 2005 to December 2007, a minority of patients (n=111) met all inclusion criteria for analysis. Grade 2-3 total PF and intralobular PF was significantly more present in smokers vs. "never-smokers" (total: 42.9 vs. 26.5%, P=0.027 and intralobular: 39.3 vs. 15.6%, P=0.013), whereas no differences could be found between never-smokers and ex-smokers and between ex-smokers and smokers. When we took into account interlobular PF, no differences between all groups were observed. No relationship between PF and age (P=0.893), body mass index (P=0.707), and pancreatic lipomatosis (P=0.916) was observed.

CONCLUSIONS

To our knowledge, no study in humans had studied the effect of tobacco smoking on pancreatic tissue. We have demonstrated for the first time that current cigarette smoking is associated with total PF-specifically, intralobular PF-as compared with nonsmokers.

Intensity and inhalation of smoking in the aetiology of laryngeal cancer

The carcinogenic effect of smoking on laryngeal cancer is well established; however, the risk pattern for detailed smoking characteristics is less clear. Thus, the aim of this analysis was to quantify the impact of different inhalation behaviours on the risk of laryngeal cancer. We conducted a population-based case control study in Germany, frequency-matched for sex and age, using a standardized questionnaire covering lifelong smoking details, including age at start, time since quitting, types of smoking products, duration, intensity and inhalation behaviour. We found higher risks for increasing duration and intensity of smoking. A clear dose-response relationship was found in all inhalation subgroups, i.e., not only for deep inhalers, but also for those puffing on a cigarette. Clearly reduced risks could be observed for quitting smoking. Changing inhalation habits might be considered as a first step to reducing the risk of developing laryngeal cancer. However, the best way to effectively reduce laryngeal cancer risk is to quit smoking.

Cigar and pipe smoking and cancer risk in the European Prospective Investigation into Cancer and Nutrition (EPIC)

The carcinogenicity of cigar and pipe smoking is established but the effect of detailed smoking characteristics is less well defined. We examined the effects on cancer incidence of exclusive cigar and pipe smoking, and in combination with cigarettes, among 102,395 men from Denmark, Germany, Spain, Sweden and the United Kingdom in the EPIC cohort. Hazard ratios (HR) and their 95% confidence intervals (CI) for cancer during a median 9-year follow-up from ages 35 to 70 years were estimated using proportional hazards models. Compared to never smokers, HR of cancers of lung, upper aerodigestive tract and bladder combined was 2.2 (95% CI: 1.3, 3.8) for exclusive cigar smokers (16 cases), 3.0 (2.1, 4.5) for exclusive pipe smokers (33 cases) and 5.3 (4.4, 6.4) for exclusive cigarette smokers (1,069 cases). For each smoking type, effects were stronger in current smokers than in ex-smokers and in inhalers than in non-inhalers. Ever smokers of both cigarettes and cigars [HR 5.7 (4.4, 7.3), 120 cases] and cigarettes and pipes [5.1 (4.1, 6.4), 247 cases] had as high a raised risk as had exclusive cigarette smokers. In these smokers, the magnitude of the raised risk was smaller if they had switched to cigars or pipes only (i.e., quit cigarettes) and had not compensated with greater smoking intensity. Cigar and pipe smoking is not a safe alternative to cigarette smoking. The lower cancer risk of cigar and pipe smokers as compared to cigarette smokers is explained by lesser degree of inhalation and lower smoking intensity.

Active and Passive Smoking and the Risk of Pancreatic Cancer in the Netherlands Cohort Study

Background: To date, cigarette smoking is the most consistent risk factor for pancreatic cancer. We prospectively examined the role of active cigarette smoking, smoking cessation, and passive smoking as determinants for pancreatic cancer.

Methods: The Netherlands Cohort Study consisted of 120,852 men and women who completed a baseline questionnaire in 1986. After 16.3 years of follow-up, 520 incident pancreatic cancer cases were available for analysis. A case-cohort approach was employed using the person-years of follow-up of a random subcohort (n = 5,000), which was chosen immediately after baseline.

Results: Compared with never cigarette smokers, both former and current cigarette smokers had an increased pancreatic cancer risk [multivariable-adjusted hazard rate ratio (HR), 1.34; 95% confidence interval (CI), 1.02-1.75 and HR, 1.82; 95% CI, 1.40-2.38, respectively]. We observed an increased pancreatic cancer risk per increment of 10 years of smoking (HR, 1.15; 95% CI, 1.08-1.22) and an HR of 1.08 per increment of 10 cigarettes/d (95% CI, 0.98-1.19). Quitting smoking gradually reduced pancreatic cancer risk and approached unity after ≥20 years of quitting. No association was observed for passive smoking exposure and pancreatic cancer risk in women; in men, this association was not investigated because &gt;90% of the men were ever smokers.

Conclusions: Overall, our findings confirmed that cigarette smoking is an important risk factor for pancreatic cancer, whereas quitting smoking reduced risk. No association was observed between passive smoking exposure and pancreatic cancer risk in women.

Impact: Quitting smoking would benefit the burden on pancreatic cancer incidence. Cancer Epidemiol Biomarkers Prev; 19(6); 1612–22. ©2010 AACR.

The association of pipe and cigar use with cotinine levels, lung function, and airflow obstruction: a cross-sectional study

BACKGROUND

Cigarette smoking is the major cause of chronic obstructive pulmonary disease, but studies on the contribution of other smoking techniques are sparse.

OBJECTIVE

To determine whether pipe and cigar smoking was associated with elevated cotinine levels, decrements in lung function, and increased odds of airflow obstruction.

DESIGN

Cross-sectional study.

SETTING

Population-based sample from 6 U.S. communities.

PARTICIPANTS

Men and women aged 48 to 90 years without clinical cardiovascular disease at enrollment who were part of MESA (Multi-Ethnic Study of Atherosclerosis).

MEASUREMENTS

The MESA Lung Study measured spirometry according to American Thoracic Society guidelines and urine cotinine levels by immunoassay on a subsample of MESA. Pipe-years and cigar-years were calculated as years from self-reported age of starting to age of quitting (or to current age in current users) multiplied by pipe-bowls or cigars per day.

RESULTS

Of 3528 participants, 9% reported pipe smoking (median, 15 pipe-years), 11% reported cigar smoking (median, 6 cigar-years), and 52% reported cigarette smoking (median, 18 pack-years). Self-reported current pipe and cigar smokers had elevated urine cotinine levels compared with never-smokers. Pipe-years were associated with decrements in FEV(1), and cigar-years were associated with decrements in the FEV(1)-FVC ratio. Participants who smoked pipes or cigars had increased odds of airflow obstruction whether they had also smoked cigarettes (odds ratio, 3.43 [95% CI, 1.75 to 6.71]; P < 0.001) or not (odds ratio, 2.31 [CI, 1.04 to 5.11]; P = 0.039) compared with participants with no smoking history.

LIMITATION

Cross-sectional design.

CONCLUSION

Pipe and cigar smoking increased urine cotinine levels and was associated with decreased lung function and increased odds of airflow obstruction, even in participants who had never smoked cigarettes.

PRIMARY FUNDING SOURCE

National Heart, Lung, and Blood Institute, National Institutes of Health.

Treating tobacco dependence in a medical setting

The US Public Health Service Guideline for Treating Tobacco Use and Dependence 2008 Update emphasizes tobacco use as a chronic medical disorder; highlights both behavioral counseling and the use of 1 or more of the 7 approved medications; and points out the utility, efficacy, and reach of telephone quitlines. The treatment of users of smokeless tobacco continues to be less than optimal. Although providing evidence-based treatment for tobacco- dependent patients is a challenge for busy physicians, a team approach including trained and certified tobacco treatment specialists (TTS) provides an efficient treatment model. TTS represent a new and growing part of the health care team and hold great potential for expanding the collective tobacco treatment expertise in the medical setting. The effective treatment of tobacco dependence frequently requires tailoring, and often intensifying, interventions (both counseling and pharmacotherapy) to meet the needs of the individual patient.

The additive effect of ethanol and extract of cigarette smoke on rabbit esophagus epithelium

AIM

The combination of alcohol and smoking takes a place in the epidemiology and pathogenesis of gastroesophageal reflux disease and squamous cancers of the esophagus. Therefore, a study was designed to assess the impact of these agents alone or in combination on the structure and function of squamous epithelium of rabbit esophagus.

METHODS

Rabbit esophageal epithelium was mounted in Ussing Chambers, exposed luminally for ethanol (1-10%), extract of cigarette smoke (EOCS) and combinations or sequential application of these agents. An in-vivo model was also used to mimic conditions more representative of human alcohol consumption.

RESULTS

Ethanol (1-10%) dose dependently decreased tissue resistance. Extract of cigarette smoke caused a reduction on transepithelial potential difference (PD), short circuit current. Combinations of EOCS, ethanol (5-10% EtOH and EOCS 1-2) showed a more pronounced decrease than agents alone, mainly the result of EOCS. In vivo studies showed that EOCS administration dropped PD dose dependently. In-vivo 10% EtOH, EOCS-2 dropped PD (55%) similar to in-vitro 5% EtOH, EOCS-1. The effect was clearly additive; boluses of 10% ethanol (36%) and EOCS-2 (17%) decreased PD and combination of agents resulted in a 55% drop on PD which is a very similar decrease compared to the sum of the separate effects of agents (53%).

CONCLUSION

Ethanol affected the barrier and cigarette smoke altered ion transport on rabbit esophageal epithelium under conditions reflecting human consumption. Results were consistent with in vivo and in vitro conditions except higher concentrations were needed in vivo. When applied, these agents showed an additive effect. Ethanol predisposed the tissue to the effect of EOCS.

Noncigarette forms of tobacco use

There are many preparations for tobacco use, which can be classified as smoking or smokeless tobacco. Among the noncigarette preparations that produce smoke, we cite cigars, pipes and narghiles. Smokeless tobacco can be found in preparations for chewing or for being absorbed by nasal and oral mucosae (snuff). However, all tobacco products deliver nicotine to the central nervous system and there is a confirmed risk of dependence. In addition, there is no safe form of tobacco use, and tobacco users have a significantly increased risk of morbidity and premature mortality due to tobacco-related diseases.

Non-small cell lung cancer: epidemiology, risk factors, treatment, and survivorship

Lung cancer is the leading cause of cancer-related mortality not only in the United States but also around the world. In North America, lung cancer has become more predominant among former than current smokers. Yet in some countries, such as China, which has experienced a dramatic increase in the cigarette smoking rate during the past 2 decades, a peak in lung cancer incidence is still expected. Approximately two-thirds of adult Chinese men are smokers, representing one-third of all smokers worldwide. Non-small cell lung cancer accounts for 85% of all lung cancer cases in the United States. After the initial diagnosis, accurate staging of non-small cell lung cancer using computed tomography or positron emission tomography is crucial for determining appropriate therapy. When feasible, surgical resection remains the single most consistent and successful option for cure. However, close to 70% of patients with lung cancer present with locally advanced or metastatic disease at the time of diagnosis. Chemotherapy is beneficial for patients with metastatic disease, and the administration of concurrent chemotherapy and radiation is indicated for stage III lung cancer. The introduction of angiogenesis, epidermal growth factor receptor inhibitors, and other new anti-cancer agents is changing the present and future of this disease and will certainly increase the number of lung cancer survivors. We identified studies for this review by searching the MEDLINE and PubMed databases for English-language articles published from January 1, 1980, through January 31, 2008. Key terms used for this search included non-small cell lung cancer, adenocarcinoma, squamous cell carcinoma, bronchioalveolar cell carcinoma, large cell carcinoma, lung cancer epidemiology, genetics, survivorship, surgery, radiation therapy, chemotherapy, targeted therapy, bevacizumab, erlotinib, and epidermal growth factor receptor.

Non-small cell lung cancer: epidemiology, risk factors, treatment, and survivorship

Lung cancer is the leading cause of cancer-related mortality not only in the United States but also around the world. In North America, lung cancer has become more predominant among former than current smokers. Yet in some countries, such as China, which has experienced a dramatic increase in the cigarette smoking rate during the past 2 decades, a peak in lung cancer incidence is still expected. Approximately two-thirds of adult Chinese men are smokers, representing one-third of all smokers worldwide. Non-small cell lung cancer accounts for 85% of all lung cancer cases in the United States. After the initial diagnosis, accurate staging of non-small cell lung cancer using computed tomography or positron emission tomography is crucial for determining appropriate therapy. When feasible, surgical resection remains the single most consistent and successful option for cure. However, close to 70% of patients with lung cancer present with locally advanced or metastatic disease at the time of diagnosis. Chemotherapy is beneficial for patients with metastatic disease, and the administration of concurrent chemotherapy and radiation is indicated for stage III lung cancer. The introduction of angiogenesis, epidermal growth factor receptor inhibitors, and other new anti-cancer agents is changing the present and future of this disease and will certainly increase the number of lung cancer survivors. We identified studies for this review by searching the MEDLINE and PubMed databases for English-language articles published from January 1, 1980, through January 31, 2008. Key terms used for this search included non-small cell lung cancer, adenocarcinoma, squamous cell carcinoma, bronchioalveolar cell carcinoma, large cell carcinoma, lung cancer epidemiology, genetics, survivorship, surgery, radiation therapy, chemotherapy, targeted therapy, bevacizumab, erlotinib, and epidermal growth factor receptor.