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Lund KE, Saebo G. Challenges in legitimizing further measures against smoking in jurisdictions with robust infrastructure for tobacco control: how far can the authorities allow themselves to go? Harm Reduct J 2024; 21:33. [PMID: 38321438 PMCID: PMC10848560 DOI: 10.1186/s12954-024-00951-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 01/28/2024] [Indexed: 02/08/2024] Open
Abstract
BACKGROUND According to a recently published study, approximately half of those who currently smoke in Norway have little or no desire to quit despite a hostile regulatory and socio-cultural climate for smoking. On this background, we discuss some challenges that regulators will face in a further tightening of structural measures to curb smoking. MAIN BODY Central to our discussion is the research literature concerned with the concept of state-paternalism in tobacco control-the line between an ethically justified interference with the freedom of those who smoke and an exaggerated infringement disproportionate to the same people's right to live as they choose. In countries with an already advanced infrastructure for tobacco control, this dilemma might become quite intrusive for regulators. We ask that if people, who smoke are aware of and have accepted the risks, are willing to pay the price, smoke exclusively in designated areas, and make decisions uninfluenced by persuasive messages from manufacturers-is a further tightening of anti-smoking measures still legitimate? Strengthening of the infrastructure for tobacco control can be seen as a "help" to people who-due to some sort of "decision failure"-continue to smoke against their own will. However, for those who want to continue smoking for reasons that for them appear rational, such measures may appear unwanted, punitive, and coercive. Is it within the rights of regulators to ignore peoples' self-determination for the sake of their own good? We problematize the "help" argument and discuss the authorities' right to elevate the zero-vision of smoking as universally applicable while at the same time setting up barriers to switching to alternative nicotine products with reduced risk. CONCLUSION We recommend that a further intensification of smoking control in countries that already have a well-developed policy in this area requires that regulators start to exploit the opportunity that lies in the ongoing diversification of the recreational nicotine market.
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Affiliation(s)
- Karl Erik Lund
- Department for Alcohol, Tobacco and Drugs, Norwegian Institute of Public Health (NIPH), Folkehelseinstituttet, Postboks 222, 0213, Skøyen, Oslo, Norway.
| | - Gunnar Saebo
- Department for Alcohol, Tobacco and Drugs, Norwegian Institute of Public Health (NIPH), Folkehelseinstituttet, Postboks 222, 0213, Skøyen, Oslo, Norway
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2
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Selya AS, Foxon F. Trends in electronic cigarette use and conventional smoking: quantifying a possible 'diversion' effect among US adolescents. Addiction 2021; 116:1848-1858. [PMID: 33394529 PMCID: PMC8172422 DOI: 10.1111/add.15385] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 10/12/2020] [Accepted: 12/16/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND AND AIMS The impact of electronic cigarettes (ECs) on nicotine use is hotly debated: some fear that ECs are a 'catalyst' to conventional smoking, while others argue that they divert adolescents from the more harmful product. This study used simulation modeling to evaluate the plausibility of catalyst and diversion hypotheses against real-world data. DESIGN A simulation model represented life-time exclusive EC use, exclusive conventional smoking and dual use as separate subpopulations. The 'catalyst' effect was modeled as EC use increasing dual use initiation (i.e. EC users also start smoking). The 'diversion' effect was modeled as EC use decreasing exclusive cigarette initiation. The model was calibrated using data from the US National Youth Tobacco Survey (NYTS). The plausibility of each scenario was evaluated by comparing simulated trends with NYTS data. This is the first study, to our knowledge, to estimate the magnitude of a diversion effect through simulation. SETTING United States. PARTICIPANTS AND MEASUREMENTS Adolescents aged 12-17 years in NYTS, a cross-sectional study from 2000 to 2019 (n = 12 500 to 31 000 per wave). Exclusive cigarette use, exclusive EC use and dual use of both products were defined using cumulative life-time criteria (100+ cigarettes smoked and/or > 100 days vaped). FINDINGS A null model (no catalyst or diversion) over-predicts NYTS smoking by up to 87%. Under the conservative assumption that the catalyst effect accounts for all dual use, an exponential decay constant of 19.6% EC users/year initiating smoking is required; however, this further over-predicts actual smoking by up to 109%. A diversion effect with an exponential decay constant of 55.4%/year or 65.4%/year, with the maximum possible opposing catalyst effect also active, is required optimally to match NYTS smoking trends (root mean square error = 286 632 versus 391 396 in the null model). CONCLUSIONS A simulation model shows that a substantial diversion effect is needed to explain observed nicotine use trends among US adolescents, and it must be larger than any possible opposing catalyst effect, if present.
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Affiliation(s)
- Arielle S. Selya
- Behavioral Sciences Group, Sanford ResearchSioux FallsSDUSA
- Department of PediatricsUniversity of South Dakota Sanford School of MedicineSioux FallsSDUSA
- Master of Public Health Program, Department of Population HealthUniversity of North Dakota School of Medicine and Health SciencesGrand ForksNDUSA
- PinneyAssociatesPittsburghPAUSA
| | - Floe Foxon
- PinneyAssociatesPittsburghPAUSA
- Department of Physics and AstronomyUniversity of NottinghamNottinghamUK
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3
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Selya AS. Reducing the smoking-related health burden in the USA through diversion to electronic cigarettes: a system dynamics simulation study. Harm Reduct J 2021; 18:36. [PMID: 33743722 PMCID: PMC7981929 DOI: 10.1186/s12954-021-00484-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 03/11/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Electronic cigarettes ("e-cigarettes") have altered tobacco smoking trends, and their impacts are controversial. Given their lower risk relative to combustible tobacco, e-cigarettes have potential for harm reduction. This study presents a simulation-based analysis of an e-cigarette harm reduction policy set in the USA. METHODS A system dynamics simulation model was constructed, with separate aging chains representing people in different stages of use (both of combustible cigarettes and e-cigarettes). These structures interact with a policy module to close the gap between actual (simulated) and goal numbers of individuals who smoke, chosen to reduce the tobacco-attributable death rate (i.e., mostly combustible cigarette-attributable, but conservatively allowing e-cigarette-attributable deaths) to that due to all accidents in the general population. The policy is two-fold, removing existing e-liquid flavor bans and providing an informational campaign promoting e-cigarettes as a lower-risk alternative. Realistic practical implementation challenges are modeled in the policy sector, including time delays, political resistance, and budgetary limitations. Effects of e-cigarettes on tobacco smoking occur through three mechanisms: (1) diversion from ever initiating smoking; (2) reducing progression to established smoking; and (3) increasing smoking cessation. An important unintended effect of possible death from e-cigarettes was conservatively included. RESULTS The base-case model replicated the historical exponential decline in smoking and the exponential increase in e-cigarette use since 2010. Simulations suggest tobacco smoking could be reduced to the goal level approximately 40 years after implementation. Implementation obstacles (time delays, political resistance, and budgetary constraints) could delay and weaken the effect of the policy by up to 62% in the worst case, relative to the ideal-case scenario; however, these discrepancies substantially decreased over time in dampened oscillations as negative feedback loops stabilize the system after the one-time "shock" introduced by policy changes. CONCLUSIONS The simulation suggests that the promotion of e-cigarettes as a harm-reduction policy is a viable strategy, given current evidence that e-cigarettes offset or divert from smoking. Given the strong effects of implementation challenges on policy effectiveness in the short term, accurately modeling such obstacles can usefully inform policy design. Ongoing research is needed, given continuing changes in e-cigarette use prevalence, new policies being enacted for e-cigarettes, and emerging evidence for substitution effects between combustible cigarettes and e-cigarettes.
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Affiliation(s)
- Arielle S Selya
- Behavioral Sciences Group, Sanford Research, 2301 East 60th Street North, Sioux Falls, SD, 57104, USA.
- Department of Pediatrics, University of South Dakota Sanford School of Medicine, 1400 West 22nd St, Sioux Falls, SD, 57105, USA.
- System Dynamics Group, Department of Geography, University of Bergen, Postboks 7802, 5020, Bergen, Norway.
- Pinney Associates, Inc, 201 North Craig St. Suite 320, Pittsburgh, PA, 15213, USA.
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Vedoy TF, Lund KE. The greater use of flavoured snus among ever-smokers versus never-smokers in Norway. Harm Reduct J 2020; 17:76. [PMID: 33066793 PMCID: PMC7568365 DOI: 10.1186/s12954-020-00419-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 09/24/2020] [Indexed: 11/26/2022] Open
Abstract
Background Similar to the debate around e-cigarettes, an increase in snus use among Norwegian adolescents has prompted debate on whether flavour options in snus should be limited. To this end, we compared use of flavoured snus among snus users with different smoking status. Methods Questions about flavoured snus use were included in an online omnibus study conducted from 2015 to 2019 (N = 65,445) that included 16,295 ever snus users (aged 15+). Current snus users (N = 9783) were asked “Do you usually use snus that has a flavouring (liquorice, mint, wintergreen, etc.)? Adjusted predicted probabilities and 95% confidence intervals (CI) were calculated from a logistic regression model. Results Less than 25% of the snus users reported never having smoked. The overall probability of using flavoured snus was .45 (95% CI .44–.46), highest among daily (.51, 95% CI .47–.54) and former daily smokers (.50, 95% CI .48–.52), and lowest among never (.41, 95% CI .39–.43) and occasional smokers without any prior history of daily smoking (.41, 95% CI .38–.44). Use of flavoured products was higher among female snus users (p = .67, 95% CI .65–.69) compared to males (p = .35, 95% CI .34–.36), highest among the youngest age group, 15–24 years (p = .58, 95% CI .56–.60) and decreased with increasing age. Conclusion Regulation that would ban or limit flavoured snus use may affect smokers—an at risk population—more than never smokers. The health authorities should be mindful of the real-world complexity governing potential harms and benefits of flavour restrictions on snus. A further assessment of flavour limitations should acknowledge that flavoured snus products also function as alternatives to cigarettes.
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Affiliation(s)
- Tord Finne Vedoy
- Department Alcohol, Tobacco and Drugs, Norwegian Institute of Public Health, PO Box 222, 0213, Skøyen, Oslo, Norway
| | - Karl Erik Lund
- Department Alcohol, Tobacco and Drugs, Norwegian Institute of Public Health, PO Box 222, 0213, Skøyen, Oslo, Norway.
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5
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Round EK, Chen P, Taylor AK, Schmidt E. Biomarkers of Tobacco Exposure Decrease After Smokers Switch to an E-Cigarette or Nicotine Gum. Nicotine Tob Res 2020; 21:1239-1247. [PMID: 30202883 PMCID: PMC6698949 DOI: 10.1093/ntr/nty140] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 07/23/2018] [Indexed: 12/21/2022]
Abstract
Introduction The aerosol composition of electronic cigarettes (ECs) suggests that exposure to toxicants during use is greatly reduced compared to exposure from combustible cigarettes (CCs). Methods This randomized, parallel-group, clinical study enrolled smokers to switch to Vuse Solo (VS) Digital Vapor Cigarettes (Original or Menthol) or Nicorette 4 mg nicotine gum (NG) in a controlled setting. Subjects who smoked CCs ad libitum for 2 days during a baseline period were then randomized to ad libitum use of either VS or NG for 5 days. Biomarkers of 23 toxicants were measured in 24-hour urine samples and blood collected at baseline and following product switch. Results A total of 153 subjects completed the study. Total nicotine equivalents decreased in all groups, but higher levels were observed in the VS groups compared to the NG groups, with decreases of 38% and 60%–67%, respectively. All other biomarkers were significantly decreased in subjects switched to VS, and the magnitude of biomarker decreases was similar to subjects switched to NG. Decreases ranged from 30% to greater than 85% for constituents such as benzene and acrylonitrile. Conclusions These results indicate that exposure to toxicants when using VS is significantly reduced compared to CC smoking, and these reductions are similar to those observed with use of NG. Although statistically significantly decreased, nicotine exposure is maintained closer to CC smoking with VS use compared to NG use. This research suggests that use of VS exposes consumers to fewer and lower levels of smoke toxicants than CCs while still providing nicotine to the consumer. Implications This is the first study to report changes in nicotine delivery and biomarkers of tobacco exposure following a short-term product switch from CCs to either an EC or NG in a controlled environment. The study shows that nicotine exposure decreased in both groups but was maintained closer to CC smoking with the EC groups. Biomarkers of tobacco combustion decreased to similar levels in both EC and gum groups.
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Affiliation(s)
- Elaine K Round
- Scientific & Regulatory Affairs, RAI Services Company, Winston-Salem, NC
| | - Peter Chen
- Scientific & Regulatory Affairs, RAI Services Company, Winston-Salem, NC
| | | | - Eckhardt Schmidt
- Scientific & Regulatory Affairs, RAI Services Company, Winston-Salem, NC
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6
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Plurphanswat N, Hughes JR, Fagerström K, Rodu B. Initial Information on a Novel Nicotine Product. Am J Addict 2020; 29:279-286. [DOI: 10.1111/ajad.13020] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 02/04/2020] [Accepted: 02/16/2020] [Indexed: 11/30/2022] Open
Affiliation(s)
| | - John R. Hughes
- Department of Psychiatry, Center for Behavior and HealthUniversity of VermontBurlington Vermont
| | | | - Brad Rodu
- James Graham Brown Cancer CenterUniversity of LouisvilleLouisville Kentucky
- Department of Medicine, School of MedicineUniversity of LouisvilleLouisville Kentucky
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7
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Warner KE. How to Think-Not Feel-about Tobacco Harm Reduction. Nicotine Tob Res 2019; 21:1299-1309. [PMID: 29718475 DOI: 10.1093/ntr/nty084] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Accepted: 04/27/2018] [Indexed: 02/04/2023]
Abstract
INTRODUCTION The debate over tobacco harm reduction (THR) has divided the tobacco control community into two camps, one expressing serious reservations about THR whereas the other believes that reduced-risk products like e-cigarettes will disrupt the cigarette market. The often emotional debate would benefit from dispassionate data-based evaluation of evidence. METHODS After briefly discussing harm reduction in public health and specifically in tobacco control, this paper identifies major issues concerning e-cigarettes and reviews relevant evidence. Issues include: e-cigarettes' risks compared to cigarette smoking; the effect of vaping on youth smoking; vaping's impact on adult smoking cessation; the net long-term public health implications of vaping; and differences in views on policy issues. The intent is to provide a broad overview of issues and evidence, directing readers to more detailed reviews of specific issues. FINDINGS Principal findings include the following: (1) while longitudinal studies suggest that vaping increases never-smoking young people's odds of trying smoking, national survey data indicate that adolescents' 30-day smoking prevalence decreased at an unprecedented rate precisely whereas vaping increased. Use of all other tobacco products also declined. (2) Recent population-level studies add evidence that vaping is increasing adult smoking cessation. (3) Vaping is likely to make a positive contribution to public health. CONCLUSIONS THR can be a complement to, not a substitute for, evidenced-based tobacco control interventions. Tobacco control professionals need to focus on objective assessment of and discussion about the potential costs and benefits of THR. IMPLICATIONS Participants on both sides of the divisive THR debate need to examine the complicated issues and evidence more objectively. This entails considering both the potential benefits and costs associated with reduced-risk products like e-cigarettes. Furthermore, it requires examining different kinds of evidence when considering specific issues. For example, those concerned by longitudinal study findings that vaping increases students' trial of cigarettes should consider US national survey evidence that youth smoking has decreased at an unprecedented rate. A review of the major issues suggests that the potential of vaping to assist adult smokers to quit outweighs the potential negatives.
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Affiliation(s)
- Kenneth E Warner
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI
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8
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Kozlowski LT. Policy Makers and Consumers Should Prioritize Human Rights to Being Smoke-Free Over Either Tobacco- or Nicotine-Free: Accurate Terms and Relevant Evidence. Nicotine Tob Res 2019; 22:1056-1058. [DOI: 10.1093/ntr/ntz113] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 07/09/2019] [Indexed: 01/07/2023]
Affiliation(s)
- Lynn T Kozlowski
- Department of Community Health and Health Behavior, School of Public Health and Health Professions, University at Buffalo, State University of New York, Buffalo, NY
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9
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Relative Risk Perceptions between Snus and Cigarettes in a Snus-Prevalent Society-An Observational Study over a 16 Year Period. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16050879. [PMID: 30862006 PMCID: PMC6427464 DOI: 10.3390/ijerph16050879] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 03/05/2019] [Accepted: 03/06/2019] [Indexed: 02/07/2023]
Abstract
Background: Most studies on perceived risks of smokeless tobacco products (SLT) have been conducted in the U.S., and the vast majority conclude that perceptions of the relative harmfulness of SLT versus cigarettes in the population are inconsistent with epidemiologically-based risk estimates, and typically conflated to that of cigarettes. We tested whether such inaccuracies also existed in Norway, where SLT-products are less toxic (Swedish snus) and SLT use is more prevalent than in the U.S. Methods: Over a 16 years period (2003⁻2018), 13,381 respondents (aged 16⁻79 years) answered questions about risk perceptions in Statistics Norway's nationally representative survey of tobacco behavior. We applied an indirect measure of comparative harm where risk beliefs for eight nicotine products were assessed independently of other products and then compared the answers. The wording of the question was: "We will now mention a variety of nicotine products and ask you how harmful you think daily use of these are. Use a scale from 1 to 7, where 1 is slightly harmful and 7 is very harmful". Mean scores with 95% confidence intervals were calculated. Results: The overall risk score for cigarettes was 6.48. The risk score for snus was 5.14⁻79.3% of the risk score of cigarettes. The relative risk scores for e-cigarettes (3.78) and NRT products (3.39) was 58.4% and 52.3% when compared to cigarettes. Perceptions of risk were stable over time. A strong association was observed between perceived risk of snus and having used snus in attempts to quit smoking. Conclusion: Perceptions of relative risk between snus and cigarettes is inconsistent with estimates from medical expert committees, which assess the overall health risk from use of Swedish snus to be minor when compared to the risk from smoking. Like the situation in the US, incorrect beliefs about SLT risks seem to be prevalent also in the snus-prevalent Norwegian setting. Accurate information on differential harms needs to be communicated. Future research should try to identify reasons why health authorities in the US and Scandinavia allow these well-documented misconceptions to persist.
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10
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Smith TT, Hatsukami DK, Benowitz NL, Colby SM, McClernon FJ, Strasser AA, Tidey JW, White CM, Donny EC. Whether to push or pull? Nicotine reduction and non-combusted alternatives - Two strategies for reducing smoking and improving public health. Prev Med 2018; 117:8-14. [PMID: 29604326 PMCID: PMC6163095 DOI: 10.1016/j.ypmed.2018.03.021] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 03/23/2018] [Accepted: 03/28/2018] [Indexed: 11/19/2022]
Abstract
Combustible cigarettes remain the most harmful and addictive tobacco product, and reducing the prevalence of smoking continues to be a critical public health goal. While nicotine is the constituent primarily responsible for addiction to cigarettes, most of the harm associated with smoking comes from byproducts of tobacco combustion. Recently, two different approaches for reducing the harms of smoking have emerged, both of which focus on breaking the link between the addiction to nicotine and the harms caused by smoking. First, the addictive potential of cigarettes could be minimized by requiring a large reduction in the nicotine content of cigarettes. Evidence for a nicotine reduction policy thus far shows that the use of very low nicotine content cigarettes results in a reduction in the number of cigarettes people smoke per day and a reduction in cigarette dependence. Second, emerging alternative nicotine delivery systems (ANDS) like electronic cigarettes may provide sufficient nicotine to act as substitutes for cigarettes while delivering much lower levels of toxicants. Evidence suggests that the emergence of ANDS has increased the percentage of smokers who are able to quit. The present paper will briefly review the evidence for each of these approaches, and consider what contemporary reinforcement and addiction theories can tell us about their likely success. We argue that the most effective endgame approach is one that pursues both nicotine reduction and alternative nicotine delivery systems as complementary.
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Affiliation(s)
- Tracy T Smith
- Psychiatry and Behavioral Sciences, Medical University of South Carolina, United States.
| | | | - Neal L Benowitz
- Departments of Medicine and Bioengineering & Therapeutic Sciences, University of California San Francisco, United States
| | - Suzanne M Colby
- Center for Alcohol & Addiction Studies, Brown University, United States
| | - F Joseph McClernon
- Department of Psychiatry and Behavioral Sciences, Duke University, United States
| | - Andrew A Strasser
- Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, United States
| | - Jennifer W Tidey
- Center for Alcohol & Addiction Studies, Brown University, United States
| | - Cassidy M White
- Department of Physiology and Pharmacology, Wake Forest University School of Medicine, United States
| | - Eric C Donny
- Department of Physiology and Pharmacology, Wake Forest University School of Medicine, United States
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Abrams DB, Glasser AM, Villanti AC, Pearson JL, Rose S, Niaura RS. Managing nicotine without smoke to save lives now: Evidence for harm minimization. Prev Med 2018; 117:88-97. [PMID: 29944902 PMCID: PMC6934253 DOI: 10.1016/j.ypmed.2018.06.010] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 06/18/2018] [Accepted: 06/21/2018] [Indexed: 01/05/2023]
Abstract
Tobacco control has made strides in prevention and cessation, but deaths will not decline rapidly without massive behavior change. Currently, inhaled smoke from combusting tobacco is chiefly responsible for prematurely killing 7.2 million people worldwide and 530,000 in the United States annually. An array of noncombustible nicotine products (NNPs) has emerged and has disrupted the marketplace. Saving lives more speedily will require societal acceptance of locating a "sweet spot" within a three-dimensional framework where NNPs are simultaneously: 1. Less toxic, 2. Appealing (can reach smokers at scale), and 3. Satisfying (adequate nicotine delivery) to displace smoking. For this harm minimization framework to eliminate smoking, a laser focus on "smoking control" (not general tobacco control) is needed. By adopting these economically viable NNPs as part of the solution, NNPs can be smoking control's valued ally. Synthesis of the science indicates that policy and regulation can sufficiently protect youth while speeding the switch away from smoking. Despite some risks of nicotine dependence that can be mitigated but not eliminated, no credible evidence counters the assertion that NNPs will save lives if they displace smoking. But scientific evidence and advocacy has selectively exaggerated NNP harms over benefits. Accurate communication is crucial to dispel the misperception of NNPs harms and reassure smokers they can successfully replace smoking cigarettes with NNPs. Saving more lives now is an attainable and pragmatic way to call for alignment of all stakeholders and factions within traditional tobacco control rather than perpetuate the unrealized and unrealizable perfection of nicotine prohibition.
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Affiliation(s)
- David B Abrams
- Department of Social and Behavioral Sciences, NYU College of Global Public Health, New York University, New York, NY, USA.
| | - Allison M Glasser
- Department of Social and Behavioral Sciences, NYU College of Global Public Health, New York University, New York, NY, USA
| | - Andrea C Villanti
- Vermont Center on Behavior and Health, Department of Psychiatry, University of Vermont, Burlington, VT, USA
| | - Jennifer L Pearson
- School of Community Health Sciences, University of Nevada, Reno, NV, USA
| | - Shyanika Rose
- Truth Initiative Schroeder Institute, Washington, DC, USA
| | - Raymond S Niaura
- Department of Social and Behavioral Sciences, NYU College of Global Public Health, New York University, New York, NY, USA
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12
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Henningfield JE, Higgins ST, Villanti AC. Are we guilty of errors of omission on the potential role of electronic nicotine delivery systems as less harmful substitutes for combusted tobacco use? Prev Med 2018; 117:83-87. [PMID: 30261245 PMCID: PMC6396307 DOI: 10.1016/j.ypmed.2018.09.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Revised: 09/03/2018] [Accepted: 09/22/2018] [Indexed: 11/28/2022]
Abstract
Two of the more controversial tobacco control and regulatory strategies in recent years are the nicotine reduction and tobacco harm reduction (THR) strategies. They have become inextricably intertwined as a successful nicotine reduction policy might only be possible in an environment in which alternative, noncombusted forms of nicotine like electronic nicotine delivery systems (ENDS) are available to address the needs of those who were unable or unwilling to completely give up nicotine. Unfortunately, ENDS have emerged as particularly controversial, in part, because they are the first product to carry reduced risk potential while being broadly appealing to cigarette smokers across demographic groups and subpopulations, and to a much smaller extent nonsmokers including, and most controversial, adolescents. In an effort to better understand some of the reasons that make this a controversial topic, we review some of the relevant history and discuss a broader dilemma that faces practitioners and policy developers of medical and public health interventions, namely, weighing the potential consequences of errors of commission versus omission. Commission errors involve a salient, direct link between an action and associated adverse or unintended consequences while omission errors are typically less salient with a more indirect link between inaction and associated adverse consequences. Decision-making research demonstrates that humans have a bias towards avoidance of commission errors and insensitivity to omission errors. This bias may be contributing to some of the aforementioned difficulties in finding common ground regarding the potential contribution of ENDS to reducing the harm of combusted tobacco use.
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Affiliation(s)
- Jack E Henningfield
- Pinney Associates, and The Johns Hopkins University School of Medicine, United States of America.
| | - Stephen T Higgins
- Vermont Center on Behavior and Health, Departments of Psychiatry and Psychological Science, University of Vermont, United States of America
| | - Andrea C Villanti
- Vermont Center on Behavior and Health, Department of Psychiatry, University of Vermont, United States of America
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Leone FT, Carlsen KH, Chooljian D, Crotty Alexander LE, Detterbeck FC, Eakin MN, Evers-Casey S, Farber HJ, Folan P, Kathuria H, Latzka K, McDermott S, McGrath-Morrow S, Moazed F, Munzer A, Neptune E, Pakhale S, Sachs DPL, Samet J, Sufian B, Upson D. Recommendations for the Appropriate Structure, Communication, and Investigation of Tobacco Harm Reduction Claims. An Official American Thoracic Society Policy Statement. Am J Respir Crit Care Med 2018; 198:e90-e105. [PMID: 30320525 PMCID: PMC6943880 DOI: 10.1164/rccm.201808-1443st] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
RATIONALE The tobacco harm reduction literature is replete with vague language, far-reaching claims, and unwarranted certainty. The American Thoracic Society has increasingly recognized the need for a framework for reliably making such claims. Evidence-based standards improving the scientific value and transparency of harm reduction claims are expected to improve their trustworthiness, clarity, and consistency. METHODS Experts from relevant American Thoracic Society committees identified key topic areas for discussion. Literature search strategy included English language articles across Medline, Google Scholar, and the Cochrane Collaborative databases, with expanded search terms including tobacco, addiction, smoking, cigarettes, nicotine, and harm reduction. Workgroup members synthesized their evidentiary summaries into a list of candidate topics suitable for inclusion in the final report. Breakout groups developed detailed content maps of each topic area, including points to be considered for suggested recommendations. Successive draft recommendations were modified using an iterative consensus process until unanimous approval was achieved. Patient representatives ensured the document's relevance to the lay public. RESULTS Fifteen recommendations were identified, organized into four framework elements dealing with: estimating harm reduction among individuals, making claims on the basis of population impact, appropriately careful use of language, and ethical considerations in harm reduction. DISCUSSION This statement clarifies important principles guiding valid direct and inferential harm reduction claims. Ideals for effective communication with the lay public and attention to unique ethical concerns are also delineated. The authors call for formal systems of grading harm reduction evidence and regulatory assurances of longitudinal surveillance systems to document the impact of harm reduction policies.
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Abrams DB, Glasser AM, Pearson JL, Villanti AC, Collins LK, Niaura RS. Harm Minimization and Tobacco Control: Reframing Societal Views of Nicotine Use to Rapidly Save Lives. Annu Rev Public Health 2018; 39:193-213. [PMID: 29323611 PMCID: PMC6942997 DOI: 10.1146/annurev-publhealth-040617-013849] [Citation(s) in RCA: 180] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Inhalation of the toxic smoke produced by combusting tobacco products, primarily cigarettes, is the overwhelming cause of tobacco-related disease and death in the United States and globally. A diverse class of alternative nicotine delivery systems (ANDS) has recently been developed that do not combust tobacco and are substantially less harmful than cigarettes. ANDS have the potential to disrupt the 120-year dominance of the cigarette and challenge the field on how the tobacco pandemic could be reversed if nicotine is decoupled from lethal inhaled smoke. ANDS may provide a means to compete with, and even replace, combusted cigarette use, saving more lives more rapidly than previously possible. On the basis of the scientific evidence on ANDS, we explore benefits and harms to public health to guide practice, policy, and regulation. A reframing of societal nicotine use through the lens of harm minimization is an extraordinary opportunity to enhance the impact of tobacco control efforts.
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Affiliation(s)
- David B Abrams
- College of Global Public Health, New York University, New York, NY 10012, USA; ,
| | - Allison M Glasser
- Schroeder Institute for Tobacco Research and Policy Studies, Truth Initiative, Washington, DC 20001, USA; ,
| | - Jennifer L Pearson
- School of Community Health Sciences, University of Nevada, Reno, Nevada 89557, USA;
| | - Andrea C Villanti
- Vermont Center on Behavior and Health, University of Vermont, Burlington, Vermont 05401, USA;
| | - Lauren K Collins
- Schroeder Institute for Tobacco Research and Policy Studies, Truth Initiative, Washington, DC 20001, USA; ,
| | - Raymond S Niaura
- College of Global Public Health, New York University, New York, NY 10012, USA; ,
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Kozlowski LT, Sweanor DT. Young or adult users of multiple tobacco/nicotine products urgently need to be informed of meaningful differences in product risks. Addict Behav 2018; 76:376-381. [PMID: 28148394 DOI: 10.1016/j.addbeh.2017.01.026] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 01/23/2017] [Indexed: 01/17/2023]
Abstract
Previously, it has been argued that health information efforts need to inform the public about meaningful differential risks from tobacco/nicotine products. The fact of multiple product use by the same individual further supports this need. When the majority of youth, for example, who use smokeless tobacco are also current tobacco smokers, it makes little sense to mount a smokeless prevention campaign that fails to include clear messages about the much greater risks from smoking. In April 2016, The Food & Drug Administration (FDA) announced a $36 million campaign for youth that "smokeless doesn't mean harmless." Research shows the public (a) already knows that smokeless tobacco is not harmless, but are (b) also largely unaware that cigarettes are much more harmful than smokeless. Though not harmless, smokeless tobacco has been estimated to be over 90% less harmful than cigarettes. 'Gateway' fears are made moot by current use of multiple tobacco/nicotine products. When multi-tobacco product use is commonplace among users, usable information on significant differences in risk is crucial for both adult and younger users. The FDA and like campaigns and health information websites should follow established ethical principles and accepted communication methods to inform the public of less-harmful tobacco/nicotine products as well as the greater harms of smoking, in keeping with the Surgeon-General's advice that reductions in smoking in particular will bring about the greatest public health advances.
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Drope J, Cahn Z, Kennedy R, Liber AC, Stoklosa M, Henson R, Douglas CE, Drope J. Key issues surrounding the health impacts of electronic nicotine delivery systems (ENDS) and other sources of nicotine. CA Cancer J Clin 2017; 67:449-471. [PMID: 28961314 DOI: 10.3322/caac.21413] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 08/28/2017] [Accepted: 08/28/2017] [Indexed: 12/20/2022] Open
Abstract
Answer questions and earn CME/CNE Over the last decade, the use of electronic nicotine delivery systems (ENDS), including the electronic cigarette or e-cigarette, has grown rapidly. More youth now use ENDS than any tobacco product. This extensive research review shows that there are scientifically sound, sometimes competing arguments about ENDS that are not immediately and/or completely resolvable. However, the preponderance of the scientific evidence to date suggests that current-generation ENDS products are demonstrably less harmful than combustible tobacco products such as conventional cigarettes in several key ways, including by generating far lower levels of carcinogens and other toxic compounds than combustible products or those that contain tobacco. To place ENDS in context, the authors begin by reviewing the trends in use of major nicotine-containing products. Because nicotine is the common core-and highly addictive-constituent across all tobacco products, its toxicology is examined. With its long history as the only nicotine product widely accepted as being relatively safe, nicotine-replacement therapy (NRT) is also examined. A section is also included that examines snus, the most debated potential harm-reduction product before ENDS. Between discussions of NRT and snus, ENDS are extensively examined: what they are, knowledge about their level of "harm," their relationship to smoking cessation, the so-called gateway effect, and dual use/poly-use. CA Cancer J Clin 2017;67:449-471. © 2017 American Cancer Society.
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Affiliation(s)
- Jeffrey Drope
- Vice President, Economic and Health Policy Research, American Cancer Society, Atlanta, GA
| | - Zachary Cahn
- Director, Economic and Health Policy Research, American Cancer Society, Atlanta, GA
| | - Rosemary Kennedy
- Program Consultant, Global Cancer Prevention and Early Detection, American Cancer Society, Atlanta, GA
| | - Alex C Liber
- Data Analyst, Economic and Health Policy Research, American Cancer Society, Atlanta, GA
| | - Michal Stoklosa
- Senior Economist, Taxation and Health, American Cancer Society, Atlanta, GA
| | - Rosemarie Henson
- Senior Vice President for Prevention and Early Detection, American Cancer Society, Atlanta, GA
| | - Clifford E Douglas
- Vice President, Tobacco Control and Director, Center for Tobacco Control, American Cancer Society, Atlanta, GA
| | - Jacqui Drope
- Managing Director, Global Cancer Prevention and Early Detection, American Cancer Society, Atlanta, GA
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Stiles MF, Campbell LR, Graff DW, Jones BA, Fant RV, Henningfield JE. Pharmacodynamic and pharmacokinetic assessment of electronic cigarettes, combustible cigarettes, and nicotine gum: implications for abuse liability. Psychopharmacology (Berl) 2017; 234. [PMID: 28634710 PMCID: PMC5548902 DOI: 10.1007/s00213-017-4665-y] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
RATIONALE Electronic cigarettes (ECs) are becoming popular alternatives for smokers, but there has been limited study of their abuse liability. OBJECTIVES The objective of this study was to evaluate the abuse liability of three Vuse Solo ECs, ranging from 14 to 36 mg in nicotine content, relative to high- and low-abuse liability comparator products (usual brand combustible cigarettes and nicotine gum, respectively) in a group of 45 EC-naïve smokers. METHODS Enrolled subjects' ratings of subjective effects and nicotine uptake over 6 h were used to measure abuse liability and pharmacokinetics following in-clinic use of each EC. RESULTS Use of Vuse Solo resulted in subjective measures and nicotine uptake that were between those of combustible cigarettes and nicotine gum, although generally closer to nicotine gum. Compared to combustible cigarettes, use of Vuse Solo resulted in significantly lower scores in measures of product liking, positive effects, and intent to use again. These pharmacodynamic findings were consistent with the pharmacokinetic data, showing that cigarettes produced substantially faster and higher levels of nicotine uptake as compared to Vuse Solo and nicotine gum. Vuse Solo resulted in more rapid initial uptake of nicotine compared to nicotine gum, but peak concentration and long-term extent of uptake were not different or were lower with Vuse. CONCLUSIONS Collectively, these findings suggest that Vuse Solo likely has an abuse liability that is somewhat greater than nicotine gum but lower than cigarettes. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02269514.
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Affiliation(s)
- Mitchell F Stiles
- RAI Services Company, 401 N. Main Street, Winston-Salem, NC, 27101, USA.
| | - Leanne R Campbell
- RAI Services Company, 401 N. Main Street, Winston-Salem, NC, 27101, USA
| | | | - Bobbette A Jones
- RAI Services Company, 401 N. Main Street, Winston-Salem, NC, 27101, USA
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Beard E, Shahab L, Cummings DM, Michie S, West R. New Pharmacological Agents to Aid Smoking Cessation and Tobacco Harm Reduction: What Has Been Investigated, and What Is in the Pipeline? CNS Drugs 2016; 30:951-83. [PMID: 27421270 DOI: 10.1007/s40263-016-0362-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
A wide range of support is available to help smokers to quit and to aid attempts at harm reduction, including three first-line smoking cessation medications: nicotine replacement therapy, varenicline and bupropion. Despite the efficacy of these, there is a continual need to diversify the range of medications so that the needs of tobacco users are met. This paper compares the first-line smoking cessation medications with (1) two variants of these existing products: new galenic formulations of varenicline and novel nicotine delivery devices; and (2) 24 alternative products: cytisine (novel outside Central and Eastern Europe), nortriptyline, other tricyclic antidepressants, electronic cigarettes, clonidine (an anxiolytic), other anxiolytics (e.g. buspirone), selective serotonin reuptake inhibitors, supplements (e.g. St John's wort), silver acetate, Nicobrevin, modafinil, venlafaxine, monoamine oxidase inhibitors (MAOIs), opioid antagonists, nicotinic acetylcholine receptor (nAChR) antagonists, glucose tablets, selective cannabinoid type 1 receptor antagonists, nicotine vaccines, drugs that affect gamma-aminobutyric acid (GABA) transmission, drugs that affect N-methyl-D-aspartate (NMDA) receptors, dopamine agonists (e.g. levodopa), pioglitazone (Actos; OMS405), noradrenaline reuptake inhibitors and the weight management drug lorcaserin. Six 'ESCUSE' criteria-relative efficacy, relative safety, relative cost, relative use (overall impact of effective medication use), relative scope (ability to serve new groups of patients) and relative ease of use-are used. Many of these products are in the early stages of clinical trials; however, cytisine looks most promising in having established efficacy and safety with low cost. Electronic cigarettes have become very popular, appear to be efficacious and are safer than smoking, but issues of continued dependence and possible harms need to be considered.
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Affiliation(s)
- Emma Beard
- Department of Epidemiology and Public Health, Cancer Research UK Health Behaviour Research Centre, University College London, London, WC1E 6BP, UK.
- Department of Clinical, Educational and Health Psychology, University College London, London, WC1E 6BP, UK.
| | - Lion Shahab
- Department of Epidemiology and Public Health, Cancer Research UK Health Behaviour Research Centre, University College London, London, WC1E 6BP, UK
| | - Damian M Cummings
- Department of Neuroscience, Physiology and Pharmacology, University College London, London, WC1E 6BT, UK
| | - Susan Michie
- Department of Clinical, Educational and Health Psychology, University College London, London, WC1E 6BP, UK
| | - Robert West
- Department of Epidemiology and Public Health, Cancer Research UK Health Behaviour Research Centre, University College London, London, WC1E 6BP, UK
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Critchley JA, Unal B. Is smokeless tobacco a risk factor for coronary heart disease? A systematic review of epidemiological studies. ACTA ACUST UNITED AC 2016; 11:101-12. [PMID: 15187813 DOI: 10.1097/01.hjr.0000114971.39211.d7] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND There is on-going debate about the wisdom of substituting smokeless tobacco products for cigarette smoking as a 'harm reduction' strategy. It is generally believed that health risks associated with smokeless tobacco use (ST) are lower than those with cigarette smoking. However, the population attributable risk of smoking is higher for cardiovascular diseases than for any cancers, and few studies or reviews have considered the cardiovascular outcomes of ST use. A systematic review was therefore carried out to highlight the gaps in the evidence base. METHODS Electronic databases were searched, supplemented by screening reference lists, smoking-related websites, and contacting experts. Analytical observational studies of ST use (cohorts, case-control, cross-sectional studies) were included if they reported on cardiovascular disease (CVD) outcomes, or risk factors. Data extraction covered control of confounding, selection of cases and controls, sample size, clear definitions and measurements of the health outcome and ST use. One or two independent reviewers carried out selection, extraction and quality assessments. RESULTS A narrative review was carried out. Very few studies were identified; only three from Sweden consider CVD outcomes and these are discrepant. There may be a modest association between use of Swedish snuff (snus) and cardiovascular disease (e.g., relative risk=1.4, 95% confidence interval 1.2-1.6) in one prospective cohort study. Several other studies have considered associations between ST use and intermediate outcomes (CVD risk factors). CONCLUSIONS There may be an association between ST use and cardiovascular disease. However, further rigorous studies with adequate sample sizes are required.
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Affiliation(s)
- Julia A Critchley
- International Health Research Group, Liverpool School of Tropical Medicine, Liverpool, UK.
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Kozlowski L, Sweanor D. Withholding differential risk information on legal consumer nicotine/tobacco products: The public health ethics of health information quarantines. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2016; 32:17-23. [DOI: 10.1016/j.drugpo.2016.03.014] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 03/23/2016] [Accepted: 03/25/2016] [Indexed: 02/07/2023]
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Franck C, Filion KB, Kimmelman J, Grad R, Eisenberg MJ. Ethical considerations of e-cigarette use for tobacco harm reduction. Respir Res 2016; 17:53. [PMID: 27184265 PMCID: PMC4869264 DOI: 10.1186/s12931-016-0370-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Accepted: 01/26/2016] [Indexed: 02/11/2023] Open
Abstract
Due to their similarity to tobacco cigarettes, electronic cigarettes (e-cigarettes) could play an important role in tobacco harm reduction. However, the public health community remains divided concerning the appropriateness of endorsing a device whose safety and efficacy for smoking cessation remain unclear. We identified the major ethical considerations surrounding the use of e-cigarettes for tobacco harm reduction, including product safety, efficacy for smoking cessation and reduction, use among non-smokers, use among youth, marketing and advertisement, use in public places, renormalization of a smoking culture, and market ownership. Overall, the safety profile of e-cigarettes is unlikely to warrant serious public health concerns, particularly given the known adverse health effects associated with tobacco cigarettes. As a result, it is unlikely that the population-level harms resulting from e-cigarette uptake among non-smokers would overshadow the public health gains obtained from tobacco harm reduction among current smokers. While the existence of a gateway effect for youth remains uncertain, e-cigarette use in this population should be discouraged. Similarly, marketing and advertisement should remain aligned with the degree of known product risk and should be targeted to current smokers. Overall, the available evidence supports the cautionary implementation of harm reduction interventions aimed at promoting e-cigarettes as attractive and competitive alternatives to cigarette smoking, while taking measures to protect vulnerable groups and individuals.
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Affiliation(s)
- Caroline Franck
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, McGill University, Montreal, QC, Canada
| | - Kristian B Filion
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, McGill University, Montreal, QC, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
- Division of Clinical Epidemiology, McGill University, Montreal, QC, Canada
| | - Jonathan Kimmelman
- Biomedical Ethics Unit, McGill University Montreal, Montreal, QC, Canada
- Department of Social Studies and Medicine, McGill University, Montreal, QC, Canada
| | - Roland Grad
- Department of Family Medicine, McGill University, Montreal, QC, Canada
| | - Mark J Eisenberg
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, McGill University, Montreal, QC, Canada.
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada.
- Division of Cardiology, Jewish General Hospital, McGill University, Montreal, QC, Canada.
- Divisions of Cardiology and Clinical Epidemiology, Jewish General Hospital/McGill University, 3755 Côte Ste-Catherine Road, Suite H-421.1, Montreal, Quebec, H3T 1E2, Canada.
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Fraser D, Borland R, Gartner C. Protocol for a randomised pragmatic policy trial of nicotine products for quitting or long-term substitution in smokers. BMC Public Health 2015; 15:1026. [PMID: 26444980 PMCID: PMC4596390 DOI: 10.1186/s12889-015-2366-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Accepted: 09/29/2015] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Smoking is Australia's leading preventable cause of premature mortality and a major contributor to the national disease burden. If quit rates do not dramatically improve, then smoking will continue to be a major public health issue for decades to come. Harm-reduction approaches using novel nicotine products like e-cigarettes as long term replacements for smoking have the potential to improve quit rates. However, little research has assessed such approaches. METHODS/DESIGN DESIGN Three-arm parallel-group pragmatic randomised controlled trial. PARTICIPANTS People living in Australia who are at least 18 years old, smoke five or more cigarettes per day and are willing to try a sample of nicotine products. INTERVENTION Participants are randomised to receive standard quit advice and medicinal nicotine (Condition A); quit or substitute advice and medicinal nicotine (Condition B); or quit or substitute advice and medicinal nicotine and e-cigarettes (Condition C). Participants choose which (if any) nicotine products to receive to try in a free sample pack followed by a two to three week free supply of their favourite product(s) and the option to purchase more at a discounted price. Follow-up surveys will assess nicotine product use and smoking. PRIMARY OUTCOME Continuous abstinence for at least 6 months. Target sample size: 1600 people (Condition A: 340; Condition B: 630; Condition C: 630) provides at least 80 % power at p = 0.05 to detect a 5 % difference in abstinence rates between each condition. DISCUSSION This trial will provide data on tobacco harm-reduction approaches and in particular the use of e-cigarettes as a replacement for smoking. TRIAL REGISTRATION Australian and New Zealand Clinical Trials Registry: ACTRN12612001210864. Date of registration: 15/11/2012.
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Affiliation(s)
- Doug Fraser
- School of Public Health, The University of Queensland, Brisbane, Australia.
| | - Ron Borland
- The Cancer Council Victoria, Melbourne, Australia.
- The University of Queensland Centre for Clinical Research, Brisbane, Australia.
| | - Coral Gartner
- School of Public Health, The University of Queensland, Brisbane, Australia.
- The University of Queensland Centre for Clinical Research, Brisbane, Australia.
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Yang T, Jiang S, Oliffe JL, Feng X, Zheng J. Environmental Smoking Restrictions and Light Cigarette Adoption Among Chinese Urban Smokers. PREVENTION SCIENCE : THE OFFICIAL JOURNAL OF THE SOCIETY FOR PREVENTION RESEARCH 2015; 16:801-10. [PMID: 25522885 DOI: 10.1007/s11121-014-0541-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Light cigarette adoption involves complex psychological and behavioral processes with many underlying factors. While numerous studies have shown that environmental restrictions on smoking are associated with higher probability of smoking cessation, it is also possible that some smokers may switch from regular to light cigarettes due to environmental pressures. The current study evaluates whether smoking restrictions in households, workplaces, and public places were respectively associated with light cigarette adoption. A cross-sectional multistage sampling process was used to recruit participants and collect data about demographics and smoking characteristics and environmental restriction variables. Multiple logistic models were employed to examine the association between environmental smoking restrictions and light cigarette adoption. Of 4735 respondents, 1592 (30.3 %) were current smokers, and 69.7 % (N = 1141) of the smokers were identified as light cigarette adopters. In a multivariate model, smoking restrictions in households, workplaces, and public places were significantly associated with higher light cigarette adoption. Under environmental smoking restrictions, which pose unique challenges to tobacco control efforts, light cigarette adoption may increase. The study findings are essential for health policy makers in designing and implementing targeted smoking cessation interventions and health education programs.
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Affiliation(s)
- Tingzhong Yang
- Center for Tobacco Control Research, Zhejiang University, School of Medicine, Hangzhou, 310058, China,
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Kiviniemi MT, Kozlowski LT. Deficiencies in public understanding about tobacco harm reduction: results from a United States national survey. Harm Reduct J 2015; 12:21. [PMID: 26135116 PMCID: PMC4487951 DOI: 10.1186/s12954-015-0055-0] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Accepted: 06/25/2015] [Indexed: 01/19/2023] Open
Abstract
Background Tobacco products differ in their relative health harms. The need for educating consumers about such harms is growing as different tobacco products enter the marketplace and as the FDA moves to regulate and educate the public about different products. However, little is known about the patterns of the public’s knowledge of relative harms. Methods Data were analyzed from the Health Information National Trends Survey (HINTS) 4 Cycle 2, a population-representative survey of US adults conducted between October 2012 and January 2013 (N = 3630). Participants reported their perceptions of the relative risks of e-cigarettes, smokeless tobacco, and different types of cigarettes compared to “traditional” cigarettes. Relative risk perceptions for each product type, as well as the consistency and accuracy of harm reduction beliefs, were analyzed. Results About 65 % of the respondents accurately reported that no cigarettes were less harmful than any others. Slightly more than half of US adults perceived e-cigarettes to be safer than regular cigarettes, a belief in line with current scientific evidence. By contrast, only 9 % of respondents perceived some smokeless tobacco products to be safer, a belief strongly supported by the evidence. Only 3.5 % of respondents had patterns of relative risk perceptions in line with current scientific evidence for all three modalities. Conclusions The discrepancy between current evidence and public perceptions of relative risk of various tobacco/nicotine products was marked; for most tobacco types, a large proportion of the population held inaccurate harm reduction beliefs. Although there was substantial awareness that no cigarettes were safer than any other cigarettes, there could be benefits from increasing the percentage of the public that appreciates this fact, especially among current smokers. Given the potential benefits of tobacco risk reduction strategies, public health education efforts to increase understanding of basic harm reduction principles are needed to address these misperceptions.
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Affiliation(s)
- Marc T Kiviniemi
- Department of Community Health and Health Behavior, University at Buffalo, State University of New York, School of Public Health and Health Professions, 3425 Main Street, Buffalo, NY, 14214, USA.
| | - Lynn T Kozlowski
- Department of Community Health and Health Behavior, University at Buffalo, State University of New York, School of Public Health and Health Professions, 3425 Main Street, Buffalo, NY, 14214, USA.
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Liu R, Dix-Cooper L, Hammond SK. Modeling flight attendants' exposure to secondhand smoke in commercial aircraft: historical trends from 1955 to 1989. JOURNAL OF OCCUPATIONAL AND ENVIRONMENTAL HYGIENE 2015; 12:145-155. [PMID: 25587876 DOI: 10.1080/15459624.2014.957830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Flight attendants were exposed to elevated levels of secondhand smoke (SHS) in commercial aircraft when smoking was allowed on planes. During flight attendants' working years, their occupational SHS exposure was influenced by various factors, including the prevalence of active smokers on planes, fliers' smoking behaviors, airplane flight load factors, and ventilation systems. These factors have likely changed over the past six decades and would affect SHS concentrations in commercial aircraft. However, changes in flight attendants' exposure to SHS have not been examined in the literature. This study estimates the magnitude of the changes and the historic trends of flight attendants' SHS exposure in U.S. domestic commercial aircraft by integrating historical changes of contributing factors. Mass balance models were developed and evaluated to estimate flight attendants' exposure to SHS in passenger cabins, as indicated by two commonly used tracers (airborne nicotine and particulate matter (PM)). Monte Carlo simulations integrating historical trends and distributions of influence factors were used to simulate 10,000 flight attendants' exposure to SHS on commercial flights from 1955 to 1989. These models indicate that annual mean SHS PM concentrations to which flight attendants were exposed in passenger cabins steadily decreased from approximately 265 μg/m(3) in 1955 and 1960 to 93 μg/m(3) by 1989, and airborne nicotine exposure among flight attendants also decreased from 11.1 μg/m(3) in 1955 to 6.5 μg/m(3) in 1989. Using duration of employment as an indicator of flight attendants' cumulative occupational exposure to SHS in epidemiological studies would inaccurately assess their lifetime exposures and thus bias the relationship between the exposure and health effects. This historical trend should be considered in future epidemiological studies.
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Affiliation(s)
- Ruiling Liu
- a Department of Environmental Health Sciences, School of Public Health , University of California , Berkeley , California
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26
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Henningfield JE. The tobacco endgame: it's all about behavior. Prev Med 2014; 68:11-6. [PMID: 25236479 DOI: 10.1016/j.ypmed.2014.09.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Revised: 09/01/2014] [Accepted: 09/08/2014] [Indexed: 11/20/2022]
Abstract
One of the ten great public health achievements in the 20th century was turning the tide on one of the greatest public health disasters of that century: the tobacco use and related disease epidemic. The premature death and disease caused by tobacco can be considered largely as a side-effect of tobacco use behavior and the disease of addiction. The spread of that disease was fostered by an industry that researched the behavioral and biological basis of tobacco use and addiction and applied its findings and knowledge to develop products and marketing approaches to increase the likelihood that people, especially young people, would try tobacco products and develop persistent use and addiction. Researchers outside of the tobacco industry also investigated the behavioral biology of tobacco use and their research has been critical in turning the tide of the tobacco and disease epidemic. The behavioral factors are considered vital to understand and address by United States Food and Drug Administration and Surgeon General, as well as the World Health Organization in their tobacco control efforts. This commentary discusses key behavioral factors in the rise and fall of the epidemic, as well as some of those increasingly discussed as potential contributors to the endgame.
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Affiliation(s)
- Jack E Henningfield
- Department of Psychiatry and Behavioral Sciences, The Johns Hopkins University School of Medicine, USA.
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Ayo-Yusuf OA, Omole OB. Snuff use and the risk for hypertension among black South African women. S Afr Fam Pract (2004) 2014. [DOI: 10.1080/20786204.2008.10873702] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Le Houezec J, Aubin HJ. Pharmacotherapies and harm-reduction options for the treatment of tobacco dependence. Expert Opin Pharmacother 2013; 14:1959-67. [PMID: 23978314 DOI: 10.1517/14656566.2013.818978] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Tobacco dependence, a chronic relapsing condition, requires repeated interventions and multiple attempts to quit. AREAS COVERED Strategies for assisting smoking cessation include behavioural counselling and pharmacotherapy. Three drugs are currently used as first-line pharmacotherapy: nicotine replacement therapy (NRT), bupropion and varenicline. Compared to placebo, the drug effect varies from RR = 2.27 for varenicline, to 1.69 for bupropion, and 1.60 for any form of NRT. Cytisine (similar to varenicline) has a RR = 3.98 compared to placebo (two trials). Second-line pharmacotherapies include nortriptyline and clonidine. This review also offers an overview of pipeline developments. EXPERT OPINION Effective medications exist, and clinicians should encourage and offer treatment to every smoker. However, most smokers try to quit by themselves, with only about 3% quitting successfully each year. Alternative interventions are needed. Harm reduction has not received much support to date. Safer alternative to tobacco smoking (smoke-free products, long-term use of cessation drugs, or electronic cigarettes) could save lives and reduce the burden of tobacco-related deaths and diseases. Despite some encouragement to develop a research agenda for e-cigarettes, particularly on the safety issues, too little attention has been brought to this area of research.
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Affiliation(s)
- Jacques Le Houezec
- Consultant in Public Health, Tobacco dependence, Amzer Glas , 176 rue de Brest, 35000 Rennes , France +332 99 33 72 67 ;
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Erik Lund K. Tobacco harm reduction in the real world: has the availability of snus in Norway increased smoking cessation? DRUGS AND ALCOHOL TODAY 2013. [DOI: 10.1108/dat-02-2013-0006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Abstract
If current trends in smoking prevalence continue, even with the implementation of enhanced tobacco control measures, millions of smokers will continue to fall ill and die as a direct result of their smoking. Many of these will be from the most deprived groups in society - smoking continues to be one of the strongest drivers of health inequalities. The personal costs of this morbidity and mortality, as well as costs to business and the economy, are unequalled and will therefore remain high for several decades to come. However, there is an addition to the tobacco control armoury that could have a marked impact on public health, but it requires radical action to be taken. This would be to embrace harm reduction, but this approach is as controversial in the case of tobacco as it is in the case of illicit drugs from where it derives. However, harm reduction remains the Cinderella of the three major strategies for reducing smoking-related harm, the others being prevention and cessation. Here we make the case that harm reduction has an important role to play in reducing the health burden of tobacco use.
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Affiliation(s)
- Ann McNeill
- UK Centre for Tobacco Control Studies, Division of Epidemiology & Public Health, University of Nottingham, UK.
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Lund KE. Association between willingness to use snus to quit smoking and perception of relative risk between snus and cigarettes. Nicotine Tob Res 2012; 14:1221-8. [PMID: 22416114 PMCID: PMC3457715 DOI: 10.1093/ntr/nts077] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Smokers are often incorrect in their assessment of the relative risk of snus and cigarettes. We have studied how perception of risks of snus compared with cigarettes was associated with the willingness of trying snus as a quit-smoking method. METHODS Fourteen thousand seven hundred and forty-four Norwegian men aged 20-50 years were selected at random from a national representative web panel and sent a questionnaire by e-mail. Of the 7,170 (48.6%) who responded, there were 1,155 former daily smokers who reported method for quitting smoking and 1,213 current daily smokers who stated their willingness to try different methods for quitting smoking. They were also asked to assess the relative risk between daily use of snus and cigarettes. RESULTS Adjusted odds ratio (AOR) for reporting willingness to try snus in future quit attempts was significantly higher (AOR = 4.82, p < .001) for the 22.9% of the current smokers who, consistent with scientific evidence, believed that the health risks were "far lower" for snus than for cigarettes compared with the 39.8% who incorrectly perceived the health risks to be "equal or higher" for snus (reference AOR = 1). About 37.2% of the daily smokers believed that the risk was "somewhat lower" for snus than for cigarettes and had a significantly higher AOR of reporting willingness to try snus (AOR = 2.31, p < .001) compared with the reference group. CONCLUSION Devising a way to inform smokers about the risk continuum of tobacco products could be an important research priority in countries where snus is allowed to compete with cigarettes for market share.
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Affiliation(s)
- Karl Erik Lund
- Norwegian Institute for Alcohol and Drug Research, P.O. Box 565 Sentrum, 0105 Oslo, Norway.
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Abstract
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.
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O'Connor RJ, Norton KJ, Bansal-Travers M, Mahoney MC, Cummings KM, Borland R. US smokers' reactions to a brief trial of oral nicotine products. Harm Reduct J 2011; 8:1. [PMID: 21219609 PMCID: PMC3032705 DOI: 10.1186/1477-7517-8-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2010] [Accepted: 01/10/2011] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND It has been suggested that cigarette smokers will switch to alternative oral nicotine delivery products to reduce their health risks if informed of the relative risk difference. However, it is important to assess how smokers are likely to use cigarette alternatives before making predictions about their potential to promote individual or population harm reduction. OBJECTIVES This study examines smokers' interest in using a smokeless tobacco or a nicotine replacement product as a substitute for their cigarettes. METHODS The study included 67 adult cigarette smokers, not currently interested in quitting, who were given an opportunity to sample four alternative oral nicotine products: 1) Camel Snus, 2) Marlboro Snus, 3) Stonewall dissolvable tobacco tablets, and 4) Commit nicotine lozenges. At visit 1, subjects were presented information about the relative benefits/risks of oral nicotine delivery compared to cigarettes. At visit 2, subjects were given a supply of each of the four products to sample at home for a week. At visit 3, subjects received a one-week supply of their preferred product to see if using such products reduced or eliminated cigarette use. RESULTS After multiple product sampling, participants preferred the Commit lozenges over the three smokeless tobacco products (p = 0.011). Following the one week single-product trial experience, GEE models controlling for gender, age, level of education, baseline cigarettes use, and alternative product chosen, indicated a significant decline in cigarettes smoked per day across one week of single-product sampling (p < 0.01, from 11.8 to 8.7 cigarettes per day), but no change in alternative product use (approximately 4.5 units per day). Biomarkers of exposure showed no change in cotinine, but a 19% reduction in exhaled CO (p < 0.001). CONCLUSIONS Findings from this study show that smokers, who are currently unwilling to make a quit attempt, may be willing to use alternative products in the short term as a temporary substitute for smoking. However, this use is more likely to be for partial substitution (i.e. they will continue to smoke, albeit at a lower rate) rather than complete substitution. Of the various substitutes offered, smokers were more willing to use a nicotine replacement product over a tobacco-based product.
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Affiliation(s)
- Richard J O'Connor
- Department of Health Behavior, Roswell Park Cancer Institute, Buffalo, NY, USA.
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Lund KE, Scheffels J, McNeill A. The association between use of snus and quit rates for smoking: results from seven Norwegian cross-sectional studies. Addiction 2011; 106:162-7. [PMID: 20883459 PMCID: PMC3021722 DOI: 10.1111/j.1360-0443.2010.03122.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM Swedish studies have shown that experience of using snus is associated with an increased probability of being a former smoker. We examined whether this result is also found in Norway. DESIGN Seven cross-sectional data sets collected during the period 2003-08. SETTING Norway. PARTICIPANTS A total of 10, 441 ever (current or former) smokers. MEASUREMENTS Quit ratios for smoking were compared for people with different histories of snus use. Motive for snus use was examined among combination users (snus and cigarettes). Smoking status was examined among snus users. FINDINGS Compared to smokers with no experience of using snus, the quit ratio for smoking was significantly higher for daily snus users in six of seven data sets, significantly higher for former snus users in two of five data sets and significantly lower for occasional snus users in six of seven data sets. Of combination users who used snus daily, 55.3% [confidence interval (CI) 44.7-65.9] reported that their motive for using snus was to quit smoking totally. This motive was reported significantly less often by combination users who used snus occasionally (35.7%, CI 27.3-44.2). Former smokers made up the largest proportion of daily snus users in six of seven data sets. In the remaining data set, that included only the age group 16-20 years, people who had never smoked made up the largest segment of snus users. CONCLUSIONS Consistent with Swedish studies, Norwegian data shows that experience of using snus is associated with an increased probability of being a former smoker. In Scandinavia, snus may play a role in quitting smoking but other explanations, such as greater motivation to stop in snus users, cannot be ruled out.
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Affiliation(s)
- Karl E Lund
- Norwegian Institute for Alcohol and Drug Research, UK.
| | - Janne Scheffels
- Norwegian Institute for Alcohol and Drug Research, University of NottinghamUK
| | - Ann McNeill
- UK Centre for Tobacco Control Studies, Division of Epidemiology & Public Health, University of NottinghamUK
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Paek HJ, Reid LN, Choi H, Jeong HJ. Promoting health (implicitly)? A longitudinal content analysis of implicit health information in cigarette advertising, 1954-2003. JOURNAL OF HEALTH COMMUNICATION 2010; 15:769-787. [PMID: 21104505 DOI: 10.1080/10810730.2010.514033] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Tobacco studies indicate that health-related information in cigarette advertising leads consumers to underestimate the detrimental health effects of smoking and contributes to their smoking-related perceptions, beliefs, and attitudes. This study examined the frequencies and kinds of implicit health information in cigarette advertising across five distinct smoking eras covering the years 1954-2003. Analysis of 1,135 cigarette advertisements collected through multistage probability sampling of three popular consumer magazines found that the level of implicit health information (i.e., "light" cigarette, cigarette pack color, verbal and visual health cues, cigarette portrayals, and human model-cigarette interaction) in post-Master Settlement Agreement [MSA] era ads is similar to the level in ads from early smoking eras. Specifically, "light" cigarettes were frequently promoted, and presence of light colors in cigarette packs seemed dominant after the probroadcast ban era. Impressionistic verbal health cues (e.g., soft, mild, and refreshing) appeared more frequently in post-MSA era ads than in pre-MSA era ads. Most notably, a majority of the cigarette ads portrayed models smoking, lighting, or offering a cigarette to others. The potential impact of implicit health information is discussed in the contexts of social cognition and Social Cognitive Theory. Policy implications regarding our findings are also detailed.
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Affiliation(s)
- Hye-Jin Paek
- Department of Advertising, Public Relations, and Retailing, College of Communication Arts and Science, Michigan State University, East Lansing, Michigan 48824, USA.
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Gartner C, Hall W. Harm reduction policies for tobacco users. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2010; 21:129-30. [DOI: 10.1016/j.drugpo.2009.10.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2009] [Revised: 10/26/2009] [Accepted: 10/27/2009] [Indexed: 11/16/2022]
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Phillips CV. Debunking the claim that abstinence is usually healthier for smokers than switching to a low-risk alternative, and other observations about anti-tobacco-harm-reduction arguments. Harm Reduct J 2009; 6:29. [PMID: 19887003 PMCID: PMC2776004 DOI: 10.1186/1477-7517-6-29] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2009] [Accepted: 11/03/2009] [Indexed: 11/10/2022] Open
Abstract
Nicotine is so desirable to many people that when they are given only the options of consuming nicotine by smoking, with its high health costs, and not consuming nicotine at all, many opt for the former. Few smokers realize that there is a third choice: non-combustion nicotine sources, such as smokeless tobacco, electronic cigarettes, or pharmaceutical nicotine, which eliminate almost all the risk while still allowing consumption of nicotine. Widespread dissemination of misleading health claims is used to prevent smokers from learning about this lifesaving option, and to discourage opinion leaders from telling smokers the truth. One common misleading claim is a risk-risk comparison that has not before been quantified: A smoker who would have eventually quit nicotine entirely, but learns the truth about low-risk alternatives, might switch to an alternative instead of quitting entirely, and thus might suffer a net increase in health risk. While this has mathematical face validity, a simple calculation of the tradeoff -- switching to lifelong low-risk nicotine use versus continuing to smoke until quitting -- shows that such net health costs are extremely unlikely and of trivial maximum magnitude. In particular, for the average smoker, smoking for just one more month before quitting causes greater health risk than switching to a low-risk nicotine source and never quitting it. Thus, discouraging a smoker, even one who would have quit entirely, from switching to a low-risk alternative is almost certainly more likely to kill him than it is to save him. Similarly, a strategy of waiting for better anti-smoking tools to be developed, rather than encouraging immediate tobacco harm reduction using current options, kills more smokers every month than it could possibly ever save.
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Affiliation(s)
- Carl V Phillips
- University of Alberta, School of Public Health, Edmonton, AB, Canada.
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Hall W, Gartner C. Supping with the Devil? The role of law in promoting tobacco harm reduction using low nitrosamine smokeless tobacco products. Public Health 2009; 123:287-91. [DOI: 10.1016/j.puhe.2008.12.018] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2008] [Accepted: 12/11/2008] [Indexed: 02/04/2023]
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Kozlowski LT. Effect of smokeless tobacco product marketing and use on population harm from tobacco use policy perspective for tobacco-risk reduction. Am J Prev Med 2007; 33:S379-86. [PMID: 18021913 DOI: 10.1016/j.amepre.2007.09.015] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2007] [Revised: 08/02/2007] [Accepted: 09/19/2007] [Indexed: 10/22/2022]
Abstract
This article presents policy perspectives on the marketing of smokeless tobacco products to reduce population harm from tobacco use. Despite consensus that smokeless tobacco products as sold in the United States are less dangerous than cigarettes, there is no consensus on how to proceed. Diverse factions have different policy concerns. While the tobacco industry is exempted from U.S. Food and Drug Administration (FDA) oversight, the pharmaceutical industry whose nicotine replacement therapy (NRT) medicines compete with smokeless tobacco as noncombustible nicotine-delivery systems are regulated by the FDA. Some public health experts support smokeless tobacco use to reduce population harm from tobacco; other public health experts oppose promoting smokeless tobacco for harm reduction. Adult consumers can freely purchase currently-marketed smokeless tobacco products and even more-deadly cigarettes. Concerns with and advantages of smokeless tobacco products are discussed. In that noncombustible medicinal nicotine-delivery systems have been proven to be effective smoking-cessation aids, smokeless tobacco, as another source of psychoactive doses of nicotine, could be used similarly, in a dose-response fashion as a smoking-cessation aid (consistent with FDA principles for evaluating generic versions of drugs). Price measures should be used on tobacco products to make costs to consumers proportional to product health risks (which would make smokeless tobacco much cheaper than cigarettes), and smokeless tobacco should be encouraged as an option for smoking cessation in adult smokers, particularly for those who have failed to stop smoking using NRT or other methods.
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Affiliation(s)
- Lynn T Kozlowski
- Department of Health Behavior, State University of New York-Buffalo, Buffalo, New York 14214-3079, USA.
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Ding YS, Ashley DL, Watson CH. Determination of 10 carcinogenic polycyclic aromatic hydrocarbons in mainstream cigarette smoke. JOURNAL OF AGRICULTURAL AND FOOD CHEMISTRY 2007; 55:5966-73. [PMID: 17602652 DOI: 10.1021/jf070649o] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Polycyclic aromatic hydrocarbons (PAHs) are one class of chemical compounds that (1) are present at low to trace levels in unburned cigarette filler, and (2) are predominantly generated during combustion. According to a recent report of the International Agency for Research on Cancer, 10 carcinogenic PAHs together with 53 other known carcinogens are present in cigarette smoke. Accurate quantification of these chemicals helps assess public health risk to both smokers and nonsmokers exposed to second-hand smoke. We have developed and validated a specific and sensitive method for measuring these 10 carcinogenic PAHs in the particulate phase of mainstream tobacco smoke. Cigarette smoke particulate, produced using standard machine smoking protocols, was collected on glass fiber Cambridge filter pads. The particulate matter was solvent extracted, purified by solid-phase extraction, and analyzed by liquid chromatography/atmospheric pressure photoionization tandem mass spectrometry using isotopically labeled analogues as internal standards. Our method's limits of detection ranged from 11 to 166 pg and achieved sufficient reproducibility and accuracy to provide useful information on a range of cigarettes having dramatically different machine-smoked tar and nicotine deliveries. The identity of each PAH analyte was established from chromatographic retention time, analyte-specific fragmentation patterns, and relative peak area ratios of the product/precursor ion pairs. This new method provides higher sensitivity, specificity, and throughput than did earlier methods. We found relatively consistent PAH levels among a selection of domestic full-flavor cigarettes. The PAH levels in smoke from highly ventilated light and ultralight cigarettes were low when smoked using ISO (International Organization for Standardization) conditions. However, if highly ventilated cigarettes were smoked under more intense conditions (e.g., larger or more frequent puffs, vents blocked), their PAH levels equaled or exceeded their full-flavor counterparts under ISO conditions.
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Affiliation(s)
- Yan S Ding
- Emergency Response and Air Toxicants Branch, Division of Laboratory Sciences, National Center for Environmental Health, Centers for Disease Control and Prevention, 4770 Buford Highway, NE, Mailstop F-47, Atlanta, Georgia 30341-3724, USA
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Gartner CE, Hall WD, Vos T, Bertram MY, Wallace AL, Lim SS. Assessment of Swedish snus for tobacco harm reduction: an epidemiological modelling study. Lancet 2007; 369:2010-2014. [PMID: 17498798 DOI: 10.1016/s0140-6736(07)60677-1] [Citation(s) in RCA: 110] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Swedish snus is a smokeless tobacco product that has been suggested as a tobacco harm reduction product. Our aim was to assess the potential population health effects of snus. METHODS We assessed the potential population health effects of snus in Australia with multistate life tables to estimate the difference in health-adjusted life expectancy between people who have never been smokers and various trajectories of tobacco use, including switching from smoking to snus use; and the potential for net population-level harm given different rates of snus uptake by current smokers, ex-smokers, and people who have never smoked. FINDINGS There was little difference in health-adjusted life expectancy between smokers who quit all tobacco and smokers who switch to snus (difference of 0.1-0.3 years for men and 0.1-0.4 years for women). For net harm to occur, 14-25 ex-smokers would have to start using snus to offset the health gain from every smoker who switched to snus rather than continuing to smoke. Likewise, 14-25 people who have never smoked would need to start using snus to offset the health gain from every new tobacco user who used snus rather than smoking. INTERPRETATION Current smokers who switch to using snus rather than continuing to smoke can realise substantial health gains. Snus could produce a net benefit to health at the population level if it is adopted in sufficient numbers by inveterate smokers. Relaxing current restrictions on the sale of snus is more likely to produce a net benefit than harm, with the size of the benefit dependent on how many inveterate smokers switch to snus.
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Affiliation(s)
- Coral E Gartner
- School of Population Health, The University of Queensland, Herston, Queensland, Australia
| | - Wayne D Hall
- School of Population Health, The University of Queensland, Herston, Queensland, Australia.
| | - Theo Vos
- School of Population Health, The University of Queensland, Herston, Queensland, Australia
| | - Melanie Y Bertram
- School of Population Health, The University of Queensland, Herston, Queensland, Australia
| | - Angela L Wallace
- School of Population Health, The University of Queensland, Herston, Queensland, Australia
| | - Stephen S Lim
- School of Population Health, The University of Queensland, Herston, Queensland, Australia
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Abstract
Nicotine in tobacco is the primary reason why most people find it hard to stop using tobacco. Nicotine creates dependence by activating the dopaminergic reward system in the brain. Physiologic withdrawal symptoms that occur when nicotine is no longer administered reinforce continued nicotine administration to avoid withdrawal. Extrapolating from this evidence has led to the development of tobacco dependence pharmacotherapy based upon the concept of replacing and/or blocking the effects of nicotine in the brain. The efficacy of nicotine replacement and blockade treatments in lessening symptoms of nicotine withdrawal and increasing quit rates has been consistently demonstrated in clinical trials. Despite the availability of efficacious medications to treat nicotine dependence, current therapies remain underutilized across the population. Health-care providers need to systematically encourage all tobacco users to quit and ensure that their tobacco-using patients use evidence-based treatments when they attempt to quit.
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Affiliation(s)
- K Michael Cummings
- Department of Health Behavior, Roswell Park Cancer Institute,Elm and Carlton Streets, Buffalo, NY 14263, USA.
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Rodu B, Godshall WT. Tobacco harm reduction: an alternative cessation strategy for inveterate smokers. Harm Reduct J 2006; 3:37. [PMID: 17184539 PMCID: PMC1779270 DOI: 10.1186/1477-7517-3-37] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2006] [Accepted: 12/21/2006] [Indexed: 02/07/2023] Open
Abstract
According to the Centers for Disease Control and Prevention, about 45 million Americans continue to smoke, even after one of the most intense public health campaigns in history, now over 40 years old. Each year some 438,000 smokers die from smoking-related diseases, including lung and other cancers, cardiovascular disorders and pulmonary diseases. Many smokers are unable--or at least unwilling--to achieve cessation through complete nicotine and tobacco abstinence; they continue smoking despite the very real and obvious adverse health consequences. Conventional smoking cessation policies and programs generally present smokers with two unpleasant alternatives: quit, or die. A third approach to smoking cessation, tobacco harm reduction, involves the use of alternative sources of nicotine, including modern smokeless tobacco products. A substantial body of research, much of it produced over the past decade, establishes the scientific and medical foundation for tobacco harm reduction using smokeless tobacco products. This report provides a description of traditional and modern smokeless tobacco products, and of the prevalence of their use in the United States and Sweden. It reviews the epidemiologic evidence for low health risks associated with smokeless use, both in absolute terms and in comparison to the much higher risks of smoking. The report also describes evidence that smokeless tobacco has served as an effective substitute for cigarettes among Swedish men, who consequently have among the lowest smoking-related mortality rates in the developed world. The report documents the fact that extensive misinformation about ST products is widely available from ostensibly reputable sources, including governmental health agencies and major health organizations. The American Council on Science and Health believes that strong support of tobacco harm reduction is fully consistent with its mission to promote sound science in regulation and in public policy, and to assist consumers in distinguishing real health threats from spurious health claims. As this report documents, there is a strong scientific and medical foundation for tobacco harm reduction, and it shows great potential as a public health strategy to help millions of smokers.
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Affiliation(s)
- Brad Rodu
- Professor of Medicine and Endowed Chair, Tobacco Harm Reduction Research, School of Medicine, University of Louisville, KY, USA
| | - William T Godshall
- Founder and Executive Director, Smokefree Pennsylvania, Pittsburgh, PA, USA
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Schnoll RA, Lerman C. Current and emerging pharmacotherapies for treating tobacco dependence. Expert Opin Emerg Drugs 2006; 11:429-44. [PMID: 16939383 DOI: 10.1517/14728214.11.3.429] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Tobacco dependence remains the leading cause of death and disease in the US and a major cause of mortality around the world, yet 1 out of 5 American adults smoke and 1.3 billion adults smoke worldwide. Nicotine replacement therapies (NRTs), bupropion and varenicline, are approved by the US FDA as first-line treatments for nicotine dependence. Clonidine and nortriptyline are recommended as second-line treatments by the Agency for Healthcare Research and Quality. Although recent data suggest that varenicline is superior to bupropion for treating nicotine dependence, a majority of smokers fail to maintain long-term abstinence from smoking using FDA-approved pharmacotherapies. Thus, continued investigation of novel medications for nicotine dependence remains a critical priority. Guided by research on multiple neurobiological mechanisms of nicotine dependence, several novel medications that mimic and/or attenuate nicotine's rewarding effects, or reduce nicotine withdrawal, are under investigation. Although existing data are limited or conflicting, there is some evidence for the efficacy of selegiline, fluoxetine, naltrexone and mecamylamine in certain subgroups of smokers. New research directions, such as fast-acting NRTs, the tailored use of NRTs for subtypes of smokers, and pharmacogenetics, hold promise for new treatment approaches and, ultimately, for reducing rates of tobacco use in the US and worldwide.
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Affiliation(s)
- Robert A Schnoll
- Department of Psychiatry, Transdisciplinary Tobacco Use Research Center, University of Pennsylvania, 3535 Market Street, 4th Floor, Philadelphia, PA 19104, USA.
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Martinet Y, Bohadana A, Fagerström K. Would alternate tobacco products use be better than smoking? Lung Cancer 2006; 53:1-4. [PMID: 16690160 DOI: 10.1016/j.lungcan.2006.03.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2006] [Accepted: 03/27/2006] [Indexed: 11/20/2022]
Abstract
Tobacco use is dominated by cigarette smoking. Most toxicity due to cigarette smoking is related to the burning process. Several observations suggest that unburned or oral tobacco is less harmful than cigarette smoking. Up to now, physicians have advised a policy based on two ideas: (i) young people should not start smoking and (ii) the only choice for smokers is to quit. However, numerous smokers cannot or do not want to give up; eventually, one out of two lifelong smokers will die from smoke-related diseases. Thus, it is legitimate to ask if alternate nicotine containing product use would be better than cigarette smoking and limit the tobacco death toll. However, the logic leading to the concept of tobacco harm reduction (THR) turns out to be much more complex than it looks at a first glance.
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Affiliation(s)
- Yves Martinet
- Unité de Tabacologie, Service de Pneumologie, Centre Hospitalier Universitaire, Nancy, France.
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Abstract
The objective of this study was to determine whether the 2004 USA Dewine-Kennedy Bill is congruent with Philip Morris' core policy principles for United States Food and Drug Administration (FDA) regulation of tobacco and what impact that would have on the public health. I compared the Dewine-Kennedy Bill with 1999 Philip Morris core policy principles for FDA regulation. Additional supporting data on FDA regulation from 1998 to the present were collected from previously secret tobacco industry documents, relevant newspaper reports from Nexis-Lexis, federal statutes, and federal regulations. The main outcome measure of the study is a comparison, summary, and analysis of the Dewine-Kennedy Bill with Philip Morris' core principles for FDA regulation, and the result is that the Dewine-Kennedy Bill is compatible with almost all of Philip Morris' core principles on FDA regulation. In conclusion, The Dewine-Kennedy Bill, at best, was mixed in terms of the enhancement of the public health. On the one hand, proponents of this legislation argued stronger FDA regulatory requirements would have some effect on reducing youth and adult tobacco consumption. On the other hand, tobacco products would have remained a politically and economically viable and legal product consumed by millions of Americans many of whom would have continued to suffer from tobacco-related illnesses and deaths.
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Affiliation(s)
- Michael Givel
- Department of Political Science, The University of Oklahoma, 455 West Lindsey, Room 2I7, Norman, USA.
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47
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Abstract
Rigorous and objective industry funded evaluation of potential reduced exposure products will require innovation and flexibility, but must begin now
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Hatsukami DK, Giovino GA, Eissenberg T, Clark PI, Lawrence D, Leischow S. Methods to assess potential reduced exposure products. Nicotine Tob Res 2005; 7:827-44. [PMID: 16298718 DOI: 10.1080/14622200500266015] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The availability of tobacco products purported to reduce toxin exposure or potentially reduce health risks necessitates the development of methods and identification of biomarkers that can be used to assess these products. These assessments occur on multiple levels and stages, from identifying constituents in the tobacco products and smoke, to human exposure and health effects trials, to postmarketing surveillance. A conference of multidisciplinary experts was convened to present and discuss methods and biomarkers to assess these products and to consider the infrastructure necessary to facilitate the evaluation process. Although no currently available set of measures was thought to be sufficient for determining the relative health risk of potential reduced exposure products, this paper provides a blueprint for future research toward this end.
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Kozlowski LT, Edwards BQ. "Not safe" is not enough: smokers have a right to know more than there is no safe tobacco product. Tob Control 2005; 14 Suppl 2:ii3-7. [PMID: 16046699 PMCID: PMC1766193 DOI: 10.1136/tc.2004.008334] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The right to health relevant information derives from the principles of autonomy and self direction and has been recognised in international declarations. Providing accurate health information is part of the basis for obtaining "informed consent" and is a recognised component of business ethics, safety communications, and case and product liability law. Remarkably, anti-tobacco and pro-tobacco sources alike have come to emphasise the message that there is "no safe cigarette" or "no safe tobacco product". We propose that the "no safe" message is so limited in its value that it represents a violation of the right to health relevant information. There is a need to go beyond saying, "there is no safe tobacco product" to indicate information on degree of risks. The "no safe tobacco" message does not contradict, for example, the mistaken belief that so called light or low tar cigarettes are safer choices than higher tar cigarettes. We encourage a kind of "rule utilitarian" ethical position in which the principle of truth telling is observed while trying to produce the greatest good for the greatest number of people. Although harm reduction approaches to easing the burden of tobacco related diseases are founded on science based comparative risk information, the right to health information is independently related to the need to promote health literacy. This right should be respected whether or not harm reduction policies are judged advisable.
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Affiliation(s)
- L T Kozlowski
- Department of Biobehavioral Health, The Pennsylvania State University, 315 East Health and Human Development, University Park, PA 16802, USA.
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Lewis S, Arnott D, Godfrey C, Britton J. Public health measures to reduce smoking prevalence in the UK: how many lives could be saved? Tob Control 2005; 14:251-4. [PMID: 16046688 PMCID: PMC1748066 DOI: 10.1136/tc.2005.011064] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To estimate the number of deaths that could be prevented in the UK by implementing population strategies to reduce smoking prevalence. DESIGN A prospective analysis of future mortality using recent national smoking prevalence data and relative risks of mortality in current smokers, ex-smokers, and never-smokers. POPULATION Smokers in the UK. INTERVENTIONS Population measures of proven effectiveness assumed to reduce smoking prevalence by 1 percentage point per year for 10 years, or alternatively by 13% over 19 years (1 percentage point per annum for seven years, 0.5 percentage point per annum for 12 years) as considered to be achievable in a recent report to the UK Chancellor of the Exchequer. MAIN OUTCOME MEASURE Estimated deaths from smoking prevented in the 35-75 year age group. RESULTS Reducing the prevalence of smoking by 1 percentage point each year for 10 years would prevent 69 049 deaths at ages between 35 and 74 years during that period. The model of reduction by 13% over 19 years would prevent 54 308 and 194 493 deaths in 10 and 19 years, respectively. Continued prevalence reductions at the current rate of 0.4 percentage points each year will prevent 23 192 deaths over 10 years. CONCLUSIONS Full implementation of simple population measures to encourage smoking cessation could prevent substantial numbers of deaths in the UK.
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Affiliation(s)
- S Lewis
- Division of Epidemiology and Public Health, City Hospital, University of Nottingham, Nottingham NG5 1PB, UK
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