A Comparison of Dependence across Different Types of Nicotine Containing Products and Coffee

INTRODUCTION

Few studies have compared the dependence to different tobacco and nicotine products. Even less is known about how it relates to dependence on other common drugs, e.g., caffeine. In this study degree of dependence was compared between snus, cigarettes, nicotine replacement (NR), electronic cigarettes and coffee.

METHODS

A random sample of Swedish citizens belonging to an internet panel were contacted from September to October 2017. The responders were asked among other related things about their use of snus, NR, traditional cigarette or e-cigarette use and coffee consumption. The indicators of dependence used were: (A) the Heavy Smoking Index, (B) The proportions that used within 30 min after raising in the morning, (C) rating the first use in the morning as the most important and (D) Stating that it would be very hard to give up entirely.

RESULTS

Significantly fewer coffee drinkers started use within 30 min of awakening compared with all other products. The first use of the day was found to be more important for snus users compared with other products. On HSI there was no difference between snus and cigarettes. Snus and cigarettes were rated as being more difficult to give up than NR and coffee.

CONCLUSION

Dependence to traditional cigarettes and snus seem to be relatively similar while NR was rated lower and coffee lowest. Since the prevalence of caffeine use in all forms is so much more prevalent than nicotine there might be more persons in the society heavily dependent on caffeine.

IMPLICATION

Tobacco products are likely more dependence forming than NR products and coffee although there might be more people dependent on caffeine. The addiction to coffee or caffeine is seldom discussed in the society probably because of the little or no harm it causes.

FUNDING

The Snus Commission in Sweden (snuskommissionen) funded the data collection. No funding used for the analysis and writing of manuscript.

Estimating the harms of nicotine-containing products using the MCDA approach

BACKGROUND

An international expert panel convened by the Independent Scientific Committee on Drugs developed a multi-criteria decision analysis model of the relative importance of different types of harm related to the use of nicotine-containing products.

METHOD

The group defined 12 products and 14 harm criteria. Seven criteria represented harms to the user, and the other seven indicated harms to others. The group scored all the products on each criterion for their average harm worldwide using a scale with 100 defined as the most harmful product on a given criterion, and a score of zero defined as no harm. The group also assessed relative weights for all the criteria to indicate their relative importance.

FINDINGS

Weighted averages of the scores provided a single, overall score for each product. Cigarettes (overall weighted score of 100) emerged as the most harmful product, with small cigars in second place (overall weighted score of 64). After a substantial gap to the third-place product, pipes (scoring 21), all remaining products scored 15 points or less.

INTERPRETATION

Cigarettes are the nicotine product causing by far the most harm to users and others in the world today. Attempts to switch to non-combusted sources of nicotine should be encouraged as the harms from these products are much lower.

Pharmacological interventions for the treatment of smokeless tobacco use

Smokeless tobacco (SLT) is used in a variety of forms throughout the world. Long-term SLT use is associated with adverse health consequences. Effective pharmacotherapies are needed to treat SLT users who want to achieve tobacco abstinence. In the current review, we discuss the pharmacological interventions identified in a recent meta-analysis of interventions for SLT users, with inclusion of additional articles identified by searching PubMed up to August 2011. Nicotine replacement therapy (NRT) has been demonstrated to increase short-term tobacco abstinence rates and to alleviate craving and withdrawal symptoms among SLT users trying to quit. Bupropion sustained release has been shown to decrease craving and attenuate post-cessation weight gain among SLT users trying to quit. Varenicline is the only available medication demonstrated to increase long-term (≥6 months) tobacco abstinence rates among SLT users. Overall, findings from studies investigating pharmacotherapies for SLT users have been relatively disappointing. SLT reduction interventions may hold some promise for increasing abstinence rates among SLT users not interested in quitting. Additional investigations of higher dose NRT and combination pharmacotherapy are needed to advance the treatment of SLT users.

Snus as a smoking cessation aid: a randomized placebo-controlled trial

INTRODUCTION

Snus is a low-nitrosamine smokeless product that appears to be safer than other smokeless products. Evidence indicates that snus has been used as an effective smoking cessation aid in Scandinavia. No randomized controlled trial has directly tested the efficacy of snus for smoking cessation.

METHODS

This randomized, double-blind, placebo-controlled multicentre trial tested the efficacy of snus for smoking cessation. Of the 250 subjects, 125 were randomized to active or placebo snus sachets. Subjects were followed up through 28 weeks after randomization. In total, 5 clinical visits and 8 telephone contacts were scheduled. Primary outcome measure was biologically verified continuous smoking abstinence from Week 6 through 28.

RESULTS

The continuous abstinence rate during Weeks 6-28 in the snus and placebo groups was 4.0% and 1.6% (odds ratio [OR]: 2.5, 95% CI: 0.4-27), respectively. The point prevalence abstinence rate at 6 weeks was 18.4% in the snus group versus 8.8% in the placebo group (OR: 2.3, 95% CI: 1.1-5.0, p = .03). At Week 28, the difference in favor of the snus group was not statistically significant (12.8% vs. 7.2%, OR: 1.9, 95% CI: 0.8-4.4). Snus was generally well tolerated. Treatment-related adverse events that were more common in the snus group were generally mild and included nausea, dyspepsia, gingivitis, hiccups, and dizziness.

CONCLUSIONS

Although the cessation rates generally were low and, at 28 weeks, did not differ between active and placebo, early quit rates suggested that snus was superior and with similar effect sizes to those with nicotine replacement. These results suggest that snus needs to be further researched as a smoking cessation treatment.

Toward a comprehensive long term nicotine policy

Global tobacco deaths are high and rising. Tobacco use is primarily driven by nicotine addiction. Overall tobacco control policy is relatively well agreed upon but a long term nicotine policy has been less well considered and requires further debate. Reaching consensus is important because a nicotine policy is integral to the target of reducing tobacco caused disease, and the contentious issues need to be resolved before the necessary political changes can be sought. A long term and comprehensive nicotine policy is proposed here. It envisages both reducing the attractiveness and addictiveness of existing tobacco based nicotine delivery systems as well as providing alternative sources of acceptable clean nicotine as competition for tobacco. Clean nicotine is defined as nicotine free enough of tobacco toxicants to pass regulatory approval. A three phase policy is proposed. The initial phase requires regulatory capture of cigarette and smoke constituents liberalising the market for clean nicotine; regulating all nicotine sources from the same agency; and research into nicotine absorption and the role of tobacco additives in this process. The second phase anticipates clean nicotine overtaking tobacco as the primary source of the drug (facilitated by use of regulatory and taxation measures); simplification of tobacco products by limitation of additives which make tobacco attractive and easier to smoke (but tobacco would still be able to provide a satisfying dose of nicotine). The third phase includes a progressive reduction in the nicotine content of cigarettes, with clean nicotine freely available to take the place of tobacco as society's main nicotine source.