Analysis of hydrazine in smokeless tobacco products by gas chromatography-mass spectrometry

Background

Due to the lower health risks associated with the use of certain categories of smokeless tobacco products (STPs) such as Swedish snus, there is interest in the comparative levels of toxic chemical constituents in different types of STPs. A method has been developed and validated for the analysis of hydrazine in STPs. Seventy four commercial STPs from the US and Sweden, representing 80-90% of the 2010 market share for all the major STP categories in these two countries, as well as three reference STPs, were analysed for hydrazine.

Results

Aqueous extracts of the STPs were treated with excess pentafluorobenzaldehyde (PFB), which reacted with hydrazine in solution to form decafluorobenzaldehyde azine (DFBA). DFBA was partitioned into hexane and then quantified by gas chromatography–mass spectrometry (GC–MS). The method was validated using five different types of STP, was linear in the range 8–170 ng/mL, and had limits of quantification (LOQ) from 26–53 ng of hydrazine per g of STP (as sold). The method was applied to the analysis of 74 contemporary STPs commercially available in the United States and Sweden, none of which were found to contain hydrazine above the LOQ or LOD. Trace levels of compounds showing chromatographic and mass spectral features consistent with hydrazine were identified at very low levels (sub-limit of detection, <10 ng/g) in the chromatograms of less than half of the 74 STPs examined; in contrast, for 40 of the STPs no evidence for the presence of hydrazine was observed. Where present, the levels of compounds consistent with hydrazine were estimated to be at least an order of magnitude lower than the only previous study to have quantified hydrazine in tobacco.

Conclusions

Our results show that hydrazine is not a prevalent constituent of STPs, and when present is not quantifiable using currently available analytical methodology.

Time to First Use Among Daily Smokers and Smokeless Tobacco Users

INTRODUCTION

Time to the first cigarette after waking up in the morning is the most validated measure of dependence among smokers, and its complement is also a good indicator of dependence for smokeless tobacco (ST) users. However, no studies have directly compared these measures.

METHODS

We used a multivariate logistic regression model to compare the time to first use (TTFU) of cigarettes and ST among white men 18+ years of age who were daily users in the 2003 Tobacco Use Supplement of the Current Population Survey. Smokers were classified as light (1-14 cigarettes per day [cpd]), moderate (15-24 cpd), and heavy (25+ cpd) and ST users were classified as former smokers or exclusive users.

RESULTS

There was no difference in TTFU within 5min between light smokers and exclusive ST users (Odds ratio [OR] = 1.3, CI = 0.95-1.7), but the latter were less likely to use tobacco within 30min (OR = 0.75, CI = 0.62-0.89). ST former smokers were more likely than light smokers to have a TTFU within 5min (OR = 1.5, CI = 1.1-2.0) but not within 30min. Moderate and heavy smokers had significantly higher odds of TTFU within both time points than light smokers.

CONCLUSION

Compared to light smokers, the likelihood of TTFU within 5min was similar among exclusive ST users and was slightly higher among ST former smokers, offering some support for the Fagerström-Eissenberg hypothesis that the dependence level of cigarettes is higher than that of ST.

The association of smoking and demographic characteristics on body mass index and obesity among adults in the U.S., 1999-2012

BACKGROUND

The National Health and Nutrition Examination Surveys (NHANES) are an exceptional data source for studies of smoking and body weight because they are the only federal survey series collecting relevant information through detailed interviews and medical examinations. The associations of smoking status and demographic factors with body weight have not been evaluated fully in recent NHANES.

METHODS

Using NHANES datasets from 1999 to 2012, this study uses ordinary-least squares and ordered probit models to investigate the association of smoking and selected demographic variables with body mass index (BMI) and the probability of being in BMI categories among adults aged 25-64 years, and it uses quantile regression to examine whether these factors affect individuals differently depending on where they are located across the BMI distribution.

RESULTS

The sample consisted of 11,123 men and 10,949 women. Current smokers had significantly lower BMI than never smokers (1.97 unit for men and 1.46 unit for women), and there was modest variation across the BMI distribution. Among former smokers, only women had a slightly higher BMI compared to never smokers (0.46 unit). Both men and women current smokers were more likely to be underweight and normal weight compared to never smokers and were less likely to be obese. Among men a one-year age increase elevated BMI by 0.2 unit throughout the BMI distribution, while for women an extra year of age increased BMI at the upper tail of the distribution more than at the lower tail. Education beyond high school was associated with a significant decrease in BMI among women, but much less so among men. Married men had higher BMI, but married women had significantly lower BMI, and this difference became larger at the upper tail.

CONCLUSIONS

Compared to never smokers, men and women current smokers had lower BMI and lower probability of obesity, while only women former smokers had elevated BMIs and increased probability of obesity. In addition, we found that age, education and marital status were associated with different effects on BMI in men and women.

A fresh look at tobacco harm reduction: the case for the electronic cigarette

Smokers of any age can reap substantial health benefits by quitting. In fact, no other single public health effort is likely to achieve a benefit comparable to large-scale smoking cessation. Surveys document that most smokers would like to quit, and many have made repeated efforts to do so. However, conventional smoking cessation approaches require nicotine addicted smokers to abstain from tobacco and nicotine entirely. Many smokers are unable – or at least unwilling – to achieve this goal, and so they continue smoking in the face of impending adverse health consequences. In effect, the status quo in smoking cessation presents smokers with just two unpleasant alternatives: quit or suffer the harmful effects of continuing smoking. But, there is a third choice for smokers: tobacco harm reduction. It involves the use of alternative sources of nicotine, including modern smokeless tobacco products like snus and the electronic cigarette (E-cig), or even pharmaceutical nicotine products, as a replacement for smoking. E-cigs might be the most promising product for tobacco harm reduction to date, because, besides delivering nicotine vapour without the combustion products that are responsible for nearly all of smoking’s damaging effect, they also replace some of the rituals associated with smoking behaviour. Thus it is likely that smokers who switch to E-cigs will achieve large health gains. The focus of this article is on the health effects of using an E-cig, with consideration given to the acceptability, safety and effectiveness of this product as a long-term substitute for smoking.

The low prevalence of smoking in the Northern Sweden MONICA study, 2009

AIMS

The purpose of this study was to describe tobacco use in the 2009 Northern Sweden cohort of the World Health Organization Multinational Monitoring of Trends and Determinants in Cardiovascular Diseases (MONICA) study.

METHODS

Subjects (N = 1698) were randomly selected from population registers, stratified for age (25-74 years old) and gender, in the two northernmost Swedish counties of Norrbotten and Västerbotten. Responses from tobacco-related questions were used to develop three mutually exclusive categories of snus use: past, current, or never use; and three comparable categories of smoking that were consistent with previous studies.

RESULTS

Among men, the prevalence of smoking (9%) and dual use (2%) remain unchanged from 2004, although the prevalence of snus use declined from 27% in 2004 to 24% in 2009. Among women, the prevalence of all forms of tobacco use declined between 2004 and 2009; smoking dropped from 16% to 11%, dual use from 2% to less than 1%, and snus use from 9% to 8%. Although overall prevalence of tobacco use was similar for younger versus older men and younger versus older women, there were notable differences in specific snus and smoking rates.

CONCLUSIONS

This study confirms that use of snus was a significant factor in the low prevalence of smoking, especially among younger men and women in Northern Sweden. Furthermore, it documents that tobacco harm reduction is entirely compatible with a population-level decline in overall tobacco use.

Polycyclic aromatic hydrocarbons in US and Swedish smokeless tobacco products

Background

Debate about the health implications of using smokeless tobacco products (STPs) has prompted considerable interest in characterising their levels of toxic and carcinogenic components. In the present study seventy smokeless tobacco products from the US and Sweden, categorized as chewing tobacco, dry and moist snuff, hard and soft pellets, plug, and loose and portion snus, were analysed for twenty one polycyclic aromatic hydrocarbons (PAHs). The tested brands represented 80-90% of the 2008 market share for the major STP categories in these two countries.

Results

There were significant differences in the total and individual PAH concentrations in the different styles of product. Substantially higher levels of total PAHs (10–60 fold) were found in moist and dry snuff and soft pellets than in the other smokeless tobacco styles. The individual PAH concentrations followed the same patterns as total PAHs except for naphthalene, for which the highest concentrations were found in snus and moist snuff. Good correlations were obtained between benzo[a]pyrene (B[a]P) and all the other PAHs except naphthalene, 1-methylnaphthalene and 2-methylnaphthalene, providing evidence for the first time that it can be used as a good marker for PAHs in STPs. Results were generally in good agreement with two previous studies of PAHs in STPs, except for naphthalene for which significantly lower concentrations were found than previously reported. Analysis of the ratios of different PAHs confirmed that the use of fire-cured tobaccos in the snuffs and soft pellet were the major source of PAHs in these product styles, and provided, for the first time, some indications as to the source of PAHs in the other STP styles, including petrogenic and other combustion sources.

Conclusions

This study confirms the presence of PAHs in STPs, and identifies substantial differences between the levels in different STP categories. Since previous studies of naphthalene concentrations in STPs differed so markedly from those found in this study, it is recommended that further work on PAH determination is undertaken to investigate the source of this discrepancy.

Evidence of sex differences in the relationship between current tobacco use and past-year serious psychological distress: 2005-2008 National Survey on Drug Use and Health

PURPOSE

Cigarette use is highly prevalent in psychiatric populations. Studies suggest that smokeless tobacco use is not significantly associated with past-year psychiatric morbidity, with evidence that tobacco use differ among sexes. The relationships between current tobacco use and past-year serious psychological distress, major depressive episode and anxiety disorder were therefore examined. Sex differences in the aforementioned relationship were also examined.

METHODS

A total of 133,221 adults from four successive independent samples of the 2005-2008 National Survey on Drug Use and Health were included. Prevalence odds ratios and 95 % confidence intervals were calculated using multivariable logistic regression adjusting for demographic factors, survey year, pregnancy (women only), past-year medical morbidity, past-year psychiatric comorbidity, and past-year substance use disorders.

RESULTS

No associations were demonstrated among smokeless tobacco users. Statistically significant sex differences were found for current tobacco use and serious psychological distress (p < 0.001). Both male and female smokers were significantly more likely to have serious psychological distress and anxiety disorder compared to never users, while only female smokers were more likely to have major depressive episode. The strongest associations were found for anxiety disorder among all adults as well as both sexes.

CONCLUSIONS

The null associations for both sexes for smokeless tobacco may support a reduced risk profile. Female cigarette smokers may be more vulnerable to subclinical distress and depression than males. Studies using other nationally representative samples are needed to confirm these data.

Tobacco harm reduction: opportunity and opposition

Purpose

This paper aims to provide a brief summary of the effectiveness and efficacy of tobacco harm reduction (THR). THR is the substitution for cigarettes of low‐risk alternatives, including Swedish or American‐style smokeless tobacco, pharmaceutical nicotine products, and electronic cigarettes. The paper then very briefly summarizes the current social and political situation regarding THR.

Design/methodology/approach

This paper is a review of the evidence.

Findings

The risk from smoke‐free tobacco/nicotine products is so low as to be unmeasurable. For most smokers, adopting THR is a lower risk option than to trying to become nicotine abstinent. THR products have been widely adopted in some populations, providing great public health benefits. There is currently an explosion of interest in electronic cigarettes. However, THR is a threat to the business model of the tobacco control industry, and so they are fighting hard to discourage it. Because they cannot admit their real motives for discouraging THR, anti‐THR activism is an entirely dishonest enterprise.

Practical implications

Tobacco harm reduction is the greatest untapped public health initiative in the developed world. It is more promising than further attempts to promote tobacco/nicotine abstinence. The future inevitably includes a large portion of the population using low‐risk tobacco/nicotine, but anti‐THR efforts might keep people smoking in the short run.

Originality/value

While most of the content of this paper is well known to experts on THR, many ostensible experts on health, as well as other opinion leaders and policy makers, are unaware of the truth.

Exploring attitudes regarding smokeless tobacco products for risk reduction

Utilizing qualitative data analysis, this study focused on the attitudes, knowledge, and beliefs relating to smokeless tobacco (ST) as a reduced-risk cigarette substitute for smokers among focus groups from the general public and from the health profession. It revealed that there is a lack of awareness and understanding of ST products, which has a significant impact on overall perception of these products as acceptable substitutes. Regulatory actions regarding tobacco by the U.S. Food and Drug Administration should enhance consumers' access to accurate information about nicotine addiction and tobacco use.

Acute myocardial infarction mortality before and after state-wide smoking bans

Rapid declines in hospital admissions for acute myocardial infarction (AMI) following smoke-free ordinances have been reported in smaller communities. The AMI mortality rate among persons age 45 + years (deaths per 100,000 persons, age-standardized to the 2000 US population) in the 3 years before adoption of the smoke-free ordinance (the expected rate) was compared with the rate observed in the first full year after the ban (the target year) in six US states. Target-year declines were also compared to those in states without smoking bans. Target-year declines in AMI mortality in California (2.0%), Utah (7.7%) and Delaware (8.1%) were not significantly different from the expected declines (P = 0.16, 0.43 and 0.89, respectively). In South Dakota AMI mortality increased 8.9% in the target year (P = 0.007). Both a 9% decline in Florida and a 12% decline in New York in the 2004 target year exceeded the expected declines (P = 0.04 and P < 0.0002, respectively) but were not significantly different (P = 0.55 and 0.08, respectively) from the 9.8% decline that year in the 44 states without bans. Smoke-free ordinances provide a healthy indoor environment, but their implementation in six states had little or no immediate measurable effect on AMI mortality.

Seven Year Follow-up of Smoking Cessation with Smokeless Tobacco

This study evaluated the tobacco use status of 63 subjects seven years after enrollment in a single-intervention smoking cessation study employing smokeless tobacco (SLT) as a nicotine substitute. Information about tobacco use and cessation attempts was obtained in interviews. The duration of follow-up and of smoke-free periods were derived from the date of the subject's enrollment and were expressed as person-years (p-y). Because the study focused on the use of SLT for smoking cessation, subjects who used SLT to quit were invited to return for verification (less than 10 parts per million of carbon monoxide in expired air). Follow-up was completed on 62 of 63 original subjects, classified according to tobacco use status at the end of the initial study. Of the 16 subjects who had quit smoking using SLT at one year, 12 were smoke-free at seven years. For all 16 subjects there was 106 p-y of follow-up, 97 (92%) of which were smoke-free. Of six subjects who had quit smoking at one year by a means other than SLT, four were smoke-free at seven years. This entire group had 42 p-y of follow-up, 34 (81%) of which were smoke-free. Of the 41 subjects who were smoking at one year, 12 had quit smoking by the seven-year mark, three of these subjects by using SLT. Total follow-up for this group was 284 p-y, of which 26 (9%) were smoke-free. Although the study is small, the long-term success rate of this pilot trial compares favorably with other cessation studies.

The scientific foundation for tobacco harm reduction, 2006-2011

Over the past five years there has been exponential expansion of interest in tobacco harm reduction (THR), with a concomitant increase in the number of published studies. The purpose of this manuscript is to review and analyze influential contributions to the scientific and medical literature relating to THR, and to discuss issues that continue to stimulate debate. Numerous epidemiologic studies and subsequent meta-analyses confirm that smokeless tobacco (ST) use is associated with minimal risks for cancer and for myocardial infarction; a small increased risk for stroke cannot be excluded. Studies from Sweden document that ST use is not associated with benign gastrointestinal disorders and chronic inflammatory diseases. Although any form of nicotine should be avoided during pregnancy, the highest risks for the developing baby are associated with smoking. It is documented that ST use has been a key factor in the declining rates of smoking and of smoking-related diseases in Sweden and Norway. For other countries, the potential population health benefits of ST are far greater than the potential risks. In follow-up studies, dual users of cigarettes and ST are less likely than exclusive smokers to achieve complete tobacco abstinence, but they are also less likely to be smoking. The health risks from dual use are probably lower than those from exclusive smoking. E-cigarette users are not exposed to the many toxicants, carcinogens and abundant free radicals formed when tobacco is burned. Although laboratory studies have detected trace concentrations of some contaminants, it is a small problem amenable to improvements in quality control and manufacturing that are likely with FDA regulation as tobacco products. There is limited evidence from clinical trials that e-cigarettes deliver only small doses of nicotine compared with conventional cigarettes. However, e-cigarette use emulates successfully the cigarette handling rituals and cues of cigarette smoking, which produces suppression of craving and withdrawal that is not entirely attributable to nicotine delivery. THR has been described as having "the potential to lead to one of the greatest public health breakthroughs in human history by fundamentally changing the forecast of a billion cigarette-caused deaths this century."

Lung cancer mortality: comparing Sweden with other countries in the European Union

AIMS

To describe how snus use has reduced smoking among men in Sweden, and to estimate how smoking-attributable lung cancer mortality would decline in other European Union countries if they had the smoking prevalence of Sweden.

METHODS

Lung cancer mortality rates (LCMRs) and numbers of deaths among men and women age 45+ years in 25 EU countries in 2002 were obtained from the World Health Organization mortality database, and the number of lung cancer deaths expected in each country at the LCMR of Sweden was calculated. LCMRs for EU countries were obtained during the period 1950-2004, and per capita consumption of nicotine from cigarettes and snus was estimated for men in Sweden from 1931 to 2004.

RESULTS

There were 172,000 lung cancer deaths among men in the EU in 2002. If all EU countries had the LCMR of men in Sweden, there would have been 92,000 (54%) fewer deaths. In contrast, the LCMR among Swedish women was the sixth highest in the EU; at the Swedish rate, deaths among EU women would have increased by 14,500 (26%). These LCMR patterns were in place for most of the last 50 years, and LCMRs among Swedish men can be correlated with snus and cigarette consumption.

CONCLUSIONS

This study shows that snus use has had a profound effect on smoking prevalence and LCMRs among Swedish men. While it cannot be proven that snus would have the same effect in other EU countries, the potential reduction in smoking-attributable deaths is considerable.

Smokeless tobacco use among men in the United States, 2000 and 2005

BACKGROUND

Compared with smoking, there is much less information about smokeless tobacco (ST) use in the United States. The purpose of this study is to characterize and compare ST use among American men in 2000 and 2005.

METHODS

We used US National Health Interview Surveys from 2000 and 2005 to estimate the prevalence of ST use, describe the demographic and socioeconomic profile of ST users and evaluate ST use according to product type and with respect to smoking.

RESULTS

The prevalence of ST use among American men was 4.4% in 2000 and 4.3% in 2005. Almost all ST users were white, about half were 25-44 years old and 80% lived in the South or Midwest, commonly in small metropolitan and rural areas. Educational and income levels of ST users were lower than those of never users of tobacco. One-third of ST users also smoked; cigarette consumption was lower among dual users than among exclusive smokers. In 2005, 1.3 million current ST users were former smokers but 3.2 million smokers were former ST users. ST users were evenly distributed between snuff (43%) and chewing tobacco (44%) in 2000 and 13% used both products. By 2005 snuff use was clearly dominant.

CONCLUSIONS

The prevalence of ST use among men is low but stable; dual use of cigarettes and ST is common, and snuff has become the dominant ST product.

Switching to smokeless tobacco as a smoking cessation method: evidence from the 2000 National Health Interview Survey

BACKGROUND

Although smokeless tobacco (ST) use has played a major role in the low smoking prevalence among Swedish men, there is little information at the population level about ST as a smoking cessation aid in the U.S.

METHODS

We used the 2000 National Health Interview Survey to derive population estimates for the number of smokers who had tried twelve methods in their most recent quit attempt, and for the numbers and proportions who were former or current smokers at the time of the survey.

RESULTS

An estimated 359,000 men switched to smokeless tobacco in their most recent quit attempt. This method had the highest proportion of successes among those attempting it (73%), representing 261,000 successful quitters (switchers). In comparison, the nicotine patch was used by an estimated 2.9 million men in their most recent quit attempt, and almost one million (35%) were former smokers at the time of the survey. Of the 964,000 men using nicotine gum, about 323,000 (34%) became former smokers. Of the 98,000 men who used the nicotine inhaler, 27,000 quit successfully (28%). None of the estimated 14,000 men who tried the nicotine nasal spray became former smokers. Forty-two percent of switchers also reported quitting smoking all at once, which was higher than among former smokers who used medications (8-19%). Although 40% of switchers quit smoking less than 5 years before the survey, 21% quit over 20 years earlier. Forty-six percent of switchers were current ST users at the time of the survey.

CONCLUSION

Switching to ST compares very favorably with pharmaceutical nicotine as a quit-smoking aid among American men, despite the fact that few smokers know that the switch provides almost all of the health benefits of complete tobacco abstinence. The results of this study show that tobacco harm reduction is a viable cessation option for American smokers.

Oral cavity and pharynx-throat cancer in the United States, 1973–2003

OBJECTIVE

To study incidence rates (Is) of oral cavity and pharynx-throat cancer in adults age 20+ years from 1973 to 2003, and to estimate how many of these cancers occurred in the United States in 2003.

STUDY DESIGN

We used data and software from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) Program to generate age-adjusted Is, reported as cases per 100,000 person-years.

RESULTS

For oral cancer, the Is for young men were stable, and Is at ages 40+ years declined by one third after the mid 1980s. Is declined by one third in women ages 40 to 74, but increased in the youngest and oldest groups. In 2003 there were 10,432 cases of oral cavity cancer among persons age 20+ years in the United States, and there were 12,157 cases of pharynx-throat cancer.

CONCLUSION

The Is of cancers of the oral cavity and pharynx-throat are stable or declining for men and women in most age groups. Of the nearly 30,000 malignant neoplasms occurring in the SEER "oral cavity-pharynx" category in 2003, almost three quarters (21,455) were detectable during a routine oral examination.

Declining mortality from smoking in the United States

The proportion of Americans who smoke cigarettes has declined 50% since 1965. The effect on mortality of this considerable reduction has received little attention and is described in this study. U.S. national data were used to enumerate current, former, and never-smokers aged 35 years or older in 1987 and 2002. Mortality rate ratios were used to estimate smoking-attributable deaths among these groups, and corresponding age-adjusted smoking-attributable mortality rates (SAMRs) were calculated. There were 402,000 deaths attributable to smoking in 1987 and 322,000 in 2002. The SAMR for men aged 35 years or more was 556 deaths per 100,000 person-years in 1987, accounting for 24% of all male deaths. By 2002 the SAMR declined 41% to 329 and accounted for only 17% of deaths. The SAMR for women in 1987 was 175, accounting for 12% of deaths. By 2002 the SAMR among women had declined 30% to 122, representing 9% of deaths. The U.S. mortality rate attributable to smoking declined about 35% between 1987 and 2002. The impact of smoking on American society will diminish even further in the foreseeable future as smoking prevalence continues its decline among men and women.