The Strategic Dialogue on Tobacco Harm Reduction: a vision and blueprint for action in the US

The importance of science-informed policy and what the data really tell us about e-cigarettes

A possible future end-game for cigarettes is explored in the context of the historical progress made to date by tobacco control. Despite good progress, there remains an urgent need to increase the use of proven tobacco control policies and practices for prevention and cessation. The problem is worse than previously thought and the 50^th anniversary United States Surgeon General’s report indicates the overwhelming majority of avoidable deaths are caused by combusting of tobacco, primarily cigarettes. The report highlights for the first time the addition of a harm minimization strategy to enhance proven tobacco control efforts and thus much more rapidly speed the obsolescence of cigarettes. Harm minimization can be two pronged. First, it can boost proven tobacco control polices to make cigarettes more expensive and less appealing and accessible to maximize the fact that cigarettes are orders of magnitude the most harmful of all tobacco delivery systems. Second, harm minimization can support use of substantially less harmful but appealing alternatives to substitute for lethal cigarettes for those users who are unable or unwilling to quit smoking. A future end-game might prudently manage emerging new products like e-cigarettes to help boost the difference in harm between them and lethal cigarettes. Harm minimization could help to accelerate the end of the century-long dominance of the cigarette in what has been called “the golden holocaust”. Rather than these emerging delivery devices being used to replace lethal cigarettes in what might be termed a David versus Goliath strategy to disrupt the status quo, there is also legitimate concern that these new products could undermine historically successful tobacco control efforts, especially youth prevention, if allowed free reign. What can the data really tell us about the potential for e-cigarettes to be helpful or harmful? The emerging but limited scientific evidence and the inherent methodological constraints in study designs, points to the need for caution in prematurely interpreting results in a manner that could mislead policymakers.

Study of cardiovascular disease biomarkers among tobacco consumers. Part 3: evaluation and comparison with the US National Health and Nutrition Examination Survey

Cardiovascular disease (CVD) biomarkers of biological effect (BoBE), including hematologic biomarkers, serum lipid-related biomarkers, other serum BoBE, and one physiological biomarker, were evaluated in adult cigarette smokers (SMK), smokeless tobacco consumers (STC), and non-consumers of tobacco (NTC). Data from adult males and females in the US National Health and Nutrition Examination Survey and a single site, cross-sectional study of healthy US males were analyzed and compared. Within normal clinical reference ranges, statistically significant differences were observed consistently for fibrinogen, C-reactive protein (CRP), hematocrit, mean cell volume, mean cell hemoglobin, hemoglobin, white blood cells, monocytes, lymphocytes, and neutrophils in comparisons between SMK and NTC; for CRP, white blood cells, monocytes, and lymphocytes in comparisons between SMK and STC; and for folate in comparisons with STC and NTC. Results provide evidence for differences in CVD BoBE associated with the use of different tobacco products, and provide evidence of a risk continuum among tobacco products and support for the concept of tobacco harm reduction.

Study of cardiovascular disease biomarkers among tobacco consumers, part 2: biomarkers of biological effect

An age-stratified, cross-sectional study was conducted in the US among healthy adult male cigarette smokers, moist snuff consumers, and non-tobacco consumers to evaluate cardiovascular biomarkers of biological effect (BoBE). Physiological assessments included flow-mediated dilation, ankle-brachial index, carotid intima-media thickness and expired carbon monoxide. Approximately one-half of the measured serum BoBE showed statistically significant differences; IL-12(p70), sICAM-1 and IL-8 were the BoBE that best differentiated among the three groups. A significant difference in ABI was observed between the cigarette smokers and non-tobacco consumer groups. Significant group and age effect differences in select biomarkers were identified.

E-cigarettes: methodological and ideological issues and research priorities

Cigarette combustion, rather than either tobacco or nicotine, is the cause of a public health disaster. Fortunately, several new technologies that vaporize nicotine or tobacco, and may make cigarettes obsolete, have recently appeared. Research priorities include the effects of vaporizers on smoking cessation and initiation, their safety and toxicity, use by non-smokers, dual use of vaporizers and cigarettes, passive vaping, renormalization of smoking, and the development of messages that effectively communicate the continuum of risk for tobacco and nicotine products. A major difficulty is that we are chasing a moving target. New products constantly appear, and research results are often obsolete by the time they are published. Vaporizers do not need to be safe, only safer than cigarettes. However, harm reduction principles are often misunderstood or rejected. In the context of a fierce ideological debate, and major investments by the tobacco industry, it is crucial that independent researchers provide regulators and the public with evidence-based guidance. The methodological and ideological hurdles on this path are discussed in this commentary.

Animal models to assess the abuse liability of tobacco products: effects of smokeless tobacco extracts on intracranial self-stimulation

BACKGROUND

Preclinical models are needed to inform regulation of tobacco products by the Food and Drug Administration (FDA). Typically, animal models of tobacco addiction involve exposure to nicotine alone or nicotine combined with isolated tobacco constituents (e.g. minor alkaloids). The goal of this study was to develop a model using extracts derived from tobacco products that contain a range of tobacco constituents to more closely model product exposure in humans.

METHODS

This study compared the addiction-related effects of nicotine alone and nicotine dose-equivalent concentrations of aqueous smokeless tobacco extracts on intracranial self-stimulation (ICSS) in rats. Extracts were prepared from Kodiak Wintergreen, a conventional product, or Camel Snus, a potential "modified risk tobacco product". Binding affinities of nicotine alone and extracts at various nicotinic acetylcholine receptor (nAChR) subtypes were also compared.

RESULTS

Kodiak and Camel Snus extracts contained levels of minor alkaloids within the range of those shown to enhance nicotine's behavioral effects when studied in isolation. Nonetheless, acute injection of both extracts produced reinforcement-enhancing (ICSS threshold-decreasing) effects similar to those of nicotine alone at low to moderate nicotine doses, as well as similar reinforcement-attenuating/aversive (ICSS threshold-increasing) effects at high nicotine doses. Extracts and nicotine alone also had similar binding affinity at all nAChRs studied.

CONCLUSIONS

Relative nicotine content is the primary pharmacological determinant of the abuse liability of Kodiak and Camel Snus as measured using ICSS. These models may be useful to compare the relative abuse liability of other tobacco products and to model FDA-mandated changes in product performance standards.

Study of cardiovascular disease biomarkers among tobacco consumers, part 1: biomarkers of exposure

A study was conducted to evaluate biomarkers of biological effect and physiological assessments related to cardiovascular disease (CVD) among adult male cigarette smokers (SMK), moist snuff consumers (MSC) and non-consumers of tobacco (NTC). Additionally, biomarkers of tobacco and tobacco smoke exposure (BoE) were measured in spot urines and are reported here. Except for the BoE to nicotine and NNK, BoE were generally greater in SMK compared with MSC, and BoE were generally not different in comparisons of MSC and NTC. Results demonstrated that MSC had lower systemic exposures to many harmful and potentially harmful constituents than SMK, which is consistent with epidemiological data that indicate a differential in CVD risk between these groups.

Methods to evaluate cytotoxicity and immunosuppression of combustible tobacco product preparations

Among other pathophysiological changes, chronic exposure to cigarette smoke causes inflammation and immune suppression, which have been linked to increased susceptibility of smokers to microbial infections and tumor incidence. Ex vivo suppression of receptor-mediated immune responses in human peripheral blood mononuclear cells (PBMCs) treated with smoke constituents is an attractive approach to study mechanisms and evaluate the likely long-term effects of exposure to tobacco products. Here, we optimized methods to perform ex vivo assays using PBMCs stimulated by bacterial lipopolysaccharide, a Toll-like receptor-4 ligand. The effects of whole smoke-conditioned medium (WS-CM), a combustible tobacco product preparation (TPP), and nicotine were investigated on cytokine secretion and target cell killing by PBMCs in the ex vivo assays. We show that secreted cytokines IFN-γ, TNF, IL-10, IL-6, and IL-8 and intracellular cytokines IFN-γ, TNF-α, and MIP-1α were suppressed in WS-CM-exposed PBMCs. The cytolytic function of effector PBMCs, as determined by a K562 target cell killing assay was also reduced by exposure to WS-CM; nicotine was minimally effective in these assays. In summary, we present a set of improved assays to evaluate the effects of TPPs in ex vivo assays, and these methods could be readily adapted for testing other products of interest.

Consumption patterns and biomarkers of exposure in cigarette smokers switched to Snus, various dissolvable tobacco products, Dual use, or tobacco abstinence

The objectives of this clinical study were to evaluate changes in tobacco product use behavior and levels of selected biomarkers of exposure (BOEs) for smokers who switched to one of six conditions during clinical confinement: exclusive use of; Camel Snus, Sticks, Strips or Orbs, controlled Dual use of cigarettes and Camel Snus, or tobacco abstinence. The controlled Dual use (DU) condition mandated a 60% reduction in cigarettes smoked per day (CPD). 167 healthy U.S. male and female smokers were randomized to the six groups (n=25-30/group). Subjects smoked their usual brand of cigarette for 1 day prior to switching to their designated intervention condition. Levels of thirty-two BOEs in plasma, whole blood, urine and feces were determined before and after switching. Questionnaires that scored nicotine dependence and withdrawal discomfort were also administered. After 5 days, exclusive Snus, Sticks, Strips, or Orbs use averaged 6.1, 5.9, 13.5, and 8.5 units/day, respectively. DU subjects smoked 7.6 CPD and used 3.2 Snus pouches/day, on average. After 5 days, substantial reductions of most biomarkers, including nicotine, were observed in all groups. Toxicant exposures were similar to being tobacco abstinent after switching exclusively to Camel Snus, Sticks, Strips or Orbs. DU reductions were more modest.

The tobacco endgame: it's all about behavior

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.

Carbonyl compounds generated from electronic cigarettes

Electronic cigarettes (e-cigarettes) are advertised as being safer than tobacco cigarettes products as the chemical compounds inhaled from e-cigarettes are believed to be fewer and less toxic than those from tobacco cigarettes. Therefore, continuous careful monitoring and risk management of e-cigarettes should be implemented, with the aim of protecting and promoting public health worldwide. Moreover, basic scientific data are required for the regulation of e-cigarette. To date, there have been reports of many hazardous chemical compounds generated from e-cigarettes, particularly carbonyl compounds such as formaldehyde, acetaldehyde, acrolein, and glyoxal, which are often found in e-cigarette aerosols. These carbonyl compounds are incidentally generated by the oxidation of e-liquid (liquid in e-cigarette; glycerol and glycols) when the liquid comes in contact with the heated nichrome wire. The compositions and concentrations of these compounds vary depending on the type of e-liquid and the battery voltage. In some cases, extremely high concentrations of these carbonyl compounds are generated, and may contribute to various health effects. Suppliers, risk management organizations, and users of e-cigarettes should be aware of this phenomenon.

Smokeless Tobacco Risk Comparison and Other Debate Messages in the News

OBJECTIVES

Public health professionals have debated the use of smokeless tobacco (SLT) over cigarettes for harm reduction. This article describes SLT and cigarette risk comparisons and other SLT "debate" messages potentially reaching the public through news stories.

METHODS

We conducted a content analysis of SLT-related 2006-10 articles from top newspapers and selected news wires.

RESULTS

About 16% of articles (N = 677) referred to SLT as less harmful than smoking, attributing these messages to public health professionals as frequently as to tobacco company representatives. About 29% of articles included an "anti" SLT message, including variously phrased warnings that SLT is not a safe smoking alternative, or other potential consequences such as youth uptake.

CONCLUSION

Professionals should begin developing and using more consistent messages about SLT's risks.

Combusted but not smokeless tobacco products cause DNA damage in oral cavity cells

The aim of this work was to investigate genomic DNA damage in human oral cavity cells after exposure to different tobacco product preparations (TPPs). The oral carcinoma cell line 101A, gingival epithelial cells HGEC, and gingival fibroblasts HGF were exposed to TPM (total particulate matter from 3R4F cigarettes), ST/CAS (2S3 smokeless tobacco extract in complete artificial saliva), and NIC (nicotine). Treatments were for 24 h using TPM at its EC-50 doses, ST/CAS and NIC at doses with equi-nicotine units, and high doses for ST/CAS and NIC. Comet assays showed that TPM, but not ST/CAS or NIC, caused substantial DNA breaks in cells; only the high ST/CAS dose caused weak DNA damage. These results were confirmed by immunofluorescence for γ-H2AX protein. These data revealed that the combusted TPP caused substantial DNA damage in all cell types, whereas the two non-combusted TPPs exerted no or only minimal DNA damage. They support epidemiologic evidence on the relative risk associated with consumption of non-combusted versus combusted tobacco products, and help to understand potential genotoxic effects of such products on oral cavity cells.

The predicted impact of reducing the nicotine content in cigarettes on alcohol use

INTRODUCTION

Product standards reducing the level of nicotine in cigarettes could significantly improve public health by reducing smoking behavior and toxicant exposure. However, relatively little is known about how the regulatory strategy could impact alcohol use, a closely related health behavior that is also a major contributor to morbidity and mortality. The primary objective of this paper is to predict the effect of nicotine reduction on alcohol use, identify priorities for future research, and highlight areas for mitigating any adverse outcomes.

METHODS

We critically reviewed and integrated literatures examining the effects of very low nicotine content (VLNC) cigarettes on smoking-related outcomes (nicotine exposure, nicotine withdrawal, and smoking as a cue to drink) and, in turn, the effects of those outcomes on alcohol use.

RESULTS

Current evidence suggests reducing the nicotine content of cigarettes may benefit public health by reducing alcohol use and problematic drinking over time as a consequence of reduced exposure to nicotine and the smoking cues associated with drinking. Nicotine withdrawal could increase risk of drinking, although these effects should be short-lived and could be mitigated by other sources of nicotine. Gender, hazardous drinking, and psychiatric comorbidities are likely to be important moderators of the effects of VLNC cigarettes.

CONCLUSIONS

It is imperative to broadly assess the public health impact of potential tobacco product regulations by including measures of closely related health behaviors that could be impacted by these interventions. Nicotine reduction in cigarettes may contribute to improved public health through reductions in alcohol use.

Electronic cigarettes. Potential harms and benefits

Use of electronic cigarettes, devices that deliver a nicotine-containing vapor, has increased rapidly across the country and globally. Perceived and marketed as a "healthier alternative" to conventional cigarettes, few data exist regarding the safety of these devices and their efficacy in harm reduction and treatment of tobacco dependence; even less is known about their overall impact on population health. This review highlights the recent data regarding electronic cigarette toxicity, impact on lung function, and efficacy in smoking reduction and cessation. Studies show that the vapor generated from electronic cigarettes has variable amounts of nicotine and potential harmful toxins, albeit at levels lower than in conventional cigarettes. The long-term carcinogenic and lung function effects of electronic cigarettes are not known. Although some data demonstrate that electronic cigarettes may be effective in reducing conventional cigarette consumption, there are no data demonstrating the efficacy of electronic cigarettes as a tool to achieve cessation. Until robust longitudinal evaluations demonstrate the safety of electronic cigarettes and efficacy in treatment of tobacco dependence, their role as a harm reduction tool is unclear.

The impact of product information and trials on demand for smokeless tobacco and cigarettes: evidence from experimental auctions

INTRODUCTION

Epidemiological and toxicological evidence suggests lower risk of smokeless tobacco (ST) products compared to cigarettes. Less is known, however, about consumer perceptions and use of novel forms of ST, including snus and dissolvable tobacco.

METHODS

In this study, we conducted in-person experimental auctions in Buffalo, NY, Columbia, SC, and Selinsgrove, PA with 571 smokers to test the impact of information and product trials on smokers' preferences. Auctions were conducted between November 2010-November 2011.

RESULTS

We found no evidence of an impact of product trials on demand in our auctions. Anti-ST information increased demand for cigarettes when presented alone, but when presented with pro-ST information it decreased demand for cigarettes. It did not decrease demand for ST products. Anti-smoking information increased demand for ST products, but did not affect cigarette demand.

CONCLUSIONS

These findings suggest that credible and effective communications about tobacco harm reduction should reinforce the negative effects of smoking.

Electronic cigarettes. Potential harms and benefits

Use of electronic cigarettes, devices that deliver a nicotine-containing vapor, has increased rapidly across the country and globally. Perceived and marketed as a "healthier alternative" to conventional cigarettes, few data exist regarding the safety of these devices and their efficacy in harm reduction and treatment of tobacco dependence; even less is known about their overall impact on population health. This review highlights the recent data regarding electronic cigarette toxicity, impact on lung function, and efficacy in smoking reduction and cessation. Studies show that the vapor generated from electronic cigarettes has variable amounts of nicotine and potential harmful toxins, albeit at levels lower than in conventional cigarettes. The long-term carcinogenic and lung function effects of electronic cigarettes are not known. Although some data demonstrate that electronic cigarettes may be effective in reducing conventional cigarette consumption, there are no data demonstrating the efficacy of electronic cigarettes as a tool to achieve cessation. Until robust longitudinal evaluations demonstrate the safety of electronic cigarettes and efficacy in treatment of tobacco dependence, their role as a harm reduction tool is unclear.

Estimating demand for alternatives to cigarettes with online purchase tasks

OBJECTIVES

To explore how advertising affects demand for cigarettes and potential substitutes, including snus, dissolvable tobacco, and medicinal nicotine.

METHODS

A Web-based experiment randomized 1062 smokers to see advertisements for alternative nicotine products or soft drinks, then complete a series of purchase tasks, which were used to estimate demand elasticity, peak consumption, and cross-price elasticity (CPE) for tobacco products.

RESULTS

Lower demand elasticity and greater peak consumption were seen for cigarettes compared to all alternative products (p < .05). CPE did not differ across the alternative products (p ≤ .03). Seeing relevant advertisements was not significantly related to demand.

CONCLUSIONS

These findings suggest significantly lower demand for alternative nicotine sources among smokers than previously revealed.

Noncombustible tobacco product advertising: how companies are selling the new face of tobacco

BACKGROUND

With declining cigarette sales, increasing restrictions, and recent Food and Drug Administration (FDA) regulation of cigarettes, there has been a dramatic rise in the marketing of noncombustible tobacco products (NCPs). However, little is known about how NCPs are advertised and to whom.

METHODS

Two full-service advertising firms were used to systematically collect all U.S. advertisements for NCPs (e-cigarettes, snus, dissolvables, and chew/dip/snuff,) running between June 1 and September 1, 2012. The advertisement and associated metadata (brand, media channel, observations, spend, and estimated reach) were examined. Attributes of print advertisements were examined relative to target demographics of the publications in which they ran.

RESULTS

Over 3 months, almost $20 million was spent advertising NCPs. Although the greatest amount spent was on the promotion of smokeless (~$8 million) and snus (~$10 million), e-cigarette advertisements were the most widely circulated. Print advertisements, the majority of which were e-cigarettes and chew/dip/snuff, were heavily tailored to middle-aged White males. Many e-cigarette print ads suggested harm reduction and use when one cannot smoke (poly-use), while chew/dip/snuff focused on masculinity.

CONCLUSIONS

Robust ongoing surveillance of NCP advertising is critical to inform the FDA and to protect public health. Both commercial advertising and public health media campaigns must ensure that content is not misleading and that it educates consumers about harm based on the available science. The way messages are framed have the potential to decrease tobacco use by promoting rather than undermining cessation of combusted products and/or by encouraging exclusive use of less harmful NCPs rather than poly-use of combusted and NCPs.

An endgame for tobacco?

Since its origins in the 1960s, tobacco control has achieved remarkable success against the scourge of tobacco-produced disease and death. Yet tobacco use, especially cigarette smoking, remains the world's leading cause of preventable premature death and is likely to do so for decades to come. Evidence-based policies seem incapable of substantially hastening the demise of smoking. Slowness in the decline of smoking in developed nations, and increasing smoking in many low- and middle-income countries has sparked interest in novel, even radical 'endgame' strategies to eliminate the toll of tobacco. This paper identifies the principal endgame proposals and, with the other papers in this volume, has the goal of expanding and deepening the endgame conversation by engaging the broader tobacco control community. While we struggle today with often widely divergent perspectives and beliefs about what is possible and how it might be achieved, we all share the same vision of the final words to this story: ‘The end’.

Combustible and non-combustible tobacco product preparations differentially regulate human peripheral blood mononuclear cell functions

Natural killer (NK) cells and T cells play essential roles in innate and adaptive immune responses in protecting against microbial infections and in tumor surveillance. Although evidence suggests that smoking causes immunosuppression, there is limited information whether the use of smokeless tobacco (ST) products affects immune responses. In this study, we assessed the effects of two preparations of cigarette smoke, ST extract and nicotine on T cell and NK cell responses using Toll-like receptor-ligand stimulated human peripheral blood mononuclear cells (PBMCs). The tobacco product preparations (TPPs) tested included whole smoke conditioned media (WS-CM), total particulate matter (TPM) and a ST product preparation in complete artificial saliva (ST/CAS). The PBMCs were stimulated with polyinosinic:polycytidylic acid (poly I:C) and lipopolysaccharide (LPS). A marked reduction of the expression of intracellular IFN-γ and TNF-α was evident in NK cells and T cells treated with WS-CM and TPM. Consistently, attenuation of ligand-induced secretion of cytokines (IL-1β, IL-10, IL-12 and TNF-α) from PBMCs treated with WS-CM and TPM were observed. While the treatment with TPPs did not alter the expression of the maturation marker CD69, WS-CM and TPM inhibited the cytolytic activity of human PBMCs. Suppression of perforin by WS-CM was also detected. Although interference from the vehicle confounded the interpretation of effects of ST/CAS, some effects were evident only at high concentrations. Nicotine treatment minimally impacted expression of cytokines and cytolytic activity. Data presented herein suggests that the function of NK cells and T cells is influenced by exposure to TPPs (based on equi-nicotine units) in the following order: WS-CM>TPM>ST/CAS. These findings are consistent with the hypothesis put forward by others that chronic smoking leads to immunosuppression, an effect that may contribute to increased microbial infections and cancer incidence among smokers.

A content analysis of smokeless tobacco coverage in U.S. newspapers and news wires

INTRODUCTION

Research attention on smokeless tobacco (SLT) has focused on SLT use, health risks, harm-reduction potential, and risk perceptions, but few studies have examined mediated communications about SLT. This study aims to contribute to the literature by providing the first description of SLT coverage in the news, an important communication channel given its ability to educate and shape public opinion about tobacco issues.

METHODS

A content analysis was conducted on SLT-related news and opinion articles between 2006 and 2010 from top circulating national and state newspapers and select news wires. Articles were coded for the main SLT topic, SLT risk references, and slant of opinion articles.

RESULTS

SLT was discussed in news/feature articles (n = 677) in terms of business (28%), new products, product regulation and harm reduction (19%), prevention/cessation (11.4%), taxation (10.2%), profiles/trends in use (9%), bans (8.1%), and tobacco industry promotional activities (4.9%). Health risk references (i.e., addictiveness, carcinogenicity, and specific health effects including oral cancer) were found in 40% of articles, though frequency differed by article topic. Although the majority of opinion articles (n = 176) conveyed an anti-SLT slant (64%), 25.6% were pro-SLT.

CONCLUSIONS

SLT topics of both national and local importance are covered in the news. Public health professionals can participate in SLT coverage by sending in press releases about new study findings, events, or resources and by submitting opinion pieces to share views or respond to previous coverage. Research on SLT news should continue given its potential to shape the public's SLT knowledge and opinions.

Nicotine reduction: strategic research plan

BACKGROUND

Reducing nicotine content in cigarettes and other combustible products to levels that are not reinforcing or addictive has the potential to substantially reduce tobacco-related morbidity and mortality. The authority to reduce nicotine levels as a regulatory measure is provided in the U.S. Family Smoking Prevention and Tobacco Control Act and is consistent with the general regulatory powers envisioned under the relevant articles of the World Health Organization's Framework Convention on Tobacco Control. Many experts have considered reducing nicotine in cigarettes to be a feasible national policy approach, but more research is necessary.

PURPOSE

This article describes proceedings from a conference that had the goals of identifying specific research gaps, describing methods and measures to consider for addressing these gaps, and considering ways to foster collaboration.

RESULTS AND CONCLUSION

Identified research gaps included determining the dose of nicotine that would be optimal for reducing and extinguishing cigarette use, examining approaches for reducing nicotine levels in the general and special populations of smokers, understanding how constituents other than nicotine may contribute to the reinforcing effects of tobacco, and identifying unintended consequences to determine ways to mitigate them. Methods that can be used ranged from brain imaging to large human clinical trials. The development and availability of valid biomarkers of exposure and effect are important. Infrastructures to facilitate collaboration need to be established.

Ending tobacco-caused mortality and morbidity: the case for performance standards for tobacco products

The US Family Smoking Prevention and Tobacco Control Act and WHO Framework Convention on Tobacco Control provide us with powerful tools to reduce the death and disease caused by the use of tobacco products. One tool that can contribute substantially toward this goal is the authority to establish performance standards for tobacco products. Conjointly with reducing levels of nicotine in cigarettes, performance and quality control standards need to be established for non-combusted tobacco products. Performance standards and incentives should be provided so that tobacco companies are compelled to manufacture and market products with very low or almost non-existent toxicity (eg, nicotine-only products).

Research required for the effective implementation of the framework convention on tobacco control, articles 9 and 10

This paper is part of a series of articles intended to set out the research questions that are relevant to the successful implementation of the various provisions of the Framework Convention on Tobacco Control (FCTC). This paper focuses on issues affecting Articles 9 and 10 of the FCTC. This paper focuses on the research that is most important for most countries, rather than on what is desirable in countries with high levels of research capacity. Articles 9 and 10 of the FCTC address the regulation of contents and emissions of tobacco products and regulation of tobacco product disclosure. Such regulation will be essential if the long-term objective of reducing the danger of tobacco products is to be achieved. There are many components of tobacco and tobacco smoke that are excessively toxic and dangerous to the user. Many of these components are carcinogenic and addictive and can be removed or reduced substantially with current known technology. The fact that these components remain in tobacco and tobacco smoke at levels that are unnecessarily dangerous is precisely the reason why the successful implementation of Articles 9 and 10 of the FCTC is important to tobacco control. This paper discusses the scientific challenges involved in successfully implementing Articles 9 and 10 of the FCTC, which focuses on regulating carcinogens and toxins in tobacco and tobacco smoke, the abuse liability of tobacco products, and the additives and engineering features in tobacco products that make tobacco products appealing to future consumers. The research issues we focus on are those required to support the early stages of regulation. As regulation proceeds, new and more sophisticated research questions will undoubtedly emerge.

The chemical composition of smokeless tobacco: a survey of products sold in the United States in 2006 and 2007

Selected toxicant concentrations and other chemical measures have been determined for 43 U.S. smokeless tobacco products sold in 2006 and 2007. Products evaluated included moist snuff, dry snuff, loose leaf, plug, dissolvable and snus tobacco brands. Reference products available for scientific research purposes and eleven Swedish products were also evaluated and compared to the commercial products studied. Chemical endpoints determined included benzo[a]pyrene (B[a]P), N'-nitrosonornicotine (NNN), N'-nitrosoanatabine (NAT), N'-nitrosoanabasine (NAB), 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK), N-Nitrosodimethylamine (NDMA), nitrite, cadmium, lead, arsenic, nickel, chromium, chloride, water, pH and nicotine. Different toxicant profiles were observed for the products studied, with snus tobacco brands generally containing relatively low concentrations of B[a]P and tobacco specific nitrosamines (TSNAs) compared to other moist snuffs. Smokeless tobacco reference product toxicant profiles were similar to corresponding commercial products, with the exception of the TSNA content of the dry snuff reference material. TSNA concentrations observed for all commercial products were lower than historically reported values, likely reflecting changes in product shelf life, tobacco curing practices and, possibly, product blend formulations during the last 20-30 years. The survey results summarized provide a temporal point of comparison with future data anticipated from FDA "harmful and potentially harmful constituents in tobacco products" reporting.

Dose-response effects of spectrum research cigarettes

INTRODUCTION

Experimental cigarettes are needed to conduct studies examining the effects of varying doses of nicotine content on smoking behavior. The National Institute on Drug Abuse contracted with Research Triangle Institute to make such cigarettes available to researchers. The goal of this study was to determine whether cigarettes that vary in nicotine content produce an expected dose-response effect.

METHOD

Two studies were conducted. The first study recruited subjects from 3 sites and consisted of a single, within-subject laboratory session. Subjects first smoked 4 puffs on their usual-brand cigarette and then in double-blind, random-order, smoked 4 puffs on each experimental cigarette that contained either low nicotine (LN, 0.4 mg/g), intermediate nicotine (IN, 5.7-5.8 mg/g), or high nicotine (HN, 11.4-12.8 mg/g). Each puffing bout was separated by a 30-min interval. Subjects completed questionnaires and were assessed for vital signs after each cigarette. The second study involved 1 site and used a between-subject design in which subjects were assigned to 1 of the 3 experimental cigarettes for 1 week. Subjective responses and biomarkers of exposure were assessed.

RESULTS

In the first study, significant dose-response effects were observed, particularly between the LN and HN cigarettes. The second study showed decreases in cigarette smoking and exposure biomarkers predominantly in the LN group, with no changes in the HN cigarette group.

CONCLUSIONS

These results are similar to those observed in prior literature, confirming that these experimental cigarettes can be used safely and with the expected pharmacological effects.

Reduced exposure evaluation of an Electrically Heated Cigarette Smoking System. Part 1: Non-clinical and clinical insights

The following series of papers presents an extensive assessment of the Electrically Heated Cigarette Smoking System EHCSS series-K cigarette vs. conventional lit-end cigarettes (CC) as an example for an extended testing strategy for evaluation of reduced exposure. The EHCSS produces smoke through electrical heating of tobacco. The EHCSS series-K heater was designed for exclusive use with EHCSS cigarettes, and cannot be used to smoke (CC). Compared to the University of Kentucky Reference Research cigarette 2R4F and a series of commercial CC, mainstream cigarette smoke of both the non-menthol and menthol-flavored EHCSS cigarettes showed a reduced delivery of a series of selected harmful and potentially harmful constituents (HPHC), mutagenic activity determined using the Salmonella typhimurium Reverse Mutation (Ames) assay, and cytotoxicity in the Neutral Red Uptake Assay. Clinical evaluations confirmed reduced exposure to HPHC and excretion of mutagenic material under controlled clinical conditions. Reductions in HPHC exposure were confirmed in a real-world ambulatory clinical study. Potential biomarkers of cardiovascular risk were also reduced under real-world ambulatory conditions. A modeling approach, 'nicotine bridging', was developed based on the determination of nicotine exposure in clinical evaluations which indicated that exposure to HPHC for which biomarkers of exposure do not exist would also be reduced.

Dependence on tobacco and nicotine products: a case for product-specific assessment

The International Classification of Diseases and the Diagnostic and Statistical Manual for diagnosing tobacco/nicotine dependence emphasize the dependence-producing drug nicotine. These diagnostic tools have been challenged on grounds of poor predictive validity, and they do not differentiate across various forms of nicotine-containing products. In fact, nicotine-containing products (e.g., tobacco cigarettes, smokeless tobacco [ST], waterpipe, electronic cigarettes [ECIGs], and nicotine replacement [NR] products) have very different characteristics both in terms of sensory and behavioral involvement and also in pharmacokinetic and pharmacodynamic effects. For example, a cigarette and a nicotine patch are very different on almost every one of these dimensions. When ability to stop using a nicotine/tobacco product is used as a criterion for dependence, success rates vary considerably across products: Tobacco cigarette cessation is more difficult than ST cessation that in turn is more difficult than NR product cessation. Based on these results, we hypothesize that there is a continuum of dependence as much as there is a continuum of harm, with tobacco cigarettes and NR products on opposite ends of both continua and other products (waterpipe and ECIGs) somewhere in between. In order to capture more precisely the dependence produced by both nicotine and its administration forms, product-specific instruments may be required. The pros and cons of this approach are discussed.

Very low nicotine content cigarettes and potential consequences on cardiovascular disease

Cigarette smoking remains highly prevalent in the U.S. and contributes significantly to cardiovascular disease (CVD). Tobacco control policies, including product regulation, can reduce smoking-related harm. One approach being considered in the U.S. is for the FDA to set a low nicotine standard for cigarettes. Such a standard could result in multiple beneficial outcomes including reduced cardiovascular toxicity related to nicotine, reduced smoking intensity in current smokers, increased cessation rates, decreased development of smoking dependence in youth, and decreased passive smoke exposure. Consequently, CVD risk in the U.S. could be dramatically improved by nicotine reduction in cigarettes. Possible pathways linking nicotine reduction in cigarettes to decreased CVD risk are discussed, while potential unintended consequences that could offset expected gains are also presented. Gaps in the literature, including limited data on CVD biomarkers and long-term CVD outcomes following the use of very low nicotine cigarettes, are discussed to highlight areas for new research.

Is smokeless tobacco use becoming more common among U.S. male smokers? Trends in Alaska

INTRODUCTION

The tobacco industry has promoted the use of smokeless tobacco (SLT) to smokers as a substitution for cigarettes when smoking is not possible, and some smokers are using SLT this way. However, few publications have examined recent trends in dual cigarette and SLT use (dual use) over time in the U.S.

MATERIALS AND METHODS

We examined trends in the use of SLT among current, former and never cigarette smokers using data on adult (aged 18+ years) males (n=16,590) from the 1996-2008 Alaska Behavioral Risk Factor Surveillance System (BRFSS). We also examined trends from 2004 to 2008 in cigarette consumption among dual users.

RESULTS

Between 1996 and 2008, the overall prevalence of current SLT use and prevalence of current smoking among Alaskan men did not significantly change over time (p-value from age-adjusted models p=.63, p=.09, respectively). When we examined trends in SLT use by smoking status, we found that the prevalence of current SLT use remained unchanged between 1996 and 2008 among former and never smokers, but almost doubled among current smokers (age-adjusted p=.004). Between 2004 and 2008, cigarette consumption remained steady among current smokers who did not use SLT, but significantly decreased among dual users (age-adjusted p<.001).

CONCLUSIONS

Our findings suggest that male smokers in Alaska are increasingly likely to use SLT, but do not appear to be switching to SLT use exclusively. We recommend that other state tobacco control programs examine trends in dual use to confirm our findings, and for programs to continue encouraging cessation of all tobacco products.

Delivery of nicotine in an extract of a smokeless tobacco product reduces its reinforcement-attenuating and discriminative stimulus effects in rats

RATIONALE

Animal models of tobacco addiction rely on administration of nicotine alone or nicotine combined with isolated constituents. Models using tobacco extracts derived from tobacco products and containing a range of tobacco constituents might more accurately simulate tobacco exposure in humans.

OBJECTIVE

To compare the effects of nicotine alone and an aqueous smokeless tobacco extract in several addiction-related animal behavioral models.

METHODS

Nicotine alone and nicotine dose-equivalent concentrations of extract were compared in terms of their acute effects on intracranial self-stimulation (ICSS) thresholds, discriminative stimulus effects, and effects on locomotor activity.

RESULTS

Similar levels of nicotine and minor alkaloids were achieved using either artificial saliva or saline for extraction, supporting the clinical relevance of the saline extracts used in these studies. Extract produced reinforcement-enhancing (ICSS threshold-decreasing) effects similar to those of nicotine alone at low to moderate nicotine doses, but reduced reinforcement-attenuating (ICSS threshold-increasing) effects at a high nicotine dose. In rats trained to discriminate nicotine alone from saline, intermediate extract doses did not substitute for the training dose as well as nicotine alone. Locomotor stimulant effects and nicotine distribution to brain were similar following administration of extract or nicotine alone.

CONCLUSIONS

The reinforcement-attenuating and discriminative stimulus effects of nicotine delivered in an extract of a commercial smokeless tobacco product differed from those of nicotine alone. Extracts of tobacco products may be useful for evaluating the abuse liability of those products and understanding the role of non-nicotine constituents in tobacco addiction.

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

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

Postmarketing surveillance for "modified-risk" tobacco products

INTRODUCTION

The U.S. Food and Drug Administration (FDA) acquired authority to regulate tobacco products in 2009. This authority will provide a structured process for manufacturers to introduce products that may have "modified-risk" for morbidity or mortality relative to traditional tobacco products, with postmarketing surveillance and studies a condition of marketing.

METHOD

A narrative review approach was taken. The author searched and integrated publicly accessible literature on tobacco product surveillance as well as drug and medical device postmarket activities currently performed by FDA.

RESULTS

FDA relies on active and passive methods for postmarket surveillance and can require specific studies and risk evaluation and mitigation strategies for certain products, including those with abuse liability. Past efforts at examining the individual and population effects of reduced harm tobacco products provide an example of integrating different data streams.

DISCUSSION

Postmarket surveillance can be viewed in terms of the Agent-Host-Vector-Environment model, and concepts from diffusion of innovations are relevant to understanding factors associated with the adoption of new products by the population. Given that active and passive surveillance approaches have different strengths and weaknesses, multiple approaches may be necessary to evaluate population-level effects. Assuring that required studies are properly conducted and reported and that data indicating significant public health harms are quickly recognized will be important going forward.

CONCLUSIONS

The advent of broad regulatory authority over tobacco provides opportunities for policy evaluation research. The research community can provide FDA with the independent science it needs to evaluate the public health impact of novel tobacco products.

Tobacco and nicotine product testing

INTRODUCTION

Tobacco product testing is a critical component of the Family Smoking Prevention and Tobacco Control Act (FSPTCA), which grants the Food and Drug Administration the authority to regulate tobacco products. The availability of methods and measures that can provide accurate data on the relative health risks across types of tobacco products, brands, and subbrands of tobacco products on the validity of any health claims associated with a product, and on how consumers perceive information on products toxicity or risks is crucial for making decisions on the product's potential impact on public health. These tools are also necessary for making assessments of the impact of new indications for medicinal products (other than cessation) but more importantly of tobacco products that may in the future be marketed as cessation tools.

OBJECTIVE

To identify research opportunities to develop empirically based and comprehensive methods and measures for testing tobacco and other nicotine-containing products so that the best science is available when decisions are made about products or policies.

METHODS

Literature was reviewed to address sections of the FSPTCA relevant to tobacco product evaluation; research questions were generated and then reviewed by a committee of research experts.

RESULTS

A research agenda was developed for tobacco product evaluation in the general areas of toxicity and health risks, abuse liability, consumer perception, and population effects.

CONCLUSION

A cohesive, systematic, and comprehensive assessment of tobacco products is important and will require building consensus and addressing some crucial research questions.

The nature, scope, and development of the global tobacco control epistemic community

Over the past 50 years, tobacco control has been transformed from a national to a global issue, becoming institutionalized in the World Health Organization (WHO) Framework Convention on Tobacco Control, the first international public health treaty negotiated under the auspices of the WHO. The global tobacco control epistemic community, a worldwide network of professionals with a common interpretation of the science in tobacco use and control, has contributed to this transformation. We investigated the development, structure, and function of this community through interviews and archival documents. Professionals in the community are bound by values and consensual knowledge developed after years of contentious debates undergirded their activities. Although these professionals play multiple roles, they recognize that scientific evidence should inform advocacy and policy activities. Public health professionals should continue to strengthen the links between science and advocacy for policy while being vigilant against industry efforts to undermine the scientific evidence on tobacco use and control.

A lack of association between severity of nicotine withdrawal and individual differences in compensatory nicotine self-administration in rats

RATIONALE

Compensatory smoking may represent an adverse consequence of smoking reduction or the use of reduced-nicotine tobacco products. Factors contributing to individual variability in compensation are poorly understood.

OBJECTIVE

The objective of this study was to examine whether severity of nicotine withdrawal as measured by elevated intracranial self-stimulation (ICSS) thresholds is related to individual differences in compensatory nicotine self-administration (NSA) following unit dose reduction.

METHODS

Rats were trained for ICSS and NSA (0.06 mg/kg per infusion). After stabilization, effects of reducing the nicotine unit dose to 0.03 mg/kg per infusion were examined. Following reacquisition of NSA (0.06 mg/kg per infusion), effects of antagonist-precipitated withdrawal and saline extinction (spontaneous withdrawal) were examined.

RESULTS

Reducing the NSA unit dose produced partial compensation as indicated by the increased infusion rates, but a 35% mean decrease in daily nicotine intake. The magnitude of compensation varied considerably among rats. Dose reduction did not elicit withdrawal in rats as a group, although there were substantial increases in ICSS thresholds in some animals. Intracranial self-stimulation thresholds were consistently elevated during precipitated and spontaneous withdrawal, confirming that rats were nicotine-dependent. Individual differences in compensation were not correlated with changes in ICSS thresholds during dose reduction, precipitated withdrawal, or spontaneous withdrawal. In a secondary analysis, greater precipitated withdrawal severity predicted greater initial nicotine seeking during extinction.

CONCLUSIONS

Severity of nicotine withdrawal was not related to the degree of compensation in this protocol. These data do not support a role for nicotine withdrawal in individual differences in compensation during reduced nicotine exposure, but do suggest that withdrawal may contribute to nicotine seeking during early abstinence.

Peers, tobacco advertising, and secondhand smoke exposure influences smoking initiation in diverse adolescents

PURPOSE

Identify demographic, social, and environmental factors associated with smoking initiation in a large, racially and ethnically diverse sample of underage youth participating in the 2006 Maryland Youth Tobacco Survey.

DESIGN

Cross-sectional, multistage, probability sample survey.

SETTING

Schools (308 middle and high schools) in Maryland.

SUBJECTS

Subjects were 12- to 17-year-old adolescents participating in a school-based survey. New smokers and nonsmokers were included in the analysis (n  =  57,072).

MEASURES

Social and media influence, secondhand smoke exposure, tobacco product use, and demographic information including age, race/ethnicity, and geographic region.

ANALYSIS

Chi-square and multiple logistic regression analyses controlling for clustering.

RESULTS

Hispanic and Hawaiian/Pacific Islander youth were most likely and Asian and Black youth were least likely to be new smokers. Smoking initiation was positively associated with higher age, living with a current smoker, secondhand smoke exposure, exposure to advertisements for tobacco products, having more friends that smoke, tobacco products offered by friends, risk perceptions, and use of other tobacco products such as smokeless tobacco and cigars. Multivariate logistic regression results suggested that composite measures of peer influence, advertising exposure, and secondhand smoke exposure were independently associated with smoking initiation.

CONCLUSIONS

Media, peer influence, and secondhand smoke exposure were the most important factors influencing smoking initiation and were common to all racial/ethnic groups in this study. Interventions combining targeted public awareness, education, and media campaigns directed at parents/guardians should be investigated.

Tobacco harm reduction and the evolution of nicotine dependence

In recent years, a renewed debate has developed around the potential for modified tobacco products to play a role in reducing tobacco-related harm. During the 1960s and 1970s medical experts recommended to smokers who could not quit that they switch to cigarettes with lower tar and nicotine content. At the time, survey data suggested that smokers who switched did not compensate for the reduction in nicotine by increasing their intake. However, public health scientists were hindered in their ability to evaluate the population impact of the reduced tar strategy by a limited understanding of nicotine addiction. Smoking dependence was seen as primarily psychological and social, rather than pharmacological or biological, until the late 1970s, when addiction researchers began to apply experimental techniques from other forms of drug abuse to study smoking behavior. This history has important lessons for current discussions about tobacco harm reduction and regulation of nicotine delivery.

The appeal of smokeless tobacco products among young Canadian smokers: the impact of pictorial health warnings and relative risk messages

INTRODUCTION

Although the health risks from smokeless tobacco (ST) are lower than cigarettes, it remains unclear how smokers might use ST products, including as a substitute, a cessation aid, or concurrently with cigarette use, if at all. Additionally, there is little evidence examining the impact of health warning labels (HWL) on ST use and perceptions.

METHODS

The current study investigated perceptions of ST products with and without HWL and a relative health risk (RHR) message. The study consisted of a full-factorial "between-subjects" experiment in which 3 HWL and a RHR message were systematically varied. Canadian smokers aged 18-30 years (N = 611) completed an online survey where they viewed four brands of ST packages altered according to the experimental conditions.

RESULTS

Approximately half of the smokers indicated that they were willing to try ST as a substitute and to help quit smoking. More than one quarter (28%) of smokers were unaware that using ST is less harmful than smoking. Pictorial HWL increased false beliefs about the RHR of ST and decreased smokers' willingness to try ST, whereas text warnings did not. Adding a RHR message communicating the lower risk of ST compared with cigarettes increased willingness to try ST when added to text HWL but decreased willingness to try ST even further when added to pictorial HWL.

CONCLUSIONS

The findings indicate relatively high levels of appeal for ST among young adult Canadian cigarette smokers. Pictorial HWL reduced the appeal of ST products and increased perceived risks, including the false belief that ST is equally harmful as cigarettes. Further research could consider evaluating designs of HWL on ST products that better balance absolute and RHR.

Prevalence of trial of snus products among adult smokers

A 2008 survey assessed the proportion of smokers in 8 geographic areas who reported trying snus. In test markets, 10% of smokers had tried snus in the past year. Among young adult men, the trial rate was 29%. Trial was more likely among Whites than among minorities, among respondents with lower education than among those with higher education, and among those without immediate plans to quit smoking than among those intending to quit in the next 30 days. The association between trial and low cessation motivation is an important target for research.