Health impact of "reduced yield" cigarettes: a critical assessment of the epidemiological evidence

E-Cigarettes and the Multiple Responsibilities of the FDA

This paper considers the responsibilities of the FDA with regard to disseminating information about the benefits and harms of e-cigarettes. Tobacco harm reduction advocates claim that the FDA has been overcautious and has violated ethical obligations by failing to clearly communicate to the public that e-cigarettes are far less harmful than cigarettes. We argue, by contrast, that the FDA's obligations in this arena are more complex than they may appear at first blush. Though the FDA is accountable for informing the public about the health risks and benefits of products it regulates, it also has other roles (and attendant responsibilities) that inform when and how it should disseminate information. In addition to being a knowledge purveyor, it is also a knowledge producer, an advisor to the public, and a practical agent shaping the material conditions in which people make health-related choices. In our view, those other roles call for caution in the way the FDA interprets and communicates the available evidence.

European adult smokers' perceptions of the harmfulness of e-cigarettes relative to combustible cigarettes: cohort findings from the 2016 and 2018 EUREST-PLUS ITC Europe Surveys

Background

This study presents perceptions of the harmfulness of electronic cigarettes (e-cigarettes) relative to combustible cigarettes among smokers from six European Union (EU) countries, prior to the implementation of the EU Tobacco Products Directive (TPD), and 2 years post-TPD.

Methods

Data were drawn from the EUREST-PLUS ITC Europe Surveys, a cohort study of adult smokers (≥18 years) from Germany, Greece, Hungary, Poland, Romania and Spain. Data were collected in 2016 (pre-TPD: N = 6011) and 2018 (post-TPD: N = 6027). Weighted generalized estimating equations were used to estimate perceptions of the harmfulness of e-cigarettes compared to combustible cigarettes (less harmful, equally harmful, more harmful or ‘don’t know’).

Results

In 2016, among respondents who were aware of e-cigarettes (72.2%), 28.6% reported that they perceived e-cigarettes to be less harmful than cigarettes (range 22.0% in Spain to 34.1% in Hungary). In 2018, 72.2% of respondents were aware of e-cigarettes, of whom 28.4% reported perceiving that e-cigarettes are less harmful. The majority of respondents perceived e-cigarettes to be equally or more harmful than cigarettes in both 2016 (58.5%) and 2018 (61.8%, P > 0.05). Overall, there were no significant changes in the perceptions that e-cigarettes are less, equally or more harmful than cigarettes, but ‘don’t know’ responses significantly decreased from 12.9% to 9.8% (P = 0.036). The only significant change within countries was a decrease in ‘don’t know’ responses in Spain (19.3–9.4%, P = .001).

Conclusions

The majority of respondents in these six EU countries perceived e-cigarettes to be equally or more harmful than combustible cigarettes.

Association of Cigarette Type and Nicotine Dependence in Patients Presenting for Lung Cancer Screening

BACKGROUND

Over decades, there have been several alterations to cigarettes, including the addition of filters and flavoring. However, lung cancer remains the leading cause of cancer-related death in the United States.

RESEARCH QUESTION

The aim of this study was to examine the association of type of cigarette on nicotine dependence in the setting of lung cancer screening.

STUDY DESIGN AND METHODS

This study is a secondary analysis of the American College of Radiology Imaging Network arm of the National Lung Screening Trial. Tobacco dependence was evaluated by using the Fagerstrӧm Test for Nicotine Dependence, the Heaviness of Smoking Index, and time to first cigarette. Clinical outcomes, including nicotine dependence and tobacco abstinence, were assessed with descriptive statistics and χ² tests, stratified according to cigarette tar level, flavor, and filter. Logistic regression was used to study the influence of variables on smoking abstinence.

RESULTS

More than one-third of individuals presenting for lung cancer screening are highly addicted to nicotine and smoke within 5 min of waking up. Smokers of unfiltered cigarettes were more nicotine dependent compared with filtered cigarette smokers (OR, 1.32; P < .01). Although smokers of light/ultralight cigarettes had lower dependence (OR, 0.76, P < .0001), there was no difference in smoking abstinence compared with regular cigarette smokers. There was no difference in outcomes when comparing smokers of menthol vs unflavored cigarettes.

INTERPRETATION

In a screening population, the type of cigarette smoked is associated with different levels of dependence. Eliciting type of cigarette and time to first cigarette has the potential to allow for tailored tobacco treatment interventions within this context.

Smokers Awareness and Risk Perceptions of Filter Ventilation

Objectives

The addition of tiny rows of holes in the tipping paper (filter ventilation) of cigarettes allows air to mix with the smoke, which can change risk perceptions. In this study, we examine smokers' knowledge and beliefs about filter ventilation.

Methods

Web-based panel surveys conducted in 2016 and 2017 of current adult cigarette smokers (N = 2355) provided data on awareness and understanding of filter vents in their cigarettes, whether they believed blocking the holes would change the taste of their cigarettes, and their perceptions about their future risk of being diagnosed with lung cancer. The most commonly used cigarette brands reported by participants also were characterized on the presence and level of ventilation holes.

Results

Approximately 40% of participants (mostly younger and male) reported awareness of the filter ventilation in their cigarettes. Only 30% of the participants were both aware of and understood the function of filter ventilation; they also were significantly more likely to worry about developing lung cancer.

Conclusion

Although misleading descriptors associated with filter ventilation are prohibited, most smokers still smoked cigarettes with filter vents, and many are unaware and misunderstand the potential risks of filter ventilation.

The hazards of smoking and the benefits of cessation: a critical summation of the epidemiological evidence in high-income countries

In high-income countries, the biggest cause of premature death, defined as death before 70 years, is smoking of manufactured cigarettes. Smoking-related disease was responsible for about 41 million deaths in the United States, United Kingdom and Canada, cumulatively, from 1960 to 2020. Every million cigarettes smoked leads to one death in the US and Canada, but slightly more than one death in the UK. The 21^st century hazards reveal that smokers who start smoking early in adult life and do not quit lose a decade of life expectancy versus non-smokers. Cessation, particularly before age 40 years, yields large reductions in mortality risk. Up to two-thirds of deaths among smokers are avoidable at non-smoking death rates, and former smokers have about only a quarter of the excess risk of death compared to current smokers. The gap between scientific and popular understanding of smoking hazards is surprisingly large.

Recommendations for the Appropriate Structure, Communication, and Investigation of Tobacco Harm Reduction Claims. An Official American Thoracic Society Policy Statement

RATIONALE

The tobacco harm reduction literature is replete with vague language, far-reaching claims, and unwarranted certainty. The American Thoracic Society has increasingly recognized the need for a framework for reliably making such claims. Evidence-based standards improving the scientific value and transparency of harm reduction claims are expected to improve their trustworthiness, clarity, and consistency.

METHODS

Experts from relevant American Thoracic Society committees identified key topic areas for discussion. Literature search strategy included English language articles across Medline, Google Scholar, and the Cochrane Collaborative databases, with expanded search terms including tobacco, addiction, smoking, cigarettes, nicotine, and harm reduction. Workgroup members synthesized their evidentiary summaries into a list of candidate topics suitable for inclusion in the final report. Breakout groups developed detailed content maps of each topic area, including points to be considered for suggested recommendations. Successive draft recommendations were modified using an iterative consensus process until unanimous approval was achieved. Patient representatives ensured the document's relevance to the lay public.

RESULTS

Fifteen recommendations were identified, organized into four framework elements dealing with: estimating harm reduction among individuals, making claims on the basis of population impact, appropriately careful use of language, and ethical considerations in harm reduction.

DISCUSSION

This statement clarifies important principles guiding valid direct and inferential harm reduction claims. Ideals for effective communication with the lay public and attention to unique ethical concerns are also delineated. The authors call for formal systems of grading harm reduction evidence and regulatory assurances of longitudinal surveillance systems to document the impact of harm reduction policies.

The epidemiology of lung cancer

The incidence and mortality from lung cancer is decreasing in the US due to decades of public education and tobacco control policies, but are increasing elsewhere in the world related to the commencement of the tobacco epidemic in various countries and populations in the developing world. Individual cigarette smoking is by far the most common risk factor for lung carcinoma; other risks include passive smoke inhalation, residential radon, occupational exposures, infection and genetic susceptibility. The predominant disease burden currently falls on minority populations and socioeconomically disadvantaged people. In the US, the recent legalization of marijuana for recreational use in many states and the rapid growth of commercially available electronic nicotine delivery systems (ENDS) present challenges to public health for which little short term and no long term safety data is available.

Impact of the removal of light and mild descriptors from cigarette packages in Ontario, Canada: switching to "light replacement" brand variants

OBJECTIVE

This study assessed cessation and brand switching among smokers in Ontario, Canada after tobacco companies' voluntary removal of 'light' and 'mild' descriptors from cigarette packages.

METHOD

We analyzed longitudinal data on brand preference and cessation from a cohort of smokers (n=632) in the Ontario Tobacco Survey in Canada from 2006 to 2008 with a longitudinal regression model.

RESULTS

While cessation differed by brand variant prior to the ban (7% light vs. 3% regular; P<0.05), it did not differ by brand variant after the ban was implemented. In 2008, when light cigarette brand variants were no longer available, 33% of the sample still reported smoking lights and 31% smoked light replacement brand variants. During each subsequent follow-up, light brand smokers had 2 times the odds of smoking regular brand variants (Adjusted OR: 2.03, 95% CI 1.80,2.29), and almost 5 times the odds of using light replacement brand variants (Adjusted OR: 4.87, 95% CI 4.07,5.84), respectively, compared to continuing to smoke lights.

CONCLUSIONS

Even after removing misleading descriptors from cigarette packs, smokers continued to report using light brand variants, and many switched to newly introduced light replacement brand variants. After full implementation of the ban, cessation did not vary by brand variant.

The impact of cigarette branding and plain packaging on perceptions of product appeal and risk among young adults in Norway: A between-subjects experimental survey

OBJECTIVES

This study examined the perceptions of cigarette packaging and the potential impact of plain packaging regulations. The hypothesis was that the branded cigarette packages would be rated more positively than the corresponding plain packs with and without descriptors.

DESIGN

Between-subjects experimental online survey. Male and female participants were separately randomised to one of the three experimental conditions: fully branded cigarette packs, plain packs with descriptors and plain packs without descriptors; participants were asked to evaluate 12 individual cigarette packages. The participants were also asked to compare five pairs of packs from the same brand family.

SETTING

Norway.

PARTICIPANTS

1010 youths and adults aged 15-22.

PRIMARY OUTCOME MEASURES

Ratings of appeal, taste and harmfulness for individual packages. Ratings of taste, harm, quality, 'would rather try' and 'easier to quit' for pairs of packages.

RESULTS

Plain with and without descriptors packs were rated less positively than the branded packs on appeal (index score 1.63/1.61 vs 2.42, p<0.001), taste (index score 1.21/1.12 vs 1.70, p<0.001) and as less harmful (index score 1.0.34/0.36 vs 0.82, p<0.001) among females. Among males, the difference between the plain with and without descriptors versus branded condition was significant for appeal (index score 2.08/1.92 vs 2.58, p<0.005) and between the plain without descriptors versus branded condition for taste (index score 1.18 vs 1.70, p<0.00). The pack comparison task showed that the packs with descriptors suggesting a lower content of harmful substances, together with lighter colours, were more positively rated in the branded compared with the plain condition on dimensions less harmful (β -0.77, 95% CI -0.97 to -0.56), would rather try (β -0.32, 95% CI -0.50 to -0.14) and easier to quit (β -0.58, 95% CI -0.76 to -0.39).

CONCLUSIONS

The results indicate that a shift from branded to plain cigarette packaging could lead to a reduction in positive perceptions of cigarettes among young people.

Compensation predicts smoking cessation failure

RATIONALE

Compensation is a potential result of decreasing the available nicotine and tar dose in cigarettes. There is little published data linking compensation with cessation.

OBJECTIVES

We sought to examine whether compensation in response to restricted cigarette yield is associated with difficulty quitting smoking.

METHODS

Questionnaires and blood samples were collected from 174 smokers interested in quitting smoking as part of a larger smoking cessation study. Participants were instructed to use a filter designed to remove 50 % of tar and nicotine from the cigarette but otherwise smoke normally. Participants returned after 3 days of using the filter for follow-up data collection.

RESULTS

Nicotine levels and cigarettes per day decreased after use of the filter. Baseline nicotine and change in nicotine pre/post filter use, but not cigarettes per day or change in cigarettes per day were associated with smoking abstinence at 30 days.

CONCLUSIONS

Smokers who demonstrate sensitivity to the biological or behavioral consequences of decreased nicotine content in tobacco smoke have greater difficulty quitting. These findings suggest the need for personalized cessation treatment linked to behavioral compensation.

Relationship of cigarette-related perceptions to cigarette design features: findings from the 2009 ITC U.S. Survey

INTRODUCTION

Many governments around the world have banned the use of misleading cigarette descriptors such as "light" and "mild" because the cigarettes so labeled were found not to reduce smokers' health risks. However, underlying cigarette design features, which are retained in many brands, likely contribute to ongoing belief that these cigarettes are less harmful by producing perceptions of lightness/smoothness through lighter taste and reduced harshness and irritation.

METHODS

Participants (N = 320) were recruited from the International Tobacco Control U.S. Survey conducted in 2009 and 2010, when they answered questions about smoking behavior, attitudes and beliefs about tobacco products, and key mediators and moderators of tobacco use behaviors. Participants also submitted an unopened pack of their usual brand of cigarettes for analysis using established methods.

RESULTS

Own-brand filter ventilation level (M 29%, range 0%-71%) was consistently associated with perceived lightness (p < .001) and smoothness (p = .005) of own brand. Those whose brand bore a light/mild label (55% of participants) were more likely to report their cigarettes were lighter [71.9% vs. 41.9%; χ(2)(2) = 38.1, p < .001] and smoother than other brands [75.5% vs. 68.7%; χ(2)(2) = 7.8, p = .020].

CONCLUSION

Product design features, particularly filter ventilation, influence smokers' beliefs about product attributes such as lightness and smoothness, independent of package labels. Regulation of cigarette design features such as filter ventilation should be considered as a complement to removal of misleading terms in order to reduce smokers' misperceptions regarding product risks.

Smoking topography and biomarkers of exposure among Japanese smokers: associations with cigarette emissions obtained using machine smoking protocols

OBJECTIVES

Although the relative risk of lung cancer due to smoking is reported to be lower in Japan than in other countries, few studies have examined the characteristics of Japanese cigarettes or potential differences in smoking patterns among Japanese smokers.

METHODS

To examine tar, nicotine and carbon monoxide (TNCO) emissions from ten leading cigarettes in Japan, machine smoking tests were conducted using the International Organization for Standardization (ISO) protocol and the Health Canada Intense (HCI) protocol. Smoking topography and tobacco-related biomarkers were collected from 101 Japanese smokers to examine measures of exposure.

RESULTS

The findings indicate considerable variability in the smoking behavior of Japanese smokers. On average, puffing behaviors observed among smokers were more similar to the parameters of the HCI protocol, and brands with greater ventilation that yielded lower machine values using the ISO protocol were smoked more intensely than brands with lower levels of ventilation. The smokers of "ultra-low/low" nicotine-yield cigarettes smoked 2.7-fold more intensively than those of "medium/high" nicotine-yield cigarette smokers to achieve the same level of salivary cotinine (p = 0.024). CO levels in expiratory breath samples were associated with puff volume and self-reported smoking intensity, but not with nominal values of nicotine-yield reported on cigarette packages.

CONCLUSIONS

Japanese smokers engaged in "compensatory smoking" to achieve their desired nicotine intake, and levels of exposure were greater than those suggested by the nominal value of nicotine and tar yields reported on cigarette packages.

Impact of the removal of misleading terms on cigarette pack on smokers' beliefs about 'light/mild' cigarettes: cross-country comparisons

AIM

This paper examines how smokers' beliefs about 'light/mild' cigarettes in Australia, Canada and the United Kingdom were affected by the removal of misleading 'light/mild' terms from packs.

DESIGN, SETTING AND PARTICIPANTS

  The data come from the first seven waves (2002-09) of the International Tobacco Control Policy Evaluation (ITC) Four-Country Survey, an annual cohort telephone survey of adult smokers in Canada, the United States, the United Kingdom and Australia (21 613 individual cases). 'Light' and 'mild' descriptors were removed in 2003 in the United Kingdom, in 2006 in Australia and in 2007 in Canada. We compare beliefs about 'light' cigarettes both before and after the bans, with those of smokers in the United States serving as the control condition.

MEASURES

  Smokers' beliefs about 'light' cigarettes were assessed using a set of statements rated on a five-point 'agree'-'disagree' scale.

FINDINGS

  The proportions of respondents reporting misperceptions about light cigarettes declined between 2002 and 2009 in all four countries. There were marked temporary reductions in reported misperceptions in the United Kingdom and Australia, but not in Canada, following the removal of 'light/mild' descriptors.

CONCLUSIONS

  Removal of 'light/mild' descriptors and tar, nicotine and carbon monoxide yield information from cigarette packs is insufficient to effectively eliminate false beliefs. The combination of alternative descriptors and design features that produce differences in taste strength and harshness, independent of actual intakes, are sufficient to produce or sustain the same misbeliefs.

Association of daily tar and nicotine intake with incident myocardial infarction: results from the population-based MONICA/KORA Augsburg Cohort Study 1984-2002

BACKGROUND

Cigarette smoking has been shown to be one of the most important risk factors for cardiovascular diseases. However, little is known about cumulative effects of daily tar and nicotine intake on the risk of incident myocardial infarction (MI) so far. To bridge this gap, we conducted an analysis in a large prospective study from Southern Germany investigating associations of daily tar and nicotine intake with an incident MI event.

METHODS

The study was based on 4,099 men and 4,197 women participating in two population-based MONICA Augsburg surveys between 1984 and 1990 and followed up within the KORA framework until 2002. During a mean follow-up of 13.3 years, a number of 307 men and 80 women developed an incident MI event. Relative risks were calculated as hazard ratios (HRs) estimated by Cox proportional hazards models adjusted for cardiovascular risk factors.

RESULTS

In the present study, male regular smokers consumed on average more cigarettes per day than female regular smokers (20 versus 15) and had a higher tar and nicotine intake per day. In men, the MI risk compared to never-smokers increased with higher tar intake: HRs were 2.24 (95% CI 1.40-3.56) for 1-129 mg/day, 2.12 (95% CI 1.37-3.29) for 130-259 mg/day and 3.01 (95% CI 2.08-4.36) for ≥ 260 mg/day. In women, the corresponding associations were comparable but more pronounced for high tar intake (HR 4.67, 95% CI 1.76-12.40). Similar associations were observed for nicotine intake.

CONCLUSIONS

The present study based on a large population-based sample adds important evidence of cumulative effects of tar and nicotine intake on the risk of incident MI. Even low or medium tar and nicotine intake revealed substantial risk increases as compared to never-smokers. Therefore, reduction of tar and nicotine contents in cigarettes cannot be seen as a suitable public health policy in preventing myocardial infarction.

Has the lung cancer risk from smoking increased over the last fifty years?

BACKGROUND

We examine whether the lung cancer risk due to smoking has increased over time.

METHODS

Lung cancer risk equations based on prospective mortality data collected from 1960 to 1972 were applied to 5-year birth-cohort-specific estimates of smoking behaviors among white males to estimate lung cancer mortality rates for U.S. white males from 1960 to 2000. These estimated rates were compared to U.S. white male mortality rates for the same birth cohorts.

RESULTS

Observed birth-cohort-specific U.S. lung cancer mortality rates are substantially higher than those expected from changes in smoking behaviors, and the proportional difference increases with advancing calendar year. This trend persisted even when the duration term was increased in the risk equation. However, adjusting for changes in cigarette design over time by adding a term for the duration of smoking after 1972 resulted in the predicted rates closely approximating the observed U.S. mortality rates.

CONCLUSION

Lung cancer risk estimates observed during the 1960s under predict current lung cancer mortality rates in U.S. white males. Adjustment for the duration of smoking after 1972 results in estimates that reasonably approximate the observed U.S. lung cancer mortality, suggesting that lung cancer risks from smoking are increasing in the United States coincident with changes in cigarette design.

Do changes in cigarette design influence the rise in adenocarcinoma of the lung?

Background

Incidence rates for adenocarcinoma of the lung are increasing and are higher in the United States than in many other developed countries. We examine whether these trends may be associated with changes in cigarette design.

Methods

Lung cancer risk equations based on observations during 1960–1972 from the American Cancer Society Cancer Prevention Study I are applied to 5-year birth cohort–specific estimates of changes in smoking behaviors to predict birth cohort–specific rates of squamous cell carcinoma and adenocarcinoma of the lung among US White men for the period 1973–2000. These expected rates are compared to observed rates for the same birth cohorts of White men in the US Surveillance, Epidemiology and End Results (SEER) data.

Results

Changes in smoking behaviors over the past several decades adequately explain the changes in squamous cell carcinoma rates observed in the SEER data. However, predicted rates for adenocarcinoma do not match the observed SEER data without inclusion of a term increasing the risk for adenocarcinoma with the duration of smoking after 1965.

Conclusion

The risk of developing squamous cell carcinoma from smoking appears to have remained stable in the United States over the past several decades; however, the risk of adenocarcinoma has increased substantially in a pattern temporally associated with changes in cigarette design.

Beliefs about the relative harm of "light" and "low tar" cigarettes: findings from the International Tobacco Control (ITC) China Survey

BACKGROUND

Many smokers in Western countries perceive "light" or "low tar" cigarettes as less harmful and less addictive than "regular" or "full flavoured" cigarettes. However, there is little research on whether similar perceptions exist among smokers in low and middle incomes, including China.

OBJECTIVE

To characterise beliefs about "light" and "low tar" cigarettes among adult urban smokers in China.

METHODS

We analysed data from Wave 1 of the ITC China Survey, a face-to-face household survey of 4732 adult Chinese smokers randomly selected from six cities in China in 2006. Households were sampled using a stratified multistage design.

FINDINGS

Half (50.0%) of smokers in our sample reported having ever tried a cigarette described as "light," "mild" or "low tar". The majority of smokers in our sample (71%) believed that "light" and/or "low tar" cigarettes are less harmful compared to "full flavoured" cigarettes. By far the strongest predictor of the belief that "light" and/or "low tar" cigarettes are less harmful was the belief that "light" and/or "low tar" cigarettes feel smoother on the respiratory system (p<0.001, OR=53.87, 95% CI 41.28 to 70.31).

CONCLUSION

Misperceptions about "light" and/or "low tar" cigarettes were strongly related to the belief that these cigarettes are smoother on the respiratory system. Future tobacco control policies should go beyond eliminating labelling and marketing that promotes "light" and "low tar" cigarettes by regulation of product characteristics (for example, additives, filter vents) that reinforce perceptions that "light" and "low tar" cigarettes are smoother on the respiratory system and therefore less harmful.

Reconciling human smoking behavior and machine smoking patterns: implications for understanding smoking behavior and the impact on laboratory studies

BACKGROUND

Recent Food and Drug Administration legislation enables the mandating of product performance standards for cigarette smoke and the evaluation of manufacturers' health claims for modified tobacco products. Laboratory studies used for these evaluations and also for understanding tobacco smoke toxicology use machines to generate smoke. The goal of this review is to critically evaluate methods to assess human smoking behavior and replicate this in the laboratory.

METHODS

Smoking behavior and smoking machine studies were identified using PubMed and publicly available databases for internal tobacco company documents.

RESULTS

The smoking machine was developed to generate smoke to allow for comparing cigarette tar and nicotine yields. The intent was to infer relative human disease risk, but this concept was flawed because humans tailor their smoking to the product, and chemical yields and toxicologic effects change with different smoking profiles. Although smoking machines also allow for mechanistic assessments of smoking-related diseases, the interpretations also are limited. However, available methods to assess how humans puff could be used to provide better laboratory assessments, but these need to be validated. Separately, the contribution of smoke mouth-holding and inhalation to dose need to be assessed, because these parts of smoking are not captured by the smoking machine. Better comparisons of cigarettes might be done by tailoring human puff profiles to the product based on human studies and comparing results across regimens.

CONCLUSIONS

There are major research gaps that limit the use of smoking machine studies for informing tobacco control regulation and mechanistic studies.

Switching to "lighter" cigarettes and quitting smoking

OBJECTIVE

Smokers who switch to "lighter" cigarettes may be diverted from quitting smoking. We assessed factors associated with switching and the association between switching and (1) making a quit attempt, and (2) recent quitting, yielding a measure of net quitting (attempts x recent quitting).

DESIGN

In 2003, a total of 30 800 ever-smokers who smoked in the past year provided history of switching and 3 reasons for switching: harm reduction, quitting smoking and flavour. Among those who made a past-year quit attempt, recent quitting was defined as >or=90-day abstinence when surveyed. Multivariable logistic regression identified determinants of outcomes.

RESULTS

In all, 12 009 (38%) of ever-smokers switched. Among switchers, the most commonly cited reasons were flavour only (26%) and all 3 reasons (18%). Switchers (vs non-switchers) were more likely to make a quit attempt between 2002 and 2003 (51% vs 41%, p<0.001, adjusted odds ratio (AOR) 1.58, (95% confidence interval (CI) 1.48 to 1.69)), but less likely to have recently quit (9% vs 17%, p<0.001; AOR 0.40 (95% CI 0.35 to 0.45)), yielding lower overall net quitting (4.3% vs 7.0%, p<0.001; AOR 0.54, (95% CI 0.47 to 0.61)). The effects of switching on outcomes were most pronounced for reasons including quitting smoking, whereas switching for harm reduction alone had no association with outcomes.

CONCLUSION

Compared with no switching, a history of switching was associated with 46% lower odds of net quitting.

Comparison of aspects of smoking among the four histological types of lung cancer

BACKGROUND

The magnitude of the link between cigarette smoking and lung cancer may vary by histological type.

METHODS

We used polytomous logistic regression to evaluate whether aspects of smoking have different effects across four histological types in the Nurses' Health Study.

RESULTS

From 1976 to 2002, we identified 1062 cases of lung cancer: squamous cell (n = 201), small cell (n = 236), adenocarcinoma (n = 543) and large cell carcinoma (n = 82), among 65 560 current or former smokers. Risk reduction after quitting ranged from an 8% reduction (relative risk (RR): 0.92, 95% CI 0.91 to 0.94) to a 17% reduction (RR: 0.83, 95% CI 0.80 to 0.86) per year for adenocarcinoma and small cell carcinoma, respectively, with a 9% reduction observed for large cell carcinoma and an 11% reduction observed for squamous cell carcinoma. The association of age at smoking initiation and former cigarette smoking was similar across types, while the association of smoking duration differed. The risk of adenocarcinoma increased by 6% per year of smoking, compared to 7% for large cell, 10% for squamous cell and 12% for small cell. The 6% difference between adenocarcinoma and small cell carcinoma is equivalent to a 3.2 to 9.7-fold increase in risk for 20 years of smoking.

CONCLUSIONS

The effects of the number of cigarettes smoked per day and years since quitting smoking are different across the major types of lung cancer, which are fully appreciated at long durations of smoking and smoking cessation. Smoking prevention and cessation should continue to be the focus of public health efforts to reduce lung cancer incidence and mortality.

Implications of the federal court order banning the terms "light" and "mild": what difference could it make?

Federal District Judge Gladys Kessler found that the major American tobacco companies violated the Racketeer Influenced and Corrupt Organizations Act, defrauding the public by deceptively marketing "light" cigarettes. Judge Kessler's ruling prohibits the defendant tobacco companies from implying health benefits through using misleading terms such as "light", "mild" or "low-tar", or through other indirect means. This ruling could be interpreted narrowly as simply prohibiting certain words, or could be interpreted broadly as prohibiting implying health benefits by any other means, including colour, numbers or images. It is important to include indirect communications, as tobacco companies easily circumvent narrow advertising bans. A narrow interpretation would be inconsistent with the court's comprehensive factual findings of fraudulent intent by the industry. A broad interpretation of the Order, including existing brands, line extensions and new tobacco products such as potential reduced exposure products that are marketed as "cigarettes", Judge Kessler's order could make a substantial contribution to protecting health.

Potential reduced exposure products (PREPs) in industry trial testimony

OBJECTIVE

To identify patterns in trial testimony that may reflect on the intentions or expectations of tobacco manufacturers with regard to the introduction of potential reduced exposure products (PREPs).

DESIGN

Research was conducted using the Deposition and Trial Testimony Archive (DATTA) collection of trial testimony and depositions housed online at Tobacco Documents Online (www.tobaccodocuments.org). Relevant testimony was identified through full-text searches of terms indicating PREPs or harm reduction strategies. The role and function of PREPs in testimony were classified according to common and contrasting themes. These were analysed in the context of broader trial arguments and against changes in time period and the market.

RESULTS

Analysis of testimony suggests that the failure of PREPs in the market tempered initial industry enthusiasm and made protection of the conventional cigarette market its major priority. The "breakthrough" character of PREPs has been de-emphasised, with trial arguments instead positioning PREPs as simply another choice for consumers. This framework legitimises the sale of conventional brands, and shifts the responsibility for adoption of safer products from the manufacturer to the consumer. Likewise, testimony has abandoned earlier dramatic health claims made with regard to PREPs, which had undermined industry arguments regarding efforts to reduce harm in conventional products. More recent testimony advocates the broad acceptance of independent guidelines that would validate use of health claims and enable the industry to market PREPs to consumers.

CONCLUSION

Trial testimony reflects the changing role and positioning of PREPs by the tobacco industry. The findings are of particular importance with regard to future evaluation and potential regulation of reduced harm products.

The temporal relationship between advertising and sales of low-tar cigarettes

OBJECTIVE AND HYPOTHESIS

To determine whether a temporal relationship exists between the advertising and sales of low-tar cigarettes. It was hypothesised that increases in the advertising of low-tar cigarettes would precede increases in sales for these cigarettes.

METHODS

The themes of cigarette advertisements were reviewed and coded for 20 low-tar cigarette brands advertised in 13 widely read magazines in the US between 1960 and 1996. These 20 brands represented most of the low-tar cigarette advertisements and cigarette sales from 1967 to 1996. Cigarette sales data were obtained from the 1994 Maxwell report that summarises all cigarette sales from 1925 to 1990. If the advertisement referred to the low-tar attributes of the cigarette advertised, the advertisement was coded as having a low-tar theme and was included in the analysis.

RESULTS

Five different graphical presentations of the relationship between the advertising and sales of the 20 low-tar cigarette brands showed a temporal relationship between low-tar advertising and sales for these brands. This relationship was observed for brands that introduced a low-tar alternative into an existing brand family (eg, Marlboro Light) and for new exclusively low-tar brands (eg, Carlton). Despite large increases in the advertising for the exclusively low-tar brands, sales of these brands remained low relative to sales of the low-tar alternative brands.

CONCLUSIONS

Increases in print advertising of 20 of the most popular low-tar cigarette brands were followed by increases in sales for these cigarettes. Despite increases in the advertising of exclusively low-tar brands in the mid-1970s and early 1980s, the sales of these brands never matched the sales of the low-tar alternative brands. This suggests that it may have been easier to get smokers to switch to low-tar brands within a brand family compared with entirely new low-tar brands. Over the past 30 years, the marketing of low-tar cigarettes as a healthier alternative to higher-tar cigarettes has resulted in these brands dominating the market, and may have kept concerned smokers from quitting.

Cessation among smokers of "light" cigarettes: results from the 2000 national health interview survey

OBJECTIVES

A large proportion of smokers erroneously believe that low-nicotine/low-tar cigarettes, also called "light cigarettes" or "lights," reduce health risks and are a rational alternative to smoking cessation. However, the availability of light cigarettes may deter smoking cessation.

METHODS

We analyzed the 32374 responses to the US 2000 National Health Interview Survey. Current and former smokers ("ever-smokers") were asked if they had ever used a lower tar and nicotine cigarette to reduce health risks. Multivariable logistic regression identified determinants of lights use and smoking cessation. Results were weighted to reflect the national population.

RESULTS

Of 12285 ever-smokers, 37% (N=4414) reported having used light cigarettes to reduce health risks. Current abstinence was less often reported by ever-smokers who had previously used light cigarettes than by ever-smokers who had never used lights (37% vs 53%, P<.01). Adjusted odds of cessation among ever-smokers who had used light cigarettes relative to those who had never used lights were reduced by 54% (adjusted odds ratio=0.46, 95% confidence interval=0.41, 0.51).

CONCLUSIONS

Use of light cigarettes was common and was associated with lower odds of current smoking cessation, validating the concern that smokers may use lights as an alternative to cessation.

The unbearable lightness of "light" cigarettes: a comparison of smoke yields in six varieties of Canadian "light" cigarettes

BACKGROUND

Labelling cigarettes as "light" or "mild" is claimed to be one of the biggest marketing scams in Canadian history. Arguably, such labelling implies that these varieties of cigarettes are less harmful than "regular" cigarettes. In Canada, a food product can be labelled "light" if there is a 25% reduction from the "reference food" and if the constituent being reduced is clearly identified (e.g., light in fat). Cigarette labelling does not comply with these regulations, however. To examine whether or not some tobacco constituents meet the 25% reduction criterion, we compared yields of 41 toxic and/or carcinogenic smoke constituents in six varieties of "light" cigarettes to the yields of "regular" cigarettes. We selected cigarettes from the two most popular Canadian brands, Du Maurier and Players.

METHODS

Using a set of data provided by Imperial Tobacco Canada and made available to the public by the Government of British Columbia, we compared yields measured under a laboratory protocol (modified ISO) that was designed to provide a more rigorous evaluation of the differences between varieties of cigarettes and a more accurate assessment of smokers' potential smoke intake than the traditional protocol (standard ISO).

FINDINGS

For all six varieties of "light" cigarettes, the yields of nicotine were higher by an average of 5% (range: 1% to 13%). The 25% reduction criterion was not met for any variety of "light" cigarettes concerning yields of tar. For all cigarettes tested, yields of tar were reduced on average by only 16% (range: 5% to 22%). For carbon monoxide (CO), only Player's Smooth Light had an over 25% reduction (30%) compared with Player's Regular. Conversely, yield of CO was 24% higher for Du Maurier Lights compared with Du Maurier Regular. As for the other smoke constituents, the majority (75%) were not reduced by 25% or more in "light" cigarettes, and a sizeable proportion of yields (e.g., acrylonitrile, benzene, chromium, m+p cresol, mercury, nickel, toluene) were larger in these varieties of cigarettes. Only yields of formaldehyde, crotonaldehyde, 1-aminonaphtalene, and proprionaldehyde were systematically reduced in all varieties of "light" cigarettes.

CONCLUSION

The six varieties of "light" cigarettes examined in this study do not differ substantially from "regular" cigarettes in terms of smoke yields. We argue that the modified ISO protocol should be implemented for a more valid comparison of potential smoke yields in all varieties of cigarettes and that labelling based on this protocol should be promoted.

The unbearable lightness of "light" cigarettes: a comparison of smoke yields in six varieties of Canadian "light" cigarettes

BACKGROUND

Labelling cigarettes as "light" or "mild" is claimed to be one of the biggest marketing scams in Canadian history. Arguably, such labelling implies that these varieties of cigarettes are less harmful than "regular" cigarettes. In Canada, a food product can be labelled "light" if there is a 25% reduction from the "reference food" and if the constituent being reduced is clearly identified (e.g., light in fat). Cigarette labelling does not comply with these regulations, however. To examine whether or not some tobacco constituents meet the 25% reduction criterion, we compared yields of 41 toxic and/or carcinogenic smoke constituents in six varieties of "light" cigarettes to the yields of "regular" cigarettes. We selected cigarettes from the two most popular Canadian brands, Du Maurier and Players.

METHODS

Using a set of data provided by Imperial Tobacco Canada and made available to the public by the Government of British Columbia, we compared yields measured under a laboratory protocol (modified ISO) that was designed to provide a more rigorous evaluation of the differences between varieties of cigarettes and a more accurate assessment of smokers' potential smoke intake than the traditional protocol (standard ISO).

FINDINGS

For all six varieties of "light" cigarettes, the yields of nicotine were higher by an average of 5% (range: 1% to 13%). The 25% reduction criterion was not met for any variety of "light" cigarettes concerning yields of tar. For all cigarettes tested, yields of tar were reduced on average by only 16% (range: 5% to 22%). For carbon monoxide (CO), only Player's Smooth Light had an over 25% reduction (30%) compared with Player's Regular. Conversely, yield of CO was 24% higher for Du Maurier Lights compared with Du Maurier Regular. As for the other smoke constituents, the majority (75%) were not reduced by 25% or more in "light" cigarettes, and a sizeable proportion of yields (e.g., acrylonitrile, benzene, chromium, m+p cresol, mercury, nickel, toluene) were larger in these varieties of cigarettes. Only yields of formaldehyde, crotonaldehyde, 1-aminonaphtalene, and proprionaldehyde were systematically reduced in all varieties of "light" cigarettes.

CONCLUSION

The six varieties of "light" cigarettes examined in this study do not differ substantially from "regular" cigarettes in terms of smoke yields. We argue that the modified ISO protocol should be implemented for a more valid comparison of potential smoke yields in all varieties of cigarettes and that labelling based on this protocol should be promoted.

Smoker and ex-smoker reactions to cigarettes claiming reduced risk

CONTEXT

The tobacco industry is introducing modified tobacco products claiming to reduce the risk of smoking (potential reduced exposure products, PREPs). If PREPs are perceived as safe, they may deter smokers from quitting and encourage re-initiation by smokers who have quit.

OBJECTIVE

To assess smokers' and ex-smokers' perceptions of PREPs and the impact of PREP claims on interest in quitting (among smokers) or in resuming smoking (ex-smokers).

DESIGN

A random-digit-dialled survey of US smokers and ex-smokers. We used Eclipse, a modified PREP cigarette, as an exemplar PREP. During the survey, the interviewer read risk reduction claims made for Eclipse by its manufacturer, assessing smokers' interest in quitting before and after the exposure.

PARTICIPANTS

1000 current cigarette smokers and 499 ex-smokers (300 quit within the last two years), over 18 years old.

MAIN OUTCOME MEASURES

Perception of risk reduction from Eclipse; interest in using Eclipse; smokers' interest in quitting was assessed using a stage of change approach (pre- and post-exposure to claims).

RESULTS

91% of smokers thought Eclipse was safer than regular cigarettes. 24% believed Eclipse was completely safe. 57.4% of smokers were interested in using Eclipse; interest was greatest among smokers who were contemplating quitting. Exposure to Eclipse's claims was followed by reduced interest in quitting. Among all ex-smokers, interest in Eclipse was 6.2%, but interest was 15.2% among young adults (18-25 years) who had stopped smoking within two years.

CONCLUSIONS

There is substantial risk that smokers will overinterpret reduced risk claims made for modified tobacco products. PREPs appeal to smokers who are contemplating quitting and exposure to reduced risk product claims appears to reduce smokers' readiness to quit. PREPs also appealed to young adults who had recently stopped smoking. Thus, reduced risk tobacco product claims can undermine adult cessation and youth prevention, possibly resulting in increased harm even if the products are less toxic.

Preliminary investigation of the advertising and availability of PREPs, the new "safe" tobacco products

The tobacco industry recently introduced a new set of "safe" cigarettes and nicotine delivery devices that purportedly entail reduced tobacco-related disease risk due to their lower level of some carcinogens and toxins. Little is know about the biological impact of these potential reduced exposure products (PREPs) and nothing is known about their advertising and availability. Hence, two pilot studies were conducted to examine the latter issues for the first time. In Study 1, we examined tobacco ads in 10 popular magazines 1998--2002 and found that only 1% of ads were for PREPs. In Study 2, we attempted to purchase PREPs in a random sample of 113 small stores and found that only 4.4% sold any PREP. These preliminary findings tentatively suggest that the industry might not yet be heavily invested in products that have the potential to increase tobacco use by decreasing its perceived harm. Studies with larger samples are recommended.

Smoking cigarettes of low nicotine yield does not reduce nicotine intake as expected: a study of nicotine dependency in Japanese males

BACKGROUND

Many Japanese believe that low-yield cigarettes are less hazardous than regular cigarettes, and many smokers consume low-yield cigarettes to reduce their risks from smoking. We evaluate the association between actual nicotine intake and brand nicotine yield, and the influence of nicotine dependence on this association.

METHODS

The study subjects included 458 Japanese male smokers, aged 51.2 +/- 9.9 years, who participated in health check-ups in a hospital in 1998 and 2000. Each subject filled out a self-administered smoking questionnaire and the score of each on the Fagerström Test for Nicotine Dependence was calculated. Urinary cotinine concentration was measured at the time of participation.

RESULTS

The geometric mean of urinary cotinine concentration was 535 ng/mgCr for those who smoked brands with the lowest nicotine (0.1 mg on the package), compared with 1010 ng/mgCr for those who smoked brands with the highest (0.9-2.4 mg, weighted mean of 1.1 mg). Thus, despite the 11-fold ratio of nicotine yield on the packages, the ratio of urinary cotinine level was less than twofold. Both nicotine yield on the package and nicotine dependence significantly increased urinary cotinine concentration, and the negative interaction between them almost attained statistical significance. Cotinine concentration in heavily dependent smokers was consistently high regardless of the nicotine yield of brands.

CONCLUSIONS

The nicotine yield of cigarettes measured by machine-smoking does not reliably predict the exposure of smokers. Smokers consuming low-yield nicotine cigarettes did not reduce actual intake of nicotine to the level that might be expected, especially for those heavily dependent on nicotine. Current labeling practices are misleading for the two-third of smokers who are moderately or highly dependent on nicotine.

Chasing Ernst L Wynder: 40 years of Philip Morris' efforts to influence a leading scientist

STUDY OBJECTIVE

To highlight strategies used by the Philip Morris tobacco company to try to manipulate the eminent scientist, Dr Ernst Wynder between 1955 and 1995.

METHODS

Systematic keyword and opportunistic searching of www.pmdocs.com for formerly internal tobacco industry documents concerning Philip Morris executives and Wynder. Available materials included reports, budget reviews, and correspondence.

MAIN RESULTS

The emergence of smoking as a priority issue on the American public health agenda can be largely attributed to Wynder's research and publicity efforts. Philip Morris viewed Wynder as a prestigious scientist whose commitment to the pursuit of reduced harm cigarettes could lend legitimacy to its desire to position itself as a responsible company intent on addressing consumer concerns. Philip Morris courted Wynder with large equipment loans and grants for more than 30 years, and used its public relations agency to sanitise press releases to remove material unacceptable to the company. Wynder consistently failed to acknowledge industry support while routinely acknowledging other funding from the National Cancer Institute and the American Cancer Society. In retrospect, Wynder realised the insidious effect of tobacco industry research support but failed to acknowledge this may have applied to his own association with the industry.

CONCLUSIONS

Industry documents reveal a deliberate attempt by Philip Morris to pursue and manipulate Dr Wynder to legitimise their company positions.

Regulatory strategies to reduce tobacco addiction in youth

Preventing tobacco addiction and achieving cessation in established users are the cornerstones of efforts to reduce tobacco use and disease. It has been increasingly recognised that reducing tobacco toxin exposure has theoretical potential to reduce disease in continuing tobacco users. This has been controversial because such approaches also carry the potential to undermine prevention and cessation. As complicated as harm reduction issues are for adults, they are still more complicated for youth. Harm reduction is not a singular approach, but rather a concept that encompasses an extremely diverse array of potential approaches. These carry equally diverse potential risks and benefits. The regulatory framework (for example, whether or not the Food and Drug Administration regulates the approach) is also predicted to be a major factor in determining the consequences of harm reduction approaches. This paper examines the various issues and potential approaches concerning the application of harm reduction to youth. We conclude that although some carry great risk, others may actually support broader tobacco control efforts to prevent tobacco use and foster cessation in youth and adults.

Smokers' beliefs about "Light" and "Ultra Light" cigarettes

OBJECTIVE

To assess beliefs about the tar and nicotine delivery characteristics and health benefits of Light and Ultra Light cigarettes among cigarette smokers.

DESIGN

Random digit dialed telephone survey conducted in September 1999.

SUBJECTS

Daily smokers (n = 2120) of Regular (46%), Light (39%), and Ultra Light (15%) cigarettes in the USA. The sample was weighted to match the US smoker population on age, sex, and ethnicity.

MAIN OUTCOME MEASURES

Beliefs about Light and Ultra Light cigarettes were summarised on three dimensions: Safety (reduced health risk), Delivery (lowered tar and nicotine delivery), and Sensation (less harsh).

RESULTS

Most smokers believed Lights and Ultra Lights were less harsh and delivered less tar and nicotine. On average, smokers believed that Lights afforded a 25% reduction in risk, and Ultra Lights a 33% reduction in risk. Light and Ultra Light cigarette smokers evaluated the risks of their own cigarette types more favourably. Light smokers had greater interest in quitting than Ultra Light smokers. Quitting intention was modestly related to beliefs about these cigarettes. Believing that Lights and Ultra Lights delivered less tar and nicotine and that they were less harsh each independently contributed to the belief that these cigarettes were safer.

CONCLUSIONS

Many Light and Ultra Light smokers believe that smoking these cigarettes impart a substantial health benefit, due in part to their experience that these cigarettes are less harsh and the belief that these cigarettes deliver less tar.