Nicotine pharmacokinetics and subjective effects of three potential reduced exposure products, moist snuff and nicotine lozenge

Effect of restricting menthol flavored cigarettes or E-cigarettes on smoking behavior in menthol smokers

Bans of menthol characterizing flavor in tobacco products have been enacted in some localities and proposed in the United States for cigarettes. To gather data regarding how restrictions for menthol in cigarettes and e-cigarettes may affect current menthol cigarette smokers, 37 African American menthol smokers participated in a pilot study in which they were asked to abstain (n = 18) or not abstain from menthol cigarettes (n = 19) for 8-weeks. All participants received menthol flavored e-cigarettes for 4 weeks and tobacco flavored e-cigarettes for 4 weeks in random order. Number of cigarettes smoked per day (estimated mean ratio [EMR] = 0.31; 95% CI: 0.13, 0.72) and exhaled CO concentrations (EMR = 0.61; 95% CI: 0.43, 0.88) were lower in the menthol cigarette abstainer group compared to the menthol cigarette non-abstainer group. Those in the menthol cigarette abstainer group reported higher scores on motivation to quit (p = 0.03) and perceived effectiveness of quitting skills (p = 0.02). There were no substantial effects seen in amount smoked or exhaled CO based on flavor of e-cigarettes provided. Higher e-cigarette use (based on reported puffs per day) was reported in the menthol cigarette abstainer (vs. non-abstainer) group (p < 0.01) and also during the 4-week period when provided with menthol (vs. tobacco) e-cigarettes (p < 0.01). These data suggest that the potential of e-cigarettes to reduce tobacco related harm may be enhanced if combined with a ban on menthol flavor in combustible cigarettes. Larger studies are needed to determine the effect of limiting menthol in e-cigarettes on smoking behavior among current menthol smokers.

Nicotine pharmacokinetics and subjective responses after using nicotine pouches with different nicotine levels compared to combustible cigarettes and moist smokeless tobacco in adult tobacco users

RATIONALE

Oral tobacco-derived nicotine products include on!® nicotine pouches (NPs) which are tobacco-leaf free and available in multiple flavors and nicotine levels. Switching completely to NPs from cigarettes and moist smokeless tobacco (MST) has the potential to reduce harm for adult tobacco consumers. However, the dependence potential of NPs is not established. Therefore, we characterized the abuse potential of NPs with different nicotine levels compared to cigarettes and MST.

OBJECTIVES

To evaluate nicotine pharmacokinetics (PK) and subjective effects of NPs (ranging from 1.5 to 8 mg nicotine) compared to own brand cigarettes (OBCs) and MST (OBMST).

METHODS

We used a randomized, in-clinic, partial single-blind, 7-way crossover design to assess nicotine PK and subjective effects in dual users of cigarettes and MST.

RESULTS

The mean nicotine Cmax for NPs increased with nicotine level, ranging from 3.5 ng/mL (1.5 mg NP) to 15.4 ng/mL (8 mg NP), compared with 12.2 ng/mL for OBCs and 9.8 ng/mL for OBMST. Nicotine tmax was much longer for all NPs and OBMST (32.5-34.4 min) compared to OBCs (8.5 min). Reductions in urges to smoke after use of the 2 mg, 3.5 mg, and 8 mg NPs were not statistically different (p > 0.05) relative to OBC. Also, NPs resulted in lower ratings of positive subjective effects relative to OBCs and OBMST.

CONCLUSIONS

Overall, based on the study results and literature reported nicotine PK values for cigarettes and MST, the abuse potential of NPs is not likely to be higher than OBCs and OBMST. NPs may be potentially acceptable switching products for users of cigarettes and MST products.

Effect on Tobacco Use and Subjective Measures of Including E-cigarettes in a Simulated Ban of Menthol in Combustible Cigarettes

INTRODUCTION

Bans of menthol characterizing flavor in tobacco products have been proposed, however there is limited data regarding the impact on current menthol cigarette smokers of including e-cigarettes in such bans.

METHODS

In this six-week pilot study, menthol smokers were randomized to receive all tobacco products from an experimental marketplace simulating either no menthol ban, a menthol ban for cigarettes but not e-cigarettes or a ban for both ("total menthol ban").

RESULTS

At the first experimental marketplace visit, all but one participant selected cigarettes with e-cigarettes selected by 38%, 69% and 40% of participants in the no ban, menthol cigarette ban and total menthol ban groups, respectively. Over the study period, the total menthol ban group smoked more than the menthol cigarette ban group (estimated mean ratio [EMR] in cigarettes per day = 1.38; 95% CI: 1.1, 1.75; p=0.006). Compared to the no ban condition, the menthol cigarette ban group smoked slightly fewer (EMR = 0.87; 95% CI: 0.68, 1.11) and the total menthol ban group smoked slightly more (EMR = 1.20; 95% CI: 1.00, 1.45) although neither difference reached statistical significance. In both menthol ban conditions, ratings were lower (vs. no ban) on several measures of craving and of cigarette effects and liking.

CONCLUSIONS

Menthol bans that include e-cigarettes may result in different patterns of tobacco use than if only combustible cigarettes are included, although e-cigarettes were not extensively used in any group. Larger studies are needed to determine which policies most likely provide the largest public health benefit.

IMPLICATIONS

Bans of menthol characterizing flavor have been proposed, however the effects on menthol cigarette smokers of including e-cigarettes in such bans are not clear. This study found that smokers randomized to a simulated ban on menthol in both cigarettes and e-cigarettes smoked more cigarettes per day over the 6-week study period than those randomized to a simulated ban on menthol in only cigarettes suggesting that smoking patterns among current menthol smokers differ depending on which products are included in a menthol ban. Larger studies are needed to determine policies most likely to provide the largest public health benefit.

Human Abuse Liability Assessment of Tobacco and Nicotine Products: Approaches for Meeting Current Regulatory Recommendations

Many regulatory bodies now recommend that tobacco product manufacturers provide information regarding new tobacco products' abuse liability to inform regulatory authorization of currently marketed tobacco products or new product applications (including premarket tobacco product applications in the United States). In addition, the US Food and Drug Administration (FDA) recommends including this information as part of modified risk tobacco product applications. Regulators, including FDA, and many public health officials and researchers consider abuse liability assessment a model which predicts the likelihood that the use of the tobacco product would result in addiction and be used repeatedly or even sporadically resulting in undesirable effects. Abuse liability of a new, potentially reduced harm product can also inform its ability to substitute completely for more harmful tobacco products. While many methods exist, no standard tobacco product abuse liability assessment has been established. The purpose of this review is to provide background information and practical recommendations for human abuse liability testing methods to meet tobacco regulatory needs. A combination of nicotine test product pharmacokinetic, subjective effect and/or behavioral response, and physiological response data relative to comparator products with known abuse liability satisfies some regulatory requirements. Implications: This review provides a practical inspection of the current, international regulatory recommendations for abuse liability assessment of tobacco and regulatory review of such information within the United States and also recommends study designs and methods for abuse liability testing of tobacco products based on scientific and regulatory knowledge. Given that tobacco product abuse liability testing is of increasing interest to regulatory bodies globally, especially with the emergence of novel tobacco products, this timely work provides background and functional recommendations for tobacco product abuse liability testing.

A Randomised Study to Investigate the Nicotine Pharmacokinetics of Oral Nicotine Pouches and a Combustible Cigarette

Background and Objectives

Nicotine pouches (NPs) are a relatively new type of oral smokeless tobacco-free nicotine product. Currently, few data are available on the nicotine pharmacokinetics or subjective effects of NP use. The objective of this study was to determine and compare the pharmacokinetics of nicotine absorption into the blood from different NP variants and a combustible cigarette.

Methods

In a randomised, controlled, crossover clinical study, nicotine pharmacokinetics and subjective effects were compared among commercially available NPs (five different brands; 6–10 mg nicotine/pouch) and a combustible cigarette. During an 8-day confinement period, 35 healthy adult participants who were current dual users of snus and combustible cigarettes used one study product each day for a defined period following overnight nicotine abstinence.

Results

Nicotine maximum plasma concentration (C_max) and area under the plasma concentration-time curve between 0 and 6 h (AUC_0–6h) were significantly greater for the Lyft 10 mg NP than for the cigarette (both p < 0.0001), while the other NPs had C_max and AUC_0–6h values that were either greater than or similar to those of the cigarette. Plasma nicotine concentration was not associated with the nicotine contents of the NPs. Time to reach maximum plasma concentration (T_max) was higher for all NPs (60–65 min) than for the cigarette (7 min). Regarding subjective effects, liking and intent to use product again scores were higher for the cigarette than for any NP and were lowest for the NP with the lowest nicotine content.

Conclusions

This study provides important insight into nicotine pharmacokinetics and subjective effects during NP use, and demonstrates that NPs can provide nicotine in amounts sufficient to replicate cigarette smokers' nicotine uptake following a switch from conventional cigarettes to these potentially less harmful NP products. Further studies are required to ascertain how physical characteristics of NPs other than nicotine content may affect nicotine delivery, pharmacokinetics and subjective responses.

ISRCTN Clinical Trial Registry

ISRCTN17828518.

Nicotine pharmacokinetics and subjective response among adult smokers using different flavors of on!® nicotine pouches compared to combustible cigarettes

RATIONALE

on!® nicotine pouches (NPs) are oral tobacco-derived nicotine products that are tobacco-leaf free and are available in a variety of flavors and nicotine strengths. Switching completely to NPs from cigarettes may present the potential to reduce harm in adult smokers (AS) unable or unwilling to quit smoking. We characterized the abuse potential of six different flavor variants of NPs compared to cigarettes.

OBJECTIVES

The objective of this study was to evaluate the nicotine pharmacokinetics (PK) and subjective effects of different flavor variants of NPs compared to participants' own brand cigarettes (OBCs) in AS.

METHODS

In this single-blind, randomized, 7-way crossover study, we assessed nicotine PK, subjective measures (using well-established questionnaires), and product use behavior associated with six flavors of 4 mg NPs and OBCs in AS that remained in clinic for the duration of the test period.

RESULTS

Nicotine C_max values ranged from 9.0 to 11.5 ng/mL for the NPs and 16.3 ng/mL for OBCs. The t_max ranged from 30.1 to 34.9 min for ONPs and 7.5 min for OBCs. Use of NPs resulted in lower ratings of urge to smoke or craving a cigarette. All the NPs were considered pleasant, but not as much as OBCs. Flavor did not appear to influence the nicotine PK or subjective responses.

CONCLUSIONS

Based on the nicotine PK parameters and subjective responses, we conclude that NPs, regardless of flavor, likely have lower abuse potential than cigarettes. Overall, this study suggests that the NPs may be potentially acceptable switching products for adult smokers.

Characterization of the Abuse Potential in Adult Smokers of a Novel Oral Tobacco Product Relative to Combustible Cigarettes and Nicotine Polacrilex Gum

Novel noncombustible tobacco products offer adult smokers (ASs) alternatives to combustible cigarettes lower on the continuum of risk; however, the abuse potential of such products has not been well studied. The objective of this study was to evaluate the abuse potential of 2 chewable tobacco‐derived nicotine containing products, VERVE Chews Blue Mint (test 1) and Green Mint (test 2), in ASs compared with own‐brand cigarettes (CIGS) and nicotine polacrilex gum (GUM) using subjective measures and nicotine pharmacokinetics. ASs used the test products during a 5‐day at‐home trial prior to completing an in‐clinic 4‐period randomized crossover study. During the study ASs used test products, CIGS, and GUM once on separate days. Responses to Tobacco/Nicotine Withdrawal and Direct Effects of Product questionnaires were documented, and blood samples were collected to assess nicotine pharmacokinetics during each product use. Nicotine pharmacokinetic parameters (C_max and AUC) were statistically significantly lower with use of test products compared with CIGS and statistically significantly higher compared with GUM. No appreciable differences were noted between the 2 flavors for any of the end points measured. Reductions in maximum urge to smoke and maximum responses to the question “Is the Product ‘Pleasant’ Right Now?” for the test products were statistically significantly lower than CIGS but comparable to GUM. Similar results were observed for responses to other items in the 2 questionnaires. The test products, under the conditions of this study, carry lower abuse potential than own‐brand cigarettes and similar to nicotine polacrilex gum.

Effect of nicotine lozenge use prior to smoking cue presentation on craving and withdrawal symptom severity

BACKGROUND

Smokers are often advised to use nicotine lozenge after cravings or withdrawal symptoms are present, which may be too late to prevent lapses. This study assesses if lozenge use prior to smoking cue exposure attenuates cue-induced increases in symptom severity.

METHODS

In this randomized, cross-over study, participants completed three laboratory sessions at which they proceeded through 4 "rooms" in a virtual reality environment. The first and last "rooms" contained neutral cues and the others contained smoking cues. At one session, a 4 mg nicotine lozenge was not given until after cue exposure (to approximate current use: i.e., after craving and withdrawal symptoms occur). At the other two sessions either a nicotine or placebo lozenge was used 15 min before cue exposure procedures. Craving and withdrawal symptoms were measured throughout each laboratory session.

RESULTS

Of 58 participants randomized; 40 completed all 3 labs. Absolute levels of craving and withdrawal symptom severity during cue exposure were lower when placebo or active lozenge was used prior to cue presentation procedures vs. no treatment until after cue presentation procedures (all p-values <0.05). There were no differences among conditions in the magnitude of symptom severity increase occurring between the first neutral room and the cue rooms.

CONCLUSIONS

Lozenge use prior to cue exposure may minimize cue induced symptom severity but when taken 15 min prior to cues the decrease is not different than placebo. Research is needed to determine if another time-frame relative to cue exposure would be more effective.

Nicotine pharmacokinetics of electronic cigarettes: A review of the literature

E-cigarettes are battery-powered electronic devices from which users can inhale nicotine following its aerosolisation from a liquid solution. Some regulators and public health bodies consider e-cigarettes as potentially playing a major role in tobacco harm reduction. Their ability to provide nicotine to smokers in both amount and in a manner and form generally similar to cigarette smoking have been proposed as key components to help smokers reduce or cease the use of combustible cigarettes. Nicotine pharmacokinetic studies of e-cigarettes have been performed for a number of years and are beginning to show how nicotine delivery is evolving as the products themselves evolve. In this review, we provide a critical overview of the literature to describe what is known about nicotine delivery from e-cigarettes. We will discuss how the progression of e-cigarette design, development, and user familiarity has allowed increases in nicotine availability to the user, in the context of how much and how rapidly nicotine is delivered during acute-use periods. This review will also provide insight into current research gaps and highlight the potential utility of modelling and the standardisation of methodologies used to assess nicotine delivery to facilitate identification of products that are best suited to displace cigarette smoking among adult smokers.

Timing of nicotine lozenge administration to minimize trigger induced craving and withdrawal symptoms

INTRODUCTION

Smokers are often advised to use nicotine lozenge when craving or withdrawal symptoms occur. This may be too late to prevent lapses. This study assessed if nicotine lozenge use prior to a common smoking trigger can minimize trigger induced increases in craving and withdrawal symptoms.

METHODS

Eighty-four smokers completed two laboratory sessions in random order. At one session, nicotine lozenge was given immediately after a stressor (to approximate current recommended use - i.e., after craving and withdrawal symptoms occur); at the other session subjects were randomized to receive nicotine lozenge at time points ranging from immediately to 30min prior to the stressor. Withdrawal symptoms and urge to smoke were measured using the Minnesota Nicotine Withdrawal Scale and the Questionnaire of Smoking Urges (QSU).

RESULTS

Relative to receiving lozenge after the stressor, a smaller increase in pre-stressor to post-stressor withdrawal symptom scores occurred when lozenge was used immediately (p=0.03) and 10min prior (p=0.044) to the stressor. Results were similar for factors 1 and 2 of the QSU when lozenge was used immediately prior to the stressor (p<0.03) and for factor 1 of the QSU when lozenge was used 10min prior to the stressor (p=0.028). Absolute levels of post-stressor withdrawal symptom and urge to smoke severity were lower when lozenge was given prior to versus after a stressor.

CONCLUSIONS

Administering the nicotine lozenge prior to a smoking trigger can decrease trigger induced craving and withdrawal symptoms. Future studies are needed to determine if such use would increase cessation rates. Clinicaltrials.gov # NCT01522963.

Snus undermines quit attempts but not abstinence: a randomised clinical trial among US smokers

BACKGROUND

Observational studies and a few clinical trials suggest that use of low nitrosamine smokeless tobacco (snus) can facilitate smoking cessation. To better understand the real-world impact of snus on smoking behaviour, a large-scale, long-term clinical trial of naturalistic snus use among smokers is needed.

STUDY DESIGN

A nationwide clinical trial compared abstinence outcomes among smokers who were randomised to receive free samples of snus versus not. Participants (N=1236) were recruited throughout the US and assessed for 1 year following a 6-week naturalistic sampling period, with high retention throughout. Primary outcomes included self-reported quit attempts, floating abstinence (any 7-day period of non-smoking) and 7-day point-prevalence abstinence at 6 months and 12 months. Secondary outcomes were changes in smoking, motivation and confidence to quit and adverse events. No tobacco industry support was provided.

RESULTS

Within snus group, 82% used at least once, and 16% were using regularly at end of sampling period. Compared to control participants, smokers in the snus group were less likely to make any quit attempt (RR=0.83; 95% CI 0.70 to 1.00), and any 24 h quit attempt (RR=0.77; 95% CI 0.63 to 0.95). There were no group differences on any measure of abstinence.

CONCLUSIONS

Provision of snus in a naturalistic context resulted in minimal uptake, and as a whole, undermined quit attempts and did not increase smoking abstinence. Results do not support the unguided, free provision of snus among smokers not motivated to quit as a means to facilitate quit attempts.

TRIAL REGISTRATION NUMBER

NCT01509586, Results.

Interventions to reduce harm from continued tobacco use

BACKGROUND

Although smoking cessation is currently the only guaranteed way to reduce the harm caused by tobacco smoking, a reasonable secondary tobacco control approach may be to try and reduce the harm from continued tobacco use amongst smokers unable or unwilling to quit. Possible approaches to reduce the exposure to toxins from smoking include reducing the amount of tobacco used, and using less toxic products, such as pharmaceutical, nicotine and potential reduced-exposure tobacco products (PREPs), as an alternative to cigarettes.

OBJECTIVES

To assess the effects of interventions intended to reduce the harm to health of continued tobacco use, we considered the following specific questions: do interventions intended to reduce harm have an effect on long-term health status?; do they lead to a reduction in the number of cigarettes smoked?; do they have an effect on smoking abstinence?; do they have an effect on biomarkers of tobacco exposure?; and do they have an effect on biomarkers of damage caused by tobacco?

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Trials Register (CRS) on the 21st October 2015, using free-text and MeSH terms for harm reduction, smoking reduction and cigarette reduction.

SELECTION CRITERIA

Randomized or quasi-randomized controlled trials of interventions to reduce the amount smoked, or to reduce harm from smoking by means other than cessation. We include studies carried out in smokers with no immediate desire to quit all tobacco use. Primary outcomes were change in cigarette consumption, smoking cessation and any markers of damage or benefit to health, measured at least six months from the start of the intervention.

DATA COLLECTION AND ANALYSIS

We assessed study eligibility for inclusion using standard Cochrane methods. We pooled trials with similar interventions and outcomes (> 50% reduction in cigarettes a day (CPD) and long-term smoking abstinence), using fixed-effect models. Where it was not possible to meta-analyse data, we summarized findings narratively.

MAIN RESULTS

Twenty-four trials evaluated interventions to help those who smoke to cut down the amount smoked or to replace their regular cigarettes with PREPs, compared to placebo, brief intervention, or a comparison intervention. None of these trials directly tested whether harm reduction strategies reduced the harms to health caused by smoking. Most trials (14/24) tested nicotine replacement therapy (NRT) as an intervention to assist reduction. In a pooled analysis of eight trials, NRT significantly increased the likelihood of reducing CPD by at least 50% for people using nicotine gum or inhaler or a choice of product compared to placebo (risk ratio (RR) 1.75, 95% confidence interval (CI) 1.44 to 2.13; 3081 participants). Where average changes from baseline were compared for different measures, carbon monoxide (CO) and cotinine generally showed smaller reductions than CPD. Use of NRT versus placebo also significantly increased the likelihood of ultimately quitting smoking (RR 1.87, 95% CI 1.43 to 2.44; 8 trials, 3081 participants; quality of the evidence: low). Two trials comparing NRT and behavioural support to brief advice found a significant effect on reduction, but no significant effect on cessation. We found one trial investigating each of the following harm reduction intervention aids: bupropion, varenicline, electronic cigarettes, snus, plus another of nicotine patches to facilitate temporary abstinence. The evidence for all five intervention types was therefore imprecise, and it is unclear whether or not these aids increase the likelihood of smoking reduction or cessation. Two trials investigating two different types of behavioural advice and instructions on reducing CPD also provided imprecise evidence. Therefore, the evidence base for this comparison is inadequate to support the use of these types of behavioural advice to reduce smoking. Four studies of PREPs (cigarettes with reduced levels of tar, carbon and nicotine, and in one case delivered using an electronically-heated cigarette smoking system) showed some reduction in exposure to some toxicants, but it is unclear whether this would substantially alter the risk of harm. We judged the included studies to be generally at a low or unclear risk of bias; however, there were some ratings of high risk, due to a lack of blinding and the potential for detection bias. Using the GRADE system, we rated the overall quality of the evidence for our cessation outcomes as 'low' or 'very low', due to imprecision and indirectness. A 'low' grade means that further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. A 'very low' grade means we are very uncertain about the estimate.

AUTHORS' CONCLUSIONS

People who do not wish to quit can be helped to cut down the number of cigarettes they smoke and to quit smoking in the long term, using NRT, despite original intentions not to do so. However, we rated the evidence contributing to the cessation outcome for NRT as 'low' by GRADE standards. There is a lack of evidence to support the use of other harm reduction aids to reduce the harm caused by continued tobacco smoking. This could simply be due to the lack of high-quality studies (our confidence in cessation outcomes for these aids is rated 'low' or 'very low' due to imprecision by GRADE standards), meaning that we may have missed a worthwhile effect, or due to a lack of effect on reduction or quit rates. It is therefore important that more high-quality RCTs are conducted, and that these also measure the long-term health effects of treatments.

Clinical Laboratory Evaluation of Electronic Cigarettes/Electronic Nicotine Delivery Systems: Methodological Challenges

OBJECTIVE

Evaluating electronic cigarettes (ECIGs) in the clinical laboratory is critical to understanding their effects. However, laboratory evaluation of ECIGs can be challenging, as they are a novel, varied, and evolving class of products. The objective of this paper is to describe some methodological challenges to the clinical laboratory evaluation of ECIGs.

METHODS

The authors gathered information about challenges involved in the laboratory evaluation of ECIGs. Challenges were categorized and solutions provided when possible.

RESULTS

Methods used to study combustible cigarettes may need to be adapted to account for ECIG novelty and differences within the class. Challenges to ECIG evaluation can include issues related to 1) identification of ECIG devices and liquids, 2) determination of short -term ECIG abstinence, 3) measurement of use behavior, and 4) assessment of dependence. These challenges are discussed, and some suggestions to inform ECIG evaluation using clinical laboratory methods are provided.

CONCLUSIONS

Awareness of challenges and developing, validating, and reporting methods used to address them aids interpretation of results and replication efforts, thus enhancing the rigor of science used to protect public health through appropriate, empirically-based, ECIG regulation.

The effect of acute exercise on cigarette cravings while using a nicotine lozenge

RATIONALE

It is imperative that smoking cessation aids effectively alleviate cigarette craving and withdrawal symptoms because their intensity has shown to predict relapse. The nicotine lozenge and a single session of exercise have both been shown to provide relief from craving for smokers who have stopped smoking. These two efficacious monotherapies have distinct mechanic pathways, and applying them concurrently may provide additive-craving relief benefit.

OBJECTIVE

This study aimed to examine whether an acute bout of moderate-intensity exercise provides additional craving relief to the nicotine replacement lozenge in recently quit smokers.

RESULTS

Thirty smokers who had abstained from smoking for 15 h were randomized to either the experimental (exercise and lozenge, n = 15) or control (lozenge alone, n = 15) condition. Craving was assessed before (baseline), during (10 and 20 min), and after (10, 20, 30, and 40 min) treatment.

RESULT

A significant condition by time interaction effect was found for craving (F(6, 23) = 2.70, p = 0.039, Wilks' Λ = 0.59, η ρ (2) = 0.41). While both conditions demonstrated reductions in craving, the reduction was significantly greater for the experimental group.

CONCLUSION

These findings demonstrate that an acute bout of exercise provides additional craving relief to the nicotine lozenge in recently quit smokers. We recommend smokers who attempt to quit employ both cessation aids simultaneously to maximize reductions in cravings.

Nicotine delivery and pharmacologic response from Verve, an oral nicotine delivery product

Verve, an oral nicotine delivery product (ONDP), was introduced by Nu Mark (Altria Client Group, Richmond VA) for smokers to use in places where smoking is prohibited. This study assessed the effect of this ONDP on plasma nicotine levels, heart rate, product satisfaction, and ability to suppress smoking urge and cigarette cravings. Thirteen daily cigarette smokers [8 men and 5 women; average age 33.4years] attended two laboratory sessions, one occurred after overnight tobacco abstinence. Plasma samples were collected before and after ONDP use and measured for nicotine. In non-abstinent smokers, mean plasma nicotine levels increased from 18.3 to 21.0ng/mL. In abstinent smokers, average nicotine levels increased from 3.1 to 4.5ng/mL. After overnight tobacco abstinence, ONDP use significantly (p<0.01) increased heart rate from 69beats per minute (bpm) to 75bpm; while urge to smoke decreased significantly (p<0.01) from a score of 8.6 to 4.9. Participants indicated moderate product satisfaction that was not changed by tobacco abstinence. Analysis of unused ONDP revealed total nicotine levels of 1.68±0.09mg/disc. Spent ONDP discs were also analyzed to determine % nicotine liberated during chewing; results were 80% in the non-abstinent and 82% in the abstinent conditions (ns). Our study results indicate that ONDP use can increase plasma nicotine levels and heart rate and reduce cigarette cravings in abstinent smokers.

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.

Comparison of craving between smoked and smokeless tobacco across a variety of cue exposures

Smokeless tobacco use is a major health issue but has received less attention in craving research. The present non-funded study aimed to assess craving associated with smokeless tobacco compared to smoked forms. Forty-eight nicotine dependent male subjects attending a deaddiction center in India were recruited. The subjects were exposed to six nicotine related and two control cues in random order for variable time durations. The urge to consume the tobacco product was rated. Tobacco-related cues produced different patterns and degrees of craving among users of smoked and smokeless tobacco. This has implications for management and drug development.

Subjective responses to oral tobacco products: scale validation

INTRODUCTION

Several noncombusted oral tobacco products have been introduced that are primarily marketed to cigarette smokers. An important component of evaluating these products involves assessment of subjective responses to the product. To date, few studies have been undertaken to examine the validity of subjective response questionnaires for oral tobacco products. The goal of this study is to examine the extent subjective responses to a product are related to product preference and extent of product use.

METHODS

Data from a study examining oral tobacco product preference were used. Smokers were asked to sample a variety of oral tobacco products that differed in formulation (snus versus dissolvables) and dose of nicotine. At the end of the sampling period, subjects were asked to choose the product that they would use to completely substitute for cigarettes for the next 2 weeks. During the sampling period, subjects completed a Product Evaluation Scale (PES) that describes subjective responses to the product. During the treatment phase, they kept record of amount of product use.

RESULTS

Subjective responses to the product on the PES were related to product choice and to some extent, the amount of product use. Product choice was associated with different characteristics of the product and smoker needs.

CONCLUSION

The PES may be a useful tool for the evaluation or oral tobacco products.

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.

Oral tobacco products: preference and effects among smokers

BACKGROUND

Recently, oral tobacco products have been marketed specifically towards cigarette smokers. These products come in different nicotine doses and formulations (snus vs. lozenge). To date, little research has been conducted to determine how smokers respond to these products. The goal of this study was to examine if smokers prefer certain oral tobacco products based on their specific characteristics.

METHODS

Smokers interested in quitting underwent a sampling phase and a treatment phase. The sampling phase consisted of testing five different products varying in nicotine dose (high vs. moderate vs. low) and formulation (snus vs. lozenge): General Snus, Camel Snus, Marlboro Snus, Stonewall and Ariva. Each product was sampled in the natural environment on separate days. At the end of the sampling period, subjects chose which product they would use during the 2-week cigarette abstinence phase.

RESULTS

General Snus (high nicotine) was not preferred by any smoker. No significant differences in preferences were observed across the other tobacco products. During the smoking cessation phase, Camel Snus was generally associated with greater craving relief and satisfaction, reduced use of cigarettes, and greater abstinence during follow-up compared to other products.

CONCLUSION

There were no differences in preferences for four of the five oral tobacco products but higher nicotine oral tobacco products were associated with better cessation outcomes among smokers who chose these products.

US smokers' reactions to a brief trial of oral nicotine products

BACKGROUND

It has been suggested that cigarette smokers will switch to alternative oral nicotine delivery products to reduce their health risks if informed of the relative risk difference. However, it is important to assess how smokers are likely to use cigarette alternatives before making predictions about their potential to promote individual or population harm reduction.

OBJECTIVES

This study examines smokers' interest in using a smokeless tobacco or a nicotine replacement product as a substitute for their cigarettes.

METHODS

The study included 67 adult cigarette smokers, not currently interested in quitting, who were given an opportunity to sample four alternative oral nicotine products: 1) Camel Snus, 2) Marlboro Snus, 3) Stonewall dissolvable tobacco tablets, and 4) Commit nicotine lozenges. At visit 1, subjects were presented information about the relative benefits/risks of oral nicotine delivery compared to cigarettes. At visit 2, subjects were given a supply of each of the four products to sample at home for a week. At visit 3, subjects received a one-week supply of their preferred product to see if using such products reduced or eliminated cigarette use.

RESULTS

After multiple product sampling, participants preferred the Commit lozenges over the three smokeless tobacco products (p = 0.011). Following the one week single-product trial experience, GEE models controlling for gender, age, level of education, baseline cigarettes use, and alternative product chosen, indicated a significant decline in cigarettes smoked per day across one week of single-product sampling (p < 0.01, from 11.8 to 8.7 cigarettes per day), but no change in alternative product use (approximately 4.5 units per day). Biomarkers of exposure showed no change in cotinine, but a 19% reduction in exhaled CO (p < 0.001).

CONCLUSIONS

Findings from this study show that smokers, who are currently unwilling to make a quit attempt, may be willing to use alternative products in the short term as a temporary substitute for smoking. However, this use is more likely to be for partial substitution (i.e. they will continue to smoke, albeit at a lower rate) rather than complete substitution. Of the various substitutes offered, smokers were more willing to use a nicotine replacement product over a tobacco-based product.

Effect of oral snus and medicinal nicotine in smokers on toxicant exposure and withdrawal symptoms: a feasibility study

BACKGROUND

Smokeless, spitless tobacco products are being introduced and marketed as cigarette substitutes. Data are needed regarding how smokers interested in cessation would use these products, the levels of resultant toxicant exposure, and the feasibility of using these products as aids for tobacco cessation.

METHODS

Smokers were randomized to receive Camel Snus (n = 51), Taboka (n = 52), or medicinal nicotine (n = 27) and required to quit smoking for 4 weeks. Measures of toxicant exposure and symptoms of craving and withdrawal were assessed prior to and during product use.

RESULTS

Concentrations of exhaled carbon monoxide, urinary cotinine, urinary 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol and its glucuronides (total NNAL), and urinary N'-nitrosonornicotine and its glucuronide (total NNN) were significantly (P values <0.05) lower at the end of treatment in each group except for total NNN in those receiving Camel Snus (P = 0.066). A significant group × time effect was observed for total NNAL concentrations (P = 0.002) with the decrease greatest in the medicinal nicotine group and smallest decrease in the Camel Snus group. No significant differences between groups were found in craving and withdrawal symptoms.

CONCLUSIONS

Enrolling smokers into a cessation study utilizing newer smokeless tobacco products is feasible. Camel Snus and Taboka use was not found to be superior to medicinal nicotine in reducing withdrawal symptoms but decreases in NNAL were smaller in users of Camel Snus.

IMPACT

This study demonstrates the feasibility of conducting a smoking cessation study utilizing these newer tobacco products. An appropriately powered study is needed to assess smoking cessation rates using these newer products compared with established, safer products such as medicinal nicotine.

Evaluating the acute effects of oral, non-combustible potential reduced exposure products marketed to smokers

BACKGROUND

Non-combustible potential reduced exposure products (PREPs; eg, Star Scientific's Ariva; a variety of other smokeless tobacco products) are marketed to reduce the harm associated with smoking. This marketing occurs despite an absence of objective data concerning the toxicant exposure and effects of these PREPs. Methods used to examine combustible PREPs were adapted to assess the acute effects of non-combustible PREPs for smokers.

METHODS

28 overnight abstinent cigarette smokers (17 men, 14 non-white) each completed seven, Latin-squared ordered, approximately 2.5 h laboratory sessions that differed by product administered: Ariva, Marlboro Snus (Philip Morris, USA), Camel Snus (RJ Reynolds, Winston-Salem, North Carolina, USA), Commit nicotine lozenge (GlaxoSmithKline; 2 mg), own brand cigarettes, Quest cigarettes (Vector Tobacco; delivers very low levels of nicotine) and sham smoking (ie, puffing on an unlit cigarette). In each session, the product was administered twice (separated by 60 min), and plasma nicotine levels, expired air CO and subjective effects were assessed regularly.

RESULTS

Non-combustible products delivered less nicotine than own brand cigarettes, did not expose smokers to CO and failed to suppress tobacco abstinence symptoms as effectively as combustible products.

CONCLUSIONS

While decreased toxicant exposure is a potential indicator of harm reduction potential, a failure to suppress abstinence symptoms suggests that currently marketed non-combustible PREPs may not be a viable harm reduction strategy for US smokers. This study demonstrates how clinical laboratory methods can be used to evaluate the short-term effects of non-combustible PREPs for smokers.

Cognitive effects of nicotine: genetic moderators

Cigarette smoking is the main preventable cause of death in developed countries, and the development of more effective treatments is necessary. Cumulating evidence suggests that cognitive enhancement may contribute to the addictive actions of nicotine. Several studies have demonstrated that nicotine enhances cognitive performance in both smokers and non-smokers. Genetic studies support the role of both dopamine (DA) and nicotinic acetylcholine receptors (nAChRs) associated with nicotine-induced cognitive enhancement. Based on knockout mice studies, beta2 nAChRs are thought to be essential in mediating the cognitive effects of nicotine. alpha7nAChRs are associated with attentional and sensory filtering response, especially in schizophrenic individuals. Genetic variation in D2 type DA receptors and the catechol-O-methyltransferase enzyme appears to moderate cognitive deficits induced by smoking abstinence. Serotonin transporter (5-HTT) gene variation also moderates nicotine-induced improvement in spatial working memory. Less is known about the contribution of genetic variation in DA transporter and D4 type DA receptor genetic variation on the cognitive effects of nicotine. Future research will provide a clearer understanding of the mechanism underlying the cognitive-enhancing actions of nicotine.

Evaluating oral noncombustible potential-reduced exposure products for smokers

INTRODUCTION

Potential-reduced exposure products (PREPs) are marketed as a way for smokers to continue using tobacco while possibly lessening their tobacco toxicant intake. Some tobacco-based PREPs are combustible and intended to be smoked, while others are noncombustible and intended to be administered orally (e.g., Camel Snus [CS] tobacco sachets and Ariva tobacco tablets). The ability of these noncombustible PREPs to reduce smokers' exposure to cigarette-delivered toxicants and suppress tobacco abstinence symptoms effectively is unclear. Clinical laboratory methods have been used to measure combustible PREP-associated toxicant exposure and abstinence symptom suppression and could be applied to evaluating the effects of orally administered noncombustible PREPs.

METHODS

In this study, 21 smokers (6 women) participated in four 5-day conditions that differed by product used: CS, Ariva, own brand cigarettes, or no tobacco. Measures included expired-air carbon monoxide (CO), the urinary metabolite of nicotine (cotinine), the urinary metabolite of the carcinogen NNK (NNAL-T), and subjective effect ratings.

RESULTS

Relative to own brand, all other conditions were associated with CO and cotinine levels that were lower and abstinence symptom ratings that were greater. Only no-tobacco use was associated with significantly lower NNAL levels. Acceptability ratings were also lower in all conditions relative to own brand.

DISCUSSION

Although these oral products reduce exposure to CO, their ineffective abstinence symptom suppression and low acceptability may limit their viability as PREPs. As with combustible PREPs, clinical laboratory study of orally administered noncombustible PREPs will be a valuable part of any comprehensive PREP evaluation strategy.

Levels of mint and wintergreen flavorants: smokeless tobacco products vs. confectionery products

Nicotine and flavorant compound levels were measured in 10 "mint"-related sub-brands and 8 "wintergreen" sub-brands of smokeless tobacco (SLT). Also analyzed were "mint"-related and "wintergreen" confectionery products. Of the "mint" SLT, "Timberwolf Packs Mint Pouches" contained the highest menthol level (5.3 mg/g); the average for the five most-highly mentholated SLT products was 4.3 mg/g. The average for the most five most-highly mentholated confectionery products was 3.5 mg/g. For hard candy, a reported average of maximum use levels is 2.1 mg/g (Burdock, 2009). Of the "wintergreen" SLT, "Hawken Wintergreen" was found to contain the highest methyl salicylate (MS) level (29.7 mg/g). The average of the five highest SLT MS levels was 23.8 mg/g, i.e., 5x higher than the level found in the confectionery product with the highest MS level (LifeSavers Wint O Green Sugar Free, 4.6 mg/g). For hard candy, a reported average of maximum use levels is 2.0 mg/g (Burdock, 2009). Assuming 23.8 mg/g MS in SLT, SLT use at 15 g/day, 100% bodily absorption of the MS, and 60 kg body weight, the average daily intake would be 6.0 mg/kg-day, i.e., 12x the acceptable daily intake (ADI) of 0.5 mg/kg-day established for this compound by a joint FAO/WHO committee.

A pilot randomized study of smokeless tobacco use among smokers not interested in quitting: changes in smoking behavior and readiness to quit

INTRODUCTION

Several prior studies suggest that smokeless tobacco use results in less carcinogenic risk than does cigarette smoking. Whether smokers will use smokeless tobacco is unclear, as is the impact of such use on long-term smoking behavior and cessation. It is equally plausible that smokeless tobacco use among smokers could either (a) increase total tobacco exposure and undermine motivation to quit or (b) decrease overall tobacco exposure, motivate smokers to quit, and enhance cessation. Either outcome is of major public health significance.

METHODS

In this small (N = 31), short-term (2 week) pilot study, smokers uninterested in quitting were randomized to (a) receive Ariva or Stonewall (both spitless and smokeless tobacco lozenges) or (b) continue smoking conventional cigarettes.

RESULTS

Ariva/Stonewall use led to a significant reduction (40%, 95% CI: 24%-55%) in cigarettes per day, no significant increases in total tobacco use (cigarettes + Ariva/Stonewall; p > .05), and significant increases in two measures of readiness to quit, either in the next month (p < .001) or within the next 6 months (p = .04), as well as significant increases in self-efficacy to quit smoking (p < .001). No such changes were found among smokers maintained on conventional cigarettes.

DISCUSSION

These results suggest no deleterious effect on short-term smoking and quitting behavior among smokers who use smokeless tobacco. More broadly, this study suggests a strong need for a large prospective randomized clinical trial to more accurately assess the long-term viability of smokeless tobacco use as a method for cessation induction among unmotivated smokers.

Evaluation of biomarkers of exposure in adult cigarette smokers using Marlboro snus

INTRODUCTION

It has been reported that adult smokers (AS) may be considering smokeless tobacco products as an alternative to smoking. The objective of this study was to evaluate the change in exposure in AS using Marlboro snus (MSNUS) (a tobacco pouch product in test market in June 2007).

METHODS

AS were randomized into the following groups--CS: subjects (n = 30) continue smoking their own brand; DU: subjects (n = 60) reduced their daily cigarette consumption by >or=50% and were allowed to use MSNUS; SN: subjects (n = 15) stopped smoking their cigarettes but were allowed to use MSNUS; NT: subjects (n = 15) were not allowed to use any tobacco products for the entire duration of the 8-day study. Biomarkers of smoke exposure (BOE) measured at baseline and postbaseline were 24-hr urinary excretion of metabolites of N-nitrosamines, nicotine (urine and plasma), aromatic amines, benzene, and polycyclic aromatic hydrocarbon; urine mutagenicity; and carboxyhemoglobin at various timepoints.

RESULTS

Statistically significant (p < .05) reductions in all the urinary BOE were observed in the DU group compared with the CS group. After correcting for the residual effect, a proportionate reduction (approximately 50%) in most of the biomarkers was observed. Even larger reductions, similar to the NT group, were observed in the SN group.

DISCUSSION

The proportionate reduction in exposure when reducing the number of cigarettes by 50% and using MSNUS, under the consumption patterns observed, suggest that the AS did not appear to alter their smoking behavior. The added exposure from MSNUS usage in this group was minimal. The AS sustained substantial reductions in exposure when using MSNUS exclusively.

Assessing consumer responses to potential reduced-exposure tobacco products: a review of tobacco industry and independent research methods

BACKGROUND

Internal tobacco industry documents and the mainstream literature are reviewed to identify methods and measures for evaluating tobacco consumer response. The review aims to outline areas in which established methods exist, identify gaps in current methods for assessing consumer response, and consider how these methods might be applied to evaluate potentially reduced exposure tobacco products and new products.

METHODS

Internal industry research reviewed included published articles, manuscript drafts, presentations, protocols, and instruments relating to consumer response measures were identified and analyzed. Peer-reviewed research was identified using PubMed and Scopus.

RESULTS

Industry research on consumer response focuses on product development and marketing. To develop and refine new products, the tobacco industry has developed notable strategies for assessing consumers' sensory and subjective responses to product design characteristics. Independent research is often conducted to gauge the likelihood of future product adoption by measuring consumers' risk perceptions, responses to product, and product acceptability.

CONCLUSIONS

A model that conceptualizes consumer response as comprising the separate, but interacting, domains of product perceptions and response to product is outlined. Industry and independent research supports the dual domain model and provides a wide range of methods for assessment of the construct components of consumer response. Further research is needed to validate consumer response constructs, determine the relationship between consumer response and tobacco user behavior, and improve reliability of consumer response measures. Scientifically rigorous consumer response assessment methods will provide a needed empirical basis for future regulation of potentially reduced-exposure tobacco products and new products, to counteract tobacco industry influence on consumers, and enhance the public health.

Abuse liability assessment of tobacco products including potential reduced exposure products

The harm produced by tobacco products is a result of frequent use of a highly toxic product. Reducing the adverse public health impact of tobacco products might be most effectively achieved by reducing the likelihood of their use and the toxicity of the products. Products that retain some characteristics of cigarettes but have been altered with the intention of reducing toxicity have been referred to as modified risk tobacco products or potential reduced exposure products (MRTP/PREP). Evaluation of their content, emission, and toxicity is discussed in other articles in this special issue. Here, we discuss the methodology that has been used to examine the likelihood of abuse or addiction. Abuse liability assessment (ALA) methodology has been used by the Food and Drug Administration (FDA) and other drug regulatory agencies world-wide for decades to assess the risks posed by a wide variety of pharmacologically active substances. ALA is routinely required among other evaluations of safety during the pre-market assessment of new drugs, and is continually adapted to meet the challenges posed by new drug classes and drug formulations. In the 2009 law giving FDA regulation over tobacco products, FDA is now required to evaluate new tobacco products including MRTP/PREPs to determine their risk for abuse and toxicity at the population level. This article describes the traditional tools and methods of ALA that can be used to evaluate new tobacco and nicotine products including MRTP/PREPs. Such ALA data could contribute to the scientific foundation on which future public policy decisions are based.

Clinical trials methods for evaluation of potential reduced exposure products

Potential reduced exposure products (PREPs) to tobacco toxicants may have promise in reducing tobacco-related morbidity or mortality or may promote greater harm to individuals or the population. Critical to determining the risks or benefits from these products are valid human clinical trial PREP assessment methods. Such an assessment involves determining the effects of these products on biomarkers of exposure and effect, which serve as proxies for harm, and assessing the potential for consumer uptake and abuse of the product. This article identifies critical methodologic issues associated with PREP assessments, reviews the methods that have been used to assess PREPs, and describes the strengths and limitations of these methods. Additionally, recommendations are provided for clinical trial PREP assessment methods and future research directions in this area based on this review and on the deliberations from a National Cancer Institute sponsored Clinical Trials PREP Methods Workshop.

Measures for assessing subjective effects of potential reduced-exposure products

Potential reduced-exposure products (PREP) may reduce toxicant exposure and thereby may possibly reduce health risks associated with conventional tobacco use. However, lessened health risk to the individual or harm to the population through the use of PREPs is unknown. Research is being conducted to evaluate the possible health effects associated with PREP use. As part of this evaluation, it is critical to provide sound measures of subjective responses to PREPs to determine the use and the abuse potential of a product, that is, the likelihood that the product will lead to addiction. The goal of this paper is to conduct a systematic review of scales that have been used to measure the subjective responses to PREPs and examine their characteristics. In this article, scales are identified and the items on the scales are described. Scales are also examined to determine whether they are sensitive in testing PREPs. Furthermore, scales to assess PREPs are recommended to investigators. Where no scales exist, items that may be critical for the development and validation of new scales are identified.

Potential reduced exposure products (PREPs) for smokeless tobacco users: clinical evaluation methodology

Several potential reduced exposure products (PREPs) for smokeless tobacco (SLT) users are marketed in the United States, though their effects are largely unknown. These products include some that are low in tobacco-specific nitrosamines (TSNs), like Stonewall, a pressed tobacco tablet, and General snus, a moist snuff product produced in Sweden. Methodology assessing the toxicant exposure and effects of cigarette-like PREPs for smokers has been developed, and might be modified for use in evaluating PREPs for SLT users. This report describes two studies examining the toxicant exposure and effects of two PREPs for SLT users. Study 1 (n = 13) consisted of four 4.5-hr laboratory sessions where SLT products (own brand, Stonewall, General snus, and tobacco-free placebo) were used for four 30-min episodes and nicotine exposure and tobacco/nicotine abstinence symptoms were measured. Study 2 (n = 19) consisted of four 5-day ad libitum use periods when participants used own brand, Stonewall, General snus, or no SLT and urinary levels of metabolites of nicotine (cotinine) and the TSN 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNAL) and abstinence symptoms were measured. Compared with own brand, Stonewall was associated with lower levels of cotinine and NNAL, while General snus was associated with similar levels of cotinine and lower levels of NNAL. Abstinence symptoms generally did not differ across tobacco conditions. These results show that clinical laboratory methods can be used to evaluate the toxicant exposure and abstinence symptom suppression associated with PREPs for SLT users.

Nicotine delivery, cardiovascular profile, and subjective effects of an oral tobacco product for smokers

The tobacco industry markets potential reduced exposure products (PREPs) to smokers, including oral products that are intended to be used in situations where cigarettes cannot. For example, Ariva, marketed by Star Scientific, is a tablet made from compressed tobacco powder and is intended for "adult smokers in situations where they cannot or choose not to smoke." No objective data are available regarding Ariva's effects in smokers, including its nicotine delivery, cardiovascular profile, or subjective effects. In this single-session, clinical laboratory study, 10 overnight-abstinent cigarette smokers were administered one Ariva tablet, followed 90 min later by two Ariva tablets, followed 90 min later by three Ariva tablets. Participants allowed each dose to dissolve in their mouths according to package instructions. Blood was sampled, heart rate monitored, and subjective effects assessed regularly. Ariva delivered nicotine in a dose-dependent manner; mean (SD) nicotine levels increased from 2.4 ng/ml (0.9) at baseline, to 3.4 ng/ml (1.4) 45 min post-1 tablet, 7.3 ng/ml (4.0) 45 min post-2 tablets, and 9.7 ng/ml (4.4) 45 min post-3 tablets. Heart rate increased after tablet administration, independent of dose. The tablets also significantly decreased subjective ratings of craving and urge, and increased ratings of nausea. Based on this short-term laboratory evaluation, Ariva exposes users to nicotine and may suppress some symptoms of tobacco abstinence, though its nausea-inducing characteristics may limit initial acceptability.

Modafinil and nicotine interactions in abstinent smokers

In this study, we examined the effects of a wakefulness-promoting medication, modafinil, alone and with the nicotine lozenge, on subjective, physiological and cognitive measures as well as on nicotine withdrawal in overnight abstinent cigarette smokers. Nineteen smokers, 13 male and 6 female, participated in a double-blind, placebo-controlled, crossover study. In each of three experimental sessions, subjects were treated orally with a single 200 mg or 400 mg dose of modafinil or placebo. Two hours and 10 min following the medication treatment, subjects received a single 2 mg nicotine lozenge. Both doses of modafinil alone increased the rating of elated-depressed on the Profile of Mood States (POMS) subscale in the direction of depressed and increased ratings of negative affect on the Positive and Negative Affect Schedule (PANAS). In contrast, the 200 mg modafinil dose combined with a 2 mg nicotine lozenge, increased the rating of energetic-tired in the direction of energetic on the POMS subscale. Modafinil attenuated self-reported rating of 'drug strength' in response to the nicotine lozenge. Modafinil, alone or in combination with the nicotine lozenge, did not affect tobacco withdrawal symptoms. There was an increase in baseline heart rate and systolic blood pressure under modafinil treatment. In addition, modafinil speeded reaction times on a modified Stroop task. The clinical utility of modafinil for smoking cessation needs to be determined in future studies.

Changing smokeless tobacco products new tobacco-delivery systems

Smokeless or noncombusted oral tobacco use as a substitute for cigarette smoking has been gaining greater interest and attention by the public health community and the tobacco industry. In order for the product to appeal to smokers, tobacco companies have been manufacturing new noncombusted oral tobacco (i.e., moist snuff) that is lower in moisture content and nitrosamine levels, packaged in small sachets and "spitless." While the primary motives of the major tobacco companies are to maintain or increase tobacco use, some members of the public health community perceive the use of noncombusted oral tobacco products as a harm reduction tool. Because cigarette smoking is associated with greater toxicant exposure compared to noncombusted oral tobacco, reduced mortality and morbidity are hypothesized to ensue, if cigarette smokers switched completely to these products. However, variability exists in levels of nicotine and toxicants and potential health consequences from use within and across countries. Therefore, promulgating noncombusted oral tobacco products as a safer alternative to smoking or as a substitute for smoking may engender more rather than less harm. To date, limited research is available on the effects of marketing noncombusted oral tobacco products to smokers, to support the use of these products as a harm reduction tool, and to determine the effects of varying levels of tobacco toxicants including nicotine on health. The need exists for manufacturing standards to lower toxicant levels of all noncombusted oral tobacco products, for the formulation of appropriate tobacco-product regulations and for the development of a strategic plan by the public health community to address this controversial topic.

Effect of smokeless tobacco product marketing and use on population harm from tobacco use policy perspective for tobacco-risk reduction

This article presents policy perspectives on the marketing of smokeless tobacco products to reduce population harm from tobacco use. Despite consensus that smokeless tobacco products as sold in the United States are less dangerous than cigarettes, there is no consensus on how to proceed. Diverse factions have different policy concerns. While the tobacco industry is exempted from U.S. Food and Drug Administration (FDA) oversight, the pharmaceutical industry whose nicotine replacement therapy (NRT) medicines compete with smokeless tobacco as noncombustible nicotine-delivery systems are regulated by the FDA. Some public health experts support smokeless tobacco use to reduce population harm from tobacco; other public health experts oppose promoting smokeless tobacco for harm reduction. Adult consumers can freely purchase currently-marketed smokeless tobacco products and even more-deadly cigarettes. Concerns with and advantages of smokeless tobacco products are discussed. In that noncombustible medicinal nicotine-delivery systems have been proven to be effective smoking-cessation aids, smokeless tobacco, as another source of psychoactive doses of nicotine, could be used similarly, in a dose-response fashion as a smoking-cessation aid (consistent with FDA principles for evaluating generic versions of drugs). Price measures should be used on tobacco products to make costs to consumers proportional to product health risks (which would make smokeless tobacco much cheaper than cigarettes), and smokeless tobacco should be encouraged as an option for smoking cessation in adult smokers, particularly for those who have failed to stop smoking using NRT or other methods.

Interventions to reduce harm from continued tobacco use

BACKGROUND

It may be reasonable to try to reduce the harm from continued smoking amongst smokers unable or unwilling to quit. Possible approaches to reduce the exposure to toxins from smoking include reducing the amount of tobacco used, and using less toxic products. The interventions evaluated in controlled trials have predominantly attempted to reduce the number of cigarettes smoked.

OBJECTIVES

To assess the effect of interventions intended to reduce the harm from smoking on the following: biomarkers of damage caused by tobacco, biomarkers of tobacco exposure, number of cigarettes smoked, quitting, and long-term health status.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group Specialised Register using free text and MeSH terms for harm reduction, smoking reduction and cigarette reduction. The initial search was in March 2006, updated in March 2007.

SELECTION CRITERIA

Randomized or quasi-randomized controlled trials of interventions in tobacco users to reduce amount smoked, or to reduce harm from smoking by means other than cessation. Outcomes were change in cigarette consumption, markers of cigarette exposure and any markers of damage or benefit to health, measured at least six months from the start of the intervention.

DATA COLLECTION AND ANALYSIS

We pooled trials with similar interventions and outcomes using a fixed-effect model. Other studies were summarised narratively.

MAIN RESULTS

The 13 included trials all evaluated interventions to help smokers cut down the amount smoked. Self-reported reduction in cigarettes per day (CPD) was validated by reduction in carbon monoxide (CO) levels. Most trials tested nicotine replacement therapy (NRT) to assist reduction. No eligible studies evaluated the use of potentially reduced-exposure products. In a pooled analysis of eight trials, NRT significantly increased the odds of reducing CPD by 50% or more for people using nicotine gum or inhaler or a choice of product compared to placebo (n=3273, odds ratio [OR] 2.02, 95% confidence interval [CI] 1.55 to 2.62). Where average changes from baseline were compared for different measures, CO and cotinine consistently showed smaller reductions than CPD. Whilst the effect for NRT was significant, small numbers of people in either treatment or control group successfully sustained a reduction of 50% or more. Use of NRT also significantly increased the odds of quitting (OR 1.90, 95% CI 1.46 to 2.47). One trial of bupropion failed to detect an effect on reduction or cessation. Four trials of different types of advice and instructions on reducing CPD did not provide clear evidence.

AUTHORS' CONCLUSIONS

There is insufficient evidence about long-term benefit to give firm support the use of interventions intended to help smokers reduce but not quit tobacco use. Some people who do not wish to quit can be helped to cut down the number of cigarettes smoked and reduce their carbon monoxide levels by using nicotine gum or nicotine inhaler. Because the long-term health benefit of a reduction in smoking rate is unclear this application of NRT is more appropriately used as a precursor to quitting.