The Hitchhiker's Guide to Tobacco Control: A Global Assessment of Harms, Remedies, and Controversies

A review of the analysis of biomarkers of exposure to tobacco and vaping products

Quantification of exposure to different chemicals from both combustible cigarettes and vaping products is important in providing information on the potential health risks of these products. To assess the exposure to tobacco products, biomarkers of exposure (BOEs) are measured in a variety of biological matrices. In this review paper, current knowledge on analytical methods applied to the analysis of biomarkers of exposure to tobacco products is discussed. Numerous sample preparation techniques are available for the extraction and sample clean up for the analysis of BOEs to tobacco and nicotine delivery products. Many tobacco products-related exposure biomarkers have been analyzed using different instrumental techniques, the most common techniques being gas and liquid chromatography coupled with mass spectrometry (GC-MS, GC-MS/MS and LC-MS/MS). To assess exposure to emerging tobacco products and study exposure in dual tobacco users, the list of biomarkers analyzed in urine samples has been expanded. Therefore, the current state of the literature can be used in preparing a preferred list of biomarkers based on the aim of each study. The information summarized in this review is expected to be a handy tool for researchers involved in studying exposures to tobacco products, as well as in risk assessment of biomarkers of exposure to vaping products.

Adherence to the Tobacco Control Act, 2007: presence of a workplace policy on tobacco use in bars and restaurants in Nairobi, Kenya

INTRODUCTION

Despite extensive knowledge about effective tobacco control interventions, the prevalence of tobacco use in many middle- and low-income countries continues to rise. In these countries, public appreciation of levels of protection provided by laws and regulations on tobacco use and exposure to tobacco smoke is limited. After ratification of the Framework Convention on Tobacco Control, Kenya enacted the Tobacco Control Act, 2007, banning smoking in public places except in designated smoking areas.

OBJECTIVE

To assess adherence to the Tobacco Control Act, 2007 by determining the presence of a workplace policy on tobacco use in bars and restaurants.

METHODS

A survey of 176 liquor licensed bars and restaurants in Nairobi County was carried out. Their managers were asked about the presence of a workplace policy governing smoking of tobacco, and observations made on provisions that determine adherence to the Tobacco Control Act, 2007.

RESULTS

Smoking took place in almost all bars and restaurants (150 (85%)). Half the establishments (86 (49%)) had a workplace policy governing tobacco use among employees, although a difference between bars (11 (23%)) and restaurants (75 (58%)) was recorded (p<0.001). Establishments at which managers had lower levels of education were less likely to have a workplace policy (p<0.001) and less likely to have 'no smoking' signs and designated smoking areas (p<0.005).

CONCLUSIONS AND RECOMMENDATIONS

Kenya's implementation of the Tobacco Control Act, 2007 does not provide sufficient protection of patrons and workers in bars and restaurants. It is important to sensitise hospitality workers to the dangers of tobacco smoke. Bar and restaurants managers should have a minimum post-secondary education level. The Tobacco Control Act, 2007 requires strengthening to ensure that bars and restaurants have a smoke-free environment.

Sustainable production of valuable compound 3-succinoyl-pyridine by genetically engineering Pseudomonas putida using the tobacco waste

Treatment of solid and liquid tobacco wastes with high nicotine content remains a longstanding challenge. Here, we explored an environmentally friendly approach to replace tobacco waste disposal with resource recovery by genetically engineering Pseudomonas putida. The biosynthesis of 3-succinoyl-pyridine (SP), a precursor in the production of hypotensive agents, from the tobacco waste was developed using whole cells of the engineered Pseudomonas strain, S16dspm. Under optimal conditions in fed-batch biotransformation, the final concentrations of product SP reached 9.8 g/L and 8.9 g/L from aqueous nicotine solution and crude suspension of the tobacco waste, respectively. In addition, the crystal compound SP produced from aqueous nicotine of the tobacco waste in batch biotransformation was of high purity and its isolation yield on nicotine was 54.2%. This study shows a promising route for processing environmental wastes as raw materials in order to produce valuable compounds.

Pathophysiological Mechanisms of Tobacco-Related CVD

Cigarette smoking is a leading preventable risk factor for the development and progression of cardiovascular diseases (CVDs). Epidemiologic studies conclusively prove that both active smoking and secondhand smoke contribute significantly to morbidity and mortality related to CVD. Cigarette smoke is a mixture of several toxic chemicals, of which nicotine, carbon monoxide, and oxidant chemicals are most commonly implicated in the pathogenesis of cardiovascular disease. Tobacco causes endothelial dysfunction, inflammation, insulin resistance, alteration of lipid profile, hemodynamic alterations, and a hypercoagulable state. All of these act synergistically as pathobiologic mechanisms of atherothrombosis in tobacco users.

Sexual orientation and smoking history: results from a community-based sample of youth in Shanghai, China

OBJECTIVE

Cigarette smoking has been found to be more prevalent among adults and youths with a minority sexual orientation (lesbian, gay, bisexual, LGB) than among the general population, while less is known about smoking among LGB youth in low- and middle-income countries. The goal of the study was to examine cigarette smoking in relation to sexual orientation in a community-based sample of youth in Shanghai, China.

METHODS

A multi-center cross-sectional survey of 17,016 youth aged 15-24 years was conducted in rural and urban areas of Hanoi, Vietnam; Taipei, Taiwan; and Shanghai, China in 2006. In this article, analysis was restricted to the 6,299 respondents in Shanghai. Assessments included ever smoking, age at first smoking, frequency of smoking, and number of cigarettes smoked daily. Logistic regression was used to estimate the association between sexual orientation and cigarette smoking.

RESULTS

Nine percent (594/6,299) of eligible participants considered themselves as LGB youths; 34.2% ever smoked, 14.81% initiated smoking before age 13, 15.9% smoked in the past 30 days, and 14.1% were moderate or heavy smokers. LGB identity predicted moderate or heavy smoking (OR 2.2, 95% CI 1.3, 3.9). Male LGB youth smoked more cigarettes daily (OR 2.2, 95% CI 1.3, 3.9) whilst female LGB youth reported less any prior cigarette use (OR 0.7, 95% CI 0.5, 1.0).

CONCLUSIONS

Few meaningful disparities in cigarette smoking were related to sexual orientation, except male LGB youth consumed more cigarettes daily. Prevention and cessation should target this population, especially male LGB youth.

Facilitators and barriers to effective smoking cessation: counselling services for inpatients from nurse-counsellors' perspectives--a qualitative study

Tobacco use has reached epidemic levels around the World, resulting in a world-wide increase in tobacco-related deaths and disabilities. Hospitalization presents an opportunity for nurses to encourage inpatients to quit smoking. This qualitative descriptive study was aimed to explore nurse-counsellors' perspectives of facilitators and barriers in the implementation of effective smoking cessation counselling services for inpatients. In-depth interviews were conducted with 16 nurses who were qualified smoking cessation counsellors and who were recruited from eleven health promotion hospitals that were smoke-free and located in the Greater Taipei City Area.  Data were collected from May 2012 to October 2012, and then analysed using content analysis based on the grounded theory approach. From nurse-counsellors' perspectives, an effective smoking cessation program should be patient-centred and provide a supportive environment. Another finding is that effective smoking cessation counselling involves encouraging patients to modify their lifestyles. Time constraints and inadequate resources are barriers that inhibit the effectiveness of smoking cessation counselling programs in acute-care hospitals. We suggest that hospitals should set up a smoking counselling follow-up program, including funds, facilities, and trained personnel to deliver counselling services by telephone, and build a network with community smoking cessation resources.

Normative influences on intentions to smoke among Greek adolescents: the moderating role of smoking status

Background

Social norms influence adolescent smoking intentions, but this effect may differentiate depending on current smoking experiences. The presented study assessed the moderation effects of smoking status on the relationship between social norms and smoking intentions among Greek adolescents.

Methods

A cross-section survey-based design was used. Overall, 251 Greek secondary school students (M age = 16.1 years, 61.2% females) completed structured and anonymous questionnaires including demographic characteristics (age, gender), subjective and descriptive social norms towards smoking, self-reported tobacco use, and intentions to smoke in the next 12 months.

Results

Linear regression analysis showed that social norms overall predicted 36.4% (Adjusted R²) of the variance in intentions. Perceived prevalence of smoking in same age peers and adults, having more close friends who smoke and perceived social approval of smoking predicted intentions to smoke in one year. Moderated regression analysis showed that the effects of social norms on smoking intentions were significantly moderated by smoking status.

Conclusions

Social norms predict smoking intentions, but this effect is stronger among ever (than never) smoker adolescents. Adolescents with smoking experiences may selectively attend to pro-smoking social cues and this perpetuates into their motivation to keep up the habit. School-based interventions should target normative beliefs and related cognitive processes, especially among adolescents who have already initiated tobacco use.

Modeling the cumulative effects of social exposures on health: moving beyond disease-specific models

The traditional explanatory models used in epidemiology are “disease specific”, identifying risk factors for specific health conditions. Yet social exposures lead to a generalized, cumulative health impact which may not be specific to one illness. Disease-specific models may therefore misestimate social factors’ effects on health. Using data from the Canadian Community Health Survey and Canada 2001 Census we construct and compare “disease-specific” and “generalized health impact” (GHI) models to gauge the negative health effects of one social exposure: socioeconomic position (SEP). We use logistic and multinomial multilevel modeling with neighbourhood-level material deprivation, individual-level education and household income to compare and contrast the two approaches. In disease-specific models, the social determinants under study were each associated with the health conditions of interest. However, larger effect sizes were apparent when outcomes were modeled as compound health problems (0, 1, 2, or 3+ conditions) using the GHI approach. To more accurately estimate social exposures’ impacts on population health, researchers should consider a GHI framework.

Radon, smoking, and lung cancer: the need to refocus radon control policy

Exposure to radon is the second leading cause of lung cancer, and the risk is significantly higher for smokers than for nonsmokers. More than 85% of radon-induced lung cancer deaths are among smokers. The most powerful approach for reducing the public health burden of radon is shaped by 2 overarching principles: public communication efforts that promote residential radon testing and remediation will be the most cost effective if they are primarily directed at current and former smokers; and focusing on smoking prevention and cessation is the optimal strategy for reducing radon-induced lung cancer in terms of both public health gains and economic efficiency. Tobacco control policy is the most promising route to the public health goals of radon control policy.

'Risking enchantment': how are we to view the smoking person?

The idea of the smoking person portrayed in public health has been criticised as being based on too narrow a view of human nature. This article discusses that view: that of a person with a stable core and epiphenomenal 'behaviours' that can be removed by rational persuasion or Pavlovian manipulation, and examines social scientific critiques of it. The social sciences explore the meanings smoking has for individuals and portray human identity as malleable, the result of ongoing interactions with human and non-human others. Aspects of smokers' experience revealed in qualitative research - descriptions of cigarettes as 'companions' or 'friends', deep reliance, sensual pleasure - are sometimes difficult to articulate but can be given full voice in the context of the literary arts. We explore some examples of these sources and argue that a complete picture of smoking meanings is impossible without reference to them. We take a pragmatic approach, following the philosopher William James, who argued that emotional and spiritual experiences contribute to the truth of human existence as much as material explanations, to suggest that this understanding should be part of a critical but supportive engagement with public health research in order to develop more nuanced and humane approaches to smoking cessation.

Cigarette design features in low-, middle-, and high-income countries

Previous studies have shown that country income grouping is correlated with cigarette engineering. Cigarettes (N = 111 brands) were purchased during 2008-2010 from 11 low-, middle-, and high-income countries to assess physical dimensions and an array of cigarette design features. Mean ventilation varied significantly across low- (7.5%), middle- (15.3%), and high-income (26.2%) countries (P ≤ 0.001). Differences across income groups were also seen in cigarette length (P = 0.001), length of the tipping paper (P = 0.01), filter weight (P = 0.017), number of vent rows (P = 0.003), per-cigarette tobacco weight (P = 0.04), and paper porosity (P = 0.008). Stepwise linear regression showed ventilation and tobacco length as major predictors of ISO tar yields in low-income countries (P = 0.909, 0.047), while tipping paper (P < 0.001), filter length (P < 0.001), number of vent rows (P = 0.014), and per-cigarette weight (P = 0.015) were predictors of tar yields in middle-income countries. Ventilation (P < 0.001), number of vent rows (P = 0.009), per-cigarette weight (P < 0.001), and filter diameter (P = 0.004) predicted tar yields in high-income countries. Health officials must be cognizant of cigarette design issues to provide effective regulation of tobacco products.

Public support for tobacco control policy extensions in Western Australia: a cross-sectional study

OBJECTIVES

Policy makers seeking to introduce new tobacco control measures need to anticipate community support to assist them in planning appropriate implementation strategies. This study assessed community support for plain packaging and smoking bans in outdoor locations in Australia.

DESIGN

Analytical cross-sectional survey.

SETTING AND PARTICIPANTS

2005 Western Australian adults participated in a computer-assisted telephone interview. Random household telephone numbers were used to obtain a representative sample.

OUTCOME MEASURES

Support for plain packaging of cigarettes and smoking bans at outdoor venues by demographic characteristics.

RESULTS

Around half of the survey respondents supported plain packaging and almost a further quarter reported being neutral on the issue. Only one in three smokers disagreed with the introduction of a plain packaging policy. A majority of respondents supported smoking bans at five of the six nominated venues, with support being strongest among those with children under the age of 15 years. The venues with the highest levels of support were those where smoke-free policies had already been voluntarily introduced by the venue managers, where children were most likely to be in attendance, and that were more limited in size.

CONCLUSIONS

The study results demonstrate community support for new tobacco control policies. This evidence can be used by public policy makers in their deliberations relating to the introduction of more extensive tobacco control regulations.

Characterizing patterns of smoking initiation in adolescence: comparison of methods for dealing with missing data

INTRODUCTION

Tobacco use is common and remains one of the leading causes of preventable death in developed countries. Smoking commonly begins in adolescence, and hence, it is important to understand how smoking behavior develops during this period.

METHODS

In a U.K.-based birth cohort, we analyzed repeated measures of smoking frequency in a sample of 7,322 young adolescents. Latent class analysis was used to summarize the data, and the resulting classes of behavior were related to a range of smoking risk factors. Results from a complete case analysis were compared with estimation using full-information maximum likelihood (FIML) and estimation using multiple imputation (MI).

RESULTS

Fifty-three percent of the sample reported having smoked a whole cigarette by age 16 years. The longitudinal data were summarized by 4 distinct patterns of smoking initiation: nonsmokers (79.7%), experimenters (10.3%), late-onset regular smokers (5.5%), and early-onset regular smokers (4.5%). Social disadvantage, other substance use, conduct problems, and female sex were strongly related to being a regular smoker; however, no risk factors studied showed any strong or consistent association with experimentation. In the complete case sample, smoking prevalence was lower, and in addition, the association between different smoking patterns and covariates was often inconsistent with those obtained through FIML/MI.

CONCLUSIONS

Most young people have experimented with tobacco smoking by age 16 years, and regular smoking is established in a substantial minority characterized by social disadvantage, other substance, use and conduct disorder. Prevention strategies should focus on this subgroup as most children who experiment with tobacco do not progress to regular smoking.

Global oral health inequalities in incidence and outcomes for oral cancer: causes and solutions

The mouth and oropharynx are among the ten most common sites affected by cancer worldwide, but global incidence varies widely. Five-year survival rates exceed 50% in only the best treatment centers. Causes are predominantly lifestyle-related: Tobacco, areca nut, alcohol, poor diet, viral infections, and pollution are all important etiological factors. Oral cancer is a disease of the poor and dispossessed, and reducing social inequalities requires national policies co-ordinated with wider health and social initiatives - the common risk factor approach: control of the environment; safe water; adequate food; public and professional education about early signs and symptoms; early diagnosis and intervention; evidence-based treatments appropriate to available resources; and thoughtful rehabilitation and palliative care. Reductions in inequalities, both within and between countries, are more likely to accrue from the application of existing knowledge in a whole-of-society approach. Basic research aimed at determining individual predisposition and acquired genetic determinants of carcinogenesis and tumor progression, thus allowing for targeted therapies, should be pursued opportunistically.

Multi-country, cross-national comparison of youth tobacco use: findings from global school-based health surveys

OBJECTIVE

Describe the prevalence of current cigarette smoking and other tobacco use among 13-15year olds across 44 countries and 110 sites participating in the Global School-based Health Survey (GSHS), and compare these results with previous findings from the Global Youth Tobacco Survey.

METHODS

The GSHS is conducted in countries using standardized sampling and survey methodology procedures. Smoking and other tobacco use prevalence was compiled from fact sheets available on the GSHS web site from the available 110 sites where the survey has been conducted and resulting data processed. Tobacco use prevalence rates are weighted to adjust for the probabilities of nonresponse and varying probabilities of selection. Boy to girl ratios were calculated to examine gender differences in tobacco use prevalence.

RESULTS

Current smoking rates ranged widely from a low of approximately 1 in 100 students in Tajikistan and India to a high of more than 1 in 4 students in certain sites in Chile and Colombia, and more than 1 in 5 in other sites in Chile, Ecuador, Argentina, and Colombia. Other tobacco use prevalence ranged from a low of 1.0% in Hangzhou, China to a high of 43.7% in Northwest Namibia.

CONCLUSION

This is the first multi-country, cross-national study of tobacco use involving GSHS data. Results provide an opportunity to examine youth tobacco use in several countries and compare results with the Global Youth Tobacco Survey (GYTS) which is a more extensive global surveillance of youth tobacco use.

Hazardous compounds in tobacco smoke

Tobacco smoke is a toxic and carcinogenic mixture of more than 5,000 chemicals. The present article provides a list of 98 hazardous smoke components, based on an extensive literature search for known smoke components and their human health inhalation risks. An electronic database of smoke components containing more than 2,200 entries was generated. Emission levels in mainstream smoke have been found for 542 of the components and a human inhalation risk value for 98 components. As components with potential carcinogenic, cardiovascular and respiratory effects have been included, the three major smoke-related causes of death are all covered by the list. Given that the currently used Hoffmann list of hazardous smoke components is based on data from the 1990s and only includes carcinogens, it is recommended that the current list of 98 hazardous components is used for regulatory purposes instead. To enable risk assessment of components not covered by this list, thresholds of toxicological concern (TTC) have been established from the inhalation risk values found: 0.0018 μg day⁻¹ for all risks, and 1.2 μg day⁻¹ for all risks excluding carcinogenicity, the latter being similar to previously reported inhalation TTCs.

Volunteered, negotiated, enforced: family politics and the regulation of home smoking

The protection of children from secondhand smoke in their homes remains a key objective for health agencies worldwide. While research has explored how parents can influence the introduction of home smoking restrictions, less attention has been paid to the role of wider familial and social networks as conduits for positive behaviour changes. In this article we explore how people living in Scotland have introduced various home smoking restrictions to reduce or eliminate children's exposure to tobacco smoke, and how some have gone on to influence people in their wider familial and social networks. The results suggest that many parents are willing to act on messages on the need to protect children from smoke, leading to the creation of patterns of smoking behaviour that are passed on to their parents and siblings and, more widely, to friends and visitors. However, while some parents and grandparents apparently voluntarily changed their smoking behaviour, other parents found that they had to make direct requests to family members and some needed to negotiate more forcefully to protect children, albeit often with positive results.

Trafficking in tobacco farm culture: Tobacco companies use of video imagery to undermine health policy

The cigarette companies and their lobbying organization used tobacco industry-produced films and videos about tobacco farming to support their political, public relations, and public policy goals. Critical discourse analysis shows how tobacco companies utilized film and video imagery and narratives of tobacco farmers and tobacco economies for lobbying politicians and influencing consumers, industry-allied groups, and retail shop owners to oppose tobacco control measures and counter publicity on the health hazards, social problems, and environmental effects of tobacco growing. Imagery and narratives of tobacco farmers, tobacco barns, and agricultural landscapes in industry videos constituted a tobacco industry strategy to construct a corporate vision of tobacco farm culture that privileges the economic benefits of tobacco. The positive discursive representations of tobacco farming ignored actual behavior of tobacco companies to promote relationships of dependency and subordination for tobacco farmers and to contribute to tobacco-related poverty, child labor, and deforestation in tobacco growing countries. While showing tobacco farming as a family and a national tradition and a source of jobs, tobacco companies portrayed tobacco as a tradition to be protected instead of an industry to be regulated and denormalized.

Tobacco industry attempts to counter the World Bank report Curbing the Epidemic and obstruct the WHO framework convention on tobacco control

In 1999 the World Bank published a landmark study on the economics of tobacco control, Curbing the Epidemic: Governments and the Economics of Tobacco Control (CTE), which concluded that tobacco control brings unprecedented health benefits without harming economies, threatening the transnational tobacco companies' ability to use economic arguments to dissuade governments from enacting tobacco control policies and supporting the WHO Framework Convention on Tobacco Control (FCTC). We used tobacco industry documents to analyze how tobacco companies worked to discredit CTE. They hired public relations firms, had academics critique CTE, hired consultants to produce "independent" estimates of the importance of tobacco to national economies, and worked through front groups, particularly the International Tobacco Growers' Association, to question CTE's findings. These efforts failed, and the report remains an authoritative economic analysis of global tobacco control during the ongoing FCTC negotiations. The industry's failure suggests that the World Bank should continue their analytic work on the economics of tobacco control and make tobacco control part of its development agenda.

Advance and retreat: tobacco control policy in the U.S. military

This archival study explored why military tobacco control initiatives have thus far largely failed to meet their goals. We analyzed more than 5,000 previously undisclosed internal tobacco industry documents made public via an online database and additional documents obtained from the U.S. military. In four case studies, we illustrate how pressures exerted by multiple political actors resulted in weakening or rescinding military tobacco control policy initiatives. Our findings suggest that lowering military smoking rates will require health policymakers to better anticipate and counter political opponents. The findings also suggest that effective tobacco control policies may require strong, explicit implementation instructions and high-level Department of Defense support. Finally, policy designers should also consider ways to reduce or eliminate existing perverse incentives to increase tobacco consumption, such as allowing exchange store tobacco sales to fund Morale, Recreation, and Welfare Programs.

Nursing interventions for smoking cessation

BACKGROUND

Healthcare professionals, including nurses, frequently advise patients to improve their health by stopping smoking. Such advice may be brief, or part of more intensive interventions.

OBJECTIVES

To determine the effectiveness of nursing-delivered smoking cessation interventions.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group specialized register and CINAHL in July 2007.

SELECTION CRITERIA

Randomized trials of smoking cessation interventions delivered by nurses or health visitors with follow up of at least six months.

DATA COLLECTION AND ANALYSIS

Two authors extracted data independently. The main outcome measure was abstinence from smoking after at least six months of follow up. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. Where statistically and clinically appropriate, we pooled studies using a Mantel-Haenszel fixed effect model and reported the outcome as a risk ratio (RR) with 95% confidence interval (CI).

MAIN RESULTS

Forty-two studies met the inclusion criteria. Thirty-one studies comparing a nursing intervention to a control or to usual care found the intervention to significantly increase the likelihood of quitting (RR 1.28, 95% CI 1.18 to 1.38). There was heterogeneity among the study results, but pooling using a random effects model did not alter the estimate of a statistically significant effect. In a subgroup analysis there was weaker evidence that lower intensity interventions were effective (RR 1.27, 95% CI 0.99 to 1.62). There was limited indirect evidence that interventions were more effective for hospital inpatients with cardiovascular disease than for inpatients with other conditions. Interventions in non-hospitalized patients also showed evidence of benefit. Nine studies comparing different nurse-delivered interventions failed to detect significant benefit from using additional components. Five studies of nurse counselling on smoking cessation during a screening health check, or as part of multifactorial secondary prevention in general practice (not included in the main meta-analysis) found nursing intervention to have less effect under these conditions.

AUTHORS' CONCLUSIONS

The results indicate the potential benefits of smoking cessation advice and/or counselling given by nurses to patients, with reasonable evidence that intervention is effective. The evidence of an effect is weaker when interventions are brief and are provided by nurses whose main role is not health promotion or smoking cessation. The challenge will be to incorporate smoking behaviour monitoring and smoking cessation interventions as part of standard practice, so that all patients are given an opportunity to be asked about their tobacco use and to be given advice and/or counselling to quit along with reinforcement and follow up.