Biological basis of tobacco addiction: Implications for smoking-cessation treatment

Documento de consenso sobre tabaquismo y riesgo vascular

Consensus statement on smoking and vascular risk About 22% of the Spanish population are daily smokers. Men are more likely to smoke than women. In Spain, women between 15-25 years of age smoke as much or more than men. Every smoker should be assessed for: physical dependence on nicotine (Fagerström test), social and psychological dependence (Glover Nilsson test), level of motivation to quit (Richmond test), probability of therapy success (Henri-Mondor and Michael-Fiore tests), and stage of behavioral change development (Prochaska and DiClementi). Advice on smoking cessation is highly cost-effective and should always be provided. Smoking is an enhancer of cardiovascular risk because it acts as a pathogen agent in the development of arteriosclerosis and is associated with ischemic heart disease, stroke, and peripheral artery disease. Smoking increases the risk of chronic lung diseases (COPD) and is related to cancers of the lung, female genitalia, larynx, oropharynx, bladder, mouth, esophagus, liver and biliary tract, and stomach, among others. Combined oral contraceptives should be avoided in women smokers older than 35 years of age due to the risk of thromboembolism. In smoking cessation, the involvement of physicians, nurses, psychologists, etc. is important, and their multidisciplinary collaboration is needed. Effective pharmacological treatments for smoking cessation are available. Combined treatments are recommended when smoker's dependence is high. For individuals who are unable to quit smoking, a strategy based on tobacco damage management with a total switch to smokeless products could be a less dangerous alternative for their health than continuing to smoke.

Effect of children secondhand smoke exposure associated with GABA concentration: Influence from parents who are extremely heavy smokers in urban households

BACKGROUND

Secondhand smoke (SHS) poses the most considerable health risk to children in urban households. However, limited evidence exists regarding the impact of children exposure to SHS on gamma-aminobutyric acid (GABA) levels. This study aimed to investigate the level of cotinine and GABA and their association with variables related to children exposed to SHS.

METHODS

A cross-sectional analysis was conducted to assess urinary cotinine and GABA levels in respondents. The study involved 85 participants aged 2-4 years who resided with parents exhibiting heavy smoking habits in urban households in Bangkok, Thailand. Urinary cotinine and GABA concentrations were utilized as biomarkers and measured using an enzyme-linked immunosorbent assay kit. An independent t-test was employed to compare contributing factors with urinary cotinine metabolites. Spearman's correlation test was utilized to assess the relationship between cotinine metabolites and GABA concentration.

RESULTS

The study found a correlation between urinary cotinine metabolites and GABA concentration among children's (r = 0.260, p-value = 0.016), particularly influenced by parents exhibiting extreme heavy smoking in urban households. Male children exhibited significantly higher urinary cotinine metabolite concentrations than females (p-value = 0.040). Moreover, significantly elevated levels of cotinine metabolites (57.37 ± 10.27 ng/ml) were observed in households where parents engaged in extreme heavy smoking.

CONCLUSIONS

This research establishes a link between urinary cotinine metabolite levels and GABA concentration among children exposed to extreme heavy smoking by their parents in urban households. Consequently, smoking might impact neurobehavioral effects, potentially leading to insomnia. The study emphasizes the importance of promoting and safeguarding non-smokers from exposure to SHS in indoor workplaces, public spaces, and households, advocating for the implementation of smoke-free public health regulations.

Recent Studies on the Development of Nicotine Abuse and Behavioral Changes Induced by Chronic Stress Depending on Gender

Nowadays, stressful situations are an unavoidable element of everyday life. Stressors activate a number of complex mental and physiological reactions in the organism, thus affecting the state of health of an individual. Stress is the main risk factor in the development of mental disorders, such as depression and other disorders developing as a result of addiction. Studies indicate that women are twice as likely as men to develop anxiety, depression and therefore addiction, e.g., to nicotine. Even though the data presented is indicative of significant differences between the sexes in the prevalence of these disorders, the majority of preclinical animal models for investigating stress-induced disorders use predominantly male subjects. However, the recent data indicates that this type of studies has also been launched in female rodents. Therefore, conducting research on both sexes allows for a more accurate understanding and assessment of the impact of stress on stress-induced behavioral, peripheral and molecular changes in the body and brain. In this manuscript we have gathered the data from 41 years (from 1981-2022) on the influence of stress on the development of depression and nicotine addiction in both sexes.

Consumer experiences of long-term oral nicotine replacement therapy and related health information-seeking: A qualitative study

BACKGROUND

Nicotine replacement therapy (NRT) delivers a therapeutic dose of nicotine to support smoking cessation, and is currently approved for short-term use (typically ≤12 weeks). Yet, research on real-world over-the-counter NRT use indicates that some consumers continue to use these products long-term. This study sought to understand consumers' experiences of long-term oral NRT use, including self-reported reasons for continued use, and health information-seeking regarding long-term use.

METHODS

In-depth semi-structured telephone interviews were conducted between May and June 2021 with 21 current and former NRT consumers aged ≥18 years from across Australia, with oral NRT use of ≥1 year. Interviews were thematically analysed using the Framework Method.

RESULTS

The majority of participants reported achieving NRT-assisted smoking cessation and related health benefits (e.g. respiratory health, improved physical appearance). However, nearly all participants reported experiencing addiction to oral NRT, with many attributing their long-term use to dependence on these products. Participants reported low engagement with NRT health information sources; just half reported consulting with a health professional regarding their long-term NRT use, and some reported negative experiences when health professional advice was sought (e.g. perceptions of not being taken seriously, perceived lack of health professional knowledge). Less than half of participants accurately identified the duration of use recommended in NRT consumer medicine information, and some reported actively dismissing this information.

CONCLUSION

Findings highlight consumers' perceived benefits of continued NRT use whilst also identifying two key concerns - the addictive potential of oral NRT, and low health information-seeking and health professional engagement regarding long-term use. While oral NRT is indisputably safer than tobacco smoking, public health strategies to raise consumer and health professional awareness about the safe use of NRT, which acknowledge the current evidence gap regarding safety and efficacy of long-term use, are needed to maximise their benefits as a harm reduction strategy for smoking cessation.

Theoretical constructs of smoking cessation among current tobacco smokers in India: a secondary analysis of Global Adult Tobacco Survey-2 (2016-2017)

BACKGROUND

Quitting tobacco smoking is a complex process, and the transtheoretical model describes the various stages of behaviour change that smokers experience to stop smoking. Predictors of intention to quit and stage of behavioural change could assist policy-makers in establishing tailor-made strategies to offer support.

OBJECTIVE

In the current study, we analysed the determinants of cessation among 9499 current smokers of India recorded during the second Global Adult Tobacco Survey (2016-2017).

METHODS

Bivariate analysis, multivariate analysis (binary logistic regression was performed for past quit attempts and intention to quit smoking in the future; multinomial logistic regression to understand predictors of various stages of change determining cessation behaviour of current smokers) was undertaken.

RESULTS

The majority of the smokers was men (91.0%), in 25-44 years age group, (42.3%), daily wagers (37.4%) and resided in the rural area (73.3%), with bidi being the most commonly smoked product (72%). Nearly 72% tried to quit without any assistance with 36.6% (precontemplation), 27% (contemplation), 28% (preparation (or action)) and 8.1% in (relapse) stage. Men ((1.049); 95% CI 1.047 to 1.051), the primary (1.192; 95% CI 1.190 to 1.193) as well as higher education, being married (1.231; 95% CI 1.229 to 1.234) and urban residence (1.167; 95% CI 1.1.65 to 1.168) were found to be associated with higher prevalence of previous quit attempts. The regression modelling found out that intent to quit reduced with increasing age and was similarly prevalent with any level of education.

CONCLUSION

Understanding stages of behavioural change could assist the stakeholders in developing individualised interventions along with the development of intensive cessation protocols in clinical and public health settings.

Influence of Nicotine from Diverse Delivery Tools on the Autonomic Nervous and Hormonal Systems

Background: Through measurements of the heart rate variability (HRV) accompanied by the pertinent biomarker assays, the effects of nicotine and byproducts derived from alternative nicotine delivery systems (ANDS) on the autonomic nervous system (ANS) and hormonal system have been investigated. Methods: HRV was studied in a group of volunteers (17 people), involving non-smokers, i.e., who never smoked before (11), ex-smokers (4) and active smokers (2). ANDS and smoking simulators, including regular, nicotine-free and electronic cigarettes; tobacco heating systems; chewing gums and nicotine packs of oral fixation (nic-packs), were used. Blood pressure, levels of stress hormones in saliva and catecholamines in the blood were also monitored. Results: HRV analysis showed relatively small changes in HRV and in the other studied parameters with the systemic use of nic-packs with low and moderate nicotine contents (up to 6 mg) compared to other ANDS. Conclusions: The HRV method is proven to be a promising technique for evaluation of the risks associated with smoking, dual use of various ANDS and studying the biomedical aspects of smoking cessation. Nic-packs are shown to be leaders in biological safety among the studied ANDS. A sharp surge in the activity of the sympathetic division of the ANS within the first minutes of the use of nicotine packs implies that nicotine begins to act already at very low doses (before entering the blood physically in any significant amount) through fast signal transmission to the brain from the nicotinic and taste buds located in the mouth area.

Highly Stable Copper Nano Cluster on Nitrogen-Doped Graphene Quantum Dots for the Simultaneous Electrochemical Sensing of Dopamine, Serotonin, and Nicotine; a Possible Addiction Scrutinizing Strategy

A highly stable copper nanocluster CuNC@N-GQD which exhibited stability for more than one year was synthesized using nitrogen doped graphene quantum dots (N-GQDs) as reducing and capping agents and smaller...

Conceptual model for the evaluation of attractiveness, addictiveness and toxicity of tobacco and related products: The example of JUUL e-cigarettes

Many new tobacco and related products (nTRP) have emerged on the market, with unknown health risks. Here, we present a conceptual model containing the factors and relations between them that contribute to the nTRP's health effects. Factors that determine attractiveness, addictiveness and toxicity of nTRP were defined based on previous assessments, literature, and expert discussions. Our model will aid in identifying key risk factors contributing to increased risk of adverse health effects for a product in a qualitative manner. Additionally, it can gauge attractiveness for specific user groups, as a determinant for population prevalence of use. Our model can be used to identify aspects of nTRP that require attention for public information or product regulation. As an example, we applied this to JUUL, a popular e-cigarette in the US. Aspects of concern for JUUL are its attractive and discrete shape, user-friendly prefilled pods, flavors, high aerosol nicotine levels, and liquids containing nicotine salts instead of free-based nicotine. The addictiveness and especially attractiveness are sufficiently high to have a large potential impact on population health due to its contribution to use and hence exposure. Products and their use can change over time; therefore market research and monitoring are crucial.

Genotoxic effect induced by dried nicotiana tabacum leaves from tobacco barns (kiln-houses) in chinese hamster lung fibroblast cells (V79)

Nicotiana tabacum is the most cultivated tobacco species in the state of Rio Grande do Sul, Brazil. Workers who handle the plant are exposed to the leaf components during the harvesting process and when separating and classifying the dried leaves. In addition to nicotine, after the drying process, other components may be found including tobacco-specific nitrosamines, polycyclic aromatic hydrocarbons, as well as pesticides residues. The objective of this study was to examine the genotoxicity attributed to the aqueous extract of dried tobacco leaves obtained from tobacco barns using Chinese hamster lung fibroblast cells (V79) as a model system by employing alkaline comet assay, micronucleus (MN) and Ames test. MTT assay was used to assess cytotoxicity and establish concentrations for this study. Data demonstrated cell viability > 85% for concentrations of 0.625-5 mg/ml while the comet assay indicated a significant increase in DNA damage at all concentrations tested. A significant elevation of MN and nuclear buds (NBUD) was found for 5 mg/ml compared to control and other dry tobacco leaves concentrations (0.625-2.5 mg/ml). Mutagenicity was not found using the Salmonella/Microsome test (TA98, TA100, and TA102 strains) with and without metabolic activation. The concentration of inorganic elements was determined employing the PIXE technique, and 13 inorganic elements were detected. Using CG/MS nicotine amounts present were 1.56 mg/g dry tobacco leaf powder. Due to the observed genotoxicity in V79 cells, more investigations are needed to protect the health of tobacco workers exposed daily to this complex mixture of toxic substances present in dry tobacco leaves.

Nicotine Addiction: Neurobiology and Mechanism

Nicotine, primary component of tobaco produces craving and withdrawal effect both in humans and animals. Nicotine shows a close resemblance to other addictive drugs in molecular, neuroanatomical and pharmacological, particularly the drugs which enhances the cognitive functions. Nicotine mainly shows its action through specific nicotinic acetylcholine receptors located in brain. It stimulates presynaptic acetylcholine receptors thereby enhancing Ach release and metabolism. Dopaminergic system is also stimulated by it, thus increasing the concentration of dopamine in nuclear accumbens. This property of nicotine according to various researchers is responsible for reinforcing behavioral change and dependence of nicotine. Various researchers have also depicted that some non dopaminergic systems are also involved for rewarding effect of nicotinic withdrawal.

Neurological systems such as GABAergic, serotonergic, noradrenergic, and brain stem cholinergic may also be involved to mediate the actions of nicotine. Further, the neurobiological pathway to nicotine dependence might perhaps be appropriate to the attachment of nicotine to nicotinic acetylcholine receptors, peruse by stimulation of dopaminergic system and activation of general pharmacological changes that might be responsible for nicotine addiction. It is also suggested that MAO A and B both are restrained by nicotine. This enzyme helps in degradation dopamine, which is mainly responsible for nicotinic actions and dependence. Various questions remain uninsurable to nicotine mechanism and require more research. Also, various genetic methods united with modern instrumental analysis might result for more authentic information for nicotine addiction.

Novel Mineral-Vitamin Treatment for Reduction in Cigarette Smoking: A Fully Blinded Randomized Placebo-Controlled Trial

INTRODUCTION

Many smokers do not achieve abstinence using current smoking cessation options. This randomized controlled trial (RCT) investigated a novel nutritional supplement to assist with quitting smoking.

METHODS

Following a baseline phase where cigarettes per day and nicotine dependence were measured, participants (n = 107) were randomized to placebo (n = 50) or micronutrient conditions (n = 57). A 4-week pre-quit phase permitted titration up to 12 capsules/day. During the quit phase (12 weeks), participants were registered with a public Quitline while consuming micronutrients or placebo. Carbon monoxide levels were measured to confirm smoking cessation.

RESULTS

Forty-five (42%) participants completed the trial. Treatment and placebo groups did not differ on the primary outcome of continuous abstinence at 12 weeks using intention-to-treat analysis; however, 28% of the micronutrient-treated group had quit versus 18% for placebo (odds ratio [OR] = 1.78, 95% confidence interval [CI] = 0.71 to 4.48), with number needed to treat = 10. Comparison of cigarette consumption (cigarettes per day) between micronutrient and placebo groups showed that those taking micronutrients reported reduced consumption throughout the trial, notably at pre-quit weeks 1 and 4, and at quit phase week 4. There were no serious adverse events, blinding was successful, and there were no substantive group differences in side effects or dropout rate.

CONCLUSION

This is the first RCT investigating the impact of micronutrients on smoking reduction, finding that micronutrients reduced harm through reduction in number of cigarettes smoked relative to placebo. The small sample and high dropout rate limit confidence in the conclusions and generalizability of the study; however, assessed by number needed to treat, micronutrients are comparable to other smoking cessation treatments but with fewer side effects. Future research using larger and longer trials including cost-effectiveness and biomarker measures is encouraged.

IMPLICATIONS

Micronutrients are being increasingly studied for the treatment of psychiatric conditions, but direct application of micronutrients as a treatment for addictions is novel. There is extensive evidence that micronutrients alleviate stress. Given that tobacco smoking is often used to cope with stress, taking micronutrients may moderate the stress of withdrawal and increase the chance of a successful quit attempt. This study is the first known RCT to investigate the use of micronutrients to support smoking cessation. Treatments that are safe, effective, relatively inexpensive, and readily available are needed and micronutrient supplements offer one such possible alternative.

Development and validation of the HPLC method for varenicline determination in pharmaceutical preparation

A simple and accurate reverse phase HPLC method has been developed and validated for quantification of varenicline in bulk drug and pharmaceutical dosage forms. Herein, an isocratic LC analysis was carried out on a Chromolith Performance RP18e column with methanol-buffer solution pH 3.5 (a buffer solution containing sodium benzoate (0.5 mmol/l) adjusted to pH 3.5 with trifluoroacetic acid (20 mmol/l) (55:45, V/V)) at a flow rate of 1.2 ml/min. The detection wavelength was set at 320 nm. The calibration curve was linear (r = 0.9999) in the studied range of concentration (0.2-10 μg/ml). The selectivity and sensitivity of the elaborated method were satisfactory, and the limits of detection and quantification was less than 20% of the specification level. Moreover, the inter- and intra-day precisions was found to be less than 3% (RSD), while the recovery values expressing inter- and intra-day accuracy was varied from 99.73 to 101.23. The varenicline solution was stable over a period of 3 days on storage under refrigeration. The utility of the developed method was examined by analysing the tablets containing VAR. As a result, the method was found to be selective, sensitive, precise and accurate.

l-tetrahydropalmatine reduces nicotine self-administration and reinstatement in rats

BACKGROUND

The negative consequences of nicotine use are well known and documented, however, abstaining from nicotine use and achieving abstinence poses a major challenge for the majority of nicotine users trying to quit. l-Tetrahydropalmatine (l-THP), a compound extracted from the Chinese herb Corydalis, displayed utility in the treatment of cocaine and heroin addiction via reduction of drug-intake and relapse. The present study examined the effects of l-THP on abuse-related effects of nicotine.

METHODS

Self-administration and reinstatement testing was conducted. Rats trained to self-administer nicotine (0.03 mg/kg/injection) under a fixed-ratio 5 schedule (FR5) of reinforcement were pretreated with l-THP (3 or 5 mg/kg), varenicline (1 mg/kg), bupropion (40 mg/kg), or saline before daily 2-h sessions. Locomotor, food, and microdialysis assays were also conducted in separate rats.

RESULTS

l-THP significantly reduced nicotine self-administration (SA). l-THP's effect was more pronounced than the effect of varenicline and similar to the effect of bupropion. In reinstatement testing, animals were pretreated with the same compounds, challenged with nicotine (0.3 mg/kg, s.c.), and reintroduced to pre-extinction conditions. l-THP blocked reinstatement of nicotine seeking more effectively than either varenicline or bupropion. Locomotor data revealed that therapeutic doses of l-THP had no inhibitory effects on ambulatory ability and that l-THP (3 and 5 mg/kg) significantly blocked nicotine induced hyperactivity when administered before nicotine. In in-vivo microdialysis experiments, l-THP, varenicline, and bupropion alone elevated extracellular dopamine (DA) levels in the nucleus accumbens shell (nAcb).

CONCLUSIONS

Since l-THP reduces nicotine taking and blocks relapse it could be a useful alternative to varenicline and bupropion as a treatment for nicotine addiction.

The tobacco-using periodontal patient: role of the dental practitioner in tobacco cessation and periodontal disease management

Although the prevalence of tobacco use has declined in some parts of the world, tobacco use remains a persistent and, in some cases, growing problem that will continue to be a fundamental challenge facing dental practitioners in the decades ahead. Dental practitioners have a unique opportunity and professional obligation to be a positive influence in reducing the economic and social burden inflicted by tobacco use on dental and general health. In this article, the current noninvasive, evidence-based approaches are presented for dental practitioners to help patients avoid initiating tobacco use, to encourage and assist patients in ceasing tobacco use and to address tobacco-induced damage to periodontal supporting tissues.

Smoking cessation behaviors three months following acute insular damage from stroke

BACKGROUND

Recent evidence suggests that the insular cortex may play an important role in cognitive and emotional processes that facilitate drug use but it is unclear whether changes to the insula would result in sustained abstinence. To better understand the role of the insula in maintaining abstinence, we examined quitting patterns in smokers with acute damage to their insula relative to other regions.

DESIGN

Prospective cohort study with 3month follow-up, beginning June 2013 and ending May 2014.

SETTING

Three acute care hospitals in Rochester, NY.

PARTICIPANTS

One-hundred-fifty-six current smokers hospitalized for acute ischemic stroke; 38 with insular infarctions and 118 with non-insular infarctions, assessed by 3 neuroradiologists.

MEASUREMENTS

Self-reported smoking status (seven-day point prevalence and continuous abstinence), complete abstinence from any nicotine product, and disruption of smoking addiction (defined by criteria on smoking status, difficulty of quitting, and urge) were assessed at three months post-stroke. Time to relapse (in days) after discharge was also assessed.

RESULTS

Insular damage was associated with increased odds of three-month continuous abstinence (OR=3.71, 95% CI: 1.59, 8.65) and complete cessation from any nicotine product (OR=2.72, 95% CI: 1.19, 6.22). Average time to relapse was longer in the insular-damaged group (17.50days, SD=19.82) relative to non-insular damage (10.42days, SD=18.49). Among quitters, insular damage was also associated with higher relative odds of experiencing a disruption of addiction compared to non-insular damage (adjusted OR=5.60, 95% CI: 1.52, 20.56).

CONCLUSIONS

These findings support the potential role of the insular cortex in maintaining smoking and nicotine abstinence. Further research is needed to establish whether the insula may be a novel target for smoking cessation interventions.

COgnitive-pulmonary disease

Over the past few decades, chronic obstructive lung disease (COPD) has been considered a disease of the lungs, often caused by smoking. Nowadays, COPD is regarded as a systemic disease. Both physical effects and effects on brains, including impaired psychological and cognitive functioning, have been demonstrated. Patients with COPD may have cognitive impairment, either globally or in single cognitive domains, such as information processing, attention and concentration, memory, executive functioning, and self-control. Possible causes are hypoxemia, hypercapnia, exacerbations, and decreased physical activity. Cognitive impairment in these patients may be related to structural brain abnormalities, such as gray-matter pathologic changes and the loss of white matter integrity which can be induced by smoking. Cognitive impairment can have a negative impact on health and daily life and may be associated with widespread consequences for disease management programs. It is important to assess cognitive functioning in patients with COPD in order to optimize patient-oriented treatment and to reduce personal discomfort, hospital admissions, and mortality. This paper will summarize the current knowledge about cognitive impairment as extrapulmonary feature of COPD. Hereby, the impact of smoking on cognitive functioning and the impact of cognitive impairment on smoking behaviour will be examined.

Pharmacotherapy of smoking cessation

Nicotine in tobacco smoke causes not only pathophysiological changes in the smoker's body, but also develops tolerance to its own action with repeated use. Repeated exposure to nicotine develops neuroadaptation of the receptors, resulting in tolerance to many of the effects of nicotine. Pharmacotherapies for smoking cessation should reduce withdrawal symptoms and block the reinforcing effects of nicotine without causing excessive adverse effects. All forms of nicotine replacement therapy (NRT) - gum, patches and inhaler - and bupropion are safe and effective for increasing smoking cessation rates in the short and long-term use. Combination NRT (more than one therapy) may be indicated in patients who have failed monotherapy.

Treatment for tobacco smoking: a new alternative?

Smoking is a very common addiction and is associated with several kinds of diseases including different forms of cancer. Nicotine is the only substance present in cigarettes that can cause dependence. There are pharmacological treatments available to smoking cessation, but all of them are associated with side effects and low efficacy. Therefore, the development of new strategies and treatments is necessary. A possibility is the supplementation with polyunsaturated fatty acids (PUFAs) of the omega 3 series. It is known that low concentration of omega 3 can affect the dopaminergic neurotransmission, resulting in hypofunctioning of the mesocortical system. This system controls the mesolimbic system, associated in rewarding and dependence mechanisms. New perspectives of treatment focus on the reestablishment of the omega 3 levels, having as a result the normalization of the dopaminergic system and the reduction of the negative symptoms of withdrawal.

Tobacco smoking: how far do the legislative control measures address the problem?

India ratified the WHO's Framework Convention on Tobacco Control in February 2004 and enacted legislation called, "Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act 2003" which specifically called for an end to direct and indirect form of tobacco advertisements. Under its Section 7, the Act also stipulates depiction of pictorial health warnings on all tobacco products. Since the enactment of the legislation, the tobacco companies are prohibited from any kind of advertisement. However, studies show that the instances of showing smoking in movies have increased significantly to 89% after the implementation of the Act. The brand placement has been also increased nearly three folds. Association of tobacco with glamour and style has also been established. Seventy-five percent of movies have showed the lead character smoking tobacco. The instances of females consuming tobacco in movies have also increased, pointing toward a specific market expansion strategy by tobacco companies using movies as a vehicle. General public does not feel that banning tobacco scenes in the movie will affect their decision to watch movies or the quality of movies. It was found that favorable images through mass media created a considerable influence on youngsters and increased their receptivity to tobacco smoking. Pictorial warning on tobacco products is yet to start. Tobacco industry's opposition to tobacco health warnings is understandable as it will adversely affect their business. However, policymakers should not evade their responsibility to mandate strong health warnings on all tobacco product packs. Legal action against offenders, investigation of the relationship and financial irregularities between film-makers and tobacco industry, and recall of the movies showing tobacco brand are the important measures recommended.