Questionable Effects of Electronic Cigarette Use on Cardiovascular Diseases From the National Health Interview Survey (NHIS, 2014-2021)

BACKGROUND

Electronic cigarettes (e-cigarettes) and cardiovascular health risks have gained attention among tobacco researchers. While the cardiovascular risks from e-cigarettes are still unclear, a recent paper by Alzahrani in Cureus claimed that current usage of e-cigarettes increases the risks of cardiovascular diseases, such as myocardial infarction and stroke, in subjects who were never cigarette smokers.

METHODS

The National Health Interview Survey (NHIS) data from 2014 to 2021 and logistic regression models were used to replicate and extend Alzahrani's analysis.

RESULTS

Only 12 never smokers who were current e-cigarette users had a myocardial infarction in all eight years. The crude odds ratio (OR) for e-cigarette use was 0.42 (95%CI: 0.24, 0.75). After adjusting for age and other confounding factors and health conditions, the OR of e-cigarette use increased to 2.48 (95%CI: 1.35, 4.55). The omission of age while adjusting for all other risk factors resulted in an OR of 0.80 (95%CI: 0.45, 1.43). In addition, the adjusted ORs for coronary heart disease and stroke were 1.12 (95%CI: 0.58, 2.17) and 1.13 (95%CI: 0.55, 2.29), respectively.

CONCLUSIONS

The findings indicate that Alzahrani's study is scientifically unreliable. The association between e-cigarette use and heart attack reported by Alzahrani was substantially driven by age, and the very small number of exposed cases makes the association very unstable. Given the nature of cross-sectional NHIS data, it is impossible to establish a robust association or causal claim that e-cigarette use "increases" the risks of any disease.

Why can't smokers quit? Longitudinal study of smokers in the US using the Population Assessment of Tobacco and Health (PATH) waves 1 to 5

Introduction

Most adult cigarette smokers have tried unsuccessfully to quit. We followed participants in the Population Assessment of Tobacco and Health (PATH) study through five waves (2013-2019), comparing smoking, quit behaviors and other characteristics between persistent smokers and those who became and stayed former smokers.

Methods

The main analysis employed treatment effects to estimate mean differences in smoking and quitting behaviors among smoker groups. Logistic models were used to estimate predicted means based on continuing smokers' demographic characteristics to ensure that any differences in outcomes did not come from differences in demographic characteristics.

Results

Among smokers enrolled in PATH Wave 1, 68 % persisted in all subsequent waves. Compared with smokers who quit after Wave 1, persistent smokers had remarkably stable smoking behaviors, including significantly higher proportions of everyday smokers, consuming 10+ cigarettes per day, and smoking within 30 min of waking up. Persistent smokers were also less likely to try to quit completely, and experienced more negative symptoms from nicotine withdrawal. They also showed less interest in quitting and were less confident of being successful than smokers who quit by the next wave. Neither electronic nicotine delivery systems nor menthol played a role in continued smoking or quitting.

Conclusions

The characteristics and behaviors of persistent smokers in this study were stable over five waves of data collection during a six-year period, suggesting that these smokers need new cessation options.

Heterogeneity and other problems in a pooled analysis of snus use and mortality

A recent analysis of Swedish snus use and mortality combined eight Swedish datasets and found that exclusive Swedish male snus users have statistically significant increased mortality from all causes, cardiovascular diseases and other causes. These findings, from the Swedish Collaboration on Health Effects of Snus Use, are in sharp contrast with previous pooled results from the same group. The discrepant results may be indicative of unresolved statistical problems that haven’t been addressed by the collaboration authors in any of their studies. The most important problem is unresolved heterogeneity among the eight cohorts, which we describe in detail, and we show how the use of the random effects method by the authors was not sufficient. We explain why the tables in the article are uninformative, and we demonstrate why the exclusion of smokers in the analysis was not validated and eliminated important information. Finally, we strongly recommend some straightforward and easily implemented corrective measures.

Mortality among male cigar and cigarette smokers in the USA

Background

Cigars and cigarettes are both smoked, but much less is known about the former’s long-term health effects, due to its low prevalence and infrequent collection of cigar information in national surveys.

Purpose

We conducted a follow-up mortality study of cigar-smoking men age 40–79 years in National Health Interview Surveys (NHIS).

Methods

We used pooled NHIS files linked to the National Death Index to obtain follow-up from year of interview to year of death or December 31, 2015. We developed categories of cigarette and cigar smoking that accommodate dual and former use of both products. We used Cox proportional hazards models, adjusted for age, race/ethnicity, marital status, education, income and region to estimate hazard ratios (HRs, 95% confidence intervals, CI) for mortality from all causes, heart diseases, malignant neoplasms, cerebrovascular disease, chronic lower respiratory diseases and two mutually exclusive categories: smoking-related and other diseases.

Results

There were 14,657 deaths from all causes, including 3426 never tobacco users, 3276 exclusive cigarette smokers and 176 exclusive cigar users. The latter had no statistically significant evidence of increased mortality from all causes, heart diseases, malignant neoplasms, cerebrovascular disease, smoking-related diseases or other causes. In contrast, the mortality experience of dual users of cigars and cigarettes and cigar smokers who formerly used cigarettes is similar to exclusive cigarette smokers.

Conclusions

This study provides evidence that male cigar smokers age 40 + years had elevated mortality risks. However, after accounting for cigarette smoking and other confounding variables, we found significantly increased mortality only among dual and former users of cigarettes.

E-cigarette Use Among US Adults: Population Assessment of Tobacco and Health (PATH) Study

Introduction

In 2011 the US Food and Drug Administration launched the Population Assessment of Tobacco and Health (PATH) Study to gather information for regulatory activities authorized by the Family Smoking Prevention and Tobacco Control Act (TCA).

Methods

Data were drawn from the first wave of the PATH survey, involving interviews of 32 320 civilian and non-institutionalized adults. In addition to conventional classifications for current, former and never smoking and e-cigarette use, we used PATH questions to classify former and current triers of these products. Descriptive statistics were used to describe the prevalence, patterns of, and reasons for e-cigarette use, and the perceptions of nicotine and e-cigarettes among user groups, according to smoking status.

Results

The prevalence of current smoking was 18%; an additional 3.1% of participants were current triers. The prevalence of current e-cigarette use was 2.4% (1.0% every day, 1.4% some days), with another 3.2% as current triers. The majority of nonsmokers who were current e-cigarette users were already current (56%) or former (34%) cigarette triers. Reasons for e-cigarette use were similar across subgroups, but patterns of use were different. Majorities of participants believed that nicotine is the main substance driving tobacco use, that nicotine causes most cancers, and that e-cigarettes were less harmful than cigarettes.

Conclusions

E-cigarettes were used primarily by current smokers and recent former smokers. The main reasons for use center around perceptions that e-cigarettes are less harmful than cigarettes to users and others.

Implications

This study reports detailed information about the prevalence, patterns of, and reasons for e-cigarette use in the first (baseline) wave of the PATH Study in 2014. In addition to conventional categories for current, former and never smoking and e-cigarette use, the PATH questionnaire facilitated classification of new usage groups consisting of current and former triers of these products, which may impact prevalence estimates.

Mortality among male smokers and smokeless tobacco users in the USA

BACKGROUND

One published study simultaneously reported the mortality associated with cigarette smoking and smokeless tobacco (ST) use in the USA. In this study, we focus only on men ages 40-79 years old and extend the follow-up by 4 years.

METHODS

We used selected years (1987-2010) of National Health Interview Survey (NHIS) Linked Mortality Files to classify 46,104 men age 40-79 years with respect to 7 categories of smoking and/or ST use. We used Cox proportional hazards models adjusted for age, race/ethnicity, marital status, education, income, health status, body mass index, and region to estimate hazard ratios (HRs; 95% confidence intervals, CI) for mortality from all causes, heart diseases, malignant neoplasms, and two mutually exclusive categories: smoking-related and other diseases.

RESULTS

There were 15,540 deaths from all causes, including 3476 never tobacco users, 4782 exclusive smokers, and 210 exclusive ST users. The latter had significant excess mortality from all causes (HR = 1.25, CI = 1.08-1.46), but not from heart diseases (HR = 1.16, CI = 0.85-1.59), malignant neoplasms (HR = 1.17, CI = 0.83-1.67), and all smoking-related diseases (HR = 1.19, CI = 0.97-1.46). However, they had higher mortality for all other causes (1.39, CI = 1.10-1.74), which was largely seen in age 40-59 years (HR = 1.68, CI = 1.11-2.54). Current smokers, with or without ST use, also had significantly elevated HRs for other causes (1.70 and 1.57, respectively), in addition to significant increases in mortality from heart diseases (1.98 and 2.00), malignant neoplasms (2.60 and 2.84), and all smoking-related diseases (2.32 and 2.47).

CONCLUSIONS

This is the first simultaneous mortality follow-up study of older American male smokers and ST users. ST users did not have excess mortality from any smoking-related diseases, but younger users had an elevation in deaths from other causes.

The composition of contemporary American and Swedish smokeless tobacco products

The major components of 70 brands of smokeless tobacco products (STPs) from Sweden and the US were determined to provide greater understanding of the general chemical composition of these products. Various styles of STPs were examined: loose and portion snus from Sweden, and chewing tobacco, dry snuff, moist snuff, hard pellet, soft pellet and plug from the US. The components analysed were major STP components such as water, nicotine, sugars, humectants, sodium ions, chloride ions and ash. The relative quantities of the components varied significantly between different styles of STP. The major component of moist snuff and Swedish loose snus is water. With Swedish portion snus water and pouch material comprise more than half of the product mass; with chewing tobaccos water and sugars comprise around 60% of the products. With these STPs, tobacco was a minor component (30–35%) of the product mass. By way of contrast, tobacco comprised the majority (around 70–90%) of the product mass with dry snuff, hard pellet and soft pellet products. Additives such as sugars, propylene glycol, glycerol, and sodium chloride comprised up to around 12% of the STPs, except for plug and chewing tobaccos where sugars comprised 15–30% by mass of the STP on average. Significant disagreements were found amongst alternative methods of determining water/moisture content for STPs. In particular the oven method, commonly used to determine moisture in tobacco, gave significantly higher values than the Karl Fischer water method when propylene glycol was present. Smaller but similar differences were found using the Near-Infrared method. Choice of measurement technique has important consequences for accuracy of toxicant levels when reporting on a dry-weight basis, a commonly used parameter in smokeless tobacco research and emerging regulatory standards. Conversion to a DWB was also found to produce a preferential bias between and within different STP categories in favour of drier products. These data provide greater understanding of differences in the compositions of contemporary smokeless tobacco products, and demonstrate challenges associated with conversion of actual product contents to dry weight basis values.

Analysis of coumarin and angelica lactones in smokeless tobacco products

Differences in health risks between different styles of smokeless tobacco products (STPs) have prompted interest in their relative levels of toxic chemicals. We report here the development of methods for the analysis of STPs for coumarin and for α-angelica lactone (α-AL), both of which have been included in various published lists of tobacco toxicants. We have also determined the concentrations of these lactones in commercial STPs from the US and Sweden, representing 80–90% of the 2010 market share for all the major STP categories in these two countries: 65 products (plus two reference products) for coumarin and 66 commercial products for α-AL. For coumarin, methanol extracts of the STPs were analysed by HPLC/MS/MS. The lower limit of quantification (LOQ) and limit of detection (LOD) were, respectively, 100 and 30 ng coumarin/g of STP on a wet weight basis (WWB). Alpha-AL was determined via direct headspace GC/MS. The LOQ and LOD were 65 and 30 ng/g WWB respectively. Coumarin was detected In 3/33 Swedish snus, 5/13 US chewing tobaccos, 16/16 moist snuffs and 5/6 dry snuffs. Concentrations in those samples with quantifiable coumarin contents ranged from 186 to 1656 ng/g WWB. Concentrations of coumarin measured in this study were consistent with levels naturally found in tobacco. None of the STPs analysed would significantly contribute to coumarin exposure in consumers compared with dietary sources, and estimated exposure levels were 1000× lower than the European Food Safety Authority Tolerable Daily Intake. Hence the relevance of coumarin to the toxicity of STPs and its inclusion in the FDA’s list of harmful and potentially harmful compounds list is questionable. Measurements of α-AL in these STPs found that the majority did not have quantifiable contents, however, for three STPs concentrations of α-AL were above the LOQ (116–140 ng/g WWB) and for four other STPs concentrations of α-AL could be estimated between the LOD and LOQ. Beta-angelica lactone was tentatively identified in three of the STPs but the levels could not be reliably quantified. The levels of α-AL in tobacco products are reported here for the first time, but the relevance of α-AL to the toxicity of STPs is also highly questionable given that it has GRAS status as a permitted food additive.

Metal emissions from e-cigarettes: a risk assessment analysis of a recently-published study

Introduction: A recent study reported levels of metal emissions in e-cigarette (EC) aerosol. Herein we present a risk assessment analysis of the published findings using total daily exposure limits. Methods: Median and 75th percentile metal concentrations in EC aerosols were used to determine the level of daily liquid consumption (g/d) that would exceed the permissible daily exposures (PDEs) defined for inhalation medications (cadmium, chromium, copper, nickel, lead, antimony and tin). For metals not having PDEs, minimal risk levels (manganese) or risk exposure levels (aluminum, iron and zinc) were converted into total daily exposure using an inhalation volume of 20 m³ (for 24 h) and 6.7 m³ (for 8 h) respectively. Results: The lowest amount of liquid consumption exceeding safety limits was found for nickel (73 g/day for median and 17 g/day for 75th percentile levels). The consumption corresponding to the 75th percentile could be associated with realistic use, although this would represent an extreme rather than average consumption. For chromium, the respective levels were 358 and 68 g/day and for lead 338 and 135 g/day. For all other metals, liquid consumption would need to be orders of magnitude higher, reaching to 1.5 million grams for aluminum. Conclusion: EC emissions contain trace levels of metals. For almost all metals, unrealistically high levels of liquid need to be consumed in order for total daily exposure to exceed established limits.

Ethyl carbamate in Swedish and American smokeless tobacco products and some factors affecting its concentration

BACKGROUND

We are interested in comparing the levels of harmful or potentially harmful constituents in Swedish and American smokeless tobacco products (STPs). We report here the concentrations of the IARC Group 2 A (probable human) carcinogen ethyl carbamate (EC) in seventy commercial STPs from the US and Sweden, representing 80-90% of the market share of the major STP categories in these countries. We also examine the effects of various additives, processing and storage conditions on EC concentrations in experimental snus samples.

RESULTS

EC was determined from aqueous extracts of the STPs using ultra performance liquid chromatography tandem mass spectrometry (UPLC/MS/MS). EC was undetectable (< 20 ng/g wet weight basis WWB) in 60% of the commercial STPs, including all the chewing tobacco (CT), dry snuff (DS), hard pellet (HP), soft pellet (SP), and plug products. Measurable levels of EC were found in 11/16 (69%) of the moist snuff (MS) samples (average 154 ng/g in those samples containing EC) and 19/32 (59%) of the Swedish snus samples (average 35 ng/g). For the experimental snus samples, EC was only observed in ethanol treated samples. EC concentrations increased significantly with ethanol concentrations (0-4%) and with storage time (up to 24 weeks) and temperature (8 °C vs 20 °C). EC concentrations were lower at lower pHs but were unaffected by adding nitrogenous precursors identified from food studies (citrulline and urea), increasing water content or by pasteurisation. Added EC was stable in the STP matrix, but evaporative losses were significant when samples were stored for several weeks in open containers at 8 °C.

CONCLUSIONS

EC was found in measurable amounts only in some moist STPs i.e. pasteurised Swedish snus and unpasteurised US MS; it is not a ubiquitous contaminant of STPs. The presence of ethanol contributed significantly to the presence of EC in experimental snus samples, more significantly at higher pH levels. Sample age also was a key determinant of EC content. In contrast, pasteurisation and fermentation do not appear to directly influence EC levels. Using published consumption rates and mouth level exposures, on average STP consumers are exposed to lower EC levels from STP use than from food consumption.

Comprehensive survey of radionuclides in contemporary smokeless tobacco products

There is considerable interest in the chemical composition of smokeless tobacco products (STPs), owing to health concerns associated with their use. Previous studies have documented levels of 210Po, 210Pb and uranium in STP samples. Here, the levels of 13 α-particle and 15 β-radiation emitting radionuclides have been measured in a broad and representative range of contemporary STPs commercially available in the United States and Sweden. For each radionuclide, the level of radioactivity and calculated mass per gram of STP are reported. The results indicate that, among 34 Swedish snus and 44 US STPs, a more complex radionuclide content exists than previously reported for these products. Of the 28 radionuclides examined, 13 were detected and quantified in one or more STPs. The most frequently identified radionuclides in these STPs were 40K, 14C, 210Po and 226Ra. Over half the STPs also contained 228Th, and an additional 8 radionuclides were identified in a small number of STPs. The presence of 14C, 3H and 230Th are reported in tobacco for the first time. The activity of β-emitters was much greater than those of α-emitters, and the β-emitter 40K was present in the STPs with both the greatest radioactivity and mass concentrations. Since the three radionuclides included in the FDA's HPHC list were either not detected (235U), identified in only three of 78 samples (238U), and/or had activity levels over fifty times lower than that of 40K (210Po, 238U), there may be a rationale for reconsidering the radionuclides currently included in the FDA HPHC list, particularly with respect to 40K. Using a model of the physical and biological compartments which must be considered to estimate the exposure of STP users to radionuclides, we conclude that exposure from α-emitters may be minimal to STP users, but 40K in particular may expose the oral cavities of STP users to β-radiation. Although a more comprehensive picture of the radioisotope content of STPs has emerged from this study, epidemiological evidence suggests that the levels of radionuclides measured in this study appear unlikely to present significant risks to STP users.

Quit Methods Used by American Smokers, 2013-2014

This report describes the quit methods used in the past 12 months by current and former smokers in the baseline Population Assessment of Tobacco and Health (PATH) Study during 2013-2014. Descriptive statistics were used to report the use of single and two or more quit methods; survey weights were used to compute population estimates. Logistic regression was used to estimate the association between past year former smokers and single quit method, including individual characteristics.

RESULTS

Of 11,402 current smokers and 4919 former smokers, 4541 had tried and 839 had quit in the past 12 months. Unaided quit attempts were the most common; the number was almost as high as all single methods combined (n = 1797 and n = 1831 respectively). The most frequently used single method was help from friends and family (n = 676) followed by e-cigarettes (n = 587). Use of e-cigarettes was the only method with higher odds of users being a former smoker than unaided attempts (OR = 1.42, 95% CI 1.12-1.81). Current use of e-cigarettes among current (34%) and former (54%) smokers was significantly higher than current use of nicotine replacement therapy (NRT).

CONCLUSIONS

In 2013-2014 e-cigarettes were used by American adult smokers as quit-smoking aids more frequently than NRT products or prescription drugs.

The Effect of Smoking on Mental Health

OBJECTIVES

The disproportionately high smoking prevalence among persons with mental health problems has raised a concern that this population is at increased risk for smoking-related illness. We investigated the effect of smoking on mental health among US adults aged 18 and older using the 2000-2010 Behavioral Risk Factor Surveillance System (BRFSS).

METHODS

Whereas previous literature has reported a significant association between smoking and mental health, identifying the causal pathway is difficult. To address the plausible reverse causality from mental health to smoking and omitted unobserved factors, we employ the method of instrumental variables (IV) by using state cigarette excise tax as an instrument for smoking.

RESULTS

Our findings show that smoking increases the number of days with poor mental health especially among individuals with more severe illness (more than 14 days in the past month).

CONCLUSIONS

Our estimates suggest that smoking causes poor mental health and its effects are concentrated for measures that indicate more severe problems. Public health policies that aim to reduce smoking also may reduce poor mental health.

The acrylamide content of smokeless tobacco products

BACKGROUND

There is considerable interest from a regulatory and public health perspective in harmful and potentially harmful constituents in tobacco products, including smokeless tobacco products (STPs). A wide range of commercial STPs from the US and Sweden, representing 80-90 % of the 2010 market share for all the major STP categories in these two countries, were analysed for the IARC Group 2A carcinogen acrylamide. These STPs comprised the following styles: Swedish loose and portion snus, US snus, chewing tobacco, moist snuff, dry snuff, soft pellet, hard pellet and plug.

RESULTS

Acrylamide was detected in all the products tested and quantified in all but one product. Concentrations ranged from 62 to 666 ng/g wet weight basis (WWB). The average levels of acrylamide (WWB) by type of STP were not significantly different (p > 0.05) except for US snus which had, on average, greater levels but with a very wide range of individual levels according to the manufacturer. Acrylamide levels in STPs were significantly and positively correlated with pH, but not with levels of either reducing sugars or ammonia nitrogen. Levels of acrylamide increased by sixfold or more (on a dry weight basis) during manufacture of a snus sample and then decreased during subsequent storage for up to 22 weeks. Acrylamide generation in tobacco generally appears to occur at lower temperatures, but longer time scales than found with food production.

CONCLUSIONS

Acrylamide is a common contaminant of STPs, formed through heat treatment of tobacco. Our data show that exposure to acrylamide from consumption of STPs is small compared with exposure from food consumption or cigarette smoking.

Associations of Proposed Relative-Risk Warning Labels for Snus With Perceptions and Behavioral Intentions Among Tobacco Users and Nonusers

INTRODUCTION

The US Food and Drug Administration can require changes in warning statements for modified risk tobacco products. We report an independent analysis of a consumer perception survey sponsored by Swedish Match as part of a Modified Risk Tobacco Product application to change warning labels for Swedish snus products.

METHODS

The survey exposed each of 4324 daily exclusive cigarette smokers, 1033 daily smokeless tobacco users, 1205 daily other tobacco users, 726 former users, and 5915 triers/never users to one of four current warnings and two proposed relative-risk labels (No tobacco product is safe, but this product presents lower risks to health than cigarettes, or No tobacco product is safe, but this product presents substantially lower risks to health than cigarettes) for snus. Descriptive and logistic regression analyses examined four outcomes: believability, harmfulness, motivation to use, and intention to buy snus.

RESULTS

Compared with the current not-safe-alternative warning, adult tobacco users who viewed the proposed labels perceived them as less believable, perceived snus as less harmful and were more likely to use and buy snus. The proposed labels had no impact on former smokers' likelihood to use and buy snus; triers/never users viewing the substantially lower risk label were more likely to buy snus.

CONCLUSIONS

Tobacco users viewing the proposed labels perceived snus as less harmful than cigarettes and may be more likely to use and buy snus. If labeling changes lead to increased snus use and cigarette reduction or abstinence, public health may benefit. If the opposite occurs, public health could suffer.

Analysis of hydrazine in smokeless tobacco products by gas chromatography-mass spectrometry

Background

Due to the lower health risks associated with the use of certain categories of smokeless tobacco products (STPs) such as Swedish snus, there is interest in the comparative levels of toxic chemical constituents in different types of STPs. A method has been developed and validated for the analysis of hydrazine in STPs. Seventy four commercial STPs from the US and Sweden, representing 80-90% of the 2010 market share for all the major STP categories in these two countries, as well as three reference STPs, were analysed for hydrazine.

Results

Aqueous extracts of the STPs were treated with excess pentafluorobenzaldehyde (PFB), which reacted with hydrazine in solution to form decafluorobenzaldehyde azine (DFBA). DFBA was partitioned into hexane and then quantified by gas chromatography–mass spectrometry (GC–MS). The method was validated using five different types of STP, was linear in the range 8–170 ng/mL, and had limits of quantification (LOQ) from 26–53 ng of hydrazine per g of STP (as sold). The method was applied to the analysis of 74 contemporary STPs commercially available in the United States and Sweden, none of which were found to contain hydrazine above the LOQ or LOD. Trace levels of compounds showing chromatographic and mass spectral features consistent with hydrazine were identified at very low levels (sub-limit of detection, <10 ng/g) in the chromatograms of less than half of the 74 STPs examined; in contrast, for 40 of the STPs no evidence for the presence of hydrazine was observed. Where present, the levels of compounds consistent with hydrazine were estimated to be at least an order of magnitude lower than the only previous study to have quantified hydrazine in tobacco.

Conclusions

Our results show that hydrazine is not a prevalent constituent of STPs, and when present is not quantifiable using currently available analytical methodology.

Time to First Use Among Daily Smokers and Smokeless Tobacco Users

INTRODUCTION

Time to the first cigarette after waking up in the morning is the most validated measure of dependence among smokers, and its complement is also a good indicator of dependence for smokeless tobacco (ST) users. However, no studies have directly compared these measures.

METHODS

We used a multivariate logistic regression model to compare the time to first use (TTFU) of cigarettes and ST among white men 18+ years of age who were daily users in the 2003 Tobacco Use Supplement of the Current Population Survey. Smokers were classified as light (1-14 cigarettes per day [cpd]), moderate (15-24 cpd), and heavy (25+ cpd) and ST users were classified as former smokers or exclusive users.

RESULTS

There was no difference in TTFU within 5min between light smokers and exclusive ST users (Odds ratio [OR] = 1.3, CI = 0.95-1.7), but the latter were less likely to use tobacco within 30min (OR = 0.75, CI = 0.62-0.89). ST former smokers were more likely than light smokers to have a TTFU within 5min (OR = 1.5, CI = 1.1-2.0) but not within 30min. Moderate and heavy smokers had significantly higher odds of TTFU within both time points than light smokers.

CONCLUSION

Compared to light smokers, the likelihood of TTFU within 5min was similar among exclusive ST users and was slightly higher among ST former smokers, offering some support for the Fagerström-Eissenberg hypothesis that the dependence level of cigarettes is higher than that of ST.

The association of smoking and demographic characteristics on body mass index and obesity among adults in the U.S., 1999-2012

BACKGROUND

The National Health and Nutrition Examination Surveys (NHANES) are an exceptional data source for studies of smoking and body weight because they are the only federal survey series collecting relevant information through detailed interviews and medical examinations. The associations of smoking status and demographic factors with body weight have not been evaluated fully in recent NHANES.

METHODS

Using NHANES datasets from 1999 to 2012, this study uses ordinary-least squares and ordered probit models to investigate the association of smoking and selected demographic variables with body mass index (BMI) and the probability of being in BMI categories among adults aged 25-64 years, and it uses quantile regression to examine whether these factors affect individuals differently depending on where they are located across the BMI distribution.

RESULTS

The sample consisted of 11,123 men and 10,949 women. Current smokers had significantly lower BMI than never smokers (1.97 unit for men and 1.46 unit for women), and there was modest variation across the BMI distribution. Among former smokers, only women had a slightly higher BMI compared to never smokers (0.46 unit). Both men and women current smokers were more likely to be underweight and normal weight compared to never smokers and were less likely to be obese. Among men a one-year age increase elevated BMI by 0.2 unit throughout the BMI distribution, while for women an extra year of age increased BMI at the upper tail of the distribution more than at the lower tail. Education beyond high school was associated with a significant decrease in BMI among women, but much less so among men. Married men had higher BMI, but married women had significantly lower BMI, and this difference became larger at the upper tail.

CONCLUSIONS

Compared to never smokers, men and women current smokers had lower BMI and lower probability of obesity, while only women former smokers had elevated BMIs and increased probability of obesity. In addition, we found that age, education and marital status were associated with different effects on BMI in men and women.

A fresh look at tobacco harm reduction: the case for the electronic cigarette

Smokers of any age can reap substantial health benefits by quitting. In fact, no other single public health effort is likely to achieve a benefit comparable to large-scale smoking cessation. Surveys document that most smokers would like to quit, and many have made repeated efforts to do so. However, conventional smoking cessation approaches require nicotine addicted smokers to abstain from tobacco and nicotine entirely. Many smokers are unable – or at least unwilling – to achieve this goal, and so they continue smoking in the face of impending adverse health consequences. In effect, the status quo in smoking cessation presents smokers with just two unpleasant alternatives: quit or suffer the harmful effects of continuing smoking. But, there is a third choice for smokers: tobacco harm reduction. It involves the use of alternative sources of nicotine, including modern smokeless tobacco products like snus and the electronic cigarette (E-cig), or even pharmaceutical nicotine products, as a replacement for smoking. E-cigs might be the most promising product for tobacco harm reduction to date, because, besides delivering nicotine vapour without the combustion products that are responsible for nearly all of smoking’s damaging effect, they also replace some of the rituals associated with smoking behaviour. Thus it is likely that smokers who switch to E-cigs will achieve large health gains. The focus of this article is on the health effects of using an E-cig, with consideration given to the acceptability, safety and effectiveness of this product as a long-term substitute for smoking.

The low prevalence of smoking in the Northern Sweden MONICA study, 2009

AIMS

The purpose of this study was to describe tobacco use in the 2009 Northern Sweden cohort of the World Health Organization Multinational Monitoring of Trends and Determinants in Cardiovascular Diseases (MONICA) study.

METHODS

Subjects (N = 1698) were randomly selected from population registers, stratified for age (25-74 years old) and gender, in the two northernmost Swedish counties of Norrbotten and Västerbotten. Responses from tobacco-related questions were used to develop three mutually exclusive categories of snus use: past, current, or never use; and three comparable categories of smoking that were consistent with previous studies.

RESULTS

Among men, the prevalence of smoking (9%) and dual use (2%) remain unchanged from 2004, although the prevalence of snus use declined from 27% in 2004 to 24% in 2009. Among women, the prevalence of all forms of tobacco use declined between 2004 and 2009; smoking dropped from 16% to 11%, dual use from 2% to less than 1%, and snus use from 9% to 8%. Although overall prevalence of tobacco use was similar for younger versus older men and younger versus older women, there were notable differences in specific snus and smoking rates.

CONCLUSIONS

This study confirms that use of snus was a significant factor in the low prevalence of smoking, especially among younger men and women in Northern Sweden. Furthermore, it documents that tobacco harm reduction is entirely compatible with a population-level decline in overall tobacco use.

Polycyclic aromatic hydrocarbons in US and Swedish smokeless tobacco products

Background

Debate about the health implications of using smokeless tobacco products (STPs) has prompted considerable interest in characterising their levels of toxic and carcinogenic components. In the present study seventy smokeless tobacco products from the US and Sweden, categorized as chewing tobacco, dry and moist snuff, hard and soft pellets, plug, and loose and portion snus, were analysed for twenty one polycyclic aromatic hydrocarbons (PAHs). The tested brands represented 80-90% of the 2008 market share for the major STP categories in these two countries.

Results

There were significant differences in the total and individual PAH concentrations in the different styles of product. Substantially higher levels of total PAHs (10–60 fold) were found in moist and dry snuff and soft pellets than in the other smokeless tobacco styles. The individual PAH concentrations followed the same patterns as total PAHs except for naphthalene, for which the highest concentrations were found in snus and moist snuff. Good correlations were obtained between benzo[a]pyrene (B[a]P) and all the other PAHs except naphthalene, 1-methylnaphthalene and 2-methylnaphthalene, providing evidence for the first time that it can be used as a good marker for PAHs in STPs. Results were generally in good agreement with two previous studies of PAHs in STPs, except for naphthalene for which significantly lower concentrations were found than previously reported. Analysis of the ratios of different PAHs confirmed that the use of fire-cured tobaccos in the snuffs and soft pellet were the major source of PAHs in these product styles, and provided, for the first time, some indications as to the source of PAHs in the other STP styles, including petrogenic and other combustion sources.

Conclusions

This study confirms the presence of PAHs in STPs, and identifies substantial differences between the levels in different STP categories. Since previous studies of naphthalene concentrations in STPs differed so markedly from those found in this study, it is recommended that further work on PAH determination is undertaken to investigate the source of this discrepancy.

Evidence of sex differences in the relationship between current tobacco use and past-year serious psychological distress: 2005-2008 National Survey on Drug Use and Health

PURPOSE

Cigarette use is highly prevalent in psychiatric populations. Studies suggest that smokeless tobacco use is not significantly associated with past-year psychiatric morbidity, with evidence that tobacco use differ among sexes. The relationships between current tobacco use and past-year serious psychological distress, major depressive episode and anxiety disorder were therefore examined. Sex differences in the aforementioned relationship were also examined.

METHODS

A total of 133,221 adults from four successive independent samples of the 2005-2008 National Survey on Drug Use and Health were included. Prevalence odds ratios and 95 % confidence intervals were calculated using multivariable logistic regression adjusting for demographic factors, survey year, pregnancy (women only), past-year medical morbidity, past-year psychiatric comorbidity, and past-year substance use disorders.

RESULTS

No associations were demonstrated among smokeless tobacco users. Statistically significant sex differences were found for current tobacco use and serious psychological distress (p < 0.001). Both male and female smokers were significantly more likely to have serious psychological distress and anxiety disorder compared to never users, while only female smokers were more likely to have major depressive episode. The strongest associations were found for anxiety disorder among all adults as well as both sexes.

CONCLUSIONS

The null associations for both sexes for smokeless tobacco may support a reduced risk profile. Female cigarette smokers may be more vulnerable to subclinical distress and depression than males. Studies using other nationally representative samples are needed to confirm these data.

Tobacco harm reduction: opportunity and opposition

Purpose

This paper aims to provide a brief summary of the effectiveness and efficacy of tobacco harm reduction (THR). THR is the substitution for cigarettes of low‐risk alternatives, including Swedish or American‐style smokeless tobacco, pharmaceutical nicotine products, and electronic cigarettes. The paper then very briefly summarizes the current social and political situation regarding THR.

Design/methodology/approach

This paper is a review of the evidence.

Findings

The risk from smoke‐free tobacco/nicotine products is so low as to be unmeasurable. For most smokers, adopting THR is a lower risk option than to trying to become nicotine abstinent. THR products have been widely adopted in some populations, providing great public health benefits. There is currently an explosion of interest in electronic cigarettes. However, THR is a threat to the business model of the tobacco control industry, and so they are fighting hard to discourage it. Because they cannot admit their real motives for discouraging THR, anti‐THR activism is an entirely dishonest enterprise.

Practical implications

Tobacco harm reduction is the greatest untapped public health initiative in the developed world. It is more promising than further attempts to promote tobacco/nicotine abstinence. The future inevitably includes a large portion of the population using low‐risk tobacco/nicotine, but anti‐THR efforts might keep people smoking in the short run.

Originality/value

While most of the content of this paper is well known to experts on THR, many ostensible experts on health, as well as other opinion leaders and policy makers, are unaware of the truth.

Exploring attitudes regarding smokeless tobacco products for risk reduction

Utilizing qualitative data analysis, this study focused on the attitudes, knowledge, and beliefs relating to smokeless tobacco (ST) as a reduced-risk cigarette substitute for smokers among focus groups from the general public and from the health profession. It revealed that there is a lack of awareness and understanding of ST products, which has a significant impact on overall perception of these products as acceptable substitutes. Regulatory actions regarding tobacco by the U.S. Food and Drug Administration should enhance consumers' access to accurate information about nicotine addiction and tobacco use.

Acute myocardial infarction mortality before and after state-wide smoking bans

Rapid declines in hospital admissions for acute myocardial infarction (AMI) following smoke-free ordinances have been reported in smaller communities. The AMI mortality rate among persons age 45 + years (deaths per 100,000 persons, age-standardized to the 2000 US population) in the 3 years before adoption of the smoke-free ordinance (the expected rate) was compared with the rate observed in the first full year after the ban (the target year) in six US states. Target-year declines were also compared to those in states without smoking bans. Target-year declines in AMI mortality in California (2.0%), Utah (7.7%) and Delaware (8.1%) were not significantly different from the expected declines (P = 0.16, 0.43 and 0.89, respectively). In South Dakota AMI mortality increased 8.9% in the target year (P = 0.007). Both a 9% decline in Florida and a 12% decline in New York in the 2004 target year exceeded the expected declines (P = 0.04 and P < 0.0002, respectively) but were not significantly different (P = 0.55 and 0.08, respectively) from the 9.8% decline that year in the 44 states without bans. Smoke-free ordinances provide a healthy indoor environment, but their implementation in six states had little or no immediate measurable effect on AMI mortality.

Seven Year Follow-up of Smoking Cessation with Smokeless Tobacco

This study evaluated the tobacco use status of 63 subjects seven years after enrollment in a single-intervention smoking cessation study employing smokeless tobacco (SLT) as a nicotine substitute. Information about tobacco use and cessation attempts was obtained in interviews. The duration of follow-up and of smoke-free periods were derived from the date of the subject's enrollment and were expressed as person-years (p-y). Because the study focused on the use of SLT for smoking cessation, subjects who used SLT to quit were invited to return for verification (less than 10 parts per million of carbon monoxide in expired air). Follow-up was completed on 62 of 63 original subjects, classified according to tobacco use status at the end of the initial study. Of the 16 subjects who had quit smoking using SLT at one year, 12 were smoke-free at seven years. For all 16 subjects there was 106 p-y of follow-up, 97 (92%) of which were smoke-free. Of six subjects who had quit smoking at one year by a means other than SLT, four were smoke-free at seven years. This entire group had 42 p-y of follow-up, 34 (81%) of which were smoke-free. Of the 41 subjects who were smoking at one year, 12 had quit smoking by the seven-year mark, three of these subjects by using SLT. Total follow-up for this group was 284 p-y, of which 26 (9%) were smoke-free. Although the study is small, the long-term success rate of this pilot trial compares favorably with other cessation studies.

The scientific foundation for tobacco harm reduction, 2006-2011

Over the past five years there has been exponential expansion of interest in tobacco harm reduction (THR), with a concomitant increase in the number of published studies. The purpose of this manuscript is to review and analyze influential contributions to the scientific and medical literature relating to THR, and to discuss issues that continue to stimulate debate. Numerous epidemiologic studies and subsequent meta-analyses confirm that smokeless tobacco (ST) use is associated with minimal risks for cancer and for myocardial infarction; a small increased risk for stroke cannot be excluded. Studies from Sweden document that ST use is not associated with benign gastrointestinal disorders and chronic inflammatory diseases. Although any form of nicotine should be avoided during pregnancy, the highest risks for the developing baby are associated with smoking. It is documented that ST use has been a key factor in the declining rates of smoking and of smoking-related diseases in Sweden and Norway. For other countries, the potential population health benefits of ST are far greater than the potential risks. In follow-up studies, dual users of cigarettes and ST are less likely than exclusive smokers to achieve complete tobacco abstinence, but they are also less likely to be smoking. The health risks from dual use are probably lower than those from exclusive smoking. E-cigarette users are not exposed to the many toxicants, carcinogens and abundant free radicals formed when tobacco is burned. Although laboratory studies have detected trace concentrations of some contaminants, it is a small problem amenable to improvements in quality control and manufacturing that are likely with FDA regulation as tobacco products. There is limited evidence from clinical trials that e-cigarettes deliver only small doses of nicotine compared with conventional cigarettes. However, e-cigarette use emulates successfully the cigarette handling rituals and cues of cigarette smoking, which produces suppression of craving and withdrawal that is not entirely attributable to nicotine delivery. THR has been described as having "the potential to lead to one of the greatest public health breakthroughs in human history by fundamentally changing the forecast of a billion cigarette-caused deaths this century."

Lung cancer mortality: comparing Sweden with other countries in the European Union

AIMS

To describe how snus use has reduced smoking among men in Sweden, and to estimate how smoking-attributable lung cancer mortality would decline in other European Union countries if they had the smoking prevalence of Sweden.

METHODS

Lung cancer mortality rates (LCMRs) and numbers of deaths among men and women age 45+ years in 25 EU countries in 2002 were obtained from the World Health Organization mortality database, and the number of lung cancer deaths expected in each country at the LCMR of Sweden was calculated. LCMRs for EU countries were obtained during the period 1950-2004, and per capita consumption of nicotine from cigarettes and snus was estimated for men in Sweden from 1931 to 2004.

RESULTS

There were 172,000 lung cancer deaths among men in the EU in 2002. If all EU countries had the LCMR of men in Sweden, there would have been 92,000 (54%) fewer deaths. In contrast, the LCMR among Swedish women was the sixth highest in the EU; at the Swedish rate, deaths among EU women would have increased by 14,500 (26%). These LCMR patterns were in place for most of the last 50 years, and LCMRs among Swedish men can be correlated with snus and cigarette consumption.

CONCLUSIONS

This study shows that snus use has had a profound effect on smoking prevalence and LCMRs among Swedish men. While it cannot be proven that snus would have the same effect in other EU countries, the potential reduction in smoking-attributable deaths is considerable.

Smokeless tobacco use among men in the United States, 2000 and 2005

BACKGROUND

Compared with smoking, there is much less information about smokeless tobacco (ST) use in the United States. The purpose of this study is to characterize and compare ST use among American men in 2000 and 2005.

METHODS

We used US National Health Interview Surveys from 2000 and 2005 to estimate the prevalence of ST use, describe the demographic and socioeconomic profile of ST users and evaluate ST use according to product type and with respect to smoking.

RESULTS

The prevalence of ST use among American men was 4.4% in 2000 and 4.3% in 2005. Almost all ST users were white, about half were 25-44 years old and 80% lived in the South or Midwest, commonly in small metropolitan and rural areas. Educational and income levels of ST users were lower than those of never users of tobacco. One-third of ST users also smoked; cigarette consumption was lower among dual users than among exclusive smokers. In 2005, 1.3 million current ST users were former smokers but 3.2 million smokers were former ST users. ST users were evenly distributed between snuff (43%) and chewing tobacco (44%) in 2000 and 13% used both products. By 2005 snuff use was clearly dominant.

CONCLUSIONS

The prevalence of ST use among men is low but stable; dual use of cigarettes and ST is common, and snuff has become the dominant ST product.

Switching to smokeless tobacco as a smoking cessation method: evidence from the 2000 National Health Interview Survey

BACKGROUND

Although smokeless tobacco (ST) use has played a major role in the low smoking prevalence among Swedish men, there is little information at the population level about ST as a smoking cessation aid in the U.S.

METHODS

We used the 2000 National Health Interview Survey to derive population estimates for the number of smokers who had tried twelve methods in their most recent quit attempt, and for the numbers and proportions who were former or current smokers at the time of the survey.

RESULTS

An estimated 359,000 men switched to smokeless tobacco in their most recent quit attempt. This method had the highest proportion of successes among those attempting it (73%), representing 261,000 successful quitters (switchers). In comparison, the nicotine patch was used by an estimated 2.9 million men in their most recent quit attempt, and almost one million (35%) were former smokers at the time of the survey. Of the 964,000 men using nicotine gum, about 323,000 (34%) became former smokers. Of the 98,000 men who used the nicotine inhaler, 27,000 quit successfully (28%). None of the estimated 14,000 men who tried the nicotine nasal spray became former smokers. Forty-two percent of switchers also reported quitting smoking all at once, which was higher than among former smokers who used medications (8-19%). Although 40% of switchers quit smoking less than 5 years before the survey, 21% quit over 20 years earlier. Forty-six percent of switchers were current ST users at the time of the survey.

CONCLUSION

Switching to ST compares very favorably with pharmaceutical nicotine as a quit-smoking aid among American men, despite the fact that few smokers know that the switch provides almost all of the health benefits of complete tobacco abstinence. The results of this study show that tobacco harm reduction is a viable cessation option for American smokers.

Oral cavity and pharynx-throat cancer in the United States, 1973–2003

OBJECTIVE

To study incidence rates (Is) of oral cavity and pharynx-throat cancer in adults age 20+ years from 1973 to 2003, and to estimate how many of these cancers occurred in the United States in 2003.

STUDY DESIGN

We used data and software from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) Program to generate age-adjusted Is, reported as cases per 100,000 person-years.

RESULTS

For oral cancer, the Is for young men were stable, and Is at ages 40+ years declined by one third after the mid 1980s. Is declined by one third in women ages 40 to 74, but increased in the youngest and oldest groups. In 2003 there were 10,432 cases of oral cavity cancer among persons age 20+ years in the United States, and there were 12,157 cases of pharynx-throat cancer.

CONCLUSION

The Is of cancers of the oral cavity and pharynx-throat are stable or declining for men and women in most age groups. Of the nearly 30,000 malignant neoplasms occurring in the SEER "oral cavity-pharynx" category in 2003, almost three quarters (21,455) were detectable during a routine oral examination.

Declining mortality from smoking in the United States

The proportion of Americans who smoke cigarettes has declined 50% since 1965. The effect on mortality of this considerable reduction has received little attention and is described in this study. U.S. national data were used to enumerate current, former, and never-smokers aged 35 years or older in 1987 and 2002. Mortality rate ratios were used to estimate smoking-attributable deaths among these groups, and corresponding age-adjusted smoking-attributable mortality rates (SAMRs) were calculated. There were 402,000 deaths attributable to smoking in 1987 and 322,000 in 2002. The SAMR for men aged 35 years or more was 556 deaths per 100,000 person-years in 1987, accounting for 24% of all male deaths. By 2002 the SAMR declined 41% to 329 and accounted for only 17% of deaths. The SAMR for women in 1987 was 175, accounting for 12% of deaths. By 2002 the SAMR among women had declined 30% to 122, representing 9% of deaths. The U.S. mortality rate attributable to smoking declined about 35% between 1987 and 2002. The impact of smoking on American society will diminish even further in the foreseeable future as smoking prevalence continues its decline among men and women.