Coral Gartner

Assessment of Swedish snus for tobacco harm reduction: an epidemiological modelling study

BACKGROUND Swedish snus is a smokeless tobacco product that has been suggested as a tobacco harm reduction product. Our aim was to assess the potential population health effects of snus. METHODS We assessed the potential population health effects of snus in Australia with multistate life tables to estimate the difference in health-adjusted life expectancy between people who have never been smokers and various trajectories of tobacco use, including switching from smoking to snus use; and the potential for net population-level harm given different rates of snus uptake by current smokers, ex-smokers, and people who have never smoked. FINDINGS There was little difference in health-adjusted life expectancy between smokers who quit all tobacco and smokers who switch to snus (difference of 0.1-0.3 years for men and 0.1-0.4 years for women). For net harm to occur, 14-25 ex-smokers would have to start using snus to offset the health gain from every smoker who switched to snus rather than continuing to smoke. Likewise, 14-25 people who have never smoked would need to start using snus to offset the health gain from every new tobacco user who used snus rather than smoking. INTERPRETATION Current smokers who switch to using snus rather than continuing to smoke can realise substantial health gains. Snus could produce a net benefit to health at the population level if it is adopted in sufficient numbers by inveterate smokers. Relaxing current restrictions on the sale of snus is more likely to produce a net benefit than harm, with the size of the benefit dependent on how many inveterate smokers switch to snus.

Refining the estimation of illicit drug consumptions from wastewater analysis: Co-analysis of prescription pharmaceuticals and uncertainty assessment

Wastewater analysis is a promising monitoring tool to estimate illicit drug consumption at the community level. The advantage of this technique over traditional surveys and other surveillance methods has been emphasized in recent studies. However, there are methodological challenges that can affect reliability. The objectives of this study were to systematically reduce and assess uncertainties associated with sampling (through a stringent optimization of the sampling method) and the back calculation of per capita drug consumption (through a refined estimation of the number of people actively contributing to the wastewater in a given period). We applied continuous flow-proportional sampling to ensure the collection of representative raw wastewater samples. Residues of illicit drugs, opioids, prescription pharmaceuticals and one artificial sweetener were analyzed by liquid chromatography coupled with tandem mass spectrometry. A parameter estimating the number of people actively contributing to wastewater over a given period was calculated from the measured loads of prescription pharmaceuticals, their annual consumption and relative excretion data. For the calculation of substance loads in sewage, uncertainties were propagated considering five individual components: sampling, chemical analysis, flow measurements, excretion rates and the number of people contributing to the wastewater. The daily consumption per 1000 inhabitants was estimated to be almost 1000 mg for cannabis and several hundred mg for cocaine, methamphetamine and ecstasy. With the best sampling practice and current chemical analysis, we calculated the remaining uncertainty to be in the range of 20-30% (relative standard deviation, RSD) for the estimation of consumed drug masses in the catchment; RSDs for the per capita consumption were lower (14-24%), as one of the biggest uncertainty components (i.e. error in flow measurements) cancels out in the proposed method for the estimation of the number of people contributing to the daily wastewater volume. In this study, we provide methodological improvements that substantially enhance the reliability of the estimation method--a prerequisite for the application of this technique to meaningfully assess changes in drug consumption and the success of drug intervention strategies in future studies.

Should the health community promote smokeless tobacco (snus) as a harm reduction measure

Background to the debate: The tobacco control community is divided on whether or not to inform the public that using oral, smokeless tobacco (Swedish snus) is less hazardous to health than smoking tobacco. Proponents of “harm reduction” point to the Swedish experience. Snus seems to be widely used as an alternative to cigarettes in Sweden, say these proponents, contributing to the low overall prevalence of smoking and smoking-related disease. Harm reduction proponents thus argue that the health community should actively inform inveterate cigarette smokers of the benefits of switching to snus. However, critics of harm reduction say that snus has its own risks, that no form of tobacco should ever be promoted, and that Swedens experience is likely to be specific to that culture and not transferable to other settings. Critics also remain deeply suspicious that the tobacco industry will use snus marketing as a “gateway” to promote cigarettes. In the interests of promoting debate, the authors (who are collaborators on a research project on the future of tobacco control) have agreed to outline the strongest arguments for and against promoting Swedish snus as a form of harm reduction.

Predicting the future prevalence of cigarette smoking in Australia: how low can we go and by when?

Background: In Australia, smoking prevalence has declined in men since the 1950s and in women since the 1980s. Future smoking prevalence in Australia is predicted from estimates of previous and current age-specific and sex-specific cessation rates and smoking uptake in young people derived from national survey data on the prevalence of smoking between 1980 and 2007. Methods: A dynamic forecasting model was used to estimate future smoking prevalence in the Australian population based on a continuation of these current trends in smoking uptake and cessation. Results: The results suggest that Australia’s smoking prevalence will continue to fall while current rates of initiation and cessation are maintained. But a continuation of current smoking cessation and initiation patterns will see around 14% of adults still smoking in 2020. Conclusions: Smoking cessation rates will need to double for Australian smoking prevalence to reach a policy target of 10% by 2020.

A Systematic Review of Peer-Support Programs for Smoking Cessation in Disadvantaged Groups

The burden of smoking is borne most by those who are socially disadvantaged and the social gradient in smoking contributes substantially to the health gap between the rich and poor. A number of factors contribute to higher tobacco use among socially disadvantaged populations including social (e.g., low social support for quitting), psychological (e.g., low self-efficacy) and physical factors (e.g., greater nicotine dependence). Current evidence for the effectiveness of peer or partner support interventions in enhancing the success of quit attempts in the general population is equivocal, largely due to study design and lack of a theoretical framework in this research. We conducted a systematic review of peer support interventions for smoking cessation in disadvantaged groups. The eight studies which met the inclusion criteria showed that interventions that improve social support for smoking cessation may be of greater importance to disadvantaged groups who experience fewer opportunities to access such support informally. Peer-support programs are emerging as highly effective and empowering ways for people to manage health issues in a socially supportive context. We discuss the potential for peer-support programs to address the high prevalence of smoking in vulnerable populations and also to build capacity in their communities.

An analysis of ethical issues in using wastewater analysis to monitor illicit drug use

AIMS To discuss ethical issues that may arise in using WWA to monitor illicit drug use in the general population and in entertainment precincts, prisons, schools and work-places. METHOD Review current applications of WWA and identify ethical and social issues that may be raised with current and projected future uses of this method. RESULTS Wastewater analysis (WWA) of drug residues is a promising method of monitoring illicit drug use that may overcome some limitations of other monitoring methods. When used for monitoring purposes in large populations, WWA does not raise major ethical concerns because individuals are not identified and the prospects of harming residents of catchment areas are remote. When WWA is used in smaller catchment areas (entertainment venues, prisons, schools or work-places) their results could, possibly, indirectly affect the occupants adversely. Researchers will need to take care in reporting their results to reduce media misreporting. Fears about possible use of WWA for mass individual surveillance by drug law enforcement officials are unlikely to be realized, but will need to be addressed because they may affect public support adversely for this type of research. CONCLUSIONS Using wastewater analysis to monitor illicit drug use in large populations does not raise major ethical concerns, but researchers need to minimize possible adverse consequences in studying smaller populations, such as workers, prisoners and students.

Prevalence of Parkinson’s disease in metropolitan and rural Queensland: A general practice survey

The prevalence of idiopathic Parkinsons disease (IPD) in Australia is unclear. We estimated the prevalence of IPD, and other forms of parkinsonism, through the study of typical caseloads in general practice. A random sample of general practitioners (GPs) throughout Queensland (401 responses from 528 validated practice addresses) was asked to estimate the numbers of patients with IPD and parkinsonism seen in the preceding year. The estimated prevalence of diagnosed IPD in Queensland was 146 per 100,000 (95% CI=136-155). A further 51 per 100,000 in the population were suspected by doctors to have IPD without formal diagnosis, whereas another 51 per 100,000 people may have non-idiopathic parkinsonism. Idiopathic Parkinsons disease was more common in rural than metropolitan areas. Although most GPs were confident in making diagnoses of IPD, the majority had little or no confidence in their ability to treat the disease, especially in its later stages. Support from neurologists was perceived by GPs to be very good in cities, but poor in remote areas.

Multiple genetic tests for susceptibility to smoking do not outperform simple family history

AIMS To evaluate the utility of using predictive genetic screening of the population for susceptibility to smoking. METHODS The results of meta-analyses of genetic association studies of smoking behaviour were used to create simulated data sets using Monte Carlo methods. The ability of the genetic tests to screen for smoking was assessed using receiver operator characteristic curve analysis. The result was compared to prediction using simple family history information. To identify the circumstances in which predictive genetic testing would potentially justify screening we simulated tests using larger numbers of alleles (10, 15 and 20) that varied in prevalence from 10 to 50% and in strength of association [relative risks (RRs) of 1.2-2.1]. RESULTS A test based on the RRs and prevalence of five susceptibility alleles derived from meta-analyses of genetic association studies of smoking performed similarly to chance and no better than the prediction based on simple family history. Increasing the number of alleles from five to 20 improved the predictive ability of genetic screening only modestly when using genes with the effect sizes reported to date. CONCLUSIONS This panel of genetic tests would be unsuitable for population screening. This situation is unlikely to be improved upon by screening based on more genetic tests. Given the similarity with associations found for other polygenic conditions, our results also suggest that using multiple genes to screen the general population for genetic susceptibility to polygenic disorders will be of limited utility.

The genetics of nicotine addiction liability: ethical and social policy implications

AIM To assess the promise and risks of technological applications of genetic research on liability to develop nicotine dependence. METHODS We reviewed (i) the evidence on the genetics of nicotine dependence; (ii) the technical feasibility of using genetic information to reduce smoking uptake and increase cessation; and (iii) policy and ethical issues raised by the uses of genetic information on addiction liability. RESULTS (i) Despite evidence from twin studies that genes contribute to addiction susceptibility, research to date has not identified commonly occurring alleles that are strongly predictive of developing nicotine addiction. Nicotine addiction is likely to involve multiple alleles of small effect that interact with each other and with the environment. (ii) Population screening for susceptibility alleles is unlikely to be effective or cost-effective. Tailoring of smoking cessation treatments with genetic information is more plausible but results to date have been disappointing. Population health strategies such as increased taxation and reduced opportunities to smoke are more efficient in reducing cigarette smoking. Tobacco harm reduction policies applied to populations may also play a role in reducing tobacco-related harm. (iii) Future uses of genomic information on addiction risk will need to assess the risks of medicalising addiction (e.g. pessimism about capacity to quit) and community concerns about genetic privacy. CONCLUSIONS Nicotine genomics is a very new and underdeveloped field. On the evidence to date, its advocates would be wise to avoid extravagant claims about its preventive applications.

Passive smoking and Parkinson disease.

Cigarette smoking is consistently associated with a reduced risk of Parkinson disease (PD), having been reported in prospective studies,1 retrospective case-control studies,2 twin studies,3 and studies of case-sibling pairs.4 Conjecture remains as to whether this association reflects a true biologic neuroprotection from tobacco smoking or whether shared genetic and behavioral factors influence both smoking propensity and PD risk. Although genetic and behavioral factors may have less influence on an individual’s exposure to passive tobacco smoke, there are no previous reports on the effects of passive smoking on the risk for PD. Here we provide evidence that passive exposure to cigarette smoke might also be less common in PD. We recruited 163 patients with PD. Inclusion criteria were community-dwelling patients who had consulted the clinic of one of the authors between October 2003 and October 2004 and received a diagnosis of definite idiopathic PD5; assessed at >27 on the Mini-Mental State Examination (MMSE); capable of completing the risk factor questionnaire; and currently listed in the Australian Commonwealth Electoral Roll …