Gregrory N. Connolly

Declining smoking in Sweden: is Swedish Match getting the credit for Swedish tobacco control’s efforts?

It is imperative that public policy be based on the most thorough, balanced, and critical appraisal of the available evidence. Regrettably, the two papers1,2 on which we were invited to comment fall short of those criteria. Bates et al 2 concluded snus played a “positive public health role” but did not weigh all available evidence nor critically appraise the methodologies, funding sources, or interpretations of the studies they included. Their “Evidence from Sweden” section included only an unpublished survey with unknown methodology,3 a newspaper article,4 and a study from northern Sweden.5 Foulds et al 1 concluded that snus had “...a direct effect on the changes in male smoking and health” with little additional evidence. However, both papers ignored published studies and selectively reported findings. A consideration of all the available evidence suggests snus played, at best, a minor role in reducing smoking in Sweden. A one year Swedish cohort study of persons aged 45–69 years at baseline in 1992–94 examined predictors of smoking cessation or change to non-daily smoking among baseline daily smokers (n  =  3550).6 At baseline, 7.0% of men and 0.4% of women used snuff. At follow up, 7.2% of daily smokers had quit and 6.5% were non-daily smokers. The study found: snus use was not associated with smoking cessation; snuff use by non-daily smokers neither predicted cessation nor prevented transition to daily smoking7; and even if snuff helped some smokers to quit, it accounted for a small fraction of cessation. In another prospective study, 5104 persons aged 16–84 years were interviewed in 1980–81 and followed up in 1988–89.8 These included 1546 daily smokers, 418 men who used snuff daily, and 129 men who used both snuff and cigarettes. By follow up, 26% of female and 28% of male …

Brand differences of free-base nicotine delivery in cigarette smoke: the view of the tobacco industry documents

The recent availability of internal tobacco industry documents provides significant insight into industry knowledge and manipulation of tobacco smoke delivery. One critical area of research is the role of smoke chemistry in determining the absorption and effects of smoke constituents, especially harm producing or pharmacologically active compounds. Independent scientific research has suggested that the nicotine dosing characteristics, hence the addiction potential of cigarettes, may be determined in part by the amount of free-base nicotine in cigarette smoke and its effects on the location, route, and speed of absorption in the body and on the sensory perception effects of the inhaled smoke. Tobacco industry documents describe the use of a number of methods internally for measuring free-base nicotine delivery. These include the common use of cigarette “smoke pH” as a means to estimate the fraction of free-base nicotine in the particulate matter (PM) in cigarette smoke, as well as efforts to measure free-base nicotine directly. Although these methods do not provide accurate absolute measures of free-base nicotine in smoke, consistencies observed in the findings across the various manufacturers indicate: (1) real relative differences in the acid/base chemistry of the smoke from different brands of cigarettes; (2) a connection between differences in free-base levels and brand-dependent differences in sensory perception and smoke “impact”; and (3) levels of free-base nicotine that are greater than have typically been publicly discussed by the industry. Furthermore, the results of these methods are generally consistent with those of a recent study from the Centers for Disease Control and Prevention which directly measured the free-base fraction of nicotine across a range of cigarette types. Consideration of the likely fundamental importance of free-base nicotine levels in cigarette smoke, together with the efforts discussed in the tobacco industry documents to measure such levels, indicates that the public health community would benefit from additional research to assess directly the delivery of free-base nicotine in cigarette smoke across brands. This may be especially useful for those products (“light”, “ultralight”, “reduced carcinogen”, etc) that have been promoted, either explicitly or implicitly, as “harm reducing”.

Prevalence and social environment of cigarette smoking in Cyprus youth

BackgroundTobacco use is the single most preventable cause of morbidity and mortality in humans. Limited data exist regarding the extent of the problem among Cyprus youth. We use the Global Youth Tobacco Survey to assess the prevalence of cigarette smoking among middle and high school students as well as the social environment in which this is taking place.MethodsThe survey was conducted by the Cyprus International Institute for the Environment and Public Health in association with Harvard School of Public Health. A two-stage cluster sample design was used to select a representative sample of students from middle and high schools registered with the Republic of Cyprus in 2005–2006. The study questionnaire consisted of 99 questions and participation in the survey was voluntary. Statistical analyses were performed taking into consideration the specific design of the study and the sample weights associated with each completed questionnaire.ResultsThe prevalence of current smoking, defined as having smoked cigarettes on one or more days of the past 30 days, is 13% among boys and 7% among girls in middle schools, and 36% among boys and 23% among girls in high schools. Furthermore, 16% of middle school students and more than 24% of high school students that had never smoked indicated that they are likely to initiate smoking within the next year. Exposure to environmental tobacco smoke is also very high with 91% of students reporting being exposed to smoke in places outside home. In addition, more than 95% of current smokers reported that they had bought cigarettes in a store during the past month and were not refused cigarettes because of their age.ConclusionSmoking prevalence among Cyprus middle and high school students is high and there are indications of an increase in the prevalence of smoking among girls over the last few years. Susceptibility rates, exposure to second-hand smoke, and access to and availability of cigarettes to youth are also high and concerning. The present survey indicates that the problem of cigarette smoking among youth in Cyprus is significant and requires collective action immediately.

The case for fire safe cigarettes made through industry documents

Objectives: To examine the extensive research undertaken by the tobacco industry over the past 25 years toward development of a fire safe cigarette. Methods: Research was conducted through a web based search of internal tobacco industry documents made publicly available through the 1998 Master Settlement Agreement. Results: The documents reveal that the tobacco industry produced a fire safe cigarette years ago, but failed to put it on the market. These findings contradict public industry claims that denied the technical feasibility and commercial acceptability of fire safe cigarettes. Internal documents also reveal a decades long, coordinated political strategy used to block proposed legislation and obfuscate the fire safe issue. Conclusions: Federal legislation mandating fire safe cigarettes is needed.

Public Attitudes Regarding Banning of Cigarettes and Regulation of Nicotine

Knowledge of current public opinion is important as the Food and Drug Administration (FDA) applies the best scientific evidence available to tobacco product regulation. Based on a nationally representative survey of the US adult population, we report 43% support for banning of cigarettes, 65% for reducing nicotine, and 77% for reducing nicotine if such an action could cause fewer children to become addicted to cigarettes. The FDA should consider protecting children by removing all but non-addictive cigarettes from the marketplace.

Male tobacco smoke load and non-lung cancer mortality associations in Massachusetts

BackgroundDifferent methods exist to estimate smoking attributable cancer mortality rates (Peto and Ezzati methods, as examples). However, the smoking attributable estimates using these methods cannot be generalized to all population sub-groups. A simpler method has recently been developed that can be adapted and applied to different population sub-groups. This study assessed cumulative tobacco smoke damage (smoke load)/non-lung cancer mortality associations across time from 1979 to 2003 among all Massachusetts males and ages 30–74 years, using this novel methodology.MethodsAnnual lung cancer death rates were used as smoke load bio-indices, and age-adjusted lung/all other (non-lung) cancer death rates were analyzed with linear regression approach. Non-lung cancer death rates include all cancer deaths excluding lung. Smoking-attributable-fractions (SAFs) for the latest period (year 2003) were estimated as: 1-(estimated unexposed cancer death rate/observed rate).ResultsMale lung and non-lung cancer death rates have declined steadily since 1992. Lung and non-lung cancer death rates were tightly and steeply associated across years. The slopes of the associations analyzed were 1.69 (95% confidence interval (CI) 1.35–2.04, r = 0.90), and 1.36 (CI 1.14–1.58, r = 0.94) without detected autocorrelation (Durbin-Watson statistic = 1.8). The lung/non-lung cancer death rate associations suggest that all-sites cancer death rate SAFs in year 2003 were 73% (Sensitivity Range [SR] 61–82%) for all ages and 74% (SR 61–82%) for ages 30–74 years.ConclusionThe strong lung/non-lung cancer death rate associations suggest that tobacco smoke load may be responsible for most prematurely fatal cancers at both lung and non-lung sites. The present method estimates are greater than the earlier estimates. Therefore, tobacco control may reduce cancer death rates more than previously noted.

The impact of the Cyprus comprehensive smoking ban on air quality and economic business of hospitality venues

BackgroundSeveral countries, including Cyprus, have passed smoke-free legislations in recent years. The goal of this study was to assess the indoor levels of particulate matter in hospitality venues in Cyprus before and after the implementation of the law on 1/1/2010, evaluate the role of enforcement, and examine the legislation’s effect on revenue and employment.MethodsSeveral hospitality venues (n = 35) were sampled between April 2007 and January 2008, and 21 of those were re-sampled after the introduction of the smoking ban, between March and May 2010. Data on enforcement was provided by the Cyprus Police whereas data on revenue and employment within the hospitality industry of Cyprus were obtained from the Cyprus Statistical Service; comparisons were made between the corresponding figures before and after the implementation of the law.ResultsThe median level of PM2.5 associated with secondhand smoking was 161 μg/m3 pre-ban and dropped to 3 μg/m3 post-ban (98% decrease, p < 0.0001). Furthermore, in the year following the ban, the hotel turnover rate increased by 4.1% and the restaurant revenue by 6.4%; employment increased that same year by 7.2% and 1.0%, respectively.ConclusionSmoke free legislations, when enforced, are highly effective in improving the air quality and reducing the levels of indoor PM2.5. Strict enforcement plays a key role in the successful implementation of smoking bans. Even in nations with high smoking prevalence comprehensive smoking laws can be effectively implemented and have no negative effect on accommodation, food, and beverage services.

Do health policy advisors know what the public wants? An empirical comparison of how health policy advisors assess public preferences regarding smoke-free air, and what the public actually prefers

BackgroundHealth policy-making, a complex, multi-factorial process, requires balancing conflicting values. A salient issue is public support for policies; however, one reason for limited impact of public opinion may be misperceptions of policy makers regarding public opinion. For example, empirical research is scarce on perceptions of policy makers regarding public opinion on smoke-free public spaces.MethodsPublic desire for smoke-free air was compared with health policy advisor (HPA) perception of these desires. Two representative studies were conducted: one with the public (N = 505), and the other with a representative sample of members of Israel’s health-targeting initiative, Healthy Israel 2020 (N = 34), in December 2010. Corresponding questions regarding desire for smoke-free areas were asked. Possible smoke-free areas included: 100% smoke-free bars and pubs; entrances to health facilities; railway platforms; cars with children; college campuses; outdoor areas (e.g., pools and beaches); and common areas of multi-dweller apartment buildings. A 1–7 Likert scale was used for each measure, and responses were averaged into a single primary outcome, DESIRE. Our primary endpoint was the comparison between public preferences and HPA assessment of those preferences. In a secondary analysis, we compared personal preferences of the public with personal preferences of the HPAs for smoke-free air.ResultsHPAs underestimated public desire for smoke-free air (Public: Mean: 5.06, 95% CI:[4.94, 5.17]; HPA: Mean: 4.06, 95% CI:[3.61, 4.52]: p < .0001). Differences at the p = .05 level were found between HPA assessment and public preference for the following areas: 100% smoke-free bars and pubs; entrances to healthcare facilities; train platforms; cars carrying children; and common areas of multi-dweller apartment buildings. In our secondary comparison, HPAs more strongly preferred smoke-free areas than did the public (p < .0001).ConclusionsHealth policy advisors underestimate public desire for smoke-free air. Better grasp of public opinion by policy makers may lead to stronger legislation. Monitoring policy-maker assessment of public opinion may shed light on incongruities between policy making and public opinion. Further, awareness of policy-maker misperceptions may encourage policy-makers to demand more accurate information before making policy.

Use of smokeless tobacco and cigarettes among Nigerian youths: implications for tobacco control policies in Africa

Background: Smokeless tobacco (SLT) use among youths in Africa is an emerging epidemic. This paper aimed to determine patterns of tobacco use among youths in Nigeria and the implications for tobacco control in Africa. Methods: The cross-sectional study was conducted in Benue state, Nigeria, in 2011. The study population comprised of 536 randomly selected senior high school students aged 9–19 years. Results: About 17.7% of high school youths were current SLT users, 19.4% were current smokers and an alarming 11.9% used both smokeless and cigarette tobacco. After adjustment, significant predictors of SLT use among youths included their parents’ smoking status (OR 1.70, 95% C.I.: 1.01–2.87, p = 0.046) and the perception of the lack of harm from tobacco use (OR 2.06, 95% C.I.: 1.08–3.92, p = 0.027). Current cigarette smoking was again predicted by parental and peer smoking status (OR 2.58, 95% C.I.: 1.55–4.31and OR 2.93, 95% C.I.: 1.84–4.66, respectively). Adjusted regression analysis for dual tobacco use provided similar results. Conclusion: Both SLT and cigarette use, as well as dual use remains high, particularly among rural youth. Tobacco control policies based on the Framework Convention on Tobacco Control (FCTC) that primarily focus on reducing smoking in Nigeria and other African nations where SLT is popular should be modified to address not only cigarettes but also SLT use given the high use of both products singly and concurrently.