John Slade

Tobacco harm reduction: conceptual structure and nomenclature for analysis and research.

The goal of tobacco control has always been to reduce death and disease due to tobacco use. Recent discussions have broadened the concept of tobacco control beyond cessation and prevention to include concepts such as the use of medications to achieve reduction in tobacco use, chemoprevention to reduce disease, modifications of tobacco products to reduce toxicity, and behavioral approaches to change smoking and tobacco use behavior. Within each of these broad domains, diverse approaches have been suggested. To facilitate clear discussion and analysis, and to avoid confusion among approaches, we catalog 19 approaches to harm reduction, distinguishing and discussing them on 11 dimensions, including their objectives, mechanisms, toxicology, expected population risks, and consumer appeal. Because there have also been so many suggested applications of medicinal nicotine to smoking intervention, we separately catalog and analyze nine applications, some of which constitute new approaches to harm reduction. The suggested framework is intended to clarify the debate, provide for common nomenclature, and facilitate analysis of diverse approaches to tobacco harm reduction.

Following the pioneers. Addressing tobacco in chemical dependency treatment.

Traditionally, tobacco has been ignored as an issue in the treatment of addictions to alcohol and other drugs. Beginning in 1985, and especially since the publication of the 1988 Surgeon Generals Report on nicotine addiction, a handful of treatment programs have worked at coming to terms with tobacco. This article explores the reasons for addressing nicotine in the course of managing other addictions and summarizes the lessons learned from the programs which have done pioneering work in this area. The reasons for addressing nicotine are compelling, and the accumulated experiences among the pioneering programs are consistently encouraging. Regional projects to help alcohol and drug treatment programs come to terms with tobacco are an appropriate next step.

The Tobacco Epidemic: Lessons from History

Tobacco has caused the greatest epidemic of the twentieth century, which is beginning to wane in the United States, but is still growing in much of the world. The epidemic developed as a result of innovations in the tobacco industry and larger cultural changes over the 75 years prior to the introduction of Camel cigarettes in 1913. Factors that set the stage for the epidemic include the development of flue-cured and Burley tobaccos, the mechanization of cigarette production with its consequent concentration of capital in a few companies, the safety match, efficient transportation systems, and innovative advertising. Between 1913 and 1963, the cigarette industry experienced almost unbroken growth in the United States. However, since the early 1950s, increasing evidence that cigarettes cause lung cancer and other diseases has dictated that product innovation concentrate on the appearance of safety. In the late 1960s and for a sustained period since 1973, cigarette consumption has declined in the United States, but in the developing world the epidemic curve of cigarette use is still on the upswing. As tobacco use declines in the United States, it is crucial that the production of tobacco products as well as their consumption be reduced. Otherwise, attempting to control the problem in the United States will not result in a net reduction in mortality around the world.

Tobacco Industry Direct Mail Marketing and Participation by New Jersey Adults

We examined adult participation in tobacco industry direct marketing: receipt of direct mail and use of coupons and brand reward programs. Participation was highest for direct mail; participation in all 3 forms differed by gender, age, and race/ethnicity; current smokers, Whites, and persons aged 25 to 64 years reported greater participation. Although tobacco industry direct marketing may influence smoking initiation, its potential to increase consumption and impede cessation is unquestionable.

Cigar use in New Jersey among adolescents and adults.

More than 3000 youths become daily smokers each day.1 Millions of youths will die from a tobacco-caused disease,2 and tobacco use remains the single leading preventable cause of death in the United States.3 However, recent data indicate that the prevalence of cigarette smoking among youths nationally has declined since 1998.4 Although the decline in cigarette use among youths is encouraging, the emergence of other tobacco products, such as cigars, as alternative forms of tobacco use by youths is alarming. The purpose of this report is to compare cigar use among adolescents and adults on the basis of data from New Jersey and the United States. n nWe used 3 sources of data in this report. For adolescents, data for New Jersey are from the 1999 New Jersey Youth Tobacco Survey, and national data are from the 1999 National Youth Tobacco Survey. For adults, data for New Jersey are from the 1998 Behavioral Risk Factor Surveillance System (BRFSS)5; cigar data were not collected in the 1999 BRFSS. Comparable adult cigar use data were not nationally available. n nThe methodology of the Youth Tobacco Survey, a school-based questionnaire, is described in detail elsewhere.6 In brief, the New Jersey Youth Tobacco Survey used a 2-stage cluster sample design to obtain a representative statewide sample of students (N = 15 871) in grades 7 through 12. Likewise, the National Youth Tobacco Survey used a 3-stage cluster sample design to produce a nationally representative sample of students (N = 15 061) in grades 6 through 12. Both surveys were conducted during the fall school semester. For the purposes of this report, we excluded sixth-grade students from the National Youth Tobacco Survey middle-school sample to standardize comparisons. n nOperational definitions of “current cigar use” were comparable in the 1999 Youth Tobacco Survey (i.e., smoked a cigar on 1 day or more in preceding 30 days) and the 1998 BRFSS (i.e., smoked a cigar in past month), offering a unique opportunity to compare youth and adult cigar smoking prevalence. Differences between prevalence estimates were considered to be statistically significant if the 95% confidence intervals did not overlap. n nLast, note that data from the Youth Tobacco Survey and the BRFSS are based on self-reports, which are subject to underreporting or overreporting. The extent of this response bias cannot be determined, but school-based surveys may tend toward overreporting, whereas telephone surveys like the BRFSS tend toward underreporting of tobacco use behaviors. n nComparisons across groups documented remarkably high levels of cigar use among youths in New Jersey and the United States (Table 1 ▶). Sex differences were apparent in both adolescents and adults, with males reporting significantly higher rates of ever and current cigar use than females. Rates of ever and current cigar smoking were similar in New Jersey and the United States among high-school students; however, the prevalence of current cigar smoking in New Jersey (18.4; 95% confidence interval (CI) = 17.1, 19.7) exceeded the national rate (15.3; CI = 13.9, 16.7) by 25%. n n n nTABLE 1 n n—Ever and Current Cigar Use by Middle-School Students, High-School Students, and Adults in New Jersey and the United States n n n nThe prevalence of cigar smoking in youths relative to adults, especially among females, in New Jersey is troublesome. Ever cigar use in New Jersey was highest among high-school students (40.5; CI = 38.7, 42.3), followed by adults (33.8; CI = 31.6, 36.0) and middle-school students (21.8; CI = 19.9, 23.7). Furthermore, current cigar use was higher among middle-school (9.3; CI = 8.3, 10.3) and high-school students (18.4; CI = 17.1, 19.7) in New Jersey than it was among New Jersey adults (6.6; CI = 5.4, 7.8). The disparity between adolescent and adult current cigar use was most dramatic among females. Middle-school (7.5; CI = 6.3, 8.7) and high-school (12.6; CI = 10.8, 14.4) females had a current cigar smoking rate 5 and 10 times higher, respectively, than that in adult women (1.3; CI = 0.6, 2.0) in New Jersey. n nAfter decades of stagnant consumption, cigar use surged during the 1990s, coinciding with increased cigar marketing, most notably the use of cigars by celebrities. By featuring celebrities such as Madonna, Michael Jordan, and supermodel Elle McPherson using cigars, the cigar industry has successfully marketed their products to adult women and adolescents of both sexes. Advertising and promotional activities have increased the visibility of cigar smoking,7 thereby “normalizing” cigar use.8,9 As is evident in New Jerseys data, the “new cigar users” are young people, including adolescent females. The effect of increased cigar marketing on young girls and women is considerable. n nCasual cigar use is often dismissed as a non–health issue. However, even moderate cigar use carries significant health risks, including increased risk for oral, oropharyngeal, and laryngeal cancers. And as is the case with other carcinogenic products, risk increases with consumption (i.e., number of cigars smoked) and depth of inhalation. Furthermore, cigars have higher total nicotine content than cigarettes do and can deliver nicotine both through smoke and through direct oral contact with the tobacco wrapper. Consequently, a special concern is that adolescent cigar use may increase vulnerability for nicotine dependence, predisposing youths to initiation of and continued use of cigarettes and other tobacco products.8 n nThe emergence of widespread cigar use among adult women and among adolescents of both sexes—combined with cigar use among men—is a significant public health threat. As funding for tobacco control increases and national rates of cigarette use appear to be declining, we must remain diligent in monitoring all forms of tobacco use. The Youth Tobacco Survey allows states such as New Jersey to monitor multiple forms of tobacco use and to examine emerging patterns among youth. However, even the most responsive surveillance system is rendered ineffectual if data are not disseminated and translated into public health policies and programs. The higher-than-expected levels of youth cigar use in New Jersey and the United States indicate that effective tobacco control programs must focus on all tobacco products, not just cigarettes.

Content analysis and key informant interviews to examine community response to the purchase, possession, and/or use of tobacco by minors.

The aim of this study was to identify and describe local ordinances in New Jersey that make it illegal for minors to purchase, possess, and/or use tobacco (PPU). A coding instrument was formulated and content analysis of each ordinance was conducted between March 1999 and January 2002. Additionally, key informant interviews with community officials were conducted by telephone between September 2000 and February 2002 to collect qualitative information on implementation and enforcement. Content analysis of identified ordinances assessed when the ordinance was enacted, specific laws and clauses included, enforcing party, area of jurisdiction, and penalties associated with a citation. Key informant interviews assessed the catalyst for enacting the ordinance, penalties, enforcement activity, and method of tracking citations. As of January 2002, 48 municipalities in New Jersey had passed mandates banning minor purchase, possession, and/or use of tobacco. Of the 48 ordinances reviewed, 71% were passed during or after 1998. Nearly all of the ordinances (94%) included prohibited minor usage of tobacco, 77% prohibited minor possession of tobacco and 23% prohibited minor purchase of tobacco. In over 80% of communities, municipal police departments were responsible for enforcement. Two out of 35 communities reached for interview reported having a formal system for tracking enforcement or citations. The results illustrate that local PPU ordinances in New Jersey vary widely both in principle and in practice, suggesting that such ordinances may be too heterogeneous and lacking in cohesion to have any impact on youth smoking.

Introductory notes on the tobacco problem

Commercial tobacco products are the leading causes of preventable death, yet they are virtually unregulated. They are popular because they are effective nicotine delivery devices, and the most addictive product (the cigarette) is also the most likely to kill.

Tobacco Product Advertising During Motorsports Broadcasts: A Quantitative Assessment

Despite a ban on advertising cigarettes and moist snuff products in electronic media in the US, advertising for these products regularly occurs through signage, uniforms, decals, and other sources at sporting events which are covered by broadcast and cable television. Additional coverage is achieved through magazine-style programs built around auto racing. The availability of estimates of the advertising value of exposure during auto races and related programming provided an opportunity for measuring the extent of this problem.

Tobacco and Other Addictions

A century ago, clinics in the United States for the treatment of addictions frequently advertised that they addressed addiction to tobacco as well as addictions to alcohol and opiates. In the intervening years, narcotics became illegal except on prescription (1914), and alcohol was prohibited for more than a decade (1919-1933). The cigarette displaced other forms of tobacco by the mid 1920s, and overall tobacco consumption grew over the first two-thirds of the 20th century. By the 1950s, most men, at all social levels (including physicians and other clinicians), smoked cigarettes. For at least decades, addictions treatment programs have aggressively ignored tobacco problems. Indeed, many have even encouraged tobacco consumption. Addiction medicine has largely lost its early, unitary clinical approach to addictions.