Chapter 10Tobacco

Tobacco is an interesting social dilemma—a product that is legal for adults to use, and that a significant proportion of adults enjoy using and expect to continue using, yet a substance that is responsible for more ad-verse health consequences and death than any other.

The Tobacco Dilemma

TOBACCO USE: SCOPE OF THE PROBLEM

Tobacco use is the leading preventable cause of disease and premature death in the United States.

443,000 deaths annually in United States ( hyperlink- review web page)

Tobacco is the single largest cause of preventable death and a risk factor for 6/8 of the leading causes of death.

TOBACCO USE: SCOPE OF THE PROBLEM

In 2009, 69.7 million Americans, or 27.7% of the population age 12 or older, reported current use of a tobacco product.

Approximately 33.5 percent of males and 22.2% of females age 12 or older were current users of any tobacco product.

ANNUAL DEATHS ATTRIBUTABLE TO CIGARETTE SMOKING (LINK)

CIGARETTE SMOKING: A COSTLY ADDICTION

Cigarette smoking is the leading preventable cause of death in the United States.

More deaths are caused each year by tobacco use than by HIV, illegal drug use, murders, alcohol use, suicides, and motor vehicle injuries combined.

Overall mortality rates decline the longer ex-smokers abstain from smoking.

Cultivated and used by Native Americans for centuries Presented tobacco leaves as a gift to

Columbus in 1492 The word “tobaco” was

adopted by the Spanish Possibly from the Arabic word

“tabbaq” meaning “medicinal herbs” Europeans discovered that

Amerindians sometimes put tobacco into tubes made from reeds, started a fire at one end of the reed, and “ drank” the smoke from the other end. Or, they did a similar thing with tobacco leaves rolled up like a cigar, or they “ drank” smoke from stone or clay pipes.

Early History

Commercial importation of tobacco into Europe in large quantities began around 1600.

It was the use of the of tobacco by the respected “affluent” members of society that eventually made tobacco a desired commodity for the masses

Early History

1500s: Beginning with a few trials by physicians,

recognition of the potential of tobacco grew during the middle of the 1500s.

French physician Jean Nicot: early proponent He was successful in “ curing” the migraine

headaches of Catherine de Medici, queen of Henry II of France, which made tobacco use very much “ in.”

Tobacco was called the herbe sainte, “ holy plant,” By 1565, the plant had been called nicotiane, after Nicot.

In 1753, Linnaeus, the Swedish “ father of taxonomy,” named the plant genus Nicotiana. When a pair of French chemists isolated the active ingredient in 1828, they acted like true nationalists and called it nicotine.

Early Medical Uses

16th and 17th centuries Tobacco viewed as having many positive

medical uses but as having a negative reproductive effect

1890s: The slow advance of medical science

through the 18th and 19th centuries gradually removed tobacco from the doctor’s black bag, and nicotine was dropped from The United States Pharmacopoeia in the 1890s.

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Early Medical Uses

Two major species grown today (out of more than 60) Nicotiana tobacum: large-leaf species

indigenous only to South America but now cultivated widely

Nicotiana rustica: small-leaf species from the West Indies and eastern North America

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Two Major Species

SPREAD OF TOBACCO USE Tobacum was indigenous only to South America, so the

Spanish had a monopoly on its production for over a hundred years. Nicotiana rustica (see previous slide) is a small-leaf species and was the plant existing in the West Indies and eastern North America when Columbus arrived.

The Jamestown colonist tried to grow the rustica variety without luck, In 1612, John Rolfe somehow got some seeds of the Spanish tobacum species. This species grew beautifully and sold well. The colony was saved, and every available plot of land was planted with tobacum

By 1619, as much Virginia tobacco as Spanish tobacco was sold in London..

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Snuff 18th century: Snuff use became

widespread as smoking decreased The middle and lower classes only

gradually changed over, but by 1770 very few people were smoking. The reign of King George III ( 1760– 1820) was the time of the big snuff.

In U.S., perceived as a British product; American use declined after the Revolution

Chewing tobacco 19th century: Most tobacco used in the

U.S. was chewing tobacco Popularity rose from “snuff” rebellion

and fear of fire hazard from smoking Smoking did not surpass chewing

until the 1920s10-13

Types of Tobacco Products

Cigars A combination of chewing and smoking Peaked in popularity in 1920 The introduction of the cigarette-rolling

machine spurred cigarette consumption because cigarettes became cheaper than cigars.

Types of Tobacco Products

Cigarettes Thin reeds filled with tobacco had been seen by

the Spanish in Yucatan in 1518. In 1844, the French were using them, and the

Crimean War circulated the cigarette habit throughout Europe.

The first British cigarette factory was started in 1856 by a returning veteran of the Crimean War, and in the late 1850s an English tobacco merchant, Philip Morris, began producing handmade cigarettes.

In the United States, cigarettes were being produced during the same period ( 14 million in 1870), but their popularity increased rapidly in the 1880s.

Types of Tobacco Products

Cigarettes The date of the first patent on a cigarette-making

machine was 1881, and by 1885 more than a billion cigarettes a year were being sold.

At the start of the 20th century, there was a preference for cigarettes with an aromatic component— that is, Turkish tobacco.

Camels, a new cigarette in 1913, capitalized on the lure of the Near East while rejecting it in actuality. The Camel brand contained just a hint of Turkish tobacco.

The first ad showing a woman smoking appeared in 1919.

Filter cigarettes, beginning in 1954, captured an increasing share of the market and now constitute over 90 percent of all U. S. cigarette sales.

Types of Tobacco Products

Product milestones: 1913 - Camels: low-priced domestic

tobacco 1939 - Pall Mall: king-size cigarettes 1954 - Winston: filter cigarettes

History: Cigarettes

1908: New York made it illegal for a woman to use tobacco in public

“protect women from themselves”

Tobacco Under Attack

1604: King James of England published an anti-tobacco pamphlet

“harmful to the brain, dangerous to the lungs”

However, he also supported the American tobacco trade in 1610

1930s and 40s: Reports linking smoking and cancer

1952: A 1952 article in Readers’ Digest called “ Cancer by the Carton” drew public attention to the issue, and led to a temporary decline in cigarette sales.

Tobacco companies’ response: 1. Formation of the Council for Tobacco Research

Not independent and tried to undermine health risk claims

2. Mass-marketing of filter cigarettes and cigarettes with lowered tar and nicotine content

Promoted as a “safer” alternative

Tobacco Under Attack

1964: Surgeon General’s report states that smoking causes lung cancer in men Tobacco sales began a

decline that continued for 40 years (see below)

Tobacco Under Attack

1965: Congress required warning labels on cigarette packages

1971: TV and radio cigarette ads banned

1990: Smoking banned on interstate buses and domestic airline flights

1995: FDA proposed further regulation of tobacco and ads - After a year of discussion, rules were proposed that further limited advertising on billboards and other public displays, sponsorship of sporting events, promotional giveaways of caps and T- shirts, and advertising in magazines with significant youth readership.

Many additional state and local bans passed

Tobacco Under Attack

Lawsuits seeking compensation for the health consequences of smoking Unsuccessful for many years- cigarette companies

clamed that consumers were responsible for their own health behaviors

Then several victories -with the disclosure of internal tobacco company documents demonstrating both the companies’ knowledge of the adverse health consequences of smoking and their efforts to hide that knowledge from customers.

Possible reasons for legal victories Changing legal climate Revelation of tobacco companies’ actions in hiding

information on the adverse effects of smoking

Tobacco Under Attack

1998 settlement between 46 states and major tobacco companies $205 billion in payments to the states Advertising regulations Enforcement of laws prohibiting sales to

minors In exchange, the companies received a

cap on certain aspects of their legal liability, which otherwise threatened to bankrupt the industry.

Tobacco Under Attack

Lower levels of nicotine Nicotine appears to be the constituent in tobacco that keeps smokers

coming back for more— People adjust their smoking behavior to obtain a consistent amount of

nicotine By taking more puffs and inhaling more deeply

Lower levels of tar Tar is the sticky brown material seen on the filter of a smoked

cigarette Based on changes in smoking behavior, there may be no advantage to

switching to a low tar–low nicotine cigarette

Does “safer” mean safe? - Beginning in the mid-1950s with the mass marketing of filter cigarettes, the tobacco companies began to promote the idea of a “ safer” cigarette, without actually admitting that there was anything unsafe about their older products.

Quest for “Safer” Cigarettes

Does “safer” mean safe? – The problem with all this is that “ safer” doesn’t mean “

safe,” and it wasn’t at all clear how much safer these low tar and nicotine cigarettes actually are for people over a life-time of smoking.

A major blow to the “ healthier cigarette” notion was dealt in 2006 when the U. S. Government obtained a conviction against nine tobacco companies and two tobacco industry trade organizations for racketeering and fraud. The purposeful manipulation of nicotine levels to increase nicotine dependence was one charge, but another was that for years the tobacco companies promoted low tar and nicotine cigarettes as safer alternatives, when their own research and other evidence showed these claims to be misleading.

Quest for “Safer” Cigarettes

Percentage of smokers by gender

Men: 25% Women: 21%

Education is the single biggest influence on smoking rates

Percentage of smokers by education High school diploma only: 30% Non-college students: 15% Undergraduate degree: 13% Full time college students: 7%

Current Cigarette Use

This difference in cigarette smoking based on college education probably reflects the considerable influences of socioeconomic status, family background, and expectations, and apparently has little to do with any knowledge a college graduate might have obtained.

1970s: use increased as smokers looked for an alternative with a lower risk of lung cancer

Most common form Moist snuff (Skoal, Copenhagen) Nicotine absorbed through mucous membranes

Advantages over cigarettes Unlikely to cause lung cancer Less expensive More socially acceptable in some circumstances

Smokeless Tobacco

Smokeless tobacco has its hazards Smokeless tobacco packages carry warning labels

Health concerns

Smokeless Tobacco

Increased risk of dental disease and oral cancer Contains potent carcinogens such as nitrosamines

Causes leukoplakia Can lead to nicotine dependence

Hookahs: Large, ornate water

pipes imported from Arab countries

Hookahs produce milder, water-filtered tobacco smoke

Prevalence of hookah smoking is unclear

Other Tobacco Products In recent years (mid 1990’s), cigar smoking had

increased In 2008, 9% of males and 2% of females reported smoking a

cigar in the past month

Major diseases linked to smoking Lung cancer Cardiovascular disease Chronic obstructive lung diseases

including emphysema

Risk increases for those who: Start young Smoke many cigarettes Continue to smoke for a long time

Smoking is the single greatest avoidable cause of death

Smoking: Adverse Health Effects

Smoking: Adverse Health Effects Cigarette packages and advertisements are required to rotate

among different warning labels

Secondhand smoke Cigarette smoke inhaled from

the environment by nonsmokers

Components of environmental smoke Mainstream smoke: the smoke

inhaled/exhaled by the smoker Sidestream smoke: the smoke

rising from the ash of a cigarette

More carcinogens in smoke But smoke is more diluted

Secondhand Smoke

Health effects difficult to fully determine but include Lung cancer Cardiovascular disease (Increased risk of COPD like symptoms in children)

1993: Environmental Protection Agency classified secondhand smoke as a known human carcinogen

Many recent laws and regulations have been passed to protect nonsmokers

Secondhand Smoke

Five million deaths worldwide each year Perhaps as high as 8 million by 2030

Demand for American cigarettes in Asia has increased markedly Demand has also increased in Third World countries

Smoking and Heath in Other Countries

Increased risk of: Miscarriage Low birth weight Sudden infant death syndrome (SIDS)

Several studies indicate effects on physiological and cognitive development Neurological problems Problems with reading and

mathematical skills Hyperactivity

Smoking and Pregnancy

Nicotine Active ingredient in tobacco A naturally occurring liquid alkaloid that is colorless

and volatile On oxidation, it turns brown and smells like burning

tobacco

Tolerance and dependence develop quickly

Highly toxic in large enough doses Lethal dose = 60 mg

A cigar contains twice that much Typically not delivered fast enough or in a high enough dose to be lethal

Nicotine Pharmacology

Use of nicotine increases the activity of liver enzymes responsible for nicotine deactivation

Contributes to tolerance May decrease the effects of other medication –

benzodiazepines and some antidepressants and analgesics

Absorption and Metabolism Inhalation is very effective

90% of inhaled nicotine is absorbed

80–90% of nicotine is deactivated in the liver and then excreted via the kidneys

Mechanism of action: Mimics acetylcholine First stimulates and then blocks receptor sites Also causes the release of adrenaline and has an indirect

sympathomimetic effect

Symptoms of nicotine poisoning: Low-level

nausea, dizziness, and general weakness Often experienced by beginning smokers

Acute poisoning tremors, convulsions, paralysis of breathing muscles,

death Relatively rare

Physiological Effects

CNS and circulatory system effects Increased heart rate and blood pressure Increased oxygen need of the heart Decreased oxygen-carrying ability of blood

Causes shortness of breath Increased platelet adhesiveness

Increases the tendency to clot Increased electrical activity in the cortex

Reduced hunger Inhibition of hunger contractions Increased blood sugar Deadening of taste buds

Physiological Effects

Nicotine is the primary reinforcing substance in tobacco

Smokers report that nicotine has both stimulant and calming effects User expectation probably plays an important

role in the effects

Behavioral Effects

1. Cigarettes and other forms of tobacco are addicting

2. Nicotine is the drug in tobacco that causes addiction

3. The processes that determine tobacco addiction are similar to those that determine addiction to drugs like heroin and cocaine

Tobacco industry claims that its products do not cause dependence

Conclusions made in the Surgeon General’s report (1988):

Nicotine Dependence

There are more than 40 million ex-smokers in the U.S. 90% report no formal treatment program

Yet there are many challenges to quitting Nicotine is a strongly reinforcing drug

And a pack-a-day smoker gets 50,000 reinforcing nicotine puffs per year

How to Stop Smoking

Replacement therapy Delivering nicotine without the

tar and carbon monoxide Produced in many forms: Gum, patches, nasal spray,

inhalers, lozenges

Pharmacological Therapy Example: Bupropion (Zyban)

How to Stop Smoking

Combining counseling and pharmacological treatments increases the odds of quitting

Tobacco

End of Lecture