Smoking and health

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Smoking and health

• Professor Martin Jarvis
• Department of Epidemiology Public Health

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Smoking as nicotine dependence

• Nicotine the driving force
• As with other drugs, complex interplay between
  pharmacology, learning mechanisms, social and
  economic influences in determining patterns of use

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The major health consequences of smoking

• Cancer
• lung
• mouth, larynx, throat, oesophagus
• bladder, cervix, kidney, pancreas
• COPD
• Coronary heart disease
• Stroke
• Peripheral vascular disease
• Pregnancy and birth complications

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Mortality associated with smoking

• At least 320 deaths every day from smoking in the
  UK, 120,000 per year
• 1/5 all deaths across all ages
• 1/4 all deaths in age group 35-64 years
• 1 in 2 lifetime risk for smokers
• 7.5 years average loss of life expectancy
• Over half of the difference in risk of death in
  middle age between professional and unskilled men
• 4 million deaths worldwide

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Scenarios for future deaths from tobacco
520
500
Trend
400
300
Cumulative deaths from tobacco (millions)
220
200
70
100
0
1950
1975
2000
2025
2050
Year
Source Peto et al
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Smoking is highly addictive

• At least 70 of smokers want to give up
• Less than half succeed before age 65
• 40 of heart attack smokers relapse while still
  in hospital within 2 days of intensive care
• 50 of patients with laryngectomies try smoking
  again
• 50 of patients with lung removed for lung cancer
  smoke again
• More than half of heroin and cocaine users and
  alcoholics rate smoking harder to quit

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Addiction
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Starting point - the cigarette

• The cigarette should be conceived not as a
  product but as a package. The product is
  nicotine. Think of the cigarette pack as a
  storage container for a days supply of
  nicotine.Think of the cigarette as the dispenser
  for a dose unit of nicotine..Smoke is beyond
  question the most optimised vehicle of nicotine
  and the cigarette the most optimised dispenser of
  smoke.
• William Dunn, Philip Morris, 1972

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Nicotine Addiction in Britain Royal College of
Physicians Feb 2000
Central conclusion smoking is best understood
as nicotine seeking behaviour

• Nicotine delivered rapidly to the brain in
  cigarette smoke should be recognised as a
  powerfully addictive drug on a par with heroin
  and cocaine, and tobacco products should be
  recognised as nicotine delivery systems.

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Rating IV nicotine and cocaineJones et al (1999)

• Compared 3 doses of cocaine and nicotine given IV
  double-blind saline placebo
• Nicotine high and rush rated stronger than
  cocaine, also jittery
• Nicotine frequently misidentified as cocaine,
  and, at highest dose, an opiate

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Nicotine as a drug of dependence

• Blood nicotine from cigarettes, snuff (oral and
  nasal) and cigars very similar
• IV nicotine suppresses smoking
• Nicotine intakes from different brands of
  cigarette very similar

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Nicotine as a drug of dependence

• Nicotine withdrawal syndrome
• Effect of nicotine replacement on successful
  quitting

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Self-assertion . . .

• To account for the fact that the beginning
  smoker will tolerate the unpleasantness we must
  invoke a psychosocial motive. Smoking a cigarette
  for the beginner is a symbolic act. The smoker is
  telling his world, 'This is the kind of person I
  am.' Surely there are variants of this theme, 'I
  am no longer my mother's child,' 'I am tough,' 'I
  am not a square.' Whatever the individual intent,
  the act of smoking remains a symbolic declaration
  of personal identity . . . Philip Morris (Bates
  no. 1003287836)

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. . . and addiction

• . . . As the force from the psychosocial
  symbolism subsides,
• the pharmacological effect takes over to
  sustain the habit . . .

Philip Morris 1969 document (Bates no. 1003287836)
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Addiction -
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Factors favouring study of smoking as compared
with other drug taking behaviours

• High prevalence
• Legal
• Little stigma, so self-reports largely accurate
• Unlike alcohol, excellent biomarker of intake
  available

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Cotinine as a biomarker of nicotine intake

• Main nicotine metabolite (70-80 converted)
• Half-life 16-20 hours
• Measurable in saliva, blood or urine
• Quantitative measure of nicotine intake 10ng/ml
  cotinine in blood 1mg nicotine daily

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Disadvantage and Smoking

• A whole range of indicators of disadvantage
  predict who smokes
• Cigarette smoking prevalence tightly linked to
  deprivation, mainly because of low rates of
  quitting in disadvantaged groups

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Indicators of socio-economic status

• Occupational class
• Educational level
• Housing tenure
• Car ownership
• Unemployment
• Living in crowded accommodation
• Single parenthood
• Divorced or separated

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Disadvantage and smoking

• Poor people are
• More likely to take up smoking
• Less likely to quit
• More heavily exposed to other peoples smoke
• Become more nicotine dependent
• Much more likely to die prematurely from smoking

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Some implications of nicotine addiction for
cessation and harm reduction

• Ineffective
• cutting down
• switching to cigars or a pipe
• switching to low tar
• Effective
• Nicotine replacement products

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One year success rates by intensity of
intervention

• Unaided quit attempt ......1-2
• Brief GP advice ...5
• Brief GP advice NRT .10
• Intensive clinic support ...15
• Intensive clinic support NRT..20-30

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Scenarios for future deaths from tobacco
520
500
Trend
400
300
Cumulative deaths from tobacco (millions)
220
200
70
100
0
1950
1975
2000
2025
2050
Year
Source Peto et al
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Scenarios for future deaths from tobacco
520
500
500
Trend
If smoking
uptake halves
400
by 2020
300
Cumulative deaths from tobacco (millions)
220
200
70
100
0
1950
1975
2000
2025
2050
Year
Source Peto et al
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Scenarios for future deaths from tobacco
520
500
500
Trend
If smoking
uptake halves
400
by 2020
340
300
Cumulative deaths from tobacco (millions)
220
If adult smoking
halves by 2020
200
190
70
100
0
1950
1975
2000
2025
2050
Year
Source Peto et al
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Conclusions

• Nicotines legal status and lack of adverse
  effects on performance have hampered recognition
  of its status as a drug of dependence
• Nicotine is pharmacologically a hard drug, on a
  par with heroin and cocaine
• Cigarette smoking is by far the biggest problem
  of drug dependence in the UK