Smoking and health

Professor Martin Jarvis Department of Epidemiology & Public Health

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

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

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

Scenarios for future deaths from tobacco

Cumulative deaths from tobacco (millions)
520
500

Trend

400

300

220
200

100

70

0 1950 1975 2000 2025 2050

Year

Source: Peto et al

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

Addiction

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

40 35 30

S chemat i c Di agr am of A r t er i al vs V en ous Ni c ot i n e Level s

Ar er t al i

l) m n g/ io n ( at r in e Conc ent Nic ot

25 20 15 10 5 0 10 -

Venous

10

20

30

40

50

60

70

Ti m e( m ns i )
c i g a re tte sm oked

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.

Rating IV nicotine and cocaine: Jones 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

P r evalence of r egular dr ug use: adults aged 16-64, GB 1993-1994

C i garet t e smoki ng %
D ri nki ng above recommended l i mi t s
2 2 2 0 0 0 0 0 0 1 0 2 0 3 0 4 0 3 2

M ari j uana Tranqui l l i zers sl eepi ng pi l l s A mphet ami nes O pi at es C ocai ne Psychedel i cs hal l uci nogens

R egu l ar d ru gu ser = every day for 2 weeks o r mo re i n p ast 12 mo n th s

O PC S Psychi at ri c M or bi di t y Sur vey: M el t zer et al 1995

B ase n =9792

Neur otic disor der % by dr inking habits GB 1993-1994

45 40

Ne urotic dis orde r %

35 30 25 20 15 10 5 0
A bst ai ner O ccasi onal Li ght M oderat e Fai rl y heavy H eavy Ver y heavy

A lcohol dr inking habits

Neur otic disor der % by sm oking habits GB 1993-1994

45 40

Ne urotic dis orde r %

35 30 25 20 15 10 5 0

N ever smo ker

E x

3-4

5-6

7-8

9-10

11-12

13-14

Tobacco dependence score

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

Nicotine as a drug of dependence

Nicotine withdrawal syndrome Effect of nicotine replacement on successful quitting

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)

. . . 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)

Addiction -

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

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

Brief dependence scale 1. How soon after waking do you smoke your first cigarette of the day?
Less than 5 minutes Between 5 and 15 minutes Between 15 and 30 minutes Between 30 min. and 1 hr Between 1 and 2 hours Longer than 2 hours

2. How easy or difficult would you find it to go without smoking for a whole day?
Very easy Fairly easy Fairly difficult Very difficult

3. How many cigarettes do you usually smoke each day?

1-10 11-20 21-30 31+

D I STR I BU TI O N O F TI M E TO FI RST CI G A RETTE I N SM O K ER S I N PR IMA R Y CA R E 30

" How soon af t er w aki ng do you sm oke your f i r st ci gar et t e of t he day?"

P ercen tag e o f smo kers

25 20 15 10 5 0

15- 30 Less t han 5- 15 5 m i nut es m i nut es m i nut es

30 m i n t o 1 hr

1 t o 2 M or e t han hour s 2 hour s

S al i va co ti n i n e (n g / ml )

450 400 350 300 250 200 150 100 50

Les s t han 5- 1 5 15- 30 30 5 m i n u t em s i nut e s m i nut e s t o n=2 60 n=3 22 n=2 05 m i n 1 t o 2M o r e t h a n 1 hr hour s 2 hour s n=1 82 n=3 07 n=2 14
M ean +

95%

CI

TI M E TO

F I RS T

CI G ARE T T E O F

T HE DAY

S ALIV A COTININE BY DE P E NDE NCE IN S MOKE RS IN P RIMARY CARE

550

Saliva cotinine (ng/ml)

440

330

220

110
M ean + 95% C I

0
N= 130

1
108

2
96

3
99

4
120

5
149

6
136

7
143

8
160

9
108

10 11
73 38

DEPENDENCE SCALE SCORE

3
2

Plasma cotinine (ng/ml)

0 .5

Geometri c mean 95%C I

0
0 1 -4 5 -9 1 0 -1 4 1 5 -1 9 2 0 -2 4 2 5 -2 9 30+

P ar tner 's daily cigar ette consum ption

PASSIVE SM OKING: COTININE IN ADULTS BY PARTNER'S CIGARETTE CONSUM PTION

2. 5

Plasma cotinine (ng/ml)

2. 0

He a lth Su rv e y fo r En g la n d 1 9 9 4 &1 9 9 6

1. 5

1. 0

0. 5

Ge o m e tric m e a n + 9 5 % CI
0. 0 0 1- 4 5- 9 10- 14 15- 19 20- 24 25- 29 30+

Pa rtn e r' s d a ily c ig a re tte c o n s u m p tio n

n= 8 3 2 8 234 231 259 155 294 60 79

CIGARETTE SM OKING 1 9 7 2 -1 9 9 8 : GB: Ge ne ra l Hous e hold Surv e y 60 50

M en

% prevalence

40 30 20 10 0
1972 1976 1980 1984 1988 1992 1996

Women

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

Indicators of socio-economic status

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

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

CIGARETTE SMOKING BY DEPRIVATION IN GREAT BRITAIN: GHS 1973 & 1998

80 70 60 50 1973 40 30 20 10 0 1998

% prevalence

0 Most affluent

5 Poorest

DEPRIVATION SCORE

SMOKING CESSATION BY DEPRIVATION IN GREAT BRITAIN: GHS 1973 & 1998

80 70 60 50 40 30 20 10 0

% quit

1973 1998

0 Most affluent

5 Poorest

DEPRIVATION SCORE

P lasm a cotinine by depr ivation in adult sm oker s: HS E 1993-1996

350

Pla s m a c otinine (ng/m l)

300 1993 1994 250 1996

200

DEPRIVAT ION SCORE

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

Nic otine inta k e pe r c iga re tte (m g)

P r edicted and actual nicotine intakes per cigar ette sm oked by nom inal nicotine yield of usual br and
1 .6 1 .4 1 .2 1 .0 0 .8 0 .6 0 .4 0 .2
0 - .1 . 1. 2. 4. 5. 6. 7. 8. 91. 0 +

He a lth Surv e y for Engla nd 1 9 9 8

Ciga re tte nic otine y ie ld (m g)

P redi ct ed

Nic otine inta k e pe r c iga re tte (m g)

P r edicted and actual nicotine intakes per cigar ette sm oked by nom inal nicotine yield of usual br and
1 .6 1 .4 1 .2 1 .0 0 .8 0 .6 0 .4 0 .2
0 - .1 . 1. 2. 4. 5. 6. 7. 8. 91. 0 +

He a lth Surv e y for Engla nd 1 9 9 8

Ciga re tte nic otine y ie ld (m g)

A ct ual P redi ct ed

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%

Scenarios for future deaths from tobacco

Cumulative deaths from tobacco (millions)
520
500

Trend

400

300

220
200

100

70

0 1950 1975 2000 2025 2050

Year

Source: Peto et al

Scenarios for future deaths from tobacco

Cumulative deaths from tobacco (millions)
520
500

Trend

400

500 If smoking uptake halves by 2020

300

220
200

100

70

0 1950 1975 2000 2025 2050

Year

Source: Peto et al

Scenarios for future deaths from tobacco

Cumulative deaths from tobacco (millions)
520
500

Trend

400

500 If smoking uptake halves by 2020 340

300

220
200

If adult smoking halves by 2020

190
100

70

0 1950 1975 2000 2025 2050

Year

Source: Peto et al

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