Mortality among male cigar and cigarette smokers in the USA.

BACKGROUND: Cigars and cigarettes are both smoked, but much less is known about the former's long-term health effects, due to its low prevalence and infrequent collection of cigar information in national surveys. PURPOSE: We conducted a follow-up mortality study of cigar-smoking men age 40-79 years in National Health Interview Surveys (NHIS). METHODS: We used pooled NHIS files linked to the National Death Index to obtain follow-up from year of interview to year of death or December 31, 2015. We developed categories of cigarette and cigar smoking that accommodate dual and former use of both products. We used Cox proportional hazards models, adjusted for age, race/ethnicity, marital status, education, income and region to estimate hazard ratios (HRs, 95% confidence intervals, CI) for mortality from all causes, heart diseases, malignant neoplasms, cerebrovascular disease, chronic lower respiratory diseases and two mutually exclusive categories: smoking-related and other diseases. RESULTS: There were 14,657 deaths from all causes, including 3426 never tobacco users, 3276 exclusive cigarette smokers and 176 exclusive cigar users. The latter had no statistically significant evidence of increased mortality from all causes, heart diseases, malignant neoplasms, cerebrovascular disease, smoking-related diseases or other causes. In contrast, the mortality experience of dual users of cigars and cigarettes and cigar smokers who formerly used cigarettes is similar to exclusive cigarette smokers. CONCLUSIONS: This study provides evidence that male cigar smokers age 40 + years had elevated mortality risks. However, after accounting for cigarette smoking and other confounding variables, we found significantly increased mortality only among dual and former users of cigarettes.

Initial Information on a Novel Nicotine Product.

BACKGROUND AND OBJECTIVES: This is the first study to assess the appeal and interest among adults in a new consumer tobacco product, ZYN. We also describe ZYN users, patterns of use, and reasons for use. METHODS: Two data sets, consisting of a ZYN-naive consumer panel (n = 5179) and ZYN users (n = 1266), were provided by Swedish Match North America. Descriptive, cross-sectional analyses and logistic regression assessed the perceptions of and likelihood of buying ZYN in the consumer panel and the characteristics of ZYN users. RESULTS: The majority of current smokeless tobacco (ST) users in the consumer panel found that ZYN was moderately-extremely appealing, while never and former tobacco users indicated much less interest; the former were more likely to buy ZYN than other groups. The highest percentage of ZYN users were former tobacco users (43%); very few were never users (4%). The most popular reason for using ZYN was "Less harmful to my health than other tobacco products," followed by "ease of use." DISCUSSION AND CONCLUSIONS: Nonusers of tobacco had very little interest in ZYN. ST users are not only more interested and likely to buy ZYN than other tobacco users, they were the largest group of regular users. SCIENTIFIC SIGNIFICANCE: The first assessment of a new nicotine product, ZYN, suggests that current and former tobacco users may perceive ZYN as a reduced-risk product. ZYN potentially could be used as a smoking/tobacco-cessation aid based on reasons of current users. (Am J Addict 2020;00:00-00).

Mortality among male smokers and smokeless tobacco users in the USA.

BACKGROUND: One published study simultaneously reported the mortality associated with cigarette smoking and smokeless tobacco (ST) use in the USA. In this study, we focus only on men ages 40-79 years old and extend the follow-up by 4 years. METHODS: We used selected years (1987-2010) of National Health Interview Survey (NHIS) Linked Mortality Files to classify 46,104 men age 40-79 years with respect to 7 categories of smoking and/or ST use. We used Cox proportional hazards models adjusted for age, race/ethnicity, marital status, education, income, health status, body mass index, and region to estimate hazard ratios (HRs; 95% confidence intervals, CI) for mortality from all causes, heart diseases, malignant neoplasms, and two mutually exclusive categories: smoking-related and other diseases. RESULTS: There were 15,540 deaths from all causes, including 3476 never tobacco users, 4782 exclusive smokers, and 210 exclusive ST users. The latter had significant excess mortality from all causes (HR = 1.25, CI = 1.08-1.46), but not from heart diseases (HR = 1.16, CI = 0.85-1.59), malignant neoplasms (HR = 1.17, CI = 0.83-1.67), and all smoking-related diseases (HR = 1.19, CI = 0.97-1.46). However, they had higher mortality for all other causes (1.39, CI = 1.10-1.74), which was largely seen in age 40-59 years (HR = 1.68, CI = 1.11-2.54). Current smokers, with or without ST use, also had significantly elevated HRs for other causes (1.70 and 1.57, respectively), in addition to significant increases in mortality from heart diseases (1.98 and 2.00), malignant neoplasms (2.60 and 2.84), and all smoking-related diseases (2.32 and 2.47). CONCLUSIONS: This is the first simultaneous mortality follow-up study of older American male smokers and ST users. ST users did not have excess mortality from any smoking-related diseases, but younger users had an elevation in deaths from other causes.

E-cigarette Use Among US Adults: Population Assessment of Tobacco and Health (PATH) Study.

Introduction: In 2011 the US Food and Drug Administration launched the Population Assessment of Tobacco and Health (PATH) Study to gather information for regulatory activities authorized by the Family Smoking Prevention and Tobacco Control Act (TCA). Methods: Data were drawn from the first wave of the PATH survey, involving interviews of 32 320 civilian and non-institutionalized adults. In addition to conventional classifications for current, former and never smoking and e-cigarette use, we used PATH questions to classify former and current triers of these products. Descriptive statistics were used to describe the prevalence, patterns of, and reasons for e-cigarette use, and the perceptions of nicotine and e-cigarettes among user groups, according to smoking status. Results: The prevalence of current smoking was 18%; an additional 3.1% of participants were current triers. The prevalence of current e-cigarette use was 2.4% (1.0% every day, 1.4% some days), with another 3.2% as current triers. The majority of nonsmokers who were current e-cigarette users were already current (56%) or former (34%) cigarette triers. Reasons for e-cigarette use were similar across subgroups, but patterns of use were different. Majorities of participants believed that nicotine is the main substance driving tobacco use, that nicotine causes most cancers, and that e-cigarettes were less harmful than cigarettes. Conclusions: E-cigarettes were used primarily by current smokers and recent former smokers. The main reasons for use center around perceptions that e-cigarettes are less harmful than cigarettes to users and others. Implications: This study reports detailed information about the prevalence, patterns of, and reasons for e-cigarette use in the first (baseline) wave of the PATH Study in 2014. In addition to conventional categories for current, former and never smoking and e-cigarette use, the PATH questionnaire facilitated classification of new usage groups consisting of current and former triers of these products, which may impact prevalence estimates.

Metal emissions from e-cigarettes: a risk assessment analysis of a recently-published study.

Introduction: A recent study reported levels of metal emissions in e-cigarette (EC) aerosol. Herein we present a risk assessment analysis of the published findings using total daily exposure limits. Methods: Median and 75th percentile metal concentrations in EC aerosols were used to determine the level of daily liquid consumption (g/d) that would exceed the permissible daily exposures (PDEs) defined for inhalation medications (cadmium, chromium, copper, nickel, lead, antimony and tin). For metals not having PDEs, minimal risk levels (manganese) or risk exposure levels (aluminum, iron and zinc) were converted into total daily exposure using an inhalation volume of 20 m3 (for 24 h) and 6.7 m3 (for 8 h) respectively. Results: The lowest amount of liquid consumption exceeding safety limits was found for nickel (73 g/day for median and 17 g/day for 75th percentile levels). The consumption corresponding to the 75th percentile could be associated with realistic use, although this would represent an extreme rather than average consumption. For chromium, the respective levels were 358 and 68 g/day and for lead 338 and 135 g/day. For all other metals, liquid consumption would need to be orders of magnitude higher, reaching to 1.5 million grams for aluminum. Conclusion: EC emissions contain trace levels of metals. For almost all metals, unrealistically high levels of liquid need to be consumed in order for total daily exposure to exceed established limits.

Associations of Proposed Relative-Risk Warning Labels for Snus With Perceptions and Behavioral Intentions Among Tobacco Users and Nonusers.

INTRODUCTION: The US Food and Drug Administration can require changes in warning statements for modified risk tobacco products. We report an independent analysis of a consumer perception survey sponsored by Swedish Match as part of a Modified Risk Tobacco Product application to change warning labels for Swedish snus products. METHODS: The survey exposed each of 4324 daily exclusive cigarette smokers, 1033 daily smokeless tobacco users, 1205 daily other tobacco users, 726 former users, and 5915 triers/never users to one of four current warnings and two proposed relative-risk labels (No tobacco product is safe, but this product presents lower risks to health than cigarettes, or No tobacco product is safe, but this product presents substantially lower risks to health than cigarettes) for snus. Descriptive and logistic regression analyses examined four outcomes: believability, harmfulness, motivation to use, and intention to buy snus. RESULTS: Compared with the current not-safe-alternative warning, adult tobacco users who viewed the proposed labels perceived them as less believable, perceived snus as less harmful and were more likely to use and buy snus. The proposed labels had no impact on former smokers' likelihood to use and buy snus; triers/never users viewing the substantially lower risk label were more likely to buy snus. CONCLUSIONS: Tobacco users viewing the proposed labels perceived snus as less harmful than cigarettes and may be more likely to use and buy snus. If labeling changes lead to increased snus use and cigarette reduction or abstinence, public health may benefit. If the opposite occurs, public health could suffer.

Time to First Use Among Daily Smokers and Smokeless Tobacco Users.

INTRODUCTION: Time to the first cigarette after waking up in the morning is the most validated measure of dependence among smokers, and its complement is also a good indicator of dependence for smokeless tobacco (ST) users. However, no studies have directly compared these measures. METHODS: We used a multivariate logistic regression model to compare the time to first use (TTFU) of cigarettes and ST among white men 18+ years of age who were daily users in the 2003 Tobacco Use Supplement of the Current Population Survey. Smokers were classified as light (1-14 cigarettes per day [cpd]), moderate (15-24 cpd), and heavy (25+ cpd) and ST users were classified as former smokers or exclusive users. RESULTS: There was no difference in TTFU within 5min between light smokers and exclusive ST users (Odds ratio [OR] = 1.3, CI = 0.95-1.7), but the latter were less likely to use tobacco within 30min (OR = 0.75, CI = 0.62-0.89). ST former smokers were more likely than light smokers to have a TTFU within 5min (OR = 1.5, CI = 1.1-2.0) but not within 30min. Moderate and heavy smokers had significantly higher odds of TTFU within both time points than light smokers. CONCLUSION: Compared to light smokers, the likelihood of TTFU within 5min was similar among exclusive ST users and was slightly higher among ST former smokers, offering some support for the Fagerström-Eissenberg hypothesis that the dependence level of cigarettes is higher than that of ST.

Questionable Effects of Electronic Cigarette Use on Cardiovascular Diseases From the National Health Interview Survey (NHIS, 2014-2021).

BACKGROUND: Electronic cigarettes (e-cigarettes) and cardiovascular health risks have gained attention among tobacco researchers. While the cardiovascular risks from e-cigarettes are still unclear, a recent paper by Alzahrani in Cureus claimed that current usage of e-cigarettes increases the risks of cardiovascular diseases, such as myocardial infarction and stroke, in subjects who were never cigarette smokers. METHODS: The National Health Interview Survey (NHIS) data from 2014 to 2021 and logistic regression models were used to replicate and extend Alzahrani's analysis. RESULTS: Only 12 never smokers who were current e-cigarette users had a myocardial infarction in all eight years. The crude odds ratio (OR) for e-cigarette use was 0.42 (95%CI: 0.24, 0.75). After adjusting for age and other confounding factors and health conditions, the OR of e-cigarette use increased to 2.48 (95%CI: 1.35, 4.55). The omission of age while adjusting for all other risk factors resulted in an OR of 0.80 (95%CI: 0.45, 1.43). In addition, the adjusted ORs for coronary heart disease and stroke were 1.12 (95%CI: 0.58, 2.17) and 1.13 (95%CI: 0.55, 2.29), respectively. CONCLUSIONS: The findings indicate that Alzahrani's study is scientifically unreliable. The association between e-cigarette use and heart attack reported by Alzahrani was substantially driven by age, and the very small number of exposed cases makes the association very unstable. Given the nature of cross-sectional NHIS data, it is impossible to establish a robust association or causal claim that e-cigarette use "increases" the risks of any disease.

The low prevalence of smoking in the Northern Sweden MONICA study, 2009.

AIMS: The purpose of this study was to describe tobacco use in the 2009 Northern Sweden cohort of the World Health Organization Multinational Monitoring of Trends and Determinants in Cardiovascular Diseases (MONICA) study. METHODS: Subjects (N = 1698) were randomly selected from population registers, stratified for age (25-74 years old) and gender, in the two northernmost Swedish counties of Norrbotten and Västerbotten. Responses from tobacco-related questions were used to develop three mutually exclusive categories of snus use: past, current, or never use; and three comparable categories of smoking that were consistent with previous studies. RESULTS: Among men, the prevalence of smoking (9%) and dual use (2%) remain unchanged from 2004, although the prevalence of snus use declined from 27% in 2004 to 24% in 2009. Among women, the prevalence of all forms of tobacco use declined between 2004 and 2009; smoking dropped from 16% to 11%, dual use from 2% to less than 1%, and snus use from 9% to 8%. Although overall prevalence of tobacco use was similar for younger versus older men and younger versus older women, there were notable differences in specific snus and smoking rates. CONCLUSIONS: This study confirms that use of snus was a significant factor in the low prevalence of smoking, especially among younger men and women in Northern Sweden. Furthermore, it documents that tobacco harm reduction is entirely compatible with a population-level decline in overall tobacco use.

Evidence of sex differences in the relationship between current tobacco use and past-year serious psychological distress: 2005-2008 National Survey on Drug Use and Health.

PURPOSE: Cigarette use is highly prevalent in psychiatric populations. Studies suggest that smokeless tobacco use is not significantly associated with past-year psychiatric morbidity, with evidence that tobacco use differ among sexes. The relationships between current tobacco use and past-year serious psychological distress, major depressive episode and anxiety disorder were therefore examined. Sex differences in the aforementioned relationship were also examined. METHODS: A total of 133,221 adults from four successive independent samples of the 2005-2008 National Survey on Drug Use and Health were included. Prevalence odds ratios and 95 % confidence intervals were calculated using multivariable logistic regression adjusting for demographic factors, survey year, pregnancy (women only), past-year medical morbidity, past-year psychiatric comorbidity, and past-year substance use disorders. RESULTS: No associations were demonstrated among smokeless tobacco users. Statistically significant sex differences were found for current tobacco use and serious psychological distress (p < 0.001). Both male and female smokers were significantly more likely to have serious psychological distress and anxiety disorder compared to never users, while only female smokers were more likely to have major depressive episode. The strongest associations were found for anxiety disorder among all adults as well as both sexes. CONCLUSIONS: The null associations for both sexes for smokeless tobacco may support a reduced risk profile. Female cigarette smokers may be more vulnerable to subclinical distress and depression than males. Studies using other nationally representative samples are needed to confirm these data.

A fresh look at tobacco harm reduction: the case for the electronic cigarette.

Smokers of any age can reap substantial health benefits by quitting. In fact, no other single public health effort is likely to achieve a benefit comparable to large-scale smoking cessation. Surveys document that most smokers would like to quit, and many have made repeated efforts to do so. However, conventional smoking cessation approaches require nicotine addicted smokers to abstain from tobacco and nicotine entirely. Many smokers are unable--or at least unwilling--to achieve this goal, and so they continue smoking in the face of impending adverse health consequences. In effect, the status quo in smoking cessation presents smokers with just two unpleasant alternatives: quit or suffer the harmful effects of continuing smoking. But, there is a third choice for smokers: tobacco harm reduction. It involves the use of alternative sources of nicotine, including modern smokeless tobacco products like snus and the electronic cigarette (E-cig), or even pharmaceutical nicotine products, as a replacement for smoking. E-cigs might be the most promising product for tobacco harm reduction to date, because, besides delivering nicotine vapour without the combustion products that are responsible for nearly all of smoking's damaging effect, they also replace some of the rituals associated with smoking behaviour. Thus it is likely that smokers who switch to E-cigs will achieve large health gains. The focus of this article is on the health effects of using an E-cig, with consideration given to the acceptability, safety and effectiveness of this product as a long-term substitute for smoking.

Why can't smokers quit? Longitudinal study of smokers in the US using the Population Assessment of Tobacco and Health (PATH) waves 1 to 5.

Introduction: Most adult cigarette smokers have tried unsuccessfully to quit. We followed participants in the Population Assessment of Tobacco and Health (PATH) study through five waves (2013-2019), comparing smoking, quit behaviors and other characteristics between persistent smokers and those who became and stayed former smokers. Methods: The main analysis employed treatment effects to estimate mean differences in smoking and quitting behaviors among smoker groups. Logistic models were used to estimate predicted means based on continuing smokers' demographic characteristics to ensure that any differences in outcomes did not come from differences in demographic characteristics. Results: Among smokers enrolled in PATH Wave 1, 68 % persisted in all subsequent waves. Compared with smokers who quit after Wave 1, persistent smokers had remarkably stable smoking behaviors, including significantly higher proportions of everyday smokers, consuming 10+ cigarettes per day, and smoking within 30 min of waking up. Persistent smokers were also less likely to try to quit completely, and experienced more negative symptoms from nicotine withdrawal. They also showed less interest in quitting and were less confident of being successful than smokers who quit by the next wave. Neither electronic nicotine delivery systems nor menthol played a role in continued smoking or quitting. Conclusions: The characteristics and behaviors of persistent smokers in this study were stable over five waves of data collection during a six-year period, suggesting that these smokers need new cessation options.

Evaluation of the national toxicology program report on carcinogens.

This study evaluates the National Toxicology Program's Report on Carcinogens program (RoCP) and compares it with the International Agency for Research on Cancer Monographs Program (IMP). We tracked agents classified in the RoCP since 1983 as known human carcinogens (A-List), or as reasonably anticipated to be human carcinogens (B-List). The first A-list included 24 agents, and twenty-four unique agents were added in the following 28years; twenty were listed by IMP as Group 1 (carcinogenic to humans) 7years before their A-list appearance. Group 1 also includes 30 or more agents eligible for, but not on, the A-list. The first B-list included 98 agents, and this increased to 185. Of these, 39 are in Group 2A (probably carcinogenic), and 122 are in Group 2B (possibly carcinogenic). Only 5% of the 204 agents ever on the B-list have been upgraded to the A-list. The RoCP is severely limited because it evaluates few agents and because its B-list does not distinguish between probable and possible human carcinogens. Further, it mislabels likely non-carcinogens as reasonably anticipated to be carcinogens. If the RoCP were terminated there would be no loss or delay of information available to scientific, public health and regulatory communities.

Acute myocardial infarction mortality before and after state-wide smoking bans.

Rapid declines in hospital admissions for acute myocardial infarction (AMI) following smoke-free ordinances have been reported in smaller communities. The AMI mortality rate among persons age 45 + years (deaths per 100,000 persons, age-standardized to the 2000 US population) in the 3 years before adoption of the smoke-free ordinance (the expected rate) was compared with the rate observed in the first full year after the ban (the target year) in six US states. Target-year declines were also compared to those in states without smoking bans. Target-year declines in AMI mortality in California (2.0%), Utah (7.7%) and Delaware (8.1%) were not significantly different from the expected declines (P = 0.16, 0.43 and 0.89, respectively). In South Dakota AMI mortality increased 8.9% in the target year (P = 0.007). Both a 9% decline in Florida and a 12% decline in New York in the 2004 target year exceeded the expected declines (P = 0.04 and P < 0.0002, respectively) but were not significantly different (P = 0.55 and 0.08, respectively) from the 9.8% decline that year in the 44 states without bans. Smoke-free ordinances provide a healthy indoor environment, but their implementation in six states had little or no immediate measurable effect on AMI mortality.

The scientific foundation for tobacco harm reduction, 2006-2011.

Over the past five years there has been exponential expansion of interest in tobacco harm reduction (THR), with a concomitant increase in the number of published studies. The purpose of this manuscript is to review and analyze influential contributions to the scientific and medical literature relating to THR, and to discuss issues that continue to stimulate debate. Numerous epidemiologic studies and subsequent meta-analyses confirm that smokeless tobacco (ST) use is associated with minimal risks for cancer and for myocardial infarction; a small increased risk for stroke cannot be excluded. Studies from Sweden document that ST use is not associated with benign gastrointestinal disorders and chronic inflammatory diseases. Although any form of nicotine should be avoided during pregnancy, the highest risks for the developing baby are associated with smoking. It is documented that ST use has been a key factor in the declining rates of smoking and of smoking-related diseases in Sweden and Norway. For other countries, the potential population health benefits of ST are far greater than the potential risks. In follow-up studies, dual users of cigarettes and ST are less likely than exclusive smokers to achieve complete tobacco abstinence, but they are also less likely to be smoking. The health risks from dual use are probably lower than those from exclusive smoking. E-cigarette users are not exposed to the many toxicants, carcinogens and abundant free radicals formed when tobacco is burned. Although laboratory studies have detected trace concentrations of some contaminants, it is a small problem amenable to improvements in quality control and manufacturing that are likely with FDA regulation as tobacco products. There is limited evidence from clinical trials that e-cigarettes deliver only small doses of nicotine compared with conventional cigarettes. However, e-cigarette use emulates successfully the cigarette handling rituals and cues of cigarette smoking, which produces suppression of craving and withdrawal that is not entirely attributable to nicotine delivery. THR has been described as having "the potential to lead to one of the greatest public health breakthroughs in human history by fundamentally changing the forecast of a billion cigarette-caused deaths this century."

Heterogeneity and other problems in a pooled analysis of snus use and mortality.

A recent analysis of Swedish snus use and mortality combined eight Swedish datasets and found that exclusive Swedish male snus users have statistically significant increased mortality from all causes, cardiovascular diseases and other causes. These findings, from the Swedish Collaboration on Health Effects of Snus Use, are in sharp contrast with previous pooled results from the same group. The discrepant results may be indicative of unresolved statistical problems that haven't been addressed by the collaboration authors in any of their studies. The most important problem is unresolved heterogeneity among the eight cohorts, which we describe in detail, and we show how the use of the random effects method by the authors was not sufficient. We explain why the tables in the article are uninformative, and we demonstrate why the exclusion of smokers in the analysis was not validated and eliminated important information. Finally, we strongly recommend some straightforward and easily implemented corrective measures.