Chronic Obstructive Pulmonary Disease hospitalization rates in Massachusetts: a trend analysis.

BACKGROUND: Chronic Obstructive Pulmonary Disease (COPD) causes a huge economic burden and >80% of COPD cases are attributable to smoking. Massachusetts introduced a comprehensive Tobacco Control Program (MTCP) in January 1993. A trend analysis of COPD hospitalization rates might indirectly reflect the potential impact of such comprehensive tobacco control programs. METHODS: Age-adjusted COPD hospitalization rates/100,000 was abstracted from the Massachusetts Community Health Information Profile Database between 1989 and 2005. Joinpoint Regression Analyses program was employed to estimate annual percent changes (APC) in COPD rates by age, sex and race. RESULTS: In 1989, 265/100,000 age-adjusted COPD hospitalization rates were reported that increased to 423/100,000 in 1993, and then declined to 329/100,000 in 2005. A significant annual decline of 5.6 percentage points was observed in overall COPD rates from 1993 onwards. A similar temporal pattern, with an age-gradient and a slower annual decline in female COPD rates relative to male COPD rates, was observed. COPD rates in both Blacks and Whites were similar to the general overall pattern. Such consistent annual declines in COPD hospitalization rates from 1993 onwards in Massachusetts also closely correspond to the introduction of the MTCP in January 1993. CONCLUSION: The findings indirectly suggest that smoking cessation should remain the cornerstone strategy for the prevention and control of COPD burden. However, additional studies across different population settings are essential for a definitive conclusion with regard to the immediate impact of a comprehensive tobacco control program on COPD hospitalization rates showing possible gender susceptibility.

Regulatory assessment of brand changes in the commercial tobacco product market.

BACKGROUND: Regulatory oversight of tobacco product design has gained momentum in the US and internationally. Appropriate standards for assessing commercial brands and characterising product features must be considered a priority. An area of potential concern is in-market design changes adopted within a single commercial brand over time. METHODS: Internal tobacco industry documents were identified and used to assess internal discussion of product guidelines and practices regarding in-market brand changes. RESULTS: Commercial tobacco products undergo a constant process of revision in-market, beginning at the most basic level of physical product characteristics and components, and including every aspect of design. These revisions commonly exceed guidelines for acceptable product variance adopted within the industry. While consumer and market testing is conducted to ensure that products remain acceptable to users, explicit marketing often may not accompany brand changes. In the absence of such marketing, it should not be assumed that a brand remains unchanged. CONCLUSIONS: For manufacturers, assessment of competitor brands includes identification and analysis of non-routine changes; that is, those changes likely to significantly alter the character of a given brand. Regulators must adopt a similar practice in determining standards for product evaluation in the face of ongoing commercial product revision.

Geographical information systems as a tool for monitoring tobacco industry advertising.

BACKGROUND: Although the use of a geographical information systems (GIS) approach is usually applied to epidemiological disease outbreaks and environmental exposure mapping, it has significant potential as a tobacco control research tool in monitoring point-of-purchase (POP) tobacco advertising. DESIGN: An ecological study design approach was applied so as to primarily evaluate and interpret the spatial density and intensity of POP and tobacco industry advertisements within <300 m to high schools in Greece with the application of GIS methodology combining mapping, photographing and global positioning data. RESULTS: The GIS approach identified 133 POP and 44 billboards within 300 m of the school gates of Heraklion schools. On average 13 POP (range 4-21) and 4.4 billboards (range 1-9) were located per school, and all had at least 1 POP within 20 m of the school gate. On average (SD) 9 (6) tobacco advertisements per POP (range 0-25) were noted, and 80% of them were below child height. The GIS protocol identified that kiosks, that were excepted from the Greek ban on tobacco advertising, in comparison to other POP, were found not only to be closer and visible from the school gates (44.1% vs 10.8%, p<0.001) but were also found to have more external advertisements (8 (5) vs 5 (3), p<0.001). CONCLUSIONS: This study demonstrates the effectiveness of a GIS system in monitoring tobacco industry advertising on a large population-based scale and implies its use as a standardised method for monitoring tobacco industry strategies and tobacco control efforts.

Developing smokeless tobacco products for smokers: an examination of tobacco industry documents.

OBJECTIVE: To investigate whether development of smokeless tobacco products (SLT) is intended to target current smokers. METHODS: This study analysed internal tobacco industry documents to describe research related to the smokeless tobacco market. Relevant documents included those detailing the development and targeting of SLT products with a particular emphasis on moist snuff. RESULTS: Cigarette and SLT manufacturers recognised that shifting demographics of SLT users, as well as indoor smoking restrictions, health concerns and reduced social acceptability of smoking could impact the growth of the SLT market. Manufacturers developed new SLT products to target cigarette smokers promoting dual cigarette and SLT use. CONCLUSIONS: Heavy marketing of new SLT products may encourage dual use and result in unknown public health effects. SLT products have been designed to augment cigarette use and offset regulatory strategies such as clean indoor air laws. In the United States, the SLT strategy may provide cigarette companies with a diversified range of products under the prospect of federal regulation. These products may pose significant challenges to efforts by federal agencies to reduce harm caused by tobacco use.

Free nicotine content and strategic marketing of moist snuff tobacco products in the United States: 2000-2006.

BACKGROUND: From 2000 to 2006, moist snuff sales have increased and now account for 71% of the smokeless tobacco market. Previous research has shown that major manufacturers of smokeless tobacco products manipulated free nicotine, the form most readily absorbed, to promote tolerance and addiction. AIM: This study examines the possibility that company-specific and brand-specific strategies of the major moist snuff manufacturers involve controlling free nicotine content and ease of dosing with products that are designed and targeted to specific groups. This study looks at the current total US moist snuff market with product design data from the Massachusetts Department of Public Health; moist snuff use from the National Survey on Drug Use and Health; market data from ACNielsen; and magazine advertising expenditures from TNS Media Intelligence. RESULTS: (1) The levels of free nicotine of moist snuff products have increased over time for several major manufacturers; (2) the number and variety of sub-brands have increased over time; (3) changes in design, as reflected by variation in free nicotine associated with pH or tobacco leaf, or both, have enhanced the ease and uniformity of dosing; (4) marketing through price and advertising has increased; and (5) youth use has increased. CONCLUSION: A combination of factors including brand proliferation, control of free nicotine and product design has most likely resulted in the expanded consumption of moist snuff, particularly among young people.

Temporal patterns in lung cancer death rates in Ireland.

BACKGROUND: Distinct temporal patterns can be identified through estimating annual-percent-changes (APC) in age-specific disease rates, but APCs in lung cancer rates among the youngest adults can also reflect the recent changing smoking habits of a population. METHOD: Lung cancer mortality rates from 1970 to 1999 were investigated in Ireland, using the Joinpoint regression modelling technique. RESULTS: In the most recent decade (1989-1999) male lung cancer death rates showed a significant annual decline (-2.4%), but female annual rates have scarcely decelerated (0.1%). The combined gender youngest adults (30-39 year-olds) showed decreasing rates, but the annual decline in the youngest female rates were significant only from 1970 to 1990 and thereafter increased non-significantly. CONCLUSION: Unlike male lung cancer death rates, the overall female rates are increasing significantly. While the combined gender youngest adult rates are decreasing, the apparent reversal in trends among the youngest female rates from 1990 onwards is worrying.

Brand differences of free-base nicotine delivery in cigarette smoke: the view of the tobacco industry documents.

The recent availability of internal tobacco industry documents provides significant insight into industry knowledge and manipulation of tobacco smoke delivery. One critical area of research is the role of smoke chemistry in determining the absorption and effects of smoke constituents, especially harm producing or pharmacologically active compounds. Independent scientific research has suggested that the nicotine dosing characteristics, hence the addiction potential of cigarettes, may be determined in part by the amount of free-base nicotine in cigarette smoke and its effects on the location, route, and speed of absorption in the body and on the sensory perception effects of the inhaled smoke. Tobacco industry documents describe the use of a number of methods internally for measuring free-base nicotine delivery. These include the common use of cigarette "smoke pH" as a means to estimate the fraction of free-base nicotine in the particulate matter (PM) in cigarette smoke, as well as efforts to measure free-base nicotine directly. Although these methods do not provide accurate absolute measures of free-base nicotine in smoke, consistencies observed in the findings across the various manufacturers indicate: (1) real relative differences in the acid/base chemistry of the smoke from different brands of cigarettes; (2) a connection between differences in free-base levels and brand-dependent differences in sensory perception and smoke "impact"; and (3) levels of free-base nicotine that are greater than have typically been publicly discussed by the industry. Furthermore, the results of these methods are generally consistent with those of a recent study from the Centers for Disease Control and Prevention which directly measured the free-base fraction of nicotine across a range of cigarette types. Consideration of the likely fundamental importance of free-base nicotine levels in cigarette smoke, together with the efforts discussed in the tobacco industry documents to measure such levels, indicates that the public health community would benefit from additional research to assess directly the delivery of free-base nicotine in cigarette smoke across brands. This may be especially useful for those products ("light", "ultralight", "reduced carcinogen", etc) that have been promoted, either explicitly or implicitly, as "harm reducing".

Effect of the New York State cigarette fire safety standard on ignition propensity, smoke constituents, and the consumer market.

OBJECTIVES: This study examines empirical evidence from the New York experience testing tobacco industry arguments made in opposition to fire safety standards for cigarettes. DESIGN: Percentages of cigarettes exhibiting full length burns (FLBs), cigarette sales before and following the implementation of the New York standards, a sample of retail cigarette prices, brand availability, and selected smoke constituent yields were compared between cigarettes sold in New York and two other states. Cigarette paper analysis was conducted on cigarettes sold in New York. RESULTS: New York cigarette brands averaged 10.0% FLBs as compared to 99.8% for California and Massachusetts brands. Reduced ignition propensity (RIP) appears to have been achieved by cigarette paper banding. Cigarette sales, prices, and brand availability do not appear to have been affected by the New York standards. Yields of the majority of smoke constituents tested did not differ substantially between RIP cigarettes sold in New York as compared to the same brands sold in Massachusetts. Average yields of tar, carbon monoxide, and two compounds were slightly higher, the yields of seven compounds were higher for one brand only, and nicotine was lower, among New York brands tested. CONCLUSIONS: RIP cigarette brands have been designed to meet the New York fire safety standards. Their introduction has not affected cigarette sales or prices in New York. There is no evidence that the small increases in smoke constituent yields affect the already highly toxic nature of cigarette smoke. Data on smoking caused fires, deaths, and injuries dating from after the change in law are not yet available. Such data will be able to address the question of whether the demonstrated reduced ignition standards are associated with reduced fires and injuries. Based on the New York experience, prior industry objections to producing RIP cigarettes are unfounded. Other states and nations should adopt similar standards.

Toward a comprehensive long term nicotine policy.

Global tobacco deaths are high and rising. Tobacco use is primarily driven by nicotine addiction. Overall tobacco control policy is relatively well agreed upon but a long term nicotine policy has been less well considered and requires further debate. Reaching consensus is important because a nicotine policy is integral to the target of reducing tobacco caused disease, and the contentious issues need to be resolved before the necessary political changes can be sought. A long term and comprehensive nicotine policy is proposed here. It envisages both reducing the attractiveness and addictiveness of existing tobacco based nicotine delivery systems as well as providing alternative sources of acceptable clean nicotine as competition for tobacco. Clean nicotine is defined as nicotine free enough of tobacco toxicants to pass regulatory approval. A three phase policy is proposed. The initial phase requires regulatory capture of cigarette and smoke constituents liberalising the market for clean nicotine; regulating all nicotine sources from the same agency; and research into nicotine absorption and the role of tobacco additives in this process. The second phase anticipates clean nicotine overtaking tobacco as the primary source of the drug (facilitated by use of regulatory and taxation measures); simplification of tobacco products by limitation of additives which make tobacco attractive and easier to smoke (but tobacco would still be able to provide a satisfying dose of nicotine). The third phase includes a progressive reduction in the nicotine content of cigarettes, with clean nicotine freely available to take the place of tobacco as society's main nicotine source.

Sweet and spicy flavours: new brands for minorities and youth.

The tobacco industry is now adding sweet and spicy flavours to its products in order to increase sales to youth and minorities

Reducing tobacco addiction through tobacco product regulation.

Tobacco product regulation has the potential to help reduce tobacco attributable disease by reducing the toxicity of these products and by reducing the prevalence of tobacco use and addiction.

Cigarette advertising in magazines: the tobacco industry response to the Master Settlement Agreement and to public pressure.

OBJECTIVE: The Master Settlement Agreement (MSA) of November 1998 prohibited participating tobacco companies from directly or indirectly targeting youth in marketing. Widely publicised information in May 2000 showed increased cigarette advertising in magazines with substantial youth readership and companies were pressed to change their practices. The responses of the tobacco industry to the MSA and to the public pressure are examined. DESIGN: Expenditures on cigarette advertisements in national magazines in the USA are compared for three periods: January to November 1998, December 1998 to June 2000, and July 2000 to November 2001. Magazines in which at least 15% of readers are youth under age 18 are focused upon. Regression models test for the significance of period differences after controlling for seasonal and long term patterns. DATA SOURCES: Commercially maintained data on advertising in US magazines and on magazine readership by age. KEY MEASURES: Monthly cigarette ad expenditures in magazines with 15%+ youth readership, and monthly proportion of ad expenditures in 15%+ youth magazines. RESULTS: Cigarette advertising expenditures in magazines with 15%+ youth readership increased dramatically after MSA implementation and fell dramatically after public pressure. The percentage allocation of expenditures to 15%+ magazines fell significantly in both periods. Results differ somewhat by company. CONCLUSIONS: The tobacco industry response to the MSA was at best modest, reducing proportional allocations of advertising to youth magazines but increasing the absolute amount of such advertising. The value of public pressure was seen in substantial reductions in both absolute and proportional spending on youth magazines, although not by all companies.

How cigarette design can affect youth initiation into smoking: Camel cigarettes 1983-93.

CONTEXT: Internal industry documents may shed light on how cigarettes are designed to promote youth smoking. OBJECTIVE: To determine changes in the design of Camel cigarettes in the period surrounding the "Smooth Character" advertising campaign and to assess the impact of these changes on youth smoking. DATA SOURCES: Internal documents made available through the document website maintained by RJ Reynolds, manufacturer of Camel cigarettes. STUDY SELECTION: Electronic searches using keywords to identify relevant data. DATA EXTRACTION: A web based index search of documents targeting "smoothness" or "harshness" and "younger adult smokers" ("YAS") or "first usual brand younger adult smokers" ("FUBYAS") in the 10 year period surrounding the introduction of the "Smooth Character" campaign was used to identify Camel related product design research projects. A snowball methodology was used: initial documents were identified by focusing on key words, codes, researchers, committees, meetings, and gaps in overall chronology; a second set of documents was culled from these initial documents, and so on. DATA SYNTHESIS: Product design research led to the introduction of redesigned Camel cigarettes targeted to younger adult males coinciding with the "Smooth Character" campaign. Further refinements in Camel cigarettes during the following five year period continued to emphasise the smoothness of the cigarette, utilising additives and blends which reduced throat irritation but increased or retained nicotine impact. CONCLUSIONS: Industry competition for market share among younger adult smokers may have contributed to the reversal of a decline in youth smoking rates during the late 1980s through development of products which were more appealing to youth smokers and which aided in initiation by reducing harshness and irritation.

How cigarette additives are used to mask environmental tobacco smoke.

OBJECTIVE: To understand the tobacco industry's research on and use of cigarette additives that alter the perception of exposure to environmental tobacco smoke (ETS). DATA SOURCES: Internal documents from four websites maintained by the major US tobacco manufacturers and company patents pertaining to the use of ETS altering additives obtained from the US Patent and Trademark Office online database. STUDY SELECTION: Electronic searches of the four industry websites and the US patent database were conducted using keywords to identify relevant data. DATA EXTRACTION: Industry documents and patents obtained using an exploratory snowball sampling method were reviewed and grouped into four general categories according to whether the additive(s) described affected ETS visibility, odour, irritation, or emissions. Accuracy of isolated findings was validated through cross comparison of the data sources. DATA SYNTHESIS: Results of this preliminary study provide evidence that tobacco manufacturers have conducted extensive research on the use of chemical additives to reduce, mask, or otherwise alter the visibility, odour, irritation, or emission of ETS. CONCLUSIONS: Findings suggest that the tobacco industry uses additives to reduce the perception of ETS. To protect the public, appropriate regulation of tobacco additives should be mandated.

Health risks associated with cigar smoking.

This article summarizes principal findings from a conference convened by the American Cancer Society in June 1998 to examine the health risks of cigar smoking. State-of-the-science reports were presented and 120 attendees (representing government and private agencies, academia, health educators, and tobacco control experts) participated in panels and summary development discussions. The following conclusions were reached by consensus: (1) rates of cigar smoking are rising among both adults and adolescents; (2) smoking cigars instead of cigarettes does not reduce the risk of nicotine addiction; (3) as the number of cigars smoked and the amount of smoke inhaled increases, the risk of death related to cigar smoking approaches that of cigarette smoking; (4) cigar smoke contains higher concentrations of toxic and carcinogenic compounds than cigarettes and is a major source of fine-particle and carbon monoxide indoor air pollution; and (5) cigar smoking is known to cause cancers of the lung and upper aerodigestive tract. JAMA. 2000;284:735-740