Tribes of Trust or Distrust, "Attitude Roots" and Encouraging Scientific Participation in the Tobacco Harm-Reduction Debate.

Implications This commentary provides an analysis of non-scientific influences on the tobacco harm reduction debate. It makes use of the "attitude roots" model and the issue of misplace trust and distrust. Greater participation in the debate by experts is encouraged, along with efforts to minimize the effects of non-scientific, biasing effects on judgments.

Modes of delivery in concurrent nicotine and cannabis use ("co-use") among youth: Findings from the International Tobacco Control (ITC) Survey.

BACKGROUND: Cannabis use is more common among nicotine users than non-users. This study characterized concurrent use of nicotine and cannabis ("co-use") among 12,064 youth aged 16-19 years residing in Canada, the United States, and England in 2017. Methods: Data were from the ITC Youth Tobacco & Vaping Survey (Wave 1). Seven modes of cannabis delivery (MOD) were characterized by country of residence and past 30-day use of combusted tobacco and electronic cigarettes. Weighted multivariable regression models were fitted to assess the correlates of co-use and each cannabis MOD. Results: Seventy percent of cannabis users reported nicotine use. Co-users exhibited behavioral and demographic differences compared to exclusive users of either substance. "Smoking cannabis without tobacco" was the most popular form of use (78%). Use of nicotine-containing e-cigarettes was associated with "using an e-cigarette to vape cannabis oil/liquid" (aOR: 4.96, 95%CI: 2.23-11.06). Combustible tobacco use was associated with "smoking cannabis with tobacco in a joint/blunt" (aOR: 2.93, 95%CI: 1.89-4.56). Country-level differences were detected. Conclusions: Nicotine use is substantial among cannabis users, and associations exist between modes of delivery for both drugs. Results underscore the importance of studying cannabis and nicotine use concurrently, and the need to address the use of both substances in developing interventions for youth users.

Origins in the USA in the 1980s of the warning that smokeless tobacco is not a safe alternative to cigarettes: a historical, documents-based assessment with implications for comparative warnings on less harmful tobacco/nicotine products.

BACKGROUND: Before the 1980s in the USA, smokeless tobacco carried no health warnings, was not judged to cause disease, and was a declining practice. In 1986, the federal government passed legislation requiring rotating warnings on "mouth cancer," "gum disease and tooth loss," and "This product is not a safe alternative to cigarettes." This paper explores the history of the establishment of these warnings with emphasis on the 'not a safe alternative' warning and the bases for claiming that smokeless was 'not safe' (absolute harm) versus 'not safer than cigarettes' (relative harm). METHODS: Results of searches of Truth Tobacco Industry Document archives and transcripts of legislative hearings were analyzed. Critical assessments were made of the evidence-base. RESULTS: New evidence of oral cancer causation emerged along with a much-publicized case of a teenager dying of oral cancer. Public health concerns also arose over a widespread, successful marketing campaign implying smokeless was a safe alternative to cigarettes. Industry wanted pre-emptive federal warnings, to prevent a diversity of pending state warnings. To avoid an addiction warning, the industry accepted a compromise 'not a safe alternative' warning, which had not been initially proposed and which the cigarette industry may have sought in order to constrain the smokeless tobacco industry. The evidence presented supported smokeless only as 'not safe' and not 'as harmful as cigarette smoking.' CONCLUSIONS: The comparative warning was a compromise to prevent an addiction warning and consistent with the preferences of cigarette companies. Prior surveys indicated that the public generally did not view smokeless tobacco as harmless, but they did generally report smokeless as less harmful than cigarettes despite expert interpretations to the contrary. As would not have been appreciated by public health supporters at the outset, subsequent research has shown that the 'not a safe alternative' message is misinterpreted by consumers to indicate that smokeless is 'not safer' than cigarettes-which was not established and has been disconfirmed by subsequent assessments of that question. Though many countries have banned smokeless tobacco (but not cigarettes), where smokeless is legally available accurate information on the nature of harms and differential harms needs to be developed.

Minors, Moral Psychology, and the Harm Reduction Debate: The Case of Tobacco and Nicotine.

Harm reduction debates are important in health policy. Although it has been established that morality affects policy, this article proposes that perspectives from moral psychology help to explain the challenges of developing evidence-based policy on prohibition-only versus tobacco/nicotine harm reduction for minors. Protecting youth from tobacco is critical, especially since tobacco/nicotine products are legal for adults, who usually begin using when young. Although cigarettes and other combustibles are the deadliest tobacco products, other products such as smokeless tobacco and electronic cigarettes, though unsafe, are upward of 90 percent less harmful than cigarettes. Disgust at contaminating the "purity" of youth, especially "good," low-risk youth, with any tobacco/nicotine products opposes harm reduction, as does contempt for violating so-called community values and disrespecting authority. Support for harm reduction arises from anger at failing to provide reduced harm to "bad," high-risk individuals and denying them the "liberty" to decide. Fast-thinking, moral-emotional intuitions are supported by rationalizations arising from slow-thinking processes. The recognition of such moral psychological influences and the efforts to minimize their impact may help lead to amelioration and compromise. This example from tobacco control, with divided concerns for low-risk and high-risk youth, can be applied to other harm reduction versus prohibition-only policies directed at minors.

Obsolete tobacco control themes can be hazardous to public health: the need for updating views on absolute product risks and harm reduction.

BACKGROUND: Leading themes have guided tobacco control efforts, and these themes have changed over the decades. When questions arose about health risks of tobacco, they focused on two key themes: 1) how bad is the problem (i.e., absolute risk) and 2) what can be done to reduce the risk without cessation (i.e., prospects for harm reduction). Using the United States since 1964 as an example, we outline the leading themes that have arisen in response to these two questions. Initially, there was the recognition that "cigarettes are hazardous to health" and an acceptance of safer alternative tobacco products (cigars, pipes, light/lower-tar cigarettes). In the 1980s there was the creation of the seminal theme that "Cigarettes are lethal when used as intended and kill more people than heroin, cocaine, alcohol, AIDS, fires, homicide, suicide, and automobile crashes combined." By around 2000, support for a less-dangerous light/lower tar cigarette was gone, and harm reduction claims were avoided for products like cigars and even for smokeless tobacco which were summarized as "unsafe" or "not a safe alternative to cigarettes." DISCUSSION: The Surgeon General in 2014 concluded that by far the greatest danger to public health was from cigarettes and other combusted products. At the same time the evidence base for smokeless tobacco and alternative nicotine delivery systems (ANDS) had grown. Product innovation and tobacco/nicotine bio-behavioral, epidemiological and public health sciences demonstrate that low nitrosamine smokeless tobacco (e.g., Swedish snus), and ANDS have substantially lower harms than cigarettes. Going forward, it is important to sharpen themes and key messages of tobacco control, while continuing to emphasize the extreme lethality of the inhaled smoke from cigarettes or from use of any combusting tobacco product. Implications of updating the leading themes for regulation, policymaking and advocacy in tobacco control are proposed as an important next step. A new reframing can align action plans to more powerfully and rapidly achieve population-level benefit and minimize harm to eliminate in our lifetime the use of the most deadly combustible tobacco products and thus prevent the premature deaths of 1 billion people projected to occur worldwide by 2100.

Coping with the Conflict-of-Interest Pandemic by Listening to and Doubting Everyone, Including Yourself.

In light of the widespread existence of financial and non-financial issues that contribute to the appearance or fact of conflict of interest, it is proposed that conflict of interest should generally be assumed, no matter the source of financial support or the expressed declarations of conflicts and even with respect to one's own work. No new model is advanced for modification of peer-review processes or for elaboration of author declarations of interest. Researchers should be assessing the quality of published work as best they can and make their own decisions on the appropriate use of the work. While some apparent sources of conflict are likely more obvious and serious than others, even subtler biases can influence scientific reports. Ignoring peer-reviewed contributions because of conflict-of-interest concerns is discouraged. Listening skeptically to all sources, including yourself, is encouraged.

Deficiencies in public understanding about tobacco harm reduction: results from a United States national survey.

BACKGROUND: Tobacco products differ in their relative health harms. The need for educating consumers about such harms is growing as different tobacco products enter the marketplace and as the FDA moves to regulate and educate the public about different products. However, little is known about the patterns of the public's knowledge of relative harms. METHODS: Data were analyzed from the Health Information National Trends Survey (HINTS) 4 Cycle 2, a population-representative survey of US adults conducted between October 2012 and January 2013 (N = 3630). Participants reported their perceptions of the relative risks of e-cigarettes, smokeless tobacco, and different types of cigarettes compared to "traditional" cigarettes. Relative risk perceptions for each product type, as well as the consistency and accuracy of harm reduction beliefs, were analyzed. RESULTS: About 65% of the respondents accurately reported that no cigarettes were less harmful than any others. Slightly more than half of U.S. adults perceived e-cigarettes to be safer than regular cigarettes, a belief in line with current scientific evidence. By contrast, only 9% of respondents perceived some smokeless tobacco products to be safer, a belief strongly supported by the evidence. Only 3.5% of respondents had patterns of relative risk perceptions in line with current scientific evidence for all three modalities. CONCLUSIONS: The discrepancy between current evidence and public perceptions of relative risk of various tobacco/nicotine products was marked; for most tobacco types, a large proportion of the population held inaccurate harm reduction beliefs. Although there was substantial awareness that no cigarettes were safer than any other cigarettes, there could be benefits from increasing the percentage of the public that appreciates this fact, especially among current smokers. Given the potential benefits of tobacco risk reduction strategies, public health education efforts to increase understanding of basic harm reduction principles are needed to address these misperceptions.

Cigarette smoking and mental illness: a study of nicotine withdrawal.

OBJECTIVES: We compared prevalence, severity, and specific symptom profiles for nicotine withdrawal across categories of mental illness. We also examined the influence of nicotine withdrawal on efforts to quit smoking among those with mental illness. METHODS: We analyzed data from 2 sources: wave 1 of the National Epidemiologic Survey on Alcohol and Related Conditions, limiting the sample to current smokers (2001-2002; n = 9913); and a 2-wave cohort telephone survey of a national sample of adult smokers (2004-2006; n = 751). RESULTS: Mental illness was associated with a substantially greater likelihood of nicotine withdrawal syndrome; approximately 44% of nicotine withdrawal syndrome diagnoses were attributable to mental illness. Symptom profiles were highly comparable between mental illness categories, although anxiety-related symptoms were better markers of withdrawal for those with an internalizing disorder. Smokers with mental illness were motivated to quit but were less likely to be successful in their quit attempts, and both dependence and withdrawal independently accounted for this lower likelihood of success. CONCLUSIONS: Nicotine withdrawal may be a particularly important target for intervention among those with mental illness who smoke cigarettes.

Variation in nicotine intake among U.S. cigarette smokers during the past 25 years: evidence from NHANES surveys.

OBJECTIVE: To estimate changes in nicotine intakes among U.S. cigarette smokers from 1988 to 2012 with the National Health and Nutrition Examination Survey (NHANES). METHODS: NHANES provides data on nationally representative samples of cigarette smokers from the civilian noninstitutionalized U.S. population. A total of 4,304 smokers aged 20 years and older were studied in NHANES III 1988-1994 and 7,095 were studied in the continuous NHANES 1999-2012. We examined serum cotinine concentrations, daily cigarette consumption, and estimated nicotine intake per cigarette, with adjustment for sex, age, racial/ethnic background, level of education, and body mass index. RESULTS: There was little overall change in nicotine intake from smoking cigarettes either in the U.S. population as a whole or in major racial/ethnic subgroups during the 25-year period from 1988. Serum cotinine averaged 223.7ng/mL (95% confidence interval [CI] = 216.1-231.3) in 1988-1994, which was not significantly different from the adjusted mean of 219.2ng/mL (95% CI = 214.1-224.4) in 1999-2012. During the same period, average daily cigarette consumption declined substantially, from 17.3 (95% CI = 16.5-18.0) in 1988-1994 to 12.3 (95% CI = 11.0-13.6) by 2012. Cotinine per cigarette smoked increased by some 42% between 1988-1994 and 2011-2012, from a geometric mean of 12.4 (95% CI = 11.7-13.1) to 17.6 (95% CI = 16.1-19.2). CONCLUSIONS: Reductions in cigarette smoking prevalence since the late 1980s, changes in cigarette product design, and the widespread introduction of smoke-free policies have not had a significant impact on nicotine intakes among U.S. smokers. Reductions in cigarette consumption have been offset by increased nicotine intake per cigarette smoked.

Nicotine withdrawal and dependence among smokers with a history of childhood abuse.

INTRODUCTION: Previous studies have found that those with a history of childhood abuse are more likely to smoke cigarettes than those without a history of abuse. Mechanisms underlying this greater prevalence are unclear. We examined whether current smokers with a history of childhood abuse reported greater levels of nicotine dependence and more severe nicotine withdrawal symptoms. METHODS: We analyzed data from a 2-wave, national, random-digit-dial survey of adult cigarette smokers (n = 751). We examined whether childhood physical, emotional, and sexual abuse were associated with greater levels of nicotine dependence. Among those who made a quit attempt (n = 368), we examined whether abuse was associated with more severe withdrawal symptoms recalled during the 14 months between surveys. For both dependence and withdrawal, we tested a mediation pathway through current serious mental illness (SMI). RESULTS: All 3 types of childhood abuse were associated with more severe withdrawal symptoms. These associations were partially mediated by SMI. Sexual abuse and physical abuse were directly associated with dependence, whereas emotional abuse was indirectly associated with dependence through SMI. CONCLUSIONS: All 3 forms of childhood abuse were associated with both dependence and withdrawal. The greater prevalence of smoking found among those with a history of childhood abuse may be explained by heightened vulnerability to nicotine dependence and withdrawal and may be partially due to comorbid mental illness.

Ending versus controlling versus employing addiction in the tobacco-caused disease endgame: moral psychological perspectives.

Even though interest in reducing or eliminating tobacco-caused diseases is a common goal in tobacco control, many experts hold different views on addiction as a target of intervention. Some consider tobacco-caused addiction as a tobacco-caused disease to be eliminated alongside the other diseases. Some consider tobacco-caused addiction as a much lower priority disease to be eliminated, and a subset of this group is prepared to employ addiction to tobacco (nicotine) as a tool to reduce other tobacco-caused disease. These varying attitudes towards ending, controlling or employing tobacco addiction to reduce damage from tobacco use constitute quite different approaches to tobacco control and cause conflict among those in tobacco control. Moral psychological analyses argue that there is more than scientific evidence involved in supporting this continuum of approaches. Divergent values also influence positions in tobacco control. Attention to these values as well as the scientific evidence should be included in policy and practice in tobacco control. It is not that one constellation of values is necessarily superior, but debates need to be informed by and engage discussions of these values as well as the scientific evidence.

Effects of a complete smoking ban on inpatients at an intermediate to long-term psychiatric facility.

The majority of research on reactions to smoking bans in psychiatric facilities focuses on staff feedback in acute inpatient settings. The purpose of this pilot study was to assess inpatient attitudes about a complete smoking ban in an intermediate to long-term psychiatric facility. One hundred inpatients were surveyed via questionnaire. Inpatients reported changes in smoking and improvements in health as a result of the ban, despite evidence of non-compliant smoking at the facility. There was evidence that inpatients perceived others' attitudes about the ban to be worse than reality. The findings from this pilot study suggest that consequences of smoking bans in psychiatric facilities are not as negative as some perceive. Smoking bans in intermediate to long-term settings may result in improvements in health among both smoking and non-smoking patients.

Cannabis Use and Perceptions Among Current and Former Military Service Members.

Background: Research indicates separation from the military may result in increased risk of alcohol use. However, there is little data on cannabis use among military service members, particularly when examining the period after separation from military service. This research examines cannabis-related perceptions and use among U.S. Army Reserve/National Guard (USAR/NG) current and former soldiers. Methods: Data come from Operation: SAFETY (Soldiers And Families Excelling Through the Years), an ongoing study examining health among male and female USAR/NG soldiers. The current sample was comprised of 401 current and former USAR/NG soldiers. Logistic regression models examined the associations between past-year cannabis use, military status (i.e., current versus former), attitudes towards recreational cannabis, perceived ease of access, and perceived risk of cannabis use, while controlling for age, problematic alcohol use, and current cigarette smoking. Results: Overall, 7.4% of current and 20.3% of former military service members used cannabis in the past year. Favorable attitudes towards cannabis use and perceived ease of accessing cannabis were associated with increased odds of use among all soldiers. In adjusted models, former military members had greater odds (AOR = 5.28, 95% CI = 2.16, 12.87) of past-year cannabis use compared to current service members. Conclusions: Findings indicate that separation from the military may be an important risk factor to consider when assessing cannabis use in the military. Additional research is needed to examine socioenvironmental factors (e.g., access to post-deployment support services and healthcare, state legalization laws, other behavioral health conditions) that contribute to former service members' cannabis use.

Perceptions of and willingness to engage in public health precautions to prevent 2009 H1N1 influenza transmission.

BACKGROUND: Recommendations about precautionary behaviors are a key part of public health responses to infectious disease threats such as the 2009 H1N1 pandemic. Individuals' interpretation of recommendations, willingness to comply, and factors predicting willingness were examined. METHODS: A telephone survey of adult residents of New York State was conducted (N = 807). Respondents reported how they interpreted recommendations, willingness to engage in recommended actions, risk perceptions for H1N1 infection, and perceived efficacy of recommendations. Demographic characteristics were used to calculate sampling weights to obtain population-representative estimates. RESULTS: There was substantial variability in interpretation of preventive actions. Willingness to engage in preventive actions also varied substantially; vaccination willingness was substantially lower than other preventive actions. No pattern of demographic characteristics consistently predicted willingness. Perceived efficacy was associated with willingness for all recommendations, and perceived severity was associated with willingness for some recommendations. CONCLUSIONS: Results suggest that individual interpretation of actions differ widely. The results suggest that current recommendations are not clear to laypeople and are open to different interpretations. These varying interpretations should be considered in crafting public health messages about precautionary behaviors.

Nicotine Addiction, Maurice Seevers, and the First Surgeon General Report on Cigarette Smoking and Health: Conflicting Terms and Interests.

OBJECTIVE: This study assessed the role of Maurice Seevers in delaying the United States Surgeon General Reports' judgment that nicotine use is a drug addiction and examined the use of addiction, as applied to nicotine (smoking), from the 1930s to 2013. METHOD: In this narrative review, Truth Tobacco Industry Documents were searched using names of those involved in the 1964 Surgeon General Report; key staff of the American Tobacco Company; and the terms addiction, addictive, dependence, habituation, and habit. Use of "addiction" to smoking was also examined in selected works from 1938 to 2013. RESULTS: Seevers had consulted for the cigarette industry and had been a long-standing advocate for judging nicotine use a drug habituation. He was primarily responsible for cigarettes being judged not addictive in 1964, over objections of other committee members. According to selection rules, he should have been ineligible for committee membership. At the time, multiple sources supported calling smoking an addiction. By the 1980s, "nicotine dependence" or "addiction" became officially accepted. CONCLUSIONS: One expert with financial and intellectual conflicts of interest delayed official judgments that nicotine was addictive. Selection rules for expert committees should be designed to minimize conflicts of interest and should be followed. Although heavy nicotine use may now be classified variously as a tobacco use disorder, addiction, or dependence, depending on the source or audience, "drug habituation" no longer has any currency. The terms used to communicate with the public are important in dealing with the individual and public health costs of tobacco use.

Easier said than done: behavioral conflicts in following social-distancing recommendations for influenza prevention.

Preventing transmission of H1N1 and other infectious diseases can require individuals to change behaviors, but recommendations to change behavior can run counter to other powerful influences. For example, instructions to not shake hands or avoid certain public gatherings can run counter to substantial social pressures to shake hands or be in attendance. These behavioral conflicts are illustrated with an experience of the relative ineffectiveness of voluntary recommendations, which highlights the importance of considering these social pressures when determining what recommendations to make and how to make them. An analysis of how social pressures influence behaviors relevant to preventing disease transmission can aid public health officials in considering how to make effective recommendations concerning H1N1 and other infectious disease situations.

How I Learned That Cigarettes Were Addictive--1970s to 1980s: A Personal History.

OBJECTIVE: This is a personal history of how I came to view cigarette smoking as an addiction to nicotine. I discuss working with Stanley Schachter and Murray Jarvik. Although I note the importance of Michael Russell (as do many colleagues), I draw attention to the considerable effect on my work of Edward Brecher through his 1972 book, Licit and Illicit Drugs. I give examples of the influence of the makers and sellers of nicotine-containing gum on my career in Canada and the United States as well as on the careers of several important colleagues. Ted Klein, who did public relations for nicotine-replacement products, is noted as an important figure in the tobacco control movement of the time, especially for those doing behavioral and smoking cessation research.