Tobacco Control

1. April 20, 2015 J. Randy Koch, Ph.D. Alison Breland, Ph.D. VCU Center for the Study of Tobacco Products Tobacco Control

2. Overview of Topics to Cover Today • Health effects of tobacco • Tobacco dependence • Epidemiology • Types of tobacco products • Cessation/Treatment • Prevention strategies • Family Smoking Prevention and Tobacco Control Act

3. Health Consequences • In the US: over 480,000 people die from tobacco related diseases each year • Globally, nearly 6 million annually • What’s in tobacco that is so harmful? • Nicotine • Carbon monoxide or CO (when burned) • Carcinogens (e.g., tobacco-specific nitrosamines, PAHs) • Morbidity and mortality caused by CO and carcinogens • Smoked tobacco use increases risk of: • coronary heart disease by 2 to 4 times • stroke by 2 times • Lung cancer by 13-23 times (women and men) • chronic obstructive lung diseases (such as emphysema) by 10 times

4. Tobacco Dependence/Withdrawal • Effects of tobacco: mild euphoria, reduced stress, increased energy, and appetite suppression • Dependence likely caused by nicotine • Symptoms of withdrawal generally start within 2 - 3 hours after the last tobacco use, and peaks about 2 - 3 days later • Intense craving for tobacco • Anxiety, restlessness, impatience • Difficulty concentrating • Drowsiness or trouble sleeping, as well as bad dreams and nightmares • Headaches • Increased appetite and weight gain • Irritability or depression

5. Global Sources of Epidemiological Data • Lack of standardized data on a global level • Global Tobacco Surveillance System—1999+ • Collaborative effort among WHO, United States Centers for Disease Control and Prevention, and the Canadian Public Health Association • Surveys • Global Youth Tobacco Survey (GYTS) • Global School Personnel Survey (GSPS) • Global Health Professions Student Survey (GHPSS) • Global Adult Tobacco Survey (GATS)

6. GYTS: Current Cigarette Smokers

7. Epidemiology: US rates • Currently, about 18% of US adults smoke cigarettes • Rates higher if you include any tobacco product

8. Adult smoking prevalence by state SOURCE: Behavioral Risk Factor Surveillance System, 2010; http://www.cdc.gov/VitalSigns/AdultSmoking/index.html#StateInfo

9. Epidemiology: US rates (adults, cigarettes only) • Gender • 20.5% of men • 15.8% of women • Race • 21.8% of American Indians/Alaska Natives • 19.7% of whites (non-Hispanic) • 18.1% of blacks (non-Hispanic) • 12.5% of Hispanics • Socio-economic status • 27.9% of adults who live below the poverty level • 17.0% of adults who live at or above the poverty level

10. Epidemiology: US rates (adults, cigarettes only) • Adults with mental illness • 36% of adults with mental illness are smokers • Adults with substance use disorders: ~80% • Adults with MH or SUD account for 40% of all cigarettes smoked in the US

11. Epidemiology: US rates for youth • Current use of cigarettes among youth: • 3.5% of middle school students • 14% of high school students • Rates higher if you include any tobacco product • 6.7% of middle school students • 23.3% of high school students • Most adult smokers (80%) began smoking before age 18

12. Types of Tobacco Products (US) • Cigarettes • Cigars • Pipes • Smokeless tobacco (“dip”, “chew” or “snus”) • Waterpipe (hookah) • E-cigarettes (not actually tobacco, although will likely be regulated as tobacco)

13. Cigarettes • Modern cigarette developed in the early 1800s • At the start of the 20th century, less than 0.5% of the population smoked • Consumption peaked in the US in 1965: ~50% of men and 33% of women smoked • Smoking and Health: Report of the Advisory Committee to the Surgeon General (1964) • Start to see changes to cigarettes: “light” “filtered”; health claims

14. FDA Regulation of tobacco products Source: United States Department of Agriculture; Centers for Disease Control and Prevention; Alcohol and Tobacco Tax and Trade Bureau

15. Cigarettes 1930

16. Cigarettes 1949

17. Cigarettes 1951

18. 1954

19. 1955

20. Types of Tobacco Products

21. Cigarettes 1976

22. Cigarettes • “Patients who are unable to stop cigarette smoking should be assisted to reduce their smoke exposure by smoking low-tar and low nicotine cigarettes . . .” (Harrison’s Internal Medicine 9th Ed., 1980, p. 941). • Smokers believe “light” and “ultra light” cigarettes decrease health risks of smoking (Kozlowski, Goldberg, et al., 1998; Giovino et al., 1996). • Smokers switch to low yield cigarettes instead of quitting (Giovino et al., 1996).

23. Cigarettes • Changes increased sales without harm reduction • “The weight of the evidence indicates that lower-tar and nicotine yield cigarettes have not reduced the risk of disease proportional to their FTC yields” (IOM, 2001). • Past modifications did not alter exposure: changing puff topography, covering vent holes • New FDA regulation has eliminated the use of “light,” “low” and “mild”

24. Types of Tobacco Products • Cigars • 5.4% of US adults use (>1 in past 30 days) • 12.6% of high school students • 2.8% of middle school students http://www.smokefree.gov/tob-cigarillo.aspx

25. Types of Tobacco Products • Pipes • Waterpipe, or hookah • Past year use among high school students: 21% (has been increasing) • CO exposure is much higher than cigarettes (Eissenberg et al., 2011)

26. Types of Tobacco Products • Smokeless tobacco • “Dip”, “Chew” (e.g., Skoal, Wintergreen) • Snus (Swedish) • Marlboro snus, Camel snus • Camel orbs, sticks, dissolvable strips • Verve disc • Health effects? In Sweden, low rates of lung cancer, but effects in US not known

27. dissolvable tobacco snus

28. Electronic Cigarettes Cartridge w/ Nicotine Solution/ E-juice/ E-liquid Atomizer Heater E-Juice/E-Liquid Nicotine Solution Propylene Glycol and/or Vegetable Glycerin Distilled Water Flavorings (Baking) Smart Chip Air Flow Sensor Rechargeable Battery 2v – 6v Use Methods Pre-Filled Dripping Fill your own Make your own LED Vaper Slide courtesy of Andrea Vansickel

29. Different ECIGS with varying power supplies. A is a V4L model (3.7 v) powered by a USB port. B is a V4L model (3.7 v) powered by internal rechargeable battery. C is a Silver Bullet powered by a 3.7 v replaceable/rechargeable battery. D is a ProVari powered by a 3.7 v replaceable/rechargeable battery and the user controls power settings ranging from 3.3 to 6.0 volts. A B C D

30. E-cigarettes • 1.9% of adults use ECIGs every day/some days (5.3% of current and former smokers use daily) Images courtesy of Bob Balster and Andrea Vansickel

32. E-cigarettes • Health effects of e-cigarettes unknown • Concerns about: • Nicotine delivery • Toxicant delivery • Currently little evidence to show that e-cigarettes are effective quit aids • VCU’s Center for the Study of Tobacco Products currently studying e-cigarettes

33. E-cigarettes: recent work from VCU From Soule, Spindle et al., (SRNT poster)

34. Summary • Overall, tobacco use has been going down in the US (by small amounts in recent years) • Use of other products may be increasing • Hard to determine long-term impact of new products • Major concern—Will people switch to new “safer” products rather than quit? Or become dual users? • Will youth start using new products?

35. Smoking cessation • ~70% of smokers say they want to quit • 45% make quit attempts • Relapse rates are high • Tobacco produces dependence: very difficult to quit • Tobacco is as addictive as heroin or cocaine

36. Smoking cessation • Medications to quit can increase likelihood of success • Nicotine replacement therapy (nicotine patch, gum, inhaler, lozenge, nasal spray) • Non-nicotine medications: • buproprion (Zyban/Wellbutrin) • varenicline (Chantix) • 1-800 QUIT-NOW (counseling) • Websites • Emerging trend: technology

37. Estimated abstinence rates—Behavioral therapies Source: Treating Tobacco Use and Dependence: 2008 Update (Clinical Practice Guideline, Fiore et al., 2008)

38. Estimated abstinence rates—Medications

39. Questions?

40. Prevention

41. Risk and Protective Factors Effective prevention programs are based on reducing risk factors and/or enhancing protective factors Related to age, gender, race, and environment A need for preventive interventions tailored to specific populations and settings Most risk and protective factors related to a broad array of youth problems, but some are unique Additive effect—goal is to affect the balance of risk and protective factors

42. Risk and Protective Factors Domains Individual Family Peer School Community

43. Risk and Protective Factors Individual Risk Factors Psychiatric disorders Novelty/sensation seeking Positive attitudes towards substance use High antisocial behavior Individual Protective Factors Ambitious life goals High religiosity

44. Risk and Protective Factors Family Risk Factors Family conflict Family history of antisocial behavior Family attitudes favorable to substance use Family Protective Factors Parental nonsmoking Parental advice not to smoke Parental monitoring Strong family bonds

45. Risk and Protective Factors Peer Risk Factors Peer tobacco use Community risk factors Exposure to tobacco advertising Perceived availability of tobacco School Risk Factors Low school connectedness Low academic achievement School misbehavior

46. Types of Prevention Strategies School-based programs Family-based programs Media campaigns Reducing youth access Excise Taxes

47. School-Based Prevention Programs Schools are most common setting for tobacco use prevention programs Provide relatively easy access to youth Can address other concerns of interest to schools Can be integrated into school curriculum

48. School-Based Prevention—What Works? Skills Training Academic Competence Social Competence Social Resistance Skills Norms Education Media Literacy Should not be one-time efforts--booster sessions

49. Life Skills Training Gilbert Botvin and colleagues, Cornell University Target Population: Grades 6, 7 and 8 or Grades 7, 8 and 9 Three year program (15, 10 and 5 session) Focus on: Drug resistance skills and information Self-management skills General social skills Interactive program using facilitated discussion, role playing, and small group activities