Smoking and health Professor Martin Jarvis Department of Epidemiology & Public Health.

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

1950 1975 2000 2025 2050

Year

0

100

200

300

400

500

Cu

mu

lati

ve d

eath

s fr

om

to

bac

co (

mil

lio

ns)

Scenarios for future deaths from tobacco

Trend

520

70

220

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 day’s 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

-10 0 10 20 30 40 50 60 70

Time (mins)

0

5

10

15

20

25

30

35

40

Nic

oti

ne C

on

cen

trati

on

(n

g/m

l)

Schematic Diagramof Arterial vs Venous

Nicotine Levels

Venous

Arterial

cigarette

smoked

Nicotine Addiction in Britain

Royal College of Physicians Feb 2000

• “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.”

Central conclusion: smoking is best understood as nicotine seeking behaviour

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

0 10 20 30 40

Prevalence of regular drug use:adults aged 16-64, GB 1993-1994

32

22

2

0

0

0

0

0

Cigarette smoking %

Drinking above

recommended limits

Marijuana

Tranquillizers

sleeping pills

Amphetamines

Opiates

Cocaine

Psychedelics

hallucinogens

OPCS Psychiatric Morbidity Survey: Meltzer et al 1995 Base n=9792

Regular drug user = every day for 2 weeks or more in past 12 months

Abstainer Occasional Light Moderate Fairly heavy Heavy Very heavy0

5

10

15

20

25

30

35

40

45

Ne

uro

tic

dis

ord

er

%Neurotic disorder % by drinking habits

GB 1993-1994

Alcohol drinking habits

Never smoker Ex 3-4 5-6 7-8 9-10 11-12 13-140

5

10

15

20

25

30

35

40

45

Ne

uro

tic

dis

ord

er

%Neurotic disorder % by smoking habits

GB 1993-1994

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 yourfirst cigarette of the day?

Less than Between Between Between Between Longer5 minutes 5 and 15 15 and 30 30 min. 1 and 2 than 2

minutes minutes and 1 hr hours hours

2. How easy or difficult would you find it to gowithout smoking for a whole day?

Very easy Fairly easy Fairly difficult Very difficult

3. How many cigarettes do you usually smokeeach day?

1-10 11-20 21-30 31+

0

5

10

15

20

25

30

Per

cen

tag

e o

f sm

oke

rs

DISTRIBUTION OF TIME TO FIRST CIGARETTEIN SMOKERS IN PRIMARY CARE

"How soon after waking do you smokeyour first cigarette of the day?"

Less than

5 minutes

5-15

minutes

15-30

minutes

30 min

to 1 hr

1 to 2

hours

More than

2 hours

50

100

150

200

250

300

350

400

450

Sal

iva

coti

nin

e (n

g/m

l)

Mean + 95% CI-

TIME TO FIRST CIGARETTE OF THE DAY

Less than

5 minutes5-15

minutes

15-30

minutes

30 min

to 1 hr

1 to 2

hours

More than

2 hours

n=307n=182n=214n=205n=322n=260

0 1 2 3 4 5 6 7 8 9 10 110

110

220

330

440

550

Sa

liv

a c

oti

nin

e (

ng

/ml)

SALIVA COTININE BY DEPENDENCE INSMOKERS IN PRIMARY CARE

Mean + 95% CI

DEPENDENCE SCALE SCORE

N = 160 108 381431361491209996108130 73

0 1 -4 5 -9 1 0 -1 4 1 5 -1 9 2 0 -2 4 2 5 -2 9 3 0 +0

1

3

Pla

sma

cotin

ine

(ng/

ml)

P ar tner 's daily cigar ette consum ption

Geometric mean ± 95%CI

0 .5

2

0 1-4 5-9 10-14 15-19 20-24 25-29 30+0.0

0.5

1.0

1.5

2.0

2.5

Pla

sm

a c

oti

nin

e (

ng

/ml)

PASSIVE SMOKING: COTININE IN ADULTSBY PARTNER'S CIGARETTE CONSUMPTION

Partner's daily cigarette consumption

Geometric mean + 95%CI

Health Survey for England

1994 &1996

8328 234 231 259 155 294 79n= 60

1972 1976 1980 1984 1988 1992 1996

0

10

20

30

40

50

60

% p

reva

len

ceCIGARETTE SMOKING 1972-1998:

GB: General Household Survey

Men

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 people’s

smoke – Become more nicotine dependent– Much more likely to die prematurely

from smoking

0 1 2 3 4 50

10

20

30

40

50

60

70

80

% p

rev

ale

nc

e

CIGARETTE SMOKING BY DEPRIVATIONIN GREAT BRITAIN: GHS 1973 & 1998

1973

1998

DEPRIVATION SCOREMost affluent Poorest

0 1 2 3 4 50

10

20

30

40

50

60

70

80

% q

uit

SMOKING CESSATION BY DEPRIVATIONIN GREAT BRITAIN: GHS 1973 & 1998

1973

1998

DEPRIVATION SCOREMost affluent Poorest

0 1 2 3 4

200

250

300

350

Pla

sm

a c

oti

nin

e (

ng

/ml)

Plasma cotinine by deprivationin adult smokers: HSE 1993-1996

1993

1994

1996

DEPRIVATION 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

0 - .1 .1- .2- .4- .5- .6- .7- .8- .9- 1.0 +

Cigarette nicotine yield (mg)

0.2

0.4

0.6

0.8

1.0

1.2

1.4

1.6

Nic

oti

ne

in

tak

e p

er

cig

are

tte

(m

g)

Predicted and actual nicotine intakes per cigarettesmoked by nominal nicotine yield of usual brand

Predicted

Health Survey for England 1998

0 - .1 .1- .2- .4- .5- .6- .7- .8- .9- 1.0 +

Cigarette nicotine yield (mg)

0.2

0.4

0.6

0.8

1.0

1.2

1.4

1.6

Nic

oti

ne

in

tak

e p

er

cig

are

tte

(m

g)

Predicted and actual nicotine intakes per cigarettesmoked by nominal nicotine yield of usual brand

Actual Predicted

Health Survey for England 1998

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%

1950 1975 2000 2025 2050

Year

0

100

200

300

400

500

Cu

mu

lati

ve d

eath

s fr

om

to

bac

co (

mil

lio

ns)

Scenarios for future deaths from tobacco

Trend

520

70

220

Source: Peto et al

1950 1975 2000 2025 2050

Year

0

100

200

300

400

500

Cu

mu

lati

ve d

eath

s fr

om

to

bac

co (

mil

lio

ns)

Scenarios for future deaths from tobacco

If smokinguptake halves

by 2020

Trend

520

70

220

500

Source: Peto et al

1950 1975 2000 2025 2050

Year

0

100

200

300

400

500

Cu

mu

lati

ve d

eath

s fr

om

to

bac

co (

mil

lio

ns)

Scenarios for future deaths from tobacco

If adult smokinghalves by 2020

If smokinguptake halves

by 2020

Trend

520

70

220

190

500

340

Source: Peto et al

Conclusions

• Nicotine’s 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