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Chapter 10

Tobacco

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A legal product used by a significant proportion of adults

But a substance responsible for more adverse health consequences and death than any other drug

The Tobacco Dilemma

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Cultivated and used by Native Americans for centuries

Presented tobacco leaves as a gift to Columbus in 1492

The word “tabaco” was adopted by the Spanish

Possibly from the Arabic word “tabbaq” meaning “medicinal herbs”

Early History

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1500s:

Recognition of the medical potential grew

French physician Jean Nicot: early proponent

Nicotine (the active ingredient) and Nicotiana (the plant genus were named after him

16th and 17th centuries

Viewed as having many positive medical uses but as having a negative reproductive effect

1890s:

Nicotine dropped from the U.S. Pharmacopoeia

Early Medical Uses

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Two major species grown today (out of more than 60)

Nicotiana tobacum: large-leaf species indigenous only to South America but now cultivated widely

Nicotiana rustica: small-leaf species from the West Indies and eastern North America

Two Major Species

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Snuff

18th century: Snuff use became widespread as smoking decreased

In U.S., perceived as a British product; American use declined after the Revolution

Chewing tobacco

19th century: Most tobacco used in the U.S. was chewing tobacco

Smoking did not surpass chewing until the 1920s

Types of Tobacco Products

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Cigarettes

Native Americans used thin reeds filled with tobacco

Factories appeared in 19th century

Habit spread widely with the advent of inexpensive machine-produced cigarettes

Currently most popular form of tobacco use

Cigars

A combination of chewing and smoking

Peaked in popularity in 1920

Types of Tobacco Products

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Product milestones:

1913 - Camels: low-priced domestic tobacco

1939 - Pall Mall: king-size cigarettes

1954 - Winston: filter cigarettes

Filter cigarettes have over 90% of the U.S. cigarette market

History: Cigarettes

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1908: New York made it illegal for a woman to use tobacco in public

“protect women from themselves”

Tobacco Under Attack

1604: King James of England published an anti-tobacco pamphlet

“harmefull to the braine, dangerous to the lungs”

Note that he also supported the American tobacco trade

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1930s and 40s: Reports linking smoking and cancer

1952: Readers’ Digest article “Cancer by the Carton”

Tobacco companies’ response:

Formation of the Council for Tobacco Research

Not independent and tried to undermine health risk claims

Mass-marketing of filter cigarettes and cigarettes with lowered tar and nicotine content

Promoted as a “safer” alternative

Tobacco Under Attack

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1964: Surgeon General’s report states that smoking causes lung cancer in men

Tobacco sales began a decline that continued for 40 years

1965: Congress required warning labels on cigarette packages

Tobacco Under Attack

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1971: TV and radio cigarette ads banned

1990: Smoking banned on interstate buses and domestic airline flights

1995: FDA proposed further regulation of tobacco and ads

Many additional state and local bans passed

Tobacco Under Attack

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Lawsuits seeking compensation for the health consequences of smoking

Unsuccessful for many years

Then several victories

1998 settlement between 46 states and major tobacco companies

$205 billion in payments to the states

Advertising regulations

Enforcement of laws prohibiting sales to minors

Possible reasons for legal victories

Changing legal climate

Revelation of tobacco companies’ actions in hiding information on the adverse effects of smoking

Tobacco Under Attack

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Lower levels of nicotine

Caveat: people adjust their smoking behavior to obtain a consistent amount of nicotine

By taking more puffs and inhaling more deeply

Lower levels of tar

Tar is the sticky brown material seen on the filter of a smoked cigarette

Based on changes in smoking behavior, there may be no advantage to switching to a low tar–low nicotine cigarette

Does “safer” mean safe?

Quest for “Safer” Cigarettes

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Percentage of smokers by gender

Men: 25%

Women: 20%

Education is the single biggest influence on smoking rates

Percentage of smokers by education

High school diploma only: 28%

Undergraduate degree: 11%

Full time college students: 5%

Non-college students: 19%

Current Cigarette Use

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1970s: use increased as smokers looked for an alternative with a lower risk of lung cancer

Most common form

Moist snuff (Skoal, Copenhagen)

Nicotine absorbed through mucous membranes

Advantages over cigarettes

Unlikely to cause lung cancer

Less expensive

More socially acceptable in some circumstances

Smokeless Tobacco

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Smokeless tobacco has its hazards

Smokeless tobacco packages carry warning labels

Health concerns

Smokeless Tobacco

Increased risk of dental disease and oral cancer
Contains potent carcinogens such as nitrosamines
Causes leukoplakia
Can lead to nicotine dependence

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Hookahs:

Large, ornate water pipes imported from Arab countries

Hookahs produce milder, water-filtered tobacco smoke

Prevalence of hookah smoking is unclear

Other Tobacco Products

In recent years, cigar smoking has increased

In 2008, 9% of males and 2% of females reported smoking a cigar in the past month

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Major diseases linked to smoking

Lung cancer

Cardiovascular disease

Chronic obstructive lung diseases

including emphysema

Risk increases for those who:

Start young

Smoke many cigarettes

Continue to smoke for a long time

Smoking is the single greatest avoidable cause of death

Smoking: Adverse Health Effects

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Smoking: Adverse Health Effects

Cigarette packages and advertisements are required to rotate among different warning labels

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Secondhand smoke

Cigarette smoke inhaled from the environment by nonsmokers

Components of environmental smoke

Mainstream smoke: the smoke inhaled/exhaled by the smoker

Sidestream smoke: the smoke rising from the ash of a cigarette

More carcinogens in smoke

But smoke is more diluted

Secondhand Smoke

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Health effects difficult to fully determine but include

Lung cancer

Cardiovascular disease

1993: Environmental Protection Agency classified secondhand smoke as a known human carcinogen

Many recent laws and regulations have been passed to protect nonsmokers

Secondhand Smoke

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Five million deaths worldwide each year

Perhaps as high as 8 million by 2030

Demand for American cigarettes in Asia has increased markedly

Demand has also increased in Third World countries

Smoking and Heath in Other Countries

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Increased risk of:

Miscarriage

Low birth weight

Sudden infant death syndrome (SIDS)

Several studies indicate effects on physiological and cognitive development

Neurological problems

Problems with reading and mathematical skills

Hyperactivity

Smoking and Pregnancy

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Nicotine

Active ingredient in tobacco

A naturally occurring liquid alkaloid that is colorless and volatile

Tolerance and dependence develop quickly

Highly toxic in large enough doses

Lethal dose = 60 mg

A cigar contains twice that much

Typically not delivered fast enough or in a high enough dose to be lethal

Nicotine Pharmacology

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Use of nicotine increases the activity of liver enzymes responsible for nicotine deactivation

Contributes to tolerance

May decrease the effects of other medication

Absorption and Metabolism

Inhalation is very effective

90% of inhaled nicotine is absorbed

80–90% of nicotine is deactivated in the liver and then excreted via the kidneys

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Mechanism of action:

Mimics acetylcholine

First stimulates and then blocks receptor sites

Also causes the release of adrenaline and has an indirect sympathomimetic effect

Symptoms of nicotine poisoning:

Low-level

Nausea, dizziness, and general weakness

Often experienced by beginning smokers

Acute poisoning

Tremors, convulsions, paralysis of breathing muscles, death

Relatively rare

Physiological Effects

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CNS and circulatory system effects

Increased heart rate and blood pressure

Increased oxygen need of the heart

Decreased oxygen-carrying ability of blood

Causes shortness of breath

Increased platelet adhesiveness

Increases the tendency to clot

Increased electrical activity in the cortex

Reduced hunger

Inhibition of hunger contractions

Increased blood sugar

Deadening of taste buds

Physiological Effects

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Nicotine is the primary reinforcing substance in tobacco

Nicotine has both stimulant and calming effects

User expectation, environmental setting, and genetics play an important role in the effects

Behavioral Effects

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Cigarettes and other forms of tobacco are addicting

Nicotine is the drug in tobacco that causes addiction

The processes that determine tobacco addiction are similar to those that determine addiction to drugs like heroin and cocaine

Tobacco industry claims that its products do not cause dependence

Conclusions made in the Surgeon General’s report (1988):

Nicotine Dependence

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There are more than 40 million ex-smokers in the U.S.

90% report no formal treatment program

Yet there are many challenges to quitting

Nicotine is a strongly reinforcing drug

And a pack-a-day smoker gets 50,000 reinforcing nicotine puffs per year

How to Stop Smoking

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Replacement therapy

Delivering nicotine without the tar and carbon monoxide

Produced in many forms:

Gum, patches, nasal spray, inhalers, lozenges

Pharmacological Therapy

Example: Bupropion (Zyban)

How to Stop Smoking

Combining counseling and pharmacological treatments increases the odds of quitting

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