Information…. (as above) However, many countries and regions, for example the European Union, are today using practices that contain questionnable or even counterproductive elements, that are not supported by scientific evidence. I am now going to discuss some selected issues, first information on cigarette packages regarding delivery of toxic substances, and then a few specific points regarding health information messages.
Informatoion on cigarette packs regarding toxic substances usually consists of printing laboratury measurements of the amounts of certain substances that the cigarette delivers to a smoking machine under certain specific conditions. But, how do we know what it delivers to a smoker? For the smoker the relevant consumer infromation must deal with himself. So, in order to design a meaningful system we have to learn about human smokers’ intake of tobacco smoke. Let’s first look at intake of nicotine
The major piece…..(as above) In this study real life smokers have been studied smoking different types of cigaretters with machine yield of nicotine ranging from about 1 mg to about 10 mg. In all smokers the actual intake of nicotine has been measured.
In this diagram each dot represents the actual daily intake of nicotine by a single individual in the representative sample of real life smokers participating in the study. In each category of cigarettes, as characterized by its machine yield of nicotine, there are enormous individual differences in intake, ranging from close to zero to 40 or 50 mg per day, almost the same range in all categories of cigarettes. Knowing the average number of cigarettes per day, it is possible to calculate the mean intake per cigarette of each type.
For each category of cigarettes the red bar indcates the machine yield of nicotine, while the blue bar indicates the mean of actual intake of nicotine per cigarette measured in smokers who smoke their usual brand belonging to that category. Smokers’ intake of nicotine per cigarette is almost the same irrespective of the machine yield. This reflects how a smoker adapts his way of smoking so that he gets the amount of nicotine required by his individual need for nicotine. So, our knowledge of nicotine intake can be summarized like this (next slide)
An individual …. (as above Intake of nicotine… (as above) Then comes the question on intake of other substances than niocotine (next slide)
As an example, let´s look at a smoker with average level of personal nicotine intake, that is 1.3 mg. What happens when he smokes a cigarette with machine yield of 9 mg tar and 1.0 mg nicotine? Since 1.0 mg nicotine is accompanied by 9 mg tar, our smokers’ intake of 1.3 mg nicotine will be accompanied by 1.3 × 9 = 11.7 mg tar. A smoker with a nicotine intake of 2 mg, will get 18 mg tar from this cigarette, etc etc.
Let´s now go back to our 1.3 mg nicotine smoker and see what happens when he smokes a cigarette with machine yield of 6 mg tar and 0.5 mg nicotine. In the smoke from this cigarette 1.0 mg nicotine is accompanied by 12 mg tar, the tar to nicotine ratio is here 12, while it was 9 for the first brand. Now the tar dose will be 12 × 1.3 = 15.6 mg tar. So, the “low tar” Brand 2 delivers more tar than the “High tar” Brand 1. A few more examples can be added (next slide)
Brand 3 has the highest tar/nicotine ratio, 16.7, and does therefore give the highest tar intake, Brand 4 has the lowest tar/nicotine ratio, 4.3, and does therefore give the lowest tar intake. Smokers´intake of other substances, as for example carbon monoxide, can be calculated in the same way. So, intake of CO is CO/nicotine ratio times personal nicotine intake.
In summary: The intake… (as above) The accompanuing amount… (as above) What would now be a meaningful kind of consumer information regarding toxicants to be printed on the packages? Certainly not machine yield figures. Instead, let´s keep in mind that the only meaningful purpose of package information regarding toxicants is something that gives the smoker a chance to compare the toxicity of different brands in order to consider switching to a possibly ess harmful alternative. What kind of data would then be relevant? (Next slide)
A possible model for a meaningful and truthful ”consumer information” on cigarette packages could look like this: (See above) The most important piece of info is the fact that nicotine intake is determined by the smoker himself. The figures in the bottom line represent the ”yield ratio to nicotine” for five toxicants. When presented in this easy-to-understand fashion they can serve as a guide for the consumer to compare toxicity of different brands and then to minimize intake by choice of brand.
Meaningful public education by labelling on tobacco packages: Some elements of the scientific background
Information on tobacco packages could encourage and help tobacco users <ul><li>to stop using tobacco or </li></ul><ul><li>find least possible harmful ways of use for those unable to stop. </li></ul>
Information on cigarette packs regarding toxic substances <ul><li>Laboratory measurements tell us what the cigarette delivers to a smoking machine. </li></ul><ul><li>But, how do we know what it delivers to a smoker? </li></ul>
Intake of Nicotine <ul><li>The major pieces of scientific background are found in: </li></ul><ul><li>Jarvis MJ, Boreham R, Primatesta P, Feyerabend C, Bryant A. N icotine yield from machine-smoked cigarettes and nicotine intakes in smokers: Evidence from a representative population survey. J Natl Cancer Inst. 2001 Jan 17;93(2):134-8 . </li></ul>
Intake of Nicotine (summary) An individual smoker’s intake of nicotine is NOT determined by the cigarette (as expressed by the machine yield of nicotine). Intake of nicotine is determined by the smoker´s personal need for nicotine (governing the way he smokes in order to get the amount he needs).
Intake of other substances <ul><li>Examples of tar intake by a smoker who </li></ul><ul><li>takes in 1.3 mg nicotine </li></ul><ul><li> Machine yield Tar intake by </li></ul><ul><li> Tar Nicotine this smoker </li></ul><ul><li>Brand 1 (high tar) 9 mg 1.0 mg 11.7 mg </li></ul>
Intake of other substances <ul><li>Examples of tar intake by a smoker who </li></ul><ul><li>takes in 1.3 mg nicotine </li></ul><ul><li>Machine yield Tar intake by </li></ul><ul><li>Tar Nicotine this smoker </li></ul><ul><li>Brand 1 (high tar) 9 mg 1.0 mg 11.7 mg </li></ul><ul><li>Brand 2 (low tar) 6 mg 0.5 mg 15.6 mg </li></ul><ul><li>6 / 0.5 = 12 mg tar per mg nicotine (tar/nicotine ratio) </li></ul><ul><li>12 (t/n ratio) 1.3 (indiv. nic. dose) = 15.6 mg (indiv. tar dose) </li></ul>
Intake of other substances <ul><li>Examples of tar intake by a smoker who </li></ul><ul><li>takes in 1.3 mg nicotine </li></ul><ul><li>Machine yield Tar intake by </li></ul><ul><li>Tar Nicotine this smoker </li></ul><ul><li>Brand 1 (high tar) 9 mg 1.0 mg 11.7 mg </li></ul><ul><li>Brand 2 (low tar) 6 mg 0.5 mg 15.6 mg </li></ul><ul><li>Brand 3 (high tar) 10 mg 0.6 mg 21.7 mg </li></ul><ul><li>Brand 4 (low tar) 3 mg 0.7 mg 5.6 mg </li></ul>
Intake of other substances (summary) <ul><li>The intake of each other substance than nicotine can be described as the amount of that substance that accompanies the smoker-determined amount of nicotine </li></ul><ul><li>The ”accompanying amount” of a substance is determined by: - the size of the personal nicotine intake - the brand-specific ratio to nicotine for the substance in … question </li></ul>
Comparing brands for toxicity <ul><li>Nicotine - No major differences according to brands (since intake is mainly regulated by the smoker) </li></ul><ul><li>Other substances - Intake can differ between brands according to the brand-specific ratio to nicotine for the substance </li></ul><ul><li>- The ratios to nicotine are about the same irrespective of the way the cigarette is smoked and can therefore serve as comparative indicators of brand-specific toxicity </li></ul>
Possible model for meaningful and truthful ”consumer information” on cigarette packages : Smokers´ intake of nicotine from one cigarette: 0.5 – 2.5 mg, depending (mainly) on HOW it is smoked One mg of nicotine from this cigarette is accompanied by: Tar: 7 mg Carbon monoxide: 8 mg Formaldehyde: 0.05 mg Hydrogen Cyanide: 0.08 mg Benzene: 0.04 mg
Data presented to the UK National Smoking Cessation Conference, London, 9-10 June 2005. Bobak A. Perceived safety of nicotine replacement products among general practitioners and current smokers in the UK: impact on utilisation <ul><li>Large proportions (37 %) of the smokers agreed that "Stop smoking products with nicotine are just as harmful as cigarettes". </li></ul><ul><li>These smokers were slightly less likely to have used NRT in the past and reported being less likely to use it during future quit attempts. </li></ul>
“ For total mortality, the estimated median relative risks for individual users of LN-SLT were 9% and 5% of the risk associated with smoking for those ages 35 to 49 and ≥50 years, respectively.” “ The risks of using LN-SLT products therefore should not be portrayed as comparable with those of smoking cigarettes as has been the practice of some governmental and public health authorities in the past.”
Range of health risk levels for smokers of different kinds of cigarettes Range of health risk levels for users of low nitrosamine smokeless tobacco Health risk level for non-tobacco users Schematic comparison of risk levels (arbritrary scale) 10 20 30 40 20 40 60 80 100
Summary (1) Product description labelling should make clear that: <ul><li>Intake of nicotine from a cigarette can be anything in a wide range and is determined (mainly) by the way the smoker smokes to adjust to his need for nicotine (while machine yield figures are irrelevant) </li></ul><ul><li>Intake of other substances (and subsequent health risks) do to some extent depend on the cigarette also (the brand-specific yield ratio to nicotine for the substance in question) </li></ul>
Summary (2) Health information messages on tobacco packages should, in addition to traditional ”health warnings”, make clear that: <ul><li>The major disease causing substances are the combustion products in tobacco smoke, not the nicotine </li></ul><ul><li>Nicotine cessation aids and low nitrosamine smokeless tobacco products are much less harmful to health than any cigarette </li></ul>