Tobacco Primer

Tobacco Primer: Four Questions about Smoking Brian A. Primack, MD, EdM, MS March 2010 Drug Free Pennsylvania

1. What’s the big deal?

Worldwide deaths, 2010

Costs
Direct and indirect medical costs from one year of smoking in the US
$157 billion (75 direct, 82 indirect)
Immunize the entire 3 rd world
$2 billion

“ The Big Lie”
In the advertisement:
Peace
Freshness
Good smells
Independence
In real life:
Coughing
Stale taste, smoke
Bad smells
Dependence (addiction)

Worldwide toll of smoking
Kills five million people annually worldwide
Will be over 10 million annually by 2050 (Some countries with 10 million or fewer people: Hungary, Sweden, Belgium, Switzerland, Senegal, Portugal, Greece, Bolivia)
Half of deaths in middle age (workforce needed for economic development)
Half of deaths in rich nations, half in developing nations
Apparent causes of death different (India TB, China COPD)

2. How can it be that bad?

Ingredients
Dried tobacco leaves
Additives
Fire

Cigarette Additives that start with A or B
Acetanisole, Acetic Acid, Acetoin, Acetophenone, 6-Acetoxydihydrotheaspirane, 2-Acetyl-3- Ethylpyrazine, 2-Acetyl-5-Methylfuran, Acetylpyrazine, 2-Acetylpyridine, 3-Acetylpyridine, 2-Acetylthiazole, Aconitic Acid, dl-Alanine, Alfalfa Extract, Allspice Extract, Oleoresin, And Oil, Allyl Hexanoate, Allyl Ionone, Almond Bitter Oil, Ambergris Tincture, Ammonia, Ammonium Bicarbonate, Ammonium Hydroxide, Ammonium Phosphate Dibasic, Ammonium Sulfide, Amyl Alcohol, Amyl Butyrate, Amyl Formate, Amyl Octanoate, alpha-Amylcinnamaldehyde, Amyris Oil, trans-Anethole, Angelica Root Extract, Oil and Seed Oil, Anise, Anise Star, Extract and Oils, Anisyl Acetate, Anisyl Alcohol, Anisyl Formate, Anisyl Phenylacetate, Apple Juice Concentrate, Extract, and Skins, Apricot Extract and Juice Concentrate, 1-Arginine, Asafetida Fluid Extract And Oil, Ascorbic Acid, 1-Asparagine Monohydrate, 1-Aspartic Acid, Balsam Peru and Oil, Basil Oil, Bay Leaf, Oil and Sweet Oil, Beeswax White, Beet Juice Concentrate, Benzaldehyde, Benzaldehyde Glyceryl Acetal, Benzoic Acid, Benzoin, Benzoin Resin, Benzophenone, Benzyl Alcohol, Benzyl Benzoate, Benzyl Butyrate, Benzyl Cinnamate, Benzyl Propionate, Benzyl Salicylate, Bergamot Oil, Bisabolene, Black Currant Buds Absolute, Borneol, Bornyl Acetate, Buchu Leaf Oil, 1,3-Butanediol, 2,3-Butanedione, 1-Butanol, 2-Butanone, 4(2-Butenylidene)-3,5,5-Trimethyl-2-Cyclohexen-1-One, Butter, Butter Esters, and Butter Oil, Butyl Acetate, Butyl Butyrate, Butyl Butyryl Lactate, Butyl Isovalerate, Butyl Phenylacetate, Butyl Undecylenate, 3-Butylidenephthalide, Butyric Acid

Why Add?
Enhance flavor
Change burn rates
Change tar/nicotine ratings
Increase delivery of nicotine

What happens when you burn?
Over 4000 chemicals, including …

Selected Chemicals Released When Cigarettes Are Burned
Benzene
Formaldehyde
Urea
Arsenic
Cyanide
Acetone
Pyridine
Ammonia
Tar
Carbon Monoxide
DDT
Butane
Cadmium

A is for Addiction
Nicotine is a carcinogen itself
Binds to adenosine receptors in the brain, releasing dopamine (rush); has effect within 10 seconds
Potent withdrawal begins within minutes
Leads to the next cigarette

B is for blood vessels
Multiple chemicals in cigarettes cause endothelial damage
Increases predisposition to clotting, plaque buildup, and heart attack

Atherosclerosis

Myocardial Infarction

Stroke = CVA (cerebro-vascular accident)

Peripheral Vascular Disease

59 year old female smoker

C is for Cancer

Some carcinogens in cigarettes
PAHs:
Benzo[ a ]anthracene, Benzo[ b ]fluoranthene, Benzo[ f ]fluoranthene, Benzo[ k ]fluoranthene, Benzo[ a ]pyrene, Chrysene, Dibenz[ a , h ]anthracene, Dibenzo[ a , i ]pyrene, Dibenzo[ a ],[1]pyrene, Indenol[1,2,3][ c , d ]pyrene, 5-Methytlchrysene
Aza-arenes:
Dibenz[ a , h ]acridine, Dibenz[ a , j ]acridine, 7H-Dibenzo[ c , g ]carbazole, Quinoline
N -Nitrosamines:
4-(methylnitrosamine)-1-(3-pyridyl)-1-butanone, N -Nitrosethylmethylamine, N -Nitrosoanabasine, N -Nitrosodiethanolamine, N -Nitrosodiethylamine, N -Nitrosodimethylamine, N -Nitrosonornicotine, N -Nitrosopyrrolidine
Aromatic Amines:
Acetaldehyde, Aldehydes, 4-Aminobiphenyl, Crotonaldehyde, Formaldehyde, 2-Naphthylamine, 2-Toluidine
Miscellaneous Organic Compounds:
Acrylonitrile, Benzene, Ethylcarbamate, 2-Nitropropane, Vinyl chloride
Inorganic Compounds:
Arsenic, Cadmium, Chromium, Hydrazine, Nickel, Polonium-210
* From Reducing the Health Consequences of Smoking: 25 Years of Progress. Washington, DC, U.S. Department of Health and Human Services, 1989.

D is for Destruction of Lungs (COPD)

E is for Environmental Smoke (Second-Hand Smoke)

Second Hand Smoke
38,000 deaths each year (more than homicide and AIDS combined)
Most pronounced in waiters, bartenders, spouses
Infants

“Safer” cigarettes …
No additives
Low tar
Low nicotine
“ Smokeless”

3. Who smokes, and why?

Gender

Wilkinsburg

“Menthol X”

Ever Smokers Who Have Quit

African Americans
Bear the greatest burden of mortality from smoking
Don’t really smoke more
Is it the menthol?

Poverty Level

“ As this 14-24 age group matures, they will account for a key share of the total cigarette volume for at least the next 25 years.” --RJ Reynolds

“ Our studies report on youngsters' motivation for starting, their brand preferences, as well as the starting behavior of children as young as 5 years old.” -- Brown and Williamson Tobacco Company

US Tobacco, quoted 1994
“ Cherry Skoal is for somebody who likes the taste of candy, if you know what I’m saying.”

Smoke Top Advertised Brands CDC, 2004

$20 Sampler

Regular $7.00
Large $10.00
Arabic Coffee, Apple, Apple Alex, Double Apple, Apricot, Banana, Candy, Cappuccino, Cherry, Carmel, Coconut, Cola, Grape, Jasmine, Lemon, Mint, Mango, Mandarin, Mixed Fruit, Orange, Pistachio, Peach Rose, Salloum, Strawberry, Vanilla, Zaghoul Light, Zaghoul, Licorice

Smoke Volume
“ A typical 1-hour long hookah smoking session involves inhaling 100-200 times the volume of smoke inhaled with a single cigarette.”
WHO, 2005
Shihadeh, 2004

Smoke Contents 1 Shihadeh and Saleh, 2005 2 Djordjevic, 2000 Compound (mg) Hookah 1 Cigarette 2 Ratio Tar 802 22.3 36 Nicotine 2.96 1.74 1.7 CO 145 17.3 8

1 Sepetdjian, 2008; 2 Gmeiner, 1977 Carcinogen (ng) Hookah 1 Cigarette 2 Ratio Benz[a]anthracene 677 35 19 Benzo[a]pyrene 370 10.1 37 Benzo[g,h,i]perlyene 307 7.9 56 Di-benzo[a,h]anthracene 140 2.5 245 Indeno[1,2,3-cd]pyrene 183 3.5 52

Tobacco Types * Includes little cigars, cigarillos

Hookah Smoking by Grade Level Primack et al., Pediatrics 2009

4. What do we do about it?

Legislation
Ban on TV advertising 1971
MSA of 1998 (no billboards)
Clean air laws

Public Service Announcements
Do have an effect
About 50 “just say yes” for each “just say no”
US PSA budget is about 1/30 of England, Canada

School Programs
“Tar Wars” – 4 th and 5 th grade
“Social influences” programs
Grade school: effect on body
Middle school: peer pressure, friends, family
High school: self esteem, aspirations

HSPP
Peterson, AV, JNCI 2000
Curriculum for youth, 3 rd -10 th grades
47.25 hours total
“Social Influences” approach
How to say no, effects on body, resisting peer influence, self esteem, etc.
20 school districts got the program, 20 did not
94% follow up, high implementation fidelity

Results of HSPP
No difference in smoking at 12 th grade
No difference in smoking 2 years after high school
No difference among boys or girls
No difference among people of other subgroups (such as family risk for smoking)

Is Media Literacy Different?

Major Reasons for Media Literacy
Fun, creative
Someone to rebel against
Developmentally appropriate
Most effective for the ones most at risk
Empowering, not protectionist

Thank You [email_address]

Tobacco Primer

by Renee Hobbs on Mar 25, 2010

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Tobacco Primer — Presentation Transcript