Thursday, August 30, 2012

Pipe Smoking and Health

Health risks associated with cigar smoking are lower than those for cigarette smoking, reflecting a lower exposure to smoke toxicants (see my earlier post here).  The same holds true for pipe smoking, as a 2004 American Cancer Society study documented (abstract here).

Dr. S. Jane Henley and colleagues examined data from the Cancer Society’s Second Cancer Prevention Survey, which enrolled participants in 1982.  They compared deaths among exclusive men pipe smokers with those among never tobacco users over the next 18 years.  They also considered the number of pipes smoked each day, duration of smoking, and how much smokers inhaled.  The results are expressed as hazard ratios (HRs, similar to relative risks); a confidence interval spanning 1.0 means the risk elevation was not statistically significant.

The table shows that pipe smokers had small to moderate elevations for several smoking-related diseases, with the risk for laryngeal cancer remarkably high.

The Health Risks of Pipe Smoking
Disease Hazard Ratio (95% Confidence Interval)
Oral cavity and pharynx3.9 (2.2 – 7.1)
Esophagus2.4 (1.5 – 4.0)
Stomach1.2 (0.7 – 1.9)
Colon Rectum1.4 (1.2 – 1.7)
Pancreas1.6 (1.2 – 2.1)
Larynx13.1 (5.2 – 33)
Lung5.0 (4.2 – 6.0)
Bladder1.5 (0.9 – 2.4)
Kidney0.9 (0.8 – 1.6)
Heart Disease 1.3 (1.2 – 1.4)
Stroke1.3 (1.1 – 1.5)
Emphysema3.0 (2.2 – 4.1)

The Cancer Society’s analysis of pipe smoking was thorough (in stark contrast to its consideration of smokeless tobacco, discussed here), producing a wealth of insights.  For example, the overall HR for lung cancer among pipe smokers was 5.0, but there was a distinct gradient related to the number of pipes smoked per day.  The HR was 2.0 with one to three pipes, but it increased to 7.7 for 11+ pipes per day.  There was a similar trend with longer duration of smoking, and inhalation played a major role.  The lung cancer HR was 2.9 for pipe smokers who didn’t inhale, but 11.1 for those reporting moderate or deep inhalation. 

Other diseases showed similar trends with dose, duration and inhalation, although some  results weren’t statistically significant.

Dr. Henley also illustrated that alcohol is a powerful risk factor for cancers of the oral cavity, pharynx, larynx and esophagus.  Pipe smokers who consumed less than one alcoholic drink per day had no increased risk for these cancers.  Those consuming 1-3 drinks had an HR of 4.7 (CI = 1.8 – 11.9), while those consuming 4+ drinks had much higher risk (HR = 15, CI = 5.9 – 39).  Never smokers consuming 4+ drinks also had elevated risk for these cancers (HR = 2.3, CI = 1.2 – 4.3). 

“These risks,” according to the researchers, “were generally smaller than those associated with cigarette smoking and similar to or larger than those associated with cigar smoking.”  This confirms one of the tenets of tobacco harm reduction: it’s the smoke that kills, and the risk is proportionate to how much, how long and how deeply smoke is inhaled.  

Wednesday, August 22, 2012

E-Cigarettes Awareness and Use

American Legacy Foundation staff, led by Dr. Jennifer Pearson, reported two surveys gauging awareness, use and perceptions of e-cigarettes.  The research was published in the American Journal of Public Health (abstract here). 

One survey, the online KnowledgePanel, included 2,649 never, current and former smokers.  The other, the Legacy Longitudinal Smoker Cohort (LLSC), surveyed 3,658 current and former smokers.  Major findings appear in the table.

In both surveys, nearly 6 out of 10 smokers were aware of e-cigarettes – a higher percentage than among former smokers (42%) or never smokers (33%) in the KnowledgePanel survey.  However, only 6-11% of current smokers had used the devices; trial among former smokers was even lower.  Only 4% of smokers had used e-cigarettes in the past 30 days.

E-Cigarette Awareness, Use and Perception of Harm
Never Smokers Former SmokersCurrent SmokersFormer SmokersCurrent Smokers
Ever Use0.8%2%11%3%6%
Less Harmful Than Cigarettes----71%--85%
Same/More Harmful----29%--15%

Among current smokers who were aware of e-cigarettes, 71-85% correctly believed they are less harmful than cigarettes.  The remainder, unfortunately, believed that e-cigarettes are just as or more harmful. 

The American Legacy Foundation “is dedicated to building a world where young people reject tobacco and anyone can quit.”  In their introduction, the authors write that e-cigarettes “could act as a starter product for combustible cigarettes, especially among youths or young adults…”, but they offer no data on e-cigarette use among youth; even among adult never smokers, ever use is a minuscule 0.5%.

Dr. Pearson and colleagues suggest that e-cigarettes “may lure former smokers to return to nicotine dependence, delay cessation among current smokers, serve as a dual-use product, or enable individuals to avoid smoking restrictions.”  None of these concerns are supported by data.  There is no evidence that e-cigarettes “lure” former smokers into nicotine dependence.  Even if this did occur, it would not be a legitimate reason to deny current smokers access to them.  There is no proof that e-cigarettes delay cessation among current smokers.  In fact, Dr. Pearson writes that “The [KnowledgePanel] survey data suggested that some smokers who were interested in quitting were using [e-cigarettes] as cessation devices…” She asserts that this was “possibly discouraging the use of proven smoking cessation treatments…”  As I discussed several weeks ago (here), pharmaceutical nicotine products are “proven” to fail for 93% of smokers; this is enough to discourage their use.

Dr. Pearson and colleagues opine that, “Given the widespread availability, awareness, and use of [e-cigarettes] by millions of consumers, [they] should not be marketed until adequately tested and regulated by the FDA.”  In the coming months, the FDA is likely to issue regulations for e-cigarettes as tobacco products. 

Already, millions of smokers are aware of e-cigarettes; a smaller number have used them; and many have learned that vaping is vastly safer than – and can successfully replace – smoking.

Wednesday, August 15, 2012

Federal Warnings Undermine Smokeless Tobacco Harm Reduction Messages

I recently discussed research showing that warnings on smokeless tobacco (ST or SLT) products discourage smokers from switching, while messages describing risk differentials between ST products and cigarettes encourage switching (here).

A new study provides further evidence that federally-mandated warnings in ST advertisements undermine the likelihood of comparative risk information motivating switching.  The study was published in the Journal of Consumer Affairs (abstract here) by Michael L. Capella, Charles R. Taylor and Jeremy Kees, professors in the School of Business at Villanova University.

Capella and colleagues modified Camel Snus advertisements to display a current federal health warning (“This product can cause mouth cancer”) with or without a harm reduction statement (HRS), such as “Using This Product is 90% Safer Than Cigarettes” or “Using This Product is 90% Less Hazardous Than Cigarettes.”  They measured the effect these messages had on perceptions of ST risks and the intention to use ST among smokers and non-smokers. 

The authors report, “In the presence of a conflicting message from the government, it is apparent that consumers are not easily swayed by the presence of an HRS…the presence of harm reduction information in an ad did not reduce smokers’ perceptions of the relative harm of SLT (vs. cigarettes) when a warning was present.  The most likely explanation for this is that the simultaneous presence of a government-mandated warning on the dangers of SLT offset the impact of the HRS…When smokers were presented with an HRS in an ad in the absence of any warning information, they reported higher beliefs that SLT is safer than cigarettes.”

This research demonstrates that federally-mandated warnings on ST products would essentially negate harm reduction messages.  The data also suggests that these warnings reinforce smokers’ mistaken beliefs that ST is as dangerous as cigarettes, effectively discouraging smokers from switching.  This is consistent with the federal government’s abstinence-only public health messaging, which basically abandons nicotine-addicted inveterate smokers.

For non-smokers, the results were promising: “While perceptions of SLT risk were generally lowered and attitudes toward SLT ads were significantly more positive as a result of exposure to harm reduction messages among nonsmokers, there was not a significant difference in intention to use SLT. Moreover, nonsmokers showed very low raw levels of intention to use SLT in any condition.  Thus, the argument that the inclusion of an HRS could help serve as a ‘gateway’ for nonsmokers is not supported by this study.”

Why did Capella and colleagues include non-smokers in their research?  They explain, “Under the law, promoting new SLT products associated with lower health risks as ‘harm reducing’ can be approved only if makers can demonstrate health benefits to society as a whole. The SLT products would need to be sure to not induce nonsmokers or would-be quitters to try SLT rather than abstaining.” (emphasis added).  In other words, a manufacturer must prove that an HRS will not induce a non-smoker, or a smoker who would otherwise quit smoking, to switch to ST. 

Capella and colleagues pefectly frame the question that the FDA must consider: “Specifically, switching to SLT reduces the risk of fatal heart and lung diseases because the tobacco is not incinerated. Hence, the primary question is no longer about whether SLT is considered by the scientific community to be of significantly less risk than cigarette smoking, but whether the population as a whole could benefit from information which communicates the relative risk of using SLT vs. smoking cigarettes.”

Scientific research would require the FDA to answer “Yes.”

Wednesday, August 8, 2012

The Surprising Economic Effects of Smoking & Quitting

Anti-tobacco forces often argue that smokers are a burden on the American economy.  When Congress debated FDA tobacco regulation in 2009, the White House advised that tobacco use “accounts for over a $100 billion annually in financial costs to the economy” (here).  In 2011, the CDC estimated smoking costs at $193 billion (here).

New data from a highly credible source reinforce a very different perspective on the issue.

In June, the non-partisan Congressional Budget Office (CBO) produced a financial analysis of a hypothetical federal cigarette tax increase (available here).  It reveals that quitting smoking is a money-saver for the government in some respects, and a money-loser in others.

Using standard methodology, the CBO studied the effects on the federal budget of “a hypothetical increase of 50 cents per pack in the federal excise tax on cigarettes and small cigars (adjusted each year to keep pace with inflation)…”  The analysis focuses mainly on the period 2013 to 2021, with long-term projections to 2085.

The CBO estimates that the tax increase would produce a gain of $41 billion through 2021.  Most of the gain ($38 billion) would come from increased tax revenues.  Another $3 billion would come from income tax receipts related to increased productivity among former smokers.

With respect to federal health care, “Medicaid would see the largest savings over the 2013-2021 period—about $560 million,” while “Medicare would have the next-largest savings in the near term—about $250 million.” 

But the CBO also reported some expenses related to cessation: “By contrast, Social Security’s Old-Age and Survivors Insurance program, which pays retirement benefits, would experience the largest net increase in costs because of the policy. On net, outlays for Social Security would rise by about $150 million over the 2013-2021 period.”

Medicaid/Medicare savings would exceed increased Social Security payments until 2025.  After that, Social Security increases due to increased longevity would exceed Medicaid/Medicare savings.

Not smoking is associated with increased longevity, which is associated with increased net costs for the health care system, rather than savings. 

A 2008 study from the National Institute for Public Health and the Environment, Tilburg University and Erasmus University in The Netherlands (access here) concluded that the average 20-year-old smoker would consume $270,000 in health care in their remaining lifetime, while the average “healthy-living” person would consume $345,000 (assuming the current euro/dollar conversion).  As the researchers explained, “…smoking is in particular related to lethal (and relatively inexpensive) diseases… Unfortunately, these life-years gained [by healthy living] are not lived in full health and come at a price: people suffer from other diseases, which increases health-care costs.”

Another study from The Netherlands (available here) in 1998 came to a similar conclusion: “From a humanitarian point of view, life is preferable to death and health to illness.  The aim of health care is not to save money but to save people from preventable suffering and death… There is no evidence that healthcare costs are increasing because citizens live unhealthier lives. In fact, quite the contrary would seem to be the case.”

Despite the research, the CDC refuses to consider smoking-related health care costs and savings.  This narrow perspective has been criticized by Vanderbilt economist Kip Viscusi: “It looks unpleasant or ghoulish to look at the cost savings as well as the cost increases and it's not a good thing that smoking kills people.  But if you're going to follow this health-cost train all the way, you have to take into account all the effects, not just the ones you like…” (quoted here). 

Wednesday, August 1, 2012

The Health Risks of Cigar Smoking

Cigarette smoking risks are well known, but cigars are also combustible tobacco products.  Do cigars present the same health risks as cigarettes?

Researchers from the Kaiser Medical Care Program, one of the nation's largest health care maintenance organizations, provided the answer in 1999 by publishing an excellent study on cigar smoking in the New England Journal of Medicine (abstract here).  They followed 16,228 never smokers and 1,546 cigar smokers - all men - for 25 years, and compared rates of several diseases among them.  Cigar smokers were divided into those smoking less than 5 cigars a day (let's call them moderate), and 5 or more (heavy).

Compared with never smokers, heavy cigar smokers were shown to have increased risks for several smoking related diseases.  They had higher risks for heart disease (Relative Risk, RR = 1.6, 95% confidence interval, CI = 1.2 – 2.0), emphysema (RR = 2.3, CI = 1.4 – 3.7), oral and pharynx cancer (RR = 7.2, CI = 2.4 – 21.2), and lung cancer (RR = 3.2, CI = 1.01 – 10.4).

The good news: Moderate cigar smokers had only a slightly higher risk for heart disease (RR = 1.2, CI = 1.03 – 1.4).  Those smoking fewer than 5 cigars daily had no significantly increased risks for stroke, emphysema, oral/pharynx cancer or lung cancer.

The comparable health risks of smokeless tobacco (ST), cigars and cigarettes are shown below.   

Health Risks Among Users of Tobacco Products
Disease Smokeless Tobacco Users Moderate Cigar Smokers Heavy Cigar SmokersCigarette Smokers
Heart DiseaseVery SmallVery SmallSmallSmall
StrokeNoneNoneNoneVery Small
Oral and Pharynx CancerNoneNoneModerateHigh
Lung CancerNoneNoneSmallHigh

Smokeless Tobacco Users - numerous epidemiologic studies discussed in this blog.
Cigars smokers - the Kaiser study discussed here.
Cigarette smokers - the Centers for Disease Control.

Risk Definitions:
None, No significant risk
Very small, Relative Risk (RR) < 2
Small, RR = 2 – 4
Moderate, RR = 4 – 8
High, RR > 8

Cigars, the data show, have few health effects when used in moderation.  One of the reasons that cigar (and pipe) smokers have lower risks than cigarette smokers is that they puff without inhaling.  In addition, they smoke less: 76 percent of cigar smokers in this study were in the moderate use group.  Those who smoke even fewer cigars probably have lower risks. 

Still, even moderate cigar smokers had a 20% increase in heart disease risk, which is consequential.  That increased risk is, however, of the same magnitude that most Americans experience when they eat meat (as compared to heart disease risk for vegetarians).  Lifestyle choices have consequences; consumers should use research results to inform their choices, including those concerning tobacco.

Cigarette smoking causes “preventable illness and premature death,” as U.S. Surgeon General David Satcher noted in 1999, but other tobacco products, including smokeless tobacco, cigars and pipes, have far fewer health risks.  Consumers should know the facts, weigh the implications, and make reasoned choices.