State-Wide Smoking Bans: Little to No Impact on Heart Attack Deaths

My research group just published a study documenting that the implementation of state-wide smoking bans in California, Utah, Delaware, South Dakota, New York and Florida had little or no immediate measurable effect on deaths from heart attack (acute myocardial infarction, AMI). The study was published in the Journal of Community Health (here).

Nicholas Peiper, Phil Cole and I studied the AMI death rate in those states before and after smoking bans were implemented, comparing those rates to historical and national trends. The results are illustrated in the figure.

The state-wide bans had no effect in California, Utah, Delaware or South Dakota (the AMI death rate actually increased almost 9% in South Dakota during the target year). But after bans in Florida and New York in 2003, AMI death rates declined 9% and 12% respectively, which exceeded the expected declines based on historical trends in those states. However, they were not significantly different from the 10% decline in the 44 states that did not have smoke-free ordinances in 2004.

Since 2004 several published reports have claimed that smoking bans in small cities result almost immediately in reductions in heart diseases. For example, in Helena, Montana hospital admissions for acute myocardial infarction (AMI) declined 40%, from 40 before to 24 after implementation of a smoke-free ordinance (here). In Pueblo, Colorado, AMI admissions dropped 27%, from 399 before to 291 over a 1.5-year period following a ban, and the authors reported that the decline occurred “within months” of implementation (here). In Bowling Green, Ohio, hospital admissions for ischemic heart disease and heart failure fell from 36 before to 22 after a ban (here), and in Monroe County Indiana, hospital admissions for AMI among non-smokers declined from 17 before to 5 after a ban (here).

But there are two problems with these claims. First, it’s dangerous to make big claims based on tiny numbers. Phil Cole and I presented evidence that the Helena and Pueblo findings “are consistent with random variation because of the small number of observations on which they are based.” (here).

Second, none of the previous reports accounted for the long-term downward trend in heart disease in the U.S. In our study smoking bans might have taken the credit for the 9% decline in Florida and the 12% drop in New York if the historic drop in AMI that occurred throughout the U.S. in 2004 was ignored. The figure above shows the impressive decline in American heart attack deaths since 1991.

We concluded that “Smoke-free ordinances may serve public health objectives by providing non-smokers with indoor environments that are free from irritating and potentially harmful pollutants. However, this study does not provide evidence that these ordinances result in a measurable immediate reduction in AMI mortality of the magnitude claimed by reports based on very small incident numbers.”

Switch and Quit Owensboro (Kentucky)

A University of Louisville public health initiative is reaching out to thousands of adult smokers in Owensboro, encouraging them to quit with assistance from the unlikeliest of sources — tobacco. The “Switch and Quit Owensboro” campaign is based on scientific evidence that switching from cigarettes to smoke-free tobacco products provides almost all of the health benefits of complete tobacco abstinence.

Switch and Quit Owensboro is the first community-based quit smoking program based on principles of tobacco harm reduction. Switching to a safer form of tobacco that satisfies smokers’ addictive desire for nicotine helps smokers quit cigarettes, and gain longer and healthier lives.

The campaign includes print, radio, billboard, social media and cinema public service messages. It is aimed primarily at adult inveterate smokers -- those who are unable or unwilling to quit using conventional approaches that emphasize total tobacco abstinence.

At the start of the campaign, an astounding 15,000 cartons of cigarettes were sold per week in Owensboro/Daviess County. Cigarette sales should decline when smokers learn about safer, satisfying smoke-free substitutes. Visit the campaign website here.

Switch and Quit Owensboro is a program of the University of Louisville James Graham Brown Cancer Center, which is committed to the prevention and treatment of cancer. The campaign aims to prevent the estimated 220 smoking-related deaths that occur in Owensboro and Daviess County, Kentucky every year.

How Many Americans Smoke?

Surprisingly, the answer is either 45.3 million or 52.7 million in 2010, depending on which federal agency does the counting. This wide variance underscores the discordant findings from government smoking data.

National statistics on smoking are provided by two federal surveys, the National Health Interview Survey (NHIS) and the National Survey on Drug Use and Health (NSDUH). I have conducted research on the differences between these two surveys (here) and I previously wrote a blog on the topic (here).

Federal officials released fresh data from both surveys last week, making the discrepancies even more stark.

The Office on Smoking and Health at the Centers for Disease Control and Prevention (CDC) counted 45.3 million American smokers, using the NHIS (available here). This number has not changed much in over 20 years. In 1990, the CDC reported that there were 45.8 million adult smokers. But as the U.S. population has grown, the percentage of smokers has declined. In 1990, smokers made up 25.5% of the adult population; by 2010, prevalence had declined to 19.3%.

The CDC notes that, “If current patterns continue, smoking prevalence is projected to fall to approximately 17% in 2020, and the national Healthy People objective to reduce smoking prevalence to < 12% will not be met.” That’s an understatement. In 1998, the government set 2010 as the target for 12% smoking prevalence (available here). That proved to be a pipedream, and the 2020 goal will prove equally unattainable. One is reminded of Albert Einstein’s definition of insanity: doing the same thing over and over again and expecting different results.

Last week, the Substance Abuse and Mental Health Services Administration, which administers NSDUH, released “selected” 2010 survey information (here). They estimated the number of smokers at a whopping 70 million, including teenagers, but they did not break out the number of adult smokers. The 2009 NSDUH survey reported 52.7 million adult smokers; the 2010 estimate likely will be similar.

It is unacceptable that two federal surveys differ by over 7 million in their adult smoking counts. Even worse is the way the government uses the divergent data to spin different stories about smoking. They use the lower NHIS numbers to boast about declining smoking rates, which they attribute to higher taxes and smoking bans. They use the higher NSDUH numbers to argue for even more onerous anti-tobacco measures.

My research (here) has explored why the NHIS and NSDUH estimates are so divergent. I have called for officials to investigate and resolve these problems so that national tobacco policy can be guided by accurate smoking data.

Insights From E-cigarette Users

When e-cigarette enthusiasts held a Vapefest in Philadelphia in March, Jonathan Foulds, a tobacco researcher at the Penn State University College of Medicine in Hershey, collected information from 104 attendees, using a 55-question survey. Dr. Foulds is the lead author on the resulting manuscript, published by the International Journal of Clinical Practice (abstract here).

About three quarters of the users were men, with an average age of 34 years; almost 80% had not used a traditional tobacco product in the past 30 days. The average duration of smoking was 16 years, and they had smoked an average of 25 cigarettes per day. The average number of quit attempts was nine. Nearly two thirds of e-cigarette users had unsuccessfully tried FDA-approved smoking cessation medications, and three quarters had tried to quit “cold turkey.” Over half had used e-cigarettes for over one year. Most participants planned to continue using e-cigarettes for at least another year; they reported that the average weekly cost was about $13.

The event attendees were e-cigarette enthusiasts, so it is not surprising that few of them used major brands that are widely available in convenience stores (such as NJOY and Smoking Everywhere). These brands have rechargeable batteries and replaceable cartridges. Instead, there was a preference for brands that have larger batteries with an extended life expectancy (eGo, Joye and Riva); the most experienced users preferred even more exotic hardware (Omega, Silver Bullet, Helix).

The findings are informative but not necessarily representative of e-cigarette users generally. However, it is likely that Philly Vapefest participants were inveterate smokers who, by switching to a form of smoke-free tobacco, substantially reduced their risk of contracting a smoking-related illness. Foulds and colleagues acknowledge that “the health risks from smoking are large and are known with certainty. Comparatively, the health risks from e-cig use are likely much smaller (if any) and temporarily switching to e-cigs will likely yield a large health benefit.” However, they inexplicably conclude that “current smokers who are interested in quitting smoking should be strongly directed towards evidence-based treatments (counseling, and approved medicines like nicotine replacement, bupropion or varenicline), rather than to e-cigs.”

Foulds and colleagues write that “we do not know enough about e-cigs to recommend them to patients.” Still, they must know that the “evidence” for evidence-based treatments is not compelling. Nicotine medicines have a 93% failure rate (here), and bupropion and varenicline are fraught with potentially serious side effects (here).

Many health professionals wrongly believe that smoking is an illness requiring treatment. In fact, smoking is a lifestyle choice – albeit an addictive and risky one – for which people need satisfying and safer substitutes. This is the core philosophy of tobacco harm reduction, and of this blog.

The Scientific Foundation for Tobacco Harm Reduction, 2006-2011

In 2006, the American Council on Science and Health (ACSH) became the first American scientific organization to formally endorse tobacco harm reduction. Their position was based on a Harm Reduction Journal review article (available here), authored by me and William Godshall, director of Smoke-Free Pennsylvania.

Over the past five years, interest in tobacco harm reduction has expanded exponentially, with a concomitant increase in the number of published studies. ACSH asked me to review and analyze influential contributions to the scientific and medical literature, and to discuss issues that continue to stimulate debate. My review, “The Scientific Foundation for Tobacco Harm Reduction, 2006-2011,” has just been published by the Harm Reduction Journal (available here).

Numerous epidemiologic studies and subsequent meta-analyses confirm that smokeless tobacco (ST) use is associated with minimal risks both for cancer and for myocardial infarction; a small increased risk for stroke cannot be excluded. Studies from Sweden document that ST use is not associated with benign gastrointestinal disorders or with chronic inflammatory diseases. Although any form of nicotine should be avoided during pregnancy, the highest risks for the developing baby are associated with smoking. It is documented that ST use has been a key factor in the declining rates of smoking and of smoking-related diseases in Sweden and Norway. For other countries, the potential population health benefits of ST are far greater than the potential risks.

In follow-up studies, dual users of cigarettes and ST are less likely than exclusive smokers to achieve complete tobacco abstinence; however, they are also less likely to be smoking. The health risks from dual use are probably lower than those from exclusive smoking.

E-cigarette users are not exposed to the many toxicants, carcinogens and abundant free radicals formed when tobacco is burned. Although laboratory studies have detected trace concentrations of some contaminants, pending FDA regulation of e-cigarettes as tobacco products is likely to remedy this issue. There is limited evidence from clinical trials that e-cigarettes deliver only small doses of nicotine compared with conventional cigarettes. However, e-cigarette use emulates the cigarette handling rituals and cues of cigarette smoking, which suppresses craving and withdrawal that is not entirely attributable to nicotine delivery.

I will end this post with the same quote that ended my review. It is from the outstanding policy paper “Tobacco harm reduction: how rational public policy could transform a pandemic,” by David Sweanor, Philip Alcabes and Ernest Drucker, published in the International Journal of Drug Policy in 2007 (available here):

"The relative safety of ST and other smoke-free systems for delivering nicotine demolishes the claim that abstinence-only approaches to tobacco are rational public health campaigns...Applying harm reduction principles to public health policies on tobacco/nicotine is more than simply a rational and humane policy. It is more than a pragmatic response to a market that is, anyway, already in the process of undergoing significant changes. It has the potential to lead to one of the greatest public health breakthroughs in human history by fundamentally changing the forecast of a billion cigarette-caused deaths this century."

E-Cigarettes - No Toxic Effects from Inhaled Propylene Glycol Aerosol

One of the key ingredients in many e-cigarette liquids is propylene glycol (PG), described by Wikipedia (here) as a “colorless, nearly odorless, clear, viscous liquid with a faintly sweet taste…” The entry also explains that PG is used “as a moisturizer in medicines, cosmetics, food, toothpaste, shampoo, mouth wash, hair care and tobacco products…, in smoke machines to make artificial smoke for use in firefighters' training and theatrical productions” and “as a moisture stabilizer (humectant) for snus” among many other applications.

A new study provides valuable information about the toxicological profile of inhaled PG aerosols in laboratory animals; it also provides an excellent general review of the agent. The authors are Michael Werley, a scientist at Altria, and colleagues from Charles River Laboratories (Scotland), WIL Research Laboratories, Battelle Memorial Institute and Virginia Commonwealth University. It was published in the journal Toxicology (abstract here).

The investigators exposed rats and dogs to high concentrations of PG aerosol for up to 28 days, followed by comprehensive systemic evaluations, especially involving the respiratory system.

They report, “In general, these studies confirmed the relatively low toxic potential of [aerosol] PG, administered by various dose routes, including the inhalation route…in the dog, no histopathological effects on the [larynx, trachea and lung] tissues were observed.” The investigators noted decreases in some assessments of red blood cells in dogs treated for 28 days, but “these effects were not clinically significant in the dog and had no effect upon their activity of health”, and “the values still within the normal historical ranges for dogs of this age, strain and sex.”

Werley and colleagues added that, “overall, PG inhalation exposure in rats and dogs produced quite limited toxicological findings, and allowed us to conclude that [aerosol] PG exposures could be conducted safely in man by the inhalation route…”

This study assessed the effects of short-term exposure to PG vapor, but the effects of long-term (months or years) exposure are unknown and unknowable. However, it provides valuable information for e-cigarette users and policy makers. First, even high concentrations of PG vapor don’t have any measurable harmful effects, which is fully consistent with its designation by the FDA as “generally recognized as safe” as a food additive for all food categories up to 2% (here). Just as important, there will be no impact on bystanders from “second-hand” exposure to e-cigarette vapor, if it occurs at all.

How to Use Smokeless Tobacco: A Primer for Smokers

If you have been directed to this page, you want to go to my update on products for smokers here.

This blog is devoted to correcting myths and misconceptions about tobacco harm reduction. Here is some practical advice on to make the switch to smoke-free tobacco products.

1. Pick the right product. Choose a pouch -- a small “teabag” containing tobacco and flavors -- or try one of the other products from this list and decide which works best for you. There are many options, so don’t be discouraged if one product doesn’t fit your lifestyle or taste.

2. If you’re using a pouch, put it in the right place. Place it under your upper lip, near the corner of your mouth. Most smokeless tobacco users put products behind their lower lip – a practice that generates tobacco juice and leads to spitting. In Sweden, snus users tuck the product behind their upper lip, where it’s spit-free and invisible. Simply pop a pouch in your mouth and move it in place with your tongue. Alternatively, pull your upper lip out with your fingers and position the pouch. At first, the pouch will feel like a cannonball. Look in the mirror, and you’ll see that it’s hardly noticeable.

3. Get your nicotine buzz, but don’t overdo it. When you inhale cigarette smoke, you get an immediate nicotine kick. The effect from smokeless tobacco takes longer, but slower nicotine uptake also means slower nicotine decline. One- or two-pack-a-day smokers who switch often need to use only 4 or 5 smokeless pouches… saving money.

Light and ultra light smokers might get too much nicotine from some smokeless products. Choose one that’s satisfying but not overwhelming.

At first, use the smokeless product for only a few minutes. You’ll learn how much time you need to get tobacco satisfaction.

4. Expect the unexpected. You might feel minor burning where you place the tobacco, and your throat might get irritated. This is from the nicotine, and it’s normal. Sipping some water or a beverage can help. You may get the hiccups, feel dizzy or experience an upset stomach, but these minor symptoms will quickly disappear.

5. Stick to the switch. Although some smokers make the transition quickly, smoke-free tobacco products don’t automatically “cure” you of wanting another cigarette. These products will make it easier to quit and they’ll make those cravings less intense, but they don’t entirely replace the smoking ritual. If you’ve smoked for years, breaking the habit can still be a challenge.

Remember, it’s the smoke that kills. Stay committed to being smoke-free.