Smoking and health

1. Smoking and health Professor Martin Jarvis Department of Epidemiology & Public Health

2. Smoking as nicotine dependence • Nicotine the driving force • As with other drugs, complex interplay between pharmacology, learning mechanisms, social and economic influences in determining patterns of use

3. The major health consequences of smoking • Cancer • lung • mouth, larynx, throat, oesophagus • bladder, cervix, kidney, pancreas • COPD • Coronary heart disease • Stroke • Peripheral vascular disease • Pregnancy and birth complications

4. Mortality associated with smoking • At least 320 deaths every day from smoking in the UK, 120,000 per year • 1/5 all deaths across all ages • 1/4 all deaths in age group 35-64 years • 1 in 2 lifetime risk for smokers • 7.5 years average loss of life expectancy • Over half of the difference in risk of death in middle age between professional and unskilled men • 4 million deaths worldwide

5. Scenarios for future deaths from tobacco 520 500 Trend 400 300 Cumulative deaths from tobacco (millions) 220 200 70 100 0 1950 1975 2000 2025 2050 Year Source: Peto et al

6. Smoking is highly addictive • At least 70% of smokers want to give up • Less than half succeed before age 65 • 40% of heart attack smokers relapse while still in hospital within 2 days of intensive care • 50% of patients with laryngectomies try smoking again • 50% of patients with lung removed for lung cancer smoke again • More than half of heroin and cocaine users and alcoholics rate smoking harder to quit

7. Addiction

8. Starting point - the cigarette “The cigarette should be conceived not as a product but as a package. The product is nicotine. Think of the cigarette pack as a storage container for a day’s supply of nicotine….Think of the cigarette as the dispenser for a dose unit of nicotine…..Smoke is beyond question the most optimised vehicle of nicotine and the cigarette the most optimised dispenser of smoke”. William Dunn, Philip Morris, 1972

10. Nicotine Addiction in Britain Royal College of Physicians Feb 2000 Central conclusion: smoking is best understood as nicotine seeking behaviour • “Nicotine delivered rapidly to the brain in cigarette smoke should be recognised as a powerfully addictive drug on a par with heroin and cocaine, and tobacco products should be recognised as nicotine delivery systems.”

11. Rating IV nicotine and cocaine:Jones et al (1999) • Compared 3 doses of cocaine and nicotine given IV double-blind + saline placebo • Nicotine ‘high’ and ‘rush’ rated stronger than cocaine, also ‘jittery’ • Nicotine frequently misidentified as cocaine, and, at highest dose, an opiate

15. Nicotine as a drug of dependence • Blood nicotine from cigarettes, snuff (oral and nasal) and cigars very similar • IV nicotine suppresses smoking • Nicotine intakes from different brands of cigarette very similar

16. Nicotine as a drug of dependence • Nicotine withdrawal syndrome • Effect of nicotine replacement on successful quitting

17. Self-assertion . . . “To account for the fact that the beginning smoker will tolerate the unpleasantness we must invoke a psychosocial motive. Smoking a cigarette for the beginner is a symbolic act. The smoker is telling his world, 'This is the kind of person I am.' Surely there are variants of this theme, 'I am no longer my mother's child,' 'I am tough,' 'I am not a square.' Whatever the individual intent, the act of smoking remains a symbolic declaration of personal identity . . .” Philip Morris (Bates no. 1003287836)

18. . . . and addiction “ . . . As the force from the psychosocial symbolism subsides, the pharmacological effect takes over to sustain the habit . . .” Philip Morris 1969 document (Bates no. 1003287836)

19. Addiction -

20. Factors favouring study of smoking as compared with other drug taking behaviours • High prevalence • Legal • Little stigma, so self-reports largely accurate • Unlike alcohol, excellent biomarker of intake available

21. Cotinine as a biomarker of nicotine intake • Main nicotine metabolite (70-80% converted) • Half-life 16-20 hours • Measurable in saliva, blood or urine • Quantitative measure of nicotine intake: 10ng/ml cotinine in blood ~ 1mg nicotine daily

28. Disadvantage and Smoking • A whole range of indicators of disadvantage predict who smokes • Cigarette smoking prevalence tightly linked to deprivation, mainly because of low rates of quitting in disadvantaged groups

29. Indicators of socio-economic status • Occupational class • Educational level • Housing tenure • Car ownership • Unemployment • Living in crowded accommodation • Single parenthood • Divorced or separated

30. Disadvantage and smoking • Poor people are: • More likely to take up smoking • Less likely to quit • More heavily exposed to other people’s smoke • Become more nicotine dependent • Much more likely to die prematurely from smoking

34. Some implications of nicotine addiction for cessation and harm reduction • Ineffective • cutting down • switching to cigars or a pipe • switching to low tar • Effective • Nicotine replacement products

37. One year success rates by intensity of intervention: • Unaided quit attempt …………………...…..….1-2% • Brief GP advice ……………………………...……5% • Brief GP advice + NRT ……………………….…10% • Intensive clinic support ………………………...15% • Intensive clinic support + NRT……………..20-30%

38. Scenarios for future deaths from tobacco 520 500 Trend 400 300 Cumulative deaths from tobacco (millions) 220 200 70 100 0 1950 1975 2000 2025 2050 Year Source: Peto et al

39. Scenarios for future deaths from tobacco 520 500 500 Trend If smoking uptake halves 400 by 2020 300 Cumulative deaths from tobacco (millions) 220 200 70 100 0 1950 1975 2000 2025 2050 Year Source: Peto et al

40. Scenarios for future deaths from tobacco 520 500 500 Trend If smoking uptake halves 400 by 2020 340 300 Cumulative deaths from tobacco (millions) 220 If adult smoking halves by 2020 200 190 70 100 0 1950 1975 2000 2025 2050 Year Source: Peto et al

41. Conclusions • Nicotine’s legal status and lack of adverse effects on performance have hampered recognition of its status as a drug of dependence • Nicotine is pharmacologically a hard drug, on a par with heroin and cocaine • Cigarette smoking is by far the biggest problem of drug dependence in the UK