Tobacco control

E-cigarettes do not improve smoking cessation, survey finds

Posted by

0


The use of e-cigarettes as a smoking cessation method did not significantly prevent relapse or successful termination, according to survey findings published in Tobacco Control.

“This is the first survey in which e-cigarettes were less popular as a smoking cessation aid than FDA-approved pharmaceutical aids,” John P. Pierce, PhD, a distinguished professor at the Herbert Wertheim School of Public Health and Human Longevity Science at UC San Diego and UC San Diego Moores Cancer Center, said in a press release. “Not only were e-cigarettes not as popular, but they were associated with less successful quitting.”

Recent former smokers who reported cigarette abstinence used
Chen R, et al. Tob Control. 2022;doi:10.1136/tobaccocontrol-2021-056901.

Pierce and colleagues evaluated data from the nationally representative PATH cohort study to determine the effectiveness of e-cigarettes as a smoking cessation aid from 2017 — when sales for nicotine e-cigarettes increased in the U.S. — to 2019. The analysis included 3,578 participants who were established smokers in 2016 with a recent quit attempt and 1,323 recent former smokers.

E-cigarette use

Between 2016 and 2017, there was a more than 40% growth in sales for e-cigarette products in the U.S., according to the researchers.

In 2017, 12.6% (95% CI, 11.3-13.9) of smokers who recently attempted to quit reported using e-cigarettes as a cessation aid (8.7% e-cigarettes only, 3.2% e-cigarettes and nicotine replacement therapy/pharmaceutical aid, 0.5% e-cigarettes and other tobacco products, and 0.2% three or more products). This marked a decline from 17.4% in 2016, according to Pierce and colleagues.

Only 2.2% (95% CI, 0-4.4) of recent former smokers said they switched to a high nicotine e-cigarette. These products were most often used as a cessation aid by respondents aged 18 to 50 years compared with those aged older than 50 years. Also, non-Hispanic white individuals, those who attended college, those with higher incomes and daily smokers were more likely to report using e-cigarettes.

Other cessation aids

Meanwhile, 2.5% (95% CI, 1.9-3.1) of respondents reported using a non-e-cigarette tobacco product as a cessation aid and 20.6% (95% CI, 18.9-22.3) used a nicotine replacement therapy or pharmaceutical aid only. The researchers reported that most respondents (64.3%) attempted the “cold turkey” method, in which no products were used.

Smoking cessation

Among respondents who reported cigarette abstinence, 18.6% (95% CI, 16-21.2) said they did not use any aids. In contrast, a lower proportion (9.9%; 95% CI, 6.6-13.2) said they used e-cigarettes.

The results further showed that e-cigarettes were associated with lower abstinence rates at 12 or more months compared with pharmaceutical aids (adjusted risk difference [aRD] = 7.3%; 95% CI, 14.4 to –0.4) or any other method (aRD = 7.7%; 95% CI, 12.2 to –3.2), according to Pierce and colleagues.

Although the finding was insignificant, the researchers also noted that respondents who switched to e-cigarettes appeared to have a higher relapse rate than those who did not switch to e-cigarettes or other tobacco products. By 2019, nearly 60% of recent former smokers who used e-cigarettes daily had resumed cigarette smoking.

While randomized clinical trials show improved cessation with e-cigarettes, they are often not conducted under “optimal conditions” and do not reflect “the effectiveness of the product in community settings,” Pierce and colleagues wrote.

An epidemic

“There is good evidence that [e-cigarettes] have become the initiation product of choice for adolescents,” Pierce told Healio. “The Surgeon General has labeled this an epidemic. Some are concerned that this effect on teens may be wiping out all of the successes in tobacco control over the past 3 decades.”

When talking to patients about smoking cessation, “clinicians can correct patient misperceptions that e-cigarettes will make their quit attempt more successful,” he said.

According to Pierce, individuals who smoke are advised to mix and match approved cessation aids. As an over-the-counter option, nicotine replacement therapy is the most popular aid, he said. It is often used in combination with varenicline or Zyban (bupropion hydrochloride, GlaxoSmithKline), he added.

In September, Pfizer voluntarily recalled all lots of its varenicline product Chantix “due to the presence of unacceptable N-nitroso-varenicline levels,” according to the FDA. The agency approved a generic version of varenicline (Par Pharmaceutical) in August.

References:

Adoption of e-cigarettes for smoking cessation in 2017 low and ineffective. https://ucsdnews.ucsd.edu/pressrelease/adoption-of-e-cigarettes-for-smoking-cessation-in-2017-low-and-ineffective. Published Feb. 7, 2022. Accessed Feb. 11, 2022.

Chen R, et al. Tob Control. 2022;doi:10.1136/tobaccocontrol-2021-056901.

Endo launches first and only generic version of Chantix (varenicline) tablets in the United States. https://investor.endo.com/news-releases/news-release-details/endo-launches-first-and-only-generic-version-chantixr. Published Sept. 22, 2021. Accessed Feb. 16, 2022.

FDA updates and press announcements on nitrosamine in varenicline (Chantix). https://www.fda.gov/drugs/drug-safety-and-availability/fda-updates-and-press-announcements-nitrosamine-varenicline-chantix. Published Sept. 17, 2021. Accessed Feb. 16, 2022.

Laboratory analysis of varenicline products. https://www.fda.gov/drugs/drug-safety-and-availability/laboratory-analysis-varenicline-products. Published Aug. 23, 2021. Accessed Feb. 16, 2022.

The Effect of Tobacco Control Measures during a Period of Rising Cardiovascular Disease Risk in India: A Mathematical Model of Myocardial Infarction and Stroke.

Posted by

0


Abstract

Background

We simulated tobacco control and pharmacological strategies for preventing cardiovascular deaths in India, the country that is expected to experience more cardiovascular deaths than any other over the next decade.

Methods and Findings

A microsimulation model was developed to quantify the differential effects of various tobacco control measures and pharmacological therapies on myocardial infarction and stroke deaths stratified by age, gender, and urban/rural status for 2013 to 2022. The model incorporated population-representative data from India on multiple risk factors that affect myocardial infarction and stroke mortality, including hypertension, hyperlipidemia, diabetes, coronary heart disease, and cerebrovascular disease. We also included data from India on cigarette smoking, bidi smoking, chewing tobacco, and secondhand smoke. According to the model’s results, smoke-free legislation and tobacco taxation would likely be the most effective strategy among a menu of tobacco control strategies (including, as well, brief cessation advice by health care providers, mass media campaigns, and an advertising ban) for reducing myocardial infarction and stroke deaths over the next decade, while cessation advice would be expected to be the least effective strategy at the population level. In combination, these tobacco control interventions could avert 25% of myocardial infarctions and strokes (95% CI: 17%–34%) if the effects of the interventions are additive. These effects are substantially larger than would be achieved through aspirin, antihypertensive, and statin therapy under most scenarios, because of limited treatment access and adherence; nevertheless, the impacts of tobacco control policies and pharmacological interventions appear to be markedly synergistic, averting up to one-third of deaths from myocardial infarction and stroke among 20- to 79-y-olds over the next 10 y. Pharmacological therapies could also be considerably more potent with further health system improvements.

Conclusions

Smoke-free laws and substantially increased tobacco taxation appear to be markedly potent population measures to avert future cardiovascular deaths in India. Despite the rise in co-morbid cardiovascular disease risk factors like hyperlipidemia and hypertension in low- and middle-income countries, tobacco control is likely to remain a highly effective strategy to reduce cardiovascular deaths.

Discussion

Substantial evidence links tobacco use to CVD, yet tobacco use in India and several other LMICs is on the rise . This worsening trend led the UN High Level Meeting on Prevention and Control of Non-Communicable Diseases to recommend that countries accelerate implementation of the FCTC. Our findings indicate that full implementation of key FCTC articles in India would yield substantial reductions in mortality from myocardial infarctions and stroke, despite projected increases in other risk factors for CVD such as hypertension and diabetes. Far from achieving “diminishing returns,” vigorous implementation of these tobacco control policies would be expected to avert 25% of all predicted CVD deaths, equivalent to over 9 million averted deaths, over the decade 2013 and 2022 under a reasonable set of modeling assumptions.

Furthermore, the population-level benefits of implementing strong tobacco control policies were five times greater than a similarly aggressive program to implement pharmacological interventions (Figure 3), assuming that India’s implementation of pharmacological therapy is no faster than in high-income nations like the UK. However, critically, we would anticipate additive benefits of implementing pharmacological interventions concurrently with strong tobacco control policies: the combined package of both pharmacological and tobacco control interventions would not be redundant, and could avert nearly a third of cardiovascular and cerebrovascular mortality over the next decade by tackling multiple risk factors for myocardial infarctions and strokes.

Among the interventions we simulated, smoke-free legislation and tax increases on both cigarettes and bidis were the most effective at the population level. Smoke-free legislation, an advertising ban, and a mass media campaign had wide confidence intervals because their degree of population effectiveness was subject to the degree of effective enforcement.

We used, to our knowledge for the first time, population-representative data to represent the co-morbid risks of CVD among both urban and rural populations in India, and among both men and women in multiple agegroups. We found that nearly all sectors of Indian society were likely to benefit from both tobacco control and pharmacological therapies. However, the populations benefiting most were urban males and persons in the 60- to 69-y-old age category. This is due to the higher baseline prevalence of co-morbid risk factors among urban males and this older age group; hence, these populations achieve greater risk reduction from the simulated interventions.

 

Conclusion

Given the complexities of India’s tobacco and CVD epidemics, it is important to understand how heterogeneities within the large Indian population may affect both the risk of disease as well as the impact of various policy and health care interventions. In this study, we provide to our knowledge the first model that incorporates population-representative data from India disaggregated by age, gender, and location for all of the major CVD risk factors as well as for specific types of tobacco use. Prior models have either used “average” Indian or regional disease rates, have not captured various types of tobacco use other than smoking, or have not incorporated the multiple risk factors affecting CVD in addition to tobacco use. This means that, for the first time, we can study some health disparities in CVD and in tobacco use within the large and varied Indian population, as well as heterogeneity in the impact of proposed interventions. These results provide clear justification for India’s Ministry of Health and Family Welfare to engage in greater enforcement of the FCTC and the Indian legislation that enacts the FCTC in the country, the Cigarettes and Other Tobacco Products Act.

Our simulations suggest that the implementation of recommended tobacco control interventions in India would yield substantial and rapid health benefits, but those benefits may accumulate most among males, urban dwellers, and older adults. Effective implementation of FCTC provisions remains a major challenge in India. At present, smoke-free legislation in India is not comprehensive and is poorly enforced . There is little indication that brief cessation advice is routinely administered, and additional resources may be required to strengthen implementation. Tobacco taxes in India would also need to be substantially increased and harmonized between different tobacco products to comply with WHO recommendations, and achieve desired population-level disease reductions . Cigarettes are currently taxed according to their physical length in India, meaning that uniform tax increases will encourage product substitution unless large price differentials between products are addressed.

Optimizing preventive interventions for CVD remains a significant challenge for developing countries like India. Our model demonstrates synergies between tobacco control and pharmacological therapies for key CVD risk factors. It does not, however, support the idea that enhanced prevalence of key risk factors renders diminished results from tobacco control interventions. Rather, policymakers should take note that fuller and faster implementation of existing FCTC provisions would likely be a substantial boon to efforts to reduce CVD mortality in India and other LMICs.

Source: PLOS

Judith MacKay: self-made scourge of the tobacco industry.

Posted by

0


PIIS0140673613609691.fx1.lrg

 

Judith MacKay learned early on in her career to wear insults as a badge of pride. “A gibbering satan”, prone to the use of “diatribes full of putrid corruption, lies, conspiracy, and total censorship” is just a taste of the many slurs that came MacKay’s way in the early 1990s. What MacKay had done to merit such attacks from US smokers’ rights groups was what she has been doing since the early 1980s: tirelessly and effectively advocating for better control of tobacco products around the world, but in Asia in particular.

As MacKay and her colleagues explain in their paper on Tobacco Control in The Lancet, as well as being one of the biggest markets for tobacco, Asia has also been at the forefront of efforts to control its use. MacKay has been a central figure in that cause. Born in Saltburn by the Sea on the UK’s northeast coast, MacKay moved to Hong Kong with her husband in 1967 after graduating in medicine from the University of Edinburgh at the age of just 22 years. And after a brief hiatus to do what she calls “a few traditional things like having babies”, and brushing up on her Cantonese, her increasing involvement with the feminist movement led MacKay to think more seriously about a long-term career.

She went back to medicine, and as a specialist in internal medicine at Hong Kong University’s hospital MacKay started to see more and more patients with tobacco-related diseases. It dawned on her that there was a pressing need “to go further up the river in public health terms”, and at the same time, she says, she was “very interested in health education, and was writing 1000 words a week for the South China Morning Post for a column on women’s health”. It was the “ballistic”, vitriolic response of the tobacco industry to a series of MacKay’s articles on women and tobacco that finally affirmed tobacco control in her mind as the cause to which she should devote her life’s work. “I left clinical medicine in 1984”, she says, “and I never looked back really”.

So how do you go about setting yourself up to influence government tobacco policy? It’s not something, as a rule, that tends to come up in medical curricula. “I was never trained on how to lobby a finance minister for a tax increase, or put out a press release, or front up to a very powerful industry”, says MacKay. But she was steadfast in the face of industry intimidation and, importantly, “she had the ear of governments because she has a persuasive style rather than confrontational approach—a skill much appreciated when dealing with conservative style Asian governments”, says Mary Assunta, Director of the International Tobacco Control Project run by Cancer Council Australia.

Working alone and often unpaid for 25 years, MacKay’s appointment in 2006 as Senior Advisor to both the World Lung Foundation component of the Bloomberg Initiative to Reduce Tobacco Use in low-income and middle-income countries and the Bill and Melinda Gates Foundation reflects the huge change in attitudes towards tobacco over the intervening years. “It’s institutionalised now”, she says: “it’s become mainstream public health in a way, whereas back in the 70s and 80s it was seen as very quirky. There was a caution and a real feeling that somehow I’d gone off the main tracks of medicine, but nowadays the understanding is much wider than it was before.” Through the WHO Framework Convention on Tobacco Control to new funding from Bloomberg and the Bill and Melinda Gates Foundation, there is a real momentum now behind tobacco control. “Almost every day I get something in the inbox about a new law that’s been created or expanded or implemented”, MacKay says. But there is also a real need to ensure that progress does not breed complacency.

The tobacco industry is no different than it has ever been, MacKay warns, although their tactics have evolved. “They’ve tried to attack the science, then moved on to attacking individuals like myself, and now they’ve moved to attacking governments”, she says. The Australian Government’s recent decision to introduce plain packaging for cigarettes attracted a lengthy challenge in the Australian High Court, along with an ongoing dispute in the World Trade Organisation. It’s a familiar story according to MacKay. “In the same week, the Minister of Health from Scotland and the Minister of Health from Iran said the same thing to me: ‘we’re bogged down with legal challenges’. It’s a delaying tactic, and they’ve delayed some legislation in India for example for almost a decade”, she notes. But apart from delaying the adoption of graphic warning labels on cigarette packaging in the USA, these challenges have been unsuccessful. “It’s a paper tiger”, she says.

The same can’t be said of MacKay herself, and she is in no doubt that over the next few years she can help persuade more governments to start setting targets and consider endgames, such as New Zealand’s recent announcement of a goal to reduce smoking prevalence to 5% by 2025. An endgame for MacKay, though, is something she’ll not be considering any time soon. “That’s the wonderful thing about public health, you can go on forever”, she says. “I really quite seriously think I’ll be campaigning on my 100th birthday.” And for the tobacco industry representatives who she assures me will be poring over this article, there can’t be much worse news than that.

Source: Lancet

 

 

Changing Social Norms about Tobacco Use, One Campus at a Time

Posted by

0


As the Assistant Secretary for Health, I have the honor of advancing a broad portfolio of public health issues on behalf of the Department of Health and Human Services (HHS). An overriding priority is reinvigorating our national commitment to tobacco control. The first-ever HHS Strategic Action Plan for Tobacco Control, entitled Ending the Tobacco Epidemic: A Tobacco Control Strategic Action Plan, commits the department to mobilizing leadership to encourage proven, pragmatic, and achievable interventions at the federal, state, and community levels.

Among other things, the action plan commits to reducing the initiation of tobacco use among young adults, a topic with special relevance to institutions of higher learning. Furthermore, the 31st Surgeon General’s Report on Tobacco, released in March, highlighted some startling statistics pertinent to this goal. Preventing Tobacco Use among Youth and Young Adults notes that 90 percent of all smokers start before age 18, and 99 percent start before age 26. Of concern, progression from occasional to daily smoking frequently occurs during the initial years following high school. Indeed, the number of smokers who initiated smoking after age 18 has increased substantially over the past decade—from 600,000 in 2002 to 1 million in 2010.

The report cites reasons for these disturbing trends. Tobacco industry expenditures related to marketing, promotion, and advertising of tobacco products exceed $1 million per hour—totaling more than $27 million a day. Targeted messages and images portray tobacco use as a desirable and appealing activity. As a result, smoking represents the current social norm in many movies, video games, websites, and communities, thereby promoting a culture that fosters tobacco dependence and disease.

Restoring the social norm to one that, instead, promotes wellness and health requires a commitment to smoke-free and tobacco-free environments.

The Affordable Care Act, the health care law of 2010, is also part of our comprehensive approach toward turning this goal into reality. Most health plans must now cover—without cost-sharing—tobacco-use screening and interventions for tobacco users. The law also makes it easier and more affordable for young adults to get health insurance coverage, by allowing them to stay on their parents’ employer-sponsored or individually purchased health plans.

Smokefree Teen, a website specifically developed to help teen smokers quit, offers several social media pages to connect teens with cessation tools.

In particular, colleges and universities can take the next step in protecting the health of their students and inspiring change through the adoption of smoke-free and tobacco-free campuses.

To launch a new chapter in ending the epidemic of smoking, I was honored to participate last week in the announcement of the Tobacco-Free College Campus Initiative(TFCCI). The University of Michigan School of Public Health in Ann Arbor hosted the September 12 event, which was webcast to nearly 500 attendees across the country. The TFCCI represents a public/private partnership involving key leaders from universities, colleges, and the public health community to promote the adoption of tobacco-free policies at institutions of higher learning. This landmark public health initiative will protect students, staff, and faculty against involuntary exposure to secondhand smoke while encouraging a change in social norms that can help reduce tobacco use.

To date, more than 700 colleges and universities, representing an estimated 17 percent of institutions of higher learning nationwide, have committed to smoke-free or tobacco-free campus policies.

HHS is pleased to recognize the leadership of institutions that promote public health in this way. Such actions exemplify a key pillar of the tobacco control action plan—“leading by example.” In fact, by adopting a tobacco-free campus policy on July 1, 2011, HHS has already joined the ranks of such institutions leading by example. This action now protects the health of our 80,000 employees who work in dozens of buildings, grounds, and facilities across the country.

It is my hope that the launch of the TFCCI will encourage all institutions of higher learning to take action. It is time for us to end the epidemic leading to the single most preventable cause of death in this nation.

Together we can make smoking history.

Dr. Howard K. Koh
Assistant Secretary for Health
U.S. Department of Health and Human Services

Source: NCI.