Perkins

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					     The history and
epidemiology of cigarette
    smoking--briefly

        Kenneth A. Perkins, Ph.D.,
         Professor of Psychiatry
 Historical Factors Increasing Cigarette Smoking
1850s           Invention of the safety match--portable lighting device
                       that enabled one to smoke almost anywhere.

Late 1800s      Development of tobacco “blends”--reduced harshness
                      of smoking.

1880s           Invention of cigarette rolling machine--greatly
                       increased supply and drove down cost of
                       cigarettes, which were previously made by hand.

Early 1900s     Modern marketing strategies--increased demand
                for cigarettes.

from Kluger R (1996) Ashes to ashes. New York: Knopf.

Note that cigarettes are a highly engineered product continually being
  refined to enhance “acceptability” to smokers (e.g. ammonia to
  increase nicotine uptake, flavorings like cocoa, menthol).
                Per Capita Cigarette Consumption--
                               U.S.
             Cigarettes were 2% of all tobacco intake in 1900; 80% in 1963
                                                                          1st Surgeon
                                                                           General's
             5000                                                            Report Broadcast     Tobacco Execs
                                                                                                  testify in
                                                                                    Ad Ban
             4500                                         End of
                                                                                                  Congress

                                                          WWII
             4000
             3500                                                             Fairness
Cigarettes




                                                                              Doctrine
             3000                                                1st
                                                                            Messages on
                                                                            TV and Radio
                                                               Smoking-
             2500                                               Cancer              Nonsmokers'
                            World War I                        Concern                Rights
             2000                                                                    Movement
                                                                                      Begins
             1500                                                                              Federal
                                                                                              Cigarette
             1000                                                                                Tax
                                                                                              Doubles
                                            Great
              500                         Depression

                0
                    1900 1910    1920     1930         1940   1950    1960       1970      1980     1990
                                                              Year
Recent trends in smoking prevalence and quitting
                                                                     Decreases in Smoking by Education
                                                              50
 Prevalence has dropped by                                    45
 half since 1964: 42% to 21%.




                                  SMOKING PREVALENCE
                                                              40                                            High
                                                                                                            School
 Men: 52% to 23%                                              35                                            grad

 Women: 34% to 19% “Heavy”                                    30                                            College
                                                                                                            grad
 smoking (>25/day) has                                        25
                                                              20
 dropped from 29% of all                                      15
 smokers in 1980 to 12% in                                    10
 2004.                                                         5
                                                               0
                                                                   1965      1980       1990         2000
 Top: Drop in prevalence is
 much greater with higher                                     90
                                                                          Trend in Quitting by Age

 education.
                                  EVER SMOKERS WHO QUIT (%)



                                                              80
                                                              70                                             under 25
 Bottom: Quitting has                                         60                                             25-44
 increased in all age groups,                                 50                                             45-64
 but less so for younger versus                               40                                             over 65
 older smokers.                                               30
                                                              20
 From Giovino et al. (2002).                                  10
                                                               0
                                                                   1965      1980       1990         2000
  Characteristics
    of current
     smokers
Current smoking is
associated with poverty
and low education.

Men: little difference by
ethnicity except higher
in Native American.

Women: lower
prevalence in non-White
ethnicities except Native
Am.
Comorbidity of smoking and psychiatric or
      substance abuse problems
Smoking prevalence is higher in those with
psychiatric or substance abuse problems
(“hardening”?)

Depression history: 30-50%
Schizophrenia: 70%
PTSD: 40-50%
ADHD: elevated but little prevalence data
Alcohol dependence: 80-90%
Cocaine dependence: 80%
Opiate dependence: 90%
                                                                                                Cotinine

   “Lights” do not reduce
                                                                     300


                                                                     250



      exposure or risk




                                  COTININE (ng/ml)
                                                                     200


                                                                          150


                                                                          100

                                                                          50



Smoking behavior and smoke                                                 0
                                                                                     0.4             0.7              1.1

                                                                                           BRAND NICOTINE "YIELD"
exposure after switching to                                                                Carbon Monoxide

“light” brands (i.e. those with
                                                                            40




                                               CARBON MONOXIDE
lower nicotine “yields”).
                                                                            30




                                                    (ppm)
                                                                            20



                                                                            10


Ninety percent of commercial                                                    0
                                                                                     0.4              0.7             1.1

brands have yields within the                                                              BRAND NICOTINE "YIELD"
                                                                                             Cigarettes Per Day
range of yields across these


                                                     CIGARETTES PER DAY
brands, 0.4-1.1 mg nicotine.
                                                                                30




                                                                                20




Adapted from Zacny & Stitzer                                                    10




(1988).                                                                          0
                                                                                       0.4             0.7             1.1

                                                                                             BRAND NICOTINE "YIELD"
“Occasional”
  smokers
Prevalence of non-daily
smoking is increasing, as
overall prevalence of daily
smoking is decreasing . Non-
daily are 20% of all smokers.

Characteristics more common
in non-daily (“some day”) vs
daily smoking:

Younger age

Non-white ethnicity

Higher education

Higher income

Hassmiller et al. (2003) AJPH, 93:
1321-7.
                                                                                         Population Exposure to Drugs (U.S.)
                                                                         100




                             EVER USED DRUGS (%)
Top: Percentage of the                                                    80

U.S. population ever using                                                60
various drugs of abuse at
least once. Bottom:                                                       40

Percentage of those ever                                                  20
using a drug who become
dependent on that drug.                                                    0
                                                                               Tobacco   Alcohol   Cannabis   Cocaine    Stimulants   Heroin
                                                                                                        DRUG
Note that, although only a
minority of ever users
become dependent, the                                                                    Rate of Dependence Among Ever Users
                                                                          35
risk of dependence is
highest among those ever                                                  30
                                                   DEPENDENCE RATE (%)




using tobacco and exceeds                                                 25

even those for cocaine                                                    20

and heroin. Data from                                                     15
Anthony et al. (1994).                                                    10

                                                                           5

                                                                           0
                                                                               Tobacco   Alcohol   Cannabis    Cocaine   Stimulants   Heroin
                                                                                                         DRUG
What accounts for high
rates of dependence on
tobacco smoking?
Time to peak arterial
concentration

           Smoking (<60 sec)   Nasal spray (5 min)

                               Gum/“Inhaler” (20 min)




                                      Patch (hrs)




                                       IV (1-2 min)
INSERT FIG SHOWING KINETICS OF CIGS AND
NRT, to illustrate why NRT might not work that well
(Ockene et al. 2000, Health Psychology)

 Predictors of Sustained
       Abstinence
 • Fewer cigs/day
 • Fewer years/smoking
 • Longer duration of prior
   abstinence
 • Older age at initiation
 • Ever quit before
 • Fewer lapses during
   current quit attempt
 • No comorbid conditions
                                          Hymowitz N et al. (1997) Tobacco Control
                                          6(suppl 2): S57-S62.
Any smoking at all on or after quit day strongly predicts failure




 Perkins et al. (2001) Journal of Consulting & Clin Psychol 69: 604-613.
Women and Smoking: A Report of the Surgeon General. Washington, DC:
US Dept of Health and Human Services, Public Health Service, Office of the
Surgeon General; 2001.
International Early Lung Cancer Action
Program Investigators (2006) Women's
Susceptibility to Tobacco Carcinogens and
Survival After Diagnosis of Lung Cancer
JAMA. 296:180-184.

Table 2. Logistic Regression Analysis of 14 435 Baseline Screenings for
Lung Cancer, Prevalence Odds Ratio, Women vs Men by Controlled
Covariates

                                Odds Ratio (CI) P Value†
None                            1.6 (1.2-2.0)           .002
Age and smoking                 1.7 (1.3-2.3)           .001


†Two-sided.
Dransfield MT, Davis JJ, Gerald LB, et al. (2006) Racial and gender
differences in susceptibility to tobacco smoke among patients with
chronic obstructive pulmonary disease. RESPIRATORY MEDICINE
100: 1110-1116

N=330 smokers over 45 years old

Figure 2. Susceptibility Indices (SI). The SI represents the change in lung function
(race-adjusted % predicted FEV1) per pack-year smoked as calculated by the formula
(%FEV1-100%)/pack-years. *Caucasians lost lung function at a slower rate than did
African-Americans (p<.01) as did †men compared to women (p=.001).
                                         8

                                                          Women
                                         7
Relative risk of myocardial infarction


                                         6


                                         5


                                         4


                                         3                 Men
                                         2


                                         1   -------------------------------------------
                                         0
                                                    <55           55-64        65-74   75-84

                                                                      Age (years)




Relative risk of myocardial infarction for current
smokers compared with never smokers, by sex

Prescott et al. (1998) Smoking and risk of myocardial infarction in women
   and men: longitudinal population study. Brit Med J 316: 1043-1047
Quit ratio (former/ever) in men vs
               women
Smoking and Tobacco Control Monographs, Monograph
12: Population Based Smoking Cessation (2000)

1995-96 data (18 and older)

             Current      Former   Quit Ratio

Men:         25.66%       25.80%   50.14%

Women:       20.73%       18.07%   46.56%
   Nicotine patch outcome at 6 months, by sex

                40


                30
  % Abstinent




                20                                       NIC patch
                                                         placebo
                10


                 0
                          Men     Women
                (N=632)

Adapted from Wetter DW et al. (1999) Gender differences in smoking
 cessation. Journal of Consulting and Clinical Psychology, 67:555-562
Update of Munafo et al (2004) meta-analysis of 11
NRT patch trials, adding 3 more trials: Women do
significantly worse on NRT patch (OR of 1.45, p=.03)
Study         log [OR] (SE)     OR CI        weight   OR (95% CI)




See Perkins & Scott (2005) Nic Tob Res 7:915-916; Munafo et al. (2004)
Nic Tob Res 6: 769-776 and 865-867.
      Bupropion meta-analysis
Scharf & Shiffman (2004, Addiction)—12 studies of
  bupropion vs placebo for smoking cessation.
No sex diff due to bupropion vs placebo but lower
  abstinence in women overall.

Bupropion vs placebo in men OR =2.53 (1.88-3.4)
Bupropion vs placebo in women OR = 2.47 (1.92-3.17)

However, overall, women were less likely than men to
  quit, whether on bupropion, OR=0.79 (0.65-0.95), or
  on placebo, OR=0.75 (0.59-0.94)
   DRD2 Genotype and Nicotine Patch
         Outcome (6 months)
           Treatment x genotype x sex interaction (p<.001)
      20
      18
      16
      14
      12
      10                                                      Nicotine
       8
                                                              Placebo
       6
       4
       2
       0
            Men-     Men-CC     Women-     Women-
            CT,TT               CT,TT       CC

N=307 men, 445 women (41% CT,TT [A1/A1, A1/A2]; 59% CC [A2/A2])
  Yudkin, Munafo, Hey, et al. (2004) British Med J (online version)
Worldwide Smoking Prevalence is still rising
 • Currently 1.2 billion smokers consuming 6 trillion
   cigarettes per year (so, 4% of smokers are U.S.)
 • Smoking kills 5 million per year, or one every 6 sec (9%
   of smoking deaths are U.S.)
 • China, with 350 million smokers, produces about 50% of
   world’s tobacco (U.S. is distant second at about 10%).
 • Traditional treatment approaches (e.g. medications, one-
   on-one counseling) not likely to be practical. Policy and
   prevention are needed.
 • WHO and other international org’s helping to reduce
   tobacco use (also Framework Agreement on curbing
   tobacco, advertising, etc.)
 • FDA issue: Regulation of nicotine levels and/or
   non-nicotine constituents responsible for health
   risks, enhancement of dependence, etc.

				
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