Meaningful public education by labelling on tobacco packages:

Some elements of the scientific background

Lars M. RamströmInstitute for Tobacco Studies

Stockholm, Sweden

National Conference on Tobacco or HealthOttawa, Canada, June 19 - 22, 2005

Information on tobacco packages could encourage and help tobacco users

• to stop using tobacco or

• find least possible harmful ways of use for those unable to stop.

Information on cigarette packs regarding toxic substances

Laboratory measurements tell us what the cigarette delivers to a smoking machine.

But, how do we know what it delivers to a smoker?

Intake of Nicotine

The major pieces of scientific background are found in:

Jarvis MJ, Boreham R, Primatesta P, Feyerabend C, Bryant A. Nicotine yield from machine-smoked cigarettes and nicotine intakes in smokers: Evidence from a representative population survey.J Natl Cancer Inst. 2001 Jan 17;93(2):134-8.

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 1.1

Nicotine yield (mg) - LGC 42

0

100

200

300

400

500

600

700

800

900

Sal

iva

coti

nin

e (n

g/m

l)Saliva cotinine by brand nicotine yield in 2031 smoker

of 0+ cigarettes per day: HSE 1998

Cotinine=173.5+138.7 (nicotine yield); r=.19, r²=.034

Nic

oti

ne

in

tak

e p

er

da

y (

mg

) 63

56

49

42

35

28

21

14

7

0

From: Jarvis et el 2001

Intake of Nicotine (summary)

An individual smoker’s intake of nicotine is NOT determined by the cigarette (as expressed by the machine

yield of nicotine).

Intake of nicotine is determined by the smoker´s personal need for nicotine (governing the way he smokes in order to get the amount he needs).

Intake of other substances

Examples of tar intake by a smoker who takes in 1.3 mg nicotine

Machine yield Tar intake by Tar Nicotine this smoker

Brand 1 (high tar) 9 mg 1.0 mg 11.7 mg

Intake of other substances Examples of tar intake by a smoker who

takes in 1.3 mg nicotine

Machine yield Tar intake by

Tar Nicotine this smoker

Brand 1 (high tar) 9 mg1.0 mg 11.7 mg

Brand 2 (low tar) 6 mg 0.5 mg 15.6 mg

6/0.5 = 12 mg tar per mg nicotine (tar/nicotine ratio)

12 (t/n ratio) 1.3 (indiv. nic. dose) = 15.6 mg (indiv. tar dose)

Intake of other substances

Examples of tar intake by a smoker who takes in 1.3 mg nicotine

Machine yield Tar intake by Tar Nicotine this smoker

Brand 1 (high tar) 9 mg 1.0 mg 11.7 mg Brand 2 (low tar) 6 mg 0.5 mg 15.6 mg Brand 3 (high tar) 10 mg 0.6 mg 21.7 mg Brand 4 (low tar) 3 mg 0.7 mg 5.6 mg

Intake of other substances (summary)

• The intake of each other substance than nicotine can be described as the amount of that substance that accompanies the smoker-determined amount of nicotine

• The ”accompanying amount” of a substance is determined by:- the size of the personal nicotine intake- the brand-specific ratio to nicotine for the substance in …question

Comparing brands for toxicity• Nicotine

- No major differences according to brands (since intake is mainly regulated by the smoker)

• Other substances- Intake can differ between brands according to the brand-specific ratio to nicotine for the substance- The ratios to nicotine are about the same irrespective of the way the cigarette is smoked and can therefore serve as comparative indicators of brand-specific toxicity

Possible model for meaningful and truthful ”consumer information” on

cigarette packages:

Smokers´ intake of nicotine from one cigarette: 0.5 – 2.5 mg, depending (mainly) on HOW it is smoked

One mg of nicotine from this cigarette is accompanied by: Tar: 7 mg Carbon monoxide: 8 mg Formaldehyde: 0.05 mg

Hydrogen Cyanide: 0.08 mg Benzene: 0.04 mg

Data presented to the UK National Smoking Cessation Conference, London, 9-10 June 2005.

Bobak A. Perceived safety of nicotine replacement products among general practitioners and current smokers in the UK: impact on utilisation • Large proportions (37 %) of the smokers

agreed that "Stop smoking products with nicotine are just as harmful as cigarettes".

• These smokers were slightly less likely to have used NRT in the past and reported being less likely to use it during future quit attempts.

“For total mortality, the estimated median relative risks for individual users of LN-SLT were 9% and 5% of the risk associated with smoking for those ages 35 to 49 and ≥50 years, respectively.”

“The risks of using LN-SLT products therefore should not be portrayed as comparable with those of smoking cigarettes as has been the practice of some governmental and public health authorities in the past.”

10 20 30 40

20

40

60

80

100

Range of health risk levels for smokers of different kindsof cigarettes

Range of health risk levels for users of low nitrosamine smokeless tobacco

Health risk level for non-tobacco users

Schematic comparison of risk levels (arbritrary scale)

Summary (1)Product description labelling should make clear that:

• Intake of nicotine from a cigarette can be anything in a wide range and is determined (mainly) by the way the smoker smokes to adjust to his need for nicotine (while machine yield figures are irrelevant)

• Intake of other substances (and subsequent health risks) do to some extent depend on the cigarette also (the brand-specific yield ratio to nicotine for the substance in question)

Summary (2)Health information messages on tobacco packages should, in addition to traditional ”health warnings”,make clear that:

• The major disease causing substances are the combustion products in tobacco smoke, not the nicotine

• Nicotine cessation aids and low nitrosamine smokeless tobacco products are much less harmful to health than any cigarette