The history and epidemiology of cigarette smoking--briefly Kenneth A. Perkins, Ph.D., Professor of...

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 demandfor 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.

0

5001000

1500

20002500

3000

3500

40004500

5000

Year

Cig

are

ttes

World War I

Great Depression

End ofWWII

1stSmoking-CancerConcern

1st SurgeonGeneral's

Report BroadcastAd Ban

Nonsmokers'Rights

MovementBegins

Federal Cigarette

TaxDoubles

FairnessDoctrine

Messages onTV and Radio

Tobacco Execs testify in Congress

Cigarettes were 2% of all tobacco intake in 1900; 80% in 1963

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990

Decreases in Smoking by Education

1980 1990 200019650

5

10

15

20

25

30

35

40

45

50

SM

OK

ING

PR

EV

ALE

NC

E

HighSchoolgrad

Collegegrad

Trend in Quitting by Age

20001990198019650

10

20

30

40

50

60

70

80

90

EV

ER

SM

OK

ER

S W

HO

QU

IT (

%)

under 25

25-44

45-64

over 65

Prevalence has dropped by half since 1964: 42% to 21%. Men: 52% to 23%Women: 34% to 19% “Heavy” smoking (>25/day) has dropped from 29% of all smokers in 1980 to 12% in 2004.

Top: Drop in prevalence is much greater with higher education.

Bottom: Quitting has increased in all age groups, but less so for younger versus older smokers.

From Giovino et al. (2002).

Recent trends in smoking prevalence and quitting

Characteristics of current

smokersCurrent 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

problemsSmoking 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 dataAlcohol dependence: 80-90%Cocaine dependence: 80%Opiate dependence: 90%

Cotinine

0.4 1.10.70

50

100

150

200

250

300

BRAND NICOTINE "YIELD"

CO

TIN

INE

(n

g/m

l)

Carbon Monoxide

0.4 1.10.70

10

20

30

40


CA

RB

ON

MO

NO

XID

E

(pp

m)

Cigarettes Per Day

0.4 1.10.70

10

20

30


CIG

AR

ET

TE

S P

ER

DA

Y

Smoking behavior and smoke exposure after switching to “light” brands (i.e. those with lower nicotine “yields”).

Ninety percent of commercial brands have yields within the range of yields across these brands, 0.4-1.1 mg nicotine.

Adapted from Zacny & Stitzer (1988).

“Lights” do not reduce exposure or risk

“Occasional” smokersPrevalence 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.)

HeroinStimulantsTobacco CocaineCannabisAlcohol0

20

40

60

80

100

DRUG

EV

ER

US

ED

DR

UG

S (

%)

Rate of Dependence Among Ever Users

HeroinStimulantsTobacco CocaineCannabisAlcohol0

5

10

15

20

25

30

35

DRUG

DE

PE

ND

EN

CE

RA

TE

(%

)

Top: Percentage of the U.S. population ever using various drugs of abuse at least once. Bottom: Percentage of those ever using a drug who become dependent on that drug.

Note that, although only a minority of ever users become dependent, the risk of dependence is highest among those ever using tobacco and exceeds even those for cocaine and heroin. Data from Anthony et al. (1994).

What accounts for high rates of dependence on tobacco smoking?

Smoking (<60 sec)

Gum/“Inhaler” (20 min)

IV (1-2 min)

Patch (hrs)

Nasal spray (5 min)

Time to peak arterial concentration

INSERT FIG SHOWING KINETICS OF CIGS AND NRT, to illustrate why NRT might not work that well

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

(Ockene et al. 2000, Health Psychology)(Ockene et al. 2000, Health Psychology)

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.

Reach for a Lucky…

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.

Lung Cancer Risk

International Early Lung Cancer Action Program Investigators (2006) Women's Susceptibility to Tobacco Carcinogens and Survival After Diagnosis of Lung CancerJAMA. 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).

Lung function: COPD

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

Women

Men

CV risk due to smoking in F vs M

-------------------------------------------

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%

Adapted from Wetter DW et al. (1999) Gender differences in smoking

cessation. Journal of Consulting and Clinical Psychology, 67:555-562

0

10

20

30

40%

Abs

tinen

t

Men Women

NIC patch

placebo

(N=632)

Nicotine patch outcome at 6 months, by sex

Review: New reviewComparison: 01 ORs, ala munafo Outcome: 01 InterORS

Study InterORS (fixed) Weight InterORS (fixed)or sub-category log[InterORS] (SE) 95% CI % 95% CI

01 Munafo reproducedabelin 0.4700 (0.8370) 0.88 1.60 [0.31, 8.25] ehrsam 0.1740 (1.6190) 0.24 1.19 [0.05, 28.42] tonnesen -1.6090 (1.3390) 0.34 0.20 [0.01, 2.76] sachs 0.7610 (0.7520) 1.09 2.14 [0.49, 9.35] richmond -0.0300 (0.6340) 1.54 0.97 [0.28, 3.36] yudkin -0.0510 (0.3800) 4.28 0.95 [0.45, 2.00] paoletti 0.7320 (0.7480) 1.10 2.08 [0.48, 9.01] killen 0.8500 (0.6940) 1.28 2.34 [0.60, 9.12] lewis 1.3960 (1.5330) 0.26 4.04 [0.20, 81.50] hughes 1.1120 (0.6750) 1.36 3.04 [0.81, 11.42] jorenby 0.2390 (0.5180) 2.30 1.27 [0.46, 3.51]

Subtotal (95% CI) 14.68 1.39 [0.93, 2.07]Test for heterogeneity: Chi² = 6.50, df = 10 (P = 0.77), I² = 0%Test for overall effect: Z = 1.59 (P = 0.11)

02 Munafo reprod. + wetter & davisabelin 0.4700 (0.8370) 0.88 1.60 [0.31, 8.25] ehrsam 0.1740 (1.6190) 0.24 1.19 [0.05, 28.42] tonnesen -1.6090 (1.3390) 0.34 0.20 [0.01, 2.76] sachs 0.7610 (0.7520) 1.09 2.14 [0.49, 9.35] davis 0.6090 (0.6640) 1.40 1.84 [0.50, 6.76] richmond -0.0300 (0.6340) 1.54 0.97 [0.28, 3.36] yudkin -0.0510 (0.3800) 4.28 0.95 [0.45, 2.00] paoletti 0.7320 (0.7480) 1.10 2.08 [0.48, 9.01] killen 0.8500 (0.6940) 1.28 2.34 [0.60, 9.12] lewis 1.3960 (1.5330) 0.26 4.04 [0.20, 81.50] hughes 1.1120 (0.6750) 1.36 3.04 [0.81, 11.42] jorenby 0.2390 (0.5180) 2.30 1.27 [0.46, 3.51] wetter 0.2500 (0.4490) 3.07 1.28 [0.53, 3.10]


03 munafo meta + davis + wetterdavis 0.6090 (0.6640) 1.40 1.84 [0.50, 6.76] wetter 0.2500 (0.4490) 3.07 1.28 [0.53, 3.10] munafometa 0.2850 (0.1930) 16.59 1.33 [0.91, 1.94]


04 Munafo reprod. + wetter & davis & shiffmanabelin 0.4700 (0.8370) 0.88 1.60 [0.31, 8.25] ehrsam 0.1740 (1.6190) 0.24 1.19 [0.05, 28.42] tonnesen -1.6090 (1.3390) 0.34 0.20 [0.01, 2.76] sachs 0.7610 (0.7520) 1.09 2.14 [0.49, 9.35] davis 0.6090 (0.6640) 1.40 1.84 [0.50, 6.76] richmond -0.0300 (0.6340) 1.54 0.97 [0.28, 3.36] yudkin -0.0510 (0.3800) 4.28 0.95 [0.45, 2.00] paoletti 0.7320 (0.7480) 1.10 2.08 [0.48, 9.01] killen 0.8500 (0.6940) 1.28 2.34 [0.60, 9.12] lewis 1.3960 (1.5330) 0.26 4.04 [0.20, 81.50] hughes 1.1120 (0.6750) 1.36 3.04 [0.81, 11.42] jorenby 0.2390 (0.5180) 2.30 1.27 [0.46, 3.51] wetter 0.2500 (0.4490) 3.07 1.28 [0.53, 3.10] shiffman 0.6450 (0.5020) 2.45 1.91 [0.71, 5.10]


05 munafo meta + davis + wetter + shiffmandavis 0.6090 (0.6640) 1.40 1.84 [0.50, 6.76] wetter 0.2500 (0.4490) 3.07 1.28 [0.53, 3.10] munafometa 0.2850 (0.1930) 16.59 1.33 [0.91, 1.94] shiffman 0.6450 (0.5020) 2.45 1.91 [0.71, 5.10]


Total (95% CI) 100.00 1.40 [1.20, 1.63]Test for heterogeneity: Chi² = 21.22, df = 44 (P = 1.00), I² = 0%Test for overall effect: Z = 4.26 (P < 0.0001)

0.001 0.01 0.1 1 10 100 1000

Favours treatment Favours control

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.

Update of Munafo et al (2004)

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)

02468101214161820

Men-CT,TT

Men-CC Women-CT,TT

Women-CC

NicotinePlacebo

Yudkin, Munafo, Hey, et al. (2004) British Med J (online version)

N=307 men, 445 women (41% CT,TT [A1/A1, A1/A2]; 59% CC [A2/A2])

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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