Tobacco Primer:Four Questions about

Smoking

Brian A. Primack, MD, EdM, MSMarch 2010

Drug Free Pennsylvania

1. What’s the big deal?

050000

100000150000200000250000300000350000400000450000500000

On 9/11/01 Annually fromsmoking

Deaths

Worldwide deaths, 2010

0

1000000

2000000

3000000

4000000

5000000

6000000

Haiti Smoking

Deaths

Costs

• Direct and indirect medical costs from one year of smoking in the US– $157 billion (75 direct, 82 indirect)

• Immunize the entire 3rd world– $2 billion

“The Big Lie”

In the advertisement:

• Peace• Freshness• Good smells• Independence

In real life:

• Coughing• Stale taste, smoke• Bad smells• Dependence

(addiction)

Worldwide toll of smoking• Kills five million people annually worldwide• Will be over 10 million annually by 2050 (Some

countries with 10 million or fewer people: Hungary, Sweden, Belgium, Switzerland, Senegal, Portugal, Greece, Bolivia)

• Half of deaths in middle age (workforce needed for economic development)

• Half of deaths in rich nations, half in developing nations

• Apparent causes of death different (India TB, China COPD)

2. How can it be that bad?

Ingredients

• Dried tobacco leaves• Additives• Fire

Cigarette Additives that start with A or BAcetanisole, Acetic Acid, Acetoin, Acetophenone, 6-Acetoxydihydrotheaspirane, 2-Acetyl-3- Ethylpyrazine, 2-Acetyl-5-Methylfuran, Acetylpyrazine, 2-Acetylpyridine, 3-Acetylpyridine, 2-Acetylthiazole, Aconitic Acid, dl-Alanine, Alfalfa Extract, Allspice Extract, Oleoresin, And Oil, Allyl Hexanoate, Allyl Ionone, Almond Bitter Oil, Ambergris Tincture, Ammonia, Ammonium Bicarbonate, Ammonium Hydroxide, Ammonium Phosphate Dibasic, Ammonium Sulfide, Amyl Alcohol, Amyl Butyrate, Amyl Formate, Amyl Octanoate, alpha-Amylcinnamaldehyde, Amyris Oil, trans-Anethole, Angelica Root Extract, Oil and Seed Oil, Anise, Anise Star, Extract and Oils, Anisyl Acetate, Anisyl Alcohol, Anisyl Formate, Anisyl Phenylacetate, Apple Juice Concentrate, Extract, and Skins, Apricot Extract and Juice Concentrate, 1-Arginine, Asafetida Fluid Extract And Oil, Ascorbic Acid, 1-Asparagine Monohydrate, 1-Aspartic Acid, Balsam Peru and Oil, Basil Oil, Bay Leaf, Oil and Sweet Oil, Beeswax White, Beet Juice Concentrate, Benzaldehyde, Benzaldehyde Glyceryl Acetal, Benzoic Acid, Benzoin, Benzoin Resin, Benzophenone, Benzyl Alcohol, Benzyl Benzoate, Benzyl Butyrate, Benzyl Cinnamate, Benzyl Propionate, Benzyl Salicylate, Bergamot Oil, Bisabolene, Black Currant Buds Absolute, Borneol, Bornyl Acetate, Buchu Leaf Oil, 1,3-Butanediol, 2,3-Butanedione, 1-Butanol, 2-Butanone, 4(2-Butenylidene)-3,5,5-Trimethyl-2-Cyclohexen-1-One, Butter, Butter Esters, and Butter Oil, Butyl Acetate, Butyl Butyrate, Butyl Butyryl Lactate, Butyl Isovalerate, Butyl Phenylacetate, Butyl Undecylenate, 3-Butylidenephthalide, Butyric Acid

Why Add?

• Enhance flavor• Change burn rates• Change tar/nicotine ratings• Increase delivery of nicotine

What happens when you burn?

Over 4000 chemicals, including …

Selected Chemicals Released When Cigarettes Are Burned

• Benzene• Formaldehyde• Urea• Arsenic• Cyanide• Acetone• Pyridine

• Ammonia• Tar• Carbon

Monoxide• DDT• Butane• Cadmium

A is for Addiction

• Nicotine is a carcinogen itself• Binds to adenosine receptors in the brain,

releasing dopamine (rush); has effect within 10 seconds

• Potent withdrawal begins within minutes• Leads to the next cigarette

B is for blood vessels

• Multiple chemicals in cigarettes cause endothelial damage

• Increases predisposition to clotting, plaque buildup, and heart attack

Atherosclerosis

Myocardial Infarction

Stroke =CVA

(cerebro-vascular accident)

Peripheral Vascular Disease

59 year old female smoker

C is for Cancer

Some carcinogens in cigarettesPAHs:• Benzo[a]anthracene, Benzo[b]fluoranthene, Benzo[f]fluoranthene,

Benzo[k]fluoranthene, Benzo[a]pyrene, Chrysene, Dibenz[a,h]anthracene, Dibenzo[a,i]pyrene, Dibenzo[a],[1]pyrene, Indenol[1,2,3][c,d]pyrene, 5-Methytlchrysene

Aza-arenes:• Dibenz[a,h]acridine, Dibenz[a,j]acridine, 7H-Dibenzo[c,g]carbazole, QuinolineN-Nitrosamines: • 4-(methylnitrosamine)-1-(3-pyridyl)-1-butanone, N-Nitrosethylmethylamine, N-

Nitrosoanabasine, N-Nitrosodiethanolamine, N-Nitrosodiethylamine, N-Nitrosodimethylamine, N-Nitrosonornicotine, N-Nitrosopyrrolidine

Aromatic Amines:• Acetaldehyde, Aldehydes, 4-Aminobiphenyl, Crotonaldehyde, Formaldehyde,

2-Naphthylamine, 2-ToluidineMiscellaneous Organic Compounds:• Acrylonitrile, Benzene, Ethylcarbamate, 2-Nitropropane, Vinyl chlorideInorganic Compounds:• Arsenic, Cadmium, Chromium, Hydrazine, Nickel, Polonium-210

* From Reducing the Health Consequences of Smoking: 25 Years of Progress. Washington, DC, U.S. Department of Health and Human Services, 1989.

D is for Destruction of Lungs (COPD)

E is for Environmental Smoke (Second-Hand Smoke)

Second Hand Smoke

• 38,000 deaths each year (more than homicide and AIDS combined)

• Most pronounced in waiters, bartenders, spouses

• Infants

“Safer” cigarettes …

• No additives• Low tar• Low nicotine• “Smokeless”

3. Who smokes, and why?

Gender

0

5

10

15

20

25

30

Men Women

Percentsmokers

Race

0

5

10

15

20

25

30

35

White AA Asian NA Hisp

PercentSmokers

Wilkinsburg

“Menthol X”

Ever Smokers Who Have Quit

0

10

20

30

40

50

60

White Black

Percent

African Americans

• Bear the greatest burden of mortality from smoking

• Don’t really smoke more• Is it the menthol?

Poverty Level

0

5

10

15

20

25

30

35

Below Above

Percentsmokers

Age

0

5

10

15

20

25

30

18-24 25-44 45-64 65+

Percentsmokers

“As this 14-24 age group matures, they will account for a key share of the total cigarette volume for at least the next 25

years.”

--RJ Reynolds

“Our studies report on youngsters' motivation for starting, their brand

preferences, as well as the starting behavior of children as young as 5

years old.”

-- Brown and Williamson Tobacco Company

US Tobacco, quoted 1994

“Cherry Skoal is for somebody who likes the taste of candy, if you know what I’m saying.”

Smoke Top Advertised Brands

0102030405060708090

100

Youth Adults

SmokeMarlboro,Camel, orNewport

CDC, 2004

$20 Sampler

Regular $7.00Large $10.00

Arabic Coffee, Apple, Apple Alex, Double Apple, Apricot, Banana, Candy, Cappuccino,

Cherry, Carmel, Coconut, Cola, Grape, Jasmine, Lemon, Mint, Mango, Mandarin, Mixed Fruit, Orange, Pistachio, Peach

Rose, Salloum, Strawberry, Vanilla, Zaghoul Light, Zaghoul, Licorice

Smoke Volume

“A typical 1-hour long hookah smoking session involves inhaling 100-200 times the volume of smoke inhaled with a single cigarette.”– WHO, 2005– Shihadeh, 2004

Smoke ContentsCompound

(mg)Hookah1 Cigarette2 Ratio

Tar 802 22.3 36

Nicotine 2.96 1.74 1.7

CO 145 17.3 8

1Shihadeh and Saleh, 2005

2Djordjevic, 2000

Carcinogen (ng) Hookah1 Cigarette2 Ratio

Benz[a]anthracene 677 35 19

Benzo[a]pyrene 370 10.1 37

Benzo[g,h,i]perlyene 307 7.9 56

Di-benzo[a,h]anthracene 140 2.5 245

Indeno[1,2,3-cd]pyrene 183 3.5 52

1Sepetdjian, 2008; 2Gmeiner, 1977

Tobacco Types

0

5

10

15

20

25

30

35

40

Cigarettes Hookah Cigars* Smokeless

Ever Used

Past 30 Days

* Includes little cigars, cigarillos

Hookah Smoking by Grade Level

0

2

4

6

8

10

12

14

16

6th 7th 8th 9th 10th 11th 12th

Ever Used

Past 30 Days

Primack et al., Pediatrics 2009

4. What do we do about it?

Legislation

• Ban on TV advertising 1971• MSA of 1998 (no billboards)• Clean air laws

Public Service Announcements

• Do have an effect• About 50 “just say yes” for each “just say

no”• US PSA budget is about 1/30 of England,

Canada

School Programs

• “Tar Wars” – 4th and 5th grade• “Social influences” programs

– Grade school: effect on body– Middle school: peer pressure, friends, family– High school: self esteem, aspirations

HSPP• Peterson, AV, JNCI 2000• Curriculum for youth, 3rd-10th grades• 47.25 hours total• “Social Influences” approach• How to say no, effects on body, resisting

peer influence, self esteem, etc.• 20 school districts got the program, 20 did

not• 94% follow up, high implementation fidelity

Results of HSPP

• No difference in smoking at 12th grade• No difference in smoking 2 years after

high school• No difference among boys or girls• No difference among people of other

subgroups (such as family risk for smoking)

Is Media Literacy Different?

Major Reasons for Media Literacy

• Fun, creative• Someone to rebel against• Developmentally appropriate• Most effective for the ones most at risk• Empowering, not protectionist

Thank You

bprimack@pitt.edu