Addiction, Withdrawal, Smoking Cessation, and Public Health Measures

AuthorJames G. Wigmore
 7
Addiction, Withdrawal, Smoking
Cessation, and Public Health Measures
“For much of the th century, smoking was regarded as a socially learned
habit and as a personal choice. . . . It is now recognised that cigarette
smoking is primarily a manifestation of nicotine addiction.
—Jarvis, “Why People Smoke” ()
Smoking is not a bad habit or personal choice, as the tobacco indus-
try would have smokers believe, but due mainly to the highly addictive
neurotoxin and pesticide that is nicotine. Nicotine is far more addictive
than either alcohol or cannabis.
“To cease smoking is the easiest thing I ever did. I ought to know because
I’ve done it a thousand times.”
—attributed to Mark Twain
Among the symptoms listed by the American Psychiatric Association
Diagnostic and Statistical Manual of Mental Disorders (DSM-) are:
• unsuccessful ef‌forts to quit or reduce intake of tobacco;
• inordinate amount of time acquiring or using tobacco products;
cravings for tobacco;
failure to attend to responsibilities and obligations due to tobacco
continued use despite adverse social or interpersonal consequences;
 | Wigmore on Nicotine and Its Drug Delivery Systems
forfeiture of social, occupational, or recreational activities in favor
of tobacco use;
• tobacco use in hazardous situations;
continued use despite awareness of physical or psychological prob-
lems directly attributable to tobacco use; and
need for increasingly larger doses of nicotine in order to obtain the
desired ef‌fect.
Nicotine addiction is due mainly to it binding with receptors in the
brain, which releases numerous neurotransmitters, especially dopamine,
resulting in the feeling of pleasure and eventually causing addiction
as smokers and other drug users continue to seek that pleasure (,
–). As if nicotine is not sucient to cause and maintain addic-
tion, the tobacco industry has added other f‌lavoring chemicals such as
pyrazine which reduce the irritation of tobacco smoke and eases the nico-
tine uptake into the lungs. Pyrazine also reinforces the learned behavior
of smoking and dopamine release ().
A good indicator of nicotine dependence is the time to the f‌irst use
of the tobacco product upon awakening. The shorter the time to the
f‌irst vape or smoke of the day, the more likely the tobacco product user
is addicted to nicotine. The median time of f‌irst use was shortest (
minutes) for polytobacco users of cigarettes, cigars, and e-cigarettes, and
users of cigarettes and cigars.The longest median time to f‌irst tobacco
use was  minutes for cigars users ().
Stressful situations tended to increase craving in dependent cigarette
smokers but did not increase the number of cigarettes smoked ().
Slow nicotine metabolizers smoked fewer cigarettes per day, as the
nicotine remained in the blood for a longer period of time than for fast
metabolizers. Slow metabolizers were not as addicted to nicotine as fast
metabolizers and generally were able to be more successful at quitting
Although cof‌fee users were more likely to be smokers, cof‌fee con-
sumption is unlikely to have a major impact on smoking rates ().
The use of tobacco products at the workplace varies according to
occupation. At some construction sites over % of the workers smoke
(). Other studies regarding nicotine addiction can be found in sec-
tion .. Written tests to determine the degree of nicotine addiction in
smokers can be found in appendices  and .
Addiction, Withdrawal, Smoking Cessation, and Public Health Measures | 
Reference Number: 
Reference Number: 70101
, ., .. ,  . . “Smoking Cessation in Preg-
nancy: A Continuing Challenge in the United States.Therapeutic Advan-
ces in Drug Safety, : –,  ( tables,  f‌igure, references)
Abstract: Smoking during pregnancy remains a serious public health
issue in the United States, with approximately , to , smoke
exposed infants born yearly. In , .% of US adults smoked (% of
women, % of men), accounting for , premature deaths yearly.
Approximately % of women report smoking during pregnancy. When
tobacco is smoked, nicotine reaches the brain in  seconds and peak
concentrations occur in  minutes. Nicotine binds to the nicotinic acetyl-
choline receptors, triggering the release of dopamine, serotonin, and
other neurotransmitters. The rapid release of dopamine causes pleasure
and addiction. Withdrawal symptoms, such as agitation and depression,
negatively reinforce addiction. Withdrawal symptoms occur in about one-
half of smokers and start within a few hours after smoking cessation. They
peak at the f‌irst week and resolve over a month. Nicotine is metabolized
by cytochrome CYPA. The slower elimination of nicotine may allow for
longer periods without withdrawal symptoms and allow more successful
quitting. By , over % of the women and % of non-Hispanic White
men smoked. The tobacco industry continues to portray smoking as sexy
or edgy behavior, one that the creative or adventurous use. Smoking is
a leading cause of preterm births (
of premature births. About % of sudden unexpected death in infants
is linked to maternal smoking. There are >, chemicals in tobacco
smoke. Nicotine and CO readily cross the placenta, and the fetal circu-
lation can exceed the maternal by % for CO and by % for nicotine.
Nicotine may have an impact on brain development. Pregnant smokers
receiving counselling have % greater cessation rate than those relying
on self-help books.
Tobacco addiction is a chronic disease involving a complex interplay
between the central nervous system, genetics, the environment, and
physical and psychological states. Addiction is positively enforced by acti-
vation of the neuronal reward systemviarapid release of dopamine in
response to nicotine. Without nicotine, withdrawal symptoms arise. This
cycle likely plays a critical role in continued smoking despite f‌inancial and
health costs. Women are more likely than men to report smoking to cope
 | Wigmore on Nicotine and Its Drug Delivery Systems
Reference Number: 
with negative psychological states or emotions including anxiety and
depression. Additionally, women who are socioeconomically disadvan-
taged, who report food insecurity, or report active post-traumatic stress
disorder or history of trauma have increased risk of smoking during preg-
nancy. Prenatal smoking is also more prevalent among younger women
aged – years old.
Reference Number: 70102
, ., . , . ,  . . “Nicotine Depend-
ence and Psychological Distress: Outcomes and Clinical Implications
in Smoking Cessation.Psychology Research and Behavior Management,
: –,  ( table,  references)
Abstract: The diagnosis of nicotine dependence was included for the
f‌irst time in the rd edition of DSM in . The US Surgeon General in
 def‌ined tobacco smoking as an addiction. Nicotine dependence is a
chronic and relapsing disease. Although approximately % of smokers
would like to stop and one-third make at least three serious attempts, less
than % of smokers succeed in stopping before the age of  years. The
Clinical Practice Guidelines recommend addressing patients’ smoking at
each visit using the f‌ive A’s: Ask about tobacco use; advise smokers to quit;
assess smoker’s willingness to make a quit attempt; assist with treatment;
and arrange follow-up.
Persistent cigarette consumption seems to be strongly inf‌luenced by two
complex factors: nicotine dependence and psychological distress. While the
level of nicotine dependence is commonly measured in smokers attending
smoking cessation programs, the assessment of psychological distress is
often neglected. However, such an evaluation should be performed, to get
a complete picture of the smoker and of‌fer a tailored intervention. Some
patients, for instance, might benef‌it from psychological support aimed at
managing psychological distress, a high level of negative af‌fectivity, or a
low psychological distress tolerance experienced while quitting.
Reference Number: 70103
, .., . , . ,  . . “DSM Criteria for
Tobacco Use Disorder and Tobacco Withdrawal: A Critique and
Addiction, Withdrawal, Smoking Cessation, and Public Health Measures | 
Reference Number: 
Proposed Revisions for DSM-.Addiction, : –,  ( tables,
 references)
Abstract: DSM- criteria for tobacco disorder and withdrawal were found
to be ambiguous and little used in tobacco research. This paper discusses
suggested improvements for inclusion in DSM-, which would be pub-
lished in .
In conclusion, substantive and psychometric considerations strongly sup-
port four new criteria for further testing and potential inclusion in the
DSM-. These criteria concern smoking heaviness, latency to smoke upon
awakening, craving to smoke, and withdrawal severity. Other criteria were
identif‌ied for additional research and possible inclusion. Little evidence
supported the inclusion of most existing DSM-IV items, but rewording
and reformulation might improve their validities.
Reference Number: 70104
, ., . ,  . . “Tobacco Use Disorder and Treatment:
New Challenges and Opportunities.Dialogues in Clinical Neuroscience,
: –,  ( tables,  references)
Abstract: Tobacco use is the cause of over  million deaths per year
globally—more than twice the deaths due to alcohol and illicit drugs
combined. The DSM- classif‌ies tobacco addiction or nicotine depend-
ence as tobacco use disorder. A typical cigarette has about – mg of
nicotine, resulting in – mg of nicotine absorbed by the smoker. Cigars
can contain – mg of nicotine, resulting in – mg absorbed.
Nicotine cartridges for EC contain – mg of nicotine and have .–.
mg absorbed for the entire cartridge. Nicotine causes release of dopa-
mine and up-regulation of receptors, resulting in nicotine dependence.
Nicotine’s short half-life of  to  hours leads to withdrawal symptoms of
irritation, frustration, anxiety, and diculty concentrating. This study
discusses various therapies for the treatment of Tobacco Use Disorder
or nicotine dependence. Clinical trials are being conducted on nicotine
vaccines, which produce antibodies that bind to nicotine and prevent it
from acting on receptors.
 | Wigmore on Nicotine and Its Drug Delivery Systems
Reference Number: 
Table: The Main Ef‌fects of Neurotransmitters Released by Nicotine
Neurotransmitter Ef‌fect
Dopamine Pleasure, appetite suppression
Norepinephrine Arousal, appetite suppression
Acetylcholine Arousal, cognitive enhancement
Glutamate Learning, memory enhancement
Serotonin Mood modulation, appetite suppression
Beta-endorphin Reduction in anxiety and tension
Gamma aminobutyric acid Reduction in anxiety and tension
Source: Adapted from Ziedonis et al, 
Tobacco use continues to increase morbidity and mortality with high rates
of tobacco-use disorders among individuals with psychiatric disorders
resulting in severe health disparities for that population. New nicotine and
tobacco products will continue to be developed, as will new treatments,
with increasing person-, home-, and community-facing technologies.
Reference Number: 70105
, .., .. ,  .. . “A Study of Pyrazines in Ciga-
rettes and How Additives Might be Used to Enhance Nicotine Addic-
tion.” Tobacco Control, : –,  ( f‌igures,  references)
Abstract: A review of more than  million internal tobacco industry
documents was conducted to determine how the addictiveness of ciga-
rettes was increased by the addition of pyrazines. Pyrazines are chemo-
sensoryagents with the general chemical formula of C₄H₄N₂, which are
formed at temperatures ≥°C during tobacco leaf curing and smoking.
Pyrazines are among the most important chemicals in tobacco, because
they act on chemoreceptors and produce the characteristic aroma and
f‌lavor of tobacco and tobacco smoke. Pyrazines reduce the irritation of
tobacco smoke in the upper airways and ease the nicotine uptake and
absorption of nicotine into the lungs. Pyrazines also reinforce the learned
behavior of smoking and enhance the nicotine’s release of dopamine.
Nicotine is known as the drug that is responsible for the addicted behav-
iour of tobacco users, but it has poor reinforcing ef‌fects when adminis-
tered alone. Tobacco product design features enhance abuse liability by
Addiction, Withdrawal, Smoking Cessation, and Public Health Measures | 
Reference Number: 
(A) optimising the dynamic delivery of nicotine to central nervous sys-
tem receptors, and af‌fecting smokers’ withdrawal symptoms, mood and
behaviour; and (B) ef‌fecting conditioned learning, through sensory cues,
including aroma, touch and visual stimulation, to create perceptions of
pending nicotine reward. This study examines the use of additives called
“pyrazines”. which may enhance abuse potential, their introduction in
“lights” and subsequently in the highly market successful Marlboro Lights
(Gold) cigarettes and eventually many major brands.
Reference Number: 70106
, .., .. ,  .. . “Dependence Symp-
toms and Cessation Intentions Among US Adult Daily Cigarette, Cigar,
and E-Cigarette Users, –.BMC Public Health, :  (pp),
 ( tables,  f‌igures,  references)
Abstract: This study determined the dependence symptoms and ces-
sation intentions in users of cigarettes, cigars, and/or ECs, using a US
National Adult Tobacco Survey (NATS) conducted of more than ,
participants between  and . Of the single tobacco product users,
there were , who used cigarettes daily,  who used cigars daily, and
 who used ECs daily. Of the daily multiple product users,  used
cigars and cigarettes,  used cigarettes and ECs, and  used cigars
and ECs. The percentage of daily tobacco users who used tobacco within
 minutes of waking up was approximately % (cigarettes), % (cigars),
% (ECs), and % for dual users.
Table: Median Time to First Tobacco Product Use After Waking Among
Daily Tobacco Users
Tobacco Use Median Time of First Tobacco Use
Cigarettes  minutes
Cigars  minutes
E-cigarettes  minutes
Cigarettes and cigars  minutes
Cigarettes and e-cigarettes  minutes
Cigarettes and cigars and e-cigarettes  minutes
Source: Adapted from Rostron et al, 
 | Wigmore on Nicotine and Its Drug Delivery Systems
Reference Number: 
This study presents important information about dependence symp-
toms and cessation intentions among US adult daily cigarette, cigar, and
e-cigarette users that increases our understanding of dependence among
tobacco users. We f‌ind that dual users of cigarettes and cigars are more
likely to report greater tobacco dependence than exclusive cigarette
smokers as measured by cpd and time to f‌irst tobacco use and that dual
cigarette and cigar users and dual cigarette and e-cigarette users are more
likely to report withdrawal and craving symptoms than exclusive cigarette
smokers. We also f‌ind that many users in all product use categories, includ-
ing exclusive users of cigars and e-cigarettes, exhibit symptoms of tobacco
dependence. These f‌indings have the potential to inform future research
and tobacco ef‌forts generally, given that tobacco use and dependence
remain signif‌icant global public health issues, while being of particular rel-
evance to the US specif‌ically, given that the FDA has extended its author-
ity to regulate all tobacco products including e-cigarettes and cigars.
Reference Number: 70107
, .,  .  . “Ef‌fects of Acute Psychosocial Stress on Ciga-
rette Craving and Smoking.Nicotine and Tobacco Research, : –
,  ( f‌igure,  references)
Abstract: This study examined cigarette craving and number of cigarettes
smoked in  female and  male daily smokers (mean age . years),
after participation in either the Trier Social Stress Test or a non-stressful
control task. Stress signif‌icantly increased cigarette craving but did not
increase smoking.
In conclusion, the f‌indings from the present study support earlier f‌indings
that acute stress increases smoking desire. Acute stress did not signif‌i-
cantly increase smoking; however, our f‌indings suggest increased pleasure
from smoking and deeper inhalations in more dependent smokers after
stress. Our results extend previous f‌indings and suggest relationships
between the severity of nicotine dependence and inf‌luences of stress on
smoking. Future studies should further investigate possible relationships
between physiological and subjective responses to stress and stress-in-
duced alterations in smoking.
Addiction, Withdrawal, Smoking Cessation, and Public Health Measures | 
Reference Number: 
Reference Number: 70108
, .., .. , . , .. , . , .. ,
.. , . , . ,  . . “Decreased Nicotinic
Receptor Availability in Smokers with Slow Rates of Nicotine Metabol-
ism.” Journal of Nuclear Medicine, :  –,  ( table,  f‌igures,
 references)
Abstract: Twelve slow nicotine metabolizing smokers (NMR
 normal nicotine metabolizing smokers (NMR >.) underwent brain
imaging after an -hour nicotine abstinence. Chronic nicotine exposure
increases the nicotinic acetylcholinergic receptor density (i.e., up-regula-
tion) and quitting smoking leads to receptor normalization.
Table: Some Smoking-Related Variables in Normal and Slow Nicotine
CPD (range) – –
Mean Fagerstrom Test for Nicotine Depend-
ence score
. .
Mean initial breath CO (PPM) . .
Mean plasm cotinine concentration (ng/mL) . .
Mean -HC concentration (ng/mL) . .
Source: Adapted from Dubrof‌f et al, 
These data suggest that slow metabolizers of nicotine exhibit reduced
nAChR availability in thalamus after  hours of abstinence from smoking,
compared to normal nicotine metabolizers. Individual variation in hepatic
metabolism inf‌luences nicotine’s half-life in plasma from approximately
 hours to  hours. In addition, nicotine levels in the brain can persist
beyond nicotine’s plasma half-life. Therefore, dif‌ferences in thalamic
nAChR availability observed between slow and normal metabolizers may
ref‌lect dif‌ferences in nicotine binding to nAChRs due to dif‌ferences in
elimination kinetics.
Reference Number: 70109
, .., .. , . , ..  ., .. ,
.. , . ,  .. . “The Nicotine Metabolite
 | Wigmore on Nicotine and Its Drug Delivery Systems
Reference Number: 
Ratio is Associated with Early Smoking Abstinence Even After Control-
ling for Factors that Inf‌luence the Nicotine Metabolite Ratio.Nicotine
and Tobacco Research, : –,  ( tables,  references)
Abstract: The smoking rate for adults in the United States and Canada
has plateaued to about %. The FDA has approved three medications
for smoking cessation; nicotine replacement therapy, bupropion, and
varenicline. Nicotine is inactivated primarily by the CYPA enzyme into
cotinine, which is further metabolized to ’-hydroxycotinine (-HC). The
-HC/COT ratio is known as the nicotine metabolite ratio (NMR). A lower
NMR indicates a slower nicotine clearance and is associated with lower
cigarette consumption and nicotine dependence scores, and a higher quit
ratio in regard to both placebo and the nicotine patch. Varenicline was
more ef‌fective in smokers with a higher NMR. This study determined the
NMR in , smokers at intake to a smoking cessation program using
LC/MS/MS. A slower rate of nicotine metabolism was set at NMR
One-week abstinence was determined by an exhaled CO concentration
of  ppm or less. Lower NMR was associated with a .× greater likeli-
hood of -week abstinence. Smokers who were abstinent at  week were
.× as likely to be abstinent long-term.
Table: Odds Ratio of -Week Smoking Abstinence Associated with
Various Factors
Predictor of -Week Abstinence (Breath CO ) OR of -Week Abstinence
Nicotine patch .×
Varenicline .×
Female sex .×
White ethnicity .×
NMR slow metabolism (NMR .×
Source: Adapted from Chenoweth et al, 
Overall, we showed that NMR, which is associated with treatment out-
come at end-of-treatment and -month follow-up,was also associated
with -week abstinence, and factors which account for variability in
NMR did not remove the association between NMR and -week abstin-
ence. This early period of abstinence represents a period of heightened
vulnerability during the process of smoking cessation, and NMR may be
useful in informing early ecacy screening approaches for compounds
undergoing development. Screening approaches may include NMR-based
Addiction, Withdrawal, Smoking Cessation, and Public Health Measures | 
Reference Number: 
randomization to treatment, as we have done in this clinical trial,or simply
including NMR in analytic models as a covariate known to alter smoking
cessation and treatment response.
Reference Number: 70110
, .., -. , .. , . , . , . , .. -
, .. ,  .. . “Does Cof‌fee Consumption Impact
on Heaviness of Smoking?” Addiction, : –,  ( tables,
f‌igures,  references)
Abstract: Cof‌fee consumption is associated with smoking. Cof‌fee drink-
ers are more likely to be smokers than non-cof‌fee drinkers and to smoke
more heavily. A Mendelian randomization analysis was conducted of cof-
fee/cigarette smoking of , persons in various European countries.
An in vitro study was also conducted on the ef‌fect of the major compon-
ents of cof‌fee, caf‌feic acid, quercetin, and p-coumaric acid on the rate of
nicotine metabolism.
Taken together, our results suggest that cof‌fee consumption is unlikely
to have a major causal impact on cigarette smoking. If it does inf‌luence
smoking, this is not likely to operate via ef‌fects of caf‌feic acid, quercetin
or p-coumaric acid on nicotine metabolism. The observational association
between cof‌fee consumption and cigarette smoking may be due to smok-
ing impacting upon cof‌fee consumption, or confounding. It is likely that
at least some of the positive observational association between cof‌fee
consumption and cigarette smoking is due to the impact of smoking upon
cof‌fee intake. There is evidence from Mendelian randomization analysis,
using a genetic variant that determines heaviness of smoking, that heavier
smoking increases cof‌fee consumption causally.
Reference Number: 70111
, ., . , . , . ,  . .
“Prevalence and Correlates of Nicotine Dependence Among Construc-
tion Site Workers: A Cross-Sectional Study in Delhi.” Lung India, :
–,  ( tables,  references)
Abstract: A survey was conducted of  male construction workers
(mean age  years) in Delhi, India. Ninety-one percent used a tobacco
 | Wigmore on Nicotine and Its Drug Delivery Systems
Reference Number: 
product. Of these, % used smokeless tobacco, % used cigarettes/
bidis, and % used both.
The prevalence of tobacco use and dependence on nicotine was very high
among construction workers compared to that in the general population.
Factors found to be signif‌icantly associated include age at initiation, lower
income group, smokeless tobacco use, lower education. Sensitization of
workers and especially youth through schools and community-based
awareness program about the problem, social support for deaddiction is
needed. Income generation is strongly recommended as part of cessa-
tion strategy for this particular group. Recognition of construction sites
as workplaces and proper implementation of the law for both forms of
tobacco is needed.
“Nicotine’s short half-life of  to  hours leads to withdrawal symptoms
of irritability, frustration, anxiety, diculty concentrating, restlessness,
depressed mood, insomnia, increased appetite, weight gain, and cravings.
—Ziedonis, Das, and Larkin, “Tobacco Use Disorder and Treatment: New
Challenges and Opportunities” ()
The American Psychiatric Association Diagnostic and Statistical Manual
of Mental Disorder (DSM-) lists seven common withdrawal symp-
toms that appear within  hours after tobacco use has been reduced or
abruptly ceased.
. Irritability, frustration, or anger.
. Anxiety.
. Diculty concentrating.
. Increased appetite.
. Restlessness.
. Depressed mood.
. Insomnia.
One of the problems with cigarette addiction is that it is not often con-
sidered to be a serious chronic recurring disease that needs to be treated
American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disor-
ders, th ed (Arlington, VA: American Psychiatric Association, ) at .
Addiction, Withdrawal, Smoking Cessation, and Public Health Measures | 
Reference Number: 
over and over again, and not just by prescribing the use of the nicotine
patch once, and if that doesn’t work, then giving up (). Patients
with other chronic recurring diseases such as diabetes and asthma who
visit a doctor’s oce are approximately × more likely to obtain con-
dition-specif‌ic medication than tobacco users (). Instead, a wide
array of smoking cessation aids should be aggressively employed, includ-
ing nicotine patches, gums, lozenges, nasal sprays, inhalers, bupropion,
and varenicline (, , , ).
About one-quarter of hospitalized smoking patients relapse after
being discharged, most within one hour of release, which shows how
smoking cessation aids need to be in place before leaving hospital and
not several days or weeks later (–). Physicians who had never tried
cigarettes were .× more likely to refer patients to smoking cessation
clinics than doctors who had tried at least one cigarette ().
Nicotine replacement therapy reliably reduces the withdrawal symp-
toms of poor concentration, craving for nicotine, irritability, and depres-
sion, which can persist for  weeks or more (–, ).
Normal nicotine metabolizers had greater diculty in stopping smok-
ing and were more successful with behavioral therapy (). Companies
that of‌fered employees a smoking cessation program with a redeemable
deposit reward had a higher abstinence rate (). Smoking cessation
programs need to be tailored to women, who may be more susceptible
to the ef‌fects of cigarettes (). Older smokers (> years of age) were
more successful at smoking cessation with nicotine replacement therapy
(NRT) ().
It is essential to immediately implement smoking cessation therapy
in smoking patients with acute coronary syndrome, COPD, and asthma
(–, , , ).
ECs are not an ef‌fective smoking cessation aid and are not approved
as such by the FDA ().
The plasma nicotine concentrations obtained by NRT are
approximately one-half the level obtained by smoking cigarettes and
NRT is not recommended to be used for a long period of time, and so
NRT does not appear to cause an increase in cancer or cardiovascular
disease risk and is considered safe (, -).
There are numerous similarities between opioid and nicotine depend-
ence, and opioid (and methadone) use can lead to an increase in nicotine
self-administration ().
 | Wigmore on Nicotine and Its Drug Delivery Systems
Reference Number: 
Reference Number: 70201
, .. “Strategies to Help a Smoker Who is Struggling to Quit.
Journal of the American Medical Association, : –,  (
tables,  references)
Abstract: The author presents a case report of a -year-old man with
hypertension and a history of depression (treated with f‌luoxetine) who
smokes  to  cigarettes daily. He has attempted to quit smoking by
using a nicotine patch for  days and took bupropion for a month, but
feels nothing works and is asking about ECs as a smoking cessation tool.
Table: Ecacy of Methods Used to Treat Tobacco Dependency
Intervention Odds Ratio of Quitting vs No Intervention
Counseling in person (individual .×
Counseling in person (group) .×
Telephone quitline .×
Brief physician advice to quit .×
Bupropion (sustained release) .×
Varenicline .×
Nicotine patch .×
Nicotine gum .×
Nicotine lozenge .×
Nicotine inhaler .×
Nicotine nasal spray .×
Source: Adapted from Rigotti, 
The case illustrates a common scenario: a smoker who wants to quit,
has little self-conf‌idence that he can do so because past quit attempts
failed, and believes that he has “tried everything.” In fact, he has not tried
everything. He has never used behavioral support, combination pharma-
cotherapy, or varenicline and his trial of NRT was inadequate. Behav-
ioral support is essential in view of his low self-conf‌idence. It could be
encouraged and arranged by referral from your oce to a free telephone
quitline. I would discourage use of the electronic cigarette because of
the absence of scientif‌ic data on its safety or ecacy for cessation and
the existence of FDA-approved ef‌fective options that he has not tried. In
place of an unapproved nicotine delivery device, he could combine the
nicotine patch with his choice of lozenge, gum, or inhaler. Alternately,
Addiction, Withdrawal, Smoking Cessation, and Public Health Measures | 
Reference Number: 
he could try varenicline, which is appropriate if his psychiatric status is
stable, careful follow-up is insured, and his concerns about using varenic-
line can be allayed. Combining bupropion and NRT is another option since
he had partial success with bupropion in the past and bupropion can be
used in individuals taking SSRIs. Whatever his next step, it is important to
encourage him to keep trying, assure him that he can succeed, monitor his
progress, and continue to of‌fer help at each visit.
Reference Number: 70202
, .., . , .. , . ,  .. . “Undertreat-
ment of Tobacco Use Relative to Other Chronic Conditions.American
Journal of Public Health, : e–e,  ( tables,  references)
Abstract: Tobacco dependence is a chronic re-occurring condition that
increases the risk of diabetes, hypertension, and cardiovascular disease.
This study compares the likelihood that a tobacco user will receive med-
ical treatment after a visit to the doctor’s oce to the likelihood that
adults with other chronic medical conditions will receive it. Between 
and , a total of , patient visits were analyzed concerning the
rate of medication and behavioral counseling provided to tobacco users
versus patients with hypertension, diabetes, hyperlipidemia, asthma, and
depression. Patients with hypertension, diabetes, or hyperlipidemia were
also more likely to receive behavioral counseling.
Table: Percentage and Adjusted OR of a Patient Receiving Condition-
Specif‌ic Medication
Condition Visits Receiving Condition-
Specif‌ic Medication (%)
Adjusted OR of Receiving
Condition-Specif‌ic Medication
Tobacco use . . (Reference)
Hypertension . .×
Diabetes . .×
Hyperlipidemia . .×
Asthma . .×
Depression . .×
Source: Adapted from Bernstein et al, 
This study indicates that tobacco use is undertreated by US physicians com-
pared with other common chronic conditions that also cause signif‌icant
 | Wigmore on Nicotine and Its Drug Delivery Systems
Reference Number: 
morbidity and mortality and for which evidence-based treatment exists. US
clinicians also appear to treat smoking less aggressively than other chronic
conditions. The reasons for this are likely multifactorial, but they need to be
addressed to improve the health of smokers. Whether the paradigm of dis-
ease management can be adapted to the treatment of tobacco dependence
is unclear, and we suggest this be considered in future prospective studies.
Reference Number: 70203
, .., . , . , -. , . --
, . ,  . . “Real-Life Ef‌fectiveness of Smok-
ing-Cessation Treatments in General Practice Clinics in Denmark.
The Escape Smoke Project.Respiratory Medicine, : –, 
(tables,  references)
Abstract: The ef‌fectiveness of general medical practice smoking cessation
treatment on  daily smokers (mean age  years) was determined in
Denmark. The average number of years smoking was  and the aver-
age number of daily cigarettes was . Overall, % had mild, % had
moderate, and % had severe nicotine dependency. Smoking cessation
methods included NRT, prescription drugs (varenicline, or bupropion),
or no medicine.
In conclusion, the present study has shown that smoking cessation in Dan-
ish general practice clinics with both experience and interest in smoking
cessation can result in rather high long-term quit rates (.%) at a rather
low cost. This was especially the case for smokers combining counseling
with smoking cessation medicine. The combination of counseling and
prescription-based smoking medicine was associated with a % higher
chance of remaining abstinent after  months using prescription-based
smoking cessation medicine compared to not using any smoking cessa-
tion medicine. General practice, that already has many of the smokers
as patients in their clinics for other reasons, is therefore one relevant
arena for accelerating ef‌fective smoking cessation with the overall goal of
decreasing the smoking prevalence and improving the health of smokers.
Reference Number: 70204
, .., .. , . , . ,  .. -
. “Rapid Relapse to Smoking Following Hospital Discharge.Pre-
ventive Medicine Reports, : (pp),  ( tables,  references)
Addiction, Withdrawal, Smoking Cessation, and Public Health Measures | 
Reference Number: 
Abstract: As approximately  million smokers are hospitalized in the US
every year, hospitalization can provide a teachable moment for patients
to quit smoking. Although a majority of patients do not smoke during
their hospital stay, as most hospitals are smoke-free, most return to
smoking after hospitalization. Of the  hospitalized smoking patients
studied between  and  at two large midwestern hospitals, %
returned to smoking within  day of discharge. Of these, .% relapsed
within  hour of discharge, .% between  and  hours after discharge,
and .%  day after discharge.
Table: Predictors of Relapse within  Day of Hospital Discharge
Factors OR of Rapid Relapse of Cigarette Smoking
Length of stay in hospital .×
Depression .×
Used tobacco during hospitalization .×
Low conf‌idence for quitting .×
Did not set a quit date .×
Heavy smoking index .×
Source: Adapted from Mussulman et al, 
Interventions to help patients stay abstinent until they can connect to
post-discharge treatment has the potential to reduce the overall health
impact caused by tobacco use and reduce health care costs in this vulnerable
population. Rapid relapse presents a signif‌icant challenge because it allows
little time for outpatient cessation supports to connect with smokers. This
study provides strong support for the need to enhance hospital-based inter-
ventions—prior to and during the process of discharge—to help smokers
maintain their intentions to quit after they leave the hospital environment.
Reference Number: 70205
, .., .. , . , .. , . -
, .. , .. , . , .. ,  -. .
“Hospitalized Smokers: A Factorial RCT of Nicotine Patches and Coun-
seling.American Journal of Preventative Medicine, : –, 
(tables,  references)
Abstract: Smokers are more likely to be hospitalized than non-smokers
and have a period of imposed abstinence while in hospital, but most
 | Wigmore on Nicotine and Its Drug Delivery Systems
Reference Number: 
return to smoking when discharged. A total of , hospitalized adult
smokers from f‌ive hospitals between  and  were given a -month
supply of nicotine patches or telephone counseling upon discharge. The
-day abstinent rate at  months was .% for the nicotine patch and
.% for the telephone counseling group.
A second possible explanation for the lack of results lies in the context of
the study and the population itself. Hospitals regularly screen for smok-
ing and most smokers stop smoking during their hospital stay. Many also
receive pharmacotherapy or counseling while hospitalized. The precipi-
tating health crisis can be a powerful motivator for change even without
intervention.The margin of improvement from any additional interven-
tion is likely to be smaller here than in other intervention contexts. The
relatively high self-reported abstinence rates overall suggest that the
population was motivated to stay quit, making it more dicult to detect
an additional intervention ef‌fect.
Reference Number: 70206
, ., . , .. , . -, .
-, . , . ,  . . “Cigarette
and E-Cigarette Use and Smoking Cessation Practices Among Phys-
icians in Poland.International Journal of Environmental Research and
Public Health, :  ( pp),  ( tables,  references)
Abstract: A survey was conducted of  physicians undergoing manda-
tory public health training in Poland in , regarding tobacco and EC
use and smoking cessation. Current cigarette and EC use was reported by
.% and .% of physicians, respectively. Current heated tobacco use was
reported by .%. Two-thirds of physicians asked patients about smoking
whereas only % asked about the use of ECs. Only .% of physicians
refer a patient to anti-smoking counseling compared to .% who refer
EC users. Physicians who had never tried cigarettes were .× more likely
to refer patients to smoking cessation clinics than doctors who had tried
at least one cigarette.
An analysis of tobacco use and smoking cessation practices (between 
and ) among physicians in developing countries shows that smoking
prevalence was highest in Central and Eastern Europe (%) and lowest
in Asia (.%). However, in some European Union (EU) countries, the
prevalence of tobacco use among physicians is equal to or even higher
Addiction, Withdrawal, Smoking Cessation, and Public Health Measures | 
Reference Number: 
than its prevalence in the general population (% in Italy; % in France;
% in Greece). The high smoking prevalence among physicians might
be explained by occupational stress, which is considered a key factor to
addiction. Moreover, this suggests an urgent need to develop smoking
cessation promotion program at workplace of physicians. In our study, the
prevalence of tobacco use among physicians was .%, which is lower than
the prevalence of tobacco use in the general population of Poland (%).
Reference Number: 70207
, .. “Why People Smoke.British Medical Journal, : –,
 ( references)
Abstract: For much of the th century and earlier, cigarette smoking
was regarded as just a habit. It is now known that chronic smoking is
due to nicotine addiction. The terminal half-life of nicotine is  hours.
Nicotine replacement therapy (gum, patch, or spray) is a reliable way to
decrease the severity of withdrawal.
Table: Ef‌fects of Nicotine Withdrawal
Symptom Duration Incidence
Light-headedness %
Sleep disturbance %
Poor concentration %
Craving for nicotine %
Irritability or aggression %
Depression %
Restlessness %
Increased appetite %
Source: Adapted from Jarvis, 
Smoking usually starts as a symbolic act of rebellion or maturity
By age , % of smokers regret having started to smoke
Nicotine from cigarettes is highly addictive—probably because it is
delivered so rapidly to the brain
Smoking a cigarette, especially the f‌irst of the day, feels good mainly
because it reverses the symptoms of nicotine withdrawal
Most smokers who switch to low tar cigarettes or reduce the number of
cigarettes they smoke continue to inhale the same amount of nicotine,
and hence tar, from the cigarettes they smoke
 | Wigmore on Nicotine and Its Drug Delivery Systems
Reference Number: 
Heavy dependence on nicotine is strongly related to socioeconomic
Smoking is a chronic relapsing addictive disease
Reference Number: 70208
-, . “Smoking and Chronic Obstructive Pulmonary Dis-
ease (COPD). Parallel Epidemics of the st Century.” International
Journal of Environmental Research and Public Health, : –, 
( table,  f‌igure,  references)
Abstract: According to the World Health Organization (WHO),  mil-
lion deaths were caused by tobacco in the th century, and if current
trends continue, up to  billion deaths will occur in the st century. More
than % of the world’s smokers live in low- and middle-income coun-
tries. Smoking is the most important causative factor in COPD. WHO
estimates that  million people have moderate to severe COPD and
more than  million people died of COPD in . About % of smok-
ers eventually develop COPD. Cigarette smoke contains an extremely
high concentration of oxidants, which causes an inf‌lammation in the
lungs and its airways. Smoking cessation is the single most ef‌fective and
cost-ef‌fective treatment for COPD.
Table: Odds Ratio of Smoking Cessation with Pharmacologic Treatment
Compared to Placebo
Treatment OR of Smoking Cessation (compared to placebo)
Nicotine gum .×
Nicotine patch .×
Nicotine inhaler .×
Bupropion .×
Varenicline .×
Source: Adapted from Laniado-Laborin, 
Tobacco use kills more than f‌ive million people a year and accounts for %
of adult deaths worldwide. COPD is a major and growing cause of mor-
bidity and mortality with smoking being recognized as its most important
causative factor. Several meta-analyses have shown that all pharma-
cotherapies for smoking cessation are twice as likely more ecacious
than placebo with an abstinence rate in the –% range at one year
Addiction, Withdrawal, Smoking Cessation, and Public Health Measures | 
Reference Number: 
when pharmacological treatment and behavioral support are combined.
Unfortunately, in spite of the initial ecacy of these pharmacotherapies,
the number of patients that remain abstinent from smoking at  year fol-
low-up is low (range –%).
Reference Number: 70209
, ..,  .. . “Tobacco Treatment and Prevention:
What Works and Why.Respiratory Care, : –,  ( table,
 references)
Abstract: Respiratory therapists frequently have contact with patients
with chronic lung diseases and are unable to advise them about smok-
ing cessation. This article summarizes all the current smoking cessation
Table: Smoking Cessation Medication and Recommended Dosage
Medication Dosage
Patch Start at  mg unless patient weighs less than  lbs or has
adverse ef‌fects,  mg if more than  cigarettes per day
Gum  mg for less than  cigarettes per day
 mg for more than  cigarettes per day
Lozenge  mg for those who smoke within  minutes of awakening
 mg for those who smoke more than  minutes after
Up to  lozenges per day;  per  hour period
Inhaler Can use  to  per day
Inhale  times per cartridge
Nasal spray Maximum of  doses per day ( dose is  spray in each
nostril, generally – doses per hour)
Bupropion SR/XL
(aka Zyban, Wellbutrin)
With XL, take one  mg pill per day
With SR,  mg twice daily
(aka Chantix)
Start use  to  weeks prior to quitting smoking
Take after eating with full glass of water
Nortriptyline Start use  to  weeks prior to quitting
Take with a full glass of water
Clonidine Start use  week prior to quitting
Take after eating with a full glass of water
Source: Adapted from Goodfellow and Waugh, 
 | Wigmore on Nicotine and Its Drug Delivery Systems
Reference Number: 
Another key element of tobacco control that pertains only to approximately
% of all health-care providers in the United States is the role of smoker.
If you are a smoker, become an ex-smoker. Now is the time to f‌inally stop.
By quitting your own addiction, becoming skilled at tobacco abuse coun-
seling, and engaging in social and political action against tobacco, you take
on a role that is vital to minimizing and preventing tobacco’s terrible toll
of death and disability. If advocacy is not for you in a public arena, at least
become a role model for respiratory therapy students, who often do not
receive adequate tobacco control and prevention counseling or formal
training in the treatment of nicotine dependence in their education pro-
grams. Share your success story and be an inspiration to someone having
a dicult time with their own tobacco control.
Reference Number: 70210
, .,  .. . “Improved Patient Outcome with Smoking Cessa-
tion: When is it Too Late?” International Journal of Chronic Obstructive
Pulmonary Disease, : –,  ( table,  f‌igures,  references)
Abstract: Three conditions are responsible for all tobacco-related morbidity
and mortality. Cardiovascular diseases (CVD) account for % of all smok-
ing-related deaths. Lung cancer accounts for % and COPD accounts for
an additional % of all tobacco-related deaths. Globally, nearly ,
people die each day due to tobacco-related disease and in , it is esti-
mated that tobacco will cause  million deaths per year. NRT, bupropion,
and varenicline are ef‌fective medications for smoking cessation.
The benef‌its of smoking cessation in CVD are almost immediate. Within
 hours of smoking cessation, there are signif‌icant improvements in
blood pressure and heart rate.Within one year of abstinence, the risk
of cardiovascular events (eg, myocardial infarction [MI] and stroke) is
reduced by half (compared with continued smoking). Between  and 
years post-smoking, the risk of stroke and coronary heart disease is “nor-
malized” to that of never smokers.On the other hand, the benef‌its of
tobacco treatment on the risk of lung cancer take much longer to achieve.
The risk of lung cancer declines steadily following smoking cessation such
that after about  years of abstinence, the risk of lung cancer is between
% and % of that for continued smokers.However, even after decades
of smoking cessation, the risk of lung cancer may never reach that of never
smokers. The benef‌its of tobacco treatment to COPD progression are
Addiction, Withdrawal, Smoking Cessation, and Public Health Measures | 
Reference Number: 
measurable within the f‌irst year of abstinence and are particularly striking
in female smokers who manage to quit smoking.After several years of
smoking cessation, the rate of decline in lung function becomes similar to
that of never smokers. However, because the lung function lost during the
time the patient smoked is never fully recovered and because lung func-
tion declines with age (even in nonsmokers), COPD patients may develop
additional symptoms and progress to a higher COPD severity class, even
after many years of smoking abstinence.
Reference Number: 70211
, .., . , .. ,  .. . “Smoking
Cessation Strategies for Patients with Asthma: Improving Patient
Outcomes.Journal of Asthma and Allergy, : –,  ( tables,
Abstract: Smoking is as common in people with asthma as it is in the gen-
eral population, but it is even higher in adolescents with asthma. Smokers
with asthma are prone to have worse symptoms and greater def‌icits in
lung function. Smokers with asthma are more likely to smoke regularly
and at a younger age.
In general, many smokers make multiple attempts before successfully
quitting. In addition to individual vulnerability to tobacco withdrawal
symptoms, factors contributing to relapse include social situations when
drinking alcohol, being around other smokers, as well as stress related
to work, relationships, and f‌inances.A dif‌ferent drug or combination of
smoking cessation medications may be trialed for smokers who have
been unsuccessful in their quit attempt or, a combination of NRT can be
repeated for a subsequent attempt.
Depending on the pharmacotherapy used, %–% of smokers who
attempt to quit abstain at  months, but around half of those who are
abstinent at  year, relapse within the next  years.Thus, follow-up by
a health professional is essential, preferably in the f‌irst week and month
after quitting and thereafter for at least  years.
Reference Number: 70212
, ..,  -. . “Discovery and Development of Varenicline for
Smoking Cessation.Expert Opinion Drug Discovery, : –, 
( tables,  f‌igures,  references)
 | Wigmore on Nicotine and Its Drug Delivery Systems
Reference Number: 
Abstract: Although % of cigarette smokers express desire to quit, only
about % remain abstinent for more than a year. Nicotine acts by binding
to the nicotinic acetylcholine receptors (nAChRs) in the central and per-
ipheral nervous system. Nicotine binding stimulates dopamine release.
Varenicline tartrate (Chantix) was developed as a smoking cessation agent
by Pf‌izer in  based on the plant-based drug cytosine. It is a highly
selective and potent partial agonist of nicotine. Nausea is the most com-
mon side-ef‌fect of varenicline, followed by insomnia. Varenicline is not
recommended for people operating vehicles or heavy equipment, because
side ef‌fects can include vision and heart rhythm issues and it has been
linked to accidents and falls. It is banned for use in pilots.
Varenicline development was based on strong theoretical rationale and
preclinical evidence. Clinical studies indicate that varenicline is safe and
more ef‌fective in sustaining abstinence than placebo, bupropion or nico-
tine replacement therapies. However, given that continuous abstinence
rates across studies remain low (~% with varenicline; ~% with
placebo), novel and more ef‌fective medications targeting other nicotinic
or glutamate receptors for smoking cessation are required.
Reference Number: 70213
, ., . , . , . , . ,  . .
“Chronic Illness and Smoking Cessation.Nicotine and Tobacco Research,
: –,  ( tables,  references)
Abstract: A telephone survey was conducted of , adults (+ years)
from Nashville, Tennessee, in the United States. Seventeen percent of
those surveyed were former smokers and % were current smokers.
Based on self-reported height and weight, % were overweight and %
were obese. A total of % reported diabetes, % reported hypertension,
and % had high cholesterol.
Participants with diabetes were more likely to report being former smok-
ers, after adjusting for sociodemographic characteristics, whereas having
hypertension or high cholesterol was not associated signif‌icantly with
smoking status. The likelihood of being a former smoker did not increase
as number of diagnosed chronic diseases increased. Participants who
were women, older (aged +), or single were signif‌icantly less likely to
be former smokers. Participants with at least a college degree, those with
Addiction, Withdrawal, Smoking Cessation, and Public Health Measures | 
Reference Number: 
incomes of ,+ US dollars, and those who were underweight or obese
were more likely to be former smokers.
Reference Number: 70214
, ., . , . , .. , . ,  ..
. “Characterising the Nicotine Metabolite Ratio and Its Associ-
ation with Treatment Choice: A Cross Sectional Analysis of Stop Smok-
ing Services in England.Scientif‌ic Reports, :  (pp),  ( tables,
 f‌igure,  references)
Abstract: Oral f‌luid samples were collected from , Stop Smoking par-
ticipants in England between  and  and were analyzed for trans
’-hydroxycotinine (-HC) and cotinine by LC/MS/MS to determine the
nicotine metabolite ratio (NMR). Samples with cotinine levels less than
 ng/mL were excluded, as the persons were light or occasional smok-
ers. Normal metabolizers of nicotine were characterized by an NMR of
.+ and slow metabolizers were
demographics were determined. Nicotine is metabolized mainly by the
liver enzyme CYPA into cotinine and then exclusively by the CYPA
into -HC. NMR is a biomarker of total nicotine clearance, as cotinine
has a long half-life. In total, the NMR of , participants were measured
and the mean NMR was .. Of these, .% were normal (mean .)
and .% were slow (mean .). High cigarette dependence was seen
in about half of the participants. Normal metabolizers were on average
older, White, from lower socioeconomic groups, and in poor physical and
psychological health. Greater diculty in stopping smoking was found in
normal metabolizers. Higher NMR occurs in women smokers due to the
estrogen induction of the CYPA enzyme. Slower metabolizers benef‌it
more from behavioral counselling alone.
Although signif‌icant associations between NMR and ethnicity, physical
health and gender were identif‌ied, these sociodemographic, smoking, and
health-related characteristics did not greatly inf‌luence variability in NMR
and did not confound allocation to either slow or normal NMR status.
This suggests that NMR status is relatively unrelated to these variables,
functioning consistently across dif‌ferent populations, thus increasing
its potential for use in clinical practice. The unexpected association of
NMR status with behavioural support should be explored further in clin-
ical trials and studies of real-world data. Given the association of NMR
 | Wigmore on Nicotine and Its Drug Delivery Systems
Reference Number: 
with pharmacotherapy ecacy, the f‌inding that NMR status is currently
not associated with pharmacotherapy choice suggests there is a need for
providers to tailor smoking cessation therapies based on rate of nicotine
metabolism as patients are not naturally selecting the option that has the
highest potential ecacy for them.
Reference Number: 70215
, .., .. , . , . , .. , 
.. . “A Pragmatic Trial of E-Cigarettes, Incentives, and Drugs for
Smoking Cessation.New England Journal of Medicine, : –,
 ( tables,  f‌igures,  references)
Abstract: Six thousand and six smokers from  companies were assigned
either to one of four smoking cessation interventions or to usual care.
Usual care included access to information regarding the benef‌its of smok-
ing cessation and a motivational text-messaging service. The other four
interventions were free cessation aids; free e-cigarettes; reward incen-
tives plus free cessation aids; or a redeemable $ deposit plus free ces-
sation aids. The primary outcome was sustained smoking abstinence for
 months after the quitting date. Sustained rates were .% in the free
cessation aids group, % in free ECs group, % in the rewards group, and
.% in the redeemable deposits group.
In summary, this trial showed that among unselected smokers, workplace
smoking-cessation programs yielded low rates of smoking abstinence
and that of‌fering free cessation aids or free e-cigarettes did not increase
abstinence among smokers who were given access to information and
motivational text messages. In contrast, programs that of‌fered f‌inancial
incentives tripled the rates of smoking cessation, reduced employers’ costs
per successful quit as compared with programs that of‌fered cessation aids
alone, and yielded total costs that compared favorably with the costs of
employing smokers.
Reference Number: 70216
, ., . , . , . ,  . . “Factors
Af‌fecting Smoking Resumption After Acute Coronary Syndromes.Hel-
lenic Journal of Cardiology, : –,  ( tables,  references)
Addiction, Withdrawal, Smoking Cessation, and Public Health Measures | 
Reference Number: 
Abstract: A study was conducted of  male and  female patients
(mean age  years) who were hospitalized between  and  with
an acute coronary syndrome. All were active smokers and smoking was
strictly prohibited during hospitalization. They were advised to attend a
smoking cessation clinic. The patients were studied for  months after
discharge. Of the  patients,  (%) were abstinent from smoking
after  year and  were relapsed smokers.
Smokers with acute coronary syndromes should be encouraged to par-
ticipate in special secondary prevention programmes. Smoking cessation
clinics contribute signif‌icantly to a reduction in smoking in this particular
group of patients.
Reference Number: 70217
, ..,  .. . “Smoking Prevalence, Behaviours, and
Cessation Among Individuals with COPD or Asthma.Respiratory Medi-
cine, : –,  ( tables,  f‌igure,  references)
Abstract: The  Canadian Community Health Survey (CCHS) was
used to determine smoking prevalence, nicotine addiction, physician
counselling, and smoking cessation in , people without COPD or
asthma, , people with asthma, and , with COPD. Women smok-
ers with COPD were .× as likely to have high or very high nicotine
addiction and women smokers with asthma were .× as likely.
The prevalence of smoking in COPD remains substantially higher than
in the general smoking population, while the prevalence of smoking in
asthma is similar to population levels. Our observation that more women
with COPD or asthma smoke, and that such women have higher nico-
tine addiction levels, may in part explain why the prevalence of COPD
and asthma is increasing more among women than men. Greater nicotine
addiction may in part explain the high prevalence of continued smoking
among individuals with COPD. In contrast, reduced desire to quit smok-
ing and fewer attempts at quitting smoking do not appear to explain the
higher prevalence of continued smoking in COPD. These f‌indings sug-
gest that more physician counselling regarding smoking cessation, coupled
with more aggressive prescription and increased access to smoking cessa-
tion medications, is needed for smokers with COPD and asthma in order
to improve cessation rates in these vulnerable populations.
 | Wigmore on Nicotine and Its Drug Delivery Systems
Reference Number: 
Reference Number: 70218
, .-., .. , .. , .. , .. ,  .. . “Does Elec-
tronic Cigarette Use Predict Abstinence from Conventional Cigarettes
Among Smokers in Hong Kong?” International Journal of Environmental
Research and Public Health, :  ( pp),  ( tables, references)
Abstract: Hong Kong has one of the lowest smoking rates in the developed
world (.% in ) and EC use remains rare (.%). The ef‌fect of ever-
use of EC (many of which do not have nicotine) was studied in  daily
smokers at baseline and  months later.
To our knowledge, this is the f‌irst report showing that ever EC use was
not prospectively associated with abstinence from conventional cigarettes
in Chinese adult smokers, most of whom were motivated to quit (as they
were participants in a quitting contest), in a region where nicotine ECs are
not widely available.
Reference Number: 70219
, .,  . . “Nicotine Replacement Therapy: An Over-
view. International Journal of Health Sciences, : –,  (
tables,  references)
Abstract: A review of nicotine replacement therapy (NRT) was conducted.
NRT is designed to reduce the motivation to consume tobacco and the
physiological and psychomotor withdrawal symptoms.
Nicotine addiction is the major factor impeding smoking cessation and
long-term abstinence. Today, several nicotine medications are available in
dif‌ferent forms, doses and f‌lavors and their use has been recommended
for all tobacco consumers who do not have medical contraindications. The
choice of NRT product should normally be guided by the patient’s pref-
erence. Current evidence suggests that all of the commercially available
forms of NRT (gum, transdermal patch, nasal spray, inhaler and sublingual
tablets/lozenges) increase their chances of successfully stopping smoking.
NRTs increase the rate of quitting by  to %.
Reference Number: 70220
, ., . -, . , . , . , . -
,  .   . “Four Years’ Follow Up at a
Addiction, Withdrawal, Smoking Cessation, and Public Health Measures | 
Reference Number: 
Smoking Cessation Clinic.Revista Portuguesa de Pneumologia, :
–,  ( table,  f‌igures,  references)
Abstract: A retrospective analysis was conducted on  patients (mean
age . years) at a smoking cessation clinic between  and .
The average smoking burden was  pack-years. Respiratory disease was
present in .% (COPD .%, other .%) and cardiovascular disease
in .%. A psychiatric disorder was diagnosed in % of the patients.
Most patients reported prior quitting attempts (.%). Most patients
had undergone NRT (patch .%; gum %; both patch and gum .%).
Sedative-hypnotics were administered in .% of the patients. Nearly
half (.%) were successful in smoking cessation.
Table: Reasons for Past Failure to Quit Smoking
Reason for Relapse Percent
Anxiety %
Lack of motivation %
Non-supportive environment %
Weight gain %
Source: Adapted from Aguiar et al, 
We found a high percentage of patients with psychiatric pathology and
a high degree of nicotine addiction, factors which when allied to stress
as a main cause of increased smoking imply paying special attention to
cognitive/behavioural support to guarantee better results.
Successful treatment is without a doubt related to compliance with
appointments, drug therapy and cognitive/behavioural therapy.
Reference Number: 70221
, .., .. ,  .. . “Tobacco Use and Cessation
Among Women: Research and Treatment-Related Issues.Journal of
Women’s Health, : –,  ( f‌igures,  references)
Abstract: In the United States, the prevalence of tobacco use among
women was % in , reached a high of % in , and had gradually
decreased to % by the time of the study. There has been relentless mar-
keting of cigarettes to women by the tobacco industry, including light
or low tar cigarettes which has sent the message that these products are
safer. Women in general tend to have faster plasma clearance of nicotine
 | Wigmore on Nicotine and Its Drug Delivery Systems
Reference Number: 
and cotinine and may benef‌it more from smoking cessation than do men.
COPD has risen dramatically in women.
Tobacco use is responsiblefor many diseases af‌fecting women today, most
notably COPD and lung cancer. With the rise in sex-targeted marketing
of tobacco products, there has been an alarming increase in the number
of tobacco-attributable diseases in women. The literature addressing sex
dif‌ferences in susceptibility to tobacco and its associated diseases as well
as sex dif‌ferences in smoking cessation is at times contradictory. Although
this is likely related to study design and selection bias, there is still intrigu-
ing evidence that sex dif‌ferences may exist. Women may be more sus-
ceptible to the ef‌fects of tobacco and, thus, more likely to succumb to
the ramif‌ications of long-term smoking. More importantly, healthcare
practitioners may be unaware of the increased susceptibility of women
to smoking-related diseases. Even smoking cessation therapies need to
be tailored specif‌ically for women, as the reasons why they smoke and
the barriers that interfere with successfully quitting are unique to women.
Strategies to help alleviate the epidemic of tobacco use in women include
a greater emphasis on patient and physician education, devising smoking
cessation programs geared specif‌ically toward women, and increasing sex-
specif‌ic research in tobacco-related diseases.
Reference Number: 70222
, ., .... , .. , ... , .. , .. , .
, . ,  .. . “Ef‌fects of Aging on the Ef‌fective-
ness of Smoking Cessation Medication.Oncotarget, : –,
 ( tables,  references)
Abstract: Two hundred and thirty-nine smokers over  years of age
and  smokers under  years of age attended a smoking cessation
clinic and received various treatments, including NRT alone, varenicline,
bupropion, and combinations thereof. The smoking cessation rates were
determined  year later.
Cessation rates were signif‌icantly dif‌ferent among younger and older par-
ticipants who were using nicotine replacement therapy (NRT) alone. Being
over  years of age was signif‌icantly associated with increased cessation
success among those who used NRT alone (OR ., % CI: . to .,
p = .). The ef‌fectiveness of varenicline and bupropion were not sig-
nif‌icantly dif‌ferent according to age groups. . . . Using age as a predictor
Addiction, Withdrawal, Smoking Cessation, and Public Health Measures | 
Reference Number: 
for tailoring smoking cessation drugs might potentially lead to a more
individualized prescription of smoking cessation therapy. These results
should be tested in randomized controlled trials.
Reference Number: 70223
, . “Smoking Cessation and COPD.European Respiratory Review,
: –,  ( tables,  f‌igures,  references)
Abstract: The main smoking cessation therapies are counselling in com-
bination with varenicline, NRT, or bupropion. The Lung Health Study
I examined , smokers with mild COPD (mean age  years) and
were involved in repeated smoking cessation attempts over the course
of years, with a quit rate of %. After . years, quitters had a higher
lung function and higher survival rate.
Table: Odds Ratio of Quitting and Type of Treatment
Treatment OR of Quitting
Nothing/usual care .×
Counselling alone .×
Counselling + antidepressants .×
Counselling + NRT .×
Counselling + varenicline .×
Source: Adapted from Tønnesen, 
An optimal approach to smoking cessation today should contain an
adequate support programme, either individual or in groups, in combin-
ation with a f‌irst-line pharmacological smoking cessation agent, i.e.NRT
(two formulations), varenicline or bupropion SR for  months. When
relapse occurs, re-treatment should be of‌fered. COPD patients need more
support than smokers without comorbidities and smoking intervention
should have top priority as it is very cost-ef‌fective, reduces the decline in
lung function and reduces morbidity and mortality.
Reference Number: 70224
, . “Which Drug to Be Used in Smoking Cessation?” Polskie
Archiwum Medycyny Wewnętrznej, : –,  ( references)
Abstract: There are three f‌irst-line smoking-cessation medications: nico-
tine replacement therapy (NRT), varenicline (a partial nicotine receptor
 | Wigmore on Nicotine and Its Drug Delivery Systems
Reference Number: 
agonist), and slow-release bupropion (an anti-depressant which releases
dopamine in the central nervous system). The plasma nicotine concen-
trations subjects reach while using NRT are approximately one-half to
two-thirds the levels reached during smoking. All three medications
nearly double the quit rate when used for – months.
Depression and suicidal attempts have been reported with varenicline use
but it is probably not induced by varenicline but by the quitting process
per se. It is recommended that the f‌irst agent to be used in smoking ces-
sation should be NRT as it is the best documented product with mild side
ef‌fects. It might be optimal to combine the patch with either gum, inhaler,
sublingual tablets or nasal spray. In subjects that have failed with NRT,
varinicline should be the choice. Bupropion SR is preferred to subjects
with depression or smokers who have failed with the previous two agents,
due to the many contra-indications and side ef‌fects of bupropion SR. With
one of the  agents combined with follow-up visits with counselling, one
can expect a -year quit rate around -%.
Reference Number: 70225
, ., . , .. , ...  , . , 
. . “Cardiovascular and Neuropsychiatric Risks of Varenicline
and Bupropion in Smokers with Chronic Obstructive Pulmonary Dis-
ease.” Thorax, –,  ( tables,  f‌igure,  references)
Abstract: The risk of serious cardiovascular events, self-harm, or depres-
sion was determined in , COPD patients using NRT, , COPD
patients using varenicline, and  COPD patients using bupropion for
smoking cessation in England between  and .
Table: Hazard Ratios (HRs) of Various Adverse Events Comparing
Bupropion or Varenicline and Nicotine Replacement Therapy (NRT)
Adverse Event HR of Bupropion
Compared to NRT
HR of Varenicline
Compared to NRT
Ischemic heart disease .× .×
Stroke .× .×
Arrhythmia .× .×
Depression .× .×
Self-harm .× .×
Source: Adapted from Kotz et al, 
Addiction, Withdrawal, Smoking Cessation, and Public Health Measures | 
Reference Number: 
Very recently, the FDA decided to remove the boxed warning for serious
mental health ef‌fects from the varenicline and bupropion labels. This
decision was based on a large randomised controlled trial that the FDA
required the drug companies to conduct, which showed no signif‌icant
increase in neuropsychiatric events in users of varenicline or bupropion
compared with users of nicotine patch or placebo.The trial thereby con-
f‌irmed evidence from meta-analyses of previous randomised controlled
trials and from observational studies indicating that a causal relationship
between the use of these drugs and serious adverse cardiovascular and
neuropsychiatric events is unlikely.
Reference Number: 70226
-, .,  .. . “Does Everyone Who Quit
Smoking Gain Weight? A Real-World Prospective Cohort Study.Jor-
nal Brasileiro de Pneumologia, : (pp),  ( tables,  f‌igures, 
Abstract: Smokers typically have a lower body weight than non-smok-
ers, in part due to nicotine and additives added by the tobacco indus-
try such as tartaric acid and -acetylpyridine, which suppress appetite
and increase basal metabolism rate. Approximately % of the women
and % of the men state that their main concern in quitting cigarettes
is weight gain. The factors that have been associated with weight gain
after smoking cessation include male gender, a higher level of nicotine
dependence, and advanced age. A total of  patients who attended an
outpatient cessation clinic in Brazil who achieved continuous smoke-free
status (eCO
Sixty-f‌ive percent had no weight gain or less than %; % had a weight
gain of more than %; and % had a weight gain of more than %. The
use of bupropion as a smoking cessation aid did not af‌fect weight gain,
even though this antidepressant is prescribed for weight loss.
The dissemination of our f‌indings could be useful for encouraging smokers
to quit. Patients should be informed that weight gain is not a signif‌icant
problem in the majority of the cases. The benef‌its of quitting smoking out-
weigh any potential risks related to weight gain. Patients should also be
informed that systemic arterial hypertension and type  diabetes mellitus,
as collateral ef‌fects of weight gain—often mentioned by patients as major
concerns—are uncommon, and that the benef‌its of quitting by far of‌fset
 | Wigmore on Nicotine and Its Drug Delivery Systems
Reference Number: 
the consequences of weight gain related to smoking cessation. Neverthe-
less, in our sample, % of the patients in whom treatment success was
achieved showed weight gains that could be harmful to their health (more
than % in relation to the baseline weight). Of the patients in whom the
treatment failed, only .% showed such weight gains.
Reference Number: 70227
, ., . , . ,  . . “Risk of Depressive Disor-
ders After Tobacco Smoking Cessation: A Retrospective Cohort Study
in Fukuoka, Japan.British Medical Journal Open, : e (pp), 
( tables,  f‌igures,  references)
Abstract: This study compared depressive disorders, according to health
checks and insurance claims, in , smokers in a cessation group and
, smokers who did not quit in Fukuoka, Japan between  and
. Overall, .% of the smoking cessation group and .% of the smok-
ing group had a history of health care for depressive disorders.
People who have the intention to stop smoking and who work as health
professionals or health-related service providers might have concerns
about depressive disorders after smoking cessation. The present results
could provide helpful information that could notinf‌luence whether pre-
scribed stop-smoking medication is used or not because smoking cessa-
tion is not associated with depressive disorders in the long term. Moreover,
successful smoking cessation has great benef‌its for reducing the risk of
many diseases, such as lung cancer, chronic obstructive pulmonary dis-
ease, cardiovascular disease and other disorders. However, most with-
drawal symptoms reach maximum intensity within a few daysand some
symptoms can persist for more than  days.Consequently, health pro-
fessionals would be required to help people who attempt smoking ces-
sation not to relapse because of withdrawals, especially in the f‌irst few
months after quitting. In addition, our results could provide evidence
that can be used to promote smoking cessation programmes as part of
government policies.
Reference Number: 70228
, .., . , .. , .. , .. , .. , 
.... . “Inf‌luence of Smoking Cessation Drugs on Blood Pres-
sure and Heart Rate in Patients with Cardiovascular Disease or High
Addiction, Withdrawal, Smoking Cessation, and Public Health Measures | 
Reference Number: 
Risk Score: Real Life Setting.BMC Cardiovascular Disorders, : (pp),
 ( tables,  references)
Abstract: The safety of smoking cessation medication on  outpatients
with cardiovascular disorders (% had hypertension) was determined
by the sequential measurement of diastolic and diastolic blood pressure,
heart rate, and exhaled CO over the f‌irst  days of treatment. A total of
 patients used NRT alone,  used bupropion alone,  used varenic-
line alone, and  used NRT and bupropion. For all treatments there was
no increase in BP or HR and there was a signif‌icant decrease in exhaled
CO (on average from  ppm to  ppm).
Our data from a real clinical practice suggest that, even in patients with
hypertension, CAD, and/or AMI, there are no signif‌icant clinical change
in blood pressure or heart rate during the use of NRT, varenicline, and/
or bupropion.
Reference Number: 70229
, ., . ,  .. . “Are Nicotine Replacement Strat-
egies to Facilitate Smoking Cessation Safe?” Journal of the Canadian
Dental Association, : –,  ( tables,  references)
Abstract: Nicotine replacement therapy (NRT) is the most widely used
pharmaceutical aid to assist people to stop smoking. Patches, gums, nasal
sprays, and sublingual nicotine replacement products are available.
However, there is no intention to suggest that NRT is not a generally safe
and ecacious aid to smoking cessation. There is no evidence that NRT
is either carcinogenic or genotoxic, and its relative safety is ref‌lected in
its over-the-counter availability in Canada. The evidence that NRT can
double the chances of successful quitting, at least among those motiv-
ated to quit, is strong. Except where contraindicated, NRT should be con-
sidered by dental health care providers as an appropriate aid to smoking
cessation. NRT should preferably be used as part of a broader smoking
cessation strategy tailored to the needs of nicotine-dependent tobacco
users. It should always be remembered that the nicotine doses delivered
by NRT are, generally, lower than those delivered through cigarette smok-
ing and that tobacco smoke contains a large number of toxins and carcino-
gens in addition to nicotine (e.g., carbon monoxide, cyanide, hydrogen
sulf‌ide, arsenic and lead). Furthermore, NRT is designed for short-term use
 | Wigmore on Nicotine and Its Drug Delivery Systems
Reference Number: 
only (normally up to  weeks) and should be discontinued if the smoker
continues to relapse over the initial -week period. Therefore, even in situ-
ations where caution is advised, the risks of NRT administration should be
carefully weighed against the continuing detrimental inf‌luence of tobacco
smoking on multiple facets of health.
Reference Number: 70230
, .., .. ,  .. . “Does Nicotine Replace-
ment Therapy Cause Cancer? Evidence from the Lung Health Study.
Nicotine and Tobacco Research, : –,  ( tables,  f‌igures,
 references)
Abstract: A study was conducted of , participants enrolled in the US
Lung Health Study whose replacement nicotine therapy and smoking
exposures were recorded for  years. Participants were encouraged to
use Nicorette gum ( mg nicotine) for at least  months and to cease use
after a maximum of . years. The mean number of pieces of gum used
over the course of the -year study was  (.%),  (.%), – (.%),
and > (.%).
Our basic question was whether nicotine replacement therapy causes can-
cer to an extent comparable to that caused by smoking cigarettes. We
failed to f‌ind evidence of such an ef‌fect of nicotine replacement therapy
in this study, and the sample size, close monitoring of the use of nicotine
replacement therapy and cigarettes, and the well-documented outcomes
of this study will be dicult for future studies to match.
Reference Number: 70231
, ., . , .. , . , .. , . ,
. , .. , . ,  . . “The Impact of
the Opioid Antagonist Naloxone on Experimentally Induced Craving
in Nicotine-Dependent Individuals.European Addiction Research, :
–,  ( tables,  f‌igures,  references)
Abstract: The f‌irst symptoms of nicotine dependence are likely to appear
within days or weeks of the f‌irst exposure to the occasional cigarette.
There are numerous similarities between opioid dependence and nico-
tine dependence. Opioids like heroin and methadone lead to an increase
in nicotine self-administration. Thirteen female and seven male nicotine
Addiction, Withdrawal, Smoking Cessation, and Public Health Measures | 
Reference Number: 
dependent outpatients (mean age  years) were deprived of nicotine for
 hours before being administered . mg or . mg/kg naloxone IV or
placebo. Neutral images or smoking-related images were then presented.
Nicotine withdrawal was monitored by HR, body temperature, respira-
tion, and other measures.
Naloxone inf‌luenced nicotine withdrawal and strengthened signif‌icantly
by cue exposure, both on objective measurement and on craving scales.
These f‌indings suggest an involvement of the endogenous opioid system
in the development and maintenance of nicotine dependence.
“The irony is that the tobacco industry uses images of health to sell death,
while health organizations use images of death to sell health.”
—Yossuf Saloojee, World Lung Conference ()
Tobacco is the most lethal and dangerous artefact made by humans. It
has resulted in more than  million deaths in the th century alone,
more than the total deaths from World War I and World War II combined.
Some of the best practices to reduce this epidemic include:
) Smoke-free public spaces
) Raising cigarette taxes to at least match the rise in inf‌lation
) Having a national tobacco smoking quit line and social media presence
) Prominent health warnings on cigarette packages
) Mass anti-smoking campaigns
) Advertising bans, including point of sale
) Removing all f‌lavors (including menthol) from tobacco products
) Lowering the nicotine content of tobacco products
) Promotion of readily available, ef‌fective smoking cessation aids
) Stricter regulation of young smokers
) Tobacco social and industry denormalization (–, , ,
, , )
The tobacco epidemic can be divided into four stages, and dif‌ferent
countries are in dif‌ferent stages (–). The f‌irst recorded prohibition
against tobacco use was in Peru in , when a papal decree declared it
was a sin for a priest to use tobacco before celebrating mass ().
 | Wigmore on Nicotine and Its Drug Delivery Systems
Reference Number: 
The tobacco industry promoted and provided money and support to
smokers’ rights groups and compared anti-smoking regulations to Hitler
and Nazi regulations; in fact, I myself have been called a tobacco Nazi on
social media. In , smokers’ rights advocates dressed in Nazi SS uni-
forms and protested against England’s secretary of state ().
Canada was the f‌irst country to implement color pictorial health
warnings, which dif‌fer among countries (–). The graphic health
warning must now cover % of the cigarette package in Canada and has
curtailed the tobacco industry from using cigarette packages as an adver-
tising vehicle (–). Internationally, English brand names and Eng-
lish writing on cigarette packages have been used to increase the allure
of cigarettes ().
Restricting vending machines is an ef‌fective but underused method
of tobacco control (). High school students in US states with min-
imal tobacco restrictions are more likely to become daily smokers ().
Lowering the nicotine concentration allowed in tobacco products has
been found to lower cravings and withdrawal symptoms and decrease
youth smoking initiation ().
Although cigarette cessation programs are expensive, with California
spending $ million annually, it has been found that the state saves
between $. and $. billion a year in reduced health care costs ().
The endgame strategy of eventually eliminating all cigarette smoking has
received wide public support, even among smokers (–).
Cigarette control needs to start with the cultivation, harvesting, and
curing of tobacco to minimize its contamination of nearby water resour-
ces and environmental damage. Tobacco leaves accumulate metals, radio-
activity, pesticides, insecticides, and fungicide ().
Social and tobacco denormalization is an important aspect of tobacco
control and smoking cessation. Over % of smokers in four countries
agree that society disapproves of smoking, and nearly % agree that
people who are important to the smoker believe that they should not
smoke (). Disseminating the RICO decision to the general popula-
tion aids in tobacco industry denormalization ().
Reference Number: 70301
, . “Lung Cancer: Preventable Disease.” Acta Medica Academica,
: –,  ( table,  f‌igures,  references)
Addiction, Withdrawal, Smoking Cessation, and Public Health Measures | 
Reference Number: 
Abstract: Tobacco use is one of the largest preventable causes of death
and disability in developing countries. It has caused  million deaths
in the th century (more than deaths in World War I and World War
II combined) and is estimated to cause  billion deaths in the st century.
Cigarette smoking increases the risk of at least  types of lung cancer.
Tobacco smoking is responsible for % of all cancer deaths and % of
lung cancer deaths. In a developing country like Bosnia and Herzegovina,
.% of the men and % of the women smoke cigarettes. More than
, children (aged – years) and . million adults (aged + years)
smoke every day in this country. Some of the best practice measures to
reduce the tobacco epidemic are ) smoke-free public places, ) raising
taxes to % of the retail price, ) of‌fering a national tobacco smoking
quit line, ) prominent warning labels on cigarette packages, ) mass
anti-smoking campaigns, and ) advertising bans.
In conclusion lung cancer is very heterogeneous disease with high tumor
mutational burden and very hard to treat when metastatic. However, it is
preventable disease in very high percentage of cases (–%). Goal is to
exterminate cigarette smoking. That can be achieved only by concerted
ef‌fort by members of family, patients themselves, physicians, researchers,
non-governmental organizations, political f‌igures and society as whole.
Best practices already exist and initial goal should be to start using them.
Reference Number: 70302
, .. “Programs and Policies to Discourage the Use of Tobacco
Products.Oncogene, : –,  ( f‌igures,  references)
Abstract: The f‌irst recorded prohibition against tobacco use was in Peru
in , where a papal decree was issued declaring that it was a sin for
any priest to use tobacco before celebrating or administrating mass. By
the late th century tobacco use was widespread, but most people only
used a small amount in the forms of pipes, cigars, chewing tobacco, or
a pinch of snuf‌f. Cigarettes replaced cigars and chewing tobacco mainly
during World War I, when free cigarettes were widely distributed to the
soldiers. Both Thomas Edison and Henry Ford voiced concerns about
the detrimental health ef‌fects of cigarettes. In the s, ef‌forts to limit
smoking were fading, partially as a result of the failure of alcohol prohibi-
tion. Cigarette advertisers and marketers were able to associate smoking
with images of health, athletic performance, wealth, and social standing,
 | Wigmore on Nicotine and Its Drug Delivery Systems
Reference Number: 
which helped fuel over  years of the growth of cigarette smoking. A
major milestone in tobacco control was the  US Surgeon General’s
Report on Smoking and Health. In the United States, due to declines in
cigarette smoking, cancers caused by smoking began to decline in the
s. Prescription-only nicotine gum for smoking cessation was intro-
duced in  and the nicotine patch in . In , the FDA allowed
over-the-counter sales of nicotine gum, patches, and other nicotine
replacement therapies.
The past  years has witnessed a dramatic change in attitudes toward and
use of tobacco by Americans that has resulted in recent declines in the inci-
dence of lung cancer. Most public health scholars believe that this change
has been accelerated by public policy interventions to reduce tobacco use.
The research literature suggests that the most potent demand reducing
inf‌luences on tobacco use have been increasing the f‌inancial cost of using
tobacco products primarily through taxation, smoke-free policies, com-
prehensive advertising bans, and paid counter-advertising. Other policies
such as the requirement of warning labels on tobacco products, restric-
tions on tobacco sales to minors and increasing access to stop smoking
services appear to have had less direct impact on cigarette consumption,
although the potential impact of these policies may not have been fully
realized to date.
Reference Number: 70303
, . “    .British Medical Journal,
: –,  ( f‌igures,  references)
Abstract: Typically, a smoking epidemic in a population develops in 
stages. First a rise, then a decline in smoking prevalence, followed  to
 years later by another rise, then a decline in smoking related diseases.
Table: Stage of the Smoking Epidemic in Various Regions
Stage of Smoking Epidemic Regions
Sub-Saharan Africa
China, Japan, Latin America, North Africa
Eastern Europe, Southern Europe
Western Europe, North America, Australia
Source: Adapted from Edwards, 
Addiction, Withdrawal, Smoking Cessation, and Public Health Measures | 
Reference Number: 
Cigarette smoking is the single biggest avoidable cause of death and dis-
ability in developed countries. Smoking is now increasing rapidly through-
out the developing world and is one of the biggest threats to current
and future world health. For most smokers, quitting smoking is the single
most important thing they can do to improve their health. Encouraging
smoking cessation is one of the most ef‌fective and cost ef‌fective things
that doctors and other health professionals can do to improve health and
prolong their patients’ lives.
Reference Number: 70304
, ..,  .. . “The Changing Public Image of Smok-
ing in the United States: –.Cancer Epidemiology, Biomarkers
and Prevention, : –,  ( references)
Abstract: The prevalence of cigarette smoking grew rapidly in the United
States (and other developed countries) during the early part of the th
century due to the development of rapid, automatic cigarette manufac-
turing machines and mass marketing and media. In , % of the US
adult population were cigarette smokers (% of men, % of women)
and half of all physicians. Due to health concerns, cigarette sales declined
and then rebounded as f‌iltered cigarettes were introduced and promoted
as safer. The tobacco industry realized in the s that f‌ilters were not
really f‌ilters, as there is no such thing as clean smoke, but smokers were
led to believe they were safer. In the years after the  Surgeon Gener-
al’s Report, the tobacco industry increased their PR and disinformation
campaigns suggesting that there was no real link between smoking and
any disease. The tobacco industry continues to work against ef‌forts by
governments to adopt policies that would ef‌fectively limit cigarette mar-
keting and protect public health.
Tobacco use behaviors have changed signif‌icantly over the past century.
After a steep increase in cigarette use rates over the f‌irst half of the th
century, adult smoking prevalence rates started declining from their peak
reached in . Improved understanding of the health risks of smoking
has been aided by the United States Surgeon General’s Reports, issued on
a nearly annual basis starting in . Among the many forces driving down
smoking prevalence were the recognition of tobacco use as an addiction
and cause of cancer, along with concerns about the ill-ef‌fects of breath-
ing secondhand smoke. These factors contributed to the declining social
 | Wigmore on Nicotine and Its Drug Delivery Systems
Reference Number: 
acceptance of smoking, especially with the advent of legal restrictions on
smoking in public spaces, mass media counter-marketing campaigns, and
higher taxes on cigarettes. This paper reviews some of the forces that have
helped change the public image of smoking, focusing on the  years since
the  Surgeon General’s report on smoking and health.
Reference Number: 70305
, ..,  .. . “‘Nicotine Nazis Strike Again’: A Brief
Analysis of the Use of Nazi Rhetoric in Attacking Tobacco Control
Advocacy.Tobacco Control, : –,  ( f‌igures,  references)
Abstract: In the s, the Tobacco Institute encouraged articles that
compared non-smokers and tobacco control measures to Hitler and Nazi
regulations. In the s, the term “health fascism” was employed. In
, smokers’ rights advocates dressed in Nazi SS uniforms and thanked
England’s secretary of state for continuing the Nazi policies during a
demonstration against the UK National No Smoking Day. The Nazi card
was also played to f‌ight against smoke-free environments.
Nazi and health fascism rhetoric has been used and promoted for dec-
ades by the tobacco industry around the world. Against the background
of Proctor’s suggestion that the use of Nazi rhetoric would increase with
stronger tobacco control ef‌forts,the current use in Germany is neither
new nor a purely German phenomenon, but probably a sign of increas-
ing strength of Germany’s tobacco control movement. The use of Nazi
and health fascism rhetoric can be regarded as part of an institutionalised
practice of the tobacco industry and its front groups to discredit tobacco
control activities and prevent the introduction of ef‌fective policies. “Play-
ing the Nazi card” is an established strategy developed f‌irst in the United
States and the United Kingdom, then widely used around the world, so
far, predominantly outside countries with a Nazi or fascist history. This
imagery is now simply being applied in Germany.
Reference Number: 70306
, ., . , . , . , .. , . -
-, . , . , . , . , . ,
. , .. , . , . , . , . -
, . ,  . . “Trends in Smoking Initiation in
Addiction, Withdrawal, Smoking Cessation, and Public Health Measures | 
Reference Number: 
Europe Over  Years: A Retrospective Cohort Study.Public Library of
Science One, : e (pp),  ( tables,  f‌igures)
Abstract: The Aging Lungs in Europe Cohorts consortium examined the
trends in smoking initiation between  and  in , subjects
(median age – years) in  European countries. In all regions com-
bined, smoking initiation before  peaked at age  years in males and
 years in females and in  peaked at  and  years, respectively.
In young adults (aged – years) initiation rates were below % and
were stable or declining over time. Tobacco use in young adolescents
is strongly inf‌luenced by friends and siblings. Early smoking initiation
is often associated with early puberty, perhaps due to a gap between
physical and social maturity. The age of puberty, regardless of gender,
has been decreasing in Europe.
An increase in tobacco prices may be a successful strategy for young
people, who are the most price-sensitive sector of the population. Current
policies on prices focus on conventional (boxed) cigarettes, and they seem
to induce a shift to cheaper products, including hand-rolled cigarettes.
Equalising taxation levels of all tobacco products, as advocated by the
Framework Convention on Tobacco Control, may limit smoking initiation
especially during early adolescence. Smoking in youth can be reduced by
preventing tobacco sales to minors through law enforcement, which may
include warnings and f‌ines to non-compliant retailers. Since young ado-
lescents generally obtain cigarettes from their peers, restricting sales to
minors can break the chain of tobacco supply to them. Reducing expos-
ure to cigarette advertising (including pack display at the point of sale),
and implementing plain packaging in combination with pictorial health
warnings, makes youth less likely to try smoking or to smoke again after
experimentation. It is still unclear whether smoking bans can reduce the
prevalence of smoking, but smoke-free places may produce an environ-
ment that is less favourable to experimentation in young adolescents.
Reference Number: 70307
, ., .. , . , -. , . --
, . , . , . ,  . . “Pictorial
Health Warning Label Content and Smokers’ Understanding of Smok-
ing-Related Risks—A Cross Country Comparison.Health Education
Research, : –,  ( tables,  f‌igures,  references)
 | Wigmore on Nicotine and Its Drug Delivery Systems
Reference Number: 
Abstract: Canada was the f‌irst county to implement pictorial health
warning labels (HWLs) on cigarettes packaging in . In , Australia,
Canada, and Mexico implemented new pictorial HWLs. A longitudinal
online interview was conducted of , adult smokers in each country
in – as to their recognition of the health risks associated with
smoking cigarettes.
Table: Disease/Toxic Constituent Health Warning Labels in Australia,
Canada, and Mexico in –
Disease/Toxic Constituent Australia Canada Mexico
Heart disease + + +
Emphysema + + +
Bladder cancer + +
Blindness + + −
Impotence − − −
Gangrene + − +
Cyanide + − −
Benzene − + −
Nitrosamines − − −
Radioactive polonium  +
Carbon monoxide + + +
Formaldehyde − + +
Source: Adapted from Swayampakala et al, 
This longitudinal study provides evidence for the specif‌ic inf‌luence of
HWL content on adult smokers’ knowledge of health ef‌fects and toxic
constituents of tobacco smoke, even as new HWL content is included
after populations are exposed to prominent pictorial HWLs for a num-
ber of years. Smokers from countries where HWLs contained information
about specif‌ic tobacco-related diseases or toxins showed higher know-
ledge about those topics than smokers from countries where HWLs do not
include that specif‌ic content. This was most evident for blindness in AU,
gangrene in AU and MX, benzene in CA and radioactive polonium in MX.
Reference Number: 70308
, .., .. , .. ,  .. . “Why Smokers Avoid
Cigarette Pack Risk Messages: Two Randomized Clinical Trials in the
Addiction, Withdrawal, Smoking Cessation, and Public Health Measures | 
Reference Number: 
United States.Social Science and Medicine, : –,  ( tables,
 f‌igures,  references)
Abstract: A random sample of , adult smokers were assigned to
receive either pictorial warnings (intervention) or test-only (control)
health warnings for their cigarette packs for  weeks between  and
. Another random sample of  adult smokers were assigned ciga-
rette pack messages about toxic chemicals in cigarettes (intervention) or
the harm of littering cigarette butts (control) for  weeks between 
and . After the implementation of larger pictorial warnings on ciga-
rette packs in Australia in , it was found that smokers were more
likely to place their packs face down and to conceal the new warnings
using cases and other means. Smokers avoid cigarette pack risk messages
because they evoke aversive types of emotions.
Policymakers should be encouraged by evidence showing that strong ciga-
rette pack risk messages, especially those with images, are likely to encour-
age smoking cessation and therefore prevent death and disease. However,
some smokers will inevitably avoid health warnings and other cigarette
pack risk messages. We argue that, in the context of cigarette pack risk
messages, avoidance is not maladaptive defensive processing but instead
a sign ofdeeperprocessing. In other words, smokers avoid warnings pre-
ciselybecausethey are hard-hitting and elicit productive types of negative
emotions, and avoidance is associated with more quitting-related behaviors.
Reference Number: 70309
, .., . , . , .. , .. ,  .. .
“Sex Dif‌ferences in Graphic Warning Label Ratings by Addictions Clients.
Tobacco Regulatory Science, : –,  ( table,  f‌igure, references)
Abstract: Four hundred and thirty-two female and  male smokers
in  drug addiction treatment programs in California rated three FDA
graphic warning labels (GWL) about smoking risks.
The FDA has sought to strengthen evidence that GWLs will reduce smok-
ing prevalence. This should include investigation of GWLs with specif‌ic
sub-populations who face tobacco-related disparities, such as women
with additional SUDs, a group with high smoking rates resistant to smok-
ing cessation. The current study found that female smokers in SUD treat-
ment did not respond dif‌ferentially to GWLs of women and/or babies but
 | Wigmore on Nicotine and Its Drug Delivery Systems
Reference Number: 
did rate GWLs more strongly overall than male smokers. Results support
the use of graphic images including babies, women, and disease images,
when developing warning labels for female smokers, including women
with additional SUDs. Our f‌indings contribute to the evidence base for
implementation of GWLs on cigarette packaging in the United States
as one component of a comprehensive tobacco control policy that may
reduce smoking cessation disparities.
Reference Number: 70310
, .., . , .. ,  .. . “Impact of Tobacco-Pack
Pictorial Warnings on Youth and Young Adults: A Systematic Review of
Experimental Studies.Tobacco Induced Diseases, :  (pp),  (
tables,  f‌igures,  references)
Abstract: A review was conducted of  studies of pictorial warning labels
(PWL) on cigarette packs and  studies of PWL on smokeless tobacco
packs. PWLs were found to increase attention, thinking about harms,
fear, disgust, more negative pack attitudes, and intention to quit smoking.
PWLs were more ef‌fective than text warnings.
Despite evidence to the contrary, young people maintain an optimistic
bias towards smoking. Young tobacco users often do not connect tobacco
use to long-term health problems. In one study, % of adolescents smok-
ers believed they could smoke for a few more years and then quit with no
adverse health ef‌fects, compared to % of adult smokers. Potentially due
to its long-term, far-of‌f consequences, young tobacco users do not see the
link between tobacco use and many chronic diseases. That said, countries
have a limited set of warnings, despite having adolescent, young adult,
and adult populations. To maximize the impact of warnings on youth and
young adults, we should ensure that we implement content that reson-
ates with younger population groups, in addition to adult smokers. While
the main target of PWLs may be adult smokers (and cessation behavior),
young people are a critical secondary audience for tobacco warnings.
Reference Number: 70311
, ..,  . . “The Package as a Weapon of Inf‌luence: Chan-
ges to Cigarette Packaging Design as a Function of Regulatory Changes
in Canada.” Tobacco Prevention and Cessation, : (pp),  (f‌igure,
 references)
Addiction, Withdrawal, Smoking Cessation, and Public Health Measures | 
Reference Number: 
Abstract: In , the Tobacco Products Labeling Regulation—Cigarettes
and Little Cigars (TPLR-CLC) was enacted in Canada. The regulations
required that all tobacco packages sold in Canada display a graphic
warning covering % of the package (up from % in ). A sample of
, tobacco products from  brands sold between  and  were
assessed to determine the tobacco companies’ response to the legislation.
Between  and , the prevalence of cigarette smoking in Canada
decreased from % to %.
Table: Changes in Cigarette Packaging Design Before and After
Increased Regulations in Canada (–)
Cigarette Packaging Characteristics Pre-Regulation Post-Regulation
High color saturation .% .%
Flip-top .% .%
Average number of cigarettes in a pack . .
Male f‌igure brands on packs .% .%
Female f‌igure brands on packs .% .%
No logo .% .%
Source: Adapted from Wade and White, 
For example, an increase in the use of f‌lip-top packaging can be seen as more
modern, elegant, or unique, which serves to increase purchasing preference
in younger people, especially younger women, who have been shown to
prefer smaller packaging styles. This preference may also explain why we
observe that the average number of cigarettes per package has decreased
over time. The increased usage of black and yellow as focal colors as well as
increased color saturation is likely an ef‌fort to attract attention, as research
shows that black and yellow are ef‌fectively used on tobacco packaging
for this purpose. Moreover, these attributes may serve to draw attention
away from the unsightly health labels and to dif‌ferentiate the brand. The
increased usage of brand variant labels and female f‌igures on packaging
may be an ef‌fect of strategies pursued by tobacco companies to inf‌luence
positive consumer perceptions of their products in light of increasingly
restrictive packaging regulations. The decreased usage of males in iconog-
raphy suggests that manufacturers may be targeting women.
 | Wigmore on Nicotine and Its Drug Delivery Systems
Reference Number: 
Reference Number: 70312
, ..., . , .. ,  .. . “Promotions on
Newport and Marlboro Cigarette Packages: A National Study.Nicotine
and Tobacco Research, : –,  ( table,  references)
Abstract: The Tobacco Industry marketing has been shown to contrib-
ute to death and disability by promoting initiation and continued use
of tobacco. The cigarette pack itself is a marketing tool. Promotions
on the outside of the pack are used to attract non-smokers or promote
brand loyalty. In , cigarettes packs were purchased by auditors in
, stores in the United States. A total of , Marlboro Red and ,
Newport Green cigarette packages were purchased. Marlboro packs were
× as likely to have promotions as Newport packs (.% vs .%). Most
of the exterior promotions were for contests (>%), while almost all
interior Marlboro promotions were for a discounted price.
Use of promotions on the interior and exterior of cigarette packs are a
mechanism that the tobacco industry uses to sell its products and should
be continually assessed for their inf‌luence on consumer behavior.
Reference Number: 70313
, .., . , . , . ,  . . “Eng-
lish on Cigarette Packs from Six Non-Anglophone Low- and Middle-
Income Countries.International Journal of Public Health, : –,
 ( tables,  f‌igures,  references)
Abstract: Low- and middle-income countries are vital to Big Tobacco.
The cigarette pack is a key to cigarette marketing which is on display
when cigarettes are purchased and can be seen up to ,× a year by
pack-a-day smokers. Over , cigarette packs from Bangladesh, Brazil,
China, Egypt, Ukraine, and Vietnam were analyzed. Over two-thirds of
the cigarette packages in these non-English-speaking countries studied
had some English printed on them. English was used mainly to com-
municate product features such as size, strength, and f‌lavor, and to con-
vey luxury, quality, and modernity.
Addiction, Withdrawal, Smoking Cessation, and Public Health Measures | 
Reference Number: 
Table: Percent of English Brand Names and Any English on Cigarette
Packs in Various Low- and Middle-Income Countries
Country English Brand Names Any English on Front of Cigarette Packs
Bangladesh % %
Brazil % %
China % %
Egypt % %
Ukraine % %
Vietnam % %
Total % %
Source: Adapted from Smith et al, 
Restricting English use should be incorporated into plain packaging policy
to protect populations from deceptive branding practices, specif‌ically pre-
senting cigarettes as an aspirational product.
Reference Number: 70314
, ., .. ,  . . “Impact of Total Vending Machine
Restrictions on US Young Adult Smoking.” Nicotine and Tobacco
Research, : –,  ( tables,  f‌igure,  references)
Abstract: The US Family Smoking Prevention and Tobacco Control Act
(TCA) of  banned tobacco vending machine sales except in adult-only
facilities. Some US counties/cities have enacted total bans on cigarette
vending machines, but currently only % of the population is af‌fected by
a total ban. The ef‌fect of a total cigarette vending machine ban on adult
and youth smoking was determined by comparing total cigarette vending
machine ban areas to those without total bans.
We f‌ind that total vending machine restrictions decrease any recent smok-
ing (OR = .;p<. net of other covariates. though the passage a>
restriction does not alter an individual’s smoking over time, living longer
in an area that has a restriction lowers the propensity that an individual
will smoke at all (OR = .;p<. we f no ef of total vending>
machine restrictions on smoking a pack daily. . . . Total vending machine
restrictions appear to be an ef‌fective, yet highly underutilized, means of
tobacco control.
 | Wigmore on Nicotine and Its Drug Delivery Systems
Reference Number: 
Reference Number: 70315
-, .., .. , .. , . , . , 
. -. “Tobacco Control Policy and Adolescent Cigarette
Smoking Status in the United States.Nicotine and Tobacco Research,
: –,  ( tables,  references)
Abstract: The ef‌fects of state-level tobacco control policies such as smoke-
free laws, cigarette pricing, and age limits on purchasing were determined
in , grade – students in  US states between  and .
Compared with students living in states with strict regulations, those liv-
ing in states with no or minimal restrictions, particularly high school stu-
dents, were more likely to be daily smokers. These ef‌fects were somewhat
reduced when logistic regressions were adjusted for sociodemographic
characteristics and cigarette price, suggesting that higher cigarette prices
may discourage youth to access and consume cigarettes independent of
other tobacco control measures.
. . . Strict tobacco control legislation could decrease the potential of
youth experimenting with cigarettes or becoming daily smokers. The f‌ind-
ings are consistent with the hypothesis that smoking policies, particularly
clean indoor air provisions, reduce smoking prevalence among high school
Reference Number: 70316
, ., .. , . , .. , .. , .
, . , .. , . , . ,  ..
. “Reduced-Nicotine Cigarettes in Young Smokers: Impact of
Nicotine Metabolism on Nicotine Dose Ef‌fects.Neuropsychopharma-
cology, : –,  ( table,  f‌igures,  references)
Abstract: Tobacco smoking remains a leading contributor to preventable
disease and death. Smoking cigarettes that deliver less than  mg nico-
tine (less than conventional cigarettes) reduces nicotine dependence and
promotes smoking cessation when combined with transdermal nicotine.
Forty-six young adult smokers ( men, mean age  years) were tested on
cigarettes that delivered ., ., ., or . mg nicotine and on con-
ventional cigarettes. Plasma nicotine and metabolites (-hydroxycotinine/
cotinine) were determined by LC-MS/MS. Cigarettes with a nicotine of
. mg or less did not alleviate withdrawal def‌icits in sustained attention.
Addiction, Withdrawal, Smoking Cessation, and Public Health Measures | 
Reference Number: 
This study of young smokers provides the f‌irst evidence that smoking-in-
duced reductions in craving and withdrawal depend on nicotine dose in
normal but not slow metabolizers. Improvement in sustained attention
during acute abstinence and ratings of cigarette characteristics both
depend on nicotine dose, regardless of metabolizer status. These f‌ind-
ings have bearing on the use of reduced-nicotine cigarettes to facilitate
smoking cessation and on policy regarding regulation of nicotine content
in cigarettes.
Reference Number: 70317
, .., . , -. , . ,  . . “Evaluation
of the Economic Impact of California’s Tobacco Control Program: A
Dynamic Model Approach.Tobacco Control, : i–i,  ( table,
 f‌igures,  references)
Abstract: The long-term net economic impact of the Tobacco Control
Program in California was determined using a series of dynamic models
of smoking-caused mortality, morbidity, health status, and health care
expenditures. The California Tobacco Control Program (CTCP) was
established in  with an annual budget of $ million a year funded
mainly by a  cent per pack increase in tobacco taxes. It is estimated
that CTCP resulted in over , person-years of life saved and over
, person-years of treatment in . The net health care savings
and years of life saved was equivalent to $ billion, or $ billion in 
dollars. These estimates did not include the impact of CTCP on SHS and
its adverse health ef‌fects on non-smokers.
Tobacco control programmes are costly. However, the benef‌its of the pro-
grammes are substantial and continue to accrue for many years. Although
those who are persuaded not to smoke will live longer, have better health
status and require additional healthcare resources during their additional
years of life, this impact is outweighed by the value of additional years of
life and better health. Public health programmes need to be evaluated
with healthcare costs, additional years of life and improved health con-
sidered as important outcomes.
Reference Number: 70318
, ..,  .. . “An Argument for Phasing Out Sales of Ciga-
rettes.Tobacco Control, : –,  ( references)
 | Wigmore on Nicotine and Its Drug Delivery Systems
Reference Number: 
Abstract: An endgame plan is discussed about phasing out the sale of
cigarettes, initially in areas with few smokers. Combustible tobacco prod-
ucts are the tobacco industry’s single largest source of prof‌it and power.
Ending sales deprives the industry of income and represents the most con-
crete way to denormalise the product. Equally importantly, ending sales
could reduce the industry’s inf‌luence in government and policy-making by
challenging its legitimacy.Notably, however, def‌ining the endpoint as end-
ing cigarette sales does not require that no one could or would ever use
tobacco (or other nicotine products). Tobacco is a product that has been
used in some form for centuries and some use (both ritual and addiction
based) is likely to continue; however, it is only since the commercialisa-
tion of cigarettes that the problems its use causes have reached epidemic
proportions. Not expecting policies to achieve total “prohibition” or zero
prevalence recognises this.
Objectors to proposed endgame-advancing policy proposals com-
monly refer to black markets or the failures and unintended consequences
of alcohol prohibition. But these objections, often supported by indus-
try-funded research, typically assume exaggerated proportions of illicit
trade. Furthermore, under Prohibition, alcohol use prevalence was high,
many users perceived their own use to be unproblematic, and posses-
sion and use were criminalised, leading to widespread law-breaking and
reduced respect for law enforcement. In contrast, phasing out cigarette
sales in a jurisdiction with already-low smoking prevalence (without ref-
erence to possession and use) is quite dif‌ferent. Many smokers already
perceive their own use to be problematic (eg, they want to quit) and thus
might be less likely to seek out illicitly sold cigarettes. Furthermore, elimin-
ating ready access to cigarettes could enhance success in cessation, since
smokers experience stronger cravings when they expect to be able to
smoke in the near future.While some illegal underground sales (whether
home-grown or through neighbouring communities) are likely to occur,
these types of activities seem unlikely to represent a black market so sub-
stantial that it would become worse for public health than the status quo.
Reference Number: 70319
, .. “The FCTC’s Evidence-Based Policies Remain a Key to
Ending the Tobacco Epidemic.” Tobacco Control, : i–i, 
Addiction, Withdrawal, Smoking Cessation, and Public Health Measures | 
Reference Number: 
Abstract: Many countries have implemented the Framework Conven-
tion on Tobacco Control (FCTC) and have dramatically reduced tobacco
consumption. The FCTC measures to control tobacco use include higher
tobacco taxes, strong warning labels, smoke-free air laws, aggressive pub-
lic education, and marketing/advertising restrictions. In the last  years,
 countries in South America alone have adopted % smoke-free laws.
For tobacco control measures to have their desired impact, it is critical to
f‌irst build a climate that enables government to act as boldly as these new
ideas propose.Too many countries have not yet done so. Australia was able
to adopt plain packaging for cigarettes in November  precisely because
it had built public support for strong tobacco control measures over the
years. To succeed, tobacco control ef‌forts must be preceded by a concerted
ef‌fort to educate the public about the magnitude of the harms caused by
tobacco and why the proposed policy is needed. Had Australia acted with-
out f‌irst building public support, the tobacco industry’s attacks—including
the attack on the Australian government as a “national nanny”—could well
have been successful and could have set back long-term progress.
Reference Number: 70320
-, ., .. , . ,  . . “Smokers’ Support
for Tobacco Endgame Measures in Canada: Findings from the 
International Tobacco Control Smoking and Vaping Survey.Canadian
Medical Association Journal Open, : E–E,  ( tables,  f‌igure,
 references)
Abstract: The smoking rate in Canada among persons  years of age or
more declined from % in  to an all-time low of % in . Canada
implemented pictorial health warnings in  and banned all f‌lavors
in cigarettes (except menthol, which was banned in ). A survey was
conducted on , cigarette smokers and , dual users (cigarettes and
ECs) in  to determine support for tobacco countermeasures. Support
was highest for reducing nicotine content (.%), raising the legal age for
purchase (.%), and banning marketing (.%) for cigarettes. Regard-
ing EC policies, support was highest for restricting age of vaping (.%),
restricting nicotine content (.%), banning vaping in smoke-free areas
(.%), and restricting marketing (.%) for vaping.
Our f‌indings show that a majority of Canadian smokers support diverse
tobacco endgame measures. Our baseline estimates suggest that
 | Wigmore on Nicotine and Its Drug Delivery Systems
Reference Number: 
innovative endgame strategies that go beyond current measures are likely
to be well received by Canadians, including smokers, who stand to be
most af‌fected by new policies. As endgame policies are implemented in
Canada, it will be important to study their impact on tobacco use, particu-
larly among vulnerable populations such as Indigenous peoples and groups
with low socioeconomic status.
Reference Number: 70321
, ...,  .. . “From Plant to Waste: The Long and
Diverse Impact Chain Caused by Tobacco Smoking.” International Jour-
nal of Environmental Research and Public Health, :  (pp), 
( f‌igure,  references)
Abstract: Cigarettes usually have two components: processed tobacco
(stick) and a synthetic f‌ilter, both of which are wrapped in paper. Cellu-
lose acetate is the main component of the f‌ilters. It is a synthetic polymer
made from cellulose with the addition of acetic anhydride and acetate,
and includes plasticizing compounds. The tobacco plant easily accumu-
lates metals from the soil into the leaves. Residues of pesticides, insecti-
cides, and fungicides also are accumulated in the leaves.
Ef‌fective mitigation of problems requires four main lines of action. The
f‌irst would be the control and supervision of the tobacco production pro-
cess, especially during planting and handling of the leaves, in order to
minimize the contamination of nearby water resources, and protect the
health of the farmers by demanding the use of personal protective equip-
ment. The second would be the unrestricted ban on smoking in all public
spaces, including beaches, imposing f‌ines in cases of noncompliance with
the legislation. This action could be an ef‌fective measure for reducing the
risk posed to passive smokers and the production of waste, thus mini-
mizing impacts on the biota. The third action would be the promotion of
educational campaigns not only addressing the risks for smokers (active
and passive) and the environment, especially the aquatic environments
and their biota, but also warning about the economic costs incurred with
cleaning the environments and treating smoking-related diseases. Finally,
it would be necessary to increase taxes on cigarette sales, in order to dis-
courage consumption and combat smuggling.
Addiction, Withdrawal, Smoking Cessation, and Public Health Measures | 
Reference Number 
Reference Number 70322
, ., .. , .. , .. ,  . .
“Tobacco Denormalization and Industry Beliefs Among Smokers from
Four Countries.American Journal of Preventative Medicine, : –,
 ( tables,  references)
Abstract: Tobacco social denormalization is a public health strategy that
endeavors to change broad social acceptance and normalization of smok-
ing into that of an abnormal practice and not a cool or desirable behavior.
Tobacco industry denormalization focuses on the tobacco industry and
its conduct and to raise people’s awareness of the industry responsibility
for disease and its manipulative tactics.
Table: Percentage of Smokers in Canada, the United States, the United
Kingdom, and Australia Who Agree with Various Statements About
Smoking and the Tobacco Industry
% Agree
Smokers’ Belief Canada United
Society disapproves of smoking % % % %
There are fewer and fewer places
I feel comfortable smoking
% % % %
People who are important to me
believe I should not be smoking
% % % %
Tobacco companies can be trusted
to tell the truth
% % % %
Tobacco companies should take
responsibility for the harm caused
by smoking
% % % %
Tobacco companies had tried to
convince the public that there is
little or no health risk from second-
hand smoke
% % % %
Source: Adapted from Hammond et al, 
Social denormalization was associated with noticing anti-smoking infor-
mation, warning labels, and ETS restrictions. Comprehensive ETS restric-
tions in bars and restaurants may be particularly ef‌fective in shaping beliefs
about smoking by breaking the association between smoking, drinking,
 | Wigmore on Nicotine and Its Drug Delivery Systems
Reference Number 
and exciting lifestyles—the very associations portrayed in tobacco mar-
keting. In addition, warning labels and anti-smoking media may inf‌luence
social norms by communicating the health ef‌fects of smoking in a highly
visible manner to smokers and those around them. Communicating such
information publicly—as opposed to communicating such information in
an individual setting such as a doctor’s oce—may be particularly ef‌fect-
ive in reducing the perceived acceptability of smoking.
Several interactions were observed between social denormalization
and policy exposure. First, noticing warning labels was most strongly
associated with social denormalization in Canada. This suggests that the
graphic Canadian warnings may be a more powerful denormalizing force
than the text warnings present in Australia, the UK, and the United States.
Reference Number 70323
, .., .. , . , .. , .. ,
.,  .. . “The RICO Verdict and Corrective State-
ments: Catalysts for Policy Change?” Tobacco Regulatory Science, :
–,  ( tables,  references)
Abstract: In , a US federal court found that Philip Morris and other
major tobacco companies were in violation of the Racketeer Inf‌luenced
and Corrupt Organization (RICO) Act. In her , page ruling, Judge
Kessler cited the tobacco companies with  distinct acts of racketeer-
ing and concluded that fraudulent conduct has permeated all aspects of
their operations. The court ordered the tobacco industry to disseminate
corrective statements (see Appendix ) through newspaper, television,
package onsets, point of sales, and corporate websites. A website survey
was conducted in May  of , exposed adults and , unexposed
adults regarding the tobacco industry. The exposed group read the RICO
statements and conclusion before answering the survey. The unexposed
group did not read the RICO information until after f‌illing in the sur-
vey. The exposed group was less likely to agree with the statement that
lawmakers should trust tobacco companies as much as they do other
companies and were more likely to support tobacco control measures.
Exposing the general population to the RICO decision should help
tobacco industry denormalization.
Addiction, Withdrawal, Smoking Cessation, and Public Health Measures | 
Reference Number 
Table: The Related Federal Court RICO Findings About the Tobacco
United States v. Philip Morris USA Inc.
Violated civil racketeering law (engaged in an organized conspiracy to commit fraud)
Committed fraud
Are likely to continue to commit fraud
Denied that they control the level of nicotine to create and sustain addiction
Suppressed and concealed scientif‌ic research
Marketed low tar and light cigarettes as less harmful despite knowing they were not
Marketed cigarettes to young people to replace smokers who die or quit smoking
Denied that secondhand smoke harms non-smokers
Denied the health consequences of smoking
Source: Adapted from Matheny et al, 
The scope of tobacco industry inf‌luences on public policy has been exten-
sive. Tobacco companies have sought to defeat—separately and in all 
states—legislation to restrict smoking inside workplaces, raise tobacco
taxes, limit tobacco marketing, advance prevention programs or research,
and reduce youth access to tobacco.When outright defeat cannot be
achieved, the companies work to delay or weaken such measures.Their
tactics include contributing to politicians’ election campaigns, dissemin-
ating public relations campaigns, creating controversy over established
facts, using front groups, hiring lobbyists, and “preempting” strong legis-
lation.The companies have been successful at promoting preemption of
ef‌fective local-level tobacco policies in many states. Most of these pree-
mptive clauses remain in ef‌fect.
Actively monitoring and exposing tobacco industry misconduct enables
ef‌fective tobacco control.

To continue reading

Request your trial

VLEX uses login cookies to provide you with a better browsing experience. If you click on 'Accept' or continue browsing this site we consider that you accept our cookie policy. ACCEPT