Addiction, Withdrawal, Smoking Cessation, and Public Health Measures

• Author: James G. Wigmore
• Pages: 567-623



 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.

7.01 ADDICTION/TOBACCO USE DISORDER

“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

use;

• 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

Binding

Neurotransmitter Ef‌fect

DopaminePleasure, appetite suppression

NorepinephrineArousal, appetite suppression

AcetylcholineArousal, cognitive enhancement

GlutamateLearning, memory enhancement

SerotoninMood modulation, appetite suppression

Beta-endorphinReduction in anxiety and tension

Gamma aminobutyric acidReduction 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 UseMedian Time of First Tobacco Use

(approximate)

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

Metabolizers

Normal

Metabolizers

Slow

Metabolizers

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.

7.02 WITHDRAWAL/SMOKING CESSATION MEASURES

“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

InterventionOdds 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

ConditionVisits 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

FactorsOR 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.” AmericanJournal 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

SymptomDuration 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

disadvantage

• 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

TreatmentOR 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

techniques.

Table: Smoking Cessation Medication and Recommended Dosage

Medication Dosage

PatchStart 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

awakening

Up to  lozenges per day;  per  hour period

InhalerCan use  to  per day

Inhale  times per cartridge

Nasal sprayMaximum 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

Varenicline

(aka Chantix)

Start use  to  weeks prior to quitting smoking

Take after eating with full glass of water

NortriptylineStart use  to  weeks prior to quitting

Take with a full glass of water

ClonidineStart 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,

references)

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 RelapsePercent

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

TreatmentOR 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 EventHR 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, 

references)

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.

7.03 PUBLIC HEALTH MEASURES

“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 EpidemicRegions

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 ConstituentAustraliaCanadaMexico

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 CharacteristicsPre-RegulationPost-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

CountryEnglish Brand NamesAny 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

students.

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, 

(references)

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’ BeliefCanadaUnited

States

United

Kingdom

Australia

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

Companies

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.