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The Hole Story: Ventilated Filters Make Smoking More Deadly

The ventilation systems built into cigarette filters in the mid-1960s to reduce tar and make smoking ‘smoother’ and ‘safer’ were responsible for the paradoxical rise in rates of lung adenocarcinoma — even as rates of other lung cancer subtypes dropped along with the number of smokers. These conclusions were in the 2014 US Surgeon General’s report on the health consequences of smoking.

http://www.medscape.com/viewarticle/880383

Now, two new weight-of-evidence reviews have pinpointed 25 “causation analysis evidence blocks” that could support an outright ban of filter ventilation, according to lead author, Peter G. Shields, MD, deputy director of the Comprehensive Cancer Center, the Ohio State University Wexner Medical Center, in Columbus, and colleagues.

The review found that between the 1960s and the 1980s, the health risks associated with smoking jumped almost 2-fold in men and increased 10-fold in female smokers. At the same time, the relative risks for adenocarcinomas rocketed from 4.6 to 19.0 in men and from 1.5 to 8.1 in women — even though the risks for other lung cancer subtypes didn’t increase. “Thus, there was a paradoxical increase for lung adenocarcinomas while squamous cell cancers decreased with decreased smoking rates,” the review authors write.

“The analysis strongly suggests that filter ventilation has contributed to the rise in lung adenocarcinomas among smokers,” they say in a report published online May 22 in the Journal of the National Cancer Institute.

“Based on these weight-of-evidence reviews, the FDA [Food and Drug Administration] should embark on a regulatory process of data evaluation and consider regulation(s) for the use of ventilation in filters, up to and including a ban on their use,” the authors conclude.

“The prime point is to rally the troops to get the FDA to focus on this,” Dr Shields told Medscape Medical News. “To me, this is a policy paper. Physicians can’t be silent.”

This is a policy paper. Physicians can’t be silent. Peter D. Shields

Ventilation holes in filters are now found in nearly every brand of cigarettes, and they make smoking even more deadly, Dr Shields elaborated in an interview.

The tiny filter holes slow down tobacco combustion, giving smokers more puffs per cigarette but also allowing more toxic constituents to form, increasing the mutagenicity of the smoke, the review authors explain. To get the requisite nicotine hit from a cigarette with a ventilated filter, a smoker must also inhale more deeply, drawing smoke farther into the lungs and exposing cells vulnerable to adenocarcinoma.

Increasing amounts of tobacco-specific nitrosamines can also be found in new blended tobaccos that provide a “smoother” smoking experience, albeit with more carcinogens, Dr Shields commented. This makes smoking more dangerous than ever before, and patients need to know this, he emphasized.

“As part of your risk counseling, tell patients who smoke that the cigarettes today are more deadly than the cigarettes from 30 or 40 years ago. We need to take away smokers’ perception that any cigarette is safe. It’s like putting your head in a chimney,” Dr Shields said.

Increased Risk for Adenocarcinoma

In an accompanying editorial, Jonathan M. Samet, MD, and Lilit Aladadyan, MS, MPH, say that ending filter ventilation “could be a ‘no regrets’ action that would benefit public health.”

Dr Samet is professor and Flora L. Thornton Chair for the Department of Preventive Medicine at the Keck School of Medicine at the University of Southern California (USC) in Los Angeles, and Aladadyan is center director for the USC Tobacco Center of Regulatory Science.

The editorialists note the review looked at a “large and somewhat poorly circumscribed body of literature” and that the evidentiary threshold required for the FDA to take action is not supported by any record of precedents.

However, they also say that the review’s conclusion about the contribution of filter ventilation to rising rates of lung adenocarcinoma in smokers “is well justified” and supports “the indictment of filter ventilation as increasing risk for adenocarcinoma.”

Filter ventilation was originally designed to lower smoking machine tar yields in so-called light cigarettes marketed primarily to women as a “healthier” alternative to regular cigarettes. “This was done to fool smokers and the public health community into thinking that they actually were safer,” Dr Shields said in a statement.

In 2009, the Family Smoking Prevention and Tobacco Control Act gave the FDA authority to ban tobacco companies from labeling and marketing cigarettes as “low tar” or “light.”

Dr Shields has served as an expert in class action suits against tobacco companies marketing light cigarettes as a healthier alternative. He’s also heard lawyers for Big Tobacco say peer-reviewed evidence was needed. “From our perspective, there is more than enough data to start the process and it’s time for regulation,” he said. “We believe that such an action would drive down the use and toxicity of conventional cigarettes and drive smokers to either quit or use less harmful products. There are some open questions about unintended consequences for enacting a ban, which provides for an important research agenda.”

Future clinical trials could assess smokers switching to filtered cigarettes without ventilation, using a panel of biomarkers to measure exposure to carcinogens and lung toxicants, markers of oxidative damage and inflammation in lung, blood, or/and urine, the review authors suggest. At present, human exposure biomarker studies do not appear to support a causal relationship, they didn’t measure exposure in the lung or “utilize known biomarkers of harm,” they note.

Smokers’ perceptions, and transition to alternate products, should also be assessed, looking at differences by race and ethnicity, sex, age, and vulnerable populations. The effect of filter ventilation on the risk for other diseases, such as chronic obstructive pulmonary disease, could also be studied, they say.

This study was supported by the National Cancer Institute of the National Institutes of Health and the FDA Center for Tobacco Products. Dr Shields and coauthors Neal L. Benowitz, MD, and Theodore M. Brasky, PhD, disclose they have served as consultants and expert witnesses in litigation against tobacco companies. Coauthor K. Michael Cummings, PhD, MPH, declares a relationship with Pfizer Inc. The study authors and editorialists have disclosed no relevant financial relationships.

China: the tipping point in tobacco control

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The Health Effects of Electronic Cigarettes

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Ethical considerations of e-cigarette use for tobacco harm reduction

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Minimum Ages of Legal Access for Tobacco in the United States From 1863 to 2015

http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2016.303172?journalCode=ajph&

ABSTRACT

In the United States, state laws establish a minimum age of legal access (MLA) for most tobacco products at 18 years. We reviewed the history of these laws with internal tobacco industry documents and newspaper archives from 1860 to 2014.

The laws appeared in the 1880s; by 1920, half of states had set MLAs of at least 21 years. After 1920, tobacco industry lobbying eroded them to between 16 and 18 years. By the 1980s, the tobacco industry viewed restoration of higher MLAs as a critical business threat. The industry’s political advocacy reflects its assessment that recruiting youth smokers is critical to its survival.

The increasing evidence on tobacco addiction suggests that restoring MLAs to 21 years would reduce smoking initiation and prevalence, particularly among those younger than 18 years.

Tobacco Plain Packaging Post–implementation Review – Department of Health

https://ris.govspace.gov.au/2016/02/26/tobacco-plain-packaging/

In April 2010 the then Prime Minister announced a decision to require all tobacco products to be sold in plain packaging. The regulation also standardised the appearance of the tobacco products themselves.

A Regulation Impact Statement (RIS) was required but not finalised before the decision. Consequently, under the Government’s best practice regulation process a Post‑implementation Review (PIR) was required.

The measure was fully implemented from 1 December 2012.

A PIR was completed by the Department of Health in February 2016 and was assessed as compliant by the Office of Best Practice Regulation (OBPR). Regulatory costings have been agreed with the OBPR.

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National (enforced) smoking bans improve health outcomes, Cochrane review shows

National smoking bans do reduce the harms of passive smoking, specifically cardiovascular disease, an updated systematic review from the Cochrane Library has found.1

Since the first version of this review in 2010, more countries have introduced national legislation to ban indoor smoking. The authors said that the updated review provided the most robust evidence yet that smoking bans have led to improved health outcomes.

A team of researchers based in Ireland included 77 studies, representing 21 countries, that investigated the effect of introducing a smoking ban on any measures of health or on smoking behaviour. They retained 12 studies from the original review and identified 65 new studies. Health outcomes were reported in 72 studies, of which 44 specifically assessed cardiovascular disease, 21 assessed respiratory disease, and seven assessed perinatal outcomes.

The review found consistent evidence of a positive effect from national smoking bans on improving cardiovascular health outcomes and reducing mortality from associated smoking related illnesses.

The clearest evidence it found was in reduced admissions for acute coronary syndrome. For example, one study in Ireland found a 12% reduction in admissions for acute coronary syndrome in the first year after the smoking ban, and another Irish study found an 18% reduction.

The greatest reductions in admissions for heart disease after smoking bans were identified in populations of non-smokers, the researchers found. Overall, they said that the evidence was of moderate quality in relation to cardiovascular disease.

But the effects of smoking bans on respiratory and perinatal health were found to be less consistent. Six of the 11 studies reported considerable reductions in admissions for chronic obstructive pulmonary disease, and seven of 12 reported considerable reductions in hospitalisations for asthma. In the seven studies looking at perinatal health the data produced conflicting results, and the study authors said that more research was needed in this area.

The review found 24 studies evaluating the effect of national smoke-free legislation on smoking behaviour. Evidence of an effect from legislative bans on smoking prevalence and tobacco consumption was found to be inconsistent, as some studies did not detect any additional change in existing prevalence trends.

Cecily Kelleher, a review author based at University College Dublin, said, “The current evidence provides more robust support for the previous conclusions that the introduction of national legislative smoking bans does lead to improved health outcomes through a reduction in secondhand smoke exposure for countries and their populations.

“We now need research on the continued longer term impact of smoking bans on the health outcomes of specific sub-groups of the population, such as young children [and] disadvantaged and minority groups.”

BMJ 2016; 352 doi: http://dx.doi.org/10.1136/bmj.i701 (Published 04 February 2016) Cite this as: BMJ 2016;352:i701

Toxicological and analytical assessment of e-cigarette refill components on airway epithelia

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Review of ITIC’s ASEAN Excise Tax Reform: A Resource Manual

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British study: e-cigs 95% less harmful than cigarettes

Brits worry too many smokers don’t recognize e-cigs’ benefits

https://www.consumeraffairs.com/news/british-study-e-cigs-95-less-harmful-than-cigarettes-081915.html

Great Britain and the United States haven’t always seen eye-to-eye. The latest example: e-cigarettes. Politicians and public health authorities in the U.S. continue to view e-cigs with caution while England has taken a more positive view — most notably a new report from Public Health England (PHE) that finds e-cigs about 95% less harmful than smoking.

“My reading of the evidence is that smokers who switch to vaping remove almost all the risks smoking poses to their health,” said Professor Peter Hajek of Queen Mary University. Hajek co-authored the report with Professor Ann McNeill of King’s College London.

The expert independent evidence review also finds “no evidence so far that e-cigarettes are acting as a route into smoking for children or non-smokers.” That contradicts a study by the University of California last year that found that adolescents who used the devices were more likely to smoke cigarettes and less likely to quit smoking.

Falling smoking rates

The review, commissioned by Public Health England (PHE) — an arm of the British Department of Health — goes further and suggests that e-cigarettes may be contributing to falling smoking rates among adults and young people.

The review found that almost all of the 2.6 million adults using e-cigarettes in Great Britain are current or ex-smokers, most of whom are using the devices to help them quit smoking or to prevent them going back to cigarettes.

It also provides reassurance that very few adults and young people who have never smoked are becoming regular e-cigarette users (less than 1% in each group).

Emerging evidence suggests some of the highest successful quit rates are now seen among smokers who use an e-cigarette and also receive additional support from their local stop smoking services.

Time to reconsider?

The report drew the expected response from the American Vaping Association, which represents manufacturers of the electronic nicotine delivery devices. It called for U.S. organizations and government agencies like the American Cancer Society, American Lung Association, Campaign for Tobacco-Free Kids, and Centers for Disease Control & Prevention (CDC) to reassess their views on vaping.

“This report represents a major win for public health. Smokers need to know that vapor products are far less hazardous than smoking and effective for quitting,” said Gregory Conley, AVA president. “With over 42 million Americans still smoking cigarettes, there is no excuse for major public health organizations to continue to propagandize against these lifesaving products.”

Attitude gap

Nothing better illustrates the attitude gap between the U.S. and Britain than the concern expressed by U.K. health officials that too many people think e-cigs are just as harmful as traditional cigarettes.

“The problem is people increasingly think they are at least as harmful and this may be keeping millions of smokers from quitting. Local stop smoking services should look to support e-cigarette users in their journey to quitting completely,” said Professor Kevin Fenton, Director of Health and Wellbeing at Public Health England. “E-cigarettes are not completely risk free but when compared to smoking, evidence shows they carry just a fraction of the harm.”

Ann McNeill, co-author of the review, agreed:

There is no evidence that e-cigarettes are undermining England’s falling smoking rates. Instead the evidence consistently finds that e-cigarettes are another tool for stopping smoking and in my view smokers should try vaping and vapers should stop smoking entirely.

E-cigarettes could be a game changer in public health in particular by reducing the enormous health inequalities caused by smoking.