Should Nicotine Content of Cigarettes Be Reduced Gradually or Suddenly? Interview with:

Dorothy K. Hatsukami, Ph.D. Forster Family Professor in Cancer Prevention Professor of Psychiatry Associate, Director Masonic Cancer Center University of Minnesota

Dr. Hatsukami

Dorothy K. Hatsukami, Ph.D.
Forster Family Professor in Cancer Prevention
Professor of Psychiatry
Associate, Director Masonic Cancer Center
University of Minnesota What is the background for this study? What are the main findings?

Response: The U.S. Food and Drug Administration is considering a rule that would reduce nicotine in all cigarettes and possibly other burned tobacco products sold in the U.S. to minimally addictive levels.   Reducing nicotine in cigarettes does not make the cigarette safer, but because nicotine is the addictive chemical in tobacco, nicotine reduction would reduce the progression towards tobacco dependence and make it easier for smokers to quit smoking.  We recently published a study in JAMA that adds to the accumulating evidence to support reducing nicotine in cigarettes and addresses if a gradual reduction or a targeted immediate reduction in nicotine in cigarettes is the best approach.

In a large clinical trial involving 1,250 smokers across 10 academic institutions, immediate reduction of nicotine was compared to a gradual nicotine reduction approach. These two groups were also compared to smokers who continued to smoke usual nicotine content cigarettes.

Key findings showed that immediate nicotine reduction is likely to result in more rapid positive public health effects.  That is, smokers in the immediate reduction group experienced significantly less exposure to toxic cigarette smoke chemicals and reported smoking fewer cigarettes per day, less dependence on cigarettes and greater number of days that they were smoke-free compared to the other two groups. On the other hand, smokers in the immediate nicotine reduction group experienced more severe but transient withdrawal symptoms and greater drop-outs.  Continue reading

Which Group Is at Highest Risk for Tobacco Use Onset? Youth or Young Adults? Interview with:
“hookah” by Ksenia M is licensed under CC BY 2.0Cheryl L. Perry, Ph.D.
Professor of Health Promotion and Behavioral Sciences
The Rockwell Distinguished Chair in Society and Health
University of Texas Health Science Center at Houston (UTHealth)
School of Public Health, Austin, Texas What is the background for this study? What are the main findings?

Response: There have been large changes in the social environment over the past 10 years that have affected tobacco use among youth and young adults. These include social media, e-cigarettes, and new regulations aimed at preventing use among youth.

Historically, nearly all onset of tobacco use, particularly cigarettes, occurred prior to high school graduation by age 18. Some recent national cross-sectional data suggested that onset might be occurring among young adults.

We decided to explore, with national and Texas data, whether onset of tobacco use was more likely to occur among young adults.

We did this by analyzing data from 3 studies over one year. Continue reading

Lung Cancer Risk Drops Almost 40% Within 5 Years of Quitting Smoking Interview with:
Hilary Tindle, MD, MPH

“Used Cigarette Butts” by Indi Samarajiva is licensed under CC BY 2.0Associate Professor of Medicine and theWilliam Anderson Spickard, Jr., MD Chair in Medicine
Founding Director of ViTAL, the Vanderbilt Center for Tobacco, Addiction and Lifestyle
Division of Internal Medicine & Public Health and Vanderbilt Ingram Cancer Center (VICC) What is the background for this study?

Response: Lung cancer is the most common cause of cancer related death for men and women ,and cigarette smoking is responsible for almost 9 of our every 10 lung cancers in the US. Lung cancer screening can reduce the risk of death from lung cancer by about 20% or even higher if screening is combined with quitting smoking.

We know that lung cancer risk is lower in people who quit smoking, compared to those who continue to smoke, but it was not clear how quickly this risk drops after quitting. Most prior studies on this subject assessed smoking status (current, former, never) at relatively few timepoints. By asking about smoking more frequently (every couple of years), we can get a better picture of a person’s true exposure to cigarette smoke and take into account periods where someone may have smoked more, less, or even quit altogether. Some people may start and stop multiple times over their lifetime.

Another question was exactly how long the risk of lung cancer stays elevated after quitting smoking. Again, by asking about smoking multiple times over someone’s lifetime, we get a better picture of how long they were truly smoke free. What are the main findings?

  •  We analyzed data from the Framingham Heart Study Original and Offspring cohorts (almost 9000 people total) to study the risk of lung cancer after quitting smoking, and to determine if the risk of lung cancer ever goes back to that of someone who has never smoked (termed a “never smoker”). Study participants were followed for a median of almost 30 years, and were asked about smoking every 2-4 years.
  • We focused on heavier smokers, who had smoked more than 21 pack-years. (A “pack-year” is a way to quantify how much someone has been exposed to cigarette smoke. Pack years are the product of years of smoking times the amount smoked. For example, someone who smoked 1 pack of cigarettes per day for 20 years would have 20 pack years. Another person who smoked 2 packs per day for 10 years would also have 20 pack years.) As expected, the risks of lung cancer were highest among current smokers, followed by former smokers, followed by never smokers.
  • Compared to never smokers, former smokers had higher lung cancer risk: about 12 times higher within 10 years since quitting (YSQ), about 7 times higher from 10-15 YSQ, about 6 times higher from 15-25 YSQ, and over 3 times higher even after 25 YSQ.
  • Compared to current smokers, former smokers had lower lung cancer risk: 39% lower within 5 YSQ, which continued to drop over time.
  • Among all former smokers, about 4 in 10 lung cancers occurred after more than 15 YSQ, which is beyond the window of eligibility for current screening guidelines.

In the future, after additional study, guidelines may decide to extend the window of lung cancer screening beyond 15 YSQ. However, additional modeling studies are likely needed before making that determination. For now, anyone who qualifies for lung cancer screening based on age, pack years, and years since quitting, should have it. What should readers take away from your report?

Response: If you currently smoke cigarettes, now is a great time to quit. The results of this study show that lung cancer risk drops almost 40% within 5 years since quitting, compared to people who continue to smoke.

If you already quit smoking, congratulations on taking that major step.

Whether you currently smoke, or if you quit smoking within the last 15 years, talk to your doctor to see if you are eligible for lung cancer screening. What recommendations do you have for future research as a result of this work?

 Response: We would like to see additional research from different groups to determine if the current lung cancer screening guidelines should potentially be altered to include those who quit more than 15 years ago. Again, this is a decision may require additional study, including an understanding of why some former smokers remain at elevated risk of lung cancer. Perhaps studying genetic variation could shed some light on this question. Is there anything else you would like to add?

Response: Yes, we would like to thank the NIH and particularly the NHLBI for supporting the Framingham Heart Study (FHS) and studies like it, and also to all the participants in the FHS for giving their information for decades, to the benefit of all Americans and the world. We consider studies such as the FHS to be “national treasures” in that they provide critical information for doctors and researchers to improve healthcare. The FHS is most often thought of as a cardiovascular dataset, but it also captures information on cancer. In the case of the current study, we re-analyzed information that was already collected, which is one of the efficient and low cost methods of conducting research. 


 Hilary A Tindle, Meredith Stevenson Duncan, Robert A Greevy, Ramachandran S Vasan, Suman Kundu, Pierre P Massion, Matthew S Freiberg. Lifetime Smoking History and Risk of Lung Cancer: Results From the Framingham Heart Study. JNCI: Journal of the National Cancer Institute, 2018; DOI: 10.1093/jnci/djy041


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More Young Women Than Men Now Get Lung Cancer Interview with:
“Woman smoking” by Pedro Ribeiro Simões is licensed under CC BY 2.0Ahmedin Jemal, DVM, PHD
Scientific Vice President, Surveillance & Health Services Rsch
American Cancer Society, Inc.
Atlanta, GA 30303 What is the background for this study? What are the main findings?

Response: Historically, lung cancer rates have been higher in men than women at all ages because of the substantially higher cigarette smoking prevalence in men.

However, cigarette smoking prevalences over the past few decades have become similar between young men and women. Consistent with this pattern, we previously reported the convergence of lung cancer rates between young men and young women. In this paper, we examined the lung cancer incidence rates in young women versus young men in the contemporary cohorts.

We found that the historically higher lung cancer incidence rates in young men than in young women have reversed in whites and Hispanics born since the mid-1960s. However, this emerging incidence patterns were not fully explained by sex difference in smoking prevalence as cigarette smoking prevalences among whites and Hispanics were not higher in young women than young men.

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Consumers Trying But Not Continuing E-Cigarettes Interview with:
“E-Cigarette/Electronic Cigarette/E-Cigs/E-Liquid/Vaping” by Vaping360 is licensed under CC BY 2.0
Wei Bao, MD, PhD
Assistant Professor
Department of Epidemiology,
College of Public Health,
University of Iowa,
Iowa City, IA 52242 What is the background for this study? What are the main findings? 

Response: Although the health effects of e-cigarettes remains unclear, e-cigarettes have been marketed as an approach for smoking cessation. Previous studies have reported an increase in e-cigarette use in US people since 2010. The current study showed that from 2014 to 2016, there was an increase in ever use of e-cigarettes but decline in current use of e-cigarettes.  Continue reading

Smoking: The Great Brain Drain Interview with:
“Stop smoking!” by Emil_95 is licensed under CC BY 2.0Janina Markidan MS III, MD Student

University of Maryland School of Medicine What is the background for this study? What are the main findings?

Response: In a study of 1,145 young men, we found a strong dose-response relationship between the number of cigarettes smoked daily and the risk of ischemic stroke.

We categorized the participants as never smokers, former smokers and current smokers. Current smokers were divided into groups based on the number of cigarettes smoked daily, 1 to 10, 11 to 20, 21 to 39, or 40 or more.

We found that men who smoked were 88 percent more likely to have a stroke than men who never smoked. Among current smokers, men who smoked fewer than 11 cigarettes daily were 46 percent more likely to have a stroke than those who never smoked. But the heavier smokers, smoking at least two packs a day, were nearly 5 times (466%) more likely to have a stroke than those who never smoked.  Continue reading

Cigarette Taxes Associated With Increased Smokeless Tobacco Use Among Adolescents Interview with:
Summer Sherburne Hawkins, PhD, MS Associate Professor School of Social Work Boston College Summer Sherburne Hawkins, PhD, MS
Associate Professor School of Social Work
Boston College What is the background for this study?

Response: Increasing cigarette taxes has been a major policy driver to decrease smoking, including adolescent smoking, while taxes on other tobacco products have received less attention. Taxes on cigarettes, smokeless tobacco, and cigars are all fiscal policies, but they are not all equal. While state taxes on cigarettes have increased substantially over the past decade, there has been little change in policies governing alternative tobacco products.

The aim of our study was to evaluate the impact of chewing tobacco and cigar taxes, cigarette taxes, and the enactment of smoke-free legislation on adolescent male and female use of smokeless tobacco and cigars.

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Fewer Cigarettes But More Vaping Among Today’s Adolescents Interview with:
“Checking your phone and vaping as you do” by Alper Çuğun is licensed under CC BY 2.0
Richard Allen Miech, PhD
Research Professor, Survey Research Center
Institute for Social Research
University of Michigan What is the background for this study? What are the main findings?

Response: Monitoring the Future conducts annual, nationally-representative surveys of ~45,000 adolescents every year to assess trends in substance use.  We track which drugs are gaining traction among adolescents and which are falling out of favor.  The survey draws separate, nationally-representative samples of 8th, 10th, and 12th grade students from about 400 total schools every year.  Once a recruited school agrees to participate, a field interviewer travels to the school to administer the paper-and-pencil survey, typically in classrooms.  The project is funded by the National Institute of Drug Abuse and is carried out by the University of Michigan.  More details on the project’s survey design and survey procedures can be found in chapter 3 here: http://monitoringthefutu vol1_2016.pdf

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Can Cigarette Butts Be Recycled Into Bricks and Concrete? Interview with:

Abbas Mohajerani BsEng, MsEng, PhD, FIEAust, MAGS. MACI Senior Lecturer School of Engineering, Civil and Infrastructure Engineering RMIT University Melbourne Victoria  Australia

Dr. Mohajerani

Abbas Mohajerani BsEng, MsEng, PhD, FIEAust, MAGS. MACI
Senior Lecturer
School of Engineering, Civil and Infrastructure Engineering
RMIT University
Melbourne Victoria  Australia What is the background for this study? What are the main findings?

Response: I knew about the harmful chemicals in cigarette butts and was not happy to see them everywhere in the environment, in our footpath, parks, and rivers. Cigarette butts (CBs) contain a large number of toxic to highly toxic chemicals and stay in the environment for a long time. Decomposition of CBs can take from a couple of months to many years depending on the environmental factors.

Cigarette butts are one of the most common types of waste found around the world. Currently about 6 trillion cigarette butts per year are deposited somewhere in the environment. This is equivalent to an estimated mass of over 1.2 million tonnes of Cigarette butts each year. And this is expected to increase significantly by 2025, mainly due to an increase in the world population.

In 2005, I started to think about different ways to recycle CBs in construction materials, and the first idea which struck me was to recycle them in fired clay bricks.

After several years of research, we came up with a proposal, that if every brick manufacturer were to produce 2.5% of their bricks with 1% Cigarette butts incorporated, all CBs produced worldwide could be recycled. A 1% CB content would have very little effect on the physical and mechanical properties of the brick. And the estimated firing energy saved by incorporating 1% CBs into clay bricks is about 10%. That is a very significant reduction in the firing energy.

This proposal was published in the journal of Waste Management in May 2016.

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Cheap Cigarettes in Europe Associated With Increased Infant Mortality Interview with:

Filippos Filippidis MD MPH PhD Lecturer in Public Health School of Public Health Imperial College London London

Dr. Filippidis

Filippos Filippidis MD MPH PhD
Lecturer in Public Health
School of Public Health
Imperial College London
London What is the background for this study? What are the main findings?

Response: Smoking kills millions of people every year. It is well established that increasing tobacco prices is the most effective way to reduce tobacco consumption and hence mitigate the devastating effects of tobacco on health. Taxation on tobacco products is high in the European Union, which makes cigarettes less affordable. However, transnational tobacco companies are known to manipulate prices, ensuring that cheap or ‘budget’ cigarettes are still available. This is particularly important for younger smokers and those of low socioeconomic status who are more sensitive in price increases.

Smoking during pregnancy, as well as exposure of pregnant women and babies to cigarette smoke increase infant mortality. There is also evidence that increasing tobacco prices is associated with lower infant mortality. However, researchers typically use average or premium cigarette prices. We analysed 54 million births from 23 European Union countries to see if the differential between average priced and budget cigarettes (i.e. the availability of cigarettes much cheaper than average priced ones) is associated with infant mortality.

We found that increasing average cigarette prices by 1 Euro per pack was associated with 0.23 fewer deaths per 1,000 live births in the same year and an additional 0.16 fewer deaths per 1,000 live births in the following year. A 10% increase in the price differential between budget and average priced cigarettes was associated with 0.07 more deaths per 1,000 live births the following year. This means that 3,195 infant deaths could potentially have been avoided in these 23 countries if there was no price difference between cigarette products over the 10-year study period.

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Holes in Cigarette Filters Linked To Increase in Lung Adenocarcinomas Interview with:
Peter G. Shields, M.D.
Deputy Director, Comprehensive Cancer Center
James Cancer Hospital
Professor, College of Medicine
Julius F. Stone Chair in Cancer Research
The Ohio State University Columbus, OH What do we know about the health effects of cigarette filters? 
Response:  The issue is that the design of the filters makes a cigarette even more dangerous, which can be regulated by the FDA. The issue is not about having a filter, but how they are made. And now we are changing the dialogue to the design of virtually all cigarettes. The holes on the filter are likely one reason the cigarettes of today are more dangerous.

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“Heat-Not-Burn” Cigarettes Release Heart Attack and Cancer-Causing Chemicals Interview with:


Prof. Reto Auer

Reto Auer, MD, MAS
Institute of Primary Health Care (BIHAM), University of Bern, Bern,
Department of Ambulatory Care and Community Medicine
University of Lausanne, Lausanne, Switzerland What is the background for this study?

Response: When the tobacco industry began to promote new “heat-not-burn” (HNB) tobacco cigarettes as a “safer” alternative to traditional cigarettes, we wanted to find out if their claims were true. Philip Morris International (PMI) created an HBN called IQOS® (I-Quit-Ordinary-Smoking). IQOS® uses tobacco sticks soaked in propylene glycol, which are inserted into a holder and heated to a maximum of 350°C. PMI claims that because its HNBs don’t combust, they emit far fewer harmful chemicals than conventional cigarettes. We decided to test their claims.

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CVS Pharmacy’s Discontinuance of Tobacco Sales Led To Big Drop In Cigarette Purchases Interview with:

Jennifer M. Polinski PhD Senior Director, Enterprise Evaluation and Population Health Analytics, CVS Health CVS Caremark Corporation Harvard School of Public Health

Dr. Jennifer Polinski

Jennifer M. Polinski PhD
Senior Director, Enterprise Evaluation and Population Health Analytics, CVS Health
CVS Caremark Corporation
Harvard School of Public Health What is the background for this study? What are the main findings?

Response: Nearly three years ago, we removed tobacco products from all CVS Pharmacy locations to help our customers on their path to better health. While there is a growing body of evidence that suggests that restricting access to tobacco helps reduce its use, we wanted to understand if our decision to remove tobacco had a nationwide impact on our customers’ purchasing behavior and presumed smoking habits.

In fact, our research findings, published in the American Journal of Public Health, show that CVS Health’s decision to remove tobacco from all CVS Pharmacy stores reduced the number of cigarette purchases across all other retail settings, including gas stations, convenience stores, and other outlets. In addition, customers who exclusively purchased cigarettes at CVS Pharmacy were 38 percent more likely to stop buying cigarettes, and those who purchased three or more packs of cigarettes per month at a CVS Pharmacy were more than twice as likely to stop buying cigarettes altogether.

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Cigarette Smoking Prevalence Varies By Gender and Occupation Interview with:
Girija Syamlal MBBS, MPH , Epidemiologist
Division of Respiratory Disease Studies
National Institute for Occupational Safety and Health
CDC, Morgantown, West Virginia
Morgantown,WV 26505

Medical Research: What are the main findings of the study?

Dr. Syamlal: During 2004–2011, of the 141 million U.S. adults, 20.7% were current cigarette smokers. Smoking prevalences were higher among men (22.8%) than women (18.3%). In both men and women, cigarette smoking prevalence varied widely by occupational group. In certain occupations, the prevalence of smoking was three times greater than the Healthy People 2020 goal that aims to reduce cigarette smoking prevalence to 12%.

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Standardized Tobacco Packaging Did Not Change Purchasing Habits Interview with: 
Michelle Scollo
Senior policy adviser, Tobacco
Centre for Behavioural Research in Cancer

Medical Research: What are the main findings of the study?

Answer:  Each November the Cancer Council Victoria conducts a survey asking smokers about their tobacco purchasing habits and smoking attitudes, intentions and behaviours. This study compared what smokers said about where and what they purchased in:

  • November 2011, a year before the introduction of world-first legislation mandating standardized packaging of tobacco products throughout Australia
  • In November 2012, while the new plain packs were being rolled out onto the market and
  • In November 2013 one year later.

The tobacco industry had strenuously opposed the legislation, but—contrary to the industry predictions and continuing claims in other countries contemplating similar legislation—we found:

1.       No evidence of smokers shifting from purchasing in small independent outlets to purchasing in larger supermarkets
2.       No evidence of an increase in use of very cheap brands of cigarettes manufactured by companies based in Asia and
3.       No evidence of an increase in use of illicit unbranded tobacco.
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