Characteristics associated with rapid transition to tobacco dependence in youth.

Epidemiologic data suggests the smoking trajectory for some adolescents escalates rapidly and that tobacco dependence can develop quickly after initiation. In this study, we examine variation in cigarette consumption and individual characteristics associated with the rapid development of tobacco dependence, focusing particularly on the 24-month interval after tobacco initiation. The analysis is based on public use data files of the National Household Survey on Drug Abuse conducted in 1994-1996. Representative samples of adolescents aged 12-17 years old, totaling 13,831, completed a standardized interview assessing demographic characteristics, tobacco involvement and past year dependence, and psychological functioning over the preceding 6-month period as assessed by the Youth Self-Report. Analyses were restricted to the 1,734 youth who had started smoking within 0-24 months prior to being assessed, of which the onset for 70% of them was between 11-24 months. Logistic regression models took into account sample weights and used a variance estimation procedure appropriate for the complex multistage sampling design. Overall, 210 recent initiators met dependence criteria (13.5%, 95% CI = 12.0-15.2). Dependent smokers had greater cigarette involvement than youth who had not transitioned to being tobacco dependent by the time of assessment. Variation in mental health and sociodemographic characteristics were also detected. Disruptive behavior (p = .05) and being female (p = .02) were associated with being tobacco dependent. The rapid transition to dependence in youth depends not only on cigarette consumption features, but may also be associated with individual characteristics.     

Initial symptoms of nicotine dependence in adolescents

OBJECTIVES: It has been assumed that nicotine dependence has a slow onset and occurs only after prolonged daily use of tobacco. A cohort of young adolescents was followed to determine when the first symptoms of nicotine dependence occur with respect to the duration and frequency of tobacco use. DESIGN: A cohort of 681 seventh grade students (age 12-13 years) from seven schools in two small cities in central Massachusetts was followed over one year. Detailed information regarding tobacco use was obtained in individual confidential interviews conducted in school three times over the year. The latency time to the onset of symptoms of nicotine dependence was measured from the time a subject first smoked at a frequency of at least once per month. RESULTS: 22% of the 95 subjects who had initiated occasional smoking reported a symptom of nicotine dependence within four weeks of initiating monthly smoking. One or more symptoms were reported by 60 (63%) of these 95 subjects. Of the 60 symptomatic subjects, 62% had reported experiencing their first symptom before smoking daily or began smoking daily only upon experiencing their first symptom. DISCUSSION: The first symptoms of nicotine dependence can appear within days to weeks of the onset of occasional use, often before the onset of daily smoking. The existence of three groups of individuals-rapid onset, slower onset, and resistant-distinguishable from one another by their susceptibility to nicotine dependence, is postulated.     

Development of symptoms of tobacco dependence in youths: 30 month follow up data from the DANDY study

OBJECTIVE: To determine if there is a minimum duration, frequency or quantity of tobacco use required to develop symptoms of dependence. DESIGN AND SETTING: A retrospective/prospective longitudinal study of the natural history of tobacco dependence employing individual interviews conducted three times annually in two urban school systems over 30 months. Detailed histories of tobacco use were obtained including dates, duration, frequency, quantity, patterns of use, types of tobacco, and symptoms of dependence. PARTICIPANTS: A cohort of 679 seventh grade students (age 12-13 years). MAIN OUTCOME MEASURES: The report of any of 11 symptoms of dependence. RESULTS: Among 332 subjects who had used tobacco, 40% reported symptoms, with a median latency from the onset of monthly smoking of 21 days for girls and 183 days for boys. The median frequency of use at the onset of symptoms was two cigarettes, one day per week. The report of one or more symptoms predicted continued smoking through the end of follow up (odds ratio (OR) 44, 95% confidence interval (CI) 17 to 114, p < 0.001). CONCLUSIONS: Symptoms of tobacco dependence commonly develop rapidly after the onset of intermittent smoking, although individuals differ widely in this regard. Girls tend to develop symptoms faster. There does not appear to be a minimum nicotine dose or duration of use as a prerequisite for symptoms to appear. The development of a single symptom strongly predicted continued use, supporting the theory that the loss of autonomy over tobacco use begins with the first symptom of dependence.     

Gender effects of reported in utero tobacco exposure on smoking initiation, progression and nicotine dependence in adult offspring.

We examined the relationship between self-reported in utero tobacco exposure and gender on smoking initiation, progression of cigarette use (i.e., telescoping), and current levels of nicotine dependence in adult treatment-seeking smokers. Subjects (N = 298) who reported "yes" (28% of the original sample) or "no" (50% of the original sample) to in utero tobacco exposure were included in the analyses. Telescoping was calculated as the difference between the age respondents smoked their "first full cigarette" and the age when they started smoking daily. Females who reported being exposed in utero transitioned from initial to daily cigarette use more rapidly than females not exposed. The opposite effect was found for males, which may be related to our finding that in utero exposure lowered the age of cigarette experimentation in exposed compared with unexposed males. Measures of current cigarette use and dependence (i.e., Fagerstr?m Test for Nicotine Dependence, prior withdrawal, number of past year quit attempts) were significantly associated with reported in utero exposure, gender, or interactions of exposure and gender. In utero tobacco exposure may accelerate the progression from experimentation to daily use in girls, result in early tobacco experimentation among boys, and produce higher levels of nicotine dependence among adult smokers.     

The development of tobacco use in adolescence among "snus starters" and "cigarette starters": an analysis of the Swedish "BROMS" cohort

Whether the use of smokeless tobacco can facilitate the transition to cigarette smoking and/or to prolonged tobacco use in adolescence is unclear. We analyzed data from a cohort of 2,938 Swedish adolescents, with six follow-up assessments of tobacco use between the ages of 11 and 18 years. The majority of tobacco users (70%) started by smoking cigarettes, 11% took up snus before smoking, and 19% used both tobacco types close in time. Ever users of tobacco at baseline had a higher risk of being current smokers and/or smokeless tobacco users at the end of follow-up compared with never users, with the highest excess relative risk for "mixed users." Adolescents who initiated tobacco use with cigarettes had a non-significantly increased probability to end up as current smokers compared with snus starters (adjusted OR=1.42; 95% CI 0.98-2.10) The OR of smoking for "mixed starters" was 2.54 (95% CI 1.68-3.91). The risk of becoming current user of any tobacco was also significantly enhanced for "mixed starters." Marked sex differences were observed in these associations, as initiation with cigarettes rather than with snus predicted current smoking or tobacco use only among females. Progression of tobacco use in adolescence is not predicted by onset with snus or cigarettes, but rather by initiation with both tobacco types close in time and/or at young age. The proportion of adolescent smoking prevalence attributable to a potential induction effect of snus is likely small.     

Brief report: pain and readiness to quit smoking cigarettes.

This study explored the relationship between smoking and significant pain. It was hypothesized that readiness to quit smoking would be negatively affected by pain issues. A cross-sectional design was used in this phone-based survey with randomly selected adult smokers. A total of 307 adult participants in the control group from a larger Quit and Win Study participated in the interview. Participants were contacted at home and completed a 20-min phone survey including measures of pain, stress, depressive symptoms, social support, tobacco use status, and readiness to quit smoking. A total of 28% reported significant pain in the past week. Participants who experienced significant pain smoked more cigarettes per day than those who did not report significant pain. However, pain was not associated with readiness to quit. More than half (58%) of those with significant pain were in the contemplation stage of change or higher. The fact that smokers with pain were just as likely as those without significant pain to be ready to quit demands that each individual patient with pain be assessed for readiness to quit so that a tailored approach can be adopted either to motivate the patient to quit or to assist the patient with evidence-based tobacco dependence treatment strategies if he or she wants such treatment. Placing formal tobacco dependence treatment programs within pain clinics and addressing pain in smoking cessation programs is recommended.     

Preliminary examination of tobacco withdrawal in adolescent smokers during smoking cessation treatment

Tobacco withdrawal symptoms have been shown to play a significant role in mediating relapse to smoking in adult smokers; however, few prospective studies have examined the course of tobacco withdrawal symptoms over time and their connection to lapse in adolescent smokers. Withdrawal symptoms were assessed weekly for 4 weeks in a sample of adolescent smokers participating in a pilot cessation intervention. Adolescent smokers experienced an exacerbation in overall withdrawal symptoms, particularly of cravings and restlessness, although symptoms were generally mild. The course of symptoms was different for boys and girls: Girls generally experienced a peak and subsequent decline in symptoms early in the establishment of abstinence, whereas boys experienced a constant level of symptoms that did not decline over the 4 weeks. Finally, withdrawal symptoms experienced on quit day were not related to lapse to smoking during the course of treatment for either boys or girls. These results suggest that although withdrawal symptoms may be uncomfortable, they may not be the most salient to a lapse to smoking for adolescent smokers attempting to quit. These findings have direct implications for the design and implementation of treatment of nicotine dependence in adolescent smokers.     

Effects of smoking abstinence and alcohol consumption on smoking-related outcome expectancies in heavy smokers and tobacco chippers.

Smoking cessation interventions often target expectancies about the consequences of smoking. Yet little is known about the way smoking-related expectancies vary across different contexts. Two internal contexts that are often linked with smoking relapse are states associated with smoking abstinence and alcohol consumption. This report presents a secondary analysis of data from two experiments designed to examine the influence of smoking abstinence, and smoking abstinence combined with alcohol consumption, on smoking-related outcome expectancies among heavy smokers and tobacco chippers (smokers who had consistently smoked no more than 5 cigarettes/day for at least 2 years). Across both experiments, smoking abstinence and alcohol consumption increased expectancies of positive reinforcement from smoking. In addition, alcohol consumption increased negative reinforcement expectancies among tobacco chippers, such that the expectancies became more similar to those of heavy smokers as tobacco chippers' level of subjective alcohol intoxication increased. Findings suggest that these altered states influence the way smokers evaluate the consequences of smoking, and provide insight into the link between smoking abstinence, alcohol consumption, and smoking behavior.     

Older versus younger treatment-seeking smokers: differences in smoking behavior, drug and alcohol use, and psychosocial and physical functioning

Quitting smoking benefits older individuals, yet few recent studies have described older smokers. The goal of this paper was to test a series of hypotheses about differences between smokers aged 50 years or older (50+) and those younger than age 50 (<50) presenting to the same treatment facility during 2002-2004 for participation in two randomized clinical trials: one exclusively for smokers aged 50+, and a second open to smokers aged 18 or older. As predicted, smokers aged 50+ were more tobacco dependent, had better psychological functioning, and had poorer physical functioning than those aged <50. Contrary to predictions, we found no differences in motivation to quit cigarette smoking or in alcohol use. Women aged 50+ were less likely to report marijuana use than women aged <50, and less likely than men to receive a positive diagnosis for alcohol abuse. Despite higher scores on measures of tobacco dependence, older smokers were less likely to be diagnosed as tobacco dependent or as having tobacco withdrawal using DSM-IV criteria. Rates of DSM-IV alcohol abuse and dependence were high in both age groups but were higher for smokers aged <50. We found no striking differences between studies in reasons for exclusion, but in both the proportion of individuals excluded due to current antidepressant use was high. Implications for the assessment and treatment of older adults are discussed.     

Disease burden of adult lung cancer and ischaemic heart disease from passive tobacco smoking in China

Objective

To address the health hazards tobacco smoking imposes upon non‐smokers in China, this paper estimates the burden of diseases in adults from passive tobacco smoking for two major diseases—lung cancer and ischaemic heart disease (IHD).

Methods

The disease burden was estimated in terms of both premature mortality and disability adjusted life years (DALYs), a measure that accounts for both the age at death and the severity of the morbidity.

Results

Passive smoking caused more than 22 000 lung cancer deaths in 2002 according to these estimates. When the toll of disability is added to that of mortality, passive smoking was responsible for the loss of nearly 230 000 years of healthy life from lung cancer. Using the evidence from other countries that links IHD to passive smoking, we estimated that approximately 33 800 IHD deaths could be attributable to passive smoking in China in 2002. Passive smoking is also responsible for the loss of more than one quarter of a million years of healthy life from IHD. Although most of the disease burden caused by active smoking occurs among men, women bear nearly 80% of the total burden from passive smoking. The number of deaths among women caused by passive smoking is about two‐thirds of that caused by smoking for the two diseases we examined.

Conclusion

Even without considering the passive smoking risks for other diseases and among children that have been documented in other countries, passive smoking poses serious health hazards for non‐smokers, especially for adult female non‐smokers in China, adding more urgency to the need for measures to be taken immediately to protect the health of non‐smokers and curb the nation''s tobacco epidemic.     

Acute effects of cigarette smoking on global cerebral blood flow in overnight abstinent tobacco smokers.

We examined whether cerebral vascular reactivity to 5% CO2/95% O2 would be a useful, independent measure of effects of tobacco smoking on global cerebral blood flow (gCBF). The acute effects during smoking one's favorite brand of cigarettes were determined after overnight tobacco abstinence. Positron emission tomography was used to quantitatively measure gCBF using H(2)15O in 10 right-handed young-adult male volunteer tobacco smokers. After a 12-hr abstinence, gCBF measurements were repeated six times at 15-min intervals: First baseline, 5% CO2/95% O2 inhalation, first cigarette smoking, second baseline, 5% CO2/95% O2 inhalation, and second cigarette smoking. Surprisingly, no significant change was seen in mean gCBF during smoking compared with baseline. However, the increase in arterial plasma concentration of nicotine correlated inversely with gCBF. Out of 19 smoking sessions, gCBF increased in 7, decreased in 7, and was unchanged in 5 sessions. The gCBF increased during smoking when baseline gCBF was relatively low, whereas gCBF decreased when baseline gCBF was relatively high. Both vascular reactivity and estimated gCBF plus arterial nicotine concentrations were useful measures to predict the changes in measured gCBF. These individual differences result in important bimodal effects of smoking on the brains of different young adult tobacco smokers.     

Smoking behaviour among young adults: beyond youth prevention

Objective: There is a widespread assumption that smoking behaviour is largely established by the age of 18 years. As a result, smoking prevention has focused almost exclusively upon youth. However, recent trends suggest that young adulthood may be an important—and largely overlooked—period in the development of regular smoking behaviour. The current study sought to examine patterns of tobacco use among young adults (aged 18–29 years) and to address the implications for tobacco control policy.

Design: Data are presented from the 2003 Canadian Tobacco Use Monitoring Survey, a national survey of smoking behaviour (n = 10 559, response rate 89%).

Main outcome measures: Measures of smoking behaviour, smoking initiation, susceptibility to smoking, and occupational status.

Results: A total of 1.4 million or 28% of young adults in Canada currently smoke, the highest proportion among all age groups. The prevalence of daily smoking rose from 8% among youth to 22% among young adults, and approximately one fifth of smokers tried their first cigarette after the age of 18 years. Smoking behaviour among young adults was also distinct from older smokers: young adults were more likely to be occasional smokers and reported lower daily consumption. Finally, smoking prevalence and cessation rates varied substantially within subgroups of young adults, as characterised by occupational setting.

Conclusions: Dramatic increases in the proportion and intensity of smoking occurs after the age of 18 years. Smoking behaviour among young adults is distinct from both youth and older adults, and warrants immediate attention from the public health community.

     

Support for spirituality in smoking cessation: results of pilot survey.

Patient spiritual resources are increasingly included in the treatment of medical conditions such as cancers and alcohol and drug dependence, but use of spiritual resources is usually excluded from tobacco dependence treatment. We hypothesized that this omission may be linked to perceived resistance from smokers. To examine this hypothesis, we conducted a pilot survey to assess whether current smokers would consider spiritual, including religious, resources helpful if they were planning to quit. Smokers at least 18 years of age at Oregon Health & Science University in Portland, Oregon, (N=104) completed a brief survey of smoking behaviors and spiritual beliefs. None were attempting to quit. Of these individuals, 92 (88%) reported some history of spiritual resources (spiritual practice or belief in a Higher Power), and of those respondents, 78% reported that using spiritual resources to quit could be helpful, and 77% reported being open to having their providers encourage use of spiritual resources when quitting. Results of logistic regression analysis indicated that those aged 31-50 years (OR=3.3), those over age 50 years (OR=5.4), and women (OR=3.4) were significantly more likely to have used spiritual resources in the past. Of the 92 smokers with any history of spiritual resources, those smoking more than 15 cigarettes/day were significantly more receptive to provider encouragement of spiritual resources in a quit attempt (OR=5.4). Our data are consistent with overall beliefs in the United States about spirituality and recent trends to include spirituality in health care. We conclude that smokers, especially heavier smokers, may be receptive to using spiritual resources in a quit attempt and that spirituality in tobacco dependence treatment warrants additional investigation and program development.     

Youth smoking prevention and tobacco industry revenue

Objectives

Epidemiological surveys make it clear that youth smoking contributes to both current and future tobacco industry revenue: over 80% of adult smokers reportedly began smoking before age 18. This paper estimates annual and lifetime revenue from youth smoking, and highlights the association between declines in youth smoking and declines in tobacco industry revenue.

Main outcome measures

This paper reports the amount of tobacco industry revenue generated by youth smoking at two points in time (1997 and 2002), and describes the distribution of youth generated tobacco income among the major tobacco companies. The authors project the amount of tobacco industry revenue that will be generated by members of two cohorts (the high school senior classes of 1997 and 2002) over the course of their lifetimes.

Results

In 1997, youth consumed 890 million cigarette packs, generating $737 million in annual industry revenue. By 2002, consumption dropped to 541 million packs and revenue increased to nearly $1.2 billion. Fifty eight per cent of youth generated revenue goes to Philip Morris USA, 18% to Lorillard, and 12% to RJ Reynolds. The authors project that, over the course of their lives, the 1997 high school senior class will smoke 12.4 billion packs of cigarettes, generating $27.3 billion in revenue. The 2002 high school senior class is projected to smoke 10.4 billion packs, generating $22.9 billion in revenue over the course of their lives.

Conclusions

Cigarette price increases from 1997 to 2002 have resulted in greater revenue for the tobacco industry, despite declines in youth smoking prevalence. However, in the absence of further cigarette price increases, declines in youth smoking are projected to lead ultimately to a loss of approximately $4 billion in future tobacco industry revenue from a single high school cohort.     

Hollywood on tobacco: how the entertainment industry understands tobacco portrayal

OBJECTIVE: To determine how people in the California-based entertainment industry think about the portrayal of tobacco use in movies and on television. Specifically, to explore who decides when to include tobacco in a project; how that decision is made; what issues are considered; what messages are intended; whether and how the issue of second-hand smoke is considered; and what advocacy methods might be useful in influencing future decisions about tobacco portrayal. DESIGN: Qualitative in-depth interviews of entertainment industry personnel,with a semi-structured interview protocol to guide the interview. SUBJECTS: 54 subjects drawn from a convenience sample of writers, actors, directors, producers, studio executives, and others involved in the film industry. RESULTS: Hollywood is heterogeneous with varying perspectives on rates of tobacco use portrayal; intentionality of the decision to use and the necessity to portray tobacco use; and its degree of acceptance of responsibility for influencing societal smoking. Tobacco depiction may originate with the writer, actor, or director and is included most frequently to elucidate character or portray reality. On-camera smoking is influenced by actors' off-camera tobacco use. CONCLUSIONS: The research presented can help advocates better understand the norms and values of those working within the entertainment industry and thereby assist them in creating more effective change strategies.     

The genetics of tobacco use: methods,findings and policy implications

Research on the genetics of smoking has increased our understanding of nicotine dependence, and it is likely to illuminate the mechanisms by which cigarette smoking adversely effects the health of smokers. Given recent advances in molecular biology, including the completion of the draft sequence of the human genome, interest has now turned to identifying gene markers that predict a heightened risk of using tobacco and developing nicotine dependence     

Smoking cessation with smokeless tobacco and group therapy: an open, randomized, controlled trial

Smokeless tobacco might be effective as an adjunct for smoking cessation. We evaluated the efficacy of smokeless tobacco and group support for smoking cessation in an open, randomized study that compared smokeless tobacco plus group support versus group support only. The study enrolled 263 healthy smokers (M (age) = 49 years) who smoked a mean of 24 cigarettes/day, with a mean of 31 pack-years. Smokeless tobacco was provided for 7 weeks (or up to 12), combined with eight group support visits provided by nurses. The control group received group support only. Smoking cessation rates were statistically significantly better in the smokeless tobacco group than in the control group during the first 7 weeks. Point-prevalence abstinence rates at 7 weeks were 36.4% versus 20.8% (OR = 2.52, p = .001), respectively; and continuous abstinence rates from weeks 4 to 7 were 31.5% versus 19.2% (OR = 1.94, p = .023), respectively. The primary outcomes (i.e., 6-month point prevalence) were 23.1% versus 20.8%, respectively (OR = 1.31, ns). Smokeless tobacco was relatively well tolerated, although 15 subjects (11.2%) stopped use due to adverse events. A total of 25 subjects (17.5 %) were still using smokeless tobacco after 6 months. This trial demonstrated short-term efficacy of smokeless tobacco in combination with group support for smoking cessation but no long-term efficacy.     

A research agenda for assessing the potential contribution of genomic medicine to tobacco control

This paper identifies research priorities in evaluating the ways in which "genomic medicine"--the use of genetic information to prevent and treat disease--may reduce tobacco-related harm by: (1) assisting more smokers to quit; (2) preventing non-smokers from beginning to smoke tobacco; and (3) reducing the harm caused by tobacco smoking. The method proposed to achieve the first aim is "pharmacogenetics", the use of genetic information to optimise the selection of smoking-cessation programmes by screening smokers for polymorphisms that predict responses to different methods of smoking cessation. This method competes with the development of more effective forms of smoking cessation that involve vaccinating smokers against the effects of nicotine and using new pharmaceuticals (such as cannabinoid antagonists and nicotine agonists). The second and third aims are more speculative. They include: screening the population for genetic susceptibility to nicotine dependence and intervening (eg, by vaccinating children and adolescents against the effects of nicotine) to prevent smoking uptake, and screening the population for genetic susceptibility to tobacco-related diseases. A framework is described for future research on these policy options. This includes: epidemiological modelling and economic evaluation to specify the conditions under which these strategies are cost-effective; and social psychological research into the effect of providing genetic information on smokers' preparedness to quit, and the general views of the public on tobacco smoking.     

Women and tobacco in Indonesia

OBJECTIVES: To present a broad exploration of the relationship of women and tobacco in Indonesia and to describe action on tobacco and health specific to women taken by government and non-government agencies. DATA SOURCES: Published and unpublished prevalence surveys, official documents, vernacular newspapers, secondary sources, unstructured interviews, and personal observations. STUDY SELECTION: Data on smoking prevalence among women was primarily sought from official household surveys but several smaller scale local surveys were also examined. The only representative national household data on smoking prevalence from 1995 suggested a national prevalence for occasional and regular smoking of 2.6% for women aged 20 years or older. Smaller, local level surveys had reported rates varying from 4% for junior high school girls, and 2.9% for women undergraduates at a provincial university, to 6.4% of women in a representative sample in Jakarta. Claims that the incidence of female smoking is increasing cannot be confirmed due to an absence of comparable national longitudinal data. CONCLUSION: Although Indonesian women are conspicuous in growing and processing tobacco, their rates of smoking are low in comparison with their male compatriots and internationally. Anecdotal evidence suggests that their disinclination to smoke is commonly attributed to cultural values, which stigmatise women smokers as morally flawed, while at the same time sanctioning smoking by men. Although there is little evidence of tobacco advertising directly targeting women, Indonesian health activists interviewed by the author felt that women are increasingly taking up smoking due to a weakening of stigma and to Western cultural influences. Cultural factors in the low rates of smoking among Indonesian women deserve closer investigation as they have proved to be a major source of health protection, albeit within a stigmatising context. More also needs to be known about the dynamics of female tobacco use in Indonesia and the factors contributing to marked geographical variations in smoking prevalence.     

Tobacco-related disease mortality among men who switched from cigarettes to spit tobacco

Background

Although several epidemiological studies have examined the mortality among users of spit tobacco, none have compared mortality of former cigarette smokers who substitute spit tobacco for cigarette smoking (“switchers”) and smokers who quit using tobacco entirely.

Methods

A cohort of 116 395 men were identified as switchers (n = 4443) or cigarette smokers who quit using tobacco entirely (n = 111 952) when enrolled in the ongoing US American Cancer Society Cancer Prevention Study II. From 1982 to 31 December 2002, 44 374 of these men died. The mortality hazard ratios (HR) of tobacco‐related diseases, including lung cancer, coronary heart disease, stroke and chronic obstructive pulmonary disease, were estimated using Cox proportional hazards regression modelling adjusted for age and other demographic variables, as well as variables associated with smoking history, including number of years smoked, number of cigarettes smoked and age at quitting.

Results

After 20 years of follow‐up, switchers had a higher rate of death from any cause (HR 1.08, 95% confidence interval (CI) 1.01 to 1.15), lung cancer (HR 1.46, 95% CI 1.24 to 1.73), coronary heart disease (HR 1.13, 95% CI 1.00 to 1.29) and stroke (HR 1.24, 95% CI 1.01 to 1.53) than those who quit using tobacco entirely.

Conclusion

The risks of dying from major tobacco‐related diseases were higher among former cigarette smokers who switched to spit tobacco after they stopped smoking than among those who quit using tobacco entirely.Several epidemiological studies have examined morbidity and mortality among users of spit tobacco (spit‐tobacco users),^1,2 but none have compared the mortality of former cigarette smokers who substitute spit tobacco for cigarette smoking (“switchers”) to those of smokers who quit using tobacco entirely. Comprehensive reviews by the US Surgeon General,³ and the International Agency for Research on Cancer⁴ and others⁵ have concluded that evidence is sufficient that the use of spit tobacco causes several types of cancer in humans. Although the evidence linking use of spit tobacco to increased risk of cardiovascular diseases is limited,⁶ these products cause acute increases in heart rate and blood pressure, as well as long‐term adverse effects on blood pressure and lipid profiles.⁷We compared mortality of switchers to those of former cigarette smokers who quit using tobacco entirely among men enrolled in a large prospective cohort.