Preventing tobacco use and harm: what is evidence based policy?

The majority of tobacco users commence in early to mid-adolescence. Tobacco smoking can be characterised as a chronic, relapsing disorder. While risk increases with amount smoked, there is no safe level of use (i.e., all use is risky). Duration of use is the most important predictor of premature death with the majority of excess morbidity and mortality avoidable if people quit before middle age. Investment in initiatives that reduce smoking among pregnant women and those at risk of cardiovascular disease provide quickest returns -in reduced health care episodes and expenditure.  Measures that successfully reduce smoking among parents probably reduce smoking uptake by children, and high levels of smoking among both children and parents appear to be associated with higher levels of illicit drug use.
The evidence base for pharmcotherapies in the treatment of tobacco dependence is very strong. Population-level initiatives such as tax increases, mass media-led campaigns and smoke-free policies are all highly cost-effective in reducing population-smoking levels, including among children and young people.
Australian tobacco control initiatives have been based on "social ecology" conceptualisations of the problem, which acknowledge the pivotal role of the media in shaping social values, and public and political opinion.
Broad social change, as well as more focused prevention and cessation initiatives, has drawn heavily on research findings from the behavioural sciences. Considerable effort (mainly, in Australian, in the NGO sector) has gone into documenting policy inputs and monitoring impact and outcome measures.
This chapter discusses why conceptualising tobacco-related harm from legal, economic and social policy perspectives should also help build support for tobacco control policy among academic and practising economists and lawyers, and in the business, welfare and government sectors.

Impact of tobacco tax reforms on tobacco prices and tobacco use in Australia

OBJECTIVE: To document the impact of changes to tobacco taxes on the range and price of tobacco sold during the period when the National Tobacco Campaign (NTC) was run.

DATA SOURCES: Information about brand availability, pack size, and price was extracted from Australian Retail Tobacconist. A retail observational survey was undertaken to monitor actual retail prices. Data on cigarette prices, brands, packet configurations, and outlets from which they were purchased were obtained from the benchmark and three follow up population telephone surveys conducted to evaluate the NTC.

METHOD: Data from the three sources were compared to see the extent to which the impact of tax changes had been offset by greater retail discounting and a more concerted effort by consumers to purchase cheaper products.

RESULTS: Smokers were unable to cushion themselves from the sharp price increases that occurred during the third phase of the NTC. Both average recommended retail prices of manufactured cigarettes and average actual cigarette prices paid by smokers increased by 25% in real prices.

CONCLUSION: The fall in smoking prevalence over the first two phases of the NTC was substantially greater than would be expected due to tax changes alone. The fall in smoking consumption over the first two phases was slightly less than would be expected and in the third considerably higher than would be expected.

Consequences of youth tobacco use: a review of prospective behavioural studies

Background Cigarette smoking represents a significant health problem and tobacco has been identified as causing more preventable diseases and premature deaths than any other drug. Although health consequences from smoking have been documented, there has been a surprising lack of research into behavioural consequences.

Aims To review what is known of the long-term relationship between patterns of tobacco use prior to age 18 years and behavioural consequences in adulthood.

Method A literature search of electronic abstraction services from 1980 to September 2005 was conducted. To be included in the review, studies had to have large, representative samples, be longitudinal studies with baseline age under 18 years and follow-up age 18 years or older and clarify effects due to attrition, leaving 16 articles that met the inclusion criteria. Two reviewers evaluated each paper.

Findings Adolescent tobacco use predicts a range of early adult social and health problems. Surprisingly few studies met the inclusion criteria. The limited evidence available suggests that adolescent tobacco smoking increases the likelihood of early adult tobacco use and the initiation of alcohol use or the development of alcohol-related problems. The link between adolescent tobacco use and subsequent cannabis use was not resolved convincingly from the studies summarized. The effects of tobacco use on later illicit drug use tended to fall away when adjusting for underlying risk factors. Existing studies of the effects of tobacco use on later mental health have many limitations. Nevertheless, a finding that youth tobacco use may predict subsequent mental health problems deserves further investigation. The possible effects of tobacco use on academic/social problems and sleep problems also warrant further investigation.

Conclusion This review highlights links between youth tobacco use and subsequent behavioural and mental health problems. It provides health care professionals with evidence of the possible harmful effects of youth tobacco smoking on later social, emotional, and behavioural well-being.

The impact of school suspension on student tobacco use : a longitudinal study in Victoria, Australia, and Washington State, United States

Context: School suspension may have unintended consequences in contributing to problem behaviors, including dropping out from school, substance use, and antisocial behavior. Tobacco use is an early-onset problem behavior, but prospective studies of the effects of suspension on tobacco use are lacking.

Method: Longitudinal school-based survey of students drawn as a two-stage cluster sample, administered in 2002 and 2003, in Washington State, United States, and Victoria, Australia. The study uses statewide representative samples of students in Grades 7 and 9 (N = 3,599). Results: Rates of tobacco use were higher for Victorian than Washington State students. School suspension remained a predictor of current tobacco use at 12-month follow-up, after controlling for established risk factors including prior tobacco and other drug use for Grade 7 but not Grade 9 students.

Conclusions: School suspension is associated with early adolescent tobacco use, itself an established predictor of adverse outcomes in young people. Findings suggest the need to explore process mechanisms and alternatives to school suspensions as a response to challenging student behavior in early adolescence.

SLC6A4 STin2 VNTR genetic polymorphism is associated with tobacco use disorder, but not with successful smoking cessation or smoking characteristics: a case control study.

The aim of this study was to determine if variable number of tandem repeats (VNTR) in the second intron (STin2) of the serotonin transporter (SLC6A4) gene was associated with tobacco use disorder, successful smoking cessation, or smoking characteristics. In this case-control study, patients with current tobacco use disorder, diagnosed according to DSM IV criteria (n = 185), and never-smokers, diagnosed according to CDC criteria (n = 175), were recruited and received 52 weeks of combined pharmacotherapy and cognitive therapy. Successful smoking cessation was defined as exhaled carbon monoxide < 6 ppm. SLC6A4 gene STin2 VNTR polymorphism was assessed using a Multiplex-PCR-based method. At baseline, participants were evaluated using the Fagerström Test for Nicotine Dependence (FTND) and the ASSIST scale.

Atherogenic index of plasma and atherogenic coefficient are increased in major depression and bipolar disorder, especially when comorbid with tobacco use disorder

There is a robust comorbidity between mood disorders and cardiovascular disorder (CVD). The atherogenic index of plasma (AIP) and the atherogenic coefficient (AC) are important atherogenic indexes. The aims of this study were to delineate whether AIP and AC are increased in mood disorders especially when comorbid with tobacco use disorder (TUD).

STin2 VNTR polymorphism is associated with comorbid tobacco use and mood disorders.

There is a significant comorbidity between mood disorders and tobacco use disorder (TUD), which may be related to both genetic and environmental factors. Gene variants of the 5-HT transporter, such as STin2 VNTR (a variable number of tandem repeats in the functional serotonin transporter intron 2) may be associated with mood disorders and TUD.

N-acetylcysteine for therapy-resistant tobacco use disorder: a pilot study

Introduction N-Acetylcysteine (NAC) may have efficacy in treating tobacco use disorder (TUD) by reducing craving and smoking reward. This study examines whether treatment with NAC may have a clinical efficacy in the treatment of TUD. Methods A 12-week double blind randomized controlled trial was conducted to compare the clinical efficacy of NAC 3 g/day versus placebo. We recruited 34 outpatients with therapy resistant TUD concurrently treated with smoking-focused group behavioral therapy. Participants had assessments of daily cigarette use (primary outcome), exhaled carbon monoxide (COEXH) (secondary outcome), and quit rates as defined by COEXH<6 ppm. Depression was measured with the Hamilton Depression Rating Scale (HDRS). Data were analyzed using conventional and modified intention-to-treat endpoint analyses. Results NAC treatment significantly reduced the daily number of cigarettes used (Δ mean±SD = -10.9 ± 7.9 in the NAC-treated versus -3.2 ± 6.1 in the placebo group) and COEXH (Δ mean± SD = -10.4 ± 8.6 ppm in the NAC-treated versus -1.5 ± 4.5 ppm in the placebo group); 47.1% of those treated with NAC versus 21.4% of placebo-treated patients were able to quit smoking as defined by COEXH<6 ppm. NAC treatment significantly reduced the HDRS score in patients with tobacco use disorder. Conclusions These data show that treatment with NAC may have a clinical efficacy in TUD. NAC combined with appropriate psychotherapy appears to be an efficient treatment option for TUD.

Tobacco use in bipolar disorder

Tobacco use in mental health in general and bipolar disorder in particular remains disproportionally common, despite declining smoking rates in the community. Furthermore, interactions between tobacco use and mental health have been shown, indicating the outcomes for those with mental health disorders are impacted by tobacco use. Factors need to be explored and addressed to improve outcomes for those with these disorders and target specific interventions for people with psychiatric illness to cease tobacco smoking. In the context of bipolar disorder, this review explores; the effects of tobacco smoking on symptoms, quality of life, suicidal behavior, the biological interactions between tobacco use and bipolar disorder, the interactions between tobacco smoking and psychiatric medications, rates and factors surrounding tobacco smoking cessation in bipolar disorder and suggests potential directions for research and clinical translation. The importance of this review is to bring together the current understanding of tobacco use in bipolar disorder to highlight the need for specific intervention.

Factors influencing insulin resistance in relation to atherogenicity in mood disorders, the metabolic syndrome and tobacco use disorder

OBJECTIVE: This study examines the effects of malondialdehyde (MDA) and uric acid on insulin resistance and atherogenicity in subjects with and without mood disorders, the metabolic syndrome (MetS) and tobacco use disorder (TUD). METHODS: We included 314 subjects with depression and bipolar depression, with and without the MetS and TUD and computed insulin resistance using the updated homeostasis model assessment (HOMA2IR) and atherogenicity using the atherogenic index of plasma (AIP), that is log10 (triglycerides/high density lipoprotein (HDL) cholesterol. RESULTS: HOMA2IR is correlated with body mass index (BMI) and uric acid levels, but not with mood disorders and TUD, while the AIP is positively associated with BMI, mood disorders, TUD, uric acid, MDA and male sex. Uric acid is positively associated with insulin and triglycerides and negatively with HDL cholesterol. MDA is positively associated with triglyceride levels. Comorbid mood disorders and TUD further increase AIP but not insulin resistance. Glucose is positively associated with increasing age, male gender and BMI. DISCUSSION: The results show that mood disorders, TUD and BMI together with elevated levels of uric acid and MDA independently contribute to increased atherogenic potential, while BMI and uric acid are risk factors for insulin resistance. The findings show that mood disorders and TUD are closely related to an increased atherogenic potential but not to insulin resistance or the MetS. Increased uric acid is a highly significant risk factor for insulin resistance and increased atherogenic potential. MDA, a marker of lipid peroxidation, further contributes to different aspects of the atherogenic potential. Mood disorders and TUD increase triglyceride levels, lower HDL cholesterol and are strongly associated with the atherogenic, but not insulin resistance, component of the MetS.

Rural adolescent alcohol, tobacco, and illicit drug use: a comparison of students in Victoria, Australia, and Washington State, United States

Purpose: There are inconsistent research findings regarding the impact of rurality on adolescent alcohol, tobacco, and illicit substance use. Therefore, the current study reports on the effect of rurality on alcohol, tobacco, and illicit
drug use among adolescents in 2 state representative samples in 2 countries, Washington State (WA) in the United States and Victoria (VIC) in Australia.
Participants: The International Youth Development Study (IYDS) recruited representative samples of students from Grade 7 (aged 12 to 13 years) and Grade 9 (aged 14 to 15) in both states. A total of 3,729 students responded to questions about alcohol, tobacco, cannabis, and other illicit substance use (n_VIC = 1,852; n_WA = 1,877). In each state, males and females were equally represented and ages ranged from 12 to 15 years.
Methods: Data were analyzed to compare lifetime and current (past 30 days) substance use for students located in census areas classified as urban, large or small town, and rural. Findings were adjusted for school clustering and
weighted to compare prevalence at median age 14 years.
Findings: Rates of lifetime and current alcohol, tobacco, and cannabis use were significantly higher in rural compared to urban students in both states (odds ratio for current substance use = 1.31).
Conclusions: In both Washington State and Victoria, early adolescent rural students use substances more frequently than their urban counterparts. Future studies should examine factors that place rural adolescents at risk for alcohol, tobacco, and illicit drug use.

Why do Bangladeshi people use smokeless tobacco products?

Despite scientific evidence about the harmful effects of smokeless tobacco (SLT), it is widely used in Bangladesh. This study explored perceptions about health effects of SLT use. Semistructured interviews were conducted with 1812 nonsmoking adults. About 40% of the participants were current SLT users or had used SLT in the past. Family members' influence was the main factor for initiation. The participants believed that people continued using SLT because of addiction (52%) and as a part of their lifestyle (23%). The majority of participants (77%) did not mention any benefit, but SLT users considered it to be a remedy for toothache (P < .05). Almost all participants mentioned that SLT was harmful and causes heart disease, cancer, and tuberculosis. Doctors' advice was the common motivating factor to quit. Health promotion interventions should highlight the adverse effects of SLT use, which outweigh the perceived benefits, and should consider addressing the role of family in SLT initiation and use.

Youth alcohol and other drug use in the United States and Australia: a cross-national comparison of three state-wide samples

Although youth drug and alcohol harm minimization policies in Australia are often contrasted with the abstinence and zero tolerance policies adopted in the United States, there has been little research directly comparing youth substance use behaviour in the two countries. Three state representative samples in Victoria, Australia (n = 7898) and in the US states of Oregon (n = 15 224) and Maine (n = 16 245) completed a common cross-sectional student survey. Rates of alcohol use (lifetime alcohol use, recent use in the past 30 days), alcohol use exceeding recommended consumption limits (binge drinking: five or more drinks in a session), other licit drug use (tobacco use), and norm-violating substance use (substance use at school, use in the past 30 days of marijuana or other illicit drug use) were compared for males and females at ages 12-17. Rates were lower (odds ratios 0.5-0.8) for youth in Maine and Oregon compared to Victoria for lifetime and recent alcohol use, binge drinking and daily cigarette smoking. However, rates of recent marijuana use and recent use of other illicit drugs were higher in Maine and Oregon, as were reports of being drunk or high at school. In contradiction of harm minimization objectives, Victoria, relative to the US states of Oregon and Maine, demonstrated higher rates of alcohol use exceeding recommended consumption limits and daily tobacco use. However, findings suggested that aspects of norm-violating substance use (substance use at school, marijuana use and other illicit drug use) were higher in the US states compared to Victoria.