Tobacco and Nicotine Lecture Notes
History of Tobacco Use
Tobacco has been used since at least the first century BC (Mishra & Mishra, 2013).
1500s: Used to treat illnesses such as asthma, earaches, headaches, colds, bowel problems, fever, sore eyes, depression, insect bites, burns (Mishra & Mishra, 2013).
1828: French chemists isolated nicotine (Kuhn et al, 2019).
Mid-1800s: Most tobacco factories produced chewing tobacco.
1880s: Invention of machine to mass produce cigarettes.
1890s: Nicotine use was no longer prescribed as medicine in the US
Early 1900s: Smoking cigars began to replace chewing tobacco.
Anti-spitting laws were put in place to prevent the spread of tuberculosis (Paoletti et al 2013).
During World War I, soldiers received a weekly ration of 50 cigarettes (Paoletti et al 2013).
General Pershing: Said cigarettes for troops are as important as bullets.
1920s-1930s: Early evidence of negative health consequences began appearing; lung cancer rates accelerated (Paoletti et al 2013).
Early 1960s: 40% of US adults were smokers.
Surgeon General Reports
1964: Concluded smokers had a 10-fold increased risk of developing lung and laryngeal cancer compared to non-smokers.
Major health scare, drop in smoking followed by another increase
1980: Health consequences of smoking for women
1986: Involuntary smoking (secondhand smoke)
1988: Nicotine addiction
1990: Health benefits of smoking cessation
1994: Preventing tobacco use among youth
1998: Preventing tobacco use among minority groups
2004: Smoking affects nearly every organ of the body
2014: Health Consequences of Smoking: 50 years of progress
2016: E-cigarette use among youth and young adults
U.S. Surgeon General = “the Nation’s Doctor”
Negative Consequences of Smoking
More than 20 million Americans have died from smoking since the release of the 1964 Report.
Research continues to newly identify diseases caused by smoking, even 50 years after the first report.
February 12, 2015, New England Journal of Medicine: Even more diseases associated with smoking
Exposure to secondhand tobacco smoke has been causally linked to cancer, respiratory, and cardiovascular diseases, and to adverse effects on health of infants and children.
Cigarette Warning Labels
1966: First caution label: “Caution, smoking may be dangerous to your health.”
1970: Warning strengthened to “The Surgeon General Has Determined that Cigarette Smoking is Dangerous to Your Health.”
1972: Manufacturers required to display the same health warning mandated on cigarette packages on all cigarette advertising.
1984: Four rotating health warnings required on all cigarette packages and advertisements beginning in 1985:
Smoking Causes Lung Cancer, Heart Disease, Emphysema, and May Complicate Pregnancy.
Quitting Smoking Now Greatly Reduces Serious Risks to Your Health.
Smoking by Pregnant Women May Result in Fetal Injury, Premature Birth, and Low Birth Weight.
Cigarette Smoke Contains Carbon Monoxide. (Paoletti et al 2013)
Master Settlement Agreement
Accord reached in November 1998 between the state Attorneys General of 46 states, five U.S. territories, the District of Columbia, and the four largest cigarette manufacturers in the United States.
Requires the tobacco industry to pay the settling states billions of dollars annually forever, forbids participating cigarette manufacturers from targeting youth, imposes restrictions on advertising and promotional activities, and bans or restricts transit advertising, outdoor advertising, product placement in media, branded merchandise, free product samples, and sponsorships (Public Health Law Center)
Smoking Trends
Smoking has decreased sharply overall.
U.S. smoking rate fell to a record low.
Cigarette smoking rates have fallen significantly for both youths and adults.
Tobacco Use among UMN Students
Current tobacco use trends over time among 18- to 24-year-old students shows a decline between 1998 and 2024
Nicotine
Nicotine promotes the release of dopamine.
Nicotine lacks the obvious mind-altering effects of alcohol, stimulants, or opioids.
People don’t use nicotine because of a rush or high. Rather, most users report that it calms them and reduces anxiety.
It is hard to know what leads to that feeling: the nicotine, the rituals associated with smoking, or the reduced craving provided by smoking
May aid alertness, concentration, and memory formation
Those with schizophrenia often self-medicate with nicotine
Used to suppress appetite—for weight maintenance/loss & to reduce hunger pangs (Kuhn et al, 2019)
Nicotine Delivery
Cigarettes are very efficient nicotine delivery devices
When someone smokes tobacco/inhales nicotine, nicotine reaches the brain within seconds (~10 seconds).
The amount of nicotine in a cigarette is enough to make an adult very sick, but most is lost in exhaled or uninhaled smoke.
Nicotine has short (20 minute) half-life.
Need to continue to smoke to maintain constant nicotine blood levels
Nicotine consumption through smokeless tobacco may be more complete, but the dose is delivered over a longer period
Repeated reinforcement - millions of puffs possible over smoking “career” (Kuhn et al, 2019)
Nicotine and Addiction
Nicotine’s rapid route to the brain provides a quick and potent hit.
Nicotine is rapidly redistributed out of the brain → the brain areas that control smoking-related behaviors are ready for more nicotine soon after the smoker finishes a cigarette (Kuhn et al, 2019)
Nicotine and Depression
Adolescents who are smokers are twice as likely as non-smoking adolescents to suffer an episode of major depression
Teens with long-term depression are more likely to be smokers than teens without depression (Kuhn et al, 2019)
Age of Onset
“Smoking regularly at age 18-20 was associated with higher odds of nicotine dependence and lower odds of smoking cessation than starting at age 21+. These negative health consequences were observed with regular smoking initiation at age 18 to 20 as well as before age 18. Therefore, efforts to prevent regular smoking initiation before age 21 could help prevent lifetime addiction to nicotine and promote smoking cessation later in life.” (Ali et al, 2020)
Risk of lung cancer is greater for those who start earlier, even when adjusted for pack years smoked.
Nearly all tobacco users start before age 21, although some individuals take it up later in life.
Even delaying onset has health benefits.
Truth Initiative (previously known as American Legacy Foundation Truth Campaign)
As of December 2019, it is illegal for a retailer to sell any tobacco product—including cigarettes, cigars and e-cigarettes—to anyone under 21.
Disparities
Clear relationship between educational level and smoking: the more educated the person, the less likely they are to smoke (percentage of college graduates who smoke cigarettes is about one-third the percentage of smokers among folks who have not attended college).
Smoking is higher among adults living below the poverty line (25.3%) than among those who do not live in poverty (14.3%) (Kuhn et al, 2019)
Menthol
Big Tobacco has a long history of targeting and exploiting Black, Indigenous, and other historically marginalized racial and ethnic groups, youth, the LGBTQ+ community, women, and others.
Tobacco companies began adding menthol to cigarettes in the 1920s-1930s to make cigarettes appear less harsh and appealing to new smokers, young people, and older smokers
The industry has targeted African Americans with menthol cigarette advertisements; nearly 9 in 10 Black youth ages 12+ who smoke use menthol cigarettes, and nearly 85% of all Black smokers use menthol cigarettes, compared to 30% of all White smokers
Studies indicate that people who smoke menthol cigarettes have more difficulty quitting than those who smoke non-mentholated cigarettes and are less likely to quit successfully, despite numerous intentions to quit and quit attempts.
Big Tobacco has vigorously fought flavor bans (Public Health Law Center, 2021)
Menthol Ban
In October 2023, “The US Food and Drug Administration has taken a “momentous” step toward banning menthol in cigarettes and banning flavored cigars, sending final rules to the White House Office of Management and Budget for review, a key regulatory step.”
The FDA has been officially exploring the possibility of a menthol ban for more than a decade. (Christensen, 2023)
Smoke
Two sources of smoke from cigarettes:
Mainstream: smoke exhaled by smokers
Sidestream: smoke from the device itself
Sidestream smoke has a higher concentration of carcinogens
EPA classified tobacco smoke “Class A” or known human carcinogen
Cause of lung cancer and heart disease
Exposure to secondhand tobacco smoke has been causally linked to cancer, respiratory, and cardiovascular diseases, and to adverse effects on health of infants and children.
Thirdhand smoke residue: health effects not yet clear
Decreasing Secondhand Smoke Exposure
1973: Arizona becomes the first state to restrict smoking in several public places. Civil Aeronautics Board requires no-smoking sections on all commercial airline flights.
1974: Connecticut passes the first state law to apply smoking restrictions in restaurants.
1975: Minnesota passes a statewide law restricting smoking in public places.
1977: Berkeley, California, becomes the first community to limit smoking in restaurants and other public places.
1987: Minnesota passes a law requiring all hospitals in the state to prohibit smoking by 1990.
1988: Congressionally mandated smoking ban takes effect on domestic airline flights <2 h
1990: Congressionally mandated smoking ban takes effect on domestic airline flights < 6 h (IOM, 2010)
1993: Los Angeles passes a ban on smoking in all restaurants.
2003: Dozens of U.S. airports are designated as smoke-free.
2004: Massachusetts, Rhode Island enact comprehensive smoke-free laws.
2005: North Dakota, Vermont, Montana, Washington enact 100% smoke-free workplace and/or restaurant and/or bar regulations.
2006: New Jersey, Colorado, Hawaii, Ohio, Nevada enact 100% smoke-free workplace and/or restaurant and/or bar regulations.
2007: Louisiana, Arizona, New Mexico, New Hampshire, Minnesota enact 100% smoke-free workplace and/or restaurant and/or bar regulations.
2008: Illinois, Maryland, Iowa, Pennsylvania enact 100% smoke-free workplace and/or restaurant and/or bars regulations. (IOM, 2010)
E-cigarettes/Vapes
Electronic Cigarettes and Vaping
Heat solution (nicotine & other additives), produce vapor, inhaled, without combustion
Vary widely in quality, safety, size, and efficiency of nicotine delivery
Long-term health effects unknown
E-cigarettes generally perceived to be less harmful than regular cigarettes by users
Commonly cited reasons for use:
Less harmful, less expensive
Help reduce tobacco craving/withdrawal
Reduce amount smoked and use as reduction/cessation aid
Prevent relapse to regular cigarettes
Vaping Associated Lung Injuries & EVALI
EVALI: E-Cigarette or Vaping use-Associated Lung Injury
First identified in 2019
Majority of cases believed to be caused by vitamin E acetate (additive in some THC-containing e-cigarettes) as primary, but not the only cause
Marketing of Tobacco
Widespread marketing, including marketing by the big U.S. tobacco companies (describing e-cigarettes as harm reduction)
In 2018, million was spent on advertisement
Juul relied heavily on social media advertising for launch and has spent more than million to market products on the internet and has paid for campaigns on Twitter, Instagram, & YouTube**
Some companies have marketed e-cigarettes in a way that circumvented smoking bans
Tobacco Use by MN Students
Vapes are the most used tobacco products by high school students in MN.
Frequent E-Cigarette Use
Frequent use of E-Cigarettes by students is increasing.
Regulating E-Cigarettes
Sale is banned in some countries, while other have full or partial measures adopted or no measure or ban.
6 Most Important and Effective Tobacco Control Methods
M: Monitor tobacco use and prevention policies
P: Protect people from tobacco smoke
O: Offer help to quit smoking
W: Warn about the dangers of tobacco
E: Enforce bans on tobacco advertising, promotion, and sponsorship
R: Raise taxes on tobacco
Oral Nicotine Pouches
Oral nicotine pouches, such as market leader Zyn, are a new and rapidly expanding category of nicotine products.
They are small white pouches filled with nicotine powder and flavors that are placed discreetly between the top lip and gum.
In 2024, 1.8% of middle and high school students reported current use of oral nicotine products.
Among students who currently used nicotine pouches, 29.3% reported frequent use (at least 20 out of the past 30 days) and 22.4% reported daily use.
Among young people currently using nicotine pouches, 85.6% used a flavored product.
Nicotine concentrations vary across brands, ranging from 2 milligrams to over 15 milligrams.
Advertisements for oral nicotine pouches often highlight themes that may appeal to young people.
Zyn gained popularity on social media via "Zynfluencers," and is also enticing users with a rewards program.
The long-term health effects of oral nicotine products are not yet known.
State of Tobacco Control: Minnesota
Tobacco Prevention and Cessation Funding: F
Smokefree Air: A
Tobacco Taxes: B
Access to Cessation Services: A
Flavored Tobacco Products: F
The American Lung Association calls for the following actions to be taken by Minnesota's elected officials to reduce tobacco use and exposure to secondhand smoke:
End the sale of all flavored tobacco products;
Remove barriers to and expand reimbursement for tobacco cessation treatment; and
Protect and increase state investments in tobacco prevention and treatment.
How to Quit
Most people quit on their own
Clinician advice associated with increased likelihood of quitting
Individual, group, or telephone counseling
Problem-solving, anticipating difficult situations, stress management training
Medications: nicotine replacement, Zyban, Chantix
1-800-QUIT-NOW
http://www.cdc.gov/tobacco/campaign/tips/stories/amanda.html