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Background: An international expert panel convened by the Independent Scientific Committee on Drugs developed a multi-criteria decision analysis model of the relative importance of different types of harm related to the use of nicotine-containing products. Method: The group defined 12 products and 14 harm criteria. Seven criteria represented harms to the user, and the other seven indicated harms to others. The group scored all the products on each criterion for their average harm worldwide using a scale with 100 defined as the most harmful product on a given criterion, and a score of zero defined as no harm. The group also assessed relative weights for all the criteria to indicate their relative importance. Findings: Weighted averages of the scores provided a single, overall score for each product. Cigarettes (overall weighted score of 100) emerged as the most harmful product, with small cigars in second place (overall weighted score of 64). After a substantial gap to the third-place product, pipes (scoring 21), all remaining products scored 15 points or less. Interpretation: Cigarettes are the nicotine product causing by far the most harm to users and others in the world today. Attempts to switch to non-combusted sources of nicotine should be encouraged as the harms from these products are much lower.
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Research Report
Eur Addict Res 2014;20:218–225
DOI: 10.1159/000360220
Estimating the Harms of
Nicotine-Containing Products
Using the MCDA Approach
David J. Nutt a Lawrence D. Phillips b David Balfour f H. Valerie Curran c
Martin Dockrell d Jonathan Foulds h Karl Fagerstrom i Kgosi Letlape k
Anders Milton j Riccardo Polosa l John Ramsey e David Sweanor g
a Imperial College London, UK;
b Department of Management, London School of Economics and Political
Science, and Facilitations Ltd., UK;
c University College London, UK;
d Action on Smoking and Health London,
e TICTAC Communications Ltd. at St. George’s, University of London, London , UK;
f University of Dundee,
Dundee , UK; g Faculty of Law, University of Ottawa, Ottawa, Canada;
h Pennsylvania State University, College
of Medicine, Hershey Pa., USA;
i Fagerström Consulting, Vaxholm, Sweden; j World Medical Association, Milton
Consulting, Stockholm, Sweden;
k World Medical Association, Johannesburg , South Africa; l Centre for the
Prevention and Cure of Tobacco Use, University of Catania, Catania , Italy
vided a single, overall score for each product. Cigarettes
(overall weighted score of 100) emerged as the most harmful
product, with small cigars in second place (overall weighted
score of 64). After a substantial gap to the third-place prod-
uct, pipes (scoring 21), all remaining products scored 15
points or less. Interpretation: Cigarettes are the nicotine
product causing by far the most harm to users and others in
the world today. Attempts to switch to non-combusted
sources of nicotine should be encouraged as the harms from
these products are much lower. © 2014 S. Karger AG, Basel
The recreational use of tobacco remains one of the
principal causes of chronic ill health and early deathworld-
wide. The tobacco epidemic was largely reflected in more
affluent Western countries but, increasingly, the illnesses
associated with tobacco use have spread to the developing
[1] . Cigarettes are considered to be the most harm-
Key Words
Smoked tobacco products · Oral tobacco products ·
Electronic cigarettes · Multi criteria decision analysis ·
Harm assessment · ENDS (electronic nicotine delivery
Background: An international expert panel convened by the
Independent Scientific Committee on Drugs developed a
multi-criteria decision analysis model of the relative impor-
tance of different types of harm related to the use of nico-
tine-containing products. Method: The group defined 12
products and 14 harm criteria. Seven criteria represented
harms to the user, and the other seven indicated harms to
others. The group scored all the products on each criterion
for their average harm worldwide using a scale with 100 de-
fined as the most harmful product on a given criterion, and
a score of zero defined as no harm. The group also assessed
relative weights for all the criteria to indicate their relative
importance. Findings: Weighted averages of the scores pro-
Received: December 23, 2013
Accepted: January 30, 2014
Published online: April 3, 2014
David Nutt
Imperial College London
Burlington Danes Building
London W12 ONN (UK)
E-Mail d.nutt @
© 2014 S. Karger AG, Basel
is is an Open Access article licensed under the terms of the
Creative Commons Attribution-NonCommercial 3.0 Un-
ported license (CC BY-NC) (,
applicable to the online version of the article only. Distribu-
tion permitted for non-commercial purposes only.
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Estimating the Harms of
Nicotine-Containing Products
Eur Addict Res 2014;20:218–225
DOI: 10.1159/000360220
ful tobacco product although other forms of tobacco used
recreationally may also result in harm to the user
[2] .
It is now widely accepted that the compulsive use of
tobacco reflects the development of dependence upon the
nicotine present in tobacco and many of the pharmaco-
logical interventions that are employed to aid smoking ces-
sation target this dependence
[3, 4] . However, in experi-
mental animals, nicotine does not have the potent addic-
tive properties that are required to explain the powerful
addiction to tobacco experienced by many habitual smok-
[5, 6] . Thus, it has been proposed that other pharmaco-
logically active substances present in tobacco smoke and
the conditioned sensory stimulation associated with inhal-
ing tobacco smoke have a significant role in the develop-
ment of dependence upon tobacco
[7–10] . Pharmacologi-
cal nicotine replacement products (NRT) were introduced
as aids to smoking cessation in the late 1970s and continue
to be used extensively in the treatment of tobacco depen-
dence. Experience with these preparations suggests that
their use is not associated with an increased risk of chron-
ic obstructive pulmonary disease, lung cancer or cardio-
vascular disease
[3, 11] although there are reports that nic-
otine may be metabolized to compounds that are poten-
tially carcinogenic
[12, 13] . Furthermore, studies with
experimental animals suggest that the ingestion of nico-
tineduring pregnancy can have adverse effects on the brain
development of the fetus and the vulnerability of the prog-
eny to nicotine dependence
[14, 15] . Relatively little direct
information is available for the effects of maternal nicotine
on human development and behaviour. However, smoke-
less tobacco has been found to have a negative effect
and Bruin et al.
[17] have argued that the possibility of
adverse effects for both the mother and fetus of NRT use
during pregnancy should not be disregarded. Thus, indi-
vidual researchers have expressed differing opinions on
the safety of pharmacological nicotine. Nevertheless, some
40 years’ experience with NRT preparations suggest that
they are safe and are not associated with significant adverse
medical consequences
[4] . This conclusion is consistent
with the compelling evidence that many of the adverse
health effects of inhaling tobacco smoke are caused by oth-
er components of the smoke such as nitrosamines, carbon
monoxide and nitric oxide
[18, 19] . Thus, despite some
differences in opinion, it seems that tobacco use lends itself
rather better than many other forms of addiction to a harm
reduction approach using pharmacological interventions
including therapeutic nicotine preparations.
Most attention with regard to the harmful effects of
tobacco use has focused on cigarettes and the evidencethat
they cause chronic illness and early death is compelling.
However, other forms of tobacco use also need to be con-
sidered. There is good evidence, for example, that Swedish
snus, a form of refined oral tobacco which is low in nitro-
samines, is at worst only weakly associated with an in-
creased risk of cancer or cardiovascular disease
[20] . By
contrast, other smokeless unrefined oral tobacco prod-
ucts seem to be associated with significantly more harm
to the user
[21] . For example, the chronic use of gutkha,
a form of smokeless tobacco popular with members of the
Asian community, is associated with the development of
disorders of the oral mucosa and oral cancer
[22] . Water
pipes, widely used in the Middle East, are finding increas-
ing favour in Western society. The potential toxic effects
of water pipe smoke have not yet been fully evaluated al-
though some concerns have been expressed about the po-
tential adverse consequences for health of using this form
of tobacco
[23, 24] . Our understanding of the potential
hazards associated with using electronic nicotine delivery
systems (ENDS, e.g. E-cigarettes) is at a very early stage.
These delivery systems are seen as an acceptable form of
recreational nicotine use with a minimal potential for sec-
ond-hand environmental contamination. Nevertheless,
there is concern that these devices should not be intro-
duced in an unregulated way until potential associated
harms are adequately evaluated
[25] .
There remains a need for policy makers to become bet-
ter informed of the relative harms of nicotine delivery sys-
tems in order to build a regulatory framework that mini-
mizes harm. The aim of the current study was to convene
a group of experts with expertise in the field of nicotine and
tobacco research from different disciplines (animal and be-
havioural pharmacology, toxicology, medicine, psychiatry,
policy and law) that could discuss and agree on the harm-
fulness of nicotine-containing products using a multi-cri-
teria decision analysis (MCDA) model and, thus, provide a
sound framework within which policy makers might work.
M e t h o d s
Study Design
The Independent Scientific Committee on Drugs selected ex-
perts from several different countries to ensure a diversity of ex-
pertise and perspective, as evident from the author list. The MCDA
[26] was conducted during a 2-day facilitated workshop
held in London in July 2013. The MCDA model for the harm of
psychoactive drugs developed by the Independent Scientific Com-
mittee on Drugs in 2010
[27] provided a starting point for this
nicotine harm study, as it covered all the potential parameters of
harm that might potentially be caused by any drug.
The MCDA process is a way to compare variables of harm in
widely different areas where traditional metrics are not available.
It works through a series of eight stages: (1) establishing context;
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(2) agreeing on the products to be evaluated and producing defini-
tions of these; (3) agreeing on the criteria on which the products
were to be compared; (4) scoring the products on each criterion;
(5) weighting the criteria; (6) calculating weighted scores to give
an overall index of the harm of each product; (7) examining results
and resolving any inconsistencies, and (8) exploring the sensitivity
of the indices to different assessments of scores and weights.
The Context
The group recognized that there are regional and national dif-
ferences in actual and perceived harm of nicotine products, so par-
ticipants agreed to take a worldwide perspective and consider aver-
age harm.
The Nicotine Products
After considering many nicotine products and the criteria for
comparing the products, the group discussed steps 2 and 3 above in
a reciprocal and iterative way so that the final set of products was
substantially different from one another in important ways. Table1
gives the final agreement about the products and their definitions.
The Criteria of Harms
The group reviewed the 16 criteria that had first been agreed by
the UK Advisory Council on the Misuse of Drugs
[28] and used by
the Independent Scientific Committee on Drugs in their 2010 deci-
sion conference on 20 psychoactive drugs
[27] . All but two criteria
were retained but where necessary were redefined to be relevant to
nicotine products. The two that were dropped were drug-specific
and drug-related mental impairment as it was thought that there
was little evidence for these with any of the nicotine products.
The criteria against which the products were evaluated are shown
at the extreme right of the harm tree in figure 1 . The main objective
was to determine an ordering of the products at the ‘Product harms’
node. The next level to the right provides separate harm groupings
of the criteria: ‘To users’ (harm to those who are using the product)
and ‘To others’ (harm as a consequence of the use of the product to
others both directly and indirectly). Assessments of the harms for all
products were made against the criteria given at the extreme right of
the value tree. The final definitions are shown in table2 .
Scoring the Products
The group scored all products on all criteria. The scoring sys-
tem used points out of 100, with 100 assigned to the most harmful
product on a given criterion and zero representing ‘no harm’.
In scaling the products, care is required to ensure that each suc-
cessive point on the scale represents equal increments of harm.
Thus, if a product is scored at 50, then it should be half as harmful
as the product scored 100. Because zero represents no harm, this
scale can be considered a ratio scale, which makes possible ratio
comparisons of the weighted scales.
Some criteria are more important expressions of harm than oth-
ers, so weighting of the criteria is required. ‘Swing weighting’ pro-
vides weights that are meaningful in MCDA. As an analogy, both
Fahrenheit and Celsius scales contain 0–100 portions, but the swing
in temperature from 0 to 100 on the Fahrenheit scale is, of course,
a smaller swing in temperature than 0–100 on a Celsius scale; it
takes 5 Celsius units to equal 9 Fahrenheit units. The purpose of
weighting is to ensure that the units of harm on the different harm
scales are equivalent, thus enabling weighted scores to be compared
and combined across the criteria. Weights are scale factors.
To assess scale factors two steps in thinking must be separated.
First, it is necessary to think about the difference in harm between
the most and least harmful products on that criterion. The next step
is to think about how much that difference in harm matters in a giv-
en context. ‘How big is the difference in harm and how much do you
care about that difference?’ This is the question that was posed in
comparing the 0-to-100 swing in harm on one scale with the 0-to-100
swing on another scale, assuming the harm is a worldwide average.
Swing weights for the User criterion were assessed first; the
largest swing, on Product-specific morbidity, the difference be-
tween cigarettes and nasal sprays was assigned a weight of 100.
Next, weights were judged for the criteria at the Other node: the
largest swing, the difference between cigarettes and small cigars for
Economic cost, was set at 100. Finally, those two 100’s were com-
pared by judging their swing weights. The swing for Product-re-
Table 1. The 12 products considered during the decision confer-
ence and their definitions
Cigarettes manufactured and hand-rolled cigarettes in which
the tobacco is wrapped in paper
Cigars smoked cigars: roll of tobacco wrapped in tobacco
Little and
small cigars
used like a cigarette wrapped in tobacco leaf,
sometimes with a filter (a product that has
emerged in response to the US tobacco taxation
system and would, in most jurisdictions be
considered cigarettes)
Pipes a tube with a small bowl at one end for smoking
Water pipe a pipe where tobacco smoke is bubbled through
non-snus (and other) smokeless refined tobacco
products used orally, including moist chewing
tobacco and snuff (common in USA)
non-snus (and other) smokeless unrefined
tobacco products used orally, including chewing
tobacco and dry snuff (products common in SE
Snus a low nitrosamine and non-fermented smokeless
tobacco product (popular in Scandinavia and now
in USA)
ENDS electronic nicotine delivery system products,
e.g. e-cigs (electronic cigarettes either cigarette-
like or personal vaporizers)
oral nicotine delivery products (including NRT
Patch dermal nicotine delivery products
Nasal sprays nasal nicotine delivery products
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Estimating the Harms of
Nicotine-Containing Products
Eur Addict Res 2014;20:218–225
DOI: 10.1159/000360220
Economic cost
International damage
Family adversities
Environmental damage
Loss of relationship
Loss of tangibles
Product-related morbidity
Product-specific morbidity
Product-related mortality
Product-specific mortality
To users
To others
Product harms
Fig. 1. Evaluation criteria organized by
harms to users and harms to others.
Table 2. Definitions of the evaluation criteria for the nicotine products
Name Description
deaths directly attributed to product misuse or abuse as in the case of accidental and deliberate poisoning
deaths indirectly attributed to the product, e.g. death due to cancer, respiratory illness, cardiovascular disease and fire
damage (morbidity, chronic ill health) to physical health directly attributed to product misuse or abuse, e.g. ulcers,
lung disease, heart disease
damage to physical health indirectly attributed to product misuse or abuse, e.g. burns, allergies
Dependence extent to which the product creates a propensity or urge to continue use despite adverse consequences and causes
withdrawal symptoms on cessation
Loss of tangibles extent of loss of tangible things (e.g. income, housing, job)
Loss of relationships extent of loss of relationships with family and friends
Injury the extent to which the product increases chances of injuries to others both directly and indirectly, e.g. traffic accident,
fetal harm, second-hand smoke, accidental poisoning, burns
Crime the extent to which the use of the product increases criminal behaviour (e.g. smuggling) directly or indirectly (at the
population level, not the individual)
the extent to which the use and production of this product causes environmental damage locally, e.g. fires, competition
for arable land, cigarette stub pollution
Family adversities
the extent to which the use of the product causes family adversities, e.g. economic well-being, future prospects of children
the extent to which the use of the product contributes to damage at an international level, e.g. deforestation,
contraband as criminal activity, counterfeiting
Economic cost the extent to which the use of the product results in effects that create direct costs to countries (e.g. health-care costs,
customs) and indirect costs (e.g. loss of productivity, absenteeism)
the extent to which the use of the product creates decline in social cohesion and decline in the reputation of the community
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lated morbidity was weighted as the larger harm that matters, so
its weight of 100 was retained. The swing for Economic cost was
assessed as 70% of that, so the original weights for all the Econom-
ic criteria were multiplied by 0.70.
As scores and weights were agreed, they were input to the Hiview
computer program
, which normalized the weights so they summed
to 100, calculated the weighted scores and displayed the results.
R e s u l t s
Figure 2 shows the overall weighted scores of the nico-
tine products as stacked bar graphs. Cigarettes and small
cigars are each several times more harmful than any of the
other products. Similarly coloured sections of the bar
graphs show a given criterion’s weighted harm value as it
contributes to the overall weighted scores of the nicotine
products. Thus, Product-related mortality and Product-
specific morbidity are the main harms for cigarettes and
small cigars, while Economic cost is also a substantial
contributor to the overall harm for cigarettes.
The stacked bar graphs can also be shown for their
separate contributions of harm ‘To users’ and harm ‘To
others’. Figure 3 gives the harm to users as the blue sec-
tion, and harm to others as red. Harm to others makes a
substantial contribution only to cigarettes, and virtually
none to the other 11 products.
Why are cigarettes considered the most harmful? Figure
4 shows the contribution that each criterion makes to ciga-
rettes’ total weighted score. Each row in the display gives the
part-score for that criterion (Wtd Diff), and it is the sum of
those part scores that gives the overall score of 99.6. These
part-scores determine the relative heights of each of the
coloured bands for the cigarettes’ bar graph in figure 4 .
Notethat cigarettes were assigned harm scores of 100 on 12
of the 14 criteria, but that just five of those 14 collectively
contribute a score of 92.7, nearly as much as the total of 99.6.
Both cigarettes and small cigars score 100 on three of
the most important criteria: Product-specific morbidi-
Fig. 2. Overall weighted scores for each of the products. Cigarettes,
with an overall harm score of 99.6, are judged to be most harmful,
and followed by small cigars at 67. The heights of the coloured por-
tions indicate the part scores on each of the criteria. Product-relat-
ed mortality, the upper dark red sections, are substantial contribu-
tors to those two products, and they also contribute moderately to
cigars, pipes, water pipes, and smokeless unrefined. The numbers
in the legend show the normalized weights on the criteria. Higher
weights mean larger differences that matter between most and
least harmful products on each criterion.
Color version available online
1 An MCDA computer program first developed at the London School of Eco-
nomics and Political Science and now available from Catalyze Ltd., www.
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Estimating the Harms of
Nicotine-Containing Products
Eur Addict Res 2014;20:218–225
DOI: 10.1159/000360220
ty, Product-related mortality and Dependence. Those
three are harms to the users, criteria which do not take
account of the extent of usage worldwide. However, cig-
arettes also score 100 on Economic cost and Injury,
which are harms to others that do take account of glob-
al usage. It is those two criteria that account for the dif-
ference in the total scores of cigarettes compared to
small cigars.
Perhaps not surprisingly, given their massively great-
er use as compared with other products, cigarettes were
ranked the most harmful, followed by small cigars as two
thirds as harmful. It is only the relative lack of harm to
others that positioned small cigars at two thirds the harm
of cigarettes. For both these products the bulk of the
Fig. 3. The products ordered by their over-
all harm scores, with the stacked bar graphs
showing the contribution to the overall
score of harms to users and harm to others.
The numbers in the legend show the sums
of the normalized weights at each node.
Fig. 4. The relative harms of cigarettes. The
cumulative weight (Cum Wt) column
shows the normalized weight for each cri-
terion. The harm score for cigarettes,
shown in the Diff column, on each criteri-
on is multiplied by the cumulative weight
of the corresponding criterion to give a
weighted score (i.e., a part-score), shown in
the Wtd Diff column. The lengths of the
green bars are proportional to the weighted
scores, so the longer the green bars, the
more that harm matters for its effects from
Color version available onlineColor version available online
To users 67££
To others 33£
Small cigars
Water pipe
Smokeless unrefined
Smokeless refined
Nasal sprays
Oral products
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harm came from morbidity and mortality areas such as
cancer, respiratory and cardiovascular disease, followed
by Economic cost, Injury and Dependence. There was a
big drop in harm from small cigars (67% of maximum
relative harm, MRH) to pipes 22%. Within the tobacco
products there was a gradual reduction in harm from
water pipe, smokeless unrefined, smokeless refined to
snus that has 5% of MRH. Among the purer non-tobacco
vehicle products ENDS were rated to have only 4% of
MRH and for the even purer NRTs the MRH was only
rated at about 2%. Thus there is wide variability in harm
among the combustible tobacco-based products, from
cigarettes (100%) to water pipe (14%) and even more
within the tobacco-based category, from cigarettes
(100%) to snus (5%). Not surprisingly the purest prod-
ucts, NRTs, with few other ingredients than nicotine
were the least harmful and pose little risk for intrinsic
harm when used for the treatment of tobacco depen-
dence. Indeed their use would bring significant benefits
not just to users but also to non-smokers and society as
a whole.
Clearly this exercise speaks to a continuum of harm
from nicotine-containing products with cigarettes at
one end and NRT products at the other end. The differ-
ences between the products are substantial and if policy
actions could help to switch use away from cigarettes
and other smoked products to purer nicotine products,
such as NRT products, massive public health gains
would occur.
There is also some evidence that the cigarettes are the
most dependence-forming product and products with
less harm also may be less dependence-forming
[9] . An
analogue can be found with alcohol where most coun-
tries have policies that steer consumption as much as
possible to alcohol-containing beverages with a low alco-
hol content.
A limitation of this study is the lack of hard evidence
for the harms of most products on most of the criteria.
That is why we adopted the decision conferencing pro-
cess: the group of experts worked face-to-face in a peer-
review setting with impartial facilitation, sharing relevant
data, knowledge and experience to ensure that all per-
spectives were heard. It is the combination of impartial
facilitation, modelling (in this case, MCDA), and infor-
mation technology (projecting the MCDA model for the
group to observe as it was constructed and explored) that
enables a group to outperform its members, thus provid-
ing the best collective expertise of the experts
[28] . An-
other weakness might be the kind of sample of experts.
There was no formal criterion for the recruitment of the
experts although care was taken to have raters from many
different disciplines.
Even if data were available for all the harms of all the
products on all the criteria, judgements would still be re-
quired to assess swing-weights. While the magnitude of
harm of the most harmful product on each criterion can
be informed by data, how much that worst-best differ-
ence matters requires an act of judgement. In this way,
MCDA separates matters of fact from value judgements.
As value judgements are at the heart of political debate, it
might be instructive to engage in a public consultation
exercise to allow different constituencies to express their
views about the weights. This could be a first step in ini-
tiating a structured deliberative discourse about nicotine-
containing products, as the politicians, the law and the
public might weight the harm criteria differently
[29] . In
addition, including the benefits of using nicotine prod-
ucts along with the harmful criteria might provide in-
sights into the nature of the benefit-harm balance.
The results of this study suggest that of all nicotine-
containing products, cigarettes (and small cigars in the
USA) are very much the most harmful. Interventions to
reduce this pre-eminence are likely to bring significant
benefits not just to users but also to non-smokers and so-
ciety as a whole. Attempts to use other forms of nicotine
such as ENDS and NRT to reduce cigarette smoking
should be encouraged as the harms of these products are
much lower.
The authors would like to thank Euroswiss Health ( Switzerland)
for funding and LIAF (Lega Italiana Anti Fumo) for supporting
this research.
Disclosure Statement
The sponsor of the study had no role in any stage of the
MCDA process or in the writing of this article, and was not pres-
ent at the workshop. All authors had full access to all the data in
the study, and had final responsibility for the decision to submit
for publication.
K.F. has served as a consultant for most companies with an
interest in tobacco dependence treatments. J.F. has served as a
consultant to manufacturers of smoking cessation products (e.g.
Pfizer, GSK, J & J, Novartis) and has received a research grant
from Pfizer. R.P. has received lecture fees from Pfizer and GSK,
a research grant from Pfizer, and he has served as a consultant
for Pfizer, Global Health Alliance for treatment of tobacco de-
pendence, and Arbi Group Srl., an e-cigarette distributor. All
other authors have no conflicts of interest to declare.
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Nicotine-Containing Products
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DOI: 10.1159/000360220
1 Warner KE: The role of research in interna-
tional tobacco control. Am J Public Health
95: 976–984.
2 WHO Report on the Global Tobacco Epi-
demic, 2013.
pdf?ua=1. Enforcing bans on tobacco adver-
tising, promotion and sponsorship WHO Li-
brary Cataloguing-in-Publication Data WHO
report on the global tobacco epidemic, 2013.
ISBN 978 92 4 150587 1 (NLM classification:
WM 290).
3 Royal College of Physicians: Harm reduction
in nicotine addiction: helping people who
can’t quit. A report by the Tobacco Advisory
Group of the Royal College of Physicians.
London, RCP, 2007. ISBN 9781860163197.
4 Cahill K, Stevens S, Perera R, Lancaster T:
Pharmacological interventions for smoking
cessation: an overview and network meta-
analysis. Cochrane Database Syst Rev 2013;
5 Caggiula AR, Donny EC, Chaudhri N, Per-
kins KA, Evans-Martin FF, Sved AF: Impor-
tance of nonpharmacological factors in nico-
tine self-administration. Physiol Behav 2002;
77: 683–687.
6 Balfour DJ: The neuronal pathways mediating
the behavioural and addictive properties of
nicotine. Handb Exp Pharmacol 2009;
7 Fowler JS, Logan J, Wang GJ, Volkow ND:
Monoamine oxidase and cigarette smoking.
Neurotoxicology 2003;
24: 75–82.
8 Rose JE: Nicotine and nonnicotine factors in
cigarette addiction. Psychopharmacology
184: 274–285.
9 Fagerstrom K, Eissenberg T: Dependence to
tobacco and nicotine products: a case for
product specific assessment. Nicotine Tob
Res 2012;
14: 1382–1390.
10 Brennan KA, Crowther A, Putt F, Roper V,
Waterhouse U, Truman P: Tobacco particu-
late matter self-administration in rats: differ-
ential effects of tobacco type. Addict Biol
2013, Epub ahead of print.
11 Murray RP, Bailey WC, Daniels K, Bjornson
WM, Kurnow K, Connett JE, Nides MA, Kiley
JP: Safety of nicotine polacrilex gum used by
3,094 participants in the Lung Health Study.
Lung Health Study Research Group. Chest
109: 438–445.
2 Stepanov I, Carmella SG, Han S, Pinto A,
Strasser AA, Lerman C, Hecht SS: Evidence
for endogenous formation of N’-nitrosonor-
nicotine in some long-term nicotine patch
users. Nicotine Tob Res 2009;
11: 99–105.
3 Tonini G, D’Onofrio L, Dell’Aquila E, Pezzuto
A: New molecular insights in tobacco-induced
lung cancer. Future Oncol 2013;
9: 649–655.
14 Slotkin TA, Lappi SE, Seidler FJ: Impact of fe-
tal nicotine exposure on development of rat
brain regions: critical sensitive periods or ef-
fects of withdrawal? Brain Res Bull 1993;
15 Levin ED, Lawrence S, Petro A, Horton K, Se-
idler FJ, Slotkin TA: Increased nicotine self-
administration following prenatal exposure
in female rats. Pharmacol Biochem Behav
85: 669–674.
16 England LJ, Kim SY, Tomar SL, Ray CS, Gup-
ta PC, Eissenberg T, Cnattingius S, Bernert JT,
Tita AT, Winn DM, Djordjevic MV, Lambe
M, Stamilio D, Chipato T, Tolosa JE: Non-
cigarette tobacco use among women and ad-
verse pregnancy outcomes. Acta Obstet Gy-
necol Scand 2010;
89: 454–464.
17 Bruin JE, Gerstein HC, Holloway AC: Long-
term consequences of fetal and neonatal nico-
tine exposure: a critical review. Toxicol Sci
116: 364–374.
18 Stepanov I, Yershova K, Carmella S, Upadhy-
aya P, Hecht SS: Levels of (S)-N’-nitrosonor-
nicotine in U.S. tobacco products. Nicotine
Tob Res 2013;
15: 1305–1310.
19 Leone A: Smoking and hypertension: inde-
pendent or additive effects to determining
vascular damage? Curr Vasc Pharmacol 2011;
9: 585–593.
20 Lee PN: Summary of the epidemiological evi-
dence relating snus to health. Regul Toxicol
Pharmacol 2011;
59: 197–214.
21 Ayo-Yusuf OA, Burns DM: The complexity of
‘harm reduction’ with smokeless tobacco as
an approach to tobacco control in low-in-
come and middle-income countries. Tob
Control 2012;
21: 245–251.
22 Javed F, Chotai M, Mehmood A, Almas K:
Oral mucosal disorders associated with habit-
ual gutka usage: a review. Oral Surg Oral Med
Oral Pathol Oral Radiol Endod 2010;
23 Maziak W, Ward KD, Afifi Soweid RA, Eis-
senberg T: Tobacco smoking using a water-
pipe: a re-emerging strain in a global epidem-
ic. Tob Control 2004;
13: 327–333.
24 Cobb CO, Shihadeh A, Weaver MF, Eissen-
berg T: Waterpipe tobacco smoking and ciga-
rette smoking: a direct comparison of toxicant
exposure and subjective effects. Nicotine Tob
Res 2011;
13: 78–87.
25 Saitta D, Ferro GA, Polosa R: Achieving ap-
propriate regulations for electronic cigarettes.
Ther Adv Chronic Dis 2014;5:50–61.
26 Dodgson J, Spackman M, Pearman A, Phillips
L: Multi-Criteria Analysis: A Manual (2000);
ed 2. London, Department for Communities
and Local Government, 2009.
27 Nutt DJ, King LA, Phillips LD, Independent
Scientific Committee on Drugs: Drug harms
in the UK: a multicriteria decision analysis.
Lancet 2010;
376: 1558–1565.
28 Advisory Council on the Misuse of Drugs:
Consideration of the Use of Multi-Criteria
Decision Analysis in Drug Harm Decision
Making. London, Home Office, 2010.
29 Farsalinos KE, Polosa R: Safety evaluation and
risk assessment of electronic cigarettes as to-
bacco cigarette substitutes: a systematic re-
view. Ther Adv Drug Safety 2014;2:67–86.
Editors’ Note
The editors are aware that K.F. has
connections with a company that is associ-
ated with one of the largest tobacco indus-
tries in the world (BAT: Nicoventures),
but would like to notice that this stand-
alone company produces smoking cessa-
tion products, i.e. electronic cigarettes,
that are now in discussion to be regarded
as a new form of NRT. NRT is widely ac-
cepted as a treatment of patients with to-
bacco dependence. Therefore, the editors
decided that the potential conflict of inter-
est of K.F. should not preclude acceptance
and publication of this article. However,
the scientific community has to discuss
the demarcation between potential con-
flicts of interest related to companies pro-
ducing addictive drugs and companies
producing therapeutics.
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... Current evidence from developed countries, mostly Sweden, suggests that SLT use is less harmful than smoking, 7,8 and a comprehensive substitution of smoking with smokeless might result in reduced harm from tobacco use. 8 Thus, at the population level, if SLT products promote smoking cessation a net public health bene t could be expected. ...
... 13,39 The toxicity pro les and health effects of SLT products used in South Asia are far less clear compared with Swedish snus, which some reports estimated to be approximately 5% as harmful as cigarettes. 7 The population health implication of the changing tobacco use landscape in South Asia with increased SLT use along with declining smoking prevalence will at least partly dependent on how SLT products are regulated. Careful pro ling of harmful and potentially harmful constituents of SLT products, establishing standards for allowable levels of harmful ingredients are pertinent regulatory actions to protect public health, especially for the socioeconomically disadvantaged groups which are disproportionately affected by SLT use. ...
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Background Tobacco use, in both smoking and smokeless forms, is highly prevalent among South Asian adults. The aims of the study were twofold: 1) describe patterns of SLT and combustible tobacco product use in four South Asian countries stratified by country and sex, and 2) assess the relationships between SLT and smoking intensity, smoking quit attempts, and smoking cessation among South Asian men. Methods Data were obtained from South Asia Biobank Study, collected between 2018 and 2022 from 148,944 men and women aged 18 years and above, living in Bangladesh, India, Pakistan, or Sri Lanka. Mixed effects multivariable logistic and linear regression were used to quantify the associations of SLT use with quitting smoking attempt, cessation, and intensity. Results Among the four South Asian countries, Bangladesh has the highest rates of current smoking (39.9% for male, 0.4% for female) and current SLT use (24.7% for male and 23.4% for female). Among male adults, ever SLT use was associated with a higher odds of smoking cessation in Bangladesh (OR, 2.88; 95% CI, 2.65, 3.13), India (OR, 2.02; 95% CI, 1.63, 2.50), and Sri Lanka (OR, 1.36; 95% CI, 1.14, 1.62). Ever SLT use and current SLT use was associated with lower smoking intensity in all countries. Conclusions In this large population-based study of South Asian adults, rates of smoking and SLT use vary widely by country and gender. Men who use SLT products are more likely to abstain from smoking compared with those who do not.
... Cancers of the mouth, cancer of pancreas, cancer of oesophagus, cancer of stomach, and other organs are among the adverse consequences of SLT products. [6,7,8] This study is being conducted on users who consume either one type or both type of tobacco (smoking and SLT forms) to assess the trends and factors influencing smokeless tobacco use in Lucknow. ...
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INTRODUCTION: Major health issues have been linked to smokeless tobacco (SLT) when taken exclusively, albeit these issues may vary depending on the product type. Cancers of the mouth, cancer of pancreas, cancer of oesophagus, cancer of stomach, and other organs are among the adverse consequences of SLT products. Therefore, this study is being conducted on users who consume either one type or both type of tobacco (smoking and SLT forms) to assess the trends and factors influencing smokeless tobacco use in Lucknow. METHOD: 400 participants were asked about their tobacco use for the study's purposes, and individuals who used both types of tobacco (smoked form and smokeless forms) were chosen. After receiving informed consent, data needed for the study was gathered using a self-structured questionnaire proforma to be filled in the participants' leisure time. A set of questions derived from GATS was used to gauge smokeless tobacco consumption. RESULT: It was observed that attitude towards smokeless tobacco was unfavorable in 195 (48.75%) of smokeless tobacco while it was favorable in 205 (51.25%) study participants. The findings were significant statistically (p=0.01). It can be concluded that SLT usage is significantly associated with factors like increased age, male gender, low education of head of family, occupation of head of family, unfavorable attitude towards SLT use, reduced knowledge regarding harmful effects SLT, increased availability and accessibility and higher social norm with greater advertisement.
... The global market for alternative risk-reduced tobacco products, such as e-cigarettes, heated tobacco products (HTPs), nicotine pouches, and snus, has been rapidly growing [1,2]. As these products are relatively new, there is a lack of consensus among policymakers on how to regulate them, particularly in terms of taxation. ...
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Taxes on the consumption of certain products have played a key role in public revenue analysis in European countries. This work assesses the differences in tax planning for new non-combustion products across some European territories. Through theoretical analysis, the paper has three distinct aspects. Firstly, we show the taxpayer profile in different countries. Secondly, the study analyzes the risks for the health system and the individual. Thirdly, the design of the national tobacco tax is based on previous experience and planning in Europe. This paper concludes with a case study for different countries: (1) Spain “vapers” and “smokers”, where the analysis is based on micro-data from the European Health Interview Survey 2020. (2) Sweden, with the analysis of snus, shows it as a practice on how to reach economic savings while decreasing economic costs thanks to the nudging of consumers towards better products. The results show taxation and, especially, land taxation should consider differences in planning in the case of new products, such as non-combustion products, given the user per capita income and the potential lower health risks involved.
... The global market for alternative risk reduced tobacco products, such as e-cigarettes, heated tobacco products (HTPs), nicotine pouches, and snus, has been rapidly growing [1,2]. As these 2 products are relatively new, there is a lack of consensus among policymakers on how to regulate them, particularly in terms of taxation. ...
Full-text available
Taxes on the consumption of certain products have played a key role in public revenue analysis in European countries. This work aims to assess the differences in tax planning on new non-combustion products across some European territories. Through theoretical analysis, the paper has three distinct aspects. Firstly, we show the taxpayer profile in different countries. Secondly, the study analyzes the risks for the health system and the individual. Thirdly, the design of the land tax is based on previous experience and planning in Europe. This paper concludes with a case study for different countries: 1) Spain “vapers” and “smokers”, where the analysis is based on micro-data from the European Health Interview Survey 2020. 2) Sweden with the analysis of snus, shows it as a practice to reach economic savings while decreasing economic costs thanks to the nudging of consumers towards better products. The results show taxation and, specially, land taxation, should consider differences in planning in the case of new products, such as the non-combustion products, given the user per capita income and the potential lower health risks involved.
... 2 Cartridge-based e-cigarettes contain even higher nicotine concentrations, with the most popular brands containing between 51 and 61 mg/ ml. 2 It is proposed that the use of ENDs to facilitate cigarette smoking cessation will reduce smoking-related harms such as cancer, respiratory and cardiovascular disease. 3 Recent evidence from a Cochrane review of random controlled trials of ENDs for smoking cessation found high-certainty evidence that ENDs are associated with higher quit rates compared to nicotine replacement therapy, and moderate-certainty evidence that nicotine-containing ENDs improve quite rates relative to nonnicotine ENDs. 4 Although ENDs may prove effective as a smoking cessation aid, substantial increases in use of ENDs among youth has also raised concerns over the growing prevalence of nicotine dependence among adolescents, including those previously naïve to cigarette smoking. 5,6 In addition, emerging evidence suggests that vaping has significant pulmonary and cardiovascular health risks. ...
Introduction Evidence suggests that e-liquid flavor and nicotine concentration are important factors in the initiation and maintenance of e-cigarette use (vaping). Flavors may increase the initiation and maintenance of vaping, and nicotine content is a factor in e-cigarette dependence and the efficacy of e-cigarettes for cigarette smoking cessation. Few human laboratory studies have assessed the joint and interactive effects of flavor and nicotine on subjective responses to e-cigarettes. Methods Regular e-cigarette users (N=89) completed a multi-session study involving a paced vaping procedure with e-liquid cartridges containing their preferred flavor (berry, menthol, or tobacco) or no flavor, with or without nicotine (18 mg). Subjective effects of vaping (satisfaction, reward, aversion, airway sensations, and craving relief) were assessed. Results Nicotine significantly increased psychological reward and craving relief, whereas flavor significantly increased vaping satisfaction and taste. Nicotine dependence severity moderated the effect of nicotine on reward, such that those with the greatest dependence severity reported the greatest reward. Conclusions These findings support differential and non-interactive effects of e-liquid nicotine content and flavor on reinforcing effects of e-cigarettes. Implications E-liquid flavor and nicotine content have independent, non-interactive effects on subjective responses to vaping under controlled laboratory conditions. Among regular e-cigarette users, vaping a preferred flavor increased taste and satisfaction, but did not interact with nicotine to alter reward or craving. Further research on the ways in which these subjective effects may motivate vaping behavior among different populations of e-cigarette users would be useful to inform regulatory policy of ENDS products.
... With the help of six criteria and 20 sub-criteria to monitor and improve the quality of service in the hospitals, they concluded that to provide a satisfactory e-service, the hospitals should focus on an interactive and accurate specialised web service that is more reliable and responsive to the customers. Nutt et al. (2014) used the MCDA method to estimate the harmfulness of 12 products, like cigarettes, cigars, pipes, water pipes, etc., containing nicotine on the basis of 14 harm criteria and finally concluded that cigarettes and small cigars are more dangerous than any other considered products. Broekhuizen et al. (2015) reviewed and classified the MCDM method used in the healthcare sector. ...
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The main objective of the study is to review different types of multi-criteria decision-making (MCDM) problems that are analysed by using the fuzzy TOPSIS method and its different variants. An effort has been made to review different studies in which either the TOPSIS method is used or its extensions have been developed to analyse any real-life MCDM problem. A total of 184 research papers were carefully selected and reviewed from 83 reputed journals published by Elsevier, Springer, Wiley, Taylor and Francis, and others from 1981 to the first quarter of 2023. These papers are selected on the basis of different kinds of applications in the fields of mathematics, engineering, science, environment, technology, management, business, etc. The selected papers are further categorised based on the application areas, publication year, contributions of the countries, authors, journals, and type of research. This study will give an idea of different types of TOPSIS methods, their extensions, and applications, along with recent trends in diverse research fields. Based on the findings, it is observed that in recent years, the number of papers in which TOPSIS and its extensions have been used has increased exponentially.
... This study is among the first to explore intentions to try, the perceived harm of, the addictiveness of, and the ease of quitting of tobacco products that span a continuum of harm [35] in a racially and ethnically diverse sample. Results broadly demonstrate that low nicotine products were preferred over high nicotine products across outcomes. ...
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Research suggests consumers may misunderstand modified risk tobacco product (MRTP) claims. We examined the effects of nicotine content across four tobacco products with and without MRTP claims among a racially and ethnically diverse sample of adults who do and do not smoke. Adults (n = 1484) aged 21–65 completed an online experiment using a 2 × 2 × 4 mixed factorial design to examine the effects of tobacco product (Classic White Snus, IQOS, JUUL e-cigarette, and VLN cigarette) and nicotine content (high vs. low) stratified by MRTP claim (present vs. absent) across four outcomes: (1) likely to try (2) serious disease if used regularly, (3) least addictive, and (4) ease of quitting smoking. Not including an MRTP claim resulted in an increased likelihood of trying a product, decreased concern of serious disease, lower perceived addictiveness, and increased ease of quitting smoking. Participants selected low nicotine IQOS without a claim as the least likely to cause serious disease. Low nicotine JUUL, without a claim, was selected as least addictive and most likely to facilitate quitting. Intentions to try were highest for low nicotine JUUL. Participants selected low-nicotine products as less addictive than high nicotine products. Regulatory efforts should consider how MRTP claims interact with different product characteristics. Subtle differences exist across outcomes between racial and ethnic groups, which indicates that further research is warranted.
... In recent years, Multi-criteria decision making (MCDM) methods have emerged as a successful tool for solving variety of decision making problems of various fields [10,[16][17][18][19][20][21]. MCDM methods have been found successful in solving challenging complex multi-criteria problems. ...
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Health, Safety, Environment (HSE) risk management in academic environment has always remained a major concern. Implementation of reliable management system that could ensure good HSE culture in universities laboratories is challenging due to diverse complications involving complex and hazardous operations and operating conditions, conduction of variety of experimentation using dangerous machines or equipment, storage, handling, usage and disposal of hazardous chemical substances and experimental waste, and the engagement of personnel having different experience and expertise level. Deployment of HSE risk management of chemicals is one of the most important risk components since the presence of chemicals in the laboratories poses severe danger to HSE even if they are not in working operation. In this research study, hazard ranking of 39 chemical products, on the basis of three criteria which include health, safety, and environment, present in the Petroleum Drilling Laboratory of Department of Petroleum Engineering of NED University of Engineering and Technology has been performed. HSE hazard performance evaluation of chemicals is conducted using popular multi-criteria decision making technique i.e. Fuzzy Technique for Order of Preference by Similarity to Ideal Solution (FTOPSIS). Four Experts provided rating of relative importance of criteria and criteria performance of each chemical using linguistic variable which were converted into Trapezoidal fuzzy numbers for calculations. According to the final results, Methylene chloride, benzene, and isopropanol proved to be the three most dangerous chemical products while E.D.T.A Solution was found be the least dangerous substance according to HSE hazards. Moreover, sensitivity analysis was also performed by changing the weight criteria. Acetone and algae oil ranking proved to be the most sensitive to criteria weights. The proposed methodology of this study can be used to rank chemicals in other similar laboratories and fields.
... 17,18 Perhaps as a consequence, smokers perceive the risk of snus use to be around 80 percent the risk of smoking 19 -an overestimate inconsistent with assessments from expert groups. [20][21][22][23] Swedish snus, while not being risk-free, has been assessed to be at the lower end of the tobacco products risk continuum, [24][25][26] and the inverse trend for smoking and snus use in Norway and Sweden have been highlighted as a proof concept of tobacco harm reduction. 20,27,28 E-cigarettes Unlike snus, indoor use of e-cigarettes in public places is prohibited, availability is limited by a domestic ban on the sale of nicotine-containing e-juice, and most of the products are bought outside Norway. ...
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Introduction: Around 50 percent of the tobacco in Norway is consumed in the form of snus, a smokeless oral tobacco. We examined Norwegian smokers' openness, and thereby the potential reach, to use e-cigarettes, nicotine replacement therapy products (NRT) and snus in the event of quitting smoking, in a society where snus use is common. Methods: Using data from an online survey of 4,073 smokers from 2019 to 2021, we calculated predicted probabilities of smokers' being open, undecided and not open to use e-cigarettes, snus and NRT in the event they should quit smoking. Results: Among daily smokers, the probability of being open to use e-cigarettes in the event of quitting smoking was .32. The corresponding probabilities for using snus and NRT were .22 and .19. Snus was the product with the highest probability of not being open (.60). NRT had the highest probability of being undecided (.39). Among smokers who had never used e-cigarettes or snus, the probabilities of being open were .13 for e-cigarettes, .02 for snus and .11 for NRT. Conclusions: In a snus-friendly norm climate where smokers have traditionally used snus as an alternative to cigarettes, the probability of using e-cigarettes in the event of smoking cessation was higher compared to both snus and NRT. However, among smokers who had never used e-cigarettes or snus, the likelihood of being open to use NRT was similar to e-cigarettes, and higher than snus, which suggest that NRT may still play a role for smoking cessation. Implications: In a snus-prevalent country in the endgame phase of the cigarette epidemic, where robust infrastructure for tobacco control in combination with the availability of snus has reduced smoking to a minimum, the remaining smokers seem to prefer e-cigarettes to snus if they should quit smoking. This indicates that availability of several nicotine alternatives might increase the likelihood of a future product replacement within the small group of remaining smokers.
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Electronic nicotine delivery systems (ENDS) have the potential to provide nicotine to tobacco consumers while reducing exposure to combustion-related toxicants. Here, we report changes in biomarkers of exposure (BoE) and biomarkers of potential harm (BoPH) in smokers who completely switched to Vuse Vibe and Vuse Ciro ENDS products, or to smoking abstinence in a randomized, controlled clinical study. Thirteen BoE (12 urinary and one blood) that indicate exposure to harmful and potentially harmful toxicants (HPHCs) were evaluated at baseline on day 5. Urinary BoPH linked to oxidative stress, platelet activation, and inflammation were also assessed at baseline, and on day 5 and day 7. Nicotine exposure was lower in Vuse Vibe and Vuse Ciro groups compared to baseline values. Urinary non-nicotine BoE decreased significantly (52.3–96.7%) in the Vuse ENDS groups, and the reductions were similar in magnitude to those observed in the abstinence group. Blood carboxyhemoglobin decreased 52.8–55.0% in all study groups. Decreases (10–50%) in BoPH were observed in all study groups. Thus, smokers who switch exclusively to Vuse Vibe or Vuse Ciro products or completely abstain from smoking are exposed to substantially lower levels of HPHCs, and experience improvements in BoPH of oxidative stress and inflammation pathways.
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Proper assessment of the harms caused by the misuse of drugs can inform policy makers in health, policing, and social care. We aimed to apply multicriteria decision analysis (MCDA) modelling to a range of drug harms in the UK. Method Members of the Independent Scientific Committee on Drugs, including two invited specialists, met in a 1-day interactive workshop to score 20 drugs on 16 criteria: nine related to the harms that a drug produces in the individual and seven to the harms to others. Drugs were scored out of 100 points, and the criteria were weighted to indicate their relative importance. Findings MCDA modelling showed that heroin, crack cocaine, and metamfetamine were the most harmful drugs to individuals (part scores 34, 37, and 32, respectively), whereas alcohol, heroin, and crack cocaine were the most harmful to others (46, 21, and 17, respectively). Overall, alcohol was the most harmful drug (overall harm score 72), with heroin (55) and crack cocaine (54) in second and third places. Interpretation These findings lend support to previous work assessing drug harms, and show how the improved scoring and weighting approach of MCDA increases the differentiation between the most and least harmful drugs. However, the findings correlate poorly with present UK drug classification, which is not based simply on considerations of harm.
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A growing body of scientific studies show that e-cigarettes may serve as an acceptable substitute for smoking tobacco cigarettes, thereby reducing or eliminating exposure to harmful elements in smoke. The success of e-cigarettes is such that sales of these products are rapidly gaining on traditional cigarettes. The rapidly evolving phenomenon is raising concerns for the health community, pharmaceutical industry, health regulators and state governments. Obviously, these products need to be adequately regulated, primarily to protect users. Depending on the form and intended scope, certain regulatory decisions may have diverse unintended consequences on public health and may face many different challenges. Ideally, before any regulations are enacted, the regulatory body will require sufficient scientific research to verify that a problem does exist, quantify the problem, explore all potential solutions including making no change at all, determine the possible consequences of each, and then select the solution that is best for public health. Here we present an overview on the existing and deeming regulatory decisions for electronic cigarettes. We challenge them, based on the mounting scientific evidence with the ultimate goal of proposing appropriate recommendations while minimizing potential unintended consequences of ill-informed regulation.
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Electronic cigarettes are a recent development in tobacco harm reduction. They are marketed as less harmful alternatives to smoking. Awareness and use of these devices has grown exponentially in recent years, with millions of people currently using them. This systematic review appraises existing laboratory and clinical research on the potential risks from electronic cigarette use, compared with the well-established devastating effects of smoking tobacco cigarettes. Currently available evidence indicates that electronic cigarettes are by far a less harmful alternative to smoking and significant health benefits are expected in smokers who switch from tobacco to electronic cigarettes. Research will help make electronic cigarettes more effective as smoking substitutes and will better define and further reduce residual risks from use to as low as possible, by establishing appropriate quality control and standards.
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Study objective To assess cardiovascular conditions and other side effects associated with the use of nicotine polacrilex (NP), 2 mg. Design A multicentered randomized control trial of early intervention for the prevention of COPD. Setting Ten university medical centers in the United States and Canada. Participants Adult smoking volunteers with evidence of early COPD; 3,923 in intervention and 1,964 controls. Intervention Smoking cessation program, including NP. Measurements Data on hospitalizations were collected annually. Data on reported NP side effects were collected at 4-month intervals for intervention participants. Results The rates of hospitalization for cardiovascular conditions and cardiovascular deaths during the 5 years of the study were not related to use of NP, to dose of NP, or to concomitant use of NP and cigarettes. About 25% of NP users reported at least one side effect, but most were very minor and transient. Side effects associated with discontinuance of NP in 5% or more of users included headache, indigestion, mouth irritation, mouth ulcers, and nausea. There was no evidence that concomitant use of NP and cigarettes was associated with elevated rates of reported side effects. Participants in the smoking cessation intervention who received intensive levels of instruction and monitoring of NP use (initially at 12 meetings during 3 months) appeared to report significantly lower rates of side effects (dizziness, headache, and throat irritation) than control participants, presumed to have less instruction and monitoring. Conclusions NP, as used in the Lung Health Study, appears to be safe and unrelated to any cardiovascular illnesses or other serious side effects.
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The International Classification of Diseases and the Diagnostic and Statistical Manual for diagnosing tobacco/nicotine dependence emphasize the dependence-producing drug nicotine. These diagnostic tools have been challenged on grounds of poor predictive validity, and they do not differentiate across various forms of nicotine-containing products. In fact, nicotine-containing products (e.g., tobacco cigarettes, smokeless tobacco [ST], waterpipe, electronic cigarettes [ECIGs], and nicotine replacement [NR] products) have very different characteristics both in terms of sensory and behavioral involvement and also in pharmacokinetic and pharmacodynamic effects. For example, a cigarette and a nicotine patch are very different on almost every one of these dimensions. When ability to stop using a nicotine/tobacco product is used as a criterion for dependence, success rates vary considerably across products: Tobacco cigarette cessation is more difficult than ST cessation that in turn is more difficult than NR product cessation. Based on these results, we hypothesize that there is a continuum of dependence as much as there is a continuum of harm, with tobacco cigarettes and NR products on opposite ends of both continua and other products (waterpipe and ECIGs) somewhere in between. In order to capture more precisely the dependence produced by both nicotine and its administration forms, product-specific instruments may be required. The pros and cons of this approach are discussed.
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To review the implications of recommending smokeless tobacco (ST) use as a harm reduction approach for low-income and middle-income countries (LMICs). Narrative review of published papers and other data sources (including conference abstracts and internet-based information) on the health risks posed by the use of ST products for individual smokers and for the population with a focus on their implications for LMICs. Swedish snus has a relatively lower toxicity profile than ST products available in other markets, including older products used in the US and products used in Africa and Asia. The experience with snus in Sweden provides information on the effects of snus use in a population where cigarette smoking was already culturally ingrained. However, population effects are likely to be different in those LMICs where smoking is not yet the dominant culturally accepted form of tobacco use. The total effect may be negative in countries where locally-popular ST products have substantially higher disease risks than Swedish snus and where there is limited regulatory and tobacco use surveillance capacity. Issues relating to how populations in LMICs respond to marketing efforts, the risks of the dual use of ST and smoking, and the capacity to regulate ST products need to be considered in making decisions about harm reduction strategies in LMICs. The public health effects of supporting ST as a harm reduction strategy may vary substantively in countries with different pre-existing tobacco use patterns.
Nicotine self-administration in rats is the most widely used animal model of tobacco dependence. There is increasing evidence, however, that non-nicotinic constituents in smoke contribute to addiction and that different tobacco products contain varying levels of these constituents. The present study firstly sought to compare self-administration of pure nicotine to tobacco particulate matter (TPM) to determine if there were differences in reward-efficacy attributable to the non-nicotine constituents. Secondly, cigarette and roll-your-own (RYO) TPM groups were included and compared to determine whether different formulations of non-nicotinic constituents could impact reward. Briefly, male Sprague Dawley rats were implanted with indwelling jugular catheters for self-administration (n = 76). The reinforcing efficacy of infusions of nicotine (0.0 or 30.0 μg/kg/infusion) versus cigarette/RYO TPM (with matched nicotine content) was determined using spontaneous acquisition of self-administration on a fixed ratio schedule. The progressive ratio schedule was then employed to determine the motivation to receive each drug and within-subject dose–response curves were also produced (7.5, 15.0, 30.0 and 60.0 μg/kg/infusion nicotine). The main finding was that the RYO TPM was more reinforcing and produced a different profile of reward-related behaviour compared with both the nicotine and the cigarette TPM groups. The conclusions were that non-nicotinic components have a role in tobacco dependence and that some tobacco products could have higher abuse liability, irrespective of nicotine levels.
Background: Smoking is the leading preventable cause of illness and premature death worldwide. Some medications have been proven to help people to quit, with three licensed for this purpose in Europe and the USA: nicotine replacement therapy (NRT), bupropion, and varenicline. Cytisine (a treatment pharmacologically similar to varenicline) is also licensed for use in Russia and some of the former socialist economy countries. Other therapies, including nortriptyline, have also been tested for effectiveness. Objectives: How do NRT, bupropion and varenicline compare with placebo and with each other in achieving long-term abstinence (six months or longer)? How do the remaining treatments compare with placebo in achieving long-term abstinence? How do the risks of adverse and serious adverse events (SAEs) compare between the treatments, and are there instances where the harms may outweigh the benefits? Methods: The overview is restricted to Cochrane reviews, all of which include randomised trials. Participants are usually adult smokers, but we exclude reviews of smoking cessation for pregnant women and in particular disease groups or specific settings. We cover nicotine replacement therapy (NRT), antidepressants (bupropion and nortriptyline), nicotine receptor partial agonists (varenicline and cytisine), anxiolytics, selective type 1 cannabinoid receptor antagonists (rimonabant), clonidine, lobeline, dianicline, mecamylamine, Nicobrevin, opioid antagonists, nicotine vaccines, and silver acetate. Our outcome for benefit is continuous or prolonged abstinence at least six months from the start of treatment. Our outcome for harms is the incidence of serious adverse events associated with each of the treatments. We searched the Cochrane Database of Systematic Reviews (CDSR) in The Cochrane Library, for any reviews with 'smoking' in the title, abstract or keyword fields. The last search was conducted in November 2012. We assessed methodological quality using a revised version of the AMSTAR scale. For NRT, bupropion and varenicline we conducted network meta-analyses, comparing each with the others and with placebo for benefit, and varenicline and bupropion for risks of serious adverse events. Main results: We identified 12 treatment-specific reviews. The analyses covered 267 studies, involving 101,804 participants. Both NRT and bupropion were superior to placebo (odds ratios (OR) 1.84; 95% credible interval (CredI) 1.71 to 1.99, and 1.82; 95% CredI 1.60 to 2.06 respectively). Varenicline increased the odds of quitting compared with placebo (OR 2.88; 95% CredI 2.40 to 3.47). Head-to-head comparisons between bupropion and NRT showed equal efficacy (OR 0.99; 95% CredI 0.86 to 1.13). Varenicline was superior to single forms of NRT (OR 1.57; 95% CredI 1.29 to 1.91), and to bupropion (OR 1.59; 95% CredI 1.29 to 1.96). Varenicline was more effective than nicotine patch (OR 1.51; 95% CredI 1.22 to 1.87), than nicotine gum (OR 1.72; 95% CredI 1.38 to 2.13), and than 'other' NRT (inhaler, spray, tablets, lozenges; OR 1.42; 95% CredI 1.12 to 1.79), but was not more effective than combination NRT (OR 1.06; 95% CredI 0.75 to 1.48). Combination NRT also outperformed single formulations. The four categories of NRT performed similarly against each other, apart from 'other' NRT, which was marginally more effective than NRT gum (OR 1.21; 95% CredI 1.01 to 1.46). Cytisine (a nicotine receptor partial agonist) returned positive findings (risk ratio (RR) 3.98; 95% CI 2.01 to 7.87), without significant adverse events or SAEs. Across the 82 included and excluded bupropion trials, our estimate of six seizures in the bupropion arms versus none in the placebo arms was lower than the expected rate (1:1000), at about 1:1500. SAE meta-analysis of the bupropion studies demonstrated no excess of neuropsychiatric (RR 0.88; 95% CI 0.31 to 2.50) or cardiovascular events (RR 0.77; 95% CI 0.37 to 1.59). SAE meta-analysis of 14 varenicline trials found no difference between the varenicline and placebo arms (RR 1.06; 95% CI 0.72 to 1.55), and subgroup analyses detected no significant excess of neuropsychiatric events (RR 0.53; 95% CI 0.17 to 1.67), or of cardiac events (RR 1.26; 95% CI 0.62 to 2.56). Nortriptyline increased the chances of quitting (RR 2.03; 95% CI 1.48 to 2.78). Neither nortriptyline nor bupropion were shown to enhance the effect of NRT compared with NRT alone. Clonidine increased the chances of quitting (RR 1.63; 95% CI 1.22 to 2.18), but this was offset by a dose-dependent rise in adverse events. Mecamylamine in combination with NRT may increase the chances of quitting, but the current evidence is inconclusive. Other treatments failed to demonstrate a benefit compared with placebo. Nicotine vaccines are not yet licensed for use as an aid to smoking cessation or relapse prevention. Nicobrevin's UK license is now revoked, and the manufacturers of rimonabant, taranabant and dianicline are no longer supporting the development or testing of these treatments. Authors' conclusions: NRT, bupropion, varenicline and cytisine have been shown to improve the chances of quitting. Combination NRT and varenicline are equally effective as quitting aids. Nortriptyline also improves the chances of quitting. On current evidence, none of the treatments appear to have an incidence of adverse events that would mitigate their use. Further research is warranted into the safety of varenicline and into cytisine's potential as an effective and affordable treatment, but not into the efficacy and safety of NRT.
We know that cigarette smoking is a leading preventable cause of carcinogenesis in lung cancer. Cigarette smoke is a mixture of more than 5000 chemical compounds, among which more than 60 are recognized to have a specific carcinogenic potential. Carcinogens and their metabolites (i.e., N-nitrosamines and polycyclic aromatic hydrocarbons) can activate multiple pathways, contributing to lung cell transformation in different ways. Nicotine, originally thought only to be responsible for tobacco addiction, is also involved in tumor promotion and progression with antiapoptotic and indirect mitogenic properties. Lung nodules are frequent in smokers and can be transformed into malignant tumors depending on persistant smoking status. Even if detailed mechanisms underlying tobacco-induced cancerogenesis are not completely elucitated, this report collects the emergent body of knowledge in order to simplify the extremely complex framework that links smoking exposure to lung cancer.
Introduction: N'-nitrosonornicotine (NNN), an esophageal and oral carcinogen present in tobacco products, has a chiral center in its structure. Of its two enantiomers, (S)-NNN exhibits higher tumorigenic potency than (R)-NNN. There is no information available on the levels of (S)-NNN in various tobacco products currently marketed in the United States. Methods: We used chiral gas chromatography analysis to determine (S)-NNN levels in a convenience sample of 37 tobacco products currently marketed in the United States: conventional smokeless tobacco, novel smokeless tobacco products, and cigarette tobacco filler. Results: Among all products analyzed here, (S)-NNN averaged 62.9 ± 6.3% (SD) of NNN. The absolute amount of (S)-NNN in conventional moist snuff averaged 1.26 ± 0.5 µg/g tobacco; in novel smokeless products 0.70 ± 0.2 µg/g tobacco; and in cigarette filler 1.36 ± 0.6 µg/g tobacco (all values are per wet weight). For each cigarette brand, the enantiomeric composition of NNN in cigarette smoke was similar to that of the corresponding tobacco filler. Conclusions: Our results demonstrate that (S)-NNN is the predominant NNN enantiomer in moist snuff, novel smokeless tobacco products, and cigarettes currently marketed in the United States. Efforts toward the reduction of NNN in U.S. tobacco products should take into account its enantiomeric composition, with particular focus on (S)-NNN as a causative agent for esophageal and oral cancers associated with tobacco use.