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Chinese "Herbal" Cigarettes Are as Carcinogenic and Addictive as Regular Cigarettes


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To examine the Chinese tobacco industry's claim that herbal cigarettes are less harmful than regular cigarettes. The study design was a cross-sectional survey. One hundred thirty-five herbal cigarette smokers and 143 regular smokers from one city in China completed a questionnaire on smoking behavior and provided a urine sample. The main outcome measures were cotinine and trans-3'-hydroxycotinine in all samples, and polycyclic aromatic hydrocarbon metabolites (PAH; 1-hydroxypyrene, naphthols, hydroxyfluorenes, and hydroxyphnanthrenes) and the tobacco specific nitrosamine 4-(methylnitrosamino)-1-(3-pyridyl)-butanol (NNAL) and NNAL-glucuronide in randomly selected 98 samples (47 from the herbal smokers' group and 51 from the regular smokers' group). Values were normalized by creatinine to correct for possible variability introduced by dilution or concentration of the urine. Health concern was among the main reasons that smokers switched to herbal cigarettes from regular cigarettes. Smokers reported increased consumption after switching to herbal cigarettes from regular cigarettes. For all the four markers analyzed (cotinine, trans-3'-hydroxycotinine, total NNAL, and total PAHs), we observed no significant difference in the levels (P = 0.169, P = 0.146, P = 0.171, and P = 0.554, respectively) between smokers of herbal cigarettes and smokers of regular cigarettes. Both total NNAL and total PAHs were significantly correlated with cotinine and trans-3'-hydroxycotinine (P < 0.001 for all four correlations). Our findings showed that herbal cigarettes did not deliver less carcinogens than regular cigarettes. The public needs to be aware of this fact, and the Chinese tobacco industry should avoid misleading the public when promoting herbal cigarettes as safer products.
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Chinese “Herbal” Cigarettes are as Carcinogenic and Addictive as
Regular Cigarettes
Quan Gan, PhD1, Jie Yang, PhD MD MPH2, Gonghuan Yang, MD2, Maciej Goniewicz,
PhD1,3, Neal L. Benowitz, MD1,3,4, and Stanton A. Glantz, PhD1,4
1Center for Tobacco Control Research and Education, University of California, San Francisco
2China Center for Disease Control and Prevention, University of California, San Francisco
3Division of Clinical Pharmacology and Experimental Therapeutics, Departments of Medicine and
Biopharmaceutical Sciences, University of California, San Francisco
4Department of Medicine and Cardiovascular Research Institute, UCSF Helen Diller Family
Comprehensive Cancer Center, University of California, San Francisco
Objective—To examine the Chinese tobacco industry's claim that herbal cigarettes are less harmful
than regular cigarettes.
Design—Cross-sectional study.
Participants—135 herbal cigarette smokers and 143 regular smokers from one city in China
completed a questionnaire on smoking behavior and provided a urine sample.
Main Outcome Measures—Cotinine and trans-3-hydroxycotinine in all samples and polycyclic
aromatic hydrocarbon metabolites (PAHs) (1-hydroxypyrene, naphthols, hydroxyfluorenes and
hydroxyphnanthrenes) and the tobacco specific nitrosamine 4-(methylnitrosamino)-1-(3-pyridyl)-
butanol (NNAL) and NNAL-glucuronide in randomly selected 98 samples (47 from the herbal
smokers' group and 51 from the regular smokers' group). Values were normalized by creatinine to
correct for possible variability introduced by dilution or concentration of the urine.
Results—Health concern was among the main reasons that smokers switched to herbal cigarettes
from regular cigarettes. Smokers reported increased consumption after switching to herbal cigarettes
from regular cigarettes. For all the four markers analyzed (cotinine, trans-3-hydroxycotinine, total
NNAL, total PAHs), we observed no significant difference in the levels (p=0.169, p=0.146, p=0.171,
p=0.554) between smokers of herbal cigarettes and smokers of regular cigarettes. Both total NNAL
and total PAHs were significantly correlated with cotinine and trans-3-hydroxycotinine (p<0.001
for all four correlations).
Conclusions—Our findings showed that herbal cigarettes did not deliver less carcinogens than
regular cigarettes. The public needs to be aware of this fact and the Chinese tobacco industry should
avoid misleading the public when promoting herbal cigarettes as safer products.
Correspondence to: Stanton A. Glantz, PhD, 530 Parnassus Avenue, Suite 366, University of California, San Francisco, San Francisco,
CA 94143-1390, 415-476-3893,
Conflicts of Interest Statement: Dr. Benowitz has served as a paid expert witness in litigation against tobacco companies on issues
related to addiction and light cigarettes. The other authors have no conflict of interest.
NIH Public Access
Author Manuscript
Cancer Epidemiol Biomarkers Prev. Author manuscript; available in PMC 2010 December 1.
Published in final edited form as:
Cancer Epidemiol Biomarkers Prev. 2009 December ; 18(12): 3497–3501. doi:
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
In Western countries, the term “herbal cigarettes” often refers to cigarettes that are made of a
mixture of different herbs and that contain no tobacco or nicotine. In China, the China National
Tobacco Corporation (CNTC) began in the late 1970s to develop tobacco cigarettes that also
contain Chinese medicinal herbs, which it also calls “herbal cigarettes” (1). In the manufacture
of these herbal cigarettes, extracts of Chinese medicinal herbs are mixed with or sprayed on
leaf tobacco (2) A host of Chinese herbs have been used as cigarette additives, from the
commonly known Ginseng to much less known ones such as Jiaogulan (2,3). Most of these
herbs are common ingredients in traditional Chinese medicine and are used for therapeutic
purposes or as dietary supplements. Since the first herbal cigarette brand in China, Changle,
was marketed by the Beijing Cigarette Factory (affiliated with the CNTC) in 1979 (2), many
herbal cigarette brands have been developed and marketed in China. In the 1990s herbal
cigarettes began to gain popularity in China. The two brands that have achieved the most sales
success in China were Jinsheng and Wuyeshen, which sold over 20 billion cigarettes in 2008,
accounting for more than 1% of all the cigarettes produced in China(4-6). (For comparison,
Lucky Strike had a 1.1% share of the US market in 1965(7), Virginia Slims had 2.6% in 2000
(8).) Most herbal brands in China, including Jinsheng and Wuyeshen, have the same machine-
determined yield of tar as regular cigarettes (15mg).
Although the market share of herbal cigarettes is still relatively small in China, herbal brands
are quickly expanding their market there and into the global market. Jinsheng's export markets
in 2008 included the Philippines, Singapore, Indonesia, Malaysia, Cambodia, Myanmar,
Canada and Taiwan (9). In 2003 Jinsheng was so successful in the Philippines that it accounted
for 90% of imported cigarettes in Manila (10). Zhongnanhai, the first herbal brand with a low
tar rating (at 1, 3, 5, 6, 8 mg) has achieved considerable success in Japan and can also be found
in the markets of the United States, Singapore, Malaysia, Taiwan, Hong Kong and Macao
Many claims of health benefits for smokers of herbal cigarettes were made by the Chinese
tobacco industry. For example, Jinsheng claims a host of benefits, including less coughing and
sputum, nourishment of the kidneys and the lungs, boosting of sexual drive (12). The health
claims Jinsheng made can also be conveniently found in a card inserted in some cigarette
packages (12). Wuyeshen claims over 60% reduction in cancer-causing nitrosamines, including
tobacco specific nitrosamines, and the inhibition of benzo(a)pyrene's carcinogenicity (13).
Several studies have attempted to evaluate the health benefits of smoking herbal cigarettes by
either measuring the yields of tobacco-specific nitrosamines in mainstream tobacco smoke
with smoking machine or cellular response to tobacco smoke in in vitro experiments (14-17).
No studies have directly measured the levels of carcinogens from herbal cigarettes in smokers'
bodies. The present study examines, for the first time, the level of metabolites of several key
tobacco constituents in herbal cigarette smokers' urine. In contrast to the claims made by the
Chinese tobacco companies that herbal cigarettes are safer than regular cigarettes, we find no
difference in the levels of nicotine or carcinogens in smokers' bodies between these two types
of cigarettes.
Sampling protocol
All subjects were smokers smoking cigarettes of Chinese brands living in one city in China.
180 herbal cigarette smokers and 180 regular cigarette smokers were recruited through three
district community centers. (Since all herbal brands are still very localized in China currently
and all of the herbal smokers in our study smoked the same brand that was produced locally,
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we chose not to disclose the name of brand to protect our local collaborators from the retaliation
by the local tobacco company.) Regular cigarette smokers smoked cigarettes with 14 or 15 mg
machine-measured tar yields per cigarette. Herbal cigarette smokers were smokers of a local
popular herbal brand with 15mg of machine-measured tar yield. Several inclusion criteria were
applied: (1) subjects had to be male smokers (because few women smoke in China); (2) subjects
had to be between the ages of 18 and 65, with no diagnosis of cancer, heart disease or major
respiratory diseases; (3) subjects had to smoke on average at least 5 cigarettes per day; and
(4) subjects had to have been smoking the current brand for at least three months; (5) when
brand-mixing was present, smokers had to smoke either regular or herbal brands at least 90%
of the time.
Each subject signed a consent form and completed a questionnaire. At the end of the
questionnaire, a 25 ml urine sample was collected.
The protocol was approved by the University of California San Francisco Committee on
Human Research and the China Center for Disease Control and Prevention Committee on
Human Subjects.
Laboratory analysis of tobacco smoke compounds in smokers' urine
The urine samples were frozen and shipped to San Francisco General Hospital for analysis in
the Tobacco Biomarker Core Facility of the UCSF Helen Diller Family Comprehensive Cancer
Center. Cotinine and trans-3-hydroxycotinine, both metabolites of nicotine, 4-
(methylnitrosamino)-1-(3-pyridyl)-butanol (NNAL) and NNAL-glucuronide, metabolites of
NNK, a tobacco specific nitrosamine and one of the most potent carcinogens in tobacco smoke
(18), and metabolites of polycyclic aromatic hydrocarbons (PAHs), which represent a class of
combustion products that include a number of carcinogens, were measured. All analytes, were
measured using liquid chromatography by methods described previously: Cotinine and
trans-3-hydroxycotinine (19),. NNAL and NNAL-glucuronide reported as total NNAL.(20),
metabolites of the PAHs including 1-hydroxypyrene, naphthols, hydroxyfluorenes and
hydroxyphenanthrenes and reported as total PAHs (21). Concentrations of cotinine, trans-3-
hydroxycotinine, total PAHs and total NNALs were normalized by urine creatinine to correct
for variations due to dilution or concentration of urine. Per cigarette level of normalized total
PAHs, total NNAL, cotinine and trans-3-hydroxycotinine were estimated by dividing the
concentrations by the number of cigarettes the subject reported smoking per day.
Every sample was analyzed for the levels of cotinine and trans-3-hydroxycotinine (for a total
of 360 samples). A random sample of 60 samples from each group of smokers (for a total of
120 samples) was analyzed for PAHs and NNAL. Nine subjects were dropped because of
incomplete demographic information in the questionnaire. Three samples were excluded from
the results due to abnormally low levels of creatinine. Twenty-seven subjects who claimed to
smoke herbal cigarettes and 19 who claimed to smoker regular cigarettes were dropped from
the study because their urine samples indicated cotinine levels (< 50 μg/liter (22)) of a typical
non-smoker. Seven smokers of regular cigarettes were dropped from the study because the
main brand they smoked had a tar level of light cigarettes (< 14mg). In sum, the results reported
in this paper are based on 278 samples for cotinine and trans-3-hydroxycotinine, 93 samples
for PAHs and NNAL.
Statistical Analysis
Survey questions were analyzed using chi-square. Levels of biomarkers were analyzed using
a Mann-Whitney rank sum test. Calculations were done with Stata 10.1.
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Demographic information for the subjects is presented in Table 1. Herbal cigarette smokers
and regular cigarette smokers did not differ in age, number of cigarettes smoked per day,
educational level, employment status or income.
Urine levels of cotinine, trans-3-hydroxycotinine total PAHs and total NNAL
Adjusted for creatinine, neither the levels of cotinine (p=0.169) nor trans-3-hydroxycotinine
(p=0.146) were significantly different between herbal smokers and regular smokers (Table 1
and Figure 1). (Unadjusted cotinine and trans-3-hydroxycotinine (ng/ml) were lower in herbal
cigarette smokers, p=0.047 and p=0.058, respectively.) The levels of total PAHs (p=0.554)
and total NNAL were not statistically different between the two groups (p=0.171) (Table 1 and
Figure 2). Results per cigarette showed the same patterns (details not shown). Both NNAL and
PAHs significantly correlated with cotinine (NNAL: rs=0.535, p<0.001; PAHs: rs=0.668,
p<0.001) and trans-3-hydroxycotinine (NNAL: rs=0.539, p<0.001; PAHs: rs=0.674, p<0.001)
(scatter plots of cotinine vs NNAL and PAHs shown in Figure 3). Using a multiple regression
model (results not shown), the relationships did not depend on the type of cigarettes the subjects
Cigarette switching
There was no significant difference in daily cigarette consumption between regular and herbal
smokers (Table 1). 106/135 (86%) of the herbal smokers had switched from regular cigarettes
a median of 6.25 years earlier (IQR: 4-10 years). Smokers reported increased numbers of
cigarettes smoked per day after switching to herbal cigarettes from regular cigarettes (Table
1). The most often cited reason for switching to herbal cigarettes was “better taste” compared
to regular cigarettes (47%). Health concern was the second most popular reason reported for
switching (24%) (Table 2). “Convenience of purchase” and “support for a local product and
business” accounted for 21% and 15% of the responses, respectively. There are two opposite
concerns about the price: some smokers switched because the current brand was more
affordable, while others switched because the current brand was more expensive and “good
for face” when offering cigarette to others, which is a common social etiquette in China.
Additionally, “no fake cigarettes” was reported by 4% of the respondents as the reason for
switching to herbal cigarettes.
The present study is the first that examines the level of tobacco toxins in the bodies of smokers
of Chinese herbal cigarettes. We examined the major metabolites of nicotine and two groups
of tobacco carcinogens among smokers of herbal cigarettes. There was no detectable difference
in levels of nicotine or total NNAL, the metabolite of the main tobacco specific carcinogen
NNK, or PAHs between herbal cigarette smokers and regular cigarette smokers.
Smokers of herbal cigarettes had lower concentrations of unadjusted cotinine and trans-3-
hydroxycotinine in the urine, but not after normalizing for creatinine. This result may suggest
slightly lower intake of nicotine from their cigarettes, or more concentrated urine among herbal
cigarette smokers. The reason for lower nicotine is unclear, as we did not measure the nicotine
content of the various types of cigarettes. The primary toxicity of nicotine is sustaining
addiction, and it is doubtful that very small differences in nicotine exposure, as were seen in
our study, would have any meaningful effect on the addiction potential of the cigarettes. In any
event, measures for tobacco smoke carcinogen biomarkers demonstrate no evidence
whatsoever of lower exposure in herbal cigarette smokers, suggesting no less cancer risk.
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While our results show that herbal cigarette smokers have similar levels of carcinogens in their
bodies as regular cigarette smokers, we could not test the industry claim that the herbal additives
inhibit the toxicity of these carcinogens. We could not locate any published studies that
examined or supported such claims.
We found significant correlations between total NNAL/total PAHs and the metabolites of
nicotine (cotinine and trans-3-hydroxycotinine). The correlations persisted after stratifying for
the type of cigarette smoked. Our findings support previous research that NNAL and cotinine
are significantly correlated among smokers (23,24). This result suggests that cotinine and
trans-3-hydroxycotinine in smokers' urine are indicative of the levels of total NNAL and total
PAHs in Chinese herbal and regular smokers due to smoking.
Herbal smokers who switched to herbal cigarettes from regular cigarettes reported increased
cigarette consumption after switching. Because of the cross-sectional design, the current study
was not able to examine the effect of this increased consumption on the nicotine and carcinogen
intake from tobacco smoke. It would be of interest for future studies, especially with short or
long-term switching experimental designs, to examine whether it was the health messages and/
or the herbal additives that triggered this increased consumption.
Many of the herbal constituents in herbal cigarettes present therapeutic benefits if used alone
(generally taken orally, rather than burned and smoked). When burned with processed tobacco
and inhaled, these herbal constituents are likely to undergo complex physical and chemical
changes. Of the three main herbal brands in China, Wuyeshen, Jinsheng and Zhongnanhai, we
did not find any literature evaluating the health benefits of Jinsheng and Zhongnanhai. Three
studies examined the safety claims of Wuyeshen (15-17). One study found reduction of tobacco-
specific nitrosamines in mainstream smoke compared to regular cigarettes (17). The other two
studies found lower toxicological effects from test animals smoking Wuyenshen and reduced
deaths in mouse embryonic cells and human endothelial cells in in vitro experiments (14-16).
None of these studies were conducted by independent researchers: one was by a researcher
from the tobacco company that manufactured Wuyeshen (17) and the others by researchers
with close ties with the tobacco industry (15,16). A full independent evaluation of the final
products, which is yet to be undertaken, would be necessary before any conclusion can be
reached to support claims of therapeutic effects of herbal cigarettes.
The marketing of herbal cigarettes as safer products by the Chinese tobacco industry, though
unfounded, has been effective; we found health concern to be the second most reported reason
for smokers to switch to herbal cigarettes (Table 2).
In 2001, Jinsheng and Zhongnanhai were among 36 most prestigious brands selected by CNTC
out of hundreds of brands in China (25). With a strong foothold in several provinces in China,
several herbal brands are being exported to Japan, Korea, countries in Southeast Asia and North
America (1,9,11). Because of the health benefits the marketing implies and the fact that smokers
in many of these countries are more health conscious, herbal cigarettes is, albeit slowly, gaining
popularity in these countries. Local regulatory agencies should be aware of the unsubstantiated
health claims and take measures to restrict the marketing of herbal cigarettes.
We express our deep appreciation to our local sampling collaborators in China, without whose help this project would
not have been possible. We are also grateful to Margaret Peng and Lisa Yu for performing the analytical chemistry,
and Drs Peyton Jacob III and Christopher Havel for supervised the laboratory analyses. This work was supported by
National Cancer Institute Training Grant CA-113710, the William Cahan Endowment and the UCSF Bland Lane
Center of Excellence on Secondhand Smoke funded by the Flight Attendants Medical Research Institute and the UCSF
Helen Diller Family Comprehensive Cancer Center, and the China CDC. The external funding agencies played no
role in the design of the project, collection and analysis of the data or preparation of the manuscript.
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Figure 1.
There is no significant difference in levels of cotinine and trans-3-hydroxycotinine
(normalized by creatinine to account for differences in urine concentration) between herbal
smokers and regular smokers.
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Figure 2.
There is no significant difference in PAHs between herbal smokers and regular smokers.
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Figure 3.
There is no significant difference in NNAL between herbal smokers and regular smokers.
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Figure 4.
Scatterplots of cotinine vs total NNAL (rs=0.535, p<0.001) and total PAHs (rs=0.668, p<0.001)
show that higher levels of cotinine are associated with higher levels of carcinogens. (Crosses:
herbal smokers; dots: regular smokers.)
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Table 1
Demographic characteristics of the subjects.
Smokers of herbal cigarettes Smokers of regular cigarettesp-value
Sample size, N 135 143
Age (yrs), Median (IQR) 48 (38-56) 48 (39-54)p=0.567*
Cigarettes per day on average
Median (Interquartile range) 20 (15-20) 20 (15-20)p=0.962*
Education, N (%)
Junior high school and below 70 (52%) 77(54%)
Secondary technical school 41 (30%) 42 (29%)
Junior college 20 (15%) 18 (12%)
College and above 4 (3%) 6 (4%)p=0.621
Employment status, N (%)
Employed 81 (60%) 94 (66%)
Unemployed 54 (40%) 49 (34%)p=0.979
Monthly income, N(%)
<500 yuan 19 (14%) 30 (21%)
500-999 yuan 40 (30%) 41 (29%)
1000-1999 yuan 58 (43%) 52 (36%)
2000-4999 yuan 17 (12%) 18 (12%)
>=5000 yuan 1 (1%) 2 (1%)p=0.567
Change in daily consumption after switching from regular cigarettes (14-15mg) to herbal cigarettes
Increased daily consumption 47% -
Decreased daily consumption 30% -
No change in daily consumption 23% -
Cotinine and trans-3-hydroxycotinine (Median and Interquartile range)
Sample size 134 142
Cotinine (μg/mg creatinine) 12.8 (5.57-22.2) 14.3 (8.00-23.7)p=0.169*
Cotinine (ng/ml) 1142 (476-2175) 1538 (666-2463)p=0.047*
trans-3-hydroxycotinine (μg/mg creatinine) 33.0 (9.88-61.4) 41.1 (15.6-65.7)p=0.146*
trans-3-hydroxycotinine (ng/ml) 2799 (732-6346) 3732 (1518-7230)P=0.058*
Total PAHs and total NNAL (Median and Interquartile range)
Sample size 44 49
Total PAHs (pmol/mg creatinine) 172 (87.1-245) 159 (126-225)p=0.554*
Total NNAL (pmol/mg creatinine) 0.454 (0.256-0.862) 0.410 (0.291-0.649)p=0.171*
*Based on Mann-Whitney signed rank test;
Based on chi-square test.
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Table 2
Reasons for herbal cigarette smokers to switch from regular cigarettes (14-15mg tar) to current herbal brands.*
Ranking of reasons Specific reasons Response (%)
1 Better taste 50 (47%)
2 Health concerns 26 (24%)
3 Convenience of purchase 22 (21%)
4 Support for local product & business 15 (15%)
5 Price 10(9%)
6 No fake cigarettes of current brand 4 (4%)
*106 out of 135 subjects who smoked herbal cigarettes answered this multiple-choice question. Percentages do not add to 100% because respondents were
allowed to report more than one reason.
Cancer Epidemiol Biomarkers Prev. Author manuscript; available in PMC 2010 December 1.
... 144 Smoking tobacco-free and nicotine-free cigarettes has been shown to be as hazardous as smoking cigarettes that do include these substances. In a study by gan et al, 146 biomarkers were analyzed from urine samples provided by 135 herbal smokers and 143 regular smokers. No difference was detected and herbal cigarettes did not deliver fewer carcinogens than regular cigarettes. ...
... No difference was detected and herbal cigarettes did not deliver fewer carcinogens than regular cigarettes. 146 If these cigarettes are not better for lung cells, the biological plausibility that these cigarettes might be better for bone cells is very low. ...
Full-text available
Objectives The aim of this study was to review the impact of smoking tobacco on the musculoskeletal system, and on bone fractures in particular. Methods English-language publications of human and animal studies categorizing subjects into smokers and nonsmokers were sourced from MEDLINE, The Cochrane Library, and SCOPUS. This review specifically focused on the risk, surgical treatment, and prevention of fracture complications in smokers. Results Smokers have an increased risk of fracture and experience more complications with delayed bone healing, even if they have already stopped smoking, because some adverse effects persist for a prolonged period. Some risks can be reduced during and after surgery by local and general prevention, and smoking cessation is an important factor in lessening this risk. However, if a patient wants to stop smoking at the time of a fracture, the cessation strategies in reducing tobacco use are not easy to implement. The patient should also be warned that using e-cigarettes or other tobaccos does not appear to reduce adverse effects on health. Conclusion The evidence reviewed in this study shows that smoking has a negative effect in terms of the risk and treatment of fractures. Cite this article: J. Hernigou, F. Schuind. Tobacco and bone fractures: A review of the facts and issues that every orthopaedic surgeon should know. Bone Joint Res 2019;8:255–265. DOI: 10.1302/2046-3758.86.BJR-2018-0344.R1.
... To describe the general situation of smoking in China, Yang et al. (2015) produced an overview. They start with a report by the National Patriotic Health Campaign Committee in 1984 which found that the average smoking rate among Chinese was 34.45%, which is higher than the global average of 14.3% (Gan et al., 2009) Past research has proven that, "It is hardly controversial to suggest that the media are powerful social actors" (Freedman, 2014, p. 319). When the media creates, gathers, and shares "health information" to encourage/discourage the audience, this process is widely conceptualised as health communication (Kreps, Bonaguro, & Query Jr, 2003). ...
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As humanity is approaching its third year under COVID-19, the virus’s grim day-to-day toll is becoming increasingly clear. By the end of 2021, over 5 million people will have died from the disease and many are continuing to die on a daily basis. The world has not even yet begun to count the psychological fallout from the disease, as only glimpses of it have become visible so far: children left behind in their schooling, depression among teenagers unable to socialise; students prevented from having campus experiences; parents at the end of their tethers because of closed schools and kindergartens; family members unable to see each other for years on end. Among survivors, “fatigue” is the most common words to be heard. Other words, unknown a few months ago, have become pedestrian, as we are all becoming (linguistic) epidemiologists: Delta and Omicron mutations, booster vaccinations, 2G, 3G, 3G++. The advantages and disadvantages of heterologous and homologous vaccinations, of mRNA vaccines vs adenovirus vector vaccines versus inactivated virus vaccines are broadly discussed. Additionally, rules and regulations change on a daily basis, and travel plans are more a guessing game than anything else. Under the reign of social media, discussions taking place oftentimes become heated and accusatory, rather than reflected and scientific. As the former spill out onto the streets, people are injured and killed. The virus is political. IJCS’s current issue pays a small tribute to this situation; in a larger expose, entitled “Screen Ontologies or Teaching the Virus a Lesson: A Few Things that Work in Online Education and a Few that Don’t”, the situation of accelerated online education is discussed. The article states that despite the fact that there were few alternatives to such online teaching, its necessity at the time should not supress necessary criticism of distance education in general. In particular, the teaching situation via screens is discussed and older philosophical and social criticisms of television culture and reintroduced and updated in order to expose the limits of screen education in particular and screen cultures in general. Finally, new ways of distance education are sketched that would usher in a post-screen education model. The second article, “Is There a Correspondence Between “Orientalism” and The Orient? – Said, Dyson and Sen” by Amitabha Gupta, revisits Edward Said’s seminal Orientalism work and, from the vantage point of 40 years after, explains how especially the work of Sen is able to provide a more fruitful approach today by circumventing some of the by now problematic premises Said relied on Naeim Sepehri’s “Psychological Effects of the Architectural-Space: Decorated Mirror-tile Artwork-A Phenomenological Approach”, discusses the usage of mirror shards in the interior decoration of palaces and mosques in Iran. He historicises this architectural feature and, with the help of recent psychological theories, demonstrates how such architectural approaches have become deeply engrained in the aesthetic of Iranian historical national narratives. “Innovation in Cultural Heritage Preservation in Taiwan: Lessons for Indonesia?” by Riela Provi Drianda, Laila Zohrah and Adiwan Fahlan Aritenang contrasts and compares cultural heritage politics and their implementation in Taiwan and Indonesia respectively. While the two cultural communities follow divergent politics of heritage conservation, the authors illustrate that many of the challenges faced by cultural heritage preservation actions, such as rapid development, profit maximisation, lack of political will and funding, and a host of others, are common to preservation efforts around the globe. Preservationists can learn from each other’s experiences, and while local givens, such as weather conditions, might differ, all preservation efforts share a number of commonalities which can best be explored together. Finally, Xiaolong Zhang’s “Media Power: Cigarette Package Design in China” explores the conflicting messages cigarette package design is sending: On the one hand, as in many other countries, the cigarette pack is supposed to alert its users that smoking kills; on the other, it is supposed to attract users to exactly this habit. Zhang traces this conflict to the differing political and economic messages being sent by the authorities. For one, tax revenues from cigarettes are an import economic factor, as are jobs in the tobacco industry; for another, the long term costs of smokers’ health-care costs have recently begun to be higher than tobacco’s economic benefits. Up to here, the Chinese situation does not seem to be so much different from the rest of the world. But Zhang shows that in China there is a strong cultural element at play that is different from other countries, and that is the social component of smoking. Via focus groups, Zhang demonstrates that smoking is variably used to exhibit status, masculinity and relational sociability. It is these features that make anti-smoking campaigns even harder to run in China than elsewhere. Holger Briel Editor-in-Chief
... While in the United States, the prevalence of smoking has decreased over the past few decades, in the developing countries, this trend has not been observed, and therefore, it is very likely that for the next few years there is a predictable increase in the incidence rates of cancers. Apart from cigarette smoking, certain behavioral practices are much more prevalent in the developing countries that also contribute to the increase in certain cancers in these populations which include betel nut (especially when mixed with slate lime) [38], herbal cigarettes [39], and shisha (pot smoking) [40]. ...
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Cancer burden is increasing worldwide in the current century, and given that its management paradigm is associated with tremendous financial, social, and physiologic complications, it is imperative that nations prepare themselves for a comprehensive management program. The developed countries are barely able to cope up with the exponential increase in the cancer-related services, and the current situation in developing countries, that is, low- and middle-income countries (LMIC) is much worse. Here, we present a general guidance for establishment of a comprehensive cancer care program, delineating the current challenges and some suggestions/recommendations to overcome the obstacles in LMICs. We touch upon the major themes related to cancer care which include (1) medical services, data, and infrastructure, (2) human resources issues, (3) quality management and access to care, and (4) the public heath crises with respect to cancer. We hope that this chapter offers practical guidance to the private and public stakeholders to alleviate the current burden of cancer-related suffering.
... It is important to note that although HSPs are nicotine-free, other chemicals like carbon monoxide, polyaromatic hydrocarbons, etc., are equally harmful to the consumer and the people in proximity. 23,30,31 The likelihood of subsequent tobacco use among non-smokers is expected to increase manifold owing to the large variety of flavours available that makes the smoking products endearing and addictive. 32 International organizations and national government agencies, health professionals and researchers have implemented various education campaigns combined with multiple i n d i a n j o u r n a l o f t u b e r c u l o s i s x x x ( x x x x ) x x x policies that have generated significant awareness about tobacco abuse. ...
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Background Herbal smoking products (HSPs) are marketed as a safer alternative to tobacco. These are easily available at affordable prices in the online retail websites. This study aimed to analyze the HSP-related informational content available in the most popular online platforms. Methods Google, Yahoo, Bing and YouTube online platforms were searched for HSP related content using appropriate keywords. First 50 search results were retrieved and screened for potential eligibility. The included web-pages were categorized as video and still records. From each included record, information regarding source, primary theme, health benefits/hazards and tone was abstracted. Additionally, video production quality, like ratio and video power index was also computed for each video record. All included records were subjected to descriptive statistics and Chi-square test, as appropriate. Level of significance was set at <0.05. Results 174 still and 94 video records were included. 35.6% of the included still records were sourced by manufacturers/suppliers while that of scientific origin was 12.1%. 83% of the video-records was posted by general public. About 90% of the included records had not mentioned anything regarding age restrictions. 67.8% of the still records and 87.2% of the video records promoted the use of HSPs. Conclusions The informational content presented online is huge, mostly posted by the general public without any scientific rationale and exclusively favors the use of HSPs. There is no age restriction as to who can access the information, making this content easily accessible to people of all ages. Such spread of information may mislead the public in adopting the smoking of these herbal products. Since HSPs may act as a potential gateway to tobacco smoking, there is an urgent need to regulate the content available online.
... [16] Research has shown that alternative cigarettes are not safe as they deliver more tar nicotine, carbon monoxide [ Table 3] and thus are worse than regular tobacco products and later may lead to tobacco smoking and addiction. [9,17] The COTPA, Section 5 states that "No person engaged in or purported to be engaged in the production, supply or distribution of cigarettes or any other tobacco products shall advertise and no person having control over a medium shall cause to be advertised cigarettes or any other tobacco products through that medium and no person shall take part in any advertisement which directly or indirectly suggests or promotes the use or consumption of cigarettes or any other tobacco products." [5] Although the ban on the advertising of herbal cigarettes comes under the purview of COTPA section 5, there is no stringent law as far as ban on availability to minors because of being tobacco less and nicotine free. ...
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Unsupervised marketing strategies of alternative smoke have made the youth fall prey to herbal smoke in the form of herbal cigarettes and hookahs. The easy online access, exotic looks, and flavors; marketed as safer, healthy alternatives, as an aid to quit smoking has made global herbal cigarette and hookah market see soaring sales in the past decade. Various studies have proven their popularity among the youth and minors with perceptions of being safer and smart alternatives. The scientific studies have shown that herbal smoke is as harmful as tobacco smoke. The marketing strategies of smoke industry to capture the minors and young adults could result in another stronger lobby besides tobacco to be dealt with in coming years. This creates an urgent need for the laws to be reviewed and amended keeping in view the changing scenario.
... From 1996 to 2000, China invested about 4.2 billion yuan in the tobacco distribution system, and 16530 distribution points were established nationwide [3]. Yang et al. summarized the overall status of the smoking prevalence in China [4]. According to the first national tobacco use survey, conducted by the National Patriotic Health Campaign Committee in 1984, the average smoking rate among the Chinese population was 34.45%. ...
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This research chooses the method of narrative literature review to analyze the barriers in implementing tobacco regulatory policies in China and explore the strategies that can overcome these challenges. China is the world’s largest producer and consumer of tobacco products. Although the prevalence of cigarette smoking declined from 34.5% to 27.7% between 1984 and 2015, the reduction over the 30 years has been slow. Therefore, effective tobacco regulatory policies are necessary. However, as the tobacco industry is one of the major sources of government revenue and an indispensable part of the national economy, the implementation of tobacco regulatory policies faces many challenges. In terms of the institutional dimension, the ambiguous attitude of national institutions and tobacco companies’ development strategies impede the enforcement of tobacco policies. In addition, the primary economic barrier to tobacco control is the unwillingness of the government to raise value-added tax on tobacco. Finally, the social customs of exchanging individual cigarettes and gifting packaged cigarettes among adults and juveniles in China hinder the implementation of tobacco regulatory policies. In this case, a combined strategy of top-down and bottom-up approaches can remove these barriers, such as using the authoritative power to control tobacco use and raising non-smokers’ awareness of smoking risks and public education.
... Use of these products has substantial health consequences; for instance, the toxicant exposure of shisha can be equivalent to that of smoking up to 50 cigarettes. One of the major health concerns reported by smokers of herbal cigarettes was that they were just as carcinogenic as regular cigarettes [10] [11]. Furthermore, the use of these products is substantial among Sudanese adolescents: in 2007, 11% of males and 9.3% of females reported they were currently using shisha [12]. ...
... Herbal cigarettes, although they may not contain tobacco, yield tar and carbon monoxide when smoked, and are thus also dangerous to health (Chen et al. 2007a, Gan et al. 2009). ...
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The Scientific Committee on Emerging and Newly Identified Health Risks (SCENIHR) has been asked to evaluate the role of tobacco additives in the addictiveness and attractiveness of tobacco products.The criteria for dependence established in humans indicate that tobacco has a high addictive potential, but it remains difficult to assess the addictiveness of individual additives. In animal studies the addictive potency of the final tobacco product cannot be assessed. The reinforcing potency of drugs is measured after intravenous injections and suggests that the abuse liability of pure nicotine is weaker than the addictive potential of tobacco products in humans. The currently used methods to define addictiveness of nicotine and additives are thus not considered adequate. In humans, the positive correlation between tobacco consumption and dependence suggests that individuals with high nicotine levels in their blood are more dependent. In animal studies using self-administration, an inverted U-shaped dose-response curve has generally been revealed suggesting that the addictiveness of nicotine is not directly linear with the dose. There is however substantial variation in the response to nicotine in both animals and humans, and genetic factors probably play an important role. No tobacco additives which are addictive by themselves have so far been identified. However, sugars, polysaccharides and cellulose fibres which are naturally present in tobacco, or sugars added in high quantities to most tobacco products, give rise to numerous aldehydes, such as acetaldehyde, in tobacco smoke. Acetaldehyde given intravenously is self-administered and enhances the addictiveness of nicotine in experimental animals. Additives that facilitate deeper inhalation (e.g. menthol) or inhibit the metabolism of nicotine may enhance the addictiveness of nicotine indirectly. Substances such as ammonia that increase the pH of the tobacco and the smoke, result in higher amounts of uncharged nicotine. However, it is uncertain if more nicotine is absorbed with higher smoke pH. For smokeless tobacco it seems that an increased pH enhances nicotine absorption in the mouth. The methods used to quantify the addictive potency of additives have limitations because of technical challenges in experimentally manipulating the presence or absence of an additive in a tobacco product. Such experiments require large technical and financial resources. In addition, there are ethical issues if testing in humans is considered. Due to these limitations, the available methodologies are not considered adequate. A number of technical characteristics of cigarettes (paper, filter, packing, geometry) influence the content of different substances in the smoke and the size of smoke particles. Many smokers compensate for a lower dose of nicotine by increasing puff volume and frequency, and by deeper inhalation. The particle size of the smoke aerosol does not seem to substantially influence the exposure to nicotine. The technical characteristics of cigarettes may thus modulate smoking behaviour but it is uncertain if this leads to a higher risk of addiction. Attractiveness is defined as the stimulation to use a product. The attractiveness of tobacco products may be increased by a number of additives but is also influenced by external factors such as marketing, price etc. Animal models do not currently exist for the assessment of attractiveness. In humans, the attractiveness of individual tobacco products may be compared in panel studies, surveys, and by experimental measures. Another method is to experimentally adjust tobacco products to exclude or include individual additives and test responses to them. However, this type of research is difficult due to ethical considerations that will usually preclude human testing of tobacco products, particularly among non-users or children. The use of fruit and candy flavours seems to favour smoking initiation in young people. Menthol also attracts a number of smokers, in particular African Americans. Some additives decrease the harshness and increase the smoothness of the smoke. Certain additives yield a full and white smoke and other additives reduce the lingering odour of the smoke in order to favour the acceptability of smoking to people around. Additives considered attractive may in principle lead to brand preference or a higher consumption of tobacco products. However, it remains difficult to distinguish the direct effects of these additives from indirect effects such as the marketing towards specific groups.
In the treatment of tobacco use disorder, current approaches focus on pharmacotherapy, nicotine replacement, and psychotherapy. However, traditional treatments have been widely used in societies for the purpose of smoking cessation for years. Although cases using traditional herbs in the self-treatment of addiction have been reported in the literature, studies on this subject are very limited. Research on certain herbs shows that they may be effective in the treatment of tobacco use disorder by different mechanisms, however, there is no evidence that they are safe to consume as cigarettes. This article aims to question the place of traditional herbs in tobacco use disorder treatment through a case who started to smoke Melissa officinalis herb to help his nicotine withdrawal.
Objective To assess the online availability and e-marketing strategies of herbal smoking products (HSPs). Methodology Google, Yahoo and Bing were searched using relevant keywords related to HSPs. The first 50 records were retrieved and duplicates were removed. Two trained and calibrated authors screened the records according to the eligibility criteria and extracted data from each selected retail-webpage as per the pre-tested data extraction form. Results Out of the initial 1044 records obtained, 73 retail webpages were finally included. Most of the webpages about HSPs hailed from India followed by the USA. The results showed 24 brands with about 189 flavour variants that are readily available online to all age groups including minors, with price per pack (20 sticks) of herbal cigarettes ranging from INR (₹) 51 to 1830 (median 588). There are no regulations regarding the sale and marketing of HSPs concerning age restrictions and display of health warnings. Conclusion HSPs are readily available online at affordable prices and attractive variants for customers of all ages. The flavour appeal and the health benefit appeal is being used to target minors and young women. There is an urgent need for some regulations on the sale and e-marketing of such products that have an enormous potential to be used as a gateway to tobacco smoking.
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To describe the development and health claims of Asian herbal-tobacco cigarettes. Analysis of international news sources, company websites, and the transnational tobacco companies' (TTC) documents. PubMed searches of herbs and brands. Twenty-three brands were identified, mainly from China. Many products claimed to relieve respiratory symptoms and reduce toxins, with four herb-only products advertised for smoking cessation. No literature was found to verify the health claims, except one Korean trial of an herb-only product. Asian herbal-tobacco cigarettes were initially produced by China by the 1970s and introduced to Japan in the 1980s. Despite initial news about research demonstrating a safer cigarette, the TTC analyses of these cigarettes suggest that these early products were not palatable and had potentially toxic cardiovascular effects. By the late 1990s, China began producing more herbal-tobacco cigarettes in a renewed effort to reduce harmful constituents in cigarettes. After 2000, tobacco companies from Korea, Taiwan, and Thailand began producing similar products. Tobacco control groups in Japan, Taiwan, and Thailand voiced concern over the health claims of herbal-tobacco products. In 2005, China designated two herbal-tobacco brands as key for development. Asian herbal-tobacco cigarettes claim to reduce harm, but no published literature is available to verify these claims or investigate unidentified toxicities. The increase in Asian herbal-tobacco cigarette production by 2000 coincides with the Asian tobacco companies' regular scientific meetings with TTCs and their interest in harm reduction. Asia faces additional challenges in tobacco control with these culturally concordant products that may discourage smokers from quitting.
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Nicotine underlies tobacco addiction, influences tobacco use patterns, and is used as a pharmacological aid to smoking cessation. The absorption, distribution and disposition characteristics of nicotine from tobacco and medicinal products are reviewed. Nicotine is metabolized primarily by the liver enzymes CYP2A6, UDPglucuronosyltransferase (UGT), and flavin-containing monooxygenase (FMO). In addition to genetic factors, nicotine metabolism is influenced by diet and meals, age, sex, use of estrogen-containing hormone preparations, pregnancy and kidney disease, other medications, and smoking itself. Substantial racial/ethnic differences are observed in nicotine metabolism, which are likely influenced by both genetic and environmental factors. The most widely used biomarker of nicotine intake is cotinine, which may be measured in blood, urine, saliva, hair, or nails. The current optimal plasma cotinine cut-point to distinguish smokers from non-smokers in the general US population is 3 ng ml(-1). This cut-point is much lower than that established 20 years ago, reflecting less secondhand smoke exposure due to clear air policies and more light or occasional smoking.
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Exposure to secondhand tobacco smoke (SHS) has been linked to increased risk for a number of diseases, including lung cancer. The tobacco-specific nitrosamine 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) is of particular interest due to its potency and its specificity in producing lung tumors in animals. The NNK metabolite 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) in urine is frequently used as a biomarker for exposure. Due to its long half-life (40-45 days), NNAL may provide a long-term, time-averaged measure of exposure. We developed a highly sensitive liquid chromatography-tandem mass spectrometry method for determination of NNAL in human urine. The method involves liquid-liquid extraction followed by conversion to the hexanoate ester derivative. This derivative facilitates separation from interfering urinary constituents by extraction and chromatography and enhances detection with electrospray ionization mass spectrometry. The lower limit of quantitation is 0.25 pg/mL for 5-mL urine specimens. Applications to studies of people with a range of different SHS exposure levels is described.
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Numerous studies have quantified total cotinine (the sum of cotinine and cotinine-N-glucuronide) and total 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol [NNAL; the sum of NNAL and its O- and N-glucuronides (NNAL-Glucs)] in the urine and blood of smokers, smokeless tobacco users, and nonsmokers exposed to environmental tobacco smoke. Analysis of hair and nails has several advantages over blood and urine testing, such as accumulation of xenobiotics during long-term exposure, ease of collection, and indefinite stability of samples. We developed sensitive methods for quantitation of nicotine, cotinine, and NNAL in human toenails. Nicotine and cotinine were analyzed by gas chromatography-mass spectrometry-selected ion monitoring. NNAL was assayed using liquid chromatography-electrospray ionization-tandem mass spectrometry-selected reaction monitoring. The detection limits of the methods were 0.01 ng/mg toenail for nicotine, 0.012 ng/mg toenail for cotinine, and 0.02 pg/mg toenail for NNAL. In 35 smokers, the mean nicotine level was 5.9 +/- 5.6 ng/mg toenail, mean cotinine was 1.6 +/- 1.3 ng/mg toenail, and mean NNAL was 0.41 +/- 0.67 pg/mg toenail. Samples collected from six nonsmokers were negative for NNAL. In smokers, NNAL correlated with cotinine (r = 0.77; P < 0.0001). The results of this study for the first time show the presence of cotinine and NNAL in human toenails. These sensitive and quantitative methods should be useful in epidemiologic studies of the role of chronic tobacco smoke exposure, including environmental tobacco smoke exposure, in human cancer.
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Recently, we developed sensitive and quantitative methods for analysis of the biomarkers of tobacco smoke exposure nicotine, cotinine, and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) in human toenails. In this study, we further evaluated the newly developed toenail biomarkers by investigating their relationship to demographic factors, reported exposure, plasma nicotine, cotinine, and trans-3'-hydroxycotinine, and urinary NNAL. Toenails of 105 smokers, mean age 38.9 years (range, 19-68), were analyzed. Fifty-five (53.4%) were male, with approximately equal numbers of Whites and African-Americans. The average number of cigarettes smoked per day was 18 (range, 5-50). There was no effect of age or gender on the toenail biomarkers. Toenail NNAL was higher in White than in African-American participants (P = 0.019). Toenail nicotine and toenail cotinine correlated significantly with cigarettes smoked per day (r = 0.24; P = 0.015 and r = 0.26; P = 0.009, respectively). Toenail nicotine correlated with plasma nicotine (r = 0.39; P < 0.001); toenail cotinine correlated with plasma cotinine (r = 0.45; P < 0.001) and plasma trans-3'-hydroxycotinine (r = 0.30; P = 0.008); and toenail NNAL correlated with urine NNAL (r = 0.53; P = 0.005). The results of this study provide essential validation data for the use of toenail biomarkers in investigations of the role of chronic tobacco smoke exposure in human cancer.
The nicotine metabolite cotinine is widely used to assess the extent of tobacco use in smokers, and secondhand smoke exposure in non-smokers. The ratio of another nicotine metabolite, trans-3'-hydroxycotinine, to cotinine in biofluids is highly correlated with the rate of nicotine metabolism, which is catalyzed mainly by cytochrome P450 2A6 (CYP2A6). Consequently, this nicotine metabolite ratio is being used to phenotype individuals for CYP2A6 activity and to individualize pharmacotherapies for tobacco addiction. In this paper we describe a highly sensitive liquid chromatography-tandem mass spectrometry method for determination of the nicotine metabolites cotinine and trans-3'-hydroxycotinine in human plasma, urine, and saliva. Lower limits of quantitation range from 0.02 to 0.1ng/mL. The extraction procedure is straightforward and suitable for large-scale studies. The method has been applied to several thousand biofluid samples for pharmacogenetic studies and for studies of exposure to low levels of secondhand smoke. Concentrations of both metabolites in urine of non-smokers with different levels of secondhand smoke exposure are presented.
Measurement of human urinary carcinogen metabolites is a practical approach for obtaining important information about tobacco and cancer. This review presents currently available methods and evaluates their utility. Carcinogens and their metabolites and related compounds that have been quantified in the urine of smokers or non-smokers exposed to environmental tobacco smoke (ETS) include trans,trans-muconic acid (tt-MA) and S-phenylmercapturic acid (metabolites of benzene), 1- and 2-naphthol, hydroxyphenanthrenes and phenanthrene dihydrodiols, 1-hydroxypyrene (1-HOP), metabolites of benzo[a]pyrene, aromatic amines and heterocyclic aromatic amines, N-nitrosoproline, 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol and its glucuronides (NNAL and NNAL-Gluc), 8-oxodeoxyguanosine, thioethers, mercapturic acids, and alkyladenines. Nitrosamines and their metabolites have also been quantified in the urine of smokeless tobacco users. The utility of these assays to provide information about carcinogen dose, delineation of exposed vs. non-exposed individuals, and carcinogen metabolism in humans is discussed. NNAL and NNAL-Gluc are exceptionally useful biomarkers because they are derived from a carcinogen- 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK)- that is specific to tobacco products. The NNAL assay has high sensitivity and specificity, which are particularly important for studies on ETS exposure. Other useful assays that have been widely applied involve quantitation of 1-HOP and tt-MA. Urinary carcinogen metabolite biomarkers will be critical components of future studies on tobacco and human cancer, particularly with respect to new tobacco products and strategies for harm reduction, the role of metabolic polymorphisms in cancer, and further evaluation of human carcinogen exposure from ETS.
Polycyclic aromatic hydrocarbons (PAHs) are ubiquitous environmental contaminants, and a number of them are carcinogenic. One approach for measuring exposure to them is to determine the concentrations of metabolites in urine. The pyrene metabolite 1-hydroxypyrene has been used as a biomarker for exposure in numerous studies. However, determination of exposure to several PAHs may be advantageous, since the relative amounts may vary depending upon the exposure source. We developed a liquid chromatography-tandem mass spectrometry method for the determination of phenolic metabolites of naphthalene, fluorene, phenanthrene, and pyrene in human urine. Following enzymatic cleavage of the glucuronide and sulfate conjugates, the phenolic metabolites are extracted from urine and converted to pentafluorobenzyl ethers. These derivatives greatly enhance the sensitivity of detection by atmospheric pressure chemical ionization in the negative ion mode. Lower limits of quantitation range from 0.01 to 0.5 ng/mL. Stable isotope-labeled internal standards were synthesized or obtained commercially. Data on urinary excretion of several PAH metabolites in urine of smokers and nonsmokers are presented.
Herbal Cigarettes in China: Not Quite Healthy
  • X Lu
Lu X. Herbal Cigarettes in China: Not Quite Healthy, But. British American Tobacco 1988:325304611-2.
The application of Shennong Extract in reducing harms from smoking
  • H Huang
  • M Zhu
  • M Zhao
Huang H, Zhu M, Zhao M. The application of Shennong Extract in reducing harms from smoking. Proceedings of the Symposium on the Harmonious Development of Tobacco Production, Human Health and Environmental Protection.