Quitting smoking early linked with improved survival rates for people diagnosed with lung cancer l

Peer-Reviewed Publication

HARVARD T.H. CHAN SCHOOL OF PUBLIC HEALTH

Key points:

• Among those diagnosed with non-small cell lung cancer—the most common form of lung cancer—current smokers had 68% higher mortality and former smokers had 26% higher mortality compared to never smokers
• The longer a patient had gone without smoking pre-diagnosis, the more improved their odds of survival were
• The study is one of few to examine mortality not just among current and never smokers, but also among former smokers—enabling more robust findings about the impacts of smoking cessation

Boston, MA—Quitting smoking early was associated with higher survival rates following a lung cancer diagnosis, according to a new study led by researchers at Harvard T.H. Chan School of Public Health. Compared to those who never smoked and were being treated for non-small cell lung cancer (NSCLC), current smokers had 68% higher mortality and former smokers had 26% higher mortality.

“Our participants’ smoking histories varied, with some having stopped smoking a few years before their diagnosis and others having stopped several decades before,” said senior author David Christiani, Elkan Blout Professor of Environmental Genetics. “This wide range gave us confidence in our results—that the benefit of pre-diagnosis smoking cessation persists even after lung cancer is diagnosed.”

The study will be published online in JAMA Network Open on May 5, 2023.

While most similar research has compared mortality among current smokers and never smokers, the majority of the study’s participants were former smokers, allowing the researchers to focus on the impacts of smoking cessation.

The study followed 5,594 patients with NSCLC—which accounts for 85% of all lung cancer cases—enrolled in the Boston Lung Cancer Survival Cohort at Massachusetts General Hospital between 1992 and 2022. Of these participants, 795 had never smoked; 3,308 were former smokers; and 1,491 were current smokers. Participants completed questionnaires about their smoking habits and other health and demographic information at baseline, with the researchers checking in on their survival every 12 to 18 months. During the study period, 3,842 of the participants died: 79.3% of the current smokers, 66.8% of the former smokers, and 59.6% of the never smokers.

While never smoking was associated with the best odds of survival after a lung cancer diagnosis, the findings showed significant associations between lower mortality and having quit smoking pre-diagnosis. The longer a patient went without smoking, the more health benefits they accrued: For former smokers, doubling the years of smoking cessation before their lung cancer diagnosis was significantly associated with prolonged survival. Conversely, doubling smoking-pack years was associated with shorter survival among current and former smokers diagnosed with NSCLC.

The researchers noted that associations between survival and smoking history may vary depending on the clinical stage at which lung cancer was diagnosed, and that the study did not account for the different kinds of treatment participants were receiving.

Other Harvard Chan School co-authors included Xinan Wang, Christopher Romero-Gutierrez, and Jui Kothari.

Funding for the study came from National Cancer Institute grant 5U01CA209414.

“Prediagnosis smoking cessation and overall survival among patients with non-small cell lung cancer,” Xinan Wang, Christopher W. Romero-Guttierez, Jui Kothari, Andrea Shafer, Yi Li, David C. Christiani, JAMA Network Open, online May 5, 2023, doi: 10.1001/jamanetworkopen.2023.11966

Visit the Harvard Chan School website for the latest news, press releases, and multimedia offerings.

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Harvard T.H. Chan School of Public Health brings together dedicated experts from many disciplines to educate new generations of global health leaders and produce powerful ideas that improve the lives and health of people everywhere. As a community of leading scientists, educators, and students, we work together to take innovative ideas from the laboratory to people’s lives—not only making scientific breakthroughs, but also working to change individual behaviors, public policies, and health care practices. Each year, more than 400 faculty members at Harvard Chan School teach 1,000-plus full-time students from around the world and train thousands more through online and executive education courses. Founded in 1913 as the Harvard-MIT School of Health Officers, the School is recognized as America’s oldest professional training program in public health.

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JOURNAL

JAMA Network Open

DOI

10.1001/jamanetworkopen.2023.11966 

METHOD OF RESEARCH

Observational study

SUBJECT OF RESEARCH

Not applicable

ARTICLE TITLE

Prediagnosis smoking cessation and overall survival among patients with non-small cell lung cancer

ARTICLE PUBLICATION DATE

5-May-2023

New Survey Data Cast Further Doubt on the FDA's Opposition to Flavored E-Cigarettes

The "epidemic" of adolescent vaping seems to be fading fast, and vaping is replacing smoking among adults, a harm-reducing trend that regulators seem determined to discourage.

JACOB SULLUM | 8.25.2022 

REASON MAGAZINE

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FDA Commissioner Robert Califf (Michael Brochstein/Zuma Press/Newscom)

A federal appeals court this week sided with several companies whose applications to sell nicotine vaping products in a variety of flavors were rejected by the Food and Drug Administration (FDA). As Reason's Elizabeth Nolan Brown noted yesterday, the U.S. Court of Appeals for the 11th Circuit ruled that the FDA's decisions were "arbitrary and capricious" because the agency ignored marketing and age-verification plans aimed at preventing underage vaping. But as Judge Robin Rosenbaum noted in her dissent, the manufacturers' victory probably will be short-lived, because the FDA seems dead set against allowing the sale of vaping products in flavors other than tobacco.

That position is puzzling, since former smokers who have switched to vaping overwhelmingly prefer nontobacco flavors, and the FDA acknowledges that "electronic nicotine delivery systems" (ENDS) hold great promise as a harm-reducing alternative to cigarettes. But the FDA insists there is no solid evidence that flavor variety makes vaping more appealing to adult smokers, even as it worries that flavor variety makes vaping more appealing to teenagers. So when the FDA reconsiders these applications on remand from the 11th Circuit, it is almost certain to reject them again, notwithstanding the steps that the companies are taking to keep their products away from underage consumers

The FDA's opposition to flavor variety is driven by concern about an "epidemic" of adolescent vaping. But as new survey data from the government-sponsored Monitoring the Future (MTF) study confirm, the surge in electronic cigarette use by teenagers that alarmed the FDA in 2018 and 2019 is already receding, even though adults can still buy flavored ENDS that remain on the market because the FDA has not yet decided whether to allow them or has not taken enforcement action against them. Those data also indicate that adolescent smoking continued to decline as vaping became more popular. The picture is similar for young adults: As vaping continued to rise among 19-to-30-year-olds in 2021, cigarette smoking hit a record low.

These trends suggest that we are seeing precisely the sort of harm-reducing substitution that the FDA claims to want. The data certainly are not consistent with the idea that the availability of ENDS has resulted in more smoking. Yet Judge Rosenbaum, who seems to think the FDA's opposition to flavored ENDS is well-grounded, avers that "vaping has been shown to be a gateway to smoking combustible cigarettes." She cites no evidence to support that claim, which seems highly implausible in light of the continuing decline in smoking among teenagers and adults.

The annual MTF survey, which University of Michigan researchers conducts under contract with the National Institute on Drug Abuse, includes students in the eighth, 10th, and 12th grades. In 2021, it shows, the prevalence of past-month nicotine vaping fell sharply in all three grades.

That rate peaked at 10.5 percent in 2020 among eighth-graders before falling to 7.6 percent last year. Among 10th- and 12th-graders, it peaked at 19.9 percent and 25.5 percent, respectively, in 2019 and had fallen to 13.1 percent and 19.6 percent, respectively, by last year. Between 2019 and 2021, the prevalence of "daily" vaping (defined as use on 20 or more occasions in the previous 30 days) fell from 2 percent to 1.1 percent among eighth-graders, from 6.8 percent to 2.5 percent among 10th-graders, and from 11.6 percent to 5.4 percent among 12th-graders.

These findings are broadly consistent with results from the National Youth Tobacco Survey (NYTS), which is sponsored by the Centers for Disease Control and Prevention (CDC). That survey shows the prevalence of past-month e-cigarette use by high school students peaking at 27.5 percent in 2019 before falling to 11.3 percent in 2021. Even though adults still have access to ENDS in a variety of flavors, the "epidemic" decried by the FDA and the CDC seems to be fading fast.

Neither survey provides any evidence of the "gateway" that Rosenbaum perceives. On the contrary, the downward trend in adolescent smoking continued even when vaping was rising sharply. Among 12th-graders in the MTF survey, the prevalence of past-month cigarette smoking fell from 10.3 percent in 2011 to 2 percent in 2021. During the same period, the prevalence of "daily" cigarette smoking fell from 4.3 percent to 0.8 percent. In the NYTS, the prevalence of past-month cigarette smoking among high school students fell from 15.8 percent in 2011 to 1.9 percent last year.

There is reason to think that ENDS, far from interfering with the decline in adolescent smoking, hastened that downward trend, which accelerated as vaping took off. The replacement of smoking by vaping is indisputably an improvement in terms of "public health," which the FDA claims to be promoting. But the agency instead portrays it as a grave danger to the youth of America. When it comes to teenagers, the FDA refuses even to consider the positive impact of such substitution.

A 2019 analysis of NYTS data found that frequent e-cigarette use was concentrated among teenagers who were current or former smokers. So far the recent decline in adolescent vaping has not led to an uptick in smoking, which makes sense if casual users, rather than teenagers who vape instead of smoking, account for most of the drop. But the FDA should be wary of any policy that makes cigarettes easier to obtain than ENDS or makes ENDS less appealing to people who otherwise would be smoking. Over the long term, the upshot could be more rather than fewer smoking-related deaths.

Logically, that analysis should include teenagers as well as adults. But the FDA insists that the health benefits of substituting ENDS for cigarettes don't count when vapers are younger than 21. So let's consider what the MTF data tell us about the potential cost of refusing to let adults buy the vaping products they demonstrably want.

"Cigarette smoking among young adults has been declining steadily since
2004 and reached new historic lows in 2021," an MTF report notes. "Cigarette use in the past 30 days decreased by more than half in the past decade," from 21.2 percent in 2011 to 9 percent in 2021.

In recent years, that downward trend in smoking by 19-to-30-year-olds has been accompanied by an upward trend in vaping. "Since it was first measured in 2017,
nicotine vaping in the past 30 days has nearly tripled among young adults to 16.1% in 2021," the report says. "Nicotine vaping in the past 12 months was reported by 21.8%, just below the all-time high of 23.6% in 2019."

Between 2017 and 2021, as the prevalence of past-month vaping in this age group rose by 160 percent, the prevalence of past-month cigarette smoking fell by 39 percent. Those trends are not consistent with Rosenbaum's theory that more vaping means more smoking. But they are consistent with the theory that many young adults are choosing to vape instead of smoke.

The FDA ostensibly would like to see more of that. The whole premise of approving the sale of ENDS as "appropriate for the protection of the public health"—the standard the FDA is supposed to apply under the Family Smoking Prevention and Tobacco Control Act—is that it will help reduce tobacco-related morbidity and mortality by offering smokers a much less hazardous way to consume nicotine. Yet the FDA claims to be unpersuaded that flavor variety plays an important role for smokers who have made that potentially lifesaving switch or might be interested in doing so.

The FDA contradictorily insists that flavor variety is important to teenagers. It thinks at least some of them will eschew vaping if tobacco is the only flavor they can find. The possibility that some teenagers therefore will smoke instead does not enter into the FDA's calculations at all. And it dismisses the danger that the same thing will happen among adults, saying ENDS manufacturers have not produced enough evidence to that effect.

Contrary to its legal duty, the FDA has not carefully weighed the costs and benefits of its supposedly youth-protecting policy. Instead, it refuses to admit there are any costs to consider.

Medication may help heavy-drinking smokers improve their health

UCLA study provides evidence that varenicline can aid them in quitting smoking, reducing drinking

UNIVERSITY OF CALIFORNIA - LOS ANGELES

Research News

 

IMAGE: LARA RAY, A UCLA PROFESSOR OF PSYCHOLOGY AND OF PSYCHIATRY AND BIOBEHAVIORAL SCIENCES WHO HOLDS UCLA'S SHIRLEY M. HATOS CHAIR IN CLINICAL NEUROPHARMACOLOGY. view more 

CREDIT: ELENA ZHUKOVA

A recent UCLA clinical trial has shown encouraging results in helping daily smokers who are also heavy drinkers quit smoking and cut down their alcohol intake.

The study of 165 people tested two prescription drugs -- varenicline, for smoking addiction, and naltrexone, which is used to treat alcoholism. Studies have shown that varenicline, marketed under the brand name Chantix, may also be effective in reducing alcohol consumption.

Participants, who ranged in age from 21 to 65, smoked at least five cigarettes a day, with male participants generally consuming more than 14 drinks a week and women more than seven per week.

Over the 12-week study period, each participant received 2 milligrams of varenicline twice a day. Roughly half the group -- 83 participants -- also received a 50-milligram dose of naltrexone daily, while the other 82 received placebo pills. They were all told to quit smoking and drink less.

When researchers followed up 26 weeks after the study's conclusion, they found that nearly 36% -- 59 participants -- had quit smoking.

"The overall smoking quit rate in the trial is impressive," said lead author Lara Ray, a professor of psychology and of psychiatry and biobehavioral sciences who holds UCLA's Shirley M. Hatos Chair in Clinical Neuropharmacology. She noted that previous studies have suggested varenicline has a success rate at six months of about 25% to 30%.

"We exceeded the overall expectation for this medication," she said. "This is especially important in a diverse group of people." Ray said that while some previous studies have shown lower-than-average smoking cessation rates among Black participants, that was not the case in the current trial, in which more than half of participants were Black.

Surprisingly, the researchers said, those who had received varenicline plus a placebo had a significantly higher smoking quit rate (45%, or 37 of 82 participants) than those who were given varenicline and naltrexone (27%, or 22 of 83 participants).

"The quit rate for varenicline alone in this sample is highly encouraging, as this is the first large-scale trial of varenicline efficacy focused solely on heavy-drinking smokers," Ray said.

While participants who received varenicline plus naltrexone had a lower smoking quit rate, they had slightly better success than the placebo group at curbing their drinking. At the start of the study, participants averaged nearly seven drinks per drinking day; those on the varenicline-naltrexone combination reduced their consumption to three drinks per drinking day over the 12-week study period, while those receiving the varenicline-placebo combination cut down to four drinks -- both impressive decreases, Ray said.

"I am excited about both the smoking cessation rates and the drinking reductions," said Ray, who is also a member of UCLA's Brain Research Institute. "These findings suggests that desirable outcomes for smoking cessation and drinking reduction are achievable."

The study, which found no difference in quit and reduction rates between men and women, was published online in the American Journal of Psychiatry June 3 and is scheduled for publication in the journal's September print issue.

Approximately 20% to 25% of smokers are also heavy drinkers. Smoking and heavy drinking are major public health concerns that reduce people's life span and quality of life, and both have also been linked to worse health outcomes for COVID-19.

As with all addictions, quitting smoking and reducing drinking are difficult and complex processes. This study confirms that medications can play a role, Ray said, but she noted that it can be challenging for patients to take more than one prescribed medication.

"Varenicline alone is doing a great job, and this trial indicates that there is not much room for naltrexone to make a difference," Ray said. "But even medications like varenicline have their limitations. Medication is only part of the solution. There remains much research to be done on addictions and how to treat them."

Ray says that those who wish to quit smoking and reduce drinking may consider talking to their doctor about the possibility of using varenicline, and she recommends that they try to quit smoking and reduce their drinking at the same time.

"There is evidence that varenicline can help them with both," Ray said. "Varenicline appears quite effective at reducing drinking and helping people to quit smoking. Given that varenicline has been found to reduce drinking in trials for alcohol use disorder, it is possible that its effects on both drinking and smoking present an optimal alternative for this group of heavy-drinking smokers."

ReJoyce Green, a UCLA doctoral student in clinical psychology who works with Ray, and Karen Miotto, a UCLA clinical professor of psychiatry and the medical director of the clinical trial, are among the study's 14 authors.

The clinical trial and Ray's research are funded by the National Institute on Drug Abuse and the National Institute on Alcohol Abuse and Alcoholism, both part of the National Institutes of Health.

The study was conducted between July 2015 and December 2019 at an outpatient research facility at UCLA.

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UVA Health, community pharmacies partner to help Appalachia residents quit smoking

Collaboration tests effectiveness of several smoking cessation approaches

Grant and Award Announcement

UNIVERSITY OF VIRGINIA HEALTH SYSTEM

 

IMAGE: UVA SCHOOL OF MEDICINE RESEARCHER MELISSA LITTLE, PHD, MPH, IS LEADING AN INITIATIVE TO HELP MORE RESIDENTS OF RURAL APPALACHIA QUIT SMOKING. view more 

CREDIT: UVA HEALTH

Fourteen independent community pharmacies will team with UVA Health to help residents of rural Appalachia quit smoking and test the effectiveness of multiple smoking cessation programs, including one based on text messaging. The project ultimately aims to lower the region’s cancer rates, which are among the highest in the country.

Backed by more than $5 million in funding from the National Cancer Institute, 14 pharmacies selected for the program in Virginia, Kentucky, North Carolina, West Virginia and Tennessee will participate in the study. 

“It is clear that publicly available smoking cessation resources are not reaching residents in this region,” said Melissa Little, PhD, MPH, a researcher in the UVA School of Medicine’s Department of Public Health Sciences and the leader of this initiative. “We are hoping that by working with local community pharmacies, we’ll be able to help more smokers interested in quitting who otherwise may not have sought help with their quit attempt.”

The Impact of Smoking in Appalachia

Rural Appalachia has some of the highest smoking rates in the United States. For example, an analysis of data from 2015 to 2019 found the smoking rate in rural Appalachian counties was 20.9%, compared with a statewide smoking rate of 13.3%. Higher rates of cancer in rural Appalachia can be attributed to smoking, Little said, as studies have shown that cigarette smoking is estimated to account for 30% of all cancer deaths and 90% of all lung cancer deaths.

However, residents of rural Appalachia are less likely to take advantage of commonly available resources to quit smoking – such as phone counseling and nicotine-replacement therapy – which Little suspects may be due to the shortage of healthcare providers in the region.

She believes community pharmacists based in rural Appalachia are ideally positioned to help residents quit smoking.

“We conducted a small demonstration study in partnership with Gates Pharmacy, a community pharmacy in Mt. Airy, N.C., to determine the feasibility of the approach,” Little said. “Overall, the project was well received by both participants interested in quitting as well as the Gates pharmacists and technicians.”

“The process of recruiting and enrolling patients was simple, the intervention guides were clear and easy to follow, and our entire staff was able to contribute in their own way to the success of the project,” said Hayley Wood, the pharmacy manager at Gates Pharmacy.

The program will evaluate the effectiveness of different combinations of smoking cessation programs. All 768 participants will receive nicotine replacement therapy through gum, a patch or both. 

Additionally, participants will be randomly selected to participate in one of three programs:

• QuitAid: Participants will have one in-person meeting and five follow-up sessions by phone over a month with a pharmacist, who will provide support and help address any questions or concerns about the nicotine-replacement therapy.
• Tobacco Quitline: Participants will have four 20- to 30-minute phone calls over four weeks from a trained tobacco treatment specialist working on the project to assist them in quitting smoking and preventing relapse.
• SmokefreeTXT: A text messaging program developed by the National Cancer Institute that sends participants three to five text messages per day for seven weeks to assist participants in quitting and preventing relapses.

For More Information

The study is expected to begin in April 2023. Pharmacies and smokers interested in the program can learn more by emailing Quitaid@hscmail.mcc.virginia.edu or by calling study coordinator Taylor Reid at 434.924.8894.

UK

Boris Johnson’s former food tsar attacks Sunak’s smoking ban: ‘Odd to prioritise cigarettes over fast food’


Archie Mitchell and Rebecca Thomas
Thu, 5 October 2023 


Boris Johnson’s former food tsar has launched an attack on Rishi Sunak’s smoking ban, saying it is “odd” to prioritise tackling cigarettes over junk food, as health leaders pile pressure on the prime minister to do more to address the growing obesity crisis.

Henry Dimbleby told The Independent that smoking is “far less” of a health issue than a poor diet, adding that smoking rates among young people are already “in freefall”.

The celebrity chef and founder of the Leon restaurant chain said that whatever government is in power in 10 years’ time will be “crippled” by the obesity crisis, and called on the prime minister to do more to tackle the issue.

NHS bosses and a former Tory health minister are among a chorus of voices urging Mr Sunak to do more to curb junk food, which they say is fuelling an obesity epidemic.

It comes after Mr Sunak used his Conservative Party conference speech to announce a proposal that would effectively ban cigarettes for anyone now aged 14 or under, by raising the age at which it is legal to purchase cigarettes by one year every year.

Mr Dimbleby told The Independent: “It seems odd to choose to go after smoking when it is already far less of a health problem than poor diet. Smoking rates are in freefall among young people.

“By 2035, the NHS is forecast to spend more treating type 2 diabetes – just one diet-related health condition – than it does today on all cancers. And it isn’t just that our diet is making us sick. It is making us poor, too. The four most common conditions keeping 2.5 million people out of work are muscular-skeletal conditions, type 2 diabetes, hypertension, and mental [illness].

“Three of those are directly caused by poor diet, and one is exacerbated by it. Whatever government is in power in 10 years’ time will be crippled by the social and economic problems caused by diet-related ill health, if we don’t act now.”

Mr Dimbleby’s intervention came after an irritable Mr Sunak defended the policy in a terse interview with the BBC, insisting that cigarettes are “different to a pack of crisps or a piece of cake”.

Henry Dimbleby said poor diets are making people sick and poor as he called on Sunak to act (Rex Features/Jason Alden)

Grilled over why he had undone plans to tackle obesity on the grounds of protecting people’s freedoms, Mr Sunak said smoking was “fundamentally different”.

The prime minister said smoking is “unequivocally the single biggest preventable cause of death, disability and illness in our society”.

But research from BioMed Central in 2021 showed that obesity now accounts for more deaths in England and Scotland than smoking among people in middle and old age. National strategies to address adiposity should be a public health priority, it said.

It follows Mr Sunak delaying measures contained in the government’s anti-obesity strategy until October 2025, saying that he “firmly believes in people’s right to choose”. The rules, which would have banned two-for-one junk-food deals, had already been pushed back and were originally planned to come into force this month.

Tam Fry, a spokesperson for the National Obesity Forum, said Mr Sunak’s smoking ban had “diverted attention from obesity, which is actually far more serious in terms of early death”.

Mr Fry told The Independent that obesity is on course to overtake smoking as the leading cause of cancer.

Asked about the difference between banning smoking and restricting fast-food consumption, Mr Fry said: “Addiction is the crux here. You can be addicted to fast food, but you’re more likely to be addicted to smoking. And once it has gripped you, a lot of people suffer tremendously from it.”

He added that both are “fundamental public health issues” that need to be tackled. But he said: “The issue of fast food, and the fact that it’s got to such a degree now that it may well overtake smoking as a cause of cancer, in my opinion is far more serious.”

Former Tory health ministerJames Bethell also urged the PM to crack down on obesity, saying the smoking ban should be a “first step”. Lord Bethell told The Independent that, in order to address obesity, Britain needs “20 different measures, all of them quite complex”.

But he said Mr Sunak will “learn a lot” from the smoking ban, and insisted that health interventions “can really be popular”.

“It will remind Downing Street that the public are hard over on things like junk food levies, gambling levies and minimum prices for drinking,” he said.

The director of the Obesity Health Alliance, Katharine Jenner, said she was “delighted” that the PM had banned smoking for future generations, but that tackling obesity needs the same focus.

“If this government really is committed to seeing the next generation grow up healthily, they also need to tackle the flood of unhealthy food and drink in our supermarkets and on our high streets,” she said.

But she added that ministers have failed to implement their own laws to “stop children being relentlessly bombarded with manipulative advertising and promotions”.

“This is not about removing choice – it’s about making the healthy choice the easy choice,” she said, calling for restrictions on junk food advertising.

And Dr Layla McCay, director of policy at the NHS Confederation, which represents hospitals, said the health service would come under “unsustainable pressure” without action to tackle obesity.

“The prime minister’s intention to ban cigarette sales for younger generations is a powerful and important step, but it comes as his government has failed to implement its own food strategy, which recommended sugar and salt taxes and restrictions on advertising,” she said.

She said the decision was “hard to justify” given obesity is one of the leading causes of preventable death and causes a number of long-term illnesses.

“The government needs to tackle this issue head-on rather than hiding behind ‘nanny-state’ excuses,” she added.

First comparison of dangers of tobacco cigarettes, e-cigarettes and waterpipes

Any smoking and vaping technique may increase risk of COVID-19 infection and death

EUROPEAN SOCIETY OF CARDIOLOGY

IMAGE: IMAGE SHOWS TOXIC COMPOUNDS, DISEASE MECHANISMS, CLINICAL OUTCOMES AND ADVERSE HEALTH EFFECTS ASSOCIATED WITH TOBACCO CIGARETTES, E-CIGARETTES AND WATERPIPES. view more 

CREDIT: EUROPEAN HEART JOURNAL

Smoking and vaping, whether by means of tobacco cigarettes, e-cigarettes or waterpipes, stiffens the arteries, causes inflammation and damages DNA, leading to a variety of health problems, according to a study published today (Friday) in the European Heart Journal [1].

In addition, smoking and vaping may increase the risk of people being infected by COVID-19, suffering worse symptoms and dying from it, say the researchers. They join the World Health Organization (WHO), the US Centers for Disease Control and Prevention, the Food and Drug Administration and the European Society of Cardiology in urging smokers to try to give up the habit, regardless of which smoking method they use.

The study is the world's first comparison of the effects of the three forms of smoking and vaping on human health and the function of cells that line blood vessels (the endothelium). It provides an overview of the available evidence about the harmful chemicals produced and the mechanisms by which smoking and vaping affect the body. The researchers also looked at the effects of each on medical conditions ranging from stroke to heart attacks and lung cancer.

The researchers found there were multiple good studies showing that, overall, tobacco cigarettes were more harmful than e-cigarettes. However, there were few good, large studies about the adverse effects of waterpipes (often referred to as hookahs, shisha or narghile) and e-cigarettes on endothelial dysfunction and so the evidence was more variable. The researchers say the long-term effects of water pipes and e-cigarettes need to be investigated more thoroughly. In the meantime, they write, "waterpipe smoking is not less harmful than tobacco smoking and thus cannot be considered a healthy alternative".

The researchers reviewed a range of studies, which they graded as providing strong, good or medium levels of evidence on the harmfulness of the three types of smoking and vaping [2]. Compared to non-smokers, tobacco cigarettes increased the risk of chronic obstructive pulmonary disease (COPD) by 704% (good level of evidence), waterpipes by 218% (strong) and e-cigarettes by 194% (good); tobacco cigarettes and waterpipes increased the risk of lung cancer by 1210% (strong) and 122% (strong) respectively, while the level of evidence for e-cigarettes was not sufficient to draw reliable conclusions.

They also looked at how much the three smoking techniques stiffened the arteries, an important prognostic indicator for the risk of heart problems and stroke. Compared to non-smokers, tobacco cigarettes increased arterial stiffness by 10%, waterpipes by 9% and e-cigarettes by 7% (medium level of evidence for all three).

The first author of the review, Professor Thomas Münzel, of the Department of Cardiology of the University Medical Centre Mainz in Mainz, Germany, said: "Our review focuses primarily on the adverse effects of these three smoking and vaping techniques on endothelial dysfunction and the relation to oxidative stress and, secondly, on clinical disease. All three forms of smoking and vaping lead to increased production of oxygen-derived free radicals in blood vessel tissue, such as superoxide. This breaks down nitric oxide, which is released by the endothelium, and is important for helping blood vessels to dilate and for protecting against inflammation and clogging of the arteries."

The researchers say the main toxic chemicals in e-cigarette vapour include formaldehyde and acrolein, as well as traces of chemicals called transition metals and volatile organic compounds (VOCs), all of which are known to damage cells. In contrast, tobacco cigarettes and waterpipe smoke contain a much more complex mixture of harmful chemicals and other substances. Waterpipe smoke contains solid particulate matter, originating mainly from the charcoal used to burn the tobacco; this is also present in lower concentrations in cigarette smoke. Nicotine is present in all three tobacco products, is addictive and is responsible for harmful biological effects as well as, to a minor extent, some beneficial effects.

Prof. Münzel said: "These different as well as overlapping profiles of toxic compounds may be a key to understand the similarities and differences in the adverse health effects of smoking and vaping, and should be further investigated in detail by future studies."

The researchers looked at the effects of smoking and vaping on COVID-19 infections. In the EHJ paper, they write: "As outlined by the WHO, tobacco cigarette and waterpipe smoking may contribute to increased burden of symptoms due to COVID-19 compared to non-smoking, including being admitted to intensive care, requiring mechanical ventilation, and suffering severe health consequences."

They conclude: "There is no doubt...that smoking cessation is and will remain the most powerful approach to prevent smoking-induced cardiovascular and respiratory disease. This may be even more important in light of the...COVID-19 pandemic as the use of tobacco products likely increases the risk for COVID-19 associated cardiovascular and other severe complications in smokers and vapers."

Prof. Münzel said: "Given the well-established harms associated with tobacco use and second-hand smoke exposure, the WHO recommends that tobacco users should quit. Proven interventions to help users give up include toll-free quit lines, mobile text-messaging cessation programmes, nicotine replacement therapies and other approved medications, particularly if you have smoked for a long time, and especially if you use tobacco cigarettes and water pipes.

"The WHO also warns that although e-cigarettes appear to be less harmful than tobacco cigarettes, there is growing evidence that they also may cause side effects in the lungs, heart and blood vessels and that e-cigarette use may increase the risk of COVID-19 infection."

The authors also address the issue of tobacco advertising. In the EU, TV and radio advertising of cigarettes, and tobacco products is not permitted. Some countries, such as Slovenia and Norway, have strict laws that ban all types of advertising, even at the point of sale. Germany is the only EU country where tobacco products, including e-cigarettes, can be advertised in public spaces via billboards. In the US, advertising of both tobacco products and e-cigarettes on billboards is allowed. The EHJ study includes maps to show where in the world e-cigarette sales are legal, and where in Europe advertising permitted.

Prof. Münzel said: "E-cigarettes are mostly considered as tobacco products, but the regulations on their advertising are not always clear."

###

Notes:

[1] "Effects of tobacco cigarettes, e-cigarettes and waterpipe smoking on endothelial function and clinical outcome", by Thomas Münzel et al. European Heart Journal. doi:10.1093/eurheartj/ehaa460

[2] Examples of studies that provided strong evidence (shown as +++ in Figure 1 in the paper) were large meta-analyses; studies providing "good" evidence (++) were single studies with over 1,000 participants; and studies providing "medium" evidence (+) were single studies with fewer than 1,000 participants.

SO I HAVE TO ASK THE RHETORICAL QUESTION, IF THIS IS THE FIRST SUCH STUDY ON WHAT BASIS DID THE CITY OF EDMONTON DECIDE TO PASS A BYLAW BANNING WATER PIPE BARS AN LOUNGES, SHISHA BARS, POPULAR AMONG LEBANESE AND SYRIANS IN THE CITY.

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Lung cancer does not decrease in line with reduced smoking

UMEA UNIVERSITY

 

IMAGE: 

BENGT JÄRVHOLM, PROFESSOR AT DEPARTMENT OF PUBLIC HEALTH AND CLINICAL MEDICINE, UMEÅ UNIVERSITY, SWEDEN

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CREDIT: MATTIAS PETTERSSON

Despite the fact that the number of people who smoke has decreased very sharply in Sweden, the number of cases of lung cancer in the population is not decreasing as much as expected. Among women lung cancer has in fact increased. This is shown in a new study at Umeå University, Sweden. The study means that the view of how long smoking affects health may change.

“Smoking is undoubtedly the most important risk factor for lung cancer. It is therefore surprising that the decline in smoking is not yet more visible in the statistics. More research is needed to find out why this is the case,” says Bengt Järvholm, professor at the Department of Public Health and Clinical Medicine at Umeå University.

The number of people who smoke has been declining in Sweden for many years. Today, one of twenty Swedes, about five percent, among men and women state that they smoke daily. In the 1960s, about one in two Swedish men between the ages of 18 and 69 smoked. Women generally started smoking later in history than men. In a large study in 1963, only slightly more than one in ten women, 11 per cent, aged 50–69 smoked, while 46 per cent of men were smokers. Among women, it was mainly younger people who smoked in the 1960s.

According to previous research, the risk of developing lung cancer decreases sharply and quickly after quitting smoking. According to a British study, the number of people who had lung cancer before the age of 75 fell from 16 percent to three percent among those who quit smoking before the age of 50.

The Umeå researchers have compared the change in smoking habits in Sweden from the 1950s with the incidence of lung cancer between 1970 and 2021 in men and women aged 40–84 years. They studied how the risk varied among men and women in different age groups. Previous studies have shown that squamous cell cancer is the form of lung cancer that has the strongest association with smoking.

The results showed that the risk of being affected varied greatly depending on the type of lung cancer, age and gender. Based on previous studies, it would have been expected that the risk of cancer would have decreased among the elderly as well. However, lung cancer was as common in 1970 as in 2021 among men aged 75–79 years. The number of squamous cell cancer had fallen sharply, while in 2021 it had instead increased six-fold for the other common form of cancer, adenocarcinoma. The risk of squamous cell cancer had increased among women in the age group 75-79 years to the same level as among men. For adenocarcinoma, the risk was similar for women and men, despite the fact that there were large differences in smoking habits among women and men in the 1970s.

The study does not provide an answer as to why the development of lung cancer does not correspond well with expectations. For that, other types of studies are required. However, there are several possible explanations. One explanation may be that people may underreport their smoking, i.e. that the reduction in smoking may be smaller in reality. Another possible explanation may be that previous assumptions have been exaggerated about how quickly the risk of being affected decreases when you quit smoking. Nor can it be ruled out that other environmental or lifestyle factors may play a role; Even those who have never smoked can get lung cancer, although it is less common. The fact that the trend is so much worse for women than for men is due to the fact that Swedish women generally started smoking later in history than men.

“The results should certainly not be interpreted as it is useless to quit smoking. On the contrary, the study emphasizes the importance of quitting early, preferably never starting, as it may be the case that the risk of lung cancer is elevated for longer than we previously thought,” says Bengt Järvholm.

The study shows that if the risk of developing lung cancer in 2021 was as high as the risk in 1970 in men and women aged 40–84, approximately 2,250 men would have suffered from lung cancer in 2021 instead of 1695 cases, i.e. a decrease of 555 cases. Among women, there would have been 544 cases instead of the current 2,181 cases, i.e. there has been an increase of 1,637 cases of lung cancer.

The study is based on data from the National Board of Health and Welfare's cancer registry, which was compared with statistics on tobacco smoking from surveys and from the sale of cigarettes.

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JOURNAL

European Journal of Public Health

DOI

10.1093/eurpub/ckae050 

METHOD OF RESEARCH

Data/statistical analysis

SUBJECT OF RESEARCH

People

ARTICLE TITLE

Changing smoking habits and the occurrence of lung cancer in Sweden—a population analysis