Thursday, August 31, 2006

Massachusetts Report Finds Increase in Cigarette Nicotine Yields During Past Seven Years

A new report released this week by the Massachusetts Department of Health (MDPH) concludes that actual nicotine yields of cigarettes have increased by approximately 10% over the period 1998-2004.

The Massachusetts method for measuring nicotine yield is an improvement on the FTC-published methods, which do not adequately account for the actual way in which cigarettes are smoked. Limitations of the FTC method include inadequate puff duration and smoke inhalation and failure to block the filter ventilation holes. "The MDPH testing method better simulates the smoking behavior of the typical smoker under typical smoking conditions. Using the Massachusetts’ method, the amount of smoke inhaled with each puff is increased and the amount of time between puffs is reduced. In addition, 50% of the cigarette filter is covered. Testing for nicotine yield using the MDPH method revealed levels that are more than twice as high as those found by the historical method."

The major conclusion of the MDPH report was the following: "For all brands tested in both 1998 and 2004 (N = 116), the total amount of nicotine delivered to the smoker has increased significantly: 1.72 mg in 1998 compared to 1.89 mg in 2004. ... For each of the major manufacturers (i.e., Brown & Williamson, Lorillard, Phillip Morris, and RJ Reynolds), the increases in nicotine delivered were significant. ... With the exception of Winston cigarettes, all brands that were tested in both 1998 and 2004 had significant increases in nicotine delivered to the smoker. This includes Basic, Camel, Doral, Kool, Marlboro, and Newport cigarettes."

The MDPH press release accompanying the report stated: "“'This data is significant,' said DPH Commissioner Paul Cote, 'since is this is the first US release of information on nicotine yield in more than six years. We want health care providers to know that smokers are getting more nicotine than in the past, and they may need additional help in trying to quit.'

Increased levels of nicotine may make it more difficult for the average smoker to quit. Increased levels of nicotine consumed by pregnant women can lead to developmental delays in childhood as well as low birth weight infants. Nicotine changes the way that insulin works in the body. Smoking raises blood sugar levels, placing smokers at higher risk for developing diabetes and making it harder for those who already have diabetes to control blood sugar levels. Medications that treat depression and other mental illnesses can lose their effectiveness when combined with nicotine. Non-smokers, especially children, who are exposed to secondhand smoke can inhale up to seven times the amount of nicotine inhaled by a smoker."

A statement by the Campaign for Tobacco-Free Kids lamented: "The fact that the tobacco companies have been able to secretly increase nicotine levels in tobacco smoke occurred only because no federal or state agency currently has regulatory authority over cigarettes or what tobacco companies put in cigarettes. ... In light of ... the new report findings, it is critical that Congress enact legislation granting the U.S. Food and Drug Administration (FDA) authority over tobacco products that would require tobacco companies to disclose to the FDA and seek approval before making changes to their products that could make them more harmful or more addictive."

The Rest of the Story

While the methodology of the report appears to be solid and the results valid, the conclusions that are being drawn from it raise some important questions.

There is a "rest of the story" here. And that rest of the story is that you can't have it both ways. You can't argue (successfully) in federal court that "low-nicotine" and "light" cigarettes do not confer any health benefit because smokers simply compensate to achieve a steady delivery of nicotine, but then argue that if switched to higher nicotine yield cigarettes, smokers will not compensate by smoking less (or inhaling less deeply).

Is it not possible that the increased nicotine content of cigarettes may have resulted in decreases in cigarette consumption, reduced puff volume and intensity, reduced puffs per cigarette, and reduced time that the smoke is held in the lungs before exhaling?

In other words, is it not possible that despite the increased nicotine yield, the overall nicotine dose delivered to smokers remained essentially the same?

Just as the overall nicotine dose remains the same when low-yield nicotine cigarettes are smoked, why would the overall dose not remain about the same when higher-yield nicotine cigarettes are smoked?

The MDPH appears to conclude that overall nicotine dose has increased, but this conclusion is made in the absence of any evidence regarding actual nicotine doses to which smokers are exposed. The conclusion assumes no change in cigarette smoking behavior, which is an unreasonable assumption, it seems to me, given what we know about how smokers change their puffing and smoking behavior in response to changes in nicotine yield of their cigarettes.

While it seems undeniably true that cigarette companies have increased the nicotine yields of their cigarettes, it does not necessarily hold that this change has resulted in an increase in overall nicotine dose, and therefore in the resulting adverse health effects that MDPH posits are occurring.

In fact, it is quite possible that higher nicotine cigarettes are (marginally) less harmful, because they result in lower cigarette consumption. If the tar delivery is unchanged, then this will result in a lower dose of tar, and a subsequent (marginal) decline in cancer and other disease risk.

In fact, one possibility that has been considered by public health practitioners (and tobacco companies) is the production of a high-nicotine, low-tar cigarette that would allow smokers to obtain current amounts of nicotine through fewer cigarettes, and therefore with lower tar delivery.

The Campaign for Tobacco-Free Kids laments this finding of increased nicotine delivery and issues its usual whine about how this means that Congress must enact the Tobacco-Free Kids/Philip Morris FDA tobacco legislation. But the lament and whine are meaningless, because would the Campaign have stated anything different if the report had found that nicotine yields had significantly dropped over this time period?

Of course not. The Campaign would simply have argued that the decreased nicotine yields are meaningless because smokers simply smoked more. In fact, they probably would have argued that adverse health effects might have increased, since smokers would be compensating by increasing the intensity of their smoking.

What is the significance of the cigarette companies increasing nicotine yields? Probably very little, other than that they are ensuring that addiction levels are maintained given the widespread passage of smoking bans that are limiting opportunities and places for smokers to smoke and encouraging smokers to cut down on the amount they smoke.

Would the FDA legislation have prevented this occurrence, and if it did, would that have been a good thing? It's not clear that giving FDA the ability to regulate nicotine levels would do any good. If FDA required greatly reduced nicotine levels, it could be a public health disaster, as smokers would greatly increase their consumption and overall tar delivery would be much higher, leading to increased disease and death.

Possibly, FDA could do the most public health good by requiring increases in the nicotine/tar ratio in cigarettes, but it's not clear that they could do this given the language of the current legislation. Obviously, the only real public health good that could come from regulation of nicotine would be to get rid of it, but the legislation ties FDA's hands in that regard, and ensures that any regulatory decision to eliminate the nicotine rests squarely in the hands of Congress (i.e., politics), where the tobacco companies would surely use their influence to block action (or they would tie it up in the courts).

Frankly, the Campaign's lament and whining is little more than hot air.

Incidentally, unless I'm missing something, we may have our next fallacious claim by a tobacco control organization, as the claim that "Non-smokers, especially children, who are exposed to secondhand smoke can inhale up to seven times the amount of nicotine inhaled by a smoker" seems implausible to me. Nicotine is much more heavily concentrated in mainstream smoke than in sidestream smoke, so I don't see how it is possible for a nonsmoker to inhale more nicotine than a smoker.

Things cut both ways, and it just doesn't make sense to me to lament the increased nicotine delivery of cigarettes over time, when in the face of a decreased nicotine delivery over time, we responded by blasting the companies for increasing health risks by forcing smokers to compensate and smoke more.

I guess the companies are in a no-win situation. If they decrease their nicotine yields, we'll blast them because smokers will compensate, nicotine intake won't change, but tar delivery will be higher and there could be a net detriment to the public's health. Now that they increase nicotine yields, we blast them because nicotine intake will increase and cause more adverse health effects, making the assumption that compensation won't take place.

There is one detrimental effect of the increased nicotine yield, which is that smokers who are being forced to cut down, or voluntarily cutting down, due to decreased opportunities and environments to smoke thanks to smoking bans, will not see the reduced nicotine delivery and reduced addiction level that otherwise might occur. This is probably the reason why the cigarette companies are increasing the nicotine yields.

The biggest problem with the Campaign for Tobacco-Free Kids' emphasis on the small increase in nicotine yield of cigarettes and on the regulation of tobacco smoke constituents is that it obscures the real issue, which is that cigarettes are a deadly product. No amount of regulation of specific tobacco constituents is going to change that basic fact. And pretending that it will is misleading to the public and represents a disservice to the protection of the public's health.

(Thanks to Bill Godshall for the tip, and for providing a cogent analysis of the potential effects of higher nicotine-yield cigarettes on smoking behavior).

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