UAC Tabacco Special Edition Newsletter

Utah Addiction Center University of Utah Health Sciences Center 410 Chipeta Way, Suite 280 Salt Lake City, Utah 84108

Non-profit Organization

Utah

The

U.S. POSTAGE PAID Salt

Special

No. 1529

Volume 2 Issue 15

Report

October 2012 Dedicated to research, clinical training, and education in chemical addiction

Drugs: A Historical Perspective

Tobacco Trends and Challenges

Contact Us

University of Utah Health Sciences Center 410 Chipeta Way, Suite 280 Salt Lake City, Utah 84108 Phone: (801) 581-8216 Fax: (801) 587-7858 E-mail: abbie.paxman@hsc.utah.edu Internet: http://uuhsc.utah.edu/uac/

Edition

Addiction Center

Lake City, Utah Permit

The Utah Addiction Center is based in the office of the University of Utah Senior Vice President for Health Sciences

Over the past 20 years, society’s attitude about tobacco has changed dramatically. The use of tobacco has gone from being INSTITUTIONAL ADVISORY BOARD chic, a mark of sophistication, and the drug of the famous and A. Lorris Betz, M.D., Ph.D. the powerful, to a filthy habit with major deadly consequences Louis H. Callister, J.D. not to be tolerated in public. This dramatic shift in attitude is Edward B. Clark, M.D. illustrated by the findings of the Monitoring the Future survey M. David Rudd, PhD, ABPP of high school seniors demonstrating that from 1998 to 2011, Patrick Fleming, LSAC, MPA the monthly use went from 37% to less than 20%. A similar Raymond Gesteland, Ph.D. reduction of ~50% in tobacco use has occurred throughout the Jay Graves Ph.D. adolescent and adult population in this country. In addition, John R. Hoidal, M.D. because of danger from “second-hand smoke”, almost all states Glen W. Hanson Ph.D, D.D.S. and communities prohibit the use of smoking tobacco in all Maureen Keefe, RN, Ph.D public places such as stores, office buildings, restaurants, Jannah Mather, Ph.D. transportation facilities and even on public streets in some Chris Ireland, Ph.D. places. These refreshing changes in perspective have been John McDonnell, Ph.D. based to a large extent on scientific discoveries that in addition Barbara N. Sullivan, Ph.D. to the highly addictive nicotine, tobacco also contains >4000 Ross VanVranken, ACSW chemicals, some of which are highly toxic such as carbon Kim Wirthlin, MPA monoxide, acetaldehyde, nitrosamines, and tar that can cause severe tissue and organ damage as well as a number of potentially deadly cancers. While the overwhelming concern about the adverse effects of using tobacco has done much to mitigate the terrible public health consequences of these products, its impact is still very disturbing. For example, tobacco-related products continue to cause: • 440,000 deaths/year (1/5 total deaths in the U.S.) • Annual costs of ~$200 billion due to health care and lost productivity by both the user and from second-hand smoke Statistics such as these remind us that even today tobacco continues to be one of the most widely used addicting substances in the U.S. with ~58 million cigarette smokers, 13 million cigar smokers, and 8 million consuming smokeless products. In fact, continued reduction of tobacco use is still the single most effective method for reducing health care costs in our country and in many other countries around the world. It has been proven that the benefits of quitting the use of tobacco in any form are almost immediate and profound; e.g., within 24 hours of quitting smoking blood pressure is significantly reduced and the likelihood of a heart attack is diminished. Research has found that a 35 year-old man who quits smoking can expect to live an additional healthy 5 years. Findings such as these remind us that while we have made great strides in the battle against tobacco use, we must not let our guard down because the fight against tobacco use is far from over.

For more information see NIDA Research Report Series, “What are the Extent and Impact of Tobacco Use,” July 2012 online, NIDA.gov

1

Nicotine Replacement Therapy ...from Snails?

Expected Impact

FDA Commissioner Margaret A. Hamburg, M.D., says she’s hopeful the graphic images will give smokers the incentive to quit and prevent potential smokers from ever starting. In fact, the phone number for the smoking cessation hotline—1-800-QUIT-NOW— will accompany each warning.

“The Tobacco Control Act requires FDA to provide current and potential smokers with clear and truthful information about the risks of smoking—these warnings do that,” she says.

The bold health warnings will cover the top 50 percent of the front and rear panels of all cigarette packages and at least 20 percent of each advertisement. They are expected to decrease the number of smokers, which will save lives and increase life expectancy.

For more information, visit www.fda.gov/cigarettewarnings.

The Centers for Disease Control and Prevention says tobacco use is the leading cause of premature and preventable death in the United States, responsible for 443,000 deaths each year. Tobacco addiction costs the U.S. economy nearly $200 billion every year in medical costs and lost productivity.

This article appears on FDA’s Consumer Updates page, which features the latest on all FDA-regulated products. http://www.fda.gov/ForConsumers/ConsumerUpdates/ ucm259624.htm *The implementation date is uncertain, due to ongoing proceedings in the case of R.J. Reynolds Tobacco Co. v. U.S. Food and Drug Administration. No. 11-1482 (D.D.C.), on appeal, No. 11-5332 (D.C. Cir.).

Michael McIntosh, M.D. Professor, Department of Psychiatry Research Professor, Department of Biology

The Magician cone snail is far from your typical garden-variety type of snail. A predatory sea dweller, this snail packs a cone-shaped shell and an uncanny knack for hunting. It stalks and paralyzes its prey, typically fish, via a poisoned harpoon. While the neurotoxins delivered by its sting may ultimately do its victim in, researchers at the University of Utah and Virginia Commonwealth University School of Medicine have found that a component of its toxin may work a different kind of magic on a set of nicotine receptors in the brain – which may one day help A cone snail smokers break the habit.

When a smoker takes a puff from a cigarette the inhaled nicotine acts on receptors in the brain in an area known as the nucleus accumbens - one of the areas of the brain associated with control motivation and reward. The series of events results in the release of neurotransmitters such as dopamine and makes the brain think it wants more nicotine.

Researchers found that a peptide known as alpha conotoxin MII may reduce motivation to use nicotine in a rat model by blocking the action of nicotine receptors. MII is a part of the cocktail of toxins injected by the Magician cone snail into its prey.

These studies to make a functional link between the activity of the MII-sensitive subclass of nicotinic receptors in this region and behavior that supports nicotine dependence. Specifically, rodents that use daily nicotine lose their motivation to alpha conotoxin MII work for nicotine when their alpha-6 containing nicotinic receptors were blocked

by MII. These findings were specific to nicotine and did not affect the rats’ motivation to work for more natural reinforcers.

Nicotine replacement therapy, and even the more selective drug varenicline, stimulate a wide array of nicotinic receptors that regulate cognition and emotion in addition to their control of tobacco use.

MII-sensitive receptors represent a much smaller pool of these receptors.

If the studies in rats hold “Quitting smoking is easy. I’ve done it a thousand times.” true in humans, blocking - Mark Twain MII-sensitive receptors Approximately 80% of adult smokers began smoking before age 18, and may be sufficient to curb nearly 70% of adult smokers want to quit but need help to quit permatobacco use without nently. When habitual smokers stop smoking on their own, without the producing undesirable use of smoking cessation aids, they may experience a variety of unpleasant withdrawal effects, including craving for tobacco, irritability, restlessness, side-effects in therapysleep disturbances, gastrointestinal disturbances, anxiety, and impaired resistant smokers.

Update: In November 2011 U.S. District Judge Richard Leon blocked the FDA requirement in order “to evaluate on merits the constitutionality of the commercial speech that these graphic images compel.” In February 2012, he issued a final ruling striking down the graphic warning requirement as unconstitutional “compelled speech.” On August 24, 2012 The US Court of Appeals for the DC Circuit has upheld this decision.

SBIRT Updates S.M.A.R.T. Coalition in Utah County is working on developing a potential pilot project with Timpanogos Hospital (E.R. Department) to implement SBIRT in their department.

The Motivation to Quit

The following SBIRT training events have been held:

Dr. Mary De St. Joseph presented on FASD and SBIRT at the Ogden Medical Surgical Society Conference May 16-18, 2012.

Dr. Sullivan presented on SBIRT at the following events:

Generations Conference - 3/29/12 SBIRT “Training of Trainers” - 3/30/12 Critical Issues Facing Children Conference - 10/3/11

concentration, judgement and psychomotor performance.

The onset of nicotine withdrawal symptoms may occur wthin hours or days of quitting and may persist from a few days to several months. Frustration over these symptoms leads many people to start smoking again.

The intensity of withdrawal effects may be mild, moderate, or severe; it is not always correlated with the amount smoked.

The Utah Addiction Center Report

Training with University of Utah Pediatric Department Salt Lake County Behavioral Health - Boot Camp for The Mental Health Integration Community Partners - 8/23/12 Utah Fall Substance Abuse Conference - 9/27/12 2

The Utah Addiction Center Report

7

The Truth About Light Cigarettes

FDA Unveils New Cigarette Health Warnings

From the Book “Drugs and Society”

by Dr. Glen R. Hanson

US Food and Drug Administration - June 21, 2011

Many smokers choose low-tar, mild, or light cigarettes because they believe that these cigarettes may be less harmful to their health than regular or full-flavor cigarettes. Unfortunately, light cigarettes do not reduce the health risks of smoking.

The only way to reduce risk to oneself and others is to stop smoking completely.

Consumers are getting a glimpse of warnings images that will be alternating on all cigarette packages and advertisements within 15 months—an effort by health officials to discourage smoking by bringing Americans face to face with tobacco-related disease.

The Food and Drug Administration unveiled the nine, color images—including some of bodies ravaged by disease—at a news conference. The images, which are paired with text health warnings, are required under the 2009 Family Smoking Prevention and Tobacco Control Act. They must appear on every cigarette pack, carton, and advertisement by September 2012.* “President Obama is committed to protecting our nation’s children and the American people from the dangers of tobacco use. These labels are frank, honest and powerful depictions of the health risks of smoking and they will help encourage smokers to quit, and prevent children from smoking,” said Health and Human Services Secretary Kathleen Sebelius.

Common questions and answers pertaining to low-tar, mild, or light cigarettes follow: Q: What about the lower tar and nicotine numbers on light cigarette packs and in ads for lights?

A. These numbers are determined using smoking machines that smoke every brand of cigarettes exactly the same way. These numbers cannot absolutely predict the amount of tar and nicotine a particular smoker may get because people do not smoke cigarettes the same way the machines do, and because no two Individuals smoke the same way.

Q: How do light cigarettes trick the smoking machines?

Nine Warnings

A: Tobacco companies design light cigarettes with tiny pinholes on the filters. These vents are uncovered when cigarettes are smoked on smoking machines. As a result, these vents dilute cigarette smoke with air when light cigarettes are puffed on by the machines, causing measurements of artificially low tar and nicotine levels. Many smokers do not know that vent holes are on their cigarette filters. Without realizing it and because it is difficult to avoid, many block the tiny vent holes with their fingers or lips - which basically turns the light cigarette into a regular cigarette. Some cigarette makers increased the length of the paper covering the cigarette filter, which decreases the number of puffs that occur during the machine test. The result is that the machine measures less tar and nicotine levels than is available to the smoker.

In November, FDA officials posted 36 images on the Internet and gave the public 90 days to comment. The agency received more than 1,700 comments from the public, retailers, health professionals, advocacy groups, the tobacco industry, state and local public health agencies, and others.

Regulators used the comments, scientific literature, and the results of an 18,000-person study to narrow the images to nine. Each of the images—a mix of illustrations and photos depicting the negative health consequences of smoking—will be paired with one of these nine printed warnings: WARNING: Cigarettes are addictive—with an image of a man smoking through a hole in his throat WARNING: Tobacco smoke can harm your children—with an image of a parent holding a baby as smoke drifts towards them WARNING: Cigarettes cause fatal lung disease—with an image of a disease-riddled lung and a healthy lung WARNING: Cigarettes cause cancer—with an image of an open sore and stained teeth on the lips and mouth of a smoker with mouth cancer WARNING: Cigarettes cause strokes and heart disease—with an image of a man who needs an oxygen mask to breathe WARNING: Smoking during pregnancy can harm your baby—with an illustration of a crying newborn in an incubator and hookedup to a monitor WARNING: Smoking can kill you—with the image of a dead man with a surgery-scarred chest WARNING: Tobacco smoke causes fatal lung disease in nonsmokers—with an image of a grieving family member WARNING: Quitting smoking now greatly reduces serious risks to your health—with an image of a man wearing an “I Quit” T-shirt The Utah Addiction Center Report

Because unlike machines, individuals crave nlcotine, they may inhale more deeply; take larger, more rapid, or more frequent puffs; or smoke a few extra cigarettes each day to get enough nicotine to satisfy their craving. This is called compensating. and it results in smokers inhaling more tar, nicotine, and other harmful chemicals than the machine-based numbers suggest.

Q: What is the scientific evidence about the health effects of light cigarettes?

A: The National Cancer Institute (NCI) has concluded that light cigarettes provide no benefit to smokers’ health. According to its report, those people who switch to light cigarettes from regular cigarettes are likely to inhale the same amount of hazardous chemicals and remain at high risk for developing smoking-related cancers and other diseases.

Q: Have the tobacco companies conducted research on the amount of nicotine and tar people actually Inhale while smoking light cigarettes?

A: The tobacco Industry’s own documents show that companies were aware that smokers of light cigarettes compensate by taking bigger puffs. Industry documents also show that the companies were aware of the difference between machine-measured yields of tar and nicotine and the amount the smoker actually inhales.

Q: What Is the bottom line for smokers who want to protect their health?

A: There is no such thing as a safe cigarette. The only proven way to reduce your risk of smokingrelated disease is to quit smoking completely. Research has shown that people who quit before age 30 eliminate almost all of their risk of developing a tobacco-related disease. Even smokers who quit at age 50 reduce their risk of dying from a tobacco-related disease.

6

The Utah Addiction Center Report

3

The Pharmacology of Nicotine the heart muscle. Initially, nicotine stimulates salivary and bronchial secretions; it then inhibits them.

The excess saliva associated with smoking is typically caused by the irritating smoke, not the nicotine itself. Nicotine and perhaps other substances in tobacco smoke tend to inhibit hunger contractions in the stomach for as long as 1 hour. At the same time, this substance causes a slight increase in blood sugar and deadens the taste buds. These factors may explain the decreased feelings of hunger experienced by many smokers. Smokers have often reported that they gain weight after they stop smoking and that their appetite increases. In addition, when someone who smokes one or more packs per day quits, there may be a decrease in heart rate (two to three beats per minute) and as much as a 10% decrease in basal metabolic rate. The body is under less stress; therefore, it converts more food into fat. Nicotine has been used as an insecticide, and at higher concentrations it can be extremely toxic. Symptoms of nicotine poisoning include sweating, vomiting, mental confusion, diarrhea, and breathing difficulty. Respiratory failure from the paralysis of muscles usually brings on death. The fatal dose for adults is 60 milligrams. Most cigarettes in the U.S. market today contain 10 milligrams or more of nicotine; through smoke, the average smoker takes in 1 to 2 milligrams of nicotine from every cigarette. It is virtually impossible to overdose, in part because a smoker feels the effects before any lethal amount can accumulate in the body.

From the Book “Drugs and Society”

by Dr. Glen R. Hanson

In 1828, nicotine was discovered to be one component of tobacco. This colorless, highly volatile liquid alkaloid is one of more than 4000 chemicals found in the smoke from tobacco products such as cigarettes. When smoked, nicotine enters the lungs and is then absorbed into the bloodstream. When chewed (tobacco chewing) or dipped (snuff dipping), nicotine is absorbed through the mucous lining of the mouth.

The amount of nicotine absorbed into the body varies according to several factors: 1. The exact composition of the tobacco used

Nicotine and other products in smoke, such as carbon monoxide, produce several other effects. As much as 10% of all the hemoglobin in smokers may be in the form of carboxyhemoglobin. This type of hemoglobin cannot carry oxygen, so as much as 10% of the smoker’s blood is effectively out of circulation as far as normal oxygen-carbon dioxide exchange is concerned. This situation could easily cause a smoker to become breathless following exertion. It is a factor in heart attacks and in the lower birthweights and survival rates of infants born to women who smoke during pregnancy.

2. How densely the tobacco is packed in the cigarette and the length of the cigarette smoked 3. Whether a filter is used and the characteristics of the filter 4. The volume of smoke inhaled 5. The number of cigarettes smoked throughout the day

What is in Tobacco Smoke?

Depending on how tobacco is taken, the rate at which it enters the bloodstream varies widely.

Cigarette smoking results in rapid distribution of nicotine throughout the body; it reaches the brain within 10 seconds of inhalation. A typical smoker will take 10 puffs on a cigarette during the 5 minutes that the cigarette is lit. Thus, a person who smokes two packs (40 cigarettes) each day gets 400 “hits” of nicotine to the brain each day. In contrast, cigar and pipe smokers typically do not inhale the smoke; nicotine is absorbed more slowly through the lining of the mouth.

Tobacco smoke contains chemicals that are harmful to both smokers and nonsmokers. At least 250 of the 1,000 chemicals In tobacco smoke are known to be harmful. These chemicals include carbon monoxide (found in car exhaust), hydrogen cyanide (used In chemical weapons), ammonia (used In household cleaners), formaldehyde (used as an embalming fluid), and toklene (found in paint thinners). More than 50 of the 250 known harmful chemicals In tobacco smoke have been found to cause cancer. These include nickel (a metallic element), benzene (a chemical found In gasoline), cadmium (a metal used In batteries), ethylene oxide (a chemical used to sterilize medical devices), polonlum-210 (a chemical element that fives off radiation), arsenic (a heavy metal toxin), and vinyl chloride (a toxic substance used In plastics manufacture).

Effects on the Central Nervous System

Nicotine produces an intense effect on the central nervous system. Research has demonstrated that nicotine activates the brain circuitry in regions responsible for regulating feelings of pleasure. In particular, nicotine increases the release of the neurotransmitter dopamine in the so-called reward or pleasure pathways of the brain. This effect likely contributes to the abuse potential of the stimulant.

The pharmacokinetic properties of nicotine also enhance its abuse potential. Cigarette smoking allows nicotine to enter the brain rapidly, with drug levels peaking within 10 seconds of inhalation.

The acute effects of this rapid increase in brain concentration dissipate within a few minutes, causing the smoker to continue to dose frequently throughout the day in an effort to maintain the pleasurable effects of the drug.

Other Effects of Nicotine

In addition to its direct effects in the brain, nicotine increases the respiration rate at low dose levels because it stimulates the receptors in the carotid artery (in the neck) that monitor the brain’s need for oxygen. It also stimulates the cardiovascular system by releasing epinephrine, which increases coronary blood flow, heart rate, and blood pressure. The effect is to raise the oxygen requirements of The Utah Addiction Center Report

4

The Utah Addiction Center Report

5

The Pharmacology of Nicotine the heart muscle. Initially, nicotine stimulates salivary and bronchial secretions; it then inhibits them.

The excess saliva associated with smoking is typically caused by the irritating smoke, not the nicotine itself. Nicotine and perhaps other substances in tobacco smoke tend to inhibit hunger contractions in the stomach for as long as 1 hour. At the same time, this substance causes a slight increase in blood sugar and deadens the taste buds. These factors may explain the decreased feelings of hunger experienced by many smokers. Smokers have often reported that they gain weight after they stop smoking and that their appetite increases. In addition, when someone who smokes one or more packs per day quits, there may be a decrease in heart rate (two to three beats per minute) and as much as a 10% decrease in basal metabolic rate. The body is under less stress; therefore, it converts more food into fat. Nicotine has been used as an insecticide, and at higher concentrations it can be extremely toxic. Symptoms of nicotine poisoning include sweating, vomiting, mental confusion, diarrhea, and breathing difficulty. Respiratory failure from the paralysis of muscles usually brings on death. The fatal dose for adults is 60 milligrams. Most cigarettes in the U.S. market today contain 10 milligrams or more of nicotine; through smoke, the average smoker takes in 1 to 2 milligrams of nicotine from every cigarette. It is virtually impossible to overdose, in part because a smoker feels the effects before any lethal amount can accumulate in the body.

From the Book “Drugs and Society”

by Dr. Glen R. Hanson

In 1828, nicotine was discovered to be one component of tobacco. This colorless, highly volatile liquid alkaloid is one of more than 4000 chemicals found in the smoke from tobacco products such as cigarettes. When smoked, nicotine enters the lungs and is then absorbed into the bloodstream. When chewed (tobacco chewing) or dipped (snuff dipping), nicotine is absorbed through the mucous lining of the mouth.

The amount of nicotine absorbed into the body varies according to several factors: 1. The exact composition of the tobacco used

Nicotine and other products in smoke, such as carbon monoxide, produce several other effects. As much as 10% of all the hemoglobin in smokers may be in the form of carboxyhemoglobin. This type of hemoglobin cannot carry oxygen, so as much as 10% of the smoker’s blood is effectively out of circulation as far as normal oxygen-carbon dioxide exchange is concerned. This situation could easily cause a smoker to become breathless following exertion. It is a factor in heart attacks and in the lower birthweights and survival rates of infants born to women who smoke during pregnancy.

2. How densely the tobacco is packed in the cigarette and the length of the cigarette smoked 3. Whether a filter is used and the characteristics of the filter 4. The volume of smoke inhaled 5. The number of cigarettes smoked throughout the day

What is in Tobacco Smoke?

Depending on how tobacco is taken, the rate at which it enters the bloodstream varies widely.

Cigarette smoking results in rapid distribution of nicotine throughout the body; it reaches the brain within 10 seconds of inhalation. A typical smoker will take 10 puffs on a cigarette during the 5 minutes that the cigarette is lit. Thus, a person who smokes two packs (40 cigarettes) each day gets 400 “hits” of nicotine to the brain each day. In contrast, cigar and pipe smokers typically do not inhale the smoke; nicotine is absorbed more slowly through the lining of the mouth.

Tobacco smoke contains chemicals that are harmful to both smokers and nonsmokers. At least 250 of the 1,000 chemicals In tobacco smoke are known to be harmful. These chemicals include carbon monoxide (found in car exhaust), hydrogen cyanide (used In chemical weapons), ammonia (used In household cleaners), formaldehyde (used as an embalming fluid), and toklene (found in paint thinners). More than 50 of the 250 known harmful chemicals In tobacco smoke have been found to cause cancer. These include nickel (a metallic element), benzene (a chemical found In gasoline), cadmium (a metal used In batteries), ethylene oxide (a chemical used to sterilize medical devices), polonlum-210 (a chemical element that fives off radiation), arsenic (a heavy metal toxin), and vinyl chloride (a toxic substance used In plastics manufacture).

Effects on the Central Nervous System

Nicotine produces an intense effect on the central nervous system. Research has demonstrated that nicotine activates the brain circuitry in regions responsible for regulating feelings of pleasure. In particular, nicotine increases the release of the neurotransmitter dopamine in the so-called reward or pleasure pathways of the brain. This effect likely contributes to the abuse potential of the stimulant.

The pharmacokinetic properties of nicotine also enhance its abuse potential. Cigarette smoking allows nicotine to enter the brain rapidly, with drug levels peaking within 10 seconds of inhalation.

The acute effects of this rapid increase in brain concentration dissipate within a few minutes, causing the smoker to continue to dose frequently throughout the day in an effort to maintain the pleasurable effects of the drug.

Other Effects of Nicotine

In addition to its direct effects in the brain, nicotine increases the respiration rate at low dose levels because it stimulates the receptors in the carotid artery (in the neck) that monitor the brain’s need for oxygen. It also stimulates the cardiovascular system by releasing epinephrine, which increases coronary blood flow, heart rate, and blood pressure. The effect is to raise the oxygen requirements of The Utah Addiction Center Report

4

The Utah Addiction Center Report

5

The Truth About Light Cigarettes

FDA Unveils New Cigarette Health Warnings

From the Book “Drugs and Society”

by Dr. Glen R. Hanson

US Food and Drug Administration - June 21, 2011

Many smokers choose low-tar, mild, or light cigarettes because they believe that these cigarettes may be less harmful to their health than regular or fullflavor cigarettes. Unfortunately, light cigarettes do not reduce the health risks of smoking. The only way to reduce risk to oneself and others is to stop smoking completely.

Consumers are getting a glimpse of warnings images that will be alternating on all cigarette packages and advertisements within 15 months—an effort by health officials to discourage smoking by bringing Americans face to face with tobacco-related disease.

The Food and Drug Administration unveiled the nine, color images—including some of bodies ravaged by disease—at a news conference. The images, which are paired with text health warnings, are required under the 2009 Family Smoking Prevention and Tobacco Control Act. They must appear on every cigarette pack, carton, and advertisement by September 2012.* “President Obama is committed to protecting our nation’s children and the American people from the dangers of tobacco use. These labels are frank, honest and powerful depictions of the health risks of smoking and they will help encourage smokers to quit, and prevent children from smoking,” said Health and Human Services Secretary Kathleen Sebelius.

Common questions and answers pertaining to low-tar, mild, or light cigarettes follow: Q: What about the lower tar and nicotine numbers on light cigarette packs and in ads for lights?

A. These numbers are determined using smoking machines that smoke every brand of cigarettes exactly the same way. These numbers cannot absolutely predict the amount of tar and nicotine a particular smoker may get because people do not smoke cigarettes the same way the machines do, and because no two Individuals smoke the same way.

Q: How do light cigarettes trick the smoking machines?

Nine Warnings

In November, FDA officials posted 36 images on the Internet and gave the public 90 days to comment. The agency received more than 1,700 comments from the public, retailers, health professionals, advocacy groups, the tobacco industry, state and local public health agencies, and others.

Regulators used the comments, scientific literature, and the results of an 18,000-person study to narrow the images to nine. Each of the images—a mix of illustrations and photos depicting the negative health consequences of smoking—will be paired with one of these nine printed warnings: WARNING: Cigarettes are addictive—with an image of a man smoking through a hole in his throat WARNING: Tobacco smoke can harm your children—with an image of a parent holding a baby as smoke drifts towards them WARNING: Cigarettes cause fatal lung disease—with an image of a disease-riddled lung and a healthy lung WARNING: Cigarettes cause cancer—with an image of an open sore and stained teeth on the lips and mouth of a smoker with mouth cancer WARNING: Cigarettes cause strokes and heart disease—with an image of a man who needs an oxygen mask to breathe WARNING: Smoking during pregnancy can harm your baby—with an illustration of a crying newborn in an incubator and hookedup to a monitor WARNING: Smoking can kill you—with the image of a dead man with a surgery-scarred chest WARNING: Tobacco smoke causes fatal lung disease in nonsmokers—with an image of a grieving family member

The Utah Addiction Center Report

A: Tobacco companies design light cigarettes with tiny pinholes on the filters. These vents are uncovered when cigarettes are smoked on smoking machines. As a result, these vents dilute cigarette smoke with air when light cigarettes are puffed on by the machines, causing measurements of artificially low tar and nicotine levels. Many smokers do not know that vent holes are on their cigarette filters. Without realizing it and because it is difficult to avoid, many block the tiny vent holes with their fingers or lips - which basically turns the light cigarette into a regular cigarette. Some cigarette makers increased the length of the paper covering the cigarette filter, which decreases the number of puffs that occur during the machine test. The result is that the machine measures less tar and nicotine levels than is available to the smoker.

Because unlike machines, individuals crave nlcotine, they may inhale more deeply; take larger, more rapid, or more frequent puffs; or smoke a few extra cigarettes each day to get enough nicotine to satisfy their craving. This is called compensating. and it results in smokers inhaling more tar, nicotine, and other harmful chemicals than the machine-based numbers suggest.

Q: What is the scientific evidence about the health effects of light cigarettes?

A: The National Cancer Institute (NCI) has concluded that light cigarettes provide no benefit to smokers’ health. According to its report, those people who switch to light cigarettes from regular cigarettes are likely to inhale the same amount of hazardous chemicals and remain at high risk for developing smoking-related cancers and other diseases.

Q: Have the tobacco companies conducted research on the amount of nicotine and tar people actually Inhale while smoking light cigarettes?

A: The tobacco Industry’s own documents show that companies were aware that smokers of light cigarettes compensate by taking bigger puffs. Industry documents also show that the companies were aware of the difference between machine-measured yields of tar and nicotine and the amount the smoker actually inhales.

Q: What Is the bottom line for smokers who want to protect their health?

A: There is no such thing as a safe cigarette. The only proven way to reduce your risk of smokingrelated disease is to quit smoking completely. Research has shown that people who quit before age 30 eliminate almost all of their risk of developing a tobacco-related disease. Even smokers who quit at age 50 reduce their risk of dying from a tobacco-related disease.

6

The Utah Addiction Center Report

3

Nicotine Replacement Therapy ...from Snails?

Expected Impact

FDA Commissioner Margaret A. Hamburg, M.D., says she’s hopeful the graphic images will give smokers the incentive to quit and prevent potential smokers from ever starting. In fact, the phone number for the smoking cessation hotline—1-800-QUIT-NOW— will accompany each warning.

“The Tobacco Control Act requires FDA to provide current and potential smokers with clear and truthful information about the risks of smoking—these warnings do that,” she says.

The bold health warnings will cover the top 50 percent of the front and rear panels of all cigarette packages and at least 20 percent of each advertisement. They are expected to decrease the number of smokers, which will save lives and increase life expectancy.

For more information, visit www.fda.gov/cigarettewarnings.

The Centers for Disease Control and Prevention says tobacco use is the leading cause of premature and preventable death in the United States, responsible for 443,000 deaths each year. Tobacco addiction costs the U.S. economy nearly $200 billion every year in medical costs and lost productivity.

This article appears on FDA’s Consumer Updates page, which features the latest on all FDA-regulated products. http://www.fda.gov/ForConsumers/ConsumerUpdates/ ucm259624.htm *The implementation date is uncertain, due to ongoing proceedings in the case of R.J. Reynolds Tobacco Co. v. U.S. Food and Drug Administration. No. 11-1482 (D.D.C.), on appeal, No. 11-5332 (D.C. Cir.).

Michael McIntosh, M.D. Professor, Department of Psychiatry Research Professor, Department of Biology

The Magician cone snail is far from your typical garden-variety type of snail. A predatory sea dweller, this snail packs a cone-shaped shell and an uncanny knack for hunting. It stalks and paralyzes its prey, typically fish, via a poisoned harpoon. While the neurotoxins delivered by its sting may ultimately do its victim in, researchers at the University of Utah and Virginia Commonwealth University School of Medicine have found that a component of its toxin may work a different kind of magic on a set of nicotine receptors in the brain – which may one day help A cone snail smokers break the habit.

When a smoker takes a puff from a cigarette the inhaled nicotine acts on receptors in the brain in an area known as the nucleus accumbens - one of the areas of the brain associated with control motivation and reward. The series of events results in the release of neurotransmitters such as dopamine and makes the brain think it wants more nicotine.

Researchers found that a peptide known as alpha conotoxin MII may reduce motivation to use nicotine in a rat model by blocking the action of nicotine receptors. MII is a part of the cocktail of toxins injected by the Magician cone snail into its prey.

These studies to make a functional link between the activity of the MII-sensitive subclass of nicotinic receptors in this region and behavior that supports nicotine dependence. Specifically, rodents that use daily nicotine lose their motivation to alpha conotoxin MII work for nicotine when their alpha-6 containing nicotinic receptors were blocked

by MII. These findings were specific to nicotine and did not affect the rats’ motivation to work for more natural reinforcers.

Nicotine replacement therapy, and even the more selective drug varenicline, stimulate a wide array of nicotinic receptors that regulate cognition and emotion in addition to their control of tobacco use.

MII-sensitive receptors represent a much smaller pool of these receptors.

If the studies in rats hold “Quitting smoking is easy. I’ve done it a thousand times.” true in humans, blocking - Mark Twain MII-sensitive receptors Approximately 80% of adult smokers began smoking before age 18, and may be sufficient to curb nearly 70% of adult smokers want to quit but need help to quit permatobacco use without nently. When habitual smokers stop smoking on their own, without the producing undesirable use of smoking cessation aids, they may experience a variety of unpleasant withdrawal effects, including craving for tobacco, irritability, restlessness, side-effects in therapysleep disturbances, gastrointestinal disturbances, anxiety, and impaired resistant smokers.

Update: In November 2011 U.S. District Judge Richard Leon blocked the FDA requirement in order “to evaluate on merits the constitutionality of the commercial speech that these graphic images compel.” In February 2012, he issued a final ruling striking down the graphic warning requirement as unconstitutional “compelled speech.” On August 24, 2012 The US Court of Appeals for the DC Circuit has upheld this decision.

SBIRT Updates S.M.A.R.T. Coalition in Utah County is working on developing a potential pilot project with Timpanogos Hospital (E.R. Department) to implement SBIRT in their department.

The Motivation to Quit

The following SBIRT training events have been held:

Dr. Mary De St. Joseph presented on FASD and SBIRT at the Ogden Medical Surgical Society Conference May 16-18, 2012.

Dr. Sullivan presented on SBIRT at the following events:

Generations Conference - 3/29/12 SBIRT “Training of Trainers” - 3/30/12 Critical Issues Facing Children Conference - 10/3/11

concentration, judgement and psychomotor performance.

The onset of nicotine withdrawal symptoms may occur wthin hours or days of quitting and may persist from a few days to several months. Frustration over these symptoms leads many people to start smoking again.

The intensity of withdrawal effects may be mild, moderate, or severe; it is not always correlated with the amount smoked.

The Utah Addiction Center Report

Training with University of Utah Pediatric Department Salt Lake County Behavioral Health - Boot Camp for The Mental Health Integration Community Partners - 8/23/12 Utah Fall Substance Abuse Conference - 9/27/12 2

The Utah Addiction Center Report

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Utah Addiction Center University of Utah Health Sciences Center 410 Chipeta Way, Suite 280 Salt Lake City, Utah 84108

Non-profit Organization

Utah

The

U.S. POSTAGE PAID Salt

Special

No. 1529

Volume 2 Issue 15

Report

October 2012 Dedicated to research, clinical training, and education in chemical addiction

Drugs: A Historical Perspective

Tobacco Trends and Challenges

Contact Us

University of Utah Health Sciences Center 410 Chipeta Way, Suite 280 Salt Lake City, Utah 84108 Phone: (801) 581-8216 Fax: (801) 587-7858 E-mail: abbie.paxman@hsc.utah.edu Internet: http://uuhsc.utah.edu/uac/

Edition

Addiction Center

Lake City, Utah Permit

The Utah Addiction Center is based in the office of the University of Utah Senior Vice President for Health Sciences

Over the past 20 years, society’s attitude about tobacco has changed dramatically. The use of tobacco has gone from being INSTITUTIONAL ADVISORY BOARD chic, a mark of sophistication, and the drug of the famous and A. Lorris Betz, M.D., Ph.D. the powerful, to a filthy habit with major deadly consequences Louis H. Callister, J.D. not to be tolerated in public. This dramatic shift in attitude is Edward B. Clark, M.D. illustrated by the findings of the Monitoring the Future survey M. David Rudd, PhD, ABPP of high school seniors demonstrating that from 1998 to 2011, Patrick Fleming, LSAC, MPA the monthly use went from 37% to less than 20%. A similar Raymond Gesteland, Ph.D. reduction of ~50% in tobacco use has occurred throughout the Jay Graves Ph.D. adolescent and adult population in this country. In addition, John R. Hoidal, M.D. because of danger from “second-hand smoke”, almost all states Glen W. Hanson Ph.D, D.D.S, Mauand communities prohibit the use of smoking tobacco in all reen Keefe, RN, Ph.D public places such as stores, office buildings, restaurants, Jannah Mather, Ph.D. transportation facilities and even on public streets in some Chris Ireland, Ph.D. places. These refreshing changes in perspective have been John McDonnell, Ph.D. based to a large extent on scientific discoveries that in addition Barbara N. Sullivan, Ph.D. to the highly addictive nicotine, tobacco also contains >4000 Ross VanVranken, ACSW chemicals, some of which are highly toxic such as carbon Kim Wirthlin, MPA monoxide, acetaldehyde, nitrosamines, and tar that can cause severe tissue and organ damage as well as a number of potentially deadly cancers. While the overwhelming concern about the adverse effects of using tobacco has done much to mitigate the terrible public health consequences of these products, its impact is still very disturbing. For example, tobacco-related products continue to cause: • 440,000 deaths/year (1/5 total deaths in the U.S.) • Annual costs of ~$200 billion due to health care and lost productivity by both the user and from second-hand smoke Statistics such as these remind us that even today tobacco continues to be one of the most widely used addicting substances in the U.S. with ~58 million cigarette smokers, 13 million cigar smokers, and 8 million consuming smokeless products. In fact, continued reduction of tobacco use is still the single most effective method for reducing health care costs in our country and in many other countries around the world. It has been proven that the benefits of quitting the use of tobacco in any form are almost immediate and profound; e.g., within 24 hours of quitting smoking blood pressure is significantly reduced and the likelihood of a heart attack is diminished. Research has found that a 35 year-old man who quits smoking can expect to live an additional healthy 5 years. Findings such as these remind us that while we have made great strides in the battle against tobacco use, we must not let our guard down because the fight against tobacco use is far from over.

For more information see NIDA Research Report Series, “What are the Extent and Impact of Tobacco Use,” July 2012 online, NIDA.gov

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