nicotine and smoking: insights from the health survey for england martin jarvis cruk health...
TRANSCRIPT
Nicotine and smoking: Nicotine and smoking: insights from the Health insights from the Health
Survey for EnglandSurvey for England
Martin JarvisMartin Jarvis
CRUK Health Behaviour UnitCRUK Health Behaviour Unit
University College LondonUniversity College London
Why the HSE?Why the HSE?
General Household Survey is official General Household Survey is official source for national prevalence and source for national prevalence and has excellent coverage of socio-has excellent coverage of socio-economic factors associated with economic factors associated with smoking. So why bother with HSE?smoking. So why bother with HSE?
Crucial added ingredient is cotinine, Crucial added ingredient is cotinine, a quantitative measure of recent a quantitative measure of recent smoke inhalationsmoke inhalation
The nicotine model: scope The nicotine model: scope and caveatsand caveats
Nicotine does not drive smoking Nicotine does not drive smoking behaviour in a simple way to the exclusion behaviour in a simple way to the exclusion of other influencesof other influences
Nicotine-seeking modulated by individual, Nicotine-seeking modulated by individual, family, social and societal influencesfamily, social and societal influences
Understanding how nicotine intakes vary Understanding how nicotine intakes vary with these factors is the aimwith these factors is the aim
Implications especially forImplications especially for Product modification and harm reductionProduct modification and harm reduction Cessation treatmentsCessation treatments
Issues to consider…..…Issues to consider…..…
PersonPerson Reliability of self-reportReliability of self-report Preferred dosePreferred dose ConsumptionConsumption Occasional smokingOccasional smoking
ProductProduct PopulationPopulation Passive smokingPassive smoking
Cotinine as a measure of Cotinine as a measure of nicotine intake and nicotine intake and
dependencedependence Main metabolite of nicotine, with t Main metabolite of nicotine, with t ½ ½
~16-20 ~16-20 hourshours
Quantitative measure of nicotine intakeQuantitative measure of nicotine intake Spot sample may give reasonable indication of Spot sample may give reasonable indication of
steady state – hence of usual daily intakesteady state – hence of usual daily intake Conversion factor: saliva cotinine 100ng/ml = Conversion factor: saliva cotinine 100ng/ml =
~6.7mg nicotine per day. Individual variation in ~6.7mg nicotine per day. Individual variation in nicotine metabolism, but estimates should be nicotine metabolism, but estimates should be reasonably accurate when averaged across reasonably accurate when averaged across groupsgroups
Cotinine is a good indicator of the extent of Cotinine is a good indicator of the extent of nicotine dependence nicotine dependence
What has cotinine got to What has cotinine got to offer?offer?
Objective check on prevalence and cessationObjective check on prevalence and cessation Objective characterisation of extent of recent Objective characterisation of extent of recent
nicotine usenicotine use Indicator of extent of nicotine dependenceIndicator of extent of nicotine dependence Measuring dependence in relation to:Measuring dependence in relation to:
Smoking historySmoking history Occasional smokingOccasional smoking Socio-economic statusSocio-economic status Product smokedProduct smoked
Health Survey for Health Survey for EnglandEngland
Representative sample nationally aged Representative sample nationally aged 16+16+
Home interview + nurse visit to take Home interview + nurse visit to take biological measurementsbiological measurements
Data collected on demographics, smoking Data collected on demographics, smoking history at interview, saliva cotinine (gas history at interview, saliva cotinine (gas chromatography) at nurse visitchromatography) at nurse visit
Sample with cotinine:Sample with cotinine: 1998 10,532 smokers 2,6891998 10,532 smokers 2,689 2001 9,451 smokers 2,1952001 9,451 smokers 2,195
.1 1 10 100 1000
Saliva cotinine (ng/ml)
0
200
400
600
800
1000
Nu
mb
er o
f re
spo
nd
ents
.1 1 10 100 >7
Saliva cotinine (ng/ml)
0
200
400
600
800
1000
Nu
mb
er o
f re
spo
nd
ents
.1 1 10 100 1000
Saliva cotinine (ng/ml)
0
200
400
600
800
1000
Nu
mb
er
of
res
po
nd
en
ts
HSE 1998 & 2001 combined
Reported nonsmokers- no passive
exposure
Reported nonsmokers- exposed toPassive smoking
Self-reported smokers
Self-reported smoking habits and cotinine concentrations
Health Survey for England 1998 & 2001 combined
Accuracy of self-reported Accuracy of self-reported smoking status by age in smoking status by age in
population surveyspopulation surveysAgeAge Never Never
smokerssmokersEx-smokersEx-smokers
% smoking by cotinine % smoking by cotinine (>14ng/ml)(>14ng/ml)
16-2416-24 7.37.3 20.220.225-3425-34 1.51.5 9.69.635-4435-44 1.61.6 6.36.345-5445-54 0.80.8 4.24.255-6455-64 0.50.5 4.04.065+65+ 1.11.1 3.03.0
All agesAll ages 2.02.0 4.94.9HSE 1998 & 2001 combined
Self-report: no smoking, no use of nicotine replacement products
How accurate are claims of How accurate are claims of quitting in population quitting in population
surveys?surveys?Reported timeReported time
since quittingsince quittingnn % smoking% smoking
by cotinineby cotinineMean Mean
cotininecotinine
(ng/ml)(ng/ml)
< 6 months< 6 months 8989 15.715.7 1361366-12 months6-12 months 150150 24.724.7 1721721-2 years1-2 years 152152 17.817.8 2042042-5 years2-5 years 465465 7.77.7 1111115-9 years5-9 years 662662 7.17.1 16216210-19 years10-19 years 13161316 3.83.8 18318320+ years20+ years 20732073 1.51.5 135135All quittersAll quitters 64076407 4.94.9 160160
HSE 1998 & 2001 combined
Nicotine intake and Nicotine intake and questionnaire indicators questionnaire indicators
of dependenceof dependence
Relation of nicotine intake Relation of nicotine intake to time to first cigarette in to time to first cigarette in
smokerssmokers Fine-grained and Fine-grained and
continuous continuous relationship. relationship.
Distinction Distinction between those between those who light up who light up within 5 min and within 5 min and those who wait those who wait for 5-15 minfor 5-15 minHSE 1998 & 2001 combined
50
100
150
200
250
300
350
400
450
Sal
iva
coti
nin
e (n
g/m
l)
SALIVA COTININE BY TIME TO FIRSTCIGARETTE IN SMOKERS: HSE 2001
Mean ± 95% CI
TIME TO FIRST CIGARETTE OF THE DAY
Less than
5 minutes
5-15
minutes
15-30
minutes
30 min
to 1 hr
1 to 2
hours
More than
2 hours
n=578n=274n=328n=332n=375n=335
"How soon after waking do you smoke
you first cigarette of the day?"
Relation of nicotine intake Relation of nicotine intake to time to first cigarette in to time to first cigarette in
smokerssmokers Relationship of Relationship of
cotinine to time cotinine to time to first cigarette to first cigarette is largely is largely independent of independent of cigarette cigarette consumptionconsumption
HSE 1998 & 2001 combined
50
100
150
200
250
300
350
400
450
Sal
iva
coti
nin
e (n
g/m
l)
SALIVA COTININE BY TIME TO FIRSTCIGARETTE IN SMOKERS: HSE 2001
UnivariateAdjusted forcigarette consumption Mean ± 95% CI
TIME TO FIRST CIGARETTE OF THE DAY
Less than
5 minutes
5-15
minutes
15-30
minutes
30 min
to 1 hr
1 to 2
hours
More than
2 hours
n=578n=274n=328n=332n=375n=335
"How soon after waking do you smoke
you first cigarette of the day?"
Cotinine by questionnaire Cotinine by questionnaire measure of dependencemeasure of dependence
Dependence Dependence scale: scale: Time to first Time to first
cigarette (1-6)cigarette (1-6) Perceived Perceived
difficulty of difficulty of abstaining for a abstaining for a whole day (0-3)whole day (0-3)
Cigarette Cigarette consumption (0-3)consumption (0-3)
HSE 1998 & 2001 combined
1 2 3 4 5 6 7 8 9 10 11 120
100
200
300
400
500
Sal
iva
coti
nin
e (n
g/m
l)
SALIVA COTININE BY DEPENDENCE INSMOKERS IN HSE 2001
Mean ± 95% CI
DEPENDENCE SCALE SCORE
N = 224 182 66241210207179130140159229 142
Variation in nicotine Variation in nicotine intake by cigarette intake by cigarette
consumptionconsumption
Relation of cotinine to Relation of cotinine to cigarette consumption in cigarette consumption in
smokerssmokers
On average, On average, cotinine cotinine increases increases linearly with linearly with consumption consumption only up to 15-20 only up to 15-20 cigarettes a daycigarettes a day
HSE 1998 & 2001 combined
0 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45+
100
200
300
400
500
Sal
iva
coti
nin
e (n
g/m
l)
SALIVA COTININE BY CIGARETTE CONSUMPTIONHEALTH SURVEY FOR ENGLAND 1998 & 2001
Mean ± 95% CI
cigarette consumption
Wide variation in preferred Wide variation in preferred nicotine intake between nicotine intake between
smokerssmokers Although on average Although on average
nicotine intake nicotine intake increases with increases with cigarette cigarette consumption, at any consumption, at any level of consumption level of consumption there is extremely there is extremely wide variation in wide variation in intake between intake between smokerssmokers
10 20 30 40
Usual daily cigarette consumption
0
100
200
300
400
500
600
700
800
900
Sal
iva
coti
nin
e (n
g/m
l)5
Health Survey for England 1998 & 2001
Cigarette consumption and nicotine intake: do light or occasional smokers
take in less per cigarette? On average, smokers On average, smokers
take in about 1 mg take in about 1 mg nicotine per cigarettenicotine per cigarette
Lighter smokers take Lighter smokers take in more per cigarette in more per cigarette than do heavierthan do heavier
Little evidence for Little evidence for take-it-or–leave-it take-it-or–leave-it smokers. smokers.
Based on equivalence 100 ng/ml saliva cotinine = 6.7mg nicotine per day(Benowitz)HSE 1998 & 2001 combined
0 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45+0
1
2
3
4
5
6
nic
oti
ne
inta
ke p
er c
igar
ette
sm
oke
d (
mg ESTIMATED NICOTINE INTAKE PER CIGARETTEBY CIGARETTE CONSUMPTION: HSE 1998 & 2001
Mean ± 95% CI
cigarette consumption
Product smoked and Product smoked and nicotine intakenicotine intake
Low yield cigarettes and Low yield cigarettes and smoke intakesmoke intake
Nicotine intake is Nicotine intake is largely independent largely independent of machine-smoked of machine-smoked nicotine deliverynicotine delivery
Since tar and nicotine Since tar and nicotine are highly correlated are highly correlated in smoke, tar in smoke, tar exposure is unlikely exposure is unlikely to differ between to differ between smokers of low- and smokers of low- and high-yield cigaretteshigh-yield cigarettes
HSE 1998 & 2001 combined
0 - .1 .1- .2- .4- .5- .6- .7- .8- .9- 1.0 +
Cigarette nicotine yield (mg)
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
Nic
oti
ne
in
tak
e p
er
cig
are
tte
(m
g)
Predicted and actual nicotine intakes per cigarettesmoked by nominal nicotine yield of usual brand
Actual Predicted
Health Survey for England 1998 & 2001 combined
Low yield cigarettes and Low yield cigarettes and smoke intakesmoke intake
Nicotine yields Nicotine yields have declined by have declined by 40% since 1980, 40% since 1980, but have but have smokers’ intakes smokers’ intakes reduced?reduced?
British Regional Heart Study baseline 1978-80
.
.
.
.
BRHS '78-80 HSE 1993 HSE 1994 SHS 1995 HSE 1996 HSE 1998 HSE 2000 HSE 2001
0.3
0.5
0.7
0.9
1.1
1.3
1.5
Cig
are
tte
nic
oti
ne
yie
ld (
mg
)
CIGARETTE NICOTINE YIELDS
FROM 1978 TO 2001
Low yield cigarettes and Low yield cigarettes and smoke intakesmoke intake
On average, nicotine On average, nicotine intakes in middle-aged intakes in middle-aged men have shown no men have shown no decline as tar/nicotine decline as tar/nicotine yields have declined by yields have declined by 40%40%
Consistent with complete Consistent with complete compensation for nicotinecompensation for nicotine
Indicates effective Indicates effective product modification will product modification will need to satisfy nicotine need to satisfy nicotine needs while reducing needs while reducing toxin exposuretoxin exposure
British Regional Heart Study baseline 1978-80, men aged 40-591990s data from HSE, age-matched to BRHS
.
.
.
.
BRHS '78-80 HSE 1993 HSE 1994 SHS 1995 HSE 1996 HSE 1998 HSE 2000 HSE 2001
0
50
100
150
200
250
300
350
400
Pla
sma
coti
nin
e (n
g/m
l)
0.3
0.5
0.7
0.9
1.1
1.3
1.5
Cig
are
tte
nic
oti
ne
yie
ld (
mg
)
CIGARETTE NICOTINE YIELD AND PLASMA COTININE
IN SURVEYS FROM 1978 TO 2001
mean ± 95%CI
Socio-economic variation Socio-economic variation in nicotine intakein nicotine intake
Cotinine in smokers by Cotinine in smokers by socio-economic statussocio-economic status
There is a marked There is a marked gradient in nicotine gradient in nicotine intake by socio-intake by socio-economic statuseconomic status
Smokers in the Smokers in the most deprived most deprived category take in on category take in on average about one-average about one-third more nicotinethird more nicotine
HSE 1998 & 2001 combined
0 1 2 3 4
200
250
300
350
Sal
iva
coti
nin
e (n
g/m
l)
Saliva cotinine by in cigarette smokers by socio-economic
deprivation category: HSE 1998 & 2001
DEPRIVATION SCOREdeprev.tc
Mean ± 95%CI
Cotinine and dependence in Cotinine and dependence in smokerssmokers
The socio-economic The socio-economic gradient in nicotine gradient in nicotine intake among intake among smokers is smokers is independent of the independent of the product smoked – product smoked – seen both in smokers seen both in smokers of manufactured of manufactured cigarettes and own-cigarettes and own-rollersrollers
HSE 1998 & 2001 combined
0 1 2 3 4
200
250
300
350
400
450
Sal
iva
coti
nin
e (n
g/m
l)
Saliva cotinine by in smokers of manufactured & own-rolled
cigarettes by deprivation category: HSE 1998 & 2001
manufactured
own rolled
DEPRIVATION SCOREdeprev.tc
Mean ± 95%CI
Variation in nicotine Variation in nicotine intake across intake across populationspopulations
National differences in National differences in nicotine dependence among nicotine dependence among
smokerssmokers
At any level of At any level of socio-economic socio-economic deprivation, deprivation, Scottish Scottish smokers have smokers have higher nicotine higher nicotine intakes than intakes than English English smokerssmokers
Scottish Health Survey 1995, 1998Health Survey for England 1996, 1998
0 1 2 3 4
250
300
350
400
450
Sal
iva
coti
nin
e (n
g/m
l)
Plasma cotinine by deprivationin adult smokers:England & Scotland compare
England
Scotland
DEPRIVATION SCORE
Passive smoking: effects of Passive smoking: effects of partner smokingpartner smoking
Dose-response Dose-response relationship relationship between partner’s between partner’s smoking and smoking and cotinine in cotinine in nonsmoking adultsnonsmoking adults
On average, dose On average, dose is about 0.7% of is about 0.7% of active smokersactive smokers
0 1-4 5-9 10-14 15-19 20-24 25-29 30+0.1
1.0
4.0
Pla
sma
coti
nin
e (n
g/m
l)
COTININE IN ADULTS BY PARTNER'S SMOKING
Partner's daily cigarette consumption
Geometric mean ± 95%CI
Health Survey for England 1998
National differences in National differences in nicotine dependence among nicotine dependence among
smokerssmokers
At any level of At any level of socio-economic socio-economic deprivation, deprivation, Scottish Scottish smokers have smokers have higher nicotine higher nicotine intakes than intakes than English English smokerssmokers
Scottish Health Survey 1995, 1998Health Survey for England 1996, 1998
0 1-4 5-9 10-19 20-49 50+
Hours per week exposed to passive smoking
0.1
1.0
4.0
Sal
iva
coti
nin
e (n
g/m
l)
PASSIVE SMOKING: COTININE IN ADULTSBY HOURS OF EXPOSURE AND HOUSEHOLD SMOKING
SmokinghouseholdNonsmokinghousehold
Geometric mean ± 95%CI
Health Survey for England 1998
0.5
2.0
Passive smoking: effects on Passive smoking: effects on childrenchildren
Similar dose-Similar dose-response in response in children with children with smoking parentssmoking parents
Exposure in Exposure in children is higher children is higher than in adults with than in adults with smoking partnersmoking partner
0 1-9 10-19 20-29 30-39 40-49 50+0
1
6
Sal
iva
coti
nin
e (n
g/m
l)
PASSIVE SMOKING: CHILDREN'S COTININEBY PARENTS' CIGARETTE CONSUMPTION
-
Parents' combined daily cigarette consumption
Geometric mean ± 95%CI
Health Survey for England 1996
737 57 115 120 67 44 24n=
Passive smoking and Passive smoking and deprivationdeprivation
In both adults and In both adults and children, extent of children, extent of exposure varies by exposure varies by socio-economic socio-economic statusstatus
0 0.1-9 10-19 20-29 30-39 40-49 50+
0.1
1.0
7.0
Sal
iva
coti
nin
e (
ng
/ml)
CHILDREN'S COTININE BY PARENTS'SMOKING AND DEPRIVATION: HSE 1996
0
1
2
3+
Parents' combined cigarette consumption
Geometric mean
Deprivation
score
0 1-9 10-19 20+0
1
4
Pla
sma
coti
nin
e (n
g/m
l) l
og
sca
le
COTININE IN ADULTS BY PARTNER SMOKINGAND LEVEL OF DEPRIVATION
0
1
2
3
Partner's daily cigarette consumption
Geometric mean ± 95%CI
Health Survey for England
1994 & 1996 combined
Deprivation
score
10 reasons why I love 10 reasons why I love the HSEthe HSE
Large and representative sampleLarge and representative sample Household sampling frame Household sampling frame Excellent coverage of demographicsExcellent coverage of demographics Smoking module as in GHSSmoking module as in GHS Brand choice questionBrand choice question Time to first cigarette questionTime to first cigarette question Cotinine – quantitative measure of smoke Cotinine – quantitative measure of smoke
intakeintake Time seriesTime series Data can be combined across years Data can be combined across years Comparison with SHS possibleComparison with SHS possible
ConclusionsConclusions
Application of cotinine in smoking studies gives Application of cotinine in smoking studies gives the opportunity for new insights into the the opportunity for new insights into the nature and determinants of nicotine nature and determinants of nicotine dependencedependence
Cross-sectional studies can yield much Cross-sectional studies can yield much information, but longitudinal studies are also information, but longitudinal studies are also needed to understand smoking careers needed to understand smoking careers
Lack of cotinine-based surveys in many Lack of cotinine-based surveys in many countries hampers understandingcountries hampers understanding
Better understanding of the contours of Better understanding of the contours of nicotine dependence important for developing nicotine dependence important for developing more effective cessation treatments and for more effective cessation treatments and for harm reductionharm reduction
Policies that ignore or misunderstand the Policies that ignore or misunderstand the dynamics of nicotine seeking are highly likely dynamics of nicotine seeking are highly likely to failto fail