Tobacco control specialist targets entry and exit gates of tobacco addiction

A large national study shows flavored tobacco products are doing what internal tobacco industry documents suggest they were designed to do: attracting young users. Meanwhile, another report says adult smokers aren't getting the potentially life-saving help they need when it comes to quitting, and that has to change – immediately. Both the study and the report feature the work of Medical University of South Carolina tobacco control specialist Michael Cummings. 

"Historically, the profitability of the tobacco industry has been determined by two factors," Cummings said. "One is the ability of the industry to attract new customers, mostly teenagers and young adults. The second is the ability to get people who use tobacco to keep using it, typically by getting them addicted to the products. If the equilibrium between the entry and exit gates of the market shifts so there are fewer new users and more people quitting smoking, this will alter tobacco product sales."

PATH study

The report highlighting the habits of young tobacco users appears in the American Journal of Preventive Medicine. It's part of the Population Assessment of Tobacco and Health Study, or PATH, a long-term effort to document the impact of tobacco use in the U.S. PATH is a joint effort of the National Institutes of Health and the Food and Drug Administration's Center for Tobacco Products. 

Cummings and colleagues studied data from 2013 to 2014, examining interviews with about 32,000 adults and 14,000 people who were from 12 to 17 years old. "A central question addressed in the study was whether flavors featured in the marketing of the product, such as menthol flavored cigarettes, exerts a significant effect on youth experimentation and progression to regular tobacco use," Cummings said. "The results from this study illustrate the widespread use of flavored tobacco products, especially in young tobacco users, and the association between first use of flavored tobacco and current tobacco use."

It's important to note a couple of things here. The survey found only about 8.5 percent of the 12- to 17-year-olds had used tobacco in the previous month, so the number of young people using tobacco is lower than in previous years, which Cummings said is a good sign. However, of the young people who had used tobacco, almost 80 percent said the product they used was flavored. As the researchers noted, evidence suggests flavored products may be the first step in developing a nicotine addiction. 

The government has already taken some steps to try to reduce the odds that kids will take up tobacco, including the 2009 Family Smoking Prevention and Tobacco Control Act. That law bans the marketing of characterizing flavors in cigarettes, with the exception of menthol. But other types of tobacco products, including cigars; hookah tobacco; smokeless tobacco and e-cigarettes; are marketed in a wide range of flavors. Some small cigars are marketed with flavors such as tropical fusion, strawberry, grape, peach and blueberry.

Flavor was in favor when it came to cigarettes, too. Fifty percent of young people in the study who had used cigarettes opted for menthol the first time they tried smoking.

Focusing on teenagers is important, Cummings said. “Nearly all tobacco initiation begins during the teenage years. It's rare to see someone take up smoking after 24 years. Teens often experiment with tobacco because their friends are doing it. The initial experience with tobacco is usually unpleasant, so adding flavoring to tobacco helps make it easer for the novice user to experiment until nicotine addiction takes hold. Not all kids who experiment go on to be regular users, but about one-third do – those who do are the ones that  become addicted to nicotine and become long-term customers of cigarette manufacturers.”

Cummings said the bottom line from this study is clear. “If we are serious about cracking down on youth tobacco use, the flavorings in tobacco products ought to be prohibited.  Flavor additives, especially those used in combustible tobacco products like cigarettes, contribute extra toxicity to the smoke. In other words, adding extra stuff to burn means more toxins are produced. Also, adding things to tobacco that  makes it easier for the novice tobacco users to inhale the smoke into airways is dangerous because it  increases the risk of nicotine addiction. "

Call for action to help smokers quit

While young tobacco users were the focus of the PATH report, a different report with a dramatic title focused on helping long-time adult smokers. The report, "Ending cigarette use by adults in a generation is possible," was put together by national tobacco control leaders, including Cummings, with input from more than 100 other leaders across the country. 

The report calls for immediate changes to dramatically curb smoking, the leading preventable cause of serious illness and death in the U.S. The goal is to reduce the number of adult smokers from 40 million to 25 million by 2024. 

The report proposes three key ways to end cigarette smoking:

• Raise taxes on cigarettes and other combustible tobacco products such as cigars, cigarillos, and pipe tobacco. The idea is to lower smoking rates, synchronize tax rates across state borders to reduce illegal sales, raise money to cover the costs of smoking-related diseases and encourage people to shift from smoking cigarettes to using lower-risk products such as e-cigarettes. “E-cigarettes are not safe, but they are much safer than smoking cigarettes," Cummings said. 

• Make it easier for smokers to get access to effective smoking cessation treatments. "Nicotine addiction is a physiological disorder, not a personality flaw," Cummings said. "Most smokers want to quit, but they struggle to say off cigarettes because they are hooked on nicotine." The most common way smokers try to quit, cold turkey, works less than 5 percent of the time. "There are medications that can improve long-term quit rates, including nicotine replacement therapy and the prescription drugs Chantix and Zyban. When you combine them with behavioral counseling and or support groups, success rates are four times better than quitting cold turkey."

• Create a "more rational" regulatory framework for tobacco products based on their relative risks. Not all tobacco products are equally dangerous, Cummings said.  Treating all tobacco products like they have the same risk as cigarettes makes no sense and is blocking efforts to introduce clearly less dangerous substitute products such as electronic nicotine delivery systems. 

The report concludes that making those changes should move to "the top of the political agenda for immediate, urgent implementation."

Cummings put it this way: “We have 40 million adult smokers in the United States, and one out two of them is going to die from tobacco-caused disease unless we do something about it now."

Tobacco cessation at MUSC Health

MUSC is already taking steps to help smokers quit. 

In 2016, public health professor Benjamin Toll was senior author of a position statement that appeared in Cancer, a peer-reviewed journal of the American Cancer Society. It called for doctors who treat smokers to not only screen them for lung cancer but also encourage them to quit smoking. 

Researchers and doctors at MUSC Health also emphasize the importance of helping cancer patients who smoke quit smoking, because it may improve the effect of their cancer treatment. They say patients should not give up and assume that since they already have cancer the worst has happened and they can keep smoking. 

And Cummings has tried to appeal to smokers' wallets, starting a "Quit and Win" contest that rewards smokers in the Tri-county area who quit smoking and meet other criteria.

“We’ve made a lot of progress in reducing tobacco use in this country over the past 50 years,” Cummings said. “In 1965, 42 percent of Americans were smoking. Today, that figure is 15 percent. Fewer kids are using tobacco and more adult smokers are trying to quit than ever before.

"However, every death from tobacco is a tragedy because it could have been prevented. With 500,000 deaths from tobacco projected this year and for each year after for the coming decade, we have a long way to go before we can declare victory over the tobacco problem," Cummings said. "Fortunately, we now have sufficient knowledge that should allow us to more rapidly decrease the total tobacco market by influencing entry and exit rates. Reducing the appeal and addictiveness of tobacco products would go a long way towards speeding up an end to the tobacco problem. All that is needed is the political will to make it happen."