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. 2003 Jun;12(2):124–132. doi: 10.1136/tc.12.2.124

Estimating the health consequences of replacing cigarettes with nicotine inhalers

W Sumner 1
PMCID: PMC1747720  PMID: 12773720

Abstract

Background: A fast acting, clean nicotine delivery system might substantially displace cigarettes. Public health consequences would depend on the subsequent prevalence of nicotine use, hazards of delivery systems, and intrinsic hazards of nicotine.

Methods: A spreadsheet program, DEMANDS, estimates differences in expected mortality, adjusted for nicotine delivery system features and prevalence of nicotine use, by extending the data and methods of the SAMMEC 3 software from the US Centers for Disease Control and Prevention. The user estimates disease risks attributable to nicotine, other smoke components, and risk factors that coexist with smoking. The public health consequences of a widely used clean nicotine inhaler replacing cigarettes were compared to historical observations and public health goals, using four different risk attribution scenarios and nicotine use prevalence from 0–100%.

Main outcome measures: Changes in years of potential life before age 85 (YPL85).

Results: If nicotine accounts for less than a third of smokers' excess risk of SAMMEC diseases, as it most likely does, then even with very widespread use of clean nicotine DEMANDS predicts public health gains, relative to current tobacco use. Public health benefits accruing from a widely used clean nicotine inhaler probably equal or exceed the benefits of achieving Healthy People 2010 goals.

Conclusions: Clean nicotine inhalers might improve public health as much as any feasible tobacco control effort. Although the relevant risk estimates are somewhat uncertain, partial nicotine deregulation deserves consideration as part of a broad tobacco control policy.

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Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Ashakumary L., Vijayammal P. L. Effect of nicotine on lipoprotein metabolism in rats. Lipids. 1997 Mar;32(3):311–315. doi: 10.1007/s11745-997-0038-8. [DOI] [PubMed] [Google Scholar]
  2. Ballard T., Ehlers J., Freund E., Auslander M., Brandt V., Halperin W. Green tobacco sickness: occupational nicotine poisoning in tobacco workers. Arch Environ Health. 1995 Sep-Oct;50(5):384–389. doi: 10.1080/00039896.1995.9935972. [DOI] [PubMed] [Google Scholar]
  3. Benowitz N. L., Gourlay S. G. Cardiovascular toxicity of nicotine: implications for nicotine replacement therapy. J Am Coll Cardiol. 1997 Jun;29(7):1422–1431. doi: 10.1016/s0735-1097(97)00079-x. [DOI] [PubMed] [Google Scholar]
  4. Centers for Disease Control and Prevention (CDC) Smoking-attributable mortality and years of potential life lost--United States, 1984. MMWR Morb Mortal Wkly Rep. 1997 May 23;46(20):444–451. [PubMed] [Google Scholar]
  5. Chowdhury P., Doi R., Tangoku A., Rayford P. L. Structural and functional changes of rat exocrine pancreas exposed to nicotine. Int J Pancreatol. 1995 Dec;18(3):257–264. doi: 10.1007/BF02784950. [DOI] [PubMed] [Google Scholar]
  6. Chowdhury P., Rayford P. L., Chang L. W. Induction of pancreatic acinar pathology via inhalation of nicotine. Proc Soc Exp Biol Med. 1992 Nov;201(2):159–164. doi: 10.3181/00379727-201-43494b. [DOI] [PubMed] [Google Scholar]
  7. Cluette-Brown J., Mulligan J., Doyle K., Hagan S., Osmolski T., Hojnacki J. Oral nicotine induces an atherogenic lipoprotein profile. Proc Soc Exp Biol Med. 1986 Jul;182(3):409–413. doi: 10.3181/00379727-182-3-rc1. [DOI] [PubMed] [Google Scholar]
  8. Cornelius M. D., Ryan C. M., Day N. L., Goldschmidt L., Willford J. A. Prenatal tobacco effects on neuropsychological outcomes among preadolescents. J Dev Behav Pediatr. 2001 Aug;22(4):217–225. doi: 10.1097/00004703-200108000-00002. [DOI] [PubMed] [Google Scholar]
  9. Day N. L., Richardson G. A., Goldschmidt L., Cornelius M. D. Effects of prenatal tobacco exposure on preschoolers' behavior. J Dev Behav Pediatr. 2000 Jun;21(3):180–188. [PubMed] [Google Scholar]
  10. Dempsey D. A., Benowitz N. L. Risks and benefits of nicotine to aid smoking cessation in pregnancy. Drug Saf. 2001;24(4):277–322. doi: 10.2165/00002018-200124040-00005. [DOI] [PubMed] [Google Scholar]
  11. DiFranza J. R., Rigotti N. A. Impediments to the enforcement of youth access laws. Tob Control. 1999 Summer;8(2):152–155. doi: 10.1136/tc.8.2.152. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Eliasson B., Taskinen M. R., Smith U. Long-term use of nicotine gum is associated with hyperinsulinemia and insulin resistance. Circulation. 1996 Sep 1;94(5):878–881. doi: 10.1161/01.cir.94.5.878. [DOI] [PubMed] [Google Scholar]
  13. Ernst M., Moolchan E. T., Robinson M. L. Behavioral and neural consequences of prenatal exposure to nicotine. J Am Acad Child Adolesc Psychiatry. 2001 Jun;40(6):630–641. doi: 10.1097/00004583-200106000-00007. [DOI] [PubMed] [Google Scholar]
  14. Galbraith J. W., Kaiserman M. Taxation, smuggling and demand for cigarettes in Canada: evidence from time-series data. J Health Econ. 1997 Jun;16(3):287–301. doi: 10.1016/s0167-6296(96)00525-5. [DOI] [PubMed] [Google Scholar]
  15. Gori G. B. Low-risk cigarettes: a prescription. Science. 1976 Dec 11;194(4271):1243–1246. doi: 10.1126/science.996552. [DOI] [PubMed] [Google Scholar]
  16. Greenland S., Satterfield M. H., Lanes S. F. A meta-analysis to assess the incidence of adverse effects associated with the transdermal nicotine patch. Drug Saf. 1998 Apr;18(4):297–308. doi: 10.2165/00002018-199818040-00005. [DOI] [PubMed] [Google Scholar]
  17. Haapanen A., Koskenvuo M., Kaprio J., Kesäniemi Y. A., Heikkilä K. Carotid arteriosclerosis in identical twins discordant for cigarette smoking. Circulation. 1989 Jul;80(1):10–16. doi: 10.1161/01.cir.80.1.10. [DOI] [PubMed] [Google Scholar]
  18. Heeschen C., Jang J. J., Weis M., Pathak A., Kaji S., Hu R. S., Tsao P. S., Johnson F. L., Cooke J. P. Nicotine stimulates angiogenesis and promotes tumor growth and atherosclerosis. Nat Med. 2001 Jul;7(7):833–839. doi: 10.1038/89961. [DOI] [PubMed] [Google Scholar]
  19. Henningfield J. E., Benowitz N. L., Slade J., Houston T. P., Davis R. M., Deitchman S. D. Reducing the addictiveness of cigarettes. Council on Scientific Affairs, American Medical Association. Tob Control. 1998 Autumn;7(3):281–293. doi: 10.1136/tc.7.3.281. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Henningfield J. E., Slade J. Tobacco-dependence medications: public health and regulatory issues. Food Drug Law J. 1998;53 Suppl:75–114. [PubMed] [Google Scholar]
  21. Hipke M. E. Green tobacco sickness. South Med J. 1993 Sep;86(9):989–992. doi: 10.1097/00007611-199309000-00002. [DOI] [PubMed] [Google Scholar]
  22. Hoffmann D., Hoffmann I., El-Bayoumy K. The less harmful cigarette: a controversial issue. a tribute to Ernst L. Wynder. Chem Res Toxicol. 2001 Jul;14(7):767–790. doi: 10.1021/tx000260u. [DOI] [PubMed] [Google Scholar]
  23. Hoffmann D., Hoffmann I. The changing cigarette, 1950-1995. J Toxicol Environ Health. 1997 Mar;50(4):307–364. doi: 10.1080/009841097160393. [DOI] [PubMed] [Google Scholar]
  24. Jacobi Johannes, Jang James J., Sundram Uma, Dayoub Hayan, Fajardo Luis F., Cooke John P. Nicotine accelerates angiogenesis and wound healing in genetically diabetic mice. Am J Pathol. 2002 Jul;161(1):97–104. doi: 10.1016/S0002-9440(10)64161-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Kozlowski L. T., Strasser A. A., Giovino G. A., Erickson P. A., Terza J. V. Applying the risk/use equilibrium: use medicinal nicotine now for harm reduction. Tob Control. 2001 Sep;10(3):201–203. doi: 10.1136/tc.10.3.201. [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Lee T. S., Hou X. Nicotine is hazardous to your heart. Chest. 1996 Feb;109(2):584–585. doi: 10.1378/chest.109.2.584-a. [DOI] [PubMed] [Google Scholar]
  27. Lindsay G. B., Rainey J. Psychosocial and pharmacologic explanations of nicotine's "gateway drug" function. J Sch Health. 1997 Apr;67(4):123–126. doi: 10.1111/j.1746-1561.1997.tb03430.x. [DOI] [PubMed] [Google Scholar]
  28. Loennechen Jan P., Nilsen Odd G., Arbo Ingerid, Aadahl Petter, Nilsen Turid, Waldum Helge L., Sandvik Arne K., Ellingsen O. Chronic exposure to carbon monoxide and nicotine: endothelin ET(A) receptor antagonism attenuates carbon monoxide-induced myocardial hypertrophy in rat. Toxicol Appl Pharmacol. 2002 Jan 1;178(1):8–14. doi: 10.1006/taap.2001.9300. [DOI] [PubMed] [Google Scholar]
  29. Malarcher A. M., Schulman J., Epstein L. A., Thun M. J., Mowery P., Pierce B., Escobedo L., Giovino G. A. Methodological issues in estimating smoking-attributable mortality in the United States. Am J Epidemiol. 2000 Sep 15;152(6):573–584. doi: 10.1093/aje/152.6.573. [DOI] [PubMed] [Google Scholar]
  30. McAllister-Sistilli C. G., Caggiula A. R., Knopf S., Rose C. A., Miller A. L., Donny E. C. The effects of nicotine on the immune system. Psychoneuroendocrinology. 1998 Feb;23(2):175–187. doi: 10.1016/s0306-4530(97)00080-2. [DOI] [PubMed] [Google Scholar]
  31. McNeill A., Foulds J., Bates C. Regulation of nicotine replacement therapies (NRT): a critique of current practice. Addiction. 2001 Dec;96(12):1757–1768. doi: 10.1080/09652140120089508. [DOI] [PubMed] [Google Scholar]
  32. Mendez D., Warner K. E., Courant P. N. Has smoking cessation ceased? Expected trends in the prevalence of smoking in the United States. Am J Epidemiol. 1998 Aug 1;148(3):249–258. doi: 10.1093/oxfordjournals.aje.a009632. [DOI] [PubMed] [Google Scholar]
  33. Mendez D., Warner K. E. Smoking prevalence in 2010: why the healthy people goal is unattainable. Am J Public Health. 2000 Mar;90(3):401–403. doi: 10.2105/ajph.90.3.401. [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. Murray R. P., Bailey W. C., Daniels K., Bjornson W. M., Kurnow K., Connett J. E., Nides M. A., Kiley J. P. Safety of nicotine polacrilex gum used by 3,094 participants in the Lung Health Study. Lung Health Study Research Group. Chest. 1996 Feb;109(2):438–445. doi: 10.1378/chest.109.2.438. [DOI] [PubMed] [Google Scholar]
  35. Navarro H. A., Seidler F. J., Eylers J. P., Baker F. E., Dobbins S. S., Lappi S. E., Slotkin T. A. Effects of prenatal nicotine exposure on development of central and peripheral cholinergic neurotransmitter systems. Evidence for cholinergic trophic influences in developing brain. J Pharmacol Exp Ther. 1989 Dec;251(3):894–900. [PubMed] [Google Scholar]
  36. Navarro H. A., Seidler F. J., Schwartz R. D., Baker F. E., Dobbins S. S., Slotkin T. A. Prenatal exposure to nicotine impairs nervous system development at a dose which does not affect viability or growth. Brain Res Bull. 1989 Sep;23(3):187–192. doi: 10.1016/0361-9230(89)90146-9. [DOI] [PubMed] [Google Scholar]
  37. Nelson D. E., Kirkendall R. S., Lawton R. L., Chrismon J. H., Merritt R. K., Arday D. A., Giovino G. A. Surveillance for smoking-attributable mortality and years of potential life lost, by state--United States, 1990. MMWR CDC Surveill Summ. 1994 Jun 10;43(1):1–8. [PubMed] [Google Scholar]
  38. Page J. A. Federal regulation of tobacco products and products that treat tobacco dependence: are the playing fields level? Food Drug Law J. 1998;53 Suppl:11–42. [PubMed] [Google Scholar]
  39. Pierce John P., Gilpin Elizabeth A. Impact of over-the-counter sales on effectiveness of pharmaceutical aids for smoking cessation. JAMA. 2002 Sep 11;288(10):1260–1264. doi: 10.1001/jama.288.10.1260. [DOI] [PubMed] [Google Scholar]
  40. Ritch W. A., Begay M. E. Smoke and mirrors: how Massachusetts diverted millions in tobacco tax revenues. Tob Control. 2001 Dec;10(4):309–316. doi: 10.1136/tc.10.4.309. [DOI] [PMC free article] [PubMed] [Google Scholar]
  41. Rodu B. An alternative approach to smoking control. Am J Med Sci. 1994 Jul;308(1):32–34. doi: 10.1097/00000441-199407000-00007. [DOI] [PubMed] [Google Scholar]
  42. Russell M. A., Jarvis M. J., Sutherland G., Feyerabend C. Nicotine replacement in smoking cessation. Absorption of nicotine vapor from smoke-free cigarettes. JAMA. 1987 Jun 19;257(23):3262–3265. [PubMed] [Google Scholar]
  43. Russell M. A. The future of nicotine replacement. Br J Addict. 1991 May;86(5):653–658. doi: 10.1111/j.1360-0443.1991.tb01825.x. [DOI] [PubMed] [Google Scholar]
  44. Sayers N. M., Drucker D. B., Telford D. R., Morris J. A. Effects of nicotine on bacterial toxins associated with cot death. Arch Dis Child. 1995 Dec;73(6):549–551. doi: 10.1136/adc.73.6.549. [DOI] [PMC free article] [PubMed] [Google Scholar]
  45. Schuh K. J., Schuh L. M., Henningfield J. E., Stitzer M. L. Nicotine nasal spray and vapor inhaler: abuse liability assessment. Psychopharmacology (Berl) 1997 Apr;130(4):352–361. doi: 10.1007/s002130050250. [DOI] [PubMed] [Google Scholar]
  46. Shultz J. M., Novotny T. E., Rice D. P. Quantifying the disease impact of cigarette smoking with SAMMEC II software. Public Health Rep. 1991 May-Jun;106(3):326–333. [PMC free article] [PubMed] [Google Scholar]
  47. Silcox D. H., 3rd, Daftari T., Boden S. D., Schimandle J. H., Hutton W. C., Whitesides T. E., Jr The effect of nicotine on spinal fusion. Spine (Phila Pa 1976) 1995 Jul 15;20(14):1549–1553. doi: 10.1097/00007632-199507150-00001. [DOI] [PubMed] [Google Scholar]
  48. Slade J., Henningfield J. E. Tobacco product regulation: context and issues. Food Drug Law J. 1998;53 Suppl:43–74. [PubMed] [Google Scholar]
  49. Slotkin T. A. Fetal nicotine or cocaine exposure: which one is worse? J Pharmacol Exp Ther. 1998 Jun;285(3):931–945. [PubMed] [Google Scholar]
  50. Stapleton J. A., Russell M. A., Sutherland G., Feyerabend C. Nicotine availability from Eclipse tobacco-heating cigarette. Psychopharmacology (Berl) 1998 Oct;139(3):288–290. doi: 10.1007/s002130050719. [DOI] [PubMed] [Google Scholar]
  51. Sweanor D. Regulatory imbalance between medicinal and non-medicinal nicotine. Addiction. 2000 Jan;95 (Suppl 1):S25–S28. doi: 10.1080/09652140032044. [DOI] [PubMed] [Google Scholar]
  52. Syversen U., Nordsletten L., Falch J. A., Madsen J. E., Nilsen O. G., Waldum H. L. Effect of lifelong nicotine inhalation on bone mass and mechanical properties in female rat femurs. Calcif Tissue Int. 1999 Sep;65(3):246–249. doi: 10.1007/s002239900692. [DOI] [PubMed] [Google Scholar]
  53. Thomas A. R., Hedberg K., Fleming D. W. Comparison of physician based reporting of tobacco attributable deaths and computer derived estimates of smoking attributable deaths, Oregon, 1989 to 1996. Tob Control. 2001 Jun;10(2):161–164. doi: 10.1136/tc.10.2.161. [DOI] [PMC free article] [PubMed] [Google Scholar]
  54. Thun M. J., Apicella L. F., Henley S. J. Smoking vs other risk factors as the cause of smoking-attributable deaths: confounding in the courtroom. JAMA. 2000 Aug 9;284(6):706–712. doi: 10.1001/jama.284.6.706. [DOI] [PubMed] [Google Scholar]
  55. Waldum H. L., Nilsen O. G., Nilsen T., Rørvik H., Syversen V., Sanvik A. K., Haugen O. A., Torp S. H., Brenna E. Long-term effects of inhaled nicotine. Life Sci. 1996;58(16):1339–1346. doi: 10.1016/0024-3205(96)00100-2. [DOI] [PubMed] [Google Scholar]
  56. Warner K. E., Peck C. C., Woosley R. L., Henningfield J. E., Slade J. Treatment of tobacco dependence: innovative regulatory approaches to reduce death and disease: preface. Food Drug Law J. 1998;53 Suppl:1–8. [PubMed] [Google Scholar]
  57. Warner K. E., Slade J., Sweanor D. T. The emerging market for long-term nicotine maintenance. JAMA. 1997 Oct 1;278(13):1087–1092. [PubMed] [Google Scholar]
  58. Woolf A., Burkhart K., Caraccio T., Litovitz T. Self-poisoning among adults using multiple transdermal nicotine patches. J Toxicol Clin Toxicol. 1996;34(6):691–698. doi: 10.3109/15563659609013830. [DOI] [PubMed] [Google Scholar]

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