EXPLAINING RACIAL/ETHNIC DIFFERENCES IN
INITIATION AND CESSATION OF CIGARETTE
SMOKING
Jonathan Foulds PhD.
Penn State – College of Medicine
jfoulds@psu.edu
We Are Penn State
Acknowledgements and conflicts.
Current and recent funding support mainly from Penn State College
of Medicine, New Jersey Department of Health and Senior
Services, but also SRNT, Cancer Institute of New Jersey, Robert
Wood Johnson Foundation, Rutgers CHF & others.
Consulting/honoraria received from pharma. companies producing
tobacco treatment meds (Pfizer, GSK, Novartis, Celtic Pharma &
others).
Compensated for testimony in litigation for plaintiffs against tobacco
companies.
Never received any funding from the tobacco industry
Wrote a regular weblog for a health website at:
www.healthline.com/blogs/smoking_cessation/
Volunteer as a “Health Expert” on the smoking cessation community
on www.WebMD.com
Thanks to numerous colleagues for sharing their slides.
Global Tobacco Use
More than 17 billion cigarettes are smoked
every day, and that number is rising.
Almost 1 billion men in the world smoke—
about 35 percent of men in high-resource
countries, and 50 percent of men in lowincome countries.
Nearly 60 percent of Chinese men are
smokers, and the country consumes
more than 37 percent of the world’s
cigarettes.
Global Tobacco Use 2
About 250 million women in the world are daily
smokers; 22 percent of women in high-resource
countries and 9 percent of women in low- and
middle-resource countries.
Cigarettes account for the largest share of
manufactured tobacco products (96 percent of
total value sales), although in South Asia, bidi
consumption exceeds cigarette consumption by
an order of magnitude and use of oral tobacco
remains a widespread problem.
Global Tobacco Use 3
About 6.3 trillion cigarettes were produced in 2010—
more than 900 cigarettes for every man, woman,
and child on the planet.
Source: The Tobacco Atlas, 2010.
http://www.tobaccoatlas.org/
Smoking kills more people in the US
than all of the following combined:
AIDS
Alcohol
Motor vehicle injuries
Fires
Heroin
Cocaine
Homicide
Suicide
My main research interests
1. Finding better ways to help more
smokers to quit and stay quit.
2. Trying to gain a better
understanding of nicotine
dependence and its assessment.
3. Assessing the potential impact of
other (non-cig) nicotine delivery
products re harm reduction.
1. Smoking Cessation
About to start a randomized trial of
motivational feedback and relapse
prevention materials for smoking
cessation in treatment-seeking
smokers.
Applied for a grant, along with Dr
Legro (OBGYN) and others to
evaluate a cell-text based cessation
intervention for pregnant smokers.
6m triple combo vs standard duration patch in
medical patients (Steinberg et al, 2009)
2. Understanding nicotine dependence
Previously published laboratory
studies showing:
- Nicotine improves some aspects of
cognitive performance and speeds
up EEG alpha waves.
- Smokers with schizophrenia absorb
higher amounts of nicotine and CO
than control smokers.
Example: Understanding nicotine
dependence (FTND & HSI)
3. Evaluating alternative nicotine products
Previously published studies showing:
- Snus use by Swedish men had a
positive public health impact in that
country.
- More Swedish men are quitting
smoking by switching to snus than
via any other smoking cessation aid.
Incidence rate for three types of cancer (by 2004) as a function of
tobacco use status in male Swedish construction workers at
recruitment (1978-92)
Incidence per 100,000 person years
90
82.3
80
Current Smokers
70
Current Snusers
60
Never Tobacco Users
50
40
30
20
13
10
6
8.6
8.8
6.9
2.7
3.1
3.9
0
Lung
Oral
Cancer Type
Pancreatic
Basic E-cig. Anatomy
THE CONTINUUM OF HARM FROM
NICOTINE-DELIVERING PRODUCTS
E-cig ?
HARM
100%
10%
0%
Current cigarette smoking: % of 12th-grade students
who reported smoking any cigarettes in the past 30
days by race, 1977–2010
45
40
35
25
White
Black
Hispanic
20
15
10
5
0
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Percent
30
Source: National Institute on Drug Abuse, Monitoring the Future Survey
What caused the dramatic
reduction in smoking among
AA youth, 1975-1992?...and
why was the decline so much
bigger than in white youth?
By 1992 White students were
almost 4 times more likely to
have smoked in the past 30
days than were their AA
counterparts.
=
Possible Explanations: Oredein &Foulds 2011
1. Differential reliability of self report?
Not supported by cotinine studies
2. Differential school dropout?
Partial support, but AA HS dropout rate began declining in
’88 and studies including dropouts still find difference.
3. AA students using other substances?
No, it came down more in AA youth over study period. e.g.
1996-2000, any illicit use prevalence: w=43%, AA=33%
Possible Explanations: Oredein &Foulds 2011
1. Stronger negative attitudes to smoking and
closer parental supervision among AA
parents?
Supported by numerous studies plus differential increase in
AA single mom households 1970-1990 (30-51%) as
compared with W households (8% to 16%).
2. Differential price sensitivity
1979-89 40% real increase in cigarette price. AA youth more
price sensitive. 1970 to 1990 massive increase in food
stamps. By 1997 90% of AA children (37% W) lived at
some time in family receiving food stamps.
Possible Explanations: Oredein &Foulds 2011
A number of protective factors are present to
a greater extent in the AA community but
we could not find clear evidence that
these increased more 1977-1992:
These include increased sensitivity/awareness of antismoking health education, increased religious
participation.
Policy Implications:
Probably the single most effective intervention to reduce
youth smoking is to increase the real price…primarily via
increases in state and federal excise taxes. This is one of
the few tax increases consistently supported by the public.
Trends in lung cancer death rates in 20- to 39-year-old non-Hispanic white and non-Hispanic
black men and women (1992-2006).
Jemal A et al. Cancer Epidemiol Biomarkers Prev
2009;18:3349-3352
©2009 by American Association for Cancer Research
Percent
% of high school students who smoked on at least 20 of the
past 30 days in US localities by race, YRBS 2009
18
16
14
12
10
8
6
4
2
0
Black
Hispanic
White
Total
Philadelphia
Seattle
Boston
San Diego
Chicago
1.2
3.1
15.6
3.6
1.4
9.8
3.5
3.4
1.8
0.9
9.4
3.1
2.2
2.2
3.7
2.8
1
3.2
9.1
2.7
New York
City
0.7
2.4
6.3
2.4
Data available at: http://www.cdc.gov/tobacco/data_statistics/tables/adult/table_6.htm

Biochemical Measures of Smoke intake,
Menthol vs non-menthol (n=125)
(Williams et al,2008)
*p<0.05, **p<0.01
Menthol
NonMenthol
Blood nicotine (ng/ml)
27.2**
22.4
Blood Cotinine (ng/ml)
294*
240
Exhaled CO
25.1*
20.7
What is the mechanism causing
menthol cigarettes to be more
addictive and carcinogenic?


Its easier to inhale more nicotine and other
toxins from a menthol cigarette in
circumstances that require it (eg expensive
cigarettes or limited smoking opportunities),
because the increased menthol dose from
increased puffing proportionately cools the
smoke harshness.
A menthol cigarette has more “elastic” or
“compensatable” nicotine (and other toxin)
delivery.
% who quit
Gundersen et al (2009). % of ever smokers (who have attempted
to quit) who have quit in the 2005 NHIS by race/ethnicity
Significantly lower quitting success among African Americans and
Hispanics if they smoke menthols (but not whites).
70
60
50
40
30
20
10
0
63 62
62
44
61
49
menthol smokers
non-menthol
smokers
W
AA
H
Conclusion
All other things being equal, menthol smokers are more
dependent than non-menthol smokers, with the effect
being larger at lower cigarette consumption (e.g.
<10pd), and larger for those who are unemployed or
living in relative poverty, particularly in an area with
expensive cigarettes.
This has a bigger impact on AA smokers as more
smoke menthols (80% v 25%) and more live in
poverty. The “menthol effect” explains a significant
portion of the black-white difference in smoking
cessation.
Policy Implications
1.
2.
3.
Raise taxes on all smoked tobacco
products.
Ban menthol as an additive to cigarettes
and also ban characterizing flavors in
cigars.
Plus all the other proven policies: fund
comprehensive tobacco control, place
pictorial health warnings on packs ,
implement comprehensive csmoke-free
air laws nationally etc..