New cigarette flavors include mint, chocolate and citrus - youth market targeted

New research from the Harvard School of Public Health finds that cigarette makers are targeting young smokers with candy and liqueur-flavored new brands that mask the harsh and toxic properties found in tobacco smoke, and in one case, embedding a hidden flavor pellet within the filter. Despite assurances from cigarette makers that they no longer target the youth market, the researchers found that new brands are being marketed to young smokers and racial/ethnic groups using colorful and stylish packaging and exploiting adolescents' attraction to candy flavors. The study appears in the November/December issue of the journal, Health Affairs.

The researchers sifted through a database of more than 7 million internal tobacco industry documents spanning more than 30 years for information on alternative flavors and flavor technology used in the development of products targeting new and younger smokers. Carrie Carpenter, lead author of the study and a research analyst at HSPH stated, "Flavored cigarettes can promote youth smoking initiation and help young occasional smokers to become daily smokers by reducing or masking the natural harshness and taste of tobacco smoke and increasing the acceptability of a toxic product." A 1993 internal document stated, "Growing interest in new flavor sensations (i.e. soft drinks, snack foods) among younger adult consumers may indicate new opportunities for enhanced-flavor tobacco products that could leverage [a brand's] current strength among younger adult smokers."

Internal research by the tobacco industry showed manufacturers that they could capitalize on youths' attraction to candy flavors. They used innovative product technology, such as a flavor pellet imbedded in one company's cigarette filters, to deliver fruit and liqueur flavors. Some of the flavored cigarettes the companies have developed include; Mandarin Mint, Mocha Taboo, Mintrigue, Kauai Kolada, Margarita Mixer and others. Fruit and candy flavors were also added to smokeless tobacco products, cigars and cigarette rolling papers.

Gregory Connolly, senior author of the study and a professor of the practice of public health at HSPH noted, "Tobacco companies are using candy-like flavors and high tech delivery devices to turn a blowtorch into a flavored popsicle, misleading millions of youngsters to try a deadly product. Adding candy flavors to a toxic product (cigarettes) isn't any different than adding sugar to contaminated meat a century ago. The only difference is that today one is regulated by the FDA and the other is not."

Dr. Cheryl Healton, president and CEO of the American Legacy Foundation, a funder of the study, commented, "The public should recognize these products for what they are - a tool to lure younger smokers to their brands, and then potentially to a lifetime of tobacco addiction."

The study; "New Cigarette Brands with Flavors That Appeal to Youth: Tobacco Marketing Strategies; Health Affairs, November/December 2005, Volume 24, number 6, was funded by the American Legacy Foundation and the National Cancer Institute.

Harvard School of Public Health is dedicated to advancing the public's health through learning, discovery, and communication. More than 300 faculty members are engaged in teaching and training the 900-plus student body in a broad spectrum of disciplines crucial to the health and well being of individuals and populations around the world. Programs and projects range from the molecular biology of AIDS vaccines to the epidemiology of cancer; from risk analysis to violence prevention; from maternal and children's health to quality of care measurement; from health care management to international health and human rights. For more information on the school visit: http://www.hsph.harvard.edu.

Kevin C. Myron
kmyron@hsph.harvard.edu
Harvard School of Public Health
http://www.hsph.harvard.edu

 

Teens targeted with candy-flavored cigarettes

The tobacco industry is continuing its targeted marketing to teens via candy-flavored cigarettes, according to an American Lung Association Tobacco Policy Trend Alert: From Joe Camel to Kauai Kolada -- the Marketing of Candy-Flavored Cigarettes. Advertising and promotion for these products uses hip-hop imagery, attractive women, and other imagery to appeal to youth in similar ways that Joe Camel did a decade ago. Tobacco products remain virtually unregulated and each day more than 5,000 kids under 18 try their first cigarette, and more than 2,000 become established daily smokers.

Increased marketing efforts for candy-flavored cigarettes came after the 1998 Master Settlement Agreement prohibited tobacco companies from using cartoon characters to sell cigarettes. The surge in advertising from top tobacco companies such as Reynolds American has successfully reached the intended audience -- youth -- in an underhanded manner. Researchers at the Roswell Park Cancer Institute in Buffalo, NY, recently released the results of several surveys that showed that 20 percent of smokers ages 17 to 19 smoked flavored cigarettes in the past 30 days while only 6 percent of smokers over the age of 25 did.

"It's appalling that the tobacco industry is not held responsible for the deadly products it continues to market and sell to young people," said John Kirkwood, President and CEO of the American Lung Association. "Clearly, the industry is trying to get young people hooked on smoking and nothing is being done to limit this targeted marketing. Cigarettes, even in assorted candy flavors, cause lung cancer and lung disease and should be banned for the sake of our children."

Action at the federal level has been minimal. A proposed bill giving the Food and Drug Administration (FDA) authority to regulate tobacco products failed to pass in Congress in 2004. Identical FDA legislation was reintroduced in March 2005. Under the proposed FDA legislation, candy and fruit flavoring in cigarettes would be immediately prohibited. The legislation would also regulate the sale, marketing and manufacturing of cigarettes.

Additional controls on the tobacco industry could come through the Department of Justice's (DOJ) lawsuit against the industry. In its proposed remedies, the DOJ has called for a complete ban on candy-flavored cigarettes.

You can make your voice heard on this issue by logging on to lungaction.org/campaign/tobaccofda and advocating for stricter regulation of the tobacco industry. The full American Lung Association Tobacco Policy Trend Alert: From Joe Camel to Kauai Kolada -- the Marketing of Candy-Flavored Cigarettes can be viewed on the web at slati.lungusa.org.

About the American Lung Association: For 100 years, the American Lung Association has been the lead organization working to prevent lung disease and promote lung health. Lung disease death rates continue to increase while other leading causes of death have declined.

The American Lung Association funds vital research on the causes of and treatments for lung disease. With the generous support of the public, the American Lung Association is "Improving life, one breath at a time."

For more information about the American Lung Association or to support the work it does, call
1-800-LUNG-USA (1-800-586-4872) or log on to
http://www.lungusa.org.

 

American Lung Association Deplores Recent Marketing Tactics By The Tobacco Industry

A new American Lung Association report, Alcohol-Flavored Cigarettes - Continuing the Flavored Cigarette Trend, shows that the tobacco industry continues to target the nation's youth and young adults with their deadly products using underhanded marketing tactics. With the world prepared to celebrate World No Tobacco Day tomorrow the American Lung Association is calling for stronger regulation of the tobacco industry for the sake of public health.

"May 31 is World No Tobacco Day, a day focusing on the impact of tobacco use on public health. Unfortunately, tobacco products remain virtually unregulated in the United States," said John L. Kirkwood, President and CEO of the American Lung Association. "Each day more than 4,000 kids under 18 try their first cigarette, and more than 1,500 other kids under 18 become established daily smokers."

R.J. Reynolds in particular has been aggressively targeting the youth and young adult market with several recent marketing campaigns that seek to link smoking with alcohol use, gambling and rebellious behavior.

The report details how R.J. Reynolds recently sold alcohol-flavored cigarettes as limited edition brands of an ongoing line of flavored cigarettes called Camel Exotic Blends. Included were packs of cigarettes with names such as Screwdriver Slots, SnakeEyes Scotch and Blackjack Gin. These new flavored cigarettes were sold as part of a larger promotional campaign called Camel Casino, which sought to link smoking with alcohol use and gambling. The promotional campaign ran from July 2005 through early 2006. Although R.J. Reynolds claimed these new cigarettes were marketed towards young adults, their appeal to youth who are beginning to experiment with alcohol is obvious.

"It's appalling that the tobacco industry is allowed to continue marketing and selling flavored cigarettes," said Kirkwood. "The industry's goal is obvious: To get young people hooked on smoking. Flavored cigarettes, like regular cigarettes, cause lung cancer and lung disease and should be banned for the sake of our children."

The Alcohol-Flavored Cigarettes - Continuing the Flavored Cigarette Trend report also divulges information about other marketing tactics recently used by R.J. Reynolds in cultivating young smokers. A campaign called Drinks on Us was exposed in December 2005 by several state Attorneys General. Customers celebrating their birthdays were mailed a promotional package that contained coasters imprinted with drink recipes some of which called for up to five shots of alcohol per drink. The campaign appeared to be designed to promote both smoking and excessive drinking.

Another separate campaign that began in spring 2006 for R.J. Reynolds' Camel Wides, a version of its Camel line of cigarettes, associates smoking with rebellious behavior using bar parties that feature graffiti artists, "rave" style paraphernalia, such as glow-in-the-dark necklaces, and offers to party-goers to get real tattoos at a discount.

"These recent marketing tactics continue to show the tobacco industry has not changed, and is continuing its attempts to hook a new generation on tobacco products," said Kirkwood.

A bill giving the Food and Drug Administration (FDA) the authority to regulate tobacco products failed to pass in Congress in 2004. Identical FDA legislation was reintroduced in March 2005, and is still pending. The proposed FDA legislation would regulate the sale, marketing and manufacturing of all tobacco products. It would also prohibit all flavorings in cigarettes except menthol.

The full American Lung Association Tobacco Policy Trend Alert Addendum: Alcohol-Flavored Cigarettes - Continuing the Flavored Cigarette Trend can be viewed on the web at http://slati.lungusa.org/alerts.asp.

About the American Lung Association

Beginning our second century, the American Lung Association is the leading organization working to prevent lung disease and promote lung health. Lung disease death rates continue to increase while other leading causes of death have declined.

The American Lung Association funds vital research on the causes of and treatments for lung disease. With the generous support of the public, the American Lung Association is "Improving life, one breath at a time."

For more information about the American Lung Association or to support the work it does, call
1-800-LUNG-USA (1-800-586-4872)
or log on to
http://www.lungusa.org.

 

Flavored Asian cigarettes are even more deadly than regular ones

Flavored Asian cigarettes, even more harmful than regular ones, are gaining a foothold among minority youth, according to a study of New Jersey middle- and high-schoolers appearing in the American Journal of Health Behavior.

Called "bidis," the exotic cigarettes from India and Southeast Asia are made of tobacco wrapped in a leaf and tied with a string. For the U.S. market, vanilla, cherry, root beer, or other flavors are added.

After sampling the New Jersey youth, Mary Hrywna, M.P.H., and colleagues found that about 12 percent of middle school students and 34 percent of high school kids used any kind of tobacco. However, 5 percent of the middle-schoolers and 9 percent of high school said they used bidis.

Black high school students were more likely to use bidis than white students. In middle school, Hispanic and black students were more than twice as likely as whites to smoke them.

Bidis' candy-like taste and a street reputation as "natural" products lead young people, especially minorities, to consider them safer than ordinary cigarettes, says Hrywna, of the University of Medicine and Dentistry of New Jersey in New Brunswick.

Students who believed that bidis were safer were more likely to smoke them, as were users of other tobacco products, the study showed.

But bidis deliver more nicotine than conventional cigarettes, increasing the likelihood of addiction and raising the risk of cancers of the throat, mouth, lungs, esophagus, stomach and liver, say the researchers.

Because enforcement of laws governing tobacco sales to minors concentrates on cigarettes, products like bidis or snuff are probably easier to buy, says Hrywna. Other researchers have found that bidis are often sold without tax stamps, suggesting they are imported illegally and thus can be sold more cheaply than conventional cigarettes.

"A comprehensive approach to youth tobacco prevention and cessation campaigns must address other tobacco products as well as cigarettes," says Hrywna. Those approaches should also pay attention to groups like black youth, who use bidis, cigars and cigarettes about equally.

Future research should try to understand just why minority youth are so attracted to bidis, says Hrywna. Tobacco control efforts must also combat the illusion that they are not as harmful as regular cigarettes.

"Public health messages targeted at youth must dispel the dangerous myth that other tobacco products like cigars and bidis are safer than conventional cigarettes," she says.

This study was supported by the New Jersey Department of Health and Senior Services and the Association of Schools of Public Health/American Legacy Foundation.

Health Behavior News Service: (202) 387-2829 or www.hbns.org.
Interviews: Contact Mary Hrywna, M.P.H., at (732) 235-9728 or e-mail hrywnama@umdnj.edu.
American Journal of Health Behavior: Visit www.ajhb.org or e-mail eglover@hsc.wvu.edu.

Center for the Advancement of Health
Contact: Ira R. Allen
Director of Public Affairs
202.387.2829
press@cfah.org

By Aaron Levin, Science Writer
Health Behavior News Service

Lung Association Applauds Justice Department For Seeking Full $280 Billion from Tobacco Industry - Urges Vigorous Pursuit of All R

Statement by John L. Kirkwood, President and CEO -

The American Lung Association welcomes the U.S. Department of Justice announcement that it is appealing to the U.S. Supreme Court an appeals court ruling barring disgorgement of illegal tobacco industry profits. This action means that the U.S. Government is again seeking $280 billion in past profits in its racketeering case against the tobacco industry.

The Department of Justice has presented a strong case that the tobacco industry has been engaged in a long-running campaign to deceive the American people about the risks of its products. And, as the marketing of candy-flavored cigarettes shows, the deception continues. Today's action should send a message that a weak settlement is not appropriate and all remedies should be vigorously pursued.

The American Lung Association urges the Department of Justice to pursue the strongest possible remedies including full funding of a nationwide cessation program, penalties if tobacco companies continue to addict children and teens, full disclosure of industry documents, restrictions on marketing, strict oversight and monitoring of industry actions and a national campaign to prevent children from becoming addicted to tobacco.

About the American Lung Association:

For 100 years, the American Lung Association has been the lead organization working to prevent lung disease and promote lung health. Lung disease death rates continue to increase while other leading causes of death have declined. The American Lung Association funds vital research on the causes of and treatments for lung disease. With the generous support of the public, the American Lung Association is "Improving life, one breath at a time." For more information about the American Lung Association or to support the work it does, call 1-800-LUNG-USA (1-800-586-4872) or log on to http://www.lungusa.org.

Study Suggests Menthol Cigarette Smokers May Have More Difficulty Quitting Smoking

Menthol and non-menthol cigarettes appear to be equally harmful to the arteries and to lung function, but smokers of menthols may be less likely to attempt or succeed at quitting, according to a report in the September 25 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.

Cigarette smoking causes about 440,000 deaths in the United States each year, according to background information in the article. African Americans tend to smoke less than European Americans, but have disproportionately high rates of cancer, cardiovascular disease and other smoking-related illnesses. "For a variety of historical and cultural reasons, including targeted advertising by the tobacco industry, African American smokers are much more likely to smoke menthol cigarettes than European American smokers (approximately 70 percent vs. 30 percent)," the authors write. Menthol is a mint-flavored compound derived from peppermint oil that could potentially increase the harm caused by cigarettes through a variety of biological mechanisms. "If menthol cigarettes were more harmful than non-menthol cigarettes, the higher exposure to menthol cigarette smoke among African American smokers could help explain racial/ethnic disparities in disease rates."

Mark J. Pletcher, M.D., M.P.H., University of California, San Francisco, and colleagues examined this hypothesis in 1,535 smokers who were part of the Coronary Artery Risk Development in Young Adults (CARDIA) Study. The researchers measured the association between exposure to menthol cigarettes and smoking cessation (quitting); coronary calcification, or a build-up of calcium in the arteries leading to the heart that is a sign of coronary artery disease; and change in pulmonary (lung) function over a 10-year period. Participants were women and men age 18 to 30 at the beginning of the study, in 1985. Each underwent a medical examination and answered questions about demographics and smoking habits in 1985 and again two, five, seven, 10 and 15 years later.

Among the smokers, 808 were women and 727 men. In 1985, 972 (63 percent) preferred menthol cigarettes and 563 (36 percent) preferred non-menthol cigarettes; 89 percent of African Americans, compared with 29 percent of European Americans, smoked menthol cigarettes. Menthol smokers were also more likely to be younger, female and unemployed, to have a lower level of education and a higher body mass index, and to drink less alcohol and smoke fewer cigarettes per day.

Those who smoked menthol cigarettes in 1985 were more likely to still be smoking at follow-up examinations--in 2000, for example, 69 percent were still smokers vs. 54 percent of non-menthol smokers. However, once the researchers factored in other social and demographic variables, most of this difference was explained by the fact that African Americans were both more likely to smoke menthols and less likely to quit smoking. "Among smokers who tried to quit, menthol seemed unrelated to quitting, but menthol was associated with a lower likelihood of trying to quit in the first place," the authors write. Analyzing the data over time, they found that menthol smokers were almost twice as likely to relapse after quitting and also were less likely to stop for a sustained period of time. Both coronary calcification and a decline in lung function over 10 years were associated with the number of cigarettes smoked, but whether the cigarettes were menthol or not did not appear to make a difference.

"Mentholation of cigarettes does not seem to explain disparities in ischemic heart disease and obstructive pulmonary disease between African Americans and European Americans in the United States but may partially explain lower rates of smoking cessation among African American smokers," the authors conclude. "It is possible, therefore, that switching from menthol cigarettes to non-menthol cigarettes might facilitate subsequent smoking cessation, especially in African Americans, and thereby reduce tobacco-related health disparities."

###

(Arch Intern Med. 2006;166:1915-1922.)

The CARDIA Study is supported by contracts from the National Heart, Lung and Blood Institute. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

Contact: Wallace Ravven
JAMA and Archives Journals

Cigarette firms designed cigarettes 'to addict women,' according to new study

A new analysis of tobacco industry documents provides evidence that cigarette companies intentionally modified their products to promote female smoking by emphasizing attributes they knew would appeal to women - stylishness and taste, as well as perceived health benefits. According to the authors, the study presents particularly troubling implications for world health, as tobacco companies seek to increase smoking among women in developing countries. The documents, made public following the 1998 Tobacco Master Settlement Agreement, are examined in a paper in the June 2005 issue of ADDICTION, an international scientific journal.

Previous studies demonstrated that marketing strategies have contributed to the association of smoking with appealing attributes including female liberation, glamour, success and thinness. Until now, however, the role of product design in targeting cigarettes to address how and why women smoke was less well understood.

"These internal documents reveal that the tobacco industry's targeting of women goes far beyond marketing and advertising," says lead author Carrie Murray Carpenter, M.S., Research Analyst, Tobacco Control Research and Training Program, Harvard School of Public Health. Carpenter and colleagues reveal that, for more than 20 years, the industry undertook a major effort to identify gender-based differences in motivational factors, smoking patterns, and product preferences in order to promote smoking among women and girls.

The Carpenter team say the resulting products exploited mistaken health notions about the relative safety of light cigarettes; created false perceptions of social and health effects through reduced sidestream smoke, appearance and odor and improved aroma and aftertaste; matched female taste preferences through flavored, smooth and mild-tasting cigarettes; and targeted physiological and inhalation differences between women and men with greater ease of draw, increased sensory pleasure and altered tar and nicotine levels. The documents also show that cigarette makers went so far as to explore the use of appetite suppressants in cigarettes to promote smoking-mediated weight control, according to the researchers.

"Carpenter and her group reveal that cigarette designs and ingredients were manipulated to make the cigarettes more palatable to women and to complement advertising allusions of smooth, healthy, weight-controlling, stress-reducing smoke," according to an accompanying editorial in ADDICTION by Jack E. Henningfield, Ph.D. and colleagues at The Johns Hopkins University School of Medicine and Johns Hopkins Bloomberg School of Public Health. "For example, so called 'light' and 'reduced tar' cigarettes were designed to undermine prevention and cessation efforts by addressing smokers' concerns about the health effects of smoking - but not by reducing the adverse health effects." Henningfield, who serves as director of The Robert Wood Johnson Foundation's Innovators Combating Substance Abuse program at Johns Hopkins University, is Adjunct Professor of Behavioral Biology, Department of Psychiatry and Behavioral Sciences in the university's School of Medicine. Quotes from tobacco industry documents are sprinkled throughout the paper. One, from a 1993 internal Philip Morris report, describes a rationale for designing longer, slimmer cigarettes and creating the illusion of a "healthier" product: "Most smokers have little notion of their brand's tar and nicotine levels. Perception is more important than reality, and in this case the perception is of reduced tobacco consumption."

The documents reveal that, beginning in the 1970s, the companies undertook internal research to identify numerous psychological and behavioral factors contributing to female-specific needs and motivations to smoke. As brand preferences shifted between the 1970s and 1990s the tobacco companies modified their product designs accordingly. "While the tobacco industry continues to target female smokers today, their current strategies are more multi-faceted and less readily identifiable than they were decades ago," the authors note.

The new paper's analysis suggests that the tobacco industry's behavior has particularly troubling implications for health officials in the developing world. While male smoking rates are declining throughout the world, female smoking rates are expected to continuing increasing and reach 20 percent by 2025, driven by the growth of female markets in developing countries. Published research predicts the rapid growth of tobacco-related disease among women in these countries, and establishes that industry efforts to target women have resulted in the elevated female smoking and related disease rates that we see today.

Henningfield views these revelations as a "call to action" for the tobacco control community: "Now that we know tobacco companies designed cigarettes to addict women, we need to look at prevention and cessation strategies to counter these efforts. Our most pressing priority should be to examine how Carpenter's findings can be used to counter the rising tide of smoking in women in developing countries, so that we don't see the corresponding increase in smoking-related deaths that we've already seen in the developed world."

Innovators Combating Substance Abuse is a national program of The Robert Wood Johnson Foundation that recognizes and rewards those who have made substantial, innovative contributions of national significance in the field of substance abuse. Each award includes a grant of $300,000, which is used to conduct a project over a period of up to three years that advances the field. The program addresses problems related to alcohol, tobacco and illicit drugs, through education, advocacy, treatment and policy research and reform at the national, state and local levels. The Innovators program is run by a national program office at The Johns Hopkins University School of Medicine. For more information on Innovators Combating Substance Abuse, please visit http://www.innovatorsawards.org.

Johns Hopkins is one of the world's premier centers for scholarship, research and patient care. The university and The Johns Hopkins Health System are separate, but closely allied, institutions. Founded in Baltimore, they now reach across the Baltimore-Washington area, with additional facilities in China, Italy and Singapore and partnerships around the world. The university comprises eight schools, a research and development division called the Applied Physics Laboratory and a number of institutes and centers.

The Health System, which has its origins in the founding of the world-famous Johns Hopkins Hospital, now comprises three hospitals, as well as other elements of an integrated system, from a community physicians group to home care. Johns Hopkins Medicine, established in 1995 to unite Hopkins' biomedical research, clinical, teaching and business enterprises, brings together The Johns Hopkins University of School of Medicine and its faculty with the facilities and programs of The Johns Hopkins Health System. The $2.7 billion enterprise is one of the largest employers in Maryland. Its components consistently are named at the top of national rankings for best hospital and best school of medicine, and its faculty consistently win the largest share of NIH research funds. Results of this research continue to advance efforts to diagnose, treat and prevent many diseases.

Harvard School of Public Health is dedicated to advancing the public's health through learning, discovery, and communication. More than 300 faculty members are engaged in teaching and training the 900-plus student body in a broad spectrum of disciplines crucial to the health and well being of individuals and populations around the world. Programs and projects range from the molecular biology of AIDS vaccines to the epidemiology of cancer; from risk analysis to violence prevention; from maternal and children's health to quality of care measurement; from health care management to international health and human rights. For more information on the school visit: http://www.hsph.harvard.edu

Contact: Dennis Tartaglia
dennist@mbooth.com
212-481-7000
M Booth & Associates
http://www.mbooth.com

 

Global Trend Of Smoking Tobacco Through A Waterpipe Or Hookah Means More Young People And Women Have Taken Up The Habit

The growing fad of smoking tobacco through a waterpipe, sometimes known as a hookah, is rapidly turning into a worrisome epidemic, according to a Georgetown University researcher who says smokers who think this form of tobacco use is less toxic than cigarettes are wrong.

"People who use these devices don't realize that they could be inhaling what is believed to be the equivalent of a pack of cigarettes in one typical 30-60 minute session with a waterpipe, because such a large quantity of pure, shredded tobacco is used," said Christopher Loffredo, Ph.D., Director of the Cancer Genetics and Epidemiology program at Georgetown University Medical Center.

His series of recently published studies documents the trend toward waterpipe tobacco smoking, showing how it has swept through the Middle East and is gaining popularity in the West, and demonstrates that the amount of cellular chromosomal damage produced inside the mouth is the same as that seen in cigarette smoking.

Yet waterpipe cafes or bars have been popping up all over the Eastern Mediterranean region over the past decade, Loffredo said. "In Egypt, we've seen boys starting to smoke the waterpipe at age 12, and young women, who are culturally discouraged from smoking cigarettes, are flocking to it," said Loffredo, who has been studying tobacco use in that country since 1997.

The trend has now hit European and American cities, especially college towns. "This is frightening because it is a gateway toward a lifetime use of tobacco, including cigarettes," he said.

Waterpipes were originally developed to smoke hashish and other substances, but were long ago adapted into a method to smoke tobacco. Use of the device is common throughout the Middle East, where it is goes by a number of different names - shisha in Egypt, hookah in Pakistan and India, and narghile in a number of countries from Turkey to Israel - but has historically been "a habit of older men, usually of low socioeconomic level, in rural areas and in older parts of cities," he said.

But the waterpipe has gained wider appeal since the early 1990s, accompanied by alterations in waterpipe size and design and also in tobacco content and flavorings, Loffredo said. "These changes are designed to attract more customers to the habit, and there has even been the introduction of tobacco home delivery service in some areas."

Several popular clubs in the Washington, DC, area, offer hookah pipes at a fee, using tobacco flavored by apples, molasses, or other ingredients. The pipe is often a social activity in that it is usually passed between participants, and is believed to be less toxic, Loffredo said.

"People think the water absorbs the toxins, and that is true to some extent if the toxins are water soluble, but tar isn't, and tar contains the carcinogens," he said. "We believe that, compared to the typical cigarette smoker, waterpipe smokers are exposed to larger total amounts of nicotine, carbon monoxide and certain other toxins."

"And because the tobacco is burning at a lower temperature, it is more tolerable to inhale deeply, and in fact you need more force to pull air through the high resistance of the water pathway," Loffredo said. "That means the tobacco smoke can be penetrating deeper in a person's respiratory tract than cigarette smoke does. The damage could be even worse than seen in cigarette smokers, but we haven't done studies long enough to quantify the true cancer risk."

Even so, the incidence of lung cancer is increasing rapidly in Egypt and other Middle Eastern countries, comparable to lung cancer rates in the U.S. after cigarette smoking became newly fashionable, Loffredo said.

His insights into "this significant and spreading epidemic of waterpipe smoking" were included in a recently released World Health Organization monograph authored by his research group. He also published a study in the July/August issue of the pathology journal Acta Cytologica about a new method his group developed to collect cheek cells from inside a participant's mouth, which can then be stained to gauge the chromosomal condition of these cells. They used this technique to study waterpipe smoking in a rural Egyptian village, and reported in a second study, published in 2003 in the Journal of the Egyptian Society of Parasitology, that the level of damage is comparable to what happens to cigarette smokers.

The trend is also having a disproportionate impact on college-aged women. Another study, reported in a forthcoming issue of the journal Nicotine and Tobacco Research, documents how women attending university in Cairo have gravitated to waterpipe tobacco smoking, which is traditionally "culturally abnormal for women to smoke cigarettes, at least in front of their husbands and families." The presence of waterpipe cafes frees women from social stigma, allowing them to view use of waterpipe tobacco in the context of social and economic liberation, Loffredo said. Yet the researchers found that these students, even those in medical school, had only an average knowledge of tobacco-related health hazards.

###

Loffredo, whose studies are funded by the National Institutes of Health, says the entire field of waterpipe health effects "is ripe for new and comprehensive research," including toxicological and pathological investigation to precisely determine heath risks, he said. "The world really didn't foresee the epidemic of waterpipe tobacco smoking, and now it is time to pay attention," Loffredo said.

About Lombardi Comprehensive Cancer Center
The Lombardi Comprehensive Cancer Center, part of Georgetown University Medical Center and Georgetown University Hospital, seeks to improve the diagnosis, treatment, and prevention of cancer through innovative basic and clinical research, patient care, community education and outreach, and the training of cancer specialists of the future. Lombardi is one of only 40 comprehensive cancer centers in the nation, as designated by the National Cancer Institute, and the only one in the Washington, DC, area. For more information, go to http://lombardi.georgetown.edu/.

Contact: Becky Wexler
Georgetown University Medical Center

 

Flavored Cigarettes: The Next Battleground

The names sound like they belong on yogurt, chewing gum or candy bars.

But Twista Lime, Warm Winter Toffee and Midnight Berry are new flavors of cigarettes. And critics say they are actually thinly veiled efforts by the U.S. tobacco industry to entice children take up smoking.

Tobacco makers strongly refute that, but the critics have their doubts and advise parents to contact their legislators to urge a ban on the smokes.

It's necessary, experts add, to help convince kids not to take up the habit. That's critical, according to the American Lung Association, because tobacco use primarily begins in early adolescence -- one-third of all smokers had their first cigarette by the age of 14.

Flavored cigarettes date back to about 1999. But the last few years have seen a "big push" in their marketing, said Paul Billings, vice president of national policy and advocacy for the American Lung Association.

Several states have introduced legislation to ban the flavored smokes, said Billings, including Connecticut, Illinois, Massachusetts, Minnesota, New Jersey, New York, North Carolina, Texas and West Virginia.

"We strongly support this legislation," he added.

The timing of the new flavored products is hardly coincidental, a group of Harvard researchers contended in a report in the November/December 2005 issue of the journal Health Affairs.

"The proliferation of new flavored brands comes at a time when advertising and marketing restrictions have made it more difficult to target young smokers," said the researchers, led by Carrie Carpenter, a Harvard School of Public Health research analyst.

She was referring to the terms of the 1998 Master Settlement Agreement between the state attorneys general and major U.S. tobacco manufacturers. The tobacco makers agreed to change the way their products are marketed and pay the states an estimated $206 billion. The companies also agreed to finance a $1.5 billion anti-smoking campaign, open documents previously kept secret, and disband trade groups the attorneys general said conspired to conceal damaging research from the public.

Carpenter's team pored over internal tobacco industry documents as well as U.S. patents, both awarded and pending applications.

"Now we have evidence from the documents that this concept of flavored cigarettes has been associated with new and younger smokers," Carpenter said, referring to what she described as a 1988 R.J. Reynolds Tobacco report, identifying young adult smokers as the company's "most critical strategic need." Because aftertaste was mentioned by young smokers as a concern, one of the methods to counteract the problem is the "pellet technology" used in some flavored products. The pellet is inserted in the filter area to provide for controlled release of the filter, she said.

"There could be health risks associated with the pellet," said Carpenter.

But a spokesman for the R.J. Reynolds Tobacco Company said the target for the new product is not minors.

"Our one and only audience, regardless of brand or style, is legal-age adults who have made the decision to smoke," Fred McConnell, manager of communications for R.J. Reynolds, said.

"We don't want children to smoke," he added, "not only because it is illegal to sell to minors in every state, but also because children lack the maturity of judgment to assess the inherent health risks of smoking."

Billings suggests parents warn their underage children about the health risks of smoking, and lobby their lawmakers to outlaw the flavored smokes.