World No Tobacco Day 2006: The Harmful Impact of Tobacco Products, Notas de estudo de Oncologia

Baixe World No Tobacco Day 2006: The Harmful Impact of Tobacco Products e outras Notas de estudo em PDF para Oncologia, somente na Docsity!

Tobacco:

deadly in any form

or disguise

WORLD NO TOBACCO DAY 2006

www.who.int/tobacco/wntd

WHO Library Cataloguing-in-Publication Data Tobacco : deadly in any form or disguise.

1. Tobacco - adverse effects. 2. Tobacco industry - legislation. 3. Tobacco use disorder. I.World Health Organization. II.WHO Tobacco Free Initiative. ISBN 92 4 156322 2 (NLM classification: QV 137) ISBN 978 92 4 156322 2 © World Health Organization 2006 All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press, at the above address (fax: +41 22 791 4806; e-mail: permissions@who.int). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use.

Photo credits: p.1: BrandX Design and layout: Kaolis - Montpellier/France - www.kaolis.fr Printed in France.

p. 6 - 9 Introduction and overview

p. 10 - 15 A global epidemic of addiction and disease

p. 10 - 12 Trends in the tobacco epidemic

p. 13 - 15 Health effects of tobacco

p. 16 - 31 The many forms of tobacco

p. 16 - 27 Tobacco products of today

01 02 03

TABLE of Contents

p. 28 - 31 Tobacco products of tomorrow and safety claims

p. 32 - 33 Regulating a deadly product

p. 33 - 34 The WHO Framework Convention on Tobacco Control

p. 35 The future horizon for tobacco testing

p. 36 - 39 Conclusions

p. 40 - 45 References

04 05 06

Tobacco addiction is a global epidemic that is ravaging the

countries and regions that can least afford its toll of disability,

disease, lost productivity and death.

Introduction and overview

The epidemic follows a course that has been documented in country after country, driven by an industry that puts profits ahead of life; its own growth ahead of the health of future generations; its own economic gain ahead of the sustainable development of struggling countries.

Now, as nations have begun to fight back and, in some countries, to turn back the epidemic, tobacco companies continue to develop new products to maintain their profits, often disguising these new products in a cloak of attractiveness and reduced harmfulness.

The challenge to health comes from large companies and small ones, from blockbuster cigarette brands, so-called organic cigarettes, chewing tobacco, waterpipes, cigars, and new hybrid products with

charcoal heating elements, aluminium nicotine cartridges and computer-chip-controlled smoke- delivery systems. The truth is clear: all tobacco products are dangerous and addictive, and every effort should be made to discourage their use in any form. Governments should, in the meantime, make every effort to regulate all types of tobacco and raise awareness about its harmful and deadly effects.

Accurate information on tobacco product ingredients, toxin deliveries and health effects is needed for all tobacco products. For cigarettes, there have been some regulatory efforts to monitor the ingredients of the product and communications efforts to pass this health information on to the public, but even these efforts have been challenged and misrepresented by tobacco companies in their continuing attempts

to maintain the appeal of their products. Thus, despite a few governmental efforts, the only source of information for most consumers is that provided voluntarily by the industry itself, with results that remain deleterious for the health of individuals and populations. Tobacco companies give many reasons for failure to fully disclose the truth about their products. A few of these companies are part of corporations that also manufacture foods, beverages and even pharmaceuticals, for which truthful labelling is required in many jurisdictions. There is no reason other than profit for the companies not to be similarly forthcoming about tobacco products, and such disclosure is one purpose of regulation.

Fortunately, tobacco control professionals learned valuable lessons from their studies of the 20th century strategies of the tobacco industry, as well as from the successes and failures of tobacco control efforts. This knowledge can be applied in order to gain a better understanding of the complexities of the various tobacco products and the motivations and misinformation spread by tobacco companies. Global health also benefits from the combined forces of the Parties to the World Health Organization’s Framework Convention on Tobacco Control. The WHO Framework Convention is a powerful tool for containment of tobacco industry strategies aimed at undermining advances in public health.

The WHO Framework Convention was the global response of countries to the globalization of the tobacco epidemic. The preamble states: “…scientific evidence has unequivocally established that tobacco consumption and exposure to tobacco smoke

World No Tobacco Day 2006

is a tool for stripping away the

disguise and revealing the truth

behind tobacco products.

cause death, disease and disability, and that there is a time lag between the exposure to smoking and the other uses of tobacco products and the onset of tobacco-related diseases”. “Tobacco products” are defined in Article 1(f) as “products entirely or partly made of the leaf tobacco as raw material which are manufactured to be used for smoking, sucking, chewing or snuffing”.

Therefore, the goals of World No Tobacco Day 2006 are to emphasize the harm associated with any use of any tobacco product, to highlight the role of the tobacco industry in undermining efforts to assess the real harm done by tobacco and to call on governments to enact stronger and wider regulation of tobacco products. The WHO Framework Convention paves the way for a better understanding of methods of regulating and controlling tobacco products. World No Tobacco Day 2006 aims to empower people and organizations with the knowledge they need to control tobacco more effectively and improve global health. It is a tool for stripping away the disguise and revealing the truth behind tobacco products

• traditional, new and future.

Currently, there are an estimated 1.3 billion smokers in the

world. The death toll from tobacco consumption is now 5 million

people a year; if present consumption patterns continue,

the number of deaths will nearly double, reaching close

to 10 million by the year 2020.

A global epidemic of addiction

and disease

The higher burden of death and disease is rapidly shifting to developing countries. Approximately one half of continuing cigarette smokers die prematurely from tobacco use. That is to say that about 650 million people (half the current smokers) alive today will eventually die from a tobacco-related disease, if they continue to smoke.

The above is the fundamental reason for regulating tobacco now. Governments, and especially legislators, have a responsibility to contribute towards regulating an industry whose main objective is to sell a product that causes harm and death.

Despite what we know about tobacco use today, tobacco consumption continues to increase worldwide. The epidemic is still expanding, especially in low- and middle-income countries. The tobacco industry has a huge potential market in these countries, where they often face weaker tobacco control measures and fi nd a great number of possible new customers, among women in particular.

The tobacco epidemic has recently expanded among women worldwide. Recent surveys show that tobacco consumption among girls is increasing drastically around the globe, and that prevalence is, in many cases, comparable to or even greater than

TRENDS in the tobacco epidemic

The wide range of serious health effects has been extensively reviewed.

However, the list of conditions caused by tobacco consumption has grown. It is now also known that tobacco use contributes to cataracts, pneumonia, acute myeloid leukaemia, abdominal aortic aneurysm, stomach cancer, pancreatic cancer, cervical cancer, kidney cancer, periodontitis and other diseases. III

These diseases join the familiar list of tobacco-related diseases, including cancer of the lung, vesicle, oesophagus, larynx, mouth and throat; chronic pulmonary disease, emphysema and bronchitis; stroke, heart attacks and other cardiovascular diseases. In fact, we know today that tobacco causes 90% of all lung cancers. IV:1180^ Tobacco seriously damages the reproductive system too, contributing to miscarriage, premature delivery, low birth weight, sudden infant death and paediatric diseases, such as attention hyperactivity deficit disorders. III^ Babies born to women who smoke are, on average, 200 grams lighter than babies born to comparable mothers who do not smoke. III:

However, those who consume tobacco are not the only ones exposed to its negative effects. Millions of people, including one half of the world’s children, are exposed to second-hand tobacco smoke, known also as passive smoking. There is conclusive evidence linking passive smoking to an increased risk of cardiovascular diseases, lung cancer and other cancers, asthma and other respiratory diseases in adults and asthma and other respiratory diseases, ear infection and sudden infant death syndrome in children, to name but a few of passive smoking’s harmful effects. V, VI

Smoking has also been linked to a risk of developing cervical cancer which is four times higher than in non-smoking women. The latest United States Surgeon General’s report on tobacco and health

concluded that smoking causes cervical cancer, VII the leading killer among cancers in women worldwide.

There is a growing body of evidence linking smoking and an increased risk of tuberculosis infection, disease and mortality. Studies carried out in India, for instance, show that half the male tuberculosis deaths in that country are caused by smoking. VIII The incidence of tuberculosis in some developing countries is high and has been aggravated lately by the HIV/AIDS epidemic. An increase in smoking prevalence in these countries could seriously increase the incidence of tuberculosis infection and mortality. Combustible (or smoked) tobacco products are also among the leading causes of residential and forest fires in many countries. These fires destroy natural habitats, homes and other property, and kill smokers and non-smokers alike, including many children.

Addiction to a deadly product: no-one is safe

Tobacco is an addictive plant containing nicotine, many carcinogens IX^ and other toxins. When transformed into products designed to deliver nicotine efficiently, its toxic effects, responsible for causing many diseases, are often magnified because the process of increasing exposure to nicotine often results in increases in exposure to the many poisons in the products. Furthermore, the addiction results in decades of exposure to high levels of tobacco poison for most users. The diverse poisons in the plant, the poisons resulting from its processing and (in the case of combustible products) combustion, are powerful and easily absorbed by many routes into the human body. Much of the disease and premature mortality

HEALTH (^) effects of tobacco

Tobacco consumption continues to be the leading preventable

cause of death in the world.

A global epidemic of addiction and disease

caused by tobacco may be considered as side-effects of the disease of addiction. Tobacco dependence itself is a disease, described in the International classification of diseases (ICD-10). X^ As a chronic disease, often involving relapses, nicotine addiction requires proper treatment.

Addiction occurs in most (not all) tobacco users, but all are vulnerable. Nicotine is the drug in tobacco that causes addiction. However, there are other chemicals in tobacco that contribute to its addictive effects.

Tobacco-delivered nicotine is a chemical cocktail of substances that enhance the addictive effects of nicotine (see box – page 19 “Cigarettes: the ultimate chemical cocktail”). Modern tobacco products are engineered to regulate the speed and amount of nicotine delivery, which contributes to the risk of developing and sustaining addiction. For example, cigarettes are designed to deliver very small doses of nicotine with each puff, but to make it possible for users to obtain much larger doses by slightly larger puffs, more frequent puffs, or holding the cigarette more deeply in the mouth. Some smokeless tobacco companies market what they have named “starter” products, targeted at young people: the starter products are slower and lower in nicotine delivery than the “maintenance” products which most experienced smokeless tobacco users move on to use. XI, XII, XIII

The potential of addiction is also enhanced by increasing the speed of nicotine delivery to increase what tobacco companies call the “nicotine kick” or “impact” of their products. XIV, XV^ Tobacco products

are designed to enhance the speed of delivery and to release higher quantities of the most potent chemical form of nicotine, namely “free base” or “non–ionized” nicotine. Adding chemicals to raise the pH makes the tobacco and smoke less acidic, thereby freeing up the nicotine. XVI, XVII, XVIII

Smokeless tobacco products are also designed and manufactured “in a manner that promotes tolerance and addiction”, as concluded by the United States Food and Drug Administration following its extensive analysis of United States and Swedish products. XIX:45108^ Specifically, manufacturers control the highly addictive “free base” portion of nicotine in the products, using buffering agents such as sodium carbonate and ammonium carbonate to manipulate the nicotine-dosing characteristics of the products. For example, products marketed as “starter” products are lower in free base nicotine and are flavoured to make them more attractive to young people. XIX, XX, XXI

The addiction results in decades

of exposure to high levels of

tobacco poison for most users.

Tobacco comes in many forms and with various methods of use, with various names and claims attached to them.

The many forms of tobacco

The manufactured products appear to be intended to enable the extraction and consumption of high enough doses of nicotine to alter the brain in order to provide pleasure and other addicting effects. All tobacco products share this ability and use.

Tobacco products in widespread use and commercial production are derived from three types of tobacco preparation:

> rolls of tobacco which are smoked (e.g. bidi, cigar, cigarette) > pipes (including waterpipes) > oral preparations for chewing and holding in the mouth or placing in the nose (e.g. snuff, snus, betel quid).

Some involve regional culture and technology, whereas others are global.

Comparison of the relative toxicity of these products is fraught with peril. Typically, their toxicity is compared with the risks associated with smoking cigarettes, and far more epidemiological studies have been conducted on cigarette smokers than on users of other tobacco products. Traditional users of other tobacco products often consume less tobacco (e.g. they smoke fewer bidis or cigars or use less tobacco in waterpipes) than cigarette smokers. The limited epidemiology for these products therefore relates to lower consumption rates and is thus not directly comparable in evaluating the relative risks of these products.

TOBACCO PRODUCTS of today

Many of today’s tobacco products have evolved over decades and centuries. Mass-produced modern cigarettes multiply the global death toll by the use of features that mask the poisons with smoother, less visible and less smelly smoke, making them more attractive and easier to use.

The cigarette is actually an elaborately designed miniature chemical factory, manufactured according to hundreds of specifications, incorporating patent-protected features and ingredients, and delivering nicotine within a range of doses calculated to maximize its addiction potential. None of these “advances” have been demonstrated to reduce health risks, but they do reinforce the image of the modern cigarette as a “clean” product, minimally contaminated by toxins.

As far as the ingredients are concerned, the core health problem starts with the tobacco itself, which contains many cancer-causing chemicals. Although some cigarette companies post partial ingredient lists on their web sites, they do not list the many ingredients in the final cigarette that might deter many people from smoking them: residual pesticides, herbicides, fertilizer, heavy metals, arsenic, cyanide and other toxins may add to the overall risk. Tobacco processing aids, such as ammonia compounds, may or may not be listed. Substances used in the manufacture of reconstituted tobacco are not necessarily listed, including the true nature of the “tobacco extract” that is sprayed on to the reconstituted tobacco material. Manufacturers do not list the many substances in the paper, glue and filters or the decorative dyes and inks in the cigarette and filter paper.

Furthermore, the ingredients which are present in unburned cigarettes go on to yield more than 4 000 additional chemicals in the miniature blast furnace of the cigarette where temperatures may exceed 800 degrees Celsius. The burning cigarette works as a miniature chemical waste dump that results in the formation of still more toxins. These include the odourless, colourless deadly gas carbon monoxide (CO), increased levels of acetaldehyde, acrolein, formaldehyde and many other substances. In fact, seemingly harmless-sounding ingredients, such as chocolate, licorice and sugars, can contribute to increased carcinogenic and addictive effects. Substances such as menthol and sweeteners can also make it easier to inhale this toxic mixture deep into the lungs, by smoothing the smoke and deadening the senses. Finally, tobacco smoke forms an aerosol that carries thousands of substances into the deepest cavities of the lung, where the poisons are concentrated and quickly spread throughout the body, leading to a diverse range of diseases.

Although it is commonly assumed that the modern cigarette filter reduces disease risk by trapping toxins, in fact its main function appears to be to help to make the cigarette a more acceptable product to the consumer. Filters are advertised and portrayed as devices that reduce exposure to dangerous toxins, but the actual health benefits have not been clearly demonstrated. This does not mean that filters should not be used, but they need to be regulated as an integral component of the cigarette. Allusions to alleged health benefits should not be made or implied in consumer communications without scientific evidence accepted by the appropriate regulatory agencies.

Cigarettes: the ultimate chemical cocktail

The many forms of tobacco

have strict standards and for which these terms imply that the healthiest ingredient is provided, without substances suspected as being unhealthy or posing risks to humans. In the case of cigarettes, the most deadly ingredient is the tobacco itself and the by-products generated when tobacco – even theoretically “pure” tobacco – is burned. These cigarettes are sometimes sold in health-food stores.

In addition, a manufactured cigarette, whether

“natural” or conventional, has many ingredients that keep it from decomposing, keep it moist, give it additional flavours and keep it burning, not to mention the paper, the glue in the paper, and the filter materials. Furthermore, cigarettes claimed to be without additives and made of “organic” tobacco have never been demonstrated to be less dangerous or addictive than conventional cigarettes. In fact, tests on some brands indicate higher levels of tar and nicotine delivery than those produced by conventional cigarettes in smoking-machine studies. XXIII^ Yet such cigarettes are increasingly popular, appealing to health-conscious addicted consumers in much the same way as “light” cigarettes did a few decades ago. XXIV, XXV

Roll-your-own (RYO) cigarettes

Increasing numbers of people roll their own cigarettes, partly for cultural reasons and partly to save money owing to the rising costs (including taxes) of commercially manufactured cigarettes.

In some countries (e.g. the United States of America, Norway and New Zealand), loose-leaf roll-your- own cigarettes represent a significant and/or growing segment of the tobacco market. XXVI, XXVII In New Zealand, for example, roll-your-own cigarettes account for about 30% of the tobacco smoked, and over one third of all smokers there, including over 60% of Maori, reportedly regularly smoke roll-your-own cigarettes. XXVI^ Similarly, over half of all Norwegian smokers smoke roll-your-own cigarettes.

Materials sold for roll-your-own cigarettes are often advertised with claims that imply they are healthier, or at least less harmful, than the materials used in commercial cigarette production. This impression is also given by the fact that they may contain less tobacco than manufactured cigarettes. Basic data on emissions of these products are severely lacking, and reliable data on how people smoke these products are not openly available.

The fact is that there are no data to indicate that roll- your-own cigarettes are less toxic than commercially manufactured cigarettes. Nor are there data confirming that roll-your-own cigarettes cause higher rates of disease and premature mortality than manufactured cigarettes. However, recent unpublished data collected by the New Zealand Ministry of Health suggest that they may lead to higher levels of tar exposure on a cigarette-by- cigarette basis. XXVIII

A 1998 study from the United Kingdom found that the mean tar yields from cigarettes produced by 57% of the smokers using roll-your-own cigarettes were above the current maximum of 15 mg per cigarette for manufactured cigarettes. XXIX

Bidis and kreteks

In the South-East Asian and Middle Eastern regions, tobacco has been traditionally smoked in a variety of forms other than conventional cigarettes. These include the smaller and often handmade bidis and kreteks. They draw heavily on regional preferences for spices and herbs, using tobacco as a major, but not necessarily the main, ingredient. Regionally, they are often made by children and women, in small shops