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Research papers: K Bjartveit and A Tverdal Health consequences of smoking 1–4 cigarettes per day Tob Control 2005; 14: 315-320 [Abstract] [Full text] [PDF]

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Health consequences of smoking 1-4 cigarettes per day

Dr Graham F. Cope   (26 September 2005)

Authors' response to Dr Graham F Cope

Kjell Bjartveit, Aage Tverdal   (6 October 2005)

Polymorphisms of genes involved in metabolism of cigarette smoke compounds, and health consequences

Mostafa Saadat   (11 October 2005)

Changes in Catalan smoking: A brief outsiders view

Noeline M Holt   (20 November 2005)

Thank you for posting this article.

Phoebe A Oelheim   (22 October 2007)

Health consequences of smoking 1-4 cigarettes per day 26 September 2005
Dr Graham F. Cope, Research and Development/Honorary Senior Research Fellow Surescreen Diagnostics Ltd/University of Birmingham Send letter to journal: Re: Health consequences of smoking 1-4 cigarettes per day graham.cope{at}surescreen.com Dr Graham F. Cope	I read the paper by Bjartveit and Tverdal with a great deal of interest(1). I welcome the fact that highlighting smoking, even a small number of cigarettes has a significant effect on ischaemic heart disease. However, these findings should be considered with a certain amount of scepticism, as the findings are based entirely on self-reported smoking habit. Biochemically validated research, both by ourselves(2), and others(3) have found that many smokers will admit to their habit, but will significantly under-report their cigarette consumption; believing that reporting a low number of cigarettes a day, say 1-4, will not incur the disapproval of the healthcare professional. Also to be taken into account is that biochemical analysis shows that the intake of nicotine and other tobacco products is extremely variable within categories of cigarette consumption, and is dependent on a number of variables such as smoke topography (number, frequency and volume of puffs from a cigarette), depth of inhalation, age, gender, yield of nicotine, etc. So some individuals who consume a small number of cigarettes a day will ingest the same level of tobacco products as other smokers with a higher daily intake. Compensation, when a smoker cuts down on cigarette consumption, but smokes more efficiently, is a factor mentioned in the text of the paper, is an example whereby cigarette consumption does not reflect nicotine intake. So, although the paper and ensuing publicity has brought to the attention of the public the dangers of any level of smoking, using self-reported information should be used with a certain degree of caution. References 1. Bjartveit K, Tverdal A. Health consequences of smoking 1-4 cigarettes per day. Tob Cont 2005; 14: 315-320. 2. Cope GF, Nayyar P, Holder R. Feedback from a point of care test for nicotine intake to reduce smoking during pregnancy. Ann Clin Bioch 2003; 40 : 674-679 3. Hobbs SD, Wilmink ABM, Adam DJ, Bradbury AW. Assessment of smoking status in patients with peripheral arterial disease. J Vasc Surg 2005; 41: 451-456.
Authors' response to Dr Graham F Cope 6 October 2005
Kjell Bjartveit, Dr (retired), Aage Tverdal Send letter to journal: Re: Authors' response to Dr Graham F Cope kjell.bjartveit{at}chello.no Kjell Bjartveit, et al.	Dear Editor, We thank Dr Graham F Cope for his valuable remarks, and agree that underreporting of daily cigarette consumption might be of importance when assessing the risk in light smokers.[1] Dr Cope refers to two papers: a cross-sectional randomised study on smoking reduction in pregnant women, and an assessment of smoking status in patients with peripheral arterial disease.[2][3] Our study did not concentrate on subgroups in need of regular medical attention; it covered all residents aged 35-49, except people with a history or symptoms indicating cardiovascular diseases (among them peripheral arterial disease) and diabetes.[4] A general population in the 1970s may be less inclined to underreport consumption, than present-day pregnant women and sick people, who do not want to incur the disapproval of the healthcare professionals. Based on a review and meta analysis Patrick and co-workers found that interviewer-administered questionnaires, observational studies, reports by adults, and biochemical validation with cotinine plasma were associated with higher estimates of sensitivity and specificity. Our study compares favourably with these points: The study includes only adults, all questionnaires were checked by a nurse in an interviewer situation, and in one of the three counties, biochemical validation was carried out in all participants by determination of serum thiocyanate.[5] Certainly, levels of thiocyanate may be influenced by factors other than smoking; nevertheless, the dose-response between mean levels of thiocyanate and reported number of cigarettes is remarkable: Number of cigarettes per day MALES FEMALES No. Mean (SD) No. Mean (SD) 0 6212 33.9 (14.0) 7908 33.5 (14.2) 1-4 169 45.3 (18.4) 515 52.0 (22.0) 5-9 855 59.6 (20.7) 1661 70.9 (24.5) 10-14 1570 69.6 (22.2) 1800 81.5 (24.0) 15-19 1056 76.3 (23.1) 569 90.8 (25.5) 20-24 699 81.5 (26.4) 247 96.1 (25.6) 25+ 235 87.3 (27.9) 36 99.7 (28.3) Finally, the attending persons reported their actual number of cigarettes per day in a special box in the questionnaire. Here they were allowed to give a range of daily consumption, for example, 10-15 cigarettes. In our analyses, however, we used the highest figure stated by the participant. Hence, a report of 3-6 cigarettes per day was categorized in the 5-9 cigarettes group. We find it reasonable to conclude that the results presented in our paper reflect a marked increased risk in light smokers. References 1. Cope GF. Health consequences of smoking 1-4 cigarettes per day. Letter to journal. Tob Cont 2005 http://tc.bmjjournals.com/cgi/eletters/14/5/315. 2. Cope GF, Nayyar P, Holder R. Feedback from a point of care test for nicotine intake to reduce smoking during pregnancy. Ann Clin Bioch 2003;40:674-679. 3. Hobbs SD, Wilmink ABM, Adam DJ, Bradbury AW. Assessment of smoking status in patients with peripheral arterial disease. J Vasc Surg 2005;41:451-456 4. Bjartveit K, Tverdal A. Health consequences of smoking 1-4 cigarettes per day. Tob Cont 2005;14:315-320. 5. Patrick DL, Cheadle A, Thompson DC, Diehr P, Koepsell S, Kinne S. The validity of self-reported smoking: a review and meta-analysis. Am J Public Health 1994;84:1086-1093. 6. Foss OP, Lund-Larsen PG. Serum thiocyanate and smoking: interpretation of serum thiocyanate levels observed in a large health study. Scan J Clin Lab Invest 1986;46:245-251.
Polymorphisms of genes involved in metabolism of cigarette smoke compounds, and health consequences 11 October 2005
Mostafa Saadat Department of Biology, Shiraz University, Iran Send letter to journal: Re: Polymorphisms of genes involved in metabolism of cigarette smoke compounds, and health consequences saadat{at}susc.ac.ir Mostafa Saadat	To the Editor, I read with great interest the article by Bjartveit and Tverdal (2005), who investigated health consequences of smoking 1-4 cigarettes per day. They found that in both sexes, smoking 1-4 cigarettes per day was associated with a significantly higher risk of dying from ischaemic heart disease and from all causes, and in women, from lung cancer [1]. Genetic studies suggest that all stages of tobacco use and dependence, maintenance of dependent smoking behavior and amount smoked are partially under genetic control [2]. Many of cigarette smoke compounds and their metabolites are substrates of phase I enzymes, represented by cytochrome P450 enzymes, and glutathione S-transferases (GSTs). Although the study investigating the association between smoking behavior and either polymorphisms of GSTT1 or GSTM1, failed to show a significant association [3], there are several reports indicating that genetic polymorphisms of CYP2A6, CYP3E1, and CYP2D6 are associated with smoking behavior [4-6]. The CYP2A6 poor-metabolizer genotypes result in altered nicotine kinetics [4]. Individuals lacking full function CYP2A6 alleles do not metabolize nicotine and are less likely to become smokers and if they do, they smoke fewer cigarettes per day in comparison with normal-nicotine metabolism persons [4]. Therefore, slow inactivators may experience higher or longer lasting levels of nicotine. This could increase effects of nicotine toxicity. Also it is reported that the CYP2D6 ultra-rapid metabolizer genotype may contribute to the probability of being addicted to smoking [5]. Taken together, it is probable that the persons smoked 1-4 cigarettes per day in the study of Bjartveit and Tverdal [1] belong to the slow metabolizer genotypes. Therefore, the results of the study should be interpreted with caution. Study with respect to polymorphisms of phase I and II genes, might be find the threshold value for daily cigarette consumption that must be exceeded before serious health consequences occur. REFERENCES 1 Bjartveit K, Tverdal A. Health consequences of smoking 1-4 cigarettes per day. Tob Control 2005;14:315-20. 2 Hall W, Madden P, Lynskey M. The genetics of tobacco use: methods, findings and policy implications. Tob Control 2002;11:119-24. 3 Saadat M, Mohabatkar H. Polymorphisms of glutathione S-transferases M1 and T1 do not account for interindividual differences for smoking behavior. Pharmacol Biochem Behav 2004;77:793-5. 4 Tyndal RF, Sellers EM. Genetic variation in CYP2A6-mediated nicotine metabolism alters smoking behavior. Ther Drug Monit 2002;24:153- 60. 5 Saarikoski ST, Sata F, Husgafvel-Pursianen K, et al. CYP2D6 ultra- rapid metabolizer genotype as a potential modifier of smoking behaviour. Pharmacogenetics 2000;10:5-10. 6 Yang M, Kunugita N, Kitagawa K, et al. Individual differences in urinary cotinine levels in Japanease smokers: relation to genetic polymorphism of drug-metabolizing enzymes. Cancer Epidemiol Biomarkers Prev 2001;10:589-93.
Changes in Catalan smoking: A brief outsiders view 20 November 2005
Noeline M Holt Send letter to journal: Re: Changes in Catalan smoking: A brief outsiders view pha{at}pha.org.nz Noeline M Holt	In a visit to Catalonia in Spain during October 2005, I noticed a number of changes in the smoking culture and regulations, compared to a visit in 2001. Smokefree legislation is expected to be passed in 2006. The Catalonia regional government plans to take up the same tough stance as Ireland, the Netherlands and Norway. But there are already changes in Catalonia. In comparison to 2001, I came across several cafes and restaurants that had smokefree areas, (some locals cynically suggested that they were there not there to protect staff but to please the tourists). In 2001, many cafes had sawdust all over the floors, partly to cope with the cigarette butts being ground under heel by smokers. This practice may still exist, but was certainly not as extensive as previously. It was also a pleasure to be served food and drink by people who were not smoking while they worked. I noticed the biggest difference in the Spanish airports. Most areas of the Barcelona and Palma airports are smokefree, with the designated areas for smoking being the occasional café and corners in the departure lounge. Every so often, a voice would boom out in Spanish and in English: “It is by decree of the King, order no ** sub section **, that this airport is designated a smokefree building. It is an offence to smoke in any area other than the areas that are designated for smoking.” Some people by habit still lit up in the smokefree areas of the airports, but others were quick to point out that they were breaking the law. I was impressed how quickly smokers reacted and put out their cigarette, or hurried over to the smoking area. There was no abuse by the smokers, it was just done. A friend of my son (who lives in Barcelona) gave up smoking while I was there. He had taken to wearing his nicotine patch proudly, like a tattoo! The patches cost 40 euros (per packet?). Among my son’s friends the women are very clear that they will not smoke while pregnant. However, there appeared to be still not too much awareness of the dangers of second hand smoke, as the women were all sure that they would start smoking again after the baby was born. This may not be the norm, as the research sample was only six. Official figures indicate that 50,000 people die from tobacco-related diseases each year in Spain, comprising 16 percent of all deaths of people over 35. Smoking kills more people than Aids, alcohol-related illnesses and traffic accidents combined.
Thank you for posting this article. 22 October 2007
Phoebe A Oelheim, Tutor Send letter to journal: Re: Thank you for posting this article. phoebefish1{at}hotmail.com Phoebe A Oelheim	Thank you for posting this article on-line. It is a public service. I have always wondered about the effects of my "light smoking" and have been advised by doctors that it was not dangerous. I am not a scientist and I appreciated the straight forward approach of the article and study. This information will be a huge help in my endeavor to quit smoking.