Clearing the Smoke Assessing the Science Base for Tobacco Harm Reduction (2001) / Chapter Skim
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, chronic obstructive pulmonary disease (COPD) , myocardial infarction, and stroke.
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However, this report focuses on tobacco products that may be less harmful or on pharmaceutical preparations that may be used alone or concomitantly with decreased use of conventional tobacco. The committee does not use the term "safer cigarette," in particular, in order to avoid leaving the impression that any product currently known is "safe." Every known tobacco-containing product exposes the user to toxic agents; every pharmaceutical product can have adverse effects.
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These include nicotine products, such as in patch, gum, inhaler, and nasal spray preparations, and a nonnicotine product that reduces the craving for tobacco. These cessation drugs could be used long term to maintain cessation or concomitantly with continued but decreased use of conventional tobacco products (see Table 1~.
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Eclipse Accord™ Nicotine gum, patches, inhaler, nasal spray Bupropion SR, nortriptyline Nicotine antagonists, clonidine 3. Are there surrogate indicators of this effect on health that could be measured in a time frame sufficient for product evaluation?
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The best means to protect individual and public health from tobacco harms are to achieve abstinence, prevent initiation and relapse, and eliminate environmental tobacco smoke exposure. Precept 4.
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Currently available PREPs have been or could be demonstrated to reduce exposure to some of the toxicants in most conventional tobacco products. Many techniques exist to assess exposure reduction, but the report contains many caveats about the use of all of them, including usually an unknown predictive power for harm.
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Even the strongest surveillance system could not alone provide minimal assurance of safety or protection of the public. Currently there is little public authority over tobacco products of any type.
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A national comprehensive surveillance system is urgently needed to collect information on a broad range of elements necessary to understand the population impact of tobacco products and PREPs, including attitudes, beliefs, product characteristics, product distribution and usage patterns, marketing messages such as harm reduction claims and advertising, the incidence of initiation and quitting, and nontobacco risk factors for tobacco-related conditions. There should be surveillance of major smoking-related diseases as well as construction of aggregate population health measures of the net impact of conventional products and PREPs.
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1. Currently available data allow estimation, albeit imprecise, of a doseresponse relationship between exposure to whole tobacco smoke and major diseases that can be monitored for evaluation of harm reduction potential.
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In addition, other biomarkers that accurately reflect mechanisms of disease must be developed to serve as intermediate indicators of disease and disease risk. Biomarkers are measurements of any tobacco constituent, tobacco smoke constituent, or effect of such a compound in a body fluid (including exhaled air)
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Animal models and in vitro testing can contribute to the evaluation of individual PREPs and to the development of a scientific basis for designing and evaluating harm reduction products. Such studies could include cell culture, animal studies, and molecular studies to document specific toxicants as the most likely causative agents, to better define pathogenic effects of tobacco smoke exposure, to better explain the relationship of disease risk regression and exposure regression (dose-response relationships)
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Most tobacco-related diseases develop clinically over many years, and the only direct and definitive way to evaluate the harm reduction value of PREPs is to monitor the health outcomes of users compared to appropriate control groups over an extended period of time. Such surveillance could be an add-on to other epidemiological studies and should include ongoing reports of smoking behavior, types of products used, and health outcomes, as well as intermittent collection of biological samples for biomarker assessment in a segment of users.
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Based on an extensive review of the scientific and medical literature, the committee concludes that although harm reduction is feasible, no currently available PREPs have been shown to be associated with biologically relevant exposure reduction or with decreased tobacco-related harm. One narrow exception is the use of nicotine gum in one study for maintenance of cessation, described in Chapters 8, 13, and 14.
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.2000a. cigarette smoking among adultsUnited States, 1998.
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Section ~ Introduction, Backgrouncl, and Conclusions
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Tobacco harm reduction refers simply to the goal of reducing harm to health from tobacco use, including environmental tobacco smoke (ETS)
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