largecigarsandcigarillosincreasedby69between1993and1997 [47]
.Accordingto researchconductedinCalifornia,between1990and1996,moreyoungadultmalethan
femalehigh-schoolgraduatespreferredtosmokecigars [48]
andthisactivityhassince overtakensmokelesstobaccouseintheUSA
[49] .Someyoungpeoplealsoreplacethe
innertobaccoofthecigarwithmarijuanaorotherillegaldrugsapracticeknownas blunting
[50] .
Accordingtoseveralstudies,cigarsmokingisperceivedtobelessdangerousthan cigarettesmokingintermsofcarcinogenicity
[51–53] .Asidefromnotionsofreduced
carcinogenicity,however,differingsmokingbehaviours,durationofsmoking,extentof inhalationandageatsmokinginitiationmustalsobetakenintoaccount
[51,54,55] .
Overall,nostudieshavebeenconductedamonglargernumbersofsmokersusingtobacco productsotherthancigarettes.Accordingtoameta-analysisofsevenstudiesinvolving
7,200 controls and 5,600 male smokers pipe and cigar, there was a dose-dependent increaseinlungcancerrisk,withcigarillosmokershavingthesameincreasedriskas
cigarettesmokersoddsratioOR:12.7vs.14.7;cigarillovs.cigarette [56]
,obviously a consequence of the inhalation of tobacco smoke. In a cohort study in 17,774 men
betweentheageof30and85years,cigarsmokerswerealsofoundtohaveanincreased riskofdevelopingcoronaryheartdiseaseOR1.27,COPDOR1.45andcancersofthe
upperrespiratoryandgastrointestinaltractOR2.02.Cigarsmokersclearlyunderesti- matetheircancerrisk,withonly7.8believingthatcigarsmokingwilldamagetheir
health.Theyalsounderplaythedamagetothehealthofthosearoundthemasaresultof passivesmoking
[57–59] .
Theuseofotherformsoftobaccoismorecommonamongmenthanwomen [6,21]
. Snufftobaccohasbeenconsumedincreasinglyduringthelast25years.Arecentlypub-
lishedstudyfromSwedenindicatesthattakingsnuffcontributestoincreasedsmoking.
U.S. Cigar Consumption Billions
1895 1875
1915 1935
1955 1975
1995
Year
2 4
6 8
10 12
14
Modern blended cigarettes introduced
Great depression Final Surgeon
General’s Report
Ban on TV Advertising of little cigars
Cigar Aficionado begins publishing
Advertising of little cigars begins on TV
Fig. 2.8
TotalU.S.cigarconsumption1880–1997andsigniicanteventsintheuseofcigars [45]
Therefore,oneshouldnotencouragetheuseofthelessharmfulsnuffinsmokingcessation programmes
[60] .
Waterpipesmokingisfamiliartoapproximately1billionpeoplearoundtheworld.Itis widelyencounteredinTurkeyandArabicandMiddleEastcountries.
Astudyintheyear2003showsthatonesinglesmokingsessionincreasedoxidationinjury 8-epi-PGF2alpha:p=0.03;MDA:p=0.001and11-DH-TXB2p=0.00003signiicantly.
Repeateddailysmokinginducedapersistentlong-lastingoxidationinjuryrelectedbyele- vatedpre-values.Theseresultsindicateasigniicantincreaseofinvivooxidativestressby
regularwaterpipesmoking [61]
. IntheUSA,thereareregionaldifferencesforchewingtobacco,withtheblackpopulation
intheSouthernstatesusingitmorethanwhitesintheNorth [62]
.Theconsumptionofsmoke- lesstobaccohasclearlyincreasedamongwhitemaleadultsduringtheperiod1970–1985
[6] ,
thoughheretooahighereducationallevelisassociatedwithlowerconsumption [28]
.In1992, thistobaccoformwasusedby11.9of12–17-yearolds.Incontrast,pipeorcigarsmoking
hasdeclinedcontinuouslysince1970,forexample,from16to4within20years [6]
.
2.6 Smokers and Other Risk Factors
Universitygraduatessmokedmorecommonlyiftheydidnotengageinanysportingor other physical activity or if they had increased numbers of sexual relationships
[21] .
Furthermore,smokingwasmoreprevalentamongthoseindividualswhosleptforlessthan 7hatnight,didnottakebreakfastinthemorninganddidnoteattheirmealsuntillaterin
theday [63–65]
.Itisalsoshownthattheparentalsmokinghabitsareaconsistentriskfac- torforadolescentsmoking.Therelativeriskofadolescentdailysmokingadjustedforage
andsexwassigniicantlyhigherformaternalonlysmokingcomparedwithpaternalonly smokingineachethnicgroup
[66] .
ASwedishprospectivepopulation-basedcohortstudypointedoutthecumulativeinlu- ence of multiple socio-economic and psychosocial chains of risks experienced during
childhood.Onemajorindingwasthefactthatbeingfromadivorcedfamilyandhaving poorcontactwiththeirparentsinluencedthesmokingdirectly.
Adolescentswithadversesocio-economicstatuswerealsolikelytobeunpopularin schoolandconsequently,theirsmokingbehaviourwasaffecteddirectly
[67] .
Inaninternationalstudyconductedinsixcountriesfrom1985to1995,thelevelof dependenceinsmokersFagerströmtestwascomparedwithsmokingprevalenceinthe
countriesconcerned [68]
.Itwasfoundthatsmokersshowedahigheraveragelevelof dependenceincountrieswithalowsmokingprevalenceUSA,Finlandcomparedwith
countries where smoking was more prevalent Poland, Austria, France. One possible explanationisthat,incountrieswithalowsmokingprevalence,the“occasionalsmokers”
orthosewithalowdependencelevelhadalreadystoppedsmokinginresponsetoexternal inluenceseducationalcampaignsetc.,whereastheremainingsmokersweremorehighly
dependent.
2.7 Smoking Behaviour and Educational Level in the EU
Asapartofastudyconductedin12Europeancountries,smokingbehaviourinmenand womenaged20–44yearsand45–74yearswascomparedwitheducationallevelbycoun-
try–somethingthathadonlyrarelybeendonebefore [69–71]
.Inthisstudy,smokersin severalcountrieswereclassiiedintermsofthehighestlevelofeducationcompletedbythe
individual [72]
.Thisclassiicationcomprisedivelevelswhere“5”wastertiaryeducation, includinguniversity:levels1–3formedthe“lowereducated”group,whilelevels4and5
werethe“highereducated”group.Thedataeducationvs.smokingbehaviourwerepro- cessedusingregressionanalysesandORswerecalculatedtoindicateanassociation.Ifthe
ORwasclearlygreaterthan1.0,anassociationwastobeacceptedbetweenloweducational levelandsmokingbehaviour.AsisapparentfromthedatasummarisedinFig.
2.9 ,consider-
abledifferencesexistedbetweenthe12countriesstudied.Amongtheyoungermen20–44- yearsold,theproportionofcurrentsmokersrangedfrom32to64,whileamongtheolder
men45–74-yearsold,itrangedfrom28to55.TheORsforcurrentsmokingweregreater than1.00,indicatinganassociationbetweenlowereducationallevelandsmokingpreva-
lenceFig. 2.10
.TheORsamongtheyoungermenwereusuallyhigherthanamongthe oldermen
[64] ,withvalues2.00beingcalculated.ThehighestORsamongyoungermen
wereobservedinNorway,Sweden,FranceandGreatBritain.Amongtheoldermen,the highestORs2.00wereobservedinGreatBritainandNorway,indicatingthatsmoking
wasmoreprevalentinthelowereducatedgroupinthosecountries.Bycontrast,inPortugal morethaninSpain,smokingwasmoreprevalentinhighereducatedmenOR1.00;atthe
same time, the prevalence of smoking among women was 5. In the more Southerly countriesoftheEUFrance,Italy,Spain,Portugal,smokingwasmoreprevalentamong
highereducatedolderwomenOR1.00Fig. 2.9
,Table 2.5
.
Portion of Smokers []
80 70
60 50
40 30
20 10
EvSmFem CuSmFem
EvSmMal CuSmMal
DK FIN
F I
N NL
D GB
P E
S CH
Fig. 2.9
SmokingprevalenceamongmenMalandwomenFemin12EuropeanUnionEUand Switerzlandcountries.DatashownforeversmokingEvSmandcurrentsmokingCuSm
[72]