Other Forms of Tobacco Use

large฀cigars฀and฀cigarillos฀increased฀by฀69฀between฀1993฀and฀1997฀ [47] .฀According฀to฀ research฀conducted฀in฀California,฀between฀1990฀and฀1996,฀more฀young฀adult฀male฀than฀ female฀high-school฀graduates฀preferred฀to฀smoke฀cigars฀ [48] ฀and฀this฀activity฀has฀since฀ overtaken฀smokeless฀tobacco฀use฀in฀the฀USA฀ [49] .฀Some฀young฀people฀also฀replace฀the฀ inner฀tobacco฀of฀the฀cigar฀with฀marijuana฀or฀other฀illegal฀drugs฀a฀practice฀known฀as฀ blunting฀ [50] . According฀to฀several฀studies,฀cigar฀smoking฀is฀perceived฀to฀be฀less฀dangerous฀than฀ cigarette฀smoking฀in฀terms฀of฀carcinogenicity฀ [51–53] .฀Aside฀from฀notions฀of฀reduced฀ carcinogenicity,฀however,฀differing฀smoking฀behaviours,฀duration฀of฀smoking,฀extent฀of฀ inhalation฀and฀age฀at฀smoking฀initiation฀must฀also฀be฀taken฀into฀account฀ [51,฀54,฀55] .฀ Overall,฀no฀studies฀have฀been฀conducted฀among฀larger฀numbers฀of฀smokers฀using฀tobacco฀ products฀other฀than฀cigarettes.฀According฀to฀a฀meta-analysis฀of฀seven฀studies฀involving฀ 7,200฀ controls฀ and฀ 5,600฀ male฀ smokers฀ pipe฀ and฀ cigar,฀ there฀ was฀ a฀ dose-dependent฀ increase฀in฀lung฀cancer฀risk,฀with฀cigarillo฀smokers฀having฀the฀same฀increased฀risk฀as฀ cigarette฀smokers฀odds฀ratio฀OR:฀12.7฀vs.฀14.7;฀cigarillo฀vs.฀cigarette฀ [56] ,฀obviously฀ a฀ consequence฀ of฀ the฀ inhalation฀ of฀ tobacco฀ smoke.฀ In฀ a฀ cohort฀ study฀ in฀ 17,774฀ men฀ between฀the฀age฀of฀30฀and฀85฀years,฀cigar฀smokers฀were฀also฀found฀to฀have฀an฀increased฀ risk฀of฀developing฀coronary฀heart฀disease฀OR฀1.27,฀COPD฀OR฀1.45฀and฀cancers฀of฀the฀ upper฀respiratory฀and฀gastrointestinal฀tract฀OR฀2.02.฀Cigar฀smokers฀clearly฀underesti- mate฀their฀cancer฀risk,฀with฀only฀7.8฀believing฀that฀cigar฀smoking฀will฀damage฀their฀ health.฀They฀also฀underplay฀the฀damage฀to฀the฀health฀of฀those฀around฀them฀as฀a฀result฀of฀ passive฀smoking฀ [57–59] . The฀use฀of฀other฀forms฀of฀tobacco฀is฀more฀common฀among฀men฀than฀women฀ [6,฀21] .฀ Snuff฀tobacco฀has฀been฀consumed฀increasingly฀during฀the฀last฀25฀years.฀A฀recently฀pub- lished฀study฀from฀Sweden฀indicates฀that฀taking฀snuff฀contributes฀to฀increased฀smoking.฀ 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 ฀฀฀Total฀U.S.฀cigar฀consumption฀1880–1997฀and฀signiicant฀events฀in฀the฀use฀of฀cigars฀ [45] Therefore,฀one฀should฀not฀encourage฀the฀use฀of฀the฀less฀harmful฀snuff฀in฀smoking฀cessation฀ programmes฀ [60] . Water฀pipe฀smoking฀is฀familiar฀to฀approximately฀1฀billion฀people฀around฀the฀world.฀It฀is฀ widely฀encountered฀in฀Turkey฀and฀Arabic฀and฀Middle฀East฀countries. A฀study฀in฀the฀year฀2003฀shows฀that฀one฀single฀smoking฀session฀increased฀oxidation฀injury฀ 8-epi-PGF2alpha:฀p฀=฀0.03;฀MDA:฀p฀=฀0.001฀and฀11-DH-TXB2฀p฀=฀0.00003฀signiicantly.฀ Repeated฀daily฀smoking฀induced฀a฀persistent฀long-lasting฀oxidation฀injury฀relected฀by฀ele- vated฀pre-values.฀These฀results฀indicate฀a฀signiicant฀increase฀of฀in฀vivo฀oxidative฀stress฀by฀ regular฀water฀pipe฀smoking฀ [61] . In฀the฀USA,฀there฀are฀regional฀differences฀for฀chewing฀tobacco,฀with฀the฀black฀population฀ in฀the฀Southern฀states฀using฀it฀more฀than฀whites฀in฀the฀North฀ [62] .฀The฀consumption฀of฀smoke- less฀tobacco฀has฀clearly฀increased฀among฀white฀male฀adults฀during฀the฀period฀1970–1985฀ [6] ,฀ though฀here฀too฀a฀higher฀educational฀level฀is฀associated฀with฀lower฀consumption฀ [28] .฀In฀1992,฀ this฀tobacco฀form฀was฀used฀by฀11.9฀of฀12–17-year฀olds.฀In฀contrast,฀pipe฀or฀cigar฀smoking฀ has฀declined฀continuously฀since฀1970,฀for฀example,฀from฀16฀to฀4฀within฀20฀years฀ [6] .

2.6 Smokers and Other Risk Factors

University฀graduates฀smoked฀more฀commonly฀if฀they฀did฀not฀engage฀in฀any฀sporting฀or฀ other฀ physical฀ activity฀ or฀ if฀ they฀ had฀ increased฀ numbers฀ of฀ sexual฀ relationships฀ [21] .฀ Furthermore,฀smoking฀was฀more฀prevalent฀among฀those฀individuals฀who฀slept฀for฀less฀than฀ 7฀h฀at฀night,฀did฀not฀take฀breakfast฀in฀the฀morning฀and฀did฀not฀eat฀their฀meals฀until฀later฀in฀ the฀day฀ [63–65] .฀It฀is฀also฀shown฀that฀the฀parental฀smoking฀habits฀are฀a฀consistent฀risk฀fac- tor฀for฀adolescent฀smoking.฀The฀relative฀risk฀of฀adolescent฀daily฀smoking฀adjusted฀for฀age฀ and฀sex฀was฀signiicantly฀higher฀for฀maternal฀only฀smoking฀compared฀with฀paternal฀only฀ smoking฀in฀each฀ethnic฀group฀ [66] . A฀Swedish฀prospective฀population-based฀cohort฀study฀pointed฀out฀the฀cumulative฀inlu- ence฀ of฀ multiple฀ socio-economic฀ and฀ psychosocial฀ chains฀ of฀ risks฀ experienced฀ during฀ childhood.฀One฀major฀inding฀was฀the฀fact฀that฀being฀from฀a฀divorced฀family฀and฀having฀ poor฀contact฀with฀their฀parents฀inluenced฀the฀smoking฀directly. Adolescents฀with฀adverse฀socio-economic฀status฀were฀also฀likely฀to฀be฀unpopular฀in฀ school฀and฀consequently,฀their฀smoking฀behaviour฀was฀affected฀directly฀ [67] . In฀an฀international฀study฀conducted฀in฀six฀countries฀from฀1985฀to฀1995,฀the฀level฀of฀ dependence฀in฀smokers฀Fagerström฀test฀was฀compared฀with฀smoking฀prevalence฀in฀the฀ countries฀concerned฀ [68] .฀It฀was฀found฀that฀smokers฀showed฀a฀higher฀average฀level฀of฀ dependence฀in฀countries฀with฀a฀low฀smoking฀prevalence฀USA,฀Finland฀compared฀with฀ countries฀ where฀ smoking฀ was฀ more฀ prevalent฀ Poland,฀ Austria,฀ France.฀ One฀ possible฀ explanation฀is฀that,฀in฀countries฀with฀a฀low฀smoking฀prevalence,฀the฀“occasional฀smokers”฀ or฀those฀with฀a฀low฀dependence฀level฀had฀already฀stopped฀smoking฀in฀response฀to฀external฀ inluences฀educational฀campaigns฀etc.,฀whereas฀the฀remaining฀smokers฀were฀more฀highly฀ dependent.

2.7 Smoking Behaviour and Educational Level in the EU

As฀a฀part฀of฀a฀study฀conducted฀in฀12฀European฀countries,฀smoking฀behaviour฀in฀men฀and฀ women฀aged฀20–44฀years฀and฀45–74฀years฀was฀compared฀with฀educational฀level฀by฀coun- try฀–฀something฀that฀had฀only฀rarely฀been฀done฀before฀ [69–71] .฀In฀this฀study,฀smokers฀in฀ several฀countries฀were฀classiied฀in฀terms฀of฀the฀highest฀level฀of฀education฀completed฀by฀the฀ individual฀ [72] .฀This฀classiication฀comprised฀ive฀levels฀where฀“5”฀was฀tertiary฀education,฀ including฀university:฀levels฀1–3฀formed฀the฀“lower฀educated”฀group,฀while฀levels฀4฀and฀5฀ were฀the฀“higher฀educated”฀group.฀The฀data฀education฀vs.฀smoking฀behaviour฀were฀pro- cessed฀using฀regression฀analyses฀and฀ORs฀were฀calculated฀to฀indicate฀an฀association.฀If฀the฀ OR฀was฀clearly฀greater฀than฀1.0,฀an฀association฀was฀to฀be฀accepted฀between฀low฀educational฀ level฀and฀smoking฀behaviour.฀As฀is฀apparent฀from฀the฀data฀summarised฀in฀Fig.฀ 2.9 ,฀consider- able฀differences฀existed฀between฀the฀12฀countries฀studied.฀Among฀the฀younger฀men฀20–44- years฀old,฀the฀proportion฀of฀current฀smokers฀ranged฀from฀32฀to฀64,฀while฀among฀the฀older฀ men฀45–74-years฀old,฀it฀ranged฀from฀28฀to฀55.฀The฀ORs฀for฀current฀smoking฀were฀greater฀ than฀1.00,฀indicating฀an฀association฀between฀lower฀educational฀level฀and฀smoking฀preva- lence฀Fig.฀ 2.10 .฀The฀ORs฀among฀the฀younger฀men฀were฀usually฀higher฀than฀among฀the฀ older฀men฀ [64] ,฀with฀values฀2.00฀being฀calculated.฀The฀highest฀ORs฀among฀younger฀men฀ were฀observed฀in฀Norway,฀Sweden,฀France฀and฀Great฀Britain.฀Among฀the฀older฀men,฀the฀ highest฀ORs฀2.00฀were฀observed฀in฀Great฀Britain฀and฀Norway,฀indicating฀that฀smoking฀ was฀more฀prevalent฀in฀the฀lower฀educated฀group฀in฀those฀countries.฀By฀contrast,฀in฀Portugal฀ more฀than฀in฀Spain,฀smoking฀was฀more฀prevalent฀in฀higher฀educated฀men฀OR฀1.00;฀at฀the฀ same฀ time,฀ the฀ prevalence฀ of฀ smoking฀ among฀ women฀ was฀ 5.฀ In฀ the฀ more฀ Southerly฀ countries฀of฀the฀EU฀France,฀Italy,฀Spain,฀Portugal,฀smoking฀was฀more฀prevalent฀among฀ higher฀educated฀older฀women฀OR฀1.00฀Fig.฀ 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 ฀฀฀Smoking฀prevalence฀among฀men฀Mal฀and฀women฀Fem฀in฀12฀European฀Union฀EU฀and฀ Switerzland฀countries.฀Data฀shown฀for฀ever฀smoking฀EvSm฀and฀current฀smoking฀CuSm฀ [72]