Increasing popularity of waterpipe tobacco smoking and electronic cigarette use: Implications for oral healthcare.

Cigarette smoking increases the risk of developing several systemic conditions including cancer, cardiovascular and pulmonary diseases. Cigarette smoking is also detrimental to oral health as it increases the incidence and severity of oral cancer, periodontal diseases and peri-implantitis, as well as impacting negatively on the dental patients' response to therapy. Therefore, consideration of smoking behavior and recommendation of smoking cessation are important parts of dental treatment planning. However, cigarettes are no longer the most popular form of tobacco use among adolescents in the United States and globally. In recent years, tobacco smoking using a waterpipe ("hookah," "shisha") and use of electronic cigarettes (ECIGs) has increased significantly. Thus, dental clinicians likely will treat more patients who are waterpipe and/or ECIG users. Yet, the literature on the health effects of waterpipe and ECIGs use is sparse. Both waterpipe and ECIGs deliver the dependence-producing drug nicotine. Waterpipe tobacco smoking has been associated with periodontitis, dry socket, premalignant lesions, and oral and esophageal cancer. The health effects of long-term ECIG use are unknown. The purpose of this review is to inform healthcare professionals about waterpipes and ECIGs, highlight emerging evidence on the biological effects of these increasingly popular tobacco products, and introduce perspectives for dental patient management and future research.

Now is the time to advocate for interventions designed specifically to prevent and control waterpipe tobacco smoking.

Waterpipe tobacco usage is spreading rapidly worldwide, with reports of more youth being waterpipe users compared to adults. In many areas of the world, waterpipe usage surpasses cigarette smoking. Waterpipes and cigarettes are both mechanisms for inhalation of tobacco smoke and therefore have serious health consequences. However, because of the many differences between the two products, prevention and control strategies that have proven effective for cigarettes may not transfer readily to waterpipe. This report highlights the differences between waterpipes and cigarettes in toxicant exposure and physiologic effects, patterns of use, social norms, the extent of evidence, and the policy environment. There is little evidence to date around effective interventions for waterpipe prevention and control. The current state of evidence for intervention to curb or control waterpipe is at ground zero and critically needs attention from both scientists and policy makers. National and global efforts aimed at cigarette prevention have succeeded, particularly in developed countries. We suggest the time has come to harness what we know works for cigarette prevention and control and adapt it to tackle the growing epidemic of waterpipe tobacco use.

Waterpipe tobacco and cigarette smoking among university students in Jordan.

SETTING: While waterpipe and cigarette smoking have been well studied in Syria and Lebanon, data from Jordan are limited. OBJECTIVES: To characterize the relative prevalence of waterpipe tobacco and cigarette smoking among university students in Jordan, and to compare the demographic and environmental factors associated with each form of tobacco use. DESIGN: We surveyed 1845 students randomly recruited from four universities in Jordan. We used multivariable logistic regression controlling for clustering of individuals within universities to determine associations between demographic and environmental covariates and waterpipe tobacco and cigarette use. RESULTS: Waterpipe tobacco smoking rates were 30% in the past 30 days and 56% ever, while cigarette smoking rates were 29% in the past 30 days and 57% ever. Past 30-day waterpipe tobacco smoking rates were 59% for males and 13% for females. Females had substantially lower odds than males of being current waterpipe (OR 0.12, 95%CI 0.10-0.15) or cigarette (OR 0.08, 95%CI 0.05-0.14) smokers. Current cigarette smoking was more significantly associated with markers of high socio-economic status (SES) than waterpipe tobacco smoking. CONCLUSION: Waterpipe tobacco smoking is as common as cigarette smoking among Jordanian university students. While cigarette smoking is consistently associated with high SES, waterpipe tobacco smoking is more evenly distributed across various populations.

Evaluating the acute effects of oral, non-combustible potential reduced exposure products marketed to smokers.

BACKGROUND: Non-combustible potential reduced exposure products (PREPs; eg, Star Scientific's Ariva; a variety of other smokeless tobacco products) are marketed to reduce the harm associated with smoking. This marketing occurs despite an absence of objective data concerning the toxicant exposure and effects of these PREPs. Methods used to examine combustible PREPs were adapted to assess the acute effects of non-combustible PREPs for smokers. METHODS: 28 overnight abstinent cigarette smokers (17 men, 14 non-white) each completed seven, Latin-squared ordered, approximately 2.5 h laboratory sessions that differed by product administered: Ariva, Marlboro Snus (Philip Morris, USA), Camel Snus (RJ Reynolds, Winston-Salem, North Carolina, USA), Commit nicotine lozenge (GlaxoSmithKline; 2 mg), own brand cigarettes, Quest cigarettes (Vector Tobacco; delivers very low levels of nicotine) and sham smoking (ie, puffing on an unlit cigarette). In each session, the product was administered twice (separated by 60 min), and plasma nicotine levels, expired air CO and subjective effects were assessed regularly. RESULTS: Non-combustible products delivered less nicotine than own brand cigarettes, did not expose smokers to CO and failed to suppress tobacco abstinence symptoms as effectively as combustible products. CONCLUSIONS: While decreased toxicant exposure is a potential indicator of harm reduction potential, a failure to suppress abstinence symptoms suggests that currently marketed non-combustible PREPs may not be a viable harm reduction strategy for US smokers. This study demonstrates how clinical laboratory methods can be used to evaluate the short-term effects of non-combustible PREPs for smokers.

A pleasure among friends: how narghile (waterpipe) smoking differs from cigarette smoking in Syria.

BACKGROUND: Throughout the Eastern Mediterranean region (EMR), tobacco is used primarily in two forms: cigarette smoking and waterpipe (called narghile (nar-GIL-eh) in Syria) smoking. OBJECTIVE: To explore whether narghile smokers are different from cigarette smokers in how their smoking habits are embedded in their everyday lives. METHODS: One-to-one interviews with 16 adult narghile smokers and 16 adult cigarette smokers about their feelings, experiences and beliefs regarding their initiation, use patterns, and attempts to quit. FINDINGS: Narghile smokers found that narghile was a pleasurable social experience embedded in cultural rituals. By contrast, cigarette smokers saw their cigarette smoking as a mundane, oppressive, personal addiction. Narghile smokers generally started in their 20s and found that smoking narghile fostered a sense of togetherness and cultural identity, while cigarette smokers started in their early teens, males having started to becoming a "real man". Unlike cigarette smokers who felt stigmatised, narghile smokers generally felt that smoking narghile was socially accepted. Cigarette smokers believed that cigarettes were harmful to their health and harmful to those around them, but narghile smokers believed smoking narghile was relatively harmless to themselves or to others. Unlike cigarette smokers who used cigarettes to manage stress, narghile smokers used narghile for entertainment, leisure, and escape. However, frequent narghile smokers confessed that they felt addicted in much the same way as cigarette smokers. Cigarette smokers and narghile smokers viewed quitting as a matter of will and conviction. Most cigarette smokers had tried to quit. Very few narghile smokers had ever tried to quit, and most were not interested in quitting. Disturbingly, some cigarette smokers had tried to quit cigarettes by switching to smoking narghile, but later relapsed to smoking cigarettes. CONCLUSIONS: This exploratory study suggests that Syrian narghile smokers are different from Syrian cigarette smokers in their perceptions and beliefs about their smoking, and in their smoking patterns and lived experiences with tobacco. Our findings indicate that further in-depth research is need in the EMR to understand both modes of smoking to develop effective mode-specific prevention and cessation approaches. This study also raises concerns about a possible pattern where cigarette smokers are using narghile as a method for quitting cigarettes, and then relapsing.

Exposure to secondhand smoke at home and in public places in Syria: a developing country's perspective.

This study employs sensitive methods to address the issue of exposure to secondhand smoke among children and women in an understudied developing country setting (Syria). The study combines data collected by the Syrian Center for Tobacco Studies as part of two international studies conducted in 2006: the Secondhand Smoke Exposure among Women and Children study (Johns Hopkins) and the Global Air Monitoring Study (Roswell Park Cancer Institute). We employed objective measures (hair nicotine, and ambient household nicotine assessed by passive monitors) to assess children's and mothers' exposure to secondhand smoke at home, and used the TSI SidePak personal aerosol monitor to sample respirable suspended particles less than 2.5 microm diameter (PM(2.5)) in the air in public places (40 restaurants/cafés in Aleppo). In homes, the mean ambient nicotine level (+/- standard deviation, SD) was 2.24 +/- 2.77 microg/m(3). Mean level of hair nicotine was 11.8 ng/mg among children (n = 54), and was higher if the mother was a smoker (19.4 +/- 23.6 ng/mg) than nonsmoker (5.2 +/- 6.9 ng/mg) (p < .05). Mean hair nicotine among nonsmoking mothers (n = 23) was 1.17 +/- 1.56 ng/mg. Children's hair nicotine level was strongly correlated with ambient household nicotine and number of cigarettes smoked daily in the house (r = .54 and r = .50, respectively, p < .001), and also was related to having a father who smoked in the children's presence. In public places, average PM(2.5) in the monitored 40 hospitality venues was 464 microg/m(3) and correlated with smoker density measured as cigarettes-waterpipes/100 m(3) (r = .31, p = 0.049). Thus, children in Syria are exposed to high levels of secondhand smoke at home, in which mothers' smoking plays a major role. Also, levels of respirable hazardous particles are high in public hospitality venues, putting customers and workers at serious health risks. Efforts to limit exposure of children and women at home and to adopt clean air policies should become a public health priority in Syria and the Arab region.

Interventions for waterpipe smoking cessation.

BACKGROUND: Waterpipe smoking is a traditional method of tobacco use, especially in the Eastern Mediterranean Region, but its use is now spreading throughout Europe and North America. It is smoked socially, often being shared between friends or family at home, or in dedicated bars and cafes that provide waterpipes to patrons. Because the smoke passes through a reservoir of water, waterpipe tobacco smoking is perceived as being less lethal than other methods of tobacco use. At least in some cultures, women and girls are more likely to use a waterpipe than to use other forms of tobacco, and it is popular among younger smokers. Accumulating evidence suggests that waterpipe smoking may be as addictive as other forms of tobacco use, and may carry similar or greater risks to health. OBJECTIVES: To evaluate the effectiveness of tobacco cessation interventions for waterpipe users. SEARCH STRATEGY: We searched the Cochrane Tobacco Addiction Review Group specialized register, in June 2007. We also searched MEDLINE, EMBASE, CINAHL and PsycINFO, using variant terms and spellings ('waterpipe' or 'narghile' or 'arghile' or 'shisha' or 'goza' or 'narkeela' or 'hookah' or 'hubble bubble'). We searched for trials, published or unpublished, in any language, and especially in regions where waterpipe use is widespread. We have also used our own existing bibliography, compiled from conducting an earlier exhaustive review of the literature on waterpipe smoking. SELECTION CRITERIA: We sought randomized, quasi-randomized or cluster-randomized controlled trials of smoking cessation interventions for waterpipe smokers of any age or gender. The primary outcome of interest was abstinence from tobacco use, preferably sustained and biochemically verified, for at least six months from the start of the intervention. DATA COLLECTION AND ANALYSIS: Each author intended to extract data and assess trial quality independently by standard Cochrane Collaboration methodologies, but no eligible trials were identified. MAIN RESULTS: We found no completed intervention trials targeting waterpipe smokers. A pilot randomized controlled trial by the authors of this review is underway, and will be reported in future updates. AUTHORS' CONCLUSIONS: Epidemiological and observational evidence suggests that waterpipe use is growing in popularity worldwide. It is widely and erroneously perceived to be less lethal than other forms of tobacco use. Women, girls, and young people are more likely to take up waterpipe smoking, especially in the Eastern Mediterranean Region. More research is needed on its addictive properties, and on the associated health risks, both for users and exposed non-smokers. Evidence-based information about waterpipe's addictive and harmful properties should be developed and disseminated in order to deglamourise and denormalise its use. High quality randomized trials are needed to guide treatment of waterpipe smoking.

The tobacco epidemic in Syria.

BACKGROUND: The Syrian Center for Tobacco Studies (SCTS) was established in response to the smoking epidemic in Syria and lack of local knowledge and expertise to confront it. OBJECTIVES: To (1) study tobacco use and local smoking practices using both qualitative and quantitative research methods; (2) develop and test an effective smoking cessation intervention for the Syrian environment; and (3) train Syrian researchers. METHODS AND RESULTS: The Aleppo Household Survey involved a representative sample of adults in Aleppo (2038 subjects, 45.2% men, mean age 35.3 years, response rate 86%). The prevalence of cigarette smoking was 56.9% among men and 17.0% among women, while the prevalence of waterpipe smoking was 20.2% among men and 4.8% among women. Daily use predominated for cigarettes (29.0%), while the opposite was seen in waterpipe use with 10.6% smoking occasionally. Interest in quitting was greater for cigarette than waterpipe smokers (74.0% v 48.6%), while quit rates were higher for waterpipe compared to cigarettes (28.2% v 16.5%). In-depth ethnographic interviews with smokers show that smoking waterpipe is often viewed as an aesthetic enjoyable experience, while smoking cigarettes is viewed as a mundane anxiety-relieving addiction. Clinical laboratory studies reveal that both waterpipe and cigarette smokers in Syria are exposed to smoke toxicants and exhibit dependence symptoms. CONCLUSIONS: All these data have been used iteratively to adapt smoking cessation interventions from developed countries to suit the local Syrian environment. Research conducted in the SCTS to date has provided a fertile training ground for Syrian researchers, as well as for the building of regional collaborations.

Standardizing questionnaire items for the assessment of waterpipe tobacco use in epidemiological studies.

Lessons from surveillance of the smoking epidemic show that the lack of adequate attention to standardizing measures and instruments for epidemiological studies has negatively influenced our ability to assess spatial and secular trends in smoking worldwide. Waterpipe smoking, another hazardous form of tobacco use, is gaining popularity worldwide, with societies in the Eastern Mediterranean region (EMR) being most affected. Several research groups are currently investigating the epidemiology of waterpipe smoking among various populations in the EMR. Initial evidence shows that in contrast to usage patterns observed in adult cigarette smoking, waterpipe smoking is characterized mainly by intermittent and social use. As such, many measures that have been traditionally used for the study of usage patterns and dependence among adult cigarette smokers are uninformative for waterpipe smoking. Thus, the need to develop standardized measures and terminology for assessment of the epidemiology of waterpipe smoking in different populations is of paramount importance. As the monitoring of waterpipe smoking is in its infancy, the development of consensus measures should facilitate the initiation of effective surveillance that can guide public health response to this emerging epidemic.

Patterns of waterpipe use and dependence: implications for intervention development.

Despite the dramatic increase of tobacco smoking via waterpipe in Arab societies, and the apparent potential of waterpipe use to produce tobacco-related disease, little is known about the pharmacological effects of this method of tobacco smoking, particularly its ability to support dependence. This review focuses on recent waterpipe research and current theories of dependence in an attempt to identify patterns of waterpipe use and features likely to reveal dependence. Recent work indicates that, relative to cigarette smoking, this form of tobacco use is characterized by more intermittent use, later age of onset, greater spread among women and lower interest in quitting or appreciation of addictive properties. Waterpipe use is associated with classic features of tobacco/nicotine dependence, as well as features unique to this tobacco use method. However, even shared features of dependence, such as craving and addiction-induced socio-cognitive behavioral changes, can be displayed differently in waterpipe users, indicating the need for waterpipe-specific research approaches. Preliminary evidence suggests that an important step toward dependence involves a transition from social to individual patterns of waterpipe use. Surveillance and research into factors affecting use and cessation of this tobacco use method should pave the way for the development of effective prevention and intervention strategies to curb the burgeoning waterpipe use epidemic.

Tobacco smoking using a waterpipe: a re-emerging strain in a global epidemic.

CONTEXT: The global tobacco epidemic may kill 10 million people annually in the next 20-30 years, with 70% of these deaths occurring in developing countries. Current research, treatment, and policy efforts focus on cigarettes, while many people in developing regions (Asia, Indian subcontinent, Eastern Mediterranean) smoke tobacco using waterpipes. Waterpipes are increasing in popularity, and more must be learned about them so that we can understand their effects on public health, curtail their spread, and help their users quit. OBJECTIVE: To conduct a comprehensive review regarding global waterpipe use, in order to identify current knowledge, guide scientific research, and promote public policy. DATA SOURCES: A Medline search using as keywords "waterpipe", "narghile", "arghile", "shisha", "hookah", "goza", "hubble bubble" and variant spellings (for example, "hooka"; "hukka") was conducted. Resources compiled recently by members of GLOBALink were used. STUDY SELECTION: Every identified published study related to waterpipe use was included. DATA SYNTHESIS: Research regarding waterpipe epidemiology and health effects is limited; no published studies address treatment efforts. Waterpipe use is increasing globally, particularly in the Eastern Mediterranean Region, where perceptions regarding health effects and traditional values may facilitate use among women and children. Waterpipe smoke contains harmful constituents and there is preliminary evidence linking waterpipe smoking to a variety of life threatening conditions, including pulmonary disease, coronary heart disease, and pregnancy related complications. CONCLUSIONS: More scientific documentation and careful analysis is required before the spread of waterpipe use and its health effects can be understood, and empirically guided treatment and public policy strategies can be implemented.

Factors related to frequency of narghile (waterpipe) use: the first insights on tobacco dependence in narghile users.

AIMS: To evaluate factors related to level of narghile (waterpipe) use as a first step towards modeling tobacco dependence among narghile users. DESIGN: Cross sectional survey done in 2003 using interviewer-administered anonymous questionnaires. SETTING: Cafes/restaurants serving narghiles in Aleppo, Syria. PARTICIPANTS: Narghile smokers (161 men and 107 women; mean age, 30.1 +/- 10.2, 161; age range, 18-68 years; response rate, 95.3%) randomly selected from the 17 cafes/restaurants sampled. MEASUREMENTS: Frequency of narghile use (daily, weekly, monthly) was assessed as a function of several factors potentially indicative of dependence, including situational characteristics (where, when, and with whom smoking occurs; seasonality of use, and sharing of narghile), attitudes, and experience with quitting narghile use, escalation of use over time, future intentions regarding use, perception of being "hooked" on narghile, and cognitions/behaviors engaged in to support use (carrying one's own narghile; think of narghile when it is not available; considering narghile for selection of cafes/restaurants). FINDINGS: Frequency of narghile use was strongly correlated with participant's subjective judgment of how hooked they are on narghile (coefficient, 0.5). Predictors of narghile use frequency according to multinomial logistic regression were: male gender, smoking mainly alone versus with others; smoking mainly at home versus outside; smoking more frequently since initiation, being hooked on narghile, carrying narghile, and considering it for cafe/restaurant choice. CONCLUSIONS: Our data reveal two main domains of a tobacco dependence syndrome likely to be relevant to narghile; the first reflects the effects of nicotine contained in narghile tobacco, and is not very different from what is seen with other tobacco products, and the second is unique to narghile and is related mainly to its social dimension, with more intensive smokers showing an increasingly individual pattern of narghile smoking.

Prevalence and characteristics of narghile smoking among university students in Syria.

SETTING: Narghile (waterpipe) smoking is increasing in all Arab societies, but little is known about its pattern of use. METHODS: In 2003, a cross-sectional survey was conducted among students at Aleppo University using an interviewer-administered questionnaire. A representative sample of 587 students participated (278 males, 309 females; mean age 21.8 +/- 2.1 years; response rate 98.8%). RESULTS: Ever narghile smoking was seen among 62.6% of men and 29.8% of women, while current smoking was seen among 25.5% of men and 4.9% of women. Only 7.0% of the men used narghile daily. Age of initiation was 19.2 +/- 2.2 and 21.7 +/- 3.2 years for men and women, respectively (P < 0.001). The salient feature of narghile smoking was its social pattern, where most users initiated and currently smoked narghile with friends. Narghile and cigarette smoking were related among students, with narghile smoking most prevalent among daily cigarette smokers. Multivariate correlates of narghile smoking were being older, male, originating from the city, smoking cigarettes, having friends who smoke narghile, and coming from a household where a greater number of narghiles were smoked daily. CONCLUSIONS: Narghile smoking is prevalent among university students in Syria, where it is mainly practiced by men, intermittently, and in the context of social activities with friends.

Characteristics of cigarette smoking and quitting among university students in Syria.

BACKGROUND: No study to date in Syria has documented the smoking and quitting characteristics in a representative sample of university students, and this study aims to fill this void. DESIGN: In 2003, a cross-sectional survey was carried out among students at Aleppo University using an interviewer-administered questionnaire. Overall, 587 students participated in the study (278 males, 309 females; mean age, 21.8 +/- 2.1 years; response rate, 98.8%). Experiences and attitudes related to smoking and quitting were assessed for two popular forms of tobacco use in Syria-cigarettes and narghile (waterpipe). RESULTS: Current cigarette smoking was reported by 30.9% of male and 7.4% of female students and daily smoking by 24.8% of male and 5.2% of female students. Narghile smoking was seen among 25.5% of men and 4.9% of women, mostly on an occasional basis. More than half of current smokers (56%) believed they could quit cigarettes, 75.2% were interested in quitting, and 78% of those had made a quit attempt in the past year. Important correlates of cigarette smoking among students were being older, male, and smoking narghile, while being older and from a poorer family were associated with increased interest in quitting. Interestingly, peers' smoking was associated with current smoking among students, but inversely with their willingness to quit. CONCLUSIONS: Cigarette smoking is mainly a problem of male students, whose narghile smoking is likely to be dramatically increasing as well, sometimes practiced as a substitute for cigarettes. The findings that most smokers in this sample are interested in quitting smoking and have tried unsuccessfully to do so indicate that cessation support for youths in this country is urgently needed.

Adapting smoking cessation interventions for developing countries: a model for the Middle East.

OBJECTIVE: To describe the rationale and methods for the development of culturally-sensitive smoking cessation interventions for primary care settings in developing countries. RATIONALE: Smokers in the Middle East have great difficulty quitting. Effective smoking cessation programs are currently lacking in the Middle East, and the development of culturally sensitive programs is hindered by the dearth of standardized information regarding tobacco use and dependence in this region. METHODS: Epidemiological and clinical laboratory methods are needed to determine the prevalence and patterns of tobacco use and nicotine dependence. One strategy is to adapt smoking cessation methods widely used in industrialized countries to the Syrian and Middle Eastern environment. In a recently initiated project, the Syrian Center for Tobacco Studies has been established to address these issues. Initial work is focusing on collecting formative data including key informant interviews, focus groups, and epidemiological surveys to assess smokers' use patterns, needs, and resources. Clinical laboratory techniques are also being applied to assess the physiological, behavioral, and subjective effects of local tobacco use methods, such as narghile (water pipe) smoking. These data will be used to help adapt existing smoking cessation interventions from industrialized countries to be evaluated in a randomized controlled trial. CONCLUSION: There is a great need to develop and disseminate effective cessation interventions in low-income countries. Successful interventions will contribute to a culturally sensitive and sustainable regional tobacco control infrastructure. This paper describes one approach to the development of such an infrastructure that is currently underway in the Middle East.

Gender and smoking status-based analysis of views regarding waterpipe and cigarette smoking in Aleppo, Syria.

BACKGROUND: Narghile (waterpipe) smoking is increasing across the Eastern Mediterranean region (EMR), though little is known about the social attitudes and perceptions related to this method of tobacco use, and how those attitudes and perceptions are influenced by gender. METHODS: Data from two cross-sectional surveys conducted in 2003 in Aleppo, Syria, were used to examine these issues. Overall, 855 participants were included (439 men, 416 women; mean age, 24.4+/-7.1 years; response rate, 97%). The current analysis focuses on responses to four similar nine-item questions tapping perceptions related to narghile smoking by women or men, and cigarette smoking by women or men. Scores on the nine items were summed to yield a total score to gauge participants' perceptions about narghile and cigarette. RESULTS: Generally, participants were less positive about women smoking relative to men smoking, and cigarette smoking relative to narghile smoking. Cigarette smoking by women was the behavior least associated with positive perceptions. Individuals who resided in the city, were economically better-off, and were Christian, had higher perception scores (i.e., more positive attitudes) toward all forms of smoking, whereas older and married participants had higher perception scores for narghile only. Smoking status of participants, especially narghile smoking, was also associated with more positive perceptions toward smoking in general. CONCLUSIONS: We conclude that preliminary analysis shows that views on different forms of smoking in Syria differ by gender and smoking status.

Tobacco specific nitrosamines and potential reduced exposure products for smokers: a preliminary evaluation of Advance.

OBJECTIVE: To develop a method for evaluating the carcinogen delivery of potential reduced exposure products (PREPs) like Advance, a PREP marketed to reduce smokers' exposure to one tobacco specific nitrosamine (TSN), NNK, a potent lung carcinogen. DESIGN, SETTING, AND PARTICIPANTS: Latin square ordered, three condition, outpatient, crossover design with 12 smokers of light or ultra-light cigarettes (15 or more cigarettes/day). In each five day condition, participants either smoked own brand, Advance, or no cigarettes. Also, on the first and last day of each condition, participants smoked one cigarette in the laboratory. MAIN OUTCOME MEASURES: Subject rated measures of tobacco/nicotine withdrawal, expired air carbon monoxide, urine concentrations of cotinine and NNAL (one TSN biomarker), puff volume, duration, number, and interpuff interval. RESULTS: Relative to own brand, Advance produced similar withdrawal suppression, slightly lower carbon monoxide, equivalent cotinine, and 51% lower NNAL concentrations. The lowest cotinine and NNAL concentrations were observed in the no cigarette condition. Participants took fewer puffs when smoking Advance. CONCLUSIONS: Past experience with PREPs that failed to reduce smoking's harm demonstrates the need for clinical methods in PREP evaluation. This study shows how assessing PREP induced changes in withdrawal and exposure to carbon monoxide, nicotine, and carcinogens may help predict PREP harm reduction potential. Adequate withdrawal suppression, slightly lower concentrations of carbon monoxide, and reduction of one TSN biomarker were observed for Advance. In the future, clinical methods like those described here may be valuable for evaluating PREPs before they are marketed publicly.

Acute effects of Advance: a potential reduced exposure product for smokers.

OBJECTIVE: To examine the acute effects of Advance, a potential reduced exposure product (PREP) for smokers marketed as a means to reduce exposure to toxic gases and tobacco specific nitrosamines. DESIGN, SETTING, PARTICIPANTS: Latin square ordered, three condition, laboratory based, crossover design with 20 smokers of light or ultra-light cigarettes (15 or more cigarettes/day). In each 2.5 hour condition, participants completed an 8-puff smoking bout from their own brand, Advance, or an unlit cigarette (that is, sham smoking) every 30 minutes for a total of four bouts. MAIN OUTCOME MEASURES: Subject rated measures of tobacco/nicotine withdrawal; carbon monoxide (CO), and heart rate; plasma nicotine concentrations. RESULTS: Relative to own brand, Advance produced similar withdrawal suppression and heart rate increase, lower CO boost, and higher plasma nicotine concentrations. CONCLUSIONS: PREPs for smokers need to be evaluated using a comprehensive strategy that includes empirical examination of acute and long term effects. Adequate withdrawal suppression and potentially lower concentrations of CO associated with Advance use are positive factors, although higher nicotine concentrations do not constitute "reduced exposure". Overall, longer exposure periods are necessary to determine carcinogen delivery. PREP evaluation is complex and should be completed objectively.