ROLL-YOUR-OWN CIGARETTES AS A RISK FACTOR FOR TOBACCO DEPENDENCE IN NEW ZEALAND

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1 ROLL-YOUR-OWN CIGARETTES AS A RISK FACTOR FOR TOBACCO DEPENDENCE IN NEW ZEALAND A report prepared as part of a Ministry of Health contract for scientific services by Dr R A Lea Dr P Truman 22 December 2009 Revised April 2010 Client Report FW10004

2 ROLL-YOUR-OWN CIGARETTES AS A RISK FACTOR FOR TOBACCO DEPENDENCE IN NEW ZEALAND Viv Smith Programme Leader Water Group P Truman Project Leader R Pirie Peer Reviewer

3 DISCLAIMER This report or document ("the Report") is given by the Institute of Environmental Science and Research Limited ("ESR") solely for the benefit of the Ministry of Health, Public Health Service Providers and other Third Party Beneficiaries as defined in the Contract between ESR and the Ministry of Health, and is strictly subject to the conditions laid out in that Contract. Neither ESR nor any of its employees makes any warranty, express or implied, or assumes any legal liability or responsibility for use of the Report or its contents by any other person or organisation. Roll-Your-Own Cigarettes as a December 2009

4 ACKNOWLEDGMENTS We thank the Quit Group for providing anonymised data for analysis. Roll-Your-Own Cigarettes as a December 2009

5 CONTENTS SUMMARY...I 1. INTRODUCTION Rationale Indices of Tobacco Dependence METHODS Study Subjects and Sample Statistical Analysis RESULTS Descriptive Statistics of Total Sample Descriptive Statistics of Factor Groups (Age, Gender, Ethnicity and Cigarette Type) Descriptive Statistics of Outcome Groups (HSI and TTFC) Multivariate Logistic Regression DISCUSSION CONCLUSION... 7 REFERENCES... 8 APPENDIX... 9 LIST OF TABLES Table 1: Demographic and Smoking Characteristics by Age Group... 3 Table 2: Demographic and Smoking Characteristics by Gender Group... 4 Table 3: Demographic and Smoking Characteristics by Ethnic Group... 4 Table 4: Demographic and Smoking Characteristics by Cigarette Type... 4 Table 5: Demographic and Smoking Characteristics HSI Group... 5 Table 6: Demographic and Smoking Characteristics TTFC Group... 5 Table 7: Multivariate Logistic Regression using HSI as Outcome... 6 Table 8: Multivariate Logistic Regression using TTFC as Outcome... 6 Roll-Your-Own Cigarettes as a December 2009

6 SUMMARY This project followed on from earlier studies indicating that roll-your-own cigarettes are equally, or more, harmful than factory made cigarettes, and from concern over the high usage of roll-your-own tobacco. Using data provided from the Quit Group, self-reported smoking characteristics from a large number of Quit Group clients were analysed to see whether they provided any evidence of increased tobacco dependence when using roll-your-own tobacco. Measures used to indicate dependence were time to first cigarette upon waking (TTFC), and the Heaviness of Smoking Index (HSI). The type of tobacco smoked (roll-your-own or factory-made) was the single strongest predictor of tobacco dependence of the variables tested, ahead of ethnicity, gender and age. The odds ratios, adjusted for ethnicity, age, gender and cigarettes smoked per day were 1.52 (TTFC; 95 % confidence limits ) and 1.28 (HSI; 95% confidence limits ). These results apply to Quitline customers who may not be completely representative of the whole population of smokers. Additionally socioeconomic factors were unable to be controlled in this study. The use of roll-your-own tobacco was clearly associated with increased tobacco dependency, suggesting a possible increased risk of dependence when using roll-your-own tobacco. This new evidence may have significance for development of tobacco control policies with respect to roll-your-own tobacco. Roll-Your-Own Cigarettes as a i December 2009

7 1. INTRODUCTION 1.1. Rationale Hand-rolled or roll-your own cigarettes (RYOs) are a popular alternative to factory-made cigarettes (FMs). In New Zealand (NZ) almost half (46%) of all smokers (1) and over 70 % of Maori smokers (2) consume RYOs exclusively or mixed with FMs. Given the efficiency gains of smoking RYO cigarettes (e.g. less tobacco used and less wasted smoke per cigarette) and therefore lower cost, RYO usage has increased relative to FMs over the longer term, especially in low socioeconomic groups (1). There is mounting evidence that RYOs are at least as harmful to the smoker as FMs, or more harmful. A laboratory-based experiment using a smoking machine to analyse NZ tobacco products has shown that some RYO tobaccos expose smokers to more tar and, for some brands, higher carcinogen concentrations per mg nicotine (3). A small clinical comparison of RYO and FM smokers indicated that although RYOs weighed less and less tobacco was burnt compared to FM, RYO smokers had increased carbon monoxide (CO) and total smoke exposure compared to FM smokers (4). Recently we have found (Lewis, Miller & Truman, unpublished) that smoke from RYO tobacco is higher in monoamine oxidase inhibitors, per milligram of nicotine, than smoke from FM cigarettes. Since monoamine oxidase inhibitors are expected to impact on addiction (5) this raises the possibility that, in addition to harm from toxicants in tar, smoking RYO cigarettes could lead to increased tobacco dependence. The present study continues the investigation of the harmful effects of RYO cigarettes compared to FM by focusing on questionnaire data from a large sample of NZ smokers seeking help to quit and testing the hypothesis that RYO cigarette smoking is associated with increased dependence on tobacco Indices of Tobacco Dependence Tobacco dependence is a disorder defined and diagnosed by internationally standardised classification criteria - primarily inability to quit smoking (6, 7). The degree (or severity) of tobacco dependence is often used to help with cessation treatment and is most commonly measured using a six-item questionnaire called the Fagerstrom test of nicotine dependence (FTND) (8). For large population-based surveys it has been shown that a more efficient version of the FTND called the Heaviness of Smoking Index (HSI) can be used to assess degree of tobacco dependence. The HSI is based on two key questions number of cigarettes smoked per day? and time to first cigarette after waking in the morning? (9). Inclusion of the number of cigarettes per day (CPD) in a tobacco dependence index has some noted drawbacks. First, although the CPD is progressively decreasing in NZ, smokers tend to "self-titrate" their nicotine level by the number, depth and duration of puffs they take to maintain their addiction. In addition, variation in rate of nicotine metabolism may influence cigarette consumption (10) meaning slower nicotine metabolisers may require fewer CPD to maintain their addiction. The latter may be particularly pertinent as a small Roll-Your-Own Cigarettes as a 1 December 2009

8 clinical study indicated that Maori smokers have genetically reduced nicotine metabolism compared to Europeans (11). Time to first cigarette (TTFC) as a tobacco dependence index is based on the premise that smokers find their blood level largely depleted of nicotine after a night s sleep. Thus upon arising in the morning a more addicted smoker will face greater withdrawal symptoms and thus be motivated to light up their first cigarette sooner after waking than those less addicted (12). Time to first cigarette (TTFC), rather than cigarettes per day (CPD) has been shown to be the single most reliable indicator of tobacco dependence, particularly in countries with strong tobacco control policies such as United Kingdom, Australia and NZ (13). 2. METHODS 2.1. Study Subjects and Sample This study is a retrospective statistical analysis of questionnaire data collected by the NZ Quitline over a 4 year period. Briefly, the NZ Quitline is a free telephone-based smoking cessation programme aimed at reduction of tobacco use and associated diseases in NZ. Quitline callers eligible for the programme are routinely given a semi-structured questionnaire to gauge their level of dependence and to guide treatment which might include nicotine replacement therapy (NRT) and/or counselling. The questionnaire database analysed was comprised of response data for individuals who called the Quitline from January 1 st, 2001 to December 31 st, 2004 and answered either cigarettes OR roll-your-owns to the question What type of cigarette do you usually smoke? Statistical Analysis The primary hypothesis tested in this study was that roll-your-own cigarettes (RYOs) are associated with increased tobacco dependence. Multivariate logistic regression was used to model the associations. The primary outcome variables were - Heaviness of smoking index (HSI) dichotomised as HSI 4 (ie. heavily dependent) or HSI <4 (ie. moderately dependent), and time to first cigarette (TTFC) dichotomised as <30mins after waking (ie. highly dependent) or 30mins after waking (ie. moderately dependent). The primary predictor variable was type of cigarette usually smoked (FM or RYO). Covariates were age, gender and ethnicity (Maori vs non-maori). Variables were coded according to the data dictionary shown in the appendix. Statistical effect sizes and significance are represented as Odds Ratios (ORs) with 95% confidence intervals (CIs). Roll-Your-Own Cigarettes as a 2 December 2009

9 3. RESULTS 3.1. Descriptive Statistics of Total Sample Of the total group (n=65466), approximately 58% were female (n=38065), 17% were Maori (n=11074) and the average age was 41 years (Standard Deviation = 21yrs). In terms of smoking characteristics, 39% usually smoked RYO cigarettes compared to 61% smoking FM cigarettes. Overall, the average no. of cigarettes smoked per day was ~19 (Standard Deviation = 8 CPD), a relatively high value, which may reflect the characteristics of the study group. Of the total group, individuals (67%) were classified as being highly dependent (TTFC <30mins after waking). The HSI could be calculated for n=43731 individuals, of which n=24960 (57%) were classified as being heavily dependent (HSI 4) Descriptive Statistics of Factor Groups (Age, Gender, Ethnicity and Cigarette Type) Tables 1-4 show the group characteristics by age, gender, ethnicity and smoking type, respectively. For age (Table 1), the youngest group (15-24 years) exhibited the highest frequency of Maori and RYO smokers (19% and 46%, respectively), and the average no. of cigarettes smoked per day was lowest in the yrs age group (15.2 CPD). For gender (Table 2), there was a higher frequency of RYO smokers in the male group compared to females (44% vs 35%). On average males smoked ~2 CPD more than females and exhibited slightly increased rates of tobacco dependence, according to HSI and TTFC, compared to females. For ethnicity (Table 3), a greater proportion of the Maori group smoked RYOs compared to non-maori (46% vs 37%). There was no difference between ethnic groups for average CPD (~18). The Maori group had a higher frequency of TTFC <30mins (72% vs 67%) but, due to similar CPD, did not exhibit higher frequency of HSI 4. For cigarette type (Table 4), a greater proportion of the RYO group were Maori compared to FM group (20% vs 15%, respectively). According to both indices, the RYO group exhibited a higher frequency of tobacco dependent smokers compared to the FM group. The average number of CPD was similar for both RYO and FM groups (~18 CPD). Table 1: Demographic and Smoking Characteristics by Age Group Variable N (%)* 7716 (11.8) (24.8) (26.1) (18.6) 7083 (10.8) 3218 (4.9) No. of females (%) 4452 (57.7) 9457 (58.4) (58.5) 7144 (58.7) 4160 (58.7) 1759 (54.7) No. of Maori (%) 1480 (19.2) 2931 (18.1) 3109 (18.2) 2052 (16.8) 861 (12.2) 272 (8.5) No. using RYOs (%) 3516 (45.6) 6836 (42.2) 7167 (41.9) 4209 (34.6) 2090 (29.5) 913 (28.4) Mean CPD (SD) 15.2 (7.4) 17.0 (7.2) 18.9 (7.8) 20.6 (8.7) 20.5 (8.8) 18.4 (8.6) HSI 4 (%) 2446 (50.2) 5933 (55.5) 6637 (60.1) 5153 (62.3) 3010 (59.3) 1094 (46.8) TTFC < 30mins (%) 5350 (70.4) (68.4) (68.7) 8466 (70.1) 4695 (66.9) 1788 (56.4) RYOs = Roll-your-owns, CPD = cigarettes per day, HSI = heaviness of smoking index, TTFC = time to first cigarette, SD = standard deviation. Roll-Your-Own Cigarettes as a 3 December 2009

10 Table 2: Demographic and Smoking Characteristics by Gender Group Variable Male Female N (%) (41.8) (58.2) Mean age in years (SD) 40.5 (18.2) 40.5 (22.2) No. of Maori (%) 3885 (14.2) 7187 (18.9) No. using RYOs (%) (43.9) (34.9) Mean cigarettes per day (SD) 20.0 (8.7) 17.6 (7.6) HSI 4 (%) (60.4) (55.0) TTFC < 30mins after waking (%) (69.9) (66.3) RYOs = Roll-your-owns, HSI = heaviness of smoking index, TTFC = time to first cigarette, SD = standard deviation Table 3: Demographic and Smoking Characteristics by Ethnic Group Variable Maori Non-Maori N (%) (16.9) (83.1) Mean age in years (SD) 38.4 (12.3) 40.9 (22.0) No. of females (%) 7187 (64.9) (56.8) No. using RYOs (%) 5061 (45.7) (37.2) Mean cigarettes per day (SD) 18.2 (9.1) 18.6 (8.0) HSI 4 (%) 3812 (56.4) (57.2) TTFC < 30mins after waking (%) 7846 (71.9) (67) RYOs = Roll-your-owns, HSI = heaviness of smoking index, TTFC = time to first cigarette, SD = standard deviation Table 4: Demographic and Smoking Characteristics by Cigarette Type Variable FM RYO N (%) (61.3) (38.7) Mean age in years (SD) 41.6 (19.7) 38.6 (21.9) No. of females (%) (61.7) (52.5) No. of Maori (%) 6013 (15) 5061 (20) Mean cigarettes per day (SD) 18.5 (8.1) 18.7 (8.9) HSI 4 (%) (56.4) 3334 (61.7) TTFC < 30mins after waking (%) (64.5) (73.0) RYO = Roll-your-own, FM = Factory made, HSI = heaviness of smoking index, TTFC = time to first cigarette, SD = standard deviation Descriptive Statistics of Outcome Groups (HSI and TTFC) Tables 5 and 6 show the demographic and smoking trends for the tobacco dependence groups based on HSI and TTFC. For HSI (Table 5), the average age of the more heavily dependent group (HSI 4) was approximately 1 year older compared to the less dependent group (HSI <4). The frequency of females was lower in the HSI 4 group but the proportion of Maori was similar between the two groups. The proportion of RYO smokers was slightly higher in the HSI 4 group. For TTFC (Table 6), there was a higher proportion of Maori in the more highly addicted group (TTFC< 30mins) compared to the TTFC 30mins group (~18% vs 15%). Moreover Roll-Your-Own Cigarettes as a 4 December 2009

11 there was a substantially higher proportion of RYO users in the TTFC< 30mins group (~42% vs 32%) and the average CPD was ~5 more in the TTFC< 30mins group compared to the TTFC 30mins group. Table 5: Demographic and Smoking Characteristics by HSI Group Variable HSI 4 HSI < 4 N (%) (57.1) (42.9) Mean age in years (SD) 41.2 (18.1) 40.6 (20.6) No. of females (%) (59.1) (64.3) No. of Maori (%) 3812 (15.3) 2950 (15.7) No. using RYOs (%) 3334 (13.4) 2069 (11.0) Mean cigarettes per day (SD)* 20.7 (5.4) 13.8 (6.2) RYOs = Roll your owns, TTFC = Time to first cigarette, HSI = Heaviness of smoking index Note that only 20% of RYO smokers completed the question regarding the number of cigarettes smoked per day, since these smokers were asked how much tobacco they used per week. * HSI is derived from CPD ie. these variables are not independent. Table 6: Demographic and Smoking Characteristics by TTFC Group Variable TTFC< 30mins TTFC 30mins N (%) (67.8) (32.2) Mean age in years (SD) 40.1 (21.0) 41.2 (19.8) No. of females (%) (56.8) (60.9) No. of Maori (%) 7846 (17.9) 3071 (14.7) No. using RYOs (%) (41.7) 6763 (32.4) Mean cigarettes per day (SD) 20.3 (8.1) 15.3 (7.1) RYOs = Roll your owns, TTFC = Time to first cigarette, HSI = Heaviness of smoking index 3.4. Multivariate Logistic Regression Multivariate logistic regression was performed on the data set to test the primary hypothesis that RYO usage was associated with increased tobacco dependence. The two tobacco dependence indices (i.e. HSI and TTFC) were included as dichotomous outcome variables as described in methods. Age, gender and ethnicity (and CPD for the TTFC outcome) were included as covariates in the analysis. Table 7 shows the regression results for HSI as outcome. These results indicated that RYOs were associated with increased HSI after adjusting for the effects of the covariates (OR adj = 1.3, 95% CI: ). Gender and age were also associated with an increased HSI, whereas the difference due to ethnicity (Maori) was not significant. Table 8 shows the results using TTFC as the outcome variable and indicates that RYOs were associated with decreased TTFC (OR = 1.5, 95% CI: ). Ethnicity (Maori), age, gender and CPD were also significantly associated with a decreased TTFC. Roll-Your-Own Cigarettes as a 5 December 2009

12 Table 7: Multivariate Logistic Regression using HSI as Outcome Predictor Variables Odds Ratio Lower 95% C.I. Upper Ethnicity (Maori) Gender (Male) 1.23** Age 1.0** Tobacco type ( RYO) 1.28** ** P < 0.001, HSI = Heaviness of smoking index, TTFC = Time to first cigarette, RYO = Roll-your-own Table 8: Multivariate Logistic Regression using TTFC as Outcome Predictor Variables Odds Ratio Lower 95% C.I. Upper Ethnicity (Maori) 1.27** Gender (Male) 0.92** Age 1.01** Cigarettes per day 1.11** Tobacco type ( RYO) 1.52** ** P < 0.001, TTFC = Time to first cigarette, RYO = Roll-your-own 4. DISCUSSION In this study we analysed questionnaire response data from a large sample of addicted smokers attempting to quit via the NZ Quitline. The principle aims of the study were to assess the demographic and smoking patterns in RYO smokers compared to FM smokers, and to determine whether using RYO tobacco is a risk factor for tobacco dependence in NZ. Descriptive analysis of the data revealed some interesting trends. In terms of demographics, we observed that RYO usage was substantially elevated in younger people, males and Maori, in agreement with earlier studies (e.g. 1). In part, this reflects the fact that RYO cigarettes are cheaper option for smokers compared to FMs. The overall proportion of RYO smokers in this study was lower than found in 2006 (1), which may reflect different methodologies, including differences between the study populations. Our study also revealed that RYO tobacco use was associated with increase risk of tobacco dependence according to both indices (ie. HSI and TTFC). For both, use of RYO tobacco was the single strongest risk indicator for tobacco dependence, compared to ethnicity, gender and age. For HSI, the odds of high tobacco dependence were moderately greater (~28%) in RYO smokers compared to FM smokers. However, there are some limitations of this statistical association. A difficulty with this analysis was to compare tobacco exposures between RYO smokers and FM smokers. We used the self-reported cigarettes per day measure for RYO Roll-Your-Own Cigarettes as a 6 December 2009

13 smokers, where available. Laugesen et al. (4) have suggested that even though the weight of tobacco used is less for RYO smokers, on average the exposure to tobacco components is similar, and possibly greater per cigarette, because of the more intensive way in which RYO cigarettes are smoked. The regression model for HSI (shown in Table 7) indicates that being of Maori ethnicity is not a significant risk factor for dependence, whereas the TTFC measure does give ethnicity as a significant risk factor. This is consistent with the notion that, on average, Maori smokers have slower nicotine metabolism, and these smokers are able to maintain their tobacco dependence despite reducing their CPD (11). The inclusion of CPD as a variable in the HSI may be masking the true dependence of this group of slow metabolisers, who may smoke less cigarettes, but be just as stongly dependent on tobacco. Of particular interest was the association of RYOs with TTFC, as TTFC is regarded as the single most reliable measure of tobacco dependence (12). Using TTFC <30mins as an outcome measure of high tobacco dependence, this study showed that RYO smokers had a 1.5 fold (or 50%) increased odds of high tobacco dependence compared to FM smokers, after adjusting for the effects of covariates, including age, gender, ethnicity and CPD. Using TTFC as a tobacco dependence indicator, the regression statistics in Table 8 also showed that Maori were at moderately increased risk (27%) of high tobacco dependence compared to non-maori. There have been some assumptions that, since there is a much greater prevalence of smoking in Maori (both RYOs and FMs), this ethnic group may have a higher dependence on tobacco than non-maori. While our study supports this assumption, based on TTFC, it should be noted that this effect may be more strongly associated with socioeconomic status. Potential limitations of the study are that Quitline callers may not be fully representative of all smokers, being self-selected for both motivation to stop smoking and asking for help to do so. As the data had been anonymised, it was not possible to include consideration of socioeconomic status using the NZ deprivation index. Such analysis could be included in future studies. 5. CONCLUSION This study has provided strong evidence that smoking roll-your-own (RYO) cigarettes may be a risk factor for increased tobacco dependence. However, it is not possible, from a study of this nature, to determine whether this is due to RYOs creating more dependence, or whether the more dependent smokers gravitate to RYO tobacco use because it is a cheaper option. This new evidence adds to the notion that RYO cigarettes are at least as likely to cause harm as factory-made cigarettes. Government should be able to utilise this evidence-base to update tobacco control policy, including taxation and warnings, regarding RYO tobacco in sales and usage. Roll-Your-Own Cigarettes as a 7 December 2009

14 REFERENCES 1. Ministry of Health. Tobacco Trends 2006: Monitoring tobacco use. Ministry of Health, Wellington, The Quit Group and the Ministry of Health Māori Smoking and Tobacco Use 2009: Ministry of Health, Wellington, Fowles, J.B. Mainstream smoke emissions for "roll-your-own" loose-leaf tobacco sold : Ministry of Health, Wellington, Laugesen, M., Epton, M., Frampton, C.M., Glover, M. & Lea, R.A. Hand-rolled cigarette smoking patterns compared with factory-made cigarette smoking in New Zealand men. BMC Public Health 9, 194-, Lewis, A., Miller, J.H. & Lea, R.A. Monoamine oxidase and tobacco dependence. Neurotoxicology 28, , World Health Organisation. International statistical classification of diseases and related health problems (ICD010). Geneva: World Health Organisation, American Psychiatric Association. Diagnostic and statistical manual of mental disorders. Washington American Psychiatric Association, Fagerstrom, K.A., Measuring degree of physical dependence to tobacco smoking with reference to individualization of treatment. Addict. Behav. 3 (3-4), , Kozlowski, L.T., Porter, C.Q., Orleans, C.T., Pope, M.A. & Heatherton, T. Predicting smoking cessation with self-reported measures of nicotine dependence: FTQ, FTND, and HIS. Drug Alcohol Depend. 34 (3), , Benowitz, N.L., Swan, G.E., Jacob, P., 3rd, Lessov-Schlaggar, C.N. & Tyndale, R.F. CYP2A6 genotype and the metabolism and disposition kinetics of nicotine. Clin. Pharmacol. Ther. 80, , Lea, R., Benowitz, N., Green, M., Fowles, J,.Vishvanath, A., Dickson, S,.Lea, M., Woodward, A., Chambers, G. & Phillips, D. Ethnic differences in nicotine metabolic rate among New Zealanders. N.Z. Med. J. 118 (1227), U1773, Kozlowski, L.T., Director, J. & Harford, M.A. Tobacco dependence, restraint and time to the first cigarette of the day. Addict. Behav., 6, , Fagerstrom, K. Time to first cigarette; the best single indicator of tobacco dependence? Monaldi Arch. Chest Dis. 59, 91-94, Roll-Your-Own Cigarettes as a 8 December 2009

15 APPENDIX Data Dictionary Variable Code Description Gender 1 Male 2 Female Age value In years Ethnicity 1 Maori 2 Non-Maori Cigarette Type 1 RYO 2 Tailored TTFC 1 <30 mins 2 >30mins Cigs/day (CPD) value no. of cigarettes CPD dichotomised 1 >20/day (high) 2 <20/day (normal) Smoking Duration value In years Smoking Intensity 1 Heavy 2 Not heavy HSI = heaviest HSI (category) 1 Heavy (high dependence) 2 Not Heavy RYO = Roll your own, TTFC = Time to first cigarette, HSI = Heaviness of smoking index Roll-Your-Own Cigarettes as a 9 December 2009

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