Light and intermittent smoking: the road less traveled.

Abstract

Tobacco control research is at a crossroads. Increasingly, investigators, policy makers, and practitioners recognize the need for concerted efforts to reduce smoking around the globe and across the entire spectrum of smokers. Research and public health efforts have targeted primarily moderate to heavy smokers and those who smoke every day. The National Household Interview Surveys that have monitored U.S. tobacco use since the 1960s did not even distinguish between daily and nondaily smoking until 1992 (Centers for Disease Control and Prevention [CDC], 1994). Our interventions, theoretical frameworks, and concepts of addiction and quitting processes were modeled on heavy daily smoking. Because the frequency, intensity, and duration of tobacco exposure are related in a dose-dependent manner to the risk of health consequences, this strategy focused on those smokers at highest risk of tobacco-related disease. However, no level of cigarette smoke is safe (U.S. Department of Health and Human Services [USDHHS], 2006). Even secondhand smoke exposure in children of light smokers has been associated with the biologically effective dose of two known carcinogen–protein adducts and general measures of genetic damage (Tang et al., 1999). Tobacco consumption among current smokers has declined over several decades (Orzechowski & Walker, 2003), and one-fifth of U.S. smokers are now intermittent or occasional smokers, defined as non-daily smokers (CDC, 2007). Many smokers, especially those in low- and middle-income countries, may be light smokers (i.e., smoking < 10–15 cigarettes/day). If we are to curb the global tobacco pandemic, that is, avoid 1 billion tobacco-related deaths in the 21st century (World Health Organization [WHO], 2008), then nicotine and tobacco researchers and researchers from other fields must expand their focus and make a concerted effort to reduce light and intermittent smoking as well as heavy, daily smoking. This paradigm shift is made more urgent by ongoing trends that forecast an increase in the overall proportion of light and intermittent smokers in the U.S. population and globally. By 2050, it is projected that 50% of the U.S. population will comprise Hispanics/Latinos, Blacks/African Americans, American Indians, Alaska Natives, Asian Americans, and Pacific Islanders. In these racial and ethnic groups, light smoking has historically been a dominant phenomenon. Long-term trends show that more than 50% of Blacks and Hispanics, irrespective of gender, age, or educational status, smoke fewer than 15 cigarettes/day and that light smoking has increased over the years in these populations (USDHHS, 1998). American Indians report smoking on average 10 cigarettes/day (Eichner et al., 2005). Similar patterns have been observed among Asian Americans, Pacific Islanders, and Alaska Natives (USDHHS, 1998). If historical patterns of smoking consumption among these racial and ethnic groups persist as their share of the U.S. population grows, the proportion of light and intermittent smokers in the United States will increase overall. Indeed, light smoking may become a more common smoking pattern with the rapid increase in tobacco use around the globe. Tobacco use is increasing more rapidly in economically developing countries than in developed countries, and more smokers live in low- and middle-income countries than in high-income countries (WHO, 2003). Smokers who live in poverty smoke fewer cigarettes per day compared with those who live at or above the poverty line (CDC, 2007), making it possible that the global expansion of tobacco use will generate an increase in the proportion of light and intermittent smokers worldwide. The global spread of effective tobacco control policies called for by the WHO Framework Convention on Tobacco Control and MPOWER report (WHO, 2008) is likely to produce quitting among some smokers while others reduce to light and intermittent smoking. These projections suggest that embedded in the tobacco pandemic is an impending pandemic of light and intermittent smoking.