A Compilation of Clinical Studies on Non Tobacco
and Non Nicotine Smoking

Reprinted from ANGIOLOOY Vol. 18, No. 4. April. 1967
Copyright 1967
Printed in USA

TABLE OF CONTENTS

THE COMPARATIVE EFFECTS ON CIRCULATION OF SMOKING TOBACCO AND LETTUCE LEAF CIGARETTES
Sandy A. Furey, M.D., Jan Schaanning, M.D.,
Stanley Spoont, M.D.,
and Newton C. Birkhead, M.D., Ph.D. Page 1

REGULAR, FILTER-TIP, AND MODIFIED CIGARETTES Nicotine Excretion, Free Fatty Acid Mobilization, and Catecholamine Excretion
Alfred Kershbaum, M.D., Samuel Bellet, M.D. Masami Hirabayashi, M.D.,
and Leonard J. Feinberg, Ph.D. Page 7

FETAL GROWTH RETARDATION IN RATS EXPOSED TO CIGARETTE SMOKE DURING PREGNANCY
M. K. Younoszai, Jean Peloso, J. C. Haworth Winnipeg,
Manitoba, Canada Page 9

TOBACCO SUBSTITUTES IV. LETTUCE CIGARETTES IN THE U.S.A.
A. Cuenot, Rev. Tabacs, Fr. Page 15

CIRCULATORY EFFECTS OF NICOTINE AEROSOL INHALATIONS AND CIGARETTE SMOKING IN MAN
A. Herxheimer, M. B. Land, Senior Lecturer in Pharmacology,
and R. L. Griffiths, B. Hamilton,Marion Wakefield, Medical Students,
The London Hospital Medical College Page 16

TOBACCO CIGARETTE SMOKING AND PATELLAR REFLEX DEPRESSION
Edward F. Domino, M.S., M.D., and Alona M. von Baumgarten ,M.D.
Ann Arbor and Detroit, Michigan Page 20

CIGARETTE NICOTINE CONTENT AS A DETERMINANT
OF HUMAN SMOKING BEHAVIOR
T. L. Goldfarb, M. E. farvik, and S. D. Glick,
Albert Einstein College of Medicine, New York Page 26

"IF YOU MUST SMOKE, LETTUCE SAID BEST TO AVOID CANCER",
Article, Minneapolis UPI Page 31

THE COMPARATIVE EFFECTS ON CIRCULATION
OF SMOKING TOBACCO AND LETTUCE LEAF CIGARETTES*

SANDY A. FUREY, M.D., JAN SCHAANNING, M.D., STANLEY SPOONT, M..D., AND NEWTON C. BIRKHEAD, M.D., PH.D.

Despite numerous recent reports on the harmful effects of cigarette smoking and the efforts of many physicians to discourage their patients from smoking, the high level of cigarette sales indicates that the use of cigarettes at present continues to be great. There is no reason to expect a decrease in cigarette smoking in the immediate future. An alternative to decreasing the harmful effects of tobacco cigarettes is to modify the cigarette itself. It has been demonstrated that circulatory changes resulting from cigarette smoking closely parallel the effects of intravenous injections of nicotine. These well-known changes include increased arterial blood pressure and pulse rate and decreased peripheral blood flow and digital skin temperatures. In an attempt to lessen these adverse effects of absorbed nicotine, different types of cigarette filters and "denicotinized" cigarettes have been introduced. Studies to date', 9-12 show that such innovations do not provide completely satisfactory means of eliminating the undesirable nicotine effects. A recent approach has been the substitution of cigarettes made of lettuce leaves instead of tobacco leaves in the hope that some of the side effects of smoking could be lessened. Although chemical analysis of the lettuce leaf cigarette revealed no nicotine, this does not exclude the possibility that these cigarettes may contain other material with effects on the circulation. The purpose of the present study was to compare some of the circulatory effects of smoking cigarettes made from dried, flavored lettuce leaves with those associated with the smoking of standard tobacco leaf cigarettes.

METHODS

The subjects were healthy young adults, six men. and four women. All were cigarette smokers of more than 10 cigarettes per day for longer than I year. Their ages ranged from 19 to 30 years. Each smoking test was carried out in the morning after complete abstinence from food and smoking for 12 hr. The subjects were studied in a constant-temperature room maintained at 25 C and 40 per cent relative humidity. They wore light clothing and rested, supine, on a standard hospital bed. The circulatory effects of smoking were measured by changes in blood pressure, pulse rate, and skin temperatures. Blood pressure was obtained by the standard cuff method and heart rate by palpation of the radial pulse. Skin temperatures were obtained from copper constantan thermocouples applied to the volar surface of the distal phalanx of the third finger of each hand, the volar surfaces of the right and left great toe, the anterior surface of the chest in the midsternal line at the angle of Louis, and the forehead. The electrical output from the thermocouples was converted to skin temperatures by a preprogrammed digital potentiometer. The accuracy of this conversion was continuously monitored by simultaneously measuring the known output from a Minneapolis-Honeywell Model 2732 potentiometer and from several built-in standardized potentials in the digital potentiometer. With the subject resting comfortably in the constant-temperature room, blood pressure, pulse rate, and skin temperatures were recorded every 4 minutes during a stabilization period of from 45 to 60 min. When two consecutive blood pressure readings varied less than 2 mm Hg and two consecutive finger temperatures less than 0.4' C, either two cigarettes of a popular filter brand or two lettuce leaf cigarettes were smoked in succession. Of each cigarette, 4 1/2 cm were smoked. The protocol was alternated so that one subject smoked lettuce leaf cigarettes and the next subject smoked tobacco cigarettes. The following day the subjects returned and, under the same conditions, smoked the other type of cigarette. Simultaneous determinations of blood pressure, pulse rate, and skin temperatures were obtained, every 4 minutes, for 32 minutes.

RESULTS

The average time required by the subjects to smoke two tobacco cigarettes in succession was 15 min (range 8 to 18 min); to smoke two lettuce leaf cigarettes, the average time was 18 min (range 12 to 26 min). The means of the values for systolic and diastolic blood pressure and pulse rate during and after the smoking of tobacco cigarettes and lettuce leaf cigarettes are shown in figures 1 and 2. The mean values of the finger temperatures are shown in figure 3. The average maximal increase in pulse rate in the ten subjects smoking two tobacco cigarettes was 22 beats per min (range 2 to 58 beats per min). The average time for the maximal increase in heart rate was 8 min from the beginning of smoking the tobacco cigarettes. The average maximal increase in pulse rate during smoking of the lettuce leaf cigarette was 4 beats per min (range 0 to 12 beats per min). The difference in pulse response to the two types of cigarettes was statistically significant (p < 0.01).

The average maximal blood pressure rise following the smoking of two tobacco cigarettes was 9 mm Hg (range 2 to 16 mm Hg) systolic and 10 mm llg (range 2 to 16 mm Hg) diastolic. The average time for the occurrence of the maximal increase in blood pressure was 8 min after the beginning of smoking. Values for systolic blood pressure began to return toward control values 20 min after the beginning of smoking, but neither systolic nor diastolic pressure had returned to the control values at the end of the observation period.

The average maximal increases in systolic and diastolic pressure during smoking of lettuce leaf cigarettes were 4 mm Hg (range 2 to 10 mm Hg) and 5 mm Hg (range 0 to 10 mm Hg), respectively. These differences in response of systolic and diastolic pressures to the smoking of the two types of cigarettes were also highly significant (p <' 0.01).

There were no consistent changes in the temperatures of the skin of the forehead or of the anterior chest during the smoking of either type of cigarette. In most subjects, the temperature of both toes remained at or near room temperature during these studies, as would be expected from the level of the room temperature chosen. The average maximum temperature decrease of both the right and left third finger during and after the smoking of two tobacco cigarettes was 4.5' C (combined range 1.7 to 7.2' C). The average maximum finger temperature decrease during and after the smoking of two lettuce leaf cigarettes was 3.1' C (right) and 3.8' C (left), with a combined range of 0.5 to 6.5' C. The differences in temperature response of the fingers to the two types of cigarettes were barely significant (p < 0.1). In response to smoking lettuce leaf cigarettes, the average maximum temperature decline occurred at 16 min after the beginning of smoking, while after tobacco cigarettes, the average temperature of the fingers was still decreasing at the end of the observation period.

DISCUSSION

The changes in blood pressure and pulse rate during and after the smoking of standard cigarettes in these subjects are similar to those reported in other studies. The changes are also similar to those produced by the administration of nicotine; presumably nicotine is the predominant etiologic factor producing these changes during smoking. The relative absence of similar changes in blood pressure and pulse rate during the smoking of lettuce leaf cigarettes can be attributed to the absence of pharmacologically significant amounts of nicotine. The changes in finger skin temperature during and after smoking of standard cigarettes has also been attributed predominantly to the action of nicotine. The fall in finger skin temperature during and after smoking of lettuce leaf cigarettes, although of a lesser degree than with tobacco leaf cigarettes, indicates that other peripheral vasoconstrictor mechanisms associated with smoking are also active in the absence of pharmacologically Significant amounts of nicotine. Two possibilities for the decreases in finger temperature with lettuce leaf cigarettes are the aromatic flavoring agents utilized in the preparation of the cigarettes or the deeper inspirations associated with smoking. Peripheral vasoconstriction in the finger during deep inspiration is a well-known phenomenon and has been reviewed by Gilliatt.13 He found that the degree of vasoconstriction in the fingers was related to the depth of inspiration as well as its rate; these changes might be expected to occur with the inspiratory excursions in smokers who inhale, as did all our subjects. If this mechanism is responsible for the decrease in finger skin temperature associated with lettuce leaf cigarettes, then presumably this effect is also present during the smoking of tobacco cigarettes but is masked by the greater vasoconstrictor effect of tobacco leaf smoke.

SUMMARY

A comparison of the changes in pulse rate, blood pressure, and skin temperatures during and after smoking of two tobacco cigarettes and two lettuce leaf cigarettes was carried out in 10 healthy subjects. The average maximal increases in pulse rate and systolic and diastolic blood pressures were 22 beats per min, 9 mm Hg and 10 mm Hg and 4 beats per min, 4 mm Hg and 5 mm Hg with the tobacco and lettuce cigarettes, respectively. These differences between responses were statistically significant (p < 0.05). Average finger skin temperature decreased to a maximum of 4.5' C with the tobacco and 3.1' C with the lettuce cigarettes. Smoking of lettuce leaf cigarettes had less effect on the circulation than smoking of tobacco cigarettes, when measured by these parameters.

Lankenau Hospital

Philadelphia, Pennsylvania

REFERENCES

1. Hines, E.A., Jr.: The effects of tobacco on blood pressure and in peripheral vascular disease. Proc. Staff Meet. Mayo Clin., 35: 337, 1960.

2. Watts, D.T., and Bragg, A.D.,: Effect of Smoking on the urinary output of epinephrine and norepinepherine in man. J. Appl. Physiol. 9: 275,1956.

3. Blackburn, H., Brozek, J., and Taylor, H.L.,: Common circulatory measurements in smokers and nonsmokers, Circulation, 22: 1112, 1960.

4. Eckstein J. W., Wood, J.E., and Wilkins, R. W.,: Comparative vasoconstrictor effects of inhaling tobacco smoke in warm and cool environments and before and after abstinence from tobacco. Am. Heart J. 53, 455, 1957.

5. Evans, W.F., and Stewart, H.J., The effect of cigarette smoking on the peripheral blood flow. Am. Heart J., 26, 78, 1943.

6. Freund, J.: Effects of cigartte smoking on the normal male peripheral circulation, utilizing multitechnical procedures. Circulation, 16: 883, 1957.

7. Freund J., and Ward, C.: The acute effect of cigarette smoking on the digital circulation in health and disease. Ann. New York Acad. Sc., 90: 95, 1960.

8. Maddock, W. G., Malcolm, R. L., and Coller, F. A.: Thromboangiitis obliterans and tobacco: the influence of sex. race, and skin sensitivity to tobacco on cardiovascular responses to smoking. Am. Heart J., 12: 46,1936.

9. Levy, R. L., Mathers, J. A. L., Mueller, A. A., and Nickerson, J. L.: Effects of smoking cigarettes on the heart in normal persons and cardiac patients. J. A. M. A., 135: 417, 1947

10. Roth, G. M.: Tobacco and the Cardiovascular System: The Effect of Smoking and of Nicotine on Normal Persons. Charles C. Thomas, Springfield, Illinois, 1951.

11. Roth, G. M., and Shick, R. M.: Effect of smoking on the cardiovascular system of man. Circulation, 17: 443, 1958.

12. Weatherby, J. H.: Skin temperature changes caused by smoking and other syrmpatho-mimetic stimuli. Am. Heart J., .04: 17, 1942.

13. Gilliatt, R. W.: Vaso-constriction in the finger after deep inspiration. J. Physiol.., 107: 76, 1948.

Regular, Filter-Tip, and Modified Cigarettes

Nicotine Excretion, Free Fatty Acid Mobilization, and Catecholamine Excretion

Alfred Kershbaum, MD, Samuel Bellet, MD,
Masami Hirabyashi, MD, Leonard J. Fienberg, PhD

A recent report from the Roswell Park Memorial Institute, at Buffalo stated that filter-tip cigarettes did not effectively remove tam and nicotine from cigarette smoke. The study was based on an analysis of the tar and nicotine content of the make of nine brands of filter-tip cigarettes, and it was concluded that filters did not protect the maker against the health hazards of smoking.

We have previously investigated certain biochemical and pharmacological effects of cigarette smoking and felt it would be of interest to determine the influence of filters and other cigarette modifications on these effects. This report presents the results of a comparative study of the effect on nicotine excretion, few fatty acid (FFA) mobilization, and catecholamine excretion of regular and filter-tip cigarettes, pipe tobacco cigarettes, and lettuce leaf cigarettes.

Method of Study.-Six normal men, ages 28 to 45, participated in this study. All were habitual smokers of 20 or more cigarettes per day for at least ten years. In each subject, the effect of smoking five different types of cigarettes on urinary nicotine excretion, plasma FFA concentration, and urinary catecholamine excretion was studied. The experiments were randomized both as to type of cigarette and chemical determination (Table 1). Experiments started at 9 AM, with food restricted after the previous evening and no smoking for at least 12 hours.

The cigarettes used were Popular standard brands of a regular Cigarette, two types of filter-tip cigarettes, pipe tobacco and a lettuce leaf cigarette, purchased at customary commercial source,. Abut three quarters of a cigarette (approximately 55 mm) were smoked in each test. the cigarette being previously measured and marked. According to oral communications with the research departments of the manufacturers in January. 1965. the regular cigarette contained 1.12 gm of tobacco, having a nicotine content of 2.01%. The standard filter cigarette had 1.01 gm of tobacco with a nicotine content of 1.91 %. The charcoal filter cigarette contained 0.98 gm of tobacco with a 1.74% nicotine content. The pipe tobacco cigarette had 1.06 gm tobacco containing 2.12% nicotine. The lettuce leaf cigarette contained shredded dry lettuce leaf with no tobacco or nicotine content.

The Procedures followed in these experiments were similar to these previously described. In the nicotine excretion studies, four cigarettes per hear war, smoked for four hours, and smoking was completed twenty minutes before the end of the four-hour period. All urine was Selected during the four-hour period and the nicotine content determined by the method f McNiven et al.' The same procedure was followed for the study of urinary catecholamine excretion and urine reactions were assayed for total free catecholamine, content by Crout's method.- For a base line catecholamine output for each subject. control experiments without smoking war, done. In the FFA mobilization experiments, two cigarettes were smoked in ten minutes: plasma FFA concentrations were obtained before and after smoking and 10, 20, and 40 minutes later.

All tests were monitored for uniformity and accuracy of amount of cigarette smoked, duration of smoking, and depth of inhalation. Data were analyzed for statistical significance of mean differences by Student's t test.

Results.-Nicotine Excretion.-The quantity of nicotine excreted in each experiment is shown in Table 2. The mean difference in nicotine excretion when regular, filter, charcoal filter, or pipe tobacco cigarettes were smoked was not significant. The difference between the lettuce leaf cigarettes and each f the tobacco cigarettes in the subjects' excretion of nicotine wait highly significant (P < 0.001).

Catecholamine Excretion.-The results of the urinary catecholamine analyses are shown in Table 4. The mean catecholamine excretion was not significantly different in the six subjects when they smoked regular, filter, charcoal filter, or pipe tobacco cigarettes. There was a significantly greater catecholamine output with each type compared to the lettuce leaf cigarettes and the "no smoking" control experiments (P < 0.001). 'Mere was no appreciable difference in output between the lettuce leaf cigarettes and the control experiments.

Comment.-In the Roswell Park study, the effectiveness of filters in removing tars and nicotine from cigarette smoke was investigated. Based on the discovery of inadequate removal of these substances, the report concluded that cigarette filters did not offer protection against the health hazards of smoking.

It was the purpose of our study to determine whether the nicotine content of cigarette smoke was indeed inadequately reduced by filters. With filters, was there still sufficient nicotine absorbed to appear in the urine in significant concentration and to affect lipid and hormonal activity? The answer to this appears to be in the affirmative, since our results showed no significant difference in urinary nicotine excretion, FFA elevation, or catecholamine excretion with filter and charcoal filter cigarettes as compared to regular cigarettes.

In the four types of tobacco cigarettes used in these experiments, the nicotine content of the mainstream smoke ranged from 0.6 mg to 1.8 mg per cigarette, with the filter types at the lower end of the scale. This varied somewhat with each type depending on the laboratory and method of analysis. It has been shown" that with customary inhaling, 96% to u?5% of the nicotine in cigarette smoke is absorbed. In animal experiments in our laboratory,'-"-" FFA and catecholamine effects and significant urinary nicotine excretion have been observed with doses of nicotine (0.02 toO.1 mg/kg) comparable to the smallest amounts absorbed in the present smoking study. Others"-" have also shown that blood pressure and catecholamine responses to nicotine occur at this dose level. These studies support the view that an effective amount of nicotine was absorbed in the tobacco smoking experiments despite the type of cigarette used. Lettuce leaf cigarettes, containing no nicotine, produced negligible effects.

The similarity in nicotine excretion and catecholamine and FFA response, which followed the different cigarettes delivering different concentrations of nicotine, is not adequately explained by this study. It may be speculated that the hormonal and lipid effects are subject to a maximal effective dose of nicotine which is in the lower dose range. The excreted nicotine, being a small fraction of the amount absorbed,' may not show differences as appreciable as those in the delivered tobacco smoke. These possibilities require further study.

On the basis of results obtained in these experiments with commonly used cigarettes and filters, it appears reasonable to conclude that there is no appreciable difference in the lipid and hormonal effects of filter and nonfilter cigarettes. In both types there is apparently sufficient nicotine absorbed from the inhaled smoke to produce these effects to a similar degree.

References

1. Medical Tribune, Sept 12, 1VA. p 3.

2. Medical World News, Sept 16,1966, p 39.

3. Kershbaum, A.. et at: Effect of Cigarette Smoking and Nicotine on Serum Free Fatty Acids, Cir Res 19:M.638 (May) 1961.

4. Kershbaum, A., et &I: The Role of Catecholamines in the

Free Fatty Acid Response to Cigarette Smoking, Circulation

29-.52-57 (July) 1963.

5. Kershbaum, A., et al: Differences in Effects of Cigar and Cigarette Smoking on Free Fatty Acid Mobilization and Catecholamine Excretion, JAMA l95:lO95-1098 (March 28) 1966.

6. Kershbaum, A., et al: Effect of Cigarette, Cigar, and Pipe Smoking and the Influence of Inhaling on Urinary Nicotine Excretion, Arch Intern Med, to be published.

7. McNiven, N.L., et al: Determination of Nicotine in Smokers' Urine by Gas Chromatography, Nature 208:788-789 (Nov 20) 1965.

8. Crout, J.R.: "Catecholemines in Urine," in Seligson, D. (ad.): Standard Methods of Clinical Chemistry, New York: Academic Prem. Inc., 1961, vol 3.

9. Gordon, R.S.. Jr.: Unesterified Fatty Acid in Human Blood Plasma:

11. Transport Function of Unesterified Fatty Acid. J Clin Invest 36:810-819 (Sept) 1957.

10. Greenburg, L.A.; Lester, D.; and Haggard. H.W.: The Absorption of Nicotine in Tobacco Smoking, i Pharmacol Exp Ther 104:162-167 (May) 1952.

11. Kershbaum, A. ' et al: Effect of Cigarette, Cigar, and Pipe Smoke Inhalation in Serum Lipid Concentrations and Urinary Catecholamine Excretion in Dogs. abstracted, Circulation 32:19-20 (Oct) 1965.

12. Kershbaum, A.. et at: Modification of Nicotine-Induced Hyperlipidemia by Antiadrenergic Agents, J Atherascler Res 6: 524-530 (Nov-Dec) 1966.

13. Watts, D.T.: The Effect of Nicotine and Smoking on the Secretion of Epinephrine, Ann NY Acad Sci 90:74-84 (Sept) 1960.

14. Armitage, A.K.: Effect of Nicotine and Tobacco Smoke on Blood Pressure and Release of Catecholamines From the Adrenal Glands, Brit J Pharmacol 25:515-523 (July) 1965.