March 2011

Spotlight

NTCC Reflects on 2010 and Plans for 2011

NTCC held its annual meeting in Washington, D.C. on March 24 to share accomplishments and provide updates on key activities related to the NTCC Tobacco Cessation Priorities for the Nation. Over the past year, NTCC and partners have been working on various initiatives to address the nine priorities. Some of these initiatives include:

1. Increase consumer demand for evidence-based tobacco cessation treatments and services.

Through funding from the Robert Wood Johnson Foundation, NTCC developed a “Consumer Reports” style card--What Works? A Guide to Quit Smoking Methods--to help smokers choose appropriate methods for quitting. The content of the card is based on Treating Tobacco Use and Dependence: 2008 Update—Clinical Practice Guideline, and was developed in collaboration with Dr. Michael Fiore and others on the Guideline panel. To supplement the printed Guide, a companion website was created to provide smokers with more detailed information. In the coming year, NTCC aims to promote the Guide to a larger audience by teaming up with mainstream consumer outlets, including Target, Walmart, CVS, and Walgreens.

Created by Dianne Barker, How to Improve Your Chances of Quitting Smoking is a brief written specifically for young adults curious about quitting smoking. It provides easy-to-read information regarding nicotine medications, including myths and facts and information on the actual use of NRTs. Quitline Services for Youth Under Age 18 highlights the way in which quitlines provide services to youth. Specifically, the brief describes why quitlines are appealing to youth and the way in which services can be tailored to this population. The Quitline Ads provide examples of ways to promote quitline services to youth. They are templates that can be used by any state to promote their state quitline. The cessation briefs and quitline ads can be accessed at www.tobacco-cessation.org.

2. Link tobacco control public policy changes to increase cessation and treatment use and demand.

Abby Rosenthal from OSH presented on public policy activities to increase cessation and treatment use and demand. OSH continues to collaborate with states to increase cigarette excise taxes, expand smoke free laws, and implement comprehensive tobacco control programs (i.e., health systems change, PHS guideline implementation, quitlines). Expansion of Medicaid’s pregnancy cessation benefit and Medicare’s cessation benefit remains another critical priority for OSH. For this year, OSH is not only focused on expanding coverage in CMS but also expanding quitline capacity and implementing PHS guidelines in HSS settings.

3. Promote the inclusion and use of tobacco control and cessation content in electronic health records (EHRs).

Caroline Cranos and Donna Warner from Multi-State Collaborative for Health Systems has had significant collaboration across states and HIT-related experts in the past year on several important HIT/EMR issues, including participation in a task group on model EMR screens for tobacco interventions. For April 2011, the Collaborative will conduct a webinar for states and their partners on Meaningful Use and NQF clinical tobacco measures sets, and why these are important.

4. Increase national, state and local longitudinal surveillance of tobacco-use cessation, including quitting motivation and behaviors, treatment beliefs and use, services, and policies.

The National Institute on Drug Abuse (NIDA) currently supports a number of longitudinal surveillance studies, including the Monitoring the Future (MTF) Study which surveys drug use trends in U.S. among 8th, 10th and 12th graders.

5. Expand access to proven, effective treatments for tobacco addiction.

David Zauche from Partnership for Prevention presented on the ActionToQuit State Grant Program. The State Grant Program requires grantees to create a state tobacco alliance, to develop a summit meeting to bring together influential players in the field, and to create a state action plan for tobacco cessation. For 2011, three new grantees were selected: Georgia, Iowa, and Michigan. More information can be found at www.actiontoquit.org.

OSH is conducting a number of activities related to expanding access to cessation treatments such as, implementation of the expanded OPM Cessation benefit, expansion of the Medicaid Pregnancy benefit and Medicare cessation benefit, and development and release of the Surgeon General’s Report: How Tobacco Smoke Causes Disease.

6. Support an expanded research agenda to achieve advances in the reach, effectiveness and adoption of tobacco cessation interventions across both individuals and populations.

The Multistate Collaborative continues to make progress on its plan to replicate Massachusetts-type Medicaid cessation benefit studies with up to 10 other states. Outreach is currently underway to obtain Medicaid data sets from four states, with an additional five states identified. The outcome of this research will include analyses of health outcomes for subpopulations and a simulation model. This past year, the Collaborative also completed an analysis of 1,000,000+ encounter records from two large health care delivery systems to demonstrate the link between tobacco interventions and improved health outcomes. Preliminary findings were presented at the October MSC conference.

NIDA has a number of upcoming research-related activities for 2011:

• RFA-DA-11-014: Predictive Animal Models for Smoking Cessation (U54)
• RFA-DA-11-009: 2011 NIDA Translational Avant-Garde Award for Medication Development (X02 and DP1)
• RFA-DA-11-004: Pharmacological Development of Agents & Formulations for Tobacco Dependence (STTR/R41)
• RFA-DA-11-015: Medication Initiative for Tobacco Dependence (MITD): A New Product Development Partnership (PDP) (UH2/UH3)

7. Launch an ongoing, extensive, national paid media campaign on cessation to help Americans quit using tobacco.

Bill Furmanski from Legacy presented on the Become An EX campaign. Since the launch in April 2008, over 2 million people have visited the official webpage, with nearly 400,000 registrations. Though EX advertisements will be discontinued, Legacy will maintain promotion of the initiative through social media outlets, including Twitter, Facebook, an iPhone application, and paid online advertisements that will drive people to the website. Evaluation of the EX campaign was conducted and results were published in February 2011 in the American Journal of Public Health. More information can be found at www.legacyforhealth.org.

8. Support the increase in the federal and state excise tax on tobacco to expand assistance for tobacco users who want to quit.

Ann Boonn from Campaign for Tobacco-Free Kids (TFK) presented on tax increases. In 2010, TFK helped to pass 5 state tobacco tax increases. For 2011, TFK will continue working in 11 states (so far) to pass tobacco tax rate increases and/or equalization, to fix federal tobacco tax definitions to close loopholes, and on federal tobacco tax equalization.

9. Build capacity for quitlines in order to provide universal access to evidence-based counseling and medications for tobacco cessation.

OSH continues to promote states’ implementation of CDC’s Best Practices, which includes funding for quitlines, health systems change, and PHS guideline implementation. OSH has also created the National Quitline Data Warehouse to track utilization, outcomes, etc. at a national and state level.

Next Steps for NTCC

After sharing updates related to each of the priorities, members discussed gaps, key opportunities, and potential activities where NTCC and partners can have a role in the next year to move each of the priorities forward. At the meeting, members suggested:

• The importance of building demand for evidence-based treatments and services (i.e., reaching out to mass media, retailers, etc.).
• Conducting an environmental scan of initiatives focused on smokeless and emerging nicotine products.
• Assessing and translating the impact and influences of the Affordable Care Act on tobacco cessation.
• Gearing future efforts on menthol and cessation, given the increasing popularity of menthol products.
• Assessing the use of cigars and “cigarellas”, as these tobacco products are marketed differently and not regulated.

If you have any comments, ideas, or suggestions for activities or opportunities, please contact Todd Phillips (tphillip@aed.org).

Back to Top

---

Research Highlights

Heavy Smoking Declines in U.S

The number of people who smoke a pack or more a day has dropped significantly in the United States, and perhaps nowhere more than in California, a new study finds.

The number of people smoking less than a pack but at least 10 cigarettes a day has also dropped significantly, added the researchers, who examined national data on smoking rates from 1965 to 2007 to come to their conclusion.

"Public health advocacy can have a major impact on social norms and lead to major changes in population behavior," said lead researcher John P. Pierce, a professor of family and preventive medicine at the University of California San Diego.

In addition, there has been a significant decline in lung cancer rates in California, and those rates will continue to drop faster than in the rest of the country over the next 15 years, he noted.

"The Tobacco Control Program in California has aimed to change social norms in the population, and this has had a major impact," Pierce said. "Such programs need to be disseminated more widely. The change in social norms in California impacted both initiation and cessation."

The report is published in the March 16 issue of the Journal of the American Medical Association.

For the study, Pierce's team collected data on 1,801,529 people who took part in the National Health Interview Surveys, 1965-1994 and the Current Population Survey Tobacco Supplements, 1992-2007.

A total of 139,176 responders were in California, and 1,662,353 were located throughout the rest of the United States.

In 1965, 56 percent of all smokers in the United States smoked a pack (20 cigarettes) a day or more. In California, this represented 23.2 percent of smokers while in the rest of the country the prevalence of heavy smokers was 22.9 percent, the researchers found.

By 2007, this prevalence of heavy smokers was 2.6 percent in California and 7.2 percent in other states, they added.

For those who smoked 10 to 19 cigarettes a day, the prevalence in 1965 was 11.1 percent in California and 10.5 percent in the rest of the country. By 2007, the prevalence in California was 3.4 percent while it was 5.4 percent in the rest of the United States, the researchers noted.

"This decline has not been accompanied by higher rates of lower-intensity smoking," Pierce said. "This decline in intensity of smoking has come about by a major change in the number of young people who have taken up even a half-pack per day habit."

There has also been a major cessation effect, Pierce added.

Danny McGoldrick, vice president for research at the Campaign for Tobacco-Free Kids, noted that "California has reduced overall smoking and high-intensity smoking much faster than the rest of the country, and this has led to declines in lung cancer rates that are larger than the rest of the country -- saving lives and health-care dollars."

California has achieved these lifesaving gains because it has put in place those policies and programs proven to reduce tobacco use, including the nation's longest running prevention and cessation program, the nation's first statewide smoke-free law and, in earlier years, higher tobacco taxes, McGoldrick said. "Every state should follow California's example," he said.

However, these gains are in jeopardy, as California has fallen behind its funding of tobacco control programs, McGoldrick said.

"To continue its progress, California must raise its tobacco tax, which has fallen well below the national average, and use some of the new revenue to increase funding for its model prevention and cessation program, which has declined significantly in recent years," McGoldrick said.

Dr. Norman H. Edelman, scientific consultant for the American Lung Association, said that "this is validation of all of our efforts."

These findings show that both prevention programs and programs to help people quit are essential, he said. In addition, laws passed that prevent public smoking have also played an important role in the decline in smoking, Edelman noted.

"The ban on public smoking seems to help people quit," he said. "But, the job is not over -- 20 percent of Americans still smoke, so there is still a long way to go. But we have begun to turn the tide in lung cancer and it looks like it's happening in chronic obstructive pulmonary disease (COPD)."

For more information, see web link:
US News March 15, 2011

More Self-Aware People Quit Smoking Easier

How your brain responds to anti-smoking messages may be useful in helping to kick the habit, a new study in the journal Nature Neuroscience reports.

"People who are more likely to potentially see the messages as relevant to them, they are more likely to quit," said lead author Hannah Faye Chua of the University of Michigan, Ann Arbor. "They could feel like, 'This is me, this is how I am right now, this is how I would like to change.'"

The study looked at 91 participants who were interested in quitting smoking, and who were smoking about 17 cigarettes a day on average. They answered questions about their health, demographic and habits and attitudes relevant to smoking and the reasons preventing them from quitting.

Researchers then used the answers to create tailored smoking cessation messages. These would target the individual's personal obstacles that make it harder to quit, as well as the person's sex and other life characteristics. The study authors exposed participants to the tailored messages as well as broader statements about smoking in general and "neutral" messages not related to smoking cessation.

Functional magnetic resonance imaging (fMRI) of participants while being exposed to these messages revealed that, for the tailored messages, specific brain regions are particularly active. But it's activity in the dorsomedial prefrontal cortex, a region associated with self-awareness - specifically, judgments and decisions about one's self - that best predicts who will quit.

All participants were given a nicotine patch and an individualized session on smoking cessation, with printed materials to take home.

Four months after the brain scan, those participants who had showed the most activity in this region while viewing tailored messages were most likely to quit. Those who quit reported being better able to avoid situations that trigger smoking, and cope with stress.

The study underscores the importance of tailoring treatments to the individual, said Dr. Bradley Peterson, director of child and adolescent psychiatry at Columbia University Medical Center in New York.

It also points to the potential for brain imaging to be used more often to establish whether a patient will respond to a particular treatment, not only in smoking cessation but for other kinds of behaviors and conditions, he said.

"It’s an important study; it’s very cleverly done and executed," he said.

The sample size of 91 participants is considered large for an imaging study. Such experiments tend to be expensive, and since there were only two possible outcomes of the experiment (responding to treatment or not) this subject pool was appropriate for statistical analysis, Peterson said.

For more information, see web link:
TIME February 27, 2011

Study Finds Smoking Linked to Breast Cancer Risk

Both smoking and exposure to secondhand smoke appear to increase the risk for breast cancer among postmenopausal women, new research shows.

Although earlier studies had found little or no connection between breast cancer and smoking, as more women smokers reach menopause the connection may be surfacing for the first time, experts noted.

"The findings are important because smoking was not previously thought to increase the risk of breast cancer, but this study adds to the increasing evidence that it does," said lead researcher Dr. Karen Margolis, a senior clinical investigator at HealthPartners Research Foundation in Minneapolis.

However, Susan Gapstur, vice president of epidemiology for the American Cancer Society, said earlier research had shown some connection between smoking and breast cancer.

"When you put together the body of work in the last few years, it calls for more studies," she said. "This study has answered that call."

"This certainly adds to the evidence that long-term smoking increases the risk for breast cancer," Gapstur said. "On the on the flip side, it appears that 20 years after stopping the risk goes down to that of an average individual. I think that's good news."

Many risk factors for breast cancer cannot be changed, such as age, genetics and family history of the disease, Margolis noted.

"Now smoking can be added to the list of things that can lower breast cancer risk that already include having children, breast-feeding, keeping alcohol consumption low, avoiding weight gain, being physically active and avoiding hormone therapy with estrogen plus progestin," she said.

The report is published in the March 1 online edition of the BMJ.

For the study, Margolis's group collected data on 79,990 women aged 50 to 79 who took part in the Women's Health Initiative study. Over 10 years of follow-up, 3,250 women developed breast cancer.

As part of the study, the women were asked if they smoked, had stopped smoking or had never smoked. The women were also asked about their exposure to secondhand smoke at home and at work.

The researchers found that women who smoked had a 16 percent increased risk of developing breast cancer. Among women who quit, the increased risk was 9 percent, they added.

The greatest risk was for women who had smoked for 50 years or longer, compared with women who never smoked, Margolis's team found. The risk was also high for women who started smoking when they were teenagers. Even after quitting, the risk continued for up to 20 years, the researchers noted.

"We also observed some evidence that extensive exposure to passive smoking may raise the risk of breast cancer," Margolis said.

Nonsmokers exposed to secondhand smoke for more than 10 years as children, more than 20 years as adults at home and more than 10 years at work had a 32 percent increased risk of developing breast cancer, the researchers found.

However, the link between breast cancer and secondhand smoke was seen in those exposed to the greatest amount of passive smoking and "therefore more research is needed to confirm these findings," the researchers noted.

Dr. Paolo Boffetta, deputy director of the Tisch Cancer Institute and Institute for Transitional Epidemiology at Mount Sinai School of Medicine in New York City and co-author of an accompanying journal editorial, said that "tobacco smoking, particularly when started early in life, may increase the risk of breast cancer."

"This evidence is becoming stronger and stronger," he said. "In previous studies, the evidence was not so strong. It is only now that women who started smoking in large numbers are getting to the age where the risk of breast cancer is getting high."

Right now, the association between smoking and breast cancer is still not a sure thing, Boffetta said, "but, it is getting more likely."

For more information, see web link:
US News March 1, 2011

Pregnant Women: Secondhand Smoke Can Harm Your Unborn Baby

Even if you don't smoke when you're pregnant, just being around smokers, can increase the risk of harming your future baby, according to a new study in the medical journal Pediatrics.

Researchers found exposure to secondhand smoke increased a non-smoking pregnant woman's chances of having a stillborn by 23 percent, and increased the risk of delivering a baby with birth defects by 13 percent.

"These results highlight the importance of smoking prevention and cessation focusing on the father in addition to the mother, during the preconception period and during the pregnancy," explains Dr. Jonathan Winickoff, Associate Professor of Pediatrics at Harvard Medical School, who is not affiliated with the study.

The team of experts reviewed virtually all available studies worldwide that focused on this health issue.

The scientists aren't exactly sure what levels of secondhand smoke are dangerous, but they do think the more exposure the higher the risks.

"We anticipate that the effect becomes significant when the woman is exposed to more than 10 cigarettes a day, which isn't a lot when you consider that some women are exposed to partners and other people's smoking habits on a daily basis. However, we need more evidence to be able to say with certainty what the true levels are," explains study author Jo Leonardi-Bee, PhD and Associate Professor in Medical Statistics at the University of Nottingham in England.

This research also suggests that secondhand smoke can be almost as dangerous to a baby as having a mother who smokes, at least when referring to stillbirths and birth defects.

Pregnant smokers have a 20 to 34 percent increased risk of having a baby who is stillborn compared to women who don't smoke, according to Dr. Winickoff. The risks weren't much less – 23 percent – for the non-smokers exposed to secondhand smoke.

The picture for birth defects is similar. The range for smoking women and birth defects is between 10 – 34 percent, and for pregnant women who are around smokers, 13 percent. Babies exposed to passive smoke were more likely to be born with major deformities of the feet, testes, or not have a brain.

"We know there are at least 400 toxic chemicals in tobacco smoke. These can get into the pregnant mother and affect her baby," says Dr. Winickoff.

Cigarettes contain heavy metals, DNA damaging agents, and class one carcinogens – the most harmful ones known.

"Protect yourself from passive smoke before and during pregnancy, not only to reduce risks of disease to yourself, but also to reduce the many harms that passive smoke can have on your future baby," says Leonardi-Bee.

For more information, see web link:
TIME March 7, 2011

Text Messaging Helps Smokers Break the Habit

A pair of related studies on smoking cessation by researchers at the University of Oregon and other institutions have isolated the brain regions most active in controlling urges to smoke and demonstrated the effectiveness of text-messaging to measure and intervene in those urges.

Both projects used the same group of test subjects -- 27 heavy smokers recruited from the American Lung Association's Freedom From Smoking program in Los Angeles.

Elliot Berkman, professor of psychology at the UO, and colleagues Emily Falk at the University of Michigan and Matthew Lieberman at UCLA, used functional magnetic resonance imaging (fMRI) in the first study to map areas of the brain in which impulse control battles are fought. They described kicking an unwanted habit such as smoking as "a war that consists of a series of momentary self-control skirmishes."

Their paper -- published online this month in Psychological Science, a journal of the Association of Psychological Science -- indicates that individuals' abilities to inhibit their responses to cravings can be predicted through fMRI testing. That means it may be possible to tailor smoking cessation programs to individuals' response-inhibition capacities.

"We are really excited about this result because it means that the brain activation we see in the scanner is predictive of real-world outcomes across a much longer time span that we thought," Berkman said. "The tasks that we use in the laboratory are simplified models of these real-world processes -- but they seem to be valid models."

The second study -- also by Berkman, Falk and Lieberman, along with Janna Dickenson of UCLA and posted online in advance of publication in the journal Health Psychology -- tested short message service (SMS) text messaging "as a user-friendly and low-cost option for ecologically measuring real-time health behaviors." Research participants were prompted by eight text messages per day for three weeks to document their ongoing cravings, mood and cigarette use.

The research showed that text messaging is at least as effective as more expensive and harder-to-use handheld data collection devices in the "brief interval assessment" of people in smoking cessation programs. The palmtop devices typically used for what smoking cessation researchers call "ecological momentary assessment" can cost more than $300 each, while 86 percent of U.S. residents already have cell phones and 91 percent of those are SMS-enabled.

"Text messaging may be an ideal delivery mechanism for tailored interventions because it is low-cost, most people already possess the existing hardware and the messages can be delivered near-instantaneously into real world situations," said the study, which is scheduled to appear this week in Health Psychology, the journal of the American Psychological Association.

The study also confirmed earlier findings that monitoring smoking cessation participants at regular intervals -- whether by text messaging or through the use of other hand-held devices -- helps to eliminate "memory biases" that are common when cravings and outcomes are reported only on a daily basis. Its findings corroborate those of other studies that have indicated the importance of rapid, real-time measurement of smoking urges and resistance to them.

Text message monitoring of the Los Angeles smoking cessation participants was also a key element in the study by Berkman and his colleagues of the three brain regions that are most involved in response inhibition -- the right inferior frontal gyrus, the pre-supplementary motor area and the basal ganglia.

In that study, the smokers initially were asked to perform a simple self-control task as an fMRI machine scanned their brains' activity. They were next given lung and urine tests to determine the physical extent of their tobacco addictions, and were asked about their cravings and smoking patterns. Then they began the smoking cessation program, and were asked to respond to text message prompts eight times per day for three weeks.

The study concluded that those participants who had shown the most activity in the key regions of their brains during testing were also the most likely to resist their cravings to smoke -- which was documented in their text message responses.

"A big question that motivates my research is: How can we effectively use neuroimaging to learn something about long-term goals like smoking session?" Berkman said. "Using fMRI together with daily text messaging seems to be an excellent way to address that question."

For more information, see web link:
EurekAlert! March 7, 2011

Quitting Smoking Might Signal Cancer

A provocative though small study suggests that the very act of quitting smoking may be a symptom of not-yet-diagnosed lung cancer.

That's the curious conclusion that researchers at Thomas Jefferson University in Philadelphia reached after they surveyed 115 lung cancer patients, all of them current or former smokers, at the Philadelphia Veterans Affairs Medical Center. The team, led by Barbara Campling, asked when the patients had stopped smoking relative to their diagnosis and onset of symptoms and how difficult or easy it had been to quit. The researchers also used a standard tool called the Fagerstrom Test for Nicotine Dependence to calculate how deeply addicted the smokers had been to nicotine at the peak of their habit.

The researchers, whose work appears in the March issue of the Journal of Thoracic Oncology, undertook the study on a hunch: They had observed that many of their lung-cancer patients had quit smoking before they were diagnosed, often without consciously deciding to do so. The scientists were aware of the common belief that people typically quit smoking in response to the appearance of symptoms suggestive of lung cancer. But they weren't convinced that was really how things work.

Their study appears to bear out their hunch. They learned that 55 of the 115 patients had quit smoking before being diagnosed, all but six of them before any cancer symptoms appeared. Of those who quit, 31 percent reported they'd done so with ease - but not because they had never been addicted: Their levels of addiction when they were smoking the most had been the same as the levels of those who hadn't quit.

The authors suggest that the presence of a lung-cancer tumor may somehow block the body's uptake of, or desire for, nicotine; perhaps, they surmise, such tumors may secrete a chemical that makes that happen.

They acknowledge that their work has limitations, among them the small sample size and the fact that the data were self-reported and after the fact. Still, they believe they're on to something that should be investigated further.

For more information, see web link:
The Washington Post March 8 2011

Secondhand Smoke Linked to Diabetes

Cigarette smoke is tied to a higher risk of type 2 diabetes, both for smokers and the people around them, a new study shows.

And the more secondhand smoke people are exposed to, the greater their risk of type 2 diabetes, according to the paper in Diabetes Care.

The potential risks of diabetes from being exposed to secondhand smoke weren't previously known, said Dr. David Nathan, who heads the Diabetes Center at Massachusetts General Hospital and is a professor at Harvard Medical School.

"This just reinforces the lesson from a public health point of view that we've been stressing for decades," which is to limit exposure to cigarette smoke, Nathan, who was not involved in the study, told Reuters Health.

For the new research, Dr. John P. Forman at Brigham and Women's Hospital in Boston and colleagues looked at the responses of more than 100,000 women to questionnaires they had answered in 1982. The women -- all nurses participating in a national study that would last several decades -- provided information about how much time they spent around cigarette smoke.

During the next 24 years, about one in 18 women were diagnosed with type 2 diabetes.

Overall, about one in 13 people in the U.S. have this disease, according to the National Institutes of Health. Type 2 diabetes, in which the body can't process sugar properly, usually develops in adults. Sometimes it can be controlled by diet and exercise, but advanced cases require insulin treatment and can have life-threatening complications.

Forman's group found that women who smoked more than two packs a day had the highest odds of developing diabetes. For every 10,000 women in the study, about 30 of the heavy smokers got diabetes every year, compared to about 25 women who didn't smoke and didn't spend time exposed to other people's cigarette smoker.

The risks were actually higher for ex-smokers and for women exposed to second-hand smoke. In both of these groups, about 39 of every 10,000 women developed diabetes each year. However, once the researchers took things such as weight status, age, and family history of diabetes into account, the ex-smokers had a 12 percent higher risk of diabetes compared to women who were regularly exposed to secondhand smoke.

Even though the smokers had a lower risk of developing diabetes in this study, that doesn't mean it's better for them to continue smoking, Nathan said.

In this study, nearly all the women were white, but type 2 diabetes affects men and women fairly equally, Nathan said.

"There's no a priori reason to think that this wouldn't apply to men as well," he told Reuters Health, since the risk factors for the disease are the same for both sexes.

Nathan said no one knows why smoking and type 2 diabetes are linked, but inflammation may play a role in both.

Forman and his team did not respond to requests for comment by deadline.

Nathan noted that the study can't prove that smoking causes diabetes. It just shows they are associated with each other.

But "did we need another reason not to smoke? I don't think so," he said.

For more information, see web link:
Reuters Health March 10, 2011

Safe to Quit Smoking Before Surgery, Anytime

Despite earlier concerns, quitting smoking in the few weeks before a surgery doesn't seem risky for patients, according to a new study.

Earlier work had hinted that kicking the habit might increase the risk of breathing problems and other complications after an operation, and some doctors advise patients not to quit close to their surgery date.

The message from the new report, however, is that "anytime is a good time" when it comes to quitting, said Dr. David Warner of the Mayo Clinic in Rochester, Minnesota.

"We have people that are telling patients to keep smoking because it's dangerous to quit," added Warner, who wasn't involved in the new research. "It's not only wrong but it has real practical implications."

Doctors say that surgery presents a unique opportunity to get smokers to quit for the long run. After all, for every surgery there's a certain window during which it is impossible for patients to light up.

But while researchers agree that encouraging patients to quit more than two months before their operation is both safe and can cut down on the risk of surgery complications, the effect of quitting within that two-month window has been more controversial.

To address that controversy, Dr. Peter Hajek of Barts and the London School of Medicine and Dentistry in the UK and his colleagues combined data from nine previous studies with a total of almost 900 patients. Each of those studies had compared the rate of complications following a surgery in smokers who stopped smoking eight weeks or less before surgery and those who didn't quit.

One of the nine studies found that recent quitters experienced fewer problems after surgery than non-quitters, and none showed that quitters were worse off. Taken together, the results showed no difference in complication rates in quitters and non-quitters for all types of complications and all surgeries combined.

Hajek said that although more studies are needed on the effect of quitting in this eight-week window, the findings debunk the idea that it's dangerous to stop smoking leading up to surgery.

"The theory on which this was based is wrong, that is clear," he told Reuters Health. "We are pretty sure that until some new evidence of harm comes along...there is no sign of any danger."

Though it might not be dangerous, quitting smoking soon before surgery doesn't seem to make it any safer, either. But if patients drop the smokes two months or more in advance, that will reduce the number of complications, Hajek said.

"It's certainly better if (patients) quit earlier," he told Reuters Health.

Of course, researchers are quick to point out, quitting smoking at any point in time will have long-term health benefits.

Warner said that the review, published in the Archives of Internal Medicine, did have its limitations. For example, combining all possible surgery complications together doesn't take into account the fact that smoking -- or quitting smoking -- might matter more for certain common complications, such as breathing problems, than for others.

Still, Warner said, "I wholeheartedly agree with the result."

But Dr. Philip Devereaux, a heart doctor and epidemiologist at McMaster University in Ontario, who wrote a commentary on the study, said the finding was far from definitive.

"It's not conclusively shown that it is safe to stop smoking prior to surgery," he told Reuters Health. For doctors, he said, "If you're seeing the patient just a few days before surgery, it's not clear at all what the optimal timing is" to recommend that the patient quit smoking.

In a disclosure with the paper, Hajek and one of his colleagues state that they have received research funding from multiple pharmaceutical companies that make smoking cessation drugs.

Hajek said that until there is more evidence on the relationship between quitting smoking and surgery complications, doctors should be encouraging patients to quit no matter how close to their surgery.

"Quit early if you can," Hajek said, "but if you can't, quitting late is also alright."

For more information, see web link:
Reuters Health March 17, 2011

For Smokers, Internet both Promotes and Undermines Smoking Cessation

According to an analysis of internet search data, the 2009 U.S. federal cigarette excise tax increase successfully drove many smokers online to find ways to quit smoking, but more often smokers responded by shopping online for tax-free or cheap cigarettes in an apparent effort to evade the tax hike. The study is the first evaluation of smokers’ responses to the federal cigarette excise tax, which increased from $0.39 to $1.01 per pack under the State Children's Health Insurance Program (SCHIP) reforms. The findings are published in the March 16 edition of PLoS One.

“Smokers can use the web to continue or kick their habit but, until now, we haven’t been able to observe these behaviors in real-time,” said John Ayers, lead author of the study and doctoral candidate at the Johns Hopkins Bloomberg School of Public Health. “This study shows how the internet is a double-edged sword both promoting and undermining smoking, which remains the leading cause of premature death in the U.S. Online vendors sell reduced or tax-free cigarettes using policy loopholes or by illegally evading the taxes all together, while health advocates use the web to promote cessation.”

For the study, Ayers and a team of scientists from University of North Carolina’s Gillings School of Global Public Health and the Informatics Program at Children’s Hospital Boston (CHIP) studied the impacts of the SCHIP tax increase by monitoring search queries to Google-powered search engines a year before and after the SCHIP tax increase. The researchers found that, around the time the SCHIP tax increase took effect, smoking cessation and tax avoidance search queries reached new highs, increasing about 50 percent and 300 percent over baseline, respectively. However, cessation searches approximated pre-tax levels within two weeks of the tax, while searches for tax-free and cheap cigarettes remained about 60 percent higher a year after the tax. Analyses of search trends for two recent state-specific cigarette excise tax increases in Florida and New York corroborated these trends.

Study coauthor Kurt Ribisl, PhD, whose research focuses on policy issues related to internet tobacco sales, noted, “I am troubled to see the spike in people searching for cheap cigarettes around the time of tax increases. These tax increases are the leading way to reduce smoking while generating substantial revenue. This is a wake-up call for states and the federal government to crack down on tax evasion from internet tobacco sales.”

“This was the first study to use real-time search query surveillance for a health policy evaluation,” said coauthor John Brownstein, PhD, director of the Computational Epidemiology Group within CHIP and co- founder of Health Map (healthmap.org). “Search query surveillance is a promising approach for low cost, public and real-time insight into population health,” he said.

“Health professionals need to anticipate how the public may respond to changes in health policies or new health information. We can create new approaches for utilizing internet searches to help the public make the best decisions to improve their health,” said Daniel Ford, MD, Vice Dean of Clinical Investigation for Johns Hopkins Medicine, who was not affiliated with the study. “It has been a challenge to find ways to engage smokers who are not actively considering quitting. When policies lead to increased internet searches for cheap cigarettes, this might provide an important opportunity for reaching these smokers,” Ford added.

“Still, most smokers want to quit smoking and it is paramount that governments implement evidence-based policies to help people quit, including raising tobacco taxes. The good news here is that in absolute terms more people searched for smoking cessation rather than illicit cigarettes, even after the taxes promoted tax evasion,” said Joanna Cohen, director of the Bloomberg School’s Institute for Global Tobacco Control.

Health advocates have options to influence online behaviors. “In the future, we can target smokers with advertisements tailored to individual search queries that discourage tax evasion and promote cessation. Had such systems already been in place to take advantage of the increases in cessation and tax evasion searches around the SCHIP tax there would likely be fewer smokers today,” said Ayers.

For more information, see web link:
HealthCanal.com March 17, 2011

Secondhand Smoke Raises the Stakes in America's Casinos

Millions of Americans visit casinos to unwind and test their luck against the hands of fate, but lurking in the shadows is a gamble few would contemplate before they stepped inside a casino's doors. The threat is not addiction. It's not the specter of losing a small fortune. The hidden danger is secondhand smoke.

According to a new study by scientists from Stanford and Tufts universities published in the journal Environmental Research, each year 50 million nonsmoking casino patrons and 400,000 nonsmoking casino workers gamble with their lives inside casinos that allow smoking. Less than 2 hours of exposure to secondhand smoke in half of the casinos surveyed is enough to impair the heart's ability to pump blood, placing susceptible casino patrons and workers at acute risk of heart disease.

Coronary heart disease is the leading cause of death in the United States and is a major cause of disability, costing the country an estimated $151.6 billion in 2007. Approximately 8 percent of the population 45 to 64 years of age, and 20 percent of those aged over 65, suffers from coronary heart disease. These older people are at greater risk from exposure to secondhand smoke. Compounding the concern, the two age groups have higher gambling rates than those under 45.

The team of experts from Stanford and Tufts examined pollution levels in 66 smoky casinos in five states, and three casinos that are smoke-free, comparing them with the pollution levels outdoors. The study is a continuation of earlier research conducted at 36 casinos in California. An additional 30 casinos were tested in four other states.

To make their measurements, the researchers operated covertly. Two to three researchers at a time entered casinos carrying small monitoring devices tucked inside purses or jackets. Combining the Stanford/Tufts data with previously published measurements from three other states, the team developed nationwide averages and ranges for pollution levels inside casinos.

The study focused on two types of air pollutants blamed for tobacco-related cancers: fine particulate matter, which deposits deep in the lungs, and a group of chemicals called particulate polycyclic aromatic hydrocarbons, or PPAHs, which include at least 10 different carcinogenic compounds. Results show that gamblers and casino workers in casinos that permit smoking are subject to levels of particulate air pollution 10 times higher than those who visit smoke-free casinos.

The researchers also found that ventilation and air cleaning do not control indoor smoke levels. "The only effective control for secondhand smoke was reducing the number of smokers," said Lynn Hildemann, a professor of environmental engineering and science at Stanford and the principal investigator for the study.

"The fewer smokers, the less polluted the air. If you switch to a nonsmoking casino, your exposure to harmful fine particulate matter levels indoors will be reduced by 90 percent, and your exposure to carcinogenic PPAH levels will decrease by 80 percent."

Unfortunately, smoke-free casinos are rare. In the United States, 88 percent of commercial casinos and nearly 100 percent of tribal casinos allow smoking.

Those patrons who seek refuge in nonsmoking areas attached to the smoking casinos – such as restaurants, where children are found – find scant protection. Unless these areas are completely sealed off from the casino, with closed doors and a separate ventilation system, the researchers found that secondhand smoke seeps in, resulting in pollution levels seven times as high as outdoors.

In contrast, the three smoke-free casinos surveyed had pollution levels as low as the outdoors. In more than nine-of-ten smoking casinos in the survey, the indoor pollution levels exceeded the World Health Organization standard for fine particulate matter.

"Casino patrons are gambling not only with their money, but with their health, and the odds are stacked against them," said Hildemann. "Casinos have always been huge draws, but in recent years we've seen an increase of family activities tied to casinos. So in addition to seniors, the health risks are starting to reach new, more vulnerable populations, particularly children."

The pervasive secondhand smoke indoors poses an even graver health threat to casino workers. In the new study, using published data measuring the levels of cotinine, a biomarker of tobacco that shows up in human tissue, Hildemann and colleagues added to earlier results and found amounts of cotinine in casino dealers who are nonsmokers were higher than in 95 percent of the nonsmoking U.S. population. Nevada casino dealers have triple the asthma rates of the general state population.

"Cotinine levels in these nonsmoking workers – who were exposed only while at work – significantly increased between the beginning and the end of their work shift. Similar results have been found in casino patrons with shorter exposures. This is clearly due to secondhand smoke in the casino," said James Repace, a biophysicist and visiting assistant clinical professor at Tufts University School of Medicine.

For more information, see web link:
Stanford Report March 25, 2011

Back to Top

Other Cessation News

Advisory Panel Urges F.D.A. to Re-examine Menthol in Cigarettes

A federal advisory panel said that removing menthol cigarettes from the market would benefit public health in the United States, but stopped short of recommending that the Food and Drug Administration take any specific actions, like restricting or banning the additive.

The advisory panel’s chairman, Dr. Jonathan M. Samet, a professor of medicine at the University of Southern California, said the committee had found ample scientific basis supporting its finding that menthol cigarettes were more harmful than regular cigarettes, a decision that could provide a legal basis for the FDA to try to limit, phase out or even ban menthol in cigarettes.

The panel found that scientific evidence did not show that individual menthol smokers inhaled more toxins or had an increased risk of disease compared with nonmenthol smokers. But it did emphasize the public health impact, determining that the availability of menthol cigarettes made smoking more attractive to youth, more appealing to African-Americans and others because the flavor was less harsh, and that it contributed to higher rates of smoking among these groups. “Removal of menthol cigarettes from the marketplace would benefit public health in the United States,” the panel’s report concluded.

Menthol was first added to cigarettes since the 1920s to make them less harsh. While Congress banned candy, fruit and spice flavoring in tobacco products, it deferred tackling the difficult issue of menthol to the FDA when it gave the agency broad authority to regulate tobacco products under a new law passed in 2009.

The report issued by the panel, known officially as the Tobacco Products Scientific Advisory Committee, represents the first salvo in what is expected to be a lengthy test of the FDA’s regulatory muscle when it comes to further restrictions on nicotine and menthol. The FDA will review the findings of the panel, and perform a separate research and policy study, Dr. Lawrence R. Deyton, director of the FDA Center for Tobacco Products, said after the advisory group wrapped up a year of work. “Now it’s up to us to do our job,” Dr. Deyton said, adding that the agency would release a progress report in about three months.

Any government action would be preceded by a proposed rule and another round of public comments and no doubt, litigation. Two tobacco companies filed a lawsuit last month to try to block the advisory committee action or force the FDA to disregard its advice, saying three of the eight panel members had financial conflicts of interest from legal and consulting work against tobacco companies, a claim the FDA denied.

While some antismoking advocates hailed the panel’s findings as the first big step toward recognizing that menthol should be banned, others criticized the committee for not taking a stronger stand that would send a powerful signal to the FDA.

Industry analysts said they believed the FDA might take a moderate action at most. Stock in Lorillard Tobacco, the Greensboro, N.C., company that is more than 90 percent dependent on menthol revenue with its leading Newport brand, closed more than 10 percent higher on Friday after the advisory panel issued its report. Menthol accounts for an estimated 27 percent of the $80 billion cigarette market in the United States and 19 million smokers — a disproportionate number of whom are African-Americans, younger and have lower incomes. Menthol is preferred by more than 80 percent of black smokers, about 22 percent of non-Hispanic white smokers and nearly half of 12- to 17-year-old smokers, according to government surveys.

Gregory N. Connolly, a professor at the Harvard School of Public Health, who resigned from the scientific panel in December, said its failure to recommend a phase-out of menthol was “unfortunate” and would harm African-Americans. The new federal law asked the panel to make recommendations, he said.

“This is a huge victory for Lorillard,” Dr. Michael Siegel, a tobacco expert and professor at the Boston University School of Public Health, wrote. He said the committee’s failure to recommend policy “swept the issue under the rug by giving the FDA an out.”

Other health advocates greeted the panel’s findings in a more positive way. “This is the most conclusive scientific finding that menthol cigarettes dramatically increase youth tobacco use and make it more difficult for African-Americans to quit,” said Matthew L. Myers, president of the Campaign for Tobacco-Free Kids. “It creates a scientific record which compels FDA to act.”

Dorothy K. Hatsukami, a panel member and professor from the Tobacco Use Research Center at the University of Minnesota, said scientific literature showed smokers who started younger were more likely to have trouble quitting and to die from smoking. “This is the population that’s particularly vulnerable to the effects of menthol cigarette smoking,” Dr. Hatsukami said.

Jonathan Daniel Heck, Lorillard’s principal scientist and a nonvoting panel member, disputed the advocates’ views, arguing that there was no evidence that menthol promoted youth smoking or made it harder to quit. Lower quitting rates by black smokers may be caused by socioeconomic or genetic factors, not menthol, the Lorillard report said.

Industry analysts cited a variety of reasons they believed the FDA would not ban menthol. Nik Modi of UBS said governments could lose billions in tax revenue if menthol smokers switched to buying in underground markets. State and federal governments collect about $43 billion a year in cigarette excise taxes, UBS said.

According to Moody’s Investor Services, prohibiting menthol cigarettes would cut overall sales by up to 10 percent. David Adelman of Morgan Stanley Research predicted that the FDA would probably seek more research, including studies of the unintended effects of such a ban, like the creation of a big underground market. He, too, anticipates a "more moderate" finding by the agency than that of the scientific panel on the public health effects, pointing out the lack of evidence suggesting that menthol harms individual smokers more than nonmenthol cigarettes.

And Mr. Modi wrote earlier this month, “FDA does not want to see Big Tobacco in court.”

For more information, see web link:
The New York Times March 18, 2011

New Test for Emphysema on the Horizon

A simple and inexpensive blood test designed to uncover early signs of emphysema may one day find its place among the standard work-up that most Americans undergo during their yearly physical, new research suggests.

Although the novel screening method has shown considerable promise in preliminary investigations sponsored by the U.S. National Institutes of Health, the researchers caution that more studies are needed before the test could become available.

An easily administered test that could spot emphysema even before symptoms show up would be an enormous boon to the care of smokers, who are the most vulnerable to the onset of the disabling and potentially deadly disease.

"We know from other studies that smokers who learn from objective evidence that their health is in danger are much more likely to quit," Dr. Ronald G. Crystal, chairman and professor of genetic medicine and internal medicine at Weill Cornell Medical College and the study's lead author, said in a news release. "That is the only thing that will help them avoid this deadly disorder."

"We need a blood test that can be administered to the 20 percent of American adults who smoke as well as nonsmokers exposed to secondhand smoke -- all who may not understand their risk of developing this progressive lung disease," he added.

Crystal, who also serves as chief of the division of pulmonary and critical care medicine at New York-Presbyterian/Weill Cornell Medical Center in New York City, reported his team's findings in the March 14 online issue of the American Journal of Respiratory and Critical Care Medicine.

Emphysema and chronic bronchitis are the two main conditions of chronic obstructive pulmonary disease (COPD). In the United States, COPD is the fourth leading cause of death and has been projected to increase as the American population ages.

The new screening mechanism for emphysema was designed to measure the presence in the bloodstream of capillary debris, known as endothelial microparticles, or EMP, that results from injury to the lung's air sacs, called alveoli. The researchers noted that air sacs are central to respiratory function, and their COPD-driven deterioration ultimately shreds the lungs, producing the Swiss-cheese appearance that's telltale of the disease.

When tested on healthy nonsmokers, healthy smokers and smokers with signs of lung disease, the new test for EMP was found to be nearly foolproof in detecting early signs of emphysema, compared with the current emphysema screening method, known as DLCO, or lung diffusion testing, which measures how well the lungs exchange oxygen and carbon dioxide.

The new test, according to the researchers, also is better than the current one at uncovering the earliest signs of disease and can be done without the involvement of a pulmonologist.

In addition, they said, being able to easily diagnose emphysema at an early stage could be the leg up that health practitioners need to get their patients who smoke to finally kick the addiction.

Dr. Neil Schachter, a professor of pulmonary medicine at Mount Sinai Medical Center in New York City, agreed.

"Only about 15 percent of smokers will go on to develop emphysema," he noted. "So if you're a gambler and a smoker, which most are in a very general sense, it may not feel that urgent to stop smoking if you think you have a better-than-even chance of beating the game.

But if you know you're in that 15 percent, it certainly is a powerful argument that physicians can bring forth to help convince people to stop smoking." "But even so, smoking is a terrible, huge addiction," Schachter stressed. "It's difficult to convince people to quit, even when they know they have symptomatic disease. So it's not clear this will actually make a difference."

Edmund J. Miller, head of the Center for Heart and Lung Research at the Feinstein Institute for Medical Research in Manhasset, N.Y., echoed this reservation.

"Since the dangers of smoking have been emphasized in many ways, and many smokers do not quit even when the most severe symptoms have developed, it is perhaps unlikely that an individual will quit because of a blood test," Miller said. He added that biomarkers and early recognition of disease processes are valuable, however, and "the test may be useful in other settings where deterioration of lung function may be a late finding that perhaps could be prevented."

"This is a new finding in emphysema," Miller said, "but these particles [EMP] have been proposed as potential biomarkers for several other diseases, including sepsis and vasculitis."

Dr. Norman Edelman, chief medical officer of the American Lung Association (ALA), agreed that it's unknown whether the new test would prove to be a quit-smoking aid.

"I cannot predict whether this new test will be an important tool in helping doctors convince their patients to stop smoking," Edelman said. "The ALA recommends that doctors make strong efforts at smoking cessation for all of their smoking patients, as it is proven that doctors' intervention is an effective way to get people to make a serious attempt to quit." How much this test might add to either the quality of the doctors' efforts or the patients' response was uncertain, he noted.

But Schachter added that early detection can make all the difference in managing emphysema.

"If you catch the disease early, while there may be some microscopic damage, you are still way ahead of the game," he said.

"And if the person stops smoking and takes proper prevention measures, such as following a healthy lifestyle, you could probably slow down the disease and maintain it at a level as either asymptomatic as it is at the time of discovery or mildly symptomatic."

For more information, see web link:
Businessweek March 11, 2011

U.S. Presses Tobacco Firms to Admit to Falsehoods About Light Cigarettes and Nicotine Addiction

A federal judge unsealed a government proposal that outlines what it wants tobacco companies to say in national advertising and on cigarette packages — that they lied to the American public about so-called light cigarettes and the addictiveness of nicotine.

Judge Gladys Kessler of the United States District Court in Washington denied a request by the tobacco companies that the recommendations, by the Justice Department, be kept secret until they submitted a response.

The so-called corrective statements were ordered as part of a civil racketeering judgment in 2006 in which Judge Kessler ruled against the tobacco companies, saying they had lied for 50 years. The statements are to appear in newspaper and magazine advertising and in attachments to cigarette packages.

Judge Kessler is also deciding how the advertisements should be displayed at retail outlets. She is expected to set a schedule for the response from the companies and her decision.

The Justice Department’s proposed statements are blunt, and are being met with stiff resistance from the tobacco companies.

One would have the tobacco companies buy ads saying in part: “We falsely marketed low tar and light cigarettes as less harmful than regular cigarettes to keep people smoking and sustain our profits. We knew that many smokers switch to low tar and light cigarettes rather than quitting because they believe low tar and lights are less harmful. They are NOT.”

Another would say in part: “We told Congress under oath that we believed nicotine is not addictive. We told you that smoking is not an addiction and all it takes to quit is willpower. Here’s the truth: Smoking is very addictive. And it’s not easy to quit. We manipulated cigarettes to make them more addictive.”

Philip Morris USA, the largest United States tobacco company, said that the government’s proposals “go beyond factual and scientific information.” The company, which makes Marlboro cigarettes and is owned by the Altria Group, signaled it would appeal to higher courts if necessary.

“The Department of Justice proposal would compel the companies to admit wrongdoing under threat of contempt,” Murray Garnick, Altria associate general counsel, said in a statement. “Such a proposal is unprecedented in our legal system and would violate basic constitutional and statutory standards.”

The tobacco companies will be proposing their own versions for the judge to consider.

For more information, see web link:
The New York Times February 23, 2011

Back to Top

Announcements

Funding Opportunities