March 30, 2009


Research Highlights
Other Cessation News



Research Highlights

Other Cessation News




Majority of U.S. Unlikely to Meet 2010 Cessation Goal

Although the prevalence of smoking has declined over the last decade in 44 states and the District of Columbia, an estimated 19.8% of adults were still smoking in 2007. This is much higher than the Healthy People 2010 target for reducing adult smoking prevalence to 12% or less (objective 27-1a).

The new data, which catalog smoking habits from 1998 to 2007, are reported in the March 13, 2009 issue of Morbidity and Mortality Weekly Report. According to the MMWR editors "the present rate of decline likely will be too slow in nearly all states to reach the Healthy People target by 2010.”

Only Utah (11.7%) and the U.S. Virgin Islands (8.7%) had already met the goal. California (14.3%) and Connecticut (15.5%) were the only other states close to meeting the 2010 goal.

States with the highest smoking prevalence were Kentucky (28.3%), West Virginia (27%), and Oklahoma (25.8%). Six states saw no change in smoking prevalence during the time period: Alabama, Arizona, Tennessee, West Virginia, Mississippi, and Oklahoma.

The MMWR editors identified underfunding of tobacco-control programs as a potential reason for failure to reach the HP2010 target. From 2002 to 2005, states cut funding for smoking prevention and cessation programs by 28% -- about $200 million. "In fiscal year 2009, no state is funding comprehensive tobacco control programs at CDC-recommended funding levels," the CDC reports. "Only nine states are funding at least half of the recommended amount." In contrast marketing by tobacco companies nearly doubled from $6.9 billion in 1998 to $13.4 billion in 2005.

The CDC notes that this month is a good time to quit smoking. On April 1, 2009, the single largest federal tobacco excise tax increase in history will go into effect, raising the excise tax for cigarettes to $1.01 from the current rate of $0.39. This increase likely will prompt some smokers to make a quit attempt.

Health care professionals need to assist smokers with their quit attempts. The CDC urges providers to follow the recommendations in the 2008 update to the US Public Health Service's Clinical Practice Guideline on Treating Tobacco Use and Dependence. Healthcare providers “should ask all patients about their use of tobacco, advise tobacco users to quit, assess their willingness to quit, assist in their quit attempt by offering medication and providing referrals to telephone-based quitlines or other counseling services and arrange for follow-up.” NTCC members can also provide support by promoting the link between this new tax and cessation, and identifying opportunities and engaging in activities to build demand for and use of evidence-based tobacco cessation products and services, particularly in underserved populations.

For more information, see "State-specific prevalence and trends in adult cigarette smoking -- United States, 1998-2007" MMWR 2009; 58: 221-226.

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Amanda Graham, Ph.D., Associate Director for Research Development at the Schroeder Institute for Tobacco Research and Policy Studies

Amanda Graham, Ph.D., is the Associate Director for Research Development at the Schroeder Institute for Tobacco Research and Policy Studies. Dr. Graham also holds an appointment as Assistant Professor (Adjunct) in the Department of Oncology at Georgetown University Medical Center and is a member of the Lombardi Comprehensive Cancer Center.

Dr. Graham is currently Principal Investigator of an NCI-funded R01 that tests the effectiveness of a widely disseminated smoking cessation Internet program ( alone and in conjunction with proactive telephone counseling. This is the first large-scale randomized trial to address the efficacy of combined Internet and phone cessation interventions. Dr. Graham was also recently awarded an NCI-funded R21 to develop effective methods to recruit Latino smokers to web-based smoking cessation programs.

Prior to joining the faculty at Georgetown in 2006, Dr. Graham was Assistant Professor in the Department of Psychiatry at Brown Medical School. While at Brown, she directed the major treatment outcome study within Brown's NCI-funded Transdisciplinary Tobacco Use Research Center and served as Investigator on a RWJF-funded study of the economic impact of tobacco smoking and the cost-savings associated with tailored cessation treatment.

Dr. Graham received her Bachelors of Science from the University of Richmond, and her Masters and Doctorate in Clinical Psychology from The Chicago Medical School. She completed her postdoctoral training at Brown Medical School in the Centers for Behavioral and Preventive Medicine in 2000 and remained on faculty in the Department of Psychiatry at Brown until 2006.

Q1: One of the areas NTCC is focused on for 2008 is new media, which includes web-based forms of communication. Can you talk a little about the importance of online interventions for tobacco cessation?

For several years we've been talking about "reach" as the main advantage of online interventions. It is commonly accepted now that web-based cessation programs have the unique ability to reach smokers with evidence-based information, sustained support, and real-time advice in ways that other treatment modalities cannot. Underlying this argument about reach was the notion that even if web-based cessation programs did not yield efficacy rates as high as other treatment modalities, the overall impact (impact = reach x efficacy) on a population-wide basis would still be significant given the large number of smokers reached. We now have evidence from a number of trials that web-based programs can yield quit rates at 6 months that look quite comparable to other intervention modalities (e.g., telephone quitlines), suggesting that perhaps the web may do well on both reach and efficacy. From a research standpoint, the Internet also provides the unique ability to track and report the various denominators that are crucial to evaluate generalizability. For example, websites can track how many people click on a recruitment notice, complete the eligibility screening, provide informed consent, and go on to fully enroll in a study. We can associate costs with each of these steps to examine the cost efficiency of online advertising to recruit smokers to treatment in ways that are much more difficult and fraught with methodological concerns in other recruitment channels (e.g., newspaper, radio). This wealth of information allows us to accurately determine the total number of smokers who were reached with the study opportunity so we can draw accurate conclusions about external validity. In addition, there is also an opportunity to characterize individuals who may drop out at any step in the enrollment process. This information can be used to improve subsequent tailoring and targeting efforts to ultimately reach the largest proportion of smokers possible.

Q2: One of the 6 core strategies for building consumer demand is "Redesigning evidence-based products and services to better meet consumers' needs and wants." How were more traditional evidence-based cessation services redesigned into web-based formats?

Many of the early efforts at translating traditional (i.e., face to face) treatments resulted in web-based programs that were theory-driven and were based on solid empirical evidence from rigorous clinical trials, but proved largely unacceptable to consumers in formal usability and feasibility testing. The assumption underlying these many of these programs was that consumers wanted and/or needed to progress through the program in a very systematic and linear manner, beginning with the process of understanding the risks associated with quitting and importance of cessation, gradually becoming prepared to quit, setting a quit date, and recycling back through the same information to prevent relapse. In reality, smokers turn to the web for help at all stages of the quitting process, many of them having recently quit on their own looking for support in maintaining abstinence. In addition, the ways that consumers use the Internet for other purposes is rarely linear and structured, which may have contributed to poor usability ratings of these early programs.

Q3: What do the newer smoking cessation web-based applications look like?

As the field has become more sophisticated, programs have become more "user centered" allowing consumers to determine which elements of treatment they find most helpful. Web-based programs have been fully integrated with telephone counseling and medication as other proven treatment modalities, and cell phone interventions are on the horizon. Given the explosion of online social networks in recent years, programs that enable consumers to connect with one another to give and receive support throughout the quitting process are likely to demonstrate some of the most powerful effects on behavior change.

Q4: In what ways do web-based smoking cessation applications have the potential to better meet consumers' needs and wants and build demand for tobacco cessation products and services?

The web provides a unique opportunity to "go where the smokers are." We know from several studies that millions of smokers actively search for information online on quitting smoking each year. We know that motivation to quit is often a fleeting experience for many smokers. Capturing smokers at this precise moment when they are open and interested in quitting and directing them to evidence-based, proven programs and services is critical. Online advertising is growing at an exponential rate - especially among populations at disproportionate risk for smoking - and numerous studies show that consumers are receptive to online advertising. Unfortunately we know relatively little about how to harness the power of online advertising to reach consumers with messages that are engaging, appealing, and effective. This is one of the research areas that we are pursuing at the Schroeder Institute. We currently have an R21 grant funded from the National Cancer Institute which brings together a bi-lingual, cross-cultural, multi-disciplinary team with expertise in tobacco control, web-based interventions, Latino culture, marketing, advertising, and health communication to address some of these questions as they pertain to Latino smokers who use the Internet.

Q5: You are the Associate Director for Research Development at the Schroeder Institute for Tobacco Research and Policy Studies (SI) at the American Legacy Foundation. What is your role in this position?

My role at the Schroeder Institute is twofold. First, as Associate Director of the SI, I'm responsible for helping to establish the necessary infrastructure so that the Schroeder Institute can function as a grantee. Many of the policies and procedures that we often take for granted at large academic institutions because they have been in place for years are things that we're having to think through and create anew at this newly establish institution. We're fortunate at the SI to have incredible resources with the American Legacy Foundation at our disposal to help with this process, and it's been an enjoyable learning experience for me working with the various units within Legacy. My second role is as a Research Investigator, continuing my program of externally funded research. I have maintained an appointment at Georgetown University in the Cancer Control Program, and continue to collaborate with colleagues there. I'm also exploring new research opportunities that are related to existing projects and that also further the mission of the SI. It's an exciting time for sure, and a busy one!

Q6: How did you get involved in tobacco control?

My main interest coming out of graduate school was in making sure that results from research were used by policymakers, clinicians, and the general public to actually make a demonstrable public health impact. I didn't know this word back then, but it turns out that dissemination is really my passion. During my year of postdoctoral training with David Abrams at Brown, it became clear to me that tobacco control would provide a perfect "test case" for dissemination and implementation research because the evidence base about what works is so well established and yet the gap between research and practice is still enormous.

Q7: What has been the most challenging aspect of your work in tobacco control?

One challenging aspect of my work comes up in conversations with colleagues who look skeptically at the value of any kind of scientific inquiry related to the Internet. These typically tend to be researchers who are steeped in very tightly controlled clinical trials that maximize internal validity often at the expense of generalizability. It's important to note that this issue of internal and external validity is not a question or either/or. We absolutely need "proof of principle" in rigorously conducted efficacy trials conducted under ideal conditions. However, I firmly believe that we also need to determine the degree to which this efficacy may be weakened or diluted when we deliver the same intervention in the real world with subjects who may be less motivated and in settings where it may be adopted less rigorously or less intensively. The Internet provides a unique opportunity to conduct this kind of research, in addition to the opportunities I mentioned above about reaching smokers with proven treatments.

Q8: What has been the most rewarding aspect of your work in tobacco control?

The most rewarding part of my work most often comes through qualitative research efforts with current and former smokers. I find that these opportunities to connect with actual smokers struggling with nicotine addiction, or celebrating recent milestones of abstinence, really help to reinvigorate me and get me thinking creatively about how to reach and help consumers.

Q9: What, in your opinion, have been the most important developments in tobacco control in the past year?

To me one exciting development in the past few years has been the data that are finally emerging about the cost efficiency, return on investment, and actual lives saved from comprehensive tobacco cessation treatment and policies. These data provide the much-needed foundation that decision makers often need to implement policies or programs that may not be popular with certain constituencies but that are so obviously in the best interest of public health.

Q10: What, in your opinion, is the most important challenge facing tobacco control in the year ahead?

Tobacco control absolutely needs to be present in discussions around healthcare reform to ensure that comprehensive, evidence-based treatments and policies are implemented and supported broadly. Quit rates have slowed in the U.S. in the past 5 years, and we are very far off from reaching the 12 percent smoking prevalence goal set in Health People 2010. Making sure that tobacco control receives the strongest support possible in healthcare reform is an incredible opportunity to boost stalled quit rates and ensure that all smokers have access to the treatments they need to quit successfully and stay quit, and that youth grow up able to resist smoking.

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Research Highlights

Links between Genes and Smoking Confirmed

Early evidence that genes may influence a person’s use of tobacco came years ago from studies of twins. More recently, genome-wide association studies (GWAS) have explored links between genes and aspects of smoking behavior, such as the age of initiation and the amount of cigarettes smoked per day.

Building on this work, researchers have now tested associations between genes and seven key events across the spectrum of smoking behavior, from initiation through the development of dependency and health outcomes. DNA from 4,600 individuals, including 2,600 smokers, was analyzed using genome-wide and candidate gene approaches. For the candidate genes, several hundred previously identified genes suspected of playing a role were specifically evaluated.

The results confirm previous reports implicating nicotine receptor genes and genes involved in the dopamine system in the brain. In particular, a gene called MAOA, which helps break down dopamine, was strongly associated with the number of cigarettes smoked per day.

No specific chromosome regions achieved the genome-wide threshold of statistical significance, but the study provides a list of priority genes for further investigation. Reporting their findings online in PLoS One on February 27, Dr. Neil Caporaso of NCI’s Division of Cancer Epidemiology and Genetics and his colleagues said that the lack of genome-wide significant results suggests that common variants individually have at most a modest influence on smoking behavior.

“This was the first such study to look at a variety of smoking behaviors,” said Dr. Caporaso. “By identifying genes involved in smoking, we hope to develop more effective prevention and treatment strategies.” Two drugs used to help smokers quit, bupropion and varenicline, are likely to interact with targets related to genes that are associated with smoking behavior, he noted.

For more information, see web link:
NCI Cancer Bulletin March 10, 2009


Study: 1-in-5 Workers Exposed to Secondhand Smoke

One in five Wisconsin workers is employed at workplaces that allow smoking, according to a report from the Paul P. Carbone Comprehensive Cancer Center at the University of Wisconsin-Madison.

The new report found that more than 660,000 employees are exposed regularly to secondhand cigarette smoke, often at hazardous levels, at work.

The study also found that more than 80 percent of those workers are employed in manufacturing, retail and wholesale businesses and transportation. Only one in five employees exposed to secondhand smoke at work are employed in the tavern and restaurant business, the report said.

“These employees may be exposed to dangerous levels of tobacco smoke for up to eight hours per day,” Dr. Patrick Remington of the Carbone Cancer Center, said in a press release. “We know that this exposure can cause long-term and serious health effects.”

Among those exposed to secondhand smoke on the job, the report found disparities based on gender, race or ethnicity, education and geographic region. For example:

  • Men are 50 percent more likely to be exposed to smoke as women.
  • Black and Hispanic workers are more likely to be exposed to smoke than white workers.
  • High school graduates are twice as likely to be exposed to smoke as college graduates.
  • Employees in northern Wisconsin were more likely to be exposed to smoke compared with those in southern Wisconsin.

A copy of the complete report can be found at

For more information, see web link:
The Business Journal of Milwaukee March 9, 2009

'Chew' Doesn't Help Addicts Quit Smoking

Use of smokeless tobacco is up, especially among teens, but those who hope it will help them quit smoking find it less than effective, researchers here said.

Smokeless tobacco use has increased, particularly in males ages 12 to 17 -- from 3.4 percent in 2002 to 4.4 percent in 2007, according to a new report by the Substance Abuse and Mental Health Services Administration.

But nearly 90 percent of smokers who started using chew as a smoking cessation aid were still smoking on a daily basis six months later.

"What this study shows is that if anything, there is lots of dual use," said Scott Tomar, Dr.P.H., of the University of Florida, a tobacco researcher who was not involved in the study. "There is an incredibly small proportion that truly quit cigarette smoking and take up smokeless tobacco use instead."

Although scientific consensus says that exclusive use of smokeless tobacco carries less risk of death and disease than cigarette smoking, Dr. Tomar said, the patterns of dual use indicate that many smokeless tobacco users are not at reduced risk.

Chew is also just as addictive as cigarette smoking and many of the pharmacologic programs for quitting cigarettes don't seem to work for smokeless tobacco users, Dr. Tomar said.

That may be attributable to different methods of absorption and a very strong behavioral component, he said.

The current study, based on results from the National Survey on Drug Use and Health (NSDUH), found that 65.5 percent of smokeless tobacco users started smoking cigarettes first, compared with 31.8 percent who started with chew.

Although smokeless tobacco use among young people has increased, the rate among the rest of the population remained relatively stable from 2002 through 2007 -- from range 3.0 percent to 3.3 percent.

Certain demographic subgroups were more likely to use smokeless tobacco than others, including American Indians and Alaska Natives.

Usage rates were highest among those who lived in rural areas and lowest among those in metropolitan areas. And people in the West and Northeast were less likely to have used chew than those in the South and Midwest.

The researchers wrote that their findings suggest that it is "important for current and former cigarette users to understand that smokeless tobacco use is not a health alternative to cigarette smoking."

For more information, see web link:
MedPage Today March 5, 2009


Secondhand Smoke May Double Likelihood of Depression

Secondhand smoke not only can irritate your lungs, it also apparently can blacken your mood as well, a large study reports.

Non-smokers exposed to cigarette smoke at home or work are more than twice as likely as those not exposed to have major depression, according to a report at the American Psychosomatic Society meeting in Chicago.

It's believed to be the first U.S. study tying secondhand smoke to depression; another in Japan came up with a similar conclusion.

Unlike the Japanese research, this study confirmed exposure to smoke by measuring cotinine — a chemical that occurs in blood after breathing in smoke. There were cotinine levels for more than 3,000 non-smoking adults in a federal health study. An additional 92,000 non-smokers only reported if they lived with or worked around smokers. Everyone also filled out questionnaires on symptoms of depression.

Whether secondhand smoke was verified by the blood, those exposed to smoke were far more likely to have symptoms of serious depression, says study leader Frank Bandiera, a public health researcher at the University of Miami School of Medicine. Even working where smoking was allowed in public places more than doubled the risk of depression, he says.

There's strong evidence that smokers have higher rates of depression than non-smokers, but studies conflict on whether the smoking came first or vice versa, Bandiera says. Animal and human studies do show that smokers have more dopamine in their brains, which he says has been tied to anxiety and depression. So secondhand smoke might have the same effect on non-smokers.

For more information, see web link:
USA Today March 4, 2009


One Drug May Help People Both Lay Down The Drink And Put Out The Cigarette

A popular smoking cessation drug dramatically reduced the amount a heavy drinker will consume, a new Yale School of Medicine study has found. Heavy-drinking smokers in a laboratory setting were much less likely to drink after taking the drug varenicline compared to those taking a placebo, according to a study published online in the journal Biological Psychiatry.

The group taking varenicline, sold as a stop-smoking aid under the name Chantix, reported feeling fewer cravings for alcohol and less intoxicated when they did drink. They were also much more likely to remain abstinent after being offered drinks than those who received a placebo, the study found.

Additionally, there were no adverse effects associated with combining varenicline with alcohol in the doses studied. When combined with low doses of alcohol, varenicline did not change blood pressure or heart rate, nor did it seem to induce nausea or dizziness.

"We anticipate that the results of this preliminary study will trigger clinical trials of varenicline as a primary treatment for alcohol use disorders, and as a potential dual treatment for alcohol and tobacco use disorders," said Sherry McKee, associate professor of psychiatry at the Yale School of Medicine and lead author of the study.

Smokers are more likely to drink alcohol and to consume greater quantities of alcohol, and they are four times more likely to meet criteria for alcohol use disorders. Diseases related to tobacco use are the leading causes of death in alcoholics.

"A medication such as varenicline, which may target shared biological systems in alcohol and nicotine use, holds promise as a treatment for individuals with both disorders" according to McKee.

McKee said that 80 percent of participants receiving varenicline did not take a drink at all, compared to 30 percent of the placebo group. The findings suggest that varenicline has the potential to be at least as effective in reducing drinking as naltrexone, another drug found to reduce alcohol consumption in heavy drinkers.

For more information, see web link:
ScienceDaily March 4, 2009


New Study: Philip Morris' "Think. Don't Smoke" Campaign Actually Increased Teens Intentions to Smoke

A recent report published in the online edition of the International Journal of Environmental Research and Public Health (IJERPH) found that Philip Morris' "Think. Don't Smoke" campaign had virtually no effect on changing teens' attitudes about tobacco or smoking initiation. In fact, it actually increased teens' intentions to smoke soon. In stark contrast, the report found the truth® campaign increased antismoking beliefs among teens, decreased their intent to smoke, and lowered the rates of teens starting to smoke.

"This is the fourth report to be released in the last few weeks that validates the truth® campaign's efforts," said Dr. Cheryl G. Healton, President and CEO of the American Legacy Foundation®. "With about 3900 youth trying their first cigarettes every day, there remains a critical need for science-based, national youth smoking prevention and effective counter-marketing campaigns that educate the nation's youth about tobacco and safeguard them from lifetime smoking addictions that have the potential to cut their lives short. Leaving smoking prevention education to the tobacco companies would clearly not be in the best interests of America's youth."

In the IJERPH paper released this month, lead author Kevin C. Davis and his team considered the differences between the approaches of the truth® campaign and a Philip Morris campaign - "Think. Don't Smoke" (TDS) - studying the two campaigns' effects on antismoking beliefs, intent to smoke and smoking initiation among youth. They considered that "the truth® campaign is marketed as a popular youth brand that features risk-taking youth, who may appear to be open to smoking, delivering facts and messages about the tobacco industry specifically. For example, many of the truth® advertisements focus on the marketing practices of the tobacco industry and its efforts to obscure the health effects of smoking. In contrast, the TDS campaign featured role model youths declaring firm decisions not to smoke and explaining their reasons for not smoking. TDS aired between 1998 and 2002 – the second largest national campaign with television ads to air during the time of the study."

Davis and his team found that confirmed exposure to truth® campaign ads resulted in three key behavioral and attitudinal changes:

  • increased agreement with antismoking beliefs
  • a decrease in the intention to smoke
  • lower rates of starting to smoke

In contrast, recall of "Think. Don't Smoke" ads were associated with an increased intention to start smoking soon. However, recall of TDS ads were not significantly associated with tobacco beliefs or smoking initiation among youth overall.

For more information, see web link:
Legacy e-News March 3, 2009


State-Specific Smoking-Attributable Mortality and Years of Potential Life Lost --- United States, 2000—2004

A recent report released by the CDC presents state-specific average annual smoking-attributable mortality (SAM) and years of potential life lost (YPLL) estimates in the United States during 2000—2004 among adults aged >35 years. In 2008, CDC reported that cigarette smoking and exposure to secondhand smoke resulted in an estimated 443,000 deaths and 5.1 million YPLL annually in the United States during 2000--2004.

The analysis was based on data from CDC's Smoking-Attributable Mortality, Morbidity, and Economic Costs (SAMMEC) system. The report also compares 2000--2004 average annual SAM rates per 100,000 population with rates for 1996--1999. From 1996--1999 to 2000--2004, declines in SAM rates occurred in 49 states and the District of Columbia (DC), reflecting progress made in lowering smoking prevalence in the United States during the past 40 years. Rates declined in men in 49 states and DC, but declined in women in only 32 states. To reduce SAM rates further, comprehensive evidence-based approaches for preventing smoking initiation and increasing cessation need to be implemented fully, and states should fund tobacco control activities at the level recommended by CDC.

During 2000--2004, the state-specific median estimate of the average annual number of smoking-attributable deaths among adults aged >35 years was 5,534 (range: 492 [Alaska] to 36,687 [California]). SAM estimates for males ranged from 314 (Alaska) to 21,407 (California) and the SAM estimates for females ranged from 178 (Alaska) to 15,280 (California). For every state, the annual number of smoking-related deaths was higher among males than females.

The average annual YPLL estimates ranged from 7,762 (Alaska) to 481,529 (California). The YPLL estimates ranged from 4,586 (Alaska) to 288,823 (California) for males and from 3,176 (Alaska) to 192,706 (California) for females.

During 2000--2004, overall average annual SAM rates per 100,000 population were lowest in Utah (138.3), Hawaii (167.6), and Minnesota (215.1), and highest in Kentucky (370.6), West Virginia (344.3), and Nevada (343.7). Median SAM rates per 100,000 population overall were 288.1 for 1996--1999 and 263.3 for 2000--2004. Changes in smoking-attributable deaths per 100,000 population during these two periods varied among states; SAM rates among adults declined the most in Nevada (-44.4 deaths per 100,000 population), California (-37.8), and Virginia (-33.4). Average annual overall SAM rates decreased from 1996--1999 to 2000--2004 in all states except Oklahoma, which experienced an increase of 26.9 deaths per 100,000. Compared with 1996--1999, average annual SAM rates declined in 2000--2004 among men in all states except Oklahoma, but increased among women in several states (Alabama, Arizona, Arkansas, Georgia, Indiana, Kansas, Kentucky, Louisiana, Mississippi, Michigan, North Carolina, Ohio, Oklahoma, South Carolina, South Dakota, Tennessee, Texas) and DC.

For more information, see web link:
MMWR January 23, 2009 58(02);29-33


New Review of Youth Tobacco Cessation Research

With a growing evidence base in youth tobacco cessation, Dr. Susan J. Curry and colleagues published the Annual Review of Psychology's first comprehensive summary of research in tobacco cessation treatment for adolescents. They reported:

    ? Behavioral interventions increase the chances of youth smokers quitting. ? Motivational enhancement and cognitive behavioral approaches are efficacious with youth. ? There is insufficient evidence for the effects of pharmacological treatments with youth smokers. ? Many innovative studies of youth smoking cessation are compromised by challenges (e.g., recruiting sufficient numbers of youth).

This synthesis of published studies addresses youth tobacco cessation from several perspectives by:

    ? Describing youth tobacco users in terms of patterns and prevalence of use, neurological and psychosocial development, nicotine addiction. ? Summarizing the state of youth tobacco cessation treatments. ? Examining the inherent challenges in building the evidence base for youth treatments. ? Exploring future directions for research.

"Therapy for Specific Problems: Youth Tobacco Cessation" appears in the January 2009 issue of the Annual Review of Psychology. A copy of the full text article is available upon request

For more information about Helping Young Smokers Quit, visit

Helping Young Smokers Quit is a national program supported by the Robert Wood Johnson Foundation (RWJF), the Centers for Disease Control and Prevention (CDC), and the National Cancer Institute (NCI). Program direction and technical assistance are provided by the Institute for Health Research and Policy at the University of Illinois at Chicago.

For more information, see web link:
Annual Review of Psychology January 2009


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Other Cessation News

Quit-smoking Hotline Shuts as Free Products Run Out

More fallout from the down economy: Michigan shut down its tobacco-quit hotline recently due to an unprecedented flood of callers phoning in to claim free nicotine replacement products.

About 400 staff members fielded more than 65,000 calls during the five-day period after the line was launched, including 21,000 during the first 24 hours and 6,000 calls in one day from smokers interested in free nicotine patches, gum and lozenges. In past years, the quit line drew 100 to 200 calls on a heavy day.

The program was intended to run through April 30, but all the medications were snapped up in five days, state Community Health officials said. The quit line will be closed until September, said James McCurtis, spokesman for the Department of Community Health, when spots open up in smoking cessation programs that smokers have to take to get the free medications.

Karen Brown, tobacco use treatment specialist for Community Health, said 2,169 people enrolled for the free classes in five days, eclipsing the old record of 2,114 who signed up over a month's time last September.

Brown said the record response is partly due to smokers needing free help during the economic recession, and partly because they want to quit before the 61-cents-per-pack increase in the federal cigarette tax takes effect on April 1.

"It costs the state $3.3 billion to treat tobacco-related diseases every year, so it's definitely good for the state when people quit smoking," Brown said.

For more information, see web link:
The Detroit News March 16, 2009


FDA Hazy on e-cigarettes' Safety

At first glance, it looks like the real thing. It's white, with a brown filter. When the tip glows red, a smoke-like puff follows. But this is not a typical cigarette -- it's an "e-cig." A what? An electronic cigarette.

Makers of e-cigs tout their product as the first healthy cigarette, free of harmful chemicals and tar typically found in tobacco products. The only ingredient: pure liquid nicotine. "Our product is comparable to the nicotine patch except people still get the oral fixation, which they love," explained Elicko Taieb, CEO of Smoking Everywhere, one of the largest distributors of electronic cigarettes.

But the U.S. Food and Drug Administration considers e-cigs an unapproved new drug because of a lack of scientific proof that they're safe or effective. The FDA is trying to halt importation of e-cigs, but isn't seizing products already being sold in the United States.

"The FDA has been detaining and refusing importations since at least last summer of these so-called 'electronic cigarettes,' " FDA spokesperson Rita Chappelle told CNN in a written statement.

Smoking Everywhere is "pretty sure" the product is safe, based on laboratory testing in Europe, Taieb said. The company declined a CNN request to review safety reports.

"There are no ingredients in our e-cigs that can cause cancer. However, it is a pretty new product, so we are not 100 percent sure of the side effects at this point," Taieb said. "But we haven't heard of any negative side effects yet, but we are pretty sure they are safe."

Electronic cigarettes run on a battery. A person inhales an e-cig as he or she would a typical cigarette. When inhaled, the battery warms liquid nicotine stored in a plastic filter. The combination of heat and liquid creates the vapor or "smoke" puff when exhaled.

Health experts say the idea of an electronic cigarette is a great alternative to tobacco smoke but more evidence is needed.

"Nicotine is not the thing in tobacco smoke that causes cancer, but inhaling pure nicotine may be dangerous," said Dr. Steven Schroeder, physician and smoking cessation expert at the University of California-San Francisco Medical Center. "We have no clue what the health effects could be."

Nicotine replacement therapies -- the patch or gum -- are safe and highly successful to help quit smoking.

Tobacco smoke causes nearly 90 percent of lung cancer deaths, according to the American Cancer Society. "If it is a choice between smoking tobacco product or a nicotine replacement -- of course, keep taking the nicotine," Schroeder said. "It is a heck of a lot healthier than tobacco smoking."

Developers of e-cigs echo the thought. "We aren't claiming electronic cigarettes help you quit altogether, but I promise our product won't cause cancer. So no matter what way you look at it, it's the healthier option," Taieb said.

Smoking Everywhere sells thousands of electronic cigarettes a day in the United States, the company said. Most are sold online or in 100 mall kiosks across the states. The company, which gave samples of e-cigs to celebrities at this year's Grammy and Oscar awards, said it expects that "big-name" actors will soon promote the product. U.S. sales are expected to double in 2009.

Sales of e-cigs have been on the rise in the United Kingdom, Switzerland, Sweden and Brazil for several years. The trend prompted the World Health Organization to issue a statement in 2008 calling for more safety testing. "If the marketers of the electronic cigarette want to help smokers quit, then they need to conduct clinical studies and toxicity analyses," the statement said.

The idea that that e-cigs may be a good tobacco smoke alternative in the future could hold true, the FDA and WHO acknowledged, but proof of the product's safety must come first.

For more information, see web link: March 13, 2009


Teen Tobacco Program Expanded

A fourth phase of funding from the North Carolina Health and Wellness Trust Fund (HWTF) will allow FirstHealth Community Health Services to continue its efforts to reduce tobacco use among young people in Hoke, Montgomery, Moore and Richmond counties while expanding the effort into Scotland County.

The new $300,000 HWTF grant will also focus on eliminating the exposure of young people to secondhand smoke.

The No. 1 cause of preventable death in the United States, tobacco use takes the lives of more than 440,000 Americans each year. It is also the leading cause of preventable death and disability in North Carolina.

"The overall goals of this new funding will be to create a greater emphasis on prevention, and awareness of tobacco education, while also promoting the need to eliminate exposure to secondhand smoke," says Brooke Love, the health educator with FirstHealth Community Health Services who coordinates the grant-supported activities in the five counties. "In the last three years, we have been successful in training a large number of young people to spread the word about the harms of tobacco use in their schools and communities."

Despite the known health risks, thousands of young North Carolinians take up tobacco use each year. According to North Carolina's 2007 Youth Tobacco Survey, 27 percent of N.C. students report using some form of tobacco.

FirstHealth and its school and community partners will use educational and policy-oriented programs with proven tobacco-prevention messages to reach teens in the five targeted counties.

FirstHealth's tobacco-use-prevention initiative depends heavily on student volunteers called Teens Against Tobacco Use (TATU) and Tobacco. Reality.Unfiltered (TRU) advocates. These young people are trained to educate their peers and elementary school students about the harmful realities of tobacco use and how to stand up to peer pressure to use tobacco. They also advocate in their schools and communities for policies against smoking and other forms of tobacco use.

According to Love, the work has made a difference. Since HWTF began funding prevention efforts in 2003, the rate of decline in high school smoking has nearly tripled.

Based on the 2007 Youth Tobacco Survey, current cigarette smoking among high school students dropped from 20.3 percent in 2005 to 19 percent in 2007. Current cigarette smoking among middle school students decreased from 5.8 percent in 2005 to 4.5 percent in 2007.

Recent studies have also shown that high schools in districts that have four years report 32 percent fewer tobacco-users than schools without the policy. All of North Carolina's 115 school districts have been 100 percent tobacco free since Aug. 1, 2008.

"With the support of HWTF and the Tobacco-Free Sandhills network, FirstHealth will continue its commitment to reduce teen tobacco-use rates," Love says.

To join the Tobacco-Free Sandhills network or to obtain more information about teen tobacco-use programs, contact FirstHealth Community Health Services at (877) 342-2255.

For more information, see web link:
The Pilot March 12, 2009


Tobacco-Free Toolkit Helps Businesses Increase Their Bottom Lines

Businesses looking for ways to rescue their bottom lines and protect the health of their employees and their families can pick up some valuable tips from a new "toolkit" that shows them how to lower their costs by reducing the use of tobacco in the workplace through personal behavior change, health benefit design, and sensible workplace policies.

The kit, entitled "Investing in A Tobacco-Free Future: How it Benefits Your Bottom Line & Community," was produced by Partnership for Prevention and the Campaign for Tobacco-Free Kids, with funding from the United Health Foundation. It is being mailed to every FORTUNE 500 company in America, and it can be accessed online at

Smoking-related illness results in almost $100 billion in health care costs each year, while smokers on average are absent from work seven to 10 more days per year than non-smokers. As the toolkit points out, businesses also incur sizable tobacco-related costs not related to health. Commercial cigarette fires cause about $500 million in damages and kill 2,000 people each year, while cleaning costs associated with smoking in the workplace total about $4 billion per year.

"Businesses can benefit by understanding the serious impact of tobacco and, by implementing programs and policies to help create a healthier community, they can achieve serious gains for maximum return," said Corrine G. Husten, MD, MPH, Partnership for Prevention’s interim president.

The toolkit shows employers how they can support tobacco control "inside the walls" of their businesses by establishing a model workplace tobacco control program. The model program includes a set of policies, benefits and programs that will encourage employees not to use tobacco in the workplace and to quit using tobacco altogether.

It also lays out how businesses can support efforts beyond their own walls to reduce tobacco use and improve health in the larger community, where employees and their families live, work and play.

"While workplace initiatives can be very effective in improving health, these efforts will have an even bigger impact if employees and their families live in healthy communities," said Matthew Myers, President of the Campaign for Tobacco-Free Kids. "By getting involved in state and community efforts to reduce tobacco use, businesses can make an even bigger difference in the health of their employees and the cost of their health care."

"All Americans should be concerned by the persistent reports that more than 20 percent of the population continues to smoke tobacco," said Reed V. Tuckson, MD, United Health Foundation board member and executive vice president and chief of medical affairs, UnitedHealth Group. "Employers have a special opportunity and incentive to positively influence the behavior of their employees and to become strong advocates in public policy discussions in their communities to control tobacco abuse and its devastating health consequences."

For more information, see web link:
Campaign For Tobacco-Free Kids Press Release March 10, 2009


Higher Cigarette Tax Might Help Some Smokers Quit: AAFP Cessation Program Provides Resources

The 62-cent-per-pack federal tax increase on cigarettes recently signed into law by President Obama will push the nation's average cost of a pack of cigarettes to approximately $5 when it takes effect April 1. That, say FPs interviewed by AAFP News Now, may prompt some smokers to consider kicking the habit.

According to numbers provided by the Campaign for Tobacco-Free Kids, the increase means that smokers will pay between $2 and $3 in state and federal taxes for a pack of cigarettes in 14 states. They will pay $3 or more in taxes in 13 states and the District of Columbia. New York smokers will bear the highest tax burden, with a combined $3.76 in state and federal taxes for every pack. And those numbers don't include local cigarette taxes, such as the $1.50 per pack paid by New York City smokers.

Every 10 percent increase in the price of cigarettes reduces youth smoking by 7 percent and overall consumption by 4 percent, says the Campaign for Tobacco-Free Kids.

AAFP President Ted Epperly, M.D., of Boise, Idaho, said the combination of the increased taxes and the weak economy should cause many smokers to think about quitting.

"This is a wonderful opportunity for family physicians to engage their patients and tell them why they must stop," Epperly said. "Smoking is the most preventable health care problem in the world, and these taxes provide another reason to stop."

The tax increase coincides with the advent of a fourth year of funding for the AAFP's Ask and Act tobacco cessation program. The Smoking Cessation Leadership Center at the University of California, San Francisco, has provided more than $90,000 to support the program this year.

The Academy's Ask and Act program encourages family physicians to ask all patients about tobacco use and then act to help those who use tobacco quit. There's strong evidence that advice from a health care professional can more than double smoking cessation success rates.

Ask and Act recently updated its "Patient Stop Smoking Guide," which walks patients through the steps of quitting. Another new resource is a waiting room brochure that warns parents about the dangers of secondhand smoke. The program also is in the process of creating an online tobacco cessation training program for constituent chapter liaisons.

"There is a synergy with the Ask and Act tools for the patient and their families," Epperly said. "If we bring together individual counseling with the doctor, medication to stop and the support of the patient's loved ones, that combination can be very powerful."

"We know raising the price (of tobacco) is one of the best things you can do to reduce smoking," said Tom Houston, M.D., director of OhioHealth's Nicotine Dependence Program and clinical professor in the family medicine department at Ohio State University in Columbus.

Houston said doctors should personalize the antismoking message when counseling a patient. For example, he said a college-aged person might be alarmed by the possibility of smoking yellowing their teeth, but a 50-year-old construction worker might be more concerned about having an early heart attack, shortness of breath or impotence.

To tie in the tax increases, Houston suggested putting a sign in the reception room that says, "Cigarettes costing too much? Talk to us about how to stop smoking."

For more information, see web link:
AAFP News Now March 3, 2009


New Anti-Smoking Ads Tell Doctors Their Patients Are All Ears

The New York State Department of Health released a new round of ads urging healthcare providers to make quitting a priority with their patients who smoke. "Your Patients Are Listening" features images of patients with oversized ears to dramatize smokers' receptiveness to cessation assistance from their doctor.

State Health Commissioner Richard F. Daines, M.D., said, "We want to challenge clinicians across the state to take time at every office visit to talk to their patients who smoke." Data show that when healthcare providers talk to their patients about smoking and offer assistance with quitting, long-term success can be dramatically increased.

"Studies show that many clinicians think they will alienate smokers by addressing the issue, but we have found that smokers expect doctors to ask them about smoking and are actually more satisfied with their care when offered assistance to quit," added Commissioner Daines.

"Your Patients Are Listening" is the second phase of the award-winning "Don't Be Silent About Smoking" campaign launched last year by the State Health Department's Tobacco Control Program and its 19 Cessation Centers across the state. The campaign reached nearly 4 in 10 physicians in New York State.

"Among doctors, nurse practitioners, and physician assistants who saw the campaign, 80 percent said the ads grabbed their attention and 65 percent reported the ads made them think about doing more to help their patients stop using tobacco," said Jeff Willett, Director of the state Tobacco Control Program. "Clinicians who saw the campaign were significantly more likely to ask their patients about smoking, advise them to quit, and provide medication to assist them. We expect the new ads to have an even greater impact on providers' behavior."

The ads for the $1.2 million campaign will run in medical journals, major daily newspapers, and other publications in New York, as well as on medical websites. The campaign's website,, offers easy-to-access information and resources to help healthcare providers assist their patients who smoke.

Campaign materials will be distributed by the state's 19 Tobacco Cessation Centers, whose staff provides free assistance, training and consultation to clinicians and healthcare organizations to improve the delivery of tobacco cessation services.

In 2008, the "Don't Be Silent About Smoking" campaign won the E-Healthcare Solutions award for Best Public Service Campaign as well as an American Graphic Design Award.

For more information, see web link:
New York State Department of Health Press Release March 2, 2009


Experts in Government, Public Health, Public Policy and Science Outline Blueprint for Reducing Death and Disease from Tobacco In the United States

To further the goal of eliminating smoking as the number one cause of preventable disease and death in the U.S., twenty six of the nation’s leading tobacco control researchers and policy experts called for regulatory control of all tobacco products. They also called for policies that encourage current tobacco users to reduce their health risks by switching from the most to the least harmful nicotine-containing products.

This group of experts, who have devoted their careers to reducing tobacco use, met in a two-year process they called The Strategic Dialogue on Tobacco Harm Reduction (the Dialogue). Their vision: a world in which virtually no one uses cigarettes. Dialogue participants concluded that realizing that vision would have a profound impact on reducing death and disease from tobacco use.

The Dialogue process was led by Dorothy Hatsukami, Ph.D., director of the University of Minnesota’s Tobacco Use Research Center and Masonic Cancer Center’s Cancer Control and Prevention Programs, and Mitchell Zeller, a former associate commissioner of the U.S. Food and Drug Administration and currently a health policy expert with Pinney Associates.

The Dialogue members’ recommendations appear in the online version of the peer-reviewed journal Tobacco Control. Their report recommends various ways to regulate tobacco products based on public health needs. It also recommends helping tobacco users who are unable or unwilling to quit to shift to the least harmful nicotine products. Prominent among the group’s recommendations are:

  • Regulation of all aspects of promotion, advertising, and labeling of tobacco products
  • Prohibition of claims touting reductions in exposure to harmful components in tobacco or smoke unless there is sufficient scientific evidence that risk has been reduced as well
  • Regulation of harmful compounds in all tobacco products
  • Accurate education of the public regarding the relative risks of different nicotine-containing products
  • Higher taxes on cigarettes
  • Expanded anti-tobacco advertising
  • Strong programs to encourage and support tobacco cessation

In addition, the Dialogue embraced the concept known as the “continuum of risk”. This principle unified Dialogue participants with differing views on more controversial issues, such as the appropriate role of oral tobacco products. The Dialogue acknowledged that cigarettes are the most harmful tobacco product and that, under the continuum, medicinal nicotine products such as nicotine gum and patches are less harmful than oral tobacco products.

“Our report is a blueprint,” said Dialogue co-chair Dorothy Hatsukami. “It lays out the key elements of a science-based regulatory program and policies to shift current tobacco users away from cigarettes. With these policies and programs, we believe that the death toll from cigarette smoking and other tobacco use can be reduced dramatically.”

“Bold thinking is required to reverse the catastrophic projections for tobacco-caused deaths in this century,” said Dialogue co-chair Mitch Zeller. “Simply put, there is no ‘one size fits all’ method to quit or reduce smoking. The public health community has failed to provide appropriate guidance on all the evidence-based methods available so that smokers concerned about their health but who find themselves unable or unwilling to quit have options on how to quit smoking successfully.”

Dialogue members also identified several issues requiring further research before policy changes could be recommended. These issues involve questions, such as whether reducing the nicotine content of cigarettes to non-addicting levels would likely lead to a reduction in smoking prevalence, and what are the key issues surrounding long-term use of safer nicotine-containing products?

The Dialogue was jointly funded by the American Legacy Foundation, the Robert Wood Johnson Foundation and the University of Minnesota Tobacco Use Research Center. Dialogue members met four times between December 2005 and August 2007.

For more information, see web link:
American Legacy Foundation News Release February 25, 2009


Expert Panel Addresses High Rates of Smoking in People with Psychiatric Disorders

Numerous biological, psychological, and social factors are likely to play a role in the high rates of smoking in people with psychiatric disorders, according to the report of an expert panel convened by the National Institute of Mental Health. The report reviews current literature and identifies research needed to clarify these factors and their interactions, and to improve treatment aimed at reducing the rates of illness and mortality from smoking in this population.

An analysis of data from the National Comorbidity Study (NCS), a nationally representative survey of psychiatric disorders in the United States, found that 41 percent of people with a psychiatric disorder smoke, about twice the rate (22.5 percent) seen in those without psychiatric diagnoses. People with psychiatric disorders consume 44.3 percent of all cigarettes smoked in this country. The high rate of smoking is an important factor in increased rates of physical illness and mortality in this group.

Despite the high smoking rates, studies of outpatient and hospital care of psychiatric patients reported that less than a quarter of outpatients with psychiatric diagnoses received counseling from their physicians aimed at smoking cessation, and in hospitals, only 1 percent of psychiatric inpatient smokers were assessed for smoking; none of the treatment plans for these patients addressed tobacco use.

The panel report suggests that the reasons for these low rates of assessment and treatment may include health professionals' acceptance of smoking by psychiatric patients as a matter of individual rights and as a means of self-medication aimed at relieving symptoms. The report goes on to note, however, that research on smoking in this population needs to explore other potential explanations for tobacco use besides self-medication.

In its review of current findings on co-occurring mental health disorders and smoking, the panel identified some provocative areas for continued research including the following:

  • Alterations in the hypothalamic-pituitary-adrenal (HPA) axis, a system in the body involved in the response to stress, have been reported in post-traumatic stress disorder (PTSD). The HPA axis is also involved in the development of nicotine tolerance. The interplay of the HPA axis with stress and nicotine may help explain the increased smoking in those with PTSD and other anxiety disorders.
  • Research suggests that the relationship between depression and smoking may be bidirectional: depression increases the risk of smoking, and chronic smoking increases a person's susceptibility to depression. The same genes may contribute to both. Decreased activity of dopamine, for example—a neurotransmitter that is central to the brain's reward system—is thought to be associated with depression; studies cited by the panel suggest that variants of genes that affect the level of dopamine function can influence the likelihood that someone with depression will smoke.
  • As many as 70 to 85 percent of people with schizophrenia use tobacco. According to the panel, psychosocial factors are important in understanding the high rates of smoking people with schizophrenia. Limited education, poverty, unemployment, and peer influence increase smoking risk; the mental health treatment system, in which smoking is not only acceptable but sometimes condoned, is also a contributor.
  • Nicotine has effects on some cognitive processes in people with schizophrenia and research has found that variants in the genes for nicotine receptors have been linked to deficits in these processes. The relationships between genes, environment, and smoking in this population are not fully understood.

The panel concluded by identifying issues that will be important for future research across these disorders:

  • Better precision is needed in defining the specific psychiatric disorders of interest in a given study. "Depression," for example, is used in reference to a number of different conditions. Similarly, clearer definitions of smoking behavior and patterns and progression of use are needed.
  • Longitudinal studies can provide more complete information on the relative risk, incidence, and course of smoking and various mental disorders.
  • More focus is needed on exploring the potential causal links between tobacco use and psychiatric disorders, including possible genetic, neurobiological, psychological, or social factors. The extent to which smoking is used as a form of self-regulation needs to be explored.
  • More information is needed on how smoking and other health related factors such as stress, obesity, and limited physical activity contribute to the illness and mortality seen in people with mental disorders.
  • The report had a number of recommendations related to smoking cessation in this population. The report noted the need for adequate sample sizes in cessation trials; greater emphasis on adapting cessation treatment to various psychiatric populations and in different treatment settings; and research on how tobacco control polices affect psychiatric populations.

The report concludes by noting that research on smoking in this population can provide insights into the mechanisms that contribute to both tobacco dependence and psychiatric disorders.

For more information, see web link:
National Institute of Mental Health Press Release February 18, 2009


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