November 2010

Spotlight

U.S. Cigarette Warning Labels Designed to Grab Smokers’ Attention

Twenty-five years have passed since the last update to cigarette warning labels. In an attempt to re-establish a decline in U.S. smoking rates, the Food and Drug Administration (FDA) earlier this month unveiled larger and more visible graphic warning labels designed to raise greater awareness about the risks of smoking. Some of the 36 images include a depiction of an emaciated lung cancer patient, a breastfeeding mother blowing smoke in the baby’s face, a corpse in a morgue, and a smoker injecting a cigarette in the arm like a hypodermic needle. Further, the proposed labels, all beginning with the word "WARNING" in capital letters include:

• Cigarettes are addictive.
• Tobacco smoke can harm your children.
• Cigarettes cause fatal lung disease.
• Cigarettes cause cancer.
• Cigarettes cause strokes and heart disease.
• Smoking during pregnancy can harm your baby.
• Smoking can kill you.
• Tobacco smoke causes fatal lung disease in nonsmokers.
• Quitting smoking now greatly reduces serious risks to your health.

The FDA will take public comment about the new labels through January 9, 2011, and will choose the final nine by June. Beginning October 22, 2011, manufacturers will then be required to use the graphic warning labels on all cigarettes sold in the U.S.

Reactions to the proposed new cigarette warning labels are mixed. While some argue that the use of fear will not work and may even backfire, others applaud the use of stronger images. A number of other countries, including Canada, Malaysia, Australia, and Brazil, already have graphic warning labels on cigarettes. In fact, some studies suggest that the use of stronger, more upsetting images may lead to greater quitting success. In a 2004 Canadian survey of smokers, researchers found that smokers who experienced emotional arousal and stronger reactions, as a result of negative images, were more likely to quit, try to quit, or reduce tobacco use in the following three months.

Public health experts hope that the FDA’s proposed new labels will restore momentum in the U.S. fight against tobacco, particularly after several years of a plateau in smoking rates. Researchers in the U.S. have found growing evidence that demonstrates the positive relationship between targeting smokers’ emotions and getting smokers to quit. In an online Tobacco Control study, data from 7,060 adult smokers revealed that ads using the ‘why to quit’ strategy along with graphic images or personal testimonials that evoke specific emotional responses were more effective than other ad categories, such as ‘how to quit’ and ‘anti-tobacco industry’ ads. Further, another study conducted by marketing researchers at the University of Arkansas, Villanova University, and Marquette University discovered that pictorial warnings had a ‘significantly positive’ effect on smokers’ intentions to quit. In other words, the evidence supports that strong, negative graphic imagery—and fear evoked from such imagery—positively influences smokers’ likelihood of quitting.

For more information, see Proposed Cigarette Product Warning Labels.

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Research Highlights

Risks: Smokers Found More Prone to Dementia

Middle-aged smokers are far more likely than nonsmokers to develop dementia later in life, and heavy smokers — those who go through more than two packs a day — are at more than double the risk, a new study reports.

Researchers analyzed the data of 23,123 health plan members who participated in a voluntary exam and health behavior survey from 1978 to 1985, when they were 50 to 60 years old.

Twenty-three years later, about one-quarter of the group, or 5,367, had dementia, including 1,136 with Alzheimer’s disease and 416 with vascular dementia.

After adjusting for other factors, the researchers concluded that pack-a-day smokers were 37 percent more likely than nonsmokers to develop dementia, and the risks went up sharply with increased smoking; 44 percent for one to two packs a day; and twice the risk for more than two packs.

Former smokers and those who smoked less than half a pack a day were no more likely to develop dementia than nonsmokers. The study was published online in Archives of Internal Medicine.

To its lead author, Dr. Rachel A. Whitmer, an epidemiologist with the Kaiser Permanente Division of Research in Oakland, Calif., the study offered a silver lining: unlike age and family history, she said, “this is one risk factor for dementia that can be changed.”

For more information, see web link:
The New York Times October 29, 2010

Specialized Interventions Help Latinos Quit Smoking

Latinos who live the United States are more likely to quit smoking when they take part in an intervention program, finds a systematic review of studies conducted by Monica Webb Hooper, Ph.D., and colleagues at the University of Miami.

According to U.S. Census data, Latinos are the largest, fastest growing minority population in the country. Webb said that Latinos tend to smoke at rates lower than whites and African-Americans; however, the longer Latinos remain in this country, the greater the likelihood of picking up the habit. Rates of smoking among many Latino immigrant communities here are higher than in their home countries.

Webb Hooper’s study appears online and in the November/December 2010 issue of the American Journal of Health Promotion.

In her review of scientific literature, Webb Hooper looked for randomized controlled trials of smoking cessation interventions specifically targeting Latinos or Hispanics living in the United States. She analyzed five studies, each looking at between 93 and 313 participants.

One study looked at an intervention using nicotine replacement therapy. The other four studies focused on providing “culturally specific” interventions, such as self-help materials or telephone, individual or group counseling delivered in the participants’ native language.

“We found evidence that the odds of quitting were significantly greater for those who received the intervention than for those in the control groups,” Webb said.

However, because there were so few studies (one of each type), it was not clear which type of intervention was most effective, especially in the long term. “There was a trend suggesting that nicotine replacement might be differentially beneficial because that study had larger effects than the others,” she said. This finding appears to contradict previous research, which she said had suggested that “Hispanics may be less likely to accept medication or anything that is perceived as medication.”

The paucity of studies that qualified for the review concerns Webb. “There is promise for providing a variety of tobacco cessation programs among Hispanics, but we definitely have significant amounts of work to be done to properly address the needs of this community.”

Paula Cupertino, Ph.D., an assistant professor of preventive medicine at the University of Kansas Medical Center, agreed that there is a pressing need to develop effective smoking cessation interventions for Latino smokers. Language, cultural and financial issues can be barriers to accessing the health care system. Even if Latino smokers want to quit, they might not be aware of resources available to help them do that.

According to Cupertino, smoking-related diseases are already the number one cause of death in Latino-Americans (which is the case for whites and African-Americans as well). Cancer rates are currently lower among Latinos, but that will probably change in coming years, Cupertino said.

“Today Latinos coming into this country tend to be younger than the rest of the population,” Cupertino said. “However, as this population grows older, we project we’ll see a greater incidence of cancer.” She said that predictions indicate cancer rates among Latinos will rise 147 percent by 2030 and that smoking cessation programs could play an important role in turning this trend around.

For more information, see web link:
NEWS-Line November 3, 2010

Survival Benefit of Smoking Cessation High After MI

Smoking cessation after myocardial infarction (MI) resulting in left ventricular (LV) dysfunction lowers all-cause mortality risk more than many pharmacologic interventions, according to a study in the American Journal of Cardiology.

Amil M. Shah, M.D., of Brigham and Women's Hospital in Boston, and colleagues conducted a randomized trial of 2,231 subjects with LV dysfunction three to 16 days after MI. Smoking status was assessed at trial entry and at regular intervals over a median 42-month follow-up. The purpose of the study was to assess the benefit of smoking cessation versus continued smoking in this population at high risk for death and recurrent MI.

The researchers found that, in subjects who smoked at baseline and survived to six months without interval cardiac events, smoking cessation at six-month follow-up was associated with a significantly lower all-cause mortality risk (hazard ratio [HR], 0.57). Smoking cessation was also associated with lower risk of other measured end points: death or recurrent MI (HR, 0.68) and death or heart failure hospitalization (HR, 0.65).

"The approximately 40 percent lower risk of all-cause mortality associated with smoking cessation compares favorably to other established therapies for patients with LV dysfunction after MI, including angiotensin-converting enzyme inhibitors (19 percent relative risk decrease), β-blockers (23 percent relative risk decrease), and aldosterone antagonists (15 percent relative risk decrease)," the authors write.

For more information, see web link:
HealthDay News November 3, 2010

Electronic Cigarettes are Increasing in Popularity but May Carry Risks

Electronic cigarettes are becoming increasingly popular among people who want to quit smoking, but an opinion piece released in the journal Annals of Internal Medicine highlights the potential hazards of e-cigarettes, suggesting they may not be as benign as they may seem.

E-cigarettes are battery-powered devices that allow users to inhale a vapor that contains nicotine and supposedly fewer toxins than real cigarettes. In studies, health-related findings have been mixed, with some reporting less nicotine is absorbed and the desire to smoke is curtailed, while others showing smoking cravings weren't affected that much.

According to the paper, the Food and Drug Administration did a lab analysis of e-cigarettes in 2009 and found small amounts of a dangerous solvent in some, as well as nicotine in an e-cigarette billed as nicotine-free.

In the paper, the authors wrote that the devices pose several health concerns: "First, e-cigarettes may pose a risk as starter products for nonusers of tobacco. Although candy-flavored tobacco products and e-cigarettes were recently banned by the FDA in efforts to hinder marketing toward children, the posturing of e-cigarettes as 'green' and 'healthy' could deceptively lure adolescents. E-cigarettes also may represent a way for adolescents and adults to skirt smoke-free indoor air laws."

More study findings show the risk to children should they get their hands on the things--the concentrated nicotine found in refill bottles could be toxic and even fatal to children.

"Health professionals," the authors write, "need to monitor the biological, social, and addictive effects of e-cigarettes and be aware of their rapid dissemination online."

For more information, see web link:
Los Angeles Times November 2, 2010

The Downside of a Cancer Study Extolling CT Scans

Are lung cancer scans really ready for prime time?

News that annual CT lung scans can reduce the risk of lung cancer death among former and current heavy smokers was celebrated by national heath officials this month. A major government study found the screening scans saved the life of one person for every 300 current or former smokers who were scanned.

But now cancer and screening experts are worried that the limited findings will be used by private screening centers to promote the test to a broader group than was studied. That, in turn, could lead to thousands of unnecessary lung scans, causing excess radiation exposure and unnecessary biopsies and surgery.

Dr. Otis W. Brawley, chief medical officer of the American Cancer Society, said he was stunned to hear a radio advertisement for an Atlanta screening center cite the study just a few days after the government had announced the results. The wording of the ad seemed to be aimed at a broad group, ranging from heavy smokers to women who had never smoked, Dr. Brawley said.

“We really need to weigh the harms associated with screening,” he said. “The scientific community still needs to digest this. To take a trial that involves people at high risk for lung cancer and to extrapolate it and say it’s good for people with intermediate or low risk is not appropriate.”

The study, called the National Lung Screening Trial, focused on a specific high-risk group: 53,000 current and former heavy smokers, aged 55 to 74, who had smoked for at least 30 pack-years. That means someone who smoked one pack a day for 30 years, two packs a day for 15 years or three packs a day for at least 10 years would qualify for the study.

Former smokers who had accumulated 30 pack-years were included only if they had stopped smoking within the previous 15 years.

The smokers and former smokers were given either annual CT lung scans or chest X-rays. Compared with conventional X-rays, the CT, or computed tomography, scans create a detailed three-dimensional image of the lungs. The study was stopped when it was found that the scanning group had a 20 percent lower risk of dying from lung cancer than those being screened with X-rays.

But the early results also showed a downside of scanning: one of every four lung scans showed an abnormality, which often led to additional worry, radiation exposure from follow-up scans and, sometimes, lung biopsies and even risky surgery. But because the study was stopped early, a full analysis of the harms caused by screening scans is still months away.

Reading the scans is tricky because harmless nodules can be misinterpreted as suspect lesions. In the study, even experienced radiologists at major cancer centers had a high rate of false positives, suggesting that the rate would be even higher in the real world.

“There is a learning curve to reading spiral CTs,” Dr. Brawley said. “I’m concerned that some radiologists might be early in that learning curve and some patients may be harmed because of it.”

While the study found a benefit to scanning a specific group of high-risk smokers, that doesn’t mean other groups will get the same benefit, says Dr. Peter B. Bach, a pulmonologist at Memorial Sloan-Kettering Cancer Center in New York. In lower-risk groups, for instance, it’s likely that thousands of people would need to be exposed to the risks of screening before a single life was saved. And it’s possible that many of those scanned unnecessarily could be seriously harmed.

“The aggregate harms to all the people’s lives who are not saved have to be taken into account,” Dr. Bach said. “Even in these highly controlled settings, about 1 percent of the people had surgery or a part of their lung removed for something they thought was cancer and it wasn’t.”

Low-dose CT scans expose patients to about the same radiation levels as mammograms.

For now, most consumers who want a scan will have to pay for it themselves, although it is expected that insurance companies eventually will approve scanning for those in high-risk groups. (Medicare officials have indicated that they will soon reconsider paying for the screening tests.) The government has estimated the cost at about $300 a scan, but some centers may charge $1,000 or more.

The day the government announced the study results, Westside Medical Imaging of Beverly Hills, Calif., issued a press release saying that the study “should once and for all settle the controversy” about whether CT lung scans save lives.

In the release, Dr. Norman E. Lepor said the scans were an “indispensable” part of annual exams for patients who have smoked for 10 years.

In an interview, Dr. Lepor said that he only offers lung scans to those at high risk, and that he turns people away who are at low risk but want the scan anyway because “they just want to know.”

Dr. Lepor said it would be “imprudent” not to incorporate the latest study data into his practice right away.

“There are people who, with good conscience and their take of the data, say it’s not ready for prime time, and there are people who look at the same data and they come to other conclusions,”

Dr. Lepor said. “This is not the first study that has supported screening. We know from our own anecdotes that we have saved a lot of lives.” Dr. Lepor said that he had just met a woman who had smoked for 50 years and was concerned about her risk. “She’s the poster person for this test,” he said.

Dr. Brawley said he’s worried that the few early press releases and radio advertisements are just the beginning of widespread promotion of screening lung scans.

“It was sort of ominous to be working Sunday evening in my home office and this thing comes on the radio,” he said. “A lot of people run out when there is a new announcement and get the new test. We’re very frightened some people are going to be harmed because of this.”

For more information, see web link:
The New York Times November 15, 2010

Smokeless Tobacco Use Widespread in Some States

Many smokers in the United States and its territories also use smokeless tobacco products such as snuff and chew tobacco, a combination that makes quitting much more difficult, a new federal study shows.

Researchers analyzed data from the 2009 Behavioral Risk Factor Surveillance System and found that the rate of smokers who also use smokeless tobacco ranged from 0.9 percent in Puerto Rico to 13.7 percent in Wyoming.

"The war against tobacco has taken on a new dimension as parts of the country report high rates of cigarette smoking and smokeless tobacco use among adults. The latest data from the Centers for Disease Control and Prevention reveal disturbing trends in smoking prevalence as more individuals use multiple tobacco products to satisfy their nicotine addiction," American Heart Association CEO Nancy Brown said. "No tobacco product is safe to consume. The health hazards associated with tobacco use are well-documented and a recent American Heart Association policy statement indicates smokeless tobacco products increase the risk of fatal heart attack, fatal stroke and certain cancers."

Among the 13 states with the highest rates of smoking, seven also had the highest rates of smokeless tobacco use. In these states -- Alabama, Alaska, Arkansas, Kentucky, Mississippi, Oklahoma and West Virginia -- at least one of every nine men who smoked cigarettes also reported using smokeless tobacco. The rates in those states ranged from 11.8 percent in Kentucky to 20.8 percent in Arkansas.

The state with the highest rate of smokeless tobacco use among adult male smokers was Wyoming (23.4 percent). Smokeless tobacco use was highest among men, young adults aged 18 to 24 and people with a high school education or less, according to the study.

Smokeless tobacco use was highest in Wyoming (9.1 percent) and West Virginia (8.5 percent) and lowest in the U.S. Virgin Islands (0.8 percent) and California (1.3 percent).

Smoking rates were highest in Kentucky (25.6 percent), West Virginia (25.6 percent) and Oklahoma (25.5 percent), and lowest in Utah (9.8 percent), California (12.9 percent), and Washington (14.9 percent).

The findings are published in the Nov. 5 issue of Morbidity and Mortality Weekly Report, a publication of the U.S. Centers for Disease Control and Prevention.

"Tobacco use is the leading preventable cause of death in this country and unfortunately smokers are also using smokeless tobacco," CDC Director Dr. Tom Frieden said in an agency news release.

"If you smoke, quitting is the single most important thing you can do to improve your health. Use of smokeless tobacco may keep some people from quitting tobacco altogether. We need to intensify our anti-tobacco efforts to help people quit using all forms of tobacco," he added.

"These new numbers are concerning. But progress is possible," Dr. Tim McAfee, director of the CDC's Office on Smoking and Health, said in the news release. "We need to fully put into practice effective strategies such as strong state laws that protect nonsmokers from secondhand smoke, higher tobacco prices, aggressive ad campaigns that show the human impact of tobacco use, and well-funded tobacco control programs, while stepping up our work to help people quit using all forms of tobacco."

For more information, see web link:
HealthDay News November 4, 2010

Study: Heavy Smoking in Midlife Hikes the Risk of Alzheimer's

As if anyone needed another reason for quitting: a new study found that heavy cigarette use in middle age more than doubles the risk of developing Alzheimer's disease or dementia down the road.

The new study looked at data on more than 21,000 Kaiser Permanente Northern California members, ages 50 to 60, surveyed between 1978 and 1985. The researchers then tracked how many of those same people were diagnosed with dementia, including Alzheimer's disease and vascular dementia, between 1994 and 2008 — when the subjects had reached an average age of 71.6 years.

A little more than 25% of the participants were diagnosed with some type of dementia in the follow-up. Heavy smokers — those who smoked more than two packs a day — were 157% more likely to develop Alzheimer's disease than nonsmokers. And they were 172% more likely to be diagnosed with vascular dementia, the second most common form of dementia, than people who did not smoke.

Lighter smoking appeared to have later cognitive risks too: compared with nonsmokers, those who smoked a half-pack to one pack a day had a 37% higher risk of dementia, and those who smoked between one and two packs a day had a 44% greater risk. For the lightest smokers (less than a half-pack a day), however, there was no difference in risk compared with people who didn't smoke.

"It is possible that smoking affects the development of dementia via vascular and neurodegenerative pathways," the study says. Similar to its role as a risk factor in stroke, smoking may affect dementia by damaging blood vessels and brain cells or increasing inflammation.

The study's authors note that the link between smoking and dementia was constant across sex and race. The study was published online by the Archives of Internal Medicine.

For more information, see web link:
TIME October 26, 2010

Anxiety Keeps Some Smokers from Quitting

Nervous people smoke more than other people. More breaking news: they also find it harder to quit. Those may not be the kinds of insights that get the attention of the Nobel committee, but a new study in the journal Addiction shows how even so straightforward an idea may yield lifesaving benefits.

The chemistry of nicotine packs a powerful addictive wallop; if it didn't, tobacco wouldn't be such a hard substance to quit. Still, plenty of people do quit; what's always puzzled epidemiologists is why a hardcore group can't. In the U.S., which leads the world in driving smoking rates down, 20% of the population still lights up. That may be less than half of what it was back in the ashtray-in-every-room Mad Men era, but it also means that more than 50 million Americans continue to smoke, even if they have to huddle outside office buildings or in parking lots to do it. Psychologist Megan Piper of the University of Wisconsin-Madison Center for Tobacco Research and Intervention (UW-CTRI) wanted to determine what keeps these dead-enders hooked.

Piper and her colleagues studied a sample group of people who had enrolled in a free UW-CTRI smoking cessation program. Of the 1,504 subjects, about one-third met the criteria for an anxiety diagnosis currently or in the past — nearly twice the incidence of anxiety in the population as a whole. Panic attacks were the most common form of anxiety, affecting 455 of the participants, followed by social anxiety (199 people) and generalized anxiety disorder (99). Some of the subjects had more than one condition.

Piper believes that underlying anxiety conditions may explain why nicotine lozenges and patches, which can be extremely effective in helping many smokers quit, seem to have far less effect on others. If it's anxiety that drove those people to smoke in the first place, nicotine supplements will satisfy only one part of their addiction — the chemical part. They'll do nothing for the emotional component.

So temperamentally dependent are anxious smokers that many, according to Piper, start to suffer withdrawal symptoms even before they actually quit — as if the dread of facing the world without a smoke is enough to trigger the cold-turkey experience. Bupropion (an antidepressant marketed as Zyban) also does not seem to do much to help anxious smokers quit, though it is not entirely clear why.

None of this means that anxious smokers who want to stop are without recourse. Piper believes that all doctors treating smokers should assess them for anxiety too. If a condition is diagnosed, proper therapy can be doubly beneficial — helping patients ease their angst and kick the butts.

For more information, see web link:
TIME October 26, 2010

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Other Cessation News

CDC: States Drag on Medicaid Coverage for Quitting Tobacco

Smoking-related health costs account for 11 percent of all Medicaid costs, but states offer only patchy support for tobacco cessation therapies, reported MedPage Today.

Research conducted by the University of California at Berkeley for the Centers for Disease Control and Prevention (CDC) in all 50 states and the District of Columbia showed that 47, or 92 percent, had at least some coverage for tobacco cessation for those enrolled in Medicaid.

Only five states – Indiana, Massachusetts, Minnesota, Montana, and Pennsylvania -- covered counseling and all medications for all enrollees without restriction. All remaining states and the District of Columbia limited types of coverage for quitting tobacco or restricted coverage to certain populations. Connecticut, Georgia, Missouri, and Tennessee offered no coverage at all.

The authors of the report said that state coverage had improved since 2007, but noted that by excluding participants, most were missing out on big cost savings. Smoking rates are nearly twice as high among Medicaid enrollees as in the general population (37 percent vs. 21 percent), and tobacco cessation treatments have been shown to improve public health and reduce costs.

"In Massachusetts, for example," the authors wrote, "a mandate for Medicaid coverage of tobacco-dependence cessation treatments was associated with a 26 percent decline in smoking rates among Medicaid enrollees."

Medicaid programs from state to state paid for different combinations of cessation medications and individual or group counseling. Researchers found various eligibility factors, from pregnancy to whether plan participants were enrolled in a fee-for-service program or in a managed care program.

The variation was considerable. Oregon, for example, covered all medications and group and individual counseling, so long as participants were in its fee-for-service plan. Alabama, however, covered nothing except for individual counseling for pregnant women.

Researchers stated that changes are coming. Under the Affordable Care Act, all pregnant women enrolled in Medicaid must have access to tobacco-dependence treatment as of Oct. 1. Also, states that offer federally recommended tobacco cessation treatments without requiring a co-pay will qualify for higher reimbursements from Medicaid after Jan. 1, 2013. Finally, states will no longer be able to exclude tobacco-cessation drugs from Medicaid benefits after January 2014.

Authors of the study noted that it had methodological limitations. Contracts from managed care organizations and written documentation of state Medicaid policies were not obtained in all cases, allowing some room for error. Also, it is possible the number of tobacco cessation programs may have been underreported because some managed care organizations offered them even when their state Medicaid contract did not require it.

The study, "State Medicaid Coverage for Tobacco-Dependence Treatments --- United States, 2009," appeared online in the Oct. 22, 2010 issue of Morbidity and Mortality Weekly.

For more information, see web link:
JoinTogether.org November 1, 2010

CDC Report Provides Fresh Evidence That State Tobacco Control Measures Work, Raises Concerns About Smokeless Tobacco Marketing

A new report released by the U.S. Centers for Disease Control and Prevention shows that rates of adult cigarette smoking and smokeless tobacco use vary widely from state to state depending on how effectively states have implemented proven strategies to reduce tobacco use. The report finds that many smokers also use smokeless tobacco, raising concerns about recent tobacco marketing that presents smokeless tobacco as a substitute for cigarettes where smoking is not allowed.

These results have important implications for the fight against tobacco use, the nation's number one cause of preventable death.

First, the report provides dramatic new evidence of the effectiveness of scientifically proven strategies to reduce tobacco use, including higher tobacco taxes, strong smoke-free workplace laws and well-funded tobacco prevention and cessation programs. The report demonstrates that states with the lowest smoking rates have implemented these measures, while those with the highest rates have not:

• The 11 states with the lowest smoking rates (there is a tie for tenth) had an average cigarette tax of $2.19 per pack at the end of 2009, while the 10 states with the highest smoking rates had an average cigarette tax of just 62 cents.
• All 11 states with the lowest smoking rates have strong smoke-free laws that include restaurants and bars; NONE of the 10 states with the highest rates has such a law.
• The states with the lowest smoking rates include several – California, Massachusetts and Washington – that have conducted sustained, effective tobacco prevention and cessation programs. Unfortunately, states have cut total funding for these programs by 28 percent, or $200 million, in the past three years, and most fall woefully short of meeting the CDC's recommended funding levels.

Second, the report raises a warning flag that recent tobacco company marketing campaigns for smokeless tobacco products may be undermining efforts to reduce smoking. The report finds that in 32 states, more than 10 percent of male smokers also currently use smokeless tobacco.

This finding comes as the tobacco industry is marketing new smokeless tobacco products as a substitute for cigarettes in the growing number of places where smoking is not permitted. Marketing for R.J. Reynolds' Camel Snus smokeless product have used the slogan "Pleasure for wherever," specifically encouraging use of the product in offices, bars, airplanes and concerts. Similarly, advertising for Philip Morris' Marlboro Snus state, "So next time smoking isn't an option, just reach for your Snus."

These products and marketing campaigns clearly discourage smokers from quitting – and truly protecting their health. As the CDC stated in its report today, "Research suggests that persons who use multiple tobacco products might have a more difficult time quitting, which might result in longer durations of product use and an increased likelihood" of tobacco-related disease and death.

In its overall findings, the report shows that adult cigarette smoking rates in 2009 ranged from highs of 25.6 percent in Kentucky and West Virginia to lows of 9.8 percent in Utah and 12.9 percent in California. Smokeless tobacco use rates ranged from a high of 9.1 percent in Wyoming to a low of 1.3 percent in California.

These widely varying rates of tobacco use result in large disparities in tobacco-related death and disease. Many of the states with the highest smoking rates also have the highest rates of lung and bronchus cancer in the nation. If every state reduced smoking to the same low rate as California, there would be nearly 12 million fewer smokers in the United States, greatly improving health and saving lives.

Tobacco use kills more than 400,000 Americans and costs the nation $96 billion in health care costs each year. Today's CDC report is another important reminder that we know how to reduce tobacco use and its devastating consequences, but need the political leadership and resources to implement these solutions nationally and in every state.

For more information, see web link:
PR Newswire November 4, 2010

Smoking Cessation Ads Using 'Why to Quit' Strategy Perceived as Most Effective

Tobacco control programs that use television advertisements to promote smoking cessation should use ads that adopt a 'why to quit' strategy with either graphic images or personal testimonials, according to a new study by RTI International scientists.

The study, published online in Tobacco Control examined how different types of smokers responded and reacted to different types of televised ads that promoted smoking cessation. Scientists examined which types of cessation-focused advertisements were associated with perceived advertisement effectiveness among smokers. They also assessed whether key smoker characteristics (e.g., cigarette consumption, desire to quit and past quit attempts) influenced perceived effectiveness of different types of cessation ads.

Cessation-focused campaigns have used a variety of message themes. The three most common broad themes for cessation campaigns include why to quit, how to quit, and anti-tobacco industry.

"While there is considerable variation in the specific execution of these broad themes, ads using the 'why to quit' strategy with graphic images or personal testimonials that evoke specific emotional responses were perceived as more effective than the other ad categories," said Kevin Davis, a senior research health economist in RTI's Public Health Policy Research Program and the study's lead author.

Ad messages that focus on how to quit are generally informational in nature, providing smokers with support in the quitting process through websites, phone numbers, and plans to help smokers get started with quitting. Anti-tobacco industry messages focus on the questionable marketing practices of the tobacco industry.

Scientists measured perceived ad effectiveness with a new four-item scale assessing the degree to which participants thought the ads made them stop and think, grabbed their attention, were believable and made them want to quit smoking. The smokers were categorized based on cigarette consumption, desire to quit and past quit attempts. The researchers examined how smoker characteristics and category of cessation ads predict perceived ad effectiveness.

The study found that smokers who had less desire to quit or had not tried quitting in the past 12 months responded significantly less favorably to all types of cessation ads tested. Greater cigarette consumption was also associated with lower perceived effectiveness, but this association was smaller in magnitude.

"These findings suggest that smokers clearly differ in their reactions to cessation-focused advertising based on their individual desire to quit, prior experience with quit attempts and, to a lesser degree, cigarette consumption. These are important considerations for campaign creators, designers and media planners," Davis said.

Data for the study was taken from the New York Media Tracking Survey Online, a web survey of 7,060 adult smokers in New York State.

The study was funded by the New York State Department of Health.

For more information, see web link:
RTI International November 8, 2010

States Urged to Fill Gap in Helping Smokers Quit

The U.S. health care reform law offers help to the majority of smokers who are trying to quit, but states need to bridge coverage gaps to ensure that all smokers have access to smoking cessation treatments, a new American Lung Association report suggests.

There are two main areas where the health care overhaul leaves large gaps in helping smokers get access to cessation treatments, according to the report.

The first gap affects Medicaid recipients. While the new federal law mandates cessation treatment coverage for pregnant women enrolled in Medicaid, that requirement applies to fewer than 1 million out of the approximately 58 million Medicaid recipients. The smoking rate among people enrolled in Medicaid is more than 60 percent higher than the rate in the general population, the lung association noted in its news release.

The second gap affects people on private insurance plans. The new law requires the majority of private health plans, which cover 64 percent of Americans, to cover smoking cessation treatments. However, the federal government hasn't issued guidance on what private insurers must cover. Until that happens, insurers may not provide comprehensive coverage.

According to the lung association, comprehensive coverage means easy access to seven medications and three types of counseling recommended by the U.S. Department of Health and Human Services. These include over-the-counter (patch, gum, lozenge) and prescription (patch, nasal spray, inhaler) nicotine replacement therapies; two non-nicotine prescription drugs called bupropion and varenicline; and individual, group and phone counseling.

To bridge major coverage gaps, states need to provide smoking cessation treatments to all adults enrolled in Medicaid and should require all private health plans to cover all smoking cessation treatments, the report stated.

Currently, eight states have laws or insurance regulations that require smoking cessation coverage in some or all private insurance plans: Colorado, Maryland, New Jersey, New Mexico, North Dakota, Oregon, Rhode Island and Vermont.

Six states provide comprehensive smoking cessation coverage for Medicaid recipients: Indiana, Massachusetts, Minnesota, Nevada, Oregon and Pennsylvania. The report also noted that Kentucky has approved funding to cover smoking cessation treatments for Medicaid recipients, and Hawaii requires managed-care organizations that contract with its Medicaid program to provide near-comprehensive coverage of smoking cessation treatments.

Five states provide comprehensive smoking cessation coverage to all state employees and dependents: Illinois, Maine, Nevada, New Mexico and North Dakota. Some smoking cessation coverage is provided for state employees in Montana, Nebraska and Florida.

"With federal health care reform taking effect, states have a historic opportunity today to ensure that all smokers have easy access to treatments that can help them quit," Charles D. Connor, president and CEO of the American Lung Association, said in the news release.

"This is a win-win formula," he added. "Quitting smoking not only saves smokers' health, it curbs the health costs that drain our state treasuries. Giving all smokers access to a comprehensive cessation benefit now is the right thing to do, and it's the smart thing to do."

For more information, see web link:
US News November 9, 2010

Las Vegas Casinos Are a Last Bastion for Smokers

The notice on the door to the hotel-casino was emphatic. “The Westin Casuarina is a Smoke Free Environment. Thank you for not smoking.” Just beyond, four people were hunched over slot machines the other afternoon, wisps of cigarette smoke swirling around them as they happily puffed away.

And it was perfectly legal. “This is good,” said Ray Wan, a flight attendant from Hawaii, lighting up a cigarette as the slot machine beeped and whirled before him.

At a time when much of the rest of the nation — indeed much of the rest of the world — is on a crusade to banish smoking in public, the casinos of Las Vegas have emerged as a smokers’ oasis, perhaps the last place free from the restrictions that have spread from restaurants to bars to malls to cars carrying children. Nevada law trumps Westin policy.

No matter that Nevada voters strongly approved a ban on public smoking four years ago: the powerful gambling industry made certain that it included an exception for casinos. Blackjack dealers and croupiers, alarmed about secondhand smoke, are pressing a $5 million federal class action lawsuit filed against the Wynn Las Vegas, to force the hotel to protect casino workers who have to sit in smoke-misted rooms. But the most the plaintiff’s lawyers expect from the case is the installation of high-technology air cleansing devices.

Even the ominous warning labels for cigarette packages proposed by health regulators seem unlikely to make a difference here.

This being Las Vegas, a place that has made an industry out of excess and risky behavior, smoking seems here to stay. Civic leaders, who might be uncomfortable enabling a habit that has, shall we say, its demonstrable downsides, point to evidence that a ban would hurt casino business, arguing that smoking is as integral to the Las Vegas experience as free drinks, playing the slots at 7 a.m. and escort services. Atlantic City banned smoking in 2008, and rolled back the ban a month later because of complaints from casinos.

“There’s been a link between smokers and gamblers for years,” said Billy Vassiliadis, an advertising executive who represents the city’s tourism industry. “A lot of people do things here that they don’t do at home. It’s part of the overall appeal of Las Vegas. You have choices here.”

So it is that in an era when smoking has become taboo in the rest of the country, smokers seem downright liberated when they step onto the Las Vegas Strip: Finally, there is someplace where they have nothing to be ashamed of as they romp through their bastion of freedom.

“I mean, where else can you come in from outside smoking a cigarette, walk straight in and keep it lit?” said Andrew Garcia, a Las Vegas native.

The other evening, a uniformed woman brandishing a tray loaded with packs of cigarettes and cigars roamed the aisles of O’Sheas Las Vegas Casino. At the Bellagio, a gambler rolled her eyes at a seatmate who tried to clear the air with a wave of her hand, while up the street, at the Flamingo, a couple, with almost theatrical defiance, lighted cigarettes and thrust them in the air as they marched under pink neon tube lights down the main hall of the casino.

“A woman sat next to me and started fanning the smoke away with her hands,” said Kelli Lee, 41, of Los Angeles, as she worked her way through a pack of Marlboro Lights while playing the slots at the Imperial Palace Casino. “Can you believe it?”

“If cigarettes were illegal, then I would say not to smoke them,” she added. “But they’re legal. Tobacco is natural. I wouldn’t come here and gamble if I couldn’t smoke.”

Paul Hynes, 36, of Toronto, hoisted a lit cigar as he and three friends, also puffing on thick cigars, walked among the croupier tables at the Bellagio. “This is part and parcel of the environment here,” Mr. Hynes said.

At the same time, a walk through the casinos at any time of day or night is a reminder of the way the world used to be. The air in sections of some casinos — especially the older ones, where the ventilation systems are not exactly state of the art — is a swirl of cigarette smoke, leaving a distinctive odor on the clothes of anyone who happens to stroll through the place.

Stephanie Steinberg, chairwoman of Smoke-Free Gaming — an organization of casino workers and patrons who are pressing casinos to ban smoking — said that while smoking was allowed in other casinos across the country, particularly on Indian reservations, Nevada had proved the most intractable. South Dakota approved a voter initiative this month to ban smoking in commercial casinos, joining Colorado, Delaware, Illinois and Montana in passing complete or partial bans.

“The problem with Nevada — and the reason it stands out as a smoking state — is because of the power and control the gaming industry has in the state,” Ms. Steinberg said.

Smoking is banned in restaurants, shops, public hallways and other nongambling parts of casinos; yet it is hard to tell where the no-smoking area ends and the yes-smoking area begins. “The reality is there’s no enforcement: People just walk around with cigarettes,” Ms. Steinberg said.

The lawsuit filed by casino workers against the Wynn argues that the atmosphere there posed a serious and direct threat to their health. But Jay Edelson, the lawyer for the lead plaintiff, Kanie Kastroll, a dealer for 20 years, said the redress being sought was limited. The workers, he said, are looking for corrective action, like cleaner air, not a full ban on smoking.

Ms. Kastroll said that dealers were often locked at tables for an hour at a time. “We get every kind of direct cigarette smoke, sometimes intentionally blown on us because they are losing,” she said. “You’re not allowed to fan, you can’t blow it back on them. Forget the employee — it’s all about their bottom line.”

A lawyer for Wynn, James J. Pisanelli, declined comment.

The issue has stirred passion among some casino workers. Buffy McKinney, whose mother, Cheryl Rose, a casino executive, died of lung cancer this year at age 62, said she was convinced that her mother had died of secondhand smoke. “Until there is a handful of casinos who are willing to put their foot down and say enough is enough, they are going to continue to fight to keep smoking allowed there,” she said.

Ms. Steinberg, for one, said she was confident that with time, even casino smoking would be banned. Until then, she said, her organization would rely on a tweak of Las Vegas’s famous marketing slogan to try to rally gamblers to their cause, or at least away from cigarette packs: “What happens in a casino stays in your lungs.”

For more information, see web link:
The New York Times November 11, 2010

Cigarette Giants in Global Fight on Tighter Rules

As sales to developing nations become ever more important to giant tobacco companies, they are stepping up efforts around the world to fight tough restrictions on the marketing of cigarettes.

Companies like Philip Morris International and British American Tobacco are contesting limits on ads in Britain, bigger health warnings in South America and higher cigarette taxes in the Philippines and Mexico. They are also spending billions on lobbying and marketing campaigns in Africa and Asia, and in one case provided undisclosed financing for TV commercials in Australia.

The industry has ramped up its efforts in advance of a gathering in Uruguay of public health officials from 171 nations, who plan to shape guidelines to enforce a global anti-smoking treaty.

This year, Philip Morris International sued the government of Uruguay, saying its tobacco regulations were excessive. World Health Organization officials say the suit represents an effort by the industry to intimidate the country, as well as other nations attending the conference, that are considering strict marketing requirements for tobacco.

Uruguay’s groundbreaking law mandates that health warnings cover 80 percent of cigarette packages. It also limits each brand, like Marlboro, to one package design, so that alternate designs don’t mislead smokers into believing the products inside are less harmful.

The lawsuit against Uruguay, filed at a World Bank affiliate in Washington, seeks unspecified damages for lost profits.

“They’re using litigation to threaten low- and middle-income countries,” says Dr. Douglas Bettcher, head of the W.H.O.’s Tobacco Free Initiative. Uruguay’s gross domestic product is half the size of the company’s $66 billion in annual sales.

Peter Nixon, a vice president and spokesman for Philip Morris International, said the company was complying with every nation’s marketing laws while selling a lawful product for adult consumers.

He said the company’s lawsuits were intended to combat what it felt were “excessive” regulations, and to protect its trademark and commercial property rights.

Cigarette companies are aggressively recruiting new customers in developing nations, Dr. Bettcher said, to replace those who are quitting or dying in the United States and Europe, where smoking rates have fallen precipitously. Worldwide cigarette sales are rising 2 percent a year.

But the number of countries adopting tougher rules, as well as the global treaty, underscore the breadth of the battleground between tobacco and public health interests in legal and political arenas from Latin America to Africa to Asia.

The cigarette companies work together to fight some strict policies and go their separate ways on others. For instance, Philip Morris USA, a division of Altria Group, helped negotiate and supported the anti-smoking legislation passed by Congress last year and did not join a lawsuit filed by R. J. Reynolds, Lorillard and other tobacco companies against the Food and Drug Administration. So far, it is not protesting the agency’s new rules, proposed last week, requiring graphic images with health warnings on cigarette packs.

But Philip Morris International, the separate company spun out of Altria in 2008 to expand the company’s presence in foreign markets, has been especially aggressive in fighting new restrictions overseas.

It has not only sued Uruguay, but also Brazil, arguing that images the government wants to put on cigarette packages do not accurately depict the health effects of smoking and “vilify” tobacco companies. The pictures depict more grotesque health effects than the smaller labels recommended in the United States, including one showing a fetus with the warning that smoking can cause spontaneous abortion.

I n Ireland and Norway, Philip Morris subsidiaries are suing over prohibitions on store displays.

In Australia, where the government announced a plan that would require cigarettes to be in plain brown or white packaging to make them less attractive to buyers, a Philip Morris official directed an opposition media campaign during the federal elections last summer, according to documents obtained by an Australian television program, and later obtained by The New York Times.

The $5 million campaign, purporting to come from small store owners, was also partly financed by British American and Imperial Tobacco. The Philip Morris official approved strategies, budgets, ad buys and media interviews, according to the documents.

Mr. Nixon, the spokesman, said Philip Morris made no secret of its financing of that effort. “We have helped them, not controlled them,” he said.

Mr. Nixon said Philip Morris agreed that smoking was harmful and supported “reasonable” regulations where none exist.

“The packages definitely need health warnings, but they’ve got to be a reasonable size,” he said. “We thought 50 percent was reasonable. Once you take it up to 80 percent, there’s no space for trademarks to be shown. We thought that was going too far.”

These days in courts around the world, the tobacco giants find themselves on the defensive far more than playing offense. The W.H.O. and its treaty encourage governments and individuals to take legal action against cigarette corporations, which have encountered growing numbers of lawsuits from smokers and health care systems in Brazil, Canada, Israel, Italy, Nigeria, Poland and Turkey.

But in other parts of the world, notably Indonesia, the fifth-largest cigarette market, which has little regulation, tobacco companies market their products in ways that are prohibited elsewhere. In Indonesia, cigarette ads run on TV and before movies; billboards dot the highways; companies appeal to children through concerts and sports events; cartoon characters adorn packages; and stores sell to children.

Officials in Indonesia say they depend on tobacco jobs, as well as revenue from excise taxes on cigarettes. Indonesia gets some $2.5 billion a year from Philip Morris International alone.

“In the U.S., they took down billboards, agreed not to sponsor music events, no longer use the Marlboro cowboy,” said Matthew L. Myers, president of the Washington-based Campaign for Tobacco-Free Kids. “They now do all of those things overseas.”

The world’s second-biggest private cigarette maker, British American Tobacco, with $4.4 billion profits on $23 billion sales in the year ending June 30, is spending millions of dollars lobbying against anti-smoking health measures, like smoke-free air policies in the European Union.

A video on the company’s Web site says some of the proven methods of reducing smoking — like taxes and display bans — encourage a black market in cigarettes and that, in turn, would finance drug, sex and weapons traffickers and terrorists.

The six-minute video, in which actors play gangsters, one with an Eastern European accent, concludes, “Only the criminals benefit.”

The conference in Punta del Este, Uruguay, will try to add specific terms to a public health treaty known as the Framework Convention on Tobacco Control, which since 2003 has been ratified by 171 nations. It would eventually oblige its parties to impose tighter controls on tobacco ingredients, packaging and marketing, expand cessation programs and smoke-free spaces and raise taxes — proven tactics against smoking.

President George W. Bush signed the treaty in 2004 but did not send it to the Senate, where a two-thirds vote is needed for ratification. President Obama hopes to submit it to the Senate next year, a White House spokesman said.

One recommendation drawing fire from tobacco farmers would either restrict or prohibit the use of popular additives, like licorice and chocolate, to blended tobacco products that account for more than half of worldwide sales.

The International Tobacco Growers’ Association says that could threaten the makers of burley tobacco, an air-cured leaf that has long been sweetened with additives, costing millions of farmers their jobs and devastating economies worldwide.

“We all know the real objective here is to eliminate tobacco consumption,” says Roger Quarles, a Kentucky grower and president of the association.

For more information, see web link:
The New York Times November 13, 2010

New Menthol Special Journal Issue Underscores Need for Federal Action

A special supplemental issue to the journal Addiction was released today focusing on menthol flavored cigarettes ("menthols") and the significant harm associated with them. This Menthol Special Journal Issue, funded by the National Cancer Institute (NCI), includes 11 new studies focusing on the prevalence of menthol flavored cigarette use, cessation success rates among menthol cigarette users and factors that might influence smoking and quitting menthols. Key findings from the special supplement include data confirming disproportionately higher rates of menthol cigarette smoking among African Americans and young adults; and menthol smokers, particularly African Americans, are also less successful when they try to quit. Young adult non-daily smokers who smoke menthols demonstrate greater signs of nicotine dependence than those who smoke non-menthols.

This special issue in Addiction -- an extensive collection of manuscripts dedicated solely to addressing research on menthol tobacco products in the past decade – provides new scientific insights, especially as they relate to African Americans and other racial/ethnic groups. The U.S. Food and Drug Administration (FDA) Tobacco Products Scientific Advisory Committee (TPSAC) is currently reviewing evidence to evaluate the impact of the use of menthols on the public's health – including the impact on young people and racial/ethnic groups and will submit its report to FDA in March 2012 on menthol flavored cigarettes. All other flavorings including chocolate, strawberry, pineapple, and grape, were banned from cigarettes in September 2009 as part of the 2009 Family Smoking Prevention and Tobacco Control Act, but menthol, the most widely used flavor in tobacco, was not included in this ban. This special issue is being released on November 18.

"These manuscripts, along with those in the prior literature, show that menthol cigarette smoking disproportionately impacts populations at risk of initiating smoking, young people, and tobacco-related health disparities," said Kola Okuyemi, MD, MPH, senior editor of the supplement. "These papers add to the body of evidence that informs future research and policy directions regarding mentholated cigarettes." The findings support the statement made to the FDA by Gardiner and Clark that "Given the overwhelming disease and death caused by smoking, menthol has no redeeming value other than it makes the poison go down more easily."

Prior research shows disproportionate marketing to and use of menthol products in youth and African American populations. Taken together, the research from today's special journal issue confirms that vulnerable populations in the United States, including African Americans, women, young people, the unemployed and those with lower levels of education are at higher risk for smoking menthol cigarettes. Among African American smokers, young adults (age 18-24) are four times more likely to smoke menthol cigarettes compared to African American smokers aged 65 and older.

While several studies in the special journal issue also confirm past research showing there are lower successful quit rates among menthol smokers, new findings show that race is associated with how menthol cigarettes affect one's quit attempt. Among African Americans, menthol cigarette smoking is associated with decreased likelihood of smoking cessation. One study specifically noted that African American and Hispanic menthol smokers are more likely to be seriously considering quitting smoking and have positive estimations of their future quitting success, but are less successful in long-term quitting smoking compared to non-menthol smokers.

"The tobacco industry has a long history of promoting menthol cigarettes to minorities and it shows," said Cheryl G. Healton, DrPH, president and CEO of Legacy. "The menthol smoking rates among minority communities are disproportionately high, and to add insult to injury, once they do decide to quit, it is often more challenging for them to do so successfully. We believe that the comprehensive findings of this special issue along with past research provide the FDA with the necessary information to ban menthol," she added.

Lorillard Tobacco Company states on its website, Understanding Menthol, that "a menthol cigarette is just another cigarette — and should be treated no differently." But, the research suggests that menthol cigarettes could be more harmful than non-menthol cigarettes. One study included in the special issue found an increased level of nicotine addiction among daily menthol smokers who only smoke a few cigarettes daily in comparison with those non-menthol smokers who smoke similar low numbers of cigarettes. Another found that young adult non-daily smokers who smoke menthol cigarettes were significantly more dependent than those who smoke non-menthol cigarettes. And while menthol smokers smoke fewer cigarettes each day compared to non-menthol smokers, current menthol and non-menthol smokers have similar health outcomes.

One study examined smoke-free policies among employed persons and reports that menthol smokers were nearly 70 percent less likely to be covered by smoke-free policies at both work and home compared to non-menthol smokers. Furthermore, evidence from tobacco control research suggests that if you raise the price of cigarettes, you can reduce smoking consumption rates. One study found that if you increase the price of menthol cigarettes by 10 percent only 2.3 percent of menthol smokers would switch to non-menthols. This study also suggests that menthol and non-menthol cigarettes are not close substitutes; that is, menthol smokers are committed to smoking menthols. If menthol were banned then strong preference for mentholated cigarettes may serve as a lever to reduce smoking prevalence when combined with increased access to effective cessation treatments.

Legacy has remained a committed member of the public health community in urging a ban on menthol cigarettes. Menthol cigarettes are the only flavor in cigarettes that have not been banned by the FDA since the agency acquired regulatory authority over tobacco products in 2009. In October 2010, Legacy joined the NAACP Legal Defense and Educational Fund, Inc., National African American Tobacco Prevention Network (NAATPN) and the African American Tobacco Control Leadership Council (AATCLC) in a collective call to ban menthol as an additive in all tobacco products.

For more information, see web link:
PR Newswire November 15, 2010

Tobacco Killed My Little Brother

By:
Michael P. O’Donnell, MBA, MPH, PhD
Editor in Chief American
Journal of Health Promotion Neil

Patrick O’Donnell died August 15, 2010 at the age of 52. He is survived by two children, ages 19 and 23, a grandson (almost 3 years old), a father, seven brothers and sisters, and lots of cousins, aunts and uncles, and friends. Neil was diagnosed on May 18, 2010 with stage 4 adenocarcinoma of the lungs with metastases to the brain and adrenal glands. He smoked cigarettes for nearly 4 decades. We buried Neil yesterday.

So many times in the last 3 months, I asked myself how all of this could be true. (1) How could Neil have started smoking? (2) Why didn’t he stop? (3) How could it have killed him? As I thought it through, and considered all the influences, I realized that it would have been more surprising if Neil had not started to smoke, if he had been able to quit, and if smoking did not kill him.

The third question is easy to answer: it is not a surprise that smoking killed Neil. Although Neil had no visible symptoms until 3 months ago, it should have been obvious to us for at least the last 2 decades that Neil would probably die prematurely of lung cancer, if not heart disease, chronic obstructive pulmonary disease (COPD), or stroke. The research literature predicts this very clearly. Ninety percent of lung cancers in men are caused by tobacco use, and men who smoke a pack of cigarettes a day are 23 times more likely to get lung cancer than men who do not.1 Neil died pretty much as predicted. Most patients with stage 4 adenocarcinoma of the lungs die within 3 to 4 months of diagnosis—Neil died within 3 months. The typical smoker loses 14 years of life because of smoking. Neil lost 16 years compared with the life expectancy for all men born in 1958 and 27 years compared with men who already had reached age 52. Neil approached the dying process with such dignity and showed remarkable kindness to all the people he encountered during his illness, even though he was in significant pain most of the time. He lost more abilities each week. First he couldn’t walk. Soon he lost some of his sight. Pain was the norm; incontinence was common. He was often confused. All of his drinks had to be thickened to avoid aspiration, which would lead to pneumonia and accelerated death. Eventually Neil’s voice was so weak that we could understand very few of his words. Toward the end, he could not feed himself. It was real. It was dying and it was death. I learned so much from Neil during this process, but that is another story.

The first question is also easy to answer. Neil started smoking because smoking was the norm in his life. Both parents and his oldest brother (not me) smoked. His mother quit when he was 10, and his dad when he was 15. Not surprisingly, kids who have at least one parent who smokes when the kids are 12 or younger are 360 times more likely to smoke than kids whose parents do not. Having an older brother who smokes further increases the odds. Having friends who smoke, especially older ones you admire, is even worse. The clincher for Neil came when he started high school. Neil was a photographer, and the head of the photography club was a senior who smoked. He supported Neil’s emerging habit by smoking with him and supplying all the cigarettes Neil needed during the school day. At first it was one cigarette a day in the photography lab. Within a few weeks, it was three a day. Neil’s school was lax about enforcing its smoking policy, so it was easy to sneak a smoke in the bathroom, the photography lab, or behind the school. Pretty soon Neil was smoking a pack and a half a day, a habit that lasted for 38 years.

The answer to the second question is more complex, and more troubling, because all of our efforts could have changed the outcome. Neil did make two serious efforts to quit. Seventeen years ago, in 1993, when Neil was 35, his primary care doctor told him he had spots on his lungs and he would be dead by the time he was 50 if he kept smoking. His doctor knew nothing about how to quit, and like most smokers who get this kind of news, Neil was too shocked and scared to do anything on his own. Several years later, Neil did quit completely for several months because his wife kept complaining about his disgusting ashtray mouth. She never noticed that he quit, the marriage eventually ended, and Neil went back to the dependable comfort of his cigarettes. Neil tried again several years later because he was concerned about his health. His doctor and his local hospital could not help him, so he turned to me. I am not a tobacco cessation counselor, and I knew less about quitting then than I do now; however, I did know how to look for help. I contacted several other hospitals and voluntary health agencies in Neil’s area, but none of them were offering quit smoking programs at the time. This was before the era of telephone quit lines, nicotine replacement therapy, and online programs. The only program Neil could find was hypnosis. Not surprisingly, hypnosis had no effect. Breaking any habit you have practiced for decades is difficult, but quitting smoking is more difficult because it also requires breaking a physical addiction to nicotine, one of the most addictive substances we know. The people who lead tobacco companies have full knowledge of the facts—that tobacco kills more than 400,000 people in the United States every year, 10 times more than car crashes, more every single week than died in the terrorists attacks the week of 9/11/2001 , more every year than all of the Americans who have died in all of the foreign wars in the history of our nation. Of course death is just the tip of the iceberg. For every smoker who dies young each year, there are more than 30 smokers who are living with debilitating chronic diseases caused by smoking, including bronchitis, emphysema, heart disease, other cancers, and other respiratory diseases. Tobacco producers have been so effective in developing their product that only 3% to 5% of people who try to quit without behavioral therapy or medicine are successful.

This whole experience leaves me with two lingering questions. The first is what could I have done, what could Neil’s primary care doctor have done, what could the rest of his family and friends have done? The answer is simple and painful. We could have saved Neil’s life. If Neil had quit smoking 15 years ago, his lungs and heart most likely would have fully recovered, and Neil would probably have lived a full life. His daughter would have a father to walk her down the aisle, his son would have a dad to help guide him in life, and his grandson would have a grandfather to adore him. My brothers and sisters, my father, Neil’s friends, and I would all have Neil in our lives. Thinking about this first question very much is too painful and not very constructive.

Thinking about the final question—what can we do going forward—is very constructive. I am publicly pledging that I will be much more assertive on this issue than I have been in the past. I hope you decide to do the same.

If you know someone who smokes, you might start a conversation by saying the following: “I have a friend who lost his brother, and I don’t want to suffer the same loss.” Starting the conversation this way is more effective than saying you want them to quit so they avoid disease and premature death. Most smokers have heard the health arguments a zillion times, and they usually tune them out. Although smokers typically underestimate the health risks of smoking, most absolutely know smoking is very dangerous. Unfortunately, scare tactics don’t work. The possible (and likely) outcomes of smoking are just too horrible for most smokers to imagine, and quitting is so difficult that most smokers don’t think about the health issues and they don’t want to hear about them from you. However, people who care about you may be willing to listen to your concerns about you suffering a loss, about you losing them from your life. This, in turn, can lead to them being more open to thinking about quitting. Most smokers (79.3%) expect to quit at some point, a majority (58.4%) plan to do so within the next 6 months, and many of them (46.8%) actually try to quit each year. Discussing the pros and cons of quitting, helping them believe they can be successful in quitting, and telling them you will help can push them from thinking about quitting to actually attempting to quit. You can assure them that people’s lungs and hearts have a remarkable ability to heal and regain their normal function once the poison of tobacco is removed. You can also help them consider cost/benefit decisions. For example, you can explain that medication to help them quit will cost less than they spend on cigarettes. If they are broke, you can offer to loan them the money for the first month’s supply and ask to be paid back from the money they save by not buying cigarettes. In the meantime, don’t make it easy to smoke. Don’t let them smoke in your house or your yard. Don’t stand outside and talk with them while they smoke. Let them know that their secondhand smoke is very dangerous to your health in addition to smelling bad. (As a side note, secondhand smoke contains at least 250 known toxic chemicals, including more than 50 that can cause cancer. It causes more than 46,000 deaths from heart disease and 3400 more from lung cancer (or 49,400 total) each year in the United States. To put this in perspective, this is 50% more than are killed in a year by homicide or suicide and nine times more than are killed in occupational accidents. Expressed in different terms, smokers who choose to smoke around friends, children, colleagues, and strangers, kill more than three times as many people each year as drinkers who choose to drink and drive. Like direct smoking, second hand smoke also makes a lot more people sick than it kills. For example, the tens of millions of children exposed to their parents’ second hand smoke have higher rates of asthma, emphysema, sudden infant death syndrome, ear infections, and retarded lung growth. Be sure to remind them that you care about them during this process. It is critical to always be conscious about showing that you love and respect the smoker, even though you despise and fear the smoking.

Note: It is easy for health promotion professionals (like me) to talk to people about these issues at work because it is expected and even welcomed. It is much more difficult for us to do this with our friends and family because we don’t want to impose our personal value systems, we don’t want to reinforce our “mother hen” image, and our past attempts with family and friends to help in this way may not have always been welcomed. We need to have a pro and con discussion with ourselves…what’s better—being able to stay in our comfort zone by avoiding these conversations or keeping a friend or family member alive? For me, it used to be professional; now it’s personal.

When they are ready to quit, you can help them gain the skills they need and you can provide support through the quitting process. You can help them find expert help through work, their health insurance company, a telephone quit line (like 1-800-QUIT-NOW), an online program (e.g., http://www.becomeanex.org/), or a local voluntary organization or hospital. You can help them have a realistic sense about how challenging it will be to quit, and let them know that many people need to make several attempts before they are successful. You can also give them hope by telling them about people you know who have successfully quit and letting them know that people who take a combination of medication and behavior therapy are six times more successful.10 You can help them engage their doctor and other family and friends so that they have a circle of supporters around them. You can also help them build a physical environment that makes it easier to stay smoke free—by washing clothes, throwing away cigarettes, and getting rid of ashtrays and other smoking paraphernalia.

Your friend will still need help staying smoke free after quitting. In fact, many smokers continue to think of themselves as a “former smoker” rather than a “nonsmoker” for up to 5 years and will be tempted to smoke all of those years. Many smokers need five to eight quit attempts before they quit for good. You can help by letting them know that relapse is normal, remind them of reasons they decided to quit in the first place, and offer to be a patient friend during all of these quit attempts.

If you want to help others beyond your close friends and family, encourage your employer to create a smoke-free campus and to pay for quit smoking programs, including medication. Help your community pass laws to prohibit smoking in public places, levy tobacco excise taxes, and mandate that schools create smoke-free campuses. Advocate that your state legislature allocate the amount of funds recommended by the Centers for Disease Control and Prevention (CDC) for tobacco prevention and treatment from the Master Settlement Agreement with the tobacco industry, rather than the 2% to 3% spent by most states.

I wrote most of this message the day after Neil died. Neil told me most of this story as I helped him in the 3 months before he died. He asked me to share the story with the hope that “others could learn from my mistakes.” Normally when I write columns in the American Journal of Health Promotion, I intend them to be read by scientists and managers who run health promotion programs. I am writing this column to anyone who has a brother, sister, spouse, parent, cousin, or friend who smokes…and wants to keep that person in their life. So please share it.

For more information, see web link:
American Journal of Health Promotion November November 19, 2010

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