September 2010

Spotlight

New Research Links Genes to Tobacco Smoke and Cessation

Growing evidence is slowly revealing the important relationship between genes and tobacco smoke. Researchers across the nation are discovering ways in which cigarette smoke influences gene expression and conversely, how genetic makeup can predict the effectiveness of cessation treatments.

University of North Carolina-Chapel Hill

In collaboration with scientists from 16 large genetic studies worldwide, researchers from the University of North Carolina-Chapel Hill found specific genetic regions associated with smoking behaviors that have significant impact on health. Published in the journal Nature Genetics, findings showed that three genetic regions had associations with the number of cigarettes smoked per day, one region was tied to smoking initiation, and another was linked to smoking cessation.

"We hope that this work will allow researchers from multiple disciplines to develop a better understanding of the genetics of addiction and evaluate how drug-gene interactions could be used to create and tailor therapies to improve the rates of smoking cessation," said Helena Furberg, UNC genetic faculty member and researcher on project.

Southwest Foundation for Biomedical Research, San Antonio, Texas

In the largest study of its kind, researchers at the Southwest Foundation for Biomedical Research (SFBR) found that exposure to cigarette smoke can negatively alter gene expression. While earlier studies looking at the relationship between gene expression and tobacco smoke involved only 42 smokers and 43 non-smokers, scientists at SFBR successfully examined 1, 240 individuals, including 297 smokers.

"Never before has such a clear link between smoking and transcriptomics been revealed, and the scale at which exposure to cigarette smoke appears to influence the expression levels of our genes is sobering," said Jac Charlesworth, Ph.D, lead author of the study.

The July report showed that humans have at least 323 genes that are affected by smoking behaviors. As compared to non-smokers, smokers had significant alterations in gene expression related to the immune system, cancer, cell death, and metabolism.

National Institute on Drug Abuse and Duke University

In the July-August issue of Molecular Medicine, scientists with the National Institute on Drug Abuse and Duke University revealed that smokers' genetic profile combined with their level of nicotine dependence can help guide treatment decisions and maximize the likelihood of successfully quitting.

The researchers scanned 520,000 genetic blood markers of smokers and created a "quit success score" based on their genetic profile; nicotine dependence was assessed by using a short questionnaire. Smokers were then randomly assigned to either a low-dose patch or high-dose patch to test whether the "quit success score" in combination with smokers' level of nicotine dependence had any predictive value.

After six months of using the patch, researchers discovered that the genetic score did in fact help in predicting successful abstinence.

"People who had both high nicotine dependence and a low or unfavorable quit-success genetic score seemed to benefit markedly from the high-dose nicotine patch, while people who had less dependence on nicotine did better on the standard patch," said Jed Rose, director of Duke's Center for Nicotine and Smoking Cessation Research.

Though more research is still needed in the area of gene expression and tobacco smoke, the growing evidence base encourages scientists as they are moving closer to customized smoking-cessation treatment and to optimizing smokers' quit attempts.

For more information, see web link:
The Seattle Times September 6, 2010

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Research Highlights

1 In 5 U.S. Adults Still Smoke

U.S. smoking rates continue to hold steady, at about one in five adults lighting up regularly, frustrated health officials reported.

About 21 percent of U.S. adults were smokers in 2009, about the same percentage as the year before, according to the Centers for Disease Control and Prevention. The smoking rate – which fell dramatically since the 1960s – has basically been flat since about 2004.

Teen smoking, at nearly 20 percent, has not been improving lately, either.

Health officials believe they've lost momentum because of cuts to anti-tobacco campaigns and shrewd marketing by cigarette companies.

The new report suggests that more than 46 million American adults still smoke cigarettes.

"It's tragic," said CDC director Dr. Thomas Frieden, who calls smoking the No. 1 preventable cause of death in the United States. He estimates that smoking kills 1,000 Americans a day.

Some experts were particularly disheartened by a CDC finding in a second report that nearly all children who live with a smoker – 98 percent – have measurable tobacco toxins in their body.

Experts say tobacco taxes and smoking bans are driving down rates in some states. But nationwide, they say progress has been halted by tobacco company discounts or lack of funding for programs to discourage smoking or to help smokers quit.

The annual smoking report was based on government surveys. The second report looked at levels in the blood of cotinine, a chemical from tobacco smoke, in a total of more than 30,000 nonsmokers between 1999 and 2008.

Overall, detectable levels of cotinine dropped over the 10 years – from about 52 percent to 40 percent. That may be due in part to more smoking bans in workplaces, restaurants and other places.

But there were several bits of bad news in that report, too:

• Most of the decline came about 10 years ago.
• More than half of U.S. children ages 3 to 11 are exposed to secondhand smoke, and the CDC says there is no safe level of exposure.
• There's been virtually no improvement for children who live with a smoker, noted Matthew L. Myers, president of Campaign for Tobacco-Free Kids, a Washington-based research and advocacy organization.

For more information, see web link:
The Huffington Post September 7, 2010

Secondhand Smoke: Ventilation Systems Are Not the Answer, Says New Study

In a scientific study of secondhand smoke exposure in St. Louis bars and restaurants, researchers at Washington University in St. Louis found that ventilation systems and "voluntary" smoke-free policies do not protect employees and customers from exposure to nicotine in the air.

Exposure to secondhand smoke is an established cause of cancer, heart disease and serious lung ailments, according to the U.S. surgeon general.

Researchers from the Center for Tobacco Policy Research at Washington University's George Warren Brown School of Social Work and at the Alvin J. Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine analyzed nicotine levels in randomly selected bars and restaurants in the City of St. Louis and St. Louis County, and in hair samples from employees of the monitored venues.

Ten bars and 10 restaurants participated in the study. Sixteen of the venues allowed smoking indoors, and four were smoke-free. Seventy-eight employees at the bars and restaurants provided hair samples and answered survey questions.

Passive sampling devices collected nicotine in each venue for seven working days during June, July and August 2009. The Johns Hopkins Bloomberg School of Public Health, which has expertise in this type of monitoring, analyzed the samples using gas chromatography with nitrogen-selective detection. Concentration of airborne nicotine was calculated by dividing the amount of nicotine collected by the sampling device by the effective volume of air sampled.

Since airborne nicotine can only come from cigarette smoke, it is a reliable, scientifically accepted marker for assessing secondhand smoke exposure. While concentrations do not directly translate to health risk, a finding of nicotine indicates the presence of a carcinogenic and toxic mixture.

Although none of the restaurant or bar venues in the study were below level of detection, median airborne nicotine levels were 31 times higher in venues where smoking is allowed, compared with those that are voluntarily smoke-free. And, not surprisingly, as the percentage of smoking clients rose, so did the nicotine concentrations.

An interesting finding was that ventilation systems, a topic of debate in St. Louis, were not only ineffective, but restaurants and bars that had them actually had higher nicotine concentrations in the air than restaurants that didn't have them, but where the number of patrons who smoked was similar.

This confirms the U.S. surgeon general's statement that "cleaning the air and ventilating buildings cannot eliminate exposures of nonsmokers to secondhand smoke."

Hair nicotine was found in all bar and restaurant employees tested, both nonsmokers and smokers alike, although the concentration was higher for employees who smoke.

Employees in both smoke and smoke-free venues, however, reported smoking-related symptoms despite their smoking status, including coughing, shortness of breath and excess phlegm. Sensory health concerns for both smoking and non-smoking employees included red or irritated eyes, scratchy throat and runny nose.

Study author Joaquin Barnoya, MD, research assistant professor in the Department of Surgery at Washington University School of Medicine, says that the cardiovascular system is very sensitive to even low doses of tobacco smoke.

"Some of the effects of secondhand smoke on the cardiovascular system in nonsmokers are comparable to the effects of active smoking," Barnoya says. "These effects occur within a half hour of exposure."

In response to a questionnaire given to employees as part of the study, 62 percent of respondents stated a preference for working in a smoke-free environment. More than half of non-smoking employees questioned said that all restaurants, bars and nightclubs should be smoke-free, with a third of smoking employees in agreement.

Of employee responders who smoke, more than half said that smoke-free legislation would help them quit, while 70 percent of former smokers said that smoke-free workplace legislation would help them remain nonsmokers.

Results of the study were presented Sept. 8 at a conference held at the Alvin J. Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine.

For more information, see web link:
Media-Newswire September 13, 2010

Lung Damage from Second Hand Smoke Observed in Rats

Secondhand smoke appears to trigger a complex inflammatory response in the lungs, a study in rats reveals.

The researchers exposed the animals to secondhand smoke five times per week for two or four months. The exposures occurred in two three-hour shifts twice a day, separated by a two-hour break. "This is much like what a human would be exposed to at a bar or casino," Adelheid Kratzer, an investigator in the pulmonary and critical care division in the department of medicine at the University of Colorado-Denver, said in an American Physiological Society news release.

Two months of exposure to secondhand smoke was enough to cause significant changes in the rats' lungs, and those changes were even more notable after four months.

Among the changes the investigators found were:

• Enlargement in the alveolar air space of the lungs, which suggests the alveolar structure had started to break down, similar to the way it does in early emphysema. The alveoli are tiny sacs where the oxygen-carbon dioxide exchange occurs during breathing.
• Increased numbers of white blood cells called macrophages in the alveolar space, indicating an immune system response.
• Elevated levels of the cytokine interleukin-18, which is produced by macrophages and is associated with strong inflammatory responses and tissue destruction.
• Inhibited growth and spread of endothelial cells lining the inside of small blood vessels of the lungs. A decrease in endothelial cells can reduce the elasticity of the blood vessel wall and increase its permeability, which can lead to chronic inflammation that's seen in patients with chronic obstructive pulmonary diseases, such as emphysema and chronic bronchitis.

Quitting Smoking Helps After Serious Heart Attack Damage

It's never too late for smokers to do their hearts good by kicking the habit -- even after a heart attack has left them with significant damage to the organ's main pumping chamber, a new study suggests.

Past studies have found that smokers who kick the habit after suffering a heart attack have a lower rate of repeat heart attacks and live longer than their counterparts who continue to smoke.

But little has been known about the benefits of quitting among heart attack patients left with a complication called left ventricular (LV) dysfunction -- where damage to the heart's main pumping chamber significantly reduces its blood-pumping efficiency.

So it has been unclear whether that dysfunction might "drown out" the heart benefits of smoking cessation, said Dr. Amil M. Shah, the lead researcher on the new study and a staff cardiologist at Brigham and Women's Hospital in Boston.

But in their study, Shah and his colleagues found that heart attack survivors with LV dysfunction may stand to benefit as much from smoking cessation as other heart attack patients do.

The researchers found that among 2,231 patients with LV dysfunction, those who quit smoking within six months of their heart attack were less likely to die within five years or suffer a repeat attack than smokers who continued the habit.

Of all patients, 463 were smokers at the time of the heart attack but had quit six months later; 268 were still smoking at the six-month mark. Among quitters, 15 percent died or suffered another heart attack by the end of the study, which followed the patients for up to five years.

That compared with a rate of 23 percent among patients who were still smoking six months after their initial heart attack.

When Shah's team accounted for a number of other factors -- including age, medical history and body weight -- smoking cessation itself was linked to a 40 percent reduction in the risk of death compared with persistent smoking.

Quitters were about 30 percent less likely to die, suffer a repeat heart attack or be hospitalized for heart failure during the study period.

"The findings aren't completely surprising," Shah told Reuters Health. But, he said, they offer reassurance to patients with LV dysfunction that they can benefit from smoking cessation -- and the magnitude of that benefit is similar to what has been seen among heart attack survivors without LV dysfunction.

"I've had patients who say, 'What's the point of quitting now?'" Shah noted. "But it's never too late to benefit from smoking cessation."

Some studies have found that smoking-cessation counseling begun in the hospital, and continued after discharge, may be particularly effective for heart attack patients.

Patients at hospitals that do not offer such counseling should speak with their cardiologist or primary care doctor about smoking cessation, Shah advised. Behavioral counseling will generally be the first step, he noted -- though for patients who ultimately need more, nicotine-replacement products or medications such as Zyban or Chantix may be options.

A number of studies have suggested that these products are generally safe for people with heart disease -- though, Shah pointed out, most of the data come from patients with stable heart disease, and not those who have just recently suffered a heart attack or other complication.

For more information, see web link:
Reuters Health August 26, 2010

New Study May Change the Way Clinicians Make Treatment Decisions for Patients Who Smoke

A study led by researchers in the Oregon Health & Science University Smoking Cessation Center may change the way clinicians make treatment decisions for their patients who smoke.

Their findings published online in the journal Addiction suggest that current treatment theories that maintain any smoking after the planned target quit day predicts treatment failure need to be expanded to take into account a more dynamic quitting process. The team's analysis points to two types of successful quitters: those who quit immediately and remain abstinent through the end of treatment and those who are "delayed" in attaining abstinence but achieve success by the end of treatment.

"In 'real-world' clinic settings, health care providers must decide whether or not to continue a specific treatment based on their clinical judgment and the published reports in the scientific literature. They can lose confidence that a specific cessation treatment is effective when the patient is unable to quit on the recommended target quit day or if the patient is unable to maintain total abstinence within the early weeks of treatment," said David Gonzales, Ph.D., the study's lead author and a senior clinical investigator in Pulmonary and Critical Care Medicine at the OHSU Smoking Cessation Center, OHSU School of Medicine.

"Patients also can become discouraged that a treatment is not working and worry about continuing to pay for treatments they believe do not work. As a result, cessation treatment for some patients may be discontinued before the prescribed treatment period is completed and the patient and/or the treatment considered a failure."

In this study, however, the data show a substantial proportion of smokers who became 'successful quitters' by the end of 12 weeks of treatment smoked in one or more weeks during the first eight weeks and were delayed in achieving a period of continuous abstinence. This was true of successful quitters treated with varenicline, bupropion and with counseling alone (placebo), Gonzales explained, and appears to be a previously unreported and natural pattern of quitting for motivated smokers who seek treatment to quit.

"Had treatment been interrupted or discontinued for these 'delayed quitters,' opportunities for achieving continuous abstinence could have been lost for up to 45 percent of quitters who were ultimately successful," Gonzales said.

Gonzales and colleagues analyzed data from two identically designed, published studies (Gonzales et al. JAMA 2006 and Jorenby et al. JAMA 2006) conducted between June 2003 and April 2005. Participants included 2,052 generally healthy adult smokers who randomly received either a smoking cessation drug - varenicline or bupropion - or a placebo for 12 weeks of treatment plus 40 weeks of follow-up. All participants received brief smoking cessation counseling at clinic visits and investigators were blinded to the treatment assignments.

Successful quitters were defined as smokers who achieved continuous abstinence, not even one puff, for the last four weeks of treatment (weeks nine through 12). Among successful quitters, two groups were identified: "immediate quitters," smokers who quit and remained abstinent from their target quit date through the end of week 12; and "delayed quitters," smokers who had periods of smoking prior to attaining continuous abstinence for at least the last four weeks of treatment.

The overall end-of-treatment quit rates for the two studies were previously shown to be higher for varenicline, but in this analysis, the researchers found cumulative continuous abstinence increased similarly for all treatments during weeks three through eight. They also found quitting patterns among delayed quitters were similar regardless of whether they took varenicline, bupropion or received counseling only (placebo).

While delayed quitters did not fare quite as well as immediate quitters following the end of active treatment, they still accounted for approximately one-third of those who remained continuously abstinent at 12 months regardless of treatment group.

"Based on these findings, we believe that treatment failure, or success for that matter, should not be assessed until the recommended period of treatment is completed. An analogy with antibiotic treatment, while not totally appropriate, is, nevertheless, a useful framework for illustrating some of the dynamics of the quitting process," explained Gonzales. "We know that some patients quit taking antibiotics when there is relief of symptoms [success] and others quit taking medication if symptoms don't seem to be resolving [failure]. In both cases discontinuing treatment prematurely risks treatment failure. Stopping smoking cessation treatment seems to have similar risks."

The take-home message for clinicians and patients, according to Gonzales, is that 'real-world' quit rates may be significantly increased by just continuing cessation treatments without interruption for patients who remain motivated to quit despite lack of success during the first eight weeks of treatment.

For more information, see web link:
The Medical News September 3, 2010

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Other Cessation News

Tobacco Signs Still Target City's Poorer Areas

The signs, wrought in soothing italics, beckon with promises of tobacco "pleasure!" at low, low prices. Across Dorchester, Mattapan, and other city neighborhoods, big signs and little signs, vertical signs and horizontal signs trumpet the availability of cigarettes at corner stores and gas stations. They are plastered on façades and propped against windows, affixed to light poles and gas pumps.

A dozen years after Massachusetts attempted to ban storefront tobacco ads within 1,000 feet of schools and playgrounds, a prohibition thwarted by a tobacco company's legal challenge, the signs remain prolific and prominent in Boston's lower-income neighborhoods, especially those with substantial African-American and Hispanic populations.

But now, empowered by Congress to regulate tobacco companies, the Food and Drug Administration is taking steps that could rein in the pastel-hued signs that industry foes say entice young customers to start smoking.

With cigarette advertising banished from the airwaves and largely absent from billboards, storefronts are some of the last bastions of tobacco marketing. The continued presence of the ads is a testament, researchers said, to the deep reach of cigarette makers in poorer communities, where merchants said company representatives sometimes personally attach ads to store exteriors.

"Tobacco advertising is still alive and well," said Dr. Michael Siegel, a tobacco control specialist at the Boston University School of Public Health. "There's a widespread perception that somehow the tobacco advertising has gone away, that it's been taken care of, that we don't have to worry about this anymore. But that's not true."

On Gallivan Boulevard, there is the Hess gas station, with signs for Newport, Marlboro, and Pall Mall on light posts and more ads in the window of the convenience store and on the pumps, at least 20 in all. On Dorchester Avenue, there is the red-brick Ashmont Convenience Store, where two Newport signs and one for Maverick cigarettes ("Everyday low price, $6.70") dominate posters touting telephone calling cards.

Hung Tran, who was behind the cash register at the Ashmont shop, said that in a neighborhood where tough times have exacted a steep toll, the signs let potential patrons know what wares he has inside.

"It's good for customers to see it," said Tran, whose brother owns the shop.

The signs, Tran said, are provided by the maker of Newport and Maverick, Lorillard Tobacco Co., which has a contract with the store. "Every three months," Tran said, "they tell me what to do."

Lorillard's director of investor relations, Robert Bannon, declined to discuss the company's marketing practices. Another major cigarette producer, R.J. Reynolds Tobacco Co., did not return phone messages.

A representative of the nation's leading tobacco maker, Philip Morris USA, defended storefront ads, citing free speech rights under the First Amendment.

"Adult consumers have a constitutionally protected interest in receiving communications from retailers and manufacturers, just as we, Philip Morris USA, have the right as a manufacturer to communicate nonmisleading information to those consumers about our products," company spokesman David Sutton said.

That position echoes a legal challenge tobacco companies are making to a New York City campaign that mandates graphic warnings at cash registers about the health perils of smoking. Massachusetts regulators proposed a similar initiative earlier this year, but put it on hold, awaiting the outcome of the New York case.

At Sandy's Variety Store, hard by Washington and Dakota streets, tobacco marketers posted new signs a few weeks back, said Arelis Villa, who has owned the shop for nearly 14 years with her husband. Three signs stand out on the red façade: one for Newport, one for Maverick American Quality, one for USA Gold.

"It doesn't make sense," Villa said, her head slowly shaking in dismay. "The government says it doesn't want minors to smoke, that it's dangerous. So I don't understand why they let the companies do a lot of advertising to convince people to smoke."

Researchers found in 2003 and 2004 that roughly 4 of every 10 dollars spent on tobacco marketing went to store signs, payments to retailers for prime shelf space, and displays inside shops. In some cases, shopkeepers received thousands of dollars through tobacco manufacturer incentive programs.

And the more tobacco promotions children encounter, the greater the risk they will start smoking, Massachusetts scientists reported in 2006.

It is no secret that ad dollars are disproportionately spent in poorer neighborhoods, said researchers, pointing to studies from the past 15 years. In the most recent, Harvard School of Public Health researchers found that stores selling cigarettes in Dorchester were significantly more likely to have signs — and bigger signs — than retailers in Brookline. The researchers, who canvassed storefronts from November 2007 to February 2008, also discovered that stores in Dorchester were more likely to advertise prices and that the prices were lower than in Brookline.

In the Dorchester ZIP code covered by the study, 02124, the median family income was $38,203; 18 percent of Dorchester adults smoke regularly. In Brookline, where the median income was $92,993, the smoking rate was only 6.5 percent.

"Does this marketing demonstrate a targeting of disadvantaged communities? Clearly," said Greg Connolly, an author of the Harvard study that appears in the American Journal of Health Promotion. "Is there a moral and economic obligation to intervene? Yes. We're not showing dignity and respect for low-income people in Boston."

Both Boston and Brookline have rules prohibiting more than 30 percent of a window from being covered by any kind of signs.

Brookline goes further, with a design guideline limiting brand-specific advertising. But a planning official said that rule is rarely enforced. Brookline was the first Massachusetts municipality to impose a ban on smoking in restaurants and bars. Health director Alan Balsam said the absence of tobacco ads is more a reflection of his town's attitude toward smoking than a recognition of obscure zoning rules.

"It just shows sometimes you don't have to hit people with a hammer," Balsam said. "It's a long slog to educate people who own businesses about tobacco control, but I think we've done a fairly good job."

In 1996, the FDA first asserted regulatory jurisdiction over tobacco companies, including advertising, but a court ruled that the federal agency was overstepping its authority.

Two years later, Massachusetts attempted to restrict storefront ads. Tobacco maker Lorillard sued, and the US Supreme Court sided with the company.

Last year, the FDA won the power to regulate tobacco companies under a landmark law passed by Congress. The agency, after soliciting public comments, is weighing what to do about ads on the exterior walls and grounds of retailers, a spokeswoman said.

Matthew Myers, president of the advocacy group Campaign for Tobacco-Free Kids, said he believes "there is no question the FDA will clamp down" on the signs. But, he said, it is less clear how.

Advertising could be banned within 1,000 feet of schools and playgrounds, as the FDA and Massachusetts proposed in the 1990s. Or the agency could shrink that to a smaller radius so that fewer retailers are affected. Or, rather than an outright prohibition, it could dictate that all tobacco ads be fashioned in a muted design, such as black and white type. The rules, Myers said, would not apply to signs in store windows.

"The question purely is what rules should be in place to govern outdoor advertising that both protect the public health and are consistent with the First Amendment," Myers said.

Why Do Most Smokers Tolerate Massive State Tax Increases?

State governments don't get a lot of fiscal good news these days, so it was surprising when the state of Connecticut announced that a recent $1-a-pack tax increase on cigarettes raised $5 million more than the state had projected. As economists would predict, the daunting total of a $3-a-pack tax in Connecticut -- the fourth-highest burden in the country -- did reduce the sale of cigarettes. Some smokers reacted to the tax by quitting, with others finding ways around the tax.

But the surprising fact is that not that many quit smoking or evaded the tax -- not enough, anyway, to cause the state to collect less in cigarette taxes than it would have without the increase. This experience is not unique to Connecticut. Over the past decade or so, several states and jurisdictions have experimented with massive cigarette tax increases, as much as 100 percent or more over the existing rate. California, for example, still has a relatively low state cigarette tax, but in January 1999, it ballooned to 87 cents a pack from 37 cents. In 2002, New York City raised the tax on a pack of cigarettes from 8 cents to $1.50, an astronomical increase of nearly 1,800 percent.

Yet according to anti-tobacco activists -- who are backed up by economic studies -- in every instance, these huge tax hikes have led to states collecting more revenue, even as many smokers swear they won't pay the taxes. Cigarettes may not quite be what economists call "perfectly price inelastic," but millions of American smokers are willing to pay much higher taxes than economic theory would suggest they should.

At the heart of nearly every tax debate in America is some version of the Laffer curve, a fancy way of describing a point of diminishing returns. An income tax of 0 percent produces no revenue; an income tax of 100 percent, it is presumed, causes people to change their behavior so as to avoid the tax, also producing nothing. Some ideal point in between will yield the maximum possible revenue.

In the late 1970s and the 1980s, this very old idea was applied to income tax and burst into prominence as part of the supply-side economics revolution. And since that time, many public officials have espoused the idea that cutting taxes will increase economic activity -- and therefore create higher revenue -- while raising taxes will have the opposite effect.

Cigarette taxes don't seem to behave this way (or at a minimum, we've yet to hit the point at which even huge tax hikes lead to lower revenue). Indeed, in many states, the very notion of tax representing a portion of the underlying cost of a pack of cigarettes -- the way that, say, a tip represents a portion of the cost of a restaurant meal -- has ceased to have much meaning. When you're paying, as New York City smokers now do, $12 for a pack of Marlboros, nearly all of that is tax; the product is, economically, an afterthought.

To hear some economists and cigarette-tax foes tell it, this situation should never have come about. They have long argued that higher taxes would encourage more people to find ways to evade or break the law. This could be as simple as driving to a place where the taxes are lower. A smoker living in eastern Washington state, where the state tax is well above the national average at $3.025 per pack, could save a lot of money by crossing the border into Idaho, where tax is well below the national average at 57 cents per pack. And thanks to mega-increases in cigarette taxes in recent years, the average tax difference between neighboring states is more than three times higher than it was in the early 1980s.

More people, then, have a theoretical incentive to hit the road for cheaper smokes. In reality, though, not many do. According to one Kennedy School study published in 2008, 40 percent of smokers live within 40 miles of another state, yet only 2 percent travel 40 miles or more to buy cigarettes. The authors conclude that the average smoker "is willing to travel 2.7 miles to save one dollar on a pack of cigarettes." For most people, the savings aren't worth more than a few minutes in the car.

Other tax evasions entail more work; bootleg cigarettes from the back of a truck, cigarettes purchased from Indian reservations, or from online outlets of varying degrees of reliability. (Evasion methods are getting more clever. The Wall Street Journal reported on the increasing popularity of roll-your-own machines at tobacco stores, which allow customers to create cigarettes that are taxed at the federal level as pipe tobacco -- one-tenth the rate of cigarette tobacco.)

Obviously, bootlegging is real, and every few weeks there are accounts of people being busted for it. As a percentage of overall American smoking activity, however, it seems modest. Reliable statistics on the prevalence of bootlegging are hard to come by, but in the 2003 version of the Census Bureau's Current Population Survey, just 0.8 percent of smokers reported buying cigarettes from the Internet, Indian reservations, or foreign countries (notably Canada). Even if that number has doubled or tripled since then, it's still not a huge portion of the 360 billion or so cigarettes consumed in this country every year.

Why do smokers tolerate tax hikes that are so out of whack with other price increases? Tax increases actually do cause some smokers (particularly younger ones) to quit and others to smoke less. Some of the taxes get paid by newly minted smokers. Secondly, rising gasoline costs in recent years have rendered useless many would-be road-trip bargain binges. Another factor, I suspect, is the self-image of many smokers. Tobacco-use surveys tell us two interesting things: A majority of smokers at any given moment are thinking about quitting, and 62 percent of smokers buy only packs, not cartons. A huge number of smokers, then, are too timid about their habit to buy enough cigarettes at a time to realize any substantial savings by going outside their normal buying outlets.

A cynical argument, frequently put forward by smokers and libertarians, is that states actually don't want too many smokers to quit, because they need the cigarette-tax revenue. There is some evidence for this. Every cigarette tax passed in recent years has been accompanied by rhetoric about getting people to quit. Yet earlier this year, the Centers for Disease Control found that of the 14 states (plus the District of Columbia) that raised cigarette taxes in 2009, none was using the additional revenue for anti-smoking efforts.

One economist (looking primarily at South Africa) has suggested that the best way to use the cost of cigarettes to get smokers to quit is to focus on affordability rather than just price. And therein, probably, lies the real answer. As punishing as recent cigarettes tax increases have been, they are not yet so high that most American smokers cannot find a way to pay for them. The question remains: How high would taxes have to go to create a far-reaching economic disincentive?

For more information, see web link:
The Washington Post September 12, 2010

NY to Ban Smoking in Times Square, Parks, Beaches

Lighting up in Times Square, Central Park and on the beach at Coney Island will become illegal under a new smoking ban announced by Mayor Michael Bloomberg.

"The science is clear: prolonged exposure to secondhand smoke - whether you're indoors or out - hurts your health. Today, we're doing something about it," Bloomberg said.

The bill must pass in the City Council, where Bloomberg has strong support.

"When this legislation is passed, all New Yorkers will be able to enjoy a walk in the park or a day at the beach without having to inhale secondhand smoke," council speaker Christine Quinn said.

"This bill will save lives and make New York City a healthier place to live," she added.

New York City has 14 miles of beaches and more than 1,700 parks, like the famous Central Park, and playgrounds.

Bloomberg, a passionate anti-smoking former smoker, braved heated opposition in 2003 to push through a ban on smoking in bars and restaurants.

The new ban would seek to eradicate smoking in popular tourist spots including pedestrian plazas such as Times Square where another Bloomberg initiative banned cars.

Violators would face fines of up to 250 dollars.

Smokers in the city, who already have to pay between 11 and 15 dollars for a packet of cigarettes, fumed.

"It's all based on an ideology of 'thou shall not smoke,'" said Audrey Silk, founder of the smokers' rights group NYC C.L.A.S.H.

"There's no scientific evidence that smoking outdoors is harming anyone else," she told AFP.

"They will have us suspend common and logical sense that tobacco smoke is a unique substance and that for everything else - we're talking exhaust fumes - there are safe levels."

A former police officer, Silk said it was impossible to chase down people sneaking a puff in places like Times Square.

"Can you imagine pulling cops off the street, instead of looking for terrorists?"

However, city council member Gale Brewer said the smoking curbs not only targeted a deadly addiction, but would make New York more pleasant.

"New York is the national leader in creating healthy cities, and promoting a healthy life style," Brewer said.

"That's why we're pushing to get butts off the beaches. And it's not just a health issue, as any beachgoer knows: despite the clean-up efforts of the Parks Department, the sand is too often used as an ashtray."

Some 7,500 New Yorkers die from smoking-related problems a year, City Health Commissioner Thomas Farley said.

One in three preventable deaths is related to smoking, while secondhand smoke causes more cancer deaths than asbestos, benzene, arsenic, and pesticides combined, the city says.

The indoors smoking ban "greatly reduced the harm that cigarettes cause to nonsmokers," Farely said. "By expanding the act to cover parks and beaches, we can reduce the toll even further."

Bloomberg, narrowly elected last year to a third term after changing the rules that would have limited him to two terms, is praised by supporters for raising quality of life in the biggest US city.

For more information, see web link:
The Independent September 19, 2010

FDA Issues Warning to E-Cigarette Makers

The Food and Drug Administration warned five makers of electronic cigarettes that they were violating federal law.

The agency said the products, devices that turn nicotine liquid into a vapor mist that users inhale, are drugs that—like other nicotine-replacement products—require FDA approval before they can be marketed. The FDA recently started regulating conventional cigarettes under a separate tobacco law.

The FDA said the e-cigarette companies are marketing their products as tools to help people quit using cigarettes. The agency suggested the companies would need to conduct clinical studies showing the products are an effective treatment for nicotine addiction.

The companies receiving warning letters were E-CigaretteDirect LLC of Parker, Colo.; Ruyan America Inc. of Minneapolis; Gamucci America, also known as Smokey Bayou Inc., of Jacksonville, Fla.; E-Cig Technology Inc. of Las Vegas and Johnson's Creek Enterprises LLC of Johnson, Wis.

The five companies represent a small portion of the estimated 300 firms that make or distribute electronic cigarettes.

William Bartkowski, president of Ruyan America, said the company hasn't distributed nicotine-containing products since last year because of the regulatory uncertainty. However, the company sells a product called the Ruyan RAPP E-Mystick that contains an herbal supplement. Mr. Bartkowski said the company would respond to FDA's letter.

The FDA said it also cited Johnson Creek Enterprises, which markets Smoke Juice, a liquid solution used to refill depleted cartridges in e-cigarettes, for deficiencies in its manufacturing processes and cited E-Cig Technology for using tadalafil, an erectile dysfunction drug, and rimonabant, a weight loss drug that's not approved for use in the U.S., in some of its products.

Johnson Creek didn't respond to a request for comment, and E-Cig Technology and Gamucci America couldn't be reached.

Keith King, the sales manager for E-CigaretteDirect, said the company doesn't promote its e-cigarette products as stop-smoking aids.

The companies have 15 days to respond to the FDA.

Michael Levy, director of labeling compliance for FDA's drug division, said the agency would wait to see what the company responses were before deciding what to do next. However, he said the FDA believes the products containing tadalafil and rimonabant should be pulled from the U.S. market.

The agency could act to remove e-cigarettes from the market, but it would likely involve a court fight.

"We have not made a decision to remove all e-cigarettes from the market," Mr. Levy said.

The FDA is already involved in a separate lawsuit with other e-cigarette companies that involve the agency's jurisdiction over the products. In 2008 the FDA started detaining some shipments from China on the grounds that they were unapproved drug devices.

Mr. Levy said the FDA can't discuss that lawsuit.

The agency also sent a letter to the Electronic Cigarette Association, the industry's trade group, outlining the steps companies can take to file for agency approval of electronic cigarettes.

"FDA invites electronic cigarette firms to work in cooperation with the agency toward the goal of assuring that electronic cigarettes sold in the United States are lawfully marketed," the letter said.

For more information, see web link:
The Wall Street Journal September 9, 2010

Another CDC Survey Finds Youth Smoking Declines Have Slowed, Underscoring Need to Step Up Tobacco Prevention Efforts

The 2009 National Youth Tobacco Survey released today by the Centers for Disease Control and Prevention provides further evidence that the United States has made dramatic progress in reducing youth smoking, but the rate of decline has slowed significantly in recent years.

Like other recent surveys, this survey sends an unmistakable message to elected officials at all levels: We know how to win the fight against tobacco – the nation's number one cause of preventable death – but our progress is at risk unless we resist complacency and step up efforts to implement proven strategies. These include well-funded tobacco prevention and cessation programs, higher tobacco taxes, smoke-free air laws, and effective regulation of tobacco products and marketing. Our nation is at a crossroads in the fight against tobacco. If elected leaders provide the resources and political will to aggressively implement these solutions, we can achieve one of the greatest public health victories in our nation's history. If they fail to do so, the nation's progress against tobacco could end and even be reversed.

The new survey again demonstrates that we know how to dramatically reduce tobacco use. Between 2000 and 2009, cigarette smoking rates declined by 39 percent among high school students (from 28 percent to 17.2 percent who have smoked in the past 30 days) and by 53 percent among middle school students (from 11 percent to 5.2 percent). There were also large declines in the percentages of high school and middle school students who were current users of any tobacco products or who had ever experimented with cigarettes. Between 2006, when the survey was last conducted, and 2009, the survey found that smoking rates declined from 19.8 percent to 17.2 percent among high school students and from 6.3 percent to 5.2 percent among middle school students. However, the CDC reported that these overall declines were not statistically significant, although there were statistically significant declines in smoking among both high school and middle school girls.

Why have smoking declines slowed in recent years? The CDC and other experts have cited several factors, including large cuts in funding for state tobacco prevention and cessation programs and the tobacco industry's continued heavy spending to market its deadly and addictive products. Between 2008 and 2010, states cut funding for tobacco prevention programs by 21 percent, from $717.7 million to $567.5 million. In contrast, the tobacco companies spent $12.8 billion on marketing in 2006 (the latest year for which data are available), and the bulk of it is spent on price discounting that has kept cigarette prices flat despite tax increases.

The challenge for elected leaders today is to finally fight tobacco use with the political will and resources that match the scope of the problem. All levels of government must do more:

At the federal level, the FDA must effectively exercise its new authority to regulate the manufacturing, marketing and sale of tobacco products. In addition, the Obama Administration and Congress must implement a national tobacco prevention and cessation campaign. The Prevention and Public Health Fund created as part of the health care reform law provides one opportunity to do so.

The states must use more of the billions of dollars they collect from the 1998 tobacco settlement and tobacco taxes to fund tobacco prevention and cessation programs. In addition, they must continue to increase tobacco taxes and enact comprehensive smoke-free laws that apply to all workplaces and public places.

Despite the progress we have made, tobacco use still kills more than 400,000 Americans and costs $96 billion in health care bills each year. We cannot declare victory until we have eliminated the death and disease caused by tobacco.

For more information, see web link:
PRNewswire August 26, 2010

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