Sir John Crofton (1912-2009)

One of the world’s most eminent medical doctor’s, died earlier this week in his home city of Edinburgh, Scotland, at the age of 97. Sir John Crofton had a great many notable achievements during his dazzling career but he is perhaps most noted for his pioneering work developing effective treatment for pulmonary tuberculosis. He was Professor of Respiratory Diseases and Tuberculosis, University of Edinburgh, 1952-77, and Chairman of the International Union against Tuberculosis and Lung Disease, 1984-88. Millions of people, from Scotland and the rest of the world, benefitted from his enormous influence in tackling TB. In the 1950s TB was one of the major global public health problems (my grandmother died from it in Scotland when my mother was a child) but nowadays, partly thanks to Sir John Crofton’s work, it is largely controlled across most of the world. Sir John published an interesting account of those pioneering days in a recent paper in the Journal of the Royal Society of Medicine:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1592068/?tool=pubmed

His work covered other areas of public health, and as a respiratory doctor he naturally took a great interest in trying to reduce the massive health effects of tobacco smoking. He was a co-founder of Action on Smoking and Health (ASH) in the United Kingdom and Scotland, an organization which has made a major impact in reducing smoking in that country.

My own contact with Sir John was brief, but left an impact. In 1994 I was a young clinical psychologist, still fairly early in a career doing research on smoking cessation at St George’s Hospital Medical School in London. I was very surprised to receive a letter, (which appeared to have been typed on an old-fashioned type-writer….quite unusual even at that time) from Sir John Crofton (and Sir Richard Doll, another major figure in global public health), inviting me to write a chapter on smoking cessation for their planned special edition of the British Medical Bulletin on Tobacco and Health. Of course I agreed immediately, and was very impressed by how quickly (and very politely) these two extremely busy scientists turned around my chapter and produced an excellent book on tobacco and health. I believe it has now been translated into other languages and the English version of the chapters is available online: http://www.ncbi.nlm.nih.gov/pubmed/8746304 .

For a fascinating account of Sir John Crofton’s life and achievements, check out this interesting obituary:
http://www.independent.co.uk/news/obituaries/sir-john-crofton-physician-whose-research-revolutionised-the-treatment-of-tuberculosis-and-lung-disease-1814817.html

Labels: jonathan foulds, Sir John Crofton, smoking cessation, TB, tobacco and health

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A Classic Study: The lung Health Study

Every now and again I like to pick one of the classic research studies on smoking cessation in order to highlight some of the key findings. Today I’m going to focus on the part of the Lung Health Study.

The Lung Health Study is certainly one of the best smoking cessation studies ever carried out, partly because of the comprehensive nature of the assessment and follow-up of its 5,887 participants and partly because it was way ahead of its time in delivering a truly “state-of-the-art” intensive smoking cessation intervention which was compared in a randomized manner to the effects of “usual care”. The Lung Health Study (LHS) was a randomized clinical trial of smoking cessation and inhaled bronchodilator therapy in smokers 35 to 60 years of age who did not consider themselves ill but had evidence of mild to moderate airway obstruction. Almost 4,000 of the participants were randomly allocated to receive a very intensive smoking cessation intervention consisting of group treatment (12 group meetings over 10 weeks), combined with aggressive use of nicotine gum. Patients’ partners were also allowed to attend for treatment, patients were encouraged to attend for retreatment if they did not quit, and were provided with ongoing relapse prevention over the 5 years of the study. They were also encouraged to continue using the nicotine gum for as long as it was helpful, and to use it even if still smoking in order to get quit. This excellent intervention resulted in 35% quit rates at the end of the first year and 22% remained sustained quitters at 5 year follow-up (compared to 9% and 5% in the “usual care” group.

This cohort was followed up for 15 years and dozens of excellent research papers have been published describing the health effects and the factors associated with quitting smoking. But one of the key results was that when they did the 15 year follow up they found that significantly more people who had been randomized to receive the smoking cessation intervention were still alive, as compared to those who were randomized to “usual medical care”. At face value this may not sound so surprising but unlike most studies of smoking and mortality this was based on analysis of a randomization to smoking-cessation treatment versus no treatment and shows that those getting smoking cessation treatment had better survival, even though the long term sustained quit rate was only 22%. So if you want proof that intensive smoking cessation treatment saves lives, this is the study that proves it.
The authors of the study estimated that the unit cost for providing the smoking cessation treatment and relapse prevention program in this study was $2,000 per patient. In comparison to almost every other healthcare intervention, this is incredibly good value for a life-saving intervention. Just for comparison, the Tobacco Dependence Clinic at UMDNJ-School of Public Health tries to provide a similarly intensive treatment for over 500 new patients per year on $102,000 of funding (i.e. $200 per patient). Although I feel that a unit cost in the range of $500-$2000 is more realistic when all the costs are included, this shows that quality smoking cessation treatment, similar to that provided in the Lung Health Study, can be provided relatively efficiently outside of a research context.

The Lung Health Study provides an excellent guide to providing quality smoking cessation treatment and the health outcomes that can be obtained.

Anthonisen NR, Skeans MA, Wise RA, Manfreda J, Kanner RE, Connett JE; Lung
Health Study Research Group. The effects of a smoking cessation intervention on
14.5-year mortality: a randomized clinical trial. Ann Intern Med. 2005 Feb
15;142(4):233-9.

Anthonisen NR, Connett JE, Kiley JP, Altose MD, Bailey WC, Buist AS, Conway WA
Jr, Enright PL, Kanner RE, O'Hara P, et al. Effects of smoking intervention and
the use of an inhaled anticholinergic bronchodilator on the rate of decline of
FEV1. The Lung Health Study. JAMA. 1994 Nov 16;272(19):1497-505.

Foulds J, Gandhi KK, Steinberg MB, Richardson D, Williams J, Burke M, Rhoads GG. Factors associated with quitting smoking at a tobacco dependence treatment clinic. American Journal of Health Behavior 2006; 30:400-412

Labels: cessation, cigarette smoking, jonathan foulds, Lung Health Study, mortality, nicotine dependence treatment, tobacco dependence treatment

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More adolescent smokers becoming addicted to menthol cigarettes

I have previously written about the increasing evidence that smokers of menthol cigarettes find it harder to quit. (You can find previous posts on menthol by typing “menthol” in the “Search health experts” box on the right). Today I want to highlight the growing evidence that a higher proportion of adolescent smokers are smoking menthols and that those who so, get addicted quicker.

Some of the best evidence for this phenomenon was contained in a paper published by colleagues here at UMFNJ-School of Public health, Drs Olivia Wackowski and Cristine Delnevo. They analyzed the results from the 2004 National Youth Tobacco Survey, which contained data from a nationally representative sample of over 13,000 U.S. high school students. They found that 46% of all HS smokers smoked menthols, but that percentage was higher for 9th graders (59%) than for 12th graders (46%). 88% of African American teen smokers smoked menthols. The menthol smoking teens were also significantly more likely to say that they felt a need for another smoke within an hour of their last cigarette and that they experience cravings for cigarettes, even when controlling for other differences between the groups. For example, while a quarter of non-menthol smoking teens reported experiencing cravings, over a third of menthol smoking teens experienced cravings.

Another similar study by James Hersey and colleagues found very similar results and suggested that menthol cigarettes are becoming a starter product for youth. A resent paper by Kreslake and colleagues analyzed tobacco industry documents and found evidence that the tobacco industry has learned that young smokers prefer a medium menthol taste, which helps mask the harshness of nicotine but doesn’t contain too strong a menthol flavor. Brands that have followed this strategy have become dominant in the young menthol smoker segment, leading to long term growth in market share. When this evidence is combined with the evidence that many menthol smokers find it harder to quit smoking (discussed previously), it provides even stronger reason for the FDA to consider regulating menthol as an additive in cigarettes.

References.
Hersey JC, Ng SW, Nonnemaker JM, Mowery P, Thomas KY, Vilsaint MC, Allen JA,
Haviland ML. Are menthol cigarettes a starter product for youth? Nicotine Tob
Res. 2006 Jun;8(3):403-13. PubMed PMID: 16801298.

Kreslake JM, Wayne GF, Alpert HR, Koh HK, Connolly GN. Tobacco industry
control of menthol in cigarettes and targeting of adolescents and young adults.
Am J Public Health. 2008 Sep;98(9):1685-92. Epub 2008 Jul 16. PubMed PMID:
18633084.

Wackowski O, Delnevo CD. Menthol cigarettes and indicators of tobacco
dependence among adolescents. Addict Behav. 2007 Sep;32(9):1964-9. Epub 2006 Dec
22. PubMed PMID: 17229528.

Labels: addiction, adolescent, cigarette, cigarette smoking, jonathan foulds, menthol, Olivia Wackowski, youth

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Are tobacco manufacturers secretly controlling nicotine levels?

This morning I noticed a news article in the online version of the Swedish/English newspaper, “The Local’ discussing claims that the Swedish tobacco Company “Swedish Match” had added a secret substance to some of their snus (Swedish moist snuff) products to make them more addictive. The article went on to document that the company acknowledges that it has introduced some new brands with higher nicotine levels, in response to “consumer demand”.

The article mentions that Swedish match deny adding a secret ingredient to make their products more addictive and quotes a Swedish Match official as saying that,

”We use it to stabilise the pH value in snus and have done so for 200 years,” (SM information director Henrik Brehmer).

Whenever I see articles like this I have to scratch my head a little bit and wonder what is new here? It is surely not a new idea that tobacco companies are designing their products to ensure that users will become or remain addicted to them. That is pretty much the entire basis for their whole industry! On the one hand news media try to sensationalize this from time to time by referring to “secret additives” and "spiking “ the product with nicotine, and on the other hand the tobacco industry representatives try to avoid use of words like “addictive’ and make it all sound like some natural or traditional production process that has nothing to do with nicotine levels or addiction. So let’s decode the quote from the SM representative. He pretty much admitted using an additive to control the pH of the product. It’s a widely known fact that the pH of the product is one of the main determinants of how much “free nicotine” is available in the product…..this being the form of nicotine that can easily be absorbed in the human body. Even fairly small adjustments to the pH of a smokeless tobacco product can cause a tenfold difference in the amount of nicotine the typical user will absorb. He referred to it as “stabilizing” the pH, but that means nothing as manufacturers always want to “stabilize” their products as a matter of quality control. It’s not a denial that they want to stabilize the pH at a level high enough to cause the user to get addicted to the high nicotine delivery.

But the issue of whether they are using a “secret” substance to control the pH or not doesn’t seem particularly important unless that substance is harmful in some other way. There’s really no surprise that they use additives to control pH and hence nicotine delivery. In fact I am much more surprised when a tobacco company fails to increase the pH of its product sufficiently to deliver an adequate dose of nicotine (as in the recent case of Marlboro Snus being test marketed in the USA).

So let’s get real. Tobacco companies are in the nicotine addiction business. They have known it for over 40 years and we have known it for over 20. They will typically develop products designed to deliver a dose of nicotine that consumers demand (i.e. get addicted to). Not everyone is the same, and so their products will vary in their nicotine delivery. I would expect any successful tobacco product to be able to deliver enough nicotine to sustain addiction. What I’m not so sure about is whether enabling a product to deliver much more nicotine than that will necessarily result in it being more addictive. It may just mean that the user ends up taking fewer “doses” because they can get more from each one (which may or may not cause it to be more addictive). The main thing we can be confident about is that so long as a product is capable of delivering a sufficient dose of nicotine to sustain addiction (at minimum an increase in blood nicotine concentration of around 8 ng/ml within 10-15 minutes of a standard unit dose), then each consumer will be able to use that product flexibly to meet their nicotine needs (i.e. to maintain their addiction). The nicotine patch delivers a higher “dose” of nicotine but the speed of delivery is too slow to produce reinforcing psychoactive effects and so is not addictive. For most users, 2mg nicotine gum doesn’t deliver enough nicotine fast enough to be satisfying/addictive (it gets a boost of 4-5 ng/ml in 20-30 minutes). Of course some users will use a lot of 2mg gum and put up with the taste for long enough to get addicted, but most do not. Incidentally, nicotine gum also has an alkaline additive to “stabilize” its pH and hence nicotine delivery.

Everyone considering using a nicotine delivery product, whether it be snuff, cigarettes or nicotine gum, should be aware that nicotine can be addictive and that the rate and amount of nicotine delivered will determine how satisfying (addictive) the product will be once you are used to it. Generally, smoked tobacco products are in a different league both in terms of speed of nicotine delivery and amount of harm done to the body, because the nicotine is delivered in smoke (along with 4000 other chemicals) directly into the lungs. Smoked tobacco is more addicting and MUCH more harmful. Generally the pharmaceutical nicotine replacement products are less addictive (satisfying) as they are designed to be used for a temporary period to help get you off cigarettes. Part of that design includes lower and slower nicotine delivery. Many researchers and clinicians feel that current nicotine replacement medications deliver too little nicotine too slowly to satisfy more highly addicted smokers. We are concerned that those smokers will either continue to smoke (and to die from it) or will switch to higher delivery smokeless tobacco products, rather than quitting tobacco altogether.

Tobacco companies definitely control the nicotine in their products and (via pH control) the nicotine delivered by their products. Its critical to their business.

Here is a link to the news article:
http://www.thelocal.se/22864/20091025/

Here is a link to a Journal article on nicotine delivery from Marlboro Snus.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2288606/

Labels: addiction, jonathan foulds, marlboro snus, nicotine, Nicotine Replacement, snus, spiking, Swedish Match

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Secondhand smoke causes heart attacks

Last week the U.S. Institute of medicine (IOM) released a new report on the role of exposure to other people’s cigarette smoke in increasing the risk of coronary artery disease and heart attacks.

The IOM requested a 10-member expert committee to review the evidence on the effects of secondhand smoke (SHS) and bans on smoking in public places on rates of heart attacks. When evaluating the effects of bans on smoking in public places, the committee focused on 11 studies that they felt had the best methodology for evaluating these effects. All 11 of these studies reported a reduction in the rates of heart attacks after a ban on smoking in public places was implemented. However, the size of the effect varied considerably from study to study (from a 6% reduction to a 47% reduction in heart attacks).

So what does this mean? Here are some of the practical implications:

- if you are a smoker, it’s important that you are aware that if you smoke near other people (i.e. to the extent they can small smoke), the smoke you leave in the air will harm the health of those other people in various ways, including increasing their risk of a heart attack.
- If you place yourself in a situation where you have to breath other people’s cigarette smoke, it will damage your own health and increase your risks of having a heart attack.
- If your state has not yet passed legislation banning smoking in all workplaces (and bars and restaurants are workplaces) then it is putting the health of those workers at risk.
- Cities and states that have passed legislation banning smoking in public places have generally seen a 20-30% reduction in the rate of heart attacks.
- Allowing smoking inside your home puts the health of all those living at home at risk.

The summary of the report, as well as the full report itself can be found online at:

http://www.iom.edu/en/Reports/2009/Secondhand-Smoke-Exposure-and-Cardiovascular-Effects-Making-Sense-of-the-Evidence.aspx

Labels: clean indoor air, environmental tobacco smoke, jonathan foulds, secondhand smoke, SHS, smoking ban, tobacco smoke pollution

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