Is cannabis smoking more harmful than cigarette smoking?

A study published in the journal, Thorax, recently hit the headlines as demonstrating that smoking a cannabis joint was at least twice as harmful to lung function as smoking a cigarette. So what are the dangers of smoking cannabis and how do these risks compare to those of smoking tobacco?

Firstly, we can’t ignore the fact that in most places and circumstances possession of cannabis is a criminal offence with potentially serious legal consequences and testing positive for cannabis use in the workplace can seriously harm your career. That being said, it is difficult to tease out the health effects of cannabis smoking, partly because almost all cannabis smokers are or have been tobacco smokers as well. The recent study compared lung effects on four groups, each consisting of around 80 volunteers: 1. Cannabis users (at least a joint a day for 5 years), 2. Cigarettes only smokers (at least 20 per day for at least a year), 3. Those who smoke both cigarettes and cannabis and 4. Never smokers. When they scanned the lungs for evidence of emphysema they found that only 1% of the cannabis only users had emphysema, as did 19% of the cigarette smokers, 16% of those using both cigarettes and cannabis and 0% of the never smokers. This appears to show that although cannabis smoking worsens lung function, structural damage is common only with cigarette smoking. This finding likely reflects the different ways in which the products are used. A cannabis joint is typically smoked with greater intensity, with larger puff volumes and breath holding, leading to greater smoke and carbon-monoxide exposure than from a single cigarette (hence the greater impact on lung function on a per-smoke basis). However, while most regular cannabis smokers will smoke less than 5 joints per day, most regular cigarette smokers will typically smoke over 15 cigarettes per day. So the overall smoke exposure is typically much greater with tobacco than with cannabis and this is a likely reason for the greater occurrence of tobacco-caused illness.

Chronic cannabis use is associated with the following health effects:
Increased risk of developing a psychotic illness
Respiratory diseases (e.g. bronchitis) and impaired lung function
Dependence (and an associated withdrawal syndrome)
Subtle disturbances of memory and attention
Cannabis use may also be associated with other health problems (e.g. lung cancer, and birth defects in children whose mother smoked cannabis during pregnancy) but the evidence is less clear for these problems.

Tobacco smoking, on the other hand, has been proven to cause a long list of diseases, including the three main causes of premature death: lung cancer, COPD and cardiovascular diseases. The status of tobacco as a legal form of drug use, its less marked psychological effects (e.g. not impairing judgment and driving ability), and the relatively short half-life of the active ingredient (nicotine half-life= 2 hours, versus days for THC) all lead to the tendency for users to take it very frequently (e.g. 15-20 cigarettes per day) and for a very long time (typically starting in teenage years and continuing daily into old age). Cannabis, on the other hand, is more commonly used either less than daily or once or twice per day, and users typically cease use prior to middle age.

So if one is to compare the health effects under typical use conditions, tobacco smoking is much more harmful to health. However, if one were to compare the effects on a “per smoke” basis then the two are likely of similar harmfulness, with cannabis having greater adverse psychological effects.

The human body was not built to inhale smoke of any kind, and whether it’s the result of burning tobacco, cannabis or lettuce, inhalation will cause damage in proportion to the quantity inhaled.

Labels: cancer, cannabis, emphysema, marijuana, psychosis

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Could smoking reduction improve your health?

Although around 70% of smokers say they would like to quit smoking, many are not planning to try to quit within the next six months. A sizeable minority are more attracted to the idea of reducing smoking rather than quitting altogether. It is also true that with increases in the cost of cigarettes and restrictions on smoking in public places, many smokers are having to reduce their smoking, whether they like it or not.

However, is there a health benefit from reducing the number of cigarettes smoked? Now this may sound like a silly question. Most of us are aware that there is a clear “dose-response” relationship between the number of cigarettes smoked and the risk of suffering from a disease such as lung cancer. But we must remember that most of the people in these studies were smokers smoking at their natural rate. A person who has always smoked 10 cigarettes per day may not be like someone who smoked 20 per day and then reduced to 10 per day. One of the effects we know about is that people who cut down their daily consumption tend to increase the amount they inhale from each cigarette. In fact it is not difficult to suck two or three times as much smoke out of a cigarette by simply inhaling more deeply and taking more puffs per cigarette. Clearly if someone inhaled twice as much smoke out of each cigarette we would not expect any health benefit from cutting the number of cigarettes per day in half.

Last month, Professors Charlotta Pisinger and Nina Godtfredsen from Denmark published a comprehensive review of the medical literature on the health effects of reduced smoking (in the journal, “Nicotine & Tobacco Research”). They defined smoking reduction as reducing the number of cigarettes per day by at least 50%. Overall, they found that such a reduction may improve some respiratory symptoms, and may reduce lung cancer risks. However, on some of the “harder” outcome measures, such as performance on lung function tests, there was no improvement from reduced smoking. Perhaps most importantly, in the largest study that looked at effects on mortality, people who cut down by 50% and maintained it over 15 years were just as likely to die early as those who didn’t cut down, and of course both groups had much higher death rates than those who quit smoking.

So overall, the data suggests that the health benefits of reduced smoking are much smaller than one might expect or hope for. It is also important to recognize that most smokers find it very difficult to reduce by much more than 50% and then maintain the lower level for a long period. When stressful life events occur, there’s a strong tendency to return to the old level of smoking. It suggests to me that it makes much more sense to make a firm plan to quit smoking altogether. If something is causing you to hesitate about quitting completely on one day, then by all means make a plan to reduce prior to quitting. But its important that your reduction has a plan (i.e. a date) by which you will reach zero cigarettes per day and keep it at that. The evidence is absolutely clear that quitting smoking results in substantial health benefits, as summarized in previous posts.
http://www.healthline.com/blogs/smoking_cessation/2007/02/how-bad-is-smoking-for-health.html

Labels: cigarette, health, nicotine addiction cigarette smoking tobacco, nicotine regulation reduction smoking smokeless

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Increase cigarette tax to pay for children’s healthcare

One of the most widely supported principles of economics is that when the price of a product increases, so its consumption decreases. While there are exceptions to this rule, it holds true of most items – including cigarettes. Consequently, one of the most certain ways to reduce the consumption of cigarettes is to increase the real price for consumers. This primarily causes smokers to reduce their consumption slightly, but it also prompts more smokers to try to quit and some of them succeed. Tax revenue is always increased. The group that is most affected by the price of cigarettes is children. It has been estimated that about half of the sizeable reduction in the proportion of US youth who smoke over the past 10 years is due to the increase in the cost of cigarettes. So as a public health policy, increasing the tax on cigarettes is about as cost effective an intervention as one can find. It decreases cigarette consumption, prevents youth from becoming addicted to cigarettes, consequently reduces future healthcare costs, and actually earns vast amounts of additional revenue, rather than costing anything. The federal tax per pack of cigarettes has remained at 39 cents for 5 years and is actually a lower proportion of the cost of a pack then was the case prior to the first Surgeon General’s report on tobacco and health in 1964!

As mentioned in my previous post, the United States health insurance system is in crisis and among the innocent victims are children whose healthcare is not covered by insurance. The current safety net for such children is called the State Children’s Health Insurance Plan (SCHIP), and the current authorization for this program runs out in a couple of months – requiring passing of new legislation to reauthorize the program.

However, the federal government is currently trying to operate under the principal that legislation requiring new spending must simultaneously create or specify the source of new or additional funding to cover it. So just over a week ago a bipartisan Senate Finance Committee voted 17-4 for a bill to re-authorize and expand SCHIP and to pay for it by increasing the federal tax per pack of cigarettes by 61 cents (i.e. taking it to $1 per pack federal tax). Both Democratic and Republican Senators backed the proposal, describing it as a “win-win twofer” that funds healthcare for uninsured children and reduces healthcare costs by discouraging smoking. However, President Bush stated that he would veto the legislation because he felt it would transfer people from the private health insurance system over to “government run medicine” and would “entail a huge tax on the American people.”

So President Bush gets to stand up for the interests of the health insurance industry and the tobacco industry at the same time, while preventing uninsured sick kids from poor families accessing healthcare. Another excellent day’s work.

For further details on this story, visit:
http://www.medicalnewstoday.com/articles/77382.php

I'd love to hear your thoughts on whether you think cigarette tax increases are a fairly good way to fund new healthcare initiatives, or if you think the President is right to veto this legislation.

Labels: cigarette tax federal health insurance children

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Health insurance coverage for nicotine dependence treatment

Last night I went to see the Michael Moore movie “SiCKO” which is an expose of the problems with the U.S. healthcare system, focusing particularly on the problems with health insurance and so-called “Health Maintenance Organizations (HMOs)”. No matter what you think of Michael Moore, if you have any interest at all in your health or that of your family, and particularly if you have any interest in this nation’s health, then you should definitely see this movie.

The movie points out some of the worst aspects of the health insurance system and then compares it to the situation in countries like Canada, the UK, Cuba and France. As someone who has been both a patient and a provider in the UK and US healthcare systems I have to say I found the portrayal in the movie to be very accurate. The United States is a great country with tremendous wealth both financially and in terms of the resilience and hard work of its people. But to my mind its healthcare system is nothing short of a national disgrace. There are many areas of business in which the free market works best, but healthcare is just not one of them. A clear example of this is the existence of hundreds of doctors and other professionals employed by HMOs basically to devise reasons to deny coverage and save the company money. A number of ex HMO employees in the movie explained that they would receive bonuses based on the proportion of denials of care/coverage the achieved, setting up a bizarre situation where staff are given incentives to provide less care for sick patients.

I suspect that unless you or your family have never been sick, or you are fortunate to have good coverage through your employer, and not to have suffered from one of the numerous illnesses that are not covered, then you won’t need any further evidence from Michael Moore or myself to know that the U.S. system is entirely broken. But you may be living under the false impression that despite its problems, the U.S. system is better than most other comparable places. As the movie shows, citizens in many other (poorer) countries have access to high quality medical care 24-7 at no (or minimal) direct cost. Doctors are able to provide healthcare according to need rather than according to individual ability to pay. Moore’s portrayal is supported by cross-national surveys on the satisfaction of citizens with their health system, in which Canada and the European nations have consistently earned higher marks than has the U.S. system. Part of the problem is that U.S. healthcare is more expensive, it treats patients more intensively (overtreats?), and it is very inefficient. So the very things that a free market is supposed to be good at (achieving lower prices and higher efficiencies via competition) do not work for healthcare. Why is this? Well part of the problem (in my humble opinion) is that some rather dim-witted people have continued to base their design of the system on ideology rather than a careful but common-sense analysis of how healthcare actually works. Take the example of a medium-sized city, - say 100,000 adults with another 100,000 in a 50-mile radius. Such a city will typically have one medium sized hospital, and just about enough medical personnel to cover most (but maybe not all) specialties. The idea of letting the market compete for best value healthcare in that (fairly typical) city is clearly ridiculous. The provider has a monopoly. In some places the health insurance company may also have a virtual monopoly. Add to the mix you as an individual developing a life-threatening illness and you really do not have a situation in which the free market system is likely to work well. So you don’t have many of the most important potential advantages of a market-based system, but you do have the disadvantages of businesses (including the doctors, hospitals, insurance companies etc) seeking to maximize profit. In the end it’s the patient that suffers.

In addition to the disadvantages of the U.S. system described above and shown in the movie, to me there is one very basic thing about the psychology of illness that makes this system bad. If ever there was a time in your life that you really don’t want to have financial worries, it’s when you or a loved one is sick. The system we have in the United States is designed to maximize financial stress whenever we get sick. Everyone in this country, except perhaps the very rich, has to live with the concern that if we are unlucky enough to get a serious illness that is expensive to treat, then everything we have built for our family is at risk, not just because of the illness but because of the cost of getting it treated. In most other comparable countries of the world, the people just have to worry about the illness, not the cost of treating it.

As you may have gathered, this is one of those topics (like global warming) that is much bigger and more important than my specific area of interest: tobacco and health. But I see on a daily basis how the U.S. system does not work well with smoking cessation. Counseling smokers and providing them with an effective smoking cessation medicine is one of the most cost-effective healthcare interventions available. But most healthcare providers cannot get paid by the insurance systems for providing such interventions and most patients cannot get the costs of their treatment covered by their insurance. If you are lucky, your health insurance will pay for your coronary artery bypass operation caused by your smoking, or for your operation and chemotherapy to treat your lung cancer. Most likely this could all have been avoided if your insurance had covered your smoking cessation treatment(s) in the first place. Instead your insurer is employing staff whose job it is to think up ways to deny you coverage: “we don’t cover over-the-counter treatments like the patch”, “we don’t cover preventive interventions”, “you have $200 per year for preventive care, but having your blood pressure measured at your last visit used that up”, “there are no tobacco treatment specialists in our network”, “your policy has a $500 deductible for preventive or behavioral interventions and smoking cessation is valued at $499”, “we don’t have a diagnosis or procedure code for smoking cessation” etc etc…” but we CAN send you a leaflet that tells you how bad smoking is for your health”!

So I’d recommend that you check out the movie and let me know what you think. If you managed to get help to quit smoking provided or paid by your health insurance, I’d love to hear about it. It’s always nice to hear about the times/places where the system works well. When you are considering who to vote for in the forthcoming elections, please check out the detail of their policy on health insurance, and also find out how big a contribution they accepted from (a) Big Pharma (b) Big Managed Care and (c) Big Tobacco. By doing that and voting for candidates who appear likely to do the best job on healthcare, we might get some much-needed change.

Labels: cessation, health-insurance, HMO, michael moore, nicotine addiction cigarette smoking tobacco, sicko, treatment

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How many medical doctors smoke?

In many countries medical doctors have been at the forefront of attempts to reduce the number of people who smoke. The medical doctor is one of the most highly respected professionals and patients place a large amount of faith in their doctor’s advice. However, concerns have been expressed about the willingness of doctors who smoke themselves to advise their patients to quit, and about the likelihood of patients taking such advice seriously if they are aware that the doctor is a smoker him/herself. So what proportion of medical doctors smoke?

In the past month Drs Derek Smith and Peter Leggat published a comprehensive international review of tobacco smoking in the medical profession from 1974-2004. The study showed that in countries like the United States, UK, Canada, Australia and New Zealand, smoking rates have dropped dramatically among doctors, from 15-20% in the 1970’s to around 5% at the end of the 20th century. However, such low smoking rates are not uniform among doctors across the world. In China, 32% of male doctors smoke (but 0% of females doctors smoke), in Italy 28% of doctors smoke (32% among men), and in Turkey or Bosnia & Herzegovina around 40% of doctors smoke.

Some may be surprised to hear that as many as 5% of US doctors smoke. But remember that doctors are human beings like the rest of us, and not immune to either infections or addictions. Many smoking doctors report that they (like most smokers) started in their teen years and so were likely addicted even prior to the decision to study medicine at college. I prefer to look at the low (and still falling) smoking rates among doctors in some countries as a very positive sign. It provides an indication of how low it is possible for smoking prevalence to go in a population that is well informed of the health risks, has relatively good access to treatment, and generally works in a smoke-free environment where smoking is not considered to be socially acceptable. It suggests that 5% may be a reasonable target for the rest of the population as well.

The full report on smoking among doctors can be found at:
http://www.biomedcentral.com/1471-2458/7/115

Labels: doctors, medical, profession, Smoking, tobacco

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How many cigarettes does it take to become addicted?

Only 35 years ago, pioneering health scientists identified smoking as an addiction, and it was only as recently as 20 years ago was there scientific consensus in the public health community that tobacco smoking is typically an addiction to nicotine just like heroin addiction. (Of course the tobacco industry knew this long before). In those early days it was thought that heavy “chain smokers” were addicted, whereas light or occasional smokers were not. However, over time, studies began to reveal that even very young smokers were absorbing significant amounts of nicotine per cigarette. One of the pioneering researchers, Professor Michael Russell (also one of my PhD supervisors), stated in 1990 that, “Over 90% of teenagers who smoke 3-4 cigarettes are trapped into a career of regular smoking which typically lasts for some 30-40 years.” At that time this was quite startling news. However, while that claim was based on evidence that 4 cigarettes predict FUTURE addiction, studies by Professor Joseph DiFranza at University of Massachusetts were beginning to show that adolescents were experiencing symptoms of addiction (e.g. craving) within a few weeks of their first cigarette. This month DiFranza and colleagues published another study of the development of tobacco addiction in adolescents. This study showed that adolescents experience symptoms of nicotine withdrawal and failed quit attempts even before they have progressed to daily smokers. Some young people report loss of control of their smoking within a day or two of smoking their first cigarette. Given that it may take only a few puffs on a cigarette to initiate the development of addiction, it seems appropriate to provide young people with clearer warnings about the addictiveness of cigarettes. It also suggests that young people, including those who are not yet daily smokers, may benefit from support in their quit attempts. Of course, if you are concerned about your kids getting hooked on tobacco, then probably the best thing you can do to reduce that risk is to not smoke yourself.

Labels: adolescent, nicotine addiction cigarette smoking tobacco

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17th Surgeon General, Dr Richard Carmona joins Healthline

I was very pleased to learn that the recent U.S. Surgeon General, Dr Richard Carmona, has joined the board of directors at Healthline. Dr Carmona was a superb Surgeon General and naturally I particularly appreciated the strong stand he took against tobacco. While he was Surgeon General two of the very best Surgeon General’s Reports on Tobacco were produced. In 2004, he marked the 40th anniversary of influential 1964 Surgeon General’s report (first to conclude that smoking causes lung cancer), by leading on a comprehensive report that provided an update on all of the known health effects of tobacco smoking. Dr Carmona also showed his awareness of the importance of the internet in providing health information by developing, a pioneering interactive 3-D online program to accompany the report and inform the public about how smoking affects the different organs of the body. That version is available at:
http://www.cdc.gov/tobacco/data_statistics/sgr/sgr_2004/sgranimation/html/welcome.html

Last year as Surgeon General he also produced the very important report on The Health Consequences of Involuntary Exposure to Tobacco Smoke. This report provided authoritative evidence summaries to help support the wave of smoke-free air legislation sweeping both the United States and the rest of the world.

I had the great pleasure of meeting Dr Carmona while he was the Surgeon General when he gave the keynote speech and received an honorary Doctor of Humane Letters degree (in recognition of his leadership in advancing the nation's public health and preparedness) at the 2004 graduation ceremony of the University of Medicine and Dentistry of New Jersey. Despite his extremely busy schedule, Dr Carmona took the time to record a special video message for attendees at a tobacco conference we were holding at the university a few days later:
http://www.tobaccoprogram.org/conf04.htm

You can learn more about Dr Carmona and his appointment at:
http://www.healthline.com/corporate/news/healthline_announces_richard_carmona.html

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Thanks to Grand Rounds 3.42

I want to thank Tara C. Smith at Aetiology for hosting Grand Rounds 3.42 this week and including my post on advice for consumers on the use of nicotine replacement therapy.

Grand Rounds 3.42 is live on Aetiology at http://scienceblogs.com/aetiology/2007/07/grand_rounds_342_1.php.

Labels: Grand Rounds Nicotine Replacement

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A Year of Smoking Takes 3 Months Off Your Life

Last Friday (July 6th) a new paper was published in the British Medical Journal by two British experts on smoking cessation: Dr Paul Aveyard and Professor Robert West. That paper primarily aimed to inform health professionals of the best ways to help their patients quit smoking. While the report contained many points that readers of this blog will be familiar with, there were a few new points (for me anyway) that are worth highlighting.

The first thing that struck me was the statement that, “Every year that smoking cessation is postponed after the age of 40 reduces life expectancy by three months.” Although the health effects of smoking are many and varied, that simple statement summarizes the evidence in a simple but impactful way. You might ask, “So what is that based on?” The citation for the statement is the 50-year follow-up study of 40,000 male British doctors, published by Sir Richard Doll and colleagues. That study found that although smokers who quit by age 35-40 were likely to live about as long as never smokers, those who continued to smoke typically died 10 years younger than never smokers. Someone who quits at age 35 is therefore likely to live to be around 85, whereas if that person continues to smoke they are more likely to die at around 75. So if that extra 40 years of smoking costs you 10 years of life, that’s consistent with losing 3 months for every year of smoking.

The authors also presented some data on the likelihood of a person succeeding in quiting smoking by age 50, assuming they try once a year starting at age 35. If the smoker just tries on their own each year, without any special assistance, there’s about a 50% chance they’ll be quit by age 50. If they use an FDA-approved smoking cessation medication each quit attempt (e.g. nicotine replacement or Chantix), there’s about a 75% chance they’ll be quit by age 50. If they use an approved cessation medication and get specialist counseling with each quit attempt, there’s about a 95% chance they will have succeeded in quitting, for good by age 50.

Now, given that by delaying success in quitting smoking from age 35 to 50 will already have cost a few years in life expectancy, I’d advise all smokers to go directly for the most effective treatment (counseling plus meds), and if it doesn’t work first time just keep trying until it does. If you use recommended treatment and keep trying to quit, the chances are very high you’ll succeed in quitting for good within the next 15 years.

The Aveyard and West paper can be downloaded from: http://www.bmj.com/cgi/content/full/335/7609/37

Best of luck.

Labels: cessation, nicotine addiction cigarette smoking tobacco

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Tobacco and Global Warming

Having spent most of my professional career focused on activities that ultimately aim to reduce the harm to health caused by tobacco, you won’t be surprised to hear that I believe its one of the most important issues affecting human health. But every now and again even I have to admit that there are a few things that are going to have an even greater impact on the health of people on planet earth. One of those is clearly the increased pollution of our planet and the consequent climate change.

Last summer, I took my eldest daughter (Georgia) to see the Al Gore movie, “An Inconvenient Truth”. We found it very convincing and whether you like Al Gore or not, I’d recommend that you get it out on DVD and watch it with your family if you havn’t seen it already. Even if you don’t like the statistical stuff, its hard to argue with photographs of massive lakes that have dried up, glaciers that have melted and polar bears that have all but run out of ice. Of course in the United States some people can’t get past the politics (i.e the fact that Gore is a Democrat) and so think this global warming stuff is probably just some liberal, left-wing, tree-hugging, anti-business, mumbo-jumbo propaganda. It would be great if that’s all it is. Unfortunately the evidence is crystal clear. 22 of the hottest years ever recorded on the planet have occurred since 1980 and 2005 was THE hottest ever. This website provides some of the evidence:
http://www.pewclimate.org/global-warming-basics/basic_science/

In the last few years the world’s top scientists have reviewed the evidence and have come to the conclusion that not only is the planet heating up but that human activities (primarily burning fossil fuels and other activities emitting greenhouse gases) are the cause (rather than just some random fluctuation). I’m no expert so I wouldn’t want you to take my word for it, but feel free to check out what the experts think:
http://en.wikipedia.org/wiki/Scientific_opinion_on_climate_change

So what can we do? Again I’m no expert, but this site has useful suggestions and information: http://www.climatecrisis.net/takeaction/

My own personal opinion is that suggestions that we all drive less, take the bike/bus etc are too inconvenient to follow and so people just won’t. Just like with tobacco, it’s really all about money and power. So I think the most important thing we can do as individuals is find out more about this threat to our families and our world, do our best to consider the environmental impact of the products we buy, but most importantly, only vote for politicians who are taking this thing seriously and are willing to implement policies that move us towards a solution. This goes all the way from your local township (can kids and adults walk or safely ride their bike around the neighborhood, or do the sidewalks stop and the end of the development so we all need to drive wherever we go?) all the way up to the presidential elections (who took the most funding from the oil companies and hired former oil company folks as “advisers”?).

So what does all this have to do with tobacco? To be honest, not a lot. I just thought that on this day (07/07/07) when the issue is being raised via the Live Earth concerts it deserved a mention on its own merits. There are, however, a couple of links to tobacco. One is of course the similarity between big tobacco and big oil. We can be certain that the big oil companies will be using all their (considerable) influence to prevent proper steps being taken on this issue, while simultaneously trying to do a good PR job of seeming warm and fuzzy. The other relevance is the fact that tobacco is itself a major cause of environmental pollution, both from the cigarette smoke itself and even more so from the industrial processes involved in bringing cigarettes to market.

For more information on tobacco’s environmental effects check out this site:
http://www.ash.org.uk/html/factsheets/html/fact22.html
If you needed another reason to quit smoking, this should give you one.

Labels: Global warming, tobacco

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Celebrate your independence from tobacco

Here in the United States, the 4th of July is the day Americans celebrate their independence from Great Britain. It was on this day in 1776 that the 12 colonies agreed on the text of the Declaration of Independence and the first copy was signed by John Hancock (President of the Congress). It is certainly appropriate to celebrate the birth of this great nation and I hope everyone in the U.S. (and Americans abroad) enjoys their barbeques and fireworks today.

However, I think it is also appropriate for all of you who have at one time been addicted to tobacco and managed to quit, to take a moment to celebrate your own independence on this day. Giving up smoking is no easy thing to do and many of you will have taken many attempts before finally succeeding.

There is also some irony in celebrating your independence from tobacco on the 4th, because in fact this great nation was partly built on the proceeds from tobacco farming. In 1609, John Rolfe arrived at the Jamestown Settlement in Virginia. He is credited as the first man to successfully raise tobacco for commercial use at Jamestown, having brought the preferred Nicotiana tabacum seeds with him from Bermuda. . Shortly after arriving, his first wife died, and he married Pocahontas, a daughter of Chief Powhatan. Rolfe made his fortune farming and exporting tobacco. In the 17th century the English government increased import taxes on tobacco by 4000 percent, (increasing dissatisfaction among colonists and moves towards independence). During its first century after independence, tobacco taxes accounted for a third of the internal revenue collected by the US government.

The need for cheap labor to drive the profitable tobacco industry was also a primary reason for the introduction of slavery in the south. At the time of the signing of the Declaration of Independence, almost 50% of the population of Virginia were African slaves, numbering almost half a million by 1860. So the first colony in America (Virginia), the introduction of slavery, and the opposition to British taxes were all largely based around the growth of the tobacco industry.

So here we are on 4th July 2007. Those who have achieved mental and financial independence from tobacco should give themselves a pat on the back for succeeding in freeing themselves from this most deadly addiction. For those readers who are still smoking, what better day to make your own personal declaration of independence?

Labels: declaration, dependence, independence, nicotine addiction cigarette smoking tobacco

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Wearing the patch prior to quitting may help

If you buy a box of nicotine patches, you will notice that the instructions for use and warnings advise against wearing the patch while taking nicotine from any other source. Many smokers interpret this as implying that something terrible will happen if they kept the patch on while smoking, and consequently when they have a lapse cigarette then often decide to take the patch off (and so obey the instructions on the box).

However, numerous studies have shown that nothing terrible happens when you smoke while wearing the patch. 15 years ago I published a study in which 30 smokers smoked normally for 2 weeks, and wore full strength nicotine patches for one of those weeks and placebo patches for the other. The smokers generally couldn’t tell which week was the week with the nicotine patches and the single participant who vomited did so while wearing placebo patches! So it appears to be very unlikely for smokers to experience adverse events caused by wearing the patch while smoking.

However, some recent studies have actually suggested that wearing the patch for a few weeks prior to the target quit date may actually increase the chances of a successful quit. One such study was carried out by Dr Schuurmans and colleagues in South Africa. They found that people who wore nicotine patches for two weeks prior to their quit day had better long term quit rates than smokers who wore placebo patches for two weeks prior to their quit date (22% vs 12% quit, 6 months later).

Interestingly, studies of the use of other forms of nicotine replacement therapy by smokers not intending to quit have also found that not only does the NRT help them to reduce their cigarette consumption, but that a significant proportion of them go on and quit completely. One such study was carried out by Dr Batra and colleagues in Germany. They recruited over 300 smokers who were interested in cutting down but not quitting. They were provided with either 4mg nicotine gum or placebo gum for a year. As well as helping with smoking reduction, the group receiving the nicotine gum had significantly more people who were quit 13 months later (12% versus 5%).

We are not clear on the mechanism whereby combining NRT with smoking prior to quitting may help subsequent cessation. It may simply be that it loosens the associations between smoking and reinforcement (by providing nicotine separately from smoking). Just to be clear, the use of NRT prior to the quit date is not yet normal practice, and may never become so. My current practice is to advise patients using the patch to put their first patch on the morning of their quit day and not before (as suggested on the box). However, as more evidence is gathered on the safety and effectiveness of NRT pre-treatment, I may have to reconsider.

Labels: cessation, nicotine, pre-treatment, replacement, Smoking

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