State-specific prevalence of cigarette smoking.

In previous posts I’ve discussed international differences in tobacco use, which showed that by international standards, male cigarette smoking prevalence is relatively low in the United States, but female smoking prevalence is higher in the US than most other parts of the world. The clearest contrast is with a countries like China, where almost two-thirds of men smoke, but only a few percent of women smoke.

On Friday (Sept 28th, 2007) the US Centers for Disease Control published the latest (2006) figures for adult cigarette smoking prevalence within each U.S. state. The median prevalence was 20.2%, but consistent with recent years, there were some large between-state differences. The highest smoking rates were in tobacco-growing states such as Kentucky (28.6%), or West Virginia (25.7%). The lowest smoking rates were in places with strong cultural prohibitions against tobacco such as Utah (9.8%) and California (14.9%).

Overall, the median smoking rates were higher for men (22.2%) than for women (18.5%). Although it is probably unwise to make too much of single-year prevalence estimates for relatively small geographic regions, such as individual states, I like to look at these to see if anything potentially interesting pops out. The California figures are always of interest as a guide to how low we can go in the rest of the United States. Although the low smoking rates in California are partly related to the high number of non-smoking immigrants to that state, they are largely due to California’s comprehensive tobacco control program that was the first to be reasonably well funded, to increase cigarette taxes, and to pass legislation requiring smoke-free indoor public places. The California program also used a hard hitting media campaign to publicize the harmfulness of tobacco smoke (including to non-smokers), and to encourage smokers to try to quit.

Kentucky provides us with a good example of what happens in a state where the tobacco industry dominates the political agenda – you get very weak tobacco control and very high smoking rates. One thing that stood out was the low smoking rate in Idaho (16.8%). I must say I have no idea why Idaho’s smoking rates are so low, but would be grateful if someone could tell me! The other odd thing I noticed was that despite the fact that men generally smoke more than women, in two states that wasn’t the case. In West Virginia 25.4% of men smoke cigarettes and 26% of women smoke them, and in Montana 18.5% of men smoke as do 19.6% of women. The very high female smoking rate in W.V. may just be a blip in the data, (?) but the Montana difference looks to be related to unusually low male smoking rates in that state. The only other part of the world where the proportion of men who smoke is consistently lower than women is Sweden, and in that case it is because many men have switched from smoking to snuff (smokeless) tobacco. If anyone out there has an explanation for the male/female smoking pattern in Montana and West Virginia I’d be interested to hear it.

If you would like to find out the latest figures for your own state, check them out via this link: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5638a2.htm

Labels: cigarette, cigarette smoking, prevalence

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Effects of smoking during pregnancy

The harmful effects of smoking during pregnancy have been known for many years and in 2001 the US Surgeon General summarized the effects as follows:

-Smoking during pregnancy is associated with increased risk for premature rupture of membranes, abruptio placentae (placenta separation from the uterus), and placenta previal (abnormal location of the placenta, which can cause massive hemorrhaging during delivery). Smoking is also associated with a modest increase in risk for preterm delivery.

-Women who smoke may have a modest increase in risks for ectopic pregnancy and spontaneous abortion.

-Infants born to women who smoke during pregnancy have a lower average birth weight and are more likely to be small for gestational age than infants born to women who do not smoke. Low birth weight is associated with increased risk for neonatal, perinatal, and infant morbidity and mortality. The longer the mother smokes during pregnancy, the greater the effect on the infant’s birth weight.

-The risk for perinatal mortality, both stillbirths and neonatal deaths, and the risk for sudden infant death syndrome (SIDS) are higher for the offspring of women who smoke during pregnancy.

Most relevant studies suggest that infants of women who stop smoking by the first trimester have weight and body measurements comparable with those of nonsmokers’ infants. Studies also suggest that smoking in the third trimester is particularly detrimental.

Although less well known, there is also fairly good evidence of harmful effects on the child’s psychological development of smoking in pregnancy. A study published by Button and colleagues in the journal, “Early Human Development” this past week concluded that, “There is strong evidence for an association between maternal smoking in pregnancy and psychological problems in offspring. The problems most frequently associated are attention problems, hyperactivity, and conduct problems.” Although there are a number of explanations for this association, animal studies confirm a direct causal effect of toxin exposure on brain development during pregnancy.

The implications are very clear: there are massive benefits to the health of the mother and the baby of quitting smoking before or during pregnancy. The following link provides some good structured advice on quitting smoking in pregnancy:

http://www.surgeongeneral.gov/tobacco/prenatal.htm

Labels: cessation, cigarette smoking, pregnancy

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Tobacco tax to renew insurance for poor kids

If you are a regular reader you may recall that a couple of months back I wrote about the legislation required to continue to provide federal funding for health insurance for uninsured children from poor families:
Increase cigarette tax to pay for children’s healthcare. 7/27/07
http://www.healthline.com/blogs/smoking_cessation/2007/07/increase-cigarette-tax-to-pay-for.html

This issue is relevant to tobacco in that the mechanism being proposed to pay for this is via an increase in the federal tax per pack of cigarettes (which has remained at 39 cents for over 5 years). Despite bipartisan support for this legislation and the funding mechanism, President Bush continues to say that he will veto the bill. However, such a veto could be over-ruled if the majority in favor is of sufficient size.

The bill proposes to add 61 cents to the federal cigarette tax, taking it to $1-00 per pack. This would have a substantial effect of reducing cigarette consumption and motivating many more smokers to try to quit. The effect would be particularly potent on young people who are more price sensitive. The net effect would be a significant reduction in future healthcare costs via a reduction in smoking caused illnesses. Lack of health insurance is one of the major public health problems in the United States and improving coverage for children from poor families is a sensible way to remedy a small part of that problem. Fully funding the SCHIP legislation via tobacco tax increases is an excellent policy that would significantly improve health and healthcare in the United States. Failure to pass this legislation will once again be doing a favor to big tobacco companies, this time at the expense of sick kids without health insurance.

Labels: health insurance, SCHIP, tobacco tax

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Does it help to add nicotine gum to bupropion?

Bupropion (marketed as Zyban for smoking cessation and Wellbutrin for depression) is approved by the US Food and Drug Administration as safe and effective for smoking cessation. It is taken in tablet form. There are also a number of nicotine replacement therapies (nicotine gum, patch, lozenge, inhaler and nasal spray) that are also approved treatments. Some previous studies have suggested that combining medications may improve smoking cessation success rates, and this has become normal practice at the tobacco treatment clinic here at UMDNJ.

Our experience in clinical practice has been that highly addicted smokers have better outcomes if they combine bupropion with NRTs. However, the only way to properly evaluate this is via a randomized placebo-controlled clinical trial. Such as study was just published in the journal, Nicotine & Tobacco Research, by Piper and colleagues at University of Wisconsin. They randomized 608 smokers to receive either (a) bupropion SR tablets plus 4mg nicotine gum, (b) buropion SR tablets plus placebo gum, or (c) placebo tablets and placebo gum, for 8 weeks, along with 6 brief counseling sessions. No more treatment was provided after the 8th week, but the participants were followed up at 6 and 12 months after the initial target quit date.

One week after the quit date, significantly more people had quit smoking while using active bupropion plus 4mg gum (47%), as compared with active bupropion plus placebo gum (38%) or placebo tablets and placebo gum (22%). At the end of treatment (8 weeks), the double medication group still had more successes (38%), as compared with active bupropion (31%) or double placebo (17%). However, at longer term follow-up (i.e. after the participants had stopped taking the medicines) the differences were relatively small. For example, at one year the quit rate was 21% for the double active group, 19% for active bupropion and 14% for double placebo.

So what does all of this mean? Firstly, it suggests that the advantage of adding nicotine gum to bupropion is real and statistically significant, but is quite small, even early in treatment. Secondly, it looks as though much of the advantage of early combination pharmacotherapy disappears at long term follow-up (off all medications). The other thing to note in this study is that the participants only used 4 pieces of gum per day. This is perhaps part of the reason for the smallish effects – the participants were only using smallish amounts of gum. Some may interpret these results as failing to demonstrate that adding nicotine gum to bupropion improves quit rates. Personally, I see a 38% quit rate at end of treatment as being meaningfully better than 31%. The drop-off after the medications are withdrawn is no surprise, and simply challenges us to consider why we continue to treat this chronic condition (tobacco dependence) with acute medications treatments. If a relative of mine was an addicted smoker seeking advice on which medicines to use, I’d probably still encourage something like bupropion plus the 21mg nicotine patch plus 4mg nicotine gum. I’d also encourage them to keep taking the full dose of all these medicines until they had experienced 14 consecutive days with no cravings, withdrawal symptoms or near lapses, and would be surprised if that day came within the first 6 months. Although each individual piece of this treatment may only add a few percent to their chances, this could be a life-saving treatment and every extra chance is worth the effort.

Labels: bupropion, Grand Rounds Nicotine Replacement, smoking cessation

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Does Chantix Cause Mental Health Problems?

The issue of Chantix effects on mental health gained national attention yesterday when the ABC News program “Good Morning America” covered the story of the bizarre and tragic death of the Texas musician, Carter Albrecht. http://www.abcnews.go.com/GMA/OnCall/Story?id=3623085&page=2

Some of the details of this tragedy can be found online via the ABC news story but the key points were that Mr Albrecht was actually killed by being shot in the head by a neighbor as he banged on the neighbor’s door, but that his girlfriend felt that his bizarre behavior may have been caused by the Chantix he was taking at the time.

Regular readers of this blog will know that this issue has come up before – see:
“Chantix: how does this new stop smoking medicine work?” 4/15/07
http://www.healthline.com/blogs/smoking_cessation/2007/04/chantix-how-does-this-new-quit-smoking.html

“Chantix and mental illness: what are the facts?” 08/12/07
http://www.healthline.com/blogs/smoking_cessation/2007/08/chantix-and-mental-illness.html

“Two new studies of Chantix (varenicline)”. 08/19/07
http://www.healthline.com/blogs/smoking_cessation/2007/08/two-new-studies-of-chantix-varenicline.html

There have been a number of comments from people who experienced frightening dreams, anxiety attacks, depression and suicidal thoughts while on the medicine, as well as the suicide of a family member. The number and pattern of these comments were sufficient to cause me some concern and so I decided to take another look at the published reports of the clinical trials of Chantix and also speak to a number of colleagues who treat many patients with Chantix, in order to try to get a sense of whether these experiences may be caused by Chantix, rather than other potential causes (including nicotine withdrawal effects).

On looking at the evidence from the clinical trials, it is more consistent with the idea that Chantix reduces depressive thoughts, rather than increases them. For example, one large study was published in JAMA on July 2006 comparing the outcomes of 352 smokers treated with Chantix (varenicline), 329 people treated with Zyban (bupropion) and 344 people treated with identical placebo pills. This was a randomized double-blind trial meaning that no-one knew which type of pills they received until the end. 22% quit completely for a year on Chantix, as did 16% on Zyban and 8% on placebo. The paper reported on changes in “negative affect” (a combination of unpleasant mood symptoms including depression and irritability). Patients on Chantix reported a significantly SMALLER increase in these symptoms than patients taking placebo. Zyban had a similar effect of reducing negative affect compared with placebo pills. The paper also listed adverse events reported by participants. The main symptom that was clearly reported more frequently by Chantix users was nausea, reported by 28% of Chantix users, compared with 13% on Zyban and 8% on placebo. Of the psychiatric disorders mentioned, only “abnormal dreams” appeared to be more common on Chantix (10%), compared with 6% on Zyban and 6% on placebo. There was no clear difference in reports of serious irritability (6%, 5%, 6%) and fewer patients on Chantix reported insomnia (14%) than did patients on Zyban (22%). In terms of “serious” adverse events, these were no more common for Chantix than placebo and the single case of a serious psychiatric event (acute exacerbation of schizophrenia) occurred in a patient taking placebo pills.

Another almost identical trial was reported by Jorenby and colleagues in the same issue of JAMA, with very similar results (i.e. higher quit rates with Chantix, along with lower reported negative affect [mood] than placebo, but higher rates of nausea.). Serious adverse events again were rare and scattered evenly across the different types of pills with little clear pattern, but there was one report of “acute psychosis, emotional lability” in the Chantix group (out of 344 taking Chantix). This study did, however, find a higher rate of “abnormal dreams” on Chantix (13%) than Zyban (6%) or placebo (4%). The earlier studies designed to identify the best dose of Chantix also had similar findings (dose-dependent increase in nausea and abnormal dreams) but no real evidence of other mental health symptoms. For example, Nides and colleagues found 10% on placebo and 12% on the high dose of Chantix reported serious “irritability’, and that “depression was not observed as an adverse event with varenicline (Chantix) treatment.”

The data sheet for prescribers of Chantix notes that 4500 people were exposed to Chantix during its premarketing development and that discontinuation of treatment due to adverse events was rare. The most frequent reason was nausea (3% for Chantix versus 0.5% for placebo). 0.3% reported discontinuing Chantix because of abnormal dreams as did 0.2% on placebo pills. As with all medications, the data sheet has a long list of symptoms experienced by participants in the trials, including “Psychotic disorder, suicidal ideation” as “rare”. Note – this does not imply that the drug caused these events – just that they occurred rarely in people taking the drug. Overall, the pattern of results from trials of Chantix suggest that with the exception of abnormal or vivid dreams, psychiatric symptoms such as depression or negative affect are LESS likely to occur in people taking Chantix to quit smoking, than in people taking placebo pills while quitting smoking.

However, one has to bear in mind that early clinical trials typically exclude patients currently being treated for mental health and other serious health problems. So the possibility remains that the drug may cause problems in types of patients that were not included in the initial trials. That’s where post-marketing surveillance is important. This is something that the pharmaceutical companies and doctors routinely carry out. For my part, I simply asked a large group of colleagues who are experienced in treating “real patients” with Chantix and other treatments, whether they had noticed any signs of worsening mental health associated with Chantix use. The clinicians I spoke to estimated that they had been involved in the treatment of over 2000 patients with Chantix, including patients with co-occurring serious mental health and other medical problems. There was a pretty clear consensus that while there were a few isolated cases (a couple) of patients reporting mental health problems, these were not noticeably more frequent than one normally encounters with other treatments (e.g. nicotine replacement or Zyban, or counseling with no medication).

So overall I am somewhat reassured that Chantix is a safe medicine that is effective at helping smokers to quit. But why the rash of reports on the internet of depression and bizarre behavior? Firstly, I don’t doubt that these people’s experiences are real and in some cases, very serious. I also think it is plausible that some (probably a minority) could be directly linked to Chantix. In some cases it could be an unusual interaction between the individual, the medicine and maybe another drug (including alcohol) they are taking. But for most, I suspect the serious behavioral/psychiatric problems experienced are unlikely to be caused by Chantix. Here are my reasons:
1. For highly addicted smokers, mood disturbance and altered thinking is common when quitting smoking, even without taking any medication.
2. The evidence described above, indicates that with the exception of abnormal dreams, Chantix reduces the severity of mood/psychological disturbance experienced while trying to quit smoking.
3. Around 3 million Americans have taken Chantix to try to quit smoking. Among that many smokers trying to quit for a month or two, one would expect a few thousand or more to have serious symptoms of depression etc even if they were not taking a medicine to help them. But when someone has these symptoms while taking a new drug, it is perfectly natural to conclude that the drug may have caused the symptom. In these days of widespread internet access, chat-rooms etc, that easily turns into a few hundred patients reporting similar symptoms on the internet while taking the same drug.

It therefore appears that if Chantix causes any serious mental health problems at all (which remains unproven), it is extremely rare (perhaps in the order of one per thousand). So my advice is that if you are considering quitting smoking and are interested in taking an FDA-approved medicine, whether it be nicotine replacement therapy, bupropion or Chantix, then you should not be put off by relatively isolated reports of side effects. The highest quality of evidence (from randomized placebo-controlled trials) demonstrates that these medicines are safe and will roughly double your chances of successfully quitting smoking. However, everyone reacts to medicines differently, and if you start to experience a worrying symptom that you believe may be caused by the medicine you should consult your doctor immediately. Even better, when you see your doctor to obtain a prescription, you should arrange a follow-up visit within a week or so of starting the medicine in order to discuss your progress, side-effects etc. If you have any concerns between appointments, call your doctor. It is also wise to get as much additional support from friends, family, telephone quitlines etc as possible. There is a national (US) toll-free number for telephone counseling (1-877-448-7848) and in the case of Chantix users in the US, there is additional support available via http://www.chantix.com/ .

Finally, anyone who believes there to be a causal link between use of a medication and a severe adverse event (e.g. depression, suicidal ideation, suicide, or any other serious adverse event), whether it be in yourself, your patient or a family member, should report it to the MedWatch program at: http://www.fda.gov/medwatch/how.htm . This is one of the main mechanisms of post-marketing surveillance that can help identify rare or previously unknown risks from medicines.

Labels: cessation, Chantix, cigarette smoking, varenicline

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Stopping smoking effects on drug metabolism

It is widely known that smoking speeds up basal metabolic rate (by around 10%) and so stopping smoking slows down the basal metabolic rate. This is one of the reasons people tend to put on weight when they stop smoking (the other reason is increased appetite resulting from the loss of nicotine’s mild appetite suppressant effects).

However, it is less widely known that cigarette smoking increases the activity of several liver enzymes that are responsible for metabolizing a number of drugs/medicines. This means that smokers frequently require a larger dose of these medicines than non-smokers, and may require the dose to be reduced after they quit smoking. One of the drugs whose metabolism is affected by smoking is caffeine. So when someone who drinks 6 cups of caffeinated coffee per day stops smoking, those 6 cups will produce blood caffeine levels up to 50% higher and so they will therefore feel as if they had about 9 cups of coffee. In the case of caffeine this could cause the person to feel anxious, restless and jittery and may also make it harder to get to sleep.

Many of the medicines that are affected by smoking are medicines used to treat psychiatric problems. These include some members a class of antianxiety drugs known as, “benzodiazepines” (e.g. diazepam), a number of anti-psychotic medicines (including some of the newer “atypical” anti-psychotic medicines e.g. olanzapine (Zyprexa), as well as older ones like haloperidol [Haldol]). Metabolism of some antidepressants is also affected in a similar way as are some other (non psychiatric) medicines. So, as with caffeine, when people who are already taking these medicines on a regular basis then quit smoking, the blood levels of these medicines may well increase by 10-40%. So depending on the medicine, this may also cause an increase in some of the side-effects caused by the medicine.

All of this serves to underline that it is a good idea to speak to your family doctor around the time you plan to quit. The family doctor should be able to identify the medicines whose metabolism is affected by tobacco, and also identify the likelihood that any new side effects that begin after ceasing smoking may be due to the effects on drug metabolism.

A list of drugs whose metabolism is known to be affected by smoking (and therefore smoking cessation) may be found at: http://smokingcessationleadership.ucsf.edu

Labels: cessation, cigarette smoking, drugs, metabolism

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Do you (or your kids) hookah?

A hookah—also known as hubbly bubbly, shisha, or narghile—is an elaborate glass based waterpipe used for smoking tobacco. You have probably seen it in movies based in Arab countries, but may not be aware that its use has become very widespread among college students in the US and other western countries. Special tobacco (usually moist with added sweeteners and flavors) is placed in the bowl at the top of the apparatus and heated with burning charcoal. During inhalation the smoke from the charcoal is pulled through the tobacco down the pipe and towards the water. After bubbling through the water, the cooled smoke surfaces and is drawn through the hose and inhaled.

The smoke delivered by a waterpipe contains similar concentrations of carbon-monoxide to the smoke inhaled from a cigarette. It also contains the usual other toxins (nicotine, tar heavy metals etc) delivered by cigarette smoke. There may be some differences resulting from the different types of tobacco and additives used with waterpipe smoking, and from the different temperature to which the tobacco is heated (about half the temperature that cigarette tobacco reaches).

However, overall we have no good data supporting the commonly held belief that waterpipe smoking is less harmful than cigarette smoking. This belief appears to be partly based on the idea that the passing of the smoke through the water somehow “cleans” the smoke. This is false. This process simply cools the smoke, making it easier to inhale, but basically the same smoke with all its toxic constituents comes out the other end via the mouthpiece and is inhaled.

Even in countries where waterpipe use is very common (some Arabic, eastern Mediteranean, and Asian countries), many users also smoke cigarettes, making it difficult to clearly identify the health risks specific to waterpipe use.

In Syria, where waterpipe use is widespread, many men acknowledge that they are addicted to the hookah. Until more is known about waterpipe use and its effects, it would be reasonable to assume that waterpipe use is about as addictive and harmful as cigarette smoking.

Over recent years, waterpipe use has increased in frequency in the United States – primarily in connection with the increased numbers of “hookah bars” which have been developed. Hookah bars are commonly found on or near college campuses, and the increase in use appears to be primarily in this age-group (16-28). These bars provide the waterpipes and tobacco for a fee, and are perceived as a novel and pleasant social experience by young people. When a group of young people find they are enjoying waterpipe smoking but perhaps spending more money or time at the hookah bar than they would like, then some start to purchase their own waterpipe and materials and smoke at their apartment. As many as 20-33% of students on some campuses have at least tried a waterpipe. In one survey, 37% of college freshmen believed that waterpipe use was less harmful than cigarette smoking. It is therefore important to make clear to young people that waterpipe smoke is just as harmful and addictive as cigarette smoke.

Labels: cigarette smoking, hookah, tobacco, waterpipe

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