Become an Ex

On previous posts I’ve talked about good websites for helping smokers quit:

Can smoking cessation internet sites help you to quit? 4/21/07
http://www.healthline.com/blogs/smoking_cessation/2007/04/can-smoking-cessation-internet-sites.html

There are quite a few good ones, and so far my favorite is at www.quitnet.com .

But I recently checked out a fairly new one and was very impressed. Its at www.becomeanex.org . It has been funded by a coalition on public health agencies, and appears to have been really well put together and is really easy to use. One of its main selling points is its emphasis on quitting smoking as a process, and its recognition that it is not all over in a month. So this site presents quitting as a process, provides loads of useful tips and advice, and is particularly good at helping you link with networks of other smokers for added support. The site makes good use of new technologies to make it easy to register, easy to communicate with other smokers trying to quit, and fairly easy to ask a question not just of others trying to quit, but also of recognized experts, like Dr Richard Hurt of the Mayo Clinic.

I found it very simple to register. You can set up your own profile, add your photo and details if you want (or not if you don’t), and there are plenty of subgroups you can join, made up of people with a particular thing in common (e.g. living in Texas, or using Chantix). The only slight problem I had was that when I clicked on some of the video components they didn’t all run smoothly. That may have just been a problem with my PC as I’m a bit technologically challenged. I believe this site is fairly new, (launched March, 2008) but I think it looks like it could be very helpful to tobacco users thinking about quitting.

Check it out and let me know what you think.
www.becomeanex.org

Labels: becomeanex, cessation, cigarette smoking, jonathan foulds, website

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Tobacco Harm Reduction

There are a bunch of policy options designed to reduce the harm to health caused by tobacco.

Right now, those option focus on reducing exposure to second-hand tobacco smoke pollution, reducing initiation of smoking among young people, and encouraging existing smokers to quit. In many developed countries these policies have had some success, with significant reductions in the proportion of the population who smoke. In some other countries there has been little progress or smoking has actually increased. At the end of the 20th century almost half of all men on the planet were smokers. Perhaps the main hope for improving this situation is via implementation of the World Health organization’s Framework Convention on Tobacco Control (FCTC). Details on the FCTC can be found at;
http://www.who.int/tobacco/framework/en/

There have also been moves to reduce the harm to health via increased regulation of the tobacco industry and the products it sells. For example, in the European Union, there are fairly tight regulations governing the advertising of tobacco, the emissions from cigarettes, the warnings on packs and also an almost complete ban on oral snuff tobacco.

In the United States, there is currently a piece of legislation that has cleared a number of initial hurdles, (but with a few more to be crossed) that would, for the first time, give the US Food and Drug Administration (FDA) the right to regulate tobacco products. Though most people agree that it is only right that the tobacco industry should be more tightly regulated, there are differences of opinion as to the way to do it that would be most likely to lead to reduced harm to health.

One model (on which the current FDA legislation appears to be based), involves reducing the potential nicotine delivery from tobacco products gradually down to the level at which they would no longer be addictive. The existing smokers would hopefully gradually switch over to nicotine replacement products or give up nicotine altogether.

Another model involves gradually reducing the permissible toxins levels that can be emitted by tobacco products, while keeping the nicotine delivery at a level that users can still be addicted. In the end this policy might end up at a similar place to the previous one, with users using clean nicotine products, without any tobacco.

Both of these models have merits. However, there may be problems with the time delay before reaching the point where there is significantly less harm being caused. There may also be challenges for enforcement, as it may be difficult for enforcement authorities to tell if a cigarette is reduced toxin/nicotine or a regular cigarette that has been smuggled in from another country. Another potential problem with both these strategies is that they pretty much put the tobacco industry out of business. Now it’s a fair bet that the tobacco industry would not want to go out of business, and would use its considerable resources and influence to prevent these policies from being implemented to their fullest extent.

This is where a similar but slightly different policy, may have some merit. With this model, the tobacco industry is given notice by regulators that smoked products can no longer be sold in this country 10 years from now. They are told that they should plan for this, by switching their consumers to products that do not involve combustion, i.e. any form of smokeless tobacco.

Now the companies won’t love this idea either. But it at least gives them a way to stay in business and also gets them out of the lung cancer and emphysema business, which has always been a slight PR negative for the tobacco industry. I believe that this policy stands the best chance of being sustainable and acceptable to all stakeholders.

If you would like to view a full slide show and talk I presented to a meeting of tobacco industry representatives that laid out this approach, it can be viewed on the supercourse (a free health teaching website) at: http://www.pitt.edu/~super1/lecture/lec31261/index.htm

Labels: cigarette smoking, FCTC, FDA, harm reduction, jonathan foulds, nicotine addiction, tobacco

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Smoking and suicide

It has long been known that people who smoke are at greater risk of attempting and committing suicide than people who don’t smoke. On the face of it this doesn’t seem particularly surprising as people who sometimes think that they would rather not live would appear to have less reason to quit smoking to improve their health and live longer.

But the recent concern about onset of depression and suicidal thoughts among people quitting smoking (who presumably are in a frame of mind in which they want to live longer when they decide to quit) has led to renewed interest in the relationship between smoking and suicide. A recently published study by Professor Ronald Kessler (Harvard University) and colleagues provided some data and analysis relevant to this issue.

The study involved a survey of a representative sample of the adult American English-speaking population (n=5692). The study found that 2.6% had seriously thought about committing suicide in the previous year, 0.7% had made a plan of how they would do it, and 0.5% had made an attempt. This study, like many prior studies, found that smokers were about two or three times as likely to have thought about or attempted suicide in the past year than non-smokers. Heavy smokers were generally more likely to have thought about suicide than light smokers.

This survey also included a diagnostic interview for recent mental disorders. Like other studies, it found that people with virtually any mental disorder (from specific phobias to bipolar disorder) were more likely to be smokers, with the strongest relationship being for substance use (people with dependence on other substances being around 5 times more likely to be smokers than those not having a substance use disorder). People with a mental disorder were also more likely to have suicidal thoughts or attempts.

The study then examined whether smokers remained at greater risk of suicidal thoughts or attempts, after controlling for mental disorders. Controlling for mental disorders reduced the association between smoking and suicidal behavior to the point that it was no longer statistically significant.

My own interpretation of the data from this and other studies, is that mental disorders or some other factors of which mental disorders are highly correlated (e.g. mental health or general satisfaction with ones life) are a risk factor for both smoking and suicidal behavior. Thus people who as kids are unhappy and have difficulties dealing with their emotion are more likely to take up smoking, and more likely to become addicted to tobacco, and as adults are less able to quit smoking and are also, by virtue of their dissatisfaction with life, more likely to consider and attempt suicide.

Thus the relationship between smoking and suicidality is very unlikely to be causal. It is also worth noting that the size of the association is not very large. About one in 200 non-smokers attempt suicide each year and about one in 100 smokers attempt suicide each year.

None of this provides a direct explanation or helps us understand what may be going on when an individual attempts suicide in close proximity to a time when they had been trying to quit smoking (with or without using Chantix). But it does give us some idea of the frequency of certain events in the population. Around 45 million Americans smoke. At least 15 million of them make a quit attempt each year, and at least 5 million have already tried Chantix. This would imply that in the past year around 450,000 smokers made a suicide attempt, and possibly as many as 150,000 of them in the same year they made a quit attempt. Assuming around 2 million Chantix users in one year, and the same rate of suicide attempts per year as other smokers, this would lead us to expect around 20,000 smokers to make a suicide attempt in the same year they used Chantix, even if a quit attempt or Chantix use had no effect on risk for a suicide attempt. The precise number of events expected by chance will of course vary a bit according to the study one bases ones estimates on. But either way, one would expect a large number of cases by chance.

Now none of this means that making a quit attempt, or taking any particular medication, could or could not affect an individual’s risk for depression or suicide. That is a more complex question. But it does demonstrate that we might expect to hear of a large number of cases of suicide attempts by smokers taking any commonly used medicine, even if that medicine had no causal relationship with the suicide attempt.

The full text of the study by Kessler and colleagues can by accessed via the following link:
http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=17502801

Labels: Chantix, cigarette smoking, jonathan foulds, suicide

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Which U.S. states smoke most and least?

The latest data on cigarette smoking prevalence by state was just released in the U.S.
Before I tell you the results, make a guess at what percentage of adults you think are cigarette smokers (a) in your state and (b) in the whole of the US?

The data are from a survey called the Behavioral Risk Factor Surveillance System (BRFSS) which is organized by CDC. It obtains a representative sample of adults in each state, and asks them loads of questions about health-related behaviors.

In 2007 (latest year data is available for), the median state cigarette smoking prevalence was 19.7%, of whom only 14.5% were daily smokers and 5.2% smoke somedays.

The states with the lowest smoking rates were Utah (11.7), California (14.3), Massachusetts (16.4), Minnesota (16.5), Washington (16.8), Oregon (16.9), Rhode Island (17), Hawaii (17) and my home state of New Jersey (17.1).

At the other end, the states with the highest smoking rates are: Kentucky (28.2), West Virginia (26.9), Oklahoma (25.8), Missouri (24.5), and Tennessee (24.3).

I find that most people overestimate the proportion of people who smoke, often by a large amount. How did you do?

So here in the United States we have some states where smoking is twice as common as in others. The main factors influencing this are the strength of tobacco control policies such as excise taxes, clean indoor air legislation, media campaigns and smoking cessation services. Utah is a bit of an outlier in that the smoking prevalence there is largely determined by the high proportion of people following the Mormon religion.

Clearly an individual smoker’s ability to quit, or the chances that your kids might start smoking is highly influenced by the environment in which we live. If you live in Kentucky, almost one in three people smoke, cigarettes are cheap, and there are few services to help smokers quit. In California only one in ten people are daily smokers, you are not allowed to smoke in any indoor public place, and there have consistent media campaigns warning about the health effects of smoking. These differences have a massive impact on the health profiles in these states, such that people living their life in Kentucky are more likely to die of lung cancer than people in California.

So if you want a healthy life for you and your kids, either advocate for tobacco control policies in your state, or move to a state that already has them.

Data on the 2007 BRFSS can be found and searched at:
http://apps.nccd.cdc.gov/brfss/display.asp?cat=TU&yr=2007&qkey=4394&state=UB

Labels: cigarette smoking, jonathan foulds, prevalence, United States

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Vote for Healthline for Webby Award

Healthline has been nominated for the prestigious Webby Award in the category of “Health."

The International Academy of Digital Arts and Sciences will choose Webby Award winners, but the People’s Choice Webby lets you decide. It’s easy:
Simply log on to http://peoplesvoice.webbyawards.com/
Register to vote (or log in if you are a returnee)
After registration, click on the Web site icon and find the Living section, under which the Health category falls
Vote for Healthline!

And be sure to pass this pass along to your friends and encourage them to vote as well!

You can find out more about this nomination and some of the factors making Healthline a deserving choice at:
http://www.healthline.com/blogs/healthline_connects/2008/04/healthline-nominated-website-for-12th.html

Labels: healthline, jonathan foulds, webby award

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Can cigarettes be made less deadly?

Since it became clear in the 1950s and 60s that cigarettes are deadly when used as intended, there have been various attempts to make them less harmful. These have included the addition of and modifications to filters, and changes in the type of tobacco used. But none of these changes has made a great deal of difference. Part of the problem is that changes that reduce the amount of one toxin often have an opposite effect on the amounts of other toxins in the smoke. Another problem is that changes to the product can affect the way it is used by consumers. The most obvious example here is that as the amount of nicotine in the tobacco decreases, so the smoker takes larger puff volumes in order to get their usual dose. The main lesson from all this is that when humans take any product, burn it, and inhale the smoke into their lungs, it is inevitably going to be very harmful to that individual’s health. Our bodies did not evolve to inhale smoke.

It is partly for this reason that I take the view that the tobacco industry should be given the strongest encouragement to move out of the smoking business entirely, and focus on smokeless tobacco as a way of making money out of nicotine addiction.

However, it’s a reality that cigarettes will be around for the foreseeable future and therefore it makes sense to try to make them less harmful. This month an influential report was published on this topic in the journal, “Tobacco Control” by a World Health Organization study group. The group (called TobReg) proposed a mandated lowering of of permissible toxicants in cigarette smoke. They took the 9 main toxicants, examined the range of levels of these toxicants emitted by international cigarette brands (and there are very wide ranges) and recommended that all cigarettes must emit an amount less than approximately the current median level found in a range of brands. This is analogous to measuring the amount of pollutants emitted by all of the new cars in the world today, and then saying that from some future point in time, all new cars must emit an amount of pollution less than the car that ranks in the middle of the current range. Clearly the standard can be tightened again in the future.

This would mean that for each toxicant, about half of the existing brands would require modification in order to comply with the standard. It means that for 9 toxicants, a far larger proportion of current brands would need to be modified in order to be fully compliant for all 9 toxicants. It should be noted that the toxicant concentrations are expressed in units per milligram of nicotine. This is a wise way to do it, which recognizes that smokers smoke for nicotine, and that it is the ratio of toxins to nicotine that is therefore important. The rationale and many complex details of the proposal are described in the report, which can be accessed for free at:
http://tobaccocontrol.bmj.com/cgi/content/full/17/2/132
A commentary can also be viewed at:
http://tobaccocontrol.bmj.com/cgi/content/full/17/2/73

These proposals are a sensible first step at making cigarettes a bit less harmful. Surprisingly there is even a chance they could be accepted by a major tobacco company. Philip Morris (now split into a separate US and a separate “international” company) may consider that despite all the hassle in complying with such regulations, they may come out smelling of roses (i.e. smelling of money) because they are in a stronger position to make the required technical changes than many smaller companies. They therefore may consider that the regulations present an opportunity for them to gain market share via more efficient regulatory compliance.

It is interesting that the approach taken in this report is almost the opposite of that which has been proposed in the United States, which involves leaving all the toxicant levels as they are, but reducing the nicotine delivery down to levels that will no longer be addictive.

I continue to believe that while both of these approaches have merit, the most direct route for the tobacco industry to stay in business but causing much less harm to health, is for it to be required to focus exclusively on smokeless tobacco products. These have already been shown to be consumer-acceptable, deliver adequate doses of nicotine, but cause far lower levels if ill-health (e.g. no lung cancer or COPD). This approach also avoids the challenging task of enforcing at the individual level. If I’m a policeman walking down the street and I see someone smoking, it is impossible to tell if that cigarette complies with the reduced nicotine or reduced toxicant regulation. If cigarettes are outlawed and only smokeless products are allowed, then enforcement is much simpler.

For smokers, it is important not to sit back and wait for these less harmful cigarettes to come along. This is a long-term project that has only just been proposed. It is highly likely that you will have died of a serious smoking-caused disease long before these proposals result in meaningfully less harmful cigarettes. So the main message remains the same:

The single best thing you can do for your health is to stop smoking completely. There are now a range of effective methods (e.g. quitlines, internet sites, etc) and medicines available that can help you to successfully quit smoking, and you should talk to your healthcare professional about which ones would suit you.

Labels: cigarette, cigarette smoking, jonathan foulds, nicotine addiction, tobacco

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