Tobacco, tobacco tobacco

Three recent articles on tobacco. First, The Boston Globe reports on the effectiveness of pharmacological treatments for nicotine addiction. The article presents a pretty pharmacological treatments as an essential part of a smoking cessation plan.

Philip Quartier, a 64-year-old stockbroker from Mission Hill, had been smoking a pack of cigarettes a day for 45 years when he quit for the first time. After five clean years, an impulse led him to pick up another cigarette eight months ago, and the biking enthusiast, who has lung disease, was frustrated to be back to his old habit.

Determined to quit for good, he dug out the subliminal motivation tapes he'd used the first time around, went back on the nicotine patch, bought a self-help book, and joined a counseling group, but several months into the process, he was getting nowhere. So in November, he got a prescription for Chantix (varenicline), a six-month-old drug that is the first new quit-smoking treatment in a decade.

The pills don't work for everyone but quickly diminished Quartier's cravings. "By the eighth day I was absolutely ready" to give cigarettes up again, he said.

Though most smokers try to quit without help, nicotine-free treatments including Chantix and longtime staples like nicotine gum and patches are more effective than trying to quit "cold turkey," according to experts and research.

Next, Dr. Wes questions the federal push toward pharmacological treatments and provides some compelling arguments:

Well it seems that nicotine patches are now part of the federal guidelines regarding smoking cessation issued by the Public Health Service, a division of the Department of Health and Human Services. But an interesting twist to these guidelines was revealed yesterday (WSJ, subscription):

(Doctor) Michael Fiore is in charge of revising federal guidelines on how to get smokers to quit. He also runs an academic research center funded in part by drug companies that make quit-smoking aids, and he personally has received tens of thousands of dollars in speaking and consulting fees from those companies. ... Dr. Fiore, a University of Wisconsin professor of medicine, headed the 18-member panel that created those guidelines. He and at least eight others on it had ties to the makers of stop-smoking products.

Those opposed to urging medication on most quitters note that cold turkey is the method used by the vast majority of former smokers. They fear the federal government's campaign could discourage potential quitters who don't want to spend money on quitting aids or don't like the idea of treating their nicotine addiction with more nicotine.

"To imply that medications are the only way is inappropriate," says Lois Biener, a senior research fellow at the University of Massachusetts at Boston who has surveyed former smokers in her state. "Most people don't want them. Most of the people who do quit successfully do so without them."

What is interesting is the way the government makes these recommendations: based on clinical trials. And who is better equipped to perform clinical trials than drug companies? (Bias 1). Further, all of the individuals in clinical trials must sign consent, and therefore have to be willing to take a drug (Bias 2). So these "clinical trials" are, by their very nature, skewed toward those willing to take a drug.

But in the interest of revealing effectiveness of these smoking cessation drugs in the real world, another type of study, an observational population trial that looks at all comers to the smoking cessation party, found this:

Studies of quitters outside clinical trials have shown no consistent advantage for medicine over cold turkey, the pharmaceutical industry's primary competitor. An unpublished National Cancer Institute survey of 8,200 people who tried quitting found that at three months, users of the nicotine patch and users of bupropion (Wellbutrin) remained abstinent at higher rates than did users of no medication. But at nine months, the no-medication group held an advantage over every category of stop-smoking medicine. The study was presented at a world tobacco conference last summer.

Finally, a recent Biological Psychiatry commentary addresses the links between alcohol and nicotine addiction, including the genetic links, shared neurobiological mechanisms, shared behaviors and treatment.

Epidemiologic data confirm that: (1) heavy drinking may stimulate smoking; (2) cessation of smoking may enhance abstinence from alcohol; and (3) combined treatment for dual addiction may achieve the most beneficial treatment outcome.

A Small Part of the Brain, and Its Profound Effects

More on the insula and nicotine addiction. (Requires free registration. If you don't wish to register, you can use www.bugmenot.com.)

According to neuroscientists who study it, the insula is a long-neglected brain region that has emerged as crucial to understanding what it feels like to be human.

They say it is the wellspring of social emotions, things like lust and disgust, pride and humiliation, guilt and atonement. It helps give rise to moral intuition, empathy and the capacity to respond emotionally to music.

Its anatomy and evolution shed light on the profound differences between humans and other animals.

The insula also reads body states like hunger and craving and helps push people into reaching for the next sandwich, cigarette or line of cocaine. So insula research offers new ways to think about treating drug addiction, alcoholism, anxiety and eating disorders.

Of course, so much about the brain remains to be discovered that the insula’s role may be a minor character in the play of the human mind. It is just now coming on stage.

The activity of the insula in so many areas is something of a puzzle. “People have had a hard time conceptualizing what the insula does,” said Dr. Martin Paulus, a psychiatrist at the University of California, San Diego.

If it does everything, what exactly is it that it does?

For example, the insula “lights up” in brain scans when people crave drugs, feel pain, anticipate pain, empathize with others, listen to jokes, see disgust on someone’s face, are shunned in a social settings, listen to music, decide not to buy an item, see someone cheat and decide to punish them, and determine degrees of preference while eating chocolate.

Damage to the insula can lead to apathy, loss of libido and an inability to tell fresh food from rotten.

Plan to vaccinate babies against drugs

The U.K.'s Daily Mail recently ran a story on a plan to vaccinate children for cocaine, heroin and tobacco. The vaccine would prevent any effects from the drugs and therefore prevent any addiction.

A group called the Transform Drug Policy Foundation has written a response on their blog. They argue that: Drug vaccines don’t really work; Giving drug vaccines to children is profoundly unethical; Even if vaccines worked it wouldn’t prevent problematic drug use, or offending.

I find it pretty unlikely that there would be any significant steps in this direction in the near future. I think it's far more likely that drugs like this will be tried with people who have developed problems before their used in preventative strategies.

Smoking manners

Japanese tobacco companies are doing their part to encourage good manners on the part of smokers. This is apparently a real ad campaign and frequently place on trains. I don't remember seeing these ads, but I do remember a similar public service warning painted on a sidewalk. It was a graphic of a cigarette poking a child in her eye. Enjoy.

Stop-smoking efforts reaching out to homeless

Homeless shelters are beginning to look at addressing nicotine addiction. The discussion sounds lot like those that have taken place among treatment centers for the last decade:

Following successful anti-tobacco campaigns geared toward pregnant women, teenagers, African-Americans, Latinos and other groups, homeless people...may be the next target.

Amid broad skepticism, nascent campaigns to get the homeless off cigarettes are bubbling up in Chicago and across the country.

A Humboldt Park shelter is holding regular meetings where the homeless can discuss their addiction to tobacco. In New York City, Zyban and other anti-smoking pills will be distributed over the next few months at homeless shelters, where 6,000 workers also will be trained in tobacco physiology. Nicotine patches have been offered at shelters in Seattle since last fall and are on the way to others in Wisconsin.

Even cessation proponents acknowledge that small gains will be seen as a victory, considering that 80 percent of the chronically homeless are addicted to smoking.

The goal, experts say, is to change the culture in shelters and possibly save millions each year in Medicaid payments for smoking-related illnesses.

Increasingly, the homeless themselves are pushing the subject. At Humboldt Park Social Services, which operates in one of the Chicago's poorest neighborhoods, residents sit around a folding table during regular meetings to discuss tobacco.

"We started talking about what can kill you, talking about AIDS and STDs, but they didn't want to hear that anymore. . . . Our clients were tired of it," said Noemi Avelar, director of operations. "They wanted to talk about smoking. They said this is what we do every day, so let's take a look at it."

Addressing addictions to heroin, cocaine and marijuana remain priorities, but tobacco use will be added to the list beginning this year, said Avelar.

So far, few shelters have jumped on the anti-smoking wagon. Most cite higher priorities among their clients, including serious psychological problems or addictions to alcohol, heroin, methamphetamines and crack.

..."We have more people addicted to nicotine than heroin, and the cigarettes can be harder to quit," Harden said. "We'd love to address smoking along the way, but right now there isn't much out there that would do much good."

The executive director of Aurora's only permanent emergency shelter said tobacco addiction is a very low priority.

"I hate tobacco, but there are a lot more serious issues I have to deal with, starting with funding," said Ryan Dowd of Hesed House. "Sure, smoking is bad and causes all sorts of health problems. So does sleeping outside and not having anything to eat."

Randal Syverson, 56, a resident at Hesed House, was openly skeptical of cessation programs.

"No house, no job, no family--a cigarette can be the only joy I'll have today," he said.

I understand the reluctance of the program staff. Locally, they're underfunded and overwhelmed with the number of clients and the broad scope of their problems. An all out push toward smoking cessation doesn't fit neatly within their mission and their clients are clearly facing larger barriers to achieving stable housing. However, shelters perform all sorts of secondary public health functions and they can at least begin to change the culture among the homeless and in shelters--from one that celebrates tobacco to one that tolerates tobacco.

At the very least, providers should begin asking clients if they want to quit, said Janet Porter, program director for the National Network on Tobacco Prevention and Poverty.

"I think we've all been surprised by the number of the homeless who say, `yes,'" Porter said.

..."What's good for someone working at a big upscale law firm is just as good for people living in the street," said Roger Valdez, manager of the county's tobacco-prevention program. "Everyone deserves clean water, air and the same chance to beat this addiction."

More on the insula and smoking

I posted earlier on an exciting study on the relationship between the insula and nicotine addiction. Here's an article with a little more detail.
[via: New Recovery]

Spot in brain may control smoking urge

A stroke patient may have revealed a key to understanding craving:

Damage to a silver dollar-sized spot deep in the brain seems to wipe out the urge to smoke, a surprising discovery that may shed important new light on addiction. The research was inspired by a stroke survivor who claimed he simply forgot his two-pack-a-day addiction - no cravings, no nicotine patches, not even a conscious desire to quit.

"The quitting is like a light switch that went off," said Dr. Antoine Bechara of the University of Southern California, who scanned the brains of 69 smokers and ex-smokers to pinpoint the region involved. "This is very striking."

Clearly brain damage isn't a treatment option for people struggling to kick the habit.

But the finding, reported in Friday's edition of the journal Science, does point scientists toward new ways to develop anti-smoking aids by targeting this little-known brain region called the insula. And it sparked excitement among addiction specialists who expect the insula to play a key role in other addictions, too.

"It's a fantastic paper, it's a fantastic finding," said Dr. Nora Volkow, director of the National Institute on Drug Abuse and a longtime investigator of the brain's addiction pathways.

"What this study shows unequivocally is the insula is a key structure in the brain for perceiving the urges to take the drug," urges that are "the backbone of the addiction," Volkow added.

Why? The insula appears to be where the brain turns physical reactions into feelings, such as feeling anxious when your heart speeds up. When those reactions are caused by a particular substance, the insula may act like sort of a headquarters for cravings.

More Nicotine Madness

Media critic Jack Shaeffer weighs in on the coverage of this week's Harvard nicotine level study. He shares the tobacco companies side of the story and says, "so what" about higher nicotine levels:

A substantial body of scientific research shows that smokers excel at milking cigarettes for the nicotine dose they desire, irrespective of how many milligrams of nicotine the actual cigarette they end up smoking contains. The well-known behavior is called "compensatory smoking." University of Waterloo professor David Hammond wrote in a sidebar to my piece last summer, "humans adjust the intensity of their smoking in response to the cigarette design and emission level. Therefore, 'lower nicotine' yield cigarettes are smoked systematically more intensely."
...

Whenever the press writes about nicotine yields, it invariably quotes some public-health advocate warning that even these incremental increases in nicotine automatically make cigarettes more addictive. But if that were true, wouldn't the press or somebody have saluted the tobacco industry for reducing the addictive potential of cigarettes whenever nicotine levels dropped? Indeed, between 1972 and 1983, the average measured nicotine (sales weighted) dropped from 1.39 milligrams per cigarette to 0.88 milligrams per cigarette. From 1989 to 1996, it dropped from 0.96 milligrams per cigarette to 0.88 milligrams per cigarette. (See this Federal Trade Commission PDF.) I don't recall hearing any cheering.

The nicotine-yield obsession blinds the press and some in the public-health establishment to the fact that, as Hammond wrote in the Slate sidebar last summer, there's enough nicotine in any commercially available cigarette "to promote and sustain addiction." All cigarettes are dangerous, no matter what their octane rating.

Researchers Confirm Rising Nicotine Rates

Phillip-Morris denies it, but a new Harvard study confirms a study done earlier this year finding that nicotine levels in cigarettes have increased over the last decade:

Researchers at the Harvard School of Public Health say they have confirmed a study released last year by health officials in Massachusetts that found steadily increasing levels of nicotine in cigarettes sold in the state from 1997 to 2005. The analysis, based on data submitted to the Massachusetts Department of Public Health by cigarette manufacturers, found that increases in smoke nicotine yield per cigarette averaged 1.6 percent each year, or about 11 percent over a seven-year period.

Tobacco report cards

The American Lung Association issued report cards for all 50 states on their tobacco policies. Michigan didn't fare too well:

REPORT CARD

STATE OF TOBACCO CONTROL 2006 MICHIGAN

Grades:
Smokefree Air - F
Youth Access - F
Tobacco Prevention and Control Spending - F
Cigarette Tax - A

Facts on the new smoking cessation medication

A new fact sheet on Varenicline (the generic name for Chantix), the newly approved smoking cessation drug. It's the first drug to target nicotine receptors.

New Smoking Cessation Resource for Treatment Providers

IRETA just released a new publication called Smoking Cessation Treatment and Substance Use Disorders. It's makes the case for addressing nicotine addiction in treatment and talks about the challenges and offers some strategies for integrating smoking cessation and going tobacco-free.

Relapse rates after lung/liver surgery

Two stories about relapse rates following surgery. One about relapse rates following lung cancer surgery:

The U.S. study of 154 smokers who had surgery to remove early stage lung cancer found that, within 12 months after their surgery, 43 percent of them had picked up a cigarette at some point and 37 percent were actively smoking. Sixty percent of patients who started smoking again did so within two months after their operation.

The second reports encouraging numbers about relapse rates following a liver transplant:

During the first year after transplantation, 22% of subjects had at least 1 drink, 10% had at least 1 heavy drinking episode,* and 5% returned to frequent drinking.** By the fifth post-transplant year, 42% had at least 1 drink, 26% had at least 1 heavy drinking episode, and 20% returned to frequent drinking.

Maybe I'm a hypersensitive to stigma, but I wonder is Forbes would have run an article about patient behavior following heart transplants--compliance rates with diet, exercise and medication.

Ban may help some butt out

Speaking of prohibition, here are some findings from public smoking bans in the heart of tobacco country:

A new study says anti-smoking laws may make it easier to quit smoking.

The study done by the University of Kentucky College of Nursing showed a 31.9 percent decrease in the number of adult smokers in Fayette County in the months following the April 2004 passage of Lexington's anti-smoking law, from 25.7 to 17.5 percent.

That compared to virtually unchanged rates of smokers in Boone, Kenton and three other Kentucky counties that had no smoking bans. The percentage of smokers remained at 27.6 percent in those counties throughout the course of the study, which looked at Center for Disease Control and Prevention public domain data from 2001 to 2005.

Dr. Ellen Hahn, of the College of Nursing, said researchers expected some decline in Fayette. But "we did not expect this magnitude."

Hahn said the decline in smoking was uniform regardless of economic status.

"Across the board, there were fewer smokers," she said.