ALL SMOKING PRODUCES TOXIC PARTICULATES

Smoking exposure during childhood may increase risk of rheumatoid arthritis

Longitudinal study uncovers significant influence of passive exposure to parental smoking on adult-onset incident seropositive rheumatoid arthritis

Peer-Reviewed Publication

BRIGHAM AND WOMEN'S HOSPITAL

A new study by investigators from Brigham and Women’s Hospital found a potential direct link between exposure to parental smoking during childhood and increased risk of seropositive rheumatoid arthritis (RA) later in life. Researchers utilized established longitudinal data from 90,923 women in the Nurses’ Health Study II (NHSII) to elucidate the relationship between passive smoking exposure and incident RA. Passive exposure was broken down into three categories, including maternal smoking during pregnancy, parental smoking during childhood, and years lived with smokers since age 18. Even with personal smoking accounted for, passive exposure to parental smoking during childhood was found to increase risk of incident seropositive RA by 75-percent. Findings are published in Arthritis & Rheumatology.

“There has been intense interest in mucosal lung inflammation from personal smoking as a site of RA pathogenesis,” said senior author Jeffrey A. Sparks, MD, MMSc, of the Department of Medicine at the Brigham. “But the majority of RA patients aren’t smokers, so we wanted to look at another inhalant that might precede RA.”

RA is an inflammatory disease characterized by arthritis at multiple joints and is associated with morbidity and mortality outcomes. Many people with RA have signs of lung inflammation, and while genetic and environmental factors contribute to risk of developing RA, smoking has long been implicated as a key RA risk factor. Personal (active) smoking is the most well-established environmental risk factor associated with RA, with passive smoking left relatively unexplored.

To link passive smoking and incident RA more conclusively, Sparks and colleagues used data from NHSII questionnaires collected biennially between 1989 and 2017 from 90,923 women aged 35-52 years. Researchers used participant medical records to confirm incident RA and serostatus. Statistical modeling was then used to estimate the direct effect of each passive smoking exposure on RA risk, as well as to control for other factors such as personal smoking.

A 75-percent higher risk of RA was found in individuals who experienced passive childhood exposure to parental smoking. This risk increased in participants who themselves became active smokers. Over the median follow-up of 27.7 years, 532 women in the cohort developed confirmed incident RA cases — the majority (352) of which were seropositive (positive for RA autoantibodies). Maternal smoking during pregnancy and years lived with smokers beyond age 18 showed no significant association with incident RA risk.

Although the all-female nurse participant pool led to high response rates and retention, the study is limited by the absence of men. The team intends to continue with longitudinal studies that encompass both men and women, as to provide critical insight into other rheumatoid conditions and even other autoimmune diseases.

“Our findings give more depth and gravity to the negative health consequences of smoking in relation to RA, one of the most common autoimmune diseases,” said lead and co-corresponding author Kazuki Yoshida, MD, ScD, of the Brigham’s Division of Rheumatology, Inflammation and Immunity. “This relationship between childhood parental smoking and adult-onset RA may go beyond rheumatology — future studies should investigate whether childhood exposure to inhalants may predispose individuals to general autoimmunity later in life.”

Conflict of Interest: None

Funding: This work was supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) under award number K23 AR069688 to Dr. Sparks. This work was additionally supported by the Rheumatology Research Foundation R Bridge Award, and by the National Institutes of Health (award numbers L30 AR066953, K24 AR052403, R01 AR049880, R01AR057327, R01 AR119246, R01 HL034594, P30 AR070253, P30 AR072577, P30 AR069625, UM1CA186107, U01 HG008685, 1OT2OD026553, and R03 AR075886). Dr. Yoshida was supported by the Rheumatology Research Foundation K Bridge Award, Brigham and Women's Hospital Department of Medicine Fellowship Award, and K23 AR076453 (NIAMS).

Nurses’ Health Study II was supported by the National Institutes of Health (U01 CA176726, R01CA67262, and U01 HL145386).

Paper cited: Yoshida K et al. “Passive Smoking Throughout the Life Course and the Risk of Incident Rheumatoid Arthritis in Adulthood Among Women” Arthritis Rheumatol. DOI: 10.1002/art.41939

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ARTICLE PUBLICATION DATE

18-Aug-2021

The Affordable Care Act linked to reduced smoking among US adults with mental health and substance use disorders

Peer-Reviewed Publication

SOCIETY FOR THE STUDY OF ADDICTION

During the first decade following passage of the Affordable Care Act (enacted March 2010), US adults with mental health and substance use disorders (MH/SUD) experienced significant increases in health insurance coverage. They also showed significant reductions in smoking and increases in recent smoking abstinence.  A new study published by the scientific journal Addiction has found that those two changes -- increased health insurance coverage and improved smoking outcomes – appear to be linked. 

This study, by a team that included researchers at Harvard Medical School/Cambridge Health Alliance, compared smoking and insurance coverage trends among almost 450,000 US adults with and without MH/SUD, using 2008-19 data from the National Survey on Drug Use and Health, an annual, cross-sectional survey. 

The study’s findings are among the first to identify meaningful, population-level reductions in smoking and increases in abstinence among adults with MH/SUD, a group that has maintained significantly higher smoking rates in recent decades despite public health measures and interventions that have driven change in the general adult population. A substantial proportion of the estimated improvements in smoking and abstinence outcome for those with MH/SUD can be explained by increases in health insurance coverage.

Changes in smoking:  From 2008 to 2019, US adults with MH/SUD reduced their smoking and increased their abstinence rates more than those without MH/SUD.* 

Changes in health insurance availability:  People with MH/SUD have historically had more limited access to care.  Health insurance coverage for people with MH/SUD increased after 2014, when ACA provisions expanded the potential pool of individuals able to afford insurance coverage and improved evidence-based treatment options for those with insurance.**

The link between changes in smoking and changes in health insurance availability:  This study found that in 2018-19, 11% of net reductions in current smoking, 12% of net reductions in daily smoking, and 12% of net increases in recent smoking abstinence coincided with greater gains in insurance coverage for adults with MH/SUD compared with adults without MH/SUD.

The study excluded adults who were 65 years or older and most likely to be covered by Medicare (public health insurance covering the elderly) and therefore less subject to most ACA provisions.

* Specifically, current smoking rates of adults with MH/SUD decreased from 37.9% to 27.9% while current smoking rates of adults without MH/SUD decreased from 21.4% to 16.3%, a significant difference in decrease of 4.9%. Daily smoking followed a similar pattern, with a difference in decrease of 3.9%.   Recent smoking abstinence rates for adults with MH/SUD increased from 7.4% to 10.9% while recent smoking abstinence rates for adults without MH/SUD increased from 9.6% to 12.0%, a difference in increase of 1.0%.

** In 2008-09, the prevalence of insurance coverage was 6.2 percentage points lower for adults with MH/SUD (71.9%) than for adults without MH/SUD (78.2%). By 2018-19, that difference had shrunk to 2.0 percentage points.

-- Ends –

For editors:

This paper is free to read for one month after publication from the Wiley Online Library: https://onlinelibrary.wiley.com/doi/10.1111/add.16052 or by contacting Jean O’Reilly, Editorial Manager, Addiction, jean@addictionjournal.org.

To speak with co-author Benjamin Cook, please contact him at Cambridge Health Alliance/Harvard Medical School by email (bcook@cha.harvard.edu) or telephone (+1 617 806 8741).

Full citation for article: Creedon TB, Wayne GF, Progovac AM, Levy DE, Lê Cook B. Trends in cigarette use and health insurance coverage among US adults with mental health and substance use disorders. Addiction. 2022. https://doi.org/10.1111/add.16052

Funding: This project was supported by the National Cancer Institute (R01CA229355-03).

Declaration of interests: None.

Addiction (www.addictionjournal.org) is a monthly international scientific journal publishing peer-reviewed research reports on alcohol, substances, tobacco, and gambling as well as editorials and other debate pieces. Owned by the Society for the Study of Addiction, it has been in continuous publication since 1884.

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JOURNAL

Addiction

DOI

10.1111/add.16052 

METHOD OF RESEARCH

Observational study

SUBJECT OF RESEARCH

People

ARTICLE TITLE

Trends in cigarette use and health insurance coverage among US adults with mental health and substance use disorders

ARTICLE PUBLICATION DATE

17-Nov-2022

Graphic Cigarette Warning Labels, the First Amendment, and Public Right to Accurate Public Health InformationGraphic Cigarette Warning Labels Back Under Legal Scrutiny

Gregory Curfman, MD^1,2,3

Author Affiliations Article Information

JAMA Health Forum. 2021;2(9):e212886. doi:10.1001/jamahealthforum.2021.2886

 Special Communication

September 24, 2021

Abstract

Importance  The 2009 Family Smoking Prevention and Tobacco Control Act required the US Food and Drug Administration (FDA) to issue a rule requiring graphic warning labels depicting the health consequences of smoking for prominent placement on cigarette packages and advertising. The tobacco industry filed a lawsuit against the FDA claiming that the required graphic labels constituted compelled speech in violation of First Amendment speech rights, and courts ruled for the tobacco industry. Subsequently, the FDA thoroughly redesigned the graphic labels and issued a revised rule, but the tobacco industry immediately filed a similar lawsuit against the FDA again on First Amendment grounds.

Observations  This article examines the delicate balance between First Amendment speech rights vs the right of the public to receive truthful, accurate, and understandable public health information. The article argues that the newly designed warning labels should easily pass First Amendment analysis. The need for new warning labels on tobacco products and advertising is a critical public health intervention to promote greater public understanding of the negative consequences of cigarette smoking, especially among the young.

Conclusions and Relevance  The legal analysis in this article marshals arguments that the First Amendment does not prohibit the requirement of the new tobacco warning labels. Commercial speech receives First Amendment protection primarily for the benefit of the public (listeners) and not the tobacco industry (compelled speakers). The balance favors the right of the public to receive accurate information about critical health risks.

Introduction

With the passage of the Federal Cigarette Labeling and Advertising Act (FCLA, 15 USC 1333) in 1965, the US government mandated for the first time that all cigarette packages and advertising materials must include the following warning label: “Caution: Cigarette smoking may be hazardous to your health.” This requirement set off a protracted conflict between the tobacco industry and the federal government, which has continued until this day, centered on the issue of compelled commercial speech.

For 2 decades following the passage of the FCLA, the US and other countries around the world applied various iterations of health warnings on cigarette packages, but all of them were based on presentation of textual warnings on packaging and advertising materials.¹ With the growing realization that textual warnings have limited effectiveness in conveying information or reducing smoking, including ineffectiveness among adolescents,² interest grew in the creation of graphic warning labels depicting with illustrations the adverse health consequences of smoking. The first country to adopt graphic warning labels was Iceland, which began to apply them in 1985.³ As government interest in the public health value of graphic warning labels grew internationally, by 2012, 49 countries had adopted them—except the US, despite that they may decrease positive perceptions of cigarettes, increase quitting cognitions, and modify smoking behavior.^4,5

Since 2009, the US Food and Drug Administration (FDA) has had the authority to regulate tobacco products. In that year, the Family Smoking Prevention and Tobacco Control Act (TCA),⁶ which granted the FDA’s regulatory authority over tobacco, was signed into law by President Barack Obama. Among the provisions in the TCA is an amendment to section 4 of the FCLA, which includes a regulation requiring that color graphic depictions of the health consequences of smoking be displayed on all cigarette packages and advertising materials.

First Amendment Protection of Commercial Speech

In 2011, the FDA issued graphic warning labels, which pictured serious health complications of cigarette smoking. The graphic labels illustrated adverse health consequences of cigarette use to more fully inform the public about the range of health complications. Before they were deployed, however, the labels were challenged in a lawsuit filed by tobacco companies (RJ Reynolds Tobacco Company v FDA).⁷ The companies’ claim was that the graphic labeling requirement constituted compelled speech that violated their First Amendment free speech rights.

The US Constitution protects speakers not only from government restrictions on their right to speak, but also from government actions to compel them to speak. As First Amendment scholar Robert Post has noted, in the realm of political speech (ie, public discourse as part of participatory democracy), there is “a constitutional symmetry between restrictions on public discourse and compulsions to participate in public discourse.”^8(p877) Both the freedom to speak and the right not to be compelled to speak receive equal constitutional protection. This symmetry does not, however, pertain to commercial speech, defined as speech intended solely to promote a commercial transaction.⁹ In this circumstance, the right of commercial speakers to speak is protected, while their right not to be compelled to speak receives lesser protection.

First Amendment protection of commercial speech has evolved over the past 4 decades. Prior to Virginia State Board of Pharmacy v Virginia Citizens Consumer Council, Inc, decided in 1976, commercial speech received little or no constitutional protection. In that case,¹⁰ the US Supreme Court invalidated a Virginia statute stating that it was unprofessional conduct for a licensed pharmacist to advertise the prices of prescription drugs, on the basis of the First and Fourteenth Amendments. This was the first case in which the Supreme Court ruled that commercial speech was not excluded from First Amendment protection.

In 1980, in Central Hudson Gas & Electric Corporation v Public Service Commission, the US Supreme Court first established a new standard of review defining when commercial speech may be regulated.¹¹ Justice Lewis Powell set out the 4-pronged Central Hudson test for commercial speech regulation:

At the outset, we must determine whether the expression is protected by the First Amendment. For commercial speech to come within that provision, it at least must concern lawful activity and not be misleading. Next, we ask whether the asserted governmental interest is substantial. If both inquiries yield positive answers, we must determine whether the regulation directly advances the governmental interest asserted, and whether it is not more extensive than necessary to serve that interest.¹¹

On the basis of the text of the opinion in Central Hudson, the test is generally considered to establish an intermediate level of scrutiny for laws or regulations that may affect commercial speech.¹² The principal rationale for allowing constitutional protection of commercial speech is that “the constitutional value of commercial speech lies in the circulation of information.”^8(p877)

First Amendment Protection of Off-label Promotion

The Central Hudson test was also used in a recent legal case involving off-label promotion of a prescription drug.¹³ In Amarin Pharma Inc v FDA (119 F Supp 3d 196 [SDNY 2015]), the court ruled that Amarin’s off-label promotion of its omega-3 fatty acid formulation, Vascepa, received First Amendment protection as commercial speech, as long as the promotional materials were truthful and nonmisleading.¹⁴ In reaching this ruling, the court applied the Central Hudson test, concluding that the FDA’s claim of misbranding did not survive application of the test. The court also referred to US v Caronia, an earlier case in which the FDA brought criminal charges against a drug representative for off-label promotional activities.¹⁵ Here too, the court applied the Central Hudson test in concluding that off-label promotion received First Amendment protection as commercial speech. Taken together, these 2 legal cases greatly strengthened protection of commercial speech by the First Amendment.

Compelled Commercial Speech

For compelled commercial speech, such as mandated disclosures about marketed products, a different standard of review has been established. In Zauderer v Office of Disciplinary Counsel, a case that involved an attorney who was advertising his services, the Office of Disciplinary Council in Ohio brought a complaint against him for inconsistencies of his advertising with state law.¹⁶ The outcome of the complaint was that the Office of Disciplinary Council required disclosure of information that was not contained in the attorney’s original advertising materials. The Supreme Court rejected the use of the Central Hudson test as the standard of review for compelled commercial speech. Justice Byron White wrote for the Court:

Because the extension of First Amendment protection to commercial speech is justified principally by the value to consumers of the information such speech provides, see Virginia Pharmacy Board v Virginia Citizens Consumer Council, Inc, 425 US 748 (1976), appellant’s constitutionally protected interest in not providing any particular factual information in his advertising is minimal.¹⁶

Justice White added:

We do not suggest that disclosure requirements do not implicate the advertiser’s First Amendment rights at all. We recognize that unjustified or unduly burdensome disclosure requirements might offend the First Amendment by chilling protected commercial speech. But we hold that an advertiser’s rights are adequately protected as long as disclosure requirements are reasonably related to the State’s interest in preventing deception of consumers.¹⁶

Thus, in Zauderer, the standard of review for compelled disclosure was determined by the Court to be “reasonably related to the State’s interest in preventing deception of consumers.”¹⁶ This standard of review is, arguably, comparable to rational basis review, and the Central Hudson test was not invoked. Although some commentators have claimed that the Zauderer standard of review applies only to situations in which the State has an interest in preventing “deception of consumers,” Post⁸ has unambiguously refuted this claim. He noted that a mandated disclosure is constitutional as long as it is “purely factual and noncontroversial” and “reasonably related” to an appropriate State interest.⁸

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JAMA Health Forum – Health Policy, Health Care Reform, Health Affairs | JAMA Health Forum | JAMA Network

Estimated Prevalence of Smoking and Smoking-Attributable Mortality Associated With Graphic Health Warnings on Cigarette Packages in the US From 2022 to 2100

Jamie Tam, PhD¹; Jihyoun Jeon, PhD²; James F. Thrasher, PhD³; et alDavid Hammond, PhD⁴; Theodore R. Holford, PhD⁵; David T. Levy, PhD⁶; Rafael Meza, PhD²

Author Affiliations Article Information

JAMA Health Forum. 2021;2(9):e212852. doi:10.1001/jamahealthforum.2021.2852

 Original Investigation

September 24, 2021

Key Points

Question  What are the estimated population health outcomes associated with implementation of graphic health warnings on cigarette packages in 2022 and with delayed implementation of the warnings since 2012, as originally planned, in the US?

Findings  In this decision analytical model using simulation modeling of smoking prevalence and smoking-attributable mortality in the US from 2012 to 2100, graphic health warnings, if implemented from 2022 to 2100, would be associated with 539 000 smoking-attributable deaths averted and 7.9 million life-years gained, and if implemented in 2012, with 718 000 deaths averted and 11.2 million life-years gained through 2100.

Meaning  These findings suggest that graphic health warnings on cigarette packages may be associated with important public health benefits, and industry litigation and procedural delays to implementation may have been harmful for public health.

Abstract

Importance  Starting in 2022, the US Food and Drug Administration (FDA) plans to require all cigarette packages in the US to display graphic health warnings depicting health harms associated with smoking. The FDA originally planned to implement such warnings in 2012, but tobacco industry litigation delayed the effort.

Objective  To assess the estimated population health outcomes associated with a policy requiring graphic health warnings on cigarette packages in the US and with a 10-year delay in implementation.

Design, Setting, and Participants  This decision analytical model used simulation modeling of smoking prevalence and smoking-attributable mortality in the US from 2012 to 2100, using the Cancer Intervention and Surveillance Modeling Network smoking population model. The study was conducted from October 2020 to July 2021.

Main Outcomes and Measures  The primary outcomes were annual adult smoking prevalence, smoking-attributable deaths averted, and life-years gained vs the baseline scenario. A baseline scenario assuming no graphic health warnings was compared with expected outcomes of implementing graphic health warnings in 2022 vs 2012. Policy effects were considered under varying assumptions of the association of the policy with smoking initiation and cessation, ranging from most conservative to most optimistic. A maximum smoking reduction scenario in which all smoking would stop by the end of 2022 was evaluated.

Results  In the baseline scenario, an estimated 13.2 million smoking-attributable deaths would have occurred from 2012 to 2100. Under a maximum smoking-reduction scenario, 5.5 million of these deaths would be averted. Implementation of graphic health warnings from 2022 to 2100 would be associated with 539 000 (range, 275 000-794 000) smoking-attributable deaths averted and 7.9 million (range, 4.0-11.6 million) life-years gained, representing less than 10% of the 5.5 million estimated smoking-attributable deaths averted and 81.8 million life-years gained in the maximum smoking-reduction scenario. Implementation from 2012 to 2100 would be associated with 33.2% (range, 32.9%-33.5%) more deaths averted (718 000; range, 365 000 to 1.1 million) and 42.7% (range, 42.3%-43.1%) more life-years gained (11.2 million; range, 5.7-16.6 million) compared with implementation in 2022.

Conclusions and Relevance  This decision analytical model estimated that FDA cigarette graphic health warnings, if implemented in 2022, would be associated with public health benefits. The model also estimated that more smoking-attributable deaths would have been averted if the policy had been implemented in 2012. Industry litigation and delays to implementing tobacco regulations may have been harmful for public health.

Introduction

Cigarette health warnings in the US have remained unchanged for the past 35 years, but starting in 2022, pending legal challenges, the US Food and Drug Administration (FDA) will require cigarette manufacturers to display graphic health warnings covering 50% of the front and back of cigarette packages. These warnings will also be required in cigarette advertisements. Cigarette health warnings will feature 1 of 13 graphic images that depict some of the negative health consequences of smoking and brief warning statements (eg, “Smoking causes COPD, a lung disease that can be fatal”).¹ The FDA originally planned to implement graphic health warnings in 2012, but tobacco industry litigation and resulting court decisions struck down the initial warnings, delaying implementation.¹ Public health organizations and physicians filed a lawsuit against the FDA for these delays, and a court-ordered deadline forced the FDA to finalize new graphic health warnings nearly a decade later.² The tobacco industry has also issued repeated legal challenges to the revised warning designs, and the implementation date is contingent on further court rulings.

Previous estimates of the potential population health benefits of graphic health warnings in the US were based on smoking prevalence trends through 2016.³ Since then, the prevalence of smoking—especially among youths and young adults—has decreased more than expected.^4,5 Recent shifts in smoking trends may affect the outcomes associated with new regulations, including graphic health warnings. Past estimates also have not separately evaluated the outcomes for specific birth cohorts. This study used a simulation model to estimate smoking prevalence and mortality outcomes associated with graphic health warnings in the US under the planned policy for 2022 and compared these with estimated outcomes if the policy had been implemented in 2012.

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JAMA Health Forum – Health Policy, Health Care Reform, Health Affairs | JAMA Health Forum | JAMA Network

E-visits tested as way to help people to quit smoking

Primary care is the best way to reach smokers, but primary care providers in rural areas – where people are more likely to smoke – are already overwhelmed. A study seeks to use e-visits to bridge the gap

Grant and Award Announcement

MEDICAL UNIVERSITY OF SOUTH CAROLINA

People who live in rural areas are both more likely to smoke and less likely to quit than people in nonrural areas, said MUSC Hollings Cancer Center researcher Jennifer Dahne, Ph.D.

Dahne, a clinical psychologist who focuses on cigarette smoking among vulnerable populations, wants to reach these people and help them to become former smokers – and along the way reduce their risks for a dozen kinds of cancer.

Dahne also serves as the co-director of remote and virtual trials for the South Carolina Clinical & Translational Research Institute based at MUSC. A remote trial, anchored by the primary care providers in their communities whom patients know and trust, looked like a possibility to help people in rural areas to quit smoking.

She’s now leading a team of researchers and clinicians, including primary care providers in communities served by MUSC Health-Florence Division and MUSC Health-Lancaster Division, on a $4.6 million grant from the National Cancer Institute to test whether a proactive electronic visit would help to promote smoking cessation.

Florence Division Chief Medical Officer Rami Zebian, M.D., is excited about the opportunity to get smoking cessation help to more people.

“This is something that's very much needed in our areas,” he said. “The percentage of smokers in Florence and Marion is huge, much higher than Charleston.”

Tobacco has been integral to the Pee Dee economy since the late 19th century. Zebian said he talks to many people who say they put their kids through college on tobacco farming. But they also note that they see the long-term effects of smoking – heart disease, strokes and cancer. As a pulmonologist, Zebian deals with some of those effects, like chronic obstructive pulmonary disease and lung cancer. And he sees a pattern among his patients.

“Every single one of my patients who has quit smoking, they all tell me one thing. They say, ‘I wish I quit sooner.’”

Dahne said that primary care is one of the best places to reach people with smoking cessation aids.

“Every time you go to your doctor, they are screening you for smoking. So, we actually have pretty good data in our electronic health record to identify our patients who smoke. And we know that most adults who smoke in this country receive care for smoking cessation from their primary care providers, and that smokers are visiting primary care providers pretty regularly,” she said.

But primary care providers are swamped.

Dahne said primary care providers have told them that while they really care about helping their patients to quit smoking, they are so busy when they have in-person appointments, managing, for example, hypertension medications, doing diabetic foot exams and everything else, that oftentimes talking about smoking cessation might fall by the wayside.

Edward McCutcheon, M.D., chief medical officer of the Lancaster Division, agreed that fitting it in is a challenge.

“There's just a tremendous number of priorities that have to be addressed in a single physician visit,” he said. “Trying to convince somebody to quit smoking in a matter of minutes just doesn't happen. Patients have become dependent on tobacco, and it’s something that has happened over years. Trying to discuss the physiology and the dependency on nicotine can be a challenge, and then trying to discuss treatment options and therapy requires a lot more time.”

Instead, during this trial, patients who are identified as smokers will receive messages through MyChart inviting them to take part in e-visits for smoking cessation. The e-visits were developed during a pilot trial that showed promising results.

Dahne explained that the e-visits will look like a questionnaire. Patients will answer questions about their smoking histories, how much they smoke and whether and how they’ve tried to quit in the past. An algorithm will then present a recommendation for a smoking cessation treatment for each participant. The algorithm prioritizes the most efficacious FDA-approved medications for smoking cessation, including varenicline, a medication better known by its brand name, Chantix. At that point, patients will have the option to agree with the recommendation or request a different approach.

The computer program doesn’t do the prescribing, though. A record of the entire e-visit will be sent to the patient’s primary care provider to review, and the provider can either prescribe the recommended medication or recommend a different plan based on the patient’s medical history. In addition to medications, all patients are provided with referrals for behavioral support to either the South Carolina Tobacco Quitline or to MUSC’s tobacco treatment program. Plus, Dahne said, the providers will be compensated for the e-visit review, so the program isn’t merely adding paperwork to their days.

At the same time that this clinical trial is running in rural areas, Dahne is running a similar trial with another grant at primary care practices affiliated with MUSC Health Charleston.

“I'm really excited to have these two grants running at the same time,” Dahne said. “We’re evaluating whether this proactive electronic visit approach works to help promote smoking cessation within these rural areas and the unique implementation barriers and facilitators within these rural clinical settings. My guess is that implementation factors are very much going to differ within our rural primary care clinics and clinics that are here as part of MUSC Charleston.”

Zebian said that quitting smoking can improve health and quality of life no matter a person’s age or health status.

“A lot of times people have misconceptions like, ‘Well, my lungs are already damaged. So what's the benefit of quitting now?’” he said. But even people with lung damage can avoid needing to use oxygen if they quit, and even people who need oxygen can add months or years to their lives by quitting. People with cancer – either lung cancer or some other type of cancer – will find their bodies respond better to treatment if they quit smoking.

“We all age. We all lose lung function,” he said. “But how fast we lose lung function is very different in people who are smokers and people who do not smoke.”

For help to quit smoking, contact the MUSC Health Tobacco Treatment Program at 843-792-9101.

About MUSC Hollings Cancer Center

MUSC Hollings Cancer Center is South Carolina’s only National Cancer Institute-designated cancer center, with the largest academic-based cancer research program in the state. The cancer center comprises more than 120 faculty cancer scientists and 20 academic departments. It has an annual research funding portfolio of more than $44 million and is dedicated to preventing and reducing the cancer burden across South Carolina. Hollings offers state-of-the-art diagnostic capabilities, therapies and surgical techniques within multidisciplinary clinics that include surgeons, medical oncologists, radiation therapists, radiologists, pathologists, psychologists and other specialists equipped for the full range of cancer care, including more than 200 clinical trials across South Carolina. For more information, visit hollingscancercenter.musc.edu.

BIG TOBBACCO LOSES

NZ

Survey shows milestone drop in smoking among Pasifika youth

Jan Kohout, Journalist
jan.kohout@rnz.co.nz


Photo: 123rf

A newly-released survey shows daily tobacco smoking rates for New Zealand Pasifika youth are at a record low of less than 2 percent.

With just 1.2 percent of Pasifika smoking daily, that is significantly less than what it used to be in 2017 when it was at 5.3 percent.

Published by Action for Smokefree 2025 (ASH), the survey is one of the largest ongoing youth smoking surveys in the world, with 29,538 Year 10 student participants, aged between 14 and 15.

The survey looks at both vaping and tobacco use.

It found that 45 percent of Pacific Year 10 students had tried vaping, 11 percent vaped daily as opposed to 1.2 percent who were daily tobacco smokers, and 2.6 percent were regular (ie, either daily weekly, monthly) smokers.

ASH director Sir Collin Tukuitonga, who is a strong advocate for Māori and Pacific health, credits the decrease in smoking rates to various smokefree messages throughout the years in Aotearoa and a general acceptance from youth that smoking is not sustainable.

"But I think what has worked generally is the messages to young people that smoking is not cool and they used prominent people to promote that message to really get young people to accept a movement away from smoking."

Tala Pasifika lead for Hapai Te Hauora's National Tobacco Control Advocacy service, Lealailepule Edward Cowley said there was a gap between people already smoking, compared to those in the 14-15 age group who could not legally purchase tobacco which showed not all age groups had stopped smoking.

"It's difficult for young people to access tobacco, which is probably why we see a drop. We really do see an increase from age 18 to 24, so whilst they are at a young age when they are at school we see a decrease when they start working and earning their own money, then are able to access and start to purchase things they want to purchase so we do see an increase in that age group."

Cancer Society medical director George Laking said adults most likely remained smokefree if they had not taken up smoking in their teenage years.

The Cancer Society's Dr George Laking Photo: Supplied

"The initiation of smoking characteristically occurs in youth, if you can get through your teen years without taking up smoking then you are less likely to take it up in general; they've basically missed the opportunity to take it up and they are not especially likely to take up smoking later on."

Dr Laking also said there was a clear decline in tobacco use for both young people and elders - a positive sign for Pacific and Māori youth.

The survey shows a clear decrease in tobacco use this year among year 10 groups which certainly suggests as Dr Laking said that young people in the future would be much less likely to pick up smoking even though some young people were currently picking up the bad habit when they were 18 years old.

However, a smokefree New Zealand in 2025 still looks grim according to Dr Laking who said there was currently a lack of regulation and legislation in place.

Tobacco use was still prevalent in Māori communities which would still take a bit of time to reduce, he said.

"It would be 50-50 chance to get to that point," he said.

The Ministry of Health is hoping to have less than 5 percent smoking rates for each ethnic demographic by that date.

To find out more about the annual ASH Year 10 Survey visit ASH Year 10 Snapshot Survey 2021 NationBuilder.

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Unlike other global crises, COVID-19 pandemic did not spark more smoking in its initial stage

UNIVERSITY OF WATERLOO

Research News

Unlike other population-level stressful events such as natural disasters, COVID-19 has not resulted in a net increase in smoking, according to a new study from the International Tobacco Control (ITC) Project, at the University of Waterloo.

The researchers also found that although nearly half of smokers reported that COVID-19 made them think about quitting, the vast majority of smokers did not change their smoking habits during the early phase of the COVID-19 pandemic.

Led by Shannon Gravely, research assistant professor with the ITC Project, the study surveyed 6,870 smokers and vapers in four high-income countries--Australia, Canada, England, and the United States--during the first global wave of COVID-19 between April and June 2020. The team examined the association between COVID-19 and thoughts about quitting smoking, changes in smoking, and factors related to positive changes such as attempting to quit or reducing smoking.

Only 1.1 per cent of smokers in the four countries attempted to quit and 14.2 per cent reduced smoking, but this was offset by the 14.6 per cent who increased smoking, with 70.2 per cent reported no change.

"It is important to note that population-level stressful events, such as 9/11 and natural disasters, have often led to increased smoking," said Geoffrey Fong, professor of psychology at Waterloo and principal investigator of the ITC Project. "So, our findings that there was no net increase in smoking in response to COVID-19 may actually represent a positive result for public health."

The study found that those who thought about quitting smoking because of COVID-19 were predominantly females, ethnic minorities, those with financial stress, current vapers, less dependent smokers, those with greater concern about personal susceptibility of infection, and those who believe COVID-19 is more severe for smokers.

According to Fong, who was a co-author of the study, this latter finding may be the key to why the COVID-19 pandemic has not led to significant increases in smoking, compared to past tragedies.

"Unlike other population stressors such as earthquakes, which are unrelated to smoking, COVID-19 severity is indeed linked to smoking," Fong said. "Public health officials have mentioned the link as yet another reason for smokers to quit, and over 80 per cent of smokers across the four countries believed that smoking made COVID-19 more severe. And this led to the lack of an increase in smoking, unlike what we have seen after other tragedies."

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The study, Smokers' cognitive and behavioural reactions during the early phase of the COVID-19 pandemic: Findings from the 2020 ITC Four Country Smoking and Vaping Survey, was recently published in the journal PLOS ONE. The authors were Gravely, Fong, Lorraine V. Craig, K. Michael Cummings, Janine Ouimet, Ruth Loewen, Nadia Martin, Janet Chung-Hall, Pete Driezen, Sara C. Hitchman, Ann McNeill, Andrew Hyland, Anne C. K. Quah, Richard J. O'Connor, Ron Borland, Mary E. Thompson, and Christian Boudreau.

The study was funded by Health Canada's Substance Use and Addictions Program.