Cessation's Key Role in Ending The Tobacco Problem

Tobacco is an unusual consumer product in that it contains carcinogens and other dangerous toxins. It would be banned under federal public health statutes if these statutes did not expressly exempt tobacco. Tobacco products are the only legal products for which the government's stated goal is to suppress use altogether rather than to promote safe or responsible use. While the nation has made significant progress in reducing tobacco use since the first Surgeon General's report on tobacco was released in 1964, tobacco use still claims about 440,000 lives every year, and secondhand smoke causes another 50,000 deaths annually. Smoking-related health costs are estimated to be $89 billion a year.

In May, the Institute of Medicine released a groundbreaking report, Ending the Tobacco Problem: A Blueprint for the Nation, to address the problems caused by tobacco. According to the report, “Substantial and enduring reductions in tobacco use cannot be achieved simply by expecting past successes to continue...Any slackening of the public health response not only will reduce forward progress, but also may lead to backsliding." The report concludes that current efforts, even if fully implemented, are insufficient to achieve this goal and would be hard-pressed to achieve even the far more modest goal of reducing the adult smoking rate from the current 20.9 percent to 15 percent. As the report states, such a modest reduction is not satisfactory because tobacco use would continue to cause a significant amount of premature death and disease.

The report sets an ambitious, but attainable goal for the nation: "To reduce tobacco use so substantially that it is no longer a significant public health problem." The report recommends a two-pronged approach to reach this goal:

1. Srengthen existing tobacco control measures to preserve and enhance the gains already made.
2. Change the regulatory landscape, including enactment of federal legislation granting the FDA authority over tobacco products and their marketing and distribution.

In addition to strengthening existing tobacco control measures through excise taxes, nationwide indoor smoking bans, and prevention interventions, the report recommends increasing cessation interventions. Despite the availability of many effective interventions, only a small proportion of tobacco users receive any type of intervention. To enhance quit attempts and smoking cessation rates, tobacco users must know that safe, effective, and accessible cessation programs, including medications, are available. To address this, the report recommends:

• Recommendation 14: All physicians, dentists, and other health care providers should screen and educate youth about tobacco use during their annual health care visits and any other visit in which a health screening occurs. Physicians should refer youth who smoke to counseling services or smoking cessation programs available in the community.
• Recommendation 16: State tobacco control agencies should work with health care partners to increase the demand for effective cessation programs and activities through mass media and other general and targeted public education programs.
• Recommendation 19: Public and private health care systems should organize and provide access to comprehensive smoking cessation programs by using a variety of successful cessation methods and a staged disease management model (i.e. stepped care), and should specify the successful delivery of these programs as one criterion for quality assurance within those systems.
• Recommendation 20: All insurance, managed care, and employee benefit plans, including Medicaid and Medicare, should cover reimbursement for effective smoking cessation programs as a lifetime benefit.

The report committee believes that strengthening existing tobacco control measures, particularly policies that increase consumer demand for proven cessation programs and comprehensive cessation policies, could have a substantial effect on tobacco use prevalence over time. The projected impact of these policies is meeting the Healthy People 2010 smoking prevalence target of 12 percent in about 2020, with a 10 percent prevalence reached in 2025.

Although achieving these levels would be a major improvement, they are not satisfactory from a public health standpoint, simply because of the large numbers of premature deaths and other serious harmful consequences that would still inevitably follow. That is why the report recommends Congress confer broad authority on FDA to regulate the manufacture, distribution, marketing and use of tobacco products. The committee believes that regulatory standard should be to “protect the public health” by reducing initiation, promoting cessation, preventing relapse, reducing consumption and reducing product hazards. Specifically related to cessation, the report recommends:

• Recommendation 30: Congress and state legislatures should enact legislation regulating the retail point of sale of tobacco products for the purpose of discouraging consumption of these products and encouraging cessation. Specifically, retail outlets choosing to carry tobacco products should be required to display and distribute information regarding products and services for cessation, and allocate a proportionate amount of space to cessation aids and nicotine replacement products.

The American Legacy Foundation, which sponsored the study that informs this report, is running a series of print advertisements to attract law makers’ attention and stimulate policy changes. The three advertisements, including one focused on the cessation recommendations, will appear in rotation through mid-November in the Capitol Hill publications Roll Call and CQ Today. The cessation ad explains how nicotine addiction stimulates and sustains long-term tobacco use and poses significant challenges to smoking cessation efforts. The ad also highlights the recommended actions, including collaborating with healthcare partners and using mass media and other public education campaigns, that can be taken to address tobacco use addiction and help smokers successfully quit. For more information, please visit http://www.americanlegacy.org.

Ending the Tobacco Problem: A Blueprint for the Nation recognizes that important advances in reducing tobacco use have been made over the past four decades since the first Surgeon General's report on tobacco. But more needs to be done to achieve faster, more certain reductions in tobacco use. The report recommends that public and private sectors work together to strengthen and implement tobacco control measures that have been proven to be effective, and that Congress should empower the state and federal governments to deploy a whole new set of tools in the fight against smoking and other forms of tobacco use. Taking these steps would put the nation on an irreversible course toward ending the tobacco problem in the United States.

For more information or to order the report, visit http://www.iom.edu/CMS/3793/20076/43179.aspx.

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Genetic Variation Affects Smoking Cessation Treatment

A new study reports that genetic variation in a particular enzyme affects the success rates of treatment with bupropion, an anti-smoking drug. The article "CYP2B6 Genotype Alters Abstinence Rates in a Bupropion Smoking Cessation Trial" appears in the September 15th issue of Biological Psychiatry.

Scientists performed CYP2B6 genotyping on smoking individuals, a gene that is known to be highly variable and whose enzyme metabolizes both bupropion and nicotine. Participants were then provided with either placebo or bupropion treatment for ten weeks. The authors discovered that individuals with the CYP2B6*6 allele of the gene benefited from bupropion treatment and maintained abstinence longer while doing poorly on placebo, with a 32.5 percent abstinent rate vs. 14.3 percent, respectively. In contrast, those in the CYP2B6*1 group did well on both bupropion and placebo, with similar abstinence rates at the end of treatment and after a six month follow-up.

Rachel Tyndale, M.Sc., Ph.D., one of the authors on this study, comments, "This first study, while requiring replication, identifies a very common genetic variant that appears to affect smoking cessation treatment outcome." This variant is present in 25-50 percent of people, thus affecting a large portion of the population.

"This study is part of our ongoing commitment to develop more accurate and personalized approaches to medicine," said NIH Director Dr. Elias A. Zerhouni. "This kind of genetic research is helping us to better understand why some people respond to certain smoking cessation treatments, and others don't."

For more information, see web link:
Biological Psychiatry, 2007 Volume 62, Issue 6

NicVAX Trials Continue to Show Promise for Smoking Cessation

Test data from both six and nine-month trial use of NABI Biopharmaceuticals’ (NABI) ongoing trial of NicVAX (nicotine conjugate vaccine), shows “statistically significant” cessation, and continued abstinence from nicotine use.

The data show the vaccine is statistically instrumental in the “ability of these patients to quit smoking and to remain abstinent. This key development -- the success of a smoking cessation vaccine -- could have an important impact on how we address smoking and smoking relapse." said Dr. Dorothy Hatsukami, Forster Family Professor in Cancer Prevention and Professor of Psychiatry at the University of Minnesota Tobacco Use Research Center.

Specifically, NABI’s vaccine approach has two advantages over the traditional a pill-based approach, according to said NABI Interim President and Chief Executive Officer Dr. Leslie Hudson. It prevents nicotine from entering the brain, rather than replacing nicotine or blocking receptors with chemicals inside the brain. As a vaccine, it remains in the body for up to 12 months, whereas pills either stop working, or the user stops taking the pills.

NABI said trials are expected to show that antibodies from NicVAX will last 12 months or longer. If that proves to be true, it would support getting through the critical first year in which relapse ranges as high as 95 percent with other therapies.

For more information, see web link:
CNN Money, September 5, 2007

Number of Quit Smoking Attempts Key To Success

International delegates attending the Oceania Tobacco Control conference in Auckland this month were asked to shift their focus from the 'quality' of smokers' quit attempts to the 'quantity' of those attempts. Applying a simple mathematical model to various population data, Professor Shu-Hong Zhu, from the University of California, demonstrated that increasing the frequency of quit attempts in the general population leads to a quicker drop in smoking prevalence than increasing the use of cessation aids.

Zhu noted that in California, smokers on average tried 12 to 14 times before quitting for good; 12 if they used cessation aids, and 14 if they did not. These figures have stayed fairly constant since data collection began in the early 1990s, even though the availability of cessation aids has increased. "What this means is that quitting aids reduce the overall number of attempts that are needed. But smokers still have to make multiple attempts, with or without these aids.”

Zhu said "What is interesting about prompting more smokers to try to quit is that it creates a perception for the remainder that everybody is doing it. It helps to establish a norm of quitting, which can further increase the likelihood that smokers will try. Changing the impression that smokers have about what other smokers are doing can be a very effective tool in encouraging more attempts.”

For more information, see web link:
Scoop Health, September 6, 2007

The Lasting Effects of Smoking

A recent study published in the journal BMC Genomics reveals that smoking can cause irreversible changes in genes, even after quitting.

The study is the largest ever to use the serial analysis of gene expression, or SAGE, technique, which allows investigators to look for gene activity in the cells. Tissue samples were taken from 24 current, former, and never smokers. The researchers examined more than 3,000,000 gene targets in the bronchial epithelium with know links to cigarette smoke exposure. While some potentially harmful genes deactivate when a smoker kicks the habit, others are permanently switched to the on position or are only partially switched off after quitting.

The finding may help explain why former smokers remain at higher risk for developing lung cancer, even years after quitting. About 85 percent of all lung cancers are attributable to smoking, and half of those cases are diagnosed among former smokers, according to background information published in the study.

"Expression levels of some of the genes related to tobacco smoking return to levels similar to never smokers upon cessation of smoking, while expression of others appears to be permanently altered despite prolonged smoking cessation," write study authors. "These irreversible changes may account for the persistent lung cancer risk despite smoking cessation."

For more information, see web link:
BMC Genomics, 2007, Volume 8, Issue 297

Analysis Finds Smoking Drops as Taxes Rise

A new analysis finds that higher state taxes on smokers have produced sharp declines in consumption. The amount of decline in smoking is directly tied to the size of the tax hike, the USA Today analysis shows. Cigarette sales fell 18 percent in North Carolina last year after the tax was raised in two steps to 35 cents from a nickel. Connecticut has increased its tax to $1.51 from 50 cents per pack in 2002. Since then, per capita consumption of cigarettes has fallen 37 percent. New Jersey has raised its tax to $2.40 from 80 cents in 2002. Smoking has dropped 35 percent. By comparison, South Carolina has kept its lowest-in-the-nation cigarette tax at 7 cents since 1977. Cigarette consumption there has fallen 5 percent since 2000.

As Congress considers raising the federal cigarette tax to $1 per pack, the nation may be about to experience one of the biggest one-time declines in smoking, health experts and economists say. Frank Chaloupka, a University of Illinois economist, predicts that smoking will drop 6 percent if the 61-cent-per-pack tax hike is passed, taking the levy to $1 a pack from 39 cents. The Senate approved the increase as a way to pay for expanded government health care for children. The House has proposed a 45-cent increase. President Bush has threatened to veto the bill.

For more information, see web link:
USA Today, August 9, 2007

Nicotine Addiction Is Quick in Youths, Research Finds

According to a study published in the July issue of The Archives of Pediatrics and Adolescent Medicine, a young cigarette smoker can begin to feel powerful desires for nicotine within two days of first inhaling and about half of children who become addicted report symptoms of dependence by the time they are smoking only seven cigarettes a month.

Researchers recruited 1,246 sixth-grade volunteers in public schools in Massachusetts, interviewing them 11 times over a four-year period. They also took saliva samples to determine blood levels of nicotine and link them to addictive behavior. At some time during the four years almost a third of the children puffed on a cigarette, more than 17 percent inhaled, and about 7.5 percent used tobacco daily.

Of the children that inhaled, almost 60 percent had lost some control over their smoking, and 38 percent developed tobacco dependence as defined by the widely used diagnostic manual published by the World Health Organization. In the 10 percent of children who were most susceptible, cravings began within two days of the first inhalation, and saliva analysis showed that being dependent did not require high blood levels of nicotine throughout the day.

For most inhalers, daily smoking was not required to cause withdrawal symptoms. More than 70 percent had cravings that were difficult to control before they were smoking every day. The biochemical analyses confirmed this: the symptoms of dependence began mostly at the lowest levels of nicotine intake. “The importance of this study is that it contradicts what has been the accepted wisdom for many decades,” said Dr. Joseph R. DiFranza, the lead author, “which is that people had to smoke at least five cigarettes a day over a long period of time to risk becoming addicted to nicotine. Now, we know that children can be addicted very quickly.”

For more information, see web link:
Archives of Pediatric and Adolescent Medicine, 2007 161:704-710

Smokers Who See More Ads for Smoking-Cessation Products are More Likely to Quit Successfully

A recent study co-funded by RWJF shows that the more magazine ads smokers see for the nicotine patch and other quit-smoking aids, the more likely they are to try to quit smoking and be successful -- even without buying the products. The study, published in the Journal of Political Economy, found that although some of the increased quitting behavior involves buying smoking-cessation products, just seeing the ads makes it more likely that smokers will try to quit. "The public health returns to smoking-cessation product advertisements exceed the private returns to the manufacturers," write the researchers.

Using databases on the consumer behavior and magazine-reading habits of 28,303 current or former smokers and advertising data in 26 consumer magazines, Alan Mathios, professor of policy analysis and management at Cornell and three colleagues explored the impact of advertising of smoking-cessation products on quitting decisions. "We think that the reason may be that important 'spillover effects' from advertising may be occurring, which has important implications for advertising for a wide range of health products," said Mathios.

For more information, see weblink:
Journal of Political Economy, 2007, Volume 115, Issue 3

Major Reduction in Teenage Smoking in New York

A report documents a reduction of almost 45 percent in youth smoking statewide since 2000, the year that New York began implementing a comprehensive tobacco control program. The Youth Tobacco Survey is taken in even-numbered years among middle school and high school students and reflects trends from 2000 to 2006. Among all middle and high school youth, the prevalence of smoking in 2000 was 19.4 percent. This rate decreased to 10.4 percent in 2006, a 44.8 percent reduction.

"Since the majority of people who become regular cigarette smokers begin during adolescence, the results of this youth survey are very encouraging," said State Health Commissioner Richard F. Daines, M.D.

The State's program takes a broad-based approach to tobacco control and prevention, including community mobilization, media campaigns and counter-marketing to promote quitting, highlight dangers of second-hand smoke, expose tobacco industry propaganda, and de-glamorize tobacco use, and cessation interventions to motivate tobacco users to quit and to support cessation efforts.

New York State is on track to achieve the national Healthy People 2010 goals in tobacco use rates among high school students. Among high school students in the state, 16.3 percent report having smoked one or more cigarettes in the past 30 days; the Healthy People 2010 goal is 16 percent. The use of any tobacco products by high school students in 2006 was 21.8 percent; the Healthy People 2010 goal is 21 percent.

For more information, see web link:
New York State Department of Health Press Release August 30, 2007

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New Campaign in New York State Targets Secondhand Smoke Around Children

Smokers, already pushed outside in New York, may be getting more grief than usual for lighting up in public places thanks to a new ad campaign designed to discourage smoking around children. The state's $5 million campaign comes at the same time a report by the U.S. Surgeon General indicates infants and young children are especially vulnerable to secondhand smoke. One print ad warns "when you smoke around your kids, they smoke too. By the age of 5 they'll have inhaled over 100 packs."

The New York State Clean Indoor Air Act prohibits smoking in virtually all workplaces, including restaurants, bars and most other public indoor spaces. Assemblyman Ivan Lafayette, D-Queens has reintroduced a bill that would also ban smoking in cars with minors younger than 16. New York City is considering separate legislation. The proposal, which Councilman James F. Gennaro, D- Queens introduced, would prohibit smoking in cars where a child under 18 is present. Fines would range from $200 to $2,000, depending on the number of violations.

Meanwhile, other states have passed similar legislation. Arkansas now bans smoking in cars with children age 6 and younger, while Louisiana has limited it when children 13 and younger are in the vehicle. Twenty other states are considering similar legislation.

The secondhand smoke ads will run in New York through the end of October, and cessation ads will begin in November and play through the holiday season

For more information, see web link:
Newsday, September 23, 2007

Scottish Smoking Ban 'Improved Health'

The smoking ban in Scotland has led to a significant advance in public health, according to the most detailed scientific study of the measure so far.

Comparisons at nine hospitals in Scotland revealed that there was a 17 percent drop in heart attack admissions since the ban was introduced in March 2006. Exposure to second-hand smoke was also down by 40 percent among adults and children during the same time period. It said the quality of air in pubs is now equivalent to that found outdoors.

The study also found that among primary school children, levels of cotinine fell by more than a third (39 percent) following the ban. In adults, cotinine levels fell by almost half (49 percent) in non-smokers from non-smoking households. Non-smokers living in smoking households continued to have high levels of second hand smoke exposure in the home.

Professor Jill Pell, who headed the research team, said "the primary aim of smoking bans is to protect non-smokers from the effects of passive smoking. Previous studies have not been able to confirm whether or not that has been achieved. What we were able to show is that among people who are non-smokers there was a reduction in heart attack admissions. This confirms that the legislation has been effective in helping non-smokers." The authors suggest that further action is urgently required to support smoking households to implement smoke-free homes and cars.

For more information, see web link:
BBC News, September 10, 2007

Fewer Utah Residents Lighting Up

The number of Utah residents who smoke is at its lowest number since tracking began in 1989 - but many of those who still light up fall into low-income, less educated or minority groups. About 9.5 percent of Utah residents reported being smokers in 2006 - 1.7 percent lower than in 2005, and 4 percent lower than in 1999, according to the 2007 Utah Tobacco Prevention and Control Program annual report released on September 4, 2007.

In the last eight years, 30 percent of Utah's adult smokers have snuffed out their habit - about 17 percent above the national average, said Lena Dibble, marketing director for the Utah Tobacco Prevention and Control Program (TPCP). Reductions in Utah's smoking rates since 1999 also include 38 percent fewer young smokers, 28 percent fewer pregnant women smokers and 50 percent less smoking inside homes with children, the report states.

While the overall decrease is promising, more than 188,000 Utah adults and youth continue to smoke, many of them people who make less than $20,000 a year, didn't finish high school or are a member of a minority group. Combined data for the years 2002 through 2006 show that 28.9 percent of African Americans smoke, as do 18.5 percent of American Indians/Alaska Natives and 12.1 percent of Hispanics. By comparison, 10.9 percent of non-Hispanic whites in Utah smoke.

Such data has prompted Utah to customize its anti-smoking messages and programs to groups most likely to puff, Dibble said. Several networks, for example, hold community cessation classes and offer educational materials at festivals. An ad campaign that followed Utah Latinos through the quitting process spurred an increase in calls to the Spanish language Utah Tobacco Quit Line, Dibble said.

For more information, see web link:
Salt Lake Tribune, September 5, 2007

Missouri to Help Reduce Smoking Among Younger Women

Missouri Department of Health and Senior Services has been awarded a grant from the March of Dimes to provide training for health care providers to help women of child-bearing age – especially those that are pregnant – quit smoking. The training program includes: interactive learning using proven strategies; techniques on integrating these strategies into the clinical setting; use of the Missouri Tobacco Quitline for smoking cessation and prevention of relapse; and a comprehensive manual.

“Smoking during pregnancy is the single most preventable cause of illness and death among mothers and infants,” said Joan Schlanker, public health consultant nurse with the department’s program for Alcohol, Tobacco and Other Drug Prevention and Awareness. “In Missouri, smoking rates among women of reproductive age, including those who are pregnant, are consistently higher than much of the rest of the nation.”

Missouri had the eighth highest smoking prevalence rate among pregnant women in the United States in 2003. According to the state health department, 18.2 percent of pregnant women in Missouri reported smoking during their pregnancy.

The Missouri Model for Brief Smoking Cessation training is built on the evidence-based 5 A's model (Ask, Advise, Assess, Assist, Arrange) for smoking cessation that was adopted by the American College of Obstetricians and Gynecologists in 2002. The 5 A’s model, a 5- to 15-minute counseling session by trained health care providers, has been proven effective with pregnant women who smoke.

For more information, see web link:
Missouri Department of Health and Senior Services News Release, August 14, 2007

Presidential Panel Calls on Nation's Leaders to Take Action on Tobacco

A new report issued by the President's Cancer Panel is a call to action on how to significantly reduce tobacco use and its devastating toll in the United States and around the world. The panel of national experts appointed by the President has concluded that the main obstacle to progress has been the lack of political will to implement proven solutions.

The report strongly criticizes the tobacco industry and states that the FDA should be allowed to regulate tobacco. The report also calls for a significant increase in the federal cigarette tax. The report calls on states to increase tobacco taxes, fund comprehensive tobacco prevention and cessation programs at levels recommended by the CDC, and to enact smoke-free laws.

The report also includes an important call for the United States to demonstrate leadership in the global fight against tobacco use by ratifying and implementing the international tobacco control treaty, the Framework Convention on Tobacco Control. The report concludes that it is shameful that the United States is not one of the 148 nations that have ratified the treaty.

Other recommendations in the report include efforts to reduce youth exposure to smoking in movies, exclude tobacco and all tobacco products from international trade agreements, require that state-funded programs offer smoking cessation services and ensure that all state cancer control plans include a tobacco control component.

For more information, see external PDF:
President's Cancer Panel 2006-2007 Annual Report

Toolkit Eliminates Tobacco-Related Health Disparities for People with Mental Illnesses

People with mental illnesses smoke at disproportionately higher rates than the general population and are at a higher risk for tobacco related illnesses like respiratory disease, coronary heart disease and chronic obstructive pulmonary disease (COPD).

The University of Colorado at Denver and Health Sciences Center (UCDHSC) in collaboration with the Colorado State Tobacco Education and Prevention Partnership (STEPP) created the Mental Health Provider Toolkit as a guide for mental health providers to support smoking cessation among people with mental illnesses. Those with mental illnesses often die 20 years sooner than the general population, and those lost years of life are often a result of tobacco use. That’s why it’s vitally important to get the new smoking cessation toolkit into the hands of mental health providers, says Jeanette Waxmonsky, PhD, with UCDHSC’s School of Medicine.

The toolkit reviews the current literature regarding tobacco use and mental illnesses including biological predispositions and psychological considerations, as well as implications for specific mental disorders. It also provides a review of the stages of change, guidelines for assessing readiness to quit, because, unlike the myth the general public often believes, people with mental illnesses can stop smoking with proper help, and treatment recommendations including pharmacotherapy, nicotine replacement and counseling. Strategies for relapse prevention are also provided.

“Providing the toolkit to mental health providers across Colorado is a way of reaching out to those in need and letting them know they are not alone in the fight against nicotine addiction,” said Waxmonsky.

For more information, see web link:
Health News Digest, August 15, 2007

Tobacco-Use Reduction Program Shows Gains

A new program aimed at reducing tobacco use among North Carolina college students was successful in its first year of operation, according to an evaluation by UNC researchers. The Tobacco-Free Colleges Initiative was established by the N.C. Health and Wellness Trust Fund. It began operating in January 2006 and has since awarded grants to 20 organizations working on close to 60 college campuses across the state.

Grantees work to establish tobacco use prevention coalitions, advance tobacco-free policies and promote the use of the Quitline NC telephone cessation service by young adults between 18 and 24 years old on North Carolina college campuses. Grantees worked on 58 different campuses in 44 counties across the state. The number of new policies, campus coalitions, college officials offering formal support and Quitline NC promotions to young adults all increased substantially since the start of the initiative.

One highlight of the first year's accomplishments include the adoption of 16 tobacco-related policies and three 100 percent tobacco-free campus policies. Other highlights include the adoption of five tobacco-free policies by campus organizations, the adoption of four designated area/perimeter policies, the adoption of two 100 percent tobacco-free policies by health care systems affecting three campuses, one policy prohibiting tobacco sales on campus and one tobacco-free policy adopted by an off-campus restaurant frequented by young adults.

For more information, see web link:
Chapel Hill News, August 12, 2007

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