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The poor more likely to smoke, research finds

PHILADELPHIA | Many people smoke after they’ve eaten. Lindell Harvey smokes because he hasn’t.
“You smoke out of anxiety because you don’t have the food you need,” said Harvey, 54, who lives alone in Crum Lynne, Pa. He receives disability checks from the Navy that keep him $2,000 below the poverty line.
Harvey relies on his Newports to see him through his hard days. “In my mind, the smoking becomes a comfort as I try to create ways to get food.”
In lives where people endure a dearth of nearly everything important — food, jobs, medical care, a safe place to live — the poor suffer an abundance of one thing:
Nicotine.
The poor are more likely to smoke than those above the poverty line.
In Philadelphia, there’s a 50 percent higher prevalence of smoking among the poor than among the non-poor, according to Giridhar Mallya, director of policy and planning for the Philadelphia Department of Public Health.
The poorest of the 10 largest U.S. cities, Philadelphia also has one of the highest rates of smoking of any big city, according to a health department report.
Lower-income neighborhoods such as Kensington, Bridesburg and Port Richmond are among the city’s most smoker-prevalent neighborhoods, department research shows.
The poor smoke to manage high levels of stress and depression, Mallya said, as much a part of poverty as empty pockets.
Then, too, the poor are more likely to be exposed to nearly ubiquitous cigarette advertising at corner stores, which exacerbates smoking, Mallya said.
It’s also harder for the poor to get smoking-cessation counseling and nicotine patches than others who may receive help through insurance, experts said.
Even as health insurance comes to the poor through the Affordable Care Act, smoking remains a problem: Smokers may be charged a premium of up to 50 percent, according to Frank Leone, director of the Comprehensive Smoking Treatment Program at the University of Pennsylvania.
Mariana Chilton, a professor at Drexel University’s School of Public Health, noted the complex link between smoking and poverty:
“When you’re deprived, it creates enormous mental anguish,” said Chilton, an expert on hunger. “One of the fastest, most convenient ways to help is a cigarette. It’ll keep you sane, and keep you from hurting yourself or others.”
Smoking is also a way to deal with hunger, Chilton said. Families without enough to eat are more likely to smoke than food-secure families, she said.
“Smoking treats hunger pangs,” Chilton said. “Instead of having lunch, mothers will feed their children, then smoke.”
That’s how it works in Camden, said Elaine Styles, 51, a laid-off day care worker.
“I smoke so I don’t have to eat,” she said. “I make sure my family eats, then I have a loosie (a cigarette sold singly for 50 cents or so) and go to bed.”
Because smoking is costly, people ask, aren’t the poor being irresponsible for misallocating money better spent on food?
Low-income smokers nationally spend 14 percent of household income on cigarettes, Mallya said. In Philadelphia, the average smoker spends about $1,000 a year on cigarettes, he added.
Mallya laments the fact that cigarettes in Philadelphia are relatively cheap — $5 to $6 a pack — compared to other cities where added taxes make them more dear. The more cigarettes cost, the fewer are smoked, he said.
The morality of buying cigarettes when you’re poor is complicated. Most poor people want to quit smoking, surveys show. But poverty itself, combined with the overwhelming power of nicotine, make stopping hard.
“People smoke knowing is not good for them,” said Leone of Penn, who is also a pulmonologist. “Nicotine gets into the part of the brain stem that creates a sense of safety, comfort, warmth. If you have to decide between buying bread or cigarettes, not buying cigarettes creates a disease and agitation in the brain that says there’s only one way to fix this situation: Just smoke.”
Yale University sociologist Elijah Anderson said people shouldn’t “blame the victim” by denigrating smoking behavior without understanding poverty, its underlying causes, and a poor person’s “limited sense of having a future.”
Among the poor, especially low-income African-Americans, menthol worsens smoking.
A flavor added to cigarettes, menthol makes the cigarette taste less harsh, which causes the smoker to take deeper, more frequent drags, Mallya said.
That, in turn, increases the harm of cigarettes.
For 50 years, menthol cigarettes were promoted in black neighborhoods; now, 90 percent of African-American smokers in Philadelphia smoke menthol cigarettes, Mallya said.
“There may be something biological at work,” Leone said, adding that science is studying whether race makes a difference. “But that doesn’t cloud the intense effort by cigarette marketers.”
In a city where black people already suffer greatly from asthma — Philadelphia is among the top-five worst asthma cities in America, experts say — smoking aggravates everything, especially among children, said Brad Collins, professor of public health and pediatrics at Temple University.
Jerry Goldstein, a pediatrician at St. Christopher’s Hospital for Children, agreed. “Second- and third-hand smoke (found on clothing and walls) are seriously exacerbating kids’ asthma,” he said.
This is not to say all is hopeless. While still high, rates of secondhand smoke exposure in the city have decreased by nearly 7 percentage points between 2004 and 2012, health department research shows. And teen smoking is down from nearly 16 percent to over 9 percent in the same time frame, while there are slightly fewer adults lighting up these days.
Mallya attributes that to an intensive public education program and his department’s efforts to help get many poor people smoking-cessation help.
But that doesn’t mean the air will clean up any time soon.
As Amy Hillier, a professor in Penn’s School of Design, who helped study cigarette advertising, said, “Sometimes a pack of Marlboros will save someone’s life in terms of stress.”

http://jacksonville.com/news/health-and-fitness/2013-10-20/story/poor-more-likely-smoke-research-finds#ixzz2iNYGsIWx

Cigarette Taxation Helps to Reduce Drinking Among Groups Considered Vulnerable

Tobacco use is the leading cause of preventable death and disability in the U.S., while heavy drinking ranks as the third leading cause of preventable death. Cigarette taxation has been recognized as one of the most significant policy instruments to reduce smoking. Given that smoking and drinking often occur together, a first-of-its-kind study has examined cigarette taxation and found that increases are associated with modest to moderate reductions in alcohol consumption among vulnerable groups.
Results will be published in the January 2014 issue of Alcoholism: Clinical & Experimental Research and are currently available at Early View.
“Smoking and heavy drinking co-occur at alarmingly high rates,” said Sherry McKee, associate professor of psychiatry at Yale University School of Medicine as well as corresponding author for the study. “Tobacco can enhance the subjective effects of alcohol and has been shown to increase the risk for heavy and problematic drinking. Smokers drink more frequently and more heavily than non-smokers, and are substantially more likely than non-smokers to meet criteria for alcohol abuse or dependence. The co-occurrence of smoking and drinking is of particular clinical significance given evidence that health consequences exponentially increase with combined versus singular abuse of alcohol and tobacco.”
“Smoking and drinking are strongly linked for a host of reasons including complementary pharmacologic effects, shared neuronal pathways, shared genetic associations, common environmental factors, and learned associations,” added Christopher W. Kahler, professor and chair of the department of behavioral and social sciences at Brown School of Public Health. “However, it is possible to intervene through behavioral treatments, pharmacotherapy, and policy to affect both behaviors in a positive way.”
“Cigarette taxes have broad population reach and have been recognized as one of the most significant policy instruments to reduce smoking,” said McKee. “Increases in cigarette taxes predict decreases in smoking initiation, increases in quitting, and reductions in cigarette-related morbidity and mortality. By increasing the price of cigarettes, taxes are thought to encourage smokers to reduce their use of cigarettes or quit altogether, and discourage non-smokers from starting to smoke.”
McKee and her colleagues examined data gathered through personal interviews with 21,473 alcohol consumers as part the National Epidemiological Survey on Alcohol and Related Conditions, a survey conducted by the National Institute on Alcohol Abuse and Alcoholism. Analyses evaluated whether increases in cigarette taxes between Waves I (2001-2002) and II (2004-2005) were associated with reductions in quantity and frequency of alcohol consumption. These analyses were conducted by gender, hazardous drinking status, age, and income group, and were further adjusted for demographics, baseline alcohol consumption, and alcohol price.
“We hypothesized that the public health benefits of cigarette taxes would extend beyond smoking to reduce alcohol consumption,” said McKee. “Results suggest that increases in cigarette taxes were associated with reductions in alcohol consumption over time among male smokers. The protective effects were most pronounced among subgroups who are most at risk for adverse alcohol-related consequences, including male heavy drinkers, young adults, and those with the lowest income.”
“These findings suggest that if states increase taxes on cigarettes, they are not only likely to reduce smoking — based on a large body of literature — but they also may have a modest impact on heavy drinking rates among men, those with lower income, and those who drink most heavily,” said Kahler. “In other words, policies that target one specific health behavior may have broader benefits to public health by affecting additional health behaviors that tend to co-occur with the targeted health behavior.”
Kelly Young-Wolff, post-doctoral research fellow at Stanford Prevention Research Center, and one of the study’s co-authors, agreed, adding that these results support research that targets the interactions of tobacco and alcohol. “Results from our study can pave the way for a productive line of future research aimed at reducing secondary public health harms such as alcohol-related violence, drunk driving, and alcohol-related morbidity and mortality.”
“While the study does not show a causal association,” added Kahler, “in the context of laboratory, clinical, and policy studies conducted to date, it suggests that policy makers and clinicians may have significant opportunities to address heavy drinking and smoking together.”
http://www.sciencedaily.com/releases/2013/08/130810063508.htm

Letter: Harm-reduction not best public policy for tobacco

There has been a good deal of talk about “harm-reduction” strategies (promoting alternative tobacco products, such as chewing tobacco or e-cigarettes, as safer alternatives to smoking cigarettes) as being good options for tobacco users to reduce the risk of using tobacco while maintaining the addiction to nicotine.
Reducing-harm strategies can be an option for an individual who wants to try to reduce his or her own risk of harm while maintaining an addiction. However, when it comes to tobacco use, harm-reduction strategies are not the best public policy to use to address the population-based well-being that public health strategies must address.
• How would it be if the public health professionals advocated for food handlers to wash their hands most of the time after using the bathroom rather than every time? After all, it would reduce the chances of contracting disease from someone who never washed his/her hands. One could say it is better than never washing one’s hands. The public policy must continue to be the best method of preventing disease transmission, that is: wash one’s hands every time, not just sometimes.
• I hear a lot about smokeless tobacco being a good alternative for adult smokers who don’t want to quit using tobacco. Consider this: It is not just adults who use chew. The sweeteners added and new products that have come on the market make it an easy way to addict our next generation to tobacco. North Dakota’s youth consume smokeless tobacco at a rate almost twice the national average (N.D., 13.6 percent, U.S., 7.7 percent). In addition, smokeless tobacco is not without its health hazards.
• E-cigarettes are often touted as a good alternative to tobacco use. We are told by some that the vapor is harmless. This is not true. It has not been regulated or studied enough to know how dangerous it is, but it is not harmless. There is another issue to consider. Have you ever noticed how candy cigarettes and now e-cigarettes mimic the activity a smoker would do with a cigarette? It models the smoking behavior and should not be discounted as harmless.
One of the core functions of public health is to promote strategies that protect the health and safety of the community. Public health providers are accountable to the community to provide up-to-date information and advocate for tried-and-true strategies to improve or maintain a community’s health status.
As a public health nurse, I cannot support harm-reduction policies that supports maintaining one’s addiction to tobacco. Harm- reduction policy is not sound public health policy.
The rationale that was brought up recently in a letter to the editor, that the tobacco user who is not willing or able to quit should have chewing tobacco or e-cigarettes researched and funded with tobacco prevention dollars in the state of North Dakota, falls short. The evidence is readily available regarding what works and how to gain access to help. The options are available, and they are FDA-approved and researched for safety and effectiveness. They are called nicotine replacement therapy and NDQuits at (800)-QUIT-NOW.
Knox, RN, is master of public health and certified tobacco treatment specialist with the Grand Forks Public Health Department Tobacco Prevention Program.
http://www.inforum.com/event/article/id/408308/

Letter: NDQuits wins a commendation

By: Jessie Azure, West Fargo, INFORUM
I would like to commend those with NDQuits on finding a creative way to reach a “tobacco at risk community!”
Clearly, representatives from the North Dakota Policy Council need to sit down and read the 2007 Best Practices manual issued by the CDC on Tobacco Prevention and Control Policy before commenting. Maybe then they’d understand the importance of reaching target populations with education and support.
Their comments make me ask a far more important question: What if the parade had been for an organization raising awareness for mental health (as this is another community with a high rate of tobacco use)? Would Zach Tiggelaar still be compelled to question such actions? I bet he’d agree that we shouldn’t dismiss one community over another; rather, look to find ways to reach all of our citizens, just as the folks at NDQuits did. After all, as Rep. Josh Boschee, D-Fargo, reminds us, the cost of tobacco is far more staggering to treat than prevent.
http://www.inforum.com/event/article/id/406374/

Mental illness, tobacco turn out to be deadly combo

By: John Lundy, Duluth News Tribune
It’s hard to quit smoking.
For individuals struggling with a mental illness, it’s even harder.
“They have higher levels of biological or physical addiction to nicotine, in many cases,” said Dr. Jill Williams, an addiction psychiatrist. “In illnesses like depression, studies show that they’re more addicted than other smokers.”
Yet mental health treatment is lagging when it comes to tobacco addiction, said Williams, who specializes in mental health and tobacco at the Robert Wood Johnson Medical School in New Jersey.
Her effort to correct brings Williams to Duluth today. At the behest of the American Lung Association in Minnesota, Williams is conducting a daylong conference for mental health professionals at the University of Minnesota Duluth.
About 75 people were signed up for the event, said Pat McKone of the lung association. Earlier this week, Williams led a similar conference in Moorhead, Minn., with 100 in attendance.
The Minnesota group brought Williams to the state because of the toll smoking takes on people with mental illness, an American Lung Association news release said. It cites studies from several states showing that people with severe mental illness die, on average, 25 years earlier than the general public. Their No. 1 cause of death? Heart disease related to tobacco use, the studies show.
Moreover, the percentage of people with mental illness who smoke is much higher than that of the general population, the Centers for Disease Control and Prevention reported earlier this year. From 2009-11, 36 percent of adults with mental illness smoked, compared with 21 percent of the rest of the population, the CDC said.
The numbers in Wisconsin are similar, but the discrepancy in Minnesota is even greater: Just over 40 percent of Minnesota adults with mental illnesses smoke, compared to just under 20 percent of the rest of the population.
Part of the problem, Williams said in a telephone interview, is the lack of treatment.
“If you get your care from the behavioral health system, it’s just unlikely that you’ll be able to get treatment for your tobacco addiction in those settings,” she said. “Traditionally, that’s not been offered there.”
People with mental illness respond to medication and counseling to treat tobacco addiction, Williams said, although it may need to be more intense. And the mental health treatment centers and residences already have the counselors trained in addiction treatment, she said. They just need the specific training for tobacco.
“That’s why these trainings are so important,” Williams said. “When we do the training, it’s not unusual that people say this is the first time they ever had training on tobacco addiction in their professional career.”
Another issue, Williams said, is addressing public policy so that people who provide tobacco treatment are reimbursed as well as people who treat other forms of addiction.
“If we paid people better to do tobacco treatment, I think a lot more of it would be available,” she said.