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A Hot Debate Over E-Cigarettes as a Path to Tobacco, or From It

By , The New York Times

Dr. Michael Siegel, a hard-charging public health researcher at Boston University, argues that e-cigarettes could be the beginning of the end of smoking in America. He sees them as a disruptive innovation that could make cigarettes obsolete, like the computer did to the typewriter.

But his former teacher and mentor, Stanton A. Glantz, a professor of medicine at the University of California, San Francisco, is convinced that e-cigarettes may erase the hard-won progress achieved over the last half-century in reducing smoking. He predicts that the modern gadgetry will be a glittering gateway to the deadly, old-fashioned habit for children, and that adult smokers will stay hooked longer now that they can get a nicotine fix at their desks.

These experts represent the two camps now at war over the public health implications of e-cigarettes. The devices, intended to feed nicotine addiction without the toxic tar of conventional cigarettes, have divided a normally sedate public health community that had long been united in the fight against smoking and Big Tobacco.

The essence of their disagreement comes down to a simple question: Will e-cigarettes cause more or fewer people to smoke? The answer matters. Cigarette smoking is still the single largest cause of preventable death in the United States, killing about 480,000 people a year.

Dr. Siegel, whose graduate school manuscripts Dr. Glantz used to read, says e-cigarette pessimists are stuck on the idea that anything that looks like smoking is bad. “They are so blinded by this ideology that they are not able to see e-cigarettes objectively,” he said. Dr. Glantz disagrees. “E-cigarettes seem like a good idea,” he said, “but they aren’t.”

Science that might resolve questions about e-cigarettes is still developing, and many experts agree that the evidence so far is too skimpy to draw definitive conclusions about the long-term effects of the devices on the broader population.

“The popularity is outpacing the knowledge,” said Dr. Michael B. Steinberg, associate professor of medicine at the Robert Wood Johnson Medical School at Rutgers University. “We’ll have a better idea in another year or two of how safe these products are, but the question is, will the horse be out of the barn by then?”

This high-stakes debate over what e-cigarettes mean for the nation’s 42 million smokers comes at a crucial moment. Soon, the Food and Drug Administration is expected to issue regulations that would give the agency control over the devices, which have had explosive growth virtually free of any federal oversight. (Some cities, like Boston and New York, and states, like New Jersey and Utah, have already weighed in, enacting bans in public places.)

The new federal rules will have broad implications for public health. If they are too tough, experts say, they risk snuffing out small e-cigarette companies in favor of Big Tobacco, which has recently entered the e-cigarette business. If they are too lax, sloppy manufacturing could lead to devices that do not work properly or even harm people.

And many scientists say e-cigarettes will be truly effective in reducing the death toll from smoking only with the right kind of federal regulation — for example, rules that make ordinary cigarettes more expensive than e-cigarettes, or that reduce the amount of nicotine in ordinary cigarettes so smokers turn to e-cigarettes for their nicotine.

“E-cigarettes are not a miracle cure,” said David B. Abrams, executive director of the Schroeder National Institute for Tobacco Research and Policy Studies at the Legacy Foundation, an antismoking research group. “They need a little help to eclipse cigarettes, which are still the most satisfying and deadly product ever made.”

Smoking is already undergoing a rapid evolution. Nicotine, the powerful stimulant that makes traditional cigarettes addictive, is the crucial ingredient in e-cigarettes, whose current incarnation was developed by a Chinese pharmacist whose father died of lung cancer. With e-cigarettes, nicotine is inhaled through a liquid that is heated into vapor. New research suggests that e-cigarettes deliver nicotine faster than gum or lozenges, two therapies that have never quite taken off.

Sales of e-cigarettes more than doubled last year from 2012, to $1.7 billion, according to Bonnie Herzog, an analyst at Wells Fargo Securities. Ms. Herzog said that in the next decade, consumption of e-cigarettes could outstrip that of conventional cigarettes. The number of stores that sell them has quadrupled in just the last year, according to the Smoke Free Alternatives Trade Association, an e-cigarette industry trade group.

“E-cigarette users sure seem to be speaking with their pocketbooks,” said Mitchell Zeller, director of the F.D.A.’s Center for Tobacco Products.

Public health experts like to say that people smoke for the nicotine but die from the tar. And the reason e-cigarettes have caused such a stir is that they take the deadly tar out of the equation while offering the nicotine fix and the sensation of smoking. For all that is unknown about the new devices — they have been on the American market for only seven years — most researchers agree that puffing on one is far less harmful than smoking a traditional cigarette.

But then their views diverge.

Pessimists like Dr. Glantz say that while e-cigarettes might be good in theory, they are bad in practice. The vast majority of people who smoke them now also smoke conventional cigarettes, he said, and there is little evidence that much switching is happening. E-cigarettes may even prolong the habit, he said, by offering a dose of nicotine at times when getting one from a traditional cigarette is inconvenient or illegal.

What is more, critics say, they make smoking look alluring again, with images on billboards and television ads for the first time in decades. Dr. Glantz says that only about half the people alive today have ever seen a broadcast ad for cigarettes. “I feel like I’ve gotten into a time machine and gone back to the 1980s,” he said.

Researchers also worry that e-cigarettes could be a gateway to traditional cigarettes for young people. The devices are sold on the Internet. The liquids that make their vapor come in flavors like mango and watermelon. Celebrities smoke them: Julia Louis-Dreyfus and Leonardo DiCaprio puffed on them at the Golden Globe Awards.

A survey from the Centers for Disease Control and Prevention found that in 2012, about 10 percent of high school students said they had tried an e-cigarette, up from 5 percent in 2011. But 7 percent of those who had tried e-cigarettes said they had never smoked a traditional cigarette, prompting concern that e-cigarettes were, in fact, becoming a gateway.

“I think the precautionary principle — better safe than sorry — rules here,” said Dr. Thomas Frieden, director of the C.D.C.

E-cigarette skeptics have also raised concerns about nicotine addiction. But many researchers say that the nicotine by itself is not a serious health hazard. Nicotine-replacement therapies like lozenges and patches have been used for years. Some even argue that nicotine is a lot like caffeine: an addictive substance that stimulates the mind.

“Nicotine may have some adverse health effects, but they are relatively minor,” said Dr. Neal L. Benowitz, a professor of medicine at the University of California, San Francisco, who has spent his career studying the pharmacology of nicotine.

Another ingredient, propylene glycol, the vapor that e-cigarettes emit — whose main alternative use is as fake smoke on concert and theater stages — is a lung irritant, and the effects of inhaling it over time are a concern, Dr. Benowitz said.

But Dr. Siegel and others contend that some public health experts, after a single-minded battle against smoking that has run for decades, are too inflexible about e-cigarettes. The strategy should be to reduce harm from conventional cigarettes, and e-cigarettes offer a way to do that, he said, much in the way that giving clean needles to intravenous drug users reduces their odds of getting infected with the virus that causes AIDS.

Solid evidence about e-cigarettes is limited. A clinical trial in New Zealand, which many researchers regard as the most reliable study to date, found that after six months about 7 percent of people given e-cigarettes had quit smoking, a slightly better rate than those with patches.

“The findings were intriguing but nothing to write home about yet,” said Thomas J. Glynn, a researcher at the American Cancer Society.

In Britain, where the regulatory process is more developed than in the United States, researchers say that smoking trends are heading in the right direction.

“Motivation to quit is up, success of quit attempts are up, and prevalence is coming down faster than it has for the last six or seven years,” said Robert West, director of tobacco studies at University College London. It is impossible to know whether e-cigarettes drove the changes, he said, but “we can certainly say they are not undermining quitting.”

The scientific uncertainties have intensified the public health fight, with each side seizing on scraps of new data to bolster its position. One recent study in Germany on secondhand vapor from e-cigarettes prompted Dr. Glantz to write on his blog, “More evidence that e-cigs cause substantial air pollution.” Dr. Siegel highlighted the same study, concluding that it showed “no evidence of a significant public health hazard.”

That Big Tobacco is now selling e-cigarettes has contributed to skepticism among experts and advocates.

Cigarettes went into broad use in the 1920s — and by the 1940s, lung cancer rates had exploded. More Americans have died from smoking than in all the wars the United States has fought. Smoking rates have declined sharply since the 1960s, when about half of all men and a third of women smoked. But progress has slowed, with a smoking rate now of around 18 percent.

“Part of the furniture for us is that the tobacco industry is evil and everything they do has to be opposed,” said John Britton, a professor of epidemiology at the University of Nottingham in England, and the director for the U.K. Center for Tobacco and Alcohol Studies. “But one doesn’t want that to get in the way of public health.”

Carefully devised federal regulations might channel the marketing might of major tobacco companies into e-cigarettes, cannibalizing sales of traditional cigarettes, Dr. Abrams of the Schroeder Institute said. “We need a jujitsu move to take their own weight and use it against them,” he said.

Dr. Benowitz said he could see a situation under which the F.D.A. would gradually reduce the nicotine levels allowable in traditional cigarettes, pushing smokers to e-cigarettes.

“If we make it too hard for this experiment to continue, we’ve wasted an opportunity that could eventually save millions of lives,” Dr. Siegel said.

Dr. Glantz disagreed.

“I frankly think the fault line will be gone in another year,” he said. “The evidence will show their true colors.”

http://www.nytimes.com/2014/02/23/health/a-hot-debate-over-e-cigarettes-as-a-path-to-tobacco-or-from-it.html?_r=0

Surgeon General Sets Tobacco End-Game as Smoking Persists

By Anna Edney, Bloomberg News
A half century after linking smoking to lung cancer, the U.S. is confronting stalled progress in kicking the habit of 42 million Americans with new evidence that many common ailments such as diabetes, arthritis and impotence can be tied to tobacco use.
Acting Surgeon General Boris Lushniak in a report today criticized the “fraudulent campaigns” by cigarette companies, weaknesses in regulation and a rebound in smoking depicted in Hollywood films. He said he’s considering greater restrictions on sales to achieve “a society free of tobacco-related death and disease.”
While a landmark 1964 report on smoking and lung cancer helped cut cigarette use by more than half to 18 percent of U.S. adults, the decline has slowed. Smoking remains the leading preventable cause of death, killing 480,000 people each year, and the U.S. may miss a 2020 goal of limiting to 12 percent the share of smoking adults, today’s report shows.
“Enough is enough,” Lushniak said repeatedly at a press conference in Washington where he presented the more than 900-page report. “It’s astonishing that so many years later we’re still making these findings.”
The report shows the U.S. must be more aggressive in promoting tobacco control than regulators have been, he said.
“What we really need to do is say ‘Now is the time,’” Len Lichtenfeld, deputy chief medical officer at the Atlanta-based American Cancer Society, said in a telephone interview.

Further Stalling

Maintaining the status quo on tobacco control will lead to further stalling in the declining rate of smoking, said Lushniak, whose job serves as the nation’s main public-health advocate. He placed part of the blame on tobacco companies.
“The tobacco epidemic was initiated and has been sustained by the aggressive strategies of the tobacco industry, which has deliberately misled the public on the risk of smoking cigarettes,” he said in the report.
Earlier this week, Altria Group Inc. (MO:US), Reynolds American Inc. (RAI:US)and other tobacco companies agreed with the U.S. on how they will publicize admissions that they deceived the American public on the dangers of smoking. Altria is the largest tobacco company in the U.S. and its Philip Morris unit makes the popular Marlboro brand of smokes.

Overwhelming Evidence

“Philip Morris USA agrees with the overwhelming medical and scientific consensus that cigarette smoking causes lung cancer, heart disease, emphysema and other serious diseases in smokers,” David Sutton, a spokesman for parent company Altria Group Inc., said in an e-mail.“ Smokers are far more likely to develop serious diseases, like lung cancer, than non-smokers. There is no safe cigarette.”
The report lists smoking as a cause of liver cancer and colorectal cancer, which is responsible for the second-largest number of cancer deaths each year. Cigarette use may cause breast cancer and women smokers’ chances of dying from lung cancer have caught up to men, the surgeon general said. Even secondhand smoke can now be linked to a higher risk of stroke, Lushniak said.
The first surgeon general report on tobacco’s ill effects was made in January 1964, when at least half of all men in the U.S. and almost 40 percent of women smoked. Congress later adopted an act that required warning labels about the health consequences of smoking and in 1970 it prohibited cigarette advertising on television and radio.

Extend Lifespans

Measures, such as city and state bans on smoking in workplaces, restaurants and bars, also have helped to prevent 8 million early deaths and extended lifespans by two decades. About 5.3 million men and 2.7 million women live longer thanks to tobacco control, according to one of six studies on the topic published last week in the Journal of the American Medical Association.
Advertising and promotional activities entice younger smokers and nicotine addiction keeps people smoking as they grow older. Portrayals of tobacco use in U.S. films rebounded in the past two years and the use of multiple tobacco products may increase initiation rates among teens and young adults, according to the report.
While the share of teens and young adults who smoke is down, the number of them who start to smoke has increased since 2002. In addition, the prevalence of U.S. students in middle and high school who used electronic cigarettes doubled in 2012, the Centers for Disease Control and Prevention said in a September report.
“There are a substantial number of diseases, not just cancer, but certain cardiovascular disease, stroke, respiratory disease, whether it’s chronic lung disease or asthma, the list goes on and on about how tobacco impacts this country,” Lichtenfeld said.

Erectile Dysfunction

Smokers also have as much as a 40 percent higher risk of developing Type 2 diabetes and the habit is attributable to erectile dysfunction and deadly ectopic pregnancies where the embryo implants in the Fallopian tube or elsewhere outside the uterus, according to the report. People exposed to second-hand smoke are as much as 30 percent more likely to have a stroke.
Women smokers were 2.7 times more likely to develop lung cancer in 1959, a number that jumped to 25.7 percent by 2010. Male smokers were 12.2 times more likely to get lung cancer in 1959 and now smokers of both genders carry almost an equal chance of being diagnosed with the disease.
In the last 50 years almost 25 trillion cigarettes have been consumed in the U.S. costing at least $130 billion a year for direct medical care and $150 billion annually in lost productivity from premature death, according to the surgeon general.

Kicking the Habit

The surgeon general recommended helping people kick the habit with more national media campaigns like the federally funded graphic advertisements that featured former smokers with missing limbs and holes in their throats. He also advocated consideration of additional cigarette taxes and legislation to extend smoke-free indoor protections.
Banning smoking “is a bigger societal issue,” Lushniak said at the press conference. “We need to have that discussion.”
The tobacco companies and the Justice Department resolved this week that “corrective statements” will appear in the print and online editions of newspapers and on television as well as on the companies’ websites. Expanded information on the adverse health effects of smoking will appear on cigarette packages, according to the agreement filed Jan. 10 in federal court in Washington.

Altria Support

“Moving forward, we believe FDA regulation, particularly as it applies to product innovation, has the potential to substantially reduce the harm caused by smoking,” Altria’s Sutton said. “We support extending its regulatory authority over all tobacco products, including those containing tobacco-derived nicotine such as e-cigarettes.”
The FDA regulates cigarettes and is poised to extend its oversight to their electronic counterparts.
While smoking substitutes such as e-cigarettes may help reduce tobacco use, more needs to be known about their health effects and how much they may help, the report said.
“However, the promotion of electronic cigarettes and other innovative tobacco products is much more likely to be beneficial in an environment where the appeal, accessibility, promotion, and use of cigarettes are being rapidly reduced,” Lushniak said.
http://www.businessweek.com/news/2014-01-17/surgeon-general-sets-tobacco-end-game-as-smoking-decline-stalls

Drugs to Stop Smoking Better Given Together?

By Crystal Phend, Senior Staff Writer, MedPage Today
Reviewed by F. Perry Wilson, MD, MSCE; Instructor of Medicine, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, BSN, RN, Nurse Planner
Doubling up on tobacco cessation drugs helped smokers quit at first, but didn’t significantly improve longer-term abstinence, a trial showed.
Quit rates at 12 weeks were a relative 36% to 49% better with the addition of sustained-release bupropion (Zyban) to varenicline (Chantix), Jon O. Ebbert, MD, MSc, of the Mayo Clinic in Rochester, Minn., and colleagues found.
One year after the 12-week treatment course, though, abstinence had fallen to where the relative 39% to 40% advantage of combination treatment lost significance, the researchers reported in the Jan. 8 issue of the Journal of the American Medical Association.
“Further research is required to determine the role of combination therapy in smoking cessation,” they concluded.
Bupropion and varenicline both tackle cravings and “rewards” from smoking but through somewhat different routes to nicotinic acetylcholine receptors, leading to hopes for additive or synergistic effects, such as with the combination of bupropion and the nicotine patch, the group noted.
Their study randomized 500 adult smokers desiring to quit to take open-label varenicline along with blinded placebo or sustained-release bupropion for 12 weeks.
For the primary outcome, abstinence rates at week 12 were significantly better with the combination in terms of prolonged cessation with no smoking from 2 weeks after the target quit date (53% versus 43.2%, odds ratio 1.49, P=0.03), although not by point-prevalence of no smoking in the prior 7 days (56.2% versus 48.6%, OR 1.36, P=0.09).
By 26 weeks, prolonged abstinence rates had fallen to 36.6% and 27.6% in the two groups, respectively (OR 1.52, P=0.03), and 7-day point-prevalence abstinence to 38.2% and 31.9% (OR 1.32, P=0.14).
At 52 weeks, neither measure showed a significant difference between groups, although the odds ratios remained roughly the same as before (OR 1.39 and 1.40).
Prolonged abstinence rates at that point were 30.9% with combination therapy and 24.5% with varenicline alone (P=0.11); 7-day point-prevalence abstinence rates were 36.6% and 29.2%, respectively (P=0.08).
However, individuals with high levels of baseline nicotine dependence did achieve a significant impact on both measures of abstinence at 52 weeks with the combination versus monotherapy in a sensitivity analysis.
Combination therapy was associated with more adverse events in terms of both anxiety (7.2% versus 3.1%, P=0.04) and depressive symptoms (3.6% versus 0.8%, P=0.03). No serious adverse events in either group were judged treatment related.
Weight gain was similar between groups through the end of follow-up (4.9 kg [11 lbs], and 6.1 kg [13 lbs], P=0.23).
The researchers cautioned that the study was limited by the 38% rate of dropout and limited generalizability “because patients with serious medical and psychiatric illnesses including those with active substance abuse were excluded.”
http://www.medpagetoday.com/PrimaryCare/Smoking/43680?xid=nl_mpt_DHE_2014-01-08&utm_content=&utm_medium=email&utm_campaign=DailyHeadlines&utm_source=WC&eun=g436493d0r&userid=436493&email=megan.houn@tfnd.org&mu_id=5533639

US is marking 50th anniversary of surgeon general report that turned the tide against smoking

Article by: MIKE STOBBE , Associated Press
ATLANTA — Fifty years ago, ashtrays seemed to be on every table and desk. Athletes and even Fred Flintstone endorsed cigarettes in TV commercials. Smoke hung in the air in restaurants, offices and airplane cabins. More than 42 percent of U.S. adults smoked, and there was a good chance your doctor was among them.
The turning point came on Jan. 11, 1964. It was on that Saturday morning that U.S. Surgeon General Luther Terry released an emphatic and authoritative report that said smoking causes illness and death — and the government should do something about it.
In the decades that followed, warning labels were put on cigarette packs, cigarette commercials were banned, taxes were raised and new restrictions were placed on where people could light up.
“It was the beginning,” said Kenneth Warner, a University of Michigan public health professor who is a leading authority on smoking and health.
It was not the end. While the U.S. smoking rate has fallen by more than half to 18 percent, that still translates to more than 43 million smokers. Smoking is still far and away the leading preventable cause of death in the U.S. Some experts predict large numbers of Americans will puff away for decades to come.
Nevertheless, the Terry report has been called one of the most important documents in U.S. public health history, and on its 50th anniversary, officials are not only rolling out new anti-smoking campaigns but reflecting on what the nation did right that day.
The report’s bottom-line message was hardly revolutionary. Since 1950, head-turning studies that found higher rates of lung cancer in heavy smokers had been appearing in medical journals. A widely read article in Reader’s Digest in 1952, “Cancer by the Carton,” contributed to the largest drop in cigarette consumption since the Depression. In 1954, the American Cancer Society announced that smokers had a higher cancer risk.
But the tobacco industry fought back. Manufacturers came out with cigarettes with filters that they claimed would trap toxins before they settled into smokers’ lungs. And in 1954, they placed a full-page ad in hundreds of newspapers in which they argued that research linking their products and cancer was inconclusive.
It was a brilliant counter-offensive that left physicians and the public unsure how dangerous smoking really was. Cigarette sales rebounded.
In 1957 and 1959, Surgeon General Leroy Burney issued statements that heavy smoking causes lung cancer. But they had little impact.
Amid pressure from health advocates, President John F. Kennedy’s surgeon general, Dr. Luther Terry, announced in 1962 that he was convening an expert panel to examine all the evidence and issue a comprehensive, debate-settling report. To ensure the panel was unimpeachable, he let the tobacco industry veto any proposed members it regarded as biased.
Surveys indicated a third to a half of all physicians smoked tobacco products at the time, and the committee reflected the culture: Half its 10 members were smokers, who puffed away during committee meetings. Terry himself was a cigarette smoker.
Dr. Eugene Guthrie, an assistant surgeon general, helped persuade Terry to kick the habit a few months before the press conference releasing the report.
“I told him, ‘You gotta quit that. I think you can get away with a pipe — if you don’t do it openly.’ He said, ‘You gotta be kidding!’ I said, ‘No, I’m not. It just wouldn’t do. If you smoke any cigarettes, you better do it in a closet,'” Guthrie recalled in a recent interview with The Associated Press.
The press conference was held on a Saturday partly out of concern about its effect on the stock market. About 200 reporters attended.
The committee said cigarette smoking clearly did cause lung cancer and was responsible for the nation’s escalating male cancer death rate. It also said there was no valid evidence filters were reducing the danger. The committee also said — more vaguely — that the government should address the problem.
“This was front-page news, and every American knew it,” said Robin Koval, president of Legacy, an anti-smoking organization.
Cigarette consumption dropped a whopping 15 percent over the next three months but then began to rebound. Health officials realized it would take more than one report.
In 1965, Congress required cigarette packs to carry warning labels. Two years later, the Federal Communications Commission ordered TV and radio stations to provide free air time for anti-smoking public service announcements. Cigarette commercials were banned in 1971.
Still, progress was slow. Warner recalled teaching at the University of Michigan in 1972, when nearly half the faculty members at the school of public health were smokers. He was one of them.
“I felt like a hypocrite and an idiot,” he said. But smoking was still the norm, and it was difficult to quit, he said.
The 1970s also saw the birth of a movement to protect nonsmokers from cigarette fumes, with no-smoking sections on airplanes, in restaurants and in other places. Those eventually gave way to complete smoking bans. Cigarette machines disappeared, cigarette taxes rose, and restrictions on the sale of cigarettes to minors got tougher.
Tobacco companies also came under increasing legal attack. In the biggest case of them all, more than 40 states brought lawsuits demanding compensation for the costs of treating smoking-related illnesses. Big Tobacco settled in 1998 by agreeing to pay about $200 billion and curtail marketing of cigarettes to youths.
In 1998, while the settlement was being completed, tobacco executives appeared before Congress and publicly acknowledged for the first time that their products can cause lung cancer and be addictive.
Experts agree the Terry report clearly triggered decades of changes that whittled the smoking rate down. But it was based on data that was already out there. Why, then, did it make such a difference?
For one thing, the drumbeat about the dangers of smoking was getting louder in 1964, experts said. But the way the committee was assembled and the carefully neutral manner in which it reached its conclusion were at least as important, said Dr. Tim McAfee, director of the Office on Smoking and Health at the Centers for Disease Control and Prevention.
At the same time, he and others said any celebration of the anniversary must be tempered by the size of the problem that still exists.
Each year, an estimated 443,000 people die prematurely from smoking or exposure to secondhand smoke, and 8.6 million live with a serious illness caused by smoking, according to the CDC.
Donald Shopland finds that depressing.
Fifty years ago, he was a 19-year-old who smoked two packs a day while working as a clerk for the surgeon general’s committee. He quit cigarettes right after the 1964 report came out, and went on to a long and distinguished public health career in which he wrote or edited scores of books and reports on smoking’s effects.
“We should be much further along than we are,” the Georgia retiree lamented.
http://www.startribune.com/lifestyle/health/238716101.html?page=all&prepage=1&c=y#continue

E-Cigarettes: Separating Fiction From Fact

By Serena Gordon
HealthDay Reporter
It’s the new year, a time when a smokers’ thoughts often turn to quitting.
Some people may use that promise of a fresh start to trade their tobacco cigarettes for an electronic cigarette, a device that attempts to mimic the look and feel of a cigarette and often contains nicotine.
Here’s what you need to know about e-cigarettes:
What is an e-cigarette?
The U.S. Food and Drug Administration (FDA) describes an e-cigarette as a battery-operated device that turns nicotine, flavorings and other chemicals into a vapor that can be inhaled. The ones that contain nicotine offer varying concentrations of nicotine. Most are designed to look like a tobacco cigarette, but some look like everyday objects, such as pens or USB drives, according to the FDA.
How does an e-cigarette work?
“Nicotine or flavorings are dissolved into propylene glycol usually, though it’s hard to know for sure because they’re not regulated,” explained smoking cessation expert Dr. Gordon Strauss, founder of QuitGroups and a psychiatrist at Lenox Hill Hospital in New York City. “Then, when heated, you can inhale the vapor.”
The process of using an e-cigarette is called “vaping” rather than smoking, according to Hilary Tindle, an assistant professor of medicine and director of the tobacco treatment service at the University of Pittsburgh Medical Center. She said that people who use electronic cigarettes are called “vapers” rather than smokers.
Although many e-cigarettes are designed to look like regular cigarettes, both Tindle and Strauss said they don’t exactly replicate the smoking experience, particularly when it comes to the nicotine delivery. Most of the nicotine in e-cigarettes gets into the bloodstream through the soft tissue of your cheeks (buccal mucosa) instead of through your lungs, like it does with a tobacco cigarette.
“Nicotine from a regular cigarette gets to the brain much quicker, which may make them more addictive and satisfying,” Strauss said.
Where can e-cigarettes be used?
“People want to use e-cigarettes anywhere they can’t smoke,” Strauss said. “I sat next to someone on a plane who was using an e-cigarette. He was using it to get nicotine during the flight.” But he noted that just where it’s OK to use an e-cigarette — indoors, for instance? — remains unclear.
Wherever they’re used, though, he said it’s unlikely that anyone would get more than a miniscule amount of nicotine secondhand from an e-cigarette.
Can an e-cigarette help people quit smoking?
That, too, seems to be an unanswered question. Tindle said that “it’s too early to tell definitively that e-cigarettes can help people quit.”
A study published in The Lancet in September was the first moderately sized, randomized and controlled trial of the use of e-cigarettes to quit smoking, she said. It compared nicotine-containing e-cigarettes to nicotine patches and to e-cigarettes that simply contained flavorings. The researchers found essentially no differences in the quit rates for the products after six months of use.
“E-cigarettes didn’t do worse than the patch, and there were no differences in the adverse events,” she said. “I would be happy if it turned out to be a safe and effective alternative for quitting, but we need a few more large trials for safety and efficacy.”
Strauss noted that “although we can’t say with certainty that e-cigarettes are an effective way to quit, people are using them” for that purpose. “Some people have told me that e-cigarettes are like a godsend,” he said.
Former smoker Elizabeth Phillips would agree. She’s been smoke-free since July 2012 with the help of e-cigarettes, which she used for about eight months after giving up tobacco cigarettes.
“E-cigarettes allowed me to gradually quit smoking without completely removing myself from the physical actions and social experience associated with smoking,” Phillips said. “I consider my e-cigarette experience as a baby step that changed my life.”
Are e-cigarettes approved or regulated by the government?
E-cigarettes are not currently regulated in a specific way by the FDA. The agency would like to change this, however, and last April filed a request for the authority to regulate e-cigarettes as a tobacco product.
The attorneys general of 40 states agree that electronic cigarettes should be regulated and sent a letter to the FDA in September requesting oversight of the products. They contend that e-cigarettes are being marketed to children; some brands have fruit and candy flavors or are advertising with cartoon characters. And, they note that the health effects of e-cigarettes have not been well-studied, especially in children.
Are e-cigarettes dangerous?
“It’s not the nicotine in cigarettes that kills you, and the nicotine in e-cigarettes probably won’t really hurt you either, but again, it hasn’t been studied,” Strauss said. “Is smoking something out of a metal and plastic container safer than a cigarette? Cigarettes are already so bad for you it’s hard to imagine anything worse. But, it’s a risk/benefit analysis. For a parent trying to quit, we know that secondhand smoke is a huge risk to kids, so if an electronic cigarette keeps you from smoking, maybe you’d be helping kids with asthma or saving babies.”
But on the flip side, he said, in former smokers, using an e-cigarette could trigger the urge to smoke again.
The other big concern is children using e-cigarettes.
“More and more middle and high school kids are using e-cigarettes,” Tindle said. “Some are smoking conventional cigarettes, too. The latest data from the CDC found the rate of teens reporting ever having used an e-cigarette doubled in just a year. We could be creating new nicotine addicts. We don’t know what the addictive properties of e-cigarettes are,” she added.
“It’s shocking that they’ve been allowed to sell to minors,” Tindle said.
More information
The U.S. Food and Drug Administration has more about electronic cigarettes.
http://health.usnews.com/health-news/news/articles/2014/01/03/e-cigarettes-separating-fiction-from-fact

Triple tobacco taxes? Researchers say yes to save 200M lives

By Cheryl K. Chumley – The Washington Times
Tripling tobacco taxes would save 200 million smokers around the world from premature deaths over the course of the next century, researchers say.
That’s because the higher costs would make it nearly impossible for many to afford the habit and at the same time serve as a deterrent to youth from taking their first puffs, scientists said, AOL Money reported.
The scientists said they reviewed 63 different studies about the causes and effects of tobacco smoking around the world — and discovered a link between lower smoking statistics and higher priced product. Raising the price of cigarettes by 50 percent lowers the rate of smoking by about a fifth, the scientists found.
So now study authors suggest that prices of tobacco should be raised significantly, by boosting taxes of the product by three times the present amount.
“The two certainties in life are death and taxes,” said study co-author Professor Sir Richard Peto, from the nonprofit Cancer Research UK, in the AOL Money report. “We want higher tobacco taxes and fewer tobacco deaths. It would help children not to start, and it would help many adults to stop while there’s still time.”
They estimate the death rate could be cut by almost half if the tax rate increase is accepted.
“Globally, about half of all young men and one in 10 of all young women become smokers and, particularly in developing countries, relatively few quit,” Mr. Peto said, in AOL Money. “If they keep smoking, about half will be killed by it. But if they stop before 40, they’ll reduce their risk of dying form tobacco by 90 percent.”
The researchers say that in the European Union alone, 100,000 lives per year of those under the age of 70 could be saved by doubling the cost of cigarettes.
http://www.washingtontimes.com/news/2014/jan/2/triple-tobacco-taxes-researchers-say-save-lives/

Be it resolved to quit ….

By KAREN HERZOG, Bismarck Tribune
It’s safe to say that “lose weight” and “quit smoking” are at the top of many a New Year’s resolution list. And they, sadly, top the failure list every year as well.
Not that it’s a contest, but some say weight loss is harder, because people can’t just “quit” eating. Others say quitting cigarettes is harder because it’s so physically addictive.
Either way, when you hear people say, about giving up unhealthy physical or mental habits, “I could never …” they truly believe it.
“Never” is not literally true, of course. If somebody were stranded on the South Pole without smokes or sweets, they would give them up. They’d have to. Or if somebody put a gun to their head and said, “eat that doughnut or smoke that cigarette, and I’ll shoot,” I’ll bet they could stop.
People can do it. They just really, really don’t want to.
Resolutions fail oftentimes because people are aiming at the wrong target — they fixate on the end product instead of resolving to follow a process. Because imagining the daily slog required for success is so less enjoyable than hazy fantasizing about the prize.
“Quit smoking” is tough, no doubt about it.
The idea that they can’t ever smoke another cigarette empowers some people and terrifies others.
That’s because there are cold turkey people and baby steps people.
Cold turkey people tend to be dramatic and competitive. These folks are the ones who will make the operatic gesture of ceremonially tossing out their last pack. This signals to the world that the gauntlet has been thrown. They have challenged the cigarette lover within them. Since they hate to lose, the next weeks will be a bloody spectacle. These are black-and-white folks — they will never have another cigarette or lapse back to two packs a day.
Baby steps people prefer stealth. They don’t appreciate commentary from the peanut gallery. It makes them uneasy to have others watch them sweat and struggle. They want to grind through the process alone to emerge one day quietly smoke-free.
Baby steps people can accept shades of gray, admitting that backsliding a few times will be part of the process.
But they persist, gradually narrowing their window for smoking — first the house is off-limits, then the car, then certain times of day. They sneak quietly away from cigarettes like a mom tiptoeing away from a baby who has finally fallen asleep.
Whichever type you are, one realization can boost your chance of success.
“Self-talk” matters.
When you’re already struggling to do something hard, coming down even harder on yourself when you falter or fail doesn’t necessary spur you on to greater commitment — it just adds another level of frustration and disappointment to carry. Then the temptation arises to just chuck it all and give up.
Instead of flogging yourself for setbacks, turn a 180 and praise yourself for making the effort. Applaud your spirit.
Despite your own resistance and those who want to sabotage your process, you have an intimate friend who supports your will to live healthier.
It’s yourself.
(Karen Herzog feels your pain. She had her last cigarette 39 years ago and still sometimes feels nostalgic for them.)
(Reach Karen Herzog at kherzogcolumn@gmail.com.)
http://bismarcktribune.com/news/columnists/karen-herzog/be-it-resolved-to-quit/article_de7c7e1e-717f-11e3-baf9-0019bb2963f4.html

Homeless North Texans being weaned from tobacco

ARLINGTON, Texas (AP) — When he was sent to Vietnam in 1970, Travis Dorsey quickly picked up a smoking habit.
As the stress of being in a war zone took its toll, Dorsey found comfort in cigarettes.
“They started giving them to us with our meals, they called them C-rations, and the next thing you know I was buying them,” Dorsey told the Fort Worth Star-Telegram (http://bit.ly/1cXO5HL). “I didn’t drink. I didn’t do drugs. The cigarette helped me deal with the stress during the day.”
Life hasn’t been easy for Dorsey since returning, and through it all he has continued to smoke.
Sixteen years ago, he was diagnosed with post-traumatic stress disorder and lost his job as an aircraft mechanic. Two years ago, his wife died from breast cancer, triggering a downward spiral.
“I tried to commit suicide here about three months ago,” Dorsey said. “I ran off the cliff and tore up my truck. I was in the hospital about 2½ months.”
Dorsey, 62, who is now staying at the Arlington Life Shelter, says he’s beginning to turn his life around. He’s resumed taking insulin for his diabetes, received counseling to cope with his wife’s loss and found a church in Arlington where he feels at home.
And he’s now looking at quitting smoking through a program started in November by Tarrant County Public Health at the Arlington Life Shelter.
“I know it’s easier to quit now because I’m not under the stress I’ve been under the last two years,” Dorsey said. “I’m laying down at night and I’m not afraid.”
The county health department plans to eventually expand the program to other homeless shelters across Tarrant County, including the Patriot House, a shelter for homeless veterans.
“I wanted to reach an audience that wasn’t already being reached,” said Vanessa Ayala, a community health worker with the department. “We try to help them manage the stress from quitting smoking and understand the effects of nicotine withdrawal and dealing with weight gain.”
Michael Businelle, an assistant professor at the University of Texas School of Public Health in Dallas, said more should be done to encourage those who are homeless to quit smoking.
Tobacco-related deaths in the U.S. are about 440,000 annually, which include deaths from secondhand smoke, according to the federal Centers for Disease Control and Prevention.
“These tobacco cessation services are generally not offered at homeless shelters while substance abuse programs are generally ubiquitous,” Businelle said. “Smokers don’t go and rob their neighbors or sell their VCRs for cigarettes like someone would do for crack, but smoking is responsible for way more deaths than drugs and alcohol combined.”
Businelle helped conduct a study with several other researchers for publication in the American Journal of Public Health, comparing homeless smokers with economically disadvantaged smokers who have a home. The study, conducted from August 2011 to November 2012, found that the homeless smoking rate of 70 percent was twice that of those living in poverty (34.7 percent).
One of the challenges Businelle found was that homeless people were exposed to as many 40 smokers a day compared with three or four among those who are not homeless.
Those who run area shelters agree that efforts to curb smoking among homeless people are needed.
“The majority of the homeless population does smoke,” said Toby Owen, executive director of the Presbyterian Night Shelter. “Offering programs would certainly be most beneficial but it’s going to have to provide more than just going cold turkey.”
In Businelle’s study, 10 participants received small incentives — gift cards — and their carbon monoxide levels were tested to see whether they had actually quit. A larger group of 58 homeless people did not receive gift cards.
The quit rate four weeks after stopping smoking was 30 percent among the group that got gift cards versus 1.7 percent among those who didn’t receive gift cards.
“The findings of this pilot study are important because smoking cessation interventions that have worked in the general population are not as effective in homeless smokers,” Businelle said. “Offering small financial incentives for smoking cessation may be a novel way to have an impact on smoking in this vulnerable population.”
Businelle has applied for a National Institutes of Health grant that would pay for a five-year study and is still waiting to see whether it gets approved. The most recent study didn’t cover enough time to draw definitive conclusions. But Businelle said it is worth exploring because of the extensive costs associated with tobacco-related illnesses.
“The study is so small you can’t really make any broad generalizations,” Businelle said. “It is a pilot study that shows there is potential.”
The Bridge homeless recovery center in Dallas has been offering smoking cessation classes and modified its courtyard this summer to include a nonsmoking area for those who want to quit. With a day shelter that brings in as many as 1,200 people daily, along with a transitional shelter and an emergency shelter, the Bridge is trying to find ways to reach as many people as possible, President and CEO Jay Dunn said.
“We’re learning about the need for smoking cessation medication and brainstorming about how to make that more accessible,” Dunn said.
At the Arlington Life Shelter, Dorsey can get nicotine replacement medication through the Veterans Administration Hospital in Dallas.
Another shelter resident, Dennis Bell, said he can get a prescription through the JPS Connection Program if he needs one.
“I don’t know that I’ll need the medication,” Bell said. “I think I can do it with just the knowledge I’ve learned in the classes. That’s my goal. Now if my body says otherwise, that’s another thing.”
Bell, 45, ended up at the Arlington Life Shelter after his home was foreclosed on and he went through a difficult divorce.
But he said he was receptive to quitting smoking after Ayala pointed out how much money it would save him.
“I knew some of the health issues but the cost of smoking wasn’t something I had really thought about,” Bell said. “It was good information.”
Bell started smoking at 19 to fit in with his friends.
“To be honest with you, it was peer pressure,” Bell said. “I guess I wanted to be in the cool crowd.”
Karen Caston, director of shelter operations at the Arlington Life Shelter, said the classes can have an impact.
“They come here to become self-sufficient,” Caston said. “Anything that helps their health, their mental state and their financial state, can’t help but be a good thing.”
http://www.fosters.com/apps/pbcs.dll/article?AID=/20131216/GJLIFESTYLES/131209301/-1/SANNEWS

Forum editorial: Progress in tobacco cessation

North Dakota was recognized last week as leader among states meeting national standards for funding anti-smoking programs. It’s a welcome designation. Moreover, it’s more evidence the state is doing an excellent job with the resources it has to educate about the risks of smoking and secondhand smoke and provide programs to help smokers quit.
No thanks to the Legislature.
At nearly every turn in the smoking debate during the last decade, lawmakers, particularly those in the Republican majority, have done the bidding of the smoking lobby and hospitality industry. Lobbyists worked to scuttle statewide smoking curbs, and their legislative allies fell into line, despite clear indications that a majority of North Dakotans wanted a smoking ban. Indeed, several cities, large and small, were ahead of the Legislature in imposing smoking restrictions, most of them via the ballot.
As in the cities, it took the ballot box to spank the Legislature. Two measures did what the legislators refused to do. The first in 2008 established a tobacco prevention and cessation program funded in large part by tobacco lawsuit settlement money. The second passed by a landslide in 2012 with every county voting “yes.” It made all public places 100 percent smoke free.
Despite dire predictions from fans of poisoning their customers (it’s their “right,” you know), the sky did not fall on the bar scene or the hospitality sector. Instead, smoking levels among adults are down significantly. There is more work to do among the state’s youth, and that’s where education programs are focused.
It’s good news. It’s good for the state’s long term public health, which, in turn, is a plus for everything else in North Dakota.
————-
Forum editorials represent the opinion of Forum management and the newspaper’s Editorial Board.
http://www.inforum.com/event/article/id/421219/

E-cigs: Just how safe are they?

Article by: JEREMY OLSON , Star Tribune
One of the great unanswered questions for smokers who are trying to quit — and for the advocacy groups trying to help them — is whether electronic cigarettes are friends or foes.
University of Minnesota researchers aim to address that dilemma with a study examining exactly what smokers inhale when they breathe e-cigarette vapors and how “vaping” affects the body. Researchers will collect blood, urine and saliva samples from at least 25 smokers who use only e-cigarettes and at least 25 who use them with traditional cigarettes.
“The first step is to say, ‘Well, how toxic are these products? What is actually in them?’ ” said Dorothy Hatsukami, associate director for cancer prevention and control in the U’s Masonic Cancer Center.
E-cigarettes, rechargeable devices that heat liquid nicotine or other flavored substances into a vapor that the user inhales, have been marketed as a safer alternative to tobacco. Yet a lack of regulation on their manufacture and contents makes it hard to know if they’re safer than traditional cigarettes and whether they can be used to safely help wean people off tobacco, Hatsukami said.
“It’s like a Wild West out there,” she said.
Some e-cigarettes that are promoted as nicotine-free, for example, have been found to contain the addictive substance, while others contain little or no nicotine despite claims to the contrary.
Some previous studies have chemically analyzed the contents of e-cigarettes. The Minnesota study aims to go a step further by examining how the contents of different kinds of e-cigarettes affect the body.
The market for e-cigarettes has grown rapidly — sales have doubled annually since 2008 and are expected to reach $1.6 billion this year. About 6 percent of adults have tried them, and the share of high school students who have tried them hit 10 percent last year, according to the U.S. Centers for Disease Control and Prevention.
Heidi Scholtz, 20, a German and theater student at Hamline University, tried her first one two years ago because she was tired of going outside in the snow and cold to smoke. Before long, she said, she was using only e-cigarettes and was surprised at what happened when the weather warmed up and she tried a cigarette.
“It tasted disgusting,” she said.
Now Scholtz uses only e-cigarettes, and has kicked a cigarette habit that started when she was 15. A close friend tried them at her urging, but now uses both.
Help smokers quit?
Studies nationally have produced mixed results about whether e-cigarettes help people quit or reduce smoking — or simply supplement real tobacco. Clearway Minnesota, a nonprofit quit-smoking group, has taken a noncommittal stance on them.
Spokesman Mike Sheldon said it’s great if they help some people quit. But, he added, the lack of science about their contents makes it hard to endorse them over proven stop-smoking strategies of counseling combined with such well-studied supplements as nicotine patches or gum.
The recent increase in youth use of e-cigarettes also is troubling, Sheldon said. “We just don’t know enough about these,” he said.
The Minnesota Clean Indoor Air Act does not apply to e-cigarettes, which can be smoked indoors unless banned by local laws or individual establishments. The city of Duluth banned them from public indoor locations because so little is known about their effect on people who inhale the vapors secondarily.
Clearway would support extending the state ban to e-cigarettes, Sheldon said. However, a group of former cigarette smokers have formed the Minnesota Vapers Advocacy Group to fight the idea.
The group’s president, Matt Black, said his first e-cigarette meant his last real cigarette. A device that physically mimicked his smoking mannerisms was key to to quitting.
“For 17 years, I was constantly hand to mouth (with a cigarette),” Black said. “I was blowing out smoke. I was breathing differently. All of those things play a role in that addiction. We found a way to maintain those habits in a way that’s not going to kill us.”
Black said he hopes the U study will ultimately find e-cigarettes safe, so more people would use them to quit real cigarettes.
Hatsukami said a key aspect of the study is looking at the different types of e-cigarettes to see if some are more harmful than others. (To enroll, call 612-624-4568.)
“Although the majority of the products don’t contain toxicants that are cancer-causing, there are a few that do,” she said. “There is a lot of variability out there.”
http://www.startribune.com/lifestyle/health/235430591.html?page=2&c=y