November Serves to Remind About the Importance of Tobacco Cessation

November is a powerful month for tobacco cessation as it marks Lung Cancer Awareness Month and the American Cancer Society's 33rd Great American Smokeout. Lung cancer remains the number one cause of cancer death and will claim three times as many men as prostate cancer and nearly twice as many women as breast cancer. Smoking tobacco accounts for more than eight out of 10 lung cancer cases (see Research Highlights for the latest on lung cancer research). NTCC members have been quite active this month as a result, continuing their tobacco control activities that included the release of several new and important studies and reports.

The American Cancer Society (ACS) marked the 33rd Great American Smokeout on November 20, 2008. The Great American Smokeout was inaugurated in 1976 to inspire and encourage smokers to quit for one day. Now, 44.2 percent of the 45.3 million Americans who smoke have attempted to quit for at least one day in the past year, and the Great American Smokeout remains a great opportunity to encourage people to commit to making a long-term plan to quit for good. The ACS offers other free resources - through Quitline and at http://www.cancer.org/GreatAmericans - that can increase a smoker's chances of quitting successfully, including tips and tools for friends, family, and coworkers of potential quitters to help them be aware and supportive of the struggle to quit smoking. Popular online social networks such as Facebook and MySpace are also becoming support channels for people who want to quit, and ACS Smokeout-related downloadable desktop applications are available on these networks to help people quit or join the fight against tobacco. More information can be found at http://www.cancer.org/docroot/subsite/greatamericans/Smokeout.asp.

Two new reports released by the U.S. Centers for Disease Control and Prevention (CDC) show that the adult smoking rate in the United States has declined to under 20 percent for the first time, but smoking rates are not declining fast enough to reduce tobacco's growing toll in lives and health care costs.

1. The first CDC report reveals that the adult smoking rate declined to 19.8 percent in 2007 from 20.8 percent in 2006. This is the first statistically significant one-year decline in adult smoking since 2003, but it still leaves the nation far short of achieving the U.S. Surgeon General's national goal of reducing adult smoking to 12 percent or less by 2010.
2. The results included in CDC's second report are less promising. They reveal that smoking rates are not declining fast enough to reduce the devastating health and financial toll of smoking in the United States. The report, which updates official government statistics regarding the toll of cigarette smoking, found that from 2000 to 2004, at least 443,000 people in the U.S. died prematurely each year as a result of smoking and exposure to secondhand smoke, an increase from 438,000 deaths annually for 1997-2001. It also found that smoking costs the nation $193 billion per year in health care expenditures and productivity losses, up from a previous estimate of $167 billion. These reports were published in the November, 14, 2008, issue of the CDC journal Morbidity and Mortality Weekly Report (MMWR) and can be found at http://www.cdc.gov/mmwr.

Although the adult smoking rate in the United States has declined to less than 20 percent for the first time in 2007, results from a new survey released by the American Legacy Foundation found that stress about the ongoing financial downturn is having a clear and immediate effect on smokers. New data indicate smokers are suffering more than ever as stress is causing smokers to delay a quit attempt, increase the number of cigarettes they are smoking, or switch to a cheaper brand instead of quitting. Moreover, some former smokers report they are starting to smoke again because of the stress over the financial situation.

Seventy-seven percent of current smokers report increased stress levels due to the current state of the economy and two-thirds of those smokers say this stress has had an effect on their smoking. One in four smokers stressed about the economy say this stress has caused them to smoke more cigarettes per day. The survey also found that 7 percent of current smokers surveyed had started smoking again due to stress over the economic crisis, even though they had previously quit. In addition, 13 percent of stressed smokers say their stress about the economy has caused them to postpone their plans to quit. More information can be found at http://www.americanlegacy.org/2753.aspx.

At a time when smokers need more help than ever to quit, a new report released by the American Lung Association (ALA) finds that most states fail to adequately protect residents and their bottom lines by providing coverage for treatments and services to help smokers quit. The new report, Helping Smokers Quit: State Cessation Coverage looks at tobacco cessation treatments and services covered by states for their residents. This tobacco policy trend report presents new, up-to-date data on state coverage of cessation treatments, including Medicaid coverage of cessation treatments, state employee health plan coverage of cessation treatments, and state laws and regulations mandating private insurance coverage of cessation treatments.

The report makes the case as to why states should be doing more to help smokers quit and includes policy recommendations. The ALA calls upon each state to provide all Medicaid recipients and state employees with comprehensive, easily-accessible tobacco cessation medications and counseling. They also recommend states eliminate artificial barriers such as co-pays, limits on the length of treatment and prior authorization requirements that can make it harder for smokers to get the help they need.

The report also provides an index of cessation services and treatments offered in each state. More information is available on their website, www.lungusa.org, including a clickable map http://www.lungusa.org/site/c.dvLUK9O0E/b.4724127 with details of coverage and resources in every state.

States are also not providing adequate funds to support tobacco prevention programs. A new report finds that 10 years after reaching more than $246 billion in legal settlements against the tobacco industry, states have failed to keep their promise to spend a significant portion of the money on programs to protect kids from tobacco and help smokers quit. The report, A Decade of Broken Promises: The 1998 State Tobacco Settlement Ten Years Later was released by NTCC members the Campaign for Tobacco-Free Kids, American Heart Association, American Cancer Society Cancer Action Network, American Lung Association and Robert Wood Johnson Foundation.

Over the past 10 years, the states have received $203.5 billion in tobacco-generated revenue - $79.2 billion from the tobacco settlement and $124.3 billion from tobacco taxes. But they have spent only 3.2 percent of their tobacco money - $6.5 billion - on tobacco prevention and cessation programs. In addition, this year, no state is funding tobacco prevention programs at the levels recommended by the U.S. Centers for Disease Control and Prevention. Only nine states are funding tobacco prevention at even half the CDC-recommended amount, and 27 states are providing less than a quarter of the recommended funding.

To accelerate declines in tobacco use the report calls on Congress and the states to follow the recommendations of recent landmark reports by the Institute of Medicine and the President's Cancer Panel, including enacting legislation granting the U.S. Food and Drug Administration authority to regulate tobacco products and significantly increasing the federal tobacco tax. The report also recommends that states should fund tobacco prevention programs at CDC-recommended levels, further increase tobacco taxes and enact comprehensive smoke-free workplace laws. The report can be found at http://www.tobaccofreekids.org/reports/settlements/.

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Amanda Graham, Ph.D., Associate Director for Research Development at the Schroeder Institute for Tobacco Research and Policy Studies

Amanda Graham, Ph.D., is the Associate Director for Research Development at the Schroeder Institute for Tobacco Research and Policy Studies. Dr. Graham also holds an appointment as Assistant Professor (Adjunct) in the Department of Oncology at Georgetown University Medical Center and is a member of the Lombardi Comprehensive Cancer Center.

Dr. Graham is currently Principal Investigator of an NCI-funded R01 that tests the effectiveness of a widely disseminated smoking cessation Internet program (QuitNet.com) alone and in conjunction with proactive telephone counseling. This is the first large-scale randomized trial to address the efficacy of combined Internet and phone cessation interventions. Dr. Graham was also recently awarded an NCI-funded R21 to develop effective methods to recruit Latino smokers to web-based smoking cessation programs.

Prior to joining the faculty at Georgetown in 2006, Dr. Graham was Assistant Professor in the Department of Psychiatry at Brown Medical School. While at Brown, she directed the major treatment outcome study within Brown's NCI-funded Transdisciplinary Tobacco Use Research Center and served as Investigator on a RWJF-funded study of the economic impact of tobacco smoking and the cost-savings associated with tailored cessation treatment.

Dr. Graham received her Bachelors of Science from the University of Richmond, and her Masters and Doctorate in Clinical Psychology from The Chicago Medical School. She completed her postdoctoral training at Brown Medical School in the Centers for Behavioral and Preventive Medicine in 2000 and remained on faculty in the Department of Psychiatry at Brown until 2006.

Q1: One of the areas NTCC is focused on for 2008 is new media, which includes web-based forms of communication. Can you talk a little about the importance of online interventions for tobacco cessation?

For several years we've been talking about "reach" as the main advantage of online interventions. It is commonly accepted now that web-based cessation programs have the unique ability to reach smokers with evidence-based information, sustained support, and real-time advice in ways that other treatment modalities cannot. Underlying this argument about reach was the notion that even if web-based cessation programs did not yield efficacy rates as high as other treatment modalities, the overall impact (impact = reach x efficacy) on a population-wide basis would still be significant given the large number of smokers reached. We now have evidence from a number of trials that web-based programs can yield quit rates at 6 months that look quite comparable to other intervention modalities (e.g., telephone quitlines), suggesting that perhaps the web may do well on both reach and efficacy. From a research standpoint, the Internet also provides the unique ability to track and report the various denominators that are crucial to evaluate generalizability. For example, websites can track how many people click on a recruitment notice, complete the eligibility screening, provide informed consent, and go on to fully enroll in a study. We can associate costs with each of these steps to examine the cost efficiency of online advertising to recruit smokers to treatment in ways that are much more difficult and fraught with methodological concerns in other recruitment channels (e.g., newspaper, radio). This wealth of information allows us to accurately determine the total number of smokers who were reached with the study opportunity so we can draw accurate conclusions about external validity. In addition, there is also an opportunity to characterize individuals who may drop out at any step in the enrollment process. This information can be used to improve subsequent tailoring and targeting efforts to ultimately reach the largest proportion of smokers possible.

Q2: One of the 6 core strategies for building consumer demand is "Redesigning evidence-based products and services to better meet consumers' needs and wants." How were more traditional evidence-based cessation services redesigned into web-based formats?

Many of the early efforts at translating traditional (i.e., face to face) treatments resulted in web-based programs that were theory-driven and were based on solid empirical evidence from rigorous clinical trials, but proved largely unacceptable to consumers in formal usability and feasibility testing. The assumption underlying these many of these programs was that consumers wanted and/or needed to progress through the program in a very systematic and linear manner, beginning with the process of understanding the risks associated with quitting and importance of cessation, gradually becoming prepared to quit, setting a quit date, and recycling back through the same information to prevent relapse. In reality, smokers turn to the web for help at all stages of the quitting process, many of them having recently quit on their own looking for support in maintaining abstinence. In addition, the ways that consumers use the Internet for other purposes is rarely linear and structured, which may have contributed to poor usability ratings of these early programs.

Q3: What do the newer smoking cessation web-based applications look like?

As the field has become more sophisticated, programs have become more "user centered" allowing consumers to determine which elements of treatment they find most helpful. Web-based programs have been fully integrated with telephone counseling and medication as other proven treatment modalities, and cell phone interventions are on the horizon. Given the explosion of online social networks in recent years, programs that enable consumers to connect with one another to give and receive support throughout the quitting process are likely to demonstrate some of the most powerful effects on behavior change.

Q4: In what ways do web-based smoking cessation applications have the potential to better meet consumers' needs and wants and build demand for tobacco cessation products and services?

The web provides a unique opportunity to "go where the smokers are." We know from several studies that millions of smokers actively search for information online on quitting smoking each year. We know that motivation to quit is often a fleeting experience for many smokers. Capturing smokers at this precise moment when they are open and interested in quitting and directing them to evidence-based, proven programs and services is critical. Online advertising is growing at an exponential rate - especially among populations at disproportionate risk for smoking - and numerous studies show that consumers are receptive to online advertising. Unfortunately we know relatively little about how to harness the power of online advertising to reach consumers with messages that are engaging, appealing, and effective. This is one of the research areas that we are pursuing at the Schroeder Institute. We currently have an R21 grant funded from the National Cancer Institute which brings together a bi-lingual, cross-cultural, multi-disciplinary team with expertise in tobacco control, web-based interventions, Latino culture, marketing, advertising, and health communication to address some of these questions as they pertain to Latino smokers who use the Internet.

Q5: You are the Associate Director for Research Development at the Schroeder Institute for Tobacco Research and Policy Studies (SI) at the American Legacy Foundation. What is your role in this position?

My role at the Schroeder Institute is twofold. First, as Associate Director of the SI, I'm responsible for helping to establish the necessary infrastructure so that the Schroeder Institute can function as a grantee. Many of the policies and procedures that we often take for granted at large academic institutions because they have been in place for years are things that we're having to think through and create anew at this newly establish institution. We're fortunate at the SI to have incredible resources with the American Legacy Foundation at our disposal to help with this process, and it's been an enjoyable learning experience for me working with the various units within Legacy. My second role is as a Research Investigator, continuing my program of externally funded research. I have maintained an appointment at Georgetown University in the Cancer Control Program, and continue to collaborate with colleagues there. I'm also exploring new research opportunities that are related to existing projects and that also further the mission of the SI. It's an exciting time for sure, and a busy one!

Q6: How did you get involved in tobacco control?

My main interest coming out of graduate school was in making sure that results from research were used by policymakers, clinicians, and the general public to actually make a demonstrable public health impact. I didn't know this word back then, but it turns out that dissemination is really my passion. During my year of postdoctoral training with David Abrams at Brown, it became clear to me that tobacco control would provide a perfect "test case" for dissemination and implementation research because the evidence base about what works is so well established and yet the gap between research and practice is still enormous.

Q7: What has been the most challenging aspect of your work in tobacco control?

One challenging aspect of my work comes up in conversations with colleagues who look skeptically at the value of any kind of scientific inquiry related to the Internet. These typically tend to be researchers who are steeped in very tightly controlled clinical trials that maximize internal validity often at the expense of generalizability. It's important to note that this issue of internal and external validity is not a question or either/or. We absolutely need "proof of principle" in rigorously conducted efficacy trials conducted under ideal conditions. However, I firmly believe that we also need to determine the degree to which this efficacy may be weakened or diluted when we deliver the same intervention in the real world with subjects who may be less motivated and in settings where it may be adopted less rigorously or less intensively. The Internet provides a unique opportunity to conduct this kind of research, in addition to the opportunities I mentioned above about reaching smokers with proven treatments.

Q8: What has been the most rewarding aspect of your work in tobacco control?

The most rewarding part of my work most often comes through qualitative research efforts with current and former smokers. I find that these opportunities to connect with actual smokers struggling with nicotine addiction, or celebrating recent milestones of abstinence, really help to reinvigorate me and get me thinking creatively about how to reach and help consumers.

Q9: What, in your opinion, have been the most important developments in tobacco control in the past year?

To me one exciting development in the past few years has been the data that are finally emerging about the cost efficiency, return on investment, and actual lives saved from comprehensive tobacco cessation treatment and policies. These data provide the much-needed foundation that decision makers often need to implement policies or programs that may not be popular with certain constituencies but that are so obviously in the best interest of public health.

Q10: What, in your opinion, is the most important challenge facing tobacco control in the year ahead?

Tobacco control absolutely needs to be present in discussions around healthcare reform to ensure that comprehensive, evidence-based treatments and policies are implemented and supported broadly. Quit rates have slowed in the U.S. in the past 5 years, and we are very far off from reaching the 12 percent smoking prevalence goal set in Health People 2010. Making sure that tobacco control receives the strongest support possible in healthcare reform is an incredible opportunity to boost stalled quit rates and ensure that all smokers have access to the treatments they need to quit successfully and stay quit, and that youth grow up able to resist smoking.

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Survey Finds Lung Cancer Patients Get Blamed for Their Disease

A majority of Americans, including many health-care workers, believe that people who have lung cancer are at least partly to blame for their disease, a new survey finds.

In the poll of nearly 1,500 American adults, researchers found 59 percent of respondents agreeing with the notion that lung cancer patients helped bring on their diagnosis.

It's a bias that over time has led to fewer resources to investigate the number one cancer killer in the U.S., and added shame to the burden that lung cancer patients must carry, experts said.

"Sadly, the stigma has been used to justify underfunding, not only of research but also of programs for early detection and treatment," said Laurie Fenton Ambrose, president and CEO of Lung Cancer Alliance, a private organization providing support and advocacy for people with lung cancer.

Lung cancer is among the leading cause of cancer deaths in the United States. The American Lung Association estimates that more then 215,000 Americans will be diagnosed with lung cancer this year, and more than 161,000 will die of the disease. Between 10 percent and 15 percent of lung cancers are diagnosed in nonsmokers, the association estimates.

Too many people cast blame for lung cancer on the individual patient, due to the mistaken belief that all cases of the disease are caused by current smoking, Ambrose said. The truth is that "over 60 percent of people with lung cancer are former or never smokers," she noted. "No one deserves this disease. It is a public health epidemic, and you don't need to be a current smoker to be diagnosed with it."

But the prejudice against lung cancer patients is affecting patients. The Lung Cancer Alliance survey, which received some finding from drug maker Astra-Zeneca, also included 204 people with lung cancer. Fifty-four percent of these patients said they felt there was a stigma attached to the disease. Thirty-one percent felt that strangers or acquaintances had said or done things that showed they blamed the patient for their cancer, and 13 percent said that even members of their treatment team had done so.

However, a "blame the victim" mentality is helping to stymie efforts toward early detection and better treatment, the experts said.

"We need earlier disease detection," said Anne Elixhauser, a senior research scientist at the Agency for Healthcare Research and Quality (AHRQ). "We need to understand at a molecular or genetic level what triggers lung cancer in people so it can be detected earlier. We need more treatment options for the earlier stages of the disease, when we have a chance for better outcomes."

Today, 70 percent of lung cancer cases are diagnosed at an advanced stage, Ambrose said, "which is why the survival rate has remained low for decades. Just as has happened in breast cancer, prostate cancer and colon cancer, a robust research pipeline can lead to a significant increase in survival."

For more information, see web link:
U.S. News & World Report November 14, 2008

Gender Is Key Factor in Determining Overall Survival Of Lung Cancer Patients

Even though some combinations of gender, race and/or marital status can factor into the overall survival of nonoperative non-small cell lung cancer patients, gender is the most significant factor impacting overall survival, according to a study presented at the 2008 Chicago Multidisciplinary Symposium in Thoracic Oncology, sponsored by ASTRO, ASCO, IASLC and the University of Chicago.

According to the National Cancer Institute, in 2008 approximately 215,020 new cases of lung cancer will be diagnosed in the United States and 161,840 people will die from the disease.

Researchers at Henry Ford Hospital in Detroit, the Radiation Therapy Oncology Group in Philadelphia, the University of Pennsylvania in Philadelphia, M.D. Anderson Cancer Center in Houston, the University of Texas Southwestern in Dallas and Emory University in Atlanta studied 1,365 lung cancer patients who were enrolled in national cooperative group trials conducted by the Radiation Therapy Oncology Group during the 1990s to determine the impact of sociodemographic factors such as gender, race and/or marital status on overall survival.

The results of the study showed that males diagnosed with non-small cell lung cancer had a 1.23 times higher mortality rate than females but that race and marital status did not significantly affect the patients' outcomes.

"Our study corroborates the fact that gender plays an important role as a prognostic factor in people diagnosed with lung cancer," Benjamin Movsas, M.D., lead author of the study and chair of the Department of Radiation Oncology at Henry Ford Hospital, said. "This underscores the importance of studying this disease entity in light of the fact that women diagnosed with lung cancer tend to have a better outcome in terms of survival."

For more information, see web link:
ScienceDaily November 14, 2008

Smoking Ban Tied to a Gain in Lives in Massachusetts

Nearly 600 fewer Massachusetts residents have died from heart attacks each year since legislators banned smoking in virtually all restaurants, bars, and other workplaces four years ago, according to a report released recently that provides some of the strongest evidence yet that such laws save lives.

The study, conducted by the state Department of Public Health and the Harvard School of Public Health, shows that a steep decline in heart attack deaths started as Boston and most of its neighbors adopted bans. Enforcement of the statewide law beginning in mid-2004 coincided with a further reduction, the study found. From 2003 to 2006, heart attack deaths in Massachusetts plummeted 30 percent, significantly accelerating what had been a more modest long-term decline.

The report, found that the number of heart attacks began dropping in communities with strong antismoking laws years before the 2004 statewide law and that similar reductions were achieved in other cities and towns only after the state ban. By the end of 2006, the rate of decline in all cities and towns had nearly converged. The authors said this pattern showed that advances in treatment of heart attacks were not responsible for the smaller number of deaths.

"This is the strongest study yet done of the effect of smoking bans on heart attacks," said Dr. Michael Siegel, a Boston University School of Public Health specialist in tobacco control who has been a critic of some antismoking laws and of previous research conducted by the state and Harvard. "You can no longer argue that these declines would have occurred simply due to medical treatment."

The health benefits of smoking bans have long stirred controversy between advocates and opponents of workplace tobacco laws. While health officials including the U.S. surgeon general have concluded that secondhand smoke is responsible for thousands of deaths annually from heart disease and lung cancer, the tobacco industry and some in the hospitality industry have suggested that the dangers of secondhand smoke are overstated and that there is little evidence that bans prevent deaths.

Led by Tom Land, director of surveillance and evaluation for the Massachusetts Tobacco Control Program, the researchers hunted for signs the reduction might be due to a factor other than tobacco laws. They considered, for instance, whether there had been an improvement in how heart attack victims were transported to hospitals. They could find nothing that swayed them from their conclusion that there was an indisputable relationship between the smoking ban and fewer heart attack deaths.

That belief was strengthened when they looked at what happened in communities that had either no job-site smoking law before the state ban or a weak law. Heart attack deaths dropped nearly 20 percent in those cities and towns during the first 17 months of the law.

By comparing communities that adopted early smoking bans with those that did not, the researchers were able to estimate that an average of 577 fewer people have died annually from heart attacks because of the law.

"People have assumed that the only benefit we will be able to measure of a smoking ban is long-term benefits," said John Auerbach, the state public health commissioner. "This study demonstrates a real connection between smoking bans and short-term improvement in health outcomes."

For more information, see web link:
Boston Globe November 12, 2008

African-Americans Smoke Less in Teens, Catch Up by 30s

African-Americans are much less likely to smoke than whites are during their teens. However, a new study finds that most of this advantage disappears by mid-adulthood.

"There is a puzzle here in that usually the health disadvantages in African-Americans show up early in life and get worse as they get older," says Fred Pampel, Ph.D., a sociology professor at the University of Colorado at Boulder. "For cigarette smoking, African-Americans tend to act in a more healthy way during their teens, but that advantage goes away by middle age."

The study appears in the December issue of the Journal of Health and Social Behavior. Pampel used data from two surveys to make his conclusions.

The National Youth Survey followed the same group of people between ages 12 to 18 in 1977 for 15 years through 1992. The National Health Interview Survey questioned different samples of people 18 and older for 30 years ending in 2006. Pampel looked at groups of white and black teens to see how their cigarette smoking patterns changed as they aged.

"The analysis found that this change is indeed real," said Pampel, and "the disappearance at older ages of the African-American advantage during the teens is more apparent among younger generations than older ones.

"The narrowing differential appears to result from the greater resources that are available to whites than African-Americans. Resources such as higher income, more education, better access to medical care and greater use of nicotine replacement products help whites quit at a faster rate," Pampel said.

C. Tracy Orleans, Ph.D., of the Robert Wood Johnson Foundation, said the study did not factor in possible socio-demographic differences in exposure to higher tobacco prices and taxes, which "deter youth onset and promote quitting, especially among low-income smokers, and protection by worksite and comprehensive smoke-free airs laws, which affect adult cessation more than youth initiation."

Gary Giovino, Ph.D., at the University at Buffalo, State University of New York, does not necessarily agree with the study's conclusions.

"I have seen the substantially reduced smoking prevalence among African-American adolescents carry over to young adults aged 30 to 34 years, suggesting greater progress and resilience than is indicated by this article," Giovino said.

For more information, see web link:
Health Behavior News Service November 10, 2008

Smoking Trends in the Nurses' Health Study 1976-2003

Since nurses play an integral role in promoting smoking cessation, understanding the prevalence of smoking among nurses is of particular interest. A recent study published in the November/December issue of Nursing Research examined trends in smoking status and characteristics for nurses over a 27-year period.

The study analyzed data from the Nurses' Health Study (NHS) from 1976 to 2002 and from the NHS II for the years 1989 to 2003. Participants were 237,648 female registered nurses (RNs). For nine five-year birth cohorts, initial notation was made of participant smoking status with follow-up assessments at two-year intervals.

The study found smoking rates have decreased for female nurses over time. At the start of NHS in 1976, current smokers comprised 33.2 percent of participants. At the start of NHS II in 1989, the percentage of current smokers was 13.5 percent. By 2002/2003, 8.4 percent of participants were current smokers. The mean cigarettes per day declined over time but still exceeded half a pack per day (15.1 cigarettes) at the end of follow-up.

Of nurses who had ever smoked, 79 percent quit. The mortality rate among current smokers was higher than that of former smokers and was approximately twice that of never smokers in all age categories. Participants who were smokers had more comorbid conditions than did participants who never smoked.

The authors noted that this study provides the first report of smoking trends among RNs in the NHS. The decline in smoking rate among female nurses mirrors the decline in smoking rate among women in the United States over the past 25 years. Increased mortality and morbidity rates indicate the devastating cost of smoking to the profession and can provide support for the urgent need for further research to encourage continued smoking cessation efforts for nursing professionals.

For more information, see web link:
Nursing Research Vol. 56 No. 7, November/December 2008

Smoking Coupled With Obesity Raises Death Risk

Everyone knows smoking and being obese is not healthy for you, but now a new study published in the November issue of The American Journal of Clinical Nutrition shows the odds of dying early are highest among obese smokers.

"We know that obesity and smoking by themselves are important health risk factors," said lead researcher Annemarie Koster, an epidemiologist at the U.S. National Institute on Aging. "We found that smoking and obesity are independent predictors of mortality, but smoking and being obese especially increases the mortality risk."

"It seems that smoking cessation was associated with significantly lower mortality risk in every weight group," she said. "Quitting smoking will definitely improve your mortality risk, no matter in what weight group you are."

For the study, Koster's group collected data on 3.5 million members of the AARP, aged 50 to 71. In 1995-1996, and again in 1996-1997, AARP sent out questionnaires asking people about diet, family history of cancer, physical activity, hormone replacement therapy, weight, waist size, and smoking.

Using the U.S. Social Security Administration Death Master File, the researchers linked the AARP data with death records of the survey participants from 1996 to 2006. During that period, almost 20,000 men and 7,500 women died.

The researchers found that as weight increased, so did the rate of death. Across all weights, people who smoked had the highest death rates.

In fact, obese smokers had a six to eight times greater risk of dying compared with normal weight people who never smoked. In addition, among smokers with a large waist, the risk of dying was five times greater than among people with the smallest waists who never smoked, Koster's team found.

Dr. Norman H. Edelman, a professor of preventive medicine, internal medicine, physiology & biophysics at Stony Brook University in New York and chief medical officer at the American Lung Association, thinks that if you have to choose between losing weight or stopping smoking, you should stop smoking.

"Especially important is the finding that smoking cessation has a great effect on lowering risk of dying, one which far outweighs the slight increased risk from the associated increase in weight," Edelman said. "Also to note, if one is obese and smokes and has to choose between weight loss and smoking cessation to improve health, the latter will have a greater protective effect," he added.

For more information, see web link:
Washington Post November 7, 2008

Living With Smoker Increases Food Insecurity

Daily access to healthy food is decreased in children and adults who live with smoking adults in comparison to those living with non-smoking adults, according to an article published in the Archives of Pediatrics & Adolescent Medicine.

The authors state that approximately 13 million U.S. children live in food-insecure households. Previously, it has been shown that this insecurity is strongly associated with household income -- and families with at least one smoker spend between two and twenty percent of their incomes on tobacco. As a result, the authors suspect that smokers, by affecting financial means, also affect the means for adequate food provisions.

To investigate the link between smoking status in families and food insecurity, Cynthia Cutler-Triggs, M.D., of the New York University School of Medicine and Bellevue Hospital Center, and colleagues examined 8,817 households with children 17 years old and younger between the years of 1999 and 2002. These groups were monitored to see if the presence or absense of adult smokers affected food security of those living in the same home. The groups were also examined in terms of age, sex, race of the child, and poverty index. Food insecurity was evaluated using the U.S. Department of Agriculture Food Security Survey Module.

In examining the factors and outcomes, the authors found that at least one smoker was present in 23 percent of children's households. In stratifying these children, they said: "32 percent of children in low-income households lived with a smoker compared with 15 percent of those in more affluent households." A total 15 percent of adults and 11 percent of children reported that they had experienced food insecurity within the last years. Severe food insecurity was experienced by a total 6 percent of adults and 1 percent of children.

The authors note that trends were apparent in the data. "Food insecurity was more common and severe in children and adults in households with smokers," they write. "Of children in households with smokers, 17 percent were food insecure vs. 8.7 percent in households without smokers." This indicated a rate of severe child food insecurity of 3.2 percent in households with smokers and 0.9 percent in those without smokers. The trend was similar for adults in these households: "For adults, 25.7 percent in households with smokers and 11.6 percent in households without smokers were food insecure, and rates of severe food insecurity were 11.8 percent and 3.9 percent, respectively."

Food insecurity rates were highest in children living in low-income households with smokers. In comparison with white families, black and Hispanic families had higher rates of child food insecurity in the smoking and non-smoking strata.

The authors conclude that smoking status should be noted when determining child health risk factors: "These data also demonstrate how pervasive this combination of child health risks is in low-income families," they write. "The burden of food insecurity is a previously unrecognized danger of adult tobacco use to be added to the ever-growing list of negative effects of adult tobacco use on children in the United States."

For more information, see web link:
Medical News Today November 5, 2008

Today's Smokers More Addicted to Nicotine

Almost 75 percent of current smokers trying to kick the habit are now highly nicotine-dependent, which is a 15-year high, a new study finds.

In fact, nicotine dependence has risen 12 percent from 1989 to 2006, and the number of highly nicotine-dependent people has gone up 32 percent, according to research presented at the American College of Chest Physicians annual meeting, in Philadelphia.

"My clinical perception has been that over the last five years, patients that I am seeing require much more intensive treatment because tobacco dependence is more severe," said lead researcher Dr. David P. Sachs, from the Palo Alto Center for Pulmonary Disease Prevention in California.

Studies have shown that the more nicotine-dependent an individual is, the less effective standard treatment will be, Sachs said. "These people will suffer severe nicotine withdrawal symptoms, and they will be more likely to relapse back to cigarette use," he explained.

For the study, Sachs' team compared the degree of nicotine dependence between 1989 and 2006 in three groups of smokers, a total of 630 in all, who enrolled in smoking cessation programs.

Nicotine dependence was measured using the Fagerstrom Tolerance Questionnaire, which assesses nicotine dependence on a scale of 0 to 11 points.

Over 15 years, scores on the questionnaire increased by 12 percent, and the number of people with scores of 7 to 11 went up 32 percent. Overall, the proportion of people who were highly nicotine-dependent rose from 55.5 percent to 73 percent over the study period, Sachs' group found.

Sachs believes that it's the most nicotine-dependent smokers who are now showing up at quit-smoking programs. "If these patients are going to get effective treatment and not be at risk for relapse, they need more intensive treatment," he said.

Dr. Norman H. Edelman is a professor of preventive medicine, internal medicine, physiology and biophysics at Stony Brook University in New York and chief medical officer of the American Lung Association. He said there could be several explanations for the increase in degree of nicotine dependence among current smokers.

"Is the reason for the increase in nicotine addiction due to the fact that cigarette companies have been increasing the nicotine content of cigarettes? Is the reason for this finding the fact that we have been successful with the less-addicted, and now have the more addicted 'hard-core' [smokers] left?" he asked.

For more information, see web link:
U.S. News & World Report October 28, 2008

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America Reaches Major Anti-Smoking Milestone

New data from the federal government show that cigarette consumption in the U.S. has decreased by an estimated 28 percent, or 135 billion cigarettes, over the past decade, which marks a major milestone in public health and tobacco control, according to the National Association of Attorneys General (NAAG) and the American Legacy Foundation.

Ten years after the state Attorneys General negotiated the landmark 1998 Master Settlement Agreement with tobacco companies, cigarette consumption has continued to decline and the landscape around tobacco use has shifted significantly. With November 23, 2008 marking the anniversary of the signing, the MSA should be recognized for the enormous impact it has had on cigarette consumption, the groups said.

"This settlement continues to send a strong message to the tobacco companies: Americans won't tolerate the marketing of this deadly product to our young people," said NAAG Tobacco Committee Co-Chair and Washington Attorney General Rob McKenna. "As a direct result of the work of the nation's attorneys general, today's kids are less exposed to pro-tobacco marketing like Joe Camel. Kids who still want tobacco products face ever-increasing roadblocks to obtaining them."

According to data from the U.S. Tobacco Tax Bureau of the U.S. Treasury, the tobacco industry sold 480.5 billion sticks in 1997, compared with sales of 344.4 billion sticks projected for 2008. Additionally, cigarette consumption in 2007 (360.5 billion sticks) declined by five percent from 2006 levels (379.5 billion sticks). That reduction marks the largest one-year percentage decrease in cigarette sales since 1999. The data and projections are based on calculations by the NAAG'S Tobacco Project using Tobacco Tax and Trade Bureau data combined with cigarette import data from U.S. Customs.

"The Master Settlement Agreement placed significant restrictions on the advertising and marketing practices of the tobacco companies, and also provided funding for an effective anti-smoking public education campaign targeted directly at youth," said Cheryl Healton, Dr. P.H., President and CEO of the American Legacy Foundation. "These new numbers conclusively demonstrate that the combination of these two factors --- together with the hard work of the Attorneys General and the public health community --- has resulted in a major reduction in smoking rates since the MSA was signed."

The broad array of restrictions on the advertising, marketing and promotion of cigarettes outlined in the MSA included prohibiting the targeting of youth in cigarette advertising. The agreement also prohibited outdoor advertising of cigarettes and the advertising of cigarettes in public transit facilities, as well as the use of cigarette brand names on merchandise, and a host of other restrictions. Furthermore, the payment provisions of the MSA were designed to compensate the states in part for the billions of dollars in health care costs associated with treating tobacco-related diseases under state Medicaid programs.

For more information, see web link:
American Legacy Foundation Press Release November 19, 2008

Coalition Backs Plan to Provide All Tobacco Users with Access to Cessation Treatment

Nearly two dozen of the nation's business, labor, insurance, government and health care leaders - including three former Secretaries of Health and Human Services and two former Surgeons General - endorsed a bold plan to provide every American with access to comprehensive tobacco cessation treatment services by the year 2020.

The National Working Group for ACTTION (Access to Cessation Treatment for Tobacco In Our Nation) unveiled the plan in a document entitled a "Call for ACTTION."

"Ending tobacco addiction is crucial to our nation's health and its economic well-being," said John M. Clymer, president of Partnership for Prevention, a nonprofit organization that coordinated the working group's efforts. "But while 70 percent of the nation's smokers say they want to quit, only 30 percent of them are using proven cessation techniques, and only 1 in 50 employers currently provide workers with any cessation treatment coverage."

The plan unveiled calls for immediate, systemic and lasting action in key areas identified in recent reports issued by the CDC, the Institute of Medicine, and the U.S. Public Health Service. Those reports cited three vital areas where the country should take action to improve access to comprehensive treatment:

• Insurance Coverage: Provide comprehensive first-dollar coverage for tobacco use treatment under all public and private insurance.
• Quitlines: Increase funding for state quitline infrastructure and promotion and provide incentives for quality improvement efforts.
• Healthcare systems: Institutionalize the routine treatment of tobacco use in all out-patient and in-patient service delivery.

A detailed listing of all the recommendations in these three areas is available online at http://www.acttiontoquit.org.

"There are many steps to a comprehensive program: first of all, providers need to remind patients that it's important to stop smoking and insurers must pay for comprehensive cessation benefits," said Julie Gerberding, director of the Centers for Disease Control and Prevention (CDC), which helped sponsor the working group and endorsed the plan.

The call was also endorsed by former HHS Secretaries Tommy Thompson, Donna Shalala and Richard Schweiker, as well as former Surgeons General Richard H. Carmona and Joycelyn Elders. In addition to Gerberding, current government officials endorsing the call included Judy Monroe, Indiana's state health commissioner and president of the Association of State and Territorial Health Officials; Nathanial Cobb, tobacco control chair at the Indian Health Service; and John Niederhuber, director of the National Cancer Institute.

Private-sector endorsements came from the National Business Group on Health, the Automotive Industry Action Group, the Service Employees International Union, United Health Group, Blue Cross Blue Shield of Texas, ClearWay of Minnesota, the Robert Wood Johnson Foundation, the Canyon Ranch Institute, Partnership for Prevention, the American Legacy Foundation, Campaign for Tobacco-Free Kids, the American Cancer Society, the American Heart Association, the American Lung Association, the North American Quitline Consortium, and the Smoking Cessation Leadership Center.

The working group's efforts were sponsored by the American Legacy Foundation, the Centers for Disease Control and Prevention, Partnership for Prevention, Pfizer, Smoking Cessation Leadership Center, and UnitedHealth Group.

For more information, see web link:
PRWeb November 18, 2008

Fight to Quit, Quit to Live

American Marines and sailors are smoking at alarming levels these days. In a recent survey by the American College of Chest Physicians (ACCP), 64 percent of the 408 Marines and sailors surveyed reported using some form of tobacco. Cigarette smoking accounted for 52 percent of tobacco use, followed by smokeless tobacco (36 percent) and the use of both (24 percent). In contrast, about 20 percent of U.S. adults smoke. Historically, tobacco use has been linked to service in the military - some may see it as a stress reliever especially during times of deployment and tours of duty that extend beyond the traditional time frame.

To help the millions of smokers who want to quit, the American Legacy Foundation® has partnered with a host of state health agencies and other national organizations an innovative way to help all smokers quit. EX® is an unprecedented new public health campaign that works to change the way smokers feel about the difficult process of quitting and guide them to valuable, free resources to build and activate successful quit attempts. The program provides with tools to:

• "Re-learn" their thinking on the behavioral aspects of smoking and how different smoking triggers can be overcome with practice and preparation
• "Re-learn" their knowledge of addiction and how medications can increase their chances for quitting success and
• "Re-learn" their ideas of how support from friends and co-workers can play a critical role in quitting.

According to the recent ACCP research, 80 percent of military smokers said that being in the military had increased their tobacco use, while 74 percent of tobacco users in the study said they wanted to quit. These statistics are in line with what research has shown for years- 70 percent of smokers want to quit but only 5 percent are successful in quitting long term.

"Our troops continue to serve extended tours of duty and experience unexpected deployment to foreign countries filled with life-threatening violence, "said Cheryl G. Healton, Dr. P.H., president and CEO of the American Legacy Foundation "The foundation applauds their sacrifice and understands their need to relieve stress, but we encourage them to find alternatives to smoking. We hope the EX program will give our troops the tools they need to win the war against tobacco addiction," she said.

More information about the EX program is available online at http://www.becomeanex.org/.

Resolution Calls for Smoking Ban on U.N. Premises Worldwide

Adi Zekcher, a United Nations staffer, buys a packet of Marlboro Lights and heads downstairs to the last remaining New York City cafe in which espresso-sipping patrons can light up for a morning cigarette.

The Vienna Cafe, home to tobacco-stained diplomats, in the basement of the U.N. headquarters, technically lies on international territory and remains unaffected by the city's five-year-old smoking ban.

But like the swirling plumes of blue Dunhill smoke, change is in the air. The General Assembly passed a resolution this month banning the sale or smoking of tobacco in the headquarters or other U.N. premises around the world.

Margaret Chan, the World Health Organisation's director general, praised the assembly's consensus decision, promising fewer U.N. "delegates, employees and visitors" will "sicken and die prematurely" from second-hand smoke.

Despite the successfully adopted resolution and Dr. Chan's sage words, dozens of customers of the Vienna Cafe still puff away on cigarettes, pipes and cigars while munching croissants. Upstairs, the U.N.'s branch of Hudson News, a newspaper kiosk, continues to sell about 40 packets of cigarettes daily to diplomats and employees.

Officials have long sought to abolish smoking in the iconic headquarters and other U.N. offices around the world - but efforts have been undermined by sketchy support and resistance from some delegations.

In 2003, about six months after New York City imposed harsh anti-smoking measures in bars throughout the metropolis, Kofi Annan sent a bulletin banning smoking at U.N. headquarters.

Following the adoption of the resolution, Ban Ki-moon, the current secretary general, is now responsible for implementing the edict and reporting back on its success or failure next year.

Michelle Montas, Mr. Ban's spokesman, said the secretary general had yet to devise a strategy to encourage the world's nicotine-hungry diplomats to relinquish their smoking rights.

"There is a smoking ban - the problem is enforcing it," Ms. Montas said. As in so many other arenas, she said, the secretary general's hands were tied. "We should try to find out why it is not reinforced by members of the different delegations… I think the question should go to them."

For more information, see web link:
The National November 8, 2008

American Lung Association Calls on President-Elect Obama to Protect Federal Workers by Making All Federal Worksites Smokefree

Each day, the simple act of going to work puts the health of thousands of federal government workers at risk. Despite an Executive Order issued in 1993, not all federal worksites are smokefree. This poses a significant health threat according to the Surgeon General who released a report in 2006 declaring that there is no safe level of exposure to secondhand smoke.

Exposure to secondhand smoke not only is the direct cause of premature death and disease in children and adults, but also has immediate adverse affects on the cardiovascular system. The simple act of breathing secondhand smoke is a scientifically proven direct cause of coronary heart disease and lung cancer.

"It's really unconscionable in 2008 to still find workplaces that expose workers to deadly secondhand smoke throughout the work day," said Bernadette Toomey, President and CEO of the American Lung Association. "What's even harder to fathom is that the federal government is one of these employers who knowingly puts their worker's health at risk."

Twenty-three states and the District of Columbia have passed comprehensive smokefree workplace laws protecting the public and workers from the dangers of secondhand smoke. Ironically, many federal workers, including those living in states with smokefree laws, are still exposed to secondhand smoke every day at work.

The American Lung Association is circulating a petition calling on President-Elect Obama to ensure that all federal workers around the country are not forced to breathe secondhand smoke while on the job. The petition can be found online at http://lungaction.org/campaign/Federal_Workplaces_Smokefree.

This immediate call to action directed at President-Elect Obama calls for the complete elimination of secondhand smoke in federal workplaces. While some federal workplaces separate smokers from nonsmokers, filter air or ventilate buildings, the Surgeon General has declared that these measures in no way offer sufficient protection.

For more information, see web link:
American Lung Association Press Release November 6, 2008

Ireland Ranked Second for Tobacco Control in Europe

Ireland is now ranked second among 27 European countries for tobacco control, according to a report released by European Network for Smoking Prevention and the Association of European Cancer Leagues. In 2005 it was in first place but slipped into second place, behind the U.K., last year when the survey was conducted.

In the report, "Progress in Tobacco Control in 30 European Countries, 2005 to 2007" all countries were scored across a number of criteria including price, public place smoking bans, public information campaign spending, advertising bans, health warning and smoking cessation treatment programs.

Prof. Luke Clancy, a founder of Ash Ireland and director general of the Tobacco Free Research Institute, said the reason Ireland's ranking had slipped was because it had no tobacco price rise in 2005 and as a result tobacco prices in the U.K. were higher for a period than they were in the Republic.

In addition he said smoking cessation programs are not as good as in the U.K., where overall smoking prevalence rates are now lower than they are here. Latest figures indicate the overall smoking prevalence rate among Irish adults is 29 percent.

Prof. Clancy said while Ireland had achieved a good result overall in its European ranking there was no room for complacency. There was still a great deal more work to be done to de-normalize smoking, particularly among young people, he said.

Some 7,000 people die in Ireland each year from smoking related diseases.

For more information, see web link:
The Irish Times October 28, 2008

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