A recent study by UK researchers was published in the online version of the Journal of Clinical Pathology that explored the recording of deaths associated with smoking. The researchers found that while doctors are willing to list alcohol as a cause of death, they are resistant to listing smoking as the cause of death, because of a fear that doing so will stigmatize the deceased.

However, the researchers say that this practice has implications when it comes to understanding the extent of negative impact of smoking on health. For instance, any statistics that rely on death certificates to estimate the death toll as a result of smoking are likely flawed. Since 1992, doctors have been permitted to list smoking and alcohol as a direct or underlying cause on a death certificate.

The researchers examined death certificates for approximately 2,000 individuals in addition to 236 post mortem reports. The deaths occurred at a large teaching hospital in London from 2003 to 2008.

The researchers found that:

• There were only two certificates in the sample that listed smoking as a cause of death.
• Ten additional certificates cited smoking as a contributory condition.
• The two cases that cited smoking as the main cause of death were cases of lung cancer and chronic obstructive pulmonary disease.
• In an additional 279 deaths, lung cancer and chronic obstructive pulmonary disease were included in the diagnoses, and in many of the cases the individual was either a current or a former smoker.
• In a total of 407 deaths, the cause was related to a condition in which smoking is generally believed to play a substantial role. However, smoking was only listed as the cause of death in two of the certificates.

The authors of the study were also surprised when examining post-mortem reports to find that not even one case listed smoking as the cause or a contributing factor in death. Doctors were much more willing to cite alcohol as a direct or contributing cause of death. The researchers believe that doctors do not perceive a similar stigma attached to death as a result of alcohol in comparison to a death related to smoking. This may be due to recent legislation that bans smoking in public places.

Clinical director of the tobacco dependence clinic for the Vancouver Coastal Health Authority, Dr. Milan Khara, said that he would like to see smoking referred to as an addiction. He believes that smokers would more readily seek help to quit if they thought of smoking as the serious addiction that it is, rather than just a bad habit they felt solely responsible for building up and; therefore, felt responsible for breaking it on their own. He wants them to see that it might not be possible for them to just put it down on their own. They may need extra help like others who suffer from addictions.

Dangers of Cigarettes

For decades, warnings about the dangers of cigarettes have been posted in advertisements and even on cigarette packages themselves. Despite health warnings, rising monetary costs of cigarettes, building restrictions for smokers, seeing relatives die of cancer, and even having cancer themselves, smokers continue to inhale.

The Centers for Disease Control and Prevention report that 443,000 die prematurely each year from smoking or second-hand smoke exposure. But, still, the U.S. Department of Health and Human Services reports that every day 3,400 youths pick up their first cigarette, while 50 million Americans continue smoking.

Why would smokers choose to continue smoking knowing such dire statistics? Dr. Khara explains that nicotine is more addictive than other drugs because as soon as it is inhaled, it enters the brain. The brain then becomes altered, which will induce the body to have withdrawal symptoms like anxiety, craving, and irritability when a person tries to quit smoking. It is not simply a habit that is easily broken.

Treatment for Smoking Addiction

Khara stresses that even though smoking is an addiction, there are still many ways to help people overcome their smoking addiction. Just like with other addictions, he encourages smokers to get counseling from health providers and medications, like nicotine gum and patches, that would help wean smokers off of nicotine. Newer technology is also helping smokers kick the addiction.

One smoker said that electronic applications helped her track how much money she was saving by not smoking and the total number of cigarettes she had resisted smoking. She also used social networks for smokers who were trying to quit so that she could share posts of her experiences and feel solace that she wasn’t alone in her battle.

Other smokers are turning to electronic cigarettes to help curb their cravings. E-cigarettes offer smokers a vaporous nicotine minus tar, carbon monoxide, and other harmful ingredients. Supporters of e-cigarettes say that smokers can gradually decrease the amount of nicotine they take in, until they finally have such minimal levels that they can quit. Non-supporters say that smokers will lose their incentive to quit because they believe the e-cigarettes work for them.

Each November 17, the American Cancer Society has The Great American Smokeout day which encourages every smoker to take a day off from smoking in hopes that the next morning they might not pick their cigarettes back up. Some anti-smoking supporters believe that raising taxes higher on cigarettes will help discourage people from starting their addiction and will encourage others to stop. Others believe counseling and medication may help. But, armed with the new terminology of "addiction" rather than "habit," smokers may find new ways to help themselves end their lifestyle of smoking cigarettes.

For Dr. Michael Ong, a researcher and associate professor of general internal medicine and health services research at UCLA’s Jonsson Comprehensive Cancer Center, and his team—the idea of primary care physicians administering smoking cessation to patients is necessary and within their capacity as medical providers, even to the most challenging patients. These include smokers who also exhibit comorbid disorders ranging from mental illness to alcohol and drug addiction. Smokers with comorbid behavioral health conditions comprise 40% of the smoking population, are more difficult to treat, and pose increasing burdens on the nation’s healthcare system. Despite these smokers’ multiple conditions, Ong and his team have found that primary care physicians can still be successful in facilitating smoking cessation to these patients. In fact, their research shows that doctor-assisted cessation counseling with challenging smokers is just as successful as cessation counseling for smokers who do not have comorbid conditions.

In a new study, Ong and his colleagues researched the quit success rate among a specific group of 1,356 patients who had reported past-year smoking in the 1998–1999 Community Tracking Study survey. To compare the smokers’ rates of successfully quitting, the researchers tracked whether or not the patients had later reported seeking cessation counseling with their primary care physician in the follow-up Healthcare for Communities Survey in 2000–2001, and how the existence of comorbid disorders impacted their success.

Without smoking cessation counseling from their primary care physician, smokers with comorbid disorders had a quit success rate of only 6%, and smokers without comorbid disorders had a quit success rate of 10.5%. However, smokers with comorbid disorders who sought out cessation counseling with their primary care physician had five times the rate of success as those who did not receive counseling. These patients’ success rate (31%) was comparable to that of patients without comorbid disorders who had also received cessation counseling from their doctor (35%). Not only were the comorbid disorder-patients nearly as successful as patients without the disorders, but the researchers also discovered that these patients were just as likely to receive cessation counseling from their primary care physician (73% and 80% respectively), indicating that most smokers may have the desire to quit and are willing to receive treatment, despite the possible presence of co-existing disorders which may complicate their efforts.

The findings from Ong’s study are significant since individuals with conditions like schizophrenia, depressive disorders, or anxiety disorders have higher rates of smoking than individuals without the disorders. With the help of their family doctor, these patients considerably increase their chance of successfully quitting.

Helping smokers who also have drug abuse or mental disorders kick the habit creates a number of health benefits—including the immediate benefit of improving individuals’ quality of life, health, and life expectancy; eliminating the risks of tobacco-related diseases among patients and their families; and reducing the costs of tobacco-related expenses in the healthcare system. The researchers’ new study is currently available in the scientific journal Nicotine & Tobacco Research.

REFERENCES/RESOURCES:

http://www.cancer.ucla.edu/Index.aspx?page=644&recordid=501&returnURL=%2findex.aspx

http://health.usnews.com/health-news/family-health/brain-and-behavior/articles/2011/08/26/quitting-even-tougher-when-smokers-battle-other-addictions
 

A study published in the journal Addiction on June 21, 2011, shows that adult-focused anti-smoking programs have also reduced smoking among adolescents. The better funded these programs are, the more effective they are at reducing smoking among both adults and adolescents.

The study found that the most important elements of an anti-smoking program include raising taxes on tobacco, making sure adult-focuses tobacco control programs are well-funded, increasing restrictions on indoor smoking, and ensuring that anti-smoking media campaigns are well-funded. While lengthy and expensive, these programs can be very effective.

The study showed three reasons why adult-focused anti-smoking policies can also reduce smoking in adolescents. First, as adult smoking decreases, young people stop seeing smoking as an adult activity. Second, when parents quit smoking, it reduces the likelihood that their children will start smoking. Third, many anti-smoking programs directly influence adolescents; for instance, there is strong evidence that media ads emphasizing the serious health consequences of smoking resonate strongly with young people.

Professor Melanie Wakefield, co-author of the study and Director of the Centre for Behavioural Research in Cancer at the Cancer Council Victoria, said that a comprehensive anti-smoking program must contain strong, consistently enforced, well-funded anti-smoking policies. She added that the only way to ensure this bonus effect is to create a rigorous anti-smoking program, choosing effective policies that are properly financed.

Source: Science Daily, Anti-Smoking Policies for Adults Also Reduce Kids’ Smoking, June 22, 2011

Published in Biological Psychiatry, the study indicates that the genes that influence a teen’s desires to smoke, and their level of susceptibility to addiction, change as the teen reaches adulthood. Researchers concluded that if a teen exhibits behavior that is especially tuned in to pleasure, disrupts home or school life and seems to have no relevance for the negative outcomes, this teen may be genetically more likely to experiment with smoking and continue to smoke.

By the numbers, teens who had specific levels of variance in two genetic areas had a three times greater likelihood of becoming a smoker, and a risk two times greater than other teens of carrying the smoking habit into their adult life.

The actual act of beginning to smoke may also be related to how a person’s genetic make-up responds to dopamine. Certain genetic variations occurring in the genes connected to dopamine processing indicated that some teens could be more influenced to start smoking as a teen. This risk could be as high as 1.3 percent over teens without this genetic variance.

It’s a different genetic influence that may dictate whether an adult begins to smoke, says the research, such as the person’s ability to cope with stress, whether or not they are depressed and their levels of anxiety. Scientifically, it’s an effect related to cholinergic receptors, which monitor things like mood and a tendency to self-medicate.

While still early in its research phase, the study could help establish the possibility of genetic screening to allow people to know how great their risk for smoking or smoking addiction is, and could also help boost research toward medications that change the way a person reacts to nicotine.

In the study, current smokers, former smokers, and non-smokers were asked to perform tasks that assessed certain cognitive skills that seem to be important for abstaining from smoking. While they performed the tasks, the researchers used functional MRI (fMRI) to track brain function. The tasks included tests of impulse control, the ability to monitor one’s behavior, and the ability to avoid distraction from smoking-related images, which elicit an automatic attention response in smokers.

The researchers found that when performing these tasks, the current smokers (compared to non-smokers) showed reduced functioning in prefrontal regions of the brain that are associated with controlling behavior. The current smokers also showed increased activity in sub-cortical regions like the nucleus accumbens, which respond to the “reward” of nicotine.

The former smokers, however, showed increased activity in the frontal lobes of the brain, areas that are important in controlling behavior. The former smokers also showed greater levels of activity in these areas of the brain than non-smokers.

This suggests that the brain regions responsible for “willpower” show more activity in those who have quit smoking. This stresses the importance of using smoking cessation therapies that focus on the cognitive skills involved in exercising willpower over cravings for nicotine.

Source: Science Daily, Brain Imaging Demonstrates That Former Smokers Have Greater Willpower Than Smokers, April 27, 2011

A new strategy, however, is being tested to determine whether it might be the answer for smokers who want the health and lifestyle benefits of quitting. The e-cigarette is a battery-powered cigarette that has a refillable nicotine cartridge and a heater that vaporizes the nicotine. Initial studies have shown that the e-cigarette has a much lower chemical content than traditional cigarettes.

A new study (Siegel, Tanwar & Wood, 2011) examined whether e-cigarettes might be a useful tool to aid in smoking cessation. The researchers sent an online survey to the first 5,000 people who purchased a new e-cigarette. The survey was issued seven months after the purchase.

There were 222 respondents to the survey, but six were eliminated because they did not meet criteria for having been a smoker. The participants completed the survey that asked questions about typical patterns of e-cigarette and cigarette use at six months after purchasing e-cigarettes for he first time. It also asked participants to compare their current smoking behaviors to smoking behaviors before beginning use of the e-cigarette.

The results of the questionnaire showed that of the 216 who were eligible to complete the survey, 143 reported a reduction in daily cigarettes smoked. 106 participants reported reduced nicotine use and 104 reported that they quit smoking for some period of time.

The authors of the study indicate that there are some limitations to the results of the analysis. The results reflect results gained by retrospective self-report, without using blood or urine tests to verify participants’ answers. In addition, the survey included users of only one e-cigarette brand, and the response rate to the survey was only 4.5 percent which may not provide an accurate representation of e-cigarette users.

The results of the study suggest that there may be a connection between reduced smoking levels and the use of e-cigarettes. However, the results are not significant when the researchers compared smokers who used e-cigarettes and smokers who did not use e-cigarettes.

Further research is required to see if the results are able to be generalized to a larger population of smokers. If the e-cigarette is successful, even for a small number of smokers, it may become a useful tool for helping people improve their health by reducing the number of chemicals entering their bodies. If e-cigarettes do not aid in complete cessation but are helpful in reducing the number of traditional cigarettes smoked, it could be a good way to help smokers improve their health.  

The researchers, from the Academy of Finland’s Research Programme on Substance Abuse and Addictions, used mice to perform the study. They added nicotine to the water of pregnant mice to test the effects of prenatal exposure to nicotine. Treating the mice with nicotine during pregnancy increased the frequency of self-administration of nicotine in the offspring compared to mice that weren’t exposed to nicotine, even at lower doses.

The study also looked at the receptor-level combined effects of opioids and nicotine, and found that opioids, which normally attach to their own receptors, also bind to nicotinic receptors, causing altered responses to nicotine. This could explain the common use of both nicotine and other substances, such as cocaine or heroin.

The results could help create new methods of addiction treatment for both smoking and substance abuse.

The study was conducted as a Finnish-Russian project between the Division of Pharmacology and Toxicology at the University of Helsinki, the Saint Petersburg Pavlov Medical University, and Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry in Moscow.

Source: Science Daily, Children of Mothers Who Smoked During Pregnancy at Increased Risk of Becoming Smokers, Mouse Study Suggests, March 22, 2011

Both of the studies were conducted with the use of functional magnetic resonance imaging (fMRI), in order to understand how the brain reacts to smoking cues when one of the medications is administered. One study examined how the brain responds to the medication bupropion, while the other assessed the effects of varenicline.

Because nicotine-dependent smokers show activation in certain areas of the brain related to attention, emotion, reward and motivation, when exposed to certain smoking-related cues, the research provides insight into how the medications help smokers quit.

The first study was led by Christopher S. Culbertson, Ph.D., of the University of California, Los Angeles, and colleagues. It examined the changes in brain activation when exposed to smoking cues in 30 smokers randomly assigned to either the medication bupropion or a placebo, which were each taken for eight weeks. Bupropion is commonly prescribed for those wishing to cease smoking.

The patients were shown 45-second videos with either smoking cues or neutral cues both at the beginning of the study and after eight weeks of medication. After viewing the video, each participant was given a five-button response box to report how strongly they craved cigarettes. Those taking bupropion reported less craving than those taking the placebo and also showed reduced activation in the areas of the brain known to be associated with cravings.

The other study was led by Teresa Franklin, Ph.D., of the University of Pennsylvania, Philadelphia, and colleagues, who examined the effects of varenicline, known for reducing withdrawal symptoms. The research team wanted to known whether the medication would also reduce craving responses in the brain when smokers were exposed to smoking cues.

The researchers administered either varenicline or a placebo to 22 smokers enrolled in the three-week program. The smokers’ brains were evaluated using fMRI before and after the medication, while “at rest” and while viewing a video clip that contained either smoking cues or neutral cues. Smokers reported their craving levels.

The results showed that while those who received the placebo continued to report cravings and exhibited activation in the areas of the brain related to drug-motivation, the participants who received varenicline experienced a reduction of brain activity associated with cravings and reported a reduction in cravings.

The authors of the studies believe that the medications may be especially helpful in treating smokers with psychiatric illness, who tend to have a very difficult time with smoking cessation. The use of the medications may also be especially helpful for certain individuals at a higher risk of relapse when exposed to smoking cues.
 

Treatment for nicotine addiction often involves behavioral and pharmacological treatments, and relapse rates are the highest during the first weeks of quitting. Dr. Hays said that many patients become discouraged when they relapse, and that repeated outpatient treatment is often the only available option for many people. However, this study shows that more intensive, residential treatment results in a high success rate compared with the more standard outpatient treatment.

The researchers compared date from 4,553 smokers who underwent a tobacco dependence consultation at the Mayo Clinic Nicotine Dependence Center (NDC) between 2004 and 2007. Of the group, 4,327 received comprehensive outpatient treatment and 226 received treatment in an intensive residential setting for eight days.

The residential patients were more dependent on tobacco than those receiving outpatient treatment; they smoked more heavily and were more likely to have associated medical and psychiatric illnesses. Dr. Hays said that residential treatment offers a protected environment, away from usual daily smoking triggers, and that treatment specialists are able to have several hours of contact with patients. Outpatients receive individual counseling sessions and follow-up counseling as well as medication, but the treatment is often spread out over several weeks and doesn’t allow the concentrated contact that residential treatment provides.

This study underscores the importance of offering residential treatment to heavy smokers who have struggled with more traditional outpatient treatment settings.

Source: Science Daily, Smoking Abstinence Found More Effective With Residential Treatment, March 7, 2011