Substance Abuse News

A nationwide smoking ban would save more than $90 million and significantly reduce hospitalizations for heart attack, according to a Henry Ford Hospital study.

After analyzing data from the 13 states that don’t have a law banning smoking in public places, researchers concluded that more than 18,596 fewer hospitalizations for heart attack could be realized from a smoking ban in all 50 states after the first year of implementation, resulting in more than $92 million in savings in hospitals costs for caring for those patients.

The study, funded by the hospital, will be presented Thursday at the American Heart Association’s annual Quality of Care and Outcomes Research conference in Washington.

Smokers Harming Themselves

“Even if you just save one heart attack, it is something significant,” says Mouaz Al-Mallah, M.D., Henry Ford’s co-director of Cardiac Imaging Reearch and lead author of the study. “When people smoke, they are not only harming themselves, they’re harming those around them who are exposed to secondhand smoke.”

A similar study conducted in 2008 by Dr. Al-Mallah found that a smoking ban in Michigan could lead to a 12 percent drop in heart attack admissions after the first year of implementation. On May 1, Michigan became the 38th state to ban smoking in public places.

Prior research involving risk reduction from smoking bans has shown that heart attack rates can be reduced by 11 percent after a comprehensive smoking ban.

Henry Ford obtained 2007 data on the number of heart attack discharges, length of stay and hospital charges from the 13 states currently without a public smoking ban. Researchers found 169,043 hospitalizations for heart attack were reported in the states with a comprehensive smoking ban. When the same 11 percent risk reduction was applied to the non-smoking states, researchers concluded it would led to 18,596 fewer heart attack admissions.

As fewer people puff on cigarettes, a new smoking trend may be gaining popularity among North American youth. A study published in the journal Pediatrics has found that almost one-quarter of young adults in Montreal had used waterpipes (also known as shishas or hookahs) in the past year.

“The popularity of waterpipes may be due in part to perceptions that they are safer than cigarettes. However, waterpipe smoke contains nicotine, carbon monoxide, carcinogens and may contain greater amounts of tar and heavy metals than cigarette smoke,” warns senior investigator Jennifer O’Loughlin, a professor at the University of Montreal Department Of Social and Preventive Medicine and a scientist at the University of Montreal Hospital Research Center.

Hookahs Popular Among Males

As part of a longitudinal cohort investigation (NDIT Study), 871 youth aged 18 to 24 completed questionnaires on their smoking habits. The research team, which included scientists from the University of Montreal, the National Institute of Public Health of Quebec and McGill University, found that 23 percent of respondents had used a waterpipe within the last 12 months and that 5 percent had used waterpipes one or more times in the past month.

The study found waterpipes to be particularly popular among young, English-speaking males who lived on their own and had a higher household income. In addition, the research team found that waterpipe users were more likely to use other psychoactive substances such as cigarettes, marijuana, illicit drugs and alcohol.

It is well-known that maternal smoking during pregnancy can have long-term effects on the physical health of the child, including increased risk for respiratory disease, ear infections and asthma. New research shows that prenatal smoking also can lead to psychiatric problems and increase the need for psychotropic medications in childhood and young adulthood.

Smoking and Psychiatric Problems

Finnish researchers found that adolescents who had been exposed to prenatal smoking were at increased risk for use of all psychiatric drugs especially those uses to treat depression, attention-deficit/hyperactivity disorder (ADHD) and addiction compared to non-exposed youths. The study will be presented Tuesday, May 4 at the Pediatric Academic Societies (PAS) annual meeting in Vancouver, British Columbia, Canada.

“Recent studies show that maternal smoking during pregnancy may interfere with brain development of the growing fetus,” said Mikael Ekblad, lead author of the study and a pediatric researcher at Turku University Hospital in Finland. “By avoiding smoking during pregnancy, all the later psychiatric problems caused by smoking exposure could be prevented.”

Smoking and Birthweight

Ekblad and his colleagues collected information from the Finnish Medical Birth Register on maternal smoking, gestational age, birthweight and 5-minute Apgar scores for all children born in Finland from 1987 through 1989. They also analyzed records on mothers’ psychiatric inpatient care from 1969-1989 and children’s use of psychiatric drugs.

Results showed that 12.3 percent of the young adults had used psychiatric drugs, and of these, 19.2 percent had been exposed to prenatal smoking.

The rate of psychotropic medication use was highest in young adults whose mothers smoked more than 10 cigarettes a day while pregnant (16.9 percent), followed by youths whose mothers smoked fewer than 10 cigarettes a day (14.7 percent) and unexposed youths (11.7 percent).

Smoking Affects Unborn Child

The risk for medication use was similar in males and females, and remained after adjusting for risk factors at birth, such as Apgar scores and birthweight, and the mother’s previous inpatient care for mental disorders.

Smoking exposure increased the risk for use of all psychotropic drugs, especially stimulants used to treat ADHD (unexposed: 0.2 percent; less than 10 cigarettes/day: 0.4 percent; and more than 10 cigarettes/day: 0.6 percent) and drugs for addiction. An increased risk for use of drugs to treat depression also was seen (unexposed: 6 percent; less than 10 cigarettes/day: 8.6 percent; and more than 10 cigarettes/day: 10.3 percent).

“Smoking during pregnancy is still quite common even though the knowledge of its harmful effects has risen in recent years,” Ekblad concluded. “Recent studies have shown that smoking during pregnancy has negative long-term effects on the health of the child. Therefore, women should avoid smoking during their pregnancy.”

Kids who have just started smoking, but not on a daily basis, don’t seem to recognize the early symptoms of dependence, according to a new study.

Published in the latest issue of Pediatrics by Chyke Doubeni, MD, MPH of the University of Massachusetts, the study found that among kids who have started smoking, “an urge to smoke or being irritable because they are not able to smoke is a sign of early dependence. But they don’t seem to recognize that symptoms such as irritability are harbingers of addiction.”

“Previous studies have already shown that there is a strong correlation between symptoms of nicotine dependence and nicotine addiction. This study shows that adolescents who start smoking, don’t appear to recognize the early signs of dependence,” Doubeni said. Other signs of early dependence that go unnoticed include experiencing a desire to smoke or craving for a cigarette.

Early Signs of Nicotine Dependence

The study concluded that nondaily use of tobacco can trigger any of these early signs of dependence. Early dependence promotes increased smoking. That in turn accelerates additional signs of dependence, which leads to even higher frequencies of smoking. Eventually, it leads to addiction.

The conclusions are based on a study that surveyed adolescent smokers every three to four months, over a four-year period from 2002-2006. The study found that over those four years, of the 370 subjects who had inhaled from a cigarette, 62% smoked at least once per month, 52% experienced dependence symptoms, and 40% went on to become daily smokers.

The study, “Early Course of Nicotine Dependence in Adolescent Smokers,” provides additional evidence supporting the Food and Drug Administration’s (FDA) recent rules placing restrictions on tobacco marketing to youth. Tobacco companies are challenging some of the FDA’s rules in court.

Using CT scans to measure blood flow in the lungs of people who smoke may offer a way to identify which smokers are most at risk of emphysema before the disease damages and eventually destroys areas of the lungs, according to a University of Iowa study.

The study found that smokers who have very subtle signs of emphysema, but still have normal lung function, have very different blood flow patterns in their lungs compared to non-smokers and smokers without signs of emphysema.

Smokers and Emphysema

This difference could be used to identify smokers at increased risk of emphysema and allow for early intervention. The findings appear this week in the Early Edition of the Proceedings of the National Academy of Sciences.

“We have developed a new tool to detect early emphysema-related changes that occur in smokers who are susceptible to the disease,” said lead study author Eric Hoffman, Ph.D., UI professor of radiology, internal medicine and biomedical engineering. “Our discovery may also help researchers understand the underlying causes of this disease and help distinguish this type of emphysema from other forms of chronic obstructive pulmonary disease. This type of CT scan could even be a tool to test the effectiveness of new therapies by looking at the changes in lung blood flow.”

Targeting COPD

As many as 24 million Americans have chronic obstructive pulmonary disease (COPD) — a group of serious lung diseases that includes emphysema — and COPD is the fourth leading cause of death nationwide. Because COPD is a group of different diseases, identifying more effective treatments may hinge on distinguishing between these diseases and targeting them separately.

The team used multi-detector row CT imaging to measure blood flow patterns in the lungs of 41 study participants — 17 non-smokers and 24 smokers. All the participants had normal lung function, but 12 of the smokers had very subtle signs of emphysema. The CT scans showed that these 12 individuals had the most disrupted patterns of blood flow compared to the other participants.

The findings also support the idea that abnormal blood flow occurs before emphysema develops.

“Although the underlying causes of emphysema are not well understood, smoking increases the risk of developing the disease,” Hoffman said. “Our study suggests that some smokers have an abnormal response to inflammation in their lungs; instead of sending more blood to the inflamed areas to help repair the damage, blood flow is turned off and the inflamed areas deteriorate.”

Repairing the Damage

The cellular pathway that turns off blood flow is helpful when an area of the lung has become permanently blocked and cannot be rescued. In that case, the lung “optimizes gas exchange” and stops supplying the area with blood. However, lung inflammation caused by smoking can be resolved and resultant damage repaired by increased blood flow, which brings oxygen and helpful cellular components to the site of injury.

This study suggests that the ability to distinguish when to turn off or when to ramp up blood flow is defective in some people — probably due to genetic differences. If this genetic difference is coupled with smoking, which increases lung inflammation, that could increase the risk of developing emphysema.

Older people who have never smoked benefit most from smoking bans, a study suggests.

A study in New Zealand showed that, three years after a smoking ban on all workplaces was introduced, hospital admissions for heart attacks among men and women aged 55-74 fell by 9 per cent. This figure rose to 13 per cent for 55-74 year olds who had never smoked.

Overall, the research showed heart attacks among people aged 30 and over fell by an average of 5 per cent in the three years following the ban.

The study, involving scientists from the University of Edinburgh, examined trends in acute heart attacks following a change in legislation. The ruling, which updates a previous law in which smoking was outlawed in some public places, makes smoking illegal in all workplaces including bars and restaurants.

Fewer Heart Attacks

Researchers also found that heart attacks were reduced for ex-smokers of all ages, and that there was a greater decrease in hospital admissions for men compared with women.

In addition, the study found that people in more affluent neighbourhoods benefited more from the ban than those in poorer areas. This may be because they visit cafes and restaurants more often or because they are more likely to use the smoking ban as an incentive to quit.

Dr Jamie Pearce, of the University of Edinburgh’s School of GeoSciences, who took part in the study, said: “This short-term research indicates a link between a smoking ban in bars and restaurants and a reduction in severe heart attacks. However, more work is needed to look at the effects of the ban in greater detail.”

The study, carried out with the Universities of Otago and Canterbury in New Zealand and the University of Southampton, was published in the Australian and New Zealand Journal of Public Health.

Nicotine takes much longer than previously thought to reach peak levels in the brains of cigarette smokers, according to new research conducted at Duke University Medical Center.

Traditionally, scientists thought nicotine inhaled in a puff of cigarette smoke took a mere seven seconds to be taken up by the brain, and that each puff produced a spike of nicotine. Using PET imaging, Duke investigators illustrate, for the first time, that cigarette smokers actually experience a steady rise of brain nicotine levels during the course of smoking a whole cigarette.

The findings, scheduled to appear online in the Early Edition of Proceedings of the National Academy of Sciences (PNAS), could lead to more effective treatments for smoking addiction.

Nicotine Accumulates in the Brain

“Previously it was thought that the puff-by-puff spikes of nicotine reaching the brain explained why cigarettes are so much more addictive than other forms of nicotine delivery, like the patch or gum,” says Jed Rose, Ph.D., director of the Duke Center for Nicotine and Smoking Cessation Research. “Our work now calls into question whether addiction has to do with the puff-by-puff delivery of nicotine. It may actually depend in part on the overall rate at which nicotine reaches and accumulates in the brain, as well as the unique habit and sensory cues associated with smoking.”

Yet, when the researchers compared 13 dependent smokers to 10 non-dependent smokers, they were surprised to find the dependent smokers had a slower rate of nicotine accumulation in the brain. “This slower rate resulted from nicotine staying longer in the lungs of dependent smokers, which may be a result of the chronic effects of smoke on the lungs,” surmises Rose.

The difference in rate of nicotine accumulation in the brain doesn’t explain why some people become addicted to cigarettes and others don’t. “Even if you correct for the speed of delivery, our study showed the non-dependent smokers eventually experienced the same high levels of nicotine in their brain as dependent smokers, yet they did so without becoming dependent. The real mystery is why.”

Sensitivity to Nicotine

Rose says the absence of addiction in these smokers could be due to genetic differences, differences in the way they smoke, or differences in the psychological effects they derive. “We’re still not able to fully explain why these people are able to smoke without becoming addicted.”

Despite the questions raised, the study provides important insights into the role of the speed and level of brain nicotine levels, and which receptors in the brain are at work. “Different receptors respond to nicotine at different levels of sensitivity,” says Rose. “Knowing the levels of nicotine that are really getting to the brain gives us clues as to which receptors are more likely to be important for the dependence-producing effects of cigarette smoking.”

New research by the Oklahoma Tobacco Research Center (OTRC) shows that concentrations of secondhand tobacco smoke inhaled in smoking rooms of restaurants and bars are exceptionally high and hazardous to health.

Hazardous Extremes

According to the study, which appears in the center’s new report “Tobacco Smoke Pollution in Oklahoma Workplaces,” the average particulate level measured in restaurant smoking rooms was beyond the hazardous extreme based on levels established by the U.S. Environmental Protection Agency. The level found in bars was even worse.

“These levels are exceptionally high and not healthy for the employees and patrons exposed to particles found in secondhand smoke,” said Heather Basara, M.D., an industrial hygienist and lead investigator on the research.

Tobacco smoke levels were evaluated based on measurements of very fine suspended particulates in the air, particles smaller than 2.5 microns, which come primarily from tobacco smoke.

Levels averaged 380 µg/m3 (micrograms per cubic meter of air) in the restaurant smoking rooms tested, and 655 µg/m3 in the bars. Restaurants with no smoking averaged just 26 µg/m3.

Very Unhealthy Levels

The EPA scale ranks outdoor levels of particulate pollution as “unhealthy” at 66-150, “very unhealthy”’ at 151-250, and “hazardous” at higher concentrations such as the levels found in the Oklahoma restaurant smoking rooms and bars tested for this report.

Robert McCaffree, M.D., Co-Director of OTRC, said, “Secondhand smoke exposure is a serious health hazard, accounting for approximately 700 deaths a year in Oklahoma, mostly from heart disease – including heart attacks – and lung cancer. Even brief exposure is harmful. Because this exposure is readily preventable, business owners and public policy makers would be well-advised to act as soon as possible to assure smokefree environments for all public places and all indoor workplaces.”

Health authorities should emphasize the positive message that the most successful method used by most ex-smokers is unassisted cessation, despite the promotion of cessation drugs by pharmaceutical companies and many tobacco control advocates.

The dominant messages about smoking cessation contained in most tobacco control campaigns, which emphasize that serious attempts at quitting smoking must be pharmacologically or professionally mediated, are critiqued in an essay in this week’s PLoS Medicine by Simon Chapman and Ross MacKenzie from the School of Public Health at the University of Sydney, Australia.

This overemphasis on quit methods like nicotine replacement therapy (NRT) has led to the “medicalization of smoking cessation,” despite good evidence that the most successful method used by most ex-smokers is quitting “cold turkey” or reducing-then-quitting. Reviewing 511 studies published in 2007 and 2 008 the authors report that studies repeatedly show that two-thirds to three-quarters of ex-smokers stop unaided and most ex-smokers report that cessation was less difficult than expected.

Pharmaceutical Influence

The medicalization of smoking cessation is fuelled by the extent and influence of pharmaceutical support for cessation intervention studies, say the authors. They cite a recent review of randomized controlled trials of nicotine replacement therapy (NRT) that found that 51% of industry-funded trials reported significant cessation effects, while only 22% of non-industry trials did. Many assisted cessation studies—but few if any unassisted cessation studies—involve researchers who declare support from a pharmaceutical company manufacturing cessation products.

The authors conclude that “public sector communicators should be encouraged to redress the overwhelming dominance of assisted cessation in public awareness, so that some balance can restored in smokers’ minds regarding the contribution that assisted and unassisted smoking cessation approaches can make to helping them quit smoking.”

With the national trend toward quitting smoking flat, psychologists are finding some success with treatments aimed at helping smokers from underserved groups, including racial and ethnic minorities and those with psychiatric disorders.

Quit Smoking Help

In the Journal of Consulting and Clinical Psychology, published by the American Psychological Association, researchers report on several effective treatments that may help these smokers in an effort to increase national smoking cessation rates. The percentage of American smokers rose from 19.8 percent in 2007 to 20.6 percent in 2008, after a 10-year steady decline in smoking rates, according to the latest figures from the Centers for Disease Control and Prevention.

“One of the reasons smoking rates have remained stagnant is because these underserved groups of smokers have not been adequately targeted by research and treatment,” said the special section editor, Belinda Borrelli, PhD, who is with the Centers for Behavioral and Preventive Medicine at Brown University Medical School. Underserved smokers include those who have a 10 percent higher smoking rate than the general population, have less access to treatments, and are more likely to be excluded from long-term treatments trials, according to Borelli.

In one article, researchers found that success in stopping smoking differed for different psychiatric disorders. For example, compared to smokers with no psychiatric disorders, smokers who had an anxiety disorder were less likely to quit smoking six months after treatment.

In the same article, researchers found that people’s barriers to quitting were directly related to what type of psychiatric disorder they had. For example, smokers who had ever been diagnosed with an anxiety disorder reported a strong emotional bond with their cigarettes while smokers ever diagnosed with a substance use disorder reported that social and environmental influences were especially likely to affect their smoking. “This information may help clinicians gauge relapse risk and identify treatment targets among smokers who have ever had psychological illnesses,” said lead author Megan Piper, PhD, from the University of Wisconsin School of Medicine and Public Health.

Comparing Treatment

Evidence-based smoking cessation treatments are addressed in another article in this special section. Researchers from the University of Miami looked at the effect of intensive cognitive-behavioral therapy on African-American smokers. They placed 154 African-American smokers wearing nicotine patches into one of two six-session interventions. Participants in the group using cognitive-behavioral techniques were taught relapse prevention strategies and coping skills, along with other techniques. The other group participated in a health education series that explained general medical conditions that are associated with smoking, such as heart disease and lung cancer.

Compared with general health education, participation in cognitive-behavioral therapy sessions more than doubled the rate of quitting at a six month follow-up, from 14 percent to 31 percent the researchers found. “We know cognitive-behavioral therapy helps people quit, but few studies have examined this treatment’s effect on African-American smokers,” said the study’s lead author, Monica Webb, PhD, of the University of Miami. “Hopefully, our findings will encourage smoking cessation counselors and researchers to utilize cognitive-behavioral interventions in this underserved population.”

Secondhand Smoke Study

Borrelli, the section editor, examined another minority group—Latinos. She measured the amount of second-hand smoke in participants’ homes and gave feedback to smokers about how much smoke their child with asthma was exposed to. For example, they were told that their child was exposed to as much smoke as if the child smoked ‘x’ number of cigarettes him- or herself during the week of the measurement – this was the experimental group. Smokers in the control group underwent standard cognitive-behavioral treatment for smoking cessation. Smokers in the experimental group were twice as likely to quit as the control group, Borrelli found. “The child’s asthma problems may provide a teachable moment for parents whereby they become more open to the smoking cessation messages,” Borrelli said. “Providing treatment that is focused on the health needs of the family, and delivered in a culturally tailored manner, has the potential to address health care disparities for Latino families.”