Some good news from California: Smoking is waaaay down!

Posted on January 2, 2011 by

It's hard for Californians to imagine that people still smoke indoors in some states

These days, Californians don’t hear a lot of  good news about our state, not with budget cuts decimating our once vaunted education system, our parks and other public services. But one thing we’ve done right is quit smoking. My state is a world leader in reducing tobacco use, and other states and countries should follow our lead.

The most recent reporting shows that adult smoking is down to 13.1 percent in California, a drop from 22.7 percent in 1988 and much lower than the national average.

A Gallup poll that asked adults “Do you smoke?” found that about 21 percent answered affirmatively across the nation. That poll found that adult smoking tends to be lower in states where cigarette taxes and education levels are higher. The smokiest states are Kentucky and West Virginia, where 31 percent of adults smoke.

California’s success is due to its comprehensive tobacco control program that began in 1988 when voters approved Proposition 99, which increased cigarette taxes by 25 cents a pack, most of which is spent on tobacco control. Since Prop. 99, California’s declining smoking rate saved 1 million lives. The California Tobacco Control Program (CTCP) credits

“…grassroots programs designed and implemented by local health departments, community coalitions and organizations, statewide projects, ethnic networks, schools, and a statewide mass media campaign…”

But the most important factor was when California became the first state to go

Most Californians wouldn't dream of letting somebody light up in their home

smoke-free, beginning in 1995. A whole generation of Californians has grown up having never smelled indoor cigarette smoke. It began with the California Smokefree Workplace Act, which stated:

“No employer shall knowingly or intentionally permit, and no person shall engage in, the smoking of tobacco products in an enclosed space at a place of employment.”

Next to higher taxes, smoke-free public places and workplaces are the biggest motivation for quitting smoking. Many, many studies have shown that enacting and enforcing smoke-free places compels people to either quit or cut down their smoking, which is why the tobacco industry hates smoke-free laws. One of the main reason’s that California’s smoking rate is so low is that we went smoke free a long time ago, and it continues to pay off.

Here's what it's all about: California's lung cancer rate is much lower than the nation's

But as great a job as California is doing, the state must do more, and other states must do a whole lot more. Even with all of California’s anti-smoking measures, 43,000 people in the state die each year from tobacco-related illness. Tobacco use costs the state $16 billion a year. Nationwide, tobacco use kills 443,000 people each year, and about 49,000 of these deaths are caused by secondhand smoke.

California banned smoking near playgrounds, and many cities have also banned it near public entryways and other places. Two years ago, California banned smoking in cars when children are present. The latest front in the war against tobacco is smoke-free apartments. Research shows that second-hand smoke travels from apartment to apartment and affects non-smoking residents, and especially kids, who can’t choose where they can live. Smoke-free multi-unit housing, which is perfectly legal, will convince even more people to quit and help reduce smoking among low-income populations, where tobacco use is highest.

When it comes to tobacco control, the rest of the country needs to emulate California. When it comes to balancing the state budget… not so much.

Click image for more than you ever need to know about California and smoking

Posted in Big Tobacco, Recovery, Second-hand smoke, Smoke-free, Tobacco, Tobacco and kids, Tobacco marketing | Tagged , , , , , , , , | 2 Comments

A doctor’s opinion: Medical marijuana should never be smoked

Posted on December 27, 2010 by

[Dear readers, This post is by my brother, Ed Gogek, MD, an Arizona physician who was very active in opposing Arizona's new medical marijuana law. The following excerpt was written as comment on new regulations for the AZ law. His position is that regs should ban medical marijuana in the smokeable form. Here's a link to his blog, where the entirety of the post can be found. jg]

Ed Gogek, MD, opposed Arizona's medical marijuana law, which squeaked by with about 4,000 votes

As a doctor, I oppose dispensing medical marijuana in a form that can be smoked. The medical profession and others in public health have made a huge effort for several decades to eliminate the smoking of tobacco because it’s such a serious health hazard, and doctors should not recommend any substance to be smoked.

Research evidence shows that smoking marijuana probably causes respiratory problems and several types of cancer, including lung cancer. The evidence is not overwhelming, mostly because there have not been enough good studies, but it’s significant.

On several pro-marijuana websites I found the claim that “there is no direct evidence linking marijuana smoking to lung cancer in humans.” That is exactly what the tobacco industry said for decades after the first studies came out linking cigarette smoking with lung cancer. What they said was technically true; until recently we did not know for certain the exact mechanism by which smoking caused cancer. However, the statistical evidence was overwhelming, so the tobacco industry was being completely disingenuous and so are the pro-marijuana groups who say marijuana doesn’t cause cancer. Anyone who claims that marijuana does not cause cancer is ignoring the research.

Two studies showed no increase in cancer in marijuana users, but negative studies are not proof unless it happens repeatedly. Also, both studies have been criticized for bias, and I believe these criticisms are accurate. One large study (Tashkin 2006) of 1200 people with head, neck and lung cancer showed no increase in cancer in marijuana smokers. Tashkin was the same researcher who had previously found that marijuana caused pre-cancerous changes in the respiratory tract, so he was surprised to find no increased cancer risk.  That large study has been criticized for selection bias—marijuana users in the control group were more likely to also smoke cigarette than the marijuana users in the group with cancer, so they did not do a good job of controlling for cigarette smoking. This really throws doubt on the results.

One other study published in the American Journal of Public Health in 1997 (Sidney et al) that found marijuana smokers had no increase in cancer has been criticized for using subjects who were too young, so cancers would not have had time to develop.

There is also research showing increased cancer rates in marijuana smokers.

A New Zealand study published in the European Respiratory Journal in 2008 looked at 79 patients with lung cancer and found the risk of lung cancer increased by 8 percent for every joint-year (averaging one joint daily for one year) and 7 percent for every pack-year (averaging one pack of cigarettes daily for one year), leading them to conclude that smoking marijuana posed the same lung cancer risk as smoking cigarettes.

Three North African case studies showed a very strong link between marijuana smoking and lung cancer, but none of these studies controlled for tobacco use, so these results are questionable.

A 2009 study done at the Fred Hutchinson Cancer Research Center in Seattle and published in the journal Cancer found that men who smoked marijuana once a week had twice the risk of testicular cancer when compared to men who never used marijuana, and marijuana was most strongly linked to nonseminoma, the most aggressive form of testicular cancer.

Research published in the journal Urology in 2006 showed increased rates of bladder cancer in marijuana smokers. They also found that marijuana-smoking patients were younger at the time of diagnosis than most patients with bladder cancer. Cigarette smoking is a major risk factor for bladder cancer, but the researchers concluded that smoking marijuana may be as bad or worse than cigarette smoking as
a risk factor for bladder cancer.

In 1999, a study published in the journal Cancer Epidemiology found that squamous cell carcinoma of the head and neck increased with marijuana use and there was a strong dose-response curve, the heavier marijuana users had higher rates of cancer. However, in 2004, a study published in Cancer Research found no association between marijuana user and squamous cell carcinoma.

This is not a complete list of studies, but there aren’t many. So it is not enough to draw definitive conclusions on marijuana and cancer. However, the evidence that marijuana smoking is linked to cancer is far more substantial than the research supporting marijuana as treatment for most of the disorders listed in Arizona’s new medical marijuana law.  Also, remember, it took decades of heavy tobacco use by large swaths of the population before we had a definitive link between smoking and cancer.

Also, in November 2010 an article printed in the European Journal of Immunology described a possible mechanism by which smoking marijuana causes cancer and the research supporting this possible mechanism. If further studies support these findings, then we will have direct evidence linking marijuana smoking to cancer in humans.

Anyone who goes on the internet will find the pro-marijuana groups misrepresenting research. What they almost always do is take one study or one bit of information and run with it as if that were the whole story. That’s how Arizona ended up with a law that says marijuana is good for glaucoma even though the Glaucoma Foundation warns patients not to use marijuana because it could make their symptoms worse.

There are even pro-marijuana websites claiming that marijuana cures cancer. This comes from research showing that certain cannabinoids might have an anti-tumor effect, but the same research also showed that marijuana smoke contained many of the same carcinogens found in tobacco or that marijuana suppresses the immune system making cancer more likely, and the pro-marijuana groups never mention that.

The American Cancer Society points out on its website that it’s hard to study marijuana and cancer because so many marijuana users also smoke cigarettes and because it’s hard to study illegal drugs. British cancer researchers noticed the same problem. Both noted a weak link between marijuana and cancer based on very limited research. Not definitive, but not negligible.

One part of the research is very clear. We know for certain that marijuana smoke contains many of the same carcinogens as tobacco smoke, produces more tar than tobacco, and that the way people smoke marijuana (down to the roach, unfiltered, inhaling deeply, holding it in) delivers more tar to the lungs than the way people smoke tobacco.

Calfornia’s Office of Environmental Health Hazard Assessment ruled in 2009 that marijuana smoke is carcinogenic. They are not calling the marijuana plant a carcinogen, just the smoke. That seems right; the research shows a link between smoking marijuana and several types of cancer also commonly caused by smoking tobacco. There is no evidence that ingesting marijuana by other methods causes cancer.

Smoking marijuana is also linked to respiratory problems. Research shows that marijuana smokers have decreased respiratory function, increased airflow obstruction, and fewer of the anti-oxidants that protect against cancer and heart disease.

In summary, smoking marijuana has been implicated in several health problems including cancer. So no doctor should be recommending marijuana in a form that can be smoked. And states with medical marijuana laws, including Arizona, should not allow such a dangerous route of administration. Following the basic dictum, First, do no harm, doctors should always prescribe medications by the least harmful route of administration.

We always try to put medications in a form that can be taken orally. For people whose illness makes it hard to take a pill or to keep one down, we have skin patches and suppositories. The last resort is injecting medicine. But there is no precedent for a medication that is smoked, and for good reason. Smoking causes cancer and lung damage.

Posted in Marijuana, Marijuana legalization, Medical marijuana, MJ lobby, Recovery, Substance abuse | Tagged , , , , , , , , , , | 3 Comments

Lower the minimum drinking age to reduce college binge drinking? Studies show that’s as crazy as it sounds

Posted on December 27, 2010 by

Do these guys think everybody drinks like this?

With almost no evidence to back up their theory, a group of college presidents, nearly all from private schools, have been pushing to lower the drinking age because they think that would reduce binge drinking on their campuses. It’s called the Amethyst Initiative, and it’s always been shocking to me. Because college presidents should understand the importance of real research evidence when urging a “radical experiment,” as one researcher put it, that has serious public health and safety ramifications for young people. Instead, they offer no evidence at all for their views. Their website contains no research to support lowering the drinking age.

But now, there is evidence about their idea – and it refutes it. A study published in the January 2011 issue of the Journal of Studies on Alcohol and Drugs took the idea of the Amethyst Initiative and applied mathematical modeling to it. The research showed that the only campuses that might benefit from lowering the drinking age would be those with an extremely heavy drinking environment, a lack of enforcement at surrounding bars and – this is important – a radical misunderstanding about normal drinking. In other words, if most students thought that all other students drank a lot more than they really did. Such a misperception would have to be “extremely large,” one researcher said. And, there’s no evidence that it is. There’s no evidence that such a university campus actually exists. So lowering the drinking age would have no effect, the report concluded.

There are plenty of other studies, however, showing that lowering the drinking age is a

This problem could get a lot worse if it became legal for 18 year olds to drink. Courtesy of SAMHSA

really bad idea. Among them:

  • A 2009 study in Alcoholism: Clinical and Experimental Research showed that the minimum 21 legal drinking age saved 732 lives a year in the US since 1982 by reducing fatal accidents
  • A 2005 study in the American Journal of Public Health showed that significantly more alcohol-involved crashes occurred among 15-to 19-year-olds after New Zealand lowered its drinking age
  • A 2010 study in the Journal of Safety Research concluded that initiatives to lower the drinking age to 18 “ignore the demonstrated public health benefits” of the minimum 21 legal drinking age.

Besides, isn’t it cavalier for presidents of exclusive private colleges to urge lowering the drinking age to supposedly help their students, without considering the health and safety of underage youth who aren’t going to college?

Posted in Alcohol, Alcohol abuse, Binge drinking, College drinking, Recovery, Substance abuse, Underage drinking, Underage drinking parties | Tagged , , , , , , , | Leave a comment

Want to end stigma? Stop talking about how addiction is a disease and start treating it like one

Posted on December 17, 2010 by

"...Habitual drunkenness should be regarded not as a bad habit but as a disease," said Dr. Benjamin Rush, an American Founding Father, in 1810

You’d think after all these years of talking about how alcoholism is a disease – the AMA declared it so in 1956 — the stigma of being an alcoholic would go away… or at least recede significantly. But no, it hasn’t. A study just released showed that most alcoholics won’t seek treatment because of stigma. And the problem is worse among men, people of color and people with lower income and less education.

Stigma has long been recognized as one of the biggest impediments for addicts seeking help. The National Institute on Drug Abuse (NIDA) has tried for years to confront stigma by telling anybody who would listen the facts about how addiction is a disease that responds as well to treatment and has about the same relapse rates as diabetes, hypertension and asthma. Basically, addiction has the same properties as other chronic illnesses.

People certainly have heard about this, but it hasn’t really sunken in.

Maybe the problem is that medical science says one thing but does another. Medicine says that addiction is a chronic disease but keeps acting like it’s a social disorder, i.e., somebody else’s problem. Most health systems today have little or no capacity to treat addiction. So what do you expect people will think?

An expensive disease...maybe we out to start treating it like one

The answer will be to truly integrate addiction treatment into primary health care, which a lot of people are talking about these days, though it hasn’t begun in any systematic way. Screening for addiction and substance use disorders needs to become an everyday occurrence at the offices of physicians, nurse practitioners, and other health care providers, and in emergency rooms, trauma centers and community clinics. Referrals for addiction need to become as routine as referrals for X-rays. And treatment for addiction needs to be like treatment for diabetes or any other chronic illness – you keep treating the condition until it’s under control.

Anti-stigma campaigns for addiction haven't worked very well. People will be convinced by action, not images

NIDA Director Dr. Nora Volkow once said that stigma “arises when we do not understand the true nature of a health condition.” But I don’t think we can convince people that addiction is a treatable disease by simply telling them over and over. What we need to do is to show them. Once addiction treatment begins in every primary care doctor’s office, once every health plan covers substance use disorders at parity with other conditions, and once treatment for addiction is delivered the same way as treatment for diabetes, only then will stigma disappear.

Posted in Uncategorized | 1 Comment

Cigarette pack warnings: US lags and Americans suffer

Posted on November 17, 2010 by

Brazil's got us beat -- now that's what I call a good cigarette pack warning

There’s been a lot of talk about the FDA’s proposed pictorial warnings on cigarette packs, including some whining by people who say they go too far. Actually, our proposed pictorial warnings are tame compared to the warnings in other countries. Many other nations, including places like Mauritius, Latvia, Djibouti and about a dozen of other countries, are way ahead of us when it comes to explicit pictorial warnings on cigarette packs.

So I ask you: Is public health for Americans less important than it is for the folks in Mauritius? Reading letters to the editor and the blogosphere, you’d think so. People lambasted “nannyism” or claimed that the pictorial warnings are dumb because they won’t work.

But they do work, and there’s a lot of research to show it, including a study

Mauritius and many other countries already have pictorial pack warnings (quick, where is Mauritius?)

from the American Journal of Preventive Medicine that compared Canada’s graphic pictorial warnings with the United States’ feeble text warnings.  The study found that Canadian smokers were more likely than U.S. smokers to think about health risks and consider quitting.

“Health warnings on U.S. packages, which were last updated in 1984, were

associated with the least effectiveness,” the study reported.

It’s not just pictorial warnings where the United States trails other nations in tobacco prevention. For example, our country has no national smokefree policies. Other countries show far more concern about the public health of their citizens than we do. And that’s strange, since we consider our country so scientifically and medically advanced. Yet we allow cigarettes to kill 440,000 Americans each year without putting up much of a fight.

This Brazilian pack label would get the attention of young men lighting one up. But the US is too uptight for such a pack warning

Heck, Namibia just passed one of the most comprehensive smoking bans in the world. Kazakhstan has tougher anti-smoking laws than a dozen U.S. states. Uruguay, Ireland, Guatemala, UK, New Zealand, Colombia and Turkey have comprehensive smokefree laws covering all types of places and institutions, according to the Tobacco Atlas. That’s equivalent to or better than some of the toughest smokefree laws in select American cities and states.

People making fun of  or grousing about the new pictorial warnings on U.S. cigarette packs either don’t know or don’t care that such warnings are becoming the international standard, and that the United States is lagging behind many other countries, including some poor countries, when it comes to tobacco prevention. With tobacco slaughtering hundreds of thousands of people each year in this country, wouldn’t it behoove us to catch up to the rest of the world?

Zzzzzz... huh, wha? Face it, US cigarette warnings are boring and nobody's paid any attention to them in decades

Posted in Addiction, Big Tobacco, Cigarette warning labels, Prevention, Recovery, Second-hand smoke, Smoke-free, Tobacco, Tobacco marketing | Tagged , , , , , , | 2 Comments

Local governments ignore laws against hookah lounges in California (not to mention their public health threat)

Posted on November 9, 2010 by

Who's minding the store at hookah bars in California? Smoking and drinking at indoor establishments is illegal

Hookah bars are proliferating in California, and around the country. Though they claim to be about a multicultural experience, they are really about attracting young people to smoke tobacco. People believe that because you smoke fruit-flavored tobacco through a waterpipe, it isn’t dangerous. Wrong! And those hookah bars in California, they are illegal, unless they only allow smoking outdoors.

Local governments aren’t following the law. For example, the San Diego County Planning Commission, at the recommendation of the county Department of Planning and Land Use, voted 6-0 in October to grant an appeal to allow the Blu Flayme hookah lounge in Spring Valley to get a license to serve beer. Planning Commissioners said that allowing the hookah lounge to sell beer was good for businesses. But it’s illegal. All of the hookah lounges in San Diego County and everywhere else in California that allow indoor smoking and serve refreshments are illegal. They violate the California Smoke-free Workplace Act and the state Business and Professions Code.

At the county planning commission hearing, the owner of the Blu Flayme contended that

Smoke-filled room at the Blu Flayme. Can somebody check state law... and maybe some IDs?

smoking hookahs is harmless because people are basically smoking sugar. I guess the planning commissioners actually believed him…

Hookah tobacco is generally about half percent crude tobacco and half percent honey, molasses or fruit pulp. But just because it’s not 100 percent tobacco doesn’t mean it’s harmless. Hookah smoke contains carbon monoxide, tar and many carcinogenic hydrocarbons. Plus, it contains much higher quantities of toxic heavy metals compared to cigarettes.

Hookah smoke is very dangerous. This is from a World Health Organization report:

A waterpipe smoking session may expose the smoker to more smoke over a longer period to time than occurs when smoking a cigarette. Cigarette smokers typically take 8-12, 40-75 ml puffs over about 5-7 minutes and inhale 0.5 to 0.6 litres of smoke. In contrast, waterpipe smoking sessions typically last 20-80 minutes, during which the smoker may take 50-200 puffs which range from about 0.15 to 1 litre each. The waterpipe smoker may therefore inhale as much smoke during one session as a cigarette smoker would inhale consuming 100 or more cigarettes.

But if government agencies that allow hookah lounges don’t care about health threats, at least they should care about breaking the law.

First of all, California Business and Professions Code Section 22962 (a) through (e) prohibits sale of alcohol or food for consumption on-site at a tobacco store. Smoking is allowed in tobacco stores, but you can’t sell food or alcohol in them. A Hookah lounge that sells alcohol and food can’t be a bona fide tobacco store. The county counsel, city attorneys and the district attorney are supposed to enforce this law

Then, Labor Code Section 6404.5 prohibits smoking tobacco in hookah pipes in an enclosed place of employment. It’s a violation of the California Smoke-free Workplace Act. Now, smoking is allowed in an establishment that’s owner-operated and if no employees or vendors ever enter the building. But even one part-time employee, volunteer, vendor, custodian, anybody entering the business for business purposes except the owner means no smoking indoors. Local law enforcement agencies and local health departments are supposed to enforce this law.

It’s all laid out in this packet from California’s Clean Air Project.

San Diego County probably has about a dozen hookah lounges that permit indoor smoking and serve food and/or alcohol. There are probably hundreds throughout California. And they’re all illegal. How a local government agency in California can support licensing an illegal establishment, especially one that harms the health of patrons and employees, is beyond me.

Posted in Big Tobacco, Recovery, Second-hand smoke, Substance abuse, Tobacco, Tobacco and kids, Tobacco marketing | Tagged , , , , , | 9 Comments

Underage drinking: Telling kids about the dangers of blah blah blah doesn’t work

Posted on October 26, 2010 by

Effective prevention programs don't bother trying to tell kids not to drink, because it doesn't work

When you’re trying to change kids’ behavior, the least effective method is to tell them to change their behavior. Pretty much every parent knows this. But for some reason, when people think about prevention of underage drinking – or any other dangerous behavior – they always think about “educating” kids about the dangers of blah blah blah. And that’s exactly what kids hear – blah blah blah.

The most effective prevention strategies are environmental strategies, not educational ones. A good example came from the Centers for Disease Control and Prevention (CDC), which recently announced that fatal crashes involving 16- to 17-year-olds dropped by more than a third between 2004 and 2008. But, the reason fatal crashes went down was not because kids are more careful behind the wheel.

“It’s not that teens are becoming safer,” said Russ Rader of the Insurance Institute for Highway Safety. “It’s that state laws enacted in the last 15 years are taking teens out of the most hazardous driving situations.”

Telling kids to drive safely doesn’t help. What protects teen drivers are graduated drivers licenses, which ban kids from driving at night or with other teens in the car. Almost every state has passed such laws, and they’ve changed the whole environment for kids and driving. Changing the environment is what works with other risks, too, like alcohol.

Social science research over the last two decades has shown that education-only prevention

What a great idea: Police and schools instructing kids on the dangers of drugs. Too bad it doesn't work

– telling kids not to do something – doesn’t work very well. Perhaps the best known education-only prevention for kids is DARE, which is still used (and supported by taxpayer dollars) even though research published in 1994 found that it doesn’t work. And there are many other education-only prevention programs still used in our communities. They make people feel good, but they don’t accomplish much, if anything.

One of the most comprehensive documents on underage drinking prevention strategies, PIRE’s Prevention of Underage Drinking: Logic Model Documentation, says that when it comes to education-only strategies “demonstrated long-term effects are rare.” A study of similar programs for college drinking prevention – called social norms marketing – “did not find a positive effect.” So it doesn’t do much good to tell older kids not to do something dangerous, either. A lot of money has been thrown at social norms marketing at U.S. universities, with little to show for it.

By the way, education-only and social norms strategies that don’t work are preferred by the alcohol industry. What a surprise.

Sorry, folks, but busting adults who let kids drink in their homes works, and more cities are doing it

What does work in underage drinking prevention? The same kind of prevention that CDC found works on reducing youth traffic fatalities: Changing the environment through enacting and enforcing effective laws. We can change the environment where kids get their hands on alcohol by raising taxes and therefore prices, so kids can’t afford as much alcohol. We can enforce laws against sales to minors through high-visibility busts of retailers who sell to kids and of people who buy alcohol for kids. And we can enact laws against adults hosting underage drinking parties, and then doing some high-visibility busts against adults who do it.

Parents intuitively know that environmental strategies work better than educational strategies. What’s the best way to protect Johnny from danger? Telling him not to do something dangerous? Or making sure that he’s not in dangerous situations?

Posted in Alcohol, Alcohol abuse, Alcohol taxes, Prevention, Social host, Underage drinking, Underage drinking parties | Tagged , , , , , , , | 1 Comment