SOURCE: Preventive Medicine 1999;28;28-32.

November 5, 1999

ATLANTA (AP) — Despite years of anti-smoking campaigns, lawsuits and bans, the smoking rate among American adults has hardly budged during the 1990s — mostly because more and more 18-to-24-year-olds are lighting up.

The Centers for Disease Control and Prevention said Thursday that 24.7 percent of adults smoked in 1997. As a result, the CDC expects to fall far short of its goal of reducing smoking to 15 percent of the adult population by 2000.

"During the 1990s we've made virtually no progress whatsoever," said Michael Eriksen, director of the CDC Office of Smoking and Health. "The fact that we can't get rates below 25 percent really speaks to the addictive power of nicotine."

About 48 million adults smoked cigarettes in 1997, according to a CDC survey that year of more than 35,000 people nationwide. The rate was the same — 24.7 percent — in 1995. It was 25.5 percent in 1990.

Among most adult age groups, smoking rates actually declined from 1990 to 1997, but the percentage of smokers ages 18 to 24 increased during that period, from 24.5 percent to 28.7 percent.

U.S. smoking rates have dropped drastically since 1965, when 44 percent of adults were lighting up. Over the following quarter-century, more health warnings came out, tobacco ads were banned from the airwaves and no-smoking signs appeared in restaurants, offices and airplanes.

However, smoking rates leveled off during the 1990s rather than continuing to drop.

At the same time, public awareness campaigns continued to warn of the dangers of smoking. The patch and nicotine gum went on the market. And states sued tobacco companies to recoup the cost of treating sick smokers.

"The bottom line on this is it just speaks to how tough it is to quit and how addictive tobacco is," Eriksen said.

Philip Morris, the nation's largest tobacco company, had no comment on the CDC report.

Health officials anticipate a drop in smoking rates in 1999 because cigarette makers raised their prices after their $206 billion legal settlement with 46 states.

And there is another sign that the numbers could begin falling — according to the U.S. Department of Agriculture, per capita cigarette consumption declined 15 percent between 1990 and 1997.

Shane Toepher, a 23-year-old student at Georgia State University in Atlanta, said the cost of cigarettes is a major reason he is trying to quit.

"It costs too much money," he said. "Smokers are aware of what's out there — that it's not good for you and it'll kill you. They just don't care."

Anti-smoking advocates said the popularity of cigarettes among young adults is troubling, but it is also the group where further reductions are most likely to occur.

"We're all pretty much agreed that the efforts to prevent youth from smoking, or getting those who have just begun to experiment to put it away, is where we're going to get success," said Joann Schellenbach, spokeswoman for the American Cancer Society.

Copyright 1999 The Associated Press. All rights reserved.

HealthNews
From the Publishers of the New England Journal of Medicine

A study showing that injecting chronic smokers with vitamin C helped their arteries widen made headlines when it was published in the July 1 Circulation. But smokers shouldn't think they can pop pills to avoid heart disease.

Cigarette smoke contains chemicals called free radicals, which initiate a chain of artery- damaging events. They make LDL ("bad" cholesterol) stickier and more likely to cause atherosclerosis (clogged arteries). Vitamin C is an antioxidant—a substance that mops up free radicals before they wreak havoc.

In this small all-male study, 10 nonsmokers and 10 long-time smokers (a pack a day for more than 20 years) were first given shots of a chemical that relaxes the lining of the arteries. The result in nonsmokers was wider arteries, but as expected, the smokers' arteries didn't respond well. Then all the men were injected with vitamin C. When researchers tried the chemical again, the smokers' arteries widened much more. But is this a "cure" for smoking-induced atherosclerosis?

"Not by a long shot," says HealthNews associate editor Harry Greene, MD. About one gram of vitamin C was injected directly into the men's arteries; you'd have to swallow a lot of pills to get this amount into your bloodstream, and daily injections aren't very appealing. Also, the widening effect was probably temporary, according to the researchers. And the study only looked at the arm arteries; coronary arteries might react differently.

Increasing your vitamin C intake probably won't help. A large study published in 1993 by Eric Rimm, an assistant professor of epidemiology at the Harvard School of Public Health, found no evidence that high intakes of vitamin C, from pills or food, could reduce smokers' risk of heart disease. His advice: "The best thing for smokers to do is quit."

Non-smoking group's butt-out campaign on cigarette packs becomes positive

By Smita Deans
Toronto Star Staff Reporter

An anti-smoking campaign that includes encouraging messages on cigarette packs was announced yesterday.

The Canadian Council for Non-Smoking said at a news conference in Toronto the idea behind putting messages on cigarette packs is that behavioural change is most likely and longer-lasting when based on positive rather than negative incentives.

``According to a survey we conducted among smokers, 70 per cent said that they found positive cigarette notices more encouraging to make them stop,'' said Frank Dwyer, president and chief executive officer of the council.

``We feel that the current notices are not sufficient.

``The proposed labels include a toll-free number you can call for help, as 82 per cent of the people we surveyed said that they would call a toll-free number to get help quitting.''

The proposal for new labels on cigarette packages has been sent to the federal health department. Dwyer said he is confident that the change will be accepted and put into force by the end of this year.

More than 40,000 Canadians die every year from smoking-related diseases, a figure that has not changed despite laws passed to reduce smoking.

``I believe that laws do not consider the effect on the smoker,'' Dwyer said. ``They only serve to alienate a majority of smokers who wish to change and need help. We are concerned with the part about helping them.''

Also included in the six-point plan are measures to curb smoking among youth, including an awareness campaign for children aged 8 to 10 that will deal with the benefits of non-smoking.

The council is hoping to work with school boards and parents to implement this program. It is scheduled for fall 2000.

``Every day, 637 young people start smoking. Isn't that a shocking statistic?'' said Maureen Kennedy Baker, the council's executive vice-president.

``That's why we have to take extra measures to ensure that young people are educated about the dangers of smoking.''

The council also plans to reach out to teens from 13 to 16 through television and radio campaigns.

The council expects the campaign will cost a total of $4 million in its first year and $4 million more in subsequent years. It has approached various levels of government to fund these programs.

``As there are about 8.5 million smokers in Canada, it represents about a dollar per smoker,'' Dwyer said.

Other aspects of the plan include day-long seminars for those who want to stop smoking. As well, passengers on airline flights lasting more than two hours will be advised to use a nicotine replacement because of a co-relation the council sees between nicotine withdrawal and air rage.

by Jane E. Brody Women's Health Digest Vol 2, Number 3 (year?)
Reprinted with permission from the New York Times Company. Copyright 1996.

The doctor could tell the patient had once been an attractive woman. But now, though only in her 50s, her face was etched with wrinkles, her features gaunt-looking with prominent underlying bones and her skin shriveled and gray with purplish blotches. Diagnosis: smoker's face.

Doctor Douglas Model of Eastbourne, England, added this condition to the medical lexicon in 1985 after surveying 116 patients and correctly identifying roughly half of current smokers by their facial features alone.

The distinctive characteristics of smoker's face, which makes people look far older than their years, were present in 46% of the current smokers, 8% of the former smokers, and none of the nonsmokers, irrespective of their age, social class, recent weight fluctuations, and exposure to sunlight.

Dr. Jeffrey B. Smith, a senior resident in dermatology at the University of South Florida in Tampa, recalled this poignant diagnosis in a review of the effects of smoking - related skin conditions: Smoking damages cells and tissues in so many ways that it can have myriad effects on the body.

Wrinkles: "For some patients the threat of wrinkles may be a more powerful motivator to help them stop smoking than the more deadly consequences of smoking," Smith wrote. He explained that, as with skin that is overexposed to sunlight, smoking causes thickening and fragmentation of elastin, the elastic fibers that are long and smooth in healthy skin. Smoking also depletes the skin's oxygen supply by reducing circulation. It decreases the formation of collagen, the skin's main structural component, and may reduce the water content of the skin, all of which increase wrinkling.

Smoking also interferes with the skin's ability to protect itself against damage by free radicals, highly reactive substances that are omnipresent in tobacco smoke. In women, smoking diminishes the level of circulating estrogen, which in turn fosters dryness and disintegration of skin tissues.

Skin Cancers: Two kinds of skin cancers, the more curable squamous cell carcinomas and the often lethal melanomas, are influenced by smoking. Smith said that although smoking did not cause melanoma, smokers with melanoma were more likely to die of their disease. They are twice as likely to have advanced disease at the time of diagnosis and are more likely to have their cancers spread within two years of diagnosis, probably because smoking impairs the immune system.

As for squamous cell carcinoma, even when exposure to sunlight was taken into account, smokers were found to be at greater risk of developing this cancer. In a study of more than 107,000 nurses, for example, the risk of developing squamous cell carcinoma was 50 per cent greater in smokers than in those who had never smoked. Smokers also tend to get particularly "large, bad" skin cancers, Smith said.

Other Cancers: Cancers of the lip, mouth, penis, anus and vulva are also more common in smokers than nonsmokers. For example, in one study of 903 female cancer patients, 60 percent of those with vulvar and anal cancers and 42 percent of those with cervical and vaginal cancers were smokers as against only 27 percent of comparable women without cancer. Smoking more than 10 cigarettes a day more than doubles a man's risk of developing penile cancer.

Delayed Wound Healing: The problem of slow or incomplete healing of wounds associated with exposure to cigarette smoke was clearly demonstrated in laboratory animals in the 1970s. Then surgeons began reporting on similar problems in patients who smoked: larger scars in women undergoing exploratory abdominal surgery, more complications and skin sloughing after facelifts and a much higher failure rate of skin grafts, for example. The more and the longer patients had smoked, the greater the likelihood of impaired wound healing. Even resuming smoking during an uneventful recovery could lead to adverse effects. Smith linked the slow healing of wounds to known effects of cigarette smoking, which constricts surface blood vessels, reduces the oxygen level in the blood, thickens the blood and impedes the laying down of collagen needed for healing.

Psoriasis and related disease: Studies of both men and women with this unsightly and discomforting skin condition have shown that smokers are about two to three times as likely to develop it as nonsmokers. And the more cigarettes smoked, the greater the risk. Palmoplantar pustulosis, a difficult-to-treat skin condition that resembles psoriasis, occurs only on the palms of the hands and soles of the feet. The skin blisters, then forms a scaly rash. It occurs almost exclusively in smokers and it does not necessarily go away when the patient quits smoking.

Oral lesions: In addition to smoker's face, there is also smoker's palate and smoker's tongue. The tars and heat of tobacco smoke can cause tiny red pimples in the mouth that result from an inflammation of the openings of salivary glands. Smokers also often develop depressions on the surface of the tongue. Potentially more serious, however, are lesions called leucoplakia, which are about six times more common in smokers than in nonsmokers. Although benign, these white patches in the mouth can become cancerous.

Buerger's disease: This blood vessel disease results in poor circulation in the lower legs, causing skin problems like burning, tingling and ulcerations. "It usually occurs in young men who smoke, men in their 30s," Smith said. "But now that women are smoking a lot more, we're seeing it in women too."

Other Skin conditions: Many skin diseases are associated with diabetes, which impairs circulation to the outer reaches of the body. A study of more than 112,000 female nurses followed for 12 years showed that current smokers faced an increased risk of developing noninsulin-dependent diabetes, and that the risk rose with the number of cigarettes smoked each day. Another study of nearly 43,000 male health professionals showed that smoking 25 or more cigarettes a day doubled a man's risk of developing diabetes.

People who smoke are much more likely to develop the bowel disorder Crohn's disease, which can cause "big, ugly-looking ulcerations, most often on the legs, and painful red nodules, usually on the lower legs," Smith said. Another condition more common in smokers is systemic lupus erythematosus, an autoimmune disease that can cause rashes on the face, scalp, hands and elsewhere, ulcerations in the mouth and hair loss."

Reuters Health

NEW YORK -- Scientists in Finland have conducted a study offering more proof that quitting smoking is not only good for your lungs but can lead to a longer life.

"In this study, never smokers, past smokers, those who quit smoking permanently or intermittently lost less of their (lung) function in later adult life than continuous smokers," lead author Dr. Margit Pelkonen of the University of Kuopio in Finland and colleagues report in the September issue of the journal Thorax.

And those with the greatest decline in lung function were most likely to die of any cause, the team found. "Too much emphasis cannot be given to the importance of smoking cessation," the researchers write.

The investigators followed 1,007 Finnish men for 30 years, beginning in 1959. All underwent medical examinations six times during the study period. Exams included a test called forced expiratory volume 0.75 (FEV 0.75), which measures the amount of air a person can expel from their lungs in 0.75 seconds. The men were also surveyed about their smoking habits. The researchers evaluated the death certificates of the men who died during the study.

Men who had never smoked had the smallest decline in lung function, with a FEV 0.75 that declined 46.4 milliliters per year. The men who smoked continuously throughout the study had the largest decline, with a drop of 66.0 milliliters each year. Past quitters, permanent quitters, and intermittent quitters had declines in lung function that fell between the two extremes.

Men who experienced the fastest decline in lung function were the most likely to die during the study.

"An increased decline in pulmonary (lung) function can lead to the development of chronic obstructive pulmonary disease (COPD) and it also seems to be a risk factor for mortality," Pelkonen and colleagues write.

COPD--a lung condition marked by progressive breathing difficulties--affects at least 16 million people and is the fourth leading cause of death in the United States. The risk of COPD and the odds of having an abnormal lung test are much higher in people who smoke cigarettes compared with people who have never smoked.

SOURCE: Thorax 2001;56:703-707.

HealthNews from the publishers of the New England Journal of Medicine

Even for smokers who want to stop, quitting cold turkey is a daunting task that's usually unsuccessful—only about 4 in 100 people who try this method still aren't smoking a year later. To improve your chances of remaining smoke-free, try establishing a strict smoking schedule in the weeks before quitting.

A method called scheduled reduction, described in the June Journal of Consulting and Clinical Psychology, works like this: Divide the minutes you are awake each day by the number of cigarettes you ordinarily smoke. The result is the time you wait between cigarettes. The trick is allowing yourself to smoke only on schedule—if you miss your appointed time by more than five minutes, you wait until your next one. The following week, make a new schedule using one third fewer cigarettes, which stretches the time between smokes. Make another one-third reduction during the third week, then quit completely on the fourth.

By following this method, twice as many volunteers were still not smoking a year later, compared to those who quit cold turkey. What's more, they reported far less tension, fatigue, and nicotine withdrawal.

By having a cigarette only at predetermined times, smokers learn to break their associations between cigarettes and mood, stress, or habits like having a cup of coffee, says author Dr. Paul Cinciripini, director of smoking cessation programs at the University of Texas M.D. Anderson Cancer Center. He believes that gradually increasing the interval between cigarettes gives smokers time to try out different strategies that help them learn to cope with their urge to smoke so they aren't overwhelmed when they stop completely.

Since the paper was just published, smokers who want to quit won't be able to find formal programs that incorporate this method for awhile. "Probably not until I write my book. If I ever get the time," Cinciripini added.