Susan M. Zbikowski, PHD, Senior Vice President, Research, Training, & Evaluation 

I am pleased to announce that Alere Wellbeing had an important paper published this month in the Journal of Environmental and Public Health. Our article, “The 2009 US Federal Cigarette Tax Increase and Quitline Utilization in 16 States,” written by Terry Bush, Susan Zbikowski, Lisa Mahoney, Mona Deprey, Paul D. Mowery, and Brooke Magnusson, describes call volumes to 16 state quitlines, characteristics of callers, and cessation outcomes before and after the 2009 federal tax increase.

You may remember back to 2009 when smokers were once again hit with a large increase in the cost of their cigarettes. On February 4, 2009, the federal government enacted a 62-cent increase in the federal cigarette tax, along with increases in other tobacco taxes, to fund expansion of the State Children’s Health Insurance Program. The federal cigarette tax increased to $1.01 per pack on April 1, 2009. Right before the increase in cigarette tax was made public, tobacco companies sneaked in their own price increase on tobacco products. This dramatic increase in the costs of smoking was likely to be a tipping point for smokers to try to quit. With support from the Centers for Disease Control and Prevention (CDC), researchers at Alere Wellbeing decided to find out if these increased costs would result in more people calling state quitlines for help.

Results of this study were just released in the Journal of Environmental and Public Health. The study showed that the federal excise tax on cigarettes was associated with a 23.5% increase in calls to quitlines and attracted somewhat different types of smokers compared with the year before the tax. In particular, it seems that the tax had a greater impact on those who had less education and who were living with other smokers based on the increase in calls from this demographic. Although we also expected that more young smokers would call, this was not the case in this study.

Another important finding from the study was that quit rates among those who called after the tax increase did not differ from quit rates among those who called before the tax increase. The lack of a significant increase in quit rates is not surprising since the participating quitlines did not provide additional or different services to callers. Nonetheless, increasing the number of callers at the same quit rate means an increase in total number of successful quitters. In these 16 states, of the 19,911 additional tobacco users who called during the time of the tax an additional 5,714 would quit smoking (19,911 more callers after tax ∗ 28.7% quit rate).

If the money raised from increased taxation on cigarettes was put into cessation treatment, then it is likely the taxes would have an even greater effect on helping smokers to quit. Numerous studies have shown that quitlines increase ones chances for quitting, especially when multiple counseling calls plus nicotine replacement medications are made available. Unfortunately, states have been cutting back on the services they provide on order to contain costs. This study from Alere Wellbeing provides important data relevant to public health policy on tobacco control. Providing evidence-based cessation services combined with tax and price increases, smoke-free laws, anti-tobacco advertising, and bans on promoting tobacco use can increase quit rates and decrease the prevalence of tobacco use.

Ken Wassum, Associate Director, Clinical Development & Support

Let’s start this week’s blog with a couple quotes from the American Cancer Society’s 4th Tobacco Atlas that demonstrate how the tobacco industry views teens: 

• “A 1984 R.J. Reynolds document stated that younger adults are the only source of replacement smokers”.
• “It is important to know as much as possible about teenage smoking patterns and attributes. Today’s teenager is tomorrow’s potential regular customer, and the overwhelming majority of smokers first begin to smoke while still in their teens….The smoking patterns of teenagers are particularly important to Philip Morris.” Philip Morris USA, 1981

While these quotes are 20 plus years old, nothing about the actions of the tobacco industry indicates that they have changed their view of teens.  It is important to remember that tobacco advertising does not sell a product – it sells a lifestyle and a look.  The ads are made to appeal to the young because that is when new smokers pick a brand.  Compared to youth, adults are much less likely switch brands.

Cigarette prices and taxes have made cigarettes quite expensive in most higher-income countries, but the same cannot be said in low and middle-income countries (LMIC).  Smoking is much more affordable and the youth of these countries often smoke at much higher rates than the US.  In fact in SE Asia and Western Pacific the rates of smoking exceed 50% compared to 25% in the US.

The 4th edition of the Tobacco Atlas points out that among adults, men are more likely to smoke than women, and in many countries there are ten times more men than women smokers. This is not the case with today’s teens and the difference in smoking rates between girls and boys is small.  In fact, more girls smoke than boys in at least 25 countries.  These teens are precious market-share to the tobacco industry.

In most high income countries there are many restrictions on tobacco advertising.  In many low- to middle-income countries, such as Indonesia, this is not the case. Tobacco ads can be placed in close proximity to schools and outdoor ad

vertising is common.  The streets are clogged with tobacco ads, small and large.  Sexy men and women in adventurous situations puff away in these ads, sending the message that “you can be sexy like me if you smoke.”

Phillip Morris International and British American Tobacco are gobbling up much of the market share and even venturing into producing kreteks which are clove/tobacco cigarettes often made in cottage industries.  According to a recently published paper by Richard Hurt, Director of the Mayo Nicotine Dependence Treatment Center, “These acquisitions allowed them to assert influences on health policy in Indonesia and to grow their business under current government policy embodied in the 2007-2020 Roadmap of Tobacco Products Industry and Excise Policy which calls for increased cigarette production by 12% over the next 15 years.”

Two things stand out to me as I look at use of tobacco by teens around the world, including the US.

• First, we are not doing enough to prevent teens from starting.  We need to do a better job educating teens about the immediate and long-term dangers of tobacco and work closely with teens who don’t smoke to develop hard-hitting counter advertising that resonates with this population to dissuade them from starting to smoke or chew tobacco.
• Second, we need to better understand how to help teens quit who have started to smoke.  Most adult oriented cessation programs have proved not to be ineffective with teens.  We need good research to inform treatment approaches that meet the needs of this important group of smokers and chewers.

* Photo Caption: “If you’re not allowed it, but you really want it, then you can have it!” - advertisement slogan for Kiss Cigarettes in Russia, 2011

Ken Wassum has been treating tobacco users for over 19 years. He is past President of The Association for the Treatment of Tobacco Use and Dependence and previously served on its Board of Directors. Join him as he blogs about the effects of the tobacco epidemic, the efforts of cessation advocates, and the work left for us to rid the world of nicotine addiction. Read Ken Wassum's blog posts.

Visit www.alerewellbeing.com to learn about Alere Wellbeing’s Quit For Life® Program, the only commercial tobacco cessation program in the U.S. with proof of effectiveness published in multiple peer-reviewed scientific journals over the course of 25 years.

Ken Wassum, Associate Director, Clinical Development & Support

Everyone in the field of tobacco dependence treatment can agree on one thing. There is no tobacco product or nicotine delivery device more dangerous than the traditional combustible cigarette. However, that is where the common ground seems to end when the discussion turns to the electronic cigarette.  And when those outside the field of tobacco dependence treatment weigh in the discussion gets even livelier! I know of no other device that has generated such strong feelings as the e-cigarette.

For those of you who may not be familiar with the e-cig it is a device that looks a lot like a cigarette. It has a cartridge with a nicotine solution, a battery, and a heating element. When the user takes a “drag” on it the battery vaporizes a small amount of the solution which the user takes into their mouth or lungs. It produces a vapor, not smoke.

A recent PubMed search using the term “electronic cigarette” yielded about 60 articles that have been published in scientific and health journals since 2007. To be very candid, I have not read all of these articles, just as I have not read every article on FDA-approved cessation medications that have been published in the past 5 years. But I have read a lot of them.

Over the past 3 years or so I have posted a number of blogs about the e-cigarette as I have been very intrigued by the device. I have worked in the field of tobacco dependence treatment for about 20 years and am committed to evidence-based treatment. I am also a former pack-a-day plus smoker who began smoking at age 16 and quit at age 41. So I know what it is to be a smoker and I have my own experience about what it took to quit. My father died of lung cancer, so like most Americans I have lost a family member to smoking. But, I also have a sound understanding of the 8700+ peer reviewed studies that provide the scientific evidence for what is proven to be effective in helping smokers quit.

Two primary things have to happen for a medication or drug delivery device (i.e. e-cigarette, nicotine patch, nicotine gum, etc.) to be an approved cessation tool. First, it has to be shown to be “effective” in helping smokers quit. To do this large studies lasting two or three years are conducted. Smokers are randomly assigned to a medication group or a “control” group who gets a placebo, but the smokers do not know which they have. For a drug to be “effective” it has to generate a statistically significant higher number of quitters using the medication than those who did not use the medication.  More than one study is required to demonstrate effectiveness.

Secondly, a medication or drug delivery device has to be proven to be “safe”. A drug or device that is not safe means that it has demonstrated harmful effects that outweigh the benefits or that demonstrate a significant risk to those who use it.
So where does this leave us with the e-cigarette when it comes to effectiveness and safety? To date a few studies have suggested that the e-cigarette might be effective in helping smokers quit. Studies by Eissenberg and others have shown the e-cig to “expose users to measureable levels of nicotine….and suppress nicotine withdrawal symptoms.” Dawkins produced similar results with a small group of smokers. Caponnetto and colleagues conducted a study where 3 smokers quit and another study where 40 smokers not interested in quitting “substantially reduced cigarette consumption”. All this is great, but the numbers are just too small to conclusively demonstrate that the device is “effective”. It looks promising, but needs more study that would randomize a much larger number of smokers to e-cigs and “placebo” e-cigs.

With regard to “safety” we have no data at all.  Analysis of a small number of e-cigs has turned up occasional toxins, albeit at very low levels. However no systematic safety analysis has been done. This is because the manufacturers of e-cigarettes made a conscious decision to not submit the product for approval as a cessation device, but as an alternative type of “cigarette”. For e-cigarettes to be considered a nicotine delivery cessation device (or medication), they have to go through the rigor of these trials. The risks are too great to use them as a cessation device on a large scale only to find that they cause long-term health problems. Safety has to be proved first.

At Alere Wellbeing we train our Quit Coaches not to “demonize” the e-cigarette. No one who comes to us using them is told that they must stop using the e-cigarette or that e-cigarettes are anywhere near as dangerous as a traditional cigarette. The same holds true for those who ask about using the e-cigarette to quit. Instead they are told that we don’t know whether they are truly effective in helping smokers quit and that we don’t know if they are safe. As such, the e-cigarette does not meet the criteria for an evidence-based method for helping smokers quit.

I personally think the electronic cigarette has great potential to be a useful tool to help smokers quit. But at this point it is just potential – we need more data to be sure we would not be doing harm in advising e-cigarette use. Until then we will recommend smokers use FDA-approved nicotine delivery medications.

Ken Wassum has been treating tobacco users for over 19 years. He is past President of The Association for the Treatment of Tobacco Use and Dependence and previously served on its Board of Directors. Join him as he blogs about the effects of the tobacco epidemic, the efforts of cessation advocates, and the work left for us to rid the world of nicotine addiction. Read Ken Wassum's blog posts.

Visit www.alerewellbeing.com to learn about Alere Wellbeing’s Quit For Life® Program, the only commercial tobacco cessation program in the U.S. with proof of effectiveness published in multiple peer-reviewed scientific journals over the course of 25 years.

Ariyah DeSouza, Recruitment Marketing Manager

In May 2011, the Centers for Disease Control and Prevention (CDC) reported on a study showing that cigarette package health warnings increase interest in quitting among smokers. The data revealed that warnings do influence smokers’ desire to quit. This finding is precisely why tobacco companies are fighting federal regulation of tobacco packaging, namely the addition of graphic warnings – which are mandated in dozens of other countries.

The fact that graphic warnings really work inspired our marketing team: why not use warning labels to promote our tobacco cessation program? A compelling campaign featuring warning labels could elicit prospective participants’ attention. And since we know from experience that, for our participants, emotional reasons (rather than scientific reasons) are what stir them to seek support for quitting tobacco, why not focus on the benefits of quitting rather than the damage to health caused by smoking?

So came to be the new Graphic Warnings Campaign for the Quit For Life® Program. Mirroring the look of the Surgeon General’s warnings on tobacco packaging, the campaign’s warnings are immediately recognizable as a positive spin on current text-only labels. Our warnings – like “Quitting Tobacco Will Put More Money in Your Wallet” – remind program-eligible populations of why they want to quit and get support to quit, rather than scare them into trying to quit. Our clients can quickly launch and easily manage the Graphic Warnings Campaign using tips in the Campaign Summary, which we include in each campaign package.

Warning labels work, and a positive spin on them will help motivate your program-eligible populations to quit for good.

Ariyah, Recruitment Marketing Manager at Alere Wellbeing, is responsible for the creation of thematic content and promotional campaigns for the program-eligible populations of Alere Wellbeing clients. Follow her blog series, Beyond Employee Benefits Communications, for ideas on how to creatively communicate employee health benefits at your organization.

Visit www.alerewellbeing.com to learn about Alere Wellbeing’s Quit For Life® Program, the only commercial tobacco cessation program in the U.S. with proof of effectiveness published in multiple peer-reviewed scientific journals over the course of 25 years.

Trisha Tinsley, Lead Trainer, Service Delivery

While I was working on my bachelor's degree, I took an addiction studies class. After learning about the most common addictive substances, our professor gave us a writing assignment to argue which substances were the most harmful. I was encouraged to consider all facets of the word “harmful.” The damage it does to the user. The harm it does to society. The harm it does to the family. After careful consideration, I concluded it was a toss-up between cigarettes and alcohol. In the end I argued that alcohol was the most harmful substance, if only due to the lack of awareness about how alcohol is a more acceptable substance of abuse.

When I was in college, cigarettes were beginning to be frowned upon socially. There was also talk in the media and government about banning smoking in public places. Increased awareness of the dangers of second hand smoke was allowing people to finally come to terms with how we are impacted by tobacco not just on a personal level. However, even in 2000, people were not as aggressive with the discussion about how we are impacted by alcohol. This is not to say that there was not information out there but it seemed like old mind sets about alcohol were still pervasive and seemed harmful to me.

April is Alcohol Awareness Month. It is the perfect time to talk about how awareness can bring about change in how we view alcohol as an addictive substance and how it affects our personal health and society.

What does “alcohol awareness” mean? It is not being aware of who shakes the best cocktail or where the best happy hour is! I want to challenge all of us to think of “awareness” as being conscious about our views and how there can be room for change. Awareness does not always mean that you become more educated about an issue. A large part of awareness is being in tune with your thoughts and feelings about an issue...This is a perfect month to check our perceptions about alcohol.

This year for Alcohol Awareness Month the Center for Disease Control (CDC) is focusing on binge drinking, especially on the harmful effects it has on women. According to the CDC, binge drinking is considered having four or more drinks on one occasion for women and five or more drinks for men. Binge drinking was a perfect issue for me to use to begin to test people’s perceptions. Due to limited time and resources I conducted an informal poll on a sample of people. I posed two scenarios to my husband, two coworkers, three acquaintances at a party, my neighbor, a woman on the bus, a friend of my husband, a yoga teacher at my gym and, of course, my mother. Not entirely a fully baked study, but the findings were interesting nonetheless.

Consider two scenarios:

Imagine a woman (Woman A) at an after-work get-together where she is hanging out with her friends. She does four shots of liquor with her friends, all within an hour and a half.

Now imagine another woman (Woman B) who is across the street from Woman A at a convention center, at a four hour-long event, sipping slowly on a glass of wine while mingling. She has about four and half glasses during the whole event.

I asked people what they thought about these scenarios. Most people couldn't get over the fact that Woman A had four shots of liquor, frowning and asking, “Is it even safe to have that many drinks in that amount of time?” I inquired, “What do you think about our lady wine drinker?” and was met with very little thoughts of concern. Then I informed my informal survey-takers that, clinically, both of these women are considered to be displaying binge drinker behavior. This puzzled my participants. Most of the people said that Woman A was an alcoholic and could be in danger, which may or may not be true. But what was revealing to me was that they did not think the Woman B was at risk at all. They perceived that she was drinking moderately; it never occurred to them that she may or may not be abusing alcohol. I informed them that drinking in moderation is considered to be having one drink a day. I still found it hard to make my point that the second woman was not drinking moderately, even to the non-drinkers I was polling.

I topped off my research by asking, “Is drinking alcohol as harmful as smoking cigarettes?” Every person said no.

I then asked, “Is having one cigarette a day the same as one drink a day?”Every person said no. They all said one cigarette a day was worse than one drink a day.

Lastly I asked, “Consider a person who smokes one cigarette per day and one person who has one drink per day. Does it cost the same to drink as it does to smoke?"

This is a question that even stumped me. But after doing math with a couple of people, we concluded that a drink can be anywhere from $2.00 to $10.00 in the state of Washington. A pack of cigarettes in the State of Washington is around $9.00. There are 20 cigarettes in a pack. $9.00 divided by 20 is .45 cents a day. Wait just a second. Not considering anything else beside the pure cost, drinking alcohol is more expensive than smoking cigarettes? This floored most of the people I talked to.

Of course, the conversation was not to encourage people to stereotype women and alcohol or to have people leave thinking smoking is a cheaper or healthier habit. The main point was to open up a dialogue on society’s preconceptions of alcohol and offer alternative ways of thinking about it – that alcohol, like tobacco, is a substance of abuse.

I help people quit smoking for a living – I help them make healthier decisions every day. As a Quit Coach® and now as a Quit Coach® trainer I have remain committed to bringing awareness of the importance of behavior change – and why drinking alcohol deserves just as much attention as smoking.

In 2006 Trisha called into the Washington State Quit Line and talked with a Quit Coach® who helped her quit smoking. After successfully quitting tobacco, she aspired to become a Quit Coach for the Quit For Life® Program and began working for Alere Wellbeing in 2009. She now works as a trainer helping Quit Coaches to work with participants who call into the Quit For Life® Program and is an active member of the Alere Wellbeing Employee Advisory Board.

Learn about the Quit For Life® Program

Read more stories from current and former Quit Coaches

Ken Wassum, Associate Director, Clinical Development & Support

For the past two or three decades, some brilliant people in the US and abroad have made a priority of reducing disease and death – and those committed to reducing the toll of tobacco continue to work tirelessly and with tremendous optimism. Having just returned from the 15th World Conference on Tobacco or Health in Singapore, I am encouraged by the progress made in some areas of tobacco control, yet very discouraged by the lack of progress in others.

Over the course of the next several weeks I will be posting a series of blog posts that address many of these issues and more in greater detail.

To get started, let’s look at some of the accomplishments we’ve made over the past couple decades:

• 174 countries have signed and ratified the World Health Organization’s Framework Convention on Tobacco Control that addresses the tobacco epidemic from both policy and treatment perspectives.
• More countries than ever provide access to toll-free tobacco Quitlines, including North America where all 50 states, 3 US territories, and 12 Canadian provinces have such services. Quitlines exist throughout Europe and in many parts of Asia and Oceania.
• Many countries with National Health Services, such as the UK, have expanded community-based clinical treatment for tobacco use.
• Graphic warnings on cigarette packs have been adopted by many countries around the world. In some countries “plain packaging” is on the horizon.
• Many countries have raised taxes on tobacco products, especially cigarettes, resulting in lower tobacco use prevalence.
• The US FDA has been given unprecedented authority to regulate tobacco products.
• Tobacco use prevalence in the US has declined from about 27% in 1991 to about 19% in 2010.

Yet, should you think these accomplishments mean we are “winning” the battle, here are some sobering, even chilling, facts:

• In 2011, tobacco use killed almost 6 million people worldwide.
• Global tobacco-related deaths have nearly tripled in the past decade.  The number of annual deaths in the US from tobacco use (443,000) has remained unchanged for the past couple decades.
• Each day, nearly 4,000 kids in the US try their first cigarette and an additional 1,000 kids under 18 years of age become new regular, daily smokers. That’s nearly 400,000 new underage daily smokers in this country each year.
• If trends continue, 1 billion people around the world will die from tobacco use and exposure during the 21st century. To put that mind-boggling number in perspective, that’s 1 person every 6 seconds.
• Tobacco tax revenues in the US have reached unprecedented levels at the state level and the national level, yet tobacco control remains shamefully under-funded and under-resourced. Margaret Chan, Director General of the World Health Organization, sums it up succinctly when she states, “Measures to tackle the epidemic remain seriously under-funded.”
• Cessation services to help tobacco users quit remains the “orphan” of tobacco control and fails to be resourced to its full potential. It has become an issue of social justice.
• The tobacco industry in their multi-national capacity have increased their efforts to both confound and delay tobacco control in the US and have increased efforts to sell their deadly products abroad, targeting women and children in developing countries. They continue to challenge the FDA in implementation of evidence-based initiatives by the Center for Tobacco Products.
• According to the March 2012 Surgeon General’s Report, one in five high school students in the US smokes, and over half of these youths also use a smokeless tobacco product. Nearly 90% of youths start smoking before the age of 18.

We are clearly at a crossroads. Smoke-free laws have taken effect across the US, and the public has the mistaken perception that the battle against tobacco use has been won. Yet those dying of tobacco-related diseases continue to die behind closed doors, away from public view. Dying from smoking is rarely quick and never painless. Many governments around the world, including the US, continue to underfund proven strategies to reduce disease and death caused by tobacco products and under-prioritize the enormity of the tobacco epidemic, especially among our children and our most vulnerable populations.

There is a lot to discuss here, so please stay tuned.

Ken Wassum has been treating tobacco users for over 19 years. He is past President of The Association for the Treatment of Tobacco Use and Dependence and previously served on its Board of Directors. Join him as he blogs about the effects of the tobacco epidemic, the efforts of cessation advocates, and the work left for us to rid the world of nicotine addiction. Read Ken Wassum's blog posts.

Visit www.alerewellbeing.com to learn about Alere Wellbeing’s Quit For Life® Program, the only commercial tobacco cessation program in the U.S. with proof of effectiveness published in multiple peer-reviewed scientific journals over the course of 25 years.

Erin Thompson Curlett, Senior Content & Social Media Marketing Manager

Today we are excited to announce our industry-leading tobacco cessation program, Quit For Life®, is now available in Spanish, removing language as a major barrier to quitting for Spanish speakers.

Quit For Life® in Spanish, available to employers and health plans, features phone-based coaching with a native Spanish-speaking Quit Coach®, integrated with Web Coach®, the most innovative and advanced online learning and social support community available for tobacco users. Clients receive dedicated account management, transparent reporting, and a customizable promotions package including a website (www.quitnow.net) and more than 100 materials and emails in Spanish.

Nearly 15 percent of our service delivery staff has been trained to support Spanish-speaking participants, including registration intake specialists, Quit Coaches, and supervisors. Quit For Life® has the highest standards for coaching in the industry, including ongoing mentoring, training, and evaluation.  As such, Spanish Quit Coaches must graduate from 12 weeks of immersive training on clinical protocols and tobacco cessation coaching, and 4 weeks of training on cultural and dialect differences, dosing regimens for medication, and symptomology. We recruit staff with a background or education in counseling, addiction studies, community health education, or social work. Our Spanish-speaking Quit Coaches are native speakers hailing from countries like Puerto Rico, Mexico, Colombia, and more.

Read the press release about Quit For Life® in Spanish

More information about Quit For Life® can be found at www.alerewellbeing.com or by emailing wellbeingsales@alere.com.

Janice Milliman, Quit Coach, Service Delivery

Smoking is so addictive that many patients continue to smoke even after being diagnosed with lung cancer. I’ve talked with several participants who continue or return to smoking after having part of their lung removed (a lobectomy) or an entire lung removed (a pneumonectomy).

Fear is one barrier to quitting. If you’re attempting something you’ve never done before or only “failed” at in the past, it’s perfectly normal to be afraid or hesitant. If someone has smoked for 30+ years and never tried to quit before, they may have no idea what life will be like without smoking. It has become such a normal part of their life that the world seems up-side-down without it. If that same person has been diagnosed with cancer and is dealing with great uncertainty about the future, it isn’t unreasonable for them to move in the direction of normalcy (smoking) versus greater uncertainty (quitting smoking).

Nearly everyone knows that smoking can cause cancer. On the other hand, most people would have difficulty listing the benefits of quitting after being diagnosed with lung cancer. The diagnosis is scary and can feel like a death sentence. Without knowing the benefits of quitting after diagnosis some patients may think, “It’s too late to quit now. The damage is done.” The truth is that quitting smoking can make a huge difference for a lung cancer patient. Quitting will still be challenging, but instead of feeling hopeless and helpless, patients can feel more in control of the outcome of their lung cancer treatment.

Quitting smoking:

• Improves circulation throughout the body and healing of surgical wounds
• Reduces the chance of infection following surgery
• Improves the efficacy of chemotherapy and radiation
• Improves quality of life because those who quit have more energy, breathe easier and typically manage stress and anxiety in a more positive way
• Reduces the chance of cancer recurrence

Most people are quick to judge, criticize and shame smokers for continuing the deadly habit after cancer diagnosis. If nagging was an effective tactic, though, most smokers would have already quit. When we are unable to identify with someone else’s situation, it is easier to pass judgment or criticize. Since we know judgment and criticism won’t help someone quit smoking, the first step is moving toward greater understanding of their situation. We’re not giving the smoker excuses to continue their habit, but through understanding we can feel and demonstrate more compassion, which in the long run will more effectively help someone quit.

Lung cancer patients who smoke aren’t stupid or foolish, but they do need their doctor’s support to understand the benefits of quitting and guidance regarding medication to manage the nicotine withdrawal symptoms. Doctors should also encourage their patients to check on additional benefits and support they may be entitled to by calling 1-800-QUIT-NOW. It is never too late to quit smoking.

Ken Wassum, Associate Director, Clinical Development & Support

Funding for quit smoking programs has fallen to the lowest level since 1999. States across the country are doing a lousy job of meeting their obligations to help smokers quit and prevent youth from starting to smoke.

Yes, we are experiencing tough economic times, but here are the facts:

In 1998, states were awarded approximately $246 billion dollars from the Master Settlement Agreement. According to the agreement this money was to be used for a variety of purposes related to the adverse health effects of tobacco use, including helping smokers quit and to prevent youth from initiating use.  In 2012 states will collect $25.6 billion yet they will spend only 1.8% of it for tobacco control and prevention. That’s less than 2 cents on the dollar.

On top of this bundle of money, states have been taking in record revenues from cigarette taxes with little to none of the money used to help those who are being taxed –smokers. With greater restrictions on where and when smokers can smoke and steadily increasing tobacco taxes, smokers are becoming isolated from the rest of society.  Low income smokers are now forced to choose between basic needs, such as housing and food, or smoking.  Given the highly addictive nature of nicotine delivered through tobacco products like cigarettes, cigars, and spit tobacco, sadly the choice is often tobacco. In essence, these people have become invisible. They huddle outside doorways to have a cigarette in the cold, or just stay home where they can smoke. In extreme cases it seems the states would prefer not to acknowledge their existence.

The American Lung Association just released their “Tobacco Prevention and Control Spending Report Card.” US states as a whole flunked – miserably. Only seven states received a passing grade and just barely. Sadly, the state whose Attorney General (now Governor) led the Master Settlement deal has all be eliminated tobacco prevention and cessation programs—grade F.

So, contrary to what states legislatures say, it is not a lack of adequate funding for tobacco prevention and control programs. At best it is a lack of political will, and our worst fear may be coming true—that states are becoming addicted to the tobacco tax revenue and it is undermining their obligation to honor the $246 billion dollar agreement.

So the bottom line is that the tobacco industry is winning, and smokers, especially lower income smokers, are paying with their lives. One out of every two smokers in America will die prematurely. One-half million will die in 2012 from smoking-related diseases. The tobacco industry spends $23 on advertising and promotion to every $1 spent by the states on helping smokers quit and to prevent our kids from starting.

We can do better than this. We have to do better than this. We need to hold the feet of state governments to the fire to force them to use the Master Settlement money as intended and to dedicate tobacco tax revenue to helping those who are dying daily from their addiction to tobacco.

Ken Wassum, Associate Director, Clinical Development & Support

Nicotine replacement therapy (NRT) has been used for decades to help smokers quit. This week’s newspapers and online sources were awash with “breaking news” that nicotine replacement therapy does not work. This study* came out of the Harvard school of public health, and frankly its findings should not be worth the hype.

I will take this a step further by saying that NRT options work better than ever. Tobacco treatment professionals now better understand how to recommend combinations of these medications as well as match them with highly effective behavioral strategies that improve quitting success greatly.

Here is what the Harvard researchers did. Between 2001 and 2006 they interviewed a total of 787 individuals who had recently quit smoking. They conducted 3 waves of interviews over the course of 5 years. Results showed that those who used NRT (nicotine patches or nicotine gum) and/or professional assistance were more likely to relapse back to smoking as those who quit without NRT or professional help. I do no dispute their findings, but I do question their interpretation of the results.

We have known for years that their findings are largely true, but it does not mean that NRT is not effective. It certainly does not mean that professional help is not effective. What it means is that those who seek treatment (counseling and/or use of quit medications) are typically more nicotine dependent than those who do not seek treatment and as a result have less success in quitting. Those who are less dependent typically feel they can quit on their own.  As Saul Shiffman pointed out in his 2008 publication** surveys of the type done by the Harvard researchers are subject to recall bias. He states, “past quit attempts are easily forgotten, particularly as many are undertaken spontaneously, and many are short-lived. Treatment seeking itself likely makes quit attempts more memorable because smokers must undertake unusual actions, like seeking counseling or purchasing and using medications. Thus, treatment failures may be remembered and unaided failures forgotten, leading to biased estimates of effectiveness.”

Many experts in the field of tobacco dependence treatment feel the Harvard study had some limitations. The most obvious was the self-selection bias, where individuals are not randomized to a certain treatment, but rather select a treatment or quitting approach based on their assessment of their own needs. I am not saying that randomized controlled trials (RCTs) for cessation medications do not have some problems – they do. In my opinion they frequently exclude too many individuals who are representative of real world smokers. But randomization goes a long way to remove the element of bias in study results.

It is sad that many reputable news agencies ran the article without doing due diligence by researching the findings. The effect is that many people who very much need to quit smoking and would benefit hugely from professional treatment will not seek help because they now may believe that these medications do not work. In fact, they do. 

In my opinion, rather than saying that medication treatments are not effective or that they are not a good use of scarce public health expenditures, what we need is more research showing us how to better implement what we already know is effective. And one of these effective treatment elements is NRT.

*Alpert, H.  A prospective cohort study challenging the effectiveness of population-based medical intervention for smoking cessation.  Tobacco Control 2012.
**Shiffman, S. Use of Smoking-Cessation Treatments in the United States. Am J Prev Med 2008.