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Addiction, Health Disparities, In the News, Public Health

Menthol cigarettes: How they’re being used by and marketed towards African Americans

Menthol pic - smallHere’s a scary statistic, included in a recently published Newsweek article: “Each year, smoking-related illnesses kill more black Americans than AIDS, car crashes, murders and drug and alcohol abuse combined, according to the Centers for Disease Control and Prevention (CDC).” And then there’s this: “More than four in five black smokers choose menthol cigarettes, a far higher proportion than for other groups… By mitigating the harshness of cigarettes and numbing the throat, menthol makes smoking more palatable, easier to start – and harder to quit.”

The article discusses advocates’ call for a ban on menthol cigarettes (all other flavored cigarettes were banned in 2009) before going on to describe the history of African Americans and menthol-cigarette use, and tobacco companies’ aggressive marketing tactics. (“The tobacco industry… positioned itself as an ally of the very community it was seducing,” writes Abigail Jones.) It also quotes Stanford’s Robert Jackler, MD, founder of Stanford Research into the Impact of Tobacco Advertising, who expresses his concerns with ads that appear in a prominent African-American publication:

…[Jackler] has analyzed Ebony magazines since the 1940s and discovered it ran 59 cigarette ads in 1990, 10 in 2011 and 19 last year.

Ebony published 21 articles about breast cancer and 11 about prostate cancer between 1999 and 2013 but did not publish a single full-length story on lung cancer in that 15-year period. “Tobacco advertising is a huge revenue stream,” says Jackler. “Ebony professes itself to be the so-called ‘heart and soul and voice of the African-American community,’ and it completely neglects smoking.”

Previously: E-Cigarettes: The explosion of vaping is about to be regulated, What’s being done about the way tobacco companies market and manufacture products, Menthol “sweetens the poison,” attracts more young smokers, Menthol cigarette marketing aimed at young African Americans and NPR’s Picture Show highlights Stanford collection of cigarette ads
Photo by Classic Film

Addiction, Public Health, Research

What the experience of Swedish snuff can teach us about e-cigarettes

snusA new study in JAMA Internal Medicine suggests that e-cigarettes don’t help tobacco smokers quit.  This study will no doubt attract enormous attention because it relates to the hottest debate in tobacco control: Whether e-cigarettes are a boon or bane to public health. E-cigarette proponents see them as a way for cigarette smokers to transition to a less damaging way of consuming tobacco; opponents worry that e-cigarettes will entice non-smokers into using a product that will ultimately be a gateway to cigarette smoking. Until more definitive data are gathered on e-cigarettes, participants in this debate would do well to examine the experience of Swedish snuff (also known as “snus”).

Snus is a smokeless tobacco that is mainly used in Scandinavia. Its use is damaging to health, but because it is not smoked and contains a low level of cancer-causing nitrosamines, the damage to users and those around them from snus is less than that of tobacco cigarettes. The fundamental question at play in the current e-cigarette debate was also raised regarding snus: Would it be a net harm or a net benefit to public health?

A study of 15,000 Swedish males examined snus use and smoking among a younger (age 16-44) and older (age 45-84) cohort. About 18 percent of tobacco smokers had previously been snus users. This gateway effect from snus to cigarettes was more common for older than younger individuals.  However, in both cohorts, the reverse pattern was far more common, leading to an overall drop in tobacco smoking. Among the younger cohort, snus accounted for six smoking quitters for each smoking starter.  In the older cohort, the benefit was less: About two smoking quitters per starter. Given the size of these effects and the prevalence of snus use, it is entirely credible to argue that snus has contributed to the declining lung cancer rate in the Swedish population.

The Swedish results would seem to make a conclusive case for the public health benefits of snus. However, a subsequent study of 1151 Finnish men had starkly different results. Only 22 participants in the study had replaced tobacco smoking with snus use. The norm in this population was to use snus to supplement rather than replace cigarette smoking, tending to increase the physical dependence of tobacco users. Although not able to draw a definitive conclusion, the authors noted that “it is likely that snus use complicates the attempts to quit smoking”.

The science on snus is thus unsatisfying for those desiring a simple answer regarding the public health value of putatively less harmful forms of tobacco. In one context, snus was enormously beneficial. In another, it appears to have made things worse. The effect of snus also varied across historical time periods as younger and older people used it in distinct ways.

The experience of e-cigarettes may very well follow the same pattern – or perhaps it is better said – the same lack of a pattern. An empirically grounded, universally valid judgment on the impact of e-cigarettes may be difficult to attain. Whether they are a net positive or negative for public health will depend on the context in which they are used, the degree to which different generations adopt them, and the regulations society sets regarding them.

Addiction expert Keith Humphreys, PhD, is a professor of psychiatry and behavioral sciences at Stanford and a career research scientist at the Palo Alto VA. He recently completed a one-year stint as a senior advisor in the Office of National Drug Control Policy in Washington. He can be followed on Twitter at @KeithNHumphreys.

Previously: E-Cigarettes: The explosion of vaping is about to be regulated
Photo by Ole C Eid

Addiction, FDA, Health Policy, Podcasts, Public Health

E-Cigarettes: The explosion of vaping is about to be regulated

E-Cigarettes: The explosion of vaping is about to be regulated

E-cigarettes are about to get zapped. To date, across the globe, they’ve been largely unregulated – and their growth since they first came on the scene in 2007 has been exponential. Now, in the first big regulatory action that is sure to spur similar responses across the pond, the European Parliament approved rules last week to ban e-cigarette advertising in the 28 EU member nations beginning in mid-2016.  The strong action also requires the products to carry graphic health warnings, be childproof and contain no more than 20 milligrams of nicotine per milliliter. It’s expected that the U.S. Food and Drug Administration will soon follow suit and the days of great independence for e-cigarettes will come to a crashing halt. A few U.S. cities, Los Angeles most recently, have banned e-cigarettes in public spaces.

e-cigUntil recently, I was completely ignorant about the whole phenomenon of e-cigarettes. What is the delivery system? Where are they manufactured? Are they a safe alternative to smoking? And how are they being marketed and to whom? Well here’s an eye opener: According to the Centers for Disease Control and Prevention, e-cigarette usage more than doubled among middle and high school students users from 2011 to 2012. Altogether, nearly 1.8 million middle and high school students nationwide use e-cigarettes.

Robert Jackler, MD, chair of otolaryngology at Stanford Medicine, has long studied the effects of tobacco advertising, marketing, and promotion through his center, SRITA (Stanford Research Into the Impact of Tobacco Advertising). After years of detailing how tobacco use became ubiquitous in the U.S. he’s now tracking the marketing of e-cigarettes, and what he’s found probably won’t surprise you. The same sales techniques that brought about the explosive growth of tobacco use are being deployed again to make e-cigarettes look sexy, cool and defiant.

While there are claims by the e-cigarette industry that e-cigarettes are important tools to help people kick the tobacco habit, there’s little evidence to date to back up that claim. And Jackler isn’t completely sold on the notion that e-cigarettes will bring about a great cessation of tobacco smoking; he sees them more as a continuity product. He told me:

What the industry would like to see you do is when you go to a place that you can’t smoke, that you pick up your e‑cigarette and you vape, and you get your nicotine dose in the airport when waiting, or when you’re in your workplace, or when you’re even in school, and that way, when you leave school or the workplace, you go back to the combustible tobacco products.

Sorry if I’m a bit cynical, but as an ex-smoker I find it hard to believe that Big Tobacco – which is increasingly getting into the e-cigarette business – doesn’t also see vaping as a way to continue to keep smokers smoking. Bubble gum flavors and packaging designed to resemble lipstick containers! Who’s really being targeted here?

After my 1:2:1 podcast (above) with Jackler, I’m convinced we’ve been down this road before and it wasn’t pretty health-wise. More than 16 million Americans suffer from a disease caused by smoking. Listen to the podcast and you be the  judge about the true intentions of those promoting e-cigarettes.

Previously: Stanford chair of otolaryngology discusses federal court’s ruling on graphic cigarette labelsWhat’s being done about the way tobacco companies market and manufacture products and Image of the Week: Vintage Christmas cigarette advertisement
Photo by lindsay-fox

Addiction, Public Health, Research

Study shows legal drinking age of 21 saves lives and reduces health risks for young adults

beer_022414New research shows that a minimum drinking age of 21 is associated with a lower rate of drunk driving collisions among young adults, as well as a reduction in risk of health problems related to heavy drinking, including dating violence, unsafe sex and suicide.

A piece published today in the Huffington post takes a closer look at the findings in light of arguments made by some that the age limit doesn’t deter binge drinking and other health hazards. From the article:

…the new review found that since the legal drinking age was set at 21, young people have been drinking less, and are less likely to get into traffic accidents.

In fact, the age 21 laws have saved up to 900 lives yearly on the road, according to estimates from the National Highway Transportation Safety Administration.

Teen drinking and driving rates have dropped by 54 percent over the last two decades, and the biggest declines were seen between 1982 and 1995, a period which included changes in the Federal law that pushed all states to increase their drinking age to 21.

During that period, the number of fatally-injured drunk drivers decreased by 57 percent among those ages 16 to 20, compared with 39 percent for those ages 21 to 24, and 9 percent for those older than 25.

Looking at whether setting the age at 21 has driven teenagers to drink more, researchers found that psychological and social studies on drinking motivations have not supported this idea.

Previously: The costs of college binge drinking, Study estimates hospitalizations for underage drinking cost $755 million per year, CDC binge-drinking study demonstrates cell phones’ value in research, Using Facebook to assess alcohol-related problems among college students and Fighting binge drinking on campus
Photo by DeusXFlorida

Addiction, In the News, Public Health

A focus on addiction, the country’s leading cause of accidental death

A focus on addiction, the country's leading cause of accidental death

Over on Wonkblog, there’s a lengthy discussion between Stanford addiction expert Keith Humphreys, PhD, and Harold Pollack, PhD, on drug overdoses, the recent death of actor Philip Seymour Hoffman, and ways to prevent others from dying. The entire piece is worth a read, but a few parts jumped out at me:

HP: Many people don’t realize that overdose is the leading cause of accidental death in the U.S. I gave a talk about five years ago in Chicago, and I mentioned that we had more overdose deaths than traffic fatalities. My audience literally did not believe me. People were absolutely convinced that I had mis-transcribed the numbers. Every year, America loses a little over 32,000 people in auto crashes, and something like 38,000 from overdose deaths annually.

KH: Yeah, it’s remarkable if you compare overdoses to AIDS, which at its peak was taking about the same number of lives. The difference in reaction is really startling. We appropriately became galvanized about HIV/AIDS, and implemented much better public policy to prevent HIV-related deaths. It’s much harder to get traction on the overdose issue, or even to get people to believe how prevalent the problem actually is.

HP: Just to note the numbers, in 1999 there were about 4,000 prescription opiate overdoses. In 2010, there were about 16,000. By comparison, there are about 10,000 gun homicides in the United States.

KH: It is pretty amazing. Many people are focusing on the return of heroin and saying, “It’s all the fault of criminals.” You’ve got to remember, 4 in 5 of people today who start using heroin began their opioid addiction on  prescription opioids. The responsibility doesn’t start today with the stereotypical criminal street dealer. We basically created this problem with legally manufactured drugs that were legally prescribed. This really flies in the face of the argument that  if we just had a flow of legal drugs, the harms would be minimal.

HP: Can I ask you an embarrassingly basic question? If someone like Philip Seymour Hoffman presumably had access to all sorts of prescription opioids, why does he end up injecting heroin?

KH: That’s actually a good question. Cost drives many people to heroin. It’s more expensive to buy oxycodone than it is to buy heroin. Presumably that was a less pressing concern for Mr. Hoffman. Perhaps the intensity of the rush of injected heroin was more reinforcing to him than opioid medications were. The prescription medications have a longer, slower cycle of action in the body. His heroin use could also be the result of habit. He had experienced a heroin problem before, many years ago. It could be that that was the drug that he knew best or was available in the networks of dealers he used. I’m speculating about somebody I don’t know, but those are some possible reasons.

For most people it’s cost. Add one other thing; when people lose their health insurance, they may need the opioids to manage their pain. People sometimes end up buying street drugs including heroin to manage their pain because they have lost the insurance that used to cover their pain medication.

Previously: A reminder that addiction is a chronic disease, Is it damaging to refer to addicts as drug “abusers?”, Breaking Good: How to wipe out meth labs, How police officers are tackling drug overdose, Do opium and opioids increase mortality risk? and How to combat prescription-drug abuse

Addiction, Health Policy, In the News, Mental Health, Stanford News

A reminder that addiction is a chronic disease

A reminder that addiction is a chronic disease

holding pills - smallerThis morning on KQED’s Forum, guests discussed addiction in the wake of the apparent heroin overdose of actor Philip Seymour Hoffman.

During the show, Stanford’s Keith Humphreys, PhD, a professor of psychiatry and behavioral sciences, noted that addiction is a disease:

Addiction is like other chronic disorders that are not curable – I mean, they can be managed, but we can’t eliminate them. Just like diabetes or low back pain or high blood pressure, you can go through treatment periods and recover your function, but that doesn’t mean that it can’t come back. And people are particularly prone to relapse in times of stress, in times of deprivation. Sometimes in also very good times people haven’t learned to celebrate and be happy without reaching for their drug or alcohol.

Humphreys, who recently served as a senior advisor in the Office of National Drug Control Policy in Washington, outlined two common barriers to receiving treatment: “Not having enough money, and being stigmatized.” But he also shared good news on how addiction is being viewed by the American public – and treated as a medical condition worthy of health insurance coverage.

“Several hundred million Americans, although they might not know it, just got better coverage for addiction treatment in their insurance,” Humphreys said. “The Affordable Care Act defines substance abuse for the first time as an essential health-care benefit. So all new plans must offer benefits, and they must offer them at parity.”

Previously: We just had the best two months in the history of U.S. mental-health policy, Is it damaging to refer to addicts as drug “abusers?”, “Brains are unmentionable:” A father reflects on reactions to daughter’s mental illness, Breaking Good: How to wipe out meth labs, How police officers are tackling drug overdose and Addiction: All in the mind?
Photo (modified from original) by vmiramontes

Addiction, Medical Education, Pediatrics, Public Health

NIDA releases new guide on treating teen substance abuse

NIDA releases new guide on treating teen substance abuse

Only 10 percent of 12- to 17-year-olds who need substance abuse treatment receive services, according to the most recent National Survey on Drug Use and Health (.pdf). To address this issue, the National Institute on Drug Abuse (NIDA) released new resources today that assist substance abuse treatment specialists, health-care providers and parents in treating teens struggling with drug abuse and identifying those who might be at high risk.

As NIDA Director Nora Volkow, MD,  explained in a release, “These new resources are based on recent research that has greatly advanced our understanding of the unique treatment needs of the adolescent.”

The online educational resource highlights both the patient and physician perspectives and provides videos demonstrating skills to use in screening adolescents at risk for or already struggling with substance use disorders. Although it was created with medical students and physician residents in mind, the curriculum is free and available for public access.

An online guide covering treatment approaches was also released. Highlights include:

  • Thirteen principles to consider in treating adolescent substance use disorders
  • Settings in which adolescent drug abuse treatment most often occurs
  • Evidence-based approaches to treating adolescent substance use disorders
  • The role of the family and medical professionals in identifying teen substance use and supporting treatment and recovery

Previously: Could better alcohol screening during doctor visits reduce underage drinking?, To reduce use, educate teens on the risks of marijuana and prescription drugs and How to prevent prescription-drug misuse among teens

Addiction, Health Policy, In the News, Mental Health, Stanford News

We just had the best two months in the history of U.S. mental-health policy

We just had the best two months in the history of U.S. mental-health policy

For decades, descriptions of the status of U.S. mental health services have included references to service cuts, funding constraints and poor access to care. That makes it only more astonishing and important that the past two months have witnessed the most expansive support for mental-health services in U.S. history. Three critical pieces of federal legislation are responsible for this remarkable turn of events.

Bipartisan support for mental-health services has probably never been this strong before at the U.S. federal level

In early November, the Obama Administration released the final regulations for implementing the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPEA) of 2008. One of the very last laws passed during the George W. Bush Administration, MHPEA affects the more than 100 million Americans who receive their health insurance through large group employers. It mandates that any insurance plan that offers benefits for the treatment of mental-health disorders must make those benefits comparable to those for other medical disorders. In other words, the higher co-pays, more intensive utilization review requirements and lower benefit caps historically applied to mental health care are now illegal.

Just seven weeks after the final MHPEA regulations were issued, Medicare ended its decades-long practice of reimbursing outpatient mental-health care at a lower rate than care for all other disorders. Historically, Medicare had covered 80 percent of all outpatient care except for mental health care, which was reimbursed at only 50 percent. Due to the final implementation of the Medicare Improvements for Patients and Providers Act of 2008 (.pdf), this disparity was eliminated on January 1, 2014. That’s good news for the approximately 50 million Americans who are covered by Medicare.

Last but not least, as everyone knows the remaining provisions of the Affordable Care Act also came into force over the past month. The ACA had already helped families facing mental illness by allowing parents to keep their children on their insurance policies until the age of 26. That was critical because addictive and psychiatric disorders almost always have onset in adolescence or young adulthood. But an even more influential feature of the law is to define substance use disorder and mental-illness treatment as essential health care benefits, and, to specify that those benefits be at parity with benefits for other disorders, such as is specified in MHPEA. This standard will apply to all plans issued through state and federal health insurance exchanges and the Medicaid expansion, as well as to insurance plans to be issued in the future that are subject to ACA regulations. The HHS Office of the Assistant Secretary for Planning and Evaluation projects the impact of these changes as improving mental-health care coverage for more than 60 million Americans.

Of course, while the above changes all were implemented in the past two months, they each were the product of many years of advocacy by office holders, political activists, grassroots organizations, clinicians and researchers. These laws coming to fruition in such a compressed time window was fortuitous in some respects, but it also reflects a new political reality in Washington: Bipartisan support for mental-health services has probably never been this strong before at the U.S. federal level. That augurs well for American families who will face the challenge of mental illness in the coming years.

Addiction expert Keith Humphreys, PhD, is a professor of psychiatry and behavioral sciences at Stanford and a career research scientist at the Palo Alto VA. He recently completed a one-year stint as a senior advisor in the Office of National Drug Control Policy in Washington. He can be followed on Twitter at @KeithNHumphreys

Previously: Managing primary care patients’ risky drinking, Full-length video available for Stanford’s Health Policy Forum on serious mental illness and How states will benefit from Medicaid expansion

Addiction, In the News, Patient Care, Public Health

Managing primary care patients’ risky drinking

Centers for Disease Control Director Thomas Frieden, MD, wants more physicians to screen patients for risky alcohol consumption. From a public health viewpoint, this makes great sense. Even at levels of consumption well below what are common among people whom we think of as “alcoholic,” heavy drinking is a risk factor for injuries, accidents and assaults. Ethanol can also interact dangerously with medications a doctor may prescribe (e.g., ibuprofen and other pain relievers, sleeping pills).

But historically, three barriers have stood in the way of physicians screening more patients for risky drinking:

  • Knowledge: There’s an old joke that using metal detectors to stop people from carrying guns (e.g., into schools) seems like a great idea up until the moment the detector goes off. If you screen for something, you’ll find it at least some of the time and be expected to respond. Some doctors don’t screen for risky drinking because they wouldn’t know what to do if they found it. Fortunately, over the past 20 years a brief counseling intervention has been developed and proven effective in multiple clinical trials. It’s an easily learnable technology that physicians find they can use across a range of patient health behaviors. But still, like any other clinical practice, it takes a long time to make these effective interventions a routine part of medical education and front line care
  • Reimbursement: Primary care doctors typically have a lot of work to do with each patient in a short amount of time. It was therefore hard to persuade them for many years to address risky drinking by patients, particularly as it was not a compensated activity. That has now completely changed with the creation of billable codes for screening and brief intervention for heavy drinking, the provision of a problem drinking screening benefit in Medicare and the Affordable Care Act’s inclusion of these interventions as an essential preventative healthcare benefit.
  • Psychological discomfort: The late Barry Rosen, MD, an outstanding addiction specialist and teacher, once listened to a psychiatric resident in my addiction medicine course say that asking patients about how much they drank was “too invasive, even rude.” Barry responded, “You think that’s invasive and rude when we are both part of the one profession that tells total strangers to ‘go into that examination room and take off all your clothes?’” Medical training should help doctors overcome their reticence by pointing out that if you can give a stranger a digital-rectal exam, draw their blood, tell them to take powerful medications and ask them about their safe sex practices, you can also ask them how much alcohol they drink.

In the future, as medicine becomes a team sport, doctors may oversee the care of risky drinking patients but not provide it directly themselves. One potential model of primary care is to have the team include a “habit specialist” who would use motivational counseling, behavioral change planning and monitoring to help patients with health behavior problems. This would certainly include heavy drinkers trying to cut consumption, but would include people attempting to lose weight, quit smoking and adhere to their diabetes care regimen. The VA is using psychologists in this role; Geisinger Health is using nurses. Both models seem a promising way to manage heavy alcohol consumption and other problematic health behaviors; it remains now to see whether they reduce the need for the acute care sufficiently for them to be economically viable across the entire health care system.

Addiction expert Keith Humphreys, PhD, is a professor of psychiatry and behavioral sciences at Stanford and a career research scientist at the Palo Alto VA. He recently completed a one-year stint as a senior advisor in the Office of National Drug Control Policy in Washington. He can be followed on Twitter at @KeithNHumphreys.

Photo in featured entry box by jenny downing

Addiction, Mental Health

Is it damaging to refer to addicts as drug “abusers?”

I’ve written quite a bit about mental-health issues over the years, and I’ve never thought twice when typing the words “substance abuse.” But then I read this excellent piece on CommonHealth – a Q&A with Harvard psychiatrist John Kelly, PhD, – and it got me thinking. In it, Kelly, a former Stanford/VA Palo Alto Health Care System scientist, addresses the stigma surrounding addiction and discusses why we shouldn’t refer to those with drug problems as “abusers.” From the piece:

It seems clear that addiction is not a good thing. It can cause people many problems, even kill them. But you’re saying that the trouble with addiction stigma is that it goes beyond seeing addiction as bad, to actually blaming the addict?

Yes. The degree of stigma is influenced by two main factors: cause — ‘Did they cause it?’ — and controllability — ‘Can they control it?’ We now know that about half the risk of addiction is conferred by genetics – what you’re born with. On controllability, neuroscience has also taught us that alcohol and other drugs cause profound changes in the structure and function of the brain that radically impair individuals’ ability to stop, despite often severe consequences.

The language we use to describe these problems may perpetuate stigma, and that can potentially harm patients and continue the suffering among families.

You pointed out at the drug reform summit that other mental health fields don’t use the term ‘abuse.’

Right. Individuals with ‘eating-related problems’, are uniformly described as ‘having an eating disorder,’ not as ‘food abusers.’ We need to do the same in the addiction field.

Because the term ‘abuse’ gives rise to the ‘abuser’ term, it is better to use the term ‘misuse.’ Furthermore, given the lack of scientific specificity associated with the ‘abuse’ and ‘abuser’ terms, its nonuse would not result in any loss of scientific accuracy.

Kelly spoke last week at a White House summit on drug policy reform. The rest of his thoughts are worth a read.

Previously: “Brains are unmentionable:” A father reflects on reactions to daughter’s mental illness and Addiction: All in the mind?

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