Showing posts with label stroke. Show all posts
Showing posts with label stroke. Show all posts

Friday, May 10, 2019

CDC Quit-Smoking Ads Lack Real-World Solutions


People regularly ask me why I’ve spent the last 25 years researching and advocating for tobacco harm reduction and related products.  While it’s difficult to provide a succinct answer, a powerful ad campaign from the Centers for Disease Control and Prevention illustrates why I am dedicated to helping smokers. The campaign is called “Tips from Former Smokers”.

For the first 15 years of my career, I was on clinical staff at the Comprehensive Cancer Center of the University of Alabama at Birmingham.  As an oral pathologist I made microscopic diagnoses of hundreds of cancers.  But as a clinician and member of a multidisciplinary team treating countless patients with mouth, throat and lung cancer, leukemia and other serious smoking-related diseases, I was compelled to search for practical quitting options for smokers just like Terrie, the patient in the CDC public service ad above.  Click here to watch the entire ad.

Those smokers reminded me always of my maternal grandfather.  He had smoked for most of his 65 years, despite the onset of heart disease that led to his early retirement from operating a dragline excavator in the coal strip mines of Western Pennsylvania.  I remember my great-grandfather, an underground coal miner who chewed tobacco until he passed away at age 99, pleading with him: “Worthy, every cigarette is another nail in your coffin.” 

My grandfather never quit, and in 1965 he suffered a stroke that left him hospitalized for months before he died.  Every night, my parents drove us 25 miles to visit him. One memory from that sad period is still with me: my grandfather, on oxygen and barely able to move or talk, begging his nurse for a cigarette.

For many tobacco opponents, patients like these are only an abstraction, numbers to be wielded in a fight for absolute prohibition.  Most extremists have never worked with smokers suffering from a devastating disease.  If they had, they would care enough to ensure that smokers are offered every option to quit before it’s too late.

That’s the frustrating thing about the CDC advertising.  It doesn’t endorse the most frequently used, and most frequently successful quitting aids: e-cigarettes.  Instead, the CDC pitches telephone quit-lines and gives smokers trite advice: “keep your mouth busy…do something else…go for a walk or a jog…take slow deep breaths.”  These tips are worthless for most of those who are desperate for their next cigarette. 

What about children?  After my lectures, I am often asked by parents, “What if my child learns about you and your ideas, then starts using smokeless tobacco or e-cigarettes?”

My answer: “What if, despite all of your good intentions and nurturing, your child becomes a smoker?  And what if, after 10 or 15 years, they are unable or unwilling to quit?  As a parent, wouldn’t you want your child to know about safer tobacco products?”

We have to keep tobacco out of the hands of children, but safer cigarette alternatives must not be regulated out of reach of their parents and grandparents, whose smoking habit leaves them desperate to avoid fatal illness.





Thursday, September 1, 2016

FDA Cigar Study Part II: Heart & Lung Disease Nearly Zero for 1-2 Cigars Per Day



As noted in my last blog post (here), data presented in a recent FDA review of cigar health risks (here) showed that smoking up to two cigars per day, while not completely safe, is neither associated with significantly increased risks for death from all causes, nor smoking-related cancers.       

Now we examine the FDA data regarding cigar-related circulatory and lung diseases. Here are the overall results:











Table 1. Relative Risks for Mortality From Circulatory Diseases and Emphysema Among Men Who Smoke Cigars
DiseaseStudy, YearRelative Risk (95% CI)


Coronary heart diseaseKahn, 19661.04 (0.96 – 1.13)

Carstensen, 19871.16 (0.84 – 1.57)

Ben-Schlomo, 19940.45 (0.17 – 1.22)

Shanks, 19981.05 (1.00 – 1.11)

Jacobs, 19991.30 (1.05 – 1.62) 1

Jacobs, 19990.93 (0.72 – 1.21) 2


StrokeKahn, 19661.08 (0.91 – 1.28)

Shanks, 19980.96 (0.87 – 1.06)


Aortic AneurysmKahn, 19662.06 (1.32 – 3.07)

Carstensen, 19875.10 (1.33 – 13.19)

Shanks, 19981.76 (1.29 – 2.35)


AtherosclerosisKahn, 19660.97 (0.69 – 1.33)


EmphysemaKahn, 19660.79 (0.25 – 1.86)

Carstensen, 19871.30 (0.00 – 7.45)

Lange, 19923.70 (1.10 – 12.00)

Shanks, 19981.42 (0.96 – 2.03)


1Age 30-74 years
2Age 75+ years
    

Compared with never smokers, cigar smokers in most studies had no elevated risks for coronary heart disease, which is one of the most common smoking-related causes of death in the U.S.; the single exception was a subgroup of men, age 30-74 years, in the Jacobs study.  Cigar smokers also did not have increased risks for two other frequent causes of death, stroke and atherosclerosis (hardening of the arteries).

Aortic aneurysm – a bulge in the heart’s main artery – is the only disease risk that is consistently elevated in cigar smokers.  It is a serious disorder but a distinctly uncommon cause of death; the mortality rate due to aortic aneurysm among those 45 and older dropped precipitously from 16 deaths per 100,000 in 2000 to 7.4 in 2014.

For men who smoke only one or two cigars a day, the health risks are even lower.


Table 2. Relative Risks for Mortality From Circulatory Diseases and Emphysema Among Men Who Smoke 1 or 2 Cigars Per Day
DiseaseShanks, 1998Other Studies


Coronary heart disease0.98 (0.91 – 1.07)1.00 (0.90 – 1.10)1


1.18 (0.76 – 1.82)2


Stroke1.01 (0.88 – 1.17)


Aortic Aneurysm1.82 (1.11 – 2.81)


Emphysema1.39 (0.74 – 2.38)


1Kahn 1966, fewer than 5 cigars per day.
2Jacobs 1999, 1 cigar per day.


No elevated risks for coronary heart disease, stroke or emphysema among men smoking 1-2 cigars per day.  The only disease that was significantly elevated was aortic aneurysm.

The Take-Home Message for Cigar Smokers

Puffing and/or inhaling the smoke of burning tobacco is not without risks.

The FDA, which now regulates tobacco products, seems inclined to treat cigars the same as cigarettes.  FDA staff wrote in their cigar study that “…cigar smoking carries many of the same health risks as cigarette smoking…We have observed that some risks associated with cigar smoking can be as high or higher than those associated with cigarette smoking, especially at the highest doses and levels of inhalation for cigar smoking.”

The problem with such a sweeping indictment is that it ignores scientific evidence and misleads cigar smokers who could substantially benefit from truthful harm reduction guidance.

Like any risky behavior, the degree of risk is proportional to dose and duration of exposure.  In other words, risk is based on frequency of cigar smoking and the degree to which smoke is puffed and/or inhaled.


Wednesday, June 18, 2014

Stroke Risk Same for Menthol and Nonmenthol Smokers



Dr. Nicholas Vozoris in 2012 reported that “…smokers of mentholated cigarettes, and in particular women and non–African Americans, have significantly increased odds of stroke compared with nonmentholated cigarette smokers.”  (reference here).  He used National Health and Nutrition Examination Surveys (NHANES) data to calculate odds ratios of 2.3 for all menthol smokers, 3.3 for women and 3.5 for non-African Americans.  Dr. Vozoris found no increased risk for hypertension, heart attack, congestive heart failure or emphysema among menthol smokers. 

If the Vozoris findings on menthol and stroke were independently confirmed, they could serve as a basis for a ban on menthol cigarettes.  Instead, an analysis of NHANES data by Dr. Brian Rostron (here) comes to an entirely different conclusion.

Dr. Rostron found that African-American menthol smokers had a significantly lower risk for stroke (OR = 0.52, 95% confidence interval= 0.28 – 0.99) than nonmenthol smokers.

“It is not clear to me,” Dr. Rostron writes, “how Vozoris obtained his findings, given that I cannot replicate his general results for stroke using the NHANES data and analyses that he specified.  Moreover, the absence of observed differences in stroke prevalence among NHANES menthol smokers would suggest that methodological or analytical issues may have affected his results.”

Dr. Rostron earlier showed that menthol smokers have lower lung cancer risks than nonmenthol smokers (here).

Promoted by the Archives of Internal Medicine (here), the Vozoris study was covered by major news media (here  and here).  The journal, which changed its name to JAMA Internal Medicine in January 2013, is not publicizing the study that corrects the deficient 2012 analysis.

Although medical journals cannot avoid publishing erroneous reports, editors should take all measures to correct the types of mistakes discovered by Rostron.