Rotting from the Inside

Smoking and the decline of the body. 

We all know smoking is bad for your health. It causes lung cancer and emphysema and contributes to heart disease. But that’s not the end of the list. Recently, Public Health England, a government organization, collected and analyzed research on the contribution smoking makes to other forms of internal body damage. Authored by Dr. Rachael Murray of the UK Centre for Tobacco and Alcohol Studies and the University of Nottingham, the study looked at the correlation between smoking and the musculoskeletal system, the cognitive system, dental health, and vision.

And the results of various meta-analyses are exactly as grim as we might expect. (You can download the PDF HERE.)

Bones, Muscle, and Tissue

Smoking does steady harm to the musculoskeletal system of habitual smokers. Osteoporosis in mature smokers may result from a loss of bone mineral density, a condition for which smoking “is a long established contributing risk factor.” There are a number of ways smoking can affect bone mineral density, says the report, including “decreased calcium absorption, lower levels of vitamin D, changes in hormone levels, reduced body mass, increased free radicals and oxidative stress, higher likelihood of peripheral vascular disease and direct effects of toxic components of tobacco smoke on bone cells.”

Moreover, smoking and broken bones go together like apple pie and ice cream, or in this case, bangers and mash. Overall in the UK, “current smokers have been reported to be at a 25% increased risk of any fracture,” the report concludes. The author notes that the greatest risk for smokers are seen at the hip and the lumbar spine, and women smokers in particular “were at a 17% greater risk of hip fracture at age 60, 41% at 70, 71% at 80 and 108% at 90.” The risk of fracture and the increased bone repair time decreases slowly in former smokers, and it may take 5 to 10 years before abstinent smokers see any statistical benefits.

Researchers have also documented a causal relationship between cigarette smoking and the onset of rheumatoid arthritis. But it is not known whether smoking cessation benefits existing patients with this condition.

As for soft tissue damage, a meta-analysis of 40 studies showed that smoking was associated with “a 33% increased prevalence of low back pain within the previous 12 months, 79% increased prevalence of chronic back pain and 114% increased prevalence of disabling lower back pain” among British smokers. Another study of 13,000 subjects showed that current and ex-smokers experienced up to 60% more pain in the lower back, upper neck and lower limbs than people who had never smoked. Smokers were also “74% more likely than non-smokers to have a rotator cuff tear,” Dr. Murray writes.

The Brain in Your Head

Chronic cigarette smoking hastens the decline in cognitive function that occurs with age. And there is a disturbing link between tobacco smoking and dementia: “A meta-analysis of eight studies published in 2008 reported that current smokers were 59% more likely than never-smokers to suffer Alzheimer’s disease and 35% more likely to suffer vascular dementia.” Earlier studies showed even higher risk percentages. Here, there is the possibility that smoking succession could reduce dementia onset. Two meta-analyses included in the report showed no association between former smoking and risk of dementia.

General cognitive impairment in adults over 50 is “consistently associated” with smoking, according to the UK report. “Faster declines in verbal memory and lower visual search speeds have been reported in male and female smokers aged 43 and 53, with the effect largest in those who smoked more than 20 cigarettes per day, independent of other potentially confounding factors.”

Dental Damage

Smoking is the primary cause of oral cancer, and the risk of developing it is three times less for non-smokers. Smoked and smokeless tobacco are linked to various non-malignant maladies of the soft and hard tissues in the oral cavity. Alcohol is a risk factor for oral cancer as well, “and is almost tripled in alcohol drinkers who smoke.”

Peridontitis, the inflammatory condition marked by bleeding gums and degeneration leading to tooth loss (and an associated greater risk of coronary heart disease) is three to four times as common in adult smokers. And although there are other confounding socioeconomic influences, smoking is also a risk indicator for missing teeth in older smokers and previous smokers. The increased peridontitis risk lasts for several years after smoking cessation.

As for cavities and general tooth decay (caries), “Although the association between smoking and prevalence of dental caries can be attributed to poor dental care and oral hygiene, a cross-section study with a four-year follow-up found that daily smoking independently predicts caries development in smokers.” 

A Dim View

Neovascular and atrophic age-related macular degeneration, the eye conditions that cause a gradual loss of vision, are causally related to cigarette smoking. "A recent meta-analysis reported significant increases in macular degeneration of between 78% and 358%, depending on the study design." Smokers tend to develop the disease ten years earlier than non-smokers, and heavy smokers are at particular risk.

Finally, a number of cohort and case-control studies show a statistically significant link between smoking and cataracts, the cloudy patches over the eye that cause blurred vision. In current smokers, the increased risk is pegged at about 50%. "Smoking cessation reduces risks over time, however, the larger the exposure the longer it takes for the risk to reduce and this risk is unlikely to return to that of a never smoker."

Photo credit: hhttp://www.healthcareaboveall.com/

Challenging the Received Wisdom on Tobacco Addiction

What does it take to get hooked on nicotine?

--Smokers who smoke five or fewer cigarettes per day can still become addicted to tobacco.

--Tobacco addiction can also be present in non-daily smokers.

--Nicotine withdrawal symptoms do not necessarily begin within 24 hours.

These and other controversial assertions come from Joseph R DiFranza, a physician with the Department of Family Medicine and Community Health at the University of Massachusetts Medical School. Dr. DiFranza recently authored a provocative examination of smoking truisms in an article for the online publication Harm Reduction Journal.

In an attack on what he calls the Threshold Model of Addiction, DiFranza defines the model as follows:

In brief, the threshold model maintains that until tobacco consumption is maintained above a threshold of 5-10 cigarettes per day (cpd) for a prolonged period, smokers are free of all symptoms of tobacco addiction. It holds that declining blood nicotine levels trigger withdrawal symptoms so quickly that addicted smokers must protect their nicotine levels by smoking at least 5 cpd. The threshold model states that until addiction is established with moderate daily smoking, smoking is motivated and maintained by peer pressure, pleasure seeking and the social rewards of smoking.

DiFranza breaks this prevailing paradigm into a half-dozen hypotheses, offering his opinion on the state of scientific evidence that, in his view, refutes every one of them:

--Hypothesis 1. Tobacco addiction cannot occur in nondaily smokers, or even in daily smokers who regularly consume fewer than 5 cpd.

DiFranza’s response:   “Although it is difficult to prove a negative, this hypothesis would be supported if study after study demonstrated that all surveyed subthreshold smokers (individuals who smoke < 5 cpd) have no symptoms of addiction…. Since no studies have demonstrated a complete lack of addiction symptoms in any representative population of subthreshold smokers, the peer reviewed literature soundly refutes the hypothesis that tobacco addiction requires as a prerequisite the daily consumption of 5-10 cigarettes. The threshold model and the DSM are wrong. “

--Hypothesis 2. Tobacco addiction requires prolonged daily use as a prerequisite.

Response: “Many subjects developed symptoms quite soon after the onset of intermittent tobacco use. These findings have been replicated in several longitudinal studies, in cross-sectional studies showing symptoms of addiction in nondaily smokers, and by case histories showing the same.”

Hypothesis 3. Nicotine withdrawal symptoms begin within 24 hours in all smokers.

“The standard subject in all early smoking studies was an adult who had been a heavy daily smoker for decades. Such individuals do experience nicotine withdrawal soon after their last cigarette. A problem arises when this observation is inappropriately generalized by applying it to all smokers, including children, novices and nondaily smokers.”

Hypothesis 4. Addicted smokers must maintain nicotine above a threshold blood concentration to avoid withdrawal.

“Since a person must smoke at least 5 cpd to maintain a minimum nicotine level throughout the day, another approach to testing this hypothesis would be to determine if all smokers that experience withdrawal symptoms smoke at least 5 cpd. This test has been completed over a dozen times, and always with the same result. Withdrawal symptoms have been reported in smokers of fewer than 5 cpd in every study that has examined this issue.”

Hypothesis 5. Psychosocial factors maintain smoking over the several years it may take to reach threshold levels of smoking.

“There must be thousands of studies that demonstrate that social factors such as socioeconomic status, smoking by family and friends, cigarette advertising, the availability of cigarettes, smoking depictions in movies, and attitudes and beliefs are predictive of which youth will try smoking. However, if such factors sustain tobacco use until tobacco addiction develops, they should predict which smokers will advance to addiction in prospective studies. But this has not been shown. None of more than 40 psychosocial risk factors for the onset of smoking was able to predict the progression to tobacco addiction. The author is aware of no studies that establish that peer pressure of other social factors sustain adolescent or young adult smoking over the 4 or 5 years it may take for smokers to reach threshold levels of smoking. “

Hypothesis 6. Increasing tolerance to the pleasurable effects of smoking drives the escalation in tobacco use up to the threshold of addiction.

“The author is not aware of any studies that demonstrate that smokers must smoke more cigarettes over time to obtain the same amount of pleasure (for example smoking 10 cpd to obtain the same pleasure initially obtained from smoking 1 cpd. Indeed, our data indicate that the pleasure obtained from smoking each cigarette actually increases in proportion to the degree of addiction, with pleasure ratings correlating strongly with addiction severity. While this is only one study, it directly contradicts the hypothesis that non-addicted novice smokers obtain much more pleasure from each cigarette than do addicted heavy smokers.”

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Tobacco Settlement Turned Upside Down

“Tobacco bonds” link state budgets to cigarette sales.

Bob Sullivan of MSNBC reports that ten years after a group of states wrestled Big Tobacco to its knees in a $200 billion settlement, the creation of “tobacco bonds” by Wall Street has allowed investors and state governments to borrow against their future tobacco settlement payments. The result? Money that was to be paid out over the next thirty years for smoking cessation programs is being redirected into infrastructure projects and shoring up municipal credit.

“A review of 660 leading bond funds covered by the investment research firm Morningstar Inc., conducted at msnbc.com’s request, showed that more than 260 are invested in tobacco bonds,” Sullivan writes on his blog, The Red Tape Chronicles.

What, you may well ask, are tobacco bonds, and where did they come from? “Perhaps from you,” Sullivan writes. “When Wall Street talked 25 states into borrowing against future tobacco payments—a process known as ‘securitization’—it sold bonds to individual investors and mutual funds that buy municipal bonds.”

The irony of that approach, says Sullivan, is that “because these states have essentially borrowed against future payments from the tobacco industry, they are now dependent on the continued vitality of cigarette sales. If Big Tobacco stumbles, states will be on the hook for these massive, billion-dollar loans.” As a lawyer involved in litigation over the tobacco settlement put it to Sullivan: “Now [the states] have an incentive not to put tobacco out of business.” More than that, any significant failure by the tobacco industry to make its payments would be “catastrophic both to state budgets and individual investors.”

It wasn’t supposed to be this way. But the settlement from the lawsuit designed to blow up Big Tobacco was just too attractive to investment bankers. Sullivan notes that Oppenheimer’s Rochester family of bond funds includes funds with up to 20 per cent of assets held in tobacco bonds. The lure to the states was that, rather than waiting for the money, they could opt for an attractive lump sum payment up front. And many states did just that.

The problem, according to a tobacco policy researcher quoted on Sullivan’s blog, is that “the states have this horribly naive view that they will outsmart Wall Street. Wall Street always gets the better deal.” Many states have settled for a payout of 50 cents on the dollar, plus additional insurance fees against the risk of tobacco companies going out of business.

Eric Lindblom, a director of the Campaign for Tobacco-Free Kids, told Sullivan: “There is a horrible failure of the states to invest even a minuscule amount of the funds for tobacco control. It’s a real tragedy for our country.”

Roughly 3 per cent of tobacco settlement money has been paid out for smoking cessation efforts over the decade since the settlement, Sullivan writes.

Photo Credit: www.treasury.state.la.us

addiction smoking

Smoking Rates Fall 18% in Indiana

What's their secret?

Addiction is a tough disease, and smoking grabs hold of the addiction-prone with a speed and ferocity that remains impressive even in a world of crack cocaine and ice amphetamine. Zyban may help, and there is the ever-controversial Chantix, as well as a plethora of nicotine replacement products. They are valuable and frequently effective additions to the arsenal of medical approaches to nicotine addiction.

Yet there remains one universally effective--if equally controversial--method of lowering smoking rates in a given population. You can increase the price.

Last year, Indiana boosted state taxes on cigarettes by a whopping 44 cents per pack. The result? Cigarette sales fell in Indiana by almost 18 per cent in the nine months since the new tax was put into effect, according to a June 3 Associated Press report. That percentage represents a decrease in sales of roughly 80 million packs of cigarettes, according to state health experts.

"This is exactly what we predicted, " Dr. Judith Monroe, the state health commissioner, told AP. "We've got to remember that smoking is an addiction... not just a bad habit."

In an editorial, the Indianapolis Star put the matter straightforwardly: "In Indiana and nationally, the research in unequivocal: Taxes reduce smoking, especially among the young. So does serious spending on smoking prevention and cessation. The state used to do the latter, and has paid the price for slacking off."

Indiana currently ranks 6th highest in the nation for smoking prevalence. In 1999, under terms of the state-by-state settlement with the tobacco industry, Indiana used its money entirely for smoking reduction programs. After seeing significant declines in smoking, the state legislature nonetheless diverted the remaining settlement money to other programs in 2003. At which point, according to the Indianapolis Star, "smoking rose again, up to second-highest in the nation," making Indiana "one of the unhealthiest states."

"More than one million Hoosiers use tobacco," Karla Sneegas of Indiana Tobacco Prevention and Cessation told the Associated Press. "But we know from our data that approximately 90 percent of those people want to quit and 30 percent are ready to quit right now."


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