Tobacco Use and Health Impacts

It’s been talked about for years, and now the government may be ready to ban menthol-flavored cigarettes.

A citizen’s group has filed a petition in federal court to require the U.S. Food and Drug Administration (FDA) to institute such a ban, and the FDA has to reply by today. Citing “people familiar with the matter, The Wall Street Journal reports that the FDA will announce a ban.

Anti-smoking groups have long targeted menthol cigarettes over claims that they promote smoking, especially among young people. The menthol flavoring is said to mask the harshness of tobacco smoke. These groups also contend that menthol cigarette smokers have a harder time quitting.

If the FDA does seek a ban, it won’t happen overnight. Tobacco companies have said they would go to court to block a ban, so it could take years for the fight to play out. 

Should the FDA go in the expected direction, it would first publish the proposed rule so that citizens and stakeholders have the opportunity to comment.

A year ago, the FDA moved to restrict flavored e-cigarette products -- notably fruit and mint flavors. However, it stopped short of placing restrictions on menthol e-cigarettes, which anti-smoking groups oppose for the same reason they want to outlaw menthol cigarettes.

Black smokers

Surveys have shown that the overwhelming majority of Black smokers prefer menthol cigarettes, and organizations promoting Black health have led efforts to get menthol cigarettes off the market. Black men have the highest death rate from lung cancer in the country, according to the Centers for Disease Control and Prevention (CDC).

"When you combine high rates of smoking with systematic racism in health care systems, you have a tremendous health disparity," Erika Sward, national assistant vice president for advocacy at the American Lung Association, told NBC News.

The Journal notes that tobacco companies will contest any menthol ban or restriction because so much of their business rests on that flavoring. Smokers who purchase menthol cigarettes tend to be younger and can be expected to be smokers for years.

More harmful?

The American Cancer Society has suggested that menthol cigarettes could be more harmful to smokers because they’re “easier” to smoke, noting that the smoke can be held in the lungs longer than unflavored tobacco.

“This helps to explain why people who smoke menthol cigarettes and get lung cancer often have their cancers located in certain parts of the lung,” the group said in a recent statement. “It also might be a reason why it is harder for people who smoke menthol cigarettes to quit.”

The White House is considering requirements that would force tobacco companies to reduce the nicotine in all cigarettes sold in the U.S. to a level that is no longer addictive, according to a report by the Wall Street Journal. 

This initiative isn’t only coming into play because of the start of the Biden administration. The FDA’s Comprehensive Plan for Tobacco and Nicotine Regulation was originally crafted on President Donald Trump’s watch. The agency determined that lowering nicotine in cigarettes to a minimally or nonaddictive level could decrease the chances that future generations become addicted to cigarettes. It might also make it easier for currently addicted smokers to quit.

Trying to strike a balance

When the FDA first proposed the plan, it said the goal was to find a reasonable middle ground between regulation and encouraging tobacco companies to develop “innovative tobacco products” that carry a lower health risk than cigarettes.

The agency is also considering a ban on menthol cigarettes as part of its goal to curb smoking rates among young people. A 2013 report on the health impact of menthol cigarettes maintained that tobacco companies used flavors to reduce the harshness of their products to make them more appealing to new smokers, almost all of whom are under age 18.

Dr. Scott Gottlieb, who served as FDA commissioner under Trump and pursued a nicotine reduction and menthol ban when he was in office, contended that these measures could save 5.6 million lives. But after Gottlieb left the agency, the FDA shelved the proposal. 

If it happens, the U.S. won’t be alone in this change. Last week, New Zealand proposed sharply reducing nicotine levels in cigarettes as part of its goal of being smoke-free by 2025.

“Any action that the FDA takes must be based on science and evidence and must consider the real-world consequences of such actions, including the growth of an illicit market and the impact on hundreds of thousands of jobs from the farm to local stores across the country,” an Altria spokesman told the WSJ.

A spokeswoman for Reynolds American Inc. -- maker of Camel and Newport cigarettes -- said that the scientific case for nicotine reduction is inconclusive and that “there are better tools for improving public health.”

Many consumers have started using marijuana to treat a number of medical conditions, including blood pressure, chronic pain, and mental health concerns. 

Now, a new study conducted by researchers from the University of Granada found that smoking marijuana may lead to vision impairments. Though the majority of cannabis users don’t recognize any changes to their vision, the researchers found that the negative effects can make it harder to perform day-to-day tasks.

“This study shows that smoking cannabis has significant adverse effects on certain visual functions, including visual acuity and contrast sensitivity, as well as in nighttime-related visual parameters such as the [visual-disturbance index] and intraocular straylight,” the researchers wrote. 

Understanding visual impairments

To understand what effect cannabis can have on consumers’ vision, the researchers observed 31 participants’ visual acuity both when they had and hadn’t smoked it. The researchers tested the participants’ night vision, contrast sensitivity, visual acuity, accommodative response, and pupil size in both trials. Additionally, participants reported on how they believed their vision was affected both with and without the drug. 

Ultimately, the researchers observed significant changes to every aspect of the participants’ vision after smoking cannabis. Some notable changes included increased susceptibility to visual glares, issues with depth perception, loss of general visual acuity, and a decreased ability to focus. 

It’s important to note that nighttime vision was also seriously compromised. The team noted that cannabis impacted the participants’ visual disturbance, which is when short flashes of light momentarily impair vision. Additionally, the participants had issues with contrast sensitivity, or the ability to pick out fine shades of lightness or darkness. 

In evaluating the participants’ perceptions of their own visual abilities both pre- and post-cannabis, the researchers learned that there was a significant contrast between actual vision and perceived vision. More than 65 percent of the participants believed they had just a slight change in vision after smoking, while 30 percent believed there was no vision change due to cannabis. 

Moving forward, the researchers hope that these findings highlight just how much consumers’ vision can be affected by cannabis and what this can mean as they go about their daily routines. 

“Our results could help generate a better understanding of the visual changes related to cannabis use and their implications for everyday tasks, raising awareness among users of the risks involved in consuming this drug,” the team wrote. 

The U.S. Food and Drug Administration (FDA) has finalized new health warnings that will soon be required on all cigarette packaging and advertising. 

The new warnings include additional statements and images that detail how smoking can impact consumers’ health; this includes higher risk of disease for the smoker and additional consequences for pregnant women who are exposed to the products.

“The 11 finalized cigarette health warnings represent the most significant change to cigarette labels in more than 35 years and will considerably increase public awareness of lesser-known, but serious negative health consequences of cigarette smoking,” said Dr. Mitch Zeller, the director of FDA’s Center for Tobacco Products. 

New warnings

The new warnings were finalized by the FDA on Tuesday, but they will not be required on cigarette packaging and advertisements until June, 2021. The agency considered a total of 13 new warnings but settled on 11 following a series of studies, a public comment period, and after considering legal and policy considerations.

The 11 text warnings (which will be accompanied by photo-realistic images) include the following:

• WARNING: Tobacco smoke can harm your children.

• WARNING: Tobacco smoke causes fatal lung disease in nonsmokers.

• WARNING: Smoking causes head and neck cancer.

• WARNING: Smoking causes bladder cancer, which can lead to bloody urine.

• WARNING: Smoking during pregnancy stunts fetal growth.

• WARNING: Smoking can cause heart disease and strokes by clogging arteries.

• WARNING: Smoking causes COPD, a lung disease that can be fatal.

• WARNING: Smoking reduces blood flow, which can cause erectile dysfunction.

• WARNING: Smoking reduces blood flow to the limbs, which can require amputation.

• WARNING: Smoking causes type 2 diabetes, which raises blood sugar.

• WARNING: Smoking causes cataracts, which can lead to blindness.

Officials say the new rules will be helpful to both smokers and nonsmokers by closing the information gap about cigarette products. 

“The new cigarette health warnings complement other critical FDA actions, including outreach campaigns targeted to both adults and youth, to educate the public about the dangers associated with using cigarettes, as well as other tobacco products,” Zeller said.

As Youtube continues to fight against the spread of misinformation, a new study conducted by researchers from the University of Pennsylvania explored how tobacco-related videos continue to make their rounds around the popular video streaming service. 

The researchers explained that viewers continue to see videos promoting the positives of tobacco use or vaping. Considering the number of young people who regularly use YouTube, and the misleading statements evident throughout the videos, this has become a serious issue. 

“The easy access of such [video] material suggests that YouTube is a fertile environment for the promotion of tobacco products despite its banning of tobacco advertising,” the researchers explained. 

Pushing boundaries

The researchers evaluated several different search criteria on YouTube to understand what kind of effect these videos are having on viewers. 

Their work revealed that viewers can easily access videos on any number of topics related to tobacco, including how to properly use tobacco, “fun ways” to utilize tobacco, or even how to vape. These videos receive millions of views, and some even suggest that any negative health effects related to tobacco use can be mitigated, though there is no scientific backing to support any of these claims. 

This is particularly concerning considering how prevalent the dangers associated with vaping have become and how many young people have taken up the habit. 

“This suggested to us that the misleading tobacco videos we identified on YouTube are part of the information environment that eludes the restrictions that apply to regular tobacco advertising and product promotion,” said researcher Patrick E. Jamieson. 

Not only are these videos misleading, but they also go against YouTube guidelines that prohibit tobacco advertisements. Moreover, they serve as a source of income for those posting them and for YouTube. 

“As our study of YouTube illustrates, producers of misleading tobacco content can primarily represent private individuals rather than tobacco manufacturers,” said researcher Dan Romer. “Indeed, the producers of the tobacco videos we identified...do not appear to be employees of the tobacco industry, it is nevertheless possible that a content creator could receive endorsement payments from a tobacco company.” 

Telling the true story

According to the researchers, the best way to combat these videos is with the truth. It’s crucial that consumers are getting the right information. 

On platforms like YouTube where these videos are most prevalent, setting up ads or videos with content that debunks these misleading messages is key to setting the record straight. 

It has already been shown that smoking during pregnancy increases the risk of Sudden Infant Death Syndrome (SIDS) dramatically. But findings from a recent study suggest that combining that habit with alcohol consumption can make matters even worse.

Researchers funded by the National Institutes of Health (NIH) say that pregnant women who continue to smoke and drink alcohol into the first trimester are more likely to bear children who are in danger of succumbing to SIDS. 

"Ours is the first large-scale prospective study to closely investigate the association between prenatal alcohol and tobacco exposure and the risk of SIDS," said Dr. Amy J. Elliot, the study’s first author. "Our findings suggest that combined exposures to alcohol and tobacco have a synergistic effect on SIDS risk, given that dual exposure was associated with substantially higher risk than either exposure alone."

Alcohol and smoking dramatically increases risk

The research team came to their conclusions after analyzing the outcomes of nearly 12,000 pregnancies. In total, 66 children died after one year -- with 28 deaths being attributed to SIDS. 

While 28 in nearly 12,000 may not seem like a high death rate to some, the researchers noted that the children of pregnant women who drank alcohol and smoked after the first trimester of pregnancy were 12 times more likely to die of SIDS when compared to other children. On their own, smoking or drinking beyond the first trimester increased risk of SIDS by five and four times, respectively. 

The researchers say these results support recommendations by health officials that women avoid alcohol and tobacco during pregnancy, and that is especially true for dual exposure.

"These findings provide still more evidence of the vital importance of the early prenatal environment to healthy postnatal outcomes. Insofar as many women quit drinking and smoking only after they learn that they are pregnant, this study argues strongly for screening for substance use early in pregnancy and intervening as soon as possible,” NIH officials said in a statement. “It also calls for stronger public health messaging regarding the dangers of drinking and smoking during pregnancy, and among women who plan to become pregnant."

The full study has been published in the journal EclinicalMedicine.

The Food and Drug Administration (FDA) announced today that it is approving the sale of two new tobacco products that have lower amounts of nicotine than traditional cigarettes.

The agency says that the products -- which are manufactured by 22nd Century Group Inc. -- meet its standards and could potentially help curb nicotine dependence and addiction rates in adult smokers. However, it makes clear that the products still carry many of the same health risks that commercial cigarettes do.

“While today’s action permits the new tobacco products to be legally sold or distributed in the U.S., it does not mean these products are safe of ‘FDA-approved,’” the FDA said in its announcement. 

“In its decision, the agency notes that the Moonlight and Moonlight Menthol cigarette products differ from conventional cigarettes in nicotine content only -- the products share similar adverse health risks as conventional cigarettes. There are no safe tobacco products and those who do not use tobacco products should not start.”

Preventing marketing to youth users

In a press release, the FDA says that the new products should not be attractive to youth users. But with that in mind, it says that it will be placing “stringent restrictions” on how the products are marketed online and on social media platforms. 

The manufacturer will also be required to regularly report to the FDA about any information it collects through research studies, sales data, and other avenues so that the agency can respond accordingly if young people start using the products. 

“The FDA may withdraw this marketing order if, among other reasons, it determines that the continued marketing of a product is no longer appropriate for the protection of public health, such as if there is an uptake of the product by youth,” the FDA stated.

A coalition of consumer and public health organizations is asking the U.S. government to change warning labels on alcoholic beverages to tell consumers of potential cancer risks.

Alcoholic beverages already carry a warning not to consume alcohol if you are pregnant or operating a motor vehicle.

In a letter to the Alcohol and Tobacco Tax and Trade Bureau (TTB) -- part of the Treasury Department -- the groups asked TTB to begin the process of amending the health warning statement currently required to appear on all alcoholic beverage labels.

The groups cite a 2016 report from the U.S. Surgeon General that documented a link between even light alcohol consumption and several common types of cancer. The groups say that the finding coincides with research from other organizations, such as the National Cancer Institute, which says “there is a strong scientific consensus that alcohol drinking can cause several types of cancer.”

The current warning label was established by a law established in 1988. The groups -- the American Institute for Cancer Research, the American Public Health Association, Breast Cancer Action, the Center for Science in the Public Interest, and the U.S. Alcohol Policy Alliance -- said the warning can be expanded to include cancer by amending the current statute.

Suggested warning

In their letter to TTB, the groups suggest that the following warning be added to alcoholic beverage labels:

GOVERNMENT WARNING: According to the Surgeon General, consumption of alcoholic beverages can cause cancer, including breast and colon cancers.

The groups say the added warning is needed because most consumers are unaware of any link between alcohol and cancer.

“The disconnect between alcohol’s impact on cancer and the awareness of that impact should raise alarm bells,” said Thomas Gremillion, director of food policy at the Consumer Federation of America (CFA). one of the organizations that signed the letter. “The industry has succeeded in putting a health halo around alcohol. The government has the responsibility to give consumers the scientific information they need to make informed decisions about alcohol, just as it does with tobacco.”

The warnings have come at a time when alcohol consumption is increasing in the U.S., with more and more consumers coming to accept it. But a 2018 study published in The Lancet found that no amount of alcohol consumption is safe.

The World Health Organization (WHO) first documented the link between alcohol and a number of different cancers in 1987. According to the groups urging a new warning label, cancers associated with alcohol consumption affect nearly 90,000 Americans each year.

Research have long documented the negative effects consumers can endure after consuming alcohol or smoking cigarettes. Now, researchers are exploring how joint use of alcohol and tobacco affects the body.

According to a study conducted by researchers from the American Chemical Society, mice that were tested after exposure to both tobacco and alcohol were more likely to have neural damage in parts of the brain associated with addiction.

“Devastating effects of exposure to alcohol and tobacco smoke on health are extensively reported in...literature,” the researchers wrote. “However, few studies have attempted to elucidate the consequences of their combined use on the central nervous system.”

Brain damage

The researchers, led by Alana Hansen, were putting themselves in the minds of consumers: many people who smoke cigarettes also consume alcohol, and vice versa. It was this thinking that led them to explore how joint use affects the brain.

To put their theory into practice, the researchers exposed mice to either six cigarettes worth of tobacco smoke, two grams of alcohol, or both, twice a day for 28 days. They then examined the mice’s brains and compared the results with mice in a control group with exposure to no outside substances.

The researchers were most interested in three specific areas of the brain: the frontal cortex, the hippocampus, and the striatum.

The researchers found that the mice who received both tobacco smoke and alcohol had inflammation across all parts of the brain they analyzed, while the hippocampus was most susceptible to oxidative damage. Moreover, when the mice were exposed to both substances, it was difficult for them to maintain neurons -- or create new ones -- in both the frontal cortex and striatum.

The results made it clear that there are risks for these substances separately, but consumers should also know that there are additional risks when they’re used simultaneously.

“Our results showed an interaction between alcohol and tobacco smoke according to the area of the brain, suggesting an additional risk of neural damage in alcoholics who smoke,” the researchers wrote.

One affects the other

A recent study conducted by researchers from Oregon State University found that consumers looking to quit smoking should also cut back on drinking alcohol.

According to the study, reducing alcohol consumption was effective in helping consumers also cut back on their nicotine habits.

“It takes a lot of determination to quit smoking, often several attempts,” said lead author Sarah Dermody. “This research suggests that drinking is changing the nicotine metabolism as indexed by the nicotine metabolite ratio, and that daily smoking and heavy drinking may be treated together.”

Federal health officials say the sharp increase in the use of vaping devices among teens has caused a significant spike in the number of teens using traditional products.

The Centers for Disease Control and Prevention (CDC) on Monday released its annual National Youth Tobacco Survey. The survey found that the number of high school students using tobacco products, which include e-cigarettes, rose by about 38 percent.

The survey revealed that more than 1 in 4 high school students and about 1 in 14 middle school students used a tobacco product in 2018.

Threatens to undo past progress

The CDC said the ongoing rise in vaping among teens threatens to undo past progress in reducing rates of tobacco use among minors.

"The skyrocketing growth of young people's e-cigarette use over the past year threatens to erase progress made in reducing youth tobacco use. It's putting a new generation at risk for nicotine addiction," CDC Director Robert Redfield said in a statement.

Products manufactured by Juul have been shown to be especially attractive to minors because they come in fruity flavors such as mango, mint, and fruit and creme. Kids and teens who use e-cigarettes could be more likely to start smoking tobacco, the CDC said, citing previous research on the subject.

In a statement, Matthew Myers, president of the Campaign for Tobacco-Free Kids, said the survey results were “deeply troubling.”

“They add to mounting concerns that the rise in youth use of e-cigarettes, especially Juul, is vastly expanding the number of kids addicted to nicotine, could be leading kids to and not away from cigarettes, and directly threatens the decades-long progress our nation has made in reducing youth smoking and other tobacco use,” Myers said.

Trends that require ‘unprecedented action’

The FDA shares the CDC’s concerns about the alarming surge in e-cigarette use among teens. Commissioner Scott Gottlieb has described the issue as an “epidemic” and repeatedly called for e-cigarette manufacturers like Juul to step up their efforts to combat youth use of their products.

On Monday, Gottlieb expressed concern that e-cigarette manufacturers may be reneging on vows they made last year to counter teen use. In January, the FDA warned that e-cigarettes could be pulled from the market entirely if youth use continues to rise.

"These trends require forceful and sometimes unprecedented action among regulators, public health officials, manufacturers, retailers and others to address this troubling problem," Gottlieb said in a statement.

Juul’s Senior Director of Communications Victoria Davis has maintained that the company is “committed to preventing youth access of JUUL products.”

Children of smoking parents are exposed to a great deal of tobacco residue and all of the chemicals that linger on furniture, clothes, and other household items long after cigarettes have been burnt out.

Now, a new study conducted by researchers from the University of Cincinnati found that thirdhand smoke exposes children to nicotine and other carcinogenic chemicals that can lead to respiratory issues.

“It just goes to show that indoor smoking bans don’t necessarily protect children from tobacco smoke exposure and related pollutants, such as thirdhand smoke,” said researcher Ashley Merianos. “It also shows that exposure to tobacco smoke toxicants is more widespread than previously thought because exposure in children is not limited to inhaling secondhand smoke.”

Keeping children healthy

The researchers had over 100 children participate in the study, all of whom had been admitted to the Cincinnati Children’s Pediatric Emergency Department because of smoke-related symptoms. All of the children had at least one person in the home who smoked, and their hands were wiped and tested for nicotine exposure.

More than 50 percent of the participants were younger than two years old, and the researchers found they had nearly 70 nanograms (ng) of nicotine on their hands. However, for children between the ages of two and four, that number tripled to over 185 ng of nicotine.

“Future work should explore the associations of hand nicotine and age to determine how children’s changing interactions with their environment and behaviors contribute to increased nicotine in two- to four-year-olds, whether handwashing decreases the risk and whether increased levels are associated with increased [secondhand smoke-related] clinical illnesses,” the researchers wrote.

The amount of nicotine found on the children also depended on how much their caregiver smoked.

Even when the children’s caregivers didn’t smoke around them, the children still had 82 ng of nicotine on their hands. The researchers found that number went up to 200 ng of nicotine when parents smoked 15 or more cigarettes each day. Children who were exposed to greater levels of nicotine were also more likely to have other health concerns, such as wheezing, coughing, and respiratory issues.

The researchers note that cleaning and handwashing are not effective methods of keeping children safe from nicotine exposure, and they encourage parents and caregivers to quit smoking in order to reduce children’s exposure to dangerous chemicals and potential health concerns.

A growing concern

A recent study found that children of smokers have a “significant” amount of nicotine on their hands, though the side-effects of second- and thirdhand smoke could be worse for children in rural and low-income areas.

“This is one of the first studies to explore the risks of very young children, especially infants, for second- or third-hand exposure to smoking,” lead author Lisa M. Gatzke-Kopp. “Our findings suggest that moving frequently, having more adults in the home, and spending less time in center-based, daycare facilities may increase a child’s exposure to smoke or smoke residue.”

In an effort to try to keep children safe from second- and thirdhand smoke, lawmakers made it illegal to smoke in federal public housing units. The law states that lit cigars, cigarettes, or pipes must be smoked at least 25 feet away from all public housing units.

The U.S. Food and Drug Administration (FDA) is prepared to ban the sale of menthol cigarettes, a report from The Wall Street Journal has suggested.

The latest report follows another report last week which suggested that the agency’s Commissioner Scott Gottlieb is planning to announce new restrictions on the sale of some flavored vaping products in an effort to curb use among teens.

Senior agency officials with knowledge of the matter told the Journal that Gottlieb may be looking to move forward with a process to have menthols banned as part of the FDA's crackdown on teen vaping.

Popular among young people

In 2013, a study concluded that menthol cigarettes were associated with an increase in use among young adults. The study found that the percent of young people who smoked non-menthol cigarettes declined, while menthol smoking rates increased.

The authors said the results of the study raised concerns that menthols are being marketed as a “starter product” for younger consumers.

“Our findings indicate that youth are heavy consumers of mentholated cigarettes, and that overall menthol cigarette smoking has either remained constant or increased in all three age groups we studied, while non-menthol smoking has decreased,” said lead researcher Dr. Gary Giovino, professor at the University at Buffalo.

“Simply stated, menthol sweetens the poison, making it easier to smoke. Young people often think menthol cigarettes are safer, in part because they feel less harsh,” Giovino said in a statement.

The same year, the FDA also said that menthol cigarettes pose a larger health risk to the public than traditionally-flavored brands because they tend to be more difficult for users to quit.

The process of finalizing a ban on menthols would reportedly take a year or longer and another year after that for the ban to be enforced, according to the Journal.

Gottlieb has stated that the FDA is currently trying to control "epidemic" levels of teens using e-cigarettes.

Just 13.9 percent of adults in the U.S. smoked cigarettes last year, according to a government report released Tuesday.

The new figures represent a decrease from previous years and indicate that the American smoking rate has reached “the lowest level ever recorded.”

In 2016, nearly 16 percent of adults aged 18 and over smoked cigarettes, according to a previous survey from the Centers for Disease Control and Prevention (CDC). In 1965, more than 40 percent of U.S. adults smoked cigarettes.

Experts say public health campaigns have helped to raise awareness of the dangers of the addictive habit, helping to drive down the overall number of smokers in recent decades.

Twice as many smoke in rural areas

The first effort to raise awareness about the adverse health effects of smoking cigarettes was made in 1964, when the Surgeon General released the first government report linking smoking with certain diseases.

However, anti-smoking campaigns like these tend to reach more city-dwellers than rural adults. Just 11 percent of adults in a metro area of one million people or more smoke, compared to nearly 22 percent in rural areas, the CDC report said.

Adults in rural areas also "had the highest rates of being obese, having experienced serious psychological distress during the past 30 days, or having diagnosed diabetes," according to the report.

Swapping smoking for vaping

Vaping is now the most common method of consuming nicotine among both high school and middle school students, according to the CDC. Around 12 percent of high schoolers used e-cigarettes in 2017, compared to about 3 percent of U.S. adults as of 2016.

Experts say the decrease in the number of cigarette smokers represents a major public health success. However, federal health officials are now facing the challenge of how to regulate e-cigarettes.

Although e-cigarettes are touted as products to help adults quit cigarettes, health experts are hesitant to promote e-cigarettes as healthier alternatives to traditional cigarettes. Some evidence has shown that e-cigarette use can lead to other forms of tobacco use among youth, and researchers are still trying to gain a clear understanding of the health effects of vaping.

"Yes, vaping doesn't have the high levels of tar and soot that are the major contributors to the cigarette lung cancer risk," Dr. Adam Lackey, chief of thoracic surgery at Staten Island University Hospital, told HealthDay News.

"But you are still inhaling heated chemicals into your body. And you are still getting nicotine, which in and of itself is not particularly healthy, aside from the addiction standpoint."

With the number of young adult vapers on the rise and the health effects of the practice still being studied, the FDA has ramped up its efforts to crack down on youth access to e-cigarettes.

A smoking habit can take years off a consumer’s life and lead to several chronic illnesses and conditions. One of the deadliest diseases, lung cancer, claims hundreds of thousands of lives every year.

That’s the bad news. The good news is that quitting now can drastically reduce your chances of contracting lung cancer later on. In a recent study, researchers from Vanderbilt University found that smokers who quit had a 39 percent reduced chance of catching the disease five years later.

“If you smoke, now is a great time to quit,” said Dr. Hilary Tindle, the study’s first author. “The fact that lung cancer risk drops relatively quickly after quitting smoking, compared to continuing smoking, gives new motivation.”

Reduced chances of lung cancer

The researchers came to their findings after analyzing nearly 9,000 health records from the Framingham Heart Study.

Over the study period, nearly 300 people were diagnosed with lung cancer, with 93 percent of cases involving “heavy smokers” who smoked at least one pack per day since the age of 21.

However, the researchers found that heavy smokers who quit had drastically improved outcomes when it came to lung cancer diagnoses, dropping by 39 percent when compared to those who continued smoking.

Danger still exists

While these findings are encouraging, the researchers point out that lung cancer rates in the group that quit smoking were still 3 times higher than for those who had never smoked. They say this highlights the importance of having regular screenings to check for the disease.

"While the importance of smoking cessation cannot be overstated, former heavy smokers need to realize that the risk of lung cancer remains elevated for decades after they smoke their last cigarette, underscoring the importance of lung cancer screening," said senior author Dr. Matthew Freiberg.

The full study has been published in the Journal of the National Cancer Institute.

The problem with tobacco is nicotine. It's addictive and makes it hard for smokers to quit or cut back. So, the U.S. Food and Drug Administration is shifting its anti-smoking efforts to take a sharper focus on nicotine.

“The overwhelming amount of death and disease attributable to tobacco is caused by addiction to cigarettes –  the only legal consumer product that, when used as intended, will kill half of all long-term users,” said FDA Commissioner Scott Gottlieb, M.D. “Unless we change course, 5.6 million young people alive today will die prematurely later in life from tobacco use."

Gottlieb said the agency envisions "a world where cigarettes would no longer create or sustain addiction, and where adults who still need or want nicotine could get it from alternative and less harmful sources."

The new initiative could be good news for the e-cigarette industry, which portrays its electronic cigarettes as nicotine delivery systems that avoid the harmful consequences of smoking tobacco. On Wall Street, shares in Altria and other tobacco companies fell after the announcement.

Nicotine "the core of the problem"

Gottlieb said the FDA will try to "strike an appropriate balance between regulation and encouraging development of innovative tobacco products that may be less dangerous than cigarettes."

That may mean adjusting some of the deadlines the agency previously imposed on manufacturers of tobacco-related products, including cigars and e-cigarettes.  

Tobacco use remains the leading cause of preventable disease and death in the United States, causing more than 480,000 deaths every year, Gottlieb noted. 

"A key piece of the FDA’s approach is demonstrating a greater awareness that nicotine – while highly addictive – is delivered through products that represent a continuum of risk and is most harmful when delivered through smoke particles in combustible cigarettes," the FDA said in a news release. 

The FDA said it plans to begin a public dialogue about lowering nicotine levels in combustible cigarettes to non-addictive levels through achievable product standards. Because almost 90 percent of adult smokers started smoking before the age of 18 and nearly 2,500 youth smoke their first cigarette every day in the U.S., lowering nicotine levels could decrease the likelihood that future generations become addicted to cigarettes and allow more currently addicted smokers to quit, it said.

“Because nicotine lives at the core of both the problem and the solution to the question of addiction, addressing the addictive levels of nicotine in combustible cigarettes must be part of the FDA’s strategy for addressing the devastating, addiction crisis that is threatening American families,” said Gottlieb.

Most people are aware that smoking cigarettes is bad for your health. Since 1964 it's been linked to lung cancer, and later to heart disease and emphysema.

But the list doesn't stop there.

Dr. John Spangler, professor of family and community medicine at Wake Forest Baptist Medical Center, says he has found that many people have been told cigarettes are bad, but haven't been told why. The harsh reality, he says, is that cigarettes cause damage throughout the body.

High blood pressure, diabetes

In addition to lung cancer and heart disease, Spangler says smoking can contribute to high blood pressure, type 2 diabetes, stroke, gum disease, arthritis, and even erectile dysfunction.

Cigarette smoke is damaging, in part, because it can contain as many as 9,000 different chemicals, many of which are toxic, and as many as 70 that have been linked to cancer.

“When you smoke, these various chemicals get into the bloodstream, are carried to all parts of the body and go right to the most susceptible cells,” Spangler said. “That’s why there’s such a wide array of negative effects from cigarettes.”

Carbon monoxide

Even carbon monoxide, the gas that results from the incomplete burning of any carbon-related material, damages the body. Too much of it interferes with the blood's capacity to transport oxygen throughout the body, including to important areas of the brain and heart. That's often why a heavy smoker suffers from shortness of breath, and even heart failure.

Tars found in cigarette tobacco are harmful because they can build up in the lungs, inflaming the linings of blood vessels and other soft tissues. It can reduce the body's ability to ward off infection, slow the healing process, and release free radicals -- a major element in the development of cancerous tumors.

Falling smoking rates

Fortunately, smoking rates in the U.S. have been steadily declining, in part because more people area aware of health issues, but also because taxes have made smoking a very expensive habit.

According to the Centers for Disease Control and Prevention (CDC), 42% of U.S. adults smoked in 1965. By 2014, the percentage had dropped to 16.8%.

Spangler says nicotine is far from the most harmful substances in cigarettes, but it is one of the most dangerous, because it's addictive. It's why people continue to smoke, even when they know the health facts.

To quit, Spangler suggests using nicotine gun or patches while trying to work on the habits -- like having a cigarette after a meal -- that keep many people lighting up and wrecking their health.

Pfizer's quit-smoking drug Chantix has had good years and bad years. But it's closing 2016 on a high note, with the FDA lifting the requirement that the drug carry the dread "black box" warning label following an extensive study of the drug's side effects. 

As far back as 2008, Chantix has been blamed for heart attacks, strokes, and an increased risk of homicidal and suicidal thoughts and actions. In 2011, the FDA ordered additional warnings on Chantix packaging after a study found a small increased risk of cardiovascular problems. 

But in July 2016, a study found that Chantix had the best smoking cessation results among women, while its effectiveness for men was less certain. And now what's said to be the largest smoking cessation study of its kind finds a reduced risk of neuropsychiatric effects. In response, the FDA has lifted the black box requirement. 

The study — EAGLES (Evaluating Adverse Events in a Global Smoking Cessation Study) — found that in patients without a history of psychiatric disorder, Chantix was not associated with an increased incidence of clinically significant neuropsychiatric adverse events in a composite endpoint comprising anxiety, depression, feeling abnormal, hostility, agitation, aggression, delusions, hallucinations, homicidal ideation, mania, panic, and irritability.

In patients with a history of psychiatric disorder, there were more events reported in each treatment group compared to the non-psychiatric cohort, and the incidence of events in the composite endpoint was higher for each of the active treatments compared to placebo. 

“For millions who smoke, stopping smoking is one of the most important steps they can take to improve their health, and Pfizer is committed to helping smokers in their quit journey,” said Freda Lewis-Hall, M.D., chief medical officer and EVP, Pfizer Inc. “We are pleased with the FDA’s decision to update the Chantix labeling based on EAGLES — the largest clinical trial of smoking cessation medications — and we expect this new information may further facilitate an informed discussion about quitting with CHANTIX between smokers and healthcare providers.”

Hall noted that smoking is the leading preventable cause of death in the U.S., responsible for roughly 540,000 deaths each year. Stopping smoking has significant health benefits, including reducing the risk of tobacco-related diseases such as lung cancer, heart disease, stroke, chronic respiratory disease and other conditions. 

Since the 1964 Surgeon General's report that linked cigarette smoking to cancer, we have known of tobacco's corrosive effects on health.

But just how corrosive is it? A new report from the Centers for Disease Control and Prevention (CDC) suggests as many as 40% of all cancer cases diagnosed in the U.S. may have a tobacco link.

While tobacco use is most closely associated with lung cancer, the reports cites evidence that it also causes cancers of the mouth and throat, voice box, esophagus, stomach, kidney, pancreas, liver, bladder, cervix, colon, and rectum, and a type of leukemia, known as acute myeloid leukemia.

In short, the report's authors conclude that avoiding tobacco use is the best way to prevent the disease, which affected about 660,000 people in the U.S. from 2009 to 2013, killing more than half.

Another way of looking at it, since 1990 about 1.3 million cancer deaths linked to tobacco have been avoided because either people quit smoking or never started in the first place. CDC Director Dr. Tom Frieden says that should just be a start.

Preventable deaths

"There are more than 36 million smokers in the U.S.," Frieden said. "Sadly, nearly half could die prematurely from tobacco-related illnesses, including six million from cancer, unless we implement the programs that will help smokers quit."

But progress has been coming faster in recent years. In a separate CDC report, health officials note that cigarette smoking among U.S. adults has dropped more than 20% from 2005. From 2014 to 2015, there was a 1.7% drop, resulting in the lowest number of adult smokers since the government began collecting data in 1965.

Cigarette smoking surged in the years after World War II, some say encouraged by the fact that every GI's rations included a pack of cigarettes. As viewers of the hit series “Mad Men” saw, cigarettes were a ubiquitous part of American life in the 1960s. In 1965, the CDC estimates more than 42% of Americans were smoking.

Currently, the CDC estimates 16.8% of U.S. adults still smoke cigarettes, leading to more than $300 billion in annual health care costs.

Although giving up on smoking is a crucial first step towards improving a person’s health, a new study shows that health hazards from the habit persist long after the last pack has been thrown out.

Researchers from San Diego State University have found that the smokers’ homes remain polluted by thirdhand smoke (THS) for at least six months after they have quit. THS is made up of minute tobacco particles that penetrate various surfaces in the home – like carpets, upholstery, pillows, blankets, clothes, wallpaper, and ceiling tiles.

“We tend to see smoke in the air and then it’s out of sight out of mind. But it leaves compounds in indoor environments that can do harm to our bodies, especially children, and sometimes we cannot see or smell it,” said lead author George E. Matt.

Pollutants stick around

The researchers came to their conclusions after conducting a six-month study on tobacco smoke pollutants found in the homes of 90 former smokers. They measured home surfaces, dust, and the fingers of the former smokers for THS pollutants at five different intervals to see if levels went down over time.

The data showed that levels of nicotine had a significant short-term reduction on household surfaces and on participants’ fingers, but levels found in dust did not change much over the six-month period. Urine tests also revealed that urinary cotinine levels, which measure exposure to tobacco, were still detectable at the study's conclusion. 

This suggests that residents were still being exposed to tobacco pollution long after they quit, which could have long-term negative impacts on their health.

The researchers say that further study will be needed to fully understand the consequences of continued THS exposure. More work will also need to be done to figure out how to remove THS from the home so that it doesn’t become a health issue.

The full study has been published in the journal Tobacco Control.

It’s no secret that tobacco products of all kinds come with certain health risks – most notably cancer. But researchers have found additional dangers associated with smokeless tobacco products, which include substances ranging from chewing tobacco to dissolvable pills and gums.

They say that these tobacco delivery methods also carry bacteria that can cause infection and lead to illness. And, as with most kinds of bacteria or pathogens, prolonged exposure increases the risk to the person using these products.

“Some species have been identified as causative agents in spice-related outbreaks of diarrhea and vomiting. Additionally, they produce a mild toxin which, in large quantities could cause illness,” said Steven Foley, coauthor of the study.

Health risks

The researchers found several bacteria that could be a cause for concern among consumers. Bacteria from the Bacillus species are known to cause the intestinal discomfort described above by Foley, but other bacteria from the Stapphylococcus species could be even more troubling.

These bacteria, which include Stapphylococcus epidermidis and Staphylococcus hominus, could turn nitrates found in the body into nitrities, which could lead to potentially carcinogenic formations.

Part of the reason that these bacteria are able to pose so much danger to people is due to the way in which smokeless tobacco products are consumed. Those using the products tend to hold them in their mouth for long periods of time so that the nicotine can enter the bloodstream. This increases the amount of time that consumers are exposed to bacteria.

The practice is especially dangerous to those who have developed gingivitis or other oral health issues, which can be common for smokeless tobacco users. Researchers say that some of the bacteria present in these products can easily enter the bloodstream in these consumers and cause dangerous heart valve infections.

Informing policy decisions

Up to this point, not much data had been collected on the microbial threats present in smokeless tobacco products. The researchers hope that their work will help the U.S. Food and Drug Administration form policies around the production and distribution of these substances so that consumers can avoid some of the dangerous health risks.

The full study has been published in Applied and Environmental Microbiology.

Cigar smokers have for years felt beleaguered. Their spouses make them smoke outside, bars and restaurants increasingly show them the door, their cardiologists berate them mercilessly, and the U.S. government makes them go through silly charades to smuggle in the Cuban cigars they cherish.

The smoke cleared briefly when President Obama visited Cuba and began the process of restoring diplomatic relations. But then, back home, the U.S. Food and Drug Administration last week issued a proposed new 499-page rule that gives it authority over tobacco sales, including cigars. 

The FDA's proposed rule would require manufacturers to go through a certification procedure to demonstrate that their product is properly labeled and fits within whatever specifications are established for each type of product -- traditional cigarette, e-cigarette, etc. It also set the minimum smoking age at 18.

Although established brands will not have to go through the certification process, the rule will make it difficult to introduce new products and create especially thorny problems for mom-and-pop tobacconists.

Health concerns

The stated goal, of course, is to keep young people from taking up the tobacco and nicotine habits and to get a handle on the rapidly growing e-cig market, which health advocates like the International Association for the Study of Lung Cancer (IASLC) argue is a gateway to addiction.

"Giving FDA authority over all tobacco products is a good thing," said Dr. Kenneth Michael Cummings, Professor, Hollings Cancer Center, Medical University of South Carolina, and member of IASLC's Tobacco Control and Smoking Cessation Committee. "It clears up a loophole in the original law that excluded products like cigars."

The National Cancer Institute also takes a stern view of cigar and pipe smoking, warning on its Cancer.gov site: "There is no safe level of tobacco use. People who use any type of tobacco product should be encouraged to quit."

But Welch and other premium cigar aficianados say they shouldn't be lumped in with the types of tobacco products that appeal to teens. 

"Most of our customers are older than 40. In fact, our median customer is 55," Welch said in an email to ConsumerAffairs. "While we carry some small cigars (cigarillos) the majority of what is being bought at sites like ours are $5-$10 per cigar. I don’t think anyone would argue that’s a price-point that’s appealing to underage smokers."

Custom-rolled

Perhaps those most in peril from the new rule are the tobacconists who roll their own cigars and sell them to a select clientele. Check the commuter train stations around New York City and you'll find a surprising number of hole-in-the-wall shops that cater to Wall Streeters who duck in regularly to load up on their favorite custom-rolled smokes. 

The Miami area is also dotted with boutique cigar stores, many claiming to have ready access to Cuban-grown tobacco. When full relations with Cuba are restored, the tobacco may be legal but it's hard to see how these mom-and-pop purveyors will be able to create a legally saleable product.

"In my opinion, it’ll be very difficult for that independent cigar shop to not only jump through the FDA hoops to get their blends approved but also the costs associated with the testing," Welch said.

Then again, it's possible the FDA will devote its resources to e-cigarettes, cigarillos, and other products before getting around to cigars, giving cigar connoisseurs at least a brief respite.

"The FDA now has the authority to regulate the manufacturing elements of the products, such as ingredients, the introduction of new products, and more. The devil is in the details of how the FDA will do this, but presumably it will base actions on a continuum-of-risk basis, addressing the most dangerous products and practices first," Dr. Cummings said in a news release.

In the long run the only tobacconists likely to avoid the new regulations are those in Canada and elsewhere who now clandestinely sell supposed Cuban cigars to U.S. consumers via the Internet.

In that bygone era, when cigarette advertisements were everywhere, Camel had a campaign that asked, “are you smoking more but enjoying it less?”

As anyone who watched episodes of Mad Men knows, everyone seemed to be smoking a lot during the 1960s. But those days are over.

Cigarette marketing is tightly limited by a court settlement and, not surprisingly, Americans are smoking less. The Federal Trade Commission (FTC), which keeps track of cigarette sales in the U.S., reports the number of cigarettes sold by the major tobacco companies to U.S. wholesalers and retailers fell from 267.7 billion in 2012 to 256.7 billion in 2013.

Advertising less

Tobacco companies also spent less on advertising and promotion during that time. Marketing dollars dropped from $9.17 billion to $8.95 billion. Much of the decline was linked to a reduction in discounts retailers and wholesalers received in order to reduce the price of cigarettes to consumers.

The FTC report shows that tobacco companies trimmed their discounts by about $2 million.

If it looks like tobacco companies are withering away, they aren't. Stock in tobacco companies remains strong on Wall Street. The tobacco companies have simply found ways to diversify and adapt.

First, American tobacco companies have looked beyond U.S. borders. Smoking is declining in the U.S. but overseas – particularly in the developing world – it's a different story.

According to The Tobacco Atlas, decades of scientific and medical evidence linking smoking to cancer and other health issues has done nothing to deter about one billion people world-wide from lighting up.

More international smokers

“The decline in smoking rates in high-income countries is more than offset by increased tobacco use in middle- and low-income countries,” the Atlas authors write. “Tobacco companies know they must find replacement smokers, and focus much of their effort in these low- and middle-income markets, which have the potential for economic and demographic growth, and thus increased profits.”

Tobacco companies have also moved more heavily into smokeless tobacco and e-cigarette products. The FTC report advertising spending for smokeless tobacco products bucked the trend, actually increasing from 2012 to 2013.

At the same time, tobacco companies sold 125.5 million pounds of smokeless tobacco in 2012, then boosted it to 128.0 million pounds in 2013. In all, smokeless tobacco revenue rose by $180 million.

New York City enacted a law in 2014 that raised the minimum age to buy cigarettes from 18 to 21. The law was aimed at reducing smoking rates, especially among young people.

A law, of course, is only as effective as its enforcement. And researchers at NYU and UCLA have found that compliance with identification (ID) checks has significantly decreased since the law went into effect last year.

Before the law changed, researchers say 29% of retailers sampled were non-compliant. After the change, 38% of sampled retailers failed to ask for ID when selling cigarettes to young people.

Researchers also examined new minimum price laws for cigarettes and found a similar pattern.

Troubling pattern

"This study reveals a troubling pattern of non-compliance with ID check and minimum price laws among some retailers in New York City," said lead author, Dr. Diana Silver, an associate professor of public health policy at NYU's College of Global Public Health. "Without serious attention to strengthening enforcement of its current laws, New York City will fail to realize the full potential of its efforts to reduce smoking."

There could be several reasons for the lack of enforcement. For one thing, a lot of retailers might still be unaware that the age limit has risen.

Researchers note the new law did not go into effect until nine months after its enactment.

Multiple jurisdictions

Then, there's the fact that enforcement measures for retailer tobacco laws involve five different city and state agencies. Researchers say they all have unique protocols, and in many cases no additional resources were allocated for inspection, prosecution, and follow-up of those violating the new laws.

Under federal law, states are required to make sure non-compliance with ID check laws never fall below 20%. Dr. James Macinko, one of the study's authors, says the current level of non-compliance is troubling.

"In addition, sales below legal minimum prices present additional challenges for controlling access to cigarettes not just among youth, but among the entire city's population," he said.

Common conceptions about smoking have changed drastically over the years. Many Americans may remember old Westerns and other films where the machismo star would deliver a clever line and take a drag of his ever-present cigarette.

However, that iconography has changed in recent years. A more health-conscious populace recognizes the dangerous health effects of smoking, and as a result, it has become much less socially acceptable. But could this new stigma be making it harder for people to quit smoking? Researchers from Penn State think that might be case.

Negative stigmas

After conducting a study, researchers believe that stigmatizing smoking can, for some people, make it harder to quit. While you might question the validity of that statement at first, it actually makes a lot of sense if you stop and think about it. Some smokers can often feel attacked when faced with negative feedback on their habit, which can make them defensive and angry – not the ideal mindset for someone looking to quit.

For the purposes of the study, researchers from the U.S., U.K., Brazil, and Germany examined nearly 600 articles that addressed smoking self-stigma. They found that responses to negative stigmas ran the gamut – while they could influence some smokers to quit, they could also be just as effective at making other smokers stick to their habit.

“Consequences of stigmatizing stereotypes ranged from increased intentions to quit smoking to increased stress to greater resistance to quitting smoking,” said Rebecca Evans-Polce, a postdoctoral fellow from Penn State.

"Universally negative" stereotype

Unfortunately, these negative stigmas are currently pretty pervasive in our culture. “The stereotypes that smokers deal with are almost universally negative,” said Sara Evans-Lacko, a research fellow from the London School of Economics and Political Science.

Other related studies have found that 30-40 percent of smokers felt that their families and society disapproved of their habit. 27 percent felt they were treated differently because of it, and 39% believed that others thought less of them.

While these statistics are more general, negative stigmas for smoking are much more potent for different groups of people. Evans-Lacko said she found that stigmas for smoking parents were particularly strong. Other studies show that women who smoke are considered much more socially unacceptable than their male counterparts.

Proper social pressure

So while providing social pressure to get people to stop smoking may be effective, making sure it is the right kind of pressure is extremely important. Those who suffer from having too few coping mechanisms would benefit from anti-smoking programs that focus on the benefits of quitting, said Evans-Lacko.

While the study was successful, Evans-Polce admits that there is still much work that needs to be done. “Future research is needed to understand what factors are related to how individuals respond to smoking stigma," she said.

The full study has been published in the journal Social Science & Medicine. 

The negative effects of smoking have been well documented in numerous studies. Doctors across the world treat patients who have suffered from the habit every day, but one such doctor has had enough. Dr. Daniel Ouellette, a pulmonologist at Henry Ford Hospital, is suggesting that the legal smoking age be raised to 21.

The suggestion, which is popular amongst anti-smoking advocates, would help limit access to tobacco products for teenagers. This, Ouellette says, would reduce smoking prevalence amongst younger demographics. Health problems related to smoking often start young, so this would be an important step.

“Most of my patients are diagnosed with emphysema or lung cancer at a relatively young age from smoking, despite the media attention given to the health risks of smoking and despite them knowing about those risks,” said Ouellette.

E-cigs not safer

Ouellette is also very against the notion that e-cigarettes are a safer product. “They're unregulated so we can't be sure what's in them. In some studies, it showed that the particulates may be comparable to that of a regular cigarette,” he said. “They also come from China, which makes it hard to know who is manufacturing them.”

Unfortunately, many middle and high school students have latched onto the product. Statistics show that e-cigarette use amongst young people tripled between 2013 and 2014. And while the product is supposed to be safe, there have been hospitalizations related to using it. Conditions attributed to their use include pneumonia, congestive heart failure, and seizure.

Even if the above conditions do not manifest, some researchers say e-cigarettes can often act as a gateway product that leads to actual cigarette smoking – which is still responsible for one in five deaths in the United States.

One study, conducted and released by the Institute of Medicine in March of 2015, concluded that raising the legal age for using tobacco products would likely prevent or delay the start of smoking for adolescents and young adults. While this may seem obvious, it is extremely important since it would lower the prevalence of many age-related health problems associated with smoking.

Many cities and states already support raising the legal age of smoking. In June, Hawaii became the first state to raise the age required to buy tobacco products to 21; since then, 90 cities in 8 different states have followed their lead. Dr. Ouellette will be giving presentations on e-cigarettes and raising the legal age for tobacco products at the American College of Chest Physicians' annual meeting, which takes place in Montreal from October 24-28. 

The Food and Drug Administration has used its newly-acquired tobacco regulating power again – this time to order R.J Reynolds to stop selling four cigarette products.

The order covers Camel Crush Bold, Pall Mall Deep Set Recessed Filter, Pall Mall Deep Set Recessed Filter Menthol and Vantage Tech 13, with the agency ruling the products don't meet guidelines set out in the Federal Food, Drug, and Cosmetic Act (FD&C; Act).

The issue, according to the FDA, is these products are different from their versions that were on the market in early 2007. More specifically, the agency concluded the current products have different characteristics than those that came before and the manufacturer failed to show that the new products do not raise different questions of public health. As a result, the four products may no longer be distributed or sold in the U.S.

Science-based review

“These decisions were based on a rigorous, science-based review designed to protect the public from the harms caused by tobacco use,” said Mitch Zeller, director of the FDA’s Center for Tobacco Products. “The agency will continue to review product submissions and exercise its legal authority and consumer protection duty to remove products from the market when they fail to meet the public health bar set forth under law.”

The Family Smoking Prevention and Tobacco Control Act, signed into law in 2009, gave the FDA new powers to regulate tobacco, which it lacked in the past. However, the agency starting exercising those powers only recently.

In late August, the FDA fired off warning letters to three cigarette manufacturers – ITG Brands LLC, Santa Fe Natural Tobacco Company Inc., and Sherman’s 1400 Broadway N.Y.C. Ltd. — for making unsubstantiated claims about their products. That was the first time the FDA acted under the 2009 law.

Changed with no notice

In this latest action the agency expressed concern the cigarette products were changed with no notice, making them different from their previous approved versions.

The FDA said the scientific basis for these four decisions include a “failure to demonstrate that increased yields of harmful or potentially harmful constituents, higher levels of menthol, and/or the addition of new ingredients in the currently marketed products– when compared to the predicate products – do not raise different questions of public health.”

There have been countless methods tried to encourage people to stop smoking. Businesses have offered smoking cessation courses and drugs for their employees who smoke. They've also made it harder to light up at work, restricting when and where employees can smoke.

Now researchers at the University of California (UC) Davis Health System have stumbled across a novel approach. Give employees a pay raise.

They're not talking about paying people not to smoke – that's one of the incentives that's been tried, with mixed results.

No, they're simply suggesting that giving someone more money in their pay envelope will make them more likely to kick the habit.

10% pay boost

In a workplace study, the researchers found that a 10% increase in wages leads to about a 5% drop in smoking rates among workers who are male or who have high school educations or less. Statistically, the extra pay improves an employee's overall chances of quitting smoking from 17% to 20%.

"Our findings are especially important as inflation-adjusted wages for low-income jobs have been dropping for decades and the percentage of workers in low-paying jobs has been growing nationwide," said study senior author Paul Leigh, professor of public health sciences and researcher with the Center for Healthcare Policy and Research at UC Davis. "Increasing the minimum wage could have a big impact on a significant health threat."

Socioeconomic divide

Earlier this year the Washington Post reported on the odd socioeconomic divide between smokers and nonsmokers. The report cited a 2008 Gallup Poll that showed the rate of smoking among people making less than $24,000 a year was more than double that of those making $90,000 or more.

The Post report speculated on three possible reasons, including the fact that lower-income smokers tend to take longer, deeper drags on their cigarettes and are more addicted to nicotine, making it less likely that they will quit.

Leigh and lead author Juan Du wanted to find out if simply raising wages, moving a smoker a little farther up the economic ladder, could make it easier to stop.

The team looked at data on wages, smoking status and state of residence for full-time employees aged 21 to 65 years from the 1999 to 2009 Panel Study of Income Dynamics. They excluded anyone who never smoked, since the goal was to evaluate influences on quitting rather than starting smoking.

"We assume that people begin smoking for reasons other than wages," said Leigh. "About 90% of smokers in the United States started smoking before age 20, so the data captured a sample of most full-time workers who have ever smoked."

Money as treatment

After reviewing the results, Leigh and Du concluded that money is a form of “treatment.” They aren't sure why, but there was a correlation between wage increases and reduced smoking among men and the less educated. They also found there were fewer smokers in states with higher minimum wages or higher rates of unionization.

But there is apparently a limit to what money can do. While better pay seemed to be linked to men kicking the habit, the researchers found no such correlation among women.

One theory? Leigh and Du speculate that men may be more likely to tie self-worth to their pay, increasing the likelihood of risky health behaviors among men in lower-paying jobs.

ITG Brands LLC, Santa Fe Natural Tobacco Company Inc., and Sherman’s 1400 Broadway N.Y.C. Ltd. — three brands that describe their cigarettes on product labeling as “additive-free” and/or “natural” – have all received warning letters from the Food and Drug Administration (FDA).

That description violates section 911 of the Federal Food, Drug, and Cosmetic Act (FD&C; Act), the FDA said.

This is the first time the FDA has exercised its authority under the Family Smoking Prevention and Tobacco Control Act of 2009 to pursue regulatory action regarding the use of “additive-free” or “natural” claims on tobacco product labeling.

“The FDA’s job is to ensure tobacco products are not marketed in a way that leads consumers to believe cigarettes with descriptors like 'additive-free' and 'natural' pose fewer health risks than other cigarettes, unless the claims have been scientifically supported,” said Mitch Zeller, director of the FDA’s Center for Tobacco Products. “This action is a milestone, and a reminder of how we use the tools of science-based regulation to protect the U.S. public from the harmful effects of tobacco use.”

2009 law

Congress moved in 2009 to give the FDA the power to regulate cigarettes, cigarette tobacco, roll-your-own tobacco, and smokeless tobacco. At the same time, the law created channels for companies to use if they wanted to make claims of modified risk for their products.

Under the law, a “modified risk tobacco product” is “any tobacco product sold or distributed for use to reduce harm or the risk of tobacco-related disease associated with commercially marketed tobacco products.”

Companies that make this claim have to go through an approval process with the FDA and be prepared to back it up. The companies getting the warning letters, the agency says, did not do this.

Specific infractions

Specifically, ITG Brands was cited for marketing its Winston cigarettes with the MRTP claim “Additive-free.”

Santa Fe Natural Tobacco was cited for its Natural American Spirit cigarettes with the MRTP claims "Natural” and “Additive-free.”

The FDA said Sherman’s 1400 Broadway N.Y.C. has been marketing its Nat Sherman cigarettes with the MRTP claim “Natural.”

To make any of those claims, the FDA has determined that these products need an FDA modified risk tobacco product order before they can be legally introduced as such into interstate commerce.

As we reported Thursday, several anti-smoking groups have petitioned the FDA to crack down on such labeling. In particular, these groups said the FDA should look into Reynolds American's Natural American Spirit cigarette brand, which uses phrases like "additive free" and "organic tobacco," making it seem like the cigarettes might be less harmful than other brands.

The groups, in a letter to the FDA, say the tobacco may be “additive free” but smoking it is still a health hazard.

Slap an "organic" label on something and it's likely to sell better, even if it costs more. But what if the product is something that's inherently harmful? Like arsenic. Or cigarettes.

A coalition of health and anti-smoking organizations want the Food and Drug Administration (FDA) to do something about Renolds American's Natural American Spirit cigarette brand, which uses phrases like "additive free" and "organic tobacco," making it seem like the cigarettes might be less harmful than other brands.

The groups don't dispute that the Natural American cigarettes are free of additives like glycerol and corn syrup found in other brands, nor that they are made with organically grown tobacco.

But the health groups say that doesn't make them less likely to cause cancer, heart disease, emphysema, and other diseases associated with smoking. Yet that's what advertisements for the cigarettes imply, the groups say.

They say the ads violate the Family Smoking Prevention and Tobacco Control Act and they want the FDA to order the ads pulled. The small-print warnings that appear in the ads and on cigarette packs are inadequate, the groups argue.

You might think that all the warnings about tobacco use would sink in. In a lot of cases it has, but in too many it hasn't happened.

While the number of kids smoking cigarettes is down, the 2014 National Youth Tobacco Survey (NYTS), co-conducted by the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA) finds, the number using other tobacco products is way up.

“This is the only nationally representative survey of middle and high school students that focuses exclusively on tobacco use,” says Benjamin J. Apelberg, Ph.D., branch chief of epidemiology at FDA’s Center for Tobacco Products.

Survey results provided a national snapshot of what tobacco products today’s middle and high school youth are using, as well as emerging trends over time.

Key findings

Here's what the survey discovered:

• In 2014, 1 in 4 high school students and 1 in 13 middle school students reported being tobacco users (using one or more tobacco products in the previous 30 days).
• Of the then-current 4.6 million youth tobacco users, 2.4 million reported using e-cigarettes.
• Between 2011 and 2014, the percentage of students reporting current use of cigarettes plunged from 15.8% to 9.2%.
• Between 2011 and 2014, hookah use among high school students doubled and e-cigarette use increased even more dramatically.
• In 2014, nearly 2.2 million students reported using 2 or more tobacco products.

The rise of e-cigarettes

Since the survey started collecting data on e-cigarettes in 2011, their current use surpassed current use of every other tobacco product -- including conventional cigarettes -- for the first time in 2014 .

“One thing the study confirms for us is that the tobacco product landscape has changed dramatically,” Apelberg says. “Middle and high school kids are using novel products like e-cigarettes and hookahs in unprecedented numbers, and many are using more than one kind of tobacco product.”

It’s something of a good news/bad news picture, says FDA epidemiologist Catherine Corey. “While we’re glad to see cigarette smoking decreasing in middle and high school youth, the increase in the use of e-cigarettes and hookahs undermines progress in reducing tobacco use among kids,” she says.

Nicotine's consequences

Nicotine is dangerous and highly addictive for kids at any age, whether it comes from an e-cigarette, hookah, cigarette or cigar. Because the brain is still developing, adolescence appears to be a particularly vulnerable time.

Research has clearly demonstrated that exposure to nicotine at a young age increases the chance that kids will become addicted. In addition to nicotine exposure, tobacco use can be harmful due to the numerous other chemicals present in tobacco products that can cause disease.

“Youth should not use tobacco in any form,” Apelberg says.

At this time, FDA has regulatory authority over cigarettes, cigarette tobacco, roll-your-own tobacco and smokeless tobacco. The agency is in the process of completing work on a rule that would extend its authority to regulate additional products that meet the legal definition of a tobacco product, such as electronic cigarettes, cigars and hookahs. FDA is also proposing a minimum age of 18 for buying tobacco.

“These latest findings serve to strengthen existing scientific evidence that novel tobacco products like e-cigarettes and hookah have great appeal to youth, and that comprehensive youth prevention efforts that focus on reducing all forms of tobacco use are needed,” says Corey.

The good news is that fewer people are smoking but the risk to those who continue to smoke may increase over time, a new study warns.

Researchers studied 346,000 deaths from 12 smoking-related cancers and found that nearly half -- 48.5% -- were attributable to cigarette smoking, according to an article published online by JAMA Internal Medicine.

Researcher Rebecca L. Siegel, M.P.H., of the American Cancer Society and coauthors provide an updated estimate because they note that smoking patterns and the magnitude of the association between smoking and cancer death have changed in the past decade.

While smoking prevalence decreased from 23.2% in 2000 to 18.1% in 2012, some data suggest the risk of cancer death among smokers can increase over time, according to background in the study.

The study estimates that of 345,962 deaths there were 167,805 attributable to smoking cigarettes. The largest proportions of smoking-attributable deaths were for cancers of the lung, bronchus and trachea (125,799, 80.2%) and larynx (2,856, 76.6%).

About half of the deaths from cancers of the oral cavity, esophagus and urinary bladder were attributable to smoking, according to the results, which were reported in a research letter.

“Cigarette smoking continues to cause numerous deaths from multiple cancers despite half a century of decreasing prevalence. … Continued progress in reducing cancer mortality, as well as deaths from many other serious diseases, will require more comprehensive tobacco control, including targeted cessation support,” the researchers said.

Study details

The authors used data from the 2011 National Health Interview Survey, the Cancer Prevention Study III and the pooled contemporary cohort. The National Health Interview Survey provides smoking prevalence estimates based on in-person interviews of a representative sample of U.S. adults and the other data sources ascertained smoking from self-administered questionnaires.

The authors mention study limitations including that study populations were less racially diverse and more educated than the U.S. population and that tobacco exposures other than cigarettes were not included in the analysis.

The tobacco industry has lost one more battle. And it's a big one.

Three international firms – Philip Morris International, a British American Tobacco subsidiary and Japan Tobacco – have been ordered to pay damages to smokers in Quebec. In Canadian dollars the award amounts to $15.6 billion, or 12.5 U.S. dollars.

As many as 1 million Canadian smokers and former smokers were part of the suit and could stand to receive varying amounts of compensation.

"The companies earned billions of dollars at the expense of the lungs, the throats and the general well-being of their customers," said Quebec Superior Court Judge Brian Riordan.

Appeals

The companies are free to appeal the ruling but are still required, according to the court order, to start paying out compensation within 60 days.

In their complaint the plaintiffs charged – and the court agreed – that the tobacco companies did not adequately warn smokers that lighting up carried a multitude of health risks. They further maintained that the defendants failed to meet their obligation under the law not to cause injury to another person.

The tobacco companies argued that health risks associated with smoking have been well known for decades. Bloomberg News reports the three companies plan to appeal the judgment.

Though tobacco stock prices dropped on the news, investors initially seemed to shrug off the verdict.

“Class actions always have big numbers attached and having it quantified is a bit of a shock,” Erik Bloomquist, an analyst at Berenberg in London, told Bloomberg. “It’s unlikely the full amount will ever be paid.”

Response

British American Tobacco issued a statement noting it was not a party to the judgment, only its Canadian subsidiary, Imperial Tobacco Canada.

“There are strong legal grounds with which to challenge both the overall judgment, and to seek a stay of the provisional execution order, which Imperial Tobacco Canada will do within 30 days of the original 27th May ruling,” the company said in a statement. “As such, no payments will be made until the request to stay the provisional execution order has been heard and a judgment made.”

The Canadian litigation began in 1998 but didn't make it to court until 2012. In 1998 the 4 largest U.S. tobacco companies entered into the Tobacco Master Settlement Agreement with the U.S. government and 46 states.

Under the agreement, the companies agreed to, among other things, curtail a number of marketing practices and pay billions of dollars to the states to compensate them for Medicaid expenses. In return, the tobacco companies have been shielded from private tort liability in the U.S.

Alarmed by an increase in the smoking rate, health departments around the country are doubling down on their efforts to persuade consumer to quit.

In New York City, the health department is distributing a one-minute television ad, “Last Dance,” produced in Australia by Quit Victoria. The ad depicts a man dying from smoking-related cancer having a last dance with his wife while their child looks on.

The new ad depicts the harsh truth about smoking – it not only devastates the health of smokers, but also families who must care for the smoker and are ultimately left behind to mourn the loss of their loved one. The ad ends by asking smokers to quit smoking today.

The NYC health department estimates its efforts in the past have motivated more than 700,000 requests to seek assistance in quitting over the last nine years. But the current rate of adult smokers has increased from 14% – its lowest point – in 2010 to 16.1% in 2013. There are currently over 1 million smokers in New York City.

“As smoking rates begin to increase in New York City, the use of powerful media campaigns is more important than ever,” said Health Commissioner Dr. Mary Bassett. “Quitting smoking is one of the most important steps one can take to improve their health. We encourage every smoker to use this campaign as a reason to quit smoking today.”

Smoking remains the leading cause of premature, preventable death in the United States. It causes cancer, heart disease, emphysema and many other illnesses. Each year, there are an estimated 12,000 smoking-related deaths in New York City alone.

The health costs of cigarette smoking are well known. They start with lung cancer and heart disease.

But smoking also imposes a stiff financial toll in the health care costs required to treat smoking related diseases. A team of researchers, including some from the Centers for Disease Control and Prevention (CDC), puts the cost at about $170 billion a year.

And if you pay taxes, you're paying a significant portion of that cost. A comprehensive study of smoking related costs puts the taxpayer share of the $170 billion at 60%, since many of the people seeking treatment are on Medicare and Medicaid.

Sixty percent of the bill

The study found that taxpayers bear 60 percent of the cost of smoking-attributable diseases through publicly funded programs such as Medicare and Medicaid. The data comes from the 2006-2010 Medical Expenditure Panel Survey and 2004-2009 National Health Interview Survey.

What's discouraging to health care policymakers is the fact that smoking rates are going down, but the financial costs of smoking are going up.

Specifically, the researchers found that smoking can be blamed for $45 billion in Medicare spending each year and nearly $40 billion for Medicaid. The rest – some $24 billion – is spent on other government-sponsored insurance programs each year.

The CDC estimates that 16 million Americans suffer from a disease caused by smoking. When you add it all up the study links smoking to 8.7% of all health care spending in the U.S. each year.

Kills 480,000 Americans a year

Cigarette smoking is believed to be responsible for more than 480,000 deaths per year in the U.S., including as many as 41,000 from secondhand smoke exposure. This works out to about 1 in 5 deaths per year, or 1,300 per day.

On average, the CDC says smokers cut 10 years off their lives, compared to non-smokers. Even at declining smoking rates, 5.6 million of Americans younger than 18 are projected to die prematurely from a smoking-related illness. That's about 1 in every 13 Americans aged 17 or younger who are alive today.

Kicking the habit

Many smokers, or course, would like to quit and each January make a New Year's resolution to kick the habit, only to be faced with making the same resolution the following January.

The American Lung Association has offered 5 tips for quitting in 2015 and making it stick. They including using medication in some instances.

“The seven FDA-approved medications, like nicotine patches or gum, really do help smokers quit,” the association says. “Many folks don’t use them correctly or don’t use them long enough, so be sure to follow the directions.”

Statistics suggest smokers need every tool at their disposal. According to StatisticBrain.com, 70% of smokers want to quit, 40% will try to quit in the coming year and only 7% will be successful on the first try.

Fans of the AMC series “Mad Men” are reminded in each episode just how much smoking was a part of American life as recently as the 1960s. Smoke-free restaurants? Not a chance.

But after decades of strict controls on marketing and sale of tobacco products and publicity about the health dangers of smoking, fewer adults are lighting up.

In its most recent Morbidity and Mortality Weekly Report (MMWR) the Centers for Disease Control and Prevention (CDC) notes that only 17.8% of U.S. adults were smokers in 2013, down from 20.9% in 2005.

More work to do

“There is encouraging news in this study, but we still have much more work to do to help people quit,” said Tim McAfee, director of the CDC’s Office on Smoking and Health. “We can bring down cigarette smoking rates much further, much faster, if strategies proven to work are put in place like funding tobacco control programs at the CDC-recommended levels, increasing prices of tobacco products, implementing and enforcing comprehensive smoke-free laws, and sustaining hard-hitting media campaigns.”

The report makes another significant observation. We have gone from an era when everyone smoked to the present, when it seems that just consumers in certain demographics do. If you live below the poverty level or have little education you are more likely to be a smoker.

And since punitive taxes have been placed on cigarettes over the years to discourage smoking, that tax falls most heavily on the people least able to pay it.

Other groups that tend to smoke in much greater numbers than the population as a whole are American Indians, residents of the South and Midwest, people with a disability and people who are lesbian, gay or bisexual.

Cutting down

But even those who still smoke are apparently trying to quit, or at least cut down. The report shows the proportion of those who light up every day fell from nearly 81% in 2005 to 76.9% in 2013.

Smokers who only smoke on some days rose from 19.2% in 2005 to 23.1% in 2013. Even among daily smokers, the number of cigarettes smoked each day is falling.

“Though smokers are smoking fewer cigarettes, cutting back by a few cigarettes a day rather than quitting completely does not produce significant health benefits,” said Brian King, a senior scientific advisor with CDC’s Office on Smoking and Health. “Smokers who quit before they’re 40 years old can get back almost all of the 10 years of life expectancy smoking takes away.”

Role of e-cigarettes

Some smokers say they have been able to cut back, or quit altogether, by using e-cigarettes – devices that create a water vapor containing nicotine that can be inhaled, just like cigarette smoke. Anti-smoking groups generally hate the devices but public health experts are conflicted.

In an interview with the NPR program “Here and Now,” Thomas J. Glynn, former director of cancer science and trends at the American Cancer Society, said the jury is still out on the safety and efficacy of e-cigarettes, but said the devices need to be considered as a possible way to get consumers to stop smoking cigarettes.

Tobacco companies have seen the declining numbers of smokers in the U.S. and have embraced e-cigarettes as a new revenue source. America's largest tobacco company, Altria, has gotten into the business of manufacturing and marketing e-cigarettes. So has Reynolds-American.

Perhaps the first tobacco company to realize the revenue potential of e-cigarettes was Lorillard, which in 2012 purchased the already-established e-cigarette brand Blu.

Sales of e-cigarettes in the U.S. are estimated to be $1.5 billion a year and poised to grow nearly 25% by 2018.

It used to be thought that smoking cigarettes would help keep you thin. Some people may still believe that, but a new study finds that, in fact, the reverse is true: exposure to cigarette smoke can cause you to gain weight -- and secondhand smoke is even more likely to do so.

“For people who are in a home with a smoker, particularly children, the increased risk of cardiovascular or metabolic problems is massive,” said Benjamin Bikman, professor of physiology and developmental biology at Brigham Young University and the author of a study published in the American Journal of Physiology: Endocrinology and Metabolism.

Bikman and BYU colleague Paul Reynolds’ interest in cigarette smoke is tied to metabolic function: they wanted to pinpoint the mechanism behind why smokers become insulin resistant. To carry out their study, they exposed lab mice to side-stream (or second-hand) smoke and followed their metabolic progression.

Sure enough, those exposed to smoke put on weight. When they drilled down to the cellular level, they found the smoke triggered a tiny lipid called ceramide to alter mitochondria in the cells, causing disruption to normal cell function and inhibiting the cells’ ability to respond to insulin.

“The lungs provide a vast interface with our environment and this research shows that a response to involuntary smoking includes altering systemic sensitivity to insulin,” Reynolds said. “Once someone becomes insulin resistant, their body needs more insulin. And any time you have insulin go up, you have fat being made in the body.”

Half the country

The finding is significant, since it's estimated that half of the U.S. population is exposed at least once daily to secondhand cigarette smoke and approximately 20% of young children live with someone who smokes in the home. Every day, almost 4,000 young adults smoke their first cigarette and 1,000 become habitual smokers.

It might at first appear that the situation is relatively hopeless, since children and other relatives of smokers often don't get to choose their families.

But in fact, Bikman and his team found that there is a way to reverse the effects of cigarette smoke by inhibiting ceramide. The researchers found the mice treated with myriocin (a known ceramide blocker) didn’t gain weight or experience metabolic problems, regardless of their exposure to the smoke.

However, when the smoke-exposed mice were also fed a high-sugar diet, the metabolic disruption could not be fixed. Now Bikman and his team are in a race with other researchers to find a ceramide inhibitor that is safe for humans.

“The idea that there might be some therapy we could give to innocent bystanders to help protect them from the consequences of being raised in a home with a smoker is quite gratifying,” he said.

And what about the smokers themselves? Bikman said that one is easier said than done.

“They just have to quit,” he said. “Perhaps our research can provide added motivation as they learn about the additional harmful effects to loved ones.”

CVS announced last February that it intended to stop selling cigarettes and tobacco products before the end of the year.

This week CVS made good on that promise, three weeks earlier than initially planned, as part of its strategy to rebrand itself as CVS Health.

The company says that banning the sale of cigarettes in its stores (though it will sell smoking-cessation supplies) is estimated to cost it $2 billion in lost sales each year.

On the other hand, if CVS did continue selling cigarettes while operating medical clinics and otherwise portraying itself as a seller of life-saving or health-improving products, the company would expose itself to charges of seriously hypocritical behavior. Most CVS stores are found in fairly well-populated retail areas close to various other businesses, so customers wishing to buy cigarettes in addition to whatever they need from CVS shouldn't have to look too far.

Last December, New York City discovered a creative new interpretation of the RICO anti-racketeering statutes originally written for use against the Mafia and other organized-crime gangs: using it to sue FedEx for shipping merchandise from the Shinnecock [Indian] Nation cigarette shops to non-Shinnecock New Yorkers.

Today, New York's state attorney general filed a $70 million lawsuit against FedEx because “FedEx’s blatant disregard for its long-standing agreement with New York, as well as federal and state law, enabled tens of millions of cheap, untaxed cigarettes to be shipped to New Yorkers.”

The Shinnecock Nation is not included in either lawsuit because it is perfectly legal for them to sell untaxed cigarettes; however, New York Public Health Law 1399-ll bans the direct shipment of cigarettes to customers in the state, ostensibly for public-health rather than tax-collection reasons.

New York Attorney General Eric T. Schneiderman said FedEx has shipped nearly 80 million contraband cigarettes to consumers across New York State, amounting to a direct tax loss to the state of over $10 million.

When CVS announced in February that it would stop selling cigarettes, it became just a matter of time until other chains followed suit or were pressured to do so by health advocates.

And, sure enough, a coalition of state attorneys general is now calling on Wal-Mart, Walgreens, Rite-Aid, Safeway and Kroger to remove all tobacco products from their shelves. 

“Pharmacies and drug stores, which increasingly market themselves as a source for community health care, send a mixed message by continuing to sell deadly tobacco products,” said New York Attorney General Eric Schneiderman. “The fact that these stores profit from the sale of cigarettes and tobacco must take a backseat to the health of New Yorkers and customers across the country. I urge these companies to do the right thing and remove tobacco products from store shelves.”

Ohio Attorney General Mike DeWine is joining Schneiderman in the effort, saying in a letter to CEOs of the chains that, "The health of our kids is just too important” to be sacrificed for profits from tobacco sales.

Tobacco-related disease is the leading cause of preventable death in the United States, causing more than 480,000 deaths in the last year alone – more than AIDS, alcohol, illegal drug use, car accidents and firearm-related deaths combined, the AGs noted in their letter.

Furthermore, health care costs and productivity losses attributable to smoking cost the nation at least $289 billion each year. Almost 90% of all adult smokers start smoking by 18 years of age. “Big Tobacco” relies on getting young people addicted to cigarettes and keeping them as life-long smokers, they said.

With fewer new smokers and more people kicking the habit – along with restrictions on advertising and marketing – cigarette sales are in decline. The Federal Trade Commission (FTC) reported a 10% decline in U.S. cigarette sales in 2009, following a 62-cent increase in the federal cigarette tax.

In 2012 Lorillard, the nation's third-largest tobacco company, acquired Blu, a brand of e-cigarettes that has experienced rapid growth from former smokers, who say e-cigarettes give them many of the pleasures of smoking, including a nicotine kick. The move was followed last year by Altria Group's release of its own e-cigarette brand, Mark Ten.

A new study in the journal Tobacco Control looks at tobacco company advertising on the Internet and finds that their campaigns now focus for the most part on e-cigarettes, snus and cigars. 

$2 billion in sales

According to the public health foundation Legacy, which conducted the study, annual sales of smokeless tobacco products now exceed $2.93 billion globally and sales of e-cigarettes continue to grow, reaching $2 billion globally in 2011. For now, e-cigarettes are unregulated in the U.S., though the Food and Drug Administration (FDA) is said to be preparing regulations.

Public health and anti-tobacco groups have expressed alarm at the growing popularity of e-cigarettes and have pushed for tight controls. But are e-cigarettes as harmful as tobacco cigarettes have been shown to be? One medical researcher, at least, thinks the jury is still out.

In an editorial in the American Journal of Respiratory and Critical Care Medicine entitled “The Promise and Problems of E-cigarettes, Jerome S. Brody, of the Department of Medicine and Pulmonary Center at Boston University, calls for more study. 

Though research is in its infancy, he notes the known problems with e-cigarettes, which deliver the nicotine without many of the other harmful chemicals in tobacco smoke. He notes that nicotine itself is problematic; it's addictive and has been implicated in a number of cancers.

Ingredients list needed

“There is sufficient evidence about the toxicity of nicotine and other components that have been found in e-cigarettes, including tobacco itself, for regulatory agencies to require a list, with concentrations, of all e-cigarette ingredients,” Brody writes.

On the other hand, he doesn't rule out that e-cigarettes might be a preferable alternative to smoking cigarettes. He notes there have been a few studies that have suggested that very thing. It's time, he says, to find out.

“There clearly is a need for a multicenter clinical trial of the value of e-cigarettes in smoking cessation programs,” he writes.

Legacy says its study shows that not only is e-cigarette advertising widespread on the Internet the ads were placed on websites with the highest average percentage of a youth audience, with some websites having a youth audience as high as 35%.

Pushing the product, not smoking cessation

The study also found that e-cigarette ads were most likely to feature themes of harm reduction; use as an aide to quit smoking; being more environmentally-friendly alternative to cigarettes; or as an alternative to cigarettes when someone cannot smoke. However, Legacy says, when you click on the ad, you typically go to a site that tells you about the product but nothing about how to quit smoking.

Legacy's concern, says CEO Robin Kovel, is e-cigarettes are not being used solely by people who want to quit smoking. Rather, she says they're hooking a whole new generation of consumers on nicotine.

"Any encouragement to use their first tobacco products and initiate a nicotine addiction could potentially lead to them becoming lifelong tobacco users and undermine our efforts to achieve a 'Generation Free' of tobacco use," Koval said.

The U.S. Food and Drug Administration has ordered Sutra Bidis cigarettes off the market in the United States. The order outlaws the importation and sale of the thin, hand-rolled cigarettes, which are produced in India.

“Historically, tobacco companies controlled which products came on and off the market without any oversight,” said Mitch Zeller, J.D., director of the FDA’s Center for Tobacco Products. “But the Tobacco Control Act gave the FDA, a science-based regulatory agency, the authority to review applications and determine which new tobacco products may be sold and distributed under the law in order to protect public health.”

Bidis are thin, hand-rolled cigarettes filled with tobacco and wrapped in leaves from a tendu tree that are tied with string. The manufacturer, Jash International, did not meet the requirements of the Tobacco Control Act to be able to continue selling these products, the FDA said.

Company didn't provide evidence

The products – Sutra Bidis Red, Sutra Bidis Menthol, Sutra Bidis Red Cone, and Sutra Bidis Menthol Cone – were found to be not substantially equivalent to tobacco products commercially marketed as of February 15, 2007, also known as "predicate products." 

The Tobacco Control Act requires the FDA to review product applications so the agency can decide whether the products are substantially equivalent to valid predicate products. If a company fails to provide the necessary information to show that their product is SE to a predicate product, the FDA has the authority to declare a product not substantially equivalent, which means that it can no longer be sold or distributed in interstate commerce.

In this case, Jash International did not provide the information necessary for the FDA to make a decision, the agency said. 

“Companies have an obligation to comply with the law – in this case, by providing evidence to support an SE application,” said Zeller. “Because the company failed to meet the requirement of the Tobacco Control Act, the FDA’s decision means that, regardless of when the products were manufactured, these four products can no longer be legally imported or sold or distributed through interstate commerce in the United States.”

The FDA said it would give retailers 30 days to sell or dispose of Sutra Bidis now in their inventory but would take enforcement action after that.

If you have gotten used to buying a pack of cigarettes or a pouch of pipe tobacco when you pick up your prescription at your local CVS drug store, be prepared to change your routine.

The parent company -- CVS Caremark -- says it will stop selling cigarettes and other tobacco products at its more than 7,600 CVS/pharmacy stores across the U.S. by October 1, 2014. That would make it the first national pharmacy chain to do so.

"Ending the sale of cigarettes and tobacco products at CVS/pharmacy is the right thing for us to do for our customers and our company to help people on their path to better health," said Larry J. Merlo, President and CEO, CVS Caremark. "Put simply, the sale of tobacco products is inconsistent with our purpose."

President Obama said CVS' decision sends "a powerful message."

“As one of the largest retailers and pharmacies in America, CVS Caremark sets a powerful example,” Obama said. “Today’s decision will help advance my Administration’s efforts to reduce tobacco-related deaths, cancer, and heart disease, as well as bring down health care costs.”

CVS' action also won praise from Health & Human Services Secretary Kathleen Sebelius, who called it "an unprecedented step in the retail industry."

"We also commend CVS Caremark on their new national smoking cessation program. With more than 7,600 CVS/pharmacy locations, this private sector health leader’s new policy will have considerable impact," Sibelius said.

The move is expected to cost CVS $2 billion in annual revenue but the company says removing tobacco will help grow its business of "working with doctors, hospitals and other care providers to improve customers' health."

Reducing the risk

Smoking is the leading cause of premature disease and death in the U.S. with more than 480,000 deaths annually. While the prevalence of cigarette smoking has decreased from approximately 42 percent of adults in 1965 to 18 percent today, the rate of reduction in smoking prevalence has stalled in the past decade.

"CVS Caremark is continually looking for ways to promote health and reduce the burden of disease," said CVS Caremark Chief Medical Officer Troyen A. Brennan, M.D., M.P.H. "Stopping the sale of cigarettes and tobacco will make a significant difference in reducing the chronic illnesses associated with tobacco use."

The American Cancer Society calls the decision "an important new development" in the fight to save lives from the devastating effects of tobacco use. "We applaud CVS Caremark for its leadership," said John R. Seffrin, Ph.D., CEO of the American Cancer Society, "and strongly encourage other industry leaders to follow suit."

Harold Wimmer, national president and CEO of the American Lung Association, applauds CVS Caremark "for boldly acting" to remove tobacco products at all its locations across the U.S. "We urge more retailers to take note of CVS Caremark's actions," he said, "and join in efforts to help reduce access to tobacco and tobacco use, and eliminate tobacco-caused deaths and disease."

Springtime launch

Meanwhile, CVS is launching a quit-smoking program this spring. It's expected to include information and treatment on smoking cessation both in stores and online. 

The program will be available broadly across all CVS/pharmacy and MinuteClinic locations and will offer additional comprehensive programs for CVS Caremark pharmacy benefit management plan members to help them to quit smoking.  

As part of a national effort to prevent youth tobacco use and reduce the number of kids ages 12 to 17 who become regular smokers, the Food and Drug Administration (FDA) has kicked off a national public education campaign.

Tobacco use remains the leading preventable cause of disease, disability and death in the U.S., causing more than 480,000 deaths each year. Each day, more than 3,200 youth under age 18 in the United States try their first cigarette and more than 700 kids under age 18 become daily smokers.

Specific audience

“The Real Cost” campaign targets the 10 million young people ages 12-17 who have never smoked a cigarette but are open to it, and those who are already trying cigarettes and are at risk of becoming regular smokers.

“We know that early intervention is critical, with almost nine out of every ten regular adult smokers picking up their first cigarette by age 18,” said FDA Commissioner Margaret A. Hamburg, M.D.

“The Real Cost” campaign uses a comprehensive multimedia approach, compelling facts and vivid imagery designed to change beliefs and behaviors over time. The ads were developed to educate youth about the dangers of tobacco use and to encourage them to be tobacco-free. The campaign uses several social media platforms to create space for teens to engage in peer-to-peer conversations about the issue in ways that are authentic to who they are.

Multifaceted campaign

Supported by the best available science, the campaign will be evaluated to measure its effectiveness over time. It is the first of several campaigns that the FDA will launch over the next few years. Subsequent campaigns will target additional distinct audiences, including multicultural youth, rural youth, and lesbian, gay, bisexual, and transgender (LGBT) youth.

“The FDA has collaborated with some of the brightest and most creative minds to develop a multimedia initiative designed to make the target audience acutely aware of the risk from every cigarette by highlighting consequences that young people are really concerned about,” said Mitchell Zeller, director of the FDA’s Center for Tobacco Products.

Graphic depictions

One approach in “The Real Cost” campaign dramatizes the health consequences of smoking by graphically depicting health consequences such as tooth loss and skin damage to demonstrate that every cigarette comes with a “cost” that is more than just financial. Another approach reframes addiction to cigarettes as a loss of control to disrupt the beliefs of youth who think they will not get addicted or feel they can quit at any time.

In addition, some ads highlight the fact that menthol cigarettes cause the same health consequences as regular cigarettes, as youth are more likely to report smoking menthol cigarettes.

Ads will run in more than 200 markets throughout the U. S. for at least 12 months. The $115 million campaign is funded by industry user fees and launches nationwide on Feb. 11. The Tobacco Control Act authorized the FDA to collect tobacco user fees from manufacturers and importers of tobacco products to implement the law.

Everybody knows smoking is bad for smokers, and any bartender will tell you second-hand smoke is annoying and harmful. But third-hand smoke? Who even knew there was such a thing?

Well, there is and it's as dangerous as second-hand smoke. Third-hand smoke is defined as the second-hand smoke that gets left on the surfaces of objects, ages over time and becomes progressively more toxic, according to a scientist at the University of California, Riverside who, along with colleagues, conducted the first animal study of the effects of third-hand smoke.

"We studied, on mice, the effects of third-hand smoke on several organ systems under conditions that simulated third-hand smoke exposure of humans," said Manuela Martins-Green, a professor of cell biology who led the study. "We found significant damage occurs in the liver and lung. Wounds in these mice took longer to heal. Further, these mice displayed hyperactivity."

The study, which was published in PLOS One, provides a basis for further studies on the toxic effects of third-hand smoke in humans and serves to inform potential regulatory policies aimed at preventing involuntary exposure to third-hand smoke, Martins-Green said.

Threat to children

Third-hand smoke is a potential health threat to children, spouses of smokers and workers in environments where smoking is, or has been, allowed. Contamination of the homes of smokers by third-hand smoke is high, both on surfaces and in dust, including children's bedrooms.

Re-emission of nicotine from contaminated indoor surfaces in these households can lead to nicotine exposure levels similar to that of smoking. Third-hand smoke, which contains strong carcinogens, has been found to persist in houses, apartments and hotel rooms after smokers move out, the researchers said.

The team led by Martins-Green found that the mice exposed to third-hand smoke in the lab showed alterations in multiple organ systems and excreted levels of a tobacco-specific carcinogen similar to those found in children exposed to second-hand smoke.

In behavioral tests the mice exposed to third-hand smoke showed hyperactivity.

"The latter data, combined with emerging associated behavioral problems in children exposed to second- and third-hand smoke suggests that with prolonged exposure, they may be at significant risk for developing more severe neurological disorders," Martins-Green said.

Previously unknown

Although the potential risks attributed to third-hand smoke exposure are increasing, virtually nothing was known about the specific health implications of acute or cumulative exposure — until now.

"There is a critical need for animal experiments to evaluate biological effects of exposure to third-hand smoke that will inform subsequent human epidemiological and clinical trials," Martins-Green said. "Such studies can determine potential human health risks, design of clinical trials and potentially can contribute to policies that lead to reduction in both exposure and disease."

Her research team was surprised to find that the damage caused by third-hand smoke extends to several organs in the body.

"More recently we have found that exposure to third-hand smoke results in changes that can lead to type II diabetes even when the person is not obese," Martins-Green said. "There is still much to learn about the specific mechanisms by which cigarette smoke residues harm nonsmokers, but that there is such an effect is now clear. Children in environments where smoking is, or has been allowed, are at significant risk for suffering from multiple short-term and longer health problems, many of which may not manifest fully until later in life."

Research has shown that children living with one or two adults who smoke in the home, where second- and third-hand smoke are abundant, are absent 40 percent more days from school due to illness than children who did not live with smokers.

It's been 50 years since the Surgeon General's report on smoking led millions of Americans to quit or never take up the habit. But even fewer Americans are smoking today, the risk of dying for those who die smoke is higher than ever, said Acting Surgeon General Boris Lushniak, M.D., M.P.H.

“Smokers today have a greater risk of developing lung cancer than they did when the first Surgeon General’s report was released in 1964, even though they smoke fewer cigarettes,” said Acting Surgeon General Boris Lushniak, M.D., M.P.H. “How cigarettes are made and the chemicals they contain have changed over the years, and some of those changes may be a factor in higher lung cancer risks. Of all forms of tobacco, cigarettes are the most deadly – and cause medical and financial burdens for millions of Americans.”

The report also says that about 5.6 million American children alive today – or one out of every 13 children under age 18 – will die prematurely from smoking-related diseases unless current smoking rates drop.

20 million dead

Over the last 50 years, more than 20 million Americans have died from smoking. The new report concludes that cigarette smoking kills nearly half a million Americans a year, with an additional 16 million suffering from smoking-related conditions. It puts the price tag of smoking in this country at more than $289 billion a year in direct medical care and other economic costs.

Today’s report comes a half century after the historic 1964 Surgeon General’s report, which concluded that cigarette smoking causes lung cancer. Since that time, smoking has been identified as a cause of serious diseases of nearly all the body’s organs.

Today, scientists add diabetes, colorectal and liver cancer, rheumatoid arthritis, erectile dysfunction, age-related macular degeneration, and other conditions to the list of diseases that cigarette smoking causes. In addition, the report concludes that secondhand smoke exposure is now known to cause strokes in nonsmokers.

Twenty years ago male smokers were about twice as likely as female smokers to die early from smoking-related disease. The new report finds that women are now dying at rates as high as men from many of these diseases, including lung cancer, chronic obstructive pulmonary disease (COPD), and heart disease. In fact, death from COPD is now greater in women than in men.

Although youth smoking rates declined by half between 1997 and 2011, each day another 3,200 children under age 18 smoke their first cigarette, and another 2,100 youth and young adults become daily smokers. Every adult who dies prematurely from smoking is replaced by two youth and young adult smokers.

The report concludes that the tobacco industry started and sustained this epidemic using aggressive marketing strategies to deliberately mislead the public about the harms of smoking. The evidence in the report emphasizes the need to accelerate and sustain successful tobacco control efforts that have been underway for decades.

It's been a half century since the U.S. Surgeon General issued a report on January 11, 1964 linking cigarette smoking and lung cancer. Since then there has been an ongoing campaign against tobacco as lung cancer cases rose.

Now, health officials say that relentless campaign is beginning to yield tangible results. A report by the Centers for Disease Control and Prevention (CDC) has documented a significant drop in lung cancer among U.S. adults from 2005 to 2009. The sharpest decline was among those aged 34-44.

The study found that lung cancer rates went down 2.6% per year among men, from 87 to 78 cases per 100,000 men and 1.1% per year among women, from 57 to 54 cases per 100,000 women. Rates fell 6.5% for adults aged 35-44.

Landmark 1964 report

The Surgeon General's 1964 report declared that cigarette smoking was responsible for a 70% increase in the mortality rate of smokers over non-smokers. It estimated that average smokers had a nine- to ten-times greater risk of developing lung cancer compared to non-smokers. The more you smoked, the report found, the greater the risk. It also found that the risk diminished if people stopped smoking. Since then health advocates have repeatedly urged Americans to kick the habit.

"These dramatic declines in the number of young adults with lung cancer show that tobacco prevention and control programs work – when they are applied," said CDC Director Dr. Tom Frieden.

Still, lung cancer is the leading cause of cancer death and the second most commonly diagnosed cancer among both men and women in the U.S. Health officials say most lung cancers are attributable to cigarette smoking and secondhand smoke. Now that smoking behaviors among women are similar to those among men, women are now experiencing the same risk of lung cancer as men.

"While it is encouraging that lung cancer incidence rates are dropping in the United States, one preventable cancer is one too many," Frieden said. "Implementation of tobacco control strategies is needed to reduce smoking prevalence and the lung cancer it causes among men and women."

The Tobacco Master Settlement of 1998 provided billions of dollars from tobacco companies to the states, but the CDC notes that little of that money is actually being used to combat smoking. The agency cites research showing that, in 2010, states only appropriated 2.4% of their tobacco revenues for tobacco control. An earlier CDC study showed that states meet with widely varying results in their efforts to control tobacco and reduce new cases of lung cancer.

Prostate cancer

While lung cancer cases are in decline, health officials say prostate cancer continues to be the most common cancer in men. According to recently published data in CA: A Cancer Journal for Clinicians, it accounts for about 25% of new cancer cases in male patients.

However, researchers say prostate cancer is not increasing, with estimated new cases and death expected to fall three percent and one percent respectively. Still, prostate cancer remains a major health threat.

"Every week I talk with at least one family man in his 40s who has prostate cancer," said Jamie Bearse, CEO of ZERO, a prostate cancer awareness organization. "Men are dying. Families are suffering. We need to stand together and make fighting prostate cancer a national priority in order to see a real change in the number of lives being saved from the disease."

The group says prostate cancer continues to be the second most deadly cancer in men, accounting for 10% of estimated new cancer deaths in 2014. The report estimates that 233,000 men will be diagnosed with prostate cancer this year, and 29,480 will die from the disease.

It's the time of year for New Years resolutions and, if you are still a smoker, chances are kicking the habit is high on your list. And chances are it was last year as well.

A study by researchers at a number of institutions, including the Johns Hopkins Bloomberg School of Public Health, finds that smokers start off resolute in early January but often are back where they started by Groundhog Day. That may be a fitting reference since the researchers say smokers often go through the same thing actor Bill Murray did in the classic film “Groundhog Day,” reliving the same experience over and over.

To try to learn why that happens the researchers say they monitored the search query logs from Google from 2008 to 2012, looking for searches related to quitting, such as "help quit smoking." Specifically, they were looking for weekly patterns in smoking cessation. They found them.

Mondays are quitting day

The study found that people look for information about quitting smoking more often early in the week, with the highest query volumes on Mondays. The pattern was consistent across six languages -- English, French, Chinese, Portuguese, Russian, and Spanish.

Why is that important? The researchers suggest a global predisposition to thinking about quitting smoking early in the week, particularly on Mondays. That, they say, suggests smokers are more receptive to anti-smoking messages on Mondays.

“On New Year’s Day, interest in smoking cessation doubles,” said the study’s lead author, John Ayers of San Diego State University. “But New Years happens one day a year. Here we’re seeing a spike that happens once a week.”

That means a New Years resolution to quit smoking is not that important. What happens, for example, if you make it for several days but then lapse back into the habit? Usually it means another uninterrupted year of smoking.

Make it a weekly ritual

A better approach to discouraging smoking, the study suggests, is a weekly campaign. That way if someone is successful for a short while but falls back into the habit, they get another opportunity right away for a “reset,” in effect starting their New Years resolution all over again.

Previous research has found that it takes seven to 10 attempts to quit before someone finally gives up cigarettes. Reaching them once a week can compress the timeline of the quitting process.

“People around the world are starting the week with intentions to quit smoking – if we can connect those people at school, work and communities we can make a regular ‘Monday Quit’ the cultural norm,” said Morgan Johnson, director of programs and research at the Monday Campaigns and another co-author of the Google paper.

If you are a smoker who is trying to quit, there are several ways you can incorporate this philosophy into your efforts to stop smoking. For starters, seek some positive reinforcement.

What to do

Find people you know who have been able to stop smoking and, at the beginning of each week, seek encouragement from them. If you make it through a week without a cigarette, celebrate.

Take a few minutes every Monday to reflect on the progress you made over the previous week and make a plan for the upcoming week. Write down any cravings you had and how you overcame them, and record any upcoming triggers you may face in the current week.

Use Mondays as a time to recalibrate and recharge your commitment. Start each week reminding yourself of the reasons you decided to quit in the first place.

Reward yourself. If you make it through a week without lighting up, use the money you may have saved on buying cigarettes to treat yourself to a movie, go out to dinner, or whatever reward you think will keep you motivated to stay quit for good.

Finally, don't beat yourself up if you cave. Most smokers do before they finally stop. Remember that you can start the process all over each Monday.

How do you fight tobacco use when it doesn't taste like tobacco?

That's a problem anti-smoking forces are facing. A report by the Centers for Disease Control and Prevention (CDC) published in the Journal of Adolescent Health says more than two out of every five middle and high school students who smoke report using either flavored little cigars or flavored cigarettes.

The study also shows that among youth cigar smokers, almost 60% of those who smoke flavored little cigars are not thinking about quitting tobacco use, compared with just over 49% among all other cigar smokers.

“Flavored or not, cigars cause cancer, heart disease, lung disease, and many other health problems. Flavored little cigars appeal to youth and the use of these tobacco products may lead to disfigurement, disability, and premature death,” said CDC Director Tom Frieden, MD, MPH. ”We need to take comprehensive steps to reduce all tobacco use for all of our youth.”

Menthol, candy and fruit

The study found that 35.4% of current youth cigarette smokers use flavored cigarettes, which could include menthol cigarettes or flavored little cigars that they mistook for flavored cigarettes. In 2009, the Family Smoking Prevention and Tobacco Control Act was enacted and prohibited the use of flavors, except menthol, in cigarettes. However, flavored little cigars are still manufactured and sold with candy and fruit flavorings.

“Little cigars contain the same toxic and cancer-causing ingredients found in cigarettes and are not a safe alternative to cigarettes,” said Tim McAfee, MD, MPH, director of the CDC’s Office on Smoking and Health. “Many flavored little cigars appear virtually indistinguishable from cigarettes with similar sizes, shapes, filters, and packaging.”

In addition to offering a wide variety of flavors that appeal to young people, little cigars are taxed at a lower rate than cigarettes at the state level. Little cigars have become more popular in recent years; sales increased 240 percent from 1997 to 2007, with flavored brands making up almost 80 percent of the market share.

Smoking remains the leading cause of preventable death and disease in the United States. The health consequences of tobacco use include heart disease, multiple types of cancer, pulmonary disease, adverse reproductive effects, and the exacerbation of chronic health conditions. And 99% of all smokers start before they’re 26 years old.

If you are among the thousands who have recently quit smoking, you can thank Uncle Sam.

According to the Centers for Disease Control and Prevention (CDC), an estimated 1.6 million smokers attempted to quit because of the agency's “Tips From Former Smokers” national ad campaign. And, as a result of the 2012 campaign, CDC says more than 200,000 people actually kicked the habit.

And even better, the agency says researchers estimate more than 100,000 will likely quit smoking permanently. These results, CDC says,exceed the campaign’s original goals of 500,000 quit attempts and 50,000 successful quits.

“This is exciting news,” said said CDC Director Tom Frieden, M.D., M.P.H. “Quitting can be hard and I congratulate and celebrate with former smokers -- this is the most important step you can take to a longer, healthier life.” Frieden says anyone who tried to quit should keep trying, adding, “it may take several attempts to succeed.’’

Smokers and nonsmokers surveyed

A study, published by the a medical journal, The Lancet, surveyed thousands of adult smokers and nonsmokers before and after the campaign. It found that millions of nonsmokers reported talking to friends and family about the dangers of smoking and referring smokers to quit services. Almost 80% of smokers and almost 75% of non-smokers recalled seeing at least one of the ads during the three-month campaign.

Calls to the quitline more than doubled during the campaign and visits to the website were more than five times higher than for the same 12-week period in 2011, according to a 2012 report.

“Hard-hitting campaigns like ‘Tips From Former Smokers’ are great investments in public health,” said Tim McAfee, M.D., M.P.H., director of the CDC Office on Smoking and Health, and lead author of the study. “This study shows that we save a year of life for less than $200. That makes it one of the most cost-effective prevention efforts.”

More to come

The Tips campaign, CDC contends, is an important counter to the more than $8 billion the tobacco industry spends annually to make cigarettes more attractive and more available. Spending on educational campaigns such as Tips, says the agency, can help to save more lives and reduce health care costs. The taxpayer-funded Affordable Care Act’s Prevention and Public Health Fund paid for the $54 million Tips 2012 campaign. A second set of Tips ads aired earlier this year and plans are under way for a new set in 2014. CDC will release initial results of the 2013 ads later this year.

This coming January marks the 50th anniversary of the first Surgeon General’s Report on smoking and health, which concluded that smoking cigarettes causes lung cancer. Smoking remains the leading cause of preventable death and disease in the United States, killing more than 1,200 people every day.  

The Food and Drug Administration (FDA) was given the authority to regulate tobacco products back in 2009 and today, it issued its first decisions -- allowing Lorillard to market two new cigarette products and denying two other applications.

Under the law -- the Family Smoking Prevention and Tobacco Control Act of 2009 -- manufacturers have to establish that a new product is "substantially equivalent to a valid predicate product already on the market."

New products are not supposed to present any more harm to public health than the "predicate" -- or previously existing -- product. Acting on that standard, the agency approved two new Lorillard Tobacco Company products -- Newport Non-Menthol Gold Box 100s and Newport Non-Menthol Gold Box. 

The four products that were not approved fell into the trap called "not substantially equivalent" (NSE). The FDA found that there was a lack of evidence to support the claim that the new product was essentially the same as an existing one.

Not "FDA-approved"

The FDA goes out of its way to note that approving a product as being substantially equivalent does not mean it is safe or less harmful than existing products. In addition the law makes clear that companies cannot say their products are FDA approved.

The tobacco industry, which heavily lobbied the Family Smoking Prevention and Tobacco Control Act of 2009, has been holding its breath to see what the FDA would do with its new, though severely restricted, authority.

Smokeless tobacco, pipes and cigars could all find themselves facing new regulations, although the hottest issue at the moment is electronic cigarettes, or e-cigs. They're not tobacco products but the FDA has been scrutinizing them and is thought to be rolling up some new regulations.

Britain recently decided to regulate electronic cigarettes, treating them as non-prescription medicine. That means the popular e-cigs will still be widely sold in convenience stores and elsewhere but the government will enforce quality and purity regulations, just as it does with aspirin, sinus remedies and other widely sold products.

“Today’s historic announcement marks an important step toward the FDA’s goal of reducing preventable disease and death caused by tobacco,” said FDA Commissioner Margaret A. Hamburg, M.D. “The FDA has unprecedented responsibility to protect public health by not allowing new tobacco products under FDA’s authority to come to market without FDA review.”

“Today’s decisions are just the first of many forthcoming product review actions to be issued,” said Mitch Zeller, J.D., director of the FDA's Center for Tobacco Products. “The FDA is committed to making science-based decisions on all product applications and providing the agency’s scientific rationale behind its actions to ensure the most transparent and efficient process possible for all involved parties, according to the law.”

There's more money going up in smoke these days.

The Federal trade Commission (FTC) says in its latest Cigarette Report that the amount spent on cigarette advertising and promotion by the nation's largest cigarette companies rose from $8.05 billion in 2010 to $8.37 billion in 2011.

The increase was due mainly to an increase in spending on price discounts, or discounts paid to cigarette retailers or wholesalers in order to reduce the price of cigarettes to consumers. Spending on price discounts alone increased from $6.49 billion in 2010 to $7.00 billion in in 2011. That was the largest category in 2011, as it has been each year since 2002.

Meanwhile, the number of cigarettes sold to wholesalers and retailers in the United States declined from 281.6 billion in 2010 to 273.6 billion in 2011.

Smokeless Tobacco Report

At the same time, spending on advertising and promotion by the major manufacturers of smokeless tobacco products was also on the rise, according to the FTC's Smokeless Tobacco Report.

The total rose from $444.2 million in 2010 to $451.7 million in 2011, with price discounts making up the largest spending category and accounting for $168.8 million. And the dollar value of sales by these manufacturers rose from $2.78 billion in 2010 to $2.94 billion in 2011.

The weight of smokeless tobacco sold rose from 120.5 million pounds in 2010 to 122.7 million pounds in 2011.

When it comes to preventing children from smoking and drinking, heart-to-heart talks are more effective than peer pressure, marketing and all the national ad campaigns. And these talks need to start while kids are still in grade school, researchers say.

Zhiyong Yang, a marketing researcher at the University of Texas at Arlington and his partners Charles M. Schaninger and Michel Laroche, wanted to see if lessons taught during early childhood, about the harms of tobacco and alcohol, stayed with children once they became teenagers.

"The findings indicate that childhood parenting strategies impact smoking and drinking in the late teens, by reducing susceptibility to negative peer influence, with self-esteem playing a critical mediating role," wrote the study authors.

Good dad, bad dad

In a report entitled The Impact of Parenting Strategies on Child Smoking Behavior: The Role of Child Self-Esteem, both Yang and Schaninger stressed the importance of building up a child's self-esteem through parental talks and attention.

But if parents use psychological control to scare their children away from alcohol and tobacco, it could backfire and make those children want to try it. 

The study authors say parental psychological control is associated with using verbally and physically abusive methods to get a child to listen.

Using this tactic can lower a child's self-esteem and increase the chances of him or her caving to outside influences. And researchers say that many children are able to build up resistance against these strong-arm approaches.

Ads for parents

And while certain ad campaigns can be a helpful addition to parents when they talk to their kids about alcohol and tobacco use, more ads need to tell parents not to use psychological control as a tactic.

"Targeting parents through multimedia ad campaigns to bring about changes in parenting strategies to reduce or avoid teen smoking offers a fruitful complementary tool to targeting teens themselves," wrote the study authors. "Such campaigns should also emphasize avoiding parental psychological control as a strategy and begin reaching parents well before their children approach late grade school."

"In fact, our research shows those negative strategies, like withholding affection, drive a teen toward smoking," the authors said.

Changing tactics

And even though showing a child warmth and attention may not be a method that's associated with keeping a child away from alcohol and tobacco, researchers say it's the best weapon parents can have.

According to Yang, if parents are using psychological control to force obedience, it's never too late to change their approach, which they'll have to do if they want to give their child the best chance of turning down peer pressure.

"First, our conclusion is that parenting styles can be changed, and that's good news for the parents and the teens," he said.

"Second, our study shows that parental influence is not only profound in its magnitude, but also persistent and long-lasting over the course of a child's entire life. Effective parenting plays the critical role as a transition belt to pass normative values of society from one generation to another."

Positive influence

At the conclusion of his research, Yang said there was enough proof to dispel the common belief that teens couldn't be influenced by their parents in the same way their peers can influence them.

"What our research determined is that parental influence is a far greater factor than those," he said. "Parenting starts from birth. What could have a greater impact than that."

Additionally, Yang says parents should tell their kids about their own negative experiences with alcohol and tobacco, since being honest with them will do more good than harm.

"There's something to be said in telling a teen how you've suffered if you've smoked or engaged in a bad behavior when you were a teen," said Yang.

According to the Centers for Disease Control and Prevention 80% of adult smokers first tried cigarettes under the age of 18 and when it comes to underage drinking, 4,700 underage youths die each year, which is why parents have to start having conversations about negative teen behavior when their kids are still in grade school.

Remember the old Virginia Slims cigarettes slogan, “you've come a long way, baby?” A special article published in this week's New England Journal of Medicine (NEJM), puts what was intended as something positive into a very negative light.

According to the NEJM article, female smokers have a much greater risk of death from lung cancer and chronic obstructive lung disease (COLD) in recent years than did female smokers 20 or 40 years ago, reflecting changes in smoking behavior.

In fact, the increase in risk of death from lung cancer and COLD in female smokers has been large enough to completely offset improvements in longevity from medical advances that have reduced death rates in the rest of the population over the last 50 years.

Smoking like a man

Women smokers today smoke more like men than women in previous generations, beginning earlier in adolescence and until recently smoking more cigarettes per day (consumption peaked among female smokers in the 1980s).

To find out if these changing patterns have caused women's risk to converge with those in men, researchers, researchers led by Michael J. Thun, MD, recently retired as vice president emeritus of the American Cancer Society (ACS), measured fifty-year trends in mortality related to smoking across three time periods (1959-65, 1982-88 and 2000-2010), by comparing five large contemporary studies with two historical ACS cohorts.

In total the study included more than 2.2 million adults 55 years and older.

The rising risk

For women who smoked in the 1960s, the risk of dying from lung cancer was 2.7 times higher than that of never-smokers. In the contemporary cohorts (2000-2010) the risk was 25.7 times higher than that of never-smokers.

The risk of dying from COLD among female smokers was 4.0 times higher than that of never-smokers in the 1960s; in the contemporary cohort, this risk increased to 22.5 times higher than never-smokers. About half of the increase in risk of both conditions occurred during the last 20 years.

In male smokers, lung cancer risk plateaued at the high level observed in the 1980s, while the risk of death from COLD continues to increase for reasons that are unclear. Men and women smokers in the contemporary cohorts had nearly identically higher relative risks (compared to never smokers) for lung cancer, chronic obstructive lung disease, ischemic heart disease, stroke, and other heart disease. This finding strongly confirms the observed prediction that "If women smoke like men, they will die like men."

Quitting by 40

The research also confirmed that quitting smoking at any age dramatically lowers mortality from all major diseases caused by smoking, and that quitting smoking is far more effective than reducing the number of cigarettes smoked. The study found smokers who quit by age 40 avoided nearly all of the excess smoking-related mortality from lung cancer and COPD.

"The steep increase in risk among female smokers has continued for decades after the serious health risks from smoking were well established, and despite the fact that women predominantly smoked cigarette brands marketed as lower in 'tar' and nicotine," said Dr. Thun. "So not only did the use of cigarette brands marketed as 'Light' and 'Mild' fail to prevent a large increase in risk in women, it also may have exacerbated the increase in deaths from chronic obstructive lung disease in male smokers, since the diluted smoke from these cigarettes is inhaled more deeply into the lungs of smokers to maintain the accustomed absorption of nicotine."

Never-smokers

Another study appearing in the same issue of the NEJM looks at longevity among current, former, and never smokers in the nationally representative National Health Interview survey. That study, led by Dr. Prabhat Jha at St. Michael's Hospital at the University of Toronto, found that persistent lifetime smokers lose an average of about 10 years of life compared to never smokers. Smokers who die prematurely lose about 20 years of life.

"The findings from these studies have profound implications for many developing countries where cigarette smoking has become entrenched more recently than in the United States, said Dr. Thun. "Together they show that the epidemic of disease and death caused by cigarette smoking increases progressively over many decades, peaking fifty or more years after the widespread uptake of smoking in adolescence. The good news is the benefits of smoking cessation occur much more quickly and are substantial at any age."

Sometimes cigarette smokers get a bad rap.

I’m not a smoker, but I do feel for them at times, because their chosen decision to smoke has been almost criminalized.

When smokers were forced to leave bars and restaurants, many believed it was a great idea, and although there were obviously some critics of the new smoking laws, there surprisingly wasn’t too much push-back from either smokers or non-smokers.

In the Southern California enclave of Burbank, my collegue Truman Lewis reports that smoking is now strictly forbidden in all areas of the apartment complex he occupies, including balconies.  This is the result of the Secondhand Smoke Control Ordinance adopted way back on April 3, 2007. The ordinance prohibits smoking in specific locations throughout the city, including multi-family residences.

Truman says this hasn't stopped him from enjoying an evening cigar on his balcony.

"The balcony overlooks the 134 (freeway). Does a single cigar really cause more pollution than ten lanes of traffic?" Lewis wonders. 

Farther north, a new law in San Rafael provides that smoking will not be allowed in multi-family homes, duplexes or condominiums -- and some may ask, if smokers can’t smoke in their own homes or in restaurants, where should they go to smoke? (The answer, of course, is that they must buy a single-family home on a big lot and keep the windows closed).

“We are happy to blaze a trail, said the mayor of San Rafael, Gary Phillips. “We’re most happy to be in the forefront of the issue because we think it will greatly benefit our residents and those visiting San Rafael, and we think it will set the tone for other cities as well.”

Smoking will also be forbidden in the downtown streets and sidewalks of San Rafael.

Smoke slithers

The primary reason for the new law is that second-hand smoke easily travels through vents, air ducts and hallways of apartment buildings and condominiums, thus potentially affecting other families and households in the  complex.

It's not just cities. States are considering putting these kinds of laws into place in an effort to make smoking so inconvenient for smokers that they’ll eventually quit.  

But does that work? Does imposing strict laws on people really get them to give up a particular lifestyle, even if that lifestyle is bad for them health-wise?  Anyone who has seen a person addicted to drugs could probably answer that question pretty easily.

Critics say the smoking ban robs folks of the option of being themselves in the privacy of their own home, and is a form of punishment for people who choose to go against the health warnings attached to smoking.

“This proposed smoking ban actually intends to punish people for what they do in their own homes,” said a critic of the ban, Thomas Ruppenthal, to the San Rafael city council. “I really feel this is tyranny.”

However, proponents of the new law say it will definitely discourage smoking across the California city, and the statistics prove it.

“The San Rafael ban is a very significant event because it will spread," said Stanford University professor Robert Proctor in an interview. “We’re on the downslope of a big curve. Smoking peaked in 1981 with 630 billion cigarettes sold in the United States. Now it’s down to 350 billion. And that number will keep on going down until smoking is a distant memory.”

Enforcement questions

However the question is, how will officials really keep people from smoking in their homes? Will the new law create a bunch of 911 calls or complaints to the police, because a non-smoker smells smoke in their apartment? Some would say those non-smokers would have good reason to make sure the law is enforced.

Up in the wine country, a Healdsburg, Calif., resident told us he resigned from his condominium association board because he was tired of dealing with complaints about second-hand smoke.

"People keep their noses pressed to the vents, hoping to gather evidence on their neighbors. Who has time for that?" he asked. "I could be over at the tasting room instead."

According to the Centers for Disease Control and Prevention (CDC), second-hand smoke contains about 250 known toxins and 50 chemicals that can cause cancer, heart disease and other illnesses.

In addition, more than 126 million non-smokers inhale secondhand smoke from places like their jobs, vehicles and you guessed it, in their homes.

No escape

But the question remains, where will smokers go where they’re not affecting others with their cigarettes, pipes, or cigars?  They won't be able to go outside much longer. Cities are beginning to ban smoking in all public areas, including the outdoors -- and not just in health-obsessed California.

The Metro subway system in the Washington, D.C., area strictly forbids smoking on its outside sidewalks, escalators and so forth. Tickets are issued with some frequency. (And don't you dare try eating a banana or snack bar either). 

New York City imposed an outdoor citywide smoking ban earlier this year. The law, which Mayor Michael Bloomberg signed in February, makes smoking illegal in New York City's 1,700 parks and on the city's 14 miles of public beaches. Smoking is also be prohibited in pedestrian plazas like Times Square and within a certain number of feet of building exits.

Think you can retreat to the wilderness? Not likely. Smoking and open fires are verboten in many areas of national parks, forests and so forth. Smoking might still be OK on glaciers but they, as we know, are melting. 

Some airports now have smoking rooms -- usually resembling holding cells. Guess that might become the last resort. But would you have to buy an airline ticket just to get into the airport to have a smoke?

Two independent studies raise new health concerns about consumption of alcohol and use of smokeless tobacco products. Both suggest a link between the products and cancer.

Presenting the study at the meeting of the American Chemical Society, researcher Silvia Balbo explained how popular alcoholic beverages may be carcinogenic and hold special risk for people of Asian descent.

Balbo says the human body breaks down, or metabolizes, the alcohol in beer, wine and hard liquor. One of the substances formed in that breakdown is acetaldehyde, a substance with a chemical backbone that resembles formaldehyde.

Formaldehyde is a known human carcinogen. Scientists also have known from laboratory experiments that acetaldehyde can cause DNA damage, trigger chromosomal abnormalities in cell cultures and act as an animal carcinogen.

First evidence

“We now have the first evidence from living human volunteers that acetaldehyde, formed after alcohol consumption, damages DNA dramatically,” Balbo said.

Balbo says moderate drinkers have much less risk because a natural enzyme in the body converts the acetaldehyde to a relatively harmless substance. However, she says about 30 percent of people of Asian descent -- almost 1.6 billion people -- are unable to metabolize alcohol to the harmless substance. That genetic variant results in an elevated risk of esophageal cancer from alcohol drinking. Native Americans and native Alaskans have a deficiency in the production of that same enzyme, she said.

Also at the meeting of the American Chemical Society, researcher Stephen Hecht presented findings suggesting smokeless tobacco products contain a substance that is a strong oral carcinogen, posing a risk for the nine million consumers who use the products.

Strong oral cavity carcinogen

“This is the first example of a strong oral cavity carcinogen that’s in smokeless tobacco,” Hecht said. “Our results are very important in regard to the growing use of smokeless tobacco in the world, especially among younger people who think it is a safer form of tobacco than cigarettes. We now have the identity of the only known strong oral carcinogen in these products.”

Hecht’s team identified the carcinogen as (S)-NNN, one of a family of hundreds of compounds called nitrosamines, most of which are capable of causing cancer. Nitrosamines occur in a variety of foods, ranging from beer to bacon, and also form naturally in the stomach when people eat foods containing high levels of nitrite.

The problem, says Hecht, is that nitrosamine levels in smokeless tobacco are far higher than in food.

Hecht said evidence has been accumulating for years that people who use smokeless tobacco have an increased risk of cancer of the mouth, esophagus and pancreas. He says these findings should prompt the federal government to ban or regulate the products.

Tobacco use among American middle school and high school students showed a slow decline from 2000 to 2011, according to a report from the Centers for Disease Control and Prevention (CDC). But when compared with other long-term studies, such as the Youth Risk Behavior Survey, the steep rate of decline from 1997 to 2003 has slowed noticeably.

The new report shows that in 2011 nearly 30 percent of high school males and 18 percent of high school females used some form of tobacco. More than eight percent of middle school males and nearly six percent of middle school females used some form of tobacco in 2011.

Increases reported

The report indicates that though tobacco use continued an 11-year downward trend, tobacco use remains high among high school students. For example, among black high school students, cigar use increased significantly -- from 7.1 percent in 2009 to 11.7 percent in 2011. In 2011, cigar use among high school males (15.7 percent) was comparable to cigarette use (17.7 percent). Cigar use includes the use of cigarette-like cigars that can be packaged and smoked like typical cigarettes, but are taxed at a lower rate, making them more appealing and accessible to youth.

While they contain the same toxic chemicals as cigarettes, no cigars are subject to restrictions on flavorings and misleading descriptors such as “light” or “low tar,” according to the report.

Smokeless tobacco use

Nearly 25 percent of high school males and more than 17 percent of high school females used some form of smoked tobacco product in 2011, while smokeless tobacco use among high school males (12.9 percent) was eight times higher than among high school females (1.6 percent).

“An overall decline in tobacco use is good news, but although 4 out of 5 teens don't smoke, far too many kids start to smoke every day,” said CDC Director Thomas R. Frieden, M.D., M.P.H. “Most tobacco use begins and becomes established during adolescence. This report is further evidence that we need to do more to prevent our nation’s youth from establishing a deadly addiction to tobacco.”

Mixed results

The study, “Current Tobacco Use Among Middle and High School Students -- United States, 2011,” published in the latest Morbidity and Mortality Weekly Report reported no significant declines in the use of any tobacco product among middle school students from 2009 to 2011. However, cigarette use declined from 19.2 percent in 2009 to 15.8 percent among Hispanic high school students.

The report reaffirms the need to return youth tobacco use trends to the more rapid rate of decline seen from the late 1990s through 2003, officials said. To further reduce tobacco use among young people, the 2012 Surgeon General’s Report recommends making tobacco products less affordable, running hard-hitting mass media campaigns, and evidence-based tobacco control and prevention programs that work in conjunction with new restrictions on the sale, distribution, and marketing of cigarettes and other tobacco products to youth.

Health consequences

Tobacco use remains the leading cause of preventable death and disease in the United States. Cigarette use and exposure to secondhand tobacco smoke kill an estimated 443,000 Americans each year.

The health consequences of tobacco use include heart disease, multiple types of cancer, lung disease, adverse reproductive effects, and the worsening of chronic health conditions. Yet nearly 4,000 kids under age 18 try their first cigarette every day.

In addition to the cost in human lives, cigarette smoking has been estimated to cost $193 billion annually in direct health care expenses and lost productivity.

Total cigarette consumption is down, but that doesn’t tell the whole story about smoking.

According to a new report from the Centers for Disease Control and Prevention (CDC), those declines have been offset by sharp increases in total adult consumption of pipe tobacco (used for roll-your-own cigarettes) and cigarette-like cigars.

Although total cigarette consumption continued an 11-year downward trend with a 2.5 percent decline from 2010 to 2011, dramatic increases in use of non-cigarette smoked tobacco products have slowed the long decline in overall consumption of smoked tobacco products.

A decline, but…

From 2000 to 2011, the largest increases were in consumption of pipe tobacco (482 percent) and large cigars (233 percent). The increase in cigars was due largely to tobacco manufacturers adding weight to many small cigars so they can be classified as large cigars and avoid higher taxes and regulation, while at the same time retaining a size and shape very similar to cigarettes.

According to the report, total consumption of all smoked tobacco products (including cigarettes, roll-your-own tobacco, pipe tobacco and cigars) declined by 27.5 percent between 2000 and 2011. However, decline was minimal (0.8 percent) between 2010 and 2011. Despite the overall decline, the consumption of non-cigarette smoked tobacco products increased by 123 percent.

Cause for alarm

“The rise in cigar smoking, which other studies show is a growing problem among youth and young adults, is cause for alarm,” said Tim McAfee, director of CDC’s Office on Smoking and Health. “The Surgeon General’s Report released this past March shows that getting young people to either quit smoking or never start smoking is the key to ending the tobacco epidemic, because 99 percent of all smokers start before they’re 26 years old.”

The study, “Consumption of Cigarettes and Combustible Tobacco -- United States, 2000-2011,” uses Treasury Department data to calculate consumption for all forms of smoked tobacco products. CDC had previously not calculated consumption estimates, and depended upon consumption data published by the U.S. Department of Agriculture, which USDA stopped reporting in 2007.

The loophole

The report notes a disparity between consumption of cigarettes and other forms of smoked tobacco because the federal excise tax on pipe tobacco and roll-your-own tobacco is lower than cigarettes. The difference led to a dramatic increase in the sale of pipe tobacco used to make roll-your-own cigarettes, a lower-priced alternative to manufactured cigarettes.

A provision in a measure signed into law in July, the Transportation and Student Loan Interest Rate bill, could limit the advantage of this price difference. The difference in manufacturing and marketing restrictions between cigarettes and cigars also is a factor in the disparity. While the Food and Drug Administration prohibits the use of flavoring or descriptors such as “light” or “low tar” in cigarettes, there are no such restrictions on cigars and pipe tobacco.

Tobacco use remains the leading cause of preventable death and disease in the United States. The health consequences of tobacco use include heart disease, multiple types of cancer, lung disease, adverse reproductive effects, and the worsening of chronic health conditions.

Cigarette use and exposure to secondhand tobacco smoke kill an estimated 443,000 Americans each year. And for every death, 20 people live with a smoking-related disease. In addition to the cost in human life, cigarette smoking has been estimated to cost $193 billion annually in direct health care expenses and lost productivity.

There are many good reasons to give up cigarettes, both health and economic. Smoking is associated with cancer and heart disease and has become increasingly expensive as federal and state governments have tacked on more and more taxes.

In Illinois, the cost recently went up as the state legislature increased the tax on cigarettes. So while there are many good reasons to quit, a lot of smokers find it's very difficult.

“Nicotine really is that addictive," said Phillip McAndrew, MD, Loyola University Health System internal medicine physician and an occupational health expert. "It’s a hard battle, but every one that we win, including increasing the cost of cigarettes through taxes, brings individual smokers to the tipping point where the pain of smoking overcomes the joys of nicotine and they quit.”

The tipping point could be a life-altering health experience, but often it’s the impact on the pocketbook that makes people really consider quitting. In Chicago it can easily cost a person $300 a month to smoke. This is more than twice as expensive as a monthly prescription of medications to help people stop smoking.

McAndrew offers these eight tips to turn a tipping point into a successful effort to kick the habit:

1. Build a team

Nicotine is powerfully addictive, but so are the psychological aspects of smoking. It's all wrapped up into pleasure. Gather people around you who can provide support and encouragement. McAndrew says you will need people who are with you in all areas of your life, especially in places that make you think of smoking.

2. Set a specific date

It is important to be specific on a date you want to quit but also give yourself time to prepare. Some people just wake up one morning and go cold turkey. McAndrew thinks you'll have more success if you set a date two to four weeks away so you have time to prepare your environment and your mind to quit.

3. Prepare for quit day

Once you've set a date, plan for how you are going to stop. Think about medications and other tactics to aid you in the fight. Keep gum or hard candy in the car or an office drawer as a substitute when you feel the need to light up.

4. Celebrate quit day

“Once the decision is made to quit smoking, start thinking about the quit day and get excited. Don’t see it as an end to a favorite habit, but a celebration of the beginning of a new, healthier life,” said McAndrew.

He suggests going out with friends or having a party to mark this special occasion. Just make sure there is no smoking allowed.

5. New mechanisms for coping with stress

Many people light up when they encounter stress, so think of ways to handle stress in your life without a cigarette. This is where a doctor, a support group and your team can really lend a hand. Devise healthier ways to deal with stress such as exercising or deep breathing.

6. Watch out for boredom

People sometimes light a cigarette when they're bored. Often this happens in the car, especially on a long drive. McAndrew suggests listening to audio books in the car to keep your mind engaged.

7. Continue to do the things you enjoy

Many people smoke because they find it pleasurable and associate quitting with a loss of pleasure. So make sure there is still plenty of pleasure that doesn't involve tobacco. If you are accustomed to taking a smoking break, go ahead and take the break -- just don't smoke. And don't hang out with others who are smoking on their break.

8. Think about those you love

This could be the biggest motivation. As McAndrew says, “quitting smoking is about so much more than ourselves." Studies have shown that second-hand smoke can be more devastating than first-hand smoke, especially for children. Children who live in homes where there is a smoker are more prone to allergies and have more colds, upper-respiratory infections and ear infections, McAndrew says.

Family Dollar's announcement that it will begin carrying tobacco products has brought a howl of protest from anti-smoking groups.

In a letter to the company's CEO, about a dozen national public health and advocacy organizations called the decision a “dire disappointment” and urged that it be reconsidered.

"Family Dollar's decision to sell tobacco goes up against the company's commitment 'to improve the quality of life of [its] customers and Team Members', given that tobacco is the No. 1 cause of preventable death in the United States," said Cheryl G. Healton, President and CEO of Legacy, a smoking cessation organization. "Selling tobacco at Family Dollar could heavily impact the lives of those Americans who already suffer disproportionately from tobacco's economic and health consequences."

The groups charge the tobacco industry has deliberately marketed tobacco brands to low socio-economic and minority youth and adults, pointing out that smoking is greatest among adults with working class jobs, low educational levels, low income, and those who are unemployed – groups that comprise the very communities Family Dollar serves.

Low-income neighborhoods

Since Family Dollar stores are often found in neighborhoods with low-income and middle income families, the groups say the company has the potential to increase access to what they call “the nation's deadliest consumer product.”

"Family Dollar Stores have traditionally served many Latino and minority communities around the country," said Dr. Jeannette Noltenius, the National Director of the National Latino Tobacco Control Network (NLTCN). "Selling tobacco products that have been proven to be addictive, that prematurely kill one of every three customers and are sold cheaply to youth creating new tobacco customers, would change the way Latinos perceive these stores, from a family friend to a family threat. We urge the owners and leadership of Family Dollar Stores to stop and think that this move will affect the health and lives of our communities and that they will be held accountable for expanding the access to these dangerous products just to make more money."

Legacy spearheaded the letter, which supports the efforts of Break Free Alliance and the Campaign for Tobacco-Free Kids. The American Academy of Pediatrics and a group comprising all living former U.S. Surgeons General, directors of the U.S. Centers for Disease Control and Prevention and secretaries of the U.S. Department of Health, Education and Welfare and Health and Human Services (Citizens' Commission to Protect the Truth) also signed the letter urging Family Dollar to reconsider its decision.

The company has defended its policy as a business decision based on customer demand.

What's the most common piece of litter being flicked onto the ground, into lakes, parks, beaches and roads? Yep, it's the cigarette butt. 

According to environmental cleanup reports, nearly 2 million cigarettes or cigarette filters and butts were picked up internationally from beaches and inland waterways as part of the annual International Coastal Cleanup (ICC) in 2010, including more than one million from the United States alone. Cigarette butts account for more than three times the number of any other item found over the past 25 years of ICC cleanups, according to Legacy, a public health organization.

Besides being unsightly and, for at least a few minutes, a fire hazard, cigarette butts have potentially toxic effects on ecosystems. In one laboratory test, one cigarette butt soaked in a liter of water was lethal to half of the fish exposed.

In observance of Earth Day on April 22, Legacy is working to raise awareness about the negative impact cigarette filters and discarded cigarette butts have on the environment. Cigarette butts contain heavy metals that can leach into waterways, posing a lethal threat to aquatic life. They are costly to local communities to clean up and dispose of as well.

Cigarette butts are made mostly of plastic, which can take years to decompose in the marine environment and down into smaller pieces. While a majority of the respondents surveyed nationally (78 percent) know that cigarette butts are not typically biodegradable and recognize their toxicity (89 percent), tobacco products are still the most prevalent type of litter collected along U.S. roadways and on beaches. These toxic pieces of trash are only biodegradable under ideal conditions and in “real world” conditions, they merely break up into small particles of plastic.

“If more than 287 billion cigarettes were sold last year, where did all those butts go?” said Cheryl G. Healton, DrPH, President and CEO of Legacy. “Cigarette manufacturers acknowledge that there is no such thing as a safe cigarette and have long known that cigarette filters don’t reduce health consequences of smoking and are a major source of coastal litter.” Cigarettes and their butts contain carcinogenic chemicals that make tobacco use the leading cause of preventable death in the United States and globally.

Cigarette litter clean-up costs can be substantial to local authorities. The Legacy poll also found that the majority (73 percent) of those surveyed believe that smokers should be responsible for cleaning up and disposing of cigarette butts after they smoke.

“Cigarette butts are commonly, unconsciously and inexcusably dumped into the global environment every year,” said Dr. Holly Bamford, Deputy Assistant Administrator for the National Ocean Service at National Oceanic and Atmospheric Association. “Once these filters make their way into our oceans, they could be mistaken for food and ingested by birds and marine life, which could cause them to choke or starve to death. We have to begin to change social norms so that just like every other form of litter, it is unacceptable to drop plastic cigarette butts anywhere other than proper receptacles,” she said.

A chemical called (S)-N’-nitrosonornicotine, or (S)-NNN, is present in smokeless tobacco products. Researchers say it is a strong oral carcinogen.

Although smokeless tobacco products have long been linked with certain cancers, including oral cavity cancers and esophageal cancers, researchers haven't been sure why. Now, they say they have a very good idea.

A chemical called (S)-N’-nitrosonornicotine, or (S)-NNN, is present in smokeless tobacco products. Researchers say it is a strong oral carcinogen.

“(S)-NNN is the only chemical in smokeless tobacco known to cause oral cancer,” said Silvia Balbo, Ph.D., research associate at the Masonic Cancer Center of the University of Minnesota in Minneapolis, Minn. “This finding provides mechanistic underpinning for the epidemiologic observations that smokeless tobacco products cause oral cancer.”

Lab rats

Balbo and colleagues reached their conclusion after a study using laboratory rats. They say the results overwhelming suggest the linkage between the chemical and oral cancers.

“Measures should be taken to reduce this chemical in smokeless tobacco,” Balbo said. “If it is not possible to stop the use of smokeless tobacco products, we should advocate for a reduction of this chemical in these products.”

Because the Food and Drug Administration regulates tobacco products, Balbo said she hoped these results will inform regulatory decisions. In the future, she and her colleagues hope to identify other chemicals that may be carcinogens in smokeless tobacco and to understand what level of these chemicals is present in smokeless tobacco products.

And it goes without saying, Balbo believes these findings are yet another reason that tobacco products should be avoided.

The U.S. Food and Drug Administration(FDA) is releasing what it says is previously unknown information about the chemicals in tobacco products, intended to help prevent misleading marketing about the risks associated with tobacco products. 

The first document released today provides guidance on how companies will comply with the requirement to report on the quantities of potentially harmful chemicals in tobacco products. The second provides guidance to companies that seek to advertise or market a tobacco product as less harmful or associated with reducing the risk of tobacco-related disease. 

"Today’s actions represent critical steps forward on providing Americans with the facts about the dangers of tobacco use and to stop children from smoking," said Health and Human Services Secretary Kathleen Sebelius. "We will continue to do everything we can to help smokers quit and prevent kids from starting this deadly addiction."

The Family Smoking Prevention and Tobacco Control Act requires tobacco product manufacturers and importers to report quantities of harmful and potentially harmful constituents (HPHCs) found in tobacco products or tobacco smoke by brand and sub-brand. These  are chemicals or chemical compounds in a tobacco product or tobacco smoke that cause, or could cause, harm to smokers or non-smokers. All of the chemicals included on the list cause or may cause serious health problems including cancer, lung disease, and addiction to tobacco products.

While there are more than 7,000 chemicals in tobacco and tobacco smoke, FDA has today established a list of 93 specific chemicals that tobacco companies will be required to report for every regulated tobacco product sold in the United States.

Time line

The FDA said it recognizes that industry may be unable to meet the deadline due to current testing limitations. In recognition of this, the draft guidance released today identifies 20 chemicals that are representative of the full list and for which testing methods are well established and widely available.

FDA intends to focus reporting enforcement on these 20 substances during 2012.

Modified risk

FDA also issued draft guidance today on submitting applications to sell modified risk tobacco products (MRTPs) -- tobacco products that are sold, distributed, or marketed with a claim to reduce harm or the risk of tobacco-related disease.

The Tobacco Control Act establishes rigorous scientific criteria an applicant’s tobacco product must meet before FDA can allow the applicant to sell that product with a claim to reduce harm. The draft guidance describes scientific studies and analyses an applicant should submit to demonstrate its product will, or is expected to, significantly reduce harm or exposure to individuals, and benefit the health of the population as a whole.

"We are  forging new territory to ensure that tobacco companies provide accurate information and do not mislead American consumers," said FDA Commissioner Margaret Hamburg, M.D. "We are committed to stopping such practices that may cause people to start or continue using tobacco products that could lead to preventable disease and death."

States like New York have very high taxes on cigarettes, both to raise revenue and to discourage smoking. But there are ways around the tax.

New York Attorney General Eric T. Schneiderman says one retailer -- Tobacco House C.C.W., Inc., in Dewitt, N.Y. -- has found a way around the tax. According to Schneiderman, consumers can purchase loose tobacco, tubes of cigarette paper and access to machinery that instantly produces assembled cigarettes onsite.

The customer leaves the store with cigarettes that were purchased without paying federal or state cigarette taxes. But Schneiderman says this "roll your own" business sells cigarettes in violation of tax and other regulatory statutes applicable to cigarettes by selling the components of cigarettes and facilitating customers' production of untaxed and unsafe cigarettes.

The lawsuit

Schneiderman has sued the business, its owner, and its employees, saying they are in violation of the Federal Contraband Cigarette Trafficking Act, the New York State Cigarette Marketing Standards Act, and New York State tax law, for selling cigarettes on which the required taxes have not been paid.

The lawsuit also charges the defendants with violating New York’s Cigarette Fire Safety Act by selling cigarettes that have not been certified as “fire-safe” to extinguish more quickly than standard cigarettes, and which bear no health warnings, both of which are required by New York State law.

“Rather than playing by the rules, this store and others like it are cheating the state out of millions of dollars per year in legitimate tax revenue and endangering public health and safety while they’re doing it,” Schneiderman said.

'Illegally low prices'

Schneiderman says the business charges “illegally low prices" for their store-made machine-rolled cigarettes, encouraging people to take up smoking and to discourage smokers from quitting.

"Additionally, because cigarettes are the number one cause of deaths by fire in this country, New York State has long required that all cigarettes sold in the state be fire-safe; these cigarettes are not,” Schneiderman said.

Tobacco House advertised “All Cigarettes $28.99 per Carton,” and sometimes even advertised a $3.00-off-per-carton coupon, bringing the price down to $25.99 per carton, prices which fall well below the amount of the taxes alone on a carton of cigarettes.

The state's lawsuit against Tobacco House seeks an injunction to stop the defendants from continuing their sale, distribution, and advertisement of non-taxed cigarettes, as well as compensation for the tax revenue lost by the state as a result of defendants’ activities.

A federal appeals court has held that graphic warnings on cigarette packs do not violate tobacco companies' First Amendment rights.

The U.S. Court of Appeals for the Sixth Circuit upheld most provisions of the new law giving the U.S. Food and Drug Administration (FDA) the power to regulate tobacco products, including the requirement for large, graphic warnings on cigarette packs. 

The court majority found that the law's requirement for large, graphic cigarette warning labels "are reasonably related to the government's interest in preventing consumer deception and are therefore constitutional." The court found that the warnings "do not impose any restriction on Plaintiff's dissemination of speech, nor do they touch on Plaintiffs' core speech. Instead, the labels serve as disclaimers to the public regarding the incontestable health consequences of using tobacco."

Key provisions

The court also upheld key provisions of the law that:

• Prohibit tobacco companies from making health claims about tobacco products without FDA review;

• Ban several forms of tobacco marketing that appeal to children, including brand name sponsorships, tobacco-branded merchandise such as caps and t-shirts, and free samples of tobacco products; and

• Prohibit tobacco companies from making statements implying that a tobacco product is safer because it is regulated by the FDA.

The ruling for the most part affirms an earlier decision by Judge Joseph H. McKinley in the U.S. District Court for the Western District of Kentucky. Judge McKinley's decision upheld the cigarette warning labels requirement and most other provisions of the law.

Separate case

In a separate, narrower case, Judge Richard Leon, of the U.S. District Court for the District of Columbia, struck down the new cigarette pack warnings. That ruling is on appeal to the U.S. Court of Appeals for the DC Circuit, with oral arguments scheduled for April 10.

In addition to finding that the warning requirement is constitutional, the ruling strongly supports Congress' findings in enacting the requirement and finds the warnings are supported by the scientific evidence and the tobacco industry's long history of deception regarding the health hazards of its products.

"Tobacco manufacturers and tobacco-related trade organizations knowingly and actively conspired to deceive the public about the health risks and addictiveness of smoking for decades," the majority opinion states. "In addition to this decades-long deception by Tobacco Companies, their advertising promoting smoking deceives consumers if it does not warn consumers about tobacco's serious health risks…

"Faced with evidence that the current warnings ineffectively convey the risks of tobacco use and that most people do not understand the full risks, the Act's new warnings are reasonably related to promoting greater public understanding of the risks. A warning that is not noticed, read, or understood does not serve its function. The new warnings rationally address these problems by being larger and including graphics."

In addition, the appeals court majority countered Judge Leon's argument that the proposed labels are meant to incite an emotional response and therefore constitute 'opinions' that don't pass legal scrutiny. "Facts can disconcert, displease, provoke an emotional response, spark controversy and even overwhelm reason, but that does not magically turn such facts into opinions," the Sixth Circuit opinion states.

There are a number of commercial products designed to help smokers kick the habit, including nicotine patches and nicotine gum. Collectively, they are known as nicotine replacement therapies (NRT).

Do they work? Researchers at the Harvard School of Public Health (HSPH) and the University of Massachusetts Boston suggest that they do not. They claims, they say, just don't add up.

"What this study shows is the need for the Food and Drug Administration (FDA), which oversees regulation of both medications to help smokers quit and tobacco products, to approve only medications that have been proven to be effective in helping smokers quit in the long-term and to lower nicotine in order to reduce the addictiveness of cigarettes," said co-author Gregory Connolly, director of the Center for Global Tobacco Control at HSPH.

The research team included lead author Hillel Alpert, research scientist at HSPH, and co-author Lois Biener of the University of Massachusetts Boston's Center for Survey Research. They followed 787 adult smokers in Massachusetts who had recently quit smoking.

How they reached their conclusions

The participants were surveyed over three time periods: 2001-2002, 2003-2004, and 2005-2006. Participants were asked whether they had used a nicotine replacement therapy in the form of the nicotine patch (placed on the skin), nicotine gum, nicotine inhaler, or nasal spray to help them quit, and if so, what was the longest period of time they had used the product continuously. They also were asked if they had joined a quit-smoking program or received help from a doctor, counselor, or other professional.

The results showed that, for each time period, almost one-third of recent quitters reported to have relapsed. The researchers found no difference in relapse rate among those who used NRT for more than six weeks, with or without professional counseling. No difference in quitting success with use of NRT was found for either heavy or light smokers.

"This study shows that using NRT is no more effective in helping people stop smoking cigarettes in the long-term than trying to quit on one's own," Alpert said. He added that even though clinical trials have found NRT to be effective, the new findings demonstrate the importance of empirical studies regarding effectiveness when used in the general population.

Dueling studies

Their findings appeared the same day as researchers at George Washington University called for including smoking cessation treatments under Medicaid, arguing the government would receive a good return on its investment in the form of improved health. The Massachusetts researchers disagree.

Biener said that using public funds to provide NRT to the population at large is of questionable value, particularly when it reduces the amount of money available for smoking interventions shown in previous studies to be effective, such as media campaigns, promotion of no smoking policies, and tobacco price increases.

Smoking cessation medications have been available over the counter since 1996, yet U.S. Centers for Disease Control and Prevention statistics show that the previous adult smoking rate decline and quitting rates have stalled in the past five years.

Most American adults who smoke wish they could quit, and more than half have tried within the past year, according to a report by the Centers for Disease Control and Prevention.

The report says 68.8 percent of current American adult smokers say they want to quit and 52.4 percent of adult smokers tried to quit within the past year.  The report says 48.3 percent of smokers who saw a health professional in the past year recalled getting advice to quit and 31.7 percent used counseling and/or medications in the past year.

The use of these effective treatments can almost double to triple rates of successfully quitting.

“More than two thirds of smokers want to quit smoking and more than half tried to quit last year,” said CDC Director Thomas R. Frieden, M.D., M.P.H.  “Smokers who try to quit can double or triple their chances by getting counseling, medicine, or both.  Other measures of increasing the likelihood that smokers will quit as they want to include hard–hitting media campaigns, 100 percent smoke–free policies, and higher tobacco prices.”

According to the report, making health care settings as well as all workplaces and public places smoke-free offers smokers additional encouragement to help them quit.  The report also notes the health care industry can increase successful quit attempts by providing comprehensive insurance coverage with no deductibles or co-payments for cessation treatments and services. 

Free help

Smokers can get free resources and help quitting by calling 1-800-QUIT-NOW (784-8669) or visiting www.smokefree.gov.

“Quitting smoking is the best thing smokers can do for their health and the health of their families,” said Tim McAfee, M.D., M.P.H., director of CDC’s Office on Smoking and Health. “We know that quitting can be challenging, but more than half of Americans who ever smoked have quit and you can too.  Talk to your health care provider and call 1-800-QUIT-NOW for free help.” 

Tobacco use remains the leading preventable cause of death and disease, including cancer, chronic obstructive pulmonary disease and other lung diseases, in the United States.  Smoking and exposure to secondhand tobacco smoke kill an estimated 443,000 Americans each year.  For every 1 smoking-related death, another 20 people live with a smoking-related disease.  

The analysis is in CDC’s Morbidity and Mortality Weekly Report. The report is being published in conjunction with the annual Great American Smokeout, observed this year on Nov. 17. Sponsored by the American Cancer Society, the Smokeout encourages smokers to use the date to make a plan to quit, or to plan in advance and quit smoking that day.

Most of the time we hear the health reasons why you shouldn't smoke, or if do do, why you should quit. Heart disease, lung cancer, emphysema – the list goes on.

But Dr. Carlos Reynes of Loyola University Health System’s Gottlieb Memorial Hospital, says there's also a very strong economic incentive not to smoke cigarettes.

“At $7 to $9 each, a pack-a-day habit sets you back between $2,500 and $3,300 each year, “ Reynes said. “And improved health also will save you trips to the doctor.”

Sometimes, smokers who are trying to save money turn to illegal cigarette sites on the Internet. Demetrios, a ConsumerAffairs.com reader who has looked into these products after purchasing some, says the products are even more dangerous than regular cigarettes.

Cheap cigarettes may be more dangerous

These companies advertises as a 'duty free shop' offering authentic international cigarette brands at bottom dollar prices,” Demetrios said. “The cigarettes you will receive will be illegal counterfeits smuggled out of China. These fake cigarettes are illegal and extremely dangerous to your health. Scientists who have analyzed Chinese cigarette knockoffs have found elevated levels of toxic heavy metals like arsenic, cadmium and lead, as well as human feces, sawdust, mold, insect eggs and rat droppings.”

Reynes is board-certified in internal medicine and also integrative medicine. For those who want to quit, he says there are a number of aids that have proven effective.

“Hypnosis and acupuncture as well as nicotene patches and chewing gums are just a few of the successful tools out there to help smokers kick the habit,” he said. “The important step is to make the effort to quit and if you are unsuccessful, to keep trying different techniques.”

Reynes says the United States is winning the war against smoking. More than three million Americans quit smoking every year and fewer are adopting the unhealthy and expensive habit. That's producing, he says, a declining smoking rate in the U.S.

“From 1965 to 2006, smoking rates fell by half, falling from 42 percent to 20.8 percent of adults and we will continue to do even better through education and incentives,” he said.

Great American Smoke Out

The Great American Smoke Out, a day sponsored by the American Cancer Society to end smoking, is Thursday, Nov. 17 and thousands of smokers are expected to take a 24-hour break from cigarettes.

While saving money is nice, Reynes says the best reason to give up smoking is to save your health. Kicking the habit, he says, pays off almost immediately.

“Twenty minutes after quitting, your heart rate and blood pressure drop. Twelve hours after quitting the carbon monoxide level in your blood drops to normal,” Reynes said Dr. Reynes. “One year after quitting the excess risk of coronary heart disease is half that of a continuing smoker’s.

An estimated 46 million adults in the United States currently smoke, and approximately half will die prematurely from smoking, according to the American Cancer Society.

Those highly graphic images the government hoped to use as warning labels on cigarette packages will not appear – at least not anytime soon.

U.S. District Judge Richard Leon has granted a stay for tobacco companies, who have sued to block the use of the labels, arguing they violate the companies' First Amendment rights. Leon granted the stay, saying he believes the tobacco companies will win in their suit against the U.S. Department of Health and Human Services (HHS).

Until that case is tried, Leon ruled the labels cannot be used.

HHS proposed the new warning labels almost exactly one year ago. They were designed to have more impact than the text warnings that have appeared on cigarette packages since the mid 1960s. The proposed new labels were to appear on the top half of the package and include graphic – some might same gruesome images – designed to deter smokers.

The nine new labels included pictures of a diseased lung, a corpse, diseased gums and a man smoking through a hole in his throat.

Public response to the images was mixed.  A ConsumerAffairs.com analysis of about 6,100 postings on Twitter, Facebook and other social media found opinion roughly evenly divided, although the number of comments was too small to draw any conclusions.

Health advocates protest

“The ruling ignores the overwhelming, decades-long need for strong cigarette warning labels and allows Big Tobacco to proceed ’business as usual,’ continuing to promote its addictive and deadly products," said Christopher W. Hansen, President, American Cancer Society Cancer Action Network.

“For decades, the tobacco industry has grown increasingly aggressive in preying upon America’s youth with misleading and fraudulent marketing practices, while the warning labels have not been changed in 25 years," Hansen added. "Larger, graphic warning labels have the potential to encourage adults to quit smoking cigarettes and deter children from starting in the first place."

"Judge Leon's ruling ignores the overwhelming scientific evidence about the need for the new cigarette warnings and their effectiveness. It also ignores decades of First Amendment precedent that support the right of the government to require strong warning labels to protect the public health," said Matthew L. Myers, President, Campaign for Tobacco-Free Kids.

Leading cause of death

In proposing the big change in warning labels, HHS pointed out that tobacco use is the leading cause of premature and preventable death in the United States -- responsible for 443,000 deaths each year. Thirty percent of all cancer deaths are due to tobacco. Each day 1,200 lives of current and former smokers are lost prematurely due to tobacco-related diseases.

The government strategy included a proposal issued by the Food and Drug Administration (FDA) titled "Required Warnings for Cigarette Packages and Advertisements."

Specifically, it detailed a requirement of the Family Smoking Prevention and Tobacco Control Act that nine new larger and more noticeable textual warning statements and color graphic images depicting the negative health consequences of smoking appear on cigarette packages and in cigarette advertisements.

The final rule was to have gone into effect in September 2012, requiring all cigarettes sold in the U.S. to carry the enhanced warning.

Five cigarette companies filed suit in Washington last year, seeking to block the warnings. The industry's lawyer argued that the government can require the tobacco companies to print a straightforward and “essentially uncontroversial” warning on the package, but said “turning cigarette packs into mini billboards for anti-smoking messages” crosses the line constitutionally.

What is it about smoking?  Everybody knows it's really bad for you but millions of people old and young, dumb and smart, rich and poor continue to smoke the evil weed, while others chew it or find other ways to get it into their system.

This is not the kind of question that can be left lying around, say public health officials.  It needs to be answered.  And so the U.S. Food and Drug Administration (FDA) and the National Institutes of Health (NIH) today announced a joint, large-scale, national study of tobacco users to monitor and assess the behavioral and health impacts of new government tobacco regulations.

We thought we might be able to help out find a few answers, so we conducted a computerized sentiment analysis of about 4.2 million comments posted over the last year on Twitter, Facebook and other social media and blogs.  Looking at about 10,000 comments from people who liked cigarettes, this is what we found:

OK, so 63% said they get pleasure, taste and smell from smoking.  Oddly, a few seemed to think cigarettes are "good for you." 

Dislikes

We found about 33,000 people who voiced very strong dislikes for cigarettes, including the smell and taste that tobacco lovers found pleasurable.  Only 7% mentioned fear of cancer.

The initiative, called the Tobacco Control Act National Longitudinal Study of Tobacco Users, is the first large-scale NIH/FDA collaboration on tobacco regulatory research since Congress granted FDA the authority to regulate tobacco products in the Family Smoking Prevention and Tobacco Control Act of 2009.

Scientific experts at NIH’s National Institute on Drug Abuse and the FDA’s Center for Tobacco Products will coordinate the effort.

“The launch of this study signals a major milestone in addressing one of the most significant public health burdens of the 21st century,” said FDA Commissioner Margaret A. Hamburg. “The results will strengthen FDA’s ability to fulfill our mission to make tobacco-related death and disease part of America’s past and will further guide us in targeting the most effective actions to decrease the huge toll of tobacco use on our nation’s health.”

40,000 smokers

Investigators will follow more than 40,000 users of tobacco-product and those at risk for tobacco use ages 12 and older. They will examine what makes people susceptible to tobacco use; evaluate use patterns and resulting health problems; study patterns of tobacco cessation and relapse in the era of tobacco regulation; evaluate the effects of regulatory changes on risk perceptions and other tobacco-related attitudes; and assess differences in attitudes, behaviors and key health outcomes in racial-ethnic, gender, and age subgroups.

“We are pleased to collaborate with the FDA on this study that may provide us with a better understanding of the impact of product regulation on tobacco prevention and cessation,” said NIH Director Francis S. Collins, M.D., Ph.D.

Study findings will help the FDA assess the impact of the Tobacco Control Act and will inform the agency about how to best use its tobacco regulatory authorities, such as making decisions about marketing of products, setting product standards, and communicating the risks from tobacco use to protect the public health.

While smoking rates have dropped significantly since their peak in the 1960s, nearly 70 million Americans ages 12 and older were current users of tobacco products in 2010. As a result, death and disease caused by tobacco use is still a tremendous public health burden.

Tobacco use is the leading preventable cause of disease, disability, and death in the United States. Cigarette smoking results in more than 443,000 premature deaths in the United States each year – more than alcohol, illegal drug use, homicide, suicide, car accidents, and AIDS combined.

Researchers at UCLA have leveled a serious charge at U.S. tobacco companies. For more than 40 years, they say, tobacco companies knew that cigarette smoke contained radioactive alpha particles that can cause cancer, but kept their findings from the public.

The analysis of dozens of previously unexamined internal tobacco industry documents, made available in 1998 as the result of a legal settlement, allegedly reveals that the industry was aware of cigarette radioactivity some five years earlier than previously thought and that tobacco companies, concerned about the potential lung cancer risk, began in-depth investigations into the possible effects of radioactivity on smokers as early as the 1960s.

Aware in 1959

"The documents show that the industry was well aware of the presence of a radioactive substance in tobacco as early as 1959," the authors write. "Furthermore, the industry was not only cognizant of the potential 'cancerous growth' in the lungs of regular smokers, but also did quantitative radiobiological calculations to estimate the long-term lung radiation absorption dose of ionizing alpha particles emitted from cigarette smoke."

The researchers say the study, published online Sept. 27 in Nicotine & Tobacco Research, adds to a growing body of research detailing the industry's knowledge of cigarette smoke radioactivity and its efforts to suppress that information.

"They knew that the cigarette smoke was radioactive way back then and that it could potentially result in cancer, and they deliberately kept that information under wraps," said the study's first author, Hrayr S. Karagueuzian, a professor of cardiology who conducts research at UCLA's Cardiovascular Research Laboratory, part of the David Geffen School of Medicine at UCLA. "Specifically, we show here that the industry used misleading statements to obfuscate the hazard of ionizing alpha particles to the lungs of smokers and, more importantly, banned any and all publication on tobacco smoke radioactivity."

Carcinogenic alpha radiation

The radioactive substance — which the UCLA study shows was first brought to the attention of the tobacco industry in 1959 — was identified in 1964 as the isotope polonium-210, which emits carcinogenic alpha radiation. Polonium-210 can be found in all commercially available domestic and foreign cigarette brands, Karagueuzian said, and is absorbed by tobacco leaves through naturally occurring radon gas in the atmosphere and through high-phosphate chemical fertilizers used by tobacco growers. The substance is eventually inhaled by smokers into the lungs.

The study outlines the industry's growing concerns about the cancer risk posed by polonium-210 inhalation and the research that industry scientists conducted over the decades to assess the radioactive isotope's potential effect on smokers — including one study that quantitatively measured the potential lung burden from radiation exposure in a two-pack-a-day smoker over a two-decade period.

Despite the potential risk of lung cancer, the study maintains that tobacco companies declined to adopt a technique discovered in 1959 and then another developed in 1980 that could have helped eliminate polonium-210 from tobacco. The 1980 technique, known as an acid-wash, was found to be highly effective in removing the radioisotope from tobacco plants, where it forms a water-insoluble complex with the sticky, hair-like structures called trichomes that cover the leaves.

The real reason?

And while the industry frequently cited concerns over the cost and the possible environmental impact as rationales for not using the acid wash, UCLA researchers uncovered documents that they say indicate the real reason may have been far different.

"The industry was concerned that the acid media would ionize the nicotine, making it more difficult to be absorbed into the brains of smokers and depriving them of that instant nicotine rush that fuels their addiction," Karagueuzian said. "The industry also were well aware that the curing of the tobacco leaves for more than a one-year period also would not eliminate the polonium-210, which has a half-life of 135 days, from the tobacco leaves because it was derived from its parent, lead-210, which has a half-life of 22 years."

"We used to think that only the chemicals in the cigarettes were causing lung cancer," Karagueuzian said. "But the case of the these hot spots, acknowledged by the industry and academia alike, makes a strong case for an increased probability of long-term development of malignancies caused by the alpha particles. If we're lucky, the alpha particle–irradiated cell dies. If it doesn't, it could mutate and become cancerous."

Karagueuzian said the findings are very timely in light of the June 2009 passage of the Family Smoking Prevention and Tobacco Control Act, which grants the U.S. Food and Drug Administration broad authority to regulate and remove harmful substances — with the exception of nicotine — from tobacco products. The UCLA research, he said, makes a strong case that the FDA ought to consider making the removal of alpha particles from tobacco products a top priority.

Does smoking a menthol-flavored cigarette brand make it harder to quit. Some say yes, some say no.

Now, researchers at The Cancer Institute of New Jersey (CINJ) and UMDNJ-School of Public Health add fuel to the debate. Their study finds that menthol cigarettes are associated with decreased quitting in the United States, and that this effect is more pronounced for African-Americans and Puerto Ricans.

The findings, which appear in the American Journal of Preventive Medicine, are being released as the Food and Drug Administration's (FDA) Center for Tobacco Products is currently considering banning menthol cigarettes after its own Tobacco Product Scientific Advisory Committee (TPSAC) concluded that “removal of menthol cigarettes from the marketplace would benefit public health in the United States.”

African-Americans object

Last fall the National Black Chamber of Commerce (NBCC) formally opposed the FDA proposal to ban menthol cigarettes, charging it was a move directed against African-Americans.

"It is no secret that menthol cigarettes provide a distinctive taste that is preferred by many African Americans," NBCC President Harry Alford said. "In making a recommendation, it is my fervent hope that the committee not make a decision based on mixed information, decades-old marketing information, inconclusive studies or preconceived notions."

Earlier this year, a study funded by the National Cancer Institute concluded smoking menthol cigarettes made it no more likely the smoker would die of cancer.

Mixed results

Authors of this latest research note that previous studies regarding the impact of smoking menthol cigarettes and smoking cessation efforts have produced mixed results. But they say some research did not take into account the overall population of smokers, while other studies lacked focus on periods of successful smoking cessation and instead targeted attempts to quit.

“Because our evidence suggests that the presence of menthol may partially explain the observed differences in cessation outcomes, the recent calls to ban this flavoring would be prudent and evidence-based,” the authors conclude.

Some cigarette flavorings have already been banned, because they were favored by young, under-age smokers. The push to add menthol to that list picked up steam in June when a Stanford School of Medicine study called the use of menthol “predatory.”

According to that study, tobacco companies increased the advertising and lowered the sale price of menthol cigarettes in stores near California high schools with larger populations of African-American students. The lead researcher for the study said the data shows a "predatory" marketing pattern geared to luring young African Americans into becoming smokers.

The FDA, meanwhile, is currently reviewing relevant studies on the subject and is expected to submit a proposal on menthol in cigarettes in the fall.

Although cigarette makers have denied using race or ethnicity to target customers, researchers at the Stanford School of Medicine say their data suggests otherwise.

According to their study, tobacco companies increased the advertising and lowered the sale price of menthol cigarettes in stores near California high schools with larger populations of African-American students. The lead researcher for the study said the data shows a "predatory" marketing pattern geared to luring young African Americans into becoming smokers.

"The tobacco companies went out of their way to argue to the Food & Drug Administration (FDA) that they don't use racial targeting," said Lisa Henriksen, PhD, senior research scientist at the Stanford Prevention Research Center. "This evidence is not consistent with those claims."

The study is published online in Nicotine & Tobacco Research and comes at a time when the FDA is gathering information on whether to ban menthol as a flavoring agent in cigarettes.

Menthol not included in flavorings ban

A federal law passed in 2008 banned 13 candy flavorings in cigarettes but allowed for the continued use of menthol. Menthol makes the smoke from tobacco smoother and less harsh; even non- menthol cigarettes often have low levels of the substance.

A draft report by the Tobacco Products Scientific Advisory Committee, which the FDA asked to investigate the harms from the use and marketing of menthol cigarettes, found that the use of menthol cigarettes is highest among minorities, teenagers and low-income populations. When these products are advertised, the copy often emphasizes the "freshness" of menthol cigarettes, and the report said many smokers mistakenly believe that the addition of menthol makes cigarettes less of a health risk.

The committee's report says that "removal of menthol cigarettes from the marketplace would benefit public health in the United States." The FDA may, or may not, follow that recommendation.

The committee is scheduled to meet July 21 in Rockville, Md., to discuss final changes to the document. An FDA spokesman said the edited version of the report will be posted soon on the agency's website, but there is no timeline yet as to when the FDA will make a decision on menthol.

"The committee was charged with considering a broad definition of harm to smokers and other populations, particularly youth," said Henriksen. "We think our study, which shows the predatory marketing in school neighborhoods with higher concentrations of youth and African-American students, fits a broad definition of harm."

Teens prefer menthol

In the Stanford study, Henriksen and her colleagues note that the preference for menthol cigarettes among teenage smokers increased from 43.4 percent in 2004 to 48.3 percent in 2008. Menthol cigarettes were also most popular among African-American smokers ages 12-17 (71.9 percent), compared to Hispanics (47 percent) and non-Hispanic whites (41 percent) of the same ages.

To find out how the leading brands of menthol and non-menthol cigarettes were promoted near California high schools, the researchers randomly selected convenience stores, small markets and other tobacco retailers within easy walking distance of 91 schools. The researchers then rated how the cigarettes were marketed in those stores. The data were collected in 2006.

The researchers found that for every 10-percentage-point increase in the proportion of African-American students at a school, the proportion of advertisements for menthol cigarettes increased by 5.9 percentage points. Additionally, the odds of an advertised discount for Newport, the leading brand of menthol cigarettes, were 1.5 times greater.

Prices of menthol and non-menthol cigarettes

When it came to price, the average per-pack price for Newport was $4.37 at the time of the study, with Marlboro - the leading non-menthol brand - averaging $3.99. It also found that for every 10-percentage-point increase in the proportion of African-American students at the nearby school, the per-pack price for Newport was 12 cents lower. Advertised discounts and prices for Marlboro, however, were unrelated to school or neighborhood demographics.

"That's important because lower prices tend to lead to increased cigarette use," Henriksen said.

In addition, the study found that for each 10-percentage-point increase in the proportion of neighborhood residents ages 10-17, the proportion of menthol advertisements increased by 11.6 percentage points, and the odds of an advertised discount for Newport was 5.3 times greater.

Although the study was limited to California high schools, the authors believe the findings would be similar throughout the country.

Under legislation passed in 2009, the warnings must be placed on all cigarette packs, cartons and ads no later than September 2012.

Despite decades of warnings and education efforts, about 20% of Americans still smoke cigarettes, leading to about 443,000 deaths each year in the U.S.

Smoking is considered the leading cause of premature death.

“These labels are frank, honest and powerful depictions of the health risks of smoking and they will help encourage smokers to quit, and prevent children from smoking,” said Health and Human Services Secretary Kathleen Sebelius. “President Obama wants to make tobacco-related death and disease part of the nation’s past, and not our future.”

The warnings, which were proposed in November 2010, were required under the Family Smoking Prevention and Tobacco Control Act which was passed with broad bipartisan support in Congress and signed into law by president Obama on June 22, 2009.

Nine images

The FDA selected nine images from the originally proposed 36 after reviewing the relevant scientific literature, analyzing the results from an 18,000 person study and considering more than 1,700 comments from a variety of groups, including the tobacco industry, retailers, health professionals, public health and other advocacy groups, academics, state and local public health agencies, medical organizations and individual consumers.

Each warning is accompanied by a smoking cessation phone number, 1-800-QUIT-NOW, which will allow it to be seen at the time it is most relevant to smokers, increasing the likelihood that smokers who want to quit will be successful.

When implemented in September 2012, all cigarettes manufactured for sale or distribution in the United States will need to include the new graphic health warnings on their packages. The introduction of these warnings is expected to have a significant public health impact by decreasing the number of smokers, resulting in lives saved, increased life expectancy, and improved health status.

“The Tobacco Control Act requires FDA to provide current and potential smokers with clear and truthful information about the risks of smoking – these warnings do that,” said Commissioner of Food and Drugs Margaret A. Hamburg, M.D.

Stop smoking? Sure, but what if you start packing on the pounds? That's been the curse of smoking cessation for many, but now a new study holds out hope of being able to stop smoking without gaining weight.

Researchers funded by the National Institute of Health (NIH) say they've found a brain mechanism – called a nicotonic receptor -- that's involved in nicotine's ability to reduce food intake in rodents.

In the study, to be published in the June 10 issue of Science, researchers found that a nicotine-like drug, cytisine, specifically activated nicotinic receptors in the hypothalamus — a brain center that controls feeding.

This resulted in the activation of a circuit that reduced food intake and body fat in a mouse model. This effect was very specific, since a drug that prevented cytisine from binding to its hypothalamic receptors blocked the reduction in food intake.

Prior research shows that the average weight gain after smoking is less than 10 pounds, but even so, fear of weight gain can discourage some people who would like to quit even though smoking is much worse than being a few pounds overweight.

Through the use of tobacco, nicotine is one of the most heavily used addictive drugs and the leading preventable cause of disease, disability, and death in the United States. According to the Centers for Disease Control and Prevention, cigarette smoking results in more than 440,000 preventable deaths each year — about 1 in 5 U.S. deaths overall. Despite the well-documented health costs of smoking, many smokers report great difficulty quitting.

Mouse model

"These mouse models allow us to explore the mechanisms through which nicotine acts in the brain to reduce food intake," said Dr. Marina Picciotto, of Yale University, New Haven, Conn. and senior author for the article. "We found that nicotine reduced eating and body fat through receptors implicated in nicotine aversion and withdrawal rather than reward and reinforcement."

"These results indicate that medications that specifically target this pathway could alleviate nicotine withdrawal as well as reduce the risk of overeating during smoking cessation," said NIDA Director Dr. Nora D. Volkow. "Although more research is warranted, such a highly selective compound might be more effective than drugs that act on more than one type of nicotinic receptor."

For information on tips to maintain a healthy weight while quitting smoking go to Forever Free: Smoking and Weight, a publication of the National Cancer Institute.

For decades people have been saying cigarettes are addictive. Now, even the heads of tobacco companies admit that it is true.

Michael E. Szymanczyk, Chairman and CEO of Altria, parent company of Philip Morris USA, addressed shareholders this week and said smoking is addictive and can be very hard to quit. His comments were reported by the Richmond Times-Dispatch.

According to the newspaper, his remarks came during a presentation to shareholders about the company's 2010 results. They came in a context of an explanation of the company's efforts to curb youth smoking.

“Because tobacco use is addictive and it can be very difficult to quit, our tobacco companies help connect adult tobacco consumers who have decided to quit with cessation information from public health authorities,” Szymanczyk reportedly told the group.

Szymanczyk's comments follow those of Philip Morris International CEO Louis Camilleri, who said smoking is addictive but “not that hard to quit.” Szymanczyk said he was doing nothing more than stating Altria's official position, as outlined on its website.

Altria owns three tobacco companies - Philip Morris USA, U.S. Smokeless Tobacco Company and John Middleton.com. Altria says these companies design their marketing programs only to enhance brand awareness, recognition and loyalty among their adult tobacco consumers to grow their market share.

“Each tobacco company has practices in place to focus their marketing activities towards adult tobacco consumers while limiting reach to unintended audiences,” Altria said on its website. “Each of our tobacco companies have programs in place designed to connect with their intended audience while helping to prevent underage access to tobacco products.”

A group of convenience stores throughout the United States have agreed to step up efforts to stop underage tobacco sales. The Assurance of Voluntary Compliance agreement (AVC) includes 40 state attorneys general and the stores operating under the names of Circle K, Dairymart, and On The Run.

Under the agreement the convenience stores will adopt specific procedures to reduce the sale of tobacco products to minors.

“This agreement will make it harder for teens to get tobacco and will keep them from a product that creates a lifelong addiction,” said Utah Attorney General Mark Shurtleff. “Circle K should be commended for their efforts to protect our children.”

The Circle K agreement covers 4,000 stores in 32 states. The terms include checking the ID of anyone who appears under 30 years old, restrictions on in-store advertising, and employee training that emphasizes eliminating underage tobacco sales and the health risks of tobacco use.

The agreement also acknowledges that the majority of adult smokers began smoking before 18 and that young people are less likely to be able to quit smoking. Signs of addiction begin to show after only smoking a few cigarettes. 

“Fortunately the number of retailers agreeing to take a strong stand against underage tobacco sales is growing,” said Assistant Attorney General Kathy Kinsman, who worked on the agreement. The agreement is part of an ongoing, multi-state enforcement effort to implement practices that were developed by public health experts and tobacco control officials. 

Ever-rising state and federal taxes on cigarettes, designed to discourage use but also generate government revenue, have made a pack of smokes very, very expensive. A pack of cigarettes can cost anywhere from over $6 to over $11, depending on the state.

That leaves smokers three alternatives; pay the price, quit, or find a cheaper way to feed their habit. Increasingly, smokers are buying machines to roll their own cigarettes, much to the consternation of some state officials.

Smokers can purchase cigarette machines or cigarette injectors. These are devices used to roll tobacco into a fairly professional-looking cigarette.

Two types of machines

There are two types of cigarette machines: the hand-held and the table-top models. They require cigarette tubes and replicate the store bought cigarettes.

Table-top cigarette injectors are reportedly able to produce the best homemade cigarette possible. Nearly all tubes have the filters in the tube. There are available from a variety of retail sources, as well as on eBay, where ConsumerAffairs.com found models for around $50.

Arkansas, among the states worried about this consumer trend, has taken the first step, approving a law that effective bans their use in the state. Act 836 of 2011, signed into law last week, was part of Arkansas Attorney General Dustin McDanial's legislative package. The Act bans commercial cigarette rolling machines, effective Jan. 1, 2012.

Same health risks

"Cigarettes from these machines may have a lower cost to smokers because of tax differences, but they carry the same high health risks. We don't want these machines in our state." McDaniel said. "I'm grateful to the General Assembly for also recognizing the potential harm to public health and providing broad, bipartisan support for this Act."

Besides consumers, McDaniel said some retail cigarette vendors operate these machines to exploit the tax discrepancies between "roll-your-own" cigarette tobacco, pipe tobacco and cigarettes. Because of the tax differences, the lower costs for "roll-your-own" cigarettes appeal to youth and an already-addicted adult population of smokers. He said he was not aware that any stores in Arkansas had offered that service.

McDaniel said that without Act 863, the tax discrepancies would hamper the Arkansas' long-term public health efforts.

Last summer the State of New Hampshire reclassified tobacco shops that installed cigarette-rolling machines as cigarette manufacturers, prompting a lawsuit by tobacco vendors.

$5 billion a year in lost tax revenue

The U.S. Department of Justice estimates that roll-your-own cigarettes cost states more than $5 billion annually. The Act allows the state to revoke the Arkansas business licenses of those manufacturers or wholesalers who act unlawfully in other states. Companies which pose an elevated risk of noncompliance with Arkansas law could also be required to post a bond as a condition of doing business there.

Licensed wholesalers must also provide more information about in-state sales to the Attorney General, Department of Finance and Administration and Arkansas Tobacco Control. The information will allow the agencies to target tax avoidance by retailers and consumers.

Despite claims that menthol in cigarettes makes them more addictive and more likely to lead to lung cancer, a new study funded by the National Cancer Institute finds no evidence to support that view.

William Blot, Ph.D., professor of Medicine, Vanderbilt-Ingram Cancer Center (VICC), Nashville, Tenn., led the study.

"Black men are known to have a higher incidence of lung cancer and are more likely to smoke mentholated cigarettes compared to white men," said Blot. "It has been hypothesized that menthol in cigarettes influences smoking behavior, perhaps increasing dependency or adversely affecting the biology of the lung. However, our large study found no evidence to support those theories."

Southern smokers surveyed

The study of lung cancer risk was based on results from the Southern Community Cohort Study (SCCS), an ongoing investigation of cancer incidence and mortality disparities among racial, and urban versus rural populations in 12 southern states. Smoking prevalence among participants in the SCCS was exceptionally high, and both menthol and non-menthol cigarette use was common.

Anti-smoking advocates have long targeted menthol in cigarettes as a reason smokers have a harder time kicking the habit. A December 2010 study suggested menthol cigarettes may provide higher levels of carbon monoxide, nicotine and cotinine per cigarette smoked than regular cigarettes, so smokers who favor menthol can still get their fix, even with fewer cigarettes.

"Menthol stimulates cold receptors, so it produces a cooling sensation. This effect may help smokers inhale more nicotine per cigarette and so become more addicted," said Jonathan Foulds, Ph.D., professor, Public Health Sciences, Penn State College of Medicine, and an author of the report.

Possible menthol ban

Last October the Food and Drug Administration's scientific advisory committee took up the matter of whether tobacco companies use menthol as a way to keep smokers hooked. The committee was directed to write a report on the subject and could recommend regulating, or even banning the substance.

At the time, the head of the National Black Chamber of Commerce defended menthol and branded the move to ban it as directed at African-Americans.

"It is no secret that menthol cigarettes provide a distinctive taste that is preferred by many African Americans," NBCC President Harry Alford said. "In making a recommendation, it is my fervent hope that the committee not make a decision based on mixed information, decades-old marketing information, inconclusive studies or preconceived notions."

Support for menthol defenders

The latest study is likely to provide ammunition for Alford and others who defend menthol. Among people smoking 20 or more cigarettes a day, menthol smokers were approximately 12 times more likely to develop lung cancer than never-smokers, while non-menthol smokers were about 21 times more likely to have the disease. The differences were mirrored for lung cancer death rates and were found to be statistically significant.

The researchers also found that both white and black menthol smokers reported smoking fewer cigarettes per day than non-menthol smokers. When it comes to the likelihood of quitting smoking, there was no significant difference between menthol and non-menthol smokers.

The authors conclude that the findings suggest menthol cigarettes are no more, and perhaps less, harmful than non-menthol cigarettes. But smoking any kind of cigarette, they quickly point out, is unhealthy.

"Cigarette smoking remains the leading cause of premature death in the United States, but undue emphasis on reduction of menthol relative to other cigarettes may distract from the ultimate health prevention message that smoking of any cigarettes is injurious to health," said Blot.

The State of New York has filed suit against six web site operators that illegally sold cigarettes to New York State residents, according to the complaint.

In filing the lawsuit, New York Attorney General Eric Schneiderman said the alleged sales are part of a disturbing trend that provides teens easy access to tobacco, and encourages a loss of hundreds of millions of dollars in state revenues.

"These vendors not only broke the law prohibiting the sale of tobacco online, but also endangered our children by making cigarettes easier and cheaper to purchase,"Schneiderman said. "With thousands of children becoming addicted smokers each year, and hundreds of thousands more expected to die because of smoking-related illnesses, our fight for a healthier New York is not over. This office has a proud history of standing up to corrupt tobacco corporations, and as Attorney General I will continue to stop those, no matter how big or powerful they might be, who put profits before the health and safety of our communities, and the laws of this state."

According to the Attorney General's complaints, the named Internet vendors accepted orders from New York State consumers and delivered the cigarettes to New York State addresses. The six vendors named in the suit are:

• Totally Tickled Limited, Inc. for discountcigarettesdomestic.com, Kentucky Smokes, and David White;

• Anton Limited for INeedSmoke.com, and Kyle Williams;

• Cigarettes-online.biz and John Sparkle;

• Best Products Solution Limited for http://cigoutlet.net/;

• Best Products Solution Limited for Smokin4free.com; and

• Best Products Solution Limited for cigoutlet.biz.

Against the law

New York State Public Health Law Section 1399-ll prohibits the shipment of cigarettes to any person in the state unless that person is licensed as a cigarette tax agent or wholesale dealer. Four of the complaints further charge that the Internet vendors violated Executive Law section 63(12) by repeating these illegal sales on more than one occasion. The state is seeking fines of up to $5,000 for each violation and injunction against future sales.

The Centers for Disease Control and Prevention report that 24,100 children under the age of 18 become new daily smokers each year. An estimated 389,000 kids now under the age of 18 in New York will die prematurely from smoking, according to the CDC.

Lost revenue

In addition to the health effects, the fiscal impact of low-cost cigarettes is staggering. The New York State Department of Health reported that in 2004, the state lost between $436 million and $576 million from the sale of low price, mainly untaxed cigarettes. Of that loss, between $106 million and $122 million derived from online tobacco sales.

Aside from the lost revenue, avoiding the cigarette tax helps smokers avoid quitting: Schneiderman believes if all smokers paid the average retail price for cigarettes, there would be between 51,026 and 76,539 fewer adult smokers in New York.

Internet tobacco prices are much lower than those in regular brick-and-mortar retail outlets because they almost never include the taxes charged by retail stores. The low-cost cigarettes make Internet tobacco products attractive to both adult and underage smokers, and help boost overall smoking levels. There is little to prevent underage online purchases as youth smokers can simply provide false identification to avoid their "age verification" procedures - which is not possible in face-to-face purchases.

No longer able to use well-known advertising symbols like Joe Camel, Camel cigarettes has adopted a "cities” campaign, decorating packages with images from Seattle, Austin, San Francisco, Las Vegas, and other trendy American cities.

But the Campaign for Tobacco-Free Kids is crying foul, calling the campaign an effort to make Camel cigarettes cool, fun and rebellious - and appealing to kids.

The group said it is reacting to parent company RJR's announcement that it will sell limited edition cigarette packs with the city names in December and January.

"It is deeply disturbing that RJR is using the good name and hard-earned reputation of these great American cities to market deadly and addictive cigarettes, especially in a way that blatantly appeals to children,” said Matthew L. Myers, president of the Campaign for Tobacco-Free Kids. "Certainly the citizens and leaders of these cities do not want to be associated with a product that kills more than 400,000 Americans every year. RJR showed truly shameless disregard for the death and suffering its products cause by calling this campaign a 'celebration' of the locations involved.”

Cigarette companies are prohibited from promoting their products on television and some other media, but not on the Internet. The activist group says RJR launched the campaign online and with direct mail. In the "Break Free Adventure" campaign, the Camel brand "visits" 10 different U.S. locations over a 10-week period. Visitors to the Camel web site can win prizes by reading a clue and guessing where Camel is that week.  

Each week, a new package design for Camel cigarettes is unveiled that features the name of that week's location and some of its iconic images. Other locations include Route 66; Bonneville Salt Flats, UT; Sturgis, SD; and Winston-Salem, NC.

The group says the locations involved have several qualities in common, including an association with independent music, fun times, rebellion and freedom of the road.

"By associating Camel cigarettes with these locations and their trendy reputations, RJR is continuing its longstanding efforts to make the Camel brand appealing to youth,” Myers said. "It truly is the Joe Camel campaign all over again.  It echoes many of the youth-appealing themes of the Joe Camel campaign, in which the now-banned cartoon camel was often depicted with fast cars and motorcycles or having fun at parties.”

The Campaign called on RJR to immediately end the marketing campaign and withdraw its plans to introduce the special edition cigarette packs. The group said it is also appealing to state attorneys general to investigate whether the promotion violates the 1998 state tobacco settlement's prohibition on tobacco marketing that targets children.

The group also said it wants the government to step up the implementation of proven measures to reduce tobacco use, including effective regulation of tobacco products and marketing, the graphic cigarette warnings unveiled this week by the U.S. Food and Drug Administration; well-funded tobacco prevention and cessation programs nationally and in every state; higher tobacco taxes; and smoke-free workplace laws.

Among children between the ages of three and 11 years old, 54 percent were exposed to secondhand smoke. Nearly all (98 percent) children who live with a smoker are exposed and have measurable levels of toxic chemicals from cigarette smoke.

Smoking rate steady

According to the report, the number of adult smokers dropped between 2000 and 2005, but smoking has remained at about 20-21 percent since 2005. In 2009, more men (nearly 24 percent) than women (about 18 percent) smoked and about 31 percent of those living below poverty level smoked. Fewer than six percent of adults with a graduate degree smoke compared with more than 25 percent of adults with no high school diploma.

Further, nearly 90 million non-smoking Americans are exposed to secondhand smoke and have measurable levels of toxic chemicals from cigarette smoke. Black non-smokers are one-third more likely than white smokers, and twice as likely as Mexican-American smokers, to have measurable exposure to tobacco.

"Smoking is still the leading preventable cause of death in this country," said CDC Director Thomas R. Frieden, M.D., M.P.H. "But progress is possible. Strong state laws that protect nonsmokers from secondhand smoke, higher cigarette prices, aggressive ad campaigns that show the human impact of smoking and well-funded tobacco control programs decrease the number of adult smokers and save lives."

On the decline

In 2009, smoking among adults was lowest in Utah, followed by California. The Golden State has had a long-running comprehensive tobacco control program. Adult smoking in California declined by about 40 percent during 1998-2006, and as a result lung cancer in California has been declining four times faster than in the rest of the nation.

Maine, New York, and Washington have seen 45-60 percent reductions in youth smoking with sustained statewide efforts. If each state supported comprehensive tobacco control programs for five years with CDC recommended levels of funding, an estimated five million fewer people would smoke, resulting in prevention of premature tobacco-related deaths.

Kicking the habit

The federal government is stepping up its efforts to reduce tobacco use in order to achieve the tobacco use targets in Healthy People 2010 and Healthy People 2020. The 2009 Family Smoking Prevention and Tobacco Control Act gives the Food and Drug Administration (FDA) authority to regulate the manufacturing, marketing, and distribution of tobacco products and has provided new opportunities to reduce tobacco use.

In addition, the Communities Putting Prevention to Work program provides guidance and funding for states and communities to change policies to prevent tobacco use and protect nonsmokers from secondhand smoke. The latter is especially important, according to CDC, given that more than half of young children are exposed to secondhand smoke. Children whose parents smoke are twice as likely to smoke themselves, but kids who grow up in communities with comprehensive smoke-free laws are much less likely to become smokers.

Smoking causes cancers of the lung, mouth, stomach, pancreas, kidney, colon, cervix, bladder and leukemia, as well as heart attacks, stroke, blindness, pneumonia, emphysema and other lung diseases, and many other health problems.

Exposure to secondhand smoke causes sudden infant death syndrome and low birth weight, acute respiratory infections, middle ear disease, exacerbated asthma, respiratory symptoms, and decreased lung function in children. It also causes heart disease and lung cancer in nonsmoking adults.

Data from 13 states surveyed indicate that polytobacco use -- the use of cigarettes in combination with other forms of tobacco (including cigars; pipes; bidis, a South Asian cigarette wrapped in a leaf; kreteks, a cigarette made with tobacco, cloves and other flavors; and others) -- is most common among men (4.4 percent), people who were single (4.8 percent), young adults ages 18-24 years (5.7 percent), and those with household incomes less than $35,000 (9.8 percent).

The report, "Any Tobacco Use in 13 States -- Behavioral Risk Factor Surveillance System, 2008," provides statistics about polytobacco use among adults over the age of 18. The report also finds that one in four adults in these states use at least one form of tobacco, such as cigarettes, cigars, or smokeless tobacco.

"Every day smoking kills more than 1,000 people and is the leading preventable cause of death," said CDC Director Thomas R. Frieden, M.D., M.P.H. "The more types of tobacco products people use, the greater their risk for many diseases caused by tobacco, such as cancer and heart disease."

Other findings

The report also found:

• Use of any tobacco ranged from 18.4 percent in New Jersey to 35 percent in West Virginia.

• Use of any tobacco was higher among non-Hispanic whites (26.2 percent) and non-Hispanic blacks (24.4 percent) than among Hispanics (19.7 percent).

• Use of any tobacco was higher among members of an unmarried couple (36.3 percent), single (30.3 percent), or widowed/divorced (29.1 percent) than among married people (21.2 percent).

• Use of any tobacco was higher among those who had less than a high school education (33.1 percent) when compared with those with some college or more (20.5 percent).

• Polytobacco use ranged from 1.0 percent in New Jersey to 3.7 percent in West Virginia.

June 23, 2010
New rules took effect this week barring cigarette companies from using words like "light, "low," or "mild" to describe their products. But research shows smokers still want to believe that some cigarettes are safer than others.

A survey sponsored by GlaxoSmithKline (GSK) Consumer Healthcare shows many smokers will choose the cigarettes in lighter-colored packaging because they incorrectly believe these cigarettes would be less harmful to their health or make it easier to quit smoking.

The survey shows more than one-third of smokers misunderstand the health impact of "light" or "mild" cigarettes. Almost half of smokers surveyed -- 44 percent -- say they typically smoke "light" or "ultra light" cigarettes, with one-quarter of these smokers saying they do so because they mistakenly believe "light" cigarettes are less harmful and/or easier to quit than regular cigarettes.

Label changes

Sixty-eight percent of smokers also say the changes prohibiting the words "light" or "mild" will not make it difficult for them to identify their preferred type of cigarettes. Eighty-seven percent say even without the words on the label, they will be able to identify what would constitute "light" cigarettes by the color and design of the packaging.

"Research has shown that many smokers choose light cigarettes because they believe these cigarettes may be less harmful to their health, and even make it easier to quit smoking," said Saul Shiffman, Ph.D., professor in the departments of psychology and pharmaceutical science at the University of Pittsburgh and Senior Scientific Advisor at Pinney Associates, which provides consulting services to GlaxoSmithKline. "Repackaged light cigarettes with different colors are just as deadly as packs bearing the lights descriptor."

California Attorney General Edmund G. Brown Jr. today announced a multi-state agreement with Valero Oil to stop young people from purchasing tobacco products at its convenience stores.

"For years gas station convenience stores have served as an illegal provider for underage smokers. Today, Valero has finally joined the growing list of companies that have made a commitment to prevent illegal access to tobacco," Attorney General Brown said. "Smoking remains a serious public-health problem in our country, and we need to do everything possible to keep young people from picking up the habit."

Every day, some 2,000 children begin smoking in this country. One-third of them will die of tobacco-related diseases. Nearly half of underage smokers said they bought their cigarettes at gas station convenience stores.

Attorneys General throughout the country reached this agreement after a nationwide investigation, led by Brown's office, of tobacco selling practices at convenience stores owned by or affiliated with Valero.

The agreement includes the following provisions:

• Valero retail personnel will receive training about the health risks associated with childhood tobacco use.

• Valero will administer independent compliance checks to monitor sales practices at company-owned convenience stores, to ensure they are not selling tobacco to minors.

• Vending machines, free samples, and self-service displays of tobacco products will be prohibited at company-owned stores.

• In-store tobacco advertisements will be limited to reduce youth demand for tobacco products.

• Valero will require all of its convenience store operators to notify the company if tobacco products are sold to minors in violation of state law.

• The states will continue to impose sanctions against stores that sell tobacco to minors.

There are over 900 Valero stations in California. Although Valero does not directly own or operate the convenience stores at many of those stations, it has agreed to adopt procedures designed to reduce tobacco sales to minors at all of its outlets.

Nationwide, 47% of underage youths who reported buying cigarettes said they got them at gas station convenience stores. Studies have linked retail tobacco marketing with underage smoking. In addition, many convenience stores are located near schools and playgrounds. Studies show that most adult smokers began smoking before the age of 18.

Recently, other multi-state agreements have been inked to curb the sale of tobacco to minors at gas station convenience stores, including Conoco, Phillips 66, 76, Exxon, Mobil, BP, ARCO, Chevron, and Shell, as well as retail and pharmacy outlets operated by Kroger, 7-Eleven, Walgreens, Rite Aid, CVS, and Wal-Mart. Participating grocery stores include Ralphs, Safeway, and Vons.

Big Tobacco suffered a big loss as Vermont Superior Court Judge Dennis Pearson found that R.J. Reynolds Tobacco Companys advertising claims of a reduced risk cigarette were deceptive and misleading, in violation of Vermonts Consumer Fraud Act and a 1998 settlement agreement and court order.

This is a huge decision with national implications and Vermont has once again led the way, said Vermont Attorney General William H. Sorrell. The Court has ruled that companies cannot make health claims about their products unless they have the proof to back them up.

This decision also shows that the tobacco industry has to live up to the promises they made in the 1998 nationwide settlement, he said.

Reynolds said it was pleased that the judge found that the company "did not willfully violate provisions" of the 1998 tobacco-industry legal settlement with states.

"It's also important to note that in his ruling, [the judge] stated that 'the tests and studies which Reynolds did rely on were for the most part adequately, and properly performed to a reasonable scientific basis,'" the company said.

RJR marketed a non-traditional cigarette, known as Eclipse, through print and internet ads between 2000 and 2007. In his ruling, Judge Pearson found that RJR ads conveyed the impression that Eclipse cigarettes would reduce any given smokers chance of developing cancer, and that RJR did not have the scientific studies to support that claim.

He also found that RJR knew that the ads would convince consumers that there would be health benefits if they switched to Eclipse. The consequences for RJRs violations will be determined at a later time.

We applaud the courts decision which requires rigorous scientific evidence before tobacco companies can claim that any of their products are less dangerous, said Cheryl G. Healton, of Legacy. We are proud of our former Board Chair, Attorney General Bill Sorrell, for bringing this action to protect the health of Vermont citizens and which we expect will be persuasive in the courts of other states as well.

The decision follows a 5-week trial that was conducted by then-Assistant Attorney General Julie Brill and Special Assistant Attorney General Barney Brannen, with support from the Tobacco Project of the National Association of Attorneys General.

This is a groundbreaking ruling that sets a precedent for stopping the tobacco industry from making deceptive and misleading health claims, said Matthew L. Myers, President of the Campaign for Tobacco-Free-Kids. The tobacco companies have a long history of making such claims in their efforts to addict new smokers and discourage current smokers from quitting. We applaud the State of Vermont for pursuing this very important case to protect public health.

The regulatory climate is far stricter today than it was when Eclipse was being marketed. Last June, President Obama signed legislation that gives the Food and Drug Administration (FDA) broad powers to regulate the tobacco industry. Tobacco companies can no longer legally market a product as less harmful than other products without the FDA's approval.

It's a generally accepted fact that smoking cigarettes is bad for your health, leading to a number of cigarette alternatives. But those who light up Chinese "herbal" cigarettes thinking they are safer are wrong, researchers say.

"The public needs to be aware that herbal cigarettes do not deliver fewer carcinogens," said lead researcher Stanton A. Glantz, Ph.D., professor of medicine in the Department of Medicine and Cardiovascular Research Institute at the University of California, San Francisco. "We hope our findings will help to dispel the myth that they are a safer alternative to conventional cigarettes; they are not."

Results of the study are published in the December issue ofCancer Epidemiology, Biomarkers & Prevention, a journal of the American Association for Cancer Research, which has a special focus on tobacco. The researchers conclude that herbal cigarettes, which combine medicinal herbs with tobacco are just as addictive and no safer than regular cigarettes.

Chinese herbal cigarettes are becoming increasingly more popular in China and elsewhere in the world. Glantz, along with colleagues in China, examined nicotine and carcinogen levels between the two marketed products. They compared 135 people who smoked herbal cigarettes and 143 people who smoked "regular" tobacco cigarettes. The study was conducted in one city in China.

"Levels of carcinogens were correlated with measures of nicotine intake, meaning that the more nicotine smokers took in, the higher the levels of carcinogens they took in," Glantz said.

Forty-seven percent of participants who switched to use of herbal cigarettes did so because herbal cigarettes had a "better taste;" 24 percent switched because of their health concerns and the notion that herbal cigarettes were a healthier alternative. Most participants who switched to herbal cigarettes reported an increase in number of cigarettes smoked per day.

"Adding herbs to the cigarettes would not be expected to affect the nicotine, which is the addictive drug in tobacco, and cancer-causing chemicals in the smoke of cigarettes," said Glantz. "The Chinese tobacco industry should avoid misleading the public when promoting herbal cigarettes as 'safer' products."

The State of Oregon has filed two settlements that prevent two national travel store chains from selling "electronic cigarettes" in Oregon. The action is the first of its kind in the country and prevents Oregonians from buying potentially dangerous products that the U.S. Food and Drug Administration has yet to approve.

"When products threaten the health and safety of Oregonians, we will take action," said Mary Williams, Oregon Deputy Attorney General. "If companies want to sell electronic cigarettes to consumers, they have to be able to prove they are safe."

The affected travel store chains, Pilot Travel Centers, which has seven centers in Oregon, and TA Operating, which has four centers in Oregon, both sell "NJOY" brand electronic cigarettes. Electronic cigarettes are actually battery operated nicotine delivery devices constructed to mimic conventional cigarette. Each "cigarette" consists of a heating element and a replaceable plastic cartridge that contains various chemicals, including various concentrations of liquid nicotine. The heating element vaporizes the liquid, which the user inhales as if it were smoke.

Despite FDA issued "Import Alerts" against NJOY and other brands of electronic cigarettes, and despite the fact that the U.S. Customs Service detained several shipments of these devices, sales of electronic cigarettes continue throughout the United States. The products are even advertised on television.

Sales persisted even though just two weeks ago the FDA warned the public about health concerns regarding electronic cigarettes. FDA tests showed a wide variation in the amount of nicotine delivered by three different samples of nicotine cartridges with the same label.

Tests also revealed the presence of nitrosamines a known carcinogen. By the time the FDA issued its warnings, the Oregon Department of Justice had already launched an active investigation of the sale and promotion of electronic cigarettes. NJOY electronic cigarettes were a target of that investigation.

The settlement prohibits the sale of electronic cigarettes in Oregon until they are approved by FDA, or until a court rules the FDA does not have the authority to regulate electronic cigarettes. Even if courts decide that the FDA does not have regulation authority, the settlement stipulates that electronic cigarettes may not be sold in Oregon unless there is competent and reliable scientific evidence to support the product's safety claims.

In addition, the companies must give the Attorney General advance notice that they intend to sell electronic cigarettes in Oregon, provide copies of all electronic cigarette advertising, and provide copies of the scientific studies they maintain substantiates their claims.

Health officials have long suspected that some cigarettes are more addictive than others. Researchers at the University of Medicine and Dentistry of New Jersey now say there's something to that — menthol cigarettes are harder to quit, particularly among African American and Latino smokers, they say.

The research team conducted a study that examined the effects of menthol on quit rates among a diverse group of nearly 1,700 smokers attending a Tobacco Dependence Clinic at the UMDNJ-School of Public Health.

"Lower quit rates among African-American and Latino menthol cigarette smokers at a tobacco treatment clinic" appears in next month's print edition of The International Journal of Clinical Practice.

"We previously found that menthol cigarette smokers take in more nicotine and carbon monoxide per cigarette. This study shows that menthol smokers also find it harder to quit, despite smoking fewer cigarettes per day," said study author Kunal Gandhi, MBBS, MPH, a researcher in the division of addiction psychiatry at the UMDNJ-Robert Wood Johnson Medical School.

"These results build on growing evidence suggesting that menthol is not a neutral flavoring in cigarettes," said Jonathan Foulds, director of the Tobacco Dependence Program. "It masks the harshness of the nicotine and toxins, affects the way the cigarette is smoked and makes it more deadly and addictive."

According to Foulds, more than 80 percent of the African American smokers attending the clinic smoke menthols, and have half the quit rate of African Americans who smoke non-menthol cigarettes.

The researchers believe the cooling effect of the menthol makes it easier to inhale more nicotine from each cigarette and, therefore, to obtain a stronger and more addictive nicotine dose.

"That may be part of the reason why African-Americans have much higher rates of lung cancer," Foulds said.

The researchers also are concerned that more young and Latino smokers are becoming addicted to menthol cigarettes. The tobacco industry may target its marketing of menthol cigarettes to groups with less cash to spend, such as youths, with the aim of getting them hooked even on fewer cigarettes per day, they said.

Their study findings may have implications for future regulation of cigarettes. Recent legislation in New Jersey and pending federal legislation bans fruit- and candy-flavored cigarettes but allows menthol to be added.

A new National Cancer Institute report has reached the government's strongest conclusion to date that tobacco marketing and depictions of smoking in movies promote youth smoking.

The 684-page report, The Role of the Media in Promoting and Reducing Tobacco Use, presents definitive conclusions that tobacco advertising and promotion are causally related to increased tobacco use, and exposure to depictions of smoking in movies is causally related to youth smoking initiation.

The report also concludes that mass media campaigns can reduce smoking, especially when combined with other tobacco control strategies. However, youth smoking prevention campaigns sponsored by the tobacco industry have been generally ineffective and may actually have increased youth smoking, the report finds.

This report provides the most current and comprehensive analysis of more than 1,000 scientific studies on the role of the media in encouraging and discouraging tobacco use. Research included in the review comes from the disciplines of marketing, psychology, communications, statistics, epidemiology, and public health.

"The media have been used to promote cigarettes and smoking through infamous advertising icons -- such as the Marlboro Man and Joe Camel -- and through tobacco images in Hollywood movies," said Ronald M. Davis, M.D., senior scientific editor, director of the Henry Ford Health System's Center for Health Promotion and Disease Prevention.

On the other hand, Davis notes the media also have been used to increase smoking cessation and reduce smoking initiation, through paid advertising campaigns and public service announcements about the dangers of smoking.

The report also concludes that:

• Cigarettes are one of the most heavily marketed products in the United States. Between 1940 and 2005, U.S. cigarette manufacturers spent about $250 billion (in 2006 dollars) on cigarette advertising and promotion. In 2005, the industry spent $13.5 billion (in 2006 dollars) on cigarette advertising and promotion in the U.S. -- $37 million per day on average.

• Much tobacco advertising targets the psychological needs of adolescents, such as popularity, peer acceptance and positive self-image. Advertising creates the perception that smoking will satisfy these needs.

• Even brief exposure to tobacco advertising influences adolescents' attitudes and perceptions about smoking and smokers, and adolescents' intentions to smoke.

• The depiction of cigarette smoking is pervasive in movies, occurring in three-quarters or more of contemporary box-office hits. Identifiable cigarette brands appear in about one-third of movies.

• When allowed by a nation's constitution, a comprehensive ban on tobacco advertising and promotion is an effective policy intervention that prevents tobacco companies from shifting marketing expenditures to permitted media.

• The tobacco industry works hard to impede tobacco control media campaigns, including attempts to prevent or reduce their funding.

Both tobacco industry and tobacco control forces are harnessing the media to influence the attitudes and behavior of the American public. In today's media landscape, which has expanded beyond traditional channels such as newspapers, magazines, radio, and television to the Internet and interactive video gaming -- the challenge is even more urgent.

Although 46 million Americans have stopped smoking, 45 million Americans -- about 20 percent of American adults -- still smoke and nearly 4,000 adolescents smoke their first cigarette each day.

Tobacco use is the single largest cause of preventable death in the United States. According to the Centers for Disease Control and Prevention, cigarette smoking is responsible for more than 400,000 premature deaths per year and reduces the life expectancy of smokers by an average of 14 years.

The editors of the report outline several steps that have been proposed to reduce use of the media in promoting tobacco use and increase its use in discouraging tobacco use, including:

• Impose a comprehensive ban on tobacco advertising and promotion;

• Adequately fund mass media campaigns and protect them from tobacco industry efforts to impede them;

• Monitor tobacco industry activities including public relations and advertising expenditures in a changing media environment;

• Use research to inform tobacco control policy and program decisions;

• Place anti-tobacco advertisements before films to partially counter the impact of tobacco portrayals in movies; and

• Increase public awareness of tobacco industry attempts to shut down public health campaigns.

"The tobacco industry tried for five years to shut down our successful truth youth smoking prevention campaign," said Dr. Cheryl Healton, president and CEO of the American Legacy Foundation.

"Ninety percent of adult smokers began before the age of 20, so cultivating new smokers is critical to Big Tobacco's business model, to replace the more than 400,000 adults who die from tobacco annually with new smokers. Keeping young people from starting to smoke is a critical part of the equation if we want to make major strides toward saving lives. Bold, effective counter-marketing campaigns that reduce smoking rates and change social norms are proven effective in doing just that," she said.

A ban on smoking in public places in Italy has sent the number of heart attacks and other acute coronary events spiraling lower according to a report in Circulation: Journal of the American Heart Association.

Researchers in Rome compared acute coronary events in the city for five years preceding a public smoking ban with those occurring one year after the ban. They found an 11.2 percent reduction in people 35 to 64 years old and a 7.9 percent reduction in those ages 65 to 74.

Smoking bans in all public and workplaces result in an important reduction of acute coronary events, said Francesco Forastiere, M.D., Ph.D., co-author of the study and head of the Environmental and Occupational Epidemiology Unit, Department of Epidemiology, Rome E. Health Authority, Italy. The smoking ban in Italy is working and having a real protective effect on population health.

The study was the first in Europe to show long-term health benefits of smoking bans in public places. It also was the first to consider in detail other factors such as temperature, air pollution, flu epidemics and time trends that affect acute coronary events such as heart attack.

The January 2005 comprehensive smoking ban in Italy included strong sanctions for smokers, businesses and workplace owners and managers. The prohibition included all indoor public places such as offices, retail shops, restaurants, pubs and discos.

Researchers compared the rate of acute coronary events from 2000 to 2004 with those occurring in 2005 after the ban was enforced.

They identified acute coronary events from hospital discharge reports with a diagnosis of myocardial infarction or unstable angina and from the regional register of causes of deaths with diagnosis of out-of-hospital coronary deaths.

The analysis was divided into three age groups: 3564, 6574 and 7584 years. Researchers collected daily data on particulate matter in 40 public places and from four fixed monitors in residential areas together with temperature readings.

They found that the indoor concentration of fine particles decreased one year after the ban.

During the period of the study there were changes in smoking habits such as:

• Frequency of smoking decreased from 34.9 percent to 30.5 percent in men and from 20.6 percent to 20.4 percent in women.

• Cigarette sales decreased 5.5 percent.

While the ban resulted in a significant reduction in acute coronary events in the two younger age groups, the older group (aged 75-84 years) showed no reduction.

When the researchers adjusted for time trends and all-cause hospitalization, the results remained statistically significant in the youngest group and in the 6574 age group. This effect was only slightly reduced when the researchers compared the post-smoking ban data of 2005 with that from 2004.

The older age group spends more time at home than in the workplace or public businesses, said Giulia Cesaroni, M.Sc., senior researcher at the Department of Epidemiology, Rome, Italy. The smoking ban has a greater effect on those of working age and those who spend a lot of their time in public places.

Young people living in low socioeconomic areas seemed to have the greatest reduction in acute coronary events after the smoking ban, researchers reported. Those living in lower socioeconomic areas have worse health conditions with more risk factors for heart attack such as obesity, hypertension, diabetes and a higher rate of active smoking.

This implies that a disadvantaged person has a higher probability of being surrounded by smokers at work and in public places unless a smoking ban is in place, Cesaroni said.

The researchers said the health benefits seen in this study probably result from a significant reduction in exposure to passive smoking. In addition, a smoking-free environment makes it easier for smokers to stop smoking.

Since coronary heart disease is a leading cause of death in Italy, the reduction observed had enormous public health implications, Forastiere said. It will be interesting to see if the effect of the ban is stable over time and if similar positive health effects can be detected in other places.

Five years after all current smokers who receive Medicaid benefits quit smoking, program expenditures would be an estimated $9.7 billion lower, according to a new report by researchers at RTI International.

The report, funded by the American Legacy Foundation, found that Medicaid expenditures attributable to current smokers account for 5.6 percent of total national Medicaid expenditures.

"Reducing the number of smokers in the United States could save taxpayers billions of dollars in Medicaid costs," said Justin Trogdon, Ph.D., an RTI health economist. "Policy makers looking for ways to reduce health care costs in America would be wise to look at areas of health behaviors that both improve health and reduce health care costs."

According to the research, New York smokers top the list, costing Medicaid $1.5 billion each year. Wyoming had the least Medicaid expenditures due to current smokers, but they still cost the program $15 million each year. The report showed that North Carolinians who smoke cost Medicaid $294 million each year.

The researchers also looked at the cost of Medicaid over the lifetime of 24-year-old smokers because nearly all smokers begin smoking before age 24.

"The benefits of preventing smoking initiation accrue over a longer time horizon," Trogdon said. "Life-cycle estimates are important in gauging the long-term impact of youth smoking prevention on state Medicaid programs. These estimates take into account the differences in life expectancy for smokers and nonsmokers as well as payments into the Medicaid system by smokers."

"This study underscores the need for strong and effective smoking prevention and cessation campaigns," said Cheryl G. Healton, Dr. PH, president and CEO of the American Legacy Foundation. "We hope that this report will serve as a tool for states to use when setting both long- and short-term goals for reducing Medicaid expenditures associated with tobacco use."

Women smokers more costly

The results showed that, over the course of their lifetime, today's 24-year-old smokers will cost Medicaid almost $1 billion. However, most of those costs are due to female smokers, not males.

The researchers found that over the course of their lifetime, tax payments by young male smokers make up for most of their extra Medicaid expenditures from smoking, but the expenditures for female smokers cost Medicaid about $1,300 per person.

This impact is highest in Texas, where the lifetime costs of 24-year old smokers to Medicaid is estimated to be $125 million. In North Carolina, those costs are expected to reach almost $37 million.

"The lifetime costs of young smokers are for one cohort of 24-year-olds," Trogdon said. "Every year a new group of young people will turn 24. Based on these findings, preventing and reducing youth smoking, especially among females, could lower Medicaid costs by billions of dollars."

The research is based on data from the 2000 through 2004 Medical Expenditure Panel Surveys.

There are many good reasons not to smoke. You could get emphysema or cancer. You could catch cold standing with all the other smokers in front of your building in the winter time.

And, it turns out, you could be at a higher risk of developing dementia.

According to researchers writing in the current issue of Neurology, people who smoke are more likely to develop Alzheimers disease or dementia than nonsmokers or those who smoked in the past. Their study followed nearly 7,000 people age 55 and older for an average of seven years.

Over that time, 706 of the participants developed dementia. People who were current smokers at the time of the study were 50 percent more likely to develop dementia than people who had never smoked or past smokers.

Smoking could affect the risk of dementia through several mechanisms, according to study author Monique Breteler, MD, PhD, of Erasmus Medical Center in Rotterdam, the Netherlands, and member of the American Academy of Neurology.

Smoking increases the risk of cerebrovascular disease, which is also tied to dementia, Breteler said. Another mechanism could be through oxidative stress, which can damage cells in the blood vessels and lead to hardening of the arteries. Smokers experience greater oxidative stress than nonsmokers, and increased oxidative stress is also seen in Alzheimers disease.

Oxidative stress occurs when the body has too many free radicals, which are waste products produced by chemical reactions in the body.

Antioxidants in the diet can eliminate free radicals, and studies have shown that smokers have fewer antioxidants in their diets than nonsmokers, Breteler said.

The researchers also looked into how smoking affects the risk of developing Alzheimers disease for people who have the gene that increases the risk of Alzheimers, called apolipoprotein E4, or APOE-4.

They found that smoking did not increase the risk of Alzheimers for those with the APOE-4 gene. But for those without the APOE-4 gene, smoking increased the risk of Alzheimers. Current smokers without the Alzheimers gene were nearly 70 percent more likely to develop Alzheimers than nonsmokers or past smokers without the Alzheimers gene.

The study was supported by Erasmus Medical Center and several governmental health organizations in the Netherlands.

While smoking is no longer considered sexy, it may prove a permanent turn-on for some genes.

Research published in the online open access journal BMC Genomics could help explain why former smokers are still more susceptible to lung cancer than those who have never smoked.

A Canadian team led by Wan Lam and Stephen Lam from the BC Cancer Agency in British Columbia, Canada, took samples from the lungs of 24 current and former smokers, as well as from non-smokers who have never smoked. They used these lung samples to create libraries using a technique called serial analysis of gene expression (SAGE), which helps to identify patterns of gene activity.

Only about a fifth of the genes in a cell are switched on at any given time, but environmental changes such as smoking lead to changes in gene activity.

The researchers found changes that were irreversible, and some changes that were reversed by stopping smoking.

The reversible genes were particularly involved in xenobiotic functions (managing chemicals not produced in the body), nucleotide metabolism and mucus secretion. Some DNA repair genes are irreversibly damaged by smoking, and smoking also switched off genes that help combat lung cancer development.

The researchers identified a number of genes not previously associated with smoking that are switched on in active smokers. One example is CABYR, a gene involved in helping sperm to swim and associated with brain tumors, which may have a ciliary function.

"Those genes and functions which do not revert to normal levels upon smoking cessation may provide insight into why former smokers still maintain a risk of developing lung cancer," according to Raj Chari, first author of the study. The study is the largest human SAGE study reported to date, and also generated a large SAGE library for future research.

Tobacco smoking accounts for 85 percent of lung cancers, and former smokers account for half of those newly diagnosed with the disease.

Children who have at least one parent who smokes have 5.5 times higher levels of cotinine, a byproduct of nicotine, in their urine, according to a study by researchers from Warwick Medical School at the University of Warwick, and the University of Leicester, published online ahead of print in Archives of Disease in Childhood.

Having a mother that smokes was found to have the biggest independent effect on cotinine in the urine -- quadrupling it. Having a smoking father doubled the amount of cotinine, one of chemicals produced when the body breaks down nicotine from inhaled smoke to get rid of it.

Sleeping with parents and lower temperature rooms were also associated with increased amounts of cotinine.

Cotinine was measured in 100 urine samples taken from infants aged 12 weeks. Seventy one of the babies had at least one parent that smoked and the parents of the other 33 were non-smokers.

Smoking babies tend to come from poorer homes, which may have smaller rooms and inadequate heating, the authors say. Higher cotinine levels in colder times of year may be a reflection of the other key factors which influence exposure to passive smoking, such as poorer ventilation or a greater tendency for parents to smoke indoors in winter.

Sleeping with a parent is a know risk factor for cot death and the authors suggest that one reason for this could be inhalation of, or closeness to clothing or other objects contaminated with, smoke particles during sleep.

Nearly 40% of under-fives are believed to be exposed to tobacco smoke at home, and smoke may be responsible for up to 6,000 deaths per year in young children.

Babies and children are routinely exposed to cigarette smoking by their caregivers in their homes, without the legislative protection available to adults in public places, according to the researchers.

But they acknowledge that there are practical difficulties in preventing smoking in private homes because it relies on parents or caregivers being educated about the harmful effects of passive smoking on their children and then acting on that knowledge.

Now, Stanford University researchers have conducted the first in-depth study on how smoking affects air quality at sidewalk cafs, park benches and other outdoor locations.

Writing in the May issue of the Journal of the Air and Waste Management Association (JAWMA), the Stanford team concluded that a non-smoker sitting a few feet downwind from a smoldering cigarette is likely to be exposed to substantial levels of contaminated air for brief periods of time.

"Some folks have expressed the opinion that exposure to outdoor tobacco smoke is insignificant, because it dissipates quickly into the air," said Neil Klepeis, assistant professor (consulting) of civil and environmental engineering at Stanford and lead author of the study.

"But our findings show that a person sitting or standing next to a smoker outdoors can breathe in wisps of smoke that are many times more concentrated than normal background air pollution levels."

Klepeis pointed to the 2006 Surgeon General's report, which found that even brief exposures to secondhand smoke may have adverse effects on the heart and respiratory systems and increase the severity of asthma attacks, especially in children.

"We were surprised to discover that being within a few feet of a smoker outdoors may expose you to air pollution levels that are comparable, on average, to indoor levels that we measured in previous studies of homes and taverns," said Wayne Ott, professor (consulting) of civil and environmental engineering at Stanford and co-author of the JAWMA study.

"For example, if you're at a sidewalk caf, and you sit within 18 inches of a person who smokes two cigarettes over the course of an hour, your exposure to secondhand smoke could be the same as if you sat one hour inside a tavern with smokers. Based on our findings, a child in close proximity to adult smokers at a backyard party also could receive substantial exposure to secondhand smoke," he added.

Unlike indoor tobacco smoke, which can persist for hours, the researchers found that outdoor smoke disappears rapidly when a cigarette is extinguished.

"Our data also show that if you move about six feet away from an outdoor smoker, your exposure levels are much lower," Klepeis added.

The public has become increasingly concerned about the effects of outdoor smoking, Ott noted. More than 700 state and local governments have passed laws restricting outdoor smoking at playgrounds, building entrances and other public areas, according to the American Nonsmokers' Rights Foundation.

Some of the strictest ordinances are in California. The city of Santa Monica, for example, recently banned smoking at parks, beaches, ATM machines, theater lines, open-air restaurants and other outdoor locations.

"Throughout the country, cities and counties are looking at various laws against outdoor smoking, and some of the proposals are pretty drastic," Ott said. "The problem is that until now, there have been virtually no scientific data to justify such restrictions. In fact, our paper is the first study on outdoor smoking to be published in a peer-reviewed scientific journal."

Turns out kicking the habit benefits more than your lungs.

Ex-smokers achieved non-smokers' level of arterial stiffness after a decade of smoking cessation, in a cross-sectional study reported in Hypertension: Journal of the American Heart Association.

"Smoking is a major risk factor, not only for lung disease and cancer, but also for heart attack, stroke and heart failure," said lead author Noor Ahmed Jatoi, M.B.B.S., D.C.N., D.M.M.D.

"Our group has previously shown that smoking a single cigarette, passive or second-hand smoking and chronic smoking all lead to stiffer arteries, which in turn increase resistance in the blood vessels and, therefore, increase the work the heart must do."

However, it was not clear if smoking cessation would be associated with reduced arterial stiffness. Stiffness in the arteries can increase blood pressure and is associated with increased risk of cardiovascular events.

The researchers studied 554 people (average age 47, 56 percent female) who had high blood pressure but had never been treated for it. Researchers divided the subjects into: current smokers (150), ex-smokers (136) and never-smokers (268).

"We categorized ex-smokers according to how long they were off cigarettes -- under one year, more than one but less than 10 years and more than 10 years of smoking cessation," said Jatoi, a Ph.D. student in clinical pharmacology at Trinity Health Sciences Centre and Hypertension Clinic at St. James's Hospital, Trinity College Dublin, Ireland.

Researchers used Arterial Pulse Wave Analysis, a technology that measures arterial stiffness. They found that current and ex-smokers of only one year had significantly higher stiffness measurements compared with non-smokers.

In ex-smokers, duration of smoking cessation was directly related to improvement in arterial stiffness. They found some improvement after one to 10 years, but arterial stiffness parameters only reached normal levels after more than a decade of smoking cessation.

"Our study reinforces the message that smoking cessation is an important step smokers can take to enhance the quality and length of their lives. It shows both the unhealthy effects of smoking and the benefit of smoking cessation on the arterial wall," he said. "The longer one stops smoking the better." However, researchers noted that results need to be confirmed in a prospective, longitudal study -- one that follows patients over time.

Fear of irate smokers is about to trump common sense in Atlantic City.

Faced with a chance to clear the air of deadly tobacco smoke in local casinos, the city council succumbed to pressure from the pro-smoking casino industry and passed a preliminary measure that will limit but not eliminate smoking.

If approved in final form in early February, smoking will be permitted on 25 per cent of Atlantic City casino floors.

That's a greater percentage the number of adults (over age 21) who still smoke in the United States.

New Jerseyans already enjoy smokefree bars and casinos and enjoy the support of anti-tobacco Gov. Jon Corzine and the state legislature.

Because casinos were exempt from the original statewide bill, the matter was left to the City Council of Atlantic City. When the casino industry argued that 3,400 jobs and 20 per cent of its revenues would be jeopardized by a smoking ban, the council accepted a compromise that called for a 75 per cent ban.

The Jersey-based Group Against Smoking Pollution (GASP) and other opponents objected, citing the recent report by the U.S. Surgeon General that passive tobacco smoke is carcinogenic even in limited quantities.

Regina Carlson, founder and executive director of the group, said breathing in a nonsmoking section offers no protection from smoke that happens to seep into that area.

Atlantic City Councilman Dennis Mason disagreed, stating that new casino smoking areas would be walled off from floor to ceiling and topped by ventilation systems that suck smoke out of the air.

Experts on the issue, as well as scientific studies, have shown such ventilation systems to be inadequate. In addition, air recirculated by heating and cooling systems would be filled with the secondhand tobacco smoke found deadly to nonsmokers.

Potential loss of jobs and revenues -- cited by bars and restaurants in big cities considering smoking bans -- have not materialized. In fact, both New York and Los Angeles reported gains in jobs, revenues, and customers because nonsmokers unable or unwilling to appear previously became new patrons.

Though 16 states and hundreds of municipalities have banned smoking in public places, most gambling venues have managed to wriggle free of such regulations. Some, like Foxwoods and Mohegan Sun in otherwise-smokefree Connecticut, stand on Native American land not bound by state jurisdiction.

Las Vegas showrooms have gone smokefree but not the city's fabled casinos. A smoking ban in Atlantic City casinos would be the largest in any American gambling destination.

A reanalysis major brand name cigarettes sold in Massachusetts from 1997 to 2005 has confirmed that manufacturers have steadily increased the levels of nicotine, the primary addictive agent in cigarettes.

The independent analysis, based on data submitted to the Massachusetts Department of Public Health (MDPH) by the manufacturers, found that increases in smoke nicotine yield per cigarette averaged 1.6 percent each year, or about 11 percent over a seven-year period (1998-2005).

In addition to confirming the magnitude of the increase, first reported in August, 2006 by MDPH, researchers from the Harvard School of Public Health (HSPH) extended the analysis to:

• Ascertain how manufacturers accomplished the increase -- not only by intensifying the concentration of nicotine in the tobacco but also by modifying several design features of cigarettes to increase the number of puffs per cigarette. The end result is a product that is potentially more addictive.

• Examine all market categories -- finding that smoke nicotine yields were increased in the cigarettes of each of the four major manufacturers and across all the major cigarette market categories (e.g. mentholated, non-mentholated, full-flavor, light, ultralight).

The analysis was performed by a research team from the Tobacco Control Research Program at HSPH led by program director Gregory Connolly, professor of the practice of public health, and Howard Koh, associate dean for public health practice at HSPH and a former commissioner of public health for the Commonwealth of Massachusetts (1997-2003). The other co-investigators were HSPH researchers Hillel R. Alpert and Geoffrey Ferris Wayne.

"Cigarettes are finely-tuned drug delivery devices, designed to perpetuate a tobacco pandemic," said Howard Koh, associate dean for public health practice at HSPH and a former commissioner of public health for the Commonwealth of Massachusetts.

"Yet precise information about these products remains shrouded in secrecy, hidden from the public. Policy actions today requiring the tobacco industry to disclose critical information about nicotine and product design could protect the next generation from the tragedy of addiction."

"Our findings call into serious question whether the tobacco industry has changed at all in its pursuit of addicting smokers since signing the Master Settlement Agreement of 1998 with the State Attorneys General," Connolly said.

"Our analysis shows that the companies have been subtly increasing the drug nicotine year by year in their cigarettes, without any warning to consumers, since the settlement. Scrutiny by the Attorneys General is imperative. Proposed federal legislation has been filed by Senator Edward Kennedy (D-Ma.) that would address this abuse and bring the tobacco industry under the rules that regulate other manufacturers of drugs."

Beginning in 1997, Massachusetts regulations have required an annual report to be filed with the MDPH by all manufacturers of cigarettes sold in Massachusetts. The reported data include machine-based measures of nicotine yield as well as measures of cigarette design related to nicotine delivery.

The Tobacco Research Program at HSPH obtained from the MDPH a complete set of brand-specific data from 1997 to 2005 and analyzed trends in smoke nicotine yield.

The discovery of an 11 percent increase in nicotine content, said Connolly, confirms recent statements by the US District Court for the District of Columbia that manufacturers have the ability to manipulate addictive additives, and, he said, "it underscores the need for continued surveillance of nicotine delivery in products created by an unregulated industry."

In an opinion in US vs. Philip Morris USA et. al., Judge Gladys Kessler wrote that tobacco companies "can and do control the level of nicotine delivered in order to create and sustain addiction" and further, that the "goal to ensure that their products deliver sufficient nicotine to create and sustain addiction influences their selection and combination of design parameters."

Cigarette smoking causes an estimated 438,000 premature deaths (or about 1 of every 5 deaths) annually in the U.S., and approximately 900,000 persons become addicted to smoking each year.

In conclusion, according to the HSPH researchers, the extended analysis of MDPH data has demonstrated its potential to reveal undisclosed hazards to human health.

They suggest that MDPH amend its unique reporting requirements to include more information about cigarette and smokeless tobacco product design features that affect nicotine delivery -- as well as testing of a sample of brands for the actual delivery of nicotine to the body.

Though getting rid of passive tobacco smoke in public places is far from a done deal, travelers can find smoking bans on almost every continent.

In North America, many states have finally banned smoking from bars and restaurants but the vast majority have not. Nor have most European countries, though Ireland, Spain, Italy, Great Britain, Norway, and Sweden have enacted restrictions and France is trying to follow.

A French parliamentary panel has recommended that smoking be banned in cafes, offices, schools, restuarants, airports, train stations, and other enclosed public places by next fall. Now it's up the government to say yea or nay.

The Health Ministry definitely favors the ban, warning that smoking kills 66,000 Frenchmen prematurely every year. But changing the prevailing laissez-fair attitude may not be difficult in a country where dogs are routinely allowed into restaurants.

Bermuda has banned smoking in bars and restuarants too. Even South America is getting into the act, with Uruguay the first country on that continent to enact a smoking ban in enclosed public places.

In Bhutan, anti-smoking laws can only be described as draconian. It is not only illegal to smoke in public there or to sell tobacco but fines are equivalent to the average worker's salary for two months.

In the United States, 16 states have smoking bans for restaurants, with 10 extending those bans to bars and taverns. Arkansas and Oklahoma have enacted new laws to protect consumers and Puerto Rico, a would-be state, has given its law teeth: it bans smoking in private cars with children under age 13, perhaps anticipating a recent study that demonstrated the dangers of the practice!

According to the North American Travel Journalists Association, travel writers who care about public health, and particularly the health of travelers, can speed legislation by including information about smoking restrictions -- whether public or private -- in their articles. They can also help win public consent for such legislation as the pending California law that would impose fines on motorists who fling cigarette butts out of car windows.

Proposed fines are so steep that they may be more than the price of the car: $3,400 for first offenders and $20,400 for anyone cited three times or more. The Southern California sponsor means business!

Also in health-conscious California, communities are starting to consider bills that would ban smoking in outdoor public places such as parks and beaches.

That would please a Washington-based lobbying group called Action on Smoking and Health (ASH), now in its 38th year; the California-based Americans for Nonsmokers Rights (ANR); and Group Against Smoking Pollution (GASP). All have aggressively promoted enactment of anti-smoking legislation.

The latest ASH newsletter states: "Restrictions on smlking to guarantee smokefree air for nonsmokers are spreading and are proving to be very effective and well-received."

"The manufacturers of so-called 'little cigars' are deceiving and endangering consumers and our children, and federal rules allow them to get away with it," said California Attorney General Bill Lockyer.

"These products are made like cigarettes, their smoke can be inhaled like cigarettes, and they present the same serious health risks as cigarettes. Yet federal regulations allow the makers to call them cigars and sell them as cigars. That allows them to evade marketing restrictions and higher taxes that apply to cigarettes, and increases youth access by lowering the prices. The federal government should close this dangerous loophole."

The petition urges the federal Alcohol Tobacco Tax and Trade Bureau (TTB) to adopt rules revising the definitions of cigars and cigarettes. The goal is to ensure that "little cigars" -- which actually are cigarettes wrapped in brown paper -- are classified, taxed and priced as cigarettes.

"Little cigars" appeal to youths because they often are sold individually or in "kiddie packs" of less than 20, which makes them cheaper, and because in many cases they are sweetened with flavors such as chocolate, vanilla, strawberry, cinnamon and spearmint. Some of the more popular brand names include Winchester, Smokers Choice, Prime Time and Cheyenne.

Federal law defines cigars as tobacco wrapped in leaf tobacco or substances containing tobacco. Federal and state laws generally define cigarettes as tobacco wrapped in paper or other substances not containing tobacco.

State and federal statutes also define cigarettes as tobacco wrapped in any substance that includes tobacco, if its appearance, the type of tobacco used in the filler, or its packaging and labeling, indicate it will be sold and purchased as a cigarette.

The problem stems from a rule issued by the TTB that sought to clarify the federal definitions. Under the rule, if manufacturers label their products cigars, the presumption is the products will not be sold or bought as cigarettes. Essentially, the rule allows the tobacco companies to self-classify their products as cigars.

Selling their brown cigarettes as cigars provides substantial benefits to manufacturers. It lets them pay significantly lower taxes and avoid the requirement under most state laws that cigarettes be sold in packs of at least 20 sticks. In combination, those two factors permit dramatically lower prices. For example, the taxes on a carton of "little cigars" in California total $3.77, compared to $16.76 for a carton of cigarettes.

Cigar makers also do not have to abide by the youth and other marketing restrictions imposed by the Master Settlement Agreement reached in 1998 between tobacco companies and 46 state Attorneys General. And most cigar makers do not have to place federal health warnings on their products.

Consumption of "little cigars" has exploded. From 1998 through 2005, consumption of the products increased by more than 2 billion sticks, from 1.638 billion to 3.772 billion, according to the U.S. Department of Agriculture.

Some data suggest "little cigars" are enjoying rising popularity among younger smokers. A study of college freshmen found that students who said they smoked were more likely to smoke little cigars than cigarettes or regular cigars. Two other studies published in 2004 and 2005 found that high school students in New Jersey and Cleveland, Ohio smoked cigars more often than cigarettes.

"While public health organizations and states have been successful in lowering cigarette smoking rates among teens, little cigar and cigar use is threatening to reverse these gains and plunge another generation into tobacco addiction," said the Attorneys General in their petition to the TTB.

Youths may mistakenly believe they are smoking a product that poses less health risks because it's labeled a cigar. But the products are made to be smoked and inhaled just like cigarettes, which means they present the same addiction and health dangers.

Additionally, while the makers call these products cigars, their advertising actually aims to sell consumers on the concept that the products are just like cigarettes, only cheaper. "So much like cigarettes, its hard to believe they are cigars," proclaims one ad.

The petition to the TTB notes that Harry Preston, national accounts manager for J.C. Newman Cigar Company, has suggested that convenience stores display little cigars near the register and instruct their clerks to tout them as an alternative to cigarettes.

The rule proposed by the AGs would eliminate the current loophole by stripping manufacturers of the ability to self-classify their products as cigars. Instead, tobacco products would be deemed cigarettes if the tobacco filler or packaging possess any one of several specific characteristics, or if "the product is marketed or advertised to consumers as a cigarette or cigarette substitute."

"This is a major step forward in our ongoing effort the shut down illegal internet cigarette traffickers," said New York Attorney General Spitzer.

"These illegal enterprises cannot remain in business without a steady supply of cigarettes, and thus restricting that supply can be very effective. We will continue to pursue this goal by asking other cigarette manufacturers to follow Philip Morris's lead and reduce the flow of their cigarettes to these illegal traffickers."

The agreed-upon protocols provide for the:

• Termination of shipments of cigarettes to any of Philip Morris's direct customers that the attorneys general have found to be engaging in illegal Internet and mail order sales;

• Reduction in the amount of product made available to direct customers found by the attorneys general to be engaged in the illegal re-sale of Philip Morris cigarettes to the Internet vendors; and,

• Suspension from the company's incentive programs of any retailer found by the attorneys general to be engaging in such illegal sales.

"Our voluntary agreement with the state attorneys general builds on Philip Morris USA's existing trade programs and policies intended to preserve the integrity of our brands and the legitimate trade channels through which they are sold," said Denise Keane, Philip Morris USA executive vice president and general counsel.

"It sets a framework for continued information sharing with law enforcement and support of their efforts to eliminate illegal sales of Philip Morris USA products."

The attorneys general believe that virtually all sales of cigarettes over the Internet are illegal because the sellers are violating one or more state and federal laws, including:

(1) state age verification laws;
(2) the federal Jenkins Act (which requires that such sales be reported to state authorities);
(3) state laws prohibiting or regulating the direct shipment of cigarettes to consumers;
(4) state and federal tax laws;
(5) federal mail and wire fraud statutes; and
(6) the federal RICO law.

Many of the sales made by foreign websites also violate federal smuggling, cigarette labeling, money laundering and contraband product laws.

The attorneys general note that Internet cigarette sales also present a significant risk to public health, because most Internet vendors illegally fail to charge taxes, and it is well-established that lower cigarette prices lead to increased smoking rates.

Moreover, while "brick-and-mortar" retailers check photo IDs to prevent children from buying cigarettes, the vast majority of Internet sellers have age verification systems that are wholly inadequate.

Numerous studies have shown that the earlier an individual begins to smoke, the more likely it is that the person will become addicted, and thus age verification through photo IDs is essential to protect children from a lifetime of smoking.

Step #3

Today's agreement is the third major development in the Attorney Generals' multi-pronged effort to restrict the payment, shipment and supply operations of the illegal Internet cigarette traffickers.

In March 2005, the attorneys generals announced that the major credit card companies had all agreed to stop processing credit card payments for the Internet retailers. Later in the year, both DHL and UPS agreed to stop shipping packages for the vendors engaged in these illegal sales.

Philip Morris notes that it previously has penalized direct customers and retailers who sold its cigarettes illegally over the Internet and through the mails. Philip Morris is now the first tobacco product manufacturer to agree to reduce the supply of cigarettes to direct customers who supply vendors engaged in the illegal re-sale of Philip Morris cigarettes on the Internet.

The attorneys general commended Philip Morris for its cooperation in the effort to reduce these illegal sales. In addition, the attorneys general will be encouraging other tobacco product manufacturers to take steps to reduce the supply of their cigarettes that are re-sold by illegal Internet cigarette traffickers.

The negotiations with Philip Morris were lead by the New York Attorney General's Office. In addition, the attorneys general from the following jurisdictions have joined this agreement: Alabama, Arkansas, American Samoa, California, Colorado, Connecticut, Delaware, District of Columbia, Georgia, Hawaii, Idaho, Illinois, Iowa, Kentucky, Louisiana, Maryland, Massachusetts, Michigan, Montana, Nevada, New Hampshire, New Mexico, New Jersey, Northern Marianas, Oklahoma, Oregon, Puerto Rico, South Carolina, South Dakota, Tennessee, Utah, Vermont, Washington, West Virginia, Wisconsin and Wyoming.

"Our children are our future, but what kind of future will they have if they start a habit that kills?" asked California Attorney General Bill Lockyer. "We, as a society, have a shared duty to protect our kids from cigarettes and other tobacco products. To its credit, ConocoPhillips has recognized its responsibility and taken an important step to become part of the solution."

The agreement was signed by the company and the Attorneys General of 40 states. It applies to outlets that operate under the Conoco, Phillips 66 and 76 brand names in 31 of the signing states. The Attorneys General of nine states that currently do not have ConocoPhillips outlets signed the agreement. If the company opens stores in those jurisdictions, the outlets will be covered by the agreement.

The ConocoPhillips "Assurance of Voluntary Compliance" (AVC) is the eighth such agreement produced by an ongoing, multi-state enforcement effort which Lockyer has helped lead. Previous agreements cover, in the signing s! tates, all Wal-Mart, Walgreens, Rite Aid and 7-Eleven stores, and all gas stations and convenience stores operating under the Exxon, Mobil, BP, ARCO and Amoco brand names.

In addition to the multi-state AVCs, Lockyer and Los Angeles City Attorney Rocky Delgadillo in December 2004 reached a similar, court-approved settlement with Safeway, Inc. That agreement covers 538 Safeway, Vons, Pavilions and Pak N Save stores in California. The settlement resolved a lawsuit brought by Lockyer and Delgadillo that alleged Safeway violated state laws designed to prevent tobacco sales to minors.

Combined, the AVCs and Safeway settlement cover roughly 55,000 retail outlets across the nation. The AVCs provide measures to reduce sales of tobacco products to minors by the nations top retail chain (Wal-Mart), number one drug store chain (Walgreens), largest oil company (ExxonMobil) and biggest retailer of tobacco products (7-Eleven).

Launched in 2000, the multi-state enforcement effort by a group of 32 Attorneys General focuses on retailers with poor records of selling tobacco products to minors. State laws prohibit such sales.

The enforcement programs goal is to secure the companies agreement to take specific corrective actions. The agreements incorporate "best practices" to reduce sales to minors, developed by the Attorneys General in consultation with researchers, and state and federal tobacco control officials.

The retailing reforms of the ConocoPhillips AVC explicitly apply to company-owned stores. The agreement, however, also calls for ConocoPhillips to take steps to ensure its franchisees comply with state laws governing the sale of tobacco products. For example, ConocoPhillips will revise its franchise contracts to specify that tobacco-product sales to minors can result in loss of the franchise.

The AVC limits in-store advertising of tobacco products to brand names, logos, other trademarks and pricing. Additionally, the agreement bans self-service displays of cigarettes and all other tobacco products. Aside from the advertising and self-service restrictions, the AVC also requires ConocoPhillips to:
• Check the ID of any person purchasing tobacco products when the person appears to be under the age of 35, and accept as proof of age only valid government-issued photo ID.
• Prohibit the following: use of vending machines to sell tobacco products, distribution of free samples, sale of cigarette look-alike products and the sale of smoking paraphernalia to minors.
• Hire an independent entity to conduct random compliance checks twice each year at all company-owned stores in the signing states.
• Train employees on state and local laws and company policies regarding tobacco sales to minors, including explaining the health-related reasons for laws that restrict youth access to tobacco.

The Attorneys General have long recognized that youth access to tobacco products ranks among the most serious public health problems. Studies show more than 80 percent of adult smokers begin smoking before the age of 18. Research indicates that every day in the United States, more than 2,000 people under the age of 18 start smoking and that one-third of those persons ultimately will die from a tobacco-related disease. Young people are particularly susceptible to the hazards of tobacco, often showing signs of addiction after smoking only a few cigarettes.

The study by researchers from Dartmouth Medical School (DMS) and Norris Cotton Cancer Center (NCCC) appears i