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ASH News and Events Bulletin - 1-15 June 2008

Tobacco News

Fall in hospital admissions for heart attack since smoking ban

More than half of hospital trusts are treating fewer heart attacks since the ban on smoking in public places came in last year.

As its first anniversary approaches on July 1, nearly six in ten NHS trusts are reporting a dramatic fall in the number of heart attack patients being admitted to emergency wards.

The figures, obtained under the Freedom of Information Act by the Daily Mail, are the first real indication of the impact of the smoking ban on hospital admissions for heart problems in England.

Coronary heart disease costs the country £3.5billion a year, but the Government has yet to publish statistics about the effects of the ban.

However, NHS records show some hospitals have seen the number of cases plummet by 41 per cent since July 2007.

There were 1,384 fewer heart attacks across England in the nine months after the legislation was introduced compared to the same period a year earlier.

That means rates have fallen by 3 per cent across the country since the ban.

It follows similar research in Scotland and Ireland that showed hospital admissions for heart attacks fell by 17 and 14 per cent respectively, in the year after the ban came in there during 2006.

Studies in France and Italy have also pointed to a link between a drop in heart attack rates and smoking restrictions.

Dr Nicholas Boon, president of the British Cardiovascular Society, said: 'This is great news. It is exactly what we hoped and expected to see.

'When you place these figures with the research in Scotland, Ireland, France and Rome, it is consistent with the observation that the ban has been followed by significant improvements in heart attack rates. It is early days, but the benefits may be greater in the long run.'

Experts believe the ban has triggered a drop in heart attacks due to both the number of people quitting and the reduction in passive smoking as fewer people are exposed to airborne toxins.

The research looked at admissions for heart attacks from 114 trusts, of which 66 saw a drop in admissions between July 2007 and March 2008 compared to that period 12 months earlier. In the remaining 48 trusts, admission rates stayed the same or increased marginally. In total, there were 42,176 admissions to all the trusts from October 2006 to June 2007.

But in the nine months after the ban, that number fell by 1,384, or three per cent.
Shrewsbury and Telford Hospitals NHS Trust saw the most significant decrease in heart attack admissions, with a drop of 41 per cent - 418 fewer.

A substantial fall in heart attack patients could save the NHS a fortune. It costs up to £5,000 to treat an emergency heart attack patient.

It is estimated that smokers have almost twice the risk of a heart attack compared to those who have never smoked.

Around ten million British adults smoke - about a quarter of the population - and there are 230,000 heart attacks each year causing around 100,000 deaths. Of these, 123,000 take place in adults aged under 75.

Research shows people in this group stand to benefit more from a smoking ban as they suffer greater exposure to smoke.

But a year after a person quits, the risk of a heart attack falls to half of that of a smoker.

Dr Mike Knapton, of the British Heart Foundation, said: 'This is very significant.

'I think we can say that this indicates the smoking ban has had a beneficial effect on the rate of heart attacks quicker than many people predicted.
This shows that the ban was the most significant public health initiative this century. These figures are also fantastically encouraging if you want to give up smoking. It suggests the benefits of stopping smoking are realised faster than you think.'

The Department of Health said: 'It is obviously good news. However it is too early to attribute this to the smokefree legislation.'

Daily Mail, 14 June 2008
http://tinyurl.com/5ubjsn

'Don't keep it in the family,' says DH anti-smoking ad

The NHS launches the second phase of its £8m anti-smoking campaign on TV tonight with an ad that plays on parental guilt about lighting up in front of the children, using the tagline "Smoking. Don't keep it in the family".

The ad, created by ad agency MCBD, is filmed from a child's perspective to the soundtrack of Shirley Temple's On Account'a I Love You.

Parents are depicted trying to protect their children by hiding their smoking habits, but these attempts are unsuccessful and the ad ends with a child standing in front of the mirror pretending to smoke, using a crayon as a cigarette.

The new commercial follows a similar TV ad launched on June 2 set to I Wanna Be Like You from The Jungle Book. The previous ad aimed to prompt smokers to quit the habit, while the NHS hopes the new one will promote its anti-smoking services, which aim to help keep smokers off cigarettes.

A poster campaign will continue the "Don't keep it in the family" theme, as well as radio, magazine and press advertising, encouraging smokers to use NHS support when they quit.

The initiative was launched after research from the US suggested that children were four times more likely to smoke in later life if their parents did.

The Guardian, 13/6/08
Link to a video of the ad: http://www.guardian.co.uk/media/video/2008/jun/13/advertising.health

Industry Watch

Philip Morris: the origins, spread and denial of nicotine freebasing

Philip Morris and other tobacco companies have been using ammonia in their manufacturing for more than half a century, and for a variety of purposes: to highlight certain flavours, to expand or "puff up" the volume of tobacco, to prepare reconstituted tobacco sheet ("recon"), to denicotinize (reduce the amount of nicotine in) tobacco, and to remove carcinogens.

By the early 1960s, however, Philip Morris had also begun using ammonia to "freebase" the nicotine in cigarette smoke, creating low-yield (reduced-tar or -nicotine) cigarettes that still had the nicotine kick necessary to keep customers "satisfied" (i.e., addicted). Freebasing involves impregnating tobacco with a salt (such as diammonium phosphate) so that the ammonia is released when the cigarette is lit, making nicotine more available to the smoker.

An analysis of tobacco industry documents has revealed how Philip Morris used this technique to drive sales of its Marlboro brand ahead of rival companies’ brands. During the 1930s and 1940s cigarette makers modified the chemistry of tobacco seeking to produce an ever-milder smoke that could be inhaled without stimulating coughing. But when demand for low-tar and lower-nicotine cigarettes arose in the 1950s and ‘60s, the industry realised that there were limits to how low nicotine levels could go without “weaning” smokers from their habit. As the researchers noted: “Cigarette manufacturers worried about producing an “emasculated” cigarette devoid of flavour and missing the grip of addiction. Freebasing solved a big part of this problem because tar and nicotine levels could now be lowered without the risk of losing customers.”

The researchers also show how Marlboro’s commercial success catalyzed efforts by the rest of the tobacco industry to discover its "secret," eventually identified as ammonia technology. Furthermore, Philip Morris later exploited the myriad uses of ammonia (e.g., for flavoring and expanding tobacco volume) to defend itself against charges of manipulating the nicotine deliveries of its cigarettes.

Stevenson T and Proctor R. The secret and soul of Marlboro. Philip Morris and the origins, spread, and denial of nicotine freebasing. AJPH 2008; 98: 1184-1194
http://www.ajph.org/cgi/content/abstract/AJPH.2007.121657v1

Recent Research

Importance of tax and mass media campaigns in reducing smoking

Australia could have almost 100,000 fewer smokers if the price of a cigarette was raised by just two cents, an Australian study has found.

A new assessment published in the American Journal of Public Health has found that raising cigarette prices and exposing people to anti-smoking advertisements are the most effective tactics to get addicts to stub out.

The study used survey data collected from the five biggest Australian cities to assess the impact of tobacco control policies and television advertising on smoking rates.

It found cigarette price and anti-smoking media campaigns have the potential to speed up the decline in smoking rates by reducing smoking uptake and increasing quitting by smokers.

Increasing the price of each cigarette by between one and 2.5 cents would result in 60,000-95,000 fewer smokers in Australia.

Exposing the population to televised anti-smoking ads an average of between four and eight times per month would have the same effect.

Up to half of these would die prematurely if they continued smoking.

"An increase in the real price of cigarettes and mass media campaigns broadcast at sufficient levels of exposure at regular intervals are critical for reducing population smoking rates," said co-author Professor David Hill, director of Cancer Council Victoria.

"A relatively small percentage change in the cost of a typical pack of cigarettes translates into measurable declines in prevalence."

Prof Hill said the results highlighted the need for governments to consider investment in tobacco control as an ongoing and essential service, as they would with primary health care and ambulance services.

"The public health gains from reducing tobacco use are huge and indisputable, but we will not see population-level change from irregular tobacco control activity," he said.

"Ongoing exposure to mass-reach interventions, such as price increases and mass media campaigns are required."

Quit executive director Fiona Sharkie said the study provided the Federal Government with a "blueprint" on the best ways to reduce smoking.

"And it will certainly be invaluable information for the new national preventative health taskforce who are currently considering ways forward to address tobacco use in Australia," Ms Sharkie said.

She said increasing the price of cigarettes was probably the most effective intervention that could be made in tobacco control.

The Australian, June 13, 2008.

Wakefield M et al. Impact of tobacco control policies and mass media campaigns on monthly adult smoking prevalence. American Journal of Public Health, published online ahead of print Jun 12, 2008. 10.2105/AJPH.2007.128991
http://www.ajph.org/

Dental caries in 3-year-old children and smoking status of parents

Summary

An association has been suggested between environmental tobacco smoke and oral disease. The present study examined the relationship between early childhood caries (ECC) and parental smoking, particularly paternal smoking, using records of 711 36-month-old children. The smoking status of parents as an independent variable was entered in the multivariable logistic regression model for caries experience as the dependent variable with confounders: sex, residential location, and possible risks of ECC such as order of birth, type of main drink, frequency of daily intake of sugar-containing snacks, daily toothbrushing by parents and use of fluoridated toothpaste.

About 65% of children were caries free. Children whose parents did not smoke (CN), those in whom only the father smoked (CF), and those whose mother smoked regardless of the smoking status of the father (CM) comprised 33%, 33% and 34% respectively. The adjusted mean number [95% CI] of decayed teeth and caries experience prevalence for CN, CF and CM were 1.2 [0.8, 1.6], 1.6 [1.2, 2.0] and 2.1 [1.7, 2.5], and 25.6%, 35.3% and 45.7% respectively. The relationship between caries experience and parental smoking was significant on multivariable analysis. The adjusted OR [95% CI] of CF and CM relative to CN was 1.52 [1.01, 2.30] and 2.25 [1.51, 3.37] respectively. These results indicate the association of ECC with parental smoking, although the association with paternal smoking was weaker than with maternal smoking.

Haniokaaa, T et al Dental caries in 3-year-old children and smoking status of parents.
Paediatric and Perinatal Epidemiology. doi:10.1111/j.1365-3016.2008.00950.x

http://www.blackwell-synergy.com/doi/abs/10.1111/j.1365-3016.2008.00950.x

Smoke exposure and increase in risk of multiple sclerosis

An association between tobacco smoke exposure and autoimmune diseases has been shown. In a cohort of female nurses, smoking has been shown to significantly increase the risk for multiple sclerosis (MS) and the risk increased with increasing exposure of smoking. Researchers in Sweden undertook a study to estimate the effect of exposure to smoking on the risk of developing MS.

Cases were identified through an epidemiological survey in northern Sweden. Elevated cotinine levels were associated with an increased risk of MS (odd ratio 2.9%; 95% CI 1.3 – 6.3). Elevated cotinine was associated with an increased risk for MS predominantly in women - OR = 3.9, whereas the risk increase in men was smaller and non-significant.

The authors conclude that smoke exposure is associated with a higher risk for MS than previously estimated. There seems to be a threshold effect present in the lower range of cotinine in its relation to MS. Modestly elevated cotinine levels suggestive of passive smoking are associated with an increased risk for MS. Smoke exposure may explain the higher incidence of MS in women. These preliminary findings need to be confirmed in an expanded material of prospectively collected samples.

Sundstrom P, Nystrom L and Hallmans G. Smoke exposure increases the risk for multiple sclerosis. Eur J Neurology 2008; 15: 579-583

Events and Publications

Events

30 June – 1 July 2008 – UK National Smoking Cessation Conference (UKNSCC)
Venue: Hilton Birmingham Metropole Hotel
The world’s largest gathering of smoking cessation practitioners, researchers and policy makers.
See www.uknscc.org for more information.

5 July – RCP Public Open Day to celebrate 60th anniversary of the NHS
Admission free. Includes information on medical education and training, guided tours of the building, and the history of medicine. Open 11am – 40pm.
Details: www.rcplondon.ac.uk

1-4 October – 11th European Health Forum Gastein: Theme - Values in Health: from vision to reality
Venue: Bad Hofgastein, Salzburg, Austria
Details: www.ehfg.org

4-8 October 2008 – European Respiratory Society Annual Congress
Details: info@ersnet.org

27-29 October - SCTRP three-day course, Central London
Contact Janice Rossabi, SCTRP Course Secretary at sctrp@yahoo.co.uk

5 December - Annual Update and Supervision Day
The annual Update and Supervision Day is the opportunity for graduates of the SCTRP Courses to ‘calibrate’ their clinical practice and share information in this fast-developing field. The programme consists of talks on new developments in treatment theory and practice, practical sessions on treatment details, and discussions of participants’ experience. As well as supervision and troubleshooting sessions, the Update provides an opportunity for networking among 100 clinicians and service co-ordinators.
For further details please contact Janice Rossabi, SCTRP Course Secretary at sctrp@yahoo.co.uk