Friday, November 6, 2009

DEPARTMENT OF VETERANS AFFAIRS TOBACCO-CONTROL ACTIVITIES

VA has long been engaged in efforts to promote tobacco cessation in veterans. VA
researchers have been at the forefront of advances in tobacco-cessation treatments. Nevertheless,
veterans served by the VA health-care system continue to have higher rates of tobacco use than
their general-population counterparts, although not as high as those of military personnel. That
suggests that many veterans quit using tobacco, but with tobacco use increasing in the military, it
is likely that many new veterans accessing the VA health-care system will also be tobacco users,
especially those who have been deployed in Iraq and Afghanistan.
Like DoD, VA has many components of a comprehensive tobacco-control plan already in
place, including effective and enforceable policies, communication mechanisms, surveillance
activities in the form of performance measures, and periodic evaluation of tobacco-control
practices. VA has developed a National Smoking and Tobacco Use Cessation Program, and it
has recently strengthened its Smoke-Free Policy for VA Health Care Facilities. But in its efforts
to become entirely tobacco-free, the department has been thwarted by congressional legislation
that requires VA medical facilities to have designated smoking areas for veterans and employees.
The committee finds that such a requirement prevents VA from protecting its patients, employees, and visitors from possible exposure to secondhand smoke and prevents it from
promoting the health of its more vulnerable patients, those who smoke.
Virtually all the VA medical centers (VAMCs) have some form of tobacco-control
program, although the programs are not standardized or uniform. Each VAMC must designate a
smoking and tobacco-use cessation lead clinician to be the point of contact for all clinical and
other communications on tobacco cessation. However, the committee finds that that position is
typically not full-time, and the lead clinicians may have other responsibilities that take
precedence. The committee also finds that the availability of tobacco-cessation services in VA
community-based outpatient clinics (CBOCs), other than the required access to medications and
brief counseling, is highly variable: some CBOCs have trained staff who offer group or
individual counseling, and others only refer patients to outside community services.
Use of the VA/DoD Clinical Practice Guideline for the Management of Tobacco Use has
been encouraged by the VA Office of Public Health Policy and Prevention, and it has been
included in the National Smoking and Tobacco Use Cessation Program. The guideline highlights
the effectiveness of using the 5 A’s for each patient. VA has been successful in ensuring that all
patients are asked about their tobacco status, are advised to quit, and are referred to a tobaccocessation
program; these prompts are included in patients’ electronic medical records and are
performance metrics for evaluating VA health-care providers. But adherence to the guidelines
beyond the minimal effort required by the prompts in the medical records is variable.
VA appears to offer a broad array of tobacco-cessation counseling interventions to
patients, but there is little information on the effectiveness of these interventions for veterans.
The guidelines do not specify particular tobacco-cessation programs to be used, and VA uses
several standard programs, including those of the American Cancer Society and the American
Lung Association. The committee does not know whether VA tailors the programs to address
special needs of veterans.
The VA/DoD clinical-practice guideline and the PHS guideline provide
recommendations for evidence-based treatment of special populations that seek medical care at
the VA. Those populations include older patients, hospitalized patients, and patients who have
mental-health disorders. The committee believes that the guidelines provide a good treatment
framework.
The committee believes that veterans would benefit from a national VA quitline for
tobacco, possibly supplemented by a computer-based cessation campaign similar to the DoD
“Quit Tobacco. Make Everyone Proud” Web site. A national quitline has the advantage of
consistency of service regardless of where veterans are. Quitline counselors should be trained to
deal with veteran-specific issues, such as PTSD. Evidence shows that people who have mentalhealth
disorders are willing and able to engage in tobacco cessation and should be encouraged to
do so. The committee believes that VA should assess whether quitline counselors can provide
tobacco-cessation medications to veterans as in the private sector without the need for veterans to
obtain prescriptions from their health-care providers, particularly for over-the-counter
medications, such as nicotine-replacement therapy.
Performance measures that assess health-care providers are a good start for improving
care, but the effect of that care on patient outcomes might be even more important. The
committee believes that VA should evaluate the long-term effect of its tobacco-cessation
programs on abstinence rates. Such information would help to show where programs could be
improved or replaced.

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Thursday, October 22, 2009

Crave Episode Frequency

Be prepared for a small spike in crave episodes on day seven, as you celebrate your first full
week of freedom from nicotine. Yes, for most of us, nicotine use was part of every celebration. Also
stay alert for subtle differences between crave-triggers. For example, the Sunday newspaper is much
thicker and may have required three cigarettes to read instead of just one.
Understanding the Big Crave – The “average” quitter will be experiencing just 1.4 crave episodes
per day within ten days. After that you may soon begin to experience entire days without encountering
a single un-reconditioned subconscious trigger. If a later crave episode ever feels more intense, it is
likely that it has been some time since your last significant challenge and you’ve dropped your guard
and defenses a bit. It can feel as though you have been sucker-punched. If one does occur, see the
distance between challenges as the wonderful sign of healing the incident reflects.
Crave Coping Techniques - One crave coping method is to practice slow deep breathing while briefly
clearing your mind of all needless chatter by focusing on your favorite person, place or thing. Another
popular three minute coping exercise is to say your ABCs while associating each letter with your
favorite food, person or place. For example, the letter “A” is for grandmother’s hot apple pie. “B” is for
warm buttered biscuits. You may never reach the challenging letter “Q.”
Embracing Craves - Another coping technique is to mentally reach out and embrace your craves.
A crave cannot cut you, burn you, kill you, or make you bleed. Try to be brave just once. In your mind,
wrap your arms around the crave’s anxiety energy and then sense as it slowly fizzles while within your
embrace. Yes, another trigger bites the dust and victory is once again yours, as you reclaim yet
another aspect of life!
Confront Your Crave Triggers - Within two weeks, you should begin to realize that everything
you once did while nicotine’s slave can again be comfortably done without it, and often better.
Meet, greet and defeat your triggers. Don’t hide from them. You need not give up anything during
recovery except nicotine.

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Thursday, September 24, 2009

Tobacco warning

WARNING - The following depression discussion is intended for those ending nicotine use cold turkey, not for those taking cessation medications. Some patients using Chantix and Champix (varenicline) have experienced changes in behavior, agitation, depressed mood, and suicidal thoughts or actions. Some experienced these symptoms when they began taking varenicline, and others developed them after several weeks of treatment or after they stopped taking it. If either you, your family or caregiver notice agitation, depressed mood, or changes in behavior that are not typical for you, or if you develop suicidal thoughts or actions, stop taking CHANTIX and call your doctor immediately. If using varenicline or any other quitting medication do not rely upon this book regarding any symptoms but instead present any and all concerns to your treating physician or pharmacists.

The above warning was necessary because depression is not some fixed and interchangeable emotion, as though some license plate that would fit every car. Like the word “wind” it can range from a soft gentle breeze to a full-blown hurricane. The word depression can range from a short period of normal and expected sadness to full-blown clinical depression with suicidal thoughts, planning or attempts.
 

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Tuesday, September 15, 2009

Symptoms relate to cold turkey cessation

The below symptoms relate to cold turkey cessation only. They are not intended for those using Chantix, Champix, Zyban, Wellbutrin, nicotine replacement products (NRT) or any other quitting product. Carefully review warnings and potential side effects noted on or inside product packaging if using any quitting product. Immediately consult your health care provider or pharmacist if any symptom or possible side-effect causes you or your loved ones concern including changes in thinking, moods or behavior.

WARNING: The list of symptoms below is NOT MEDICAL ADVICE but simply an outline of documented recovery symptoms. IMMEDIATELY contact our physician should you experience any condition or symptom that causes you CONCERN or ALARM, including continuing depression.

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Tuesday, August 25, 2009

Why we smoke?

We need not guess as to what happens inside a human brain that’s subjected to nicotine during recovery. The evidence seen on brain PET scans is undeniable. Just one puff of nicotine and within ten seconds up to 50% of the brain’s nicotinic-type acetylcholine receptors will become occupied by nicotine. While the smoker’s conscious mind may find itself struggling with tobacco toxin tissue burning sensations and carbon monoxide induced dizziness, well-engineered dopamine payattention pathways will find the resulting dopamine “aaah” sensation nearly impossible to forget.

We may actually walk away from the relapse experience thinking we have gotten away with using. But it won’t be long before our brain is begging for more. Recovery isn’t about battling an entire pack, pouch, tin or box of our particular nicotine delivery vehicle. It’s about that first bolus of nicotine striking the brain, a hit that will end our journey, cost us liberty, and land us behind bars.

Unfortunately, conventional “quitting” wisdom invites relapse with statements such as “Don’t let a little slip put you back to smoking.” As Joel says, it’s like telling the alcoholic, “Don’t let a sip put you back to drinking” or the heroin addict, “Don’t let shooting-up put you back to using.” Experts are fond of stating that “on average, it takes between 3-5 serious quit attempts before breaking free of tobacco dependence,” and that “every time you make an effort you’re smarter and you can use that information to increase the likelihood that your subsequent quit attempt is successful.” What these so called experts fail to reveal is the precise lesson eventually learned.

Why? Why can’t it be taught and mastered prior to a user’s first attempt ever? They don’t teach it because most don’t understand it themselves. Instead they excuse failure before it even occurs, as if trying to protect the particular quitting product they are pushing from being blamed for defeat.

The lesson eventually gleaned from the school of hard-recovery-knocks is that “if I take so much as one puff, dip or chew I will relapse.” Just one, just once and defeat is all but assured. “The idea that you can’t quit the first time is absolutely wrong,” says Joel.120 “The only reason it takes most people multiple attempts to quit is that they don’t understand their addiction to nicotine. How could they, no one really teaches it. People have to learn by screwing up one attempt after another until it finally dawns on them that each time they lost it, it happened by taking a puff. If you understand this concept from the get-go, you don’t have to go through chronic quitting and smoking.”

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Wednesday, August 12, 2009

Buried Alive by Nicotine

Try to remember. What was it like being you? What was it like to function every morning without nicotine, to finish a meal, travel, talk on the phone, have a disagreement, start a project or take a break without putting nicotine into your body? What was it like before nicotine took control? What was it like residing inside a mind that did not want for nicotine?
One of the most fascinating aspects of drug addiction is just how quickly nearly all remaining memory of life without the external chemical are buried by high definition dopamine “aaah” memories generated by using it. It’s a common thread among all drug addicts. We’ll discuss this in more detail later but I pose this to you now. How can we claim to like or love something when we have almost no remaining memory of what life without it was like? What basis exists for honest comparison? Why be afraid of returning to a calm and quiet place where you no longer crave a chemical that today, every day, you cannot seem to get off your mind, a chemical that is a mandatory part of every day’s plan?
Why fear arriving here on Easy Street with nearly a billion comfortably recovered nicotine addicts? Is freedom of thought and action a good thing or bad? If good, then why fear life without it? How wonderful would it be to again reside inside an undisturbed mind where addiction chatter gradually becomes infrequent, then rare? Again, I ask you, “What was it like being you?” Why fear coming home? Slave to the world of “nicotine normal,” we were each provided a new identity.
brain dopamine pathways did their designed job and did it well. They left us convinced that our next nicotine fix was central to survival, as important as drinking water or eating food. I recently read disturbing comments posted by more than a hundred long-term nicotine gum addicts. One, a 36 year-old woman, wrote, “I have to say, I traded one problem for another. I chew 4 mg 24/7 and can go through 170 pieces in less than 6 days. I have been chewing Nicorette now for 12 years. If I run out for a short time my mood becomes irrational. It is costing me more money than I have.
 I have chosen Nicorette over food many times.” Although the word “quitting” is part of the fabric of nicotine cessation, such thinking can unconsciously tease and play upon old nicotine use memories, making us feel as though we’ve left something of tremendous value behind. If allowed, it can tease and inflame false fears, fears born of nicotine urge and replenishment memories, durable memories whose purpose was to convince us that nicotine is vital to survival, memories that should never have been present in the first place, memories only made possible because a foreign substance entered the brain and was able to disrupt priorities.
When you think about “quitting” I hope you’ll ponder when the real “quitting” took place. The journey home is about recognizing and embracing truth. But be prepared; learning that for years we were fooled and lived a lie can invoke a host of emotions including anger. Baby steps, patience, honesty and you too will soon be entirely comfortable again engaging all aspects of life without nicotine. Contrary to deeply held beliefs that were pounded into your brain by an endless cycle of urges and rewards, you are leaving absolutely nothing of value behind. To quote a line from one of my favorite movies, “even the love in our heart, we get to bring it with us!”
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Wednesday, August 5, 2009

Smoking tolerance

Tolerance ever so gradually pulls us deeper and deeper into dependency’s forest. We find ourselves sucking a wee bit harder, holding the smoke longer, or smoking more nicotine in order to achieve the desired effect. Two a day, three, four, four smoked hard, our brains gradually grow additional nicotinic-type acetylcholine receptors.
 Over time, most of us require more nicotine in order to match last month’s or last year’s “aaah” reward sensation. My “aaah”s were no more powerful smoking five cigarettes a day at age fifteen than when smoking 60 per day at age forty. I needed that much more in order to achieve the same remembered effect. I know, you’re probably thinking, you’ve been at the same nicotine intake level for some time now and it’s likely vastly less than the three packs-a-day I was smoking. While we don’t yet fully understand wide variations in levels of nicotine use, we know that genetics probably explains most differences.
 There is also the fact that some of our mothers, like mine, smoked during pregnancy. I was born with my brain wired for nicotine. I came into this world as nicotine’s slave and likely spent the first few days in withdrawal. As Duke University’s Professor Slotkin puts it, “nicotine alters the developmental trajectory of acetylcholine systems in the immature brain, with vulnerability extending from fetal stages through adolescence.”
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Friday, July 17, 2009

ESTIMATED TOBACCO IMPACT ON THE PRIVATE SECTOR

FDA would impose a number of private-sector mandates, as defined in UMRA, on companies that manufacture or import tobacco products. CBO estimates that the total direct cost of these mandates would exceed the threshold established by UMRA ($139 million in 2009, adjusted annually for inflation) in each year, beginning with 2010.
 The bill would assess a fee on manufacturers and importers of tobacco products to cover the cost to FDA of regulating those products. The aggregate payments would sum to $235 million in 2010, and rise to more than $500 million a year by 2013. The bill would impose new requirements related to the labeling and advertising of cigarette and smokeless tobacco products. New warnings on packaging and 13 advertisements would have to be larger, and, in the case of cigarette warning labels, include pictorial graphics.
The bill would also prohibit cigarettes or any of their component parts from containing certain additives or flavors (other than tobacco or menthol) that are a characterizing flavor of the tobacco product or tobacco smoke. CBO has not been able to determine whether the direct cost of these provisions would be significant.
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Tuesday, July 7, 2009

Demand for cigarettes

The use of a rational addiction model for modelling the demand for cigarettes has been controversial. Critics of the model argue that nobody would sit down at an initial period, survey future income, production technology, investment/addictive function, and consumption preference for a lifetime, maximize the discounted value of his expected utility and decide to become an alcoholic.
Empirical work for testing the rational addictive behaviours has also yielded mixed results. In spite of the large number of studies on demand for cigarettes, only a few studies have been conducted for developing countries, despite the increasing cigarette consumption.
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Thursday, July 2, 2009

Expenditure on cigarettes

Households spend about one third of their income on food. Expenditure on cigarettes constituted 2.4 percent of total expenditure in 1987 and 1994, this share being higher in rural areas than urban centres due to the lower rural incomes.
Expenditure on cigarettes is nearly equal to the total expenditure on health and is more than double that of tea and coffee, nearly 7 times the share of fish, and more than half the share of milk and milk products. The proportion of consumer expenditure which goes to cigarettes is higher for people on higher incomes.
Taxes on cigarettes
Both domestic and imported cigarettes are taxed in Turkey. Domestic tobacco is subject to a tax of more than 200 percent, and tobacco is an important source of indirect tax revenue. The tax from tobacco amounted to US$2 300 million, which was more than one eighth of total indirect tax revenue in 1998.
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