SRNT Newsletter - Vol. 5 No. 2
May-July 1999

Those findings we frequently cite—are they accurate?

Statistics, Scientists under Fire

By Janet Brigham
SRNT Newsletter Editor


Nearly every grant application, every presentation, or every news story about tobacco hinges on some version of well-known statistics:

Recently, several reporters and researchers have brought those and other statistics into question. Their overt challenges to scientific findings have carried inflammatory titles: "Lies, Damned Lies, & 400,000 Smoking-Related Deaths," and "Smoking Out Bad Science," and "Big Lies about Tobacco."

These articles are not published in obscurity. A Boston Globe columnist’s article on "big lies" told by scientists was carried in major metropolitan newspapers in the United States. The Wall Street Journal’s European edition carried two additional articles, one attacking statistics on secondhand smoke, the other attacking tobacco-control efforts of the World Bank and the World Health Organization.

Tobacco research advocates were labeled "crusaders," their work was characterized as having a "hysterical tone," and scientists were dismissed as not being credible. Years of work and hundreds of studies were shrugged off as "falsehoods" and "lies."

When such articles initially are reprinted or reported in newspapers, they carry the impact of appearing to be news. Rebuttals typically take the form of letters to the editor, where they may share space with local residents’ complaints about road maintenance and zoning laws. In many cases, the damage is done and the credibility of peer-reviewed research is somewhat undone with the widespread publication of inaccuracies and misrepresentations.

No movement is without its critics, but it is worth noting that these charges against tobacco-control efforts also bring into question the accuracy of peer-reviewed scientific findings and the credibility and motives of scientists.

Such statements might not endure long if they were subjected to the same peer-review scrutiny as the science they question. They do, however, serve one useful function: They open a discussion about the purposes and findings of scientific research on nicotine and tobacco.

A case in point started with an article in the magazine Regulation, sponsored by the Cato Institute, a "think-tank" in the United States. The article—downloadable from the institute’s website but otherwise not a high-profile element of popular culture—questioned the number of tobacco-related deaths in the United States. The article received little public notice until Globe columnist Jeff Jacoby cited the "big lies" with this opening commentary:

A newspaper ad, full-page. Stark background. Large type. "Cigarettes kill more Americans every year than car wrecks, plane crashes, AIDS, alcohol, drugs, suicides, and homicides combined." It’s a terrifying statistic. Good thing it’s not true.

Jacoby then quoted "pervasive" "falsehoods" as cited by Elizabeth Whelan, president of the "American Council on Health and Science" (actually the American Council on Science and Health), and other sources. Noting their "rhetoric" as "ghastly," Jacoby quoted from the Regulation paper, relying on its authors’ assertions apparently without the same skepticism he applied to scientists whose work they questioned

The two Regulation authors, Robert A. Levy and Rosalind B. Marimont, are not without credentials. Levy is a Cato Institute senior fellow and an adjunct professor at Georgetown University Law Center; Marimont is retired from the U.S. National Institute of Standards and Technology and the "National Institute [sic] of Health."

They summarized a sizable body of scientific literature on tobacco and health with such sections as "Third-Rate Thinking and Secondhand Smoke," in which they criticized a World Health Organization report on passive exposure to tobacco smoke. They referred to a U.S. Environmental Protection Agency’s report on environmental tobacco smoke as "junk science," and questioned the classification of diseases as being smoking-related. They concluded that "the scare-mongering that has passed for science is appalling. Not only is tobacco far less pernicious than Americans are led to believe, but its destructive effect is amplified by all manner of statistical legerdemain."

acoby, reporting their assertions, stated that 39% of the Centers for Disease Control and Prevention’s 1990 calculations of 419,000 U.S. tobacco-related deaths in 1990—or 164,000 deaths—could not be attributed to tobacco use. He noted, "A smoker who dies from pancreatic cancer...is not a victim of tobacco. To call him one is to engage in sophistry, not science."

He quoted Levy and Marimont in adding that "the supposed 400,000 smoking-related victims" are only "computer-generated phantom deaths, not real deaths." Jacoby insisted, "Measured by years of life lost, smoking is a much smaller problem than alcohol consumption." As proof, he added that "the number of young people killed by smoking is—zero."

Jacoby’s observations, reprinted in newspapers carrying his column, stirred interest and comment from local health professionals and academicians. The U.S. Office on Smoking and Health responded to the Jacoby article with a statement from Director Michael Eriksen (see next page).

It is difficult to gauge the fallout from an article such as Jacoby’s column, or from The Wall Street Journal’s May 5 article by Lorraine Mooney, containing this charge:

The smoker who is supposedly burdened with a personality-splitting addiction is about to be taxed further, and the money will go to health evangelists who will then lecture the addict. The approach should alarm those selling other so-called addictive products, such as alcohol, coffee and chocolate.


 What is the best response? In most cases, replying to an attack with similar tone results only in rhetorical. Instead, a straightforward statement of facts, delivered calmly and professionally, provides a more powerful—and accurate—message.

A Response to the Critics 


The following reply was sent to newspapers printing the article by columnist Jeff Jacoby. The reply is by Michael Eriksen, director of the Office on Smoking and Health of the National Center for Chronic Disease Prevention and Health Promotion: 

A commentary by Jeff Jacoby ...challenges the science used by the Centers for Disease Control and Prevention (CDC) to estimate how many people die from cigarette smoking each year in the United States. The commentary was based on an article by Robert Levy and Rosalind Marimont in the latest issue of Regulation magazine, which contains numerous errors about the harm of smoking and the risks of secondhand smoke. We would like to take this opportunity to clarify the method by which CDC estimates smoking-related deaths.

First, Levy and Marimont claim that the government counts as a smoking-related death all smokers who die from a certain disease, even if they had other risk factors for that disease. This is not true. For each disease, CDC attributes only a percentage of the deaths as being due to smoking, based on the best medical science. For example, for heart disease, CDC estimates that the proportion of deaths due to smoking is only 16 percent for persons age 65 and older. For lung cancer, in which the authors acknowledge smoking as a "high risk factor," CDC considers only 83 percent of the deaths as being smoking-related.

The authors also stress that other risk factors must be statistically controlled for if the impact of a single factor like smoking is to be reliably determined. We agree, and conducted a careful analysis to examine this very issue. Our findings conclude that controlling for other risk factors changed the proportion of deaths attributed to lung cancer by only one to two percent, and the proportion of deaths from heart disease by less than one percent—hardly the huge impact alleged by the authors.

The authors also claim that many of the deaths from tobacco are not premature deaths. However, studies that have followed smokers and nonsmokers for many years have found that smokers are three times more likely to die between the ages of 45 and 64 and two times more likely to die between the ages of 65 and 84 than those who have never smoked. Although a certain proportion of smoking-related deaths occur among older Americans, the fact is that 33 percent of nonsmokers live to age 85, compared with only 12 percent of smokers.

Finally, the authors claim that smoking-related deaths estimated by CDC are not real deaths, but "computer-generated phantom deaths" using non-representative populations to calculate risk. In 1989, the State of Oregon asked physicians to report on death certificates whether tobacco use contributed to the death. Between 1989 and 1996, physicians reported that tobacco contributed to 20 percent of Oregon deaths, the exact percentage of deaths attributed to smoking over the same time period using CDC's method. The CDC estimate and the Oregon death certificate data differed in their cumulative estimates of the number of smoking-attributable deaths for the eight years by only 61 deaths—a difference of about one tenth of one percent. This real-life experience provides strong evidence that the statistical methods used by CDC provide an accurate calculation of the real deaths occurring daily in the United States that are caused by tobacco use.

Cigarette smoking and other tobacco use is the single most-studied health risk factor in the history of medicine. Scientific facts support our estimate that each year, more than 400,000 deaths in this country are prematurely caused by smoking-related diseases.

President’s Message
Challenges for the 21st Century

By Dorothy Hatsukami
SRNT President, 1999-2000 

First, I want to acknowledge how appreciative I feel having been elected president of SRNT. After Jack Henningfield’s great leadership, I think we have a very smooth and productive course set for us. Now that we have Thomas Miller Associates as our management firm, we are in good hands.

Being president of SRNT has given me quite an appreciation of all the areas being impacted by our members and how much of a role we play in determining the future agenda for research and policy, both within the United States and internationally. Currently, Karl Fagerström, Ann McNeill, David Balfour, and Jacques LeHouezec are planning a 25-26 November 1999 SRNT scientific meeting in London, UK, entitled "Tobacco Addiction. New Horizons for the 21st Century." Ron Borland is having a satellite SRNT symposium in Australia in conjunction with the International Society of Behavioral Medicine, and I am representing SRNT at a November meeting in Kobe, Japan, that is focused on tobacco use in women and youth.

We are also currently applying for nongovernmental organization (NGO) status with the World Health Organization. Presently, John Hughes, Jack Henningfield, Saul Shiffman, Sharon Hall, Neal Benowitz, Robin Mermelstein, and I are leading work groups that are addressing specific treatment outcome methodology issues by reviewing the literature and undertaking data analyses of currently existing data sets. Many SRNT members have volunteered to be members of this work group. The results of our endeavors will be presented at a meeting held prior to our annual scientific meeting. This preconference event will occur on February 17, and the scientific meeting will be held on 18-20 February 2000 at the Crystal Gateway Marriott Hotel in Arlington, Virginia. So mark your calendars!

As you can see, SRNT members have been extraordinarily active, and I haven’t even begun to describe the work being done by all the other volunteers of our organization. This work includes developing and assisting in public policy, enhancing minority representation, ensuring the visibility of SRNT in important arenas including the public media, and, most importantly, fostering the development of new scientists and ensuring the communication among scientists through our meetings, journal (first issue has been mailed!), newsletter, and electronic communications.

I attended a meeting in my community recently, whose goal was to discuss the best tobacco interventions to implement for the State of Minnesota. The two main questions I heard raised were, "What is the evidence to support a particular treatment?" and, "When will researchers have the answer on the effectiveness of treatments for particular populations?" These questions were indicative of how much we, as scientists, have contributed to present policies and interventions, and also how much we still need to know. This observation led to my own reflections of where we have been in research in recent years and where we need to go as we approach the 21st century.

Over the past 50 years, scientists have identified the cholinergic receptors, which are targeted by nicotine. We also have learned about the areas of the brain that are associated with the reinforcing effects of nicotine and the numerous neurotransmitters that are released by nicotine, which are responsible for its psychoactive effects. More recently, we have identified different subtypes of the nicotinic cholinergic receptors that may have varied functions.

The future of research in this area rests on determining (a) whether the anatomy of these receptor subtypes varies across individuals, making some people more vulnerable to initiating and maintaining tobacco use than others; (b) whether the discovery of the various functions of these subtypes will lead to potential treatments for nicotine addiction; (c) whether treatment of diseases may benefit from nicotine or nicotinic analogs; and (d) how these different receptor subtypes may contribute to the addictive process.

In the past 50 years, we have also become aware of the plethora of harmful consequences associated with tobacco use and smoke for the individual user, the fetus, and those who are subjected to tobacco smoke. The future of research will include (a) how to reduce these harmful effects by altering the tobacco product itself (e.g., low-nicotine cigarettes, reducing nitrosamines in the product, and reducing the harmful smoke emitted from the cigarettes and cigars); (b) developing chemoprevention agents; (c) identifying and delivering effective treatment for those who are most susceptible to harmful effects from tobacco, including nicotine addiction; and (d) and intermediary treatment methods to reduce tobacco exposure other than what should be the ultimate goals of prevention and cessation.

As we turn towards the 21st century, we have focused our attention on individual susceptibility to tobacco use. We have come to understand that the genetic factors associated with the initiation of tobacco use may be different than the factors associated with the maintenance of use. We also have come to know that individuals’ different responses to nicotine may be a result of inherent physiologic differences, such as the rate of nicotine metabolism, impact of hormones, developmental stage, or differences in receptor sensitivity or number.

Future research will provide greater clarification on the neurobiological mechanisms of these differences. Differences in susceptibility may also be a function of social and cultural factors, such as the broader and immediate social/cultural norms, the interaction of these norms, and the attributes of the individual (e.g., self-esteem, negative affect, school achievement, risk taking, development stage).

Treatment research has made tremendous strides during the past 20-40 years. Once tobacco use was considered to lead to nicotine addiction and harmful effects, systematic research was conducted on psychosocial and pharmacological treatments. Multicomponent psychosocial treatments have been shown to demonstrate the greatest efficacy, and components that lead to greater treatment success have been identified through meta-analytic studies.

Several nicotine- and non-nicotine-based pharmacological treatments have been developed. Treatments with broader community outreach (e.g., health care provider interventions, telephone counseling) have been found to be effective. We have also learned that treatments that are appropriate to stages of change are important.

Our future challenges reside in determining whether treatments individualized to specific needs will augment treatment success, identifying typologies of smokers and treatments that match these typologies, developing more sophisticated treatments that target various aspects of addiction, capitalizing on the electronic communication age for innovative intervention methods, and disseminating effective interventions into our communities.

In the past several years, public policies that effectively control tobacco use have been examined. We now know that tobacco use can be reduced significantly by increasing the price of tobacco products, environmental restrictions on tobacco use, and perhaps anti-smoking marketing campaigns. The goal has been to change the accessibility, availability, and cultural norms of tobacco use. Our future resides in determining—

Developing effective tobacco control programs internationally, particularly in developing countries, will be one of the most important challenges in the 21st century.

As we look toward the future, communication and collaboration among scientists of various disciplines in the areas of tobacco and nicotine become increasingly necessary. The U.S. National Cancer Institute and the U.S. National Institute on Drug Abuse recommend a "transdisciplinary" approach.

We are fortunate to have a scientific organization such as SRNT to facilitate communications among scientists with different disciplines and to provide a forum for thoughtful discourse. We also are fortunate to have such strong feelings of camaraderie and willingness to help among our members.

Thanks to everybody, and I look forward to the coming year.

RWJF Grant Supports New Journal

The Robert Wood Johnson Foundation has awarded $199,656 over four years as a grant-in-aid to the Society for Research on Nicotine and Tobacco in support of editorial functions for SRNT’s journal, Nicotine & Tobacco Research.

The grant will also provide critical support to inform the public and the scientific community about progress in nicotine and tobacco research. A science writer will prepare nontechnical summaries of all forthcoming articles in a section at the front of the journal.

Articles will be selected by the editorial board of the journal for broader dissemination to general news publications and to professional and scientific news agencies. Ovide Pomerleau, chair of the Publications Committee, will serve as the project officer for the award.

The foundation, based in Princeton, New Jersey, USA, is the largest philanthropic organization in the United States devoted exclusively to health and health care.


SRNT Requests Treatment Methodology Ideas

SRNT is seeking member involvement in next year’s SRNT Treatment Methodology Conference, where scientists will examine existing information and analyze data to address methodological issues related to treatment outcome research.

SRNT is opening up involvement in this process to all members of the Society. Members desiring to participate in a work group are invited to contact chairpersons for the work groups.

Purpose and Procedures

The primary aim of the proposed series of work study groups and conferences will be to address some of the fundamental methodological issues faced by researchers undertaking treatment studies. These issues involve treatment outcome measures, methods for biochemical verification, statistical analyses, and outcome measures for adolescents. Each of these topic areas will undergo rigorous scientific, empirically-based examination.

The process for this examination will include the following elements:

Work groups will address four topic areas, with the work groups thoroughly exploring the most crucial areas to be examined, determining the most important issue to address in the methodology of treatment outcome research, assessing and analyzing existing data, and discussing future research needs.

Outcome Measures. The three outcome measures include: (1) abstinence, slips, and relapse; (2) reduction of tobacco exposure; and (3) tobacco withdrawal symptoms and craving.

Abstinence, Slips, and Relapse. Chair is John Hughes (John.Hughes@UVM.EDU). This work group will examine issues such as point prevalence vs. continuance abstinence measures, grace periods, soft endpoints that allow some smoking, definitions of lapse and relapse, the need for long-term followup, handling of post-treatment non-cigarette tobacco use or continuance of nicotine replacement medication, and use of nontraditional abstinence measures. The group will be especially interested in data sets of nonpharmacological interventions, minimal interventions, interventions with follow-up periods of at least two years, and interventions for special populations.

Tobacco Withdrawal and Craving. Chair is Saul Shiffman (shiffman@pinneyassociates.com). This group will examine the measurement of craving and withdrawal, particularly in clinical trials. Issues that might be considered by the group include the relationship between craving and withdrawal in smoking cessation and maintenance, the utility of relief of craving and withdrawal as an outcome of treatment; assessment content, samples, baseline data, assessment timing; and methods for assessing acute relief of craving.

Reduction of Tobacco Exposure. Chair is Jack Henningfield (jhenning@pinneyassociates.com). The primary goals of this work group will be: determining whether reduction of tobacco exposure is a valid endpoint for those who are unwilling or unable to completely abstain, examining this endpoint category with comparable endpoints in other areas of addiction medicine, determining appropriate biomarkers for smoking reduction, and examining the public health benefit or costs of smoking reduction.

Work group participants with experience related to reduction of tobacco use and other forms of substance dependence, experts in the management of other disease states in which reduction of some adverse effect is considered a legitimate goal (e.g., cardiologists), and individuals with broad public health perspectives on this topic are welcome.

Biochemical Verification. Chair of this group will be Neal Benowitz (nbeno@itsa.ucsf.edu). In this work group, the issues to be addressed include determining which biomarkers are most useful for assessing tobacco use, extent of passive smoke exposure, studying tobacco use that occurs during treatment with nicotine medications, identifying nicotine intake as a potential indicator of severity of addiction, optimal cutoff points for various biomarkers, considering populations with varying prevalence of smoking, and passive exposure

Statistical Analyses. Chair is Sharon Hall (smh@itsa.ucsf.edu). Statistical techniques applicable to clinical trials are expanding rapidly. Investigators in the field of smoking treatment outcome research have a range of techniques available to them but often have little basis for making decisions between technically complex methods. This data analysis task force will explore the utility of data analysis methods relevant to smoking treatment trials with the goal of formulating a series of questions, and, where possible, providing recommendations about optimal statistical techniques. The group will focus on the utility of different methods of endpoint analysis, imputation of missing data, and methods to detect interactions.

Volunteers from a variety of disciplines and statistical perspectives are welcome. The committee also invites investigators who have available datasets related to these issues.

Adolescent Outcome Measures. Chairs are Robin Mermelstein (robinm@uic.edu) and Dorothy Hatsukami (hatsu001@tc.umn.edu). As more interest has been directed at adolescent tobacco dependence treatment, several methodological issues involved in assessing treatment outcome results in adolescents have become apparent. These issues include methodological pitfalls in measuring abstinence among adolescents with irregular smoking patterns, the validity and reliability of self-reported abstinence and biochemical verification, the characteristics of withdrawal and craving among adolescents, and treatment outcome goals. Participants with experience treating adolescents are invited.

SRNT Joins in WHO Partnership Project

SRNT is among a growing number of organizations joining the World Health Organization’s European Partnership Project on Tobacco Dependence.

The idea for the project was conceived at the 1998 SRNT European meeting in Copenhagen, Denmark. When WHO Director General Gro Harlem Brundtland launched the WHO European Partnership Project on Tobacco Dependence in a speech at the World Economic Forum, she refered to tobacco as a "main risk factor" for poor health in the next century. SRNT’s goals in this partnership are to provide technical and scientific advice and to channel new thinking on reducing tobacco dependence.

Since first conceived, the project has expanded to comprise a broad coalition of interests from the public and private sector. One of its main strengths is that it brings together three major pharmaceutical companies that manufacture treatment products for tobacco dependence.

Broad support for the project also comes from both non-governmental and governmental agencies, including the Commission of the European Union, which in 1998 introduced directive 98/43/EC banning tobacco advertising and sponsorship.

Tobacco users of all ages benefit from stopping their tobacco use, but particularly before middle age, when quitting reduces much excess risk. Brief advice from a health care provider increases the proportion of smokers abstinent for 6 months or longer by 2-3%, and effectiveness is doubled through the use of treatment products. Quitting tobacco use also ranks as one of the most cost-effective of all medical treatments. For relatively modest costs, treatments are guaranteed to bring population health gains and in the long run reduce tobacco-related health care costs, releasing resources for other health needs. WHO’s position is that a partnership project based on the shared goal of reducing tobacco dependence can make an important contribution to public health.


Initial Focus

Some initiatives within the project will be pan-European. However, initial focus will be on four target countries: France, Germany, Poland, and the United Kingdom. In recent years, these countries have made considerable headway in creating a policy environment supportive to treating tobacco dependence. Over the longer term, the intention is to ensure that information and experience from the project transfer to other countries in the European Region, particularly those countries most in need. The European Region of WHO consists of 51 member states, with 870 million people. The region stretches from Greenland in the west to the Pacific shore of the Russian Federation in the east, and from the Arctic Circle in the north to the Mediterranean shore in the south.


Scope of the Project

The Partnership Project, which has been launched for an initial period of three years, has five main activities:

A Project Group consisting of representatives from public and private sectors, including experts from the target countries and the scientific community, has been set up to oversee progress on the activities and to gain political endorsement for the project.


Delivering Services

The Partnership Project is oriented toward achieving changes in the policy environment that will enable current smokers to reduce or to quit their tobacco consumption. To achieve these objectives, new information, tools, and practices will be required, and the project group has designed a program of work focused on delivering products that will both demonstrate progress and will support necessary changes in policy and practice. Some of these services include:

An Invitation to Potential Partners

A wide range of private and public sector partners have already joined forces in this endeavour. Many other stakeholders will be involved through the exchange of information, dissemination of products, and attendance at conferences and meetings. WHO also invites other partners and stakeholders to join this initiative, which provides a unique opportunity for clearly focused and committed action to reduce tobacco dependence and promote public health in Europe.


To obtain further details or information on becoming a partner of the project, contact: Patsy Harrington, project manager, telephone +45 39171302, e-mail <PHA@who.dk>; or Peter Anderson, regional adviser, Tobacco or Health, telephone +45 39171248, e-mail <PAN@who.dk>;address: WHO Regional Office for Europe, 8 Scherfigsvej, 2100 Copenhagen, Denmark

SRNT Expands Internationally

By Karl Olov Fagerström, Chairman
SRNT Global Network Committee

Since the American Society of Addiction Medicine meeting in 1993, where Ovide Pomerleau, John Hughes, and John Rosecrans asked persons interested in tobacco and nicotine to come together to discuss the formation of a society, SRNT has gotten off to a very good start.

The new journal Nicotine & Tobacco Research is good proof of that. So far, SRNT has been mainly a U.S. enterprise. The large majority of members are from the U.S., and virtually all activities have been in the U.S. There was one exception to that: a conference in Copenhagen, Denmark, in August 1998. This conference was planned mainly because of John Hughes’ interest and encouragement. However, because of a situation regarding the professional management of SRNT at that time, the whole organization of that conference had to be taken over by local people. The local organizing committee consisted of myself as chairman, with Lars Ramström, Paul Tvaermose, Stig Jörgensen, Michael Kunze, Roberto Masironi, and David Balfour.

The conference was well attended and regarded by many as a success, and thoughts were raised as to why should not also Europe try to stimulate nicotine and tobacco research, as had been done so well in the U.S.

Actually, it is not fair to mention just Europe. In other parts of the world, SRNT members wanted to be active locally. This movement was perceived and acted on by members of the SRNT executive committee, with Jack Henningfield, who was then president of SRNT. Due to their interest, an SRNT Global Network Committee (GNC) was formed.


The Global Network Committee

The committee’s objective is sketched out as being responsible for planning scientific meetings, carrying out training activities, conducting regional scientific and public policy liaison, and initiating membership and development campaigns to strengthen research of nicotine and tobacco.

The GNC, listed alphabetically, consists of Ron Borland, Chairman Karl Olov Fagerström, Peter Hajek, Dorothy Hatsukami, Steve Heishman, Jack Henningfield, Natasha Herrera, John Hughes, Vice Chairman Jacques Le Houezec, Scott Leischow, Yumiko Mochizuki, Mitch Nides, and Joy Schmitz.


SRNT Europe

In Europe we have formed a core group consisting of David Balfour, Anil Batra, Chairman Karl Fagerström, Vice Chairman Jacques Le Houezec, Ann McNeill, and Stefano Nardini. We are currently recruiting a larger advisory group that will geographically represent most countries in Europe.

 

Activities outside the United States

A second SRNT conference in Europe is planned in London November 25-26 this year. This conference is co-organised by the U.K. Health Education Authority, the Society for the Study of Addiction, and the Royal College of Physicians. In conjunction with this conference, the World Health Organization Europe Regional Office will have a satellite meeting on the WHO Partnership project (see page 8) on November 24. Jacques Le Houezec is the SRNT representative in this project. The conference, which will include participation of the U.K. Minister for Public Health and others, will include excellent activities about to be implemented from the U.K. document Smoking Kills: A White Paper on Tobacco <www.official-documents.co.uk/document/cm41/4177/4177/htm>.

On the SRNT website <www.srnt.org>, you can find more information about the London program, how to register etc. To all of you in the United States, welcome to Europe, and learn from us. It is time that we return a bit of all we have learned from you.

Another activity that we hope you will soon see is that we intend to make our website more international. It will start with a page about SRNT in French, plus a French translation of the abstracts from Nicotine & Tobacco Research. Jacques Le Houezec is instrumental in this. In Australia, we are planning to have a collaboration with the International Society for Behavioral Medicine during their conference in Brisbane in March 2000. Ron Borland, representing SRNT, will organize a tobacco/nicotine stream to go through the meeting.

We hope that the internationalization of SRNT can go as fast and as well as the growth happened in the United States. Certainly the world needs a solid foundation of research on which to base it activities against tobacco smoking.

If you have ideas of what we could do in the Global Network Committee, please let us hear from you. It is by working together both within SRNT and with external bodies that we can turn SRNT into an international organization that can contribute most effectively to the understanding of nicotine and tobacco, and thereby reduce death and disease from tobacco use.

SRNT Joins U.K. Groups for November Meeting

The 1999 European conference this November in London will be a joint effort among SRNT, the Society for the Study of the Addictions, the Health Education Authority in England, and the Royal College of Physicians.

SRNT’s second European conference, titled Addiction: New Horizons for the 21st Century, will be held 25-26 November 1999 in London, U.K.

London was chosen as the location because of important scientific developments in tobacco control recently, most notably the publication of the November 1998 U.K. document Smoking Kills: A White Paper on Tobacco <www.official-documents.co.uk/document/cm41/4177/4177/htm>.

Other recent publications such as "Smoking Cessation Guidelines and Their Cost Effectiveness" (Thorax, 1998, 53 [Supplement 5]:S1-S38) have also attracted international interest. Also, a new Royal College of Physicians report on nicotine addiction is scheduled for release in November.

The Minister for Public Health in England has been invited to address the conference, discussing the white paper and developments over the course of the first year of its use.

Other sessions will focus on nicotine and tobacco research from other European countries. For example, a symposium on nonnicotine interventions in the treatment of smoking cessation is scheduled. One morning’s sessions will be dedicated to submitted posters and oral communications. Abstract submissions are due September 1.

For more information about the conference, contact Laura Bass at <laura.bass@hea.org.uk>. Regarding abstract submissions, contact Karl Fagerström <karl.fagerstrom@swipnet.se>.

Further information, including a preliminary program, will then be forwarded to those expressing an interest. Additional information is available from Ann McNeill, Health Education Authority, Trevelyan House, 30 Gt. Peter St., London SW1P 2HW. Telephone + 44 171 413 203. Fax + 44 171 413 2632

Guidelines Available

The U.K. document "Smoking Cessation Guidelines and their Cost Effectiveness" was published in Thorax, The Journal of the British Thoracic Society. Copies of the supplement are available at a cost of £10 per copy from the Subscriptions Fulfilment Dept., BMJ Publishing Group, BMA House, Tavistock Square, London WC1H 9JR, UK. Telephone 0171 383 6270. Fax 0171 383 6402. Email <subscriptions@bmjgroup.com>. Also available from Health Education Authority at HEA Customer Services, Marston Book Services, P.O. Box 269,. Abingdon, Oxon OX14 4YN, UK. Telephone 01235 465565. Fax 01235 465556.

Nancy Rigotti

Doing What a Physician Should Do –Preventing Tobacco’s Consequences

By Raine Riggs
Assistant Editor, SRNT Newsletter


As an intern at Massachusetts General Hospital (MGH) in 1979, Nancy Rigotti found herself frustrated with the limits of treatments available to patients with smoking-related chronic illnesses.

She recalls one smoker with chronic obstructive pulmonary disease who was admitted to the hospital in respiratory failure. Before the patient was intubated, Rigotti asked her why she had started smoking. The patient replied that decades earlier, her doctor had advised her to start smoking to avoid gaining weight. She had never been able to quit. A few days later, the patient was dead.

Another time, Rigotti received a telephone call from a pregnant patient who knew she should stop smoking and asked how to do so. Rigotti had never received any smoking cessation training as a medical student at Harvard Medical School, and when she asked more senior colleagues for advice, no one was able to help her.

"It seemed to me that it was very reasonable for patients to get help stopping smoking from their doctor," says Rigotti. "But, none of us seemed to think that it was part of our jobs. I thought it was foolish of us to spend so much time caring for the health consequences of patients’ tobacco use and so little time trying to prevent those consequences. So I did some research, learned five new facts, and became an instant expert at my institution."

Rigotti describes herself as a "generalist at heart." Her career in academic medicine follows the "triple threat" model, consisting of work as a clinician, a teacher, and a researcher. She spends one day a week as a primary care physician in a women’s health practice at MGH, where some of her patients have been under her care for twenty years. She also teaches a preventive medicine course at Harvard Medical School, where she is an assistant professor. The course didn’t exist when she was a student, but is now a required part of the curriculum that she pioneered. Finally, she is the director of the Tobacco Research and Treatment Center at MGH.

Rigotti has conducted nicotine and tobacco research ranging from survey research to clinical trials to policy assessment. "Some people make careers that are discipline-focused," she says. "They take a methodology, like cost-effectiveness analysis, and apply it to many different problems. I’m much more content-focused. I want to reduce tobacco-related death and suffering. To do that, I have to work across disciplines. You can make a career either way. The important thing is to do what fascinates or intrigues you."

She enjoys cross-disciplinary research and especially values the contributions of her colleagues who are behavioral and social scientists. Her first experience on a cross-disciplinary research team was at the Institute for the Study of Smoking, Behavior, and Policy at Harvard’s Kennedy School of Government, which she joined after she completed her training in internal medicine. The goal of the institute was to make smoking research more policy-relevant by bringing together policymakers with experts from varied disciplines, including medicine, epidemiology, psychology, and economics.

"It was a wonderful opportunity for a young faculty member to meet and work with very bright people in many fields," Rigotti says.

During her five years at the institute, her work focused on the impact of the wave of non-smoking laws and policies that were just appearing. In 1989, she was recruited to be a scientific editor of the 25th anniversary U.S. Surgeon General’s report on tobacco. "For me as a doctor, it was on-the-job training in public health," she says.

After the institute closed in 1990, Rigotti continued to pursue her interest in policy research. Since then, she has examined the effect of youth access restrictions. Her most recent study compared six towns in Massachusetts. Three towns enforced youth access restrictions, and the other three did not. While sales to minors decreased in the towns where the restrictions were enforced, youth smoking did not decrease.

"The teens didn’t perceive that it was any more difficult to buy tobacco after enforcement started than it was before it started," she explains. "I wish we had found a different result, but the value of policy research is to figure out what works and what’s the most effective use of our limited resources for tobacco control. I don’t write off the youth access laws yet, but I doubt that they’re sufficient by themselves. Supply reduction alone doesn’t work for any other drug of abuse. Why should we assume that it would work for nicotine?"

While continuing her policy research, Rigotti also started the MGH Tobacco Research and Treatment Center to provide clinical services to hospital patients, employees, and the Boston community. The center has been a site for several clinical trials of tobacco dependence treatment medications and counseling. She has a particular interest in exploring ways to take advantage of the window of opportunity provided by a smoker’s hospitalization.

"Twenty years ago as a medical resident, I wondered whether smokers who get sick enough to require a hospital stay might be persuaded to quit," she says. "I’m still working on that question."

Since 1993, hospitals in the United States have been smoke-free by law, requiring temporary tobacco abstinence of smokers. At MGH, Rigotti has conducted randomized trials of bedside counseling for smoking cessation. She found that brief interventions work in the short term, but that the effectiveness wears off over time. When follow-up telephone calls end, many patients relapse to smoking. Currently, Rigotti is adding medications to the counseling, and increasing the duration of follow-up as ways to improve treatment outcome.

"As a doctor, I’m interested in treating individual patients," Rigotti says. "However, I realized early on in my career that even if I were the best counselor and got all of my patients to quit smoking, that alone wouldn’t make a large dent in the problem of tobacco-related diseases and death. The only way to really solve the problem is to work simultaneously at the individual, community, and policy levels. Otherwise, it’s like trying to drain the ocean with a teacup."

Rigotti believes it is unfortunate that so few physicians are involved in nicotine and tobacco research. But she believes that as medicine moves from the traditional biomedical model to a broader biopsychosocial model, this is changing. Already, more young physicians are interested in tobacco dependence treatment and tobacco research than in the past. The appearance of new drugs to treat smoking has increased physicians’ interest in intervening with their patients who smoke. Rigotti herself has expanded her work to assess how well physicians are adhering to clinical guidelines on smoking treatment and to examine managed-care practices.

Aside from her research, teaching, and clinical duties, Rigotti has also begun to act as a mentor for young physicians and investigators. She says that mentoring is the "most fun" of all that she now does. "It is a very rewarding process to watch younger colleagues develop. Plus, I learn a lot from them," she says.

What advice does she give to her students? First, she advises them look for a topic that fascinates them and that they truly care about. "Don’t be afraid to take on a new field; you’ll rapidly become the expert and have a chance to be creative," she says.

Second, she tells them to find a mentor. "Mentors are so important," she says. "They open doors of opportunity. When I didn’t have a mentor, my career moved much more slowly than it did during the times when I did have a mentor. If you have to, look outside of your institution for a mentor, or go elsewhere. It’s that important."

Third, she tells students to work across disciplines and to build collaborations with others in related fields. "I used to think that I had to get a Ph.D. to do this research," she says. "Then, I realized that it was much more productive, and more fun, to work with...colleagues in other fields. Different disciplines bring different ideas to the table and set the stage for new, creative insights into solving different problems."

Fourth, Rigotti advises students not to be discouraged when they discover that an idea they thought was original is already being pursued by someone else. "I used to get frustrated when this happened to me. I wondered if I would ever think of something no one else had," she says. "But David Abrams suggested a better way to think about this. His view was that if you have the same ideas as more senior, funded investigators, then you’ve identified the cutting edge. There is always room for another, slightly different, study on the topic. I think that was great advice."

Rigotti is enthusiastic about the future of nicotine and tobacco research. She predicts important advances in genetics research, medications development, public policy research, behavioral interventions, and exposure reduction, although she cautions against "jumping on the bandwagon" too soon.

"No single treatment will solve the problem," she says. "The only way to cut down on deaths is to focus on both prevention and treatment and to work at both individual and environmental levels."

Future Events 

Addressing Tobacco In Managed Care, 6-8 February 2000, Atlanta, Georgia, USA. Third Annual Conference: Shaping Solutions for Today’s Health Care Market. Sponsored by American Association of Health Plans, ATMC National Technical Assistance Office Partners. Abstract deadline 2 August 1999. <www.aahp.org/services/initiatives/tobacco/Tobacco_Abstract.pdf> .

SRNT European Conference, 25-26 November 1999, London, UK. Tobacco Addiction: New Horizons for the 21st Century. Also supported by the Society for the Study of the Addictions, the Health Education Authority, and Royal College of Physicians in England. Abstract submission deadline 1 September 1999. Contact Karl Fagerström at <karl.fagerstrom@swipnet.se>. Further information available from Ann McNeill, Health Education Authority, Trevelyan House, 30 Gt. Peter St., London SW1P 2HW UK. Telephone + 44 171 413 2032; fax + 44 171 413 2632, email <Ann.McNeill@hea.org.uk>. (See article, page 11).


SRNT Sixth Annual Meeting, 18-20 February 2000, Crystal Gateway Marriott Hotel, Arlington, Virginia, USA. Abstract deadline 1 October 1999. Preconference treatment methodology meeting, 17 February 2000. For more information contact the SRNT Central Office (see contact information, p. 2, left column).


11th World Conference on Tobacco or Health, 6-10 August 2000, Chicago, Illinois, USA. Tobacco: the Growing Epidemic. Fax (404) 325-2217.

News and Other Offerings

Annual Meeting News. SRNT Annual Meeting Program Chair David Wetter has announced a 1 October 1999 abstract submission deadline for the 2000 Sixth Annual SRNT Meeting, scheduled for 18-20 February 2000 at the Crystal Gateway Marriott Hotel in Arlington, Virginia, USA. The hotel is easily accessible to the Washington, D.C., area through the Metro rapid transit system and is close to Ronald Reagan National Airport.


Publications Committee. Jacques LeHouezec of Paris, France, has been appointed co-chair of the SRNT Publications Committee. In addition to serving as chair of the European SRNT Organizing Committee, LeHouezec prepares French abstracts of articles published in Nicotine & Tobacco Research. His appointment is part of an SRNT effort to encourage appointment of co-chairs from outside North America.


Journal Publishing. The first issue of the new SRNT journal Nicotine & Tobacco Research should have reached SRNT members’ mailboxes by now. The second issue is being printed. A supplemental issue with reports from a meeting on transdisciplinary research is in publication as well. A second supplemental issue being published later this year will include presentations from the 1998 Addicted to Nicotine meeting. The journal publishes quarterly regular issues.


Logo Contest! Now that SRNT is more than five years old, it is time to give the organization a consistent visual identity. All SRNT members (professionals, students, and associates) are invited to design and submit a logo that can be used on stationery, envelopes, printed materials, promotional materials (such as satchels or pens given to those attending meetings)—in short, a graphic designation of SRNT’s full name, of the SRNT abbreviation, or of a symbol that could represent the organization.

A symbol would have the advantage of allowing the Society’s name to be published alongside the symbol in any language, as would be appropriate for stationery or business cards.

The winning entry will be chosen "blind" by SRNT’s board. Winner of the SRNT Logo Contest will receive free registration for the 2000 Annual Meeting. A professional graphic designer will adapt the logo for publication.

Submit designs by mail or fax to SRNT Newsletter Editor Janet Brigham, Ph.D., Center for Health Sciences, SRI International, 333 Ravenswood Ave., Menlo Park, CA 94025 USA; fax (650) 859-5099