SRNT Newsletter - Vol. 5 No. 4
January 2000
One billion tobacco deaths predicted by
century's end
By Janet Brigham, Ph.D.
SRNT Newsletter Editor
A relieved world ushered in the year 2000 with fireworks and revelry recently, not realizing that the next century
could bring an unprecedented spread of tobacco-related death and disease.
Not long before the celebrations, epidemiologist Richard Peto announced that the approximately 100 million persons
who died during the 1900s as a result of exposure to tobacco could be but a small fraction of those likely to be
affected by tobacco-related health consequences during the first century of the 2000s. He predicted that an additional
900 million persons are likely to die as a result of tobacco use over the next 100 years, if current trends continue,
bringing the two-century toll to 1 billion.
Peto, whose calculations and predictions of the worldwide cost of tobacco use are a mainstay of tobacco research,
announced his recent findings at World Health Organization (WHO) Partnership to Reduce Tobacco Dependence meeting
in London, England. SRNT is a member of the Partnership.
WHO set up the Partnership in 1999 to promote the implementation of evidence-based treatment as a vital part of
tobacco control policy in WHO's European Region. The November 24 Meeting on Evidence-Based Treatment presented
the empirical basis for tobacco dependence treatment and its cost effectiveness, provided information on developing
an evidence-based approach, and established core recommendations on treatment for tobacco dependence. Jacques
Le Houezec of France represented SRNT with a presentation titled "Treatment: What works?"
Peto's keynote predictions indicated that even as medical and technological advances reduced mortality rates from
many causes, tobacco-related deaths increased. Most of the 100 million tobacco-related deaths in the 1900s occurred
in developed countries, where culturally accepted tobacco use compromised the health of tobacco users as they entered
middle and old age.
He explained that tobacco-related death is one of only two major causes of death that are increasing worldwide.
HIV infection is the other cause. Peto predicted that the 900 million additional deaths will occur if current
tobacco-use patterns do not change:
¨ If both males and females in developed countries continue to initiate and maintain tobacco use at present
rates.
¨ If tobacco use continues to expand in developing countries.
¨ If tobacco use trends persist.
¨ If rates of quitting remain at their present relatively low levels.
The magnitude of the total death toll of 1 billion tobacco users means that even moderate changes in any of these
factors could result in millions of persons being spared tobacco-related disease and premature death.
Peto explained that tobacco eventually kills half of those who use it regularly. One in four persons who die
from tobacco-related causes will die before age 70. Those who die in middle age lose between 20 and 25 years of
life, on average. Some 20% of nonsmokers who live past middle age will still be alive at 85, but only 10% of smokers
will live to age 85.
The risk of premature death is actualized as tobacco users approach middle age, when their decades of tobacco
use contributes to the development of cardiovascular and respiratory diseases and cancer.
Who will be among the first deaths of the 21st century? The answer, as Peto explained, is those who are presently
tobacco users and who are now initiating tobacco use. This emphasizes the need for effective treatment of tobacco
dependence, since the best way to prevent the deaths of these hundreds of millions of tobacco users is for them
to quit using tobacco. Much of the risk of premature death can be avoided if users quit before middle age.
Prevention efforts will be instrumental in preventing tobacco-related deaths during the second half of the 21st
Century, since those most likely to die then from tobacco-related disease are those who have not yet begun using
tobacco. A time lag of about 40 years separates an initial increase in tobacco use and the consequential increase
in tobacco-related deaths.
"Stopping smoking works," Peto emphasized. "Stopping smokers works amazingly well. Stopping smoking
avoids most of the risk of death, even if smokers stop in middle age….We have failed to concentrate enough on those
who have been smoking 10 to 30 years. If they wait until they have incurable lung cancer, it's too late. If they
stop before they develop a serious disease, they will avoid most of their risk of being killed by tobacco."
A widespread belief that cancer as a whole is increasing is incorrect, Peto stated. "Take away the effects
of smoking, and cancer has a slight downward drift…. Tobacco rates are what drive it. There is no increase in
lung cancer among U.S. nonsmokers. The same is true in eastern and western Europe and North America."
Smoking causes about half of cancer deaths, he said. Also, if women's smoking rates continue to increase, their
deaths will follow. Heart attacks are five times as common among smokers as nonsmokers. Smokers can avoid 80
of heart disease risk if they quit smoking.
"When you have one billion deaths to deal with, you can do quite a lot by even moderate changes."
The 90 participants at the meeting represented all European Union countries except three. Representatives from
Iceland, Latvia, Lithuania, Estonia, Hungary, Poland, Czech Republic, Slovenia, Romania, Bulgaria, Malta, Switzerland,
Israel all participated.
Le Houezec's presentation on efficacious treatment was followed by Christine Godfrey's comments on the cost effectiveness
of smoking cessation. She is with the Centre for Health Economics at the University of York, UK. Robert West
of London University provided an update on pharmacological treatments. Teresa Salvador of Centro des Estudios
Sobre Promotion de la Salud in Madrid, Spain, explained brief interventions. Martina Poetschke Langer of the German
Institute for Research on Cancer described the role of intensive treatment services.
An international panel representing tobacco experts, nurses, midwives, medical associations, and pharmacists explored
possibilities for European consensus on evidence-based treatment.
President's message
Priorities and thanks
By Dorothy Hatsukami, Ph.D.
SRNT President, 1999-2000
This will be my last column as president of SRNT, so I want to take the time to thank you for giving me this opportunity
to serve you. I have learned a lot, met many people, developed new friendships and have been impressed by the
amount of work that members of SRNT do to ensure the success of our organization.
Our SRNT journal is very strong and of excellent quality under the leadership of our Editors Gary Swan and David
Balfour, our associate editors, and the Publications and Communications Committee Chair Ovide Pomerleau.
Janet Brigham and Raine Riggs have done an excellent job on our newsletter. Gary Giovino has kept us informed
about important public policy issues. I could list many people. Suffice it to say that all the council and committee
chairs and members have done an incredible amount of work despite their busy professional (and personal) lives.
Thanks to all of them.
As I indicated in the previous President's Message, my goal during this presidency was to get SRNT back on track.
I think we have achieved this goal, but we still need to tie up some loose ends.
We still are in the process of achieving financial stability, and I have no doubt that we will achieve this goal.
The Membership Committee has developed an aggressive, strategic plan to increase its memberships. We have received
funding from the National Institute of Drug Abuse to support some of the cost of our annual scientific meeting,
thanks to the efforts of Maxine Stitzer and others. (See p. 3.) We are making cuts in certain areas of spending
in order to save money. Finally, we are soliciting donations from our members, so please consider this tax-deductible
contribution.
My other priorities during this presidency have included the following:
· Forging relationships with other scientific organizations, with primary focus on the Society for Behavioral
Medicine (SBM). Meetings will be held with SBM for the next two years, with concerted efforts to coordinate the
scientific programs. We are planning to meet in Seattle on 23-25 March 2001. So mark your calendars!
· Greater involvement of governmental and non-profit agencies in the activities of SRNT. We are accomplishing
this by not only obtaining funding from NIH for our annual scientific meeting, but also by obtaining funding from
National Institute on Drug Abuse (NIDA), National Cancer Institute, Centers for Disease Control, and Robert Wood
Johnson Foundation for the SRNT Treatment Outcome Methodology conference.
· We also co-sponsored a meeting with CDC focusing specifically on Adolescent Treatment Outcome Methods
and Methodology meeting in Atlanta, Georgia, in October 1999. The results will be presented at the preconference
meeting prior to our SRNT annual scientific meeting (17 February 2000). We also will have active involvement of
these agencies at our annual meeting.
· Also, we were fortunate to be invited to the NIDA Constituents meeting, at which the participants gave
feedback on NIDA's past achievement and future goals.
· We also expanded our international involvement and worked toward establishing nongovernmental organization
status.
The European meeting was superb and much thanks to Karl Fagerström, Ann McNeill, David Balfour, Jacques Le
Houezec, Anil Batra, and Stefano Nardini. We definitely have a strong presence in Europe and hope to expand our
presence in other parts of the world in the future.
We are in the process of achieving non-governmental organization status with the World Health Organization (WHO).
This status is important because of the increased role and priority that WHO has established in developing global
strategies for tobacco control.
For those who are not familiar with the Framework Convention on Tobacco Control, I would recommend obtaining a
copy. A draft can be obtained through the WHO website <www.who.int/toh>.
The need for science to inform these strategies is very important. I had the opportunity to meet with Director-General
Dr. Brundtland to discuss the potential resources that SRNT provides to help WHO in its endeavors.
Furthermore, I was fortunate enough to represent SRNT at the WHO meeting in Kobe, Japan, in November. In addition,
many of our SRNT members are actively involved in WHO activities, and WHO Europe was one of the sponsors of the
SRNT European meeting, along with Health Education Authority and the Society for the Study of Addiction.
I would be remiss not to thank the pharmaceutical companies for their generous financial support of many of our
programs and agenda items.
And finally, thanks for Thomas Miller and Associates, particularly Sarah Evans, SRNT executive director, for all
their work in getting us back on track and tolerating all the curve balls that were sometimes sent their way.
Again, I am grateful for the opportunity to serve you, and I have no doubt that you will be in excellent hands
with William Corrigall as your next president.
U.S. institute funds SRNT annual meetings, starting with 2000 gathering
near D.C.
The U.S. National Institute on Drug Abuse has granted SRNT three years of funding to help underwrite the Society's
meetings.
The award will provide SRNT with $40,000 US per year, starting with the 2000 Annual Meeting in the Washington,
D.C., area February 18-20.
Spearheading the submission of the proposal was Maxine Stitzer, former SRNT president and professor of psychiatry
at the Johns Hopkins University School of Medicine. Stitzer explained in the proposal that SRNT is the first organization
in the United States primarily devoted to promoting research on nicotine and tobacco and disseminating findings
from this research.
SRNT President Dorothy Hatsukami and Program Council Chair Stephen Heishman are also listed as key personnel in
the grant.
SRNT also holds, in alternate years, one-day special topics meetings that explore timely research in depth. The
2000 special topics meeting will focus on outcomes measures for clinical trials aimed at tobacco cessation.
The Society's sixth annual meeting will be its first "stand-alone" meeting not held in conjunction with
another major scientific meeting. Abstracts and symposia have been accepted and scheduled for this year's gathering
at the Crystal Gateway Marriott in Arlington, Virginia, near the nation's capital of Washington, D.C. For information,
see <www.srnt.org> or contact the central office.
London conference joins SRNT, other scientists in timely exchange
The Second International Meeting of SRNT in November 1999 attracted hundreds of tobacco researchers, clinicians,
and policymakers-so many, in fact, that the proceedings had to be transmitted beyond the large lecture hall into
two additional meeting rooms.
The gathering, at London's Olympia Conference Center, was co-sponsored by the Health Education Authority (HEA)
of England, the World Health Organization Europe, and The Society for the Study of Addiction. The proceedings
drew hundreds of participants who had not attended previous SRNT meetings in Europe or the United States.
Proceedings included a summary of the state of implementation of a nationwide stop-smoking program sponsored by
England's HEA and administered through Health Action Zones. The update described actions during the year following
publication of the landmark white paper Smoking Kills. Although the program will follow guidelines established
in England that correspond to those introduced in other countries, adaptations are likely.
Clinical treatment of tobacco dependence was the focus of the first symposium presentations. Topics included
the neurobiology and clinical efficacy of bupropion, dextrose as a treatment aid, immunization against nicotine's
reward effects, and monoamine oxidase inhibitors as a treatment for tobacco dependence.
A Royal College of Physicians Report symposium on nicotine addiction included presentations on tobacco dependence
and nicotine addiction, management of dependence, titration and compensation in lower-delivery cigarettes, economics
of nicotine regulation, and regulatory approaches.
Oral presentations were diverse and represented findings from throughout the world. Reports of current research
and potential avenues of scientific inquiry came from scientists in Germany, Italy, Canada, Switzerland, Sweden,
the United Kingdom, the United States, Denmark, and Australia.
Research training not matched to death causes, says new Health
and Behavior Alliance report
Behavioral and social factors are implicated in 9 of 10 leading causes of death in the United States. However,
less than 10% of National Institutes of Health (NIH) research training funds go to the behavioral and social sciences,
a new report shows.
Research conducted by the Center for the Advancement of Health, on behalf of the Health and Behavior Alliance,
in which SRNT participates, analyzed data and made recommendations to NIH and to policymakers. Data included NIH
research training data and reports of activities at each NIH institute, and findings from interviews with trainees
and advisers.
The report noted that in 1998, NIH spent $64 million on behavioral and social science research training, out of
$659 million spent on research training overall. The report, "Cultivating Capacity: Advancing NIH Research
Training in the Health-Related Behavioral and Social Sciences," is the first comprehensive effort to study
NIH-supported behavioral and social science training.
Two institutes-the National Institute of Alcohol Abuse and Alcoholism and the National Institute of Mental Health-spent
more than 30% of their 1998 training funds on the behavioral and social sciences; eight institutes spent 5% or
less.
"Behavioral and psychosocial factors influence the onset of some diseases, the progression of many, and the
management of nearly all," said Jessie Gruman, executive director of the Center for the Advancement of Health,
commenting on the report. "To do so, however, we must increase the amount and effectiveness of research training
to build the nation's capacity to conduct interdisciplinary health and behavior research."
She continued: "NIH and its institutes need to weigh the expected future burden of morbidity and mortality
related to behavioral and social factors in health and disease. They must fund the training and other programs
that will equip scientists with the skills and knowledge to understand not only the mechanisms underlying these
effects, but also [to] develop interventions to ameliorate them."
Gruman noted that it is possible that low funding of behavioral and social science training is related to a lower
number of applications being submitted from those areas. "We found that several factors influence the applicants'
decisions to apply for training grants, including knowledge and encouragement, compensation, preparation time,
and perceived competition."
Full and condensed versions of the report are available from the Center for the Advancement of Health. Contact
<cfah@cfah.org> by email, telephone (202) 387-2829, fax (202) 387-2857, or send mail to: Center for the
Advancement of Health, 2000 Florida Ave. NW, Suite 210, Washington, D.C. 20009-1231, USA.
Smoking Don't Get No Respect
Addressing subtle, blatant oversights in journals and online search program
By John R. Hughes
University of Vermont
Two recent examples of ignoring smoking and nicotine dependence range from the blatant to the subtle.
The blatant example is the May 1999 issue of Addiction. This issue contains a report and five commentaries on
cost estimates for alcohol and drug abuse (94:631-648). Despite the "comprehensive" nature of the report
and the 17 pages of text, not a single person mentions that this report omits the one drug disorder that has the
highest cost to society, i.e., nicotine.
The subtle example is Medline, the dominant database in medicine. I examined how Medline treats alcohol versus
tobacco studies. Medline states that studies of tobacco use should be placed under the categories of Smoking and
Smoking Cessation, which are subcategories of the category Habits.
Medline states that articles focusing on nicotine dependence should be found under the category Tobacco Use Disorder,
which is a subcategory under Substance Use Disorders. Similarly, Medline states that alcohol use should be placed
under Alcohol Drinking, under Drinking Behavior, and Alcohol Dependence under Substance Use Disorders.
In the last three years, the National Library of Medicine cataloguers had placed 8,949 articles under Smoking
and 448 under Tobacco Use Disorder, as compared to 4,051 articles under Alcohol Drinking and 4,354 under Alcoholism.
Does this mean that only 3% (448/9337) of the smoking articles are based on the dependence model, and 97% are
not, whereas 53% (4354/8505) of the alcohol articles are based on a dependence model? This would be ironic, given
that about 85% of adult tobacco use is due to tobacco dependence and only about 10% of adult alcohol use is due
to alcohol dependence.
My semi-random examination of the articles in these Medline categories indicates a bias. For example, a
study of withdrawal symptoms from smoking cessation is almost always placed under Smoking Cessation (i.e., in the
Habit category), but a study of alcohol withdrawal is almost always placed under Alcoholism (i.e., in the Dependence
category). Interestingly, even studies of nicotine agonists for treatment (a dependence-based treatment if there
ever was one) are placed under Smoking Cessation, but treatments such as family confrontations are placed under
Alcoholism.
Sounds like the National Library of Medicine needs a wake-up call that these days most scientists consider smoking
as much a dependence as alcoholism.
Jas Ahluwalia
An enthusiastic, energetic mentor working with the 'understudied'
By Raine L. Riggs
Assistant Editor
Listening to Jasjit S. Ahluwalia talk about his life and work brings to mind a whirling dervish of energy. He
is enthusiastic about every topic. He laughs unabashedly at himself. He tells personal stories, like the one
about meeting his wife, that could easily be made into a television movie-of-the-week. His enthusiasm and good
humor are contagious.
Ahluwalia received his medical degree and a master's in public health from Tulane University in 1987. Since then,
he has completed an Internal Medicine residency at the University of North Carolina at Chapel Hill, received a
master's degree in Health Policy from the Harvard School of Public Health, completed a two-year clinical epidemiology
and general medicine fellowship at Harvard Medical School, served as an assistant professor of medicine at Emory
University School of Medicine, and finally, joined the University of Kansas School of Medicine as vice-chair, director
of research, associate professor of Preventive Medicine, and associate professor of Internal Medicine.
When asked why he decided to move to Kansas City, he replies, "Well, it's easy to make fun of places you've
never been. I have absolutely no regrets about moving here. In fact, I'm loving the opportunity to build a department
and a nicotine dependence research team." He goes on to sound like a spokesman for the Kansas Board of Tourism,
even trying to convince this interviewer that she should move to Kansas for her internship year.
Ahluwalia was born in India but grew up in the United States, in the suburbs of New York City. Despite his many
years in the United States, he met his wife in India. The couple had much in common, including similar values,
a passion for education, a commitment to helping underserved populations, and a love of fun. Two days after meeting
her, Ahluwalia said to Harsohena, "In you I find exactly what I've been looking for." They were married
the following Monday, one week after their first meeting.
Harsohena K. Ahluwalia came to the United States a little more than one month later, completed her pediatric residency,
and then obtained an Epidemic Intelligence Service Fellowship at the Centers for Disease Control. She is now a
faculty member of the University of Kansas School of Medicine.
"She's the backbone of my life," says Ahluwalia. "She provides a calming aspect to my life. We've
been married for six years, and it's been truly wonderful."
They juggle a dual academic career household by making sure they do a lot of things together, traveling together
as much as possible, and eating out a lot. He reports that it can be a challenge to maintain mutual respect for
the other's career. For example, Harsohena was not eager to leave Atlanta for Kansas, but was willing to make
that sacrifice when Ahluwalia was offered his position there.
Ahluwalia was inspired as a nicotine dependence researcher as a second year resident in Chapel Hill. He was asked
to give a presentation on health promotion and disease prevention. He chose to speak about tobacco. He selected
the topic in part because he had been so impressed by a presentation given by C. Everett Koop at Tulane. "Koop
has been very influential in my professional development," says Ahluwalia. "He basically changed the
face of tobacco in this country during his term as U.S. Surgeon General."
Ahluwalia's first job as a physician was at Emory University's inner-city Grady Hospital in Atlanta, where he
saw countless cases of smoking and alcohol-related illnesses among his patients. "These were preventable
or delayable illnesses, like heart attacks, cirrhosis, and chronic obstructive pulmonary disease. One out of every
two admissions was related to smoking or alcohol and that solidified my interest in the field."
Currently, Ahluwalia runs the University of Kansas School of Medicine's Department of Preventive Medicine in Kansas
City, which includes twenty faculty members. "I have a heavy administrative load," he says. "Half
the stuff I do has nothing to do with tobacco or health. It's stuff like, 'Should we get a new coffee machine
for the office?'"
When he isn't arbitrating coffee machine disputes, Ahluwalia divides his time among mentoring, educating students
and the public, working with various professional organizations, conducting research, and traveling internationally
to promote tobacco control.
"In much of my work, there is a theme of working with the very underserved," he explains. "I,
along with my faculty colleagues, enjoy working with populations who have traditionally been ignored. For example,
with Dr. Kim Richter, I am interested in looking at smoking cessation among methadone maintained patients; with
Dr. Kola Okuymim, at low rate smokers, and with Dr. Kari Harris, at preventing progression among college smokers.
For all three of these projects, we have grants pending."
Ahluwalia is also proud of his work with African American smokers. "Before my research, all we had were
correlational surveys. There were no intervention studies," he says. "Now, we provide a service and
concurrently learn more about smoking among minorities. It's really community-based, service-oriented research."
His work with African American smokers has included the first randomized trial of pharmacotherapy with African
American smokers. That study was followed by research aimed at changing physician counseling patterns by using
smoking status as a vital sign, and then by a randomized trial of culturally sensitive cessation materials with
500 African American smokers. Currently, Ahluwalia is running an NIH-funded trial to examine the use of motivational
interviewing in a clinical trial of bupropion with 600 African American smokers.
Another community-based, service-oriented project that Ahluwalia ran this year was the University of Kansas' Mini-Medical
School. Ahluwalia served as the dean of the Mini-Med School, which was open to the public and ran one evening
per week for eight weeks. The purpose of the lecture series was to inform the public about what goes on in an
academic medical center. The program was a tremendous success, with 220 students enrolled and 140 on the waiting
list. Ahluwalia gave the first lecture, which was on tobacco control. Other topics included AIDS vaccines, renal
disease, and skin cancer. Graduates of the program received certificates and tee-shirts at a graduation ceremony.
"It was an amazing experience. It actually changed people's lives. After my talk, which wasn't even a 'how
to quit' talk, two people quit smoking and another participant gave the handouts to his neighbors, who then both
quit."
Because Ahluwalia did not have a mentor early in his training, he makes it a priority to provide mentoring for
his students, post-docs, and junior faculty. He has served as the primary mentor for four M.P.H. students, four
medical students, two post-docs, and five junior faculty. He believes that the most important thing a mentor can
do for students is to spend time with them.
"Eighty percent of 'mentees' don't have a good mentorship experience," he says. "I try to spend
a lot of time with students. I have an open-door policy, which is good and bad. I get interrupted 15-20 times
a day, but those that I mentor feel like I'm there for them when they need me. Also, I try to give my students
opportunities I didn't have, like being invited to meetings and conferences."
Ahluwalia says that, as a young physician and researcher, he used the country as his mentor by attending as many
meetings as he could. He credits many SRNT members, including Tracy Orleans, Nancy Rigotti, Dorothy Hatsukami,
Harry Lando, Richard Hurt, Michael Fiore, and Neil Benowitz, with helping him during his professional development.
Ahluwalia hopes to encourage more physicians to become involved in nicotine and tobacco research and treatment.
He believes there are few M.D.s in the field because it is not very glamorous and because physicians are typically
more interested in curative, rather than preventive, research. "If you need glamour, you can make it glamorous,"
he says. "I, for one, am having a ball!"
Toward that goal of bringing more physicians into the field, Ahluwalia has obtained a grant to train general
internal medicine and pediatric physicians to become researchers. Through this faculty development grant, physicians
receive M.P.H. degrees, build research skills, and are exposed to research, including tobacco-related topics.
When asked how he has time for all of these activities, Ahluwalia replies that he surrounds himself with "quality
team members."
"A lot of people pay lip service to teams, but I actually do it and value it," he says. "It makes
my job considerably easier. I know what to look for in prospective employees, and I'm very thorough about interviewing
and selecting them." He looks for people who are hard workers, who stay at a job long enough to see projects
finished, and whose personalities fit in with the rest of the team.
"Good people are the backbone of everything I do. I hire the best people, from the secretarial staff to
faculty," he says. "Out of the twenty people I've hired since coming to Kansas, I haven't regretted
a single hire." Another key to Ahluwalia's success is his ability to organize and delegate. "I never
say yes to a request unless I know I can deliver."
Despite his best efforts at organization and delegation, Ahluwalia still wishes he had more personal time. "I'd
just like some more time to play tennis."
Letters to the Editor
Cessation? Treatment? Readers weigh options
Editor's Note: An article by John Slade (Vol. 5 No. 3, pp. 1, 4-5) explored implications of the term smoking cessation.
The following letters to the editor comment on his considerations, and include a response from Dr. Slade. Further
editorial commentary on use of technically meaningful terms such as smoking cessation, tobacco dependence, and
nicotine dependence is welcome.
To the editor:
In his recent article "Cessation: It's time to retire the term," Dr. Slade points out the problems
of using the term cessation to describe all treatment activities toward stopping smoking or reducing the health
risks of smoking. He suggests instead the phrase treating tobacco dependence. I agree with most of his points
that the term cessation can connote the habit paradigm, trivializes our treatment activities, etc. However, I
do believe the term should be retired for the reasons outlined below.
Millions of smokers stop every year without treatment. Clearly we need some word to describe this phenomenon,
and treating nicotine dependence will not do. Dr. Slade states that the word cessation is awkward because cessate
is not a verb. However, the true root for cessation is cease, and it is reasonable to say that someone "ceased
smoking." In addition, the alternatives Dr. Slade suggests-stopping or quitting-are, to me, just as awkward
gerunds. Other terms such as self-recovery have been suggested, but they carry their own baggage.
Many of the interventions to promote stopping smoking are not treatment. Worksite restrictions, increasing taxes,
mass media, and other public health activities are typically not thought of as treatments, but rather as interventions.
Treatment is typically reserved for the application of an intervention by a therapist to a given individual for
a given disorder. None of the above require therapists, focus on a given individual, nor assume a disorder is
present, yet all are as important as "treatment" in reducing the damage from tobacco.
Not all smokers are nicotine dependent. One problem with Dr. Slade's substitute phrase is that not all smokers
meet accepted criteria for nicotine dependence. One could state that all smokers are dependent to some degree.
However, the empirical basis for this assertion is suspect given recent work on chippers, teenagers, etc. The
logical basis for this assertion is also suspect Would one agree that 100% of those who use alcohol and marijuana
regularly have some dependence? If not, why would this be true for nicotine but not alcohol or marijuana? In
summary, in my opinion, tobacco use and nicotine dependence are not synonymous; rather, tobacco dependence is a
subset of tobacco use. Thus, if we were to restrict our treatments to "treating nicotine/tobacco dependence,"
then we would have to refuse treatment to hundreds of thousands of smokers.
A suggested compromise. One of the strengths of the tobacco control movement is that our interventions are so
diverse and comprehensive. However, with such a diversity, I do not think any one label can adequately describe
all our activities. Thus, I suggest we retain both the terms cessation and treatment, but that we use them more
carefully. I agree with Dr. Slade that we should use the word treatment, not cessation, to refer to interventions
based on a dependence model, or to interventions that involve a therapist-patient interaction. This definition
would include over-the-counter medications, brief advice, and other nontraditional therapies but would exclude
mass media, patient education, etc. I suggest that we retain the word cessation and use it to describe stopping
smoking when there is no apparent treatment being applied, or to describe non-dependence-based interventions such
as taxation, media, denormalization, worksite restrictions, etc.
Finally, once we settle the battle over cessation, we should turn to the phrase that really gets us in trouble:
tobacco control. First of all, most advocates don't want to control tobacco use; they want to eliminate it.
The more important problem, especially in the United States, is that no one likes to be controlled. Use of the
term control only helps our opponents paint us as rigid, moralistic "health Nazis." After all, what
do you call someone who engages in tobacco control? Of course, a tobacco controller.
John Hughes, M.D.
Professor, Department of Psychiatry
University of Vermont
Burlington, Vermont, USA
To the editor:
I appreciate Dr. Hughes' thoughtful parsing of cessation into both a clinical and a public health usage. He proposes
that the clinical form of the term be dropped while the public health form be retained. Unfortunately, such a
course would be unnecessarily confusing to folk outside a quite small circle of tobacco specialists.
When the commissioner of health in New Jersey talks about "smoking cessation," her mind is focused on
clinical interventions. For specialists in the field to now go back and try to be careful and pure in our usage
of the term, limiting it to what had been the less prominent meaning will confuse non-specialists.
It is time to stop using the term cessation altogether. The alcohol field does not use cessation, in either a
clinical or a public health sense, so alternative terms are available.
What diagnosis might a clinician apply to a tobacco use condition that presents for treatment that does not meet
dependence criteria? The Diagnostic and Statistical Manual [of the American Psychiatric Association] offers 292.9,
Nicotine-Related Disorder Not Otherwise Specified. It may be, as experience in this area develops further, that
a diagnosis of Tobacco (or Nicotine) Abuse should be considered for a future revision of the DSM.
In the meantime, we as a field should give the term cessation an honorable, well-deserved, complete retirement
from its decades of double duty in both the clinical and public health arenas.
John Slade, M.D.
Program in Addictions, School of Public Health
University of Medicine and Dentistry of New Jersey
New Brunswick, NJ, USA
To the editor:
Challenging the appropriateness of scientific terminology is important, and we applaud Dr. Slade for calling attention
to the contextual difficulties associated with the term smoking cessation. However, there are several issues that
we believe should be considered in the smoking cessation versus treatment of nicotine dependence debate.
· First, in our view, the two can be conceptually different; thus, each deserves its respective place in
the English language. Treatment of nicotine dependence denotes an action-provision of a cognitive service, or
intervention, from an external source, whether it be a self-help stop-smoking program or one-on-one counseling
by a health care provider. In contrast, the term smoking cessation is much broader. Its meaning can encompass
intervention (treatment for tobacco use), outcome (quitting), or both, depending on how the term is used grammatically.
How does treatment of nicotine dependence apply to the smoker who quits cold turkey, without assistance, or "treatment"?
In our books, this person has attained "cessation."
· Second, the phrase treatment of nicotine dependence seemingly is more relevant to interventions targeted
to the physiologically-addicted smoker. This overlooks the fact that interventions also are needed to eliminate
tobacco use by social smokers, chippers, and persons who are in the early phases of their smoking careers yet who
may not be dependent on nicotine. A substantial proportion of adolescents and chippers exhibit low scores on nicotine
dependence measures, and therefore their smoking may predominantly be determined by factors other than the pharmacological
actions of nicotine. Consequently, intervention programs aimed at these groups commonly address coping with social
pressure and other relevant factors rather than treatment of nicotine dependence.
Third, it is not clear how tobacco users will respond to the notion of a "treatment" program. Treatment
is associated with disease, and although it is arguable that smoking is a disease, it is likely that many smokers
do not perceive it as such. Hence, we are hesitant to endorse alterations in usage until it is determined whether
treatment of nicotine dependence is language that will attain public acceptance.
Finally, the term smoking cessation is so widely endorsed by clinicians and researchers that it may be inappropriate
to dismiss it completely, at least not in the foreseeable future.
In summary, we recommend that treatment of nicotine dependence be used in reference to interventions that do,
in fact, "treat" nicotine-dependent tobacco users. However, even in these cases, the desired outcome
is smoking cessation.
Alexander V. Prokhorov, M.D., Ph.D.
Assistant Professor
Department of Behavioral Science
University of Texas, M.D. Anderson Cancer Center
Houston, Texas, USA
Karen S. Hudmon, Dr.P.H., R.Ph.
Public Health Reseacher
Center for Health Sciences
SRI International
Menlo Park, California, USA
The Insider smokes media, tobacco industry
By Janet Brigham, Ph.D.
SRNT Newsletter Editor
The scene was a familiar one for many of us. I stood at a microphone, facing a conference hall filled with participants
and press. I flipped through a series of PowerPoint slides as I explained the basics of tobacco dependence.
Nicotine is an addictive substance, I told the audience. It crosses the blood-brain barrier to achieve reinforcing
psychoactive effects. The modern cigarette, I added, is carefully designed to deliver nicotine in optimally effective
ways. In subsequent questions, in a press conference, and in workshops, no one questioned these facts.
Just a few days earlier, a feature film about tobacco had opened in North America. Movie critics applauded it,
although some principals whose lives were fictionalized in the film clearly were displeased. The tobacco industry
squirmed visibly. The film, The Insider, dramatizes the events that turned former tobacco executive Jeffrey Wigand
into a "whistleblower" whose statements confirmed reports that tobacco industry executive knew nicotine
was addictive, that nicotine content was manipulated in cigarettes, and that consumer safety was ignored.
We have come a long way in a short time. Yesterday's explosive scientific revelations are today's accepted knowledge.
For this fact, we have many SRNT members to thank. Among them is one of SRNT's best known members, Wigand himself.
He was first introduced to members of SRNT in 1997, when he gave a keynote address at the annual meeting.
In 1995, Wigand was propelled into prominence when he testified about tobacco industry knowledge and practices
and cooperated with the CBS television program 60 Minutes in bringing the information to public attention.
The film's 2:40 timespan goes quickly. This well-acted film depicts a reluctant Everyman hero and invisible villains.
It starts with an ominous, pounding beat that underscores the tension of facing unknown dangers. (The beat is
audible at:
<www. http://movies.go.com/insider/index_flash.html>; "cookies" need not be accepted)
Unlike many feature films, few people are seen smoking in the film-a young street child early in the film, a few
people seen from a distance. None of the central characters aree depicted drag on cigarettes as they weighed life-changing
decisions.
The sense of threat operates on multiple levels. The movie opens with a blindfolded broadcast journalist traveling
at gunpoint to arrange an interview with a Middle Eastern figure surrounded by bodyguards and automatic weapons.
In parallel, Wigand finds himself imperiled when compelled to violate a confidentiality agreement with the company
that dismissed him. The broadcasting corporation (CBS) initially shrinks from potential lawsuits that might erupt
should they run an interview with Wigand.
In one of the odder twists in which reality is stranger than fiction, the tobacco company-apparently concerned
about potential image problems-was reported to have surveyed moviegoers as they emerged from theaters early in
the film's United States run. Viewers were asked whether they believed that the company would engage in the threatening
behaviors depicted (although unattributed) in the film, including placing a bullet in Wigand's mailbox and sending
death threats by email. Apparently the company believed that engaging in such threatening activities would dampen
their public image.
Curiously, however, the tobacco company did not also ask whether the same viewers believed that tobacco companies
contribute to tobacco-related disease and death. Perhaps, in the eyes of marketers, the question of whether it
is worse to threaten a former employee than to contribute to death and disease is moot.
Discrepancies of fact do remind us that the film was-as it states-fictionalized for dramatic effect. Nonetheless,
the revelations about nicotine and tobacco were real, and the impact of Wigand's statements reminds us that we
too have changed, and can change, the world one research finding and one smoker at a time.
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. <www.aahp.org/services/initiatives/tobacco/Tobacco_abstract.pdf>.
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 SRNT Central Office (see contact information, p. 2, left column). Detailed information available on SRNT
Website, <www.srnt.org>. Contact <skirschbaum@tmahq.com>.
11th World Conference on Tobacco or Health, 6-10 August 2000, Chicago, Illinois, USA. Theme "Tobacco: the
growing epidemic." Contact conference secretariat manager, American Medical Association, 515 North State
Street, Chicago, Illinois 60612, USA. Phone 312-464-5159, fax 312-464-4111; email <11thWCTOH@ama-assn.org>.
Call for abstracts will be announced in January 2000. Hotels for the meeting are the Chicago Hilton and Towers
and the Palmer House Hilton. Post-conference tours of the United States cities Washington, D.C., Orlando, Florida,
and San Francisco, California, will be available.
The program will feature a unique assortment of activities and workshops.
Goals of the conference are to promote sharing information and ideas, developing consensus on approaches to tobacco
control, networking, identifying uses of technology, and organizing community intervention and advocacy. Professionals
from a variety of disciplines may attend.
Sixth International Congress of Behavioral Medicine, 15-18 November 2000, Carlton Crest Hotel, Brisbane City Hall,
Brisbane, Queensland, Australia. Hosted by the Australian Society of Behavioural Health and Medicine on behalf
of the International Society of Behavioral Medicine. Abstract submission deadline is 1 February 2000. Email <icbm2000@im.com.au>,
telephone 61-(0)7-3369-0477, fax 61-(0)7-3369-1512. Early-bird registration deadline is 1 August 2000. The congress
theme is Behavioral Medicine and Public Health in the New Millennium.
News and other offerings
A winner. French researcher Jacques Le Houezec has won the SRNT Logo Contest. His design has been adapted for
publication use by a professional graphic designer, Mary Rose O'Leary of Los Angeles, California. O'Leary drew
on Le Houezec's novel choice of color and of the SRNT acronym. Before Le Houezec's submission, the various logos
presenting SRNT's name had been spelled out in full and displayed in several colors, typically brown or green.
The final design will be unveiled at the annual meeting.
Billing errors. A small number of SRNT members may have been billed in error for their subscriptions to the SRNT
journal Nicotine & Tobacco Research. Separate billing for the journal is an error, since SRNT membership dues
include a subscription to the journal. Any members who have been erroneously billed by the journal's publisher,
Taylor $ Francis/Carfax Publishing should contact the SRNT Central Office by email <sevans@tmahq.com>, or
using the contact information in the box on p. 2 of the SRNT Newsletter.
Ferno Award applications. SRNT's central office is accepting applications and nominations for two awards. The
Ferno Award for Innovative Research consists of $25,000 per year for two years, and the Ferno Award for Clinical
Research on Nicotine and Tobacco consists of $2,000 and an expense-paid trip to the 7th SRNT annual meeting. Awards
are open to both members and nonmembers of SRNT. Information about the awards is available on the SRNT website
at <www.srnt.org/news/awards.htm> and from the SRNT central office.
Website to watch. The Office on Smoking and Health of the U.S. Centers for Disease Control and Prevention sponsors
a website with a wealth of helpful information for researchers. Check this site: <www.cdc.gov/tobacco>.