Tobacco use: still a problem

It’s safe to say that over the past few decades, billions of dollars have been spent in the United States on reducing tobacco use.

It has had an impact. The number of adults who smoke has declined steadily, from about 43 percent in 1965 to the current rate of approximately 20 percent. Among high school students, the age group in which tobacco use most often starts, the smoking rate has fallen as well. Smoke-free workplaces and eating establishments are widespread.

This should be reason to reflect on the progress that has been made. But to those who work in the field of tobacco control, it isn’t enough.

ClearWay Minnesota launched a new campaign this week whose title conveys a blunt message: “Still a Problem.”

Some facts from the website:

- Smoking is linked to health problems that range from coronary artery disease and high blood pressure to lung cancer, oral and neck cancer, chronic bronchitis and increased risk of type 2 diabetes.

- More than a quarter-million children in Minnesota are exposed to secondhand smoke at home.

- Almost half of the adults who responded to the 2010 Minnesota Adult Tobacco Survey said they were exposed to secondhand smoke within the past week.

- Progress in reducing tobacco use among adolescents in Minnesota appears to have stalled. According to the 2011 Minnesota Youth Tobacco and Asthma Survey, 77,000 middle school and high school students are current tobacco users; collectively they will buy or smoke 13.4 million packs of cigarettes this year – enough when stacked sideways to span the entire state from north to south.

- Smoking costs $3 billion in excess health costs annually in Minnesota. This works out to $554 per individual Minnesotan.

None of this information should come as a surprise. The American public has been exposed to public health messages about the physical and economic toll of tobacco use for decades, perhaps to the point of tuning it out.

Tobacco control efforts can be at odds with individual rights and interests, as any smoker forced to huddle outside the company loading dock for a cigarette break might tell you. When a federal appeals court struck down the U.S. Food and Drug Administration’s graphic new warnings for cigarette labels earlier this year, the decision came down to free speech protection.

Yet the other side of this is that for every smoker who doesn’t wish to quit, there’s someone else who does. Last year the U.S. Centers for Disease Control and Prevention analyzed data from the 2010 National Health Interview Survey involving more than 27,000 adults over the age of 18. Among those who smoked, seven out of 10 said they wanted to quit, and half had attempted to quit during the previous year.

Despite long-standing anti-tobacco campaigns, it’s somewhat startling to realize how pervasive tobacco use still is. A new small-scale study, to be published in the upcoming issue of the Pediatrics journal, found that many parents who smoke do so in their car in the presence of their children, and only a minority had a smoke-free policy for the family vehicle.

In another recently published study, researchers observed patients at a large urban hospital and found that among those who smoked, nearly one in five continued to light up during their hospital stay – even though the hospital had a smoke-free policy.

Tobacco smuggling also remains a significant global issue that robs Third-World governments of tax revenue and is thought to contribute to the funding of organized crime. An in-depth report developed by an international team of journalists concluded that the illicit tobacco trade is so widespread and so lucrative that tobacco has become “the world’s most widely smuggled legal substance.”

So is tobacco use “still a problem”? Let the public look at the evidence and judge for themselves.

Linkworthy 4.0: The overdue edition

I’m way overdue for another edition of Linkworthy, my semi-occasional collection of links to interesting health-related stuff recently encountered on the web.

Besides, it’s time we all moved on from the Hatfield-McCoy post, which has accumulated several thousand hits since being published three days ago and is perhaps in need of a rest. (I’m just sayin’.)

Regional news first: The latest issue of Prairie Business Magazine includes a cover story about the use of high-tech diagnostic imaging, how the technology has evolved and how it’s being used in daily care. As a bonus, there’s also a story exploring the demand for doctors in rural health.

Did anyone catch the news earlier this week about a proposal by Michael Bloomberg, mayor of New York City, to ban extra-large soft drinks? On the surface, this might sound like a good tactic in the so-called war on obesity. Many people are questioning, however, the likelihood that a ban on large sodas will make much difference. The critics have weighed in here and here. The most colorful quote probably comes from the online commenter who opined that “we are like a bunch of lemmings headed for tyranny.”

Speaking of obesity, few people could have failed to miss the recent news about a study that discovered exercise does not in fact benefit everyone. Researchers analyzed six earlier studies and found that in about 10 percent of the participants, heart-related measures such as blood pressure, insulin level, cholesterol and triglycerides worsened with exercise.

The spinmeisters have been hard at work. Some are pointing out, and rightly so, that this was only one study – and a relatively small one, at that. Others worry that folks will use it as an excuse to avoid exercise. What this study really seems to be saying, however, is that we need to be careful about cookie-cutter assumptions that a particular intervention or lifestyle is always good for everyone, because often there are exceptions to the rule.

After blogging about three years ago on needle phobia, I heard from a couple of people who have this fear and who felt their anxiety often wasn’t taken seriously by health care providers. So I was intrigued to come across the news that MIT has developed a high-powered liquid injection device that squirts a thin stream of medicine directly into the skin.

According to the developers, it’s so fast and precise that it can barely be felt. But it’s a little premature to hope the device could be coming soon to a health facility near you. The injector device is still in the prototype stage and hasn’t yet been tested on humans. There’s also the not-insignificant matter of cost. Nevertheless, it’ll be interesting to see whether this Star-Trekkian concept catches on.

Most of us have probably heard about Munchausen’s disease, or Munchausen by proxy, in which people go to great lengths to fake illness in themselves or someone close to them. Now it seems there may be a new version of this behavior: Munchausen by Internet.

A rather chilling story from the BBC News Magazine details the behavior – and impact – of individuals who go online and convincingly pretend to be sick or to have someone in their family who is sick. Some of these hoaxes can be incredibly elaborate – for example, a woman in the U.S. who faked having cancer, HIV, anorexia and heart problems, and went so far as to post online pictures of herself in a hospital bed with an oxygen mask and feeding tube.

Many fakers seem to crave attention, and the Internet is the ideal medium for their manipulations, the article notes. “It gives the perpetrator a quick hit of attention, a feeling of being valued, but without really having done anything to deserve it. Just as online fraudsters dream of easy money, these people crave easy attention. And it is, perhaps, just another form of fraud – emotional, rather than financial fraud.”

Consider setting aside a chunk of time for the final piece in today’s series of links, an in-depth look at the huge global business of tobacco smuggling. Cigarettes are the most widely smuggled legal substance in the world, generating multibillion-dollar profits, fueling organized crime and corruption, and diverting much-needed tax revenue from governments.

Since 1999, a team of reporters with the International Consortium of Investigative Journalists has been examining this issue. They’ve just published a new series of reports, assembled by journalists from 15 countries, that takes a look at the influence of organized crime and terrorists groups as well as “the continued complicity of distributors, wholesalers, and tobacco companies themselves” in the illicit tobacco trade.

Most people are likely unaware of the impact of tobacco smuggling, its ties to crime and its impact on developing nations where cigarettes increasingly are being introduced and sold on the black market. This ambitious news project explains what’s happening and, more importantly, why it matters.

Fessing up to tobacco use

It’s a question many of us are routinely asked during a visit to the doctor: Do you smoke or use tobacco?

Ideally, nothing less than the truth should suffice – but according to a newly released poll, about one in 10 people opt to conceal their smoking status from their health provider.

The survey, which involved 3,146 American adults who were either current or former smokers and was conducted by Legacy, a national public health organization, offers some interesting insight into the evolving social attitudes surrounding tobacco use – namely, a stigma that seems to be making it harder for some smokers to confess their habit to a doctor. About 13 percent of those who participated in the poll said they didn’t tell their doctor that they smoked.

According to the survey findings, smokers had a variety of reasons for concealing their tobacco use. Some were ashamed; others didn’t want to be nagged or lectured. But what’s especially noteworthy is this: The more stigmatized they felt, the less likely they were to disclose their smoking status.

The poll uncovered another interesting fact: Although the majority of smokers said they were honest with their doctor about whether they smoked, 25 percent did not seek help from a doctor or nurse during their most recent attempt to quit – and hence may have missed out on an important source of support.

Public health policy in the United States is strongly focused on reducing tobacco use. One of the key strategies has been to make it so uncomfortable to smoke – via higher cigarette taxes, smoke-free restaurants, higher health insurance premiums and so on – that people are either motivated to quit or discouraged from taking up the habit in the first place.

There’s evidence that it all contributes to making a difference. According to the most recent figures available from the U.S. Centers for Disease Control and Prevention, the number of American adults who smoke declined from 20.9 percent in 2005 to 19.3 percent in 2010.

It’s worth asking, though, whether efforts to make smoking socially unacceptable might reach a point of diminishing returns. In an accompanying news release, Cheryl Healton, president and CEO of Legacy, notes there’s been “a significant shift in the social climate” surrounding tobacco use in the U.S. in recent years.

“As an unintended result of higher prices of cigarettes, increased measures to ban smoking in public places, and create smoke-free workplaces, many smokers may feel marginalized and less compelled to discuss smoking with their physicians and other providers,” she said.

And when smokers don’t want to disclose their habit for fear of being judged, “it becomes a missed public health opportunity” to connect them with resources that might help them quit, Healton said.

The findings from the survey prompted Legacy to put together a guide that helps clinicians discuss tobacco use with their patients in ways that are sensitive and appropriate rather than stigmatizing. Although it’s ultimately up to smokers to decide to quit, how health providers approach the issue clearly does seem to matter.

Photo: Wikimedia Commons

The other tobacco

When a senior at Minnewaska Area High School was suspended from the basketball team recently after running afoul of Minnesota State High School League rules on tobacco use, it brought attention to an often under-recognized issue: the use of chewing tobacco, particularly among young men.

To recap: Basketball player Shane Bosek served a two-week suspension and was removed as a team captain after 12 tins of smokeless tobacco were found in his car during a random check at the school last month. Although he’s 18 and didn’t break the law, tobacco use of any kind is still against the rules for students participating in League-sanctioned sports.

Call it the other tobacco – the one that doesn’t quite get the same amount of attention as cigarettes.

Indeed, there seems to be a unique and rather specific culture surrounding the use of chewing tobacco, aka chew, plug, dip, smokeless tobacco, snus, etc. It’s often associated with baseball: Watch any major league baseball game and you’re likely to spot it – that wad tucked inside a player’s cheek that looks like an extra-large mouthful of bubble gum but probably came from a tin of Skoal instead.

Chew also seems to enjoy a manly, outdoorsy image. According to recent new state-by-state statistics, smokeless tobacco use among American adults is highest in Wyoming, where one in six men dips tobacco. The reason? So-called rodeo culture is thought to be the influence.

A few facts about smokeless tobacco use:

- It’s less than half as common as cigarettes and is found mostly among men. It’s estimated that somewhere between 6 and 9 percent of adult American men use chewing tobacco. Women use smokeless tobacco too but in much fewer numbers; the prevalence is believed to be less than 1 percent.

- Its use is surprisingly high among teens. When the CDC released the results of its National Youth Tobacco Survey for 2009, the findings indicated that 11.1 percent of high school-aged boys and 1.5 percent of high school girls were current users of smokeless tobacco. Among middle school students who were surveyed, 4.1 percent of the boys and 1.2 percent of the girls reported using smokeless tobacco at least once in the past 30 days.

- The most recent Minnesota Student Survey suggests the incidence in Minnesota is similar. Among 12th-grade boys, 6 percent said they used smokeless tobacco daily during the preceding month, and 2 to 3 percent reported using it anywhere from three to 29 days during the past month.

- About half of smokeless tobacco users start when they’re in their teens. Products often are marketed with mint, fruit or other candy-like flavors that tend to appeal to young people.

- Teens who use smokeless tobacco appear to be more likely to smoke cigarettes as well.

- Young adult men ages 18 to 25 are another demographic group that’s prone to using smokeless tobacco. Nor is it uncommon to find chew users in workplace settings such as woodworking factories or grain elevators, where smoking is hazardous.

- Even though smokeless tobacco isn’t inhaled, it can be addictive. The nicotine is absorbed through the lining of the mouth and thence into the bloodstream. Researchers have found comparable levels of nicotine in the blood of both smokeless tobacco and cigarette users. Some studies also have found that the nicotine from smokeless tobacco lingers in the bloodstream longer than that from cigarettes.

- Use of smokeless tobacco, especially long-term use, comes with a number of health risks. Cancer of the mouth, throat, lips, tongue and esophagus is one of them. The sugar and other irritants in the tobacco can lead to tooth decay and gum disease. Smokeless tobacco use also has been linked with an increased risk of heart disease and high blood pressure.

The health care community hasn’t always been attuned to smokeless tobacco. Opportunities to identify it can sometimes be missed in health screenings that ask, “Do you smoke?” rather than “Do you use tobacco products of any kind?” Because the behavior, culture and chemistry surrounding the use of smokeless tobacco isn’t exactly the same as for cigarettes, cessation techniques often need to be tailored. For instance, smokeless tobacco can contain high levels of salt, leading to salt cravings among people who are trying to quit. Products such as gum or mint snuff might also need to be employed to wean the user from the ritual of dipping and chewing.

Smokeless tobacco hasn’t always had a high profile among the general public either. If you’ve been watching the news, however, there are some signs this is changing. Some colleges are considering bans on its use – Garden City Community College in Garden City, Kan., for instance, where some students apparently are getting tired of seeing used chew and snuff left in the sinks and drinking fountains. And major-league baseball is currently under pressure to ban smokeless tobacco; chew has already been banned from the minor leagues since 1993.

Chew is “baseball’s bad habit,” declared the Chicago Tribune last week, predicting that if youths no longer have ballplayers to emulate, the number of young people using it will drop.

Photo: Wikimedia Commons

Tobacco tactics: too graphic?

The images grab your attention, to say the least: A toe tag dangling from a body in the morgue. A man lying in a coffin. A smoker exhaling through a tracheotomy in his neck.

Under a new campaign, announced Wednesday by the U.S. Food and Drug Administration, cigarette packs will carry large, bold warning labels about the health consequences of smoking. The new labels will be accompanied by blunt warnings. “Cigarettes are addictive.” “Smoking can kill you.”

Federal officials hope the warnings will motivate smokers to quit – or to avoid starting the tobacco habit in the first place. Despite more than four decades of anti-smoking efforts, it’s estimated that about 20 percent of American adults and 19 percent of teens are smokers. Tobacco use remains one of the leading preventable causes of death in the United States, taking 440,000 lives annually. What has the health and prevention community especially concerned is how the decline in tobacco use has plateaued in recent years.

Will new, graphic warnings about the health consequences of smoking bring new energy to the national tobacco prevention campaign? Many observers and experts say yes.

The New York Times talked to Matthew L. Myers, president of the Campaign for Tobacco-Free Kids, who called the proposed new warning labels “the most important change in cigarette health warnings in the history of the United States.”

From the Times:

Studies suggest that pictorial warnings are better at getting the attention of adolescents than ones that feature only text; make smokers more likely to skip the cigarette they had planned to smoke and more likely to quit; and make adolescents less likely to start smoking.

It’s also thought that the more brutal and blunt the message is, the better it might be able to motivate people of all ages to avoid tobacco.

Not everyone agrees. Some people are questioning whether the proposed labels will prove to be effective, while others think the FDA has gone too far. More than 600 people have weighed in, pro and con, in the New York Times online discussion. One person declared, “Anything less is a cop-out.” But someone else felt scare tactics don’t work in the long run: “The shock factor wears off quickly and smokers become desensitized to the images.”

The proposed new labels aren’t a done deal yet. The public has until Jan. 11 to submit official comments to the FDA. Final regulations won’t be issued until next June.

In the meantime, what do readers think? Do you think the graphic warnings will be effective? Or do you think they’re going overboard? Post your thoughts in the comment section below.

Addicted to tobacco

Society sometimes has little empathy for smokers who are trying to quit their tobacco habit. ”Can’t quit? Try harder. And why did you even start in the first place?” tends to be the common attitude.

Well, after viewing a couple of online clips from a new public television documentary, I see this issue in an entirely different light. “Tobacco Addiction: The Unfiltered Truth” was produced by Twin Cities Public Television and ClearWay Minnesota and premieres on Sunday. Additional air dates and times are planned over the next few weeks.

The filmmakers have taken an unusually compelling approach by seeking out firsthand stories from people who have struggled with nicotine addiction.

These aren’t individuals you would necessarily associate with a tobacco habit. For instance, there’s Brad Piepkorn, who has asthma yet started smoking when he was 17 and hasn’t been able to successfully quit. Brad is an articulate, clean-cut college graduate. Other people, including his boss, see him as an unlikely candidate for tobacco addiction. But as Brad explains, “Anyone can fall victim.”

Then there’s Pamela Gold, a businesswoman and grandmother who managed to quit after 35 years of smoking. Like any other addiction, tobacco can take control and smokers often don’t even realize the extent to which they’re hooked, “because it is a part of our lives,” she says.

Tobacco use, addiction and cessation have been extensively studied. It’s safe to say we know far more than we did 20 years ago or even 10 years ago.

Here’s some of what has been learned:

- The vast majority of smokers start when they’re in their teens, an age when many kids can be rebellious, experimental and vulnerable to peer pressure, or believe it’ll be easy for them to set aside the cigarettes once they reach adulthood.

- Smoking during adolescence has been linked with a far greater likelihood of addiction, possibly due to psychological or pathophysiological factors associated with this stage of human development. Although it’s possible for people to pick up the tobacco habit later in life, it’s much less common.

- Environment seems to matter. Children who grow up in households where at least one adult is a smoker are at greater risk of becoming a smoker too. In the policy arena, smoke-free policies appear to help prevent and reduce tobacco use and motivate smokers to try to quit.

- Youth prevention has the greatest and most long-term impact on reducing tobacco use in the United States. Some of the most successful strategies involve making it more difficult for kids to obtain tobacco, such as raising the cost of cigarettes or placing all tobacco products behind store counters.

- Nicotine dependence often makes it extremely difficult for many smokers to quit. Although the addiction is partly physical, it also contains psychological components. Smokers can find themselves as dependent on their smoking rituals – lighting up the first cigarette of the day, for instance, or their daily smoke break with their coworkers - as they are on the nicotine.

- Failure to quit the first time doesn’t necessarily signal complete failure. Many tobacco users make multiple attempts before they’re able to successfully quit.

- Although some smokers manage to quit by going cold turkey, many need more than this and will probably require some medical help in order to quit.

- Readiness is important. Not everyone wants to quit, and of those who do, not all of them are ready for it. Nor is there a one-size-fits-all strategy for cessation; what works for one person may be less effective for someone else.

There’s an enormous public debate in the United States about health, lifestyle choices and individual control. Many Americans believe it all comes down to individual responsibility but it isn’t always this simple. Perhaps “The Unfiltered Truth,” with its stories of tobacco use and addiction, will add a human, personal and necessary perspective to the discussion.

Photo: Wikimedia Commons

Noteworthy 1.0

Noteworthy stuff that has crossed my desk in recent days:

- It’s all about the nicotine: Efforts to reduce the health impact of tobacco use have historically concentrated on two key strategies: finding ways to help people successfully stop smoking, and preventing them from starting the habit in the first place. But in a rather striking development, a group of tobacco research and policy experts recommends giving new priority to the development of lower-nicotine cigarettes that are less addictive.

The thinking is that by lowering the nicotine level in cigarettes, current smokers will be less likely to become dependent. Also, adolescents might be less likely to experiment with smoking and progress into addiction. The proposal appears in the most recent edition of the Tobacco Control journal.

At first glance, it seems counterintuitive. Why would you focus on reducing the nicotine level in cigarettes, yet allow the behavior itself, i.e. smoking, to continue? But the researchers explain that prior studies suggest smokers won’t necessarily just smoke more to make up for the lower amount of nicotine in each cigarette; often they’ll smoke fewer cigarettes and many of them eventually quit altogether.

The authors of the Tobacco Control article think this strategy could reduce the prevalence of adult smoking in the U.S. from 20 percent, which is the current number, to 5 percent. It should be noted that the researchers include some heavy-hitters from Minnesota: Dr. Dorothy Hatsukami, who is director of the University of Minnesota’s Tobacco Use Research Center and the Masonic Cancer Center’s Cancer Control and Prevention Research Center, and Mark LeSage of the Minneapolis Medical Research Foundation and University of Minnesota.

- Reading the fine print: OK, so the health care reform law is controversial. But look at what it’s delivering to Minnesota: nearly $3.4 million in grant money to help boost the supply of health care professionals, especially in primary care.

Here’s how the money is being distributed: $1.3 million to the College of St. Scholastica in Duluth to expand the number of slots in its training program for primary care nurse practitioners and nurse midwives; $1.9 million to Hennepin Healthcare Systems to increase the number of primary care residencies for physicians in training; and a $149,000 planning grant to the Minnesota Department of Employment and Economic Development so it can assess the state’s current health care workforce and develop a plan to address the gaps.

Nationally, the Affordable Care Act is allotting a whopping $320 million to strengthen the health care workforce in the U.S. The grants are being coordinated through the U.S. Department of Health and Human Services.

Grouse all you want about the health care reform bill and its 2,000-page heft; this is one juicy tidbit that could prove to be enormously beneficial for the future of primary care.

- The kids are all right: How are the kids doing? They’re all right, at least in Minnesota – but there are hints of trouble, according to a newly released report from Children’s Hospitals and Clinics of Minnesota.

A couple of key findings: Children in Minnesota fall below the national average in childhood obesity. Among Minnesota children ages 10 to 17, 11 percent are considered obese; the national average is 16 percent. Almost three-fourths of children in the seven-county Twin Cities metro area also live in households with private insurance coverage.

Although this sounds encouraging, a closer look at the data reveals several areas of concern. Children from lower-income families aren’t as healthy as those from households that are better off. These youngsters also are less likely to have access to health care. There’s also considerable variation in health care coverage across the state. Nearly 13 percent of children in northwestern Minnesota are uninsured, and the lack of dental insurance is highest in the west central and southwestern parts of the state.

The report is the first in a series of whitepapers by Children’s Hospitals and Clinics, examining some of the most critical current issues facing children’s health. Data for the reports is analyzed by the State Health Access Data Assistance Center at the University of Minnesota.

Look for these issues to come up in the Minnesota governor’s race. On Oct. 11, Children’s Hospitals and Clinics and the Minnesota Early Learning Foundation will host a debate featuring all three candidates – Mark Dayton, Tom Emmer and Tom Horner – from noon to 1 p.m. at the Minnesota Children’s Museum in St. Paul. Can’t be there in person? Participate through social media channels at www.minnesotachildrensforum.org.

- Going local: How feasible is it for hospitals to buy local foods? Nearly 40 health care facilities in Maryland and Washington, D.C., gave it a try this summer, serving at least one food from a local farmer each day during a weeklong Buy Local Challenge. Collectively they spent more than $15,000 on fruits, vegetables, eggs and meat from local farms. More than half of the hospitals who joined the challenge were already buying local fruits and vegetables during the growing season.

Obviously there are challenges for hospitals who want to go local with some of their food purchases. Cost and institutional efficiency are major issues, as are nutritional requirements. There are also the medical needs of patients to consider. (Would lime Jell-O qualify as a local food?) Still, it’s an area in which hospitals can potentially set a community example in healthful, sustainable food choices.

Until I saw this news release, I wasn’t aware there’s an international organization called Health Care Without Harm, and that it has a “Healthy Food in Health Care Pledge” that to date has been signed by more than 300 U.S. hospitals. The pledge commits these hospitals to gradually increasing the amount of local and sustainably produced foods they serve to patients, staff, visitors and surrounding communities.

- Dog-gone amazing: We’ve all heard of service dogs and therapy dogs, and the benefits they can bring to their human companions. It seems some service dogs are now taking on a new role – sniffing out diabetes.

Assistance Dogs of the West in Santa Fe, N.M., is training dogs to detect the rise and fall of blood sugar levels via the scent of skin and breath in a person with diabetes. ADW says they placed a scent-trained dog with a man with diabetes just last month.

I’ve always thought dogs were amazingly wonderful creatures but this sounded rather far-fetched, so I did some online research, and sure enough, a small handful of studies have found that some dogs can tell when their human is having a hypoglycemic attack and can be trained to sound an alert. It’s obviously a huge leap to suggest people with diabetes would benefit from having a service dog, nor does there appear to be any scientific evidence yet that would support this. But to those of us who love animals, it’s a nice reminder of how smart and how aware the canine species can be and why it’s good to have dogs in our lives.

HealthBeat photo by Anne Polta

A new wrinkle in the war on teen smoking

Back when I was in high school, one of the hottest issues on many high school campuses was whether to provide students with a smoking lounge.

Then as now, school officials, and society in general, didn’t approve of teen tobacco use. There seemed to be an unspoken level of tolerance, however. It was commonplace for kids who smoked to light up in the school building or on school property. As I recall, the bathrooms across the hall from the principal’s office were where the smokers at my high school always hung out. The air reeked so strongly of cigarette smoke that the rest of the students wouldn’t set foot inside.

Give the kids their own smoking lounge and they can smoke to their heart’s content without bothering their classmates, or so the thinking went.

It would be hard to imagine any high school nowadays even contemplating such a thing. Policies are much more stringent about tobacco use on high school campuses, and teen smoking rates are down significantly compared to even 15 years ago.

It’s a constantly moving target, though. And one of the latest wrinkles comes from a direction I’m not sure anyone would have anticipated: In the push to curb youth obesity, we may be unwittingly shifting the focus away from youth tobacco prevention.

That’s one of the premises, at least, of a couple of intriguing articles that appeared late last week in the New York Times. The U.S. has fallen short of its goal to lower the number of high school-aged youths who smoke, the first article notes:

"People are getting the image that it’s cool to use nicotine as a drug," Terry F. Pechacek of the Centers for Disease Control and Prevention said in an interview. "We need to bring back our voice, our antismoking mass media campaign."

The popularity of hookah bars and smokeless nicotine products, Mr. Pechecek said, are the modern equivalent of the banned Joe Camel cartoon in their appeal to youths. And some experts worry that the new health campaign against obesity – spearheaded by Michelle Obama from the White House – may be hampering donations to antitobacco campaigns as public health issues shift in emphasis and compete for funds.

A second article poses the question more bluntly: "If you had to choose one public health problem to attack, which would it be: teenage smoking or childhood obesity?"

When the scientific evidence is weighed, the benefits of youth tobacco prevention are more firmly established, the article points out. For one thing, contrary to what many among the public might believe, the death toll from obesity has been difficult to accurately pin down. The death toll from tobacco, on the other hand, has been relatively well documented.

For another thing, the article points out, intervention strategies and their long-term benefits are harder to measure for childhood obesity prevention than for tobacco prevention:

Even if it were possible to calculate the lifetime health risks a fat child faces, combating obesity is not so easy. Jeffrey Friedman, an obesity researcher at Rockefeller University, notes that there are many assumptions about what will work – more healthful foods in schools, a soda tax, getting children to be more active. Yet no interventions, when tested in large studies, have caused a big difference in children’s or teenagers’ weights.

There’s the addiction component as well. There can be many reasons why children are obese, and so-called food addiction is only one – and probably not even the most prevalent. Few could argue with any scientific validity, however, that nicotine is not addictive; indeed, it’s one of the factors that makes the habit so hard to quit for so many people.

It all makes you wonder why it has to be either-or. Should ramping up the war against childhood obesity have to be at the expense of youth tobacco prevention? Why can’t there be room in the prevention tent for both?

To the extent that we no longer talk about smoking lounges for high school students, there has been measurable change in how teen tobacco use is regarded. But if the fact that close to 20 percent of American teens still smoke is any indication, there’s room for improvement yet. On the front lines of youth tobacco prevention, it seems we can ill afford to become complacent or distracted.

West Central Tribune file photo

The hard road to healthy behavior

Most of us know what behaviors we should adopt for better health: Stay away from tobacco, avoid weight gain, be physically active and eat lots of fresh fruit and vegetables. Translating this into action is much harder, though. I mean, if it were easy, we’d all be doing it, right?

In the big national discussion about health care costs and the need for prevention, behavior has received considerable attention. The argument runs like this: If Americans would only take more personal responsibility and make better choices, they’d be healthier and less likely to burden the system with high-cost, preventable diseases.

To a large extent, this is entirely true – but it’s not the whole picture. Behavioral choices don’t happen in isolation; they take place in the context of a social and cultural environment that might make it easier, or harder, for people to do what they need to keep themselves healthy.

This is why the state of Minnesota’s new approach to prevention is so intriguing. Late last month the Minnesota Department of Health announced $47 million in grant awards for the Statewide Health Improvement Program, an initiative funded by the Legislature as part of the 2008 health reform bill. Virtually every Minnesotan can expect to get a slice of the action; 86 of Minnesota’s 87 counties, plus eight tribal governments, are receiving funds.

Prevention typically has focused on individuals and how to motivate them to change their behavior. This approach isn’t always successful, however, especially in the long term. One agency that learned this lesson the hard way is the CDC, which ended up replacing its “5 A Day” program after studies revealed the initiative had only a minimal impact on getting Americans to eat five daily servings of fresh fruits and vegetables.

What’s different about SHIP - and what ultimately might make it more successful in the long haul – is its focus on the policies, systems and environments that influence how people make health-related decisions. There’s some evidence this is a strategy that works. Raising the cigarette tax, for instance, has been shown to cut down on tobacco use. Similar results have been found when workplaces, restaurants, colleges and the like become smoke-free.

Most of the counties receiving SHIP money will be using the funds to help them plan their strategies. Kandiyohi County is ahead of the curve, however, and is moving into the implementation phase already. Some of the activities will be focused on the school environment – for example, implementing policies and practices that encourage children to walk or bike to school and to use the school gym and playgrounds. The local initiative also will take aim at nutrition and improving local access to fresh food.

Individuals still have to take responsibility for maintaining their own health. They still have to make good decisions. But perhaps it’ll be easier for them to do the right thing, and less likely for their good intentions to get derailed, if they’re surrounded by a more supportive environment. This aspect of health often tends to be ignored, and it’s high time we started recognizing it.

West Central Tribune file photo by Gary Miller