TIME Culture

Up in Smoke: The Rise and Fall of Big Tobacco

"According to this survey, more doctors smoke Camels than any other cigarette," is just one of the phrases we no longer hear in commercials

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Earlier this week, a $27.4 billion deal was announced that will merge two of the largest American tobacco companies, Reynolds American and Lorillard.

The deal comes at a time when cigarette smokers are at a steady decline. Even so, Marlboro still makes some lists of most valuable brands in the world.

And while it’s hard to remember the days when Camels were advertised as the most preferred cigarettes by doctors, a small segment of the industry is quickly growing: e-cigarettes.

Above, take a quick look at the history of America’s complicated relationship with the addictive habit.

TIME Smoking

This Is The New Best Way to Quit Smoking, Study Finds

Combining varenicline and the nicotine patch was more effective in helping smokers quit after six months than the drug alone

Quitting smoking can be a frustrating challenge, and no single therapy works dramatically well. Nicotine replacement strategies – the patch, gum or lozenges—can help wean smokers off nicotine gradually, but don’t often work in keeping smokers abstinent over the long term. The prescription drug varenicline, or Chantix, which curbs smoking by occupying and blocking the same nicotine receptors in the brain used by the nicotine in cigarettes, makes nicotine less pleasurable. But studies show that it’s only about 33% effective in keeping smokers off cigarettes after 12 weeks.

Researchers in South Africa, however, report in JAMA that combining varenicline with the nicotine patch boosted that quit rate to 49% among a group of 435 smokers who were randomly assigned to take either the pills and the patch or the pills and a placebo patch. Smokers on the pills and patch were nearly twice as likely to be abstinent after six months than those who took the pills alone with a dummy patch.

MORE: Nicotine Gum and Patch Don’t Help Smokers Quit Long Term

“The efficacy of combining the two drugs cannot be readily explained,” Dr. Coenraad Koegelenberg, lead author of the study from Stellenbosch University in Cape Town, wrote in an email response to questions about the findings.

It’s possible that the timing of the pills and the patch worked in the smokers’ favor. While both varenicline and the nicotine patch target the same nicotine receptors in the brain, they have different effects; the nicotine from the patch activates the nicotine receptors and provides the same pleasurable sensations that cigarettes would, while varenincline is designed to bind and block the effects of nicotine on the brain. Varenincline is more effective at binding to these receptors, while nicotine from the patch is slower to activate, so starting on the patch may wean smokers from nicotine, and the varenicline may have helped them to drop cigarettes completely.

MORE: Hope for Quitters? Scientists Devise a New Nicotine Vaccine

Interestingly, the one-two punch didn’t work by lowering craving for nicotine. They also did not find a significantly increased risk of side effects, including depression or nausea, in the varenicline group. The U.S. Food and Drug Administration in 2009 added a black box warning alerting users to the potential for suicidal thoughts, although a 2013 study found no greater risk of depression among smokers with depression or who had had depression in the past.

The results raise important questions about how current smoking cessation treatments might be more effective if used in combination. Currently, varenicline is not recommended with other nicotine-replacement strategies; for that to change, other studies showing similar results to this one would be needed.

TIME Cancer

The Government’s Super Scary New Anti-Smoking Campaign

CDC

The CDC releases its next set of graphic ads to encourage smokers to kick the habit for good—or else

The newest phase of the Centers for Disease Control and Prevention’s (CDC) graphic campaign to persuade America’s 42 million smokers to quit—”Tips from Former Smokers”—launches today, and it’s heart wrenching.

Since 2012, the campaign has featured real former smokers dealing with serious health problems spawned by their addiction, and this round is bound to make smokers and non-smokers alike squirm. It’s an especially graphic campaign from the CDC’s tobacco office, which has not shied away from bold, conversation-starting efforts to curb smoking.

Here’s an example: Shawn provides tips on how to live with a hole in your neck. Amanda, meanwhile, smoked during pregnancy and gave birth to her baby two months early.

Here are the newest ads, which the CDC provided early to TIME:

Amanda, a 30-year-old who smoked while pregnant. Her 3 lb daughter spent weeks in an incubator.

Brett, 49, who lost most of his teeth to gum disease by age 42. He takes out most of his teeth on camera.

Rose, 59, whose lung cancer resulted in surgery, chemotherapy and radiation.

Shawn, 50, who breathes through the opening in his throat due to smoking-related throat cancer.

Brian, 45, whose smoking and HIV led to clogged blood vessels and resulted in a stroke.

Felicita, 54, who lost all of her teeth to gum disease by age 50.

Terrie, who died of cancer last September at age 53

Previously released ads ran earlier this year in February, and a CDC spokesperson told TIME that the “effort had immediate and strong impact.” During the last set of the ads’ nine-week run, they generated over 100,000 additional calls to the CDC’s quit line, 800-QUIT-NOW. On average, the CDC says weekly quitline calls were up 80% while the ads were on the air compared to the week before they began running. Preliminary estimates show there were nearly 650,000 unique visitors to the the agency’s website during those nine weeks.

The ads will be placed on cable TV, on radio, in print, on billboards, and in movie theater and online starting July 7. The CDC is also launching a social media campaign to support its tradition-media plays.

Of course, considering tobacco is a $100 billion market, and the industry continues to spend billions every year, the campaign is a drop in the pond. But it certainly stands out.

If you want to quit smoking, you can call l 1-800-QUIT-NOW or visit www.cdc.gov/tips.

MONEY Health Care

Obamacare Will Help You Quit Smoking—Or Charge You for Your Habit

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Robert A. Di Ieso, Jr.

Q: I heard Obamacare requires health plans to help people quit smoking. Is that true?

A: You’re right. Under the health reform law, the vast majority of people now have access to tobacco cessation programs at no cost, says Katie McMahon, a policy expert at the American Cancer Society Cancer Action Network, an advocacy group.

Implementation of this benefit initially was inconsistent, though, she says. A 2012 report from Georgetown University Health Policy Institute found that coverage varied widely, and that in many cases, it was impossible for consumers to determine what, if any, benefit their plan had. The Obama administration recently clarified the requirements.

Now, anyone insured through an employer-sponsored health plan or an individual policy purchased via the exchange gets the following paid for 100%: two attempts per year to quit, each including four counseling sessions and a 90-day supply of a medication approved by the FDA for this purpose, according to McMahon. Two of the medications require a prescription from the doctor; the others come over-the-counter.

A counseling session can be an individual, group or phone based-program offered through your employer, or a one-on-one session with a behavioral health specialist. (To find a specialist, call your state’s quit line—find it through 1-800-QUIT-NOW—or ask your primary care physician.)

One caveat: Not all Medicaid plans offer the benefit. Only Medicaid plans in states that decided to expand their Medicaid program under the health reform law—about half did—are required to pay for these services, says McMahon.

The good news for those looking to kick the habit is that research suggests having insurance coverage for treatment improves the chances that a person will stop, according to the Georgetown University Health Policy Institute. And combining counseling with medication is more effective than using either therapy alone, according to the United States Preventive Services Task Force, which is charged with evaluating the latest scientific evidence on preventive services.

The bad news is that the health reform law takes a carrot-and-stick approach when it comes to smoking. While it includes this coverage to help people quit, it also allows insurers to charge smokers up to 50% higher premiums. So if the health consequences aren’t enough to convince you to conquer your addiction, maybe money will motivate you.

TIME E-Cigarettes

10 New E-Cig Brands Hit the Market Every Month

A series of studies shows just how prevalent e-cigarettes are, and what that means for smokers, non-smokers and would-be smokers alike

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In the most comprehensive look at e-cigarettes to date, from how they are used to how they are marketed and where they are sold, researchers are surprised by how quickly the devices have taken hold worldwide.

In nine studies published in the journal Tobacco Control by the State and Community Tobacco Control Research Initiative (SCTC), scientists looked at where e-cigarettes are sold, the status of state laws regulating e-cig sales and use, and how taxes and pricing may affect the popularity of the devices, among other topics.

MORE: 5 Sketchy Things We Still Don’t Know About E-Cigarettes

When it comes to e-cig marketing, researchers found that about 10.5 new brands appear online every month, touting 242 novel flavors. “The most surprising thing was how quickly they became available across the country,” says Frank Chaloupka, a professor economics at University of Illinois and a co-author of the study. “A few years ago, they were hardly available anywhere, and by 2012, they were available in about a third of the stores we were going into.”

He and his colleagues found that at least initially, e-cigs were targeted in areas with weaker tobacco regulations, including areas with lower taxes and more lenient smoking policies in public places. E-cig makers, says Chaloupka, likely focused their early marketing strategies in areas with the greatest density of smokers.

MORE: Industry Is Winning the E-Cig Regulation Battle

That may be shifting, however, as the latest data suggests that e-cigarettes are now marketed more heavily in higher income communities, and less so in lower income neighborhoods, which traditionally have higher proportions of smokers. That may be because e-cig manufacturers are promoting claims that their products are safer than traditional cigarettes and are also hoping to capture those who may turn to their devices to help them quit smoking. “Groups that are more likely to switch to e-cigarettes in the long run are more interested in the health benefits, and tend to be more highly educated and have higher incomes” says Chaloupka.

That’s supported by evidence from some of the other studies in the series; scientists led by researchers at Harvard University’s School of Public Health conducted the largest study of e-cig use in Europe and found that the bulk of users were young smokers who had tried to kick the habit in the past year. These smokers were twice as likely to try e-cigs as smokers who hadn’t tried to quit.

MORE: Here’s Why Bacteria Like E-Cigs

On the one hand, the quick penetration of e-cigs into nearly every retail outlet, from pharmacies to convenience stores, grocery stores and gas stations may help more smokers to try the devices and try to quit. On the other hand, the ubiquity of the devices, and the unsubstantiated claims about their safety over regular cigarettes, may lead younger smokers to try them and potentially serve as a gateway to tobacco-based cigarettes. “Just the fact that their availability increased so rapidly means that people, especially kids, may see them a lot more in the stores they go into, and perceive them as normative, and that could by contributing to the big increases in use that we are now seeing,” says Chaloupka. The percentage of teens who have ever tried e-cigarettes doubled from 3.3% in 2011 to nearly 7% in just one year, according to the latest data from the Centers for Disease Control and Prevention.

The Food and Drug Administration recently announced its intention to regulate e-cigarettes as tobacco products; although they don’t contain tobacco, the agency says the devices meet the “statutory definition of a tobacco product.” As such, the FDA wants to ban sales to minors, require health warnings and keep e-cigs out of vending machines. The proposal is up for public comment until July, and may take another year before they become enforceable. In the meantime, 34 states have laws addressing e-cigs, but primarily to prevent minors from buying them and to ensure they don’t violate existing smoke-free air laws.

MORE: The Future of Smoking

The safety of e-cigarettes isn’t clear yet, despite claims by some manufacturers that they are less dangerous than traditional cigarettes. While they don’t envelop smokers in the carcinogenic smoke emitted by burning tobacco, they do contain other compounds such as propylene glycol, which the FDA is still studying for its health effects.

TIME E-Cigarettes

Teen Smoking Is Way Down. But What About E-cigs?

Cigarette smoking among high school students has dropped to lowest level in two decades

Rates of cigarette smoking among high school students has dropped to lowest level in 22 years, the CDC reports.

In 2013, the smoking rate among high school students hit 15.7%, which means the U.S. government has already reached its goal of lowing the teen smoking rate to 16% of less by 2020. That’s according to the National Youth Risk Behavior Survey (YRBS), which began in 1991. Another important data set on teen smoking and drug use—Monitoring the Future (MTF)—reports the rate is at 16.3%. Regardless, both surveys show fewer kids are smoking.

That’s good news, and it’s likely thanks to a combination of several factors, the most important being the rising costs of cigarettes. Others include the growing stigmatization of smoking, with half of states prohibiting smoking in places like bars and restaurants. The adult smoking rate is dropping too, which means teens have fewer smoking role models.

If teens are passing around fewer packs of cigarettes, does that mean they’re not smoking other things? Past data has shown a 123% increase in the consumption of other smokable tobacco products like cigars and pipes, though the recent numbers from the larger data sets show no change in smokeless tobacco use since 1999, and a drop in cigar use.

CDC

One question you’re likely going to see is whether teens are switching to e-cigarettes. E-cigarettes is a subject the public health community is uncharacteristically split on. On one side of the spectrum, you have critics arguing that it’s possible e-cigarettes serve as a gateway to regular cigarettes. One vocal critic being the head of the CDC himself. “The increased use of e-cigarettes by teens is deeply troubling,” said CDC Director Dr. Tom Frieden in a statement about teen tobacco use going down. “Nicotine is a highly addictive drug. Many teens who start with e-cigarettes may be condemned to struggling with a lifelong addiction to nicotine and conventional cigarettes.”

Emerging data points to certain trends, but e-cigs are still so new. Earlier this fall, a CDC report showed that e-cig use among teens, while still low, had doubled in a year, from 3.3% in 2011 to 6.8% in 2012.

Dr. Kenneth Warner, a professor of health management and policy at the University of Michigan School of Public Health, looked back through the data and found that among kids who have never smoked a conventional cigarette, only 0.7% have ever tried an e-cigarette within the last 30 days. What this shows is that the same kids who are smoking regular cigarettes are smoking e-cigs.

“Everyone thinks they are right and the logical thing is that nobody knows,” says Warner. “This is a huge-stakes issue, because the proliferation of e-cigs has the potential to either reduce the cigarette problem or increase it over time among kids.”

The reality is we have a long way to go. It took 40 years to get the adult smoking rate down to around 20%, and it won’t be easy to cut it in half again. Warner and his colleague David Mendez have created a smoking-prevalence model that’s been used since the 1990s. Their predictions show that at the rate we are going, we might not be able to hit a 10% adult smoking rate until the middle of the century. But that’s if we don’t try anything radically different.

“I believe we will do better because I don’t think we’ll stick with just status quo tobacco control,” says Warner. “In my judgment, the future lies in how effectively FDA can regulate cigarettes and other [nicotine] products.”

The FDA announced it is expanding its regulatory powers to cover more tobacco products including e-cigs, but anti-smoking advocates are arguing it’s still not enough.

“The data on kids is great, but we have a long way to go before we can pack up and go home and say we solved the problem,” says Warner.

You can read more on the latest CDC numbers here.

 

 

 

TIME Advertising

What to Say to Your Kids About E-Cig Ads

A woman smokes an e-cigarette.
A woman smokes an e-cigarette. PAUL J. RICHARDS—AFP/Getty Images

What parents can do to offset the impact of a steep rise in TV ads for electronic cigarettes aimed at teens and young adults.

If your kids watch “The Bachelor,” “Big Brother” or “Survivor”—and there is a good chance that they do—odds are growing fast that they are seeing ads for one of the most controversial products to hit the market in years: e-cigarettes.

It’s time for parents to strike back.

A study published today in Pediatrics suggests that e-cigarette makers are aiming their products at young people, ages 12 to 24, by increasing advertising during the shows (such as those above) and on the channels (including AMC, Country Music Television, Comedy Central and TV Land) they watch most.

“If current trends in e-cigarette television advertising continue, awareness and use of e-cigarettes are likely to increase among youth and young adults,” says the study, which was conducted by a team from the nonprofit research institute RTI International and the Florida Department of Health.

The impact of e-cigs, devices that vaporize an addictive nicotine-laced liquid solution into an aerosol mist that simulates the act of tobacco smoking, is hotly debated. On one side are those who argue that e-cigs are much safer than conventional tobacco cigarettes and help people addicted to them to quit. On the other side are those who say e-cigs still pose serious risks, including from liquid nicotine.

What can be said, with great certainty, is that we don’t know nearly enough about the long-term health effects of e-cigs to let young people get hooked on them. And as a parent, this is precisely why the study in Pediatrics and other analyses that have shown e-cigarette companies are spending tens of millions of advertising dollars targeting our kids are so alarming.

So, in the absence of any government regulation of e-cig advertising, here are a few things parents can do:

For starters, as always, the best thing we can do is talk to our kids. Let them know that e-cigarette companies have them in their sights and, as I’ve written, are trying to reel them in with fun flavors and sexy ads that are designed to make them feel all grown up. Tell them that these companies have a vested interest in promoting the idea that e-cigs aren’t bad for them—but the fact is, we aren’t really sure. And share that some experts are concerned that because they contain nicotine, e-cigs may be a gateway to real cigarettes.

Second, set clear expectations. We need to make sure that our kids understand that we don’t want them to vape and will be disappointed if they do. The Campaign for Tobacco-Free Kids has found that “parental attitudes, opinions, and feelings about their kids’ smoking status greatly influence whether or not kids will smoke, even when the parents smoke.” Vince Willmore, the organization’s vice president of communications, says the same principle is sure to hold true for vaping.

Third, set a good example. You should certainly express to your kids your own struggles to quit cigarette smoking, if that’s the case, but don’t vape around them. If you do, they may think it’s something to emulate—especially given the onslaught of ads reinforcing that vaping-is-cool message.

The Pediatrics study found that 50% of youth, ages 12 to 17, were exposed to an average of 21 e-cigarette ads from October 2012 to September 2013, and half of young adults, ages 18 to 24, were exposed to an average of 35 e-cigarette ads during the same period.

That’s a sharp rise from just a couple of years earlier, according to the study. In all, youth exposure to e-cigarette ads on TV increased 256% from 2011 to 2013, and exposure for young adults jumped 321%. More than 80% of the advertisements were for the brand blu eCigs.

The tactic seems to be working. The Centers for Disease Control reported last year that 1.8 million middle- and high-school students said they had tried e-cigarettes in 2012—double the number from the previous year.

“When I give talks about e-cigs I call them ‘Back to the Future’ because I feel like I’ve gotten into a DeLorean and gone back in time,” says Stanton Glantz, a professor of medicine at the University of California, San Francisco and the director of the Center for Tobacco Control Research and Education. “E-cig marking today looks a lot like what conventional advertising for tobacco looked like in its heyday.”

That shouldn’t be surprising. Many of the same companies that have long sold tobacco products—including R.J. Reynolds, Philip Morris parent Altria and Lorillard—have now gotten into the e-cigarette business.

Which leads me to the last thing that parents should do: Advocate. You can begin by writing in and supporting the Food and Drug Administration’s proposed new rules that include banning the sale of e-cigarettes to anyone under 18. But we need to go even further. Urge lawmakers and the White House to ban e-cigarette advertising from television—as has been the case with cigarette ads since 1971.

With e-cigs, tobacco companies are clearly taking a page out of their old playbook. It’s time for regulators to do the same.

 

 

 

TIME Addiction

Scientists to WHO: Don’t Classify E-Cigs As Tobacco Products

A woman smokes a "Blu" e-cigarette in Washington, D.C., on Sept. 25, 2013.
A woman smokes a "Blu" e-cigarette in Washington, D.C., on Sept. 25, 2013. Jim Watson—AFP/Getty Images

The move by the WHO would push 178 countries to impose tough restrictions on the products, which some scientists say provide a less harmful alternative for smokers.

A group of 53 top scientists warned the World Health Organization Thrusday not to classify e-cigarettes in the same category as other tobacco products, a move that would lead to significant restrictions on the devices in most countries around the world.

The scientists say that electronic cigarettes are in fact “part of the solution” in the fight against smoking because they can provide a healthier alternative to traditional cigarettes, Reuters reports.

“Even though most of us would prefer people to quit smoking and using nicotine altogether, experience suggests that many smokers cannot or choose not to give up nicotine and will continue to smoke if there is no safer alternative available that is acceptable to them,” the scientists wrote.

The devices have exploded in use and spawned a $3 billion industry worldwide, but the scientific research on their safety and their potential to be a “gateway” to other tobacco products is still developing.

If the WHO were to classify e-cigarettes as tobacco products—a move they are rumored to be considering, according to Reuters—178 signatories to the Framework Convention on Tobacco Control would be expected to impose strict measures on them to restrict demand, like raising taxes and banning some forms of advertising. The U.S. is one of the few non-signatories to the FCTC, though the Food and Drug Administration has moved to regulate e-cigs.

The FCTC is scheduled to meet in October in Moscow, where it will consider any proposed regulations.

[Reuters]

TIME cities

Washington D.C. Is The Fittest City In The U.S.

Lower death rates, ample parks and a healthy appetite for fruits and vegetables are just some of the factors that vaulted the nation's capital to the top of the list

Washington D.C. has topped a ranking of America’s 50 largest cities, arranged from fittest to flabbiest.

The new study, released on Wednesday by the American College of Sports Medicine, ranked the cities by two broad measures of public health: Personal health indicators such as prevalence of smoking and diabetes and the average city-dweller’s intake of fruits and vegetables, and environmental health, which included measures such as access to public parks, bike lanes and farmer’s markets. A panel of 26 health experts weighted the measures by importance, and voila, a health index was formed, allowing whole metropolises to size one another up like competitive weightlifters.

Washington D.C. topped the list, knocking Minneapolis-St. Paul’s off of its three-year winning streak (though the Twin cities came in a close second). Oklahoma City, Louisville, and Memphis rounded out the bottom of the list.

The authors stress that some of the rankings capture marginal differences between cities and that they all have areas of strength worth emulating and weaknesses worth addressing.

“We have issued the American Fitness Index each year since 2008 to help health advocates and community leader advocates improve the quality of life in their hometowns,” said Walter Thompson, chair of the AFI Advisory Board.

In other words, they’re all beautiful in their own way, and they all could use some work.

TIME States

Young Children Are Getting Sick Working on U.S. Tobacco Farms

Tobacco farm - Warfield, VA
Tobacco farmer in Warfield, Va., on Aug. 30, 2013 Matt McClain—The Washington Post/Getty Images

A new Human Rights Watch report finds that child laborers, some as young as 7 years old, who work on tobacco farms in North Carolina, Kentucky, Tennessee and Virginia, "get so sick that they throw up, get covered by pesticides and have no real protective gear"

Children as young as 7 years old are suffering serious health problem from toiling long hours in tobacco fields to harvest pesticide-laced leaves for major cigarette brands, according to a report released Wednesday.

New York City–based advocacy group Human Rights Watch (HRW) interviewed more than 140 youngsters working on tobacco farms in North Carolina, Kentucky, Tennessee and Virginia, where most American tobacco is sourced.

They reported nausea, vomiting, headaches and other health problems associated with nicotine poisoning, known colloquially as green tobacco sickness, which is common among agricultural workers who absorb the toxic substance through their skin.

“The U.S. has failed America’s families by not meaningfully protecting child farmworkers from dangers to their health and safety, including on tobacco farms,” said Margaret Wurth, HRW children’s-rights researcher and co-author of the report.

“Farming is hard work anyway, but children working on tobacco farms get so sick that they throw up, get covered by pesticides and have no real protective gear.”

Much of what HRW documented remains legal. While strict provisions govern child labor in industrial environments, U.S. agriculture labor laws are much looser, allowing 12-year-olds to labor for unlimited hours outside of school on any size of farm. On small farms, there is no minimum age set for child workers.

HRW called on tobacco giants to ensure safe working practices and source responsibly. The global tobacco industry generates annual revenues of around $500 billion, but some 6 million people die each year from smoking-related diseases.

Not everyone favors stricter controls. Republican Kentucky state senator Paul Hornback says he worked in tobacco fields from when he was 10 years old and doesn’t think further legislation is necessary. “It’s hard manual labor, but there’s nothing wrong with hard manual labor,” he told the Associated Press.

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