What One Cardiologist Thinks About the CVS Caremark Decision to Ban Cigarette Sales

By now the world has heard the remarkable news: that CVS Caremark will no longer be selling its tobacco products in any of its stores.  Locked and loaded with the news, the American Heart Association, American College of Cardiologists, local public health experts, Phillip Morris, and even the former-smoking President of the United States was quick to applaud the news by publishing press releases. 

But when press releases and major announcements of a single company's business decision floods the airwaves, newsfeeds, and radio spots, my bullsh*t antenna goes up. 

This is not to say that CVS Caremark's announcement wasn't nice to hear.  It was.  But making me feel better isn't going to stop people from smoking.   Is pulling the supply of cigarettes from one pharmacy/convenience store chain really going to affect the incidence of smoking in America?  Is it really going to "send a message" to other convenience stores and states who make billions of dollars from the sale of cigarettes each year?  Can we really sit and applaud this action while more and more states (like Illinois) seem to feel that smoking marijuana is just fine for our health?  

Please. 

After all, despite the public's widespread knowledge of the dangers of smoking, being ridiculously taxed, stored behind counters, and withheld from minors for years, tobacco smoking is seeing a huge resurgence in both the young and old in America.

But politicians and public health experts, reeling from this reality, are desperately in need of some good news to spin.  They need to show the world how their self-righteous drum beats of preventing disease by restricting the supply of cigarettes at one business will make a difference to people's consumption behavior. 

It seems these same people have forgotten Prohibition.

To understand smoking in America, you have to meet smokers where they are - specifically their social circumstance.  People are growing up in a time of unprecedented pessimism in America.  They can't get jobs.  They are incredibly anxious, fractionated, and uncertain about their futures.  They are desperate to belong, to gain their own identity, to feel imporant, and to belong to a set of peers.  If smoking helps them achieve their own set of personal, social, or professional needs, no feel-good corporate policy announcement is going to change their minds about using cigarettes.

Supply-side public policy edicts will never affect psychology.

How do I know this?  Because I see people who smoke despite knowing these risks every day.  I know this because I am one of the most argent anti-smoking promoters to my kids.  As a cardiologist and father, how else could I be?  Throughout my entire career and my kids' entire lives, they've heard about the dangers of smoking, the addictive potential of nicotine, the poisons in the smoke, and the horrible cases I saw of lung, oral, and bladder cancer in my training.  My wife and I have never allowed cigarettes to be smoked in our house and have we have never smoked.

But despite all of our harping and example-setting, I recently learned that one of my young-adult kids has started smoking.  He felt so conflicted about this decision that he knew he was making, he recently met with my wife and me over dinner to explain.  His reasons were specific to him and him alone.   He just didn't want to lie to us about his decision and I know for certain that this decision wasn't because he didn't know the dangers of smoking or what it could do to him.  Were we happy about this? Of course not.  But the decision is his and I know that if he wants something, he's going to get it, even if CVS Caremark doesn't carry cigarettes any longer.  Hopefully, as his life circumstances change, he'll quit.

This is why we need to get over ourselves about the CVS Caremark business decision to stop selling cigarettes - there are just too many other confounding variables and mixed messages out there that are bringing people to smoke.  Sure the CVS Caremark announcement was good news but good news and one pharmacy chain's decision to not sell tobacco products won't really affect the booming incidence of smoking in America.  CVS Caremark's announcement has already come and gone.  Smoking, however, is still here.

To me, when we start focusing on why people are smoking despite the known well-known dangers of this habit we'll be much closer to gaining a real foothold on this public health problem.

Anything else is just spin.

-Wes

Why the US Debt Reduction Talks Remain Stalled

... because one of the principle negotiators smokes and the other one quit.

-Wes

Tot Smoking: Sad But True

"Little Ardi Rizal has been puffing away since he was 18 months old, and is now up to two packs a day, his family said. The chain-smoking tot is reportedly so out of shape, he can only get around on a toy car."

As doctors, we still have to pretend this is the sixth case like this we've seen, but it never gets any easier.

-Wes

Nevada Supreme Court Denies Insurance to Smoker

Could this be the start of a trend?

The Nevada Supreme Court on Friday upheld a ruling that a Las Vegas police officer was not entitled to coverage for heart disease.

Under state law, a police officer continuously employed for more than five years is entitled to the presumption that any heart disease is work related. Patricia Guesman, however, was denied coverage by both the hearing officer and a district judge.

The Supreme Court noted coverage is not automatic if “after the police officer's annual medical exam, the examining physician ordered her in writing to correct a predisposing condition that was within her ability to correct and the officer failed to do so.”

The three-justice panel of Ron Parraguirre, Michael Douglas and Kris Pickering pointed out that smoking is a predisposing condition to heart disease. Guesman was warned to stop smoking but failed to do so.

So I guess when the Nevada state's finest develops any form of heart disease (i.e., critical aortic stenosis not typically associated with smoking) and treatment is required, the cost burden will shift from the state to the federal government.

Perfect.

Gee, I wonder why they didn't exclude treatments for oral and bladder cancers, too?

-Wes

PS: All this while Nevada works to ease up on its smoking ban.

Leading By Example

While I support the President at signing tough new no-smoking legislation, shouldn't he lead by example?

There are fewer touchier questions inside the White House than this: Is Mr. Obama still smoking? One administration official declined to answer on Monday, but pointed out that the president spoke in the present tense, “I know how difficult it can be to break this habit,” as opposed to, “I know how difficult it was to break this habit.”

If we're going to make the case repeatedly for "prevention" as a cornerstone of health care reform (and supposed health care "savings"), I would suggest he practice what he preaches.

-Wes

New Clinical Risk Factor Score for Atrial Fibrillation

A new "score" to assess the clinical risk factors for the development of atrial fibrillation was published in Lancet today based on epidemiologic variables from the Framingham Heart Study and found:

"457 (10%) of the 4764 participants developed atrial fibrillation. Age, sex, body-mass index, systolic blood pressure, treatment for hypertension, PR interval, clinically significant cardiac murmur, and heart failure were associated with atrial fibrillation and incorporated in a risk score (p<0·05, except body-mass index p=0·08), clinical model C statistic 0·78 (95% CI 0·76–0·80). Risk of atrial fibrillation in 10 years varied with age: more than 15% risk was recorded in 53 (1%) participants younger than 65 years, compared with 783 (27%) older than 65 years. Additional incorporation of echocardiographic measurements to enhance the risk prediction model only slightly improved the C statistic from 0·78 (95% CI 0·75–0·80) to 0·79 (0·77–0·82), p=0·005. Echocardiographic measurements did not improve risk reclassification (p=0·18).

Although the "score" they developed seems too cumbersome to be applied easily in the clinical setting, I thought the most interesting findings of their study was what was NOT found to be a clinical predictor of atrial fibrillation risk: alcohol, hypercholesterolemia, smoking or diabetes. (Almost a quarter of their cohort (22%) were classified as "moderate to heavy alcohol consumers" and nearly a third (32%) were smokers).

So when you're at the bar this weekend, relax!

At least statistically you won't be at increased risk of getting atrial fibrillation.

-Wes

Smoke-Free White House?

It seems the White House is a smoke free zone. So what will happen when Barack Obama, who we find has yet to quit smoking, takes up residence there?

"Uh, excuse me Mr. President, we have to ask you to put out that cigarette."

"Tom, I'm tired of all of your nagging! You big ol' senators think you know it all. If I weren't so perplexed about the health care system and needed someone to take the fall when the next attempt at reform fails, you'd be fired! You hear me? Fired, I tell you! So be glad I offered you that post over there at the Department of Health and Human Services. Hey, how's the sale of your book going now that I appointed you? Good? Glad to hear it! Now you go about your way now and leave me alone. I've got bigger fish to fry with this damn economy. Criminy!"

"But Mr. President, sir, the White House has balconies..."

"Tom, dammit! Stop! Wouldn't you suck on one of these babies if you had to figure out a way to shore up our economy? I don't see you working like I am. I hired all of those famous economists and they keep telling me this and that - who knows what's right? And if I get cancer, well then, heck, at least I'd be leading by example and supporting the continued reliance on health care to support our economy, right? I mean look at all the new jobs we've created there - even now as the rest of the economy tanks. You could scan me and test me time and time again, then give me one of those super duper chemo drugs that costs, what, $5000 per month, and save my sorry little butt so I can get back to work. So I don't have to stop smoking, Tom. The nation needs me in this time of crisis to show them the way!"

"But health care's struggling, too, Mr. President. I mean ER's are seeing more and more of the uninsured, they're overcrowded. Pressures being put on hospitals to see these folks who can't pay..."

"What do you mean, hospitals are hurting? I know that some are doing quite well. Some are building like crazy. Some are growing. Don't tell me hospitals are hurting!"

"Really, Mr. President, some are. Lots of them have thought about closing - not because they can't continue seeing patients and raising prices. It seems it's really because they couldn't get credit to update their facilities and make 'em look as nice as their competitors. So all they could see were the locals. They couldn't attract people from outside their locale that could actually pay their bills and got stuck with the hoi polloi - and lots of those common folk have lost their insurance when they lost their job, Mr. President."

(Loud sucking sound heard, followed by a plume of smoke rising from the Predident's lips) "Oh, hell, Tom, you're such a fuddy duddy. We all know who's paying their bills! Medicare! What the hell you taking about? Those guys just keep seeing the over-65 crowd and they're set! You know as well as I do that we're providing them a bigger continuing bailout package than GM! Maybe WAY more! They just hire those hospitalists to keep ordering tests and workin' like beavers and with all those fancy electronic medical records auto-ordering tests and immunizations and drugs, hell, they're in the money. We pay 'em well enough, Tom. They'll make it. Let's focus on the big stuff. Don't weigh me down in such trivialities - we have the finest health care system in the world."

"But Mr. President, aren't we suppose to find all that waste, fraud and abuse in the hospitals? With those damn electronic records, that's getting hard! Won't that take even more money from the hospitals?"

"Tom, seriously. You know how this works. If the programs are making it tough to find some loopholes, just change the rules! That's what we do, remember? All we have to do is find a few million here and there so the press feels we're doing our job to save our health system from ourselves and it'll buy time. Don't get bogged down in such trivialities. We need our hospitals right now! Just make those doctors fall in line a bit more! Withhold a few more billion of their pay and then offer them a chance to earn back a few more percent in payments by prescribing electronically! We all know only 15% of those suckers don't have EMR's, so that should be a win-win for us, right? And the pharmacies and drug companies will love us, too, as those scrips go flying out the door! And speaking about the drug companies, can't we jack up the FDA's drug review fees some more? They're under your umbrella. There's a revenue stream if I've EVER seen one! And what's up with Grassley? Doesn't he know what's important right now? Geez! Isn't there another committee we can give him?"

"(* cough *) Mr. President. The smoking..."

"There you go again, Tom. Look, just give the people what they want. Make it look free, or affordable, and for God sake, universal. Right now we've got the world by the balls. Make a new line item deduction on peoples' paychecks. Make the businesses pay, too, and we'll get through this. Don't start to ask about why things cost so much. Just get it done. Don't worry about all the middle men. Hell, if we start trimming there, we'll have a real mess on our hands! You know what the unemployment numbers would look like then? Just keep it complex. Keep it fuzzy, and keep those billing, collections, and regulatory people employed, dammit! You know how to do it: make sure every last sucker scrubs their hands with expensive gels rather than plain ol' soap and water. Feed the economy, Tom, feed it! (*sssslllluuuurrrrrpppp*)"

"Okay, Mr. President, but what about your daughters. What will they think about your smoking..."

"Tom, leave them out of this. Look, I'm already giving them a puppy..."

-Wes

Text Messaging Your Smoking Status

With insurance rates tied to a history of smoking, this will never happen here.

-Wes

Where Has All the Money Gone?

I heard this on the radio this morning:

On the 10th anniversary of the $246 billion settlement, the Campaign for Tobacco Free Kids has done an analysis of where the money's been going.

The group's Danny McGoldrick says only 9 states are funding tobacco prevention programs at even half the recommended federal level.

Illinois, he says, is near the bottom of the list. It ranks 43rd, spending just $9.5 million dollars of its $900 million share of the settlement on smoking prevention programs this year.

Seems we know the answer:

"...the states are expected to face significant budget shortfalls in the coming year as a result of the weak economy. The last time the states faced budget shortfalls, they cut funding for tobacco prevention programs by 28 percent between 2002 and 2005. The cutbacks are a major reason why smoking declines subsequently stalled..."

Talk about "spreading the wealth." I just hope it's not short-sighted.

-Wes

Reference: See the full report (pdf).

Quote of the Day

Today, San Francisco's city board of supervisors will vote on whether to bar cigarette sales at pharmacies and retail stores with in-store clinics that treat common ailments such as sore throats and sinus infections as of October 1. Opponents of the tobacco ban believe stores will get out of the clinic business if they are forced to choose between providing health care and selling cigarettes:

"We do not understand how forcing retailers to choose between having an in-store clinic and selling tobacco products serves the broader goal of providing consumers with easier access to high-quality, affordable health care"
- Tine Hansen-Turton
Executive Director of the Convenient Care Association

Perhaps, Ms. Hansen-Turton, it's because healthcare is about commitment to real health, not just convenience and profit. Frankly, I can't think of a better way to promote sore throats and sinus infections than to sell cigarettes, too.

-Wes

Image reference.

Should Teens be Fined for Smoking?

Eric Zorn, syndicated columnist at the Chicago Tribune, likes the PUP laws (laws that ban the "purchase, use and possession" of tobacco by minors) that fine teens for smoking. And he has supporters:

That makes sense, said John Banzhaf, executive director of Washington-based Action on Smoking and Health. PUP laws "serve to draw parents into the situation" and give children an additional reason to resist peer pressure.

"Treating cigarettes like we do alcohol would go a long way" toward discouraging teen smoking, Banzhaf said. And if you stop a teen from smoking, he said, the odds are overwhelming that he'll never be a smoker.

While I admire his bravery, I beg to differ.

Why do the police and I have to be drawn "into the situation?" Isn't there enough of a power struggle regarding separation going on already in adolescence?

Not only do police have bigger fish to fry, the very people who like such a laws inforced on teens all-too-often will be the same people who pay their own teens' tobacco possesion fines for them.

-Wes

With Cigarettes: Men Suck

My job is secure.

I was awestruck by a Center for Disease Control (CDC) report yesterday that demonstrated that, on average, one of five people over the age of 18 still smoke.

More importantly, the prevalence (at least in Illinois) is even higher for younger adults ages 18-35: one in four. And we're not talking about just casual smokers who later quit. No, we're talking about people who have already smoked over 100 cigarettes in their lifetime and say they currently smoke every day or some days. If true, these data are remarkably concerning and mean that we've got a lot to learn about how to implement public health policy on a grass roots level. It also speaks to how little the recent $200 billion tobacco settlement did for protecting our youth.

But then came the next remarkable statistic from this data that missed the headlines: men sucked more (on cigarettes, that is).

Without exception, the prevelence of men smoking exceeded that of women in every state. Why was this? Does testosterone combined with nictotine have a differential addictive effect? Or are we just more gullible to the influence of advertisers? Or is it because men don't seek health care as often as women and hence aren't reminded as often about the adverse effects of smoking? Who knows, maybe this is the reason guys have a consistently shorter longevity than gals.

Or is it because men are less educated than women? Fewer and fewer men are entering college now, relative to women. The educational system in America, with its unchecked growth in costs (especially in colleges) stays clear of this issue because it's not politically correct. And college admissions officers have admitted that acceptance standards are lower for men than women. But even from pre-college days, an increasing population of male children are failing to excel in grade school and high school relative to women. It's as though the old ways of teaching with bland coarse curriculae and drum-beat learning exercises has failed in comparison to the draws of action-packed video games (like the record-breaking Halo 3) that suck time from the active pursuit of learning and fail to engage our young men and boys. Many a child (mine included) have fettered away ridiculous amounts of time on these games to find themselves coming up short on tomorrow's exam.

This is not to blame the video game industry for the demise of male education in America. The problem is much more deep-seated than that. Attracting male educators to serve as role models to our education system is rarely discussed, but the need is keen, especially in early childhood education. Reworking our curriculae to stay in touch with the ever-rapid expansion of information and information delivery while "un-plugging" our families from the incessant influx of media influences might help too.

Certainly, I am not a specialist in education, but an educator and a guy who thinks about health. And there is a clear connection between the quality (and quantity) of education and the influence of public health initiatives - like smoking cessation - and we we'll never fix one problem without fixing them both.

-Wes

Pseudosmoking

Just when you think you've seen it all, comes "digital smoking."

What new schemes to take your money will they think of next?

-Wes

Still Smoking? Look at This

From England, this picture is one of many to appear on cigarette packs to make people think twice about smoking:

However, this particular package slogan might be considered misleading given the proximity of the turmor to this man's airway and carotid arteries: his death might not be so slow after all...

-Wes

21:00 - And if this is not enough, comes this report today suggesting that gene expression changes brought on by heavy smoking may persist long after the smoker has kicked the habit.

Cigarette Wrapper Can Create a Heart

Here's instructions on making a plastic heart from a cigarette package wrapper. Funny, the instructions state:

"When melting the plastic, try not to breathe the evaporation, it can be a bit toxic."

Never mind the toxicity of the cigarettes, I guess.

But hey, at least the plastic heart might replace the heart you destroy, eh?

-Wes

An Unforeen Consequence of Smoking Bans

With the decline in cigarette consumption in Illinois with our new state-wide smoking ban, it seems our senators will have to increase the increase in cigarette taxes to make up for budget shortfalls.

Might this happen with the new Congressional initiative to fund the State Children's Health Insurance Program (SCHIP) program?

-Wes

Cigar Smokers Are Fumed

Tax Mike Ditka's cigars to support health care for more needy children? Sounds nice like a plan.

But what happens when the government wants to provide more health care to uninsured or underinsured adults, too? Who or what will be taxed then?

Meanwhile, the third-party medical juggernaut continues with UnitedHealth's net profits soaring.

-Wes

Taking the Fall With Reduced Risk Cigarettes

Try this experiment some time. It was shown to me in medical school.

Take a brand new box of pristine sticks of chalk - you know - the kind your teachers always used on a blackboard in school. Open the top and be sure all of the pieces of chalk are in one piece but do not remove them from the box. Close the top of the box again.

Now, hold the box of chalk really high over a solid concrete surface (a tile floor usually works well, too).

Now, drop the box and observe it hitting the floor.

Open the box and examine the contents. No doubt you will find many, many shattered sticks of chalk. But almost as certainly, there will be one or two sticks that are still pristine, whole pieces of chalk that survived the fall.

Now why would this have been shown to our medical school class?

Because the speaker was explaining how to counteract this excuse posed to doctors when they attempt to ask a patient to stop moking: "But my mother smoked all her life and she never got cancer!" Statistically, you see, some survive even after they were subjected to the risks of smoking. Just like some pieces of chalk survive when their box is dropped to the floor.

So when I read that Phillip Morris wants to produce a "reduced risk" cigarette or new tobacco products with a "reduced risk" of cancer, I can't help but think that their efforts will be just like dropping a box of chalk from a little lower altitude, hoping that a few more sticks of chalk will survive.

Wouldn't it be better not to drop the box at all?

-Wes

Waist of a $246 Billion Tobacco Settlement

Overlawered has the story.

Sick. Just sick.

-Wes

Is Your Child Coughing?

... you might want to check the bus:

For weeks, Tony Anders' daughter complained to her dad about the cigarette smoke on her school bus. When the 4th grader started coughing up phlegm earlier this year, Anders decided to check out the bus for himself.

When the bus pulled up, Anders followed his daughter aboard -- and into a smoky haze. Incredulous, he asked the driver if he had been smoking. "He kind of waited a minute," Anders recalled. "We're sitting in a fog of smoke so he couldn't lie about it. He was just like, 'Yeah.'"

I won't spoil the story, but fortunately, it ends happily for all.

-Wes