New drug bans

Different Marlboro Menthol cigarette boxes.
Different Marlboro Menthol cigarette boxes. (Photo credit: Wikipedia)

The European Union is banning menthol cigarettes.

Are legalization advocates troubled by this? I’m asking sincerely.

Same thing with K2 and Spice. They were banned in Michigan earlier this year, without protest.

At what point does the conversation turn to the issue of eliminating restrictions on access to prescription drugs? If recreational use of pot or heroin (I recognize that a lot of pot legalization advocates do not advocate legalizing all drugs.) are legalized and regulated, why not fentanyl and vicodin? What principles or values should guide these decisions?

What should we think about e-cigarettes?

k300_flavors_fruitsMotherlode notes a trend in e-cigarettes and is concerned:

I was standing outside our neighborhood ice cream shop one recent evening when I noticed a plume of smoke rise above a gaggle of teenagers waiting in line ahead of me.

“Wow,” I thought, “that takes some serious chutzpah.” These kids were smoking in public without the fear of getting caught.

A few minutes later, I realized that it wasn’t actually smoke coming out of their mouths; it was vapor, being inhaled and exhaled from battery-operated electronic cigarettes.

E-cigs are devices that vaporize an addictive nicotine-laced liquid solution into an aerosol mist that simulates the act of tobacco smoking. Also known as “personal vaporizers” and “electronic nicotine delivery systems,” e-cigs are sold in trendy shops and are increasingly turning up in bars, clubs, workplaces and other spots where traditional tobacco cigarettes have long been outlawed.

As a mother, I find this terribly distressing.

I’ve spent years telling my children that smoking can kill you. And thanks to decades of sensible public health policies — including laws banning cigarette advertising and smoking in public places — as well as brutally graphic antismoking marketing campaigns, my 15- and 21-year-old kids have grown up in a culture in which puffing on cigarettes is stigmatized. Last year, cigarette smoking among teens fell to a record low.

Now, it seems, all that progress is about to vaporize. “Smoking,” at least in the form of vaping, is becoming cool again. This week, the Centers for Disease Control reported that 1.8 million middle- and high-school students said they had tried e-cigarettes in 2012 — double the number from the previous year.

Kleiman urges restraint in regulating e-cigarettes:

The FDA’s desire to have enough authority to require e-cigarette sellers to manufacture them properly and label them accurately, to limit marketing aimed at minors, and to be able to force the removal of unsafe product from the market, seems quite reasonable. What’s not reasonable, and what is likely to be bad, on balance, for health, is the idea that anything that delivers nicotine vapor should have the same rules applied to it as an actual cigarette.

At the same time, he acknowledges the unknowable:

None of this is simple or straightforward. I can imagine myself, five years from now, bitterly regretting not having spotted the e-cigarette menace before it got out of control. But regulations can do harm as well as good, and what I’m not hearing right now is much willingness to think carefully and proceed with caution. The principle of aggregate harm minimization, net of benefits (and nicotine does have benefits, including at least a temporary cognitive boost) still seems to me the right approach, for nicotine no less than for cannabis or cocaine. Unless and until someone can point to demonstrated and serious risks, rather than speculative ones, e-cigarettes ought to be thought of mostly as a part of the solution rather than as a part of the problem.

What does Kleiman mean by part of the solution? A recent study found that e-cigarettes outperformed traditional nicotine replacement for smokers trying to quit:

the New Zealand government funded a head-to-head comparison study. Chris Bullen and his colleagues at the National Institute for Health Innovation in Auckland gave e-cigarettes to 289 smokers who were trying to quit. A separate group of 295 people were given nicotine patches, while 73 received dummy nicotine-free e-cigarettes.

Six months later, the team asked participants if their attempts to quit had been a success. Those who had used the nicotine e-cigarettes had the highest success rate: 7.3 per cent had managed to stay away from tobacco. Of the nicotine patch users, 5.8 per cent had quit. And of those taking the placebo around 4 per cent were successful.

“The quitting rates were about 25 per cent better than patches for the e-cigarettes, but statistically we’re more confident with saying that they were comparable, rather than superior,” says Bullen.

Vaportrim-Fruit-Flavored-PuffsWhile we’re trying to understand e-cigarettes, manufacturers are embedding themselves in our culture. In the U.S., it’s been using b-list celebrities, appealing to current smokers’ sense of oppression and marketing them as a diet aid. In the U.K., they are using sport:

Merthyr Town Football Club is to rename its ground the Cigg-e Stadium after its sponsor, an electronic cigarette firm.

The Southern League club has signed a three-year deal with the company which has just opened a shop in the town.

 

 

The benefits of harm reduction are not as obvious as they seem

Warning: This Area Contains Tobacco Smoke
Warning: This Area Contains Tobacco Smoke (Photo credit: tbone_sandwich)

Theodore Dalrymple points out the inconsistency in the British Medical Journal’s vigorous advocacy for harm reduction where heroin is concerned and its squeamishness with harm reduction for nicotine. He pulls a passage from BMJ and inserts comments:

What, then, does the BMJ, so much in favour of harm reduction for heroin addicts, say about harm reduction for smokers?

A broad perspective suggests potential problems [from a public health perspective].

Firstly, the new nicotine containing products are not intuitively appealing; smokers will need to be persuaded of their benefits. For public health there is a key benefit: it is easier to use them than to   quit. Here I interject that the same is true of the methadone or other substitute for heroin. But for most smokers quitting is the best option and should be presented as achievable and attractive.

   So rolling out harm reduction puts public health in the contradictory position of having to emphasise both the difficulties and attractions of quitting. Why should harm reduction for heroin addiction be any different, one might ask? A related danger is that children will pick up on this apparent confusion. While previous generations were told simply that tobacco is bad, new ones would learn that nicotine is acceptable – just be careful how you access it. This is precisely the burden of public health “education” with regard to heroin and other drug addiction. Moreover, promotion of harm reduction might reduce the perceived “cost” of uptake. Would not the same effect apply to the medical treatment of drug addiction, to say nothing of the provision of free needles? Finally, the fact that e-cigarettes deliberately mimic conventional ones (even to emitting fake smoke) may result in the inadvertent modelling of smoking. Would not the prescription of injectable methadone not do the same? More broadly, the media, which in the UK have become a reliable supporter of comprehensive control measures, might also struggle with this more complex position. How much media effort, one is inclined to ask, ‘reliably’ goes into supporting ‘comprehensive control measures’ with regard to illicit drugs? Thus the benefits of harm reduction are not as obvious as they seem.

The article goes on to criticise harm reduction in tobacco because of the obvious, if not entirely consistent, commercial interests that the tobacco and pharmaceutical industries have in it.

Dead space is the part of the syringe where fluid is retained once the plunger is fully depressed. High-dead-space syringes retain fluid both in the syringe itself and in the needle; low-dead-space syringes expel all the fluid in the syringe, retaining only a small amount of fluid. (In low-dead-space syringes, the needle is not detachable.)

In experiments that mimicked drug injections, the high-dead-space syringes retained 1,000 times as many microliters of blood, even after rinsing. For people carrying HIV with viral loads between one million copies and 2,000 copies per milliliter, the capacious syringes could carry multiple copies of HIV, “whereas,” William A. Zule and his coauthors write, “low-dead-space syringes would retain even a single copy only a fraction of the time.”

What’s interesting here, is that needle exchange advocates have been so busy arguing that they are the obvious answer to injection disease transmission on pragmatic and moral grounds, while insisting that there are no social costs (ignoring the fact that needle sharing persists among exchange users, discarded syringes are a problem, they often ignore treatment access problems and that they make convey despair to addicts and communities), that they seem to have never stopped to ask if we could make syringes safer.

These low-dead-space syringes in universal use might be much more effective than needle exchanges and prevent transmissions through accidental pokes. If so, will they follow the evidence?

Quitting Smoking and Anxiety

A 21 mg dose Nicoderm CQ patch applied to the ...
(Photo credit: Wikipedia)

 

A recent study finds that quitting smoking reduces anxiety:

 

The study followed 491 smokers attending NHS smoking cessation clinics in England. All participants were given a nicotine patch and attended eight weekly appointments.

Of the sample, 21.6% (106 people) had a diagnosed mental health problem, primarily mood and anxiety disorders.

All participants were assessed for their anxiety levels at the start of the research, and were also asked whether their motives for smoking were ‘mainly for pleasure’, ‘mainly to cope’ or ‘about equal’.

Six months after the start of the trial, 68 of the smokers (14%) had managed to quit smoking – 10 of these had a current psychiatric disorder. The researchers found a significant difference in anxiety between those who had successfully quit and those who had relapsed.

All of those who had quit smoking showed a decrease in anxiety. People who had previously smoked to cope showed a more significant decrease in anxiety compared to those who had previously smoked for pleasure.

 

However, some people who tried to quit and failed became more anxious:

 

Among the smokers who relapsed, those smoking for enjoyment showed no change in anxiety, but those who smoked to cope and those with a diagnosed mental health problem showed an increase in anxiety

 

I wonder if another study looking at the natural history of attempts to quit smoking may offer a little insight into that increase in anxiety:

 

Within the month of the study, 32% of smokers had multiple episodes of intentions to not smoke, and 64% transitioned among smoking as usual, abstinence, and reduction status on multiple occasions. When participants reported that they intended not to smoke the next day, 56% of the time they did not make a quit attempt the next day. Just under half (44%) of quit attempts occurred on days with no intentions to quit the night before. Most quit attempts (69%) lasted less than a day. Reduction in cigs/day was as common as abstinence.

 

It’s striking how fluid motivation and attempts to quit are. Relapses don’t mean I’m a smoker. Quitting is a process. Many smokers probably constantly evaluate their status in that process.

 

 

The social cost of smoking

 

English: This photo illustrates smoke in a pub...
English: This photo illustrates smoke in a pub, a common complaint for those concerned with passive smoking. (Photo credit: Wikipedia)

Apparently, Singapore was an early adopter of designated smoking areas and non-smoking areas. However, this wasn’t driven by health concerns. Rather, it was driven by aesthetic concerns–primarily smell.

In a fascinating paper published recently in Urban Studies, Qian Hui Tan observes that smokers are “purveyors of sensory pollution” – creating a scent that, like all odors, can invade and take over. When that space is public, the impact can be immense, segregating and stratifying public spaces.

Tan visited some of these places and interviewed both smokers and non-smokers about how they think about the segregation of smokers to certain areas and the impact of smoking scents on people nearby.

Based on these conversations, Tan has compiled a collection of anecdotal evidence about smokers’ experiences being made to feel unclean or burdensome on those around them, and some of the efforts they take to reduce the olfactory impact their smoking on people they come into contact with. From smoking downwind to keeping more space from people after smoking, the smokers questioned said they had become sensitive to the way they are perceived after coming back from a smoke break.

And because of the invasive unavoidability of smell, the presence of cigarette smoke or its odor results in an inevitable “sensory appraisal” by others, according to Tan.

It doesn’t take a huge leap to imagine that this might be a non-significant factor in the relationship between smoking and relapse.

 

The political left and prohibition

"Legalization Now" Banner At The May...
“Legalization Now” Banner At The May Day Immigration Rights Rally (Washington, DC) (Photo credit: takomabibelot)

Andrew Sullivan picks up on Jack Meserve’s discussion of the political left and prohibition:

Meserve:

Think of a few of the currently illegal vices: recreational drug use, gambling, prostitution. With some exceptions, the left has been in favor of legalization or decriminalization of these activities. Now think of legal vices: gluttony, cigarette smoking, alcohol use. On these habits, we’ve supported bans, onerous restrictions on place and time of consumption, and increasingly aggressive fines and taxes. There seems very little consistency between these positions, and few have even attempted justifying the differences. Progressives have been guilty of letting our temperament rather than our reason guide the policies; bans on activities like drug use are seen as naive or old-fashioned, but legal vices like cigarette smoking are public-health or collective-action problems to be solved through brute government action.

Then, Sullivan offers some reader reactions to Meserve. Here are just a couple:

…legalization isn’t being pursued as a public health issue.  It’s being pursued to make sure people don’t face fines, criminal charges, arrest, or jail time for using a substance that is less harmful and addictive than other legal substances.  Any public health aspects come into play when you discuss how pot would be regulated ONCE it is legal.  But Meserve doesn’t discuss or raise any public comments about what happens post legalization in the piece.

another:

Why is the pot legalization initiative on the ballot in Washington when legalization has failed to qualify so many times before, despite our alleged libertinism?  Well, this one contains a 25% excise tax dedicated to substance abuse prevention and healthcare in general, a state-run store regime was added, age limits put in, and specific concentrations of THC in the bloodstream for DUI were defined.  These things were absent in prior initiatives, meaning that had they qualified and passed, anyone could have set up shop across from a kindergarten to sell. It’s almost instead of us being a bunch of stoned hippies just out for a good time, we wanted to make sure that this vice was legalized in the most thoughtful, responsible way possible, while also making provisions for ameliorating possible social harms caused by legalization.  That’s left-wing social engineering at its best.

No. 1 Littered Item in the United States is on Roads and Beaches?

…cigarette butts are the No. 1 littered item every year on U.S. roadways and beaches.

Cigarette butt. ‪Norsk (bokmål)‬: Sigarettsneip.

It had to be about 19 years ago that I flicked a cigarette butt to the ground and stepped on it outside of a meeting. My sponsor ran over and picked up and threw it out saying, “What’s wrong with you. Don’t you know that’s littering?”

I didn’t.

I had some weird blindness to the fact that every time I tossed a butt out the car window or onto the ground, I was littering. Littering was outside of my values and I was so obviously littering and was completely blind to it. Not even a twinge of shame.

I knew he was right and I was embarrassed. I never did it again after that day.