Tuesday, March 2, 2010

Why Barack Obama should come clean about his smoking and what he can do to quit

As a physician I believe that your personal health should be private. I can certainly understand why the American people would want the right to know about a potential presidential candidate's health prior to an election. However, afterwards, the health of a President, unless life threatening should probably remain private. That said, the President recently had a complete physical and the results of that physical are now public. In addition to knowing the President's blood pressure and cholesterol numbers, we now also know according to a New York Time's report (President in ‘Excellent Health,’ Routine Checkup Finds) that President Barack Obama continues to smoke. Though I still believe that health should be a private matter for patients, even if that patient happens to be the President, since our President has chosen to reveal his health information, I think that he should officially come clean about how much he smokes. According to the New York Times report, all we know is that he doesn't smoke on a daily basis, but rather smokes infrequently. In June, the President was quoted as saying, “Have I fallen off the wagon sometimes? Yes. Am I a daily smoker, a constant smoker? No.”

Tobacco smoke in the US is an important matter. It is currently the single leading cause of preventable death and accounts for billions of dollars in health care costs. Given our current health care crisis, including the escalating costs of health care, I think it would be important for the President to discuss the burden of tobacco in this country as well as his own struggle in quitting cigarette smoking.

Now as far as what the President can do, a lot depends on how much he smokes. My guess is that he probably smokes a few cigarettes a few days a week during stressful times. If this is the case, then withdrawal is likely a minimal concern, and his nicotine consumption is probably just reinforcing this very bad habit. If that is the case, stress management techniques are probably the best way to quit. I advise patients who smoke only a few cigarettes a day to think about what else they can do to manage their stress besides smoking. For example, taking a walk, reading a book, meditation, prayer, etc. Something that is relaxing and reduces stress. Certainly our President is under a lot of stress and one can understand why he would need some sort of stress relieving activity. Smoking cigarettes is obviously not the best way to reduce stress.

If the President does smoke more than just a few cigarettes a day, the current guidelines recommend that most patients benefit from pharmacotherapy (medication). Nicotine replacement in the form of lozenges, gum or the patch have been effective in doubling quit rates. Even more effective than nicotine replacement are pills, specifically buproprion or Chantix (Varenicline). Recently there's been some concern about safety issues regarding Chantix, ( see More FDA warnings should not be cause for worry. and Where's the Good News about Chantix? ) initially brought up by the FDA. However, these safety concerns have not seemed to have panned out, and more recent studies seem to indicate that Chantix is very safe given certain precautions, specifically worsening of mental conditions. Patients using any form of a medication should be aware that quitting cigarettes (with or without medication) can worsen underlying mental health conditions, such as depression or anxiety.

In addition, I have blogged previously about Electronic Cigarettes , which I have received a number of comments (also see More on Electronic Cigarettes or E-cigs ). I think those who responded are mostly e-cigarette users that have misunderstood my objections to e-cigarettes. My objection is not that I am opposed to the existence of electronic cigarette. It's more that e-cigarettes are not regulated, so 1) their safety cannot be completely ascertained and 2) they are being promoted as a smoking cessation treatment, which they have not proven to do. E-cigarettes are likely a healthier alternative to tobacco smoke, but should be regulated by the FDA since they do contain nicotine. I'm also bothered that electronic cigarettes are sold in our shopping malls, and can potentially be purchased by children. Electronic cigarettes are probably less carcinogenic, than tobacco cigarettes. However, nicotine itself has unhealthy effects, and the goal of smoking cessation should be getting off nicotine completely. All of the treatments for smoking cessation such as the patch and the gum and even the pills are only supposed to be used for short periods of time, usually three months to no more than 6 months. Electronic cigarettes might be safer replacement for tobacco cigarettes, but are not designed to get patients off of nicotine. Generally, most of the nicotine replacement products work by giving patients a continuous supply of nicotine, and eventually weaning that level down once the patient has been off tobacco cigarettes for a few weeks. For example, with the nicotine gum or lozenge, you don't take a piece of gum every time you crave a cigarette. Rather, you use the gum continuously throughout the day, starting with about 15 pieces per day eventually decreasing the number. Theoretically, the electronic cigarette could be used in that manner, but by just replacing a tobacco cigarette, you are not addressing the behavioral issues related to smoking cessation. So, while I believe that electronic cigarettes may be safe, I also believe they should be regulated by the FDA and should not (until proven) be used or promoted as smoking cessation agents.

The President could also call 1-800 QUIT NOW. This is a 24/7 support line designed to help patients quit tobacco products. It is free and fully funded by money from this tobacco settlements. This program can be used use in conjunction with treatment from your health care provider as well as with medication, nicotine replacement and other smoking cessation techniques.

Bottom Line: While I do believe the President's health is a personal matter, since he has come out admitting that he is still smoking cigarettes despite his promises to our First Lady, I believe that he should admit to exactly how much he still smokes as well as further discuss his own personal struggles with his addiction. This will hopeful bring additional attention to the problem of cigarette smoking, which remains the single leading cause of preventable death in our country.


james said...

I think what vapers are concerned about in regard to regulation is that regulating the electronic cigarette in the way FDA wants to will mean, at the very least, pulling them off the shelves for several years. There is little doubt that for some of the tens of thousands of people who have switched to electronic cigarettes this will mean death.

James said...

You can see my full response here: http://www.ecigarettedirect.co.uk/ashtray-blog/2010/03/a-reply-to-dr-mintz-on-the-electronic-cigarette.html

James said...

I've now posted our response to your response, as had David Atherton of Freedom to Choose:


Vocal EK said...

I don't believe that you understand the thinking of the FDA. They don't want to regulate electronic cigarettes. The FDA wants to permanently remove electronic cigarettes from the market because they are the only product on the market today that provides adequate replacement of nicotine. FDA doesn't believe in replament. FDA, like you, believes in nicotine weaning, leading to permanent abolishment.

Face the facts: There are over 46 million continuing smokers in the U.S. The majority of these smokers have already tried several of the so-called effective products approved for smoking cessation. Each time, when they achieved nicotine abstinence, they became too ill to carry out their daily responsibilities.

For me, and for millions like me, these effects are not temporary. We have depression, attention deficit disorder, schizophrenia, mild cognitive impairment, anxiety, fibromyalgia and other neurobiological disorders. One thing these disorders have in common is that some of the symptoms respond beautifully to nicotine. Another thing these disorders have in common is that all of the FDA-approved treatments for them have severe side effects.

I know you don't want to believe that for some people nicotine is a safer and healthier choice. But the research is out there. Here is just one reference, but there are many, many more. Xue, Y. & Domino, E.F., Tobacco/nicotine and endogenous brain opioids. Progress in Neuro-Psychopharmacology and Biological Psychiatry, Volume 32, Issue 5, 1 July 2008, Pages 1131-1138. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2582831/
"Smoking is a major public health problem with devastating health consequences. Although many cigarette smokers are able to quit, equal numbers of others cannot! Standard medications to assist in smoking cessation, such as nicotine replacement therapies and bupropion, are ineffective in many remaining smokers."

My 88-year old mother has "Lewy Body Disease". Look it up. It's related to Parkinson's disease. It manifests as dementia, with muscle stiffening and impaired gait. It is caused by a buildup of Lewy Bodies in the brain. It may be inherited. There is absolutely no way I would ever be willing to give up using nicotine. Nicotine is the only known subtance that prevents the build-up of Lewy Bodies.

What frightens me to no end is that the FDA has packed its Tobacco Control Panel with nicotine-abolitionists. Not a one of the members believes in tobacco harm reduction. I fear that they will systematically remove from the market all tobacco products that are safer than smoking, and then lower the nicotine levels of cigarettes to near zero. They will leave millions of us high and dry, in pain, depressed, anxious, and confused, with no way out.

Carl Phillips stated, "Thus, discouraging a smoker, even one who would have quit entirely, from switching to a low-risk alternative is almost certainly more likely to kill him than it is to save him. Similarly, a strategy of waiting for better anti-smoking tools to be developed, rather than encouraging immediate tobacco harm reduction using current options, kills more smokers every month than it could possibly ever save." http://www.ncbi.nlm.nih.gov/pubmed/19887003