August 28th, 2009 by Jonathan Foulds, Ph.D. in Better Health Network, Health Policy, Opinion
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I’ve been bemused by the debate on healthcare reform taking place in the U.S. right now. I used to thing that the single topic that people talk the most nonsense about is sport. You know, my sport is better than your sport, my team is better than your team etc. All good fun, but usually nonsense. And then I’ve watched pundits on TV and heard ordinary Americans talk about healthcare reform and wow….its got the sports conversations beaten for absolute gibberish.
So despite a reluctance to get involved because I recognize it’s an extremely complicated issue, I now feel compelled to say a few words. Part of it is because unlike most of the people expressing an opinion, I’ve worked and been a patient in the healthcare system in a country with “socialized medicine” (UK) and I also currently work and am sometimes a patient in the United States healthcare system.
So lets start off with a few basics. The United States has some of the most highly trained healthcare staff and by far and away the best healthcare technology in the world. Just to give an example, there are more scanners (MRI, PET, SPECT etc) within a 15 mile radius of my office in central New Jersey than in the whole of Scotland (population about 5 million). And the United States spends far more on healthcare than any other country in the world. But despite that vast wealth of resources that befits the worlds greatest economic power, the United States falls way down the league table on basic objective measures of health outcomes, and similarly down the league on patient satisfaction with healthcare. There are really very few people, (who have looked further than the end of their own nose into this issue) who don’t acknowledge there’s a very serious problem.
For many in the United States, the problem is not so apparent. So if, like me, you and your immediate family are fortunate enough to be relatively healthy, and to be covered by a relatively good employment-based health insurance package, then it may seem OK. It’s when you get very sick, or are unfortunate enough to lose your job, that some of the basic problems with the U.S. system become more apparent. It’s when you get sick that you may find that your policy doesn’t cover the kind of treatment you need, or has a high deductible (amount you have to pay before the insurance takes over). And its when you lose your job and have to start paying out of pocket for health insurance that you realize it is extremely expensive. And of course if you have a gap in coverage and get sick then the new insurer may refuse to cover your “pre-existing condition”.
To me, the single time in your life when you don’t want added financial stress is when you are sick. But many aspects of the U.S. system direct coverage and services to those who need it least (healthy, young ,well insured employees) and become a nightmare for those who need good healthcare most (aging, sick unemployed people). Now when you talk to people in countries like Britain about this, they are generally appalled and quickly see the problem. But one of the things that has surprised me most about the debate in the United States is that a significant proportion of people here seem to really believe that the old “survival of the fittest” philosophy is appropriate here. The attitude seems to be something like: “If someone gets sick and didn’t have the fore-thought to get adequate health insurance to cover the treatment, then that was their own fault. Why should I work my ass off to look after my family and their healthcare needs for some lazy unemployed person to get healthcare for free?”
So somewhere deep in the psyche of many Americans there is a basic belief that healthcare (insurance) is just like auto insurance….something we are all individually responsible for, and if we cant afford it, that’s tough. Many do not believe that healthcare access for all is a basic requirement of a civilized society (like roads and schools).
So President Obama and others who are currently trying to change the U.S. healthcare system have a tough task ahead. It is currently being made much tougher by some bizarre reporting on this topic by the right wing media (Fox etc). We hear weird stories about “death panels” of government bureaucrats who will decide which sick people should have the plug pulled on their healthcare under government healthcare. We hear weird stories that in countries with socialized medicine it’s the government, not the doctor who decides on what treatment is provided. Well I can tell you that I never saw “Big Brother” interfering in doctors’ clinical practice until I came to the United States. In this country it is bureaucrats working for health insurance companies, generally with no medical qualifications, who deny coverage for appropriate medical treatment hundreds of thousands of times a day.
Often coverage is not denied on clinical grounds, but rather for a whole series of “technical” reasons (wrong diagnostic code, doctor not part of that health insurance plan, pre-existing condition, patient already used annual entitlement for that type of care, patient had that treatment already for longer than policy will pay, treatment carried out at a non-approved facility [go to one 30 miles away], patient hasn’t completed the 6-monthly confirmation of details form, health insurance company doesn’t cover that type of illness/service etc etc). But the underlying strategy is to make it so difficult to get a treatment covered and paid for, that fewer people will go for treatment, and fewer doctors will provide certain procedures because it is so much hassle for them to get paid for it. So the insurance companies hire more people to try to find ways to deny coverage and payments, and doctors have to employ billing specialists to figure out how they can get paid for providing treatment. And the result is an extremely inefficient beaurocratic mess.
Surely a country like the United States can do much better than this?
Now you might be wondering what any of this has to do with smoking? Well one link is that many health insurance policies in the United States do not cover a range of interventions they call “preventive” or “wellness enhancing” interventions. Frequently that means that patients cannot get tobacco dependence treatment (medicines or counseling) covered and so they don’t get the treatment. This is despite the fact that such treatment is one of the most cost-effective clinical interventions available. So an important part of the new proposals for healthcare reform is an increased emphasis on preventive healthcare. This is certainly a step in the right direction.
This post, A Scottish View Of US Healthcare Reform, was originally published on
Healthine.com by Jonathan Foulds, Ph.D..
July 29th, 2009 by Jonathan Foulds, Ph.D. in Better Health Network, Health Tips
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Last week marked the 10th anniversary of a smoking cessation website called “whyquit.com”. Now those of you who know me, and know that website and its director, Mr John Polito, may wonder why I’m choosing to give it some free publicity. The website is strongly against the use of all pharmacological aids for smoking cessation, and some would argue that it does harm by misinforming smokers about the harms and benefits of these smoking cessation aids. However, although I certainly do agree that the site does misinform about pharmacological aids, it also has a number of positive qualities and presents a different perspective that may appeal to and help some smokers.
The site started 10 years ago primarily to tell the story of a few individuals who were killed very young by smoking caused diseases. The idea was to vividly tell their tragic stories and to inspire others to quit tobacco and so avoid the same. In 2000 Joel Spitzer, an experienced smoking cessation counselor and author joined whyquit and the site took on more of a role of advising smokers how to quit using a very clear philosophy based on the “cold turkey” method.
The site has a large amount of educational material, including free pdf copies of lengthy books by Polito and one by Spitzer. The descriptions of individual cases of tobacco-caused diseases are informative and will inspire some to avoid the same harrowing experience. The site also has a discussion forum called, “Freedom from nicotine.” But once again the fundamentalist opposition to the use of pharmacotherapy aids is evident in the rules for use of “Freedom from nicotine”. The site states that,
“A single-minded program, those applying for posting privileges must have quit all forms of nicotine delivery cold turkey within the past 30 days, without use of any products, pills or procedures, and remained 100% nicotine-free for at least 72 hours. A nicotine-free forum, any nicotine relapse – even one puff, dip or chew – permanently revokes posting privileges.”
This is a rather unusual requirement for people to use a quit smoking discussion site, and it seems rather odd to ban people “permanently” from using the discussion forum, because they had a puff or chewed a piece of nicotine gum.
The site contains a large number of factual inaccuracies, particularly when referring to research on the use of pharmacotherapy for smoking cessation and the evidence on it. There are too many examples to mention, but just to mention a few:
– the site states that nicotine withdrawal lasts 72 hours. Most studies of nicotine withdrawal symptoms find these to be significantly raised after the first week, and typically not returning to normal levels for 3 weeks.
– The site asserts that in “real life” studies nicotine replacement therapy doesn’t work and “cold turkey” always produces a higher quit rate. An example of a study refuting that claim is provided below (West and Zhou, 2007)
– The site asserts that placebo-controlled trials of pharmacological treatments are all severely flawed because participants can sometime guess better than chance (.e.g. because the medicines work so well at treating nicotine withdrawal that participants can tell what the got, so the study is not perfectly “double blind”). On this point the site is somewhat out on a limb as most scientific research bodies regard the randomized placebo-controlled trial as amongst the best ways to find out if a drug treatment works or not.
– The idea that the results are entirely due to participants’ awareness of whether or not they received the drug also doesn’t bare much scrutiny. For example, in dose-response studies or studies where there is also an “active” comparison, participants are less able to identify what treatment they received, but the higher dose typically does better than the lower dose, and both do better than placebo.
– The site is also highly critical of anyone who has been funded in any way by pharmaceutical companies, and implies that such a conflict of interest almost certainly causes those individuals (including myself) to lose all independent judgment. While I agree that researchers should declare their sources of funding and that readers should weigh that information when reading research reports, the idea that the whole field has been bought and sold to the pharmaceutical industry is blatantly false. It is not at all uncommon for researchers receiving pharma funds to publish studies with disappointing results for the pharma company, including reports of potentially serious side effects.
(e.g. Foulds, J., Stapleton, J., Hayward, M., Russell, M.A.H., Feyerabend, C., Fleming, T., and Costello, J. Transdermal nicotine patches with low- intensity support to aid smoking cessation in outpatients in a general hospital: a placebo-controlled trial. Arch Fam Med 1993; 2: 417-423.
Foulds, J. and Toone, B. A case of nicotine psychosis? Addiction 1995; 90: 435-437).
The reality is that for years academic researchers have been encouraged by our employers to build bridges with private industry in order to make scientific advances, and do so with their eyes open. Most acknowledge our funding as openly as possible without becoming very tedious (e.g. my funding sources are mentioned on my home page on healthline and also on my program website, rather than on every single blog post). Most of us draw the line at funding from the tobacco companies because they have such a clear and consistent history of distorting science and using primarily for PR purposes, and largely because their ultimate purpose is to sell a product that is extremely harmful to health, rather than products designed to improve health.
However, the point here is not to quibble with every single point or inaccuracy on the site. Rather readers should be aware that in among the inspirational stories and plenty of good advice on this site, there is an almost fundamentalist agenda that its just wrong to use medicines to help you quit smoking. If you agree with that, or are prepared to take it with a pinch of salt, then you may find other aspects of this “single minded program” to be helpful.
Here’s an example of a recent “real world” study finding that smokers using NRT have a higher quit rate
This post, Whyquit.com: Factually Inaccurate, But Doing Some Good Nonetheless, was originally published on
Healthine.com by Jonathan Foulds, Ph.D..
July 10th, 2009 by Jonathan Foulds, Ph.D. in Uncategorized
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As many of you may know, the famous tobacco control scientist and advocate, Professor Stan Glantz, has over the past few years been focusing on the issue of depictions of smoking in movies. Part of the concern stems from good evidence that young people are highly influenced by movies due to their cultural value and glamorous nature.
The other part stems from a history of use of “product placement” in movies. This refers to the movie producers agreeing to include a specific product in their movie in return for some incentive (typically money). A famous example of this is a letter from Sylvester Stallone agreeing to smoke particular brands of cigarettes in his movies for $500,000. So when one combines the financial power of the tobacco industry with product placement we end up with a hell of a lot more gratuitous smoking in movies than is necessary.
Of course the movie companies and many movie enthusiasts argue about the need for art to imitate life etc., etc. However numerous examples demonstrate that to be a lot of nonsense. Professor Glantz points to depictions of Marlboro cigarettes being dragged around or used by aliens in movies like Men In Black. Is it really true that those aliens prefer Marlboros and so showing the brand was necessary for the movie to be accurate? Mmm….I doubt it.
My favorite example comes from the film “A Beautiful Mind”. The movie stars Russell Crowe in the lead role portraying the (still living and working) Princeton University professor, John Nash. In real life, John Nash suffered from schizophrenia but did not smoke. In the movie he suffered from schizophrenia, but smoked. I’m not sure why the producers changed this aspect of reality or what it added to the movie.
But these are details. Professor Glantz’ main point is that movies made to be viewed by kids do not need to include smoking, and therefore should be given an R rating if they do, just as they are if they depict illicit drug use. Note that an R doesn’t stop people under 17 from seeing the movie in a movie theater. It just means they need to be accompanied by an adult. It also doesn’t ban smoking from movies, it just means that movies with smoking in them will receive an R rating, just as sex, drugs, cursing and certain types of violence will get a movie an R rating. Of course the movie industry is very clear that a large part of its audience is kids and particularly teens. The net effect of the rating changes professor Glantz is recommending would be that gratuitous smoking will be taken out of many movies and particularly those aimed at kids.
I must admit that I didn’t initially pay much attention to this proposal, and my natural inclination was to doubt whether it really was worth the effort. But while I was at the UK National Smoking Cessation Conference in London last week I heard Professor Glantz talk about this idea and I came around to thinking its maybe not as extreme as I first thought. In fact he convinced me that it’s a reasonably sensible idea that would likely result in thousands fewer teens taking up smoking. Sometime soon the full audio recording of Professor Glantz’ presentation will be posted on the conference website along with his slides. I’ll post the link when its available, but for now those interested in this subject may want to check out the following website:
http://smokefreemovies.ucsf.edu/
This post, Should Movies With Smoking In Them Receive An R-Rating?, was originally published on
Healthine.com by Jonathan Foulds, Ph.D..
June 22nd, 2009 by Jonathan Foulds, Ph.D. in Better Health Network, Health Policy
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On Friday 12th June, the US Senate voted in favor of a bill that gives the Food and Drug Administration the power to regulate tobacco products. President Obama (who as a Senator was a sponsor of the bill, as was John McCain) has indicated he will sign the bill into law.
Public health advocates have been fighting for FDA regulation of tobacco for over 15 years. However, not every public health advocate has supported this particular piece of legislation, and the fact that Philip Morris Tobacco Company supported it caused many to have doubts. But now that the bill is finally going to be law, what will it mean? As a guide to this, I’d recommend that you read the slides from a paper by Mitch Zeller at the recent Virginia Youth Tobacco Conference. Much of this post is adapted from his slides. These outline the key parts of the bill and what they mean in some detail and are worth a careful read, (Mitch Zeller is the former Associate Commissioner and Director of the Office of Tobacco Programs at the Food and Drug Administration). Download his slides here.
The bill does not require FDA to regulate tobacco exactly the same way it does pharmaceuticals (drugs and devices), partly because it would be impossible for any tobacco product to demonstrate that it is safe and effective for its purpose. So instead the legislation creates a new, parallel set of rules and procedures just for tobacco, but using much of the same regulatory framework that was created for drugs. The new standard around which the tobacco bill is based is THE PROTECTION OF PUBLIC HEALTH.
-Section 904 mandates that FDA will receive brand-specific information on ingredients, nicotine delivery, and any smoke constituent FDA identifies as harmful or potentially harmful
– Companies must also provide FDA with all documents developed after the bill is enacted related to health, toxicological, behavioral, or physiologic effects of current or future products.
– FDA also has the right to request any such industry document produced prior to the enactment of this law.
– FDA can issue performance standards to prohibit or limit the allowable levels of substances in a finished tobacco product. FDA is granted this power in section 907. Products that don’t comply with the levels established in product standards can’t be sold.
– Nicotine cannot be banned but it can be reduced to very low levels.
– FDA needs to have supporting science to back up any standards it requires, or any ingredients it wants banned.
Clearly the tobacco product standards are going to be a key part of regulation of tobacco. Here’s what the bill says on these: Read more »
This post, FDA Regulation Of Tobacco: What Does It Mean?, was originally published on
Healthine.com by Jonathan Foulds, Ph.D..
May 18th, 2009 by Jonathan Foulds, Ph.D. in Better Health Network
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I’ve previously written about what face-to-face smoking cessation services typically do, largely based on my own experience. However, while at the SRNT annual conference I met two Smoking Cessation Advisors working in Lancashire, England who appeared to have a successful service, so thought it worth sharing some of their information.
Jan Holding and Eileen Ward manage a UK National Health Service (NHS) Stop Smoking Service in Lancashire in the north of England. Both are nurses by training and many of the 14 staff providing the treatment have primarily a nursing background. Their service sees around 450 new clients per month (i.e. over 5000 new clients per year). Services are provided at “community sessions” at various locations all over their catchment area, and clients are given their own hand-held record which they keep, and take with them to sessions, enabling them to attend whichever community location suits them at the time. While clients can make scheduled appointments, the service is also flexible, allowing clients to “drop-in” to community sessions without an appointment. Although some initial assessment sessions take place in a group format, most of the sessions are delivered in a one-to-one format via a relatively brief discussion with a smoking cessation advisor. These community sessions often take place in a large community room from 4pm to 8 pm in the evening, with multiple types of services being provided in the same room at the same time at different corners (e.g. initial assessments in one corner, prescribing of varenicline in another, and nicotine replacement therapy in another). It is not uncommon for around 200 clients to attend a single community session.
Clients are frequently encouraged to use NRT prior to quitting smoking (about half do this) and usually use more than one smoking cessation medicine (more than half do). Nicotine replacement therapy is provided via a voucher system requiring either no cost to the client, or just a co-pay (around $10 USD).
The service runs 6 days per week and includes evening sessions, and aims to reduce most of the usual barriers to entering treatment. Their “3 As” approach emphasizes “Accessibility, Availability and Adaptability”. They also specifically try to develop smoking cessation advisors who are passionate about their role, have a positive attitude to the importance of quitting smoking, and are therefore very committed to that work, as well as being knowledgeable about it.
My understanding is that the quit rates at this service are pretty good. But perhaps the best testimony to its success is the fantastic volume of clients who attend…..largely influenced by positive word-of-mouth via other clients. The success of this service reminds us that there isn’t just one way to do it, that all smoking cessation counselors and systems may need to be flexible and adaptable in order to help as many smokers to quit as possible.
For further information on what a smokers’ clinic does, see: What does a tobacco treatment clinic do?
This post, Smoking Cessation Programs: Lessons From The UK, was originally published on
Healthine.com by Jonathan Foulds, Ph.D..
