DC Medical Malpractice & Patient Safety Blog

Sometimes, we read an article or book about health, medicine and/or patient safety that’s fascinating but too long to summarize fairly in a blog post. So here’s a shout-out to a few recent stories you might want to look up, on a common theme.

According to the Centers for Disease Control and Prevention (CDC), drug overdose death rates in the U.S. have more than tripled since 1990 and have never been higher. Most of these deaths, says the CDC were caused by prescription drugs. In the last several months, the Los Angeles Times has published a series of investigative articles about the epidemic of prescription deaths. The four-part series explains how legal drugs have deadly outcomes, how reckless doctors and rogue pharmacists contribute to the problem, how regulatory authorities allow problems to fester and what they can do to address it. Link here.

Also, see our blog, “Doctors Don’t Know Dangers of Narcotics, and FDA Leaves Drug Makers in the Driver’s Seat.”

“NPR’s Akathisia Blind Spot,” was posted on Paul John Scott’s website devoted to “groupthink in science medicine and fitness—popular culture and the madness of crowds.” In the eloquent essay, he indicts the media for continuing to ignore a major side effect of a class of anti-depressant drugs known as SSRIs—selective serotonin reuptake inhibitors--including Celaxa and Lexapro. “[T] he problems with SSRIs and suicide seems no closer to being articulated in the culture at large, let alone resolved, beyond a few ardent voices and the small print on some drug labels that, thanks to the silent skepticism of so many, no one really knows what to think of.” Link here.

“Bad Pharma: How Drug Companies Mislead Doctors and Harm Patients,” Dr. Ben Goldacre’s new book, addresses our culture’s willingness to believe that drug treatment is based on evidence, that doctors are familiar with the latest drug studies, that drug research is pure science unpolluted by conflicts of interest and that when it comes to drug safety, regulators have our back.

As readers of this blog know, that’s fiction. Goldacre shows how the manipulation of the prescription drug market has been protected from public scrutiny because it’s too complex to capture in a sound bite. Goldacre untangles the tale in the hope that all patients and medical professionals can understand the tricks and distortions inherent in Big Pharma. Link here.

Last year we wrote about a report issued by the Centers for Disease Control and Prevention, “Grand Rounds: Prescription Drug Overdoses — a U.S. Epidemic.” Powerful painkillers continue to be overprescribed, abused and mismanaged by doctors, as told in horrifying detail in an ongoing series by the Los Angeles Times.

The FDA, in acknowledgment of so much going wrong in the prescribing and use of opioids, will begin holding public hearings next month. Better late than never, considering that:

• Prescription drug abuse is the fastest growing drug problem in the U.S.


• In one recent year in the U.S. one death due to drug overdose occurred every 19 minutes.


• The recent increase in unintentional drug overdose deaths has been driven by the increased use of prescription narcotics.

The feds are seeking information from the public and scientific data about these narcotic drugs for the two-day hearing on Feb. 7-8 at the Bethesda Marriott in Maryland. Anyone wishing to appear at the hearing should visit the FDA link above—the deadline for oral presentations is Jan. 18, but other written and electronic communications will be accepted through April 8. If you have a story about the harms of narcotic painkillers, this is the time to tell it.

As reported on AboutLawsuits.com, FDA officials will consider the diagnosis and understanding of patient pain; methods professionals use to distinguish various types of pain; definitions for terms such as mild, moderate or severe in diagnosis. Specific drug concerns, such as product composition, abuse deterrence, dosage controls and prescribing practices are also key.

Many opioid drugs, including Vicodin, Oxycontin and Methadone, are abused not only by medical patients, but street users. AboutLawsuits says that officials hope to find balance in minimizing drug abuse while preserving access to such drugs by patients with a legitimate need.

Although it has many supporters (also known as nicotine addicts), the tobacco industry has few friends. That’s not only because it markets a lethal product, but because of its inability to cop to its health-corroding properties and its history of lying. According to the Centers for Disease Control and Prevention (CDC), tobacco use kills more than 400,000 people every year in the U.S.

Under the Master Settlement Agreement in 1998, as described by the California Department of Justice, seven tobacco companies agreed to change the way their products are marketed and pay the states an estimated $206 billion. They agreed to finance a $1.5 billion anti-smoking campaign, open previously secret industry documents and disband industry trade groups that state attorneys general said conspired to conceal damaging research from the public.

Fourteen years after the settlement, the annual study sponsored by the Campaign for Tobacco Free Kids reports that “states continue to spend only a minuscule portion of their tobacco revenues to fight tobacco use. The states have also failed to reverse deep cuts to tobacco prevention and cessation programs that have undermined the nation’s efforts to reduce tobacco use.” This is so even though in this budget year the states will collect a record $25.7 billion in revenue from the tobacco settlement and tobacco taxes.

The study concluded that states:

• will spend only 1.8 percent of the $25.7 billion ($459. 5 million) on programs to prevent kids from smoking and help smokers quit—that’s less than two cents of every dollar in tobacco revenue spent to fight its use.


• have failed to reverse deep cuts that reduced tobacco prevention funding by 36 percent from fiscal year 2008 to fiscal year 2012. The $459.5 million the states have allocated this year is the second lowest amount they have spent on tobacco prevention programs since 1999, when they first received settlement funds.


• are falling woefully short of recommended funding levels for tobacco prevention
  programs set by the CDC—only 12.4 percent of the $3.7 billion the CDC
  recommends for all the states combined.

As the New York Times reported earlier this month, the settlement gave states total freedom about how to spend the money. Many use the dough to fund programs unrelated to tobacco, and to plug budget holes. Public health observers decry the fact that there’s no guarantee any money is earmarked for tobacco prevention and cessation programs.

In the last four fiscal years, federal funds for smoking prevention amounted to about $522 million. As The Times notes, tobacco companies spend $8 billion a year promoting their product.

Public health officials strongly believe that anti-smoking programs work. California’s smoking rate was above the national average 20 years ago; today it’s the second-lowest in the country. Officials attribute that decline to, as The Times puts it, “modest but consistent spending on programs that help people quit and prevent children from starting.”

According to the report, Washington State saved $5 in tobacco-related hospitalization costs for every $1 it spent during the first 10 years of its program.

But thanks to budget cuts, some states have as much as abandoned their efforts to curb smoking. State financing for North Carolina’s program has been eliminated, Ohio has not allocated any funds for its once-successful program and for three successive years Washington State has cut its program by about 90 percent.

Another threat to what has been a promising national effort to reduce smoking and its ill effects came in a court ruling earlier this month. An appeals court in Washington, D.C., reaffirmed a decision that forcing tobacco companies to put graphic warnings on cigarette packages violates their free-speech rights (see our post from August).

You might recall the shock value of the labels at issue—they included images of sewn-up cadavers and diseased lungs and gums. The images were approved by the FDA in 2011 and were to appear in September.

According to the Winston-Salem Journal, the court denied the FDA’s request to reconsider affirming the earlier ruling to block the images with a two-sentence order. “[T]he government has failed to carry both its burden of demonstrating a compelling interest and its burden of demonstrating that the rule is narrowly tailored to achieve a constitutionally permissible form of compelled commercial speech.”

“The graphic images are neither factual nor accurate.”

The FDA has 90 days to appeal, and if it does, the case goes to the U.S. Supreme Court.

In what some people might call an only-in-America episode, an Ohio federal appeals court in March upheld use of the graphic labels. Tobacco manufacturers, of course, have petitioned the U.S. Supreme Court to review the Ohio decision. The feds have until Dec. 26 to file a response, and it could be February at the earliest before the justices decide whether to take the case.

'Tis the season, apparently, for adjudicating tobacco cases. In November, a federal judge ruled that tobacco companies must spend their own money on an advertising campaign telling people that they lied about the dangers of smoking cigarettes. As described in a story by Reuters, this might be the harshest sanction arising from the 1999 Justice Department case accusing tobacco companies of racketeering.

The campaign will appear in various media for as long as two years. If that seems extreme, consider that the court referred to “past deception” by cigarette makers dating to at least 1964.

The judge ordered the advertising campaign in 2006, and six years later the companies are still arguing about the wording. And the tobacco companies could always appeal this decision, too. So it will be a while before any public act of contrition occurs. But here, according to Reuters, are a couple of the potential apologies:

• "A federal court has ruled that the defendant tobacco companies deliberately deceived the American public by falsely selling and advertising low tar and light cigarettes as less harmful than regular cigarettes."


• "Smoking kills, on average, 1,200 Americans. Every day."

As a spokesman for Tobacco-Free Kids told Reuters, "Requiring the tobacco companies to finally tell the truth is a small price to pay for the devastating consequences of their wrongdoing."

If anyone still doubts that tobacco and tobacco smoke are harmful, consider a story recently published on ScienceDaily.com. “It is a known fact that active maternal smoking during pregnancy has negative effects on child health, such as attention deficit and hyperactivity disorder (ADHD),” it said, and “new research suggests that second-hand smoke, or environmental tobacco smoke (ETS), may be just as harmful.”

The study by researchers at the University of Pennsylvania School of Nursing examined data from 646 mother-child pairs in China, where more than 7 in 10 men smoke. One in 4 children whose mothers were exposed to smoke exhibited behavior problems compared to 16 in 100 children of unexposed mothers. The children whose mothers were exposed to passive smoke performed worse on speech, language skills and intelligence tests. They also showed more conduct disorders.

As the study’s lead author said, "The key message for pregnant women is to protect their growing fetus from exposure to second-hand smoke."

Stay tuned—although there is no doubt tobacco is a deadly product, the powerful forces that turn it into consumer goods have lots of money to indulge their irresponsible and venal instincts.

A Maryland-based medical staffing agency is at the center of allegations that it placed a rogue radiological technician into a number of hospitals in Maryland and other states. The technician is believed to have infected dozens of people with hepatitis C.

Maxim Staffing Solutions, a national firm with headquarters in Columbia, Maryland, placed technician David Kwiatkowski into three Baltimore hospitals: Baltimore Veterans Affairs Medical Center, Johns Hopkins Hospital and Maryland General Hospital, and also at Southern Maryland Hospital in Clinton, between 2008 and 2010.

Kwiatkowski was arrested in late July in New Hampshire after he was caught in a hospital stealing narcotic drugs that were intended for patients. He now faces federal charges.

The four Maryland hospitals are sending notices to several hundred patients to get testing for hepatitis C, a viral infection of the liver that, in bad cases, can lead to liver destruction and need for transplant.

Whether Maxim had reason to suspect the technician's danger to patients has yet to be determined. Lawsuits are likely against Maxim and another staffing agency that sent him to hospitals in as many as seven states in the last few years.

It's also unclear whether any of the Maryland hospitals had an inkling of problems with the technician. But at least two other hospitals, the prestigious UPMC Hospital in Pittsburgh and the Arizona Heart Hospital in Phoenix, fired Kwiatkowski after finding him with narcotic drugs.

A couple of months ago, we wrote about the sloppy, widespread clinical practices that put patients at risk of contracting hepatitis C, but this case, it appears, goes well beyond carelessness.

Maxim Staffing is alleged to have sent Kwiatkowski to UPMC in the spring of 2008. There, he was observed by another employee placing a syringe containing fentanyl, a Schedule II narcotic, in his pants. He replaced the missing syringe with another containing another liquid. Management confronted him, found three empty syringes with fentanyl labels on his person and an empty morphine syringe in his locker. His urine tested positive for fentanyl and opiates.

He was fired.

But UPMC did not report the theft, use or diversion of its controlled substances to any government agency or law enforcement authority. The technician was free to practice his alleged crimes elsewhere, and Maxim placed him in a matter of weeks into the first of four Maryland hospitals where he worked.

By the time he tested positive for hepatitis C in June 2010, dozens of patients who had undergone cardiac catheterizations at the hospitals that had employed him had been exposed to a common strain of hepatitis C. Most of them have learned only in recent months of their diagnosis. Based on this information, thousands of cardiac catheterization patients at hospitals where he worked are being tested for hepatitis C.

As noted in our backgrounder, hepatitis C can cause liver failure. The blood thins, and patients bleed easily. In the worst cases, called fulminant hepatic failure, the brain swells and the patient goes into a coma. About half of these patients die without an emergency liver transplant.

In July, a warrant was issued in New Hampshire for the technician’s arrest for acquiring a controlled substance by misrepresentation, fraud, forgery, deception or subterfuge, and for tampering with a consumer product with reckless disregard for the risk he posed to others of death or bodily injury, and for the serious bodily injury that has befallen others.

It’s shocking enough that a drug addict in a position to contaminate hospital equipment with a deadly virus not only would be hired and rehired and rehired without regard for his illness or the harm he created for others. But that the hospital and the staffing agencies that knew about the risk failed to report his crimes is unconscionable.

The tech was placed by Maxim into the four Maryland hospitals AFTER his firing from the Pittsburgh hospital. What excuse does Maxim have for failing to find out what had happened in Pittsburgh and for enabling his further crimes? We will find out in the coming lawsuits.

We do know this much. As a result of this infected technician being given access to patients in seven states across the country, dozens of people face a dire infection, and countless others are left to wonder if and when it will strike. With a hep C diagnosis comes significant costs for treatment and care, the possible loss of livelihood and maybe even life itself. And none of it had to happen.

Early this year the Centers for Disease Control and Prevention issued a report quantifying the epidemic of drug overdoses and adverse events from the use of opioids, otherwise known as narcotics. The report, “Grand Rounds: Prescription Drug Overdoses — a U.S. Epidemic,” pointed out that too many doctors prescribe powerful painkillers such as OxyContin without completely understanding the complexity of alleviating chronic pain and without having the necessary information about the risks and often exaggerated benefits of narcotics.

So a lot of interested parties looked forward to last week, when the FDA issued guidelines for prescribing the dangerous drugs. A lot of interested parties were disappointed.

Known as the risk evaluation and mitigation strategy (REMS), the process requires 20 drug manufacturers to sponsor physician education programs about how to prescribe their products, 30 of which are affected. The material will be created by medical education companies, and will include patient-education brochures.

That’s nice, but a story on FDA Law Blog was clear about the program’s deficits: “[M]ore than three years after beginning the opioid REM process, the final REMS … amounts to essentially a mere education and monitoring program. …[D] espite FDA’s statement in 2009 that “voluntary programs have not been successful in getting us where we need to go with maintaining access to legitimate patients and dramatically decreasing the serious adverse event reports,” the healthcare professional education provided by the REMS is in fact voluntary.”

And, as noted on MedPage Today, the guidelines were criticized not only because doctors aren't required to educate themselves about the drugs, but for empowering the industry that produces the problematic products to sponsor education about them and for not including powerful short-acting narcotics such as Vicodin.

The new REMS sound like a language course that teaches students all about nouns, pronouns and adverbs, but lacks lesson plans for conjugating verbs.

As Dr. Andrew Kolodny, chair of psychiatry at Maimonides Medical Center in New York, told MedPage, "These educational programs are likely going to do more harm than good. Nowhere does it say that prescribers should tell patients these drugs are addictive. And these programs give the implied message that there's evidence for using opioids in long-term, noncancer chronic pain."

We addressed some of these issues a few months ago in our post about the demise of American Pain Foundation, which had demonstrated a shocking conflict of interest between its information campaign and its pharmaceutical sponsors.

Kolodny said that the new, unimproved REMS offers the same version that the FDA’s own advisory committee deep-sixed two years ago. He said the REMS is a windfall for the medical education companies retained by the drug manufacturers, about five of which already generate much of the industry-sponsored education for opioids.

A better approach ties a practitioner’s DEA license or certification to his or her mastery of opiate indications, risks and benefits. For example, Kolodny noted, is a drug called buprenorphine (Suboxone), an opiate that also treats addiction. Before a doctor may prescribe it, he or she must complete an eight-hour class.

It’s not a lot to ask when you consider that:

• Prescription drug abuse is the fastest growing drug problem in the U.S.


• Approximately 23 million prescriptions for extended-release and long-acting opioids were written in 2011.


• In one recent year in the U.S. one death due to drug overdose occurred every 19 minutes.


• The recent increase in unintentional drug overdose deaths has been driven by the increased use of prescription narcotics.


• In one recent year, for every unintentional overdose death related to narcotics, nine patients were admitted for substance abuse treatment, 35 visited emergency departments, 161 reported drug abuse or dependence and 461 reported nonmedical uses of these drugs.


• In the 10 years between 1997 and 2007, the distribution of morphine per person increased more than 600 percent. According to the CDC, that’s enough morphine for everyone in the U.S. to take a typical, 5 mg dose of Vicodin every four hours for three weeks.

The physician education courses under the new REMS would last about 2 to 3 hours and cover how to weigh the risks and benefits of opioid therapy and how to recognize the potential for abuse and addiction. The first courses are to be scheduled by March next year.

The FDA estimates that there are 320,000 prescribers of long-acting narcotics in the U.S.; 1 in 4 is expected to be trained by the end of the program's first year. The goal is to have 6 in 10 trained by the third year.

But doctor education programs alone can’t reduce the terrible toll of narcotic abuse and industry-wide ignorance of best pharmaceutical intervention practice. Practices such as “doctor shopping,” in which consumers go from doctor to doctor in search of prescriptions for illegal pharmaceuticals, or seek out multiple practitioners who each prescribe the desired drug, even for a legitimate condition, have to be addressed. There are state laws against such behavior, but their routine enforcement is wanting.

“[O] nly a few states,” according to the CDC, “have laws regulating for-profit clinics that distribute controlled prescription drugs with minimal medical evaluation. Laws against such ‘pill mills’ as well as laws that require physical examinations before prescribing might help reduce the diversion of these drugs for nonmedical use.” (We recently retold the story of one pill-pushing doctor who did get busted for murder related to fatal overdoses.)

The CDC also says the plug can be pulled on doctor shopping by tracking prescriptions in a database, and by insurance companies paying attention to claims processing and limiting reimbursements for narcotic prescriptions to designated doctors and pharmacies.

A meatier set of guidelines by the FDA also would be nice.

When psychiatrists, psychologists, researchers and insurers want to identify and classify a psychiatric disorder, they turn to the Diagnostic and Statistical Manual of Mental Disorders. Compiled by the American Psychiatric Association, and widely known as the DSM, the reference guide spells out criteria for making a given diagnosis. As the body of science grows and the understanding of mental disorders evolves, cultural priorities change. The DSM does too. It’s a dynamic resource.

Originally published in the 1950s, the DSM was intended as a public health service to document the incidence and prevalence of mental illness and to classify mental illnesses with objective criteria. By its third edition in 1980 (DSM-III), it had become the primary reference for clinicians. (A few years ago, we wrote about how some writers of the DSM-IV had financial links to the pharmaceutical industry.)

Another revision, DSM-V, is scheduled to be released next spring.

According to Kaiser Health News, the new changes affect more than a dozen categories of disorders including substance use and addiction.

Gone from the new guidelines would be the diagnostic categories of "substance abuse" (which embraces short-term problems including driving drunk) and "substance dependence" ( a chronic problem marked by tolerance or withdrawal). Instead, "substance use and addictive disorders" would cover both.

The merged criteria would be applied to the use of alcohol, cigarettes, illicit or prescription drugs and other substances into a single, 11-item list of problems typically associated with these disorders--being unable to reduce or control the use of the substance, and failing to meet one’s obligations.

Diagnoses would be based on how many criteria the patient meets: 0 to 1 = no disorder; 2 to 3 = mild disorder; 4 to 5 = moderate disorder; 6 or more = severe disorder.

Advocates contend that by creating a category for mild disorders, it might be easier to identify and address drug or alcohol problems before they become serious. It might be easier, they say, for primary care doctors to be reimbursed by insurers for screening for alcohol and drug problems, and conducting short counseling sessions that have been shown to be effective.

Under the federal health care reform law adopted in 2010, screening and behavioral counseling to reduce alcohol misuse is covered as a free preventive benefit for people in many health plans.

According to the National Institute on Alcohol Abuse and Alcoholism, a man is at risk for developing a substance use disorder if he drinks more than four drinks in a single day and more than 14 drinks per week; a woman’s risk is three drinks in a single day and more than seven drinks per week.

Some experts interviewed by KHN are troubled by the 11-point list of criteria that moves substance use disorders along a continuum from mild to severe. They say that clinical research does not support a natural escalation from nonuse to occasional use to risky use to addiction.

Some people, they point out, suffer sadness or transient depression when bad things happen to them, but that doesn’t mean they’ll progress to psychotic depression. The same could be true for substance abuse.

What if a college student had an episode of frat-party binge drinking and missed classes because of it (earning a score of 2)? What if he’s labeled as having a mild addictive disorder that might not be accurate? What if he resists treatment because he resents the label of “addict”?

Still, if your pattern is to drink heavily only in a social or recreational setting, you might be at risk for a substance use disorder. Consider that you might be putting yourself and others in danger.

Substance abuse might not have affected your work or personal life, but if certain events regularly prompt you to drink too much or take illicit drugs, you have a much higher risk of having a car accident or liver problems. If that describes you, consult your primary care doctor about the possibility of short-term treatment.

A report recently published by the Centers for Disease Control and Prevention (CDC) drew a scary picture of prescription drug problems in the U.S. “The epidemic of prescription drug overdoses in the United States has worsened over the last decade, and by 2008, drug overdose deaths (36,450) were approaching the number of deaths from motor vehicle crashes (39,973), the leading cause of injury death in the United States.”

“These increases occurred,” the report read, “despite numerous warnings and recommendations over the past decade for voluntary education of providers about more cautious use of OPRs [opioid pain relievers].”

Some doctors just aren’t getting the message: One study showed that only about 3 in 100 physicians account for more than 60 in 100 OPR prescriptions. One of them, it appears, might be Hsiu-Ying "Lisa" Tseng, an osteopath practicing in a Los Angeles suburb. Last month, authorities finally said “enough” to Tseng, and charged her with murder in connection with three fatal overdoses.

Narcotic drugs—OPRs—are at the heart of this grim reality. We’ve looked at their dicey history before, and efforts to make them safer. By 2010, the report said, OPR sales were sufficient to medicate every American adult with a standard dose of hydrocodone (Vicodin) every four hours for month. Is it any wonder that sales of these morphine-like drugs such as Oxycontin, Percocet and Dilaudid paralleled the OD death trend?

As recounted by the Los Angeles Times, Tseng also stands accused of recklessly prescribing narcotic painkillers and other addictive drugs, but the murder charge is, according to The Times, “a rare attempt to hold a physician criminally liable for patients' deaths.”

Tseng told The Times in 2010 that she had been confronted about her prescribing habits by her patients' loved ones. At the time, she absolved herself of any problem they might be having. “‘They call me all sorts of names — drug doctor, drug-dealing doctor.… I tell parents a lot of times it's their problem."

The three dead patients named in the district attorney’s complaint died in 2009 after traveling long distances to see Tseng, a general practitioner. One came all the way from Arizona.

According to The Times, the Drug Enforcement Administration had been investigating Tseng for years even as her patients continued to overdose. The feds were considering charging her under a drug-dealing statute.

In addition to the deaths, the L.A. district attorney has charged Tseng with 20 counts of prescribing painkillers and anti-anxiety drugs to people who had no legitimate need for the medications. She was nabbed by investigators working under cover as "patients." The drugs she allegedly prescribed included the common black-market drugs oxycodone and alprazolam. Some of Tseng’s patients had been charged with dealing drugs, and family members told The Times that they suspected their loved ones of selling some of their prescriptions to finance their habit.

Tseng was in deep trouble even before her murder rap. She had agreed previously to surrender her medical license in settlement of gross negligence charges related to more than a dozen patients (three of whom died) to whom she allegedly prescribed excessive amounts of drugs without taking the standard-care precautions of checking a state-run prescription database to see if they were already being prescribed similar drugs from other doctors.

Cases like Tseng’s and that of Michael Jackson’s doctor, Conrad Murray, who was convicted of involuntary manslaughter, are highly unusual. Brian Liang, director of the Institute of Health Law Studies at the California Western School of Law, told The Times, “We don't generally criminalize negative medical outcomes. It is very rare for a physician to get hit with gross negligence to the point of criminality. That's a very difficult standard."

Said Tseng to The Times a couple of years ago: "I never intended to kill anybody."

But it looks like she did. And it looks like she was given plenty of time to do it. Yes, it’s nice that somebody is bringing down the hammer on a supposed “caregiver” who’s really a dangerous threat. But we want to know what took you so long?

We’re well into the new year, and by now many of your resolutions may have been consigned to the “next year” bin. But if you’re trying to quit smoking, no time is better than the present. Every year nearly half a million people die prematurely from smoking-related illnesses including lung cancer, heart disease and pulmonary disease. Smoking is the No. 1 cause of preventable death in the U.S.

And let’s not forget, as the Centers for Disease Control and Prevention point out, that it’s not just about you: Approximately 88 million nonsmokers, including more than 5 in 10 children ages 3 to 11, are exposed to secondhand smoke, a particularly ominous reality. Even brief exposure can be dangerous because nonsmokers inhale many of the same poisons in cigarette smoke as smokers.

Seven in 10 smokers want to quit, and as noted in a recent story on Kaiser Health News, most smokers need help. That might mean counseling, support groups or a variety of nicotine-replacement products whose efficacy we examined last week.

And the FDA is convening a panel to study yet another tobacco delivery system called “dissolvables”—melt-in-your-mouth tobacco products some observers believe help people quit, and others say are a gateway to greater tobacco use that pose cancer risks of their own.

We spend nearly $100 billion every year on health-care problems related to tobacco, yet in this country 1 in 5 adults still smokes, a ratio that hasn’t changed in years. Why?

It's been known for a century how hard it is to quit smoking. As Mark Twain said with a twinkle in his eye: "Giving up smoking is the easiest thing in the world. I know because I've done it thousands of times."

Now modern life gives us another thousand reasons why quitting tobacco takes a back seat to other government priorities. KHN noted, “Scrambling to address budget problems, states this year will spend less than 2 percent of their tobacco-tax and tobacco-settlement billions on programs to help people quit smoking or prevent them from starting, according to a recent report by a coalition of public-health organization. In the past four years, state spending on tobacco prevention and cessation has declined by 36 percent, to $457 million.”

The State of Tobacco Control, a recently released report by the American Lung Association, confirmed the grim news about waning public interest in anti-tobacco measures. It graded the federal government, all 50 state governments and the District of Columbia to determine if tobacco control laws are adequately protecting citizens from the enormous toll tobacco use takes on lives and the economy.

They’re not. According to the ALA:

• Tobacco prevention and quit-smoking programs in several states were stung by funding cuts or were virtually eliminated, including a highly successful program in Washington State.


• Higher cigarette prices keep kids from starting to smoke, but for the first year since the Lung Association began releasing the report in 2003, no state raised its tobacco tax significantly. New Hampshire actually cut its cigarette tax by a dime per pack.

“Today’s report calls out states for their failures to protect children. If states completely retreat, it will bring even more tragic human consequences across America,” said Charles D. Connor, president and CEO of the ALA. “A race to the bottom is not necessary, when millions of lives are at stake.”

Only four states received all passing grades, while six states received straight Fs on the report card. To see how your state rated, click here.

As public funding diminishes, corporate attention is growing. Last year 2 in 3 companies with more than 200 employees offered them smoking cessation programs, and so did nearly 1 in 3 smaller companies. Nearly 1 in 4 companies with more than 20,000 employees charge smokers more for health insurance premiums

That’s not necessarily a good idea, some public health authorities say, because it can encourage smokers to drop their coverage. But employers say asking them to pay more for coverage is only fair. "The cost of medical care for smokers is considerably higher," Helen Darling, chief executive of the National Business Group on Health told KHN. "Employers are increasingly saying that if someone costs the pool more, they should pay more."

The Affordable Care Act (ACA), the federal health law passed in 2010, expanded coverage for smoking cessation. States must provide tobacco-cessation coverage for all pregnant women in their Medicaid programs at no cost. Anti-smoking activists, of course, want much broader coverage, especially for Medicaid recipients; almost 3 in 10 of adults living below the poverty line are smokers.

The ACA also requires new health plans to screen adults for tobacco use and provide free stop-smoking interventions. Specifics, though, are wanting—advocates hope federal guidelines will provide coverage for more than a single four-session counseling module, for example, or a standard 12-week round of medication.

We’re determined to keep covering the toll of nicotine addiction, the companies in whose interest it is to keep you hooked and the legislative efforts to address tobacco and health care. If you’re determined to quit, here are some suggestions for getting help.

• The online stop-smoking program Legacy is a nonprofit created under the settlement between the states and the tobacco industry.


• Another free program whose scientific credentials are acknowledged by the American Cancer Society is, EX, is a project of the National Alliance for Tobacco Cessation.


• A national toll-free number, (800) QUIT NOW, routes callers to free support services including medication in the handful of states that provide it.

Because the effects of nicotine are deadly, because cigarettes are so addictive (some research indicates it’s harder to kick nicotine than it is heroin), any and all efforts should be made to quit smoking.

In trying to wean themselves off of “cancer sticks,” many people turn to nicotine replacement in the form of patches that deliver minute amounts of the chemical compound over time, or via chewing gum, inhalers or nasal spray. But a study released last week indicates that these measures aren’t what they’re cracked up to be.

As widely reported, a study of 787 adults who had quit smoking within the previous two years showed that nearly more than 3 in 10 had relapsed. Subjects who had used nicotine patches, gum, inhalers or nasal sprays were just as likely to relapse as those who had quit without them.

Published in the journal Tobacco Control, the findings contradict the results of several randomized clinical trials conducted before the FDA approved the nicotine replacement products. In those trials, subjects using the replacement products were as much as three times more likely than those who didn’t to kick the smoking habit.

“This may indicate that some heavily dependent smokers perceive NRT [nicotine replacement therapy] as a sort of ‘magic’ pill, and upon realizing it is not, they find themselves without support in their quitting efforts, doomed to failure,” the researchers wrote.

As you might expect, the product manufacturers found fault with the study. They claimed that most of the adults in the study who used nicotine replacement products failed to use them for the recommended eight weeks.

If you’re among the Americans who collectively spend more than $1.5 billion on nicotine replacements every year and still can’t stop smoking, the researchers say it might be a function of time—you have a better chance of staying clean if you’re smoke-free for at least six months. And professional counseling is helpful too, although there’s no guarantee of success.

The one guarantee is that those who do quit smoking feel better, and almost every part of their bodies will show its appreciation for taking away the poison.