Tagged Smoking and Tobacco

More Nonsmoking Teens Inhaling Flavored Nicotine

A study shows that many teenagers who would have never smoked are now vaping.

A study shows that many teenagers who would have never smoked are now vaping. Katie Orlinsky for The New York Times

Many teenagers who never would have smoked cigarettes are now “vaping” with flavored e-cigarettes, leading to a new generation using nicotine at rates not seen since the 1990s, a new study suggests.

The study, released Monday in the journal Pediatrics, tracked the use of cigarettes and e-cigarettes among 5,490 California high school seniors who graduated between 1995 and 2014. E-cigarettes do not burn tobacco, but are battery-operated inhalers that heat up and vaporize liquid containing flavors and nicotine, a practice known as vaping. The liquids used in vaping range in taste from traditional tobacco and menthol flavors to fruity and sweet combinations like gummi bear, banana bread and cotton candy.

When e-cigarettes came on the market in 2007, some public health experts hoped that they would serve as a substitute for traditional tobacco products and lead to declines in tobacco use.

But the data from the latest study, conducted by researchers at the University of Southern California, tell a different story. E-cigarettes do not appear to have made a dent in regular cigarette use — the number of high school seniors who reported smoking tobacco in the past 30 days has largely plateaued. In 2004, the number of 12th graders who reported smoking tobacco in the past 30 days was 9 percent; in 2014 that number was just under 8 percent.

But the rate of teenagers using nicotine — either through tobacco cigarettes or e-cigarettes — is on the rise. About 14 percent of Southern California high school seniors in 2014 said they had smoked or vaped in the last 30 days. Researchers say they have not seen similar levels of nicotine use among teenagers since 1995, when 12th grade smoking rates were 19 percent.

The numbers suggest that rather than prompting teenagers to replace cigarette smoking with vaping, e-cigarettes instead have enticed an entirely new group of teenagers to use nicotine. While the study focused on California teenagers, researchers say the numbers are consistent with national trends.

“Kids are not just using e-cigarettes instead of cigarettes. That is what we were frankly hoping to find,” said Jessica Barrington-Trimis, the lead author of the study and a postdoctoral scholar research associate in the department of preventive medicine at the U.S.C. Keck School of Medicine. All of the teenagers that were expected to be using cigarettes in 2014 are using them, she said, “and then there is a whole group of kids using e-cigarettes on top of that.”

The amount of nicotine in the liquids used with e-cigarettes — often called “vape juice — varies, and users can purchase liquid with no nicotine or nicotine content ranging from 3 milligrams per milliliter to 18 milligrams per milliliter or even higher. While earlier studies have suggested that some teens are using nicotine-free vaping liquids, researchers say the majority of teens appear to be using nicotine-infused liquid in their e-cigarettes.

Dr. Jonathan Winickoff, professor of pediatrics at MassGeneral Hospital for Children and Harvard Medical School, who wrote an accompanying paper in Pediatrics, said this is the first study of e-cigarette use in adolescents to show such a strong longitudinal sample with such a drastic effect.

“We had a trend of decreasing nicotine use,” said Dr. Winickoff. “What the e-cigarette has done is halted that decrease in its tracks…. We don’t want a fifth of our high school students graduating with nicotine addiction.”

While e-cigarettes do appear to be safer than smoking tobacco, they are not risk free. Nicotine disrupts neurotransmitter activity and is highly addictive, particularly in a developing brain. And the liquids contain solvents, formaldehyde and other ingredients that pose health risks when inhaled.

While it’s true that there are nicotine-free vaping liquids, the e-cigarette industry is not regulated, which makes it hard to know what ingredients are actually in any given product. Though the Food and Drug Administration recently took jurisdiction over e-cigarettes, it will be years before any regulations are put into effect. Currently, many products continue to be made in China with little — if any — oversight by the United States.

“The F.D.A. has done tests on these vaping products that supposedly do and do not contain nicotine, and what is advertised is really not what’s in the product,” Dr. Winickoff said. “When the product is labeled as no nicotine, they’ve found nicotine. So kids don’t know what they’re getting, and as a pediatrician it really scares me.”

Not everyone agrees that e-cigarettes pose a significant risk to teenagers. Dr. Michael Siegel, professor of community health sciences at the Boston University School of Public Health, countered that many teenagers say they are using e-cigarettes that contain only flavorings and no nicotine, and therefore are not getting addicted.

“E-cigarette use among teenagers is a largely social phenomenon,” he said. “The fact that you tend to see teenagers doing this in groups, not out in the cold vaping alone, suggests that e-cigarettes are not addictive.”

But there is a growing body of research showing that e-cigarettes do serve as a gateway to traditional tobacco products. Last month, the U.S.C. researchers also reported in Pediatrics that adolescents who vape are six times more likely to smoke cigarettes in early adulthood as non users.

“Once kids get hooked on e-cigarettes, they are more likely to go on to become cigarette smokers,” said Stanton A. Glantz, director of the Center for Tobacco Control Research and Education at the University of California, San Francisco.

More Nonsmoking Teens Inhaling Flavored Nicotine Through Vaping

A study shows that many teenagers who would have never smoked are now vaping.

A study shows that many teenagers who would have never smoked are now vaping. Katie Orlinsky for The New York Times

Many teenagers who never would have smoked cigarettes are now “vaping” with flavored e-cigarettes, leading to a new generation using nicotine at rates not seen since the 1990s, a new study suggests.

The study, released Monday in the journal Pediatrics, tracked the use of cigarettes and e-cigarettes among 5,490 California high school seniors who graduated between 1995 and 2014. E-cigarettes do not burn tobacco, but are battery-operated inhalers that heat up and vaporize liquid containing flavors and nicotine, a practice known as vaping. The liquids used in vaping range in taste from traditional tobacco and menthol flavors to fruity and sweet combinations like gummi bear, banana bread and cotton candy.

When e-cigarettes came on the market in 2007, some public health experts hoped that they would serve as a substitute for traditional tobacco products and lead to declines in tobacco use.

But the data from the latest study, conducted by researchers at the University of Southern California, tell a different story. E-cigarettes do not appear to have made a dent in regular cigarette use — the number of high school seniors who reported smoking tobacco in the past 30 days has largely plateaued. In 2004, the number of 12th graders who reported smoking tobacco in the past 30 days was 9 percent; in 2014 that number was just under 8 percent.

But the rate of teenagers using nicotine — either through tobacco cigarettes or e-cigarettes — is on the rise. About 14 percent of Southern California high school seniors in 2014 said they had smoked or vaped in the last 30 days. Researchers say they have not seen similar levels of nicotine use among teenagers since 1995, when 12th grade smoking rates were 19 percent.

The numbers suggest that rather than prompting teenagers to replace cigarette smoking with vaping, e-cigarettes instead have enticed an entirely new group of teenagers to use nicotine. While the study focused on California teenagers, researchers say the numbers are consistent with national trends.

“Kids are not just using e-cigarettes instead of cigarettes. That is what we were frankly hoping to find,” said Jessica Barrington-Trimis, the lead author of the study and a postdoctoral scholar research associate in the department of preventive medicine at the U.S.C. Keck School of Medicine. All of the teenagers that were expected to be using cigarettes in 2014 are using them, she said, “and then there is a whole group of kids using e-cigarettes on top of that.”

The amount of nicotine in the liquids used with e-cigarettes — often called “vape juice — varies, and users can purchase liquid with no nicotine or nicotine content ranging from 3 milligrams per milliliter to 18 milligrams per milliliter or even higher. While earlier studies have suggested that some teens are using nicotine-free vaping liquids, researchers say the majority of teens appear to be using nicotine-infused liquid in their e-cigarettes.

Dr. Jonathan Winickoff, professor of pediatrics at MassGeneral Hospital for Children and Harvard Medical School, who wrote an accompanying paper in Pediatrics, said this is the first study of e-cigarette use in adolescents to show such a strong longitudinal sample with such a drastic effect.

“We had a trend of decreasing nicotine use,” said Dr. Winickoff. “What the e-cigarette has done is halted that decrease in its tracks…. We don’t want a fifth of our high school students graduating with nicotine addiction.”

While e-cigarettes do appear to be safer than smoking tobacco, they are not risk free. Nicotine disrupts neurotransmitter activity and is highly addictive, particularly in a developing brain. And the liquids contain solvents, formaldehyde and other ingredients that pose health risks when inhaled.

While it’s true that there are nicotine-free vaping liquids, the e-cigarette industry is not regulated, which makes it hard to know what ingredients are actually in any given product. Though the Food and Drug Administration recently took jurisdiction over e-cigarettes, it will be years before any regulations are put into effect. Currently, many products continue to be made in China with little — if any — oversight by the United States.

“The F.D.A. has done tests on these vaping products that supposedly do and do not contain nicotine, and what is advertised is really not what’s in the product,” Dr. Winickoff said. “When the product is labeled as no nicotine, they’ve found nicotine. So kids don’t know what they’re getting, and as a pediatrician it really scares me.”

Not everyone agrees that e-cigarettes pose a significant risk to teenagers. Dr. Michael Siegel, professor of community health sciences at the Boston University School of Public Health, countered that many teenagers say they are using e-cigarettes that contain only flavorings and no nicotine, and therefore are not getting addicted.

“E-cigarette use among teenagers is a largely social phenomenon,” he said. “The fact that you tend to see teenagers doing this in groups, not out in the cold vaping alone, suggests that e-cigarettes are not addictive.”

But there is a growing body of research showing that e-cigarettes do serve as a gateway to traditional tobacco products. Last month, the U.S.C. researchers also reported in Pediatrics that adolescents who vape are six times more likely to smoke cigarettes in early adulthood as nonusers.

“Once kids get hooked on e-cigarettes, they are more likely to go on to become cigarette smokers,” said Stanton A. Glantz, director of the Center for Tobacco Control Research and Education at the University of California, San Francisco.

Smoking Damages Sperm

Everyone knows that a woman who smokes and plans to become pregnant should stop smoking. A new study suggests that the future father should quit, too.

Brazilian researchers analyzed the sperm of 20 smokers and 20 nonsmokers and found that the smokers’ sperm was damaged in ways that could reduce the chance of fertilization and might also lead to health problems in the baby.

The DNA in smokers’ sperm was fragmented, probably because of oxidative stress from the cadmium and nicotine in cigarette smoke. Sperm DNA fragmentation has been shown in other studies to be associated with an increased risk of genetic problems in the offspring as well as with an increased risk of childhood cancer. Mitochondria, the energy centers of cells, were also less active in the sperm of smokers.

The study, in BJU International, also found that smokers had a larger percentage of nonintact acrosomes, the part of the head of the sperm that releases enzymes that allow the sperm to penetrate the ovum’s shell. And the researchers discovered alterations in the proteins in smokers’ seminal plasma that might impair fertilization.

“All these effects were found in smokers,” said the senior author, Ricardo Pimenta Bertolla of the São Paulo Federal University. The message, he said, is straightforward: Smoking alters a man’s capacity to produce sperm that can successfully fertilize an egg.

No Such Thing as a Healthy Smoker

Paul Rogers

Smokers who think they are escaping the lung-damaging effects of inhaled tobacco smoke may have to think again, according to the findings of two major new studies, one of which the author originally titled “Myth of the Healthy Smoker.”

Chronic obstructive pulmonary disease, or C.O.P.D., may be among the best known dangers of smoking, and current and former smokers can be checked for that with a test called spirometry that measures how much air they can inhale and how much and how quickly they can exhale. Unfortunately, this simple test is often skipped during routine medical checkups of people with a history of smoking. But more important, even when spirometry is done, the new studies prove that the test often fails to detect serious lung abnormalities that cause chronic cough and sputum production and compromise a person’s breathing, energy level, risk of serious infections and quality of life.

“Current or former smokers without airflow obstruction may assume that they are disease-free,” but that’s not necessarily the case, one of the research teams pointed out. These researchers projected that there are 35 million current or former smokers older than 55 in the United States with unrecognized smoking-caused lung disease or impairments. Many, if not most, of these people could get worse with time, even if they have quit smoking. They are also unlikely to be referred for pulmonary rehabilitation, a treatment that can head off encroaching disability.

Perhaps most important, those currently smoking may be inclined to think they’ve dodged the bullet and so can continue to smoke with impunity. Doctors, who are often reluctant to urge patients with symptoms to quit smoking, may be even less likely to recommend smoking cessation to those with normal spirometry results.

Referring to C.O.P.D., one of the researchers, Dr. Elizabeth A. Regan, said, “Smoking is really taking a terrible toll on our society.” Dr. Regan, a clinical researcher at National Jewish Health in Denver, is the lead author of one of the new studies, published last year in JAMA Internal Medicine. “We live happily in the world thinking that only a small percentage of people who smoke get this devastating disease,” she said. “However, the lungs of millions of people in the United States are negatively impacted by smoking, and our methods for identifying their lung disease are relatively insensitive.”

Even when the results of spirometry are normal, Dr. Regan added, “a lot of smokers have respiratory symptoms. They get sick often, are more likely to be hospitalized with bronchitis or pneumonia, and have evidence on CT scans of thickened airway walls or emphysema that impair breathing.”

Dr. Prescott G. Woodruff, lead author of the other study, published May 12 in The New England Journal of Medicine, said in an interview, “Smokers have much more lung disease than we previously thought. The 15 to 20 percent who get C.O.P.D. is a gross underestimate.” Too often, Dr. Regan’s team pointed out, symptoms like shortness of breath and limits on exercise are “dismissed as normal aging.”

The multicenter study headed by Dr. Woodruff, a pulmonologist at the University of California, San Francisco, found that smokers with normal findings on spirometry nonetheless are likely to have chronic respiratory symptoms like cough, phlegm, wheezing, shortness of breath and chest tightness; lower than normal exercise tolerance; and evidence on a CT scan of chronically inflamed airways in the lungs. They also use more antibiotics to control respiratory infections and drugs called glucocorticoids to alleviate breathing difficulty. They pay more visits to doctors and emergency rooms and have more hospital admissions because of a flare-up of respiratory symptoms.

In other words, they are far more prone than nonsmokers to experiencing terrifying episodes of troubled breathing.

Of course, while lung disease is most prevalent, it is hardly the only adverse health effect of smoking, a source of noxious substances that can damage almost every organ system in the body. The list of smoking-related diseases has grown exponentially since smoking was labeled a probable cause of lung cancer 52 years ago in the first Surgeon General’s report on smoking and health. The decades since have added many other deadly cancers, heart disease, stroke, high blood pressure, blood clots, peripheral artery disease, Type 2 diabetes, rheumatoid arthritis, cataracts and macular degeneration, as well as C.O.P.D.

The new findings by the two investigative teams prompted Dr. Leonardo M. Fabbri of the University of Modena and Reggio Emilia in Italy to write an editorial accompanying the New England Journal study titled “Smoking, Not C.O.P.D., as the Disease.” He explained that the results of the two studies “suggest that smoking itself should be considered the disease and should be approached in all its complexity.”

The challenge ahead, Dr. Fabbri wrote, is to identify patients with smoking-related lung damage who do not yet have obstructive disease and devise ways to treat them to reduce their symptoms and prevent flare-ups.

A clinical trial to begin later this year, sponsored by the National Heart, Lung and Blood Institute, will examine whether treatments like use of a bronchodilator will help to alleviate symptoms in those without obstructive disease. Unfortunately, “the cost of bronchodilator medication has gone through the roof,” Dr. Woodruff said. Decades ago, people with breathing problems like asthma used aerosol bronchodilators that included chemicals called fluorocarbons. But these were banned for environmental reasons in the mid-1970s, and the replacements that drug manufacturers came up with are still not available in generic form, keeping prices high.

Dr. Woodruff said that rehabilitative exercise, one of the best treatments for C.O.P.D., should also help people with lung damage short of obstruction because it improves the ability of muscles to use available oxygen more efficiently.

To improve exercise tolerance, patients are encouraged to walk as fast as they can for as long as they can, rest, then walk some more. Most patients find this easiest to do on a treadmill, where speed and incline can be precisely regulated and the results measured. But if such equipment is unavailable or too costly to access, walking indoors or outdoors can be helpful if geared to a specific distance and speed that are gradually increased.

Most critical, of course, is for smokers with or without symptoms of lung disease to quit smoking, which can reduce the severity of respiratory symptoms and slow the decline in lung function, Dr. Regan’s team wrote. However, the team added, quitting smoking “does not eliminate the risk of progressive lung disease,” which means that the lungs of former smokers may need to be examined periodically.

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Graphic Cigarette Warnings Deter Smokers

Putting graphic pictorial health warnings on cigarette packages was required by a law passed in 2009, but a tobacco company convinced a federal appellate court to delay implementation, claiming there was no evidence that pictures helped people quit.

Now a randomized controlled trial, published in JAMA Internal Medicine, has provided the evidence.

In a four-week trial, 2,149 smokers were randomly assigned to use packs of cigarettes with either pictorial or text-only warnings. At the end of each week, researchers surveyed the participants about their smoking.

The two groups had the same baseline desire to quit and similar understanding of the harms of smoking. But by the end of the study, 40 percent of those in the pictorial warning group had quit for at least a day, and 5.7 percent were not smoking during the seven days before their final interview, compared with 34 percent and 3.8 percent respectively in the text-only group.

The pictorial warnings were more effective for both sexes and across races, ethnicities and socioeconomic levels.

“This is the first well-controlled study that demonstrates a change in behavior,” said the lead author, Noel T. Brewer, a professor of health behavior at the University of North Carolina. “It’s time for the U.S. to adopt pictorial warnings. Delaying is causing people to continue smoking and die as a result.”

After a Cancer Diagnosis, Reversing Roles With My Mother

Steven Petrow (left) with his siblings, Jay and Julie, and mother, Margot Petrow, on her 84th birthday in February.

Steven Petrow (left) with his siblings, Jay and Julie, and mother, Margot Petrow, on her 84th birthday in February. Caroline Petrow-Cohen

If anything about my mother was conventional, it was the smoking. Like many of her generation she smoked early and often, and I swear she waited to light up until we were hermetically sealed in our family’s Ford Country Squire. My brother, sister and I hated it — we tried over and over to get her to quit. She made some attempts: Patches and gum, even hypnosis by a Russian. She had some short-term successes, but soon enough I could smell the smoke on her breath or see the burnt-out butts hidden in her desk drawer ashtray.

The last time I begged Mom to quit, she shot back with a stern rebuke: “I very much appreciate your concern,” followed by an expletive. The message was clear: Mind my own business. Indeed, Mom has always been “spirited.”

From both ends, ours was not an easy relationship.

Four years ago, at 80, Mom wound up in the emergency room after she passed out in bed; her carotid artery was 90 percent blocked. The doctor ordered a routine pre-op chest X-ray and found a mass that turned out to be lung cancer. “Did my smoking have anything to do with this?” Mom asked the handsome cancer surgeon, almost flirtatiously. “Yes,” he told her. “Then I’ll quit,” she said. And that, finally, made her stop, once and for all.

A few weeks later “Dr. Handsome,” as the family began referring to him, took out part of her left lung at the very same New York cancer hospital where I’d had cancer surgery three decades before. I’d wound up there only because Mom had insisted that I get a second opinion after my first operation, an orchiectomy to remove my cancerous testicle, at a hospital on the opposite coast. While I’d been overjoyed when the oncologist told me I was a candidate for “watchful waiting” and that he’d “never lost a patient,” Mom thought the latter comment quite odd for a doctor who treated cancer patients. I caved, flew east, and learned I needed more treatment, stat. Score one for Mom.

During Mom’s first hospitalization for her cancer our roles flipped. I became her caregiver, and she became my charge. With nurses busy elsewhere, I made sure her bedpan got changed, or contacted the surgeon to boost her pain medications when needed. On a no less important matter, I made sure she got a chocolate, not vanilla, milkshake daily. After my own stays in the hospital, I had learned how to “work” the hospital staff, using genuine praise, patience and small gifts of candy.

I also had that firsthand knowledge of what it meant to suddenly become a cancer patient, dependent on the kindness of strangers and family alike. I knew what it was like to face the mechanical roar of the CT scanners, not to mention the anxiety and fear that your book of life may be coming to an end sooner than you’d expected.

Some days I held Mom’s hand, her Jungle Red manicure always perfect, as the nurses pricked her repeatedly to get a good line. Other times I’d just sit with Mom and let her talk. About my father. My sibs. And herself.

Increasingly, she asked me about my cancer travails, which included multiple surgeries and four rounds of chemo. “I can’t believe you went through all this,” she said time and again. Still, I’d been in my 20s; mom was now in her 80s. As different as our cancers were, not to mention our ages, I’d become her travel guide in this new country of illness.

Then one day she piped up, her voice an octave or two higher than usual: “I’m afraid.”

“Afraid of what?” I asked.

“Of the pain of dying. And leaving you kids.”

I told her we’d make sure she didn’t suffer. And as for the three kids, I told her not to worry about us. “We’re all in our 50s now,” I reminded her.

As I had decades ago, Mom recovered from her first operation. And also like me, she moved into a netherworld I knew all too well: The “after” stage, during which you struggle to believe it’s over, all the while dreading its return.

Last year I moved her semi-annual scan from late December to mid-January. With bad news always a possibility, why risk ruining the holiday? I was glad I’d done that when the scan showed a new mass. Although the doctor was the official bearer of the bad news, it was left to my brother, sister and me to explain what that meant, all the while reassuring her we’d be there to help.

As it turned out, one of the most important decisions she’d have to make was what treatment, if any, she should soldier through to combat this new malignancy. Dr. Handsome recommended radiation, but he didn’t sound very optimistic. I decided Mom needed a second opinion, maybe even a third, and with some cajoling — just as she had urged me on so many years before — she sat down with a radiation oncologist. He was much more encouraging about what to expect, and she took his advice.

And so it was not too many months ago, after helping her back into her street clothes and into the Uber after her daily radiation, that we were headed home from the hospital. She grasped my hand tightly and told me how glad she was that I was with her. “Whatever our problems were,” she said, “I’m happy they’re behind us.” I squeezed her hand back.

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Out With the Old

Illustration by Sam Island

Experiments involving health and well­-being typically require their subjects to change just one aspect of their lives. Focusing on a single variable like diet or exercise makes it simpler to collect data and draw conclusions. But some researchers at the University of California, Santa Barbara, recently wondered if this minimalist approach might be shortchanging people’s potential to improve their health. Maybe it’s better to address all of our bad habits at once rather than try to make incremental changes to our lives.

For their study, published in March in the journal Frontiers in Human Neuroscience, the researchers put 31 college students, who tend to have flexible daily schedules, through a series of physical, cognitive and emotional tests and gave them brain scans. Roughly half the students served as a control group and continued their daily routines; the other half overhauled their lives completely. Every morning, they visited the school for an hour of supervised stretching, resistance training and balance exercises, followed by an hour of training in mindfulness and stress reduction, which included quiet walks and meditation. In the afternoon, they exercised for an additional 90 minutes. Twice a week they completed two interval-style endurance workouts on their own. They attended lectures about nutrition and sleep and kept daily logs detailing their exercise, diets, sleep patterns and moods.

After six weeks, the students retook the original tests. Those in the control group showed no changes. But the others were substantially stronger, fitter and more flexible. They performed much better on tests of thinking, focus and working memory. They also reported feeling happier and calmer; their self-esteem was much higher. Their brain scans showed a pattern of activity believed to indicate a greatly enhanced ability to stay focused.

These improvements, especially on measures of mood and stress reduction, generally exceeded by a great deal what had been seen in many past experiments whose subjects altered only one behavior. The study’s authors suggest that one kind of change, like starting an exercise regimen, may amplify the effects of another, like taking up meditation. What’s more, the improvements persisted: According to Michael Mrazek, the director of research at the Center for Mindfulness and Human Potential at U.C.S.B. and the study’s lead author, another set of tests six weeks after the experiment’s end showed that the change-everything students still scored much higher than they originally had on measures of fitness, mood, thinking skills and well-being, even though none of them were still exercising or meditating as much as they did during the experiment.

Of course, this study couldn’t isolate which elements of the lifestyle makeover were essential, or how the various changes influenced one another. There were too many moving parts. Dr. Mrazek says that he and his colleagues plan to tackle these issues in future experiments. For now, he says, the results suggest that “the limits of the human capacity for change may be much greater than we, as scientists, have given people credit for.”

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Dr. Thomas Farley Takes on Big Food and Big Tobacco

Dan Deitch

A century ago, most local health departments concentrated their efforts on fighting infectious diseases like cholera, polio and tuberculosis. But today, many health departments have a very different focus: cancer, heart disease and Type 2 diabetes, some of America’s leading killers. Fighting these diseases often means promoting changes in lifestyle and behavior, and no health department has done that more aggressively than New York City’s.

Under former Mayor Michael R. Bloomberg, New York’s health commissioners — first Dr. Thomas R. Frieden, and then Dr. Thomas A. Farley — took on smoking, sugary drinks, sodium, trans fats and binge drinking. Those battles weren’t always successful. A state court struck down the city’s controversial soda tax initiative, and critics complained that New York City was becoming a “nanny” state.

But Dr. Farley, who served as New York’s health commissioner from 2009 to 2014, says the city’s efforts helped demonstrate that the key to eradicating lifestyle-related diseases is by changing environments — making bad choices harder and good ones easier. He makes a case for this approach in his latest book, “Saving Gotham: Billionaire Mayor, Activist Doctors, and the Fight for Eight Million Lives,” which shares the behind-the-scenes story of the Bloomberg administration’s radical approach to fighting chronic disease.

Dr. Farley, who later served as the Joan H. Tisch Distinguished Fellow in Public Health at Hunter College and chief executive of the Public Good Projects, is now the health commissioner of Philadelphia, where earlier this month the mayor proposed a soda tax as a way to fund schools, libraries, and parks and recreation centers. Recently we caught up with Dr. Farley to talk about his book, his battles with the beverage industry and how his approach to public health may have influenced other health departments around the world. Here are edited excerpts from our conversation.

Q.

Why did you write your latest book, “Saving Gotham”?

A.

I wanted to show that there’s a way to fight disease other than through expensive medical care. In the United States, we spend roughly twice as much per capita for medical care as other high-income countries, and our health statistics are close to last. People naturally assume we’re going to solve this problem through medical care. But it doesn’t fit with those statistics. There’s a different approach — a public health approach — that costs very little. The book tells the story of how with using that public health approach we were able to prevent the leading causes of death and save many lives.

Q.

As New York City’s health commissioner you led many public health campaigns. Which had the most impact?

A.

I would say it was our efforts to reduce smoking. During the time of the Bloomberg administration, smoking rates fell by about 25 percent in New York. Since then they’ve fallen by about a third. That’s about 400,000 fewer smokers. And that alone should save thousands if not tens of thousands of lives. At the same time, sugary drink consumption fell by about a third, and heart disease mortality fell by about 40 percent.

Q.

Did these efforts ultimately translate into an increase in life expectancy?

A.

Absolutely. During the Bloomberg years, life expectancy at birth in New York City increased by about 3.2 years. During the same period, life expectancy in the U.S. as a whole increased by 1.8 years. So we were fast outpacing the rest of the country, and that increase in life expectancy was bigger than it was in any other big city in America.

Q.

Some of your health initiatives created a lot of controversy. Where did you find the most resistance?

A.

There was controversy, but most of the resistance came from industry. In the book, I show how some of the biggest risks today are coming from companies that make, sell and market products that over a lifetime make us sick, like cigarettes and sugary drinks.

When New York City passed the smoke-free air rule that made bars and restaurants smoke free, it was a radical idea. And that idea has now spread across most of the U.S. and almost all of Europe — so much so that it’s almost hard to imagine what it would be like to have smoking in a bar or restaurant. The book shows how those good ideas can quickly spread from one city to others, despite resistance from industry.

Q.

The beverage industry says that sugary drink taxes disproportionately hurt the poor economically. How do you respond?

A.

I would say that the poor are disproportionately suffering from obesity and Type 2 diabetes as a consequence of sugary drinks. They drink more sugary drinks now than people who have more money. Because people with lower incomes are more price-sensitive, they will disproportionately benefit from efforts to reduce sugary drink consumption.

Q.

The new soda tax proposal in Philadelphia was presented as a way to generate more revenue for the city, rather than as a “sin tax.” Do you think that will make it more appealing to the public?

A.

This is something that is central to the mayor’s agenda, and I think his way of approaching it is terrific. The revenue from the sugary drink tax will go for pre-K, for what they call community schools — which is providing services for children so they can stay in school and learn — and for rebuilding the city’s parks and recreation centers. All of those preferentially benefit people of lower income in Philadelphia. All of those are very popular and will benefit health over the long term. It’s a great way to match up the benefits of the tax revenue with a source of revenue that is also good for health.

Q.

You have spent a lot of time fighting the beverage industry. Have you seen any change in their response over the years?

A.

The beverage companies understand that they’re going to have to change the way that they do business. And they are making changes — but they’re not making changes fast enough. They still market very heavily these products that are major contributors to our health problems. In the end, they will move only as fast as we push them.

Q.

How did New York’s health initiatives impact the greater public health landscape?

A.

That was another theme I tried to bring out in the book. This is the story of a local health department reinventing itself to take on the biggest health problems of our time. Before the Bloomberg period, most local health departments were seen as organizations that did restaurant inspections and rat control. We showed that local health departments could take on smoking and make a meaningful difference in life expectancy. That model is now being copied by local health departments around the country. And that’s why I think local health departments are where you’re seeing public health innovation right now.

Q.

Are there any common misconceptions about the role of public health agencies that you have tried to dispel?

A.

A thing that people often don’t understand and that I hoped to show in the book is that health is political, but not in the way that most people think. If you ask most reporters about the politics of health, they’re going to talk about Obamacare. But as you saw in the book, the fights we faced over health were with the tobacco industry and with the food industry. I hope people read the book just for the story, because it’s a great story, but that in the end they will have learned the great value of public health.

Few Americans Follow 4 Main Pillars of Heart Health

Most Americans know that a heart-healthy lifestyle includes eating a healthful diet, not smoking, being physically active and keeping weight and body fat down. But a new study found that fewer than 3 percent of American adults could claim all four healthy elements.

Only 2.7 percent of the Americans in the study were nonsmokers who ate a reasonably good diet, including eating plenty of vegetables and whole grains and avoiding saturated fat; got at least 150 minutes of moderate exercise a week; and had a healthy percentage of body fat, defined as up to 20 percent for men and 30 percent for women.

The results were “shocking,” said Ellen Smit, an associate professor at Oregon State University College of Public Health and Human Sciences and the senior author of the report. “I think it’s a wake-up call.”

The study, published in Mayo Clinic Proceedings, was based on data gathered from the National Health and Nutrition Examination Survey from 2003 to 2006 and included a nationally representative sample of 4,745 Americans.

Eating habits were self-reported, which can be unreliable, but other measures were based on objective tests, including blood samples to verify smoking status, a sophisticated X-ray test to determine body fat, and accelerometers to measure physical activity.

 

In Hospitals, Smoke-Free Doesn’t Mean Abuse-Free

James Yang

The substance user and the hospital are bound by the most ambivalent of relationships. Heavy users — of tobacco, alcohol or harder drugs — see far more of the wards than the average citizen and, it is safe to say, like them even less.

They need hospitals. They hate hospitals. Hospitals make them well and sick at the same time. We are their doctors and nurses, their parents, their arresting officers, parole officers, judge and jury. Needless to say, we are not trained for the last five roles, nor are we particularly good at them.

A single principle guides us: You cannot use your drug of choice on our premises, no matter how much you may need it and prefer it to our proffered alternatives. Around that immutable core swirl large clouds of negotiation, compromise, duplicity, manipulation and general misery for all involved.

On some days it seems as if we spend all our energies managing not the conditions we are trained to manage but the addictions that complicate them.

One patient is tying his shoes as we make our rounds in the morning, and tells us cheerfully that he is going out for a smoke. He’ll be right back. We inform him, not without sympathy, that in our hospital smoking breaks are not allowed. If he leaves for even half an hour he will officially be considered discharged. His bed will be given to someone else, and to resume his medical care, he will have to go back to the emergency room and start the cycle all over again.

We propose a nicotine patch instead, but the nurses have already given him a patch, to no effect. Few other compromises are possible between the smoke-free hospital and the hard-core, implacable smoker. The discussion grows heated. We wind up discharging him on the spot, just a little sooner than we had in mind.

The patient in the next room has been in the bathroom for almost an hour. We need to examine him. We knock on the bathroom door. He yells out that he’s fine.

When he finally drifts out, drowsily readjusting the dressing covering the intravenous line in his arm, he doesn’t look fine. He looks as high as a kite, and come to think of it, the two visitors lounging by his bed do, too. We sigh. No easy compromises will be possible for him.

It was back in the 1980s that most American hospitals became officially smoke-free (and cigarette butts began accumulating in stairwells and side exits). The big exceptions were the V.A. hospitals: In fact, theVeterans Health Care Act of 1992 specifically required V.A. facilities to establish designated smoking areas for clients. In 2008, those areas were all moved outdoors, and most V.A. hospitals still have them.

This policy has been bitterly criticized as the worst kind of tobacco industry manipulation, but it does serve a useful function: It allows medical care to proceed without major interruption. Granted, that care is often for tobacco-related conditions, a cycle that strikes some observers as a common-sense, harm-reduction approach to the real world, and others as completely insane.

Still, smokers pose fewer challenges than intravenous drug users, like that young man who wandered out of his bathroom to face our interrogation. He has an infected heart valve, and is receiving high doses of antibiotics through an intravenous line in his arm, a portal to his bloodstream that is apparently proving too tempting for him to ignore.

He needs antibiotic treatment, and we have no oral options for him. Among other considerations, if his guests keep providing him with substances to shoot into that line, it may well become infected and unusable, and he will get even sicker than he is.

He promises never to do it again.

So now what? We have a set of programmed responses, none particularly satisfying or effective.

We can give him some methadone to keep him from withdrawing. We can screen his visitors or post a watcher at his bedside. Some hospitals transfer patients like him to an expensive intensive care bed for even more careful monitoring. Some make contracts and threaten to kick patients out for violations. (Can we really kick them out, as desperately sick as they are? I’ve never actually seen that happen.)

Addiction experts point out that hospitalizations offer an excellent opportunity to urge addicts into treatment. Unfortunately, inpatient acute care hospital wards are spectacularly ill equipped to provide that treatment, which would require a specially trained, dedicated team of medical and mental health professionals able to treat infection and addiction at the same time, in the same bed, on the same premises. It doesn’t sound like a particularly expensive proposition, but it must be one, because it’s another thing I’ve never seen happen.

Instead, we routinely plan for patients to be transferred to drug treatment programs when they are discharged. Quite a few don’t last that long. Our patient will prove to be one of them: After a few more days, he will suddenly be gone, well enough to walk out of the hospital (and take his intravenous line with him).

Presumably, he will try to make it out in the world until he gets too sick and lands in another hospital, where events will repeat themselves in yet another baffling health care cycle.

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