A few weeks ago I happened across a news release from the American Heart Association that caught my attention. On an annual basis the AHA publishes its own top ten list (who doesn’t?) of the most influential research publications of the year. This year’s registry included the usual basic science papers with names that range from the arcane (“Circulating transforming growth factor-β in Marfan syndrome”) to the nearly unpronounceable (“Functional cardiomyocytes derived from human induced pluripotent stem cells”). In case you missed the purpose of the latter study, the authors package it up for you in a tidy soundbite: “The aim of this study was to characterize the cardiac differentiation potential of human iPS cells generated using OCT4, SOX2, NANOG, and LIN28 transgenes compared to human embryonic stem (ES) cells.” Oh, so that’s it?

I’m not knocking these studies—I’m not sure I’m even smart enough to read them—I just found that I gravitate more toward research that has direct application to my daily patient interactions.  One study in particular caught my eye and I was pleased to see it make the AHA’s top ten.  I had read it when in was published in September and was somewhat surprised at the findings.

Researchers studied the rate for heart attacks in three separate communities in the United States: New York state, Bowling Green, Ohio, and Pueblo, Colorado.  As far as I can tell, the only thing these three locales had in common was the precise reason they were put under the microscope: within the last few years their local legislators had passed strong laws that limited in public places such as restaurants and places of employment.  The authors observed a 15% drop in the number of heart attacks in the first year after the ban was put into effect and this decline only steepened with time.  After three years the rate of heart attacks among the general population had plummeted by 36%.

Didn’t we already know this?  Is this really news?  After all, the National Health and Nutrition Examination Survey measured nicotine levels among non adults and found that only 13% of those living in regions with bans tested positive compared to 46% living in jurisdictions without legislation.  In 2006 the Surgeon General’s office devoted an entire annual publication to exposing the deleterious effects of secondhand smoke.

What’s different about this study, and why it is so important, is that this is the first real proof we have directly linking treatment (banning in public places) to effect (decreasing heart attacks).  Yes, indeed, curbing the freedom of smokers to light up within the confines of an office or a restaurant not only enhances the pleasantness of the environment, it also directly impacts the health of those nearby.  And passing a law that pushes the smoker into the well-vented outdoors produces a real, measurable, and immediate effect on the risk of heart attack among the broader population.  It’s this kind of direct evidence that really moves the opinion of those in a position to enact public policy.

In June of last year Omaha enacted its own ban on in public confines.  The local paper’s editorials were filled with tirades about the loss of freedom imposed by this draconian edict.  These letters came from tobacco’s most valued customers who vow to never give up the habit and don’t see the problem with the rest of us sucking in a few fumes now and again.

But I maintain that freedom from undeserved heart attacks and death is more important to our society than is the freedom to light up whenever and wherever you’d like.  It sounds like communities in New York, Ohio and Colorado believe the same and are now reaping the rewards of their decision.

I was recently reading an article published in the British Journal of Medicine in 1987 on the history of coronary care units.  As you may know, the coronary (or cardiac) care unit (CCU) is the specialized ward of the hospital where patients with cardiac problems are closely monitored and intensively treated.  They are staffed by experienced nurses and monitored around the clock by technicians trained in recognizing heart rhythm problems.  The concept of the CCU is now so commonplace that it’s hard to imagine a time when it was considered revolutionary.

The CCU was developed in the 1960s in response to a rise in the perceived incidence of coronary artery disease and heart attacks.  Prior to World War II most of our civilian health casualties were victims of infectious diseases such as tuberculosis and pneumonia.  The recognized heart problems were principally those involving congenital abnormalities and acquired valvular problems (acute rheumatic fever).  In the entire year of 1959 only six articles in the British Heart Journal centered on coronary artery disease.  People were simply too busy dying from other things to bother themselves with heart attacks.

The advent of antibiotics, good nutrition, and workplace safety led the way for people to live long enough to develop coronary atherosclerosis.  Unfortunately there wasn’t much anyone could really do about it.  The mainstay therapy for a heart attack in the 1960s was to simply let the disease runs it’s course and offer bypass surgery only if the patient survived long enough to develop chronic chest pain.  Consider this quote cited in the BJM article by the early CCU advocate Gunnar Biörck:

“There are few diseases in the sphere of internal medicine where the average mortality during four to six weeks hospitalization is over 30%, and if the patients with shock are particularly considered, the figure is more than twice as large.”

Imagine that—30% death rate among heart attack patients (over 60% if the patient presents with shock)!  It was out of the recognition of this abysmal survival statistic that the concept of the CCU was born. 

As time progressed the medical community began to recognize the importance of aggressive therapies to restore blood flow to the blocked artery.  In the early 1970s the median time from the onset of symptoms to the initiation of therapy (at the time it was mainly nitroglycerin, oxygen and morphine) was greater than 8 hours.  These days the standard of care dictates that we reestablish blood flow within the first 90 minutes of the patient entering the emergency department.  It’s not unusual to have a patient resting in a CCU bed—having already undergone successful placement of a coronary stent—within an hour after presenting with chest pain.

Bear this historical progression in mind as I relate a conversation I recently had with a young man who came to our hospital with a heart attack.  When I met him in the emergency department he was sweaty and pale, wide-eyed with fear.  His EKG showed abnormalities reflective of a significant heart attack.  Because he came in during the day we were able to whisk him into the catheterization lab with very little delay and open his occluded artery.

The following morning, as I exhorted him to give up his cigarette habit, he interrupted me to share his thoughts on the need for change in his health habits:

“I don’t need to quit .  This heart attack thing was a piece of cake. I figure if this happens again I’ll just come in here and you guys will take care of it just like you did yesterday.  By the way, when can I go home?”

I have to admit I couldn’t fault his logic even if his level of understanding was sorely deficient.  Dr. Biörck in the quote above spoke of a “four to six weeks hospitalization” as the norm for patients with heart attacks.  In the 1950s and 60s the average cardiac patient would lounge around the hospital for weeks with strict instructions to engage in no more exertion than was required to summon the pinafore-clad nurse for his daily constitutional.  The hard-driving business executive laid low by a coronary event would spend months away from the office as he recuperated amid doting family members.  Manual laborers would find themselves permanently disabled and incapable of resuming their usual employment.

Now, as suggested by my impulsive patient, it’s a totally different world.  These days, thanks to advances in coronary reperfusion (angioplasty, stents, bypass surgery), medications (beta-blockers, statins, aspirin), and aggressive early detection and treatment standards, we’ve chopped Dr. Biörck’s 4 to 6 weeks down to a mere 48 hours. 

Of course, this is all a very good thing and we should be nothing short of ecstatic that a heart attack is no longer the death sentence that it was 50 years ago.  I just wish sometimes that a few of my patients would get a little more spooked over the whole ordeal, that they would recognize this experience as a brief introduction to their own mortality and sincerely commit to the changes they need to make.

I was rummaging through my old medical school texts the other day and came across an antique book that came from my father’s old collection. How to Keep Well, authored by Dr. Albert F. Blaisdell and originally sold in 1897 for the staggering sum of 45 cents, contained a lengthy recitation on the subject of tobacco use. Having often heard of the medical establishment’s early embrace of I expected to find paragraphs extolling the merits of cigarettes: strengthening the constitution, regulating the bowels, purging evil humors—that sort of thing.

Instead I found passages that are anything but laudatory:

“The use of cigarettes cannot be too severely condemned.  Cigarettes are so common and so cheap that their use to an injurious extent by thousands of young people is becoming a very serious matter.  Tobacco often produces palpitation of the heart, certain forms of dyspepsia, irritation of the throat and lungs, and a general breaking-up of the nervous system.”

The link between cigarette and lung cancer was first made in a 1950 report in the British Journal of Medicine.  Fourteen years later the surgeon general’s office began stamping the now ubiquitous warnings on the sides of cigarette cartons.  From that point on we’ve been inundated with a slew of public service campaigns, educational initiatives and tobacco cessation programs.

Here’s my confusion.  It’s pretty clear to me that medical professionals from Dr. Blaisdell in 1897 to C. Everett Koop in 1984 have done a pretty darn good job of educating us Americans on the dangers of .  I’d be willing to wager that you couldn’t find a single man, woman or child in this country who doesn’t know that will kill you.  How is it, then, that people—especially teenagers—ignore all they know and take up the habit?  It certainly can’t be that we haven’t educated them enough.  What is it?

Here are some sobering facts about cigarette use among teens (courtesy of the American Lung Association):

• According to a 2001 national survey of high school students, the overall prevalence of current cigarette use is about 28 percent.
• Half of adults who smoke were regular smokers by their 18th birthday, and 90 percent started by the age of 21.  The average age of daily initiation for new smokers in 2006 was 19 years.
• People who begin at an early age are more likely to develop a severe addiction to nicotine than those who start at a later age. Of adolescents who have smoked at least 100 cigarettes in their lifetime, most of them report that they would like to quit, but are not able to do so.
• Half of teenage smokers who are unable to quit will ultimately die from their habit.

I guess I just don’t see the allure and romance in sucking tar and carcinogens into your lungs, especially if you know that you stand a good chance of someday dying a horrible miserable death from it, not to mention the stale, stagnant stench that you emanate while you’re still alive.

Dr. Blaisdell got it right with this last part on what he calls “the use of tobacco from a moral point of view”:

“Tobacco has the power, through its effect upon the brain and nerves, to deaden the user’s affection for his family and friends as well as his sense of politeness, or propriety as to the rights of others.  All have a right to pure air to breathe.

“The smoker puffs his tobacco smoke into the faces of people on the street-cars and the ferries, in waiting-rooms, hotels, and places of amusement, regardless of the fact that it may be very disagreeable to others.”

In the end I’m not sure that more education will fix the problem of kids taking up .  One thing that might help is a good example set by parents, especially those of you who are smokers.  Show your children that good health is a vital part to a happy life by kicking the habit now instead of when your heart and lungs are already in decay.  Put your knowledge into action and be an example of good living.

I think it’s time we start applying the good advice we were given 112 years ago.

If you were to spend the next twenty years two packs of cigarettes a day you would be entering into a habit that 45 million other Americans (roughly 20% of the adult population) engage in.  During the course of the next two decades you would spend somewhere around $55,000 (based on the average price of cigarettes today and not accounting for inflation or rise in taxes) and have nothing more to show for it than yellow teeth, a smoker’s cough, and a dramatically increased risk of stroke, heart attack, cancer, and emphysema.  The 55 grand that you will have spent represents only the direct, out-of-pocket cost, and doesn’t take into account the indirect financial burden your habit will have on the healthcare system.  You will be paying higher premiums to your insurance company, and they would in turn be paying higher bills to your doctors, hospitals and pharmacies.  It costs a lot of money to treat chronic heart and lung disease.

Of course, you could prevent all this by not taking up the habit at all.  If you already smoke, you could save yourself a lot of money and misery by quitting today.  It would take determination, fortitude, and persistence.  Given the high financial toll affixed to a lifetime of cigarette use you’d think that your insurance company would jump at the chance to nip the habit in the bud with a therapy that costs only a few hundred dollars.      

Chantix (varenicline) is a relatively new medication (available since August 2006) that has done more for cessation that any previously developed drug.  While there’s no such thing as a magic bullet to help people kick the habit, Chantix is about as close as we’ve ever had.  In the largest study of tobacco cessation, the use of Chantix increased the participants’ chance of remaining smoke-free by three-fold when compared to other conventional methods.

The drug isn’t cheap, though.  A month’s worth of therapy runs about $120 and most patients are encouraged to stay on the drug for 90 days.  Still, $360 seems like a bargain if you compare it to the sums of money I described above.  You’d think insurance companies would fall over themselves trying to provide this for their patients, wouldn’t you?  Think again.

My experience is that the insurance providers here in Omaha almost universally deny coverage for Chantix and require that patients pay out of pocket if they want to fill the prescription.  This sort of shortsightedness bothered me for a while, but after I put some thought to it I’ve come to the conclusion that I’m glad insurance companies don’t cover it and I hope they never do.

Right now most smokers I speak to have heard of Chantix and are under the impression that it is effective.  There is a certain amount of spontaneous word-of-mouth advertising among smokers that leads them to assume a better efficacy than is perhaps realistic. As I offer them a prescription for the medication I find that each patient reacts in one of two fairly predictable ways. 

1. “Insurance doesn’t cover it?  I can’t afford $120 a month for a pill.  Forget it.”
   
   
2. “Insurance doesn’t cover it?  No problem.  I’m already spending $120 a month on cigarettes anyway, and if I can quit I’ll save all kinds of money down the road.  Sure I’ll take the prescription.”

My belief is that the requirement for out-of-pocket payment screens out those patients who are not really serious about quitting , leaving only those who will make an honest effort.  This biases the population who receives the drug and selects for people who are more likely to be successful at giving up tobacco.  In turn, the “word on the street” is that the drug is highly effective with few failures.

I’d like to keep it this way.  I’d like people to continue to believe that Chantix is going to work for them if they are serious enough about quitting that they are willing to part with their own cash.  I don’t want the public perception of Chantix watered down by a lot of treatment failures among patients who are ambivalent about quitting, but who take the drug because it is free to them.

A couple of other issues about Chantix to keep in mind:

1. On July 2 the New York Times reported that experts at the FDA are raising concerns about Chantix.  Federal drug regulators warned that patients taking Chantix “should be watched closely for signs of serious mental illness, as reports mount of suicides among the drugs’ users.”  I don’t really know what to make of this but I plan to continue to offer Chantix to willing patients.  I’ll probably ask patients with a history of depression to clear this therapy with their primary doctors prior to initiation.
   
   
2. A moderate number of patients on Chantix report gastrointestinal side effects.  Most of the symptoms are tolerable and worth the effort if the patient can stick with the medication.  Here’s a good resource to read up on the use of Chantix and its potential side effects.

On an unrelated note, I’d like to make you aware of a service our clever web experts offer with our cardiology blog.  Click here and you’ll be able to sign up to have this blog sent to you via email whenever a new article is posted.  As always, I encourage you to submit comments and questions about any post you find interesting (if you find nothing I say interesting you can comment on that, too).