Thwarting science by protecting the received wisdom on tobacco addiction from the scientific method

In their commentary, Dar and Frenk call into question the validity of all published data that describe the onset of nicotine addiction. They argue that the data that describe the early onset of nicotine addiction is so different from the conventional wisdom that it is irrelevant. In this rebuttal, the author argues that the conventional wisdom cannot withstand an application of the scientific method that requires that theories be tested and discarded when they are contradicted by data. The author examines the origins of the threshold theory that has represented the conventional wisdom concerning the onset of nicotine addiction for 4 decades. The major tenets of the threshold theory are presented as hypotheses followed by an examination of the relevant literature. Every tenet of the threshold theory is contradicted by all available relevant data and yet it remains the conventional wisdom. The author provides an evidence-based account of the natural history of nicotine addiction, including its onset and development as revealed by case histories, focus groups, and surveys involving tens of thousands of smokers. These peer-reviewed and replicated studies are the work of independent researchers from around the world using a variety of measures, and they provide a consistent and coherent clinical picture. The author argues that the scientific method demands that the fanciful conventional wisdom be discarded and replaced with the evidence-based description of nicotine addiction that is backed by data. The author charges that in their attempt to defend the conventional wisdom in the face of overwhelming data to the contrary, Dar and Frenk attempt to destroy the credibility of all who have produced these data. Dar and Frenk accuse other researchers of committing methodological errors and showing bias in the analysis of data when in fact Dar and Frenk commit several errors and reveal their bias by using a few outlying data points to misrepresent an entire body of research, and by grossly and consistently mischaracterizing the claims of those whose research they attack

Can tobacco dependence provide insights into other drug addictions

Within the field of addiction research, individuals tend to operate within silos of knowledge focused on specific drug classes. The discovery that tobacco dependence develops in a progression of stages and that the latency to the onset of withdrawal symptoms after the last use of tobacco changes over time have provided insights into how tobacco dependence develops that might be applied to the study of other drugs. As physical dependence on tobacco develops, it progresses through previously unrecognized clinical stages of wanting, craving and needing. The latency to withdrawal is a measure of the asymptomatic phase of withdrawal, extending from the last use of tobacco to the emergence of withdrawal symptoms. Symptomatic withdrawal is characterized by a wanting phase, a craving phase, and a needing phase. The intensity of the desire to smoke that is triggered by withdrawal correlates with brain activity in addiction circuits. With repeated tobacco use, the latency to withdrawal shrinks from as long as several weeks to as short as several minutes. The shortening of the asymptomatic phase of withdrawal drives an escalation of smoking, first in terms of the number of smoking days/month until daily smoking commences, then in terms of cigarettes smoked/day.The discoveries of the stages of physical dependence and the latency to withdrawal raises the question, does physical dependence develop in stages with other drugs? Is the latency to withdrawal for other substances measured in weeks at the onset of dependence? Does it shorten over time? The research methods that uncovered how tobacco dependence emerges might be fruitfully applied to the investigation of other addictions

Symptoms of Diminished Autonomy over Cigarettes with Non-Daily Use

Data from a nationally representative sample of smokers (ages 12–22 years, n=2,091) was examined to investigate the prevalence of symptoms of diminished autonomy over cigarettes. Six symptoms were assessed: failed cessation, smoking despite a desire to quit, and a need or urge to smoke, irritability, restlessness, or disrupted concentration attributed to nicotine withdrawal. One or more of the six symptoms were present in 18.9% of subjects who smoked less often than once per week. Among subjects who had not smoked 20 cigarettes in their lifetime, 12.6% had symptoms of nicotine withdrawal, and 25% had made an unsuccessful quit attempt

Revue systématique d’essais comparatifs randomisés d’interventions d’abandon du tabac chez les jeunes

Contexte : Bien que l’usage de la cigarette demeure courant parmi les jeunes, on en sait encore bien peu sur la façon de les aider à cesser de fumer. Seulement quelques revues systématiques d’essais comparatifs randomisés (ECR) ont évalué l’efficacité des interventions d’abandon du tabac chez les jeunes.Objectif : Résumer les connaissances sur l’efficacité des interventions visant à aider les jeunes à cesser de fumer en se basant sur des données probantes provenant d’ECR.Sélection des études et extraction des données : Nous avons retenu tous les ECR publiés qui évaluaient les interventions d’abandon du tabac ciblant les jeunes âgés de 20 ans et moins et qui rapportaient l’abstinence au tabac selon une analyse en intention de traiter. Nous avons relevé les études pertinentes provenant de huit revues de synthèse décrivant des études portant sur des interventions d’abandon du tabac publiées entre 2002 et 2006, ainsi qu’une recherche menée dans les bases de données PubMed et PsycINFO entre 2001 et novembre  2006. Nous rapportons l’abstinence au tabagisme au moment du suivi le plus prolongé. Les auteurs ont sélectionné d’un commun accord les données retenues pour cette revue.Résultats : Nous avons identifié 16 ECR auxquels ont participé 6 623 jeunes ; 11 études évaluant des interventions comportementales qui comprenaient 5 764 participants; quatre examinant des interventions pharmacologiques qui comptaient 529 participants ; et une se penchant sur l’acupuncture au laser qui comportait 330 participants. Trois interventions comportementales menées en milieu scolaire sur quatre et une intervention réalisée en milieu de soins de santé sur quatre ont fait augmenter de façon significative l’abstinence au tabac, quatre semaines à 24 mois suivant les interventions. Parmi les quatre ERC qui évaluaient les interventions pharmacologiques réalisées à l’aide soit de bupropion, de timbres ou de gommes à la nicotine, une étude, où le timbre à la nicotine a été utilisé en combinaison avec un counseling cognitivo-comportemental, a montré une hausse marquée, quoique non significative, de l’abstinence six mois après la date d’abandon.Conclusion : Il existe encore peu de preuves démontrant l’efficacité des interventions d’abandon du tabac chez les jeunes. Quatre programmes en milieu scolaire et une intervention dans un établissement de santé ont mis en évidence une certaine efficacité, tandis que pour la thérapie pharmacologique, les résultats ne sont pas encore concluants.Background: Cigarette use remains common among young people but little is known about how to help adolescent smokers quit. There are few systematic reviews of randomized controlled trials (RCTs) that evaluate the effectiveness of cessation interventions for youth.Objective: To synthesize knowledge on the effectiveness of cessation interventions targeted to youth based on evidence from RCTs.Selection of studies and data extraction: We retained all published RCTs with intention to treat analyses that evaluated cessation interventions targeted to youth aged ≤ 20 years. Relevant studies were identified from eight review articles of smoking cessation intervention studies published between 2002 and 2006, and from a search conducted in PubMed and PsycINFO databases from 2001 to November 2006. The outcome of primary interest was abstinence at the longest reported follow-up. Extraction of data was by consensus of the authors. Results: We identified 16 RCTs with a total of 6623 participants; 11 studies that included 5764 participants evaluated behavioural interventions, four with 529 participants evaluated pharmacological interventions, and one with 330 participants evaluated a laser acupuncture intervention. Three of four behavioural interventions conducted in school settings, and one of four conducted in a health care setting significantly increased abstinence four weeks to 24 months after the interventions. Of four RCTs that evaluated pharmacological interventions using either bupropion or nicotine patch or gum, one study using the nicotine patch coupled with cognitive-behavioural counselling showed a marked albeit non-significant increase in abstinence six months after quit date.Conclusion: There is still limited evidence demonstrating the efficacy of smoking cessation interventions in youth. Four school-based programs and one intervention in a health care setting have shown efficacy, while results for pharmacological therapy are inconsistent across studies.Contexto: si bien el tabaco sigue siendo de uso corriente entre los jóvenes, todavía no se sabe mucho sobre cómo ayudarlos a dejar de fumar. Solamente algunas revisiones sistemáticas de ensayos comparativos aleatorizados han evaluado la eficacia de las intervenciones dirigidas a lograr el abandono del tabaco entre los jóvenes.Objetivo: resumir los conocimientos sobre la eficacia de las intervenciones destinadas a ayudar a jóvenes a dejar de fumar sobre la base de los datos probados de los ensayos comparativos aleatorizados.Selección de estudios y extracción de datos: hemos retenido todos los ensayos comparativos aleatorizados publicados, que evalúan las intervenciones de abandono del tabaco en los jóvenes de 20 años y menos, y que informan sobre la abstinencia de tabaco, según un análisis que tiene la intención de tratar. Hemos seleccionado los trabajos pertinentes provenientes de ocho revistas de síntesis, que describen estudios referidos a intervenciones de abandono del tabaco publicados entre 2002 y 2006, así como una investigación llevada a cabo en las bases de datos PubMed et PsycINFO, realizada entre 2001 y noviembre de 2006. Informamos sobre la abstinencia del tabaquismo en el momento de seguimiento más prolongado. Los autores han seleccionado de común acuerdo los datos retenidos por esta revista.Resultados: hemos identificado dieciséis estudios comparativos aleatorizados en los que participaron 6.623 jóvenes; once estudios que evalúan las intervenciones comportamentales, con 5.764 participantes; cuatro que examinan las intervenciones farmacológicas en las que intervienen 529 participantes y uno que se centra en la acupuntura al láser, con 330 participantes. Tres intervenciones comportamentales realizadas en medio escolar de cada cuatro y una intervención realizada en el medio de la atención sanitaria de cada cuatro, aumentaron de manera significativa la abstinencia al tabaco, cuatro semanas a 24 meses después de las intervenciones. Entre los cuatro estudios comparativos aleatorizados que evaluaban las intervenciones farmacológicas, realizadas ya sea con ayuda de bupropion, de parches o de gomas de mascar a la nicotina, uno de ellos, en el que se utilizó un parche de nicotina en combinación con orientación psicológica cognitivo-comportamental, indicó un aumento marcado, aunque no significativo, de la abstinencia, seis meses después de la fecha de abandono.Conclusión: existen todavía pocas pruebas que demuestren la eficacia de las intervenciones de abandono del tabaco entre los jóvenes. Cuatro programas en medio escolar y una intervención en un establecimiento de salud evidenciaron una cierta eficacia, mientras que los resultados no son todavía concluyentes en lo que se refiere a la terapia farmacológica

Enforcement of underage sales laws as a predictor of daily smoking among adolescents – a national study

<p>Abstract</p> <p>Background</p> <p>With a goal to reduce youth smoking rates, the U.S. federal government mandated that states enforce laws prohibiting underage tobacco sales. Our objective was to determine if state compliance with tobacco sales laws is associated with a decreased risk of current daily smoking among adolescents.</p> <p>Methods</p> <p>Data on tobacco use were obtained from a nationally representative sample of 16,244 adolescents from the 2003 Monitoring the Future survey. The association between merchant compliance with the law from 1997–2003 and current daily smoking was examined using logistic regression while controlling for cigarette prices, state restaurant smoking policies, anti-tobacco media, and demographic variables.</p> <p>Results</p> <p>Higher average state merchant compliance from 1997–2003 predicted lower levels of current daily smoking among adolescents when controlled for all other factors. The odds ratio for daily smoking was reduced by 2% for each 1% increase in merchant compliance. After controlling for price changes, media campaigns and smoking restrictions, a 20.8% reduction in the odds of smoking among 10^thgraders in 2003 was attributed to the observed improvement in merchant compliance between 1997 and 2003. A 47% reduction in the odds of daily smoking could be attributed to price increases over this period.</p> <p>Conclusion</p> <p>Federally mandated enforcement efforts by states to prevent the sale of tobacco to minors appear to have made an important contribution to the observed decline in smoking among youth in the U.S. Given similar results from long-term enforcement efforts in Australia, other countries should be encouraged to adopt the World Health Organization Framework on Tobacco Control strategies to reduce the sale of tobacco to minors.</p

Systematic literature review assessing tobacco smoke exposure as a risk factor for serious respiratory syncytial virus disease among infants and young children

BACKGROUND: The role of environmental tobacco smoke (ETS) exposure as a risk factor for serious respiratory syncytial virus (RSV) disease among infants and young children has not been clearly established. This systematic review was conducted to explore the association between ETS exposure and serious RSV disease in children younger than 5 years, including infants and young children with elevated risk for serious RSV disease. METHODS: A systematic review of English-language studies using the PubMed and EMBASE databases (1990-2009) was performed to retrieve studies that evaluated ETS as a potential risk factor for serious RSV illness. Studies assessing risk factors associated with hospitalization, emergency department visit, or physician visit due to RSV (based on laboratory confirmation of RSV or clinical diagnosis of RSV) in children under the age of 5 years were included. RESULTS: The literature search identified 30 relevant articles, categorized by laboratory confirmation of RSV infection (n = 14), clinical diagnosis of RSV disease (n = 8), and assessment of RSV disease severity (n = 8). Across these three categories of studies, at least 1 type of ETS exposure was associated with statistically significant increases in risk in multivariate or bivariate analysis, as follows: 12 of 14 studies on risk of hospitalization or ED visit for laboratory-confirmed RSV infection; 6 of 8 studies of RSV disease based on clinical diagnosis; and 5 of the 8 studies assessing severity of RSV as shown by hospitalization rates or degree of hypoxia. Also, 7 of the 30 studies focused on populations of premature infants, and the majority (5 studies) found a significant association between ETS exposure and RSV risk in the multivariate or bivariate analyses. CONCLUSION: We found ample evidence that ETS exposure places infants and young children at increased risk of hospitalization for RSV-attributable lower respiratory tract infection and increases the severity of illness among hospitalized children. Additional evidence is needed regarding the association of ETS exposure and outpatient RSV lower respiratory tract illness. Challenges and potential pitfalls of assessing ETS exposure in children are discussed

"May I Buy a Pack of Marlboros, Please?" A Systematic Review of Evidence to Improve the Validity and Impact of Youth Undercover Buy Inspections

Most smokers become addicted to tobacco products before they are legally able to pur- chase these products. We systematically reviewed the literature on protocols to assess underage purchase and their ecological validity. We conducted a systematic search in May 2015 in PubMed and PsycINFO. We independently screened records for inclusion. We con- ducted a narrative review and examined implications of two types of legal authority for proto- cols that govern underage buy enforcement in the United States: criminal (state-level laws prohibiting sales to youth) and administrative (federal regulations prohibiting sales to youth). Ten studies experimentally assessed underage buy protocols and 44 studies assessed the association between youth characteristics and tobacco sales. Protocols that mimicked real-world youth behaviors were consistently associated with substantially greater likelihood of a sale to a youth. Many of the tested protocols appear to be designed for compliance with criminal law rather than administrative enforcement in ways that limited ecological validity. This may be due to concerns about entrapment. For administrative enforcement in particular, entrapment may be less of an issue than commonly thought. Commonly used underage buy protocols poorly represent the reality of youths' access to tobacco from retailers. Compliance check programs should allow youth to present them- selves naturally and attempt to match the community’s demographic makeup