My eyes are drawn to eco-friendly packaging when I shop for
groceries. It is how I pick my laundry detergent, dish soap and many other
products from the litany of options. But I’ve learned to double-check whether
these items are actually better for the environment, because there are a lot of
misleading labels.
Companies know that pro-environmental marketing works. A new
Stanford study shows
it is even effective for cigarettes.
The researchers surveyed over 900 adults on their perception
of two major cigarette brands: Pall Mall and Natural American Spirit. Pall Mall
is marketed as a discount brand, while Natural American Spirit is marketed as environmentally
friendly. For instance, the Natural American Spirit’s “Respect the Earth” campaign
advertises a “zero-waste-to-landfill” facility and uses a logo with three
tobacco leaves that mimics the recycling symbol.
The study participants were a mixture of current smokers,
former smokers and people who have never smoked. All three groups consistently
ranked Natural American Spirit cigarettes as being healthier and better for the
environment than the Pall Mall cigarettes.
“Ecofriendly and natural food products are seen as safer for health,” said the study lead author Anna Epperson, PhD, a postdoctoral fellow with the Stanford Prevention Research Center, in a recent Stanford news release. “That couldn’t be farther from the truth when it comes to cigarettes.”
Both brands are actually manufactured by the same company,
Reynolds American. And they have the same health
impacts, including a significantly higher risk of heart disease, cancer and
chronic obstructive pulmonary disease. They are also commonly discarded, resulting
in toxic chemicals leaching into the soil and water supplies.
“All commercially available cigarettes will kill more than half of long-term users if smoked as intended. Marketing language that obscures these health harms, even indirectly through questionable pro-environment claims, ought to be prohibited,” the study authors concluded.
This warning may be particularly important to the San Francisco Bay Area and other pro-environment and pro-health regions, where Natural American Spirit cigarettes are especially popular according to Epperson.
Nathaniel Morris, MD, a resident in psychiatry at Stanford, said he learned almost nothing about marijuana during medical school. Its absence made some sense, he explained in a recent JAMA Internal Medicineeditorial: why focus on marijuana when physicians must worry about medical emergencies such as cardiac arrest, sepsis, pulmonary embolisms and opioid overdoses?
However, marijuana use has dramatically changed in the few years since he earned his medical degree, he pointed out. Thirty-three states and Washington, D.C. have now passed laws legalizing some form of marijuana use, including 10 states that have legalized recreational use. And the resulting prevalence of marijuana has wide-ranging impacts in the clinic.
“In the emergency department, I’ve come to expect that results of urine drug screens will be positive for tetrahydrocannabinol (THC), whether the patient is 18 years old or 80 years old,” he said in the editorial. “When I review medications at the bedside, some patients and families hold out THC gummies or cannabidiol capsules, explaining dosages or ratios of ingredients used to treat symptoms, including pain, insomnia, nausea, or poor appetite.” He added that other patients come to the ED after having panic attacks or psychotic symptoms and physicians have to figure out whether marijuana is involved.
Marijuana also impacts inpatient units. Morris described that some patients smuggle in marijuana and smoke in their rooms, while others who abruptly stop their use upon entering the hospital experience withdrawal symptoms like sleep disturbances and restlessness.
The real problem, he said, is that many physicians are unprepared and poorly educated about marijuana and its health effects. This is in part because government restrictions have made it difficult to study marijuana, so there is limited research to guide clinical decisions.
Although people have used marijuana to treat various health conditions for years, the U.S. Food and Drug Administration (FDA) has not approved the cannabis plant for treating any health problems. The FDA has approved three cannabinoid-based drugs: a cannabidiol oral solution used to treat a rare form of epileptic seizures and two synthetic cannabinoids used to treat nausea and vomiting associated with cancer chemotherapy or loss of appetite in people with AIDS.
In January 2017, the National Academies of Science, Engineering, and Medicine published a report that summarizes the current clinical evidence on the therapeutic effects and harmful side effects of marijuana products. However, more and higher quality research is needed, Morris said.
Physicians also need to be educated about marijuana through dedicated coursework in medical school and ongoing continuing medical education activities, he said. Morris noted that physicians should receive instruction pertinent to their fields — such as gastroenterology fellows learning about marijuana’s potential effects on nausea or psychiatry residents learning about associations between marijuana and psychosis.
“These days, I find myself reading new studies about the health effects of marijuana products, attending grand rounds on medical marijuana, and absorbing tips from clinicians who have more experience related to marijuana and patient care than I do,” Morris said. “Still, I suspect that talking with patients about marijuana use and what it means to them will continue to teach me the most.”
This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.
The book brings together an interdisciplinary group of scholars — including Stanford editors Matthew Kohrman, PhD, a professor of anthropology, and Robert Proctor, PhD, a professor of history. Together the team has investigated how transnational tobacco companies have worked to triple the world’s annual cigarette consumption since the 1960s. They focus on the China National Tobacco Corporation, which currently produces forty percent of cigarettes sold globally.
In a recent Freeman Spolgi Institute Q&A, Kohrman discusses how he got involved in this work. “When I began my ethnographic fieldwork on tobacco in China, I initially studied mostly consumer behavior. But I quickly realized that focusing solely on cigarette consumption, without considering the relationship between supply and demand, was like studying obesity while ignoring food,” he says.
Kohrman explains that cigarettes have become the single greatest cause of preventable death in the world today and the problem is getting worse. “Instead of declining as we would expect based on our impressions living here in California, the number of daily cigarette smokers around the world is projected to continue climbing,” he says. In particular, he explains the big tobacco companies are targeting less-educated people from lower- and middle-income countries.
Kohrman does offer some hope in light of the Chinese government’s recent initiatives to restrict tobacco advertising and smoking in public places. But he says that there is a lot more work to do.
“The road towards comprehensive tobacco prevention in China is going to be a long one,” Kohrman concludes.
This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.
Alcoholics struggling to stay sober are faced with countless triggers that can lead to relapse — driving past a bar, getting together with former drinking buddies or even just feeling down.
And this is a big problem. Alcoholism is a growing epidemic responsible for at least a quarter trillion dollars in US health care costs per year, as well as inestimable anguish. Current medical therapies suffer from high rates of noncompliance and variable effectiveness.
In the future, severe alcoholics with multiple failed attempts at intensive medical therapies and in-patient rehabilitation may have a different treatment option for their addiction — deep brain stimulation (DBS) — as recently reported in a review article by Stanford researchers in Neurosurgical Focus.
Currently, deep brain stimulation therapy for alcohol use disorders is not approved by the U.S. Food and Drug Administration, but it is widely used to treat Parkinson’s disease and obsessive-compulsive disorder.
“DBS is a minimally-invasive brain surgery,” explained senior author Casey Halpern, MD, an assistant professor of neurosurgery at Stanford. “For Parkinson’s, we place deep brain stimulators to restore normal function of the region in the brain known to be dysfunctional. Patients improve immediately when a small dose of current is delivered to this area. We anticipate a similar treatment will be possible for alcoholism. At the moment, we’re performing animal studies to optimize this potential therapy and to learn its underlying mechanism of action.”
For alcohol use disorders, researchers are targeting the nucleus accumbens, which plays a central role in the brain’s reward circuitry. They previously found that brain stimulation of this region could reduce impulsive behavior.
“The nucleus accumbens is triggered when patients anticipate a reward or prior to completing a rewarding behavior. It’s been shown to be perturbed in both addictive disorders and OCD,” said Allen Ho, MD, a Stanford neurosurgery resident working with Halpern. “By targeting this brain structure with stimulation, we hope to modulate the reward circuit in the brain to help patients resist the temptation to indulge in a binge and other addictive behaviors.”
The review article outlines extensive animal studies and pilot human subject studies have shown promising reductions in alcohol consumption and, in some cases, long-term abstinence.
According to Ho, this success is in part due to the fact that DBS doesn’t rely on patient compliance with therapy sessions, in-patient rehab, medications and abstinence. “Once the patient makes a decision to undergo treatment and the stimulator is implanted and turned on, they don’t have to make a conscious decision to pursue treatment — it is ‘on’ all the time,” said Ho.
Brain surgery may sound scary, but Ho explained that DBS is one of the safest and least invasive operations that they do as neurosurgeons. He believes alcoholics will consider the treatment since the addiction can devastate their lives, he said.
The Stanford team also hopes to apply deep brain stimulation to other addictions. “Should DBS prove effective for alcoholism, we anticipate a similar therapy could be very helpful for all addictions and even obesity,” said Halpern.
This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.
Image of Beth Darnall courtesy of Stanford Pain Medicine
Given America’s opioid epidemic, reducing opioid use has become a national priority. But for patients with chronic pain, successfully lowering their long-term dose can prove quite challenging.
A new Stanford study suggests that a patient-centered tapering program may be the solution for many opioid users with chronic pain. The researchers conducted a voluntary opioid reduction study focused on helping patients feel in control. This differed from traditional programs with forced, more aggressive dose tapering.
“Slow and steady wins this race. In most cases there is no urgency so we took several months to help patients make the transition comfortably,” said first author Beth Darnall, PhD, a Stanford clinical associate professor of anesthesiology, perioperative and pain medicine.
Another key aspect of their tapering program was the cultivation of a trusting patient-physician bond. “Many patients are fearful about reducing opioids. Our study methods focused on providing education to help allay their fears, as well as strengthening that bond to help patients succeed and achieve best outcomes,” Darnall explained.
Specifically, the team studied patients with non-cancer chronic pain who were being treated with long-term opioids through a community pain clinic in Colorado. Of the 110 patients invited to participate, 68 volunteered to reduce their opioids and 51 completed the study.
Participating patients were given a self-help book on reducing opioids and an individual plan to slowly taper their dose. They also completed a survey on their demographics, drug use, pain levels and psychosocial measures — both at the beginning of the study and 4 months later.
Physicians lowered each patient’s dose as much as possible over one year, pausing or stopping as needed, Darnall explained. Many patients reduced their dose by over 50 percent.
Darnall summarized their findings:
“We found many patients were interested in joining a voluntary opioid taper program if recommended to them by their doctor. And those who engaged in the opioid taper substantially reduced their opioid dose over 4 months without experiencing increased pain — even for those on high-dose opioids who had been taking them for years. Our pilot data suggest that many patients are open to a tapering pathway, if it is presented to them compassionately and in a patient-centered way.”
The team is now testing their voluntary tapering program in a large, multi-site study on almost 900 patients taking long-term opioids — using voluntary tapering alone or combined with behavioral pain treatment.
“We recognize that it’s not enough to just reduce patient risks with opioid reduction; we also need to help patients with chronic pain learn the tools to best help themselves,” said Darnall. “We hypothesize that patients will have better opioid and pain reduction when they learn to self-manage their pain and symptoms through one of these two group behavioral treatment classes.”
This is a reposting of my Scope blog post, courtesy of Stanford School of Medicine.
The public’s opinion of tobacco use has dramatically changed over time. Gone are the days when cigarette companies advertise using slogans like “fresh as mountain air” or “more doctors smoke Camels than any other cigarette.” We now know that cigarettes cause blindness and tuberculosis, among many other conditions, and are highly addictive.
But in the era of nicotine e-cigarettes that are touted as cool and harmless, have we really changed our ways? I spoke with Robert Proctor, PhD, a professor of history at Stanford, to learn about his work.
What inspired you to research the history of cigarette design?
“Cigarettes are the world’s leading preventable cause of death, killing about 6 million people worldwide every year. A physician might hope to heal a thousand or perhaps ten thousand people over a career, but what if we could save these 6 million people annually? It was this hope of saving lives that led to my exploring how cigarettes have been designed, and how they might be stopped.”
Where do you find your research materials?
“The Legacy Tobacco Documents Library is a real treasure. I use it to explore the industry’s myriad secret projects — like Project Subculture Urban Marketing, a secret Reynolds campaign from the 1990s to target gays and the homeless in San Francisco. I also use it to find out what they’ve been adding to cigarettes—like diammonium phosphate, a free-basing agent used to boost the potency of the nicotine molecule. I also use it to find out who has been working for the industry, as grantees or expert witnesses. Historically that included dozens of Stanford professors, but I don’t know any still working in that capacity today.”
What do you think about the FDA’s plan to reduce nicotine in cigarettes?
“As I explained in a recent op-ed for the New York Times, the Food and Drug Administration will try to mandate the reduction of nicotine in cigarettes to a sub-addictive level. However, they will encounter ferocious resistance from the industry, which sees nicotine as the indispensable ingredient of their business. For beginning smokers, nicotine is actually a negative in the smoking experience. Once addicted, most smokers regret having started. It will be crucial for the FDA to reduce nicotine sufficiently to make sure new users don’t become addicted. De-nicotinization is easy. Multiple techniques are available to achieve this, including genetic technologies and some of the same techniques used to de-caffeinate coffee.”
Have you also studied e-cigarettes?
“I have studied e-cigarettes but not as intensively. Many of the same techniques once used to market traditional cigarettes have been revived for e-cigarettes and other vaping devices, as Robert Jackler, MD, and his colleagues have shown so beautifully. E-cigarettes may help some smokers quit, but they are more likely to renormalize smoking and act as gateways to regular cigarettes. They also serve as bridge products to keep smokers from quitting nicotine entirely, which is why the big cigarette makers have all launched new vaping devices.”
What more can be done?
“Physicians often know the right thing to do, but may not have the power to make that happen — that is medical impotence. A third of all cancer deaths, for example, are caused by cigarettes. Just knowing that, though, isn’t enough to do any good, since there are powerful forces dedicated to making sure we keep pulling smoke into our lungs. Much more could be done to solve such problems — the new age minima for purchasing cigarettes should help. I also believe we need to explore what I call ‘the causes of causes.’ Cigarette smoking causes disease, but what causes cigarette smoking? Too often we end with the individual, rather than going upstream to the source of the problem in the first place. Stop the manufacture of cigarettes, for example, and you stop having to yank out tumors from lungs or putting people on oxygen. We need more upstream thinking in the practice of medicine.
We also need to think more about health in our own community. For instance, Stanford got a failing grade from the Santa Clara County Public Health Department in 2011 as the most cigarette-friendly campus in the Bay area — for allowing the sale and use of cigarettes on campus. We did finally manage get the sale of cigarettes in the student union stopped, after years of painful protest.”
Editor’s note: Stanford has a smoke-free environmentpolicythat prohibits smoking in all buildings, facilities, vehicles, covered walkways and during indoor or outdoor athletic events. Smoking has been banned on the School of Medicine campus for a decade.
This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.
Resolving America’s opioid crisis is clearly more difficult than just saying “no” to opioid use.
A key complication is that many opioid addicts also have mental health issues, said Mark McGovern, PhD, a professor of psychiatry and behavior sciences who joined Stanford in January. McGovern’s research focuses on patients with both psychiatric and addiction disorders. I connected with him via email.
What inspired you to focus on patients with both psychiatric and substance use disorders?
“In my personal experience and clinical practice, it seemed obvious that many people who had a problem with alcohol or drugs also had a mental health issue, whether it was depression, anxiety or something else. When I entered the world of research, the epidemiological and clinical prevalence data verified my anecdotal experience. About 70 percent of patients with a diagnosis of a drug or alcohol disorder have another psychiatric disorder. And of those with a psychiatric disorder, approximately 50 percent have had a substance use problem at some point. Ironically, our mental health care system, including our education and training programs, are organized as if people have one or the other problem but not both. It turns out that if a person has both types of disorders, their life outcomes are significantly worse. This struck me as an enormous health-care disparity.”
How do you treat these patients?
“I spent the past 20 years designing interventions that address these ‘co-occurring disorders’ within the same treatment course. We worked with systems of care — including large organizations, counties, states, tribes and nations — to reconfigure services to provide integrated care. These efforts included the use of both psychotropic and addiction medications, integrated combined therapies, and changes in attitude, philosophy, organizational structure and financing.
We need to address these behavioral health issues in both primary care and specialty settings.
Common problems such as depression, anxiety, alcohol and drug use disorders are ubiquitous in primary care settings. As with any medical condition, early intervention before disease progression results in better outcomes. Further, most people with these conditions don’t seek specialty care, but typically do see their doctor for other problems or routine health-care visits. Unfortunately, substance use disorders typically aren’t screened for in primary care, and they are currently addressed in only the most obvious and severe cases. People at Stanford are just beginning to develop an innovative ‘unified model of behavioral health integration’ that fully addresses the complex array of behavioral health conditions.”
How do you use addiction medications?
“Before I arrived at Stanford, I was at Dartmouth where I consulted with the states of northern New England — Vermont, New Hampshire and Maine — to combat the opioid addiction epidemic, including heroin and prescription narcotics. There are three FDA-approved medications for opioid addiction: methadone, buprenorphine and naltrexone. Unfortunately, even though they are very effective, these medicines are not widely available to people with opioid addiction. We worked most closely with physician practice groups across Vermont to prescribe buprenorphine and naltrexone and deliver high quality care. For example, we used learning collaboratives to engage physicians, improve access to buprenorphine and reduce the variability between different doctors. Overdose death rates in all New England states except Vermont have continued to rise, whereas Vermont’s has decreased since 2015. And the number of Vermonters receiving addiction medications has grown from 800 in 2013 to close to 5000 today.
I remember meeting my patient Bobby (a pseudonym) who was a general contractor with a successful business. He injured his back in 2004 and was prescribed Percocet for pain by his primary care physician. Gradually, he noticed that he needed more medication to get the same pain relief, emotional relief and stress reduction. Over time, Bobby shuffled from doctor to doctor to obtain opioid prescriptions allegedly for his family members. He transitioned to heroin by 2006. Prior to his opioid addiction, Bobby had no history of illegal activities and no substance problem. Bobby’s wife did some online research and learned about addiction medications. They were both drawn to the possibility of buprenorphine because he might be able to get it from a ‘regular doctor’ without going to rehab and ruining his business. Bobby was seen in our clinic and responded extremely well to the medication, and discontinued his use of other opioids. Interestingly, he said that he still had occasional pain but it was more important to be ‘functional than pain free.’”
What advice do you give to trainees?
“When educating medical students, psychiatric residents and fellows and clinical psychology interns at Stanford, I advise them to:
Understand addiction as a chronic medical condition that has its basis in the brain, even though its manifestations radiate across the person’s life, relationships and world.
Empathize with the person who is suffering with this condition, who may not be able to accept or describe it clearly, but who is nonetheless struggling to control It’s not their choice; it is not their ‘Plan A’ in life.
Know that effective treatments are available, and that you can provide them.
Have high hopes that recovery is possible for patients with addiction.”
This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.
As of the recent election, seven states and the District of Columbia have now legalized marijuana for recreational use and 19 other states have legalized medical marijuana. And this legalization has raised concerns about driving under the influence of marijuana.
A number of research groups are now focusing on ways to identify drivers impaired by marijuana. As recently reported by KQED, the Center of Medicinal Cannabis Research at the University of California, San Diego, are working to “gather data about dosages, time and what it takes to impair driving ability — and then create a viable roadside sobriety test for cannabis.” And a group of Stanford engineers have created a test called a ‘potalyzer.’
The Stanford effort was led by Shan Wang, PhD, a Stanford professor of materials science and engineering and of electrical engineering. He and his colleagues developed a mobile device that detects the amount of tetrahydrocannabinol (THC) molecules in saliva. (THC is the main psychoactive agent in marijuana.)
The test would allow police officers to collect a saliva sample from the driver’s mouth with a cotton swab, analyze it with the new device, and then read the results on a smartphone or laptop in as little as three minutes.
The technology combines magnetic nanotechnology with a competitive immunoassay. During the test, saliva is mixed with antibodies that bind to both THC molecules and magnetic nanoparticles. The mixture is placed on a disposable test chip, inserted into the handheld device and the THC-antibody-nanoparticles are detected by magnetic biosensors. The biosensor signal is then displayed on a Bluetooth-enabled device.
Wang’s group focused on developing a THC saliva test because it is less invasive and may correlate better with impairment than THC urine or blood tests. Also key is the need for a very sensitive test. A Stanford news release explains:
“Wang’s device can detect concentrations of THC in the range of 0 to 50 nanograms per milliliter of saliva. While there’s no consensus on how much THC in a driver’s system is too much, previous studies have suggested a cutoff between 2 and 25 ng/ml, well within the capability of Wang’s device.”
There is still a lot to do before police can deploy this ‘potalyzer’ device, including making it more user-friendly, getting it approved by regulators and investigating whether there is a better biomarker to detect marijuana impairment than THC. In addition, the test may not work well for THC edibles, the researchers wrote in a recent paper published in Analytical Chemistry.
On the upside, the Stanford technology could also be used to test for morphine, heroin, cocaine or other drugs — and for multiple drugs at the same time.
More research is needed, but there is now a new funding source in California: Proposition 64 allots millions of dollars per year to research marijuana and develop ways to identify impaired drivers.
This is an expanded version of my Scope blog story, courtesy of Stanford School of Medicine.
Opiates produce a sense of euphoria that is highly addictive. If addicts stop taking the drugs, they are faced with opiate withdrawal, which can feel like the worst imaginable stomach flu with symptoms that include muscle aches, sweating, nausea, vomiting, diarrhea and a runny nose.
Stanford researchers have identified and suppressed the neural pathway responsible for theses withdrawal symptoms in opiate-addicted mice, as reported in Nature.
Xiaoke Chen, PhD, the lead investigator and an assistant professor of biology, explains in a news release:
Most research that studies drug addiction is focused on the reward pathway because that is the reason you start to take drugs, but people who really get addicted also take drugs to get rid of the withdrawal effect. This is especially important in opiate addiction.
Chen’s team studied the nucleus accumbens, a group of neurons that plays a key role in addiction through its response to both rewarding and aversive stimuli. They used fluorescent proteins to identify a clear link between the nucleus accumben and another brain center associated with drug-seeking behavior called the paraventricular nucleus of the thalamus (PVT).
Next, the researchers used optogenetics to turn neurons in this nucleus accumben-PVT pathway off, by introducing light-sensitive molecules and then hitting them with light from an optical fiber. The news release explains:
Using optogenetic tools, the scientists were then able to revert the pathway to its original strength, effectively erasing the effects of the drug. Although the research was conducted in mice, Chen said that it suggests that reprogramming the circuit holds promise for treating opiate addiction in humans.
Chen’s research may guide the development of treatments for many people with exaggerated aversive response to stimuli, including those with drug addiction, anxiety and depression.
This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.
Scientists Talk Funny 