ADVANCE Perspective: Respiratory Managers

Billionaires to Fund $500 Million Anti-Smoking Campaign

2008-07-23T19:29:00Z

Bill Gates and New York City Mayor Michael R. Bloomberg have pledged $500 million for a global anti-smoking campaign.

The campaign, nicknamed Mpower, will urge governments in poor- and middle-income countries to raise tobacco taxes, outlaw smoking in public places, outlaw advertising to children, ban free giveaways of cigarettes, implement antismoking advertising campaigns, and provide citizens nicotine patches and smoking cessation products.

The campaign will focus on the five countries that are home to most of the world's smokers: China, India, Indonesia, Russia, and Bangladesh. Read more.

Doctor Bilks Medicare for More than Half Million Dollars

2008-07-22T16:14:00Z

A Miami-area doctor was sentenced last week to 41 months in prison for her role in schemes to defraud the Medicare program to the tune of $621,646, according to a news release from the U.S. Department of Justice.

A jury convicted the physician of writing prescriptions for medications and durable medical equipment that patients didn't want or need. A second physician, pharmacies, several DME companies, and even patients were in on the act.

More than 30 patients took delivery of homemade compounded aerosolized medications for COPD between February 2001 and June 2003. One Medicare beneficiary, who was paid to accept the prescriptions, testified that she threw all the medication away once she received it.

The compounding pharmacies were shut down in June 2003 but this case is just one of 82 cases against 142 defendants in southern Florida.

This site from the National Center for Policy Analysis documents how problematic Medicare fraud was in the 1990s.

Is it still too easy for people to file false claims or have the various investigations helped clean up these schemes?

Big Pharma: No More Physician Freebies

2008-07-10T18:13:00Z

You could arrive home from your next conference a little more empty-handed than usual.

The pharmaceutical industry is announcing a voluntary ban on doling pens, mugs, and other gifts as part of drug marketing campaigns.

The ban does not place limits on consulting arrangements, speaking fees, office lunches, or educational dinners at swanky restaurants.

Read more about it in The New York Times.

Is the ban a good idea, or a half-hearted attempt for positive public relations? (I'm leaning toward the latter.)

What's been your favorite vendor giveaway?

Attack Iran with Cigarettes?

2008-07-09T19:23:00Z

Presidential hopeful John McCain on Tuesday responded to a report of rising U.S. cigarette exports to Iran by saying it may be "a way of killing ‘em.," Reuters reported. The report noted that U.S. exports to Iran rose tenfold during the Bush administration, with cigarettes being the biggest export.

"Maybe that's a way of killing ‘em," McCain said to reporters at a Pittsburgh campaign stop. "I meant that as a joke, as a person who hasn't had a cigarette in 28 years," he said, laughing.

Suggesting the U.S. could potentially use cigarettes as weapons against another country, even in jest, begs the question - how many of its own is the U.S. killing with these particular weapons of mass destruction.

Singer Winehouse diagnosed with emphysema

2008-06-25T21:46:00Z

British singer Amy Winehouse was smoking cigarettes Monday, just one week after checking into an exclusive London rehab program where doctors diagnosed her with early signs of emphysema, reports USmagazine.com.

The 24-year-old singer is perhaps best known for crooning about her alcohol and drug addiction problems in songs such as "Rehab." Recently, she has made headlines for a video claiming to show her smoking crack cocaine, another video of her singing racist chants, and when her husband, Blake Fielder-Civil, allegedly offered a fellow inmate at London's Pentonville Prison $40,000 to have Babyshambles frontman Pete Doherty "smashed to pieces" because Fielder-Civil thought Winehouse was having an affair with the singer/guitarist.

Now, her father tells the Daily Mail that the addictions that fuel her turbulent lifestyle may end her life.

"With smoking the crack cocaine and the cigarettes her lungs are all gunked up," Mitch Winehouse said. "There are nodules around the chest and dark marks. She's got 70 percent lung capacity."

Despite her press agents' attempts to downplay the diagnosis, the news has spurred public interest in chronic obstructive pulmonary disease and sent lay media scrambling to find experts to explain the diagnosis.

"Winehouse Hospitalized: Emphysema or 'Crack Lung'?" asked ABCnews.com.

"Doctors say Mitch Winehouse's description of the chest X-ray, which suggests scarring and inflammation, leads them to suspect that crack lung could be the culprit," the ABC news medical team wrote. "While emphysema is a chronic condition that develops over time, crack lung is an acute injury to the lung, and could have caused such a sudden trip to the hospital"

If unchecked, the emphysema could spell the end of Winehouse's singing career, Dr Keith Prowse, the chairman of the British Lung Foundation, told the Daily Telegraph. The disease could reduce her lung capacity, causing problems when she holds long notes or hits high notes, and difficulty with her voice's volume, he said.

Winehouse still plans to perform live at Nelson Mandela's 90^th birthday concert on June 27, the Mirror reports. An emergency crew will be on standby at the nearest hospital.

Most Winehouse's fans have reacted with fear, dismay, and an earnest attempt to collect information about her condition. One even researched emphysema and posted information that had been reviewed by the faculty of Harvard Medical School. But not all fans plan to continue attending Winehouse's concerts.

"I cannot in good conscience circuitously support her horrible drug habit. And neither should you," wrote columnist Michael Lewittes in the Huffington Post. "Concert promoters need to stop booking her. The public needs to stop buying her music. And radio stations need to stop playing her singles."

Can Barack Please Have a Cigarette?

2008-06-24T21:37:00Z

That's how graduate student and writer Paul Devlin started off his open letter to Michelle Obama at the end of April. He went as far as saying that the future of the free world and perhaps Barack Obama's campaign depends on him getting his nicotine fix:

Maybe he could have one this weekend? He really needs to win Indiana. Also, keep in mind: tobacco and North Carolina, they kind of go together, you know. Sure, he'll probably win there anyway, but a larger margin is always good.

Link

Devlin's not the only one suggesting cigarettes could help Obama blaze his way into the White House. New York Times writer Tony Horwitz had this advice for the presidential hopeful: "Lose the Nicorette. Light up instead."

He argues smoking could increase Obama's appeal and bond to everyday Americans:

Bumming a smoke on the rope line, soiling the sleeve of his pristine suit with cigarette ash, and interrupting the flow of his soaring oratory with a smoker's hack would go a long way toward dispelling his effete image.

Link

Like many Americans, Obama's inspiration for quitting was his spouse. He stamped out the habit when he first hit the campaign trail last October. At the end of May, his primary care physician released a statement to reporters confirming his success with nicotine replacement therapy. "His own history included intermittent cigarette smoking," said David L. Scheiner, MD. "He has quit this practice on several occasions and is currently using Nicorette gum with success."

Soon after, on June 10, Obama told reporters in St. Louis he slipped up and smoked a few cigarettes in the past few months. Some argue those cigarettes could help him form a bond with Americans, but couldn't his determination to stay the course help him to develop an even stronger one?

His admitted moments of weakness I'm sure come as no surprise to current and former smokers and the health care providers that care for them. In fact, these slip-ups could provide a sense of relief for those who are in the same boat as Obama, struggling to break their addiction.

So why aren't we seeing more articles about how Obama's effort to break the habit could benefit his campaign and America? It seems pretty promising. His quitting success might even inspire an avid smoker who's not ready to kick the butts yet.

Can Barack please pass the Nicorette?

Dear Abby Advises Smoker on How to Refuse Quitting Advice

2008-06-21T15:50:00Z

Nowadays, the pressure is on for smokers to quit - but some feel their habit and its health risks are no one's business but their own.

Dear Abby published a letter from "Not Ready to Kick the Butts in Kenosha," a smoker who was sick of hearing lectures about why he should quit. He asked how to politely tell the concerned individuals to butt out.

When people decide they need to lecture me on why I should quit, how should I politely respond that I don't need their advice? I will decide on my own when I am ready to quit and make the effort. I understand they are trying to help my overall health, but it's really none of their business.

Link

The advice sage reluctantly agreed with the distraught smoker, and other readers' reactions poured in. Dr. Steven in Reno said Not Ready to Kick the Butts had him smoking .

Please tell me if you think you'll ever receive letters signed "Not Ready to Get a Disability Check Every Month Because I Won't Quit," or "Not Ready to Let Everybody Else Pay 80 Percent of My $276,000 Hospital Bill," or "Not Ready to Let Everyone Else Pay $1,500 a Month for My Oxygen and Medications."

Another reader had this frightening anecdote to share:

A chain-smoking Marine Corps gunnery sergeant once told me: "Anyone can quit smoking. It takes a REAL man to risk lung cancer."

At least some other readers took respiratory health into account.

One asthma sufferer said the smoker should have more concern for those with respiratory diseases irritated by smoke, and a grief-stricken wife recounted the pain of watching cancer devour her husband. You can read all of the responses here, and feel free to leave your own in our comments section.

Air travel industry bans antismoking drug in pilots, air traffic controllers

2008-05-30T19:20:00Z

Airplane pilots and air traffic controllers no longer can use the smoking cessation drug varenicline.

The Federal Aviation Administration banned the drug, marketed as Chantix, last week, citing potential side effects that could threaten aircraft safety. The ban effects 150 pilots and 30 air traffic controllers known to be using Chantix.

An F.A.A. spokeswoman said the decision was based on emerging data connecting Chantix to a host of health problems, including falls, hearth rhythm disturbances, heart attacks, seizures, and diabetes. The drug has been associated with psychiatric disturbances such as suicidal and homicidal thoughts, paranoia, and hallucinations.

A report by the Institute for Safe Medication Practices, a nonprofit consumer watchdog, 227 reports of suicide and suicide attempts, 397 cases of possible psychosis, and 525 reports of hostility or aggression between May 2006 - when Chantix was approved - and December 2007.

These adverse-event reports are submitted to the Food and Drug Administration by doctors, patients, and plaintiffs' lawyers, and don't necessarily establish a causal relationship between a drug and a side effect. However, the reports of bizarre behaviors and health effects have been chilling, causing critics to question the effectiveness of the FDA's drug approval process.

It's comforting to know pilots and air traffic controllers will be Chantix-free. And for an airline industry awash in consumer complaints about delays, security concerns, and misplaced bags, this one of the first positive stories I've heard in a long time.

ATS Coverage: Mind and Body

2008-05-21T12:01:00Z

Another important theme at this year's ATS meeting is the importance of assessing not only physical health but also psychological well-being. A study at Harvard Medical School found mothers' levels of stress can influence the fetus's development of immunity and increase sensitivity to allergen exposure and potential risk for future asthma.

The team analyzed levels of maternal stress as well as exposure to dust mites in their home. They studied umbilical cord blood for IgE expression, a biomarker of the child's immunity at birth. They found increased IgE expression in the cord blood of infants whose mothers had higher stress levels even when exposed to a relatively low level of dust mites during the pregnancy. Their findings show that the mother's stress during pregnancy intensified the effect of dust exposure on the child's immunity.

This suggests that to reduce potential asthma and allergy risks, physicians must initiate multi-factorial interventions. They have to educate expectant mothers not only about environmental factors but also about the importance of caring for mental health. The study suggests the need to bring back ancillary services including psychological support in clinical care, said study author Rosalind Wright, MD, MPH.

A study from the University of Washington School of Medicine looked at the link between lung disease and stress from the other side. Researchers examined the prevalence of post-traumatic stress disorder in caregivers of lung transplant patients. They found symptoms of depression and PTSD are four to five times more prevalent among caregivers of deceased lung transplant patients than in the general population. These findings again reinforce the need for more attention to emotional health in respiratory care.

The authors believe trained counselors to help family members with emotional needs and financial issues could reduce the caregiver stress. In addition, the study also found family members who felt their loved ones had a lower quality of dying and death or poorly controlled pain symptoms were more likely to have symptoms of PTSD. This suggests that in addition to ancillary services, improving care in the respiratory department can help to reduce patient and caregiver stress.

ATS Coverage: COPD Awareness a Dominating Theme at 2008 Meeting

2008-05-20T18:02:00Z

Raising COPD awareness certainly has been a dominating theme at this year's ATS conference. At this week's press breakfast with ATS Leadership, all three panel members mentioned this focus as an area that ATS will continue to promote. In a survey that asked what "COPD" stands for, many respondents answered "the Colorado Police Department," said Monica Kraft, MD, chair of ATS's international conference committee. Responses like these are part of the reason the ATS continues to encourage its members and the medical community to spread awareness and education about the deadly disease, she said.

Patient advocates also have played an integral part in encouraging attendees to take part in this effort. Before hearing the latest scientific data about the epidemiology, treatment, and prevention in a session about COPD exacerbations, attendees heard an account from alpha-1 advocate Len Geiger. He shared his experiences as a COPD patient who encountered many exacerbations before finally seeking medical attention and many more before receiving a proper diagnosis. (Photo: Monica Kraft, MD, speaking at ATS.)

As a healthy, non-smoking, athletic man in his early 30s, Geiger's initial concerns about his shortness of breath and frequent bronchial infections were dismissed by his doctor. Years later, he was misdiagnosed with asthma and prescribed an albuterol inhaler. On his 35th birthday, Geiger was unable to walk his parents to their car because he couldn't catch his breath. A return to the doctor and more tests revealed he had alpha-1 antitrypsin deficiency and an FEV1 of just 38 percent.

Geiger immediately began the fight to retain his lung function. He quit his job as a sales rep to limit exposure to infections, began augmentation therapy, and started an intense exercise regime. About six years ago, nearly on the brink of death, Geiger got the call telling him he had a second chance at life. The Shroyers had lost their 14-year-old daughter Korinne but had decided to donate her organs. Geiger received her lungs in a double-lung transplant procedure at the University of Virginia Medical Center and shortly after wrote her parents a letter to thank them for the gift of life.

The Shroyers responded and soon they met. Geiger and Korinne's father began participating in marathons and other athletic events together to raise awareness about lung disease and organ donation. Geiger now lives a healthy, fulfilling life with his new wife and their 2-year-old daughter, named Ava Corinne after the young girl whose lungs saved his life. (The Geiger's changed the spelling slightly.)

The moral of the story - you can never be thorough enough. Some doctors look at the patient's demographic rather the symptoms and miss a critical - albeit sometimes rare - diagnosis. Also don't overlook the value of the patient perspective. While you may have the expertise to explain the epidemiology and treatment regime to patients, their peers offer the added benefit of a hand to hold that's already been through it all.

ATS Coverage: COPD-The Rodney Dangerfield of Diseases

2008-05-20T17:50:00Z

Attendees of the ATS President's Lecture today heard a different type of professional opinion than they have heard at this lecture in the past. Grace Anne Dorney Koppel, national spokesperson for the National Heart, Lung, and Blood Institute, served as the first patient advocate to deliver the esteemed lecture.

Dorney Koppel's husband and veteran news anchor, Ted Koppel, gave the introduction and spoke about his wife's veracious fight against COPD.

In a speech titled "A Declaration of War on COPD," Dorney Koppel said, "You are the experts on the epidemiology and management of my disease. But I am an expert on how this beast feels inside me and how it has affected my strength and vitality." (Photo: Dorney Koppel speaking at ATS).

A long-time smoker who quit 13 years ago, Dorney Koppel was diagnosed with severe COPD in 2001. She had about 26 percent of predicted lung function at the time.

She has spent years educating herself about this deadly disease, reading professional journals and medication packaging inserts alike. She completed pulmonary rehabilitation and continues to exercise to increase her endurance each day. Dorney Koppel now has a stable predicted lung function of 60 percent to 65 percent with a diagnosis of mild-to-moderate COPD.

Doctors and patients must partner together, she said. "You can learn something from each of us."

Dorney Koppel also encouraged partnerships with other specialists and general practitioners. She advocated especially for earlier diagnosis and spirometry screening. The message about COPD is not yet out in all parts of the medical community, she said. She pushed for attendees to take the time to educate general practitioners about the use of spirometry as about 90 percent of COPD patients are treated by family doctors, and many will never see a pulmonary specialist.

She also talked about the struggle of living with an incurable disease and the stigma that the disease is self-induced. "COPD is like the Rodney Dangerfield of diseases," she said. "We don't get no respect."

However, she recognized the paradigm shifts respiratory professionals have made in understanding patients and not passing judgment. "We've learned to be healers, not judgers," she said. "Doctors are the men and women in white coats, not black robes. There is no room for shame and blame in this deadly disease."

I challenge you to educate health care professionals and patients about COPD before 2020 when the tsunami of lung disease engulfs us, she said. She also appealed to attendees to find a cure for the disease in addition to pushing for more education and awareness. To aid her call for a cure, Dorney Koppel recalled the words of T.S. Eliot, who himself died from COPD. "Only those who will risk going too far can possibly find out how far one can go."

Online community protests over inhaler switch

2008-04-24T16:27:00Z

It seemed as if the switch from CFC inhalers to HFA inhalers would go off without a hitch.

Manufacturers increased production to prevent shortages, and the American Lung Association even produced a public service announcement announcing the change.

But now, a backlash is forming. A small group of people with asthma is raising a commotion online - saying that the new inhalers don't work as well and, because most HFA inhalers don't have dose-counters, the devices could threaten their lives during an asthma attack.

The group started an online petition, fueled by blogs and forums. More than 2,000 people have signed it, complete with comments raging against the change. (Some signatories chose to have their names remain private.)

Their complaints range from the higher cost, to the bad taste, to allegations that the new inhalers don't work or even make symptoms worse.

Even consumer affairs websites are getting in on the act: this one chronicles several episodes where the inhaler made the person with asthma feel worse.

Patients are slowly learning that at least some inhalers contain ethanol and can worsen an attack. (PDF).

For tips on helping your patients adjust, visit the AAAAI article on transitioning to HFA inhalers. A patient assistance program from the partnership for prescription assistance could help defray the costs.

New York launches powerful antismoking ads

2008-04-17T18:57:00Z

Combating an industry that has spent decades building an image that smoking is cool, New York City is airing gruesome images of suffering and disfigurement on television and in subways and taxis.

New York City's Department of Health and Mental Hygiene has launched a series of commercials profiling a Bronx woman - Marie - who has had nearly 20 amputations. The ads coincide with the city's nicotine-patch giveaway, happening through May 1.

Marie developed Buerger's disease after smoking for 12 years. Buerger's disease, also known as thromboangiitis obliterans, is characterized by a narrowing or blockage of the veins and arteries of the extremities, reducing blood flow to these areas. The first symptom patients often experience is extreme pain in the lower arms and legs while they are at rest. Buerger's disease occurs in 6 out of 10,000 people, mostly in young or middle-aged males with a history of smoking or chewing tobacco.

image: New York City Department of Health and Mental Hygiene

Marie went to the emergency room after experiencing such severe pain she couldn't eat or sleep. Surgeons removed parts of her fingers, parts of her foot, and one leg below the knee.

She can't hang pictures or screw on a lightbulb because she has no fingertips.

"Everything I do now I have to stop and think, because just me banging my hand or something could cause me to lose my fingers," she said in the commercial. "That's not living."

The commercials show close-up images of the saw bone, clippers, and medical equipment used in her amputations. Marie holds up her severed fingertips to the camera.

The Health Department learned about Marie through a telephone survey of smokers. After hearing her story, the surveyor asked if she would be interested in sharing her story, according to Jennifer 8. Lee of The New York Times.

As a result of her amputations, her friends didn't want to call her, she said. Her kids became embarrassed of her appearance. Her companion of 10 years left her. "He couldn't take it anymore," she said.

Marie was able to quit smoking in 2006, according to The Times. She used the nicotine patch.

Don’t be a fool, stay in school…it might help you quit smoking.

2008-04-01T20:16:00Z

Education level affects smokers' responses to TV ads that promote smoking cessation, according to a new study from the University of Wisconsin. Researchers surveyed 452 adult smokers of different socioeconomic and educational levels and found better-educated smokers are more likely to respond to TV ads that encourage them to quit. However, they found the effect of messages about secondhand smoke is the same across educational levels. You can read the full results here.

So what does this all mean? Well it means health care professionals and smoking cessation campaigns need to make sure their approaches are varied. The experts I interviewed for my industry report about smoking cessation in the April issue all stressed the need for varied educational resources and interventions.

While an ad on TV may not be enough to get some smokers motivated, an encouraging word during oxygen treatment may work. Or maybe while they're getting settled into their rooms, a little conversation about why they've been putting it off could be the nudge they need. The extra step you take may make the difference.

If you'd like to try some new approaches to smoking cessation with your patients but you find yourself stumped, you can check out some of the resources I listed in the article. You could get a conversation going with other respiratory professionals by joining the AARC's Tobacco-free Lifestyle Roundtable at http://www.aarc.org/community/tobacco_free_roundtable/index.asp. Or share some of your own ideas in the comment section below.

Scenting the way to reduce fragrance-induced asthma attacks

2008-03-24T18:38:00Z

Minnesota just became the third state nationwide to consider a campaign for scent-free schools. Rep. Karen Clark proposed educating students about how their Burberry, Marc Jacobs and Axe contribute to classmates' health problems, including asthma.

(Clark, along with lawmakers in Rhode Island and Massachusetts, considered then dropped all-out fragrance bans.)

This bill (HF3944) would let public schools volunteer to deliver a bouquet of fact sheets, posters, and parent letters to the student body. After a one-year trial, the commissioner of health would report the campaign's progress in rural, urban and suburban schools.

Research has indicated that odors ranging from cigarette smoke to perfumes can trigger asthma attacks and a host of other medical problems. Yet many people have bristled at the idea of regulating smells.

"Are the Fragrance Sensitive being too Scents-itive?" asked an Atlantic Highlands Herald columnist. "Isn't this going a bit too far?" queried collaborative blog Hub Politics.

Too much perfume or cologne is far better than body odor, suggested a post on the student forum CollegeNET.

Others say the campaign simply will not work. "I can't imagine high school teens all awash in their ‘peer group thing' allowing themselves to be told what to smell like, especially by the state legislature," wrote Consent of the Governed blogger Judy Aron.

But a growing body of people has voiced support of the ban. "The fact that it's making some kids sick, I guess, is reason enough to forbid it in schools," wrote Sanford Herald editor Billy Liggett on his blog.

Is this a problem best addressed by laws and regulations?

The Nova Scotia port city of Halifax taken a different approach: effectively banning perfumes within city limits through the stringent bans in office buildings, schools, hospitals, and the symphony hall.

Both Mr. Manners and this online nurses' forum suggest that work-place professionals can first talk to the ‘fragrant' offender then visit Human Resources to resolve scent-induced respiratory problems. Would this work in schools?

At least one site, though, raises the realistic idea that it's either lawmakers or lawsuits.

What's the real solution?