smoking tobacco william p. wattles, ph.d. psychology 314
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Smoking TobaccoSmoking Tobacco
William P. Wattles, Ph.D.
Psychology 314
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Dose Response relationshipDose Response relationship
A quantitative relationship between the dose of a drug and the degree of an effect caused by the drug
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Analyze nutrition from a chain restaurant.Analyze nutrition from a chain restaurant.
Choose a restaurant not chosen by someone else. First come, first served.
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Analyze nutrition from a chain restaurant.Analyze nutrition from a chain restaurant.
1. Obtain a fact sheet with nutritional information.
2. Analyze the fat content of at least ten items
3. Discuss the nutritional strengths and weaknesses of several items
4. Suggest which items appear healthier.5. Attach the fact sheet to the paper.
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American Legacy FoundationAmerican Legacy Foundation
Building a world where young people reject tobacco and anyone can quit.
http://www.americanlegacy.org/
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The Smoking Scourge Among Urban Blacks The Smoking Scourge Among Urban Blacks
http://www.nytimes.com/2007/10/20/health/20tobacco.html
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Employers see savings in helping smokers to quitEmployers see savings in helping smokers to quit
http://www.nytimes.com/2007/10/26/business/26smoking.html?_r=1&oref=slogin
Workplace initiative Workplace initiative
Act Now to Avoid Tobacco Surcharge October 31 is the deadline to certify with
the Employee Insurance Program (EIP) whether you use tobacco. Effective January 1, 2010, a $25-a-month surcharge will be added to the health insurance premium of subscribers who use tobacco
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SegueSegue
Article:Lack Of Progress Found In Reducing Smoking
About 48 million Americans smoked in 1997 according to a survey.The Disease Control and Prevention Centers estimated that 23.9 percent of men and 18.1 percent of women smoked regularly. the overall smoking rate for adults is 20.9 percent.
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Costs of smokingCosts of smoking
An estimated 430,070 Americans die each year from diseases caused by smoking.
Smoking is responsible for an estimated one in five U.S. deaths and costs the U.S. at least $97.2 billion each year in health care costs and lost productivity.
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You don’t always die from tobaccoYou don’t always die from tobacco
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The respiratory systemThe respiratory system
Diaphragm and intercostal muscles contract to increase volume of chest.
Resulting loss in pressure causes air to flow in
Air flows in through the – nasal passages– pharynx– larynx– trachea– bronchi and bronchioles
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Gas exchangeGas exchange
Occurs in the alveoli alveolus A tiny, thin-walled, capillary-
rich sac in the lungs where the exchange of oxygen and carbon dioxide takes place. In this sense, also called air sac.
Bubbles with thin skin Due to diffusion pressure carbon
dioxide moves from the blood and oxygen to it.
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Foreign material enters via respiratory systemForeign material enters via respiratory system
Mucociliary escalator. protective mechanism– mucous– cilia
smoke decreases the effectiveness of the Mucociliary escalator.
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Chronic obstructive pulmonary diseaseChronic obstructive pulmonary disease
Chronic obstructive pulmonary disease (COPD) includes emphysema and chronic bronchitis--diseases that are characterized by obstruction to air flow.
Emphysema and chronic bronchitis frequently coexist.
Thus physicians prefer the term COPD Fourth leading cause of death in the
U.S. 96,000 deaths annually
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Chronic obstructive pulmonary diseaseChronic obstructive pulmonary disease
Approximately 80 to 90 % of COPD cases are caused by smoking; a smoker is 10 times more likely than a nonsmoker to die of COPD.
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Chronic obstructive pulmonary diseaseChronic obstructive pulmonary disease
Other known causes are frequent lung infections and exposure to certain industrial pollutants.
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Chronic BronchitisChronic Bronchitis
Chronic bronchitis is an inflammation and eventual scarring of the lining of the bronchial tubes.
An estimated 14 million people suffer from chronic bronchitis, the seventh leading chronic condition in America.
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Chronic BronchitisChronic Bronchitis
Symptoms of chronic bronchitis include:– chronic cough,
increased mucus– frequent clearing
of the throat– shortness of
breath.
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EmphysemaEmphysema
Emphysema causes irreversible lung damage. The walls between the air sacs within the lungs lose their ability to stretch and recoil. They become weakened and break.
Elasticity of the lung tissue is lost, causing air to be trapped in the air sacs and impairing the exchange of oxygen and carbon dioxide.
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EmphysemaEmphysema
Symptoms of emphysema include cough, shortness of breath and a limited exercise tolerance.
Diagnosis is made by pulmonary function tests, along with the patient's history, examination and other tests.
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EmphysemaEmphysema
An estimated two million Americans have emphysema. Of the emphysema sufferers, 61 % are male, and 39 % are female.
While more men suffer from the disease than women, the condition is increasing among women.
Between 1982 and 1994 the emphysema prevalence rate in women increased 11 %.
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CigarettesCigarettes
Cigarettes contain at least 43 distinct cancer-causing chemicals.
Smoking is directly responsible for 87 % of lung cancer cases and causes most cases of emphysema and chronic bronchitis.
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CigarettesCigarettes
Smoking is also a major factor in coronary heart disease and stroke; may be causally related to malignancies in other parts of the body; and has been linked to a variety of other conditions and disorders, including slowed healing of wounds, infertility, and peptic ulcer disease.
Causes “cigarette skin”
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Cigarette SkinCigarette Skin
Premature facial wrinkling in young people is associated with smoking. Therefore, it is suggested this should now be added to the list of disorders with which smoking is considered a causative factor
International Journal of Dermatology.
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Cigarette SkinCigarette Skin
Smokers tend to look older than non-smokers of the same age Smokers' facial skin is more likely than non-smokers to have:
wrinkles, crow's feet and a sallow, yellow-grey colouring Smokers' skin can be prematurely aged by between 10 and 20
years
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Smoking in pregnancySmoking in pregnancy
Smoking in pregnancy accounts for an estimated 20 to 30 % of low-birth weight babies, up to 14 % of preterm deliveries, and some 10 % of all infant deaths.
Even apparently healthy, full-term babies of smokers have been found to be born with narrowed airways and curtailed lung function.
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Smoking in pregnancySmoking in pregnancy
Only about 30 % of women who smoke stop smoking when they find they are pregnant.
26% of women in Kentucky and West Virginia smoke during pregnancy. Nationwide it is about 12%
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Who smokes?Who smokes?
20.9% of adults smoke down from high of 41% in 1965. Approx.. 50 million
25% once smoked 50% never smoked warning labels Since 1967 television ads banned since 1970 Men (23.9%) smoke slightly more than
women (18.1%)
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Who smokes by race?Who smokes by race?
Blacks over 18 years of age have the highest amount of smokers
Whites 21.9% Blacks 21.5% Hispanic 16.2% Asian 14.4%
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Smoking prevalence among people with disabilities is nearly 50 percent higher than among people without disabilities (29.9 percent vs. 19.8 percent), according to a new study from the Centers for Disease Control (CDC)
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Who smokes by education?Who smokes by education?
People with less formal education tend to smoke more
G.E.D. 43.2% 9-11 years 32.6% college degree 10.7% graduate degree 7.1%
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Who smokes by state?Who smokes by state?
Kentucky has the highest number of adult smokers (27.6%)
Utah has the lowest number of adult smokers (10.5%)
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Smoking and taxesSmoking and taxes
States with the highest cigarette taxes, such as Connecticut, Massachusetts, Montana, Washington, New Jersey have lower rates of adult smokers!
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Smoking and taxesSmoking and taxes
States with the lowest cigarette taxes, such as South Carolina, Missouri, Mississippi, Tennessee, Kentucky, North Carolina have higher rates of adult smokers!
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Cigarette Tax and smoking rank by state
correlation
= .40
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Who smokes by ageWho smokes by age
Nationwide, 70.2% of high school students have tried cigarette smoking. More than one-third (36.4%) of high school students were current cigarette smokers, i.e., smoked at least one cigarette in the past 30 days.
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Who smokes by ageWho smokes by age
White students (19.9%) were more likely than African-American (7.2%) or Hispanic (10.9%) students to smoke frequently.
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Who smokes by countryWho smokes by country
In developed countries, 41% of men and 21% of women regularly smoke cigarettes.
In developing countries, 50% of men smoke, and 8% of women.
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Smoking rates by country
Ranked by men’s rate
rank m nation men women1 Bangladesh 69 152 Korea 68.2 6.73 Russian 67 304 Latvia 67 125 Dominican Republic 66.3 13.66 Tonga 65 147 Turkey 63 248 China 61 79 Fiji 59.3 30.6
10 Japan 59 14.811 Sri Lanka 54.8 0.812 Algeria 53 1013 Indonesia 53 414 Samoa 53 1.615 Saudi Arabia 52.7 016 Estonia 52 2417 South Africa 52 1718 Kuwait 52 1219 Lithuania 52 1020 Poland 51 2921 Seychelles 50.9 10.322 Bolivia 50 21.423 Albania 49.8 7.924 Cuba 49.3 24.525 Bulgaria 49 1726 Thailand 49 427 Spain 48 2528 Mauritius 47.2 3.729 Greece 46 2830 Papua New Guinea 46 2831 Israel 45 3032 Cook Islands 44 2633 Czech Republic 43 3134 Slovakia 43 2635 Jamaica 43 1336 Philippines 43 837 Cyprus 42.5 7.238 Austria 42 2739 Peru 41 1340 Malaysia 41 441 Uruguay 40.9 26.6
42 France 40 2743 Hungary 40 2744 Argentina 40 2345 Malta 40 1846 Mongolia 40 747 Iraq 40 548 India 40 349 Uzbekistan 40 150 Brazil 39.9 25.451 Egypt 39.8 152 Morocco 39.6 9.153 Mexico 38.3 14.454 Lesotho 38.3 155 Italy 38 2656 Portugal 38 1557 El Salvador 38 1258 Chile 37.9 25.159 Guatemala 37.8 17.760 Denmark 37 3761 Germany 36.8 21.562 Norway 36.4 35.563 Netherlands 36 2964 Switzerland 36 2665 Honduras 36 1166 Columbia 35.1 1967 Slovenia 35 2368 Costa Rica 35 2069 Swaziland 33 870 Luxembourg 32 2671 Singapore 31.9 2.772 Canada 31 2973 Iceland 31 2874 Belgium 31 1975 Ireland 29 2876 Australia 29 2177 United States 28.1 23.578 United Kingdom 28 2679 Pakistan 27.4 4.480 Finland 27 1981 Turkmenistan 26.6 0.582 Nigeria 24.4 6.783 Paraguay 24.1 5.584 New Zealand 24 2285 Bahrain 24 686 Sweden 22 2487 Bahamas 19.3 3.8
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Smoking rate by country Ranked by women’s rate
41 Finland 27 1942 Malta 40 1843 Guatemala 37.8 17.744 Bulgaria 49 1745 South Africa 52 1746 Bangladesh 69 1547 Portugal 38 1548 Japan 59 14.849 Mexico 38.3 14.450 Tonga 65 1451 Dominican Republic 66.3 13.652 Jamaica 43 1353 Peru 41 1354 El Salvador 38 1255 Kuwait 52 1256 Latvia 67 1257 Honduras 36 1158 Seychelles 50.9 10.359 Algeria 53 1060 Lithuania 52 1061 Morocco 39.6 9.162 Philippines 43 863 Swaziland 33 864 Albania 49.8 7.965 Cyprus 42.5 7.266 China 61 767 Mongolia 40 768 Korea 68.2 6.769 Nigeria 24.4 6.770 Bahrain 24 671 Paraguay 24.1 5.572 Iraq 40 573 Pakistan 27.4 4.474 Indonesia 53 475 Malaysia 41 476 Thailand 49 477 Bahamas 19.3 3.878 Mauritius 47.2 3.779 India 40 380 Singapore 31.9 2.781 Samoa 53 1.682 Egypt 39.8 183 Lesotho 38.3 184 Uzbekistan 40 185 Sri Lanka 54.8 0.886 Turkmenistan 26.6 0.587 Saudi Arabia 52.7 0
rank w nation men women1 Denmark 37 372 Norway 36.4 35.53 Czech Republic 43 314 Fiji 59.3 30.65 Israel 45 306 Russian 67 307 Canada 31 298 Netherlands 36 299 Poland 51 29
10 Greece 46 2811 Iceland 31 2812 Ireland 29 2813 Papua New Guinea 46 2814 Austria 42 2715 France 40 2716 Hungary 40 2717 Uruguay 40.9 26.618 Cook Islands 44 2619 Italy 38 2620 Luxembourg 32 2621 Slovakia 43 2622 Switzerland 36 2623 United Kingdom 28 2624 Brazil 39.9 25.425 Chile 37.9 25.126 Spain 48 2527 Cuba 49.3 24.528 Estonia 52 2429 Sweden 22 2430 Turkey 63 2431 United States 28.1 23.532 Argentina 40 2333 Slovenia 35 2334 New Zealand 24 2235 Germany 36.8 21.536 Bolivia 50 21.437 Australia 29 2138 Costa Rica 35 2039 Belgium 31 1940 Columbia 35.1 1941 Finland 27 19
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Why smoke?Why smoke?
Why do you smoke? Why do you think people smoke? Is smoking cool? How could it be viewed as cool or sexy? What does someone get out of
smoking?
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In the beginning, smoking is about image. Three thousand American teens will light up for the first time today and, for most, says 17-year-old Alexandria Drouin, "It's like, `I want to look cool.' "
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Is smoking cool?Is smoking cool?
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TV ads features a 46-year-old woman who says she's been smoking since she was 13 and can't kick her addiction, even after losing her voice box to throat cancer in 1992.
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Identified only as "Debi," the woman smokes through a hole in her throat, telling the audience she tried to quit when she became aware of dangers to her health, but couldn't.
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Teenagers and smokingTeenagers and smoking
Reasons for starting:– tension control– rebelliousness– social pressure
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Nicotine is an addictive drug, which reaches the brain faster than drugs that enter the body intravenously. Smokers become not only physically addicted to nicotine.
Smokers also link smoking with many social activities, making smoking a difficult habit to break.
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In 1994, an estimated 46 million adults were former smokers. Of the current smokers, 33.2 million persons reported they wanted to quit smoking completely.
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Quitting SmokingQuitting Smoking
An estimated 30% of smokers make at least one quit attempt per year.
81% fail within the first month.
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Smoking and advertisingSmoking and advertising
The cigarette companies spend $15 billion annually on advertising and marketing campaigns to addict a new generation of customers. That's $41 million every day.
http://www.ftc.gov/reports/cigarette05/050809cigrpt.pdf
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Cigarette AdvertisingCigarette Advertising
Newspapers Magazines Outdoor Transit Point-of-Sale Price Discounts Promotional Allowances – Retailers Promotional Allowances – Wholesalers Promotional Allowances – Other Sampling Distribution Specialty Item Distribution – Branded Specialty Item Distribution - Non-Branded
Public Entertainment – Adult-Only Public Entertainment – General-Audience Sponsorships Endorsements & Testimonials Direct Mail Coupons Retail-Value-Added – Bonus Cigarettes Retail-Value-Added – Non-Cigarette Bonus Company Website Internet – Telephone
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Quit smoking and advertisingQuit smoking and advertising
Florida begins to spend $50 million of Big Tobacco's money to pay for a teen-directed, guerrilla-style advertising campaign designed to reverse the rising rate at which young people are taking up cigarettes, cigars and chewing tobacco.
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Movie industryMovie industry
One full-page newspaper ads attacked the movie industry for making smoking glamorous in films.
"We're your best customers. So why are you trying to kill us?”
"Why does the film industry continue to glamorize an addictive habit that often ends in a slow, agonizing death?"
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That, say those in charge of the ad campaign, is the key. "The aim here is to make rebelling against manipulation as cool as smoking”
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Bluntness, not subtlety, appears to be the key to reaching both children and adults. according to a review of broadcast and billboard messages funded by state tobacco taxes published in the March 11 issue of the Journal of the American Medical Association. "To compete with tobacco industry advertising, anti-tobacco advertisements need to be ambitious, hard-hitting, explicit, and in your face,"
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No smoking lawsNo smoking laws
California outlawed smoking in restaurants in 1994. The prohibition was extended to bars and gambling establishments four years later. Efforts to repeal it have failed.
In stark contrast to predictions of economic ruin, bars around the state appear to have enjoyed a healthy increase in business during the first year of a controversial smoking ban, fresh sales data show.
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EconomicsEconomics
Researchers in 1997 found that 100% smokefree restaurant and bar ordinances do not adversely impact revenues. Sales tax data, comparing restaurant sales in 15 cities to total retail sales in the same cities, and restaurant sales in 15 comparison cities. The researchers also examined five cities and two counties with smokefree bar ordinances.
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EconomicsEconomics
In 1999, a study in the Journal of the American Medical Association analyzed hotel revenues in the states of California, Vermont and Utah and the cities of New York, Los Angeles, San Francisco, Boulder, Colo., and Mesa and Flagstaff, Ariz. The study found either a statistically significant increase in hotel revenues or no significant change
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Secondhand smoke is a known carcinogen . Exposure to secondhand smoke causes approximately 35,000 heart disease deaths and 3,000 lung cancer deaths among nonsmokers in the United States every year
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Movies glamorize smokingMovies glamorize smoking
Teenagers are more likely to think smoking is cool after they've watched their Hollywood idols light up on screen -- unless they've just seen an advertisement reminding them that tobacco is dangerous.
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Pechmann StudyPechmann Study
In a recent study involving more than 800 Southern California ninth-graders, Pechmann found that showing just one 30-second anti-smoking ad immediately before a film in which cigarettes play a role makes teens immune to images that glamorize smoking.
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Pechmann StudyPechmann Study
Those who saw the anti-smoking ad emerged from the film with negative views about smoking, while the others expressed positive attitudes.
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PHILADELPHIA --PHILADELPHIA --
Police have been told to stub out their cigarettes permanently after a newspaper photograph showed an officer smoking as he helped lift a man in a wheelchair outside a burning building
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Both the New York City and Los Angeles police departments have strict policies barring uniformed officers from smoking in public
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Arkansas hospitalsArkansas hospitals
Arkansas Act 134 of 2005, the law that prohibits the smoking of
tobacco products in hospitals and on their grounds, becomes effective on October 1.
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Tobacco company anti-smoking adsTobacco company anti-smoking ads
New anti-smoking ads from the tobacco companies deserve close scrutiny. In December 1998, the world's largest tobacco company launched a national media campaign to prevent youth smoking.
http://www.philipmorrisusa.com
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That's the whole point of this campaign - to make not smoking look so uncool that it may motivate kids to smoke.
They want you to reject the ad, because a rejection of any anti-smoking advertisement is the best response expected.
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Stanford StudyStanford Study
Exposure to the tobacco industry's anti-smoking ads:
(a) does more to encourage than discourage youth smoking (a boomerang effect), and
(b) makes youth resistant to criticism of the tobacco industry (an inoculation effect).
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A National Legal-Action Antismoking Organization A National Legal-Action Antismoking Organization
http://www.ash.org/
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Advertising tax deductionAdvertising tax deduction
In May, House Republicans proposed erasing the tobacco industry's tax deduction for advertising. (Like all businesses, the tobacco industry is allowed to deduct the costs associated with marketing its products.)
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Advertising tax deductionAdvertising tax deduction
The repeal would have cost the tobacco industry an estimated $1.6 billion a year, raising the possibility that the companies might spend less on advertising. The media did not want to lose the $5.1 billion tobacco spent on advertising and promotion in
1996.
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First amendment? First amendment?
After the media lobbying, the provision was quietly dropped in June.
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Quitting smokingQuitting smoking
In 1995, an estimated 68.2% of current smokers reported that they wanted to quit smoking completely.
Quit attempts, abstaining from smoking for at least one day during the preceding 12 months, were made by about 45.8% of current every-day smokers.
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Many do quitMany do quit
About 23.3% of US adults (25 million men and 19.3 million women) were former smokers in 1995
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Self-helpSelf-help
Of smokers using the self-help approach, about 20% remain tobacco-free for about 1 year.
In the U.S., about 90% of successful quitters have used some form of self-help method either alone or with other methods.
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Self-helpSelf-help
The most successful self-help materials address the physical, psychological, and social components of nicotine addiction and smoking behavior.
The self-help information contains tips on topics like quitting, diet, exercise, relaxation, and how to stay off cigarettes on a long-term basis.
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Group HelpGroup Help
Some organizations, like the American Cancer Society, also offer highly structured group support programs so that an individual does not have to face the problem alone. These groups try to aid in the adjustment to a non-smoking lifestyle.
Of smokers participating in group programs, about 33% are successful at 1 year.
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NICOTINE GUMNICOTINE GUM
In 1984, the FDA approved nicotine polacrix gum as a prescription drug marketed under the brand name Nicorette.
Nicorette is one of the fastest selling prescription drugs with the majority of requests for the drug being made by patients.
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NICOTINE GUMNICOTINE GUM
This gum contains nicotine but less than that in cigarettes (about 2mg per stick instead of the 6-8mg in a single cigarette).
The nicotine is slowly released when chewed (90% of the nicotine is released in 20-30 minutes).
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NICOTINE GUMNICOTINE GUM
Used properly, this gum helps the nicotine addict to slowly wean themselves from cigarettes by first substituting the gum and then chewing less and less of the gum.
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NICOTINE GUMNICOTINE GUM
Most patients are advised to use the gum for 3-6 months.
Side effects of the gum may include: nausea, dizziness, or overdoses.
Studies have suggested that the gum is effective in decreasing the amount of symptoms experienced with the withdrawal syndrome.
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Nicotine gumNicotine gum
There have been reports that use of the gum with behavioral treatments has provided success at 1 year in up to 37%.
Without counseling and a physician's instructions, success is low.
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Nicotine PatchesNicotine Patches
In the early 1990's, the FDA approved the use of nicotine patches as prescription drugs. These have been marketed under the brand names Habitrol and Nicoderm.
Nicotine patches are put on the skin (transdermal) and deliver nicotine in lower amounts than those present in cigarettes.
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Anti-DepressantsAnti-Depressants
Several anti-depressant drugs have been studied for their potential use in smoking cessation.
Recent studies of bupropion (a serotonin uptake inhibitor) have shown that this drug may be useful in heavily addicted smokers when used in combination with behavioral methods of quitting.
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Anti-DepressantsAnti-Depressants
There appears to be an increased quit rate and a decreased relapse rate with bupropion as compared to control subjects.
It is thought that bupropion may work by decreasing the withdrawal symptoms associated with nicotine addiction.
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Self-ManagementSelf-Management
Self-Monitoring Stimulus Control Nicotine Fading
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Tobacco Cessation GuidelineTobacco Cessation Guideline
Office of the Surgeon General– http://www.surgeongeneral.gov/tobacco/
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Tobacco dependence is a chronic condition that often requires repeated intervention.
However, effective treatments exist that can produce long-term or even permanent abstinence.
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Because effective tobacco dependence treatments are available, every patient who uses tobacco should be offered at least one of these treatments.– Patients willing to try to quit tobacco use should be
provided treatments identified as effective in this guideline.
– Patients unwilling to try to quit tobacco use should be provided a brief intervention designed to increase their motivation to quit.
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There is a strong dose-response relation between the intensity of tobacco dependence counseling and its effectiveness.
Treatments involving person-to-person contact (via individual, group, or proactive telephone counseling) are consistently effective, and their effectiveness increases with treatment intensity (e.g., minutes of contact).
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Smoking CessationSmoking Cessation
Three types of counseling and behavioral therapies were found to be especially effective and should be used with all patients attempting tobacco cessation: – Provision of practical counseling (problem
solving/skills training). – Provision of social support as part of treatment
(intra-treatment social support). – Help in securing social support outside of
treatment (extra-treatment social support).
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Medication and tobacco useMedication and tobacco use
Numerous effective pharmacotherapies for smoking cessation now exist. Except in the presence of contraindications, these should be used with all patients attempting to quit smoking.
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Five first-line pharmacotherapies were identified that reliably increase long-term smoking abstinence rates: – Bupropion SR. – Nicotine gum. – Nicotine inhaler. – Nicotine nasal spray. – Nicotine patch.
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Tobacco dependence treatments are both clinically effective and cost-effective relative to other medical and disease prevention interventions. Therefore, insurers and purchasers should ensure that:
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InsuranceInsurance
All insurance plans include as a reimbursed benefit the counseling and pharmacotherapeutic treatments identified as effective in this guideline.
Clinicians are reimbursed for providing tobacco dependence treatment just as they are reimbursed for treating other chronic conditions.
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Quitting smoking is the most positive and healthy lifestyle change you can make to improve your overall health and well-being. The moment you stop smoking is the start of an amazing and magical healing process that takes place within your body.
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Phillip Morris Phillip Morris
Philip Morris U.S.A. believes that the conclusions of public health officials concerning environmental tobacco smoke are sufficient to warrant measures that regulate smoking in public places.
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Life Skills TrainingLife Skills Training
provide students with the necessary skills to resist social (peer) pressures to smoke, drink and use drugs,
help them to develop greater self-esteem, self-mastery, and self-confidence,
enable children to effectively cope with social anxiety
increase their knowledge of the immediate consequences of substance use
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