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VOL. 6 • NO. 3
© November 2011
Making smoking history: Quitting now is the best cure despite recent medical advances Kim McNeill didn’t realize that her habit of smoking just a few cigarettes a day could result in lung cancer. A few years ago she was diagnosed and treated for Stage 3B — a very advanced — lung cancer at Boston Medical Center. (Yawu Miller photo)
Kim McNeill was 21 years old when she tried her first cigarette and learned to blow smoke rings. “I was trying to be cute,” she remembered. After a while, McNeill said she would find any excuse to light up — after meals, talking on the phone, waiting for a bus — and thought her habit of four or five cigarettes a day was relatively harmless. It wasn’t. Those “excuses” began to take a toll. McNeill got a persistent cough that didn’t go away. “I thought I had a cold,” she said. But the cough got worse and the chest pains intensified. When tightness in her chest crept in, she knew something was wrong. “I thought I had pneumonia,” she said. A series of tests in the emergency room at Boston Medical Center produced a different diagnosis — cancer. “It sounded like
death to me,” McNeill remembered. “I went home and I cried. It was the worst sensation in the world.” Given the nature of lung cancer, McNeill’s fears were real. The American Cancer Society (ACS) estimates that in 2011 lung cancer will account for almost 157,000 — or 27 percent — of all cancer deaths, making it the most deadly of all cancers. The disease is more lethal than cancers of the breast, colon, prostate and liver combined. At more than 221,000 new cases each year it is second only to prostate cancer in men and breast cancer in women. The tragedy is that lung cancer is largely preventable. The ACS estimates that almost 90 percent of all lung cancer deaths are attributed to smoking and exposure to second-hand smoke. The longer a person smokes and the more cigarettes smoked,
the greater the risk. Roughly 443,000 deaths a year are caused by cigarette smoking, according to the Centers for Disease Control and Prevention (CDC), and that includes more than 15 different types of cancer as well as several cardiovascular and respiratory diseases. Smoking affects every organ in the body. Lung cancer takes a long period of time to develop. Dr. Michael Ebright, assistant professor of cardiothoracic surgery and co-director of the Lung Cancer CyberKnife Program at Boston Medical Center, explained that the time lapse gives some smokers the feeling that they have beaten the odds. “Most people start [smoking] in their teens,” Ebright said, “but don’t develop cancer until their 50’s or 60’s.There’s a latency period before you develop cancer.” But Ebright is quick to point out that there are some lung cancers that are extremely aggressive and develop quickly. The signs and symptoms of the disease are many — a persistent cough, coughing up blood, chest pains, shortness of breath, wheezing or hoarseness. But these can indicate a myriad of other illnesses as well. “A new cough that has been persistent is cause for concern,” he explained. “Any time you cough up blood requires a trip to the doctor.” But often, according to Ebright, by the time the symptoms emerge, the disease has advanced. “Only 20-25 percent are discovered early,” he said. And that is not good. The National Cancer Institute (NCI) has determined that the 5-year survival rate for cases that have metastasized or spread beyond the lungs drops to under 4 percent. Though lung cancer remains the most deadly cancer and the second most common cancer in both men and women, improvements are beginning to emerge. New cases of the disease are dropping in this country, particularly in the West, according to the latest figures from the CDC. Rates of deaths are on the decline as well. Yet, despite these changes, the impact of lung cancer is hard on black males. Although the incidence and death rates of lung cancer are comparable in black and white women, black men pose a different problem. According to data from the NCI, the incidence and death McNeill, continued to page 4
Health experts warn against second-hand and now third-hand smoke It took a while before 70-year-old Meena Carr figured out that her scratchy throat and persistent cough was attributable to her husband’s second-hand smoke. “You have a problem, but you live with it so long, you’re not aware of it,” she explained. But it was the plight of her grandson who had asthma that triggered Carr to take action. “You wouldn’t understand until your child wakes you up in the middle of the night saying ‘I can’t breathe,’ ” she said. The family never attributed his multiple visits to the emergency room to exposure to tobacco — especially since no one in the household smoked at the time. But the neighbors did. That’s when Carr said she realized that closing the front door does not provide a protective barrier from another person’s smoke. Carr, a non-smoker, did not sit idly by. She and a small group of residents decided that the new Washington-Beech Housing Development under construction in Roslindale would be smoke-free. They solicited the assistance of the Committee for Boston Public Housing (CBPH) whose mission is to “improve the quality of life for Boston’s public housing residents.” The CBPH did a survey and discovered that buildings that had a higher rate of kids with asthma also had a higher number of smokers. That was not unusual. According to a report cited by the Boston Public Health Commission, more than 23 percent of residents in Boston public housing had asthma compared to 15
Meena Carr (left) and Westlyn Bruno are members of a committee that was successful in making Washington-Beech, a public housing development in Roslindale, smokefree. (Ernesto Arroyo Photo) percent of residents in non-public housing. Armed with that information, the group began a campaign to educate the residents of the perils of smoking — not only for
the smoker, but for innocent bystanders. Especially children. The message was often directed to parents who tried to protect their children by smoking outside of their presence. “You have a baby and you smoke at work,” she explained. “When you come in from work and hold your baby close to you, your baby inhales the fumes. You’re the one who is causing the problem.” The residents listened and responded. When a grant was given to build the new Washington Beech, more than 80 percent of the residents — even the smokers — agreed to make the complex a no-smoking residence. That is also the goal of the Boston Public Health Commission. They are launching the Boston Smoke-Free Homes campaign and are asking property owners to register their apartments and rental homes as smoke-free (www.bostonsmokefreehomes. org). Boston Mayor Thomas M. Menino is taking this pledge one step further and is proposing to make all developments in the Boston Housing Authority (BHA) smoke-free in 2012. It is well known that second-hand smoke — the combination of the burning end of a tobacco product and the smoke breathed out by smokers — can cause heart disease and lung cancer in non-smokers. According to the Centers for Disease Control and Prevention (CDC), second-hand smoke causes roughly 46,000 premature deaths each year in this country from heart disease and another 3,400 from lung cancer. There are many perks to going smoke-free. Cost is one. A
Carr, continued to page
Smoking It’s better to never start than stop
Trying to pick the best time to quit tobacco? Whether this is your first or fifth attempt, today is the perfect day to launch a new plan. Start by thinking hard about the facts. All tobacco products — cigarettes, cigars and smokeless options like chewing tobacco or snuff — cause cancer. And not just lung cancer, either. According to the American Cancer Society, using tobacco raises risks for cancers of the mouth, lips, nose, sinuses, voice box, throat, stomach, pancreas, kidney, bladder, uterus, cervix and other sites in the body. One in five deaths can be traced to tobacco. Twenty more people wind up with serious health problems for each person who dies. Smoking leads to heart disease, strokes and lung diseases like emphysema and bronchitis. It prompts further complications in people with diabetes. Second-hand smoke kills thousands of people annually and harms many more. Children of smokers are
more likely to have ear infections and lung infections like pneumonia and bronchitis. Youngsters who have asthma suffer attacks more often and more severely. “When you quit, you begin to stop the damage,” said Dr. Thomas Hawkins, medical director for health informatics at Blue Cross Blue Shield of Massachusetts. “Your risk for heart disease goes down 50 percent in twelve months. Cancer risks also decline, although more slowly.” Your health improves vastly in many ways (see “Reaping the benefits”). And your wallet benefits, too.
Who smokes?
Among adults, 21 percent of African Americans, 15 percent of Hispanics and 12 percent of Asian Americans reported smoking in 2009. Every day, nearly 3,500 children ages 12 to 17 have their first cigarette.
Are you ever too old to quit?
No. While smokers 65 or older are just half as likely to try quitting as 18 to 24 year olds, older smok-
ers are nearly twice as likely to succeed when they do try. That’s good since they have much to gain. A 2011 study of older adults found less cognitive decline over a two-year period in those who quit or never smoked versus those who continued smoking. Other research shows older smokers who quit have two to three years longer life expectancy, lower odds for a second heart attack or amputation and better lung function, which may translate to more mobility and independence.
What helps?
Check with your health plan about quit tobacco programs and incentives. Experts recommend a quit plan tailored to your needs that involves a combination of approaches: • Set a quit date and regular check-in dates to report on how you’re doing. • Identify great reasons to quit. • Identify your smoking triggers and plan to avoid them. • Recall past slip-ups and plan around them. • Learn which nicotine replacement products (patches, gum, lozenges, sprays and inhalers) could help you. • Talk to your doctor about medicines that help quash cravings and withdrawal symptoms. • Seek support from your doctor, a smoking cessation counselor, loved ones or social networking sites for others who are trying to quit.
What step should you take first?
Choose one of the following:
• Call your doctor, who can prescribe helpful medicines and refer you to a smoking cessation program. • Contact your health care plan about smoking cessation programs. Blue Cross Blue Shield of Massachusetts members can call the number on the front of their ID card or find a full-featured quit program at www.my bluehealthma.com complete with tools that let you track your progress, show just how many days quitting adds to your life, and total up the cash you’re saving. There are also community forums and “ask an expert” tools. • Request a step-by-step guide to quitting from Smokefree.gov (www.smokefree.gov or 1-800-QUITNOW). Quitline counselors are available by phone — or even via text message — to answer questions and offer encouragement every step of the way. Perseverance really counts! To quit tobacco successfully, people often have to try several times. Understanding why you failed in the past can help you succeed next time. What ruined your resolve? Which situations or people made cravings impossible to resist? How could you handle stress better? Should you talk to your doctor or a smoking cessation counselor about which nicotine replacements or other medicines might work best for you? Would more support or other incentives encourage you to stick with quitting?
Reaping the Benefits Want more reasons to quit? According to the American Cancer Society, you’ll reap major health benefits.
BE Healthy • http://behealthy.baystatebanner.com
Time after quitting
Health benefits
20 minutes
Blood pressure and heart rate drop
12 hours
Carbon monoxide in your blood returns to normal levels
2 to 3 months
Circulation and lung function improve
1 to 9 months
Coughing and shortness of breath grow better
1 year
Heart disease risk drops by half
2 to 5 years
Stroke risk decreases to that of a non-smoker
5 years
Risks for certain cancers (mouth, throat, esophagus and bladder) are halved, and cervical cancer risk drops to that of a non-smoker.
10 years
Risk of lung cancer death is cut in half
Questions & Answers
1. Is it safer to smoke cigars or pipes than cigarettes? Although some population studies indicate that pipe or cigar smoking has a lower risk of causing lung cancer than cigarette smoking, there is still an increased risk of lung cancer when compared to non-smokers. It is also not Hiran C. Fernando, MBBS, FRCS clear from these large popu- Director, Center for Minimally Invasive lation studies how the actual Esophageal Surgery Boston Medical Center tobacco dose compares between people who smoke cigarettes exclusively and people who smoke a pipe or cigars exclusively. 2. What symptoms in particular may indicate lung cancer? Lung cancer can present in many ways. Some patients will have no symptoms and their cancer is found on a routine chest X-ray or clinical examination. In many cases patients will present with symptoms related to the cancer’s direct effects on their lungs. For instance, patients may have shortness of breath, a lung infection, such as pneumonia, or coughing up of blood. In other instances there may be symptoms outside of the lungs such as bone pain, headaches and even unexplained weight loss. 3. If a person does not inhale when smoking is there still a risk of cancer? Yes. There is a risk of cancer for anyone who smokes. 4. Is it true that there is little value in stopping smoking since damage to the lungs from tobacco is irreversible? The risk of cancer is reduced in a person who stops smoking compared to someone who continues to smoke. However the risk is not eliminated altogether and is still higher than that of a lifetime non-smoker. Another consideration is that smoking also affects the lungs in other ways, such as causing emphysema. This can be an issue for patients who are found to have a cancer that may be curable by surgery but may not be candidates simply because they do not have the breathing reserve to tolerate an operation. The best advice is to make every effort to stop smoking and encourage family members to do the same.
Lung Cancer A Deadly Transformation
Healthy Lungs
Smoker’s Lungs
The major purpose of the lungs is the exchange of gas. We breathe in oxygen from the air and breathe out carbon dioxide, a waste product. Oxygen is essential to the body; it provides the fuel our cells and organs require to function. The average adult takes 15 to 20 breaths a minute. According to the U.S. Surgeon General, even occasional smoking causes immediate damage to the lungs. Inhaling a small amount of tobacco smoke can damage a person’s DNA, which can lead to cancer. Tobacco also destroys the tiny air sacs of the lungs, which results in emphysema. While healthy lung tissue is pink in color, lungs with emphysema or cancer are black.
SIGNS AND SYMPTOMS • Persistent cough • Blood-streaked sputum • Constant chest pain • Repeated bouts of pneumonia or bronchitis
• Shortness of breath, wheezing or hoarseness • Fatigue • Loss of weight or appetite for no known cause
5. What is the most frequent cause of lung cancer in non-smokers? About 10-15 percent of all lung cancer deaths occur in non-smokers, probably largely due to exposure to second-hand cigarette smoke. This may be from a spouse or perhaps from parents when growing up. One study of 526 female patients with lung cancer in Northeast England demonstrated that 99 percent of these patients had at least 10 years of second-hand smoke exposure. Other factors may lead to an increase in lung cancer risk, such as asbestos, radon and silica exposure. 6. Can lung cancer be detected in the early stages when treatment is more successful? Currently, there is no generally approved screening test for lung cancer. That being said, there is a very good chance of curing lung cancer if found in its early stages. Even if a patient can not tolerate the standard surgery to treat lung cancer because of diseases such as emphysema, there are now other options that can be offered that still provide the chance for a cure. These options include minimally invasive and robotic surgery, which allow faster recovery, radio-frequency ablation (which involves placing a probe into the cancer and “cooking” it) and a special kind of radiation therapy called stereotactic body radiation therapy. 7. Does excessive alcohol use increase the risk of lung cancer? No. Excessive alcohol use does not increase the risk of lung cancer, although it is associated with a number of other problems that may prevent a patient from getting treated for cancer or lead to complications after treatment for lung cancer.
RISK FACTORS • Smoking
Smoking is responsible for almost 90 percent of all cases of lung cancer.
• Second-hand smoke
The U.S. Surgeon General has concluded that there is no risk-free level of exposure to second-hand smoke.
• Industrial and environmental exposure Exposure to certain substances, such as radon, a colorless gas often found in the home, asbestos and arsenic, may increase the risk, especially in smokers.
• Personal or family history
A person who has had lung cancer or has a parent or sibling with lung cancer may be at increased risk.
• Radiation to the chest
Radiation to the chest to treat other cancers may increase the incidence of lung cancer, especially in those who smoke. The information presented in BE HEALTHY is for educational purposes only, and is not intended to take the place of consultation with your private physician. We recommend that you take advantage of screenings appropriate to your age, sex, and risk factors and make timely visits to your primary care physician.
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are not exempt from its hazards if they live in a house of smokers. report from the Boston Tobacco Prevention In children it causes severe asthma and Control Program indicated that apartattacks, respiratory and ear infections and ment turnover costs can be two to seven sudden infant death syndrome. times greater for a unit in which the resident “Parents are aware of the impact of smoked. Insurance rates are less and the risk smoke on children,” Boynton-Jarrett said. of fire is reduced. Furthermore, in a city like “Some might feel guilt about their habit.” Boston, where 85 percent of the residents So essential is a smoke-free environare non-smokers, a smoke-free apartment or ment to the health of children that the home is a prime attraction. hospital has introduced into the medical But it’s the health concerns that are record a tool to screen for smoking around primarily driving this resolution. The children. The purpose is to determine 2008 Behavioral Risk Factor Surveillance all environments the child might inhabit System, a survey sponsored by the CDC, that could expose him or her to seconddetermined that a higher percentage of hand smoke that a parent might overlook. public housing residents in Boston had Often it is places you would least expect asthma, high blood pressure and diabetes it — day care, for example or the grandthan the general population. Moreover, 25 mother’s house. percent smoked compared to 13 percent of But even refraining from smoking non-public housing residents. around a child may not provide full protecUnfortunately, tion. Winickoff is smoke doesn’t credited with coining have boundaries. the term “third-hand Second-hand smoke smoke” — a toxic seeps under doors combination of gases and through shared and particles that ventilation systems. lingers long after That is the finding of smoking. Dr. Jonathan P. WinAccording to a icoff, a pediatrician recent report in Enat Massachusetts vironmental Health General Hospital. Perspectives, thirdHe and his hand smoke consists co-researchers of residual pollutants measured cotinine, a from tobacco smoke chemical byproduct that remain in dust of nicotine exposure, and on surfaces. Acin the blood of 5,000 Renee D. Boynton-Jarrett, M.D. cording to Winickchildren across the off, you don’t have Pediatrician Boston Medical Center country that lived to see the smoke, as in apartments or atyou do in secondtached homes. They found that 73 percent of hand smoke. If you smell it, it’s there. the children tested positive for the chemical, The issue of third-hand smoke is a the highest level being found in children fairly new concept, but preliminary studies who lived in large multi-unit buildings. have shown that house dust in smokers’ The kicker is that none of these homes and even the dashboards of cars were children lived with someone who smoked. contaminated with nicotine. Winickoff suggests that smoke may seep More disturbing was that dust and through walls or air ducts exposing children surfaces of homes were contaminated who live in neighboring units. even when smokers tried to limit exposure Dr. Renee D. Boynton-Jarrett, a pediato smoke by turning on fans or opening trician at Boston Medical Center, explained windows. It was found that the remnants that her major concern is the health of the of smoking cling to pillows, carpets and child, but that is so intertwined with the upholstery. It even clings to toys. And that is health of the caregiver, that she winds up the concern of Boynton-Jarrett. Infants and more often with two, rather than one patient. toddlers put things in their mouths. Particularly when it comes to smoking. Even smoking outdoors is not a solution “Children of smokers are more likely — smoke clings to clothes, hair and skin. to smoke,” she explained. “They get a level Boynton-Jarrett offers suggestions. “Wear a of comfort around smoking. They adopt the coat when you smoke outside to protect your same behavior [as their parents] and they clothing from the pollutants,” she said. “Wash initiate smoking early.” your hands before you touch your kids.” Infants and toddlers pose a different But one piece of advice prevails. “Try kind of problem. They don’t smoke, but they quitting,” she said. Carr, continued from page
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According to the National Cancer Institute, tobacco smoke contains more than 7,000 chemicals, including substances that are toxic to the body and carcinogens, or cancer-causing elements.
McNiell, continued from page 1
packs a day for 15 years should discuss the value rates in black men are roughly one-third higher of the low-dose scan with their doctors. than the rates in white men. The reason for this The treatment for lung cancer has also difference is unclear, particularly given the fact made great strides in the past few years. There is that smoking is more prevalent among whites. newer chemotherapy and now treatments can be Another puzzling change is the unexplained personalized. That is, treatment can be directed increase in the incidence of lung cancer among toward a person’s particular genetic mutation that non-smokers. It is well known that smoking accaused the cancer. An advanced form of radiation counts for 90 percent of all cases of lung cancer. called stereotactic body radiation therapy has But in the past few years lung cancer has been found to improve survival in patients with increased in female non-smokers. “We don’t inoperable early-stage lung cancer. know why,” said Ebright, who cited the case There are advances in surgery as well. In of Dana Reeves, Christopher Reeve’s wife. A video-assisted thoracic surgery, it is possible to life-long non-smoker, she died of lung cancer at reach the tumor without spreading the ribs apart, the age of 44, almost thereby reducing the 30 years younger than trauma of the surgery the median age for and recovery time. smokers. Though lung canAlthough no cer kills more people professional organizathan any other cancer, tion as yet recommends Ebright is optimistic. screening for lung “Lung cancer is not cancer, steps have been necessarily a death taken in this direction. sentence,” he said. During the National Ask McNeill. In Lung Screening Trial it spite of her more than was found that people 30 years of smoking, at risk of lung cancer fate was on her side. — heavy current She was strong and, and former smokers surprisingly, accordbetween the ages of ing to Ebright, her 55 and 74 — who thoracic surgeon, had Michael Ebright, M.D. Co-Director, Lung Cancer received a newer type good lung function. of CT scan called low- CyberKnife Program She also was able Boston Medical Center dose spiral CT had a to withstand a very 20 percent lower risk aggressive treatment of dying from lung cancer than participants who of chemotherapy and radiation followed by received standard chest X-rays. The scan was surgery. able to detect early lung cancers and provide McNeill said she made the best of it. more detailed pictures than the X-ray. The prob- She crocheted during her chemotherapy or lem is that the screening is very expensive and watched movies. no standard work-up for abnormal findings has The excuses stopped. And so did the been established, according to Ebright. smoking. Invasive tests are not without risk. The McNeill admits that some things are more lesions that are small are particularly perplex- difficult for her now that she is missing part of ing. “Some stay small,” he said, implying that her left lung. additional testing and treatment may not be “I have trouble on inclines,” she explained. warranted. “I can do almost anything; I just take more time. Yet, despite these shortcomings, Ebright Now I’m the tortoise instead of the hare.” recommends that people in this age category who But she’s not complaining. “I have life,” have smoked a pack a day for 30 years or two she said.
Need help to kick the habit? It’s a call or click away Organization Method
Contact Information
Mass. Smokers’ Helpline
Telephone
800-QUIT-NOW or 800-784-8669
www.trytostop.org
Interactive website
800-879-8678
QuitWorks
Interactive website
www.quitworks.org
Smokefree.gov
Interactive website
877-784-8669
National Cancer Institute Smoking quitline
Telephone
877-44U-QUIT or 877-448-7848
LiveHelp Online Chat Instant messaging
https://cissecure.nci.nih.gov/live help/welcome.asp
Boston Tobacco Prevention
617-534-4718
Educational material
and Control Program
tobaccocontrol@bphc.org
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