The Surgeon General’s Report on Secondhand Smoke

U.S. Surgeon General Richard Carmona released today a major review of the scientific evidence on secondhand smoke: The Health Consequences of Involuntary Exposure to Tobacco Smoke. This subject was last reviewed by the Surgeon General’s office twenty years ago, under Dr. C. Everett Koop.

The comprehensive study examined the link between secondhand smoke and a large number of diseases to determine if the evidence demonstrated a causal link between secondhand smoke and each disease. It also studied the extent to which nonsmokers were exposed to secondhand smoke in public places where smoking occurred.

The major conclusions of the studies are:

  • Secondhand smoke causes premature death and disease in children and in adults who do not smoke.
  • Children exposed to secondhand smoke are at an increased risk for sudden infant death syndrome, acute respiratory infections, ear problems, and more severe asthma. Smoking by parents causes respiratory symptoms and slows lung growth in their children.
  • Exposure of adults to secondhand smoke has immediate adverse effects on the cardiovascular system and causes coronary heart disease and lung cancer.
  • The scientific evidence indicates that there is no risk-free level of exposure to secondhand smoke.
  • Many millions of Americans, both children and adults, are still exposed to secondhand smoke in their homes and workplaces despite substantial progress in tobacco control.
  • Eliminating smoking in indoor spaces fully protects nonsmokers from exposure to secondhand smoke. Separating smokers from nonsmokers, cleaning the air, and ventilating buildings cannot eliminate exposures of nonsmokers to secondhand smoke.

This is a major contribution to public awareness about secondhand smoke and will very likely inform and encourage the drive to ban smoking in public buildings. I hope it will also persuade smokers who are parents to quit.

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What Do You Call This Kind of Medical Practice?

About a month ago I attended the annual conference of the Society for Innovative Medical Practice Design (SIMPD), a national organization of physicians like me who have decided to stop working for insurance companies, and start working for our patients. The conference was very inspirational. We heard distinguished speakers including Tommy Thompson, former Secretary of the Department of Health and Human Services, Regina Herzlinger, Professor of Business Administration at the Harvard Business School, and Connie Mariano, M.D., who was White House physician to three sitting American Presidents. Their presentations had a common theme: American medical care is in serious trouble. We heard that health care is increasingly expensive, physicians are increasingly overworked and demoralized, and patients are increasingly frustrated by the inadequate time, attention and education they receive. The solution will not come from government or from insurance companies. After all, they created the problem. The solution will come from empowering patients to spend more of their healthcare dollars directly, and giving them increasing options of how to spend them. In this context, physicians who sever their relationships with insurance companies and work only for their patients will be an important part of the solution. We will revitalize patient expectations, provide examples of a fulfilling career to the next generation of medical students, and remove ourselves from the diminishing stream of insurance reimbursements. In short, we will be good for patients, good for other doctors, and good for the nation.

Hearing the speakers was very interesting, but even more enjoyable was meeting the other physicians who attended the conference. I was impressed by what an idealistic (and fairly young) bunch we were. The doctors I met had very similar stories. Many were frustrated at having to see 30 patients a day. Some were on the verge of dropping out of medicine entirely before discovering this new practice model. Some were motivated by extra time to spend with family, some by the nagging realization that they were not delivering good care in their high-volume practice, some by the desire to abandon the complexities of insurance billing. I almost never heard income mentioned as a motivation. These doctors aren’t in it for the money. They’re trying to reclaim their profession.

A question that I frequently heard asked by the doctors was “What should we call this kind of practice?” Small patient-focused medical practices have been called “concierge medicine” or “boutique medicine” but neither of those terms was very popular with the doctors. “Retainer-based medicine” has also been used in media articles about such practices. SIMPD uses the phrase “patient financed medical care” which is more descriptive, but is too long and hasn’t caught on either. Business and policy articles have begun using the phrase “consumer-driven health care”. For example, the National Center for Policy Analysis, a free market think tank, recently released their analysis paper Consumer-Driven Health Care Spurs Innovation in Physician Services.

Eventually I think it will be patients who settle on a name for this kind of practice which is patient centered and patient financed. I’m honestly curious what you think of the various names, or whether you have a name that you think is better. Please send me your thoughts. Since you’ll be responsible for fixing American healthcare; you might as well decide what to call the solution.

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The Effects of Coffee and Napping on Nighttime Highway Driving

This issue of Annals of Internal Medicine has the most relevant medical study I’ve read in a long time. We’ve all been in the scary situation of driving late at night while sleepy and struggling to stay awake. This study asked the important question: Does drinking coffee or taking a nap improve driving late at night?

The study design involved having volunteer drivers each take 90 minute drives on different weeks under four different conditions. One drive was during the day, as a control. The other three drives were from 2:00 a.m. to 3:30 a.m. One night time drive was 30 minutes after drinking 125 ml (about a half a cup) of coffee containing 200 mg of caffeine. Another drive was 30 minutes after drinking the same amount of decaffeinated coffee (containing 15 mg of caffeine). Another drive was 30 minutes after awakening from a 30 minute nap which was taken at a highway rest area with the participant sleeping in the car with the driver seat reclined. The participants didn’t know if they were drinking coffee or decaf.

Driving quality was measured by videotaping the road from the car and counting inappropriate crossings of the painted lines that separate lanes. A driving instructor accompanied the driver and was prepared to take over control of the car. (So don’t try this at home!)

The results were interesting. The drivers drinking decaf did much worse (i.e. had more line crossings) than they did in their daytime drives. Both after napping and after drinking real coffee drivers did better on average than after drinking decaf, but not as well as during the daytime drive. The improvements due to a nap and due to coffee were about the same.

The authors conclude

Of interest, some participants respond very well to caffeine but do not improve greatly after a nap, while others benefit more from a short sleep than from caffeine. Both [coffee and napping] should be proposed and promoted to decrease the risk for accidents at night. Both countermeasures are about equally efficient in reducing line crossings, and we have no preference of one over the other. Participants should choose according to their own physiologic response.

The moral of this study is to try to avoid driving late at night. If you have to drive when sleepy, it’s better to first take a nap and drink some coffee, but that still won’t make you as safe as you are when driving during the day.

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Increased Weight is Associated with Heartburn

Gastroesophageal reflux disease (GERD), in which acid from the stomach rises into the esophagus causing heartburn, is a very common and uncomfortable problem. A connection between GERD and increased weight has long been suspected.

This recent study in The New England Journal of Medicine makes a fascinating connection between being overweight and having symptoms of GERD in women. The study looked at over ten thousand women in the Nurses’ Health Study, one of the largest studies of American women that followed a large group of women and tracked multiple aspects of their health. The study gave the women a questionnaire to grade the severity and frequency of heartburn and acid regurgitation. They compared the results of the questionnaires to the women’s body mass index (BMI).

The BMI is a way to adjust a person’s weight for her height and allows us a rough guideline by which to decide if a person’s weight is too high. You can calculate your BMI with the CDC’s BMI calculator.

The results of the study were surprisingly strong. Not only was there a strong correlation between BMI and heartburn, the correlation persisted even in the normal BMI ranges. That means that even in women of normal weight, a few pounds of weight gain resulted in a higher risk of heartburn. Women who had recently lost weight were also less likely to have heartburn than women who had gained weight.

This was a purely observational study, so this can only show that weight and heartburn are associated. It can not prove that one causes the other. I would love to see an experiment in which patients with heartburn are randomized to two groups, one which receives antacids, and a second who receives antacids plus diet and exercise aimed at weight loss. If the second group lost more weight and had less heartburn, this would prove that weight is partially responsible for heartburn symptoms.

There are already lots of other good reasons to keep our weights down: lower blood pressure, lower cholesterol, and better control of diabetes. It’s possible that less frequent heartburn should be added to that list.

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Many Americans Unaware They Have Diabetes

A new study from the National Institutes of Health (NIH) and Centers for Disease Control highlights how common type II diabetes is among American adults. The study is summarized in this NIH news release. 6.5% of American adults have diabetes. Even more alarming is that a third of them don’t know they have it.

Type II diabetes has serious potential consequences, and its high prevalence makes it a common cause of disability. Type II diabetes is the most common cause of blindness, kidney failure, and limb amputation, and is a major risk factor for strokes and heart attacks. The many Americans with undiagnosed diabetes are at high risk for these complications, all of which are potentially preventable.

The news release listed the following risk factors that increase the probability of diabetes.

You are at greater risk of developing pre-diabetes and type 2 diabetes if you:

  • are age 45 or older
  • have a family history of diabetes
  • are overweight
  • have an inactive lifestyle (exercise less than three times a week)
  • are members of a high-risk ethnic population (e.g., African American, Hispanic/Latino American, American Indian and Alaska Native, Asian American, Pacific Islander)
  • have high blood pressure: 140/90 mm/Hg or higher
  • have an HDL cholesterol less than 35 mg/dL or a triglyceride level 250 mg/dL or higher
  • have had diabetes that developed during pregnancy (gestational diabetes) or have given birth to a baby weighing more than 9 pounds
  • have polycystic ovary syndrome, a metabolic disorder that affects the female reproductive system
  • have acanthosis nigricans (dark, thickened skin around neck or armpits)
  • have a history of disease of the blood vessels to the heart, brain, or legs
  • have had impaired fasting glucose or impaired glucose tolerance on previous testing.

Anyone who sees a physician regularly has most likely been tested for diabetes. But if you know someone with some of these risk factors who hasn’t seen a physician in a few years, suggest to him that he get checked by his doctor. What he doesn’t know can definitely hurt him.

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A Small Part of the Solution

A sad fact of our current healthcare marketplace is that a large number of Americans can’t afford medical care other than in the emergency room. It’s impossible to have a private practice without considering those for whom even the basics of primary care are an unaffordable luxury.

Since I went into private practice six years ago, I made a commitment to volunteer caring for indigent patients. One afternoon every month I volunteer at the Simms/Mann Health and Wellness Center (formerly called the Burke Health Center) which is a clinic in Santa Monica operated by the Venice Family Clinic. Their internal medicine clinic is staffed by UCLA residents and supervised by attending faculty physicians, like me. It’s a great opportunity for me for lots of reasons. I interact with and teach UCLA residents (and remind myself that I was one just a decade ago). I demonstrate to residents (who are exposed mostly to role models who are employees of large medical groups) that they can build a career in which they work for their patients, not for administrators. Most importantly, I help care for patients who otherwise would have no access to care. I always look forward to my afternoons at Simms/Mann.

So if you call on the third Wednesday of every month and ask to see me in the afternoon, my receptionist will politely suggest a different time. Now you know why. This summer, after I withdraw from Medicare, I’ll start spending two afternoons a month there.

Will two afternoons a month fix the problem of indigent health care? No. But imagine what could happen if more doctors got out of their non-stop high-volume practice, spent more time with each patient, and then donated some time for patients who can afford nothing.

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The Evidence on Acupuncture

I’ve introduced you to the Medical Letter in a previous post. It’s a great source of unbiased reviews of the medical literature. In their most recent issue, the Medical Letter reviewed the available evidence about acupuncture. Since I can’t link to the full text (it’s available only to subscribers) I’ll summarize their review.

Anesthesia The studies supporting the use of acupuncture for postoperative pain and nausea suggest it may be useful as an adjunct to traditional anti-nausea and pain medications, not as a sole treatment.

Cancer palliative care The results of studies of acupuncture for cancer pain or for chemotherapy-related nausea have been mixed. One review of several studies showed a small advantage in using acupuncture for nausea in addition to standard anti-nausea medicine.

Low back pain Acupuncture is more effective than no treatment or than sham acupuncture (inserting needles at points other than the traditional acupuncture points) for low back pain. One study suggested that acupuncture was more effective than physical therapy.

Headache Results of studies of acupuncture for chronic headaches have been mixed, with some demonstrating no benefit over standard therapy, and others showing that acupuncture decreases need of pain-relieving medication.

Osteoarthritis of the knee More than one study has shown that acupuncture is effective in treating arthritis.

Other uses Acupuncture is currently used in smoking cessation, weight loss, addiction, depression, and stroke. There is no convincing evidence that acupuncture is effective for these problems.

The article concludes:

Acupuncture alone has not been shown in rigorous, duplicated studies to benefit any defined medical condition. It may be worth trying in patients with chronic pain, especially low back pain that is refractory to conventional management. It may also be effective as an adjunct to other drugs for headache and to antiemetics for chemotherapy-related nausea and vomiting.

Proponents of evidence-based medicine are sometimes accused of being dismissive of non-western medicine, so I think it’s important to fairly assess the evidence of all therapies, regardless of where they originate. Acupuncture clearly has a proven role in some conditions.

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Gastric Banding is a Reasonable Treatment Option for Obesity

Obesity is a serious problem in America and in my practice. Obesity predisposes to type II diabetes, high blood pressure, and high cholesterol. It also increases stress on joints and worsens arthritis. Nevertheless, losing weight for most patients is very difficult. Dietary modification and exercise have been the most proven weight loss techniques, but many patients can not adhere to a strict exercise and diet regimen.

More recently, surgical treatments for weight loss have offered an alternative for patients who have not lost weight with diet and exercise. Though these treatments seemed promising, until now there have been no rigorous randomized trials comparing surgical treatments to diet and exercise.

The most recent issue of the Annals of Internal Medicine features a trial in which mild to moderately obese patients were randomized to receive medication aimed at weight loss, and intensive diet and exercise counseling versus laparoscopic gastric banding. Gastric banding involves surgically placing a small belt around the stomach which can be adjusted to different lengths to constrict the stomach and promote satiety. Because it is placed laparoscopically (with scopes through small incisions) it involves a much faster recovery than gastric bypass and is frequently done as an outpatient.

The study showed that the patients treated surgically had more weight loss and better quality of life than those treated medically, after being followed for two years. This is the strongest evidence so far that surgical approaches to weight loss are effective. That’s encouraging news for patients who have struggled for years unsuccessfully with diet and exercise.

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Homocysteine: A Risk Factor Worth Ignoring

Last month’s New England Journal of Medicine has a great lesson about how we should think about risk factors.

It’s been long known that homocysteine is a risk factor for heart disease. That means that, when looking at large numbers of people, those with high levels of homocysteine have more heart attacks on average than those with low levels. Too frequently, we confuse a risk factor with a cause, and we jump to the conclusion that homocysteine causes heart attack. A risk factor, however, is not necessarily a cause. It may simply be a marker of risk.

It has also been long known that supplements of vitamin B12, vitamin B6 and folic acid decrease homocysteine levels in patients with elevated levels. This persuaded many doctors (me included) to recommend these vitamins to our patients with elevated homocysteine in the hopes that doing so would help prevent heart attacks. A study in April’s New England Journal of Medicine demonstrates that our hopes were not founded.

The study randomly assigned patients who recently had a heart attack to take the vitamin supplements or placebo. The patients who were on vitamin supplements had significant lowering of their homocysteine but no difference in their risk of a future heart attack. The implications are clear: homocysteine is a marker of cardiac risk, but altering it does not alter the risk itself.

I’m asking my patients taking the supplements for heart-attack prevention to discontinue them. We should instead be focusing our attention on risk factors for heart disease that have been proven to prevent heart attacks when well controlled: blood pressure, cholesterol, diabetes, and smoking.

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American Death Rate Drops Sharply

The National Center for Health Statistics released the statistics on the number of deaths in 2004. The results document the biggest drop in the American death rate in almost 70 years.

The findings are summarized in this AP article.

The center said drops in the death rates for heart disease, cancer and stroke accounted for most of the decline.

“We were surprised by the sharpness of the decrease. It’s kind of historical,” said statistician Arialdi Minino, lead author of the report.

The government also said that U.S. life expectancy has inched up again to 77.9 years, a record high but still behind that of about two dozen other countries.

This is terrific news. It suggests that the new treatments in the last few decades for high blood pressure, high cholesterol and diabetes are finally making a difference in decreasing the death rate from stroke and heart disease. The fact that the death rates from cancer are also decreasing may be a tribute to the increased focus on cancer screening and early detection.

We can hope that this trend continues in the future.

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