Anti-Smoking Efforts Light Up

In an effort to discourage Americans from smoking, the Food and Drug Administration (FDA) recently unveiled a proposal requiring cigarette packages and advertisements to display large, color graphic warnings.  The proposal calls for nine warning statements accompanied by a color graphic depicting the health consequences of smoking, such as addiction, stroke and heart disease, cancer, open sores, harm to children via second-hand smoke, harm during pregnancy, and death.  (Click here and here to see the 36 proposed statements and color graphics.)  Members of the public can submit their comments to the FDA until January 11, 2011.  The FDA will make its selection in June 2011.  Come October 2012, the warnings will cover 50% of the front and back of a cigarette package, and 20% of the space of a cigarette advertisement.

So what brought about this change?  You may have missed the news last summer, but a new law called the Family Smoking Prevention and Tobacco Control Act (Tobacco Control Act) gave the FDA the authority to regulate tobacco products and required these large, graphic modifications to cigarette packages and advertisements.  According to FDA Commissioner Margaret Hamburg, “every pack will become a mini-billboard that tells the truth about smoking.”  The American Academy of Physicians notes that

[t]he FDA has taken several steps since it was given authority to regulate the tobacco industry last year. The agency already has prohibited the use of the terms ‘light,” “low” and “mild” in cigarette marketing and packaging; banned cigarettes with fruit, candy, and spice flavors; and restricted the sale and marketing of tobacco products so that young people are less likely to be exposed to tobacco ads.

Approximately 20% of Americans smoke.  The government hopes to reduce that number to 12% by 2020.

In August 2009, R.J. Reynolds Tobacco Company (maker of Camel, Pall Mall, Doral, Kool, Winston, and Salem) and several other tobacco companies filed a lawsuit in the Western District of Kentucky to “protect their First Amendment right to communicate with adult tobacco consumers products.”  ¶51 of the complaint stated that

[b]ecause the Act virtually eliminates Plaintiffs’ ability to communicate to adult consumers through advertising, the only remaining vehicle for such communication is product packaging. But the Act destroys this as well, seizing a substantial portion of Plaintiffs’ packaging for a Government-drafted anti-tobacco message–including, for cigarette packaging and advertising, the use of shocking, graphic color imagery–as well as other mandated information….

The tobacco companies didn’t win on that point.  Obviously.

However, America won’t be the first country to employ “scare tactics” (and I use that phrase in a neutral way).  Canada, England, Brazil, Thailand, Turkey, and Australia are among the 39 countries to cover their cigarette packages with graphic warning labels that “tell it like it is” (that phrase was less neutral).  Last month, the Canadian Cancer Society released its “Cigarette Package Health Warnings: International Status Report” which summarized health warning requirements by country/jurisdiction and showed graphic labels from around the world.  (Ironically, the report comes across as a little competitive when it compares the size of the graphic labels.)

Yet supporters and critics alike question the effectiveness of this approach.

Take our neighbors to the north.  Although The Wall Street Journal reported that smoking rates dropped 3% among Canadians after their graphic warning labels appeared, the newspaper also noted how “other tobacco prevention measures, such as cigarette tax increases and new restrictions on public smoking, came at the same time.”  On NPR’s All Things Considered, David Sweanor, a law professor at the University of Ottawa, observed that

[w]hat we see with these sorts of warnings is that it does increase motivation…. People are more aware of the risks. They are wanting to quit. But that has to be combined with services that make it more likely.

Professor Sweanor went on to say that the desired outcome — fewer smokers – has been disappointing because the “[Canadian] government hasn’t provided enough access to smoking cessation programs.”

At home, The Wall Street Journal interviewed Jonathan Whiteson, medical director of NYU Langone Medical Center’s cardiac and pulmonary wellness and rehabilitation program, who suggested the labels should promote a “positive message” emphasizing the benefits of a smoke-free life, because

[w]hen we emphasize feeling good, the sense of mastery that comes from making a behavioral change or the promise of an enhanced chance of avoiding heart disease or cancer — that [produces] a much more positive and effective response from patients.

Mr. Whiteson added that smokers already are aware of the negative consequences of smoking, but just might be in denial about them.  He also noted how the public generally becomes desensitized to shocking images.

So could reverse psychology work better?  A relatively recent study published in the Journal of Experimental Psychology found that certain smokers who based their self-esteem on smoking were not deterred by death-related warnings.  Instead, the study found that

warning messages that were unrelated to death effectively reduced smoking attitudes the more recipients based their self-esteem on smoking. This finding can be explained by the fact that warnings such as ”Smoking brings you and the people around you severe damage” and ”Smoking makes you unattractive” may be particularly threatening to people who believe the opposite, namely that smoking allows them to feel valued by others or to boost their positive self-image. To the degree that warning messages undermine the high smoking-based self-esteem, smoking may be devalued.

I was interested to come across this study because Prescriptions, a NY Times blog, recently wrote about R.J. Reynolds’ special-edition packs of Camel linking the cigarettes with hip images of certain American cities, including the Williamsburg neighborhood in Brooklyn.  The Williamsburg package says

Some call it the most famous hipster neighborhood.  But it’s not about hip. It’s about breaking free. It’s about last call, a sloppy kiss goodbye and a solo saunter to a rock show in an abandoned building.  It’s where a tree grows.  It’s Camel in the Williamsburg corner of Brooklyn.

If self-esteem and smoking are connected for some people… well, I can see a spin-off warning statement and graphic there which might be an effective deterrence.  Can you?

Alongside the FDA graphic warnings proposal, the Department of Health and Human Services has announced other tobacco-related projects in the works, including:

• The Affordable Care Act is giving Americans in private and public health plans access to recommended preventive care, like tobacco use cessation, at no additional cost.
• The American Recovery and Reinvestment Act (ARRA) invested $225 million to support local, state and national efforts to promote comprehensive tobacco control and expand tobacco quitlines.
• The Prevent All Cigarette Trafficking Act (PACT) aims to stop the illegal sale of tobacco products over the Internet and through mail order, including the illegal sale to youth. [...]
• The Children’s Health Insurance Program Reauthorization Act (CHIPRA) raised the federal cigarette tax by 62 cents per pack.  Raising the price of tobacco products is a proven way to reduce tobacco use, especially among price-sensitive populations such as youth.

Just as an FYI, check out this NY Times article about ongoing efforts in other countries to restrict the the marketing of cigarettes.

Why You Should Never Mix Two Kinds of Drain Cleaner Together

This article is not so much a health reform post as it is perhaps a public service announcement–or a warning.  Two weeks ago I found myself sitting in an Emergency Room hooked up to a steady stream of oxygen; the recipient of various and sundry breathing treatments.  My follow-up visit to the doctors’ brought more breathing treatments, a steroid prescription, and the assurance that the x-rays showed that my lungs had suffered no permanent damage and that my breathing would return to normal in a week or two to a month. For the most part, it has.

The culprit? Drain cleaners–specifically:  two kinds inadvertently mixed. I heaved and coughed and choked as though my lungs were on fire for almost an hour before I made my way to the hospital. I simply could not breathe, and breathing itself was (and remained for almost a week) painful. But I kept my head, and remembered to bring the offending chemicals with me.

To make a long story short, the sink upstairs in my old house was clogged. I purchased a nondescript drain cleaner which contained hydrochloric acid. Unbeknownst to me, my upstairs tenant had already poured drain cleaner in the sink but did not tell anyone. When I made my way to the sink, it was filled with a pool of blue liquid. On the sink counter was a bottle of blue liquid hand soap. I assumed that the liquid filling the the sink was the blue hand soap mixed with water which would not drain. I was wrong, and dangerously so.  The blue liquid was another kind of drain cleaner; it contained sodium hypochlorite–which is bleach.

Apparently, the combination of hydrochloric acid and sodium hypochlorite (bleach) creates chlorine gas–which was used for chemical warfare early in World War I, a precursor to mustard gas. The following passage, culled from a few different sources will relay the pertinents  better than I can:

Concentrated hydrochloric acid (fuming hydrochloric acid) forms acidic mists. Both the mist and the solution have a corrosive effect on human tissue, with the potential to damage respiratory organs, eyes, skin, and intestines. Upon mixing hydrochloric acid with common oxidizing chemicals, such as sodium hypochlorite (bleach, NaClO) or potassium permanganate (KMnO₄), the toxic gas chlorine is produced.

Chlorine is a toxic gas that irritates the respiratory system. Chlorine is detectable in concentrations of as low as 0.2 ppm. Coughing and vomiting may occur at 30 ppm and lung damage at 60 ppm. About 1000 ppm can be fatal after a few deep breaths of the gas.^[4] Breathing lower concentrations can aggravate the respiratory system, and exposure to the gas can irritate the eyes.^[47]

Chlorine’s toxicity comes from its oxidizing power. When chlorine is inhaled at concentrations above 30ppm it begins to react with water and cells which change it into hydrochloric acid (HCl) and hypochlorous acid (HClO).

Chlorine gas, also known as bertholite, was first used as a weapon in World War I by Germany on April 22, 1915 in the Second Battle of Ypres. As described by the soldiers it had a distinctive smell of a mixture between pepper and pineapple. It also tasted metallic and stung the back of the throat and chest. Chlorine can react with water in the mucosa of the lungs to form hydrochloric acid, an irritant which can be lethal. The damage done by chlorine gas can be prevented by a gas mask, or other filtration method, which makes the overall chance of death by chlorine gas much lower than those of other chemical weapons. It was pioneered by a German scientist later to be a Nobel laureate, Fritz Haber of the Kaiser Wilhelm Institute in Berlin, in collaboration with the German chemical conglomerate IG Farben, who developed methods for discharging chlorine gas against an entrenched enemy. It is alleged that Haber’s role in the use of chlorine as a deadly weapon drove his wife, Clara Immerwahr, to suicide. After its first use, chlorine was utilized by both sides as a chemical weapon, but it was soon replaced by the more deadly gases phosgene and mustard gas.^[40]

I was exposed to the blue pool of gas for about ten minutes all told as I attempted to clear the sink in various ways. At first I believed that the irritation and coughing was being caused by the drain cleaner merely doing its work, and that I had just gotten an untoward whiff. Later, when I saw the offending bottle of drain cleaner tucked away in the corner and realized I had mixed two kinds of poison together  I got air but had to go back to bail out the liquid so it would not continue to emit the gas and  endanger others. I warned my son, gave him both bottles of drain cleaner and told him I had inhaled the gas from them, that I had to go back upstairs to clear the sink, and that if something were to happen to me he was to call 911, tell them what happened and give them the bottles of drain cleaner. I didn’t pass out.

The vicious coughing, inability to breathe, and pain got considerably worse in the next half hour. The oxygen and breathing treatments at the hospital helped a great deal, as did those I received at the doctors’ next day. The worst of it lasted about 4 days, though now I’m almost entirely back to snuff.

The truth is, I know to not mix two kinds of drain cleaner together, but made an incorrect and costly assumption regarding the origin of the blue liquid. But as I’ve told this story over the last two weeks, I was surprised at how many people did not know. Thus this post.

Having said that, although I did know that one wasn’t supposed to mix these common household products together, I certainly didn’t know that doing so could create a gas so toxic it was once used for chemical warfare. And having said that, not to let the J.D. at the end of my name take over, but the warnings on the labels of these two products which are sold right next to each other come nowhere close to expressing the magnitude of the harm of which they are capable of in combination. The small type letters on the back of the bottle would do far better service as large letters highlighted by a skull and crossbones on the front. More effective labeling could, I believe, without significant cost have a significant impact on health and safety.