Do Graphic Anti-Tobacco Warnings Work?

As background information, in 2009, the Family Smoking Prevention and Tobacco Control Act required graphic warnings on cigarette packs and in at least 20% of cigarette advertising, but the tobacco industry quickly sued the FDA to keep the images off their products and in 2011, a federal judge sided with Big Tobacco, based on their First Amendment free speech rights. The FDA has yet to issue a new rule requiring graphic warning despite a lawsuit by a number of public health groups.

There are published data supporting the proposition that graphic images depicting the harms of smoking are effective. In a study from 2016, published in JAMA Internal Medicine, researchers found that graphic pictorial warnings (eg. rotting teeth, badly diseased lung, tracheostomy hole) effectively increased intentions to quit, forgoing cigarettes, quit attempts, and successfully quitting smoking. In a study from Georgetown University Medical Center, young adult participants (ages 18-30) who viewed graphic warning labels were more motivated to quit smoking than were those who did not see graphic images.

A novel research study just published, researchers constructed a mock 1,500 square foot fully-equipped convenience store (including tobacco wall behind the checkout counter) to test the efficacy of a graphic pictorial warning at a point-of-sale location (which is ground-zero for Big Tobacco advertising). The study involved 441 adolescents (11-17 years old), who were surveyed about their attitudes towards cigarettes and on a number of different shopping interests both before and after visiting the mock store. About 5% reported a prior history of smoking and about 20% were considered “high risk” for future cigarette use. A poster with graphic image (a close-up of a smoker’s mouth with cancerous lesions and discolored teeth caused by smoking and warning that cigarettes cause cancer) was placed either near the tobacco wall, near the cash register, both locations, or not at all.

What did they find?

The graphic image had no impact on committed never smokers, no matter the location. However, in a counterintuitive response, those adolescents at high risk for future use actually revealed a statistically significant (p<0.045) heightened smoking susceptibility after viewing the graphic image. Why this occurred is not known, but might be explained by a defensive reaction, causing the adolescent to discount or downplay the health risks portrayed by the poster.

This study may have important implications for tobacco control policy makers. For high-risk adolescents, graphic images may actually do the opposite of their intended result.

Lung Cancer Screening May Help Smokers Quit

Tobacco use is reported as the leading cause of preventable illness and death in our country, with more than 400,000 deaths attributable to the use of tobacco products each year in the United States. It is estimated that about 70% of smokers report that they want to quit.

Researchers from the UK found evidence suggesting that integrating CT screening for lung cancer with evidence-based smoking cessation interventions could prompt quitting in motivated high-risk smokers.

Amongst the participants in the UK Lung Cancer Screening Trial (UKLS), 1546 current smokers were randomized to receive either screening low-dose CT (LDCT) or no LDCT. The researchers found that those who underwent LDCT were more likely to quit. Specifically, those who received an initial LDCT were over twice as likely (adjusted OR 2.38, CI 1.56-3.64, p<0.001) to quit within two weeks and 60% more likely (adjusted OR 1.60, CI 1.17-2.18, p=0.003) to have remained smoke-free at up to two years. Those who needed additional LDCT (because the initial study was abnormal) were over twice as likely (adjusted OR 2.29, CI 1.62-3.22, p=0.007) as controls and over twice as likely (adjusted OR 2.43, CI 1.54-3.84, p<0.001) as those getting a negative result.

Thus, even getting a negative LDC T was not a “license to smoke,” but an abnormal scan provided additional stimulus to quitting over and above that of screening participation. These results mirror the results from the Danish Lung Cancer Screening Trial and the US National Lung Screening Trial.


It’s All in the Labeling or How to Get Your Child to Eat His Veggies

In a study recently published in JAMA Internal Medicine, researchers from Stanford University have shown what restauranteurs have known for years- describe your dishes in an indulgent manner and patrons will be enticed to buy. Image result for types of zucchini

Researchers performed the study at the University’s cafeteria, with a total of 27,933 diners (undergraduate students, graduate students, and staff) over the 2016 autumn academic calendar.

Each day, one featured vegetable dish was randomly labeled in one of four ways: basic, healthy restrictive, healthy positive, or indulgent. For example, butternut squash could be “butternut squash” (basic), “butternut squash with no added sugar” (healthy restrictive), “antioxidant-rich butternut squash” (healthy positive), or “twisted garlic-ginger butternut squash wedges” (indulgent). The kicker was that all meals looked and tasted the same and there was no difference in how they were served.

The researchers found that labeling the vegetables in an indulgent way significantly increased not only the selection of the vegetable, but the amount consumed as well. Vegetables labeled indulgently were chosen 25% (p=.04) more often than basic, 41% (p=.001) more often than healthy restrictive, and 35% (p=.01) more often than healthy positive. Similarly, indulgent labeling increased the amount consumed by 23% (p=.03) compared to basic, 33% (p=.004) compared to healthy restrictive, and 16% (NS) compared to healthy positive. There was no significant differences amongst basic, healthy restrictive and healthy positive groups for either outcome.

It’s seems a better strategy to speak of healthy foods in an indulgent manner, focusing on taste and flavors. Instead of “eat your zucchini,” you can try “who wants the slow-cooked garlicky heirloom zucchini with freshly chopped tarragon?”


Get off your butt, or Add 10 minutes for health

According to the World Health Organization (WHO), the minimal weekly level of leisure time exercise for adults is 150 minutes of moderate-intensity aerobic activity or 75 minutes of vigorous-intensity aerobic activity. Most studies had examined the benefits of such exercise spread across 3 or more days per week.

In a study of over 55,000 adults, Lee et al evaluated the benefits of running on mortality. The participants had a mean age of 44 and mean follow-up of 15 years. Runners had a 30% lower all-cause mortality and 45% lower cardiovascular disease (CVD) mortality compared to non-runners. Runners lived on average 3 years longer. Of interest, running distance, time, frequency and pace did not significantly affect the mortality. Even running slowly (< 6 minutes/mile) 1-2 times per week for a total time of < 51 minutes was associated with mortality benefit. In fact, 5-10 minutes every day at slow speeds had mortality benefit.

In a more recent;y published study, researchers in England found that “weekend warrior” mode for just 1 or 2 sessions per week lowered all-cause mortality risk, CVD mortality risk and cancer mortality risk. There were almost 64,000 adult respondents, all over age 40, during 561,159 person-years of follow-up. The mean age was 58.6 years.

Participants were divided into four groups: (1) “Inactive” (no reported moderate or vigorous activity); (2) “Insufficiently active” (< 150 minutes moderate or < 75 minutes vigorous activity weekly); (3) “Regularly active” (meeting WHO recommendations with ≥ 150 minutes moderate or ≥ 75 minutes vigorous activity weekly over ≥ 3 sessions); or (4) “Weekend warrior” (≥ 150 minutes moderate or ≥ 75 minutes vigorous activity weekly but over only 1-2 sessions). Of the total participants, 62.8% were “inactive,” 22.4% were “insufficiently active,” 11.1% were “regularly active,” and 3.7% were “weekend warriors.” The BMI was similar for all groups. Occupational and domestic physical activity were not included. Weekend warriors were equally likely to exercise in 1 versus 2 sessions. Weekend warriors were more likely to be men and, as expected, tended to have more vigorous level of activity.

Compared the Inactive group (1), there was a significant reduction of all-cause mortality (30%), CVD death (40%), and cancer death risk (18%) amongst the Weekend warriors. There were similar risk reductions for group 2 and group 3 compared to group 1. Thus, even just 1 or 2 days of moderate to vigorous activity or exercise is sufficient to reduce risks for all-cause mortality, CVD mortality, and cancer mortality. Although men tended to  be “weekend warriors,” there was similar benefit for women.

What do these studies tell us? Even “insufficient” levels of activity or “weekend warrior” mode are associated with lower risks for all-cause mortality, CVD death, and cancer death compared to those adults who get no moderate to vigorous activity. In fact, just 5-10 minutes every day at slow speeds had mortality benefit.

Watching Too Much TV Could Kill You

In the Nurses’ Health Study, researchers had found a significantly increased risk (2.3) for pulmonary embolism (PE) for those who sat for >40 hours per week compared to those who spent < 10 hours sitting per week.

In a study recently published in the American Heart Association’s journal Circulation, researchers analyzing data from the Japanese Collaborative Cohort Study, involving >86,000 participants followed for more than 19 years, found that watching television for 5 or more hours per day increased the risk of death from PE 2.5-fold and watching TV for 2.5-4.9 hours daily had a 1.7-fold increase of PE death. These results were controlled for such factors as obesity, diabetes mellitus, hypertension, smoking, sports activity, age and sex. The risks could actually have been even higher since deaths from PE are likely underreported given the difficulty in diagnosis.

Sitting and watching TV for more than 5 hours per day significantly increased the risk of dying from blood clots. The current study participants were queried before computers, tablets and smartphones became such popular sources of entertainment, leading to the question as to whether sitting and watching these would be associated with the same or similar risk.

Prolonged sitting has been associated with venous stasis, a potential mechanism for development of deep venous thrombosis (DVT) and subsequent PE. Perhaps analogous to long airplane travel, it is best to get up frequently and to exercise and stretch your legs while binge-watching.