RESEARCH STUDY-1

A Research Study In Saint louis University, America
Cigarette Smoking And Weight Loss In Nursing Home Residents
By

Margaret-Mary G. Wilson, MD,MRCP 
Assistant Professor
Division of Geriatric Medicine,
Saint Louis University

Shahnaz Habib MBBS,
Clinical research assistant
Division of Geriatric Medicine,
Saint Louis University

Carolyn Philpot CGNP
Clinical Nurse Practitioner
Division of Geriatric Medicine,
Saint Louis University

OBJECTIVE:

To evaluate body weight trends of elderly smokers following admission into a Long Term Care Facility.

STUDY DESIGN AND POPULATION:

Cross-sectional survey of 88 nursing home residents with six month follow-up.

MAIN OUTCOME MEASURES:

Fifty-one of 88 residents were included in the study. Body weight, height, body mass index (BMI) and serum albumin were documented on admission into the nursing home. Data collection was repeated at monthly intervals over a six-month period.
RESULTS: The study population comprised 17(8M, 9F) smokers and 34(19M, 15F) non-smokers. Smokers had a lower body mass index on admission compared with non-smokers (24.2"3 and 27.4"9 respectively; p=0.04; Odds ratio [95% CI] for smokers versus non-smokers = 1.629 [0.498 to 5.32] ).Twelve (71%) smokers and 20 (59%) non-smokers gained weight (p=0.2). Four (24%) smokers and 12 (35%) non-smokers lost weight (p=0.3). Smokers who lost weight did so at a faster rate than non-smokers (13.3 "3.8 lbs and 7.8"2.4 lbs respectively over six months; p=0.02). Similarly, weight gain occurred at a slower rate in smokers compared with non-smokers (5.6"1.3lbs and 8.2lbs respectively over six months; p=0.004)

CONCLUSIONS:

Weight loss in cigarette smokers may occur at a more rapid in residents who smoke compared with non-smokers. Similarly, weight gain occurs at a slower rate in smokers. Smoking cessation should be encouraged as a critical adjunct to nutritional intervention in nursing home residents with nicotine dependence and weight problems.

Introduction

Intensive public health education has led to a decline in cigarette smoking over the past four decades. Increasingly, organizations and institutions are adopting non-smoking policies 1,2. Within long-term care (LTC), residents' rights to autonomy and self-determination preclude the enforcement of mandatory non-smoking policies 3. Epidemiological studies show that cigarette smoking is associated with progressive weight loss 4,5,6. However, although weight loss is an index of poor outcomes and increased mortality in nursing home residents, smoking cessation strategies are excluded from most nutritional and weight management LTC pathways 7,8. 9,10.
Our study was designed to examine the relationship between cigarette smoking and body weight of residents admitted to a long-term care facility over a six-month period. Non- smokers were compared with smokers.

Methods

The study was conducted in a long-term care geriatric facility affiliated with Saint Louis University. All residents of the facility were screened for the study. Exclusion criteria included congestive cardiac failure, malabsorption syndrome, chronic diarrhea, chronic obstructive airway disease, cor pulmonale, liver cirrhosis, or chronic renal failure. Residents with a Mini-mental State Examination score < 18 or a Geriatric Depression score > were also excluded 11,12. Enteral tube feeding and life expectancy less than six months were additional exclusion criteria.
Data collated included admission weight and monthly weights for six months following admission into the facility. The height and body mass index (BMI) on admission and monthly thereafter for six months were also obtained. Serum albumin levels within one month of admission and within one month of termination of the study were obtained. Residents were identified as smokers or non-smokers. Smokers were defined as residents who had smoked 10 cigarettes daily for at least ten years. Non-smokers were defined as residents who had not smoked any cigarettes over the preceding ten years. Residents who fell into neither category were excluded from the study. Data obtained from non-smokers were compared with data obtained from smokers. Significant differences between groups was evaluated using Sato's method to determine odds ratios (OR) and 95% confidence intervals (CI) and the Student's t-test with two-tailed tests of significance for continuous variables 13. A p value of less than 0.05 was considered significant. Informed consent was obtained from all subjects. The study was approved by the Institution Review Board of the Saint Louis University and the Executive Board of the Long Term Care facility.

Results

Eighty-eight residents were screened for the study. Fifty-one residents were eligible for inclusion, comprising 17 (8M, 9F) residents who smoked and 34 (19M, 15F) residents who were non-smokers. Eight (7M, 1F) smokers were admitted with body mass indices (BMI) less than 22, compared with 12 (7M, 5F) non-smokers (OR [95% CI] for smokers versus non-smokers = 1.629[0.498 to 5.32] ).
Table 1 shows the admission data for both smokers and non-smokers.
Fig 1 shows the trend of weight change over the six-month study period among smokers and non-smokers. Among the subset of residents that gained weight the mean weight gain among smokers was 5.6 "1.3lbs compared with 8.2"2.4lbs among non-smokers (p=0.004). Among the subset of residents that lost weight over the study period, the mean weight lost among smokers was 13.3"3.8lbs compared with 7.8"2.4lbs among non-smokers (p=0.02).

Discussion

Approximately 25% of nursing home residents smoke cigarettes 10, 14. Available evidence indicates that smoking cessation strategies are less successful within the long-term care setting. Studies show that adults who continue to smoke into late life are less likely to cease smoking out of concern for long-term health effects. Some older smokers erroneously believe that the passage of time has proven that they are no longer susceptible to the adverse health consequences of smoking. Likewise, older adults who suffer from smoking related illness often consider the damage permanent and irreversible and are therefore difficult to convince of the benefits of smoking cessation 15. Within the nursing home environment, low levels of perceived self-efficacy, the presence of other smokers and the reluctance of some health professionals to aggressively educate residents regarding the dangers of smoking pose additional obstacles to smoking cessation 16.
Currently, in most long-term care facilities in the United States, the institutional smoking policy is driven mainly by fire and safety concerns 17,18. Thus, residents are more likely to perceive smoking cessation policies as intrusive legislation rather than as an integral component of effective health maintenance. Development of more comprehensive smoking policies that highlight specific adverse health effects relevant to nursing home residents may be more successful in encouraging smoking cessation.
Body weight is a critical parameter of care and outcomes determinant within the nursing home setting. Convincing evidence indicates increased mortality in long term care residents with weight loss 19,20,21. Our data showed that smokers admitted into long term care had a BMI compared with non-smokers possibly as a result of the long-term effect of smoking on suppressing weight gain 5,8,22. In addition, although the prevalence of weight loss was not significantly different between smokers and non-smokers, smokers who lost weight in the nursing home, did so at a faster rate than non-smokers (Fig 1). Our study also showed that nursing home residents who smoked gained weight at a slower rate, compared with their non-smoking counterparts. It is conceivable that negative effects of smoking on food intake, such as anorexia and reduced olfactory and gustatory receptor sensitivity, may have a synergistic effect in the presence of other adverse nutritional risk factors, thereby accelerating weight loss 23,24,25, 26.

Cytokine-mediated weight loss is an attractive hypothesis to explain smoking related weight loss. However, available data is controversial. Cancer related cachexia is driven by increased elaboration of pro-inflammatory cytokines. The resultant metabolic abnormalities have been thought to account for the failure of conventional nutritional supplementation to maintain weight in affected cancer patients 27. Similar studies in smokers have failed to reveal a consistent alteration in cytokine levels 28,29. However, evidence indicates that smoking reduces baseline levels of soluble IL-1 receptor antagonist serum levels thereby resulting in reduced antagonism of pro-inflammatory interleukins 30. Weight loss in smokers may therefore result from a dual mechanism involving increased catabolism and reduced energy consumption.

Applications

These findings justify a more aggressive approach to nutritional support in smokers with low body weight or significant weight loss. Effective strategies include the administration of fortified meals and frequent nutritional supplementation with energy dense food supplements. Additionally, flavor-enhanced foods may be effective in increasing energy intake in older smokers as enhanced gustatory stimulation may combat the hypoageusia associated with both smoking and aging 31.
In smokers who continue to lose weight despite aggressive nutritional supplementation, orexigenic agents, such as megesterol acetate and dronabinol, may be helpful. Recent evidence indicates that megesterol acetate may enhance weight gain in nursing home residents. However, the absence of relevant data mandates cautious use of megesterol in smokers to avoid the possibility of a synergistic or additive increase in the risk of thrombo-embolic events. Dronabinol (delta-9-tetrahydrocannabinol) is the active ingredient of Cannabis sativa, approved for use by the Food and Drug Administration (FDA) as an orexigenic agent in Acquired Immune Deficiency Syndrome (AIDS). Recent evidence indicates that Dronabinol induces weight gain in older persons with dementia. However, it remains unclear whether weight gain in such patients is due to a direct orexigenic effect or a reduction in physical energy expenditure. Further research is needed to determine the precise role of Dronabinol as an orexigenic agent in older persons 32,33,34.

Effective weight loss intervention programs in long term care must incorporate parallel smoking cessation strategies. Clinical Practice Guidelines, such as those issued by the United States Department of Health and Human Services offer practical templates for such strategies 35,36, 37. In addition, emphasis should be placed on the immediate benefits of discontinuing smoking, such as enhanced taste, increased appetite, weight gain and an increased feeling of well-being. Residents with weight loss who opt to participate in a smoking cessation program may benefit from a structured support group directed toward both smoking cessation and weight maintenance.
The role of medication in LTC residents with weight loss is unclear. Nicotine replacement therapy may not be appropriate, as animal studies have shown that nicotine administration reduces food consumption and decreases body weight 38. Data in humans is lacking. However, residents who lose weight on nicotine replacement therapy may benefit from a trial of Bupropion in the absence of a history of seizures or co-existent antidepressant therapy.

Limitations of this study include lack body weight measurements prior to admission, small sample size and the imbalance in numbers between smokers and non-smokers. Larger prospective studies may prove helpful.

Conclusion

Smokers in long-term care facilities lost weight more rapidly than non-smokers. Similarly, weight was regained more slowly in smokers. Long term care health professionals must be cognizant of the role of smoking in perpetuating weight loss. Interdisciplinary programs that integrate nutritional support and smoking cessation strategies should be an integral component of resident care in LTC facilities that permit smoking. 

Acknowledgements: The authors gratefully acknowledge the valuable editorial assistance of Janice D. Hicks.

References

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SECONDHAND SMOKE-3

SECONDHAND SMOKE

The Surgeon General's report: Secondhand smoke kills people who don't smoke, and makes others sick

Environmental tobacco smoke (ETS), also known as secondhand smoke, has also been shown to increase the risk of lung cancer. The 2006 Surgeon General's report on secondhand smoke stated that:

• Many millions of Americans, both children and adults, are still exposed to secondhand smoke in their homes and workplaces, even though there has been a great deal of progress in tobacco control.

• Secondhand smoke causes premature death and disease in children and adults who do not smoke.

• Children exposed to secondhand smoke are at an increased risk for sudden infant death syndrome (SIDS), respiratory infections, ear problems, and more severe asthma. Smoking by parents causes breathing (respiratory) symptoms and slows lung growth in their children.

• Secondhand smoke immediately affects the heart and blood circulation in a harmful way. Over a longer time it also causes heart disease and lung cancer.

• The scientific evidence shows there is no safe level of exposure to secondhand smoke.

• The only way to fully protect non-smokers from exposure to secondhand smoke indoors is to prevent all smoking in that indoor space or building. Separating smokers from non-smokers, cleaning the air, and ventilating buildings cannot keep non-smokers from being exposed to secondhand smoke.

ANTISMOKING NEWSFILE-4

Single Largest Cigarette Tax Hike Goes Into Effect Wednesday

WASHINGTON  - However they satisfy their nicotine cravings, tobacco users are facing a big hit as the single largest federal tobacco tax increase ever takes effect Wednesday.

Tobacco companies and public - health advocates, longtime foes in the nicotine battles, are trying to turn the situation to their advantage. The major cigarette makers raised prices a couple of weeks ago, partly to offset any drop in profits once the per-pack tax climbs from 39 cents to $1.01.

Medical groups see a tax increase right in the middle of a recession as a great incentive to help persuade smokers to quit.

Tobacco taxes are soaring to finance a major expansion of health insurance for children. President Obama signed that health initiative soon after taking office.

Other tobacco products, from cigars to pipes and smokeless, will see similarly large tax increases, too. For example, the tax on chewing tobacco will go up from 19.5 cents per pound to 50 cents. The total expected to be raised over the 4 1/2 year-long health insurance expansion is nearly $33 billion.

Smokers are mulling their options.

Standing outside an office building in downtown Washington last week, 29-year-old Sam Sarkhosh puffed on a Marlboro Light. His 8-year-old daughter has been pleading with him to quit, he explained, and he has set a goal to give up smoking by his 30th birthday.

"I'm trying to quit smoking, and it could help," said Sarkhosh, an information systems specialist. "I don't think it will stop me from buying cigarettes every now and then, but definitely not as often." A friend who smokes Camels went out and bought four cartons in advance, he said.

The tax increase is only the first move in a recharged anti-smoking campaign. Congress also is considering legislation to empower the Food and Drug Administration to regulate tobacco. That could lead to reformulated cigarettes. Obama, who has agonized over his own cigarette habit, said he would sign such a bill.

Prospects for reducing the harm from smoking are better than they have been in years, said Dr. Timothy Gardner, president of the American Heart Association. The tax increase "is a terrific public health move by the federal government," he said. "Every time that the tax on tobacco goes up, the use of cigarettes goes down."

About one in five adults in the United States smokes cigarettes. That's a gradually dwindling share, though it isn't shrinking fast enough for public health advocates.

The Centers for Disease Control and Prevention says cigarette smoking results in an estimated 443,000 premature deaths each year, and costs the economy $193 billion in health care expenses and lost time from work. Smoking is a major contributor to heart disease, cancer and lung disease.

Public health officials are urging individual doctors and staff at telephone "quit lines" in every state to make the most of the tax increase by reaching out to smokers. But it's unclear how deeply the tax will cut into tobacco consumption.

Eric Lindblom, research director for the Campaign for Tobacco-Free Kids, says he expects a drop of at least 6 percent to 7 percent among young smokers.

Philip Gorham, who tracks the tobacco business for Morningstar, the investment research firm, said he expects an overall drop of 4 percent to 5 percent this year. What happens after that is less certain, especially as the economy recovers.

"I would expect a road bump this year," said Gorham. "But these companies will still be extremely profitable. I still think they will make their return on capital by wide margins in the long run."

Philip Morris USA, the largest tobacco company and maker of Marlboro, is forecasting a drop, but spokesman Bill Phelps said he cannot predict how big. Philip Morris raised Marlboro prices by 71 cents a pack early this month, and prices on smaller brands by 81 cents a pack. Other major companies followed suit.

The pricing moves raised eyebrows. "That's nothing more than greed," said Kevin Altman, an industry consultant who advises small tobacco companies. "They weren't required to charge that until April 1. They are just putting that into their pockets."

Responded Phelps: "We raised our prices in direct response to the federal excise tax increase, and people who are upset about that should find out how their member of Congress voted, and contact him or her."

Some policy analysts have questioned the wisdom of boosting tobacco taxes to finance health care for children. They argue that the fate of such a broad program should not depend on revenues derived from a minority of the adult population, many of whom have low incomes and are hooked on a habit. The tobacco industry is also warning that the steep increase will lead to tax evasion through old-fashioned smuggling or by Internet purchase from abroad.

But smoking control advocates such as Lindblom say tobacco taxes should be even higher. "There's a lot of room to go after cigars and smokeless," he said. "We are certainly hopeful that health care reform will include some more increases."

Standing outside a Washington department store, attorney Margaret Webster, 42, puffed on a Marlboro Ultra Light and lamented the fact that the government is reaching deeper into her pocketbook.

"I don't think we (smokers) like it," she said. "But I've heard so many people say they were going to quit when the price went up ... and they're still smoking."

ANTISMOKING NEWSFILE-2

Tobacco tax worries store owners

Premium cigarettes now cost up to $6.99 a pack, and regular cigarettes cost at least $4.25.

As of yesterday, mom-and-pop stores joined gas stations in increasing the prices of cigarettes, per the law signed Feb. 5 by Gov. Felix Camacho, which increases the tobacco tax from $1 to $3.

Some customers entered stores to ask, "Have you raised your prices yet?" while others simply walked in, glanced behind the counter, and walked back out, said Na's Market manager Smith Bae.

"I'm a smoker. Even me, I try to quit," he said, a light-green pack of cigarettes jutting from his own breast pocket. "It's very hard."

As a small store manager, he said he didn't understand how a tax increase would help people's health.

"Why only for the cigarette? What about the beer?" he asked, adding alcohol has far more adverse effects than smoking, such as causing vehicle accidents and bar brawls.

After having changed the price of cigarettes yesterday, he was worried the price spike may be bad for his business, though he said it was too soon to tell.

Before the tax hike was implemented, some customers tried to buy from him in bulk.

Meanwhile, Chalan Pago resident Liz Mesa, who smokes, said it would have been hard for people to buy in bulk before the price increase due to economic conditions. Cigarettes wouldn't have been on their list of top priorities, she said.

"Most customers knew about the tax hike thanks to media coverage," said Kyong Duke, a manager at Shine Market in Chalan Pago.

However, for a few disappointed, even angry, customers, store owners had to explain yesterday the price increase was caused by a change to local law.

"Some customers, they were not too nice," Duke said.

She said tobacco sales were very slow yesterday, just as one customer came in, asked if the price had been increased, and summarily walked back out.

Money for health

The money raised by the new taxes will go into the Healthy Futures Fund, a pool of money that can be appropriated by the Legislature for health agencies, substance abuse awareness programs and public safety programs. About a third of the money will go to the hospital, the Guam Cancer Trust Fund and the Guam Cancer Registry, according to Pacific Daily News files.

According to Mesa, whose carton usually lasts her about 15 days because she's "not a heavy smoker," some other longtime smokers may find it hard to kick the habit and may just cut back on other purchases.

Mangilao resident Mary Bamba, who sat smoking at the Sunshine Plaza in Chalan Pago-Ordot, said yesterday a lot of people she knew were getting mad about the increase.

"It's ridiculous," she said. "Gas goes up 10 cents and what? Tobacco goes up (more than) a dollar? That's too much."

And if the tax hike was supposed to deter people from smoking, she said most smokers "cannot quit just like that," though the price hike may help a select few.

"Maybe 10, 20 percent will quit," Duke agreed. "They'll be shocked at first, but they're going to continue."




Utah Tobacco Tax Hike Passes

April 01, 2010 - SALT LAKE CITY -- Utah Governor Gary Herbert let a $1 per-pack cigarette tax increase go into law without his signature, The Associated Press reported.

That tax, part of House Bill 196, also raise taxes on a number of tobacco products. The tax on cigars will increase from 35 percent to 86 percent of the manufacturer's sale price, while the tax on moist snuff will rise from 75 cents to $1.83 per ounce, according to the report.

Herbert repeatedly said he opposes increasing taxes, but the tobacco tax was built into the budget to which he and legislative leaders agreed, the AP reported. And Herbert said in a statement earlier this week that it would be fiscally irresponsible for him to veto the tax, as it would create an imbalance in the state budget, particularly in the areas of public and higher education, the report stated.
The tax takes effect July 1.