Smoking and mortality from tuberculosis and other diseases in India: retrospective study of 43000 adult male deaths and 35000 controls.

BACKGROUND: In India most adult deaths involve vascular disease, pulmonary tuberculosis, or other respiratory disease, and men have smoked cigarettes or bidis (which resemble small cigarettes) for several decades. The study objective was to assess age-specific mortality from smoking among men (since few women smoke) in urban and in rural India. METHODS: We did a case-control study of the smoking habits of 27000 urban and 16000 rural men who had died in the state of Tamil Nadu, southern India, from medical causes (ie, any cause other than accident, homicide, or suicide), and of 20000 urban and 15000 rural male controls. The main analyses are of mortality at ages 25-69 years. FINDINGS: In the urban study area, the death rates from medical causes of ever smokers were double those of never smokers (standardised risk ratio at ages 25-69 years 2.1 [95% CI 2.0-2.2]). The risks were substantial both for cigarette smoking (the main urban habit) and for bidi smoking. Of this excess mortality among smokers, a third involved respiratory disease, chiefly tuberculosis (4.5 [4.0-5.0], smoking-attributed fraction 61%), a third involved vascular disease (1.8 [1.7-1.9], smoking-attributed fraction 24%), 11% involved cancer (2.1 [1.9-2.4], smoking-attributed fraction 32%), chiefly of the respiratory or upper digestive tracts, and 14% involved alcoholism or cirrhosis (3.3 [2.9-3.8], not attributed to smoking). Among ever smokers, the absolute excess mortality from tuberculosis was substantial throughout the age range 25-69 years. (A separate survey of 250000 men living in the urban study area found that ever smokers are three times as likely as never smokers to report a history of tuberculosis, corresponding to a higher rate of progression of chronic subclinical infection to clinical disease.) The proportional excesses of respiratory, vascular, and neoplastic mortality at ages 25-69 years among ever smokers in the urban study area were replicated, each with similarly narrow CI for the risk ratio, in the rural study area (where bidi smoking predominated), and are taken to be largely or wholly causal. For urban and for rural death from medical causes at older ages (> or =70 years), the standardised risk ratio was 1.3. INTERPRETATION: Smoking, which increases the incidence of clinical tuberculosis, is a cause of half the male tuberculosis deaths in India, and of a quarter of all male deaths in middle age (plus smaller fractions of the deaths at other ages). At current death rates, about a quarter of cigarette or bidi smokers would be killed by tobacco at ages 25-69 years, those killed at these ages losing about 20 years of life expectancy. Overall, smoking currently causes about 700000 deaths per year in India, chiefly from respiratory or vascular disease: about 550000 men aged 25-69 years, about 110000 older men, and much smaller numbers of women (since few women smoke)

Smoking increases the risk of death from tuberculosis four-fold in adult males in India

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Neural Responses to BEGIN- and END-Stimuli of the Smoking Ritual in Nonsmokers, Nondeprived Smokers, and Deprived Smokers

Drug-associated stimuli (cues) have a prominent role in addiction research because they are able to provoke craving and relapses. Generally, drug cues are seen as conditioned excitatory stimuli, which elicit drug seeking and usage. However, newer data suggest differential effects for smoking stimuli depending on their stage in the smoking ritual. Specifically, stimuli associated with the terminal stage of smoke consumption (END-stimuli) may evoke reactivity opposite to the reactivity evoked by stimuli associated with the beginning of smoke consumption (BEGIN-stimuli). This fMRI study compared 20 nondeprived smokers with 20 nonsmokers to unravel the influence of smoking-related pictures displaying the beginning (BEGIN-stimuli) and termination (END-stimuli) of the smoking ritual on neural activity in the addiction network. In addition, 20 deprived smokers (12 h deprivation) were investigated to explore the effects of deprivation on the processing of these stimuli. In nondeprived smokers, BEGIN-stimuli reliably activated the addiction network (for example, the ventral striatum, orbitofrontal cortex, and anterior cingulate cortex (ACC)). In contrast, END-stimuli triggered a differential pattern of activations as well as deactivations; deactivations were found in the ventral striatum and the ACC. Deprivation had no clear effect on the responses triggered by BEGIN-stimuli, but affected the reactivity to END-stimuli. Our data clearly suggest that stimuli associated with different stages of the smoking ritual trigger differential neuronal responses. While BEGIN-stimuli generally seem to activate the addiction network, END-stimuli presumably have some inhibitory properties. This new finding might add to a more differentiated understanding of cue reactivity and addiction

Ethical issues raised by proposals to treat addiction using deep brain stimulation

Deep brain stimulation (DBS) has been proposed as a potential treatment of drug addiction on the basis of its effects on drug self-administration in animals and on addictive behaviours in some humans treated with DBS for other psychiatric or neurological conditions. DBS is seen as a more reversible intervention than ablative neurosurgery but it is nonetheless a treatment that carries significant risks. A review of preclinical and clinical evidence for the use of DBS to treat addiction suggests that more animal research is required to establish the safety and efficacy of the technology and to identify optimal treatment parameters before investigating its use in addicted persons. Severely addicted persons who try and fail to achieve abstinence may, however, be desperate enough to undergo such an invasive treatment if they believe that it will cure their addiction. History shows that the desperation for a "cure" of addiction can lead to the use of risky medical procedures before they have been rigorously tested. In the event that DBS is used in the treatment of addiction, we provide minimum ethical requirements for clinical trials of its use in the treatment of addiction. These include: restrictions of trials to severely intractable cases of addiction; independent oversight to ensure that patients have the capacity to consent and give that consent on the basis of a realistic appreciation of the potential benefits and risks of DBS; and rigorous assessments of the effectiveness and safety of this treatment compared to the best available treatments for addiction. © 2010 Springer Science+Business Media B.V