To the Editor. In a recent article, Tonnesen et al suggest that a nicotine inhaler in smoking cessation could be implemented in general practitioner offices with high success rates and that it would be "acceptable" to patients. In addition, the program is described as "low intervention." Results from their study do not support such statements

Goldstein, A.

Jorgensen, S.

Mikkelsen, K.

Norregaard, J.

Tonnesen, P.

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broadcast antismoking commercials, smoking restrictions inrestaurants and private workplaces, the radio and televisionad ban, and the tar/nicotine listing requirement.3 The 1971radio and television ad ban resulted in about a 27.8% savingsin real ad spending for cigarette companieswith no detectablereduction in demand.3 To be prudent, a total ad ban should beaccompanied by controls on the introduction ofnew cigarettebrands/varieties and by antismoking policies known to reduceconsumption.Such effective measures include excise tax increases, res¬taurant smoking restrictions, and broadcasting antismokingcommercials. For each 10% increase in real cigarette price, ademand decrease of approximately 3.7% results.3 For each10% increase in the smoking-age population covered by gov¬ernment smoking restrictions, a drop in demand of around6.5% is seen.3 An optimal antismoking agenda would givehighest priority to these efficacious policies.William L. Simonich, PhDCancer Treatment Centers of AmericaZion, Ill1. Gostin LO, Brandt AM. Criteria for evaluating a ban on the advertisement of cig-arettes: balancing public health benefits with constitutional burdens. JAMA. 1993;269:904-909.2. Bergler R. Advertising and Cigarette Smoking: A Psychological Study. Bern,Switzerland: Hans Huber Publishers; 1981.3. Simonich WL. Government Antismoking Policies. New York, NY: Peter LangPublishing Inc; 1991.In Reply.\p=m-\Smokingis a highly complex and insufficientlyunderstood behavior. Consequently, effective reductions insmoking behavior are likely to be achieved through a com-prehensive public health strategy based on the best availabledata. At the same time, antismoking policies must be re-spectful of human rights and avoid promoting intolerance ofsocially unacceptable behaviors.Dr Simonich is correct to warn that a ban on advertisingcould sharply reduce the cost of doing business for cigarettemanufacturers. Since the cigarettemarket exhibits some priceelasticity, significant increases in taxes may be necessary tomaintain or increase the price of cigarettes.We support a multidimensional public health approach tocigarette smoking, including tax increases, health education,smoking prevention, and cessation programs. We urge somecaution regarding the remaining two suggestions made bySimonich\p=m-\government-imposedsmoking restrictions and aban on the introduction of new brands of cigarettes.Government-imposed smoking restrictions can represent abroad spectrum of policies with widely varying impacts onpublic health. While we support the restrictions on smokingin public areas that many states and municipalities haveenacted, more aggressive government-imposed smoking re¬strictions could be perceived as punitive and unduly invasive.Most data on secondhand smoke are based on studies involv¬ing long-term exposure rather than casual transient exposureto smoke.1 For this reason, any government ban on smokingwould require careful assessment of both its public healthbenefits as well as its potential intrusiveness. Policies, suchas an ad ban, that focus attention and responsibility squarelyon the tobacco industry for the risks of their product mayhave certain benefits over policies directed at individualsmokers.The proposal to ban the introduction ofnew cigarette brandsis also problematic. While government could constitutionallyban the manufacture of cigarettes, it has chosen not to do so. Ifgovernment continued to allow the manufacture of cigarettesbut prohibited the introduction of new brands, it probablywould be regarded as arbitrary and capricious. In order for sucha law to pass constitutional muster, advocates would have toshowwhy newbrands pose a serious and special danger to pub¬lic health over and above currently existing brands.It is true that the empirical data to support a ban oncigarette advertising are equivocal. However, given the vastcomplexity of designing studies that show a causal relation¬ship between advertising and smoking, any evaluation of aban must rest on a careful assessment of many factors. Theprofound harms of smoking, the history of unsuccessful reg¬ulation of the industry, the unique characteristics of ciga¬rettes in American life, and the minimum burdens on FirstAmendment values lead us to reiterate our conclusion that aban on cigarette advertising would be an important part of acomprehensive public health strategy.Lawrence O. Gostin, JDAmerican Society of Law, Medicine, and EthicsBoston, MassAllan M. Brandt, PhDHarvard Medical SchoolBoston, Mass1. Respiratory Health Effects ofPassive Smoking: Lung Cancer and Other Disor-ders. US Environmental Protection Agency, Office for Research and Development,Office of Health and Environmental Assessment; 1992.Nicotine Inhaler for Smoking CessationTo the Editor.\p=m-\Ina recent article, T\l=o/\nnesenet al1 suggestthat a nicotine inhaler in smoking cessation could be imple-mented in general practitioner offices with high success ratesand that it would be "acceptable" to patients. In addition, theprogram is described as "low intervention." Results fromtheir study do not support such statements.Their study involved volunteers whowere recruited throughnewspaper advertisements and who were motivated to quitsmoking. Furthermore, subjects came to the clinic for a totalof eight visits within 1 year, with each visit lasting "from 30to 60 minutes." Subjects saw videotapes on smoking cessa-tion, had group instructions about the use of the nicotineinhaler, had assessments with fiscal and biological parame-ters, and received individual counseling. Such broad and ex-pensive interventions are admirable, but in my practice aswell as that of most primary care physicians, I don't thinkthey would be classified as low-intervention efforts. More-over, I am surprised that despite such efforts, the placebogroup had only a 5% successful smoking cessation rate at 1year. In a prior study by T0nnesen et al,2 23% of participantsin a smoking cessation trial who were randomized to placebowere abstinent at 1 year.The claim that nicotine inhalers will be acceptable to pa¬tients also seems premature given experiences with the useof the nicotine patch, the cost ofwhich has been unacceptablefor many of my patients. Will the nicotine inhaler, when itreaches the market (as I'm sure it will) cost as much or morethan the patch when used at a per-unit dose? Furthermore,did the patients in the study receive their inhalers free ofcharge? If both answers are yes, then I expect that theinhaler will be less acceptable than envisioned, thus makingsuccess rates less than reported. Effectiveness trials withother nicotine replacement strategies have shown them to beless successful than that reported in controlled researchreports.3Finally, did patients truly use an average of 3.8 inhalersper day, with each inhaler on average good for 300 puffs, asreported? If true, then the average patient puffed 1.2 perminute every hour for 16 hours a day. Again, I am not suremy patients would find this acceptable.Adam Goldstein, MDUniversity of North CarolinaChapel Hill1. T\l=o/\nnesenP, N\l=o/\rregaardJ, Mikkelsen K, J\l=o/\rgensenS, Nilsson F. A double-blindtrial of a nicotine inhaler for smoking cessation. JAMA. 1993;269:1268-1271.2. T\l=o/\nnesenP, Fryd V, Hansen M, Helsted J, Gunnersen AB, Forchammer H. Ef-fect of nicotine chewing gum in combination with group counseling on the cessationof smoking. N Engl J Med. 1988;318:513-518.3. Hughes JR, Gast SW, Keenan RM, Fenwick JW, Healy ML. Nicotine vs placebogum in general practice. JAMA. 1989;261:1300-1305.In Reply\p=m-\Ourenrollment in the nicotine inhaler study was al-most supersonic: all 286 smokers were enrolled in 5 days in theafternoon after working hours. Many subjects felt that the ses-sions were unsatisfactcorydue to the hurry and lack of personalcontact. The subjects saw a 7-minute videotape at entry only.This could also be arranged in a primary care setting.We believethat the primary care physician could take advantage of his orher knowledge of, and partnership with, the smoker, and so theconsultation time need not bemore than 5 to 10 minutes. The lowsuccess rate in the placebo group in our study is a reflection ofthe minimal psychological support provided, combined with arelatively low degree of motivation to quit in moderatelynicotine-dependent subjects. In contrast,we have attained high-er success rates when we used nicotine gum in combination withgroup meetings.1The inhaler was delivered free of charge, which might haveenhanced compliance with the device. As the cost of theinhalermight influence optimal usage, reimbursement for thecost of the inhaler as well for other nicotine products wouldbe desirable.The subjects using the active nicotine inhaler attained anicotine substitution that was 24% to 43% of their smokinglevels. They used from one to 14 inhalers daily. It is notpossible to see when the nicotine inhaler is empty. However,the subjects were told to replace the inhaler when they feltit had no more effect. It is our impression that they used theinhaler almost as often during the day as when smokingcigarettes but had to puff harder and more often comparedwith when using cigarettes. Using the inhaler does not seemto be more difficult than using the nicotine gum.Last, we should optimize the implementation of smokingcessation in general practice since the efficacy of this treat¬ment in its current state is as cost-effective as other pre¬ventive measures.2 Lack of time is not a legitimate excuse fornot "treating" the smoking behavior.Philip T\l=o/\nnesen,MD,Jesper N\l=o/\rregaard,MDKim Mikkelsen, MDStig J\l=o/\rgensen,MDBispebjerg HospitalCopenhagen, Denmark1. T\l=o/\nnesenP, Fryd V, Hansen M, Helsted J, Gunnersen AB, Forchammer H. Ef-fect of nicotine chewing gum in combination with group counseling on the cessationof smoking. N Engl J Med. 1988;318:513-518.2. Fowler G. Educating doctors in smoking cessation. Tobacco Control. 1993;2:5-6.Persistent Ear Discomfort and Neck PainTo the Editor.\p=m-\Weread with interest the excellent synopsisof otorhinolaryngologic causes of persistent ear discomfortand neck pain by Leliever.1 In our experience, in addition toeustachian tube dysfunction, an often overlooked cause of thesymptoms described is activation ofmyofascial trigger pointsin the clavicular division of the sternocleidomastoid muscle(although some have questioned the basic concept2,3).As characterized by Travell and Simons,4 when activatedsternocleidomastoid trigger points are present and producecharacteristic referred ear and neck pain on one side in thepattern described in the question posed to LeLiever,1 suchpoints are usually found on the opposite side as well. Thiswould account for the bilateral distribution of the patient'spain, as well as her increased pain on flexion of her neck.Travell and Simons note that persons with such trigger pointsalso often experience referred frontal headaches and referredautonomic phenomena, especially postural dizziness and equi-librium disturbances.4Though some dispute the validity of the method,5,6 we havehad considerable success demonstrating such activated trig¬ger points with liquid crystal thermography, validated bythorough physical palpation of the clavicular division(s) of theinvolved sternocleidomastoid muscle(s) and by disappear¬ance of referred ear pain after treatment of the triggerpoint(s). Occasionally, chronic ear pain can result from acti¬vation of trigger points in the upper part of the deep layer ofthe ipsilateral masseter muscle; an activated trigger point inthe medial pterygoid muscle can also produce chronic ear painon the same side, but this is often accompanied by more jawpain than was described in the case presented to LeLiever.4David E. Conwill, MD, MPHB. H. Cook, MD, PhDUniversity of Mississippi Medical CenterJackson1. LeLiever WC. Eustachian tube dysfunction. JAMA. 1993;269:809.2. Deyo PA. Back pain: the history and physical examination. JAMA. 1993;269:356.3. Deyo PA. TENS for chronic low back pain. N Engl J Med. 1990;323:1425.4. Travell JG, Simons DG. Myofascial Pain and Dysfunction: The Trigger PointManual. Baltimore, Md: Williams & Wilkins; 1983:202-235, 249-259.5. Cotton P. AMA's Council on Scientific Affairs takes a fresh look at thermography.JAMA. 1992;267:1885-1887.6. Swerdlow B, Dieter JNI. An evaluation of the sensitivity and specificity of med-ical thermography for the documentation of myofascial trigger points. Pain.1992;48:205-213.Suicide Attempts and the Nicotine PatchTo the Editor.\p=m-\Withinrecent months, four pharmaceuticalmanufacturers have brought nicotine replacement patchesonto the US market for the treatment ofnicotine dependence.The package inserts for these nicotine patches warn physi-cians that the risks of nicotine replacement therapy in pa-tients with known cardiovascular or peripheral vascular dis-ease should be weighed carefully against the benefits of smok-ing cessation. We write to report the case of a patient withknown coronary artery disease who attempted suicide bymeans of nicotine overdose using nicotine patches.Report of a Case.\p=m-\Ourpatient was a 44-year-old manwho presented in October 1992 with a single episode ofmajor depression and recurrent suicidal ideation. Diagnos-tic evaluation resulted in additional diagnoses of patholog-ical gambling, alcohol dependence syndrome, and nicotinedependence. The patient had undergone coronary angio-plasty in August 1992 for coronary artery disease. Twoweeks prior to his October hospital admission, he at-tempted suicide by means of nicotine overdose. He placedseven 21-mg nicotine patches on his chest and begansmoking cigarettes, two at a time. Prior to applying thepatches, he had flushed the patch enclosures down thetoilet. It was his intent to precipitate myocardial infarc¬tion, and he had planned to hurriedly remove the patchesand similarly dispose of them once he developed chestpain. He also brewed and consumed a pot of double-strength coffee. Approximately 2 hours into this attempt,having experienced no chest pain or other untoward symp¬toms, he became anxious that he might actually succeed inhis suicide attempt and abruptly removed all the patchesand discontinued smoking.Comment.—We contacted Marion Merrell Dow Ine (oralcommunicationwith ElizabethMcManamy, RPH, Global Prod¬uct Safety Specialist, February 1993), the producer of Nico-derm, regarding other reports ofoverdose or attempted over¬dose with Nicoderm. The pharmaceutical company had fourreports of overdose on record, one of which was intentional

Nicotine inhaler for smoking cessation [4]

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Nicotine inhaler for smoking cessation [4]

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