Hookah Research Results

The vast amount of research on smoking has been done on the harms of cigarettes, presumably because they’re the most common form of tobacco use and probably the most harmful. Recently, hookahs have become more popular, especially amongst college age people. In addition, in the Middle East and other parts of the world, hookahs are very popular. Some people are under the impression that hookahs are a safe alternative to cigarettes. They believe that the water filters out a lot of the harmful chemicals in hookahs and that whatever the water doesn’t get, the charcoal will get rid of.

Unfortunately, there aren’t too many studies done on the health effects of hookahs. Although it’s generally agreed that the volume of smoke per hookah session is quite high (in fact, one 40 minute session can result in inhaling as much smoke as dozens upon dozens of cigarettes), the fact that the tobacco is not heated to as high of a temperature as in a cigarette may result in a lower amount of exposure to toxic compounds.

A recent study in Cancer Epidemiology, Biomarkers & Prevention compared the amount of nicotine and various carcinogens inhaled via hookah versus cigarettes, and found that while those who used hookahs had significantly less exposure to nicotine and certain carcinogens, levels of carbon monoxide and carcinogens such as benzene were higher. Benzene exposure for example is linked to the development of leukemia.

The study didn’t measure hard outcomes (i.e. it didn’t compare rates of cancer, heart disease, etc. between hookah users to those that smoke cigarettes). In fact, there aren’t any good, long-term head to head studies addressing this.

A 2010 review from the International Journal of Epidemiology did show that hookah smokers had more than double the risk of developing lung cancer, respiratory infections, and low birth weight babies, and 3 to 5 times the risk of having periodontal disease compared with nonsmokers. Of note, risks of throat and bladder cancers were not higher (which is the case in cigarette users).

The bottom line is that at this time, it’s unclear if hookah smoking is any better than smoking cigarettes. And even if it is, it certainly isn’t a safe habit, exposing the body to many harmful substances and increasing the risk of developing lung cancer and other diseases.

So if you do currently smoke a hookah as a safe alternative to cigarettes, quit, and take up a healthier habit (join a gym, play sports, take up gardening etc.)

- Tamir

(Image credit: Psych Central)

Varenicline Update

Let me preface this post by stating that I have no financial or commercial ties to the manufacturer of Varenicline. This is written purely for the benefit of anyone who’s trying to quit and wants to know more about the different options out there.

Varenicline (otherwise known as Chantix in the United States and Champix in several other countries) remains one of the main medications that we use to help people quit smoking. A couple of years ago, questions were raised regarding a possible increased risk of heart attacks amongst users of Varenicline, based on a study in the Canadian Medical Journal.

Subsequently, the FDA issued a warning stating that Varenicline may be associated with a small risk of heart attacks in those who have heart disease.

In our book, I mentioned that due to the possible increased risk of heart attacks, I tended to shy away from using Varenicline in people with established heart disease.

Since then, more recent data from 2 separate studies published in the British Medical Journal,

1) Svanström et al (2012)

2) Prochaska & Hilton (2012)

did NOT show any significant association between the use of Varenicline and heart disease (although it’s worth noting that the study by Prochaska and Hilton did show a trend towards increased risk, though it didn’t reach statistical significance – which means that the small increased risk may have been due to chance). Furthermore, several people criticized the methodology of the original study condemning Varenicline.

So, where does this leave us? Varenicline probably doesn’t significantly increase the risk of heart attacks, even in those with heart disease. However, it’s impossible at this time to 100% exclude such a risk. On the other hand, MANY people who smoke will end up having a heart attack, and quitting smoking is probably the single best thing they can do to decrease their risk of having a heart attack. Therefore, if I have a smoker with heart disease who wants to quit smoking, in most cases I will probably offer other options first, but when push comes to shove, if Varenicline is the only thing that works, or if it has worked well for the patient during past quit attempts, then I have no problem offering it to them after a discussion of the risks and benefits.

One final note. In our book, I mentioned that Varenicline is associated with gastrointestinal side effects such as nausea, and that it does run a small risk of having people become depressed or even suicidal (which I haven’t yet witnessed personally, but there are such reports in the medical literature and the FDA does have an official warning regarding this issue). One other side effect which I neglected to mention in the book (due to an oversight) was the possible risk of insomnia and abnormal dreams, neither of which are per se dangerous, but are obviously quite distressing.

- Tamir

Preventing worse menopausal symptoms

Many women going through menopause experience a variety of unpleasant symptoms; among the most bothersome are hot flashes and night sweats. With the exception of estrogen replacement therapy, which can unfortunately increase the risk of developing blood clots and breast cancer, there aren’t very effective treatments (yes, there are various medications and herbs that are used, but practically speaking, for many patients, these don’t produce satisfactory results).

Recent research conducted by the University of Queensland School of Population Health shows that there are many modifiable risk factors that can contribute to worsening hot flashes and nights sweats. The study team sampled 10,000 women, and found that those who smoked, gained weight, were diabetic, and drank too much alcohol had significantly worse symptoms.

So if you’re currently going through menopause or are going to be there soon, this may be yet another good reason to quit smoking, lose some weight if you’re overweight, and cut down on the alcohol if you’re over doing it in that department.

- Tamir

(Image credit: 34-menopause-symptoms.com)

Killer commutes

Unfortunately, many of us face very long commutes to work. If you’ve been stuck in traffic, stressed out about being late, grabbed a fast food meal because “who has time to make dinner after a long work day and an even longer commute,” lit up another cigarette which would hopefully help you cope (somewhat), you’ve had the realization that long commutes are probably unhealthy.

Researcher Erika Sandow from Sweden recently presented results of a study she did looking at health records of over 50,000 people and comparing the health of those with long versus short commutes. Those who commuted more than 30 miles a day were more likely to die younger, have heart disease, obesity, and stress. Women seemed to have it worse than men. In addition, earlier work from Professor Sandow found that those with long commutes also faced much high divorce rates.

Obviously, in this economy, we often are simply lucky to be holding a job. So I’m not suggesting simply quitting your job even if you do face a long commute. However, if you have the option of switching to a job closer to home, even if the pay is a little less, then it may be something to consider. In addition, if you’re currently stuck with a job that has a long commute, then be mindful of your health habits:

If you’re stressed out, then work on relaxation techniques such as deep breathing.
Don’t light up cigarette after cigarette in the car out of frustration – pick up some chewing gum or ask your doctor for some nicotine replacement products if you need them.
Make sure to squeeze in a little exercise every day, even if you do come home late; doing 15-20 minutes is better than nothing, especially when most of the rest of your day consists of sitting.
Pack healthy snacks and meals for the road if you come home too late or leave the house too early to sit down for a proper meal. Don’t snack on chips, candies, and fast food in the car. You can cook 1-2 times a week in larger volumes, and then pack individual meals to have ready.
Put on some music you enjoy and that soothes you in the car, or purchase audiobooks to listen to, to keep you engaged and to keep your mind off the endless road ahead.

- Tamir

(Image credit: Yaffe Real Estate.)

Do What You Like

Many times when I bring up the topic of a regular exercise routine with patients who don’t currently exercise (or haven’t done so in a long time), they’ll ask me, “What type of exercise should I do?” Similarly, when discussing adopting a healthier diet, a patient will often ask me, “What diet should I follow?”

As we discuss in our book, there isn’t one golden approach to a healthy lifestyle. Although there are numerous health gurus out there who push their own brand of health and exclude all others (and often their way is full of “must have” nutritional supplements and videos that can cost an arm and a leg), the reality is that by following general health principles, you can improve your own health a tremendous amount, all the while doing it in a way that’s palatable to you.

There are numerous diet and exercise programs out there: Low carb, low fat, vegetarianism, paleo diets, no sugar, no white flour, gluten free, various gimmick diets centered around shakes and supplements, etc. etc. Similarly for exercise, there’s running, weight lifting, calisthenics, sports, swimming, biking, yoga, tai chi, other forms of martial arts, dance, etc. etc.

Most programs out there have something beneficial to offer. However, as human beings, we’re all unique individuals who have our likes and dislikes. For example, broccoli is a healthy vegetable. But if I told every person out there that they must include broccoli as part of a healthy diet, I would have many people who simply couldn’t follow such a diet due to their dislike of broccoli. However, if I advised people to simply include more vegetables in their diet, I would likely have more success given the fact that most people probably enjoy, or at least tolerate, some types of vegetables.

Similarly, if I told everyone that they must go on a brisk walk for 30 minutes on most days of the week (a healthy habit indeed), I will likely have several people who eagerly comply (especially if they live in a scenic area with a temperate climate). However, there are many people out there who for various reasons (they live in a bad neighborhood where it’s unsafe to walk, it’s too cold, too rainy, or too hot to walk, they dislike walking, they have chronic foot pain), won’t walk. So when people ask me what type of exercise they should take up, I simply tell them to start doing anything that they enjoy that will make them “huff and puff” a little (I do want to briefly mention that before embarking on an exercise program more intense than light walking, people at risk for heart attacks, strokes, joint pain, etc. should be cleared by their physician).

Even in the realm of smoking cessation, there are different approaches. Forcing everyone to chew nicotine gum or to wear a patch is just not realistic.

The bottom line is to make meaningful changes that you can stick to long term. I can tell you that if you don’t enjoy something, then it probably won’t last.

I know that some of you might be thinking that you enjoy smoking, don’t enjoy any fruits or vegetables, and think that the most physical kind of activity that you’ll tolerate is flipping channels on the TV or walking to the fridge. Hey, it’s a free country, and at the end of the day you can choose to treat your body the way you want. However, what I’m suggesting is finding a happy medium in which you at least adopt some healthy lifestyle measures without spending the balance of your life waking up at 4 am for a 10 mile run followed by hours of push-ups and feasting on nothing more than alfalfa sprouts, steamed asparagus and boiled chicken (unless of course, that’s what you enjoy).

- Tamir

(Image links back to source: NBC News)

Beyond alcohol – be mindful of what you drink

Many times in my career, I’ve seen people seem to ignore the amount of calories they consume through drinks. And I am not referring to alcoholic drinks (a topic on its own).

Most people are aware that sodas are bad for them and contain a lot of sugar (which they do). However, most fruit juices, as well as sweetened regular and ice tea, fruit punch and other fruit flavored beverages, lemonade, many coffee and related drinks loaded with sugar and cream, as well as many smoothies and health shakes are often loaded with calories. These excess calories are usually from sugar, and often from a particularly unhealthy type of sugar: high fructose corn syrup.

Although an orange or an apple does have some sugar, it also has fiber, which slows down the absorption of the sugar in the body. Furthermore, one serving of fruit juice will contain the sugar from several oranges or apples without any of the fiber, causing a spike in blood sugar levels. That’s why people whose blood sugar drops too low (such as diabetics who accidentally took too much insulin or who didn’t eat enough after using insulin) are told to drink orange juice or grape juice.

Energy drinks are also quite popular today, as are sports drinks. You need only look at the multiple TV commercials of a sweaty athlete gulping down a Gatorade to understand why every weekend warrior thinks that they need to go through bottles of the stuff to “replenish electrolytes” during their 90 minute softball game. Sports drinks are little more than water, sugar, and a tiny bit of salt. Average people partaking in regular exercise do not need to chug these incessantly in order to replenish salt lost during sweating; what they obtain from drinking water and following a regular healthy diet more than suffices.

You may not be aware that adding a few sugar laden beverages a day may mean >500 calories of pure sugar – enough to derail an otherwise healthy diet or trip to the gym. If you just burned several hundred calories during a brutal workout, you may have blown it by consuming a couple of sports drinks while exercising and then treating yourself to a jumbo latte with all the fixings at Starbucks.

Most servings of sodas, lemonade, ice tea, juices, sports drinks, energy drinks, and other sweetened beverages contain around 150 calories. Some fruit smoothies, and some of the large coffee drinks in commercial coffee shops, as well as “supersized” sodas and slurpees can contain double or even triple that amount of calories.

Web MD has a nice little table showing approximate calorie counts of some common drinks.

Of note, diet drinks (i.e., those containing artificial sweeteners), although having few if any calories, have also been linked to obesity and diabetes for reasons not completely understood.

In addition, all of the above sweetened drinks, as well as diet sodas and many other diet drinks containing citric acid (a common additive which gives drinks a lemony flavor) cause tooth decay, which is another reason to avoid them.

Water is probably the best way to go. Black coffee and unsweetened black or green tea are not bad for most people; indeed they may have some health benefits. Plain seltzer is probably fine as well since it’s little more than carbonated water. Adding a squeeze of lemon to water and/or seltzer can add a little flavor for those who find these drinks too “plain.”

- Tamir

Blame Your Genes?

You may have noticed that some people who take up smoking have no problem quitting, even when they’ve been smoking a lot, whereas others seem to quickly become addicted, even if they initially smoked only a few cigarettes on the weekend.

A recent study published in JAMA Psychiatry sheds some light on these differences. The researchers discovered that having a certain genetic profile made people more likely to become addicted and smoke more heavily. Interestingly enough, having the “high-risk” profile didn’t affect whether or not a person took up smoking to begin with.

If you’re having a hard time quitting, you may be wondering if you have the high-risk genetic profile. Is that why you’re struggling to quit?

At this point in time, it’s not possible for any of us not directly involved in a research study to know our genetic profile with respect to cigarette addiction. That’s why it’s important to not take up smoking in the first place. If you do smoke occasionally, give it up, since you don’t know whether you’re at a higher risk of getting hooked.

On the other hand, if you’re already addicted, and are having a hard time quitting, then by no means give up and resign yourself to a life of poor health. The rates of heavy smoking and propensity for addiction in people with the high-risk genetic profile was roughly 20-40% higher than in the low-risk group (depending on the outcome measured). This means that although you may be facing a harder time trying to quit, and perhaps are currently smoking more cigarettes than someone with a low-risk genetic profile, you still have a good chance to end up smoke-free if you keep trying.

Genes only go so far to explain human behavior. We are all born with certain predispositions. Some people have more of a tendency to overeat, others are lazy, and others hate exercise. You will agree with me that in most cases, with enough desire, people can improve their lot in life. Smoking cessation is no exception.

Heart-healthy habits can also decrease the risk of cancer

The American Heart Association came out with a list of 7 recommendations (named Life’s Simple 7) to attempt to increase heart health in the United States. These recommendations (in no particular order) are:

1. Being physically active
2. Maintaining a healthy weight
3. Eating a healthy diet
4. Maintaining healthy cholesterol levels
5. Keeping blood pressure down
6. Regulating blood sugar levels
7. Not smoking

In a study published in the March 18th edition of the American Heart Association journal, the authors found that adhering to the above guidelines significantly reduced the risk of developing cancer as well. Specifically, of the 13,000 or so people who were followed for 17-19 years, those that adapted 6-7 of the guidelines had a 51% reduced risk of developing cancer, those that followed 4 had a 33% lower risk, those that followed 3 had a roughly 25% risk, and even those who followed a couple of the recommendations had a 21% reduced risk.

Even when smoking was taken out of the equation (since smoking is one of the biggest contributors to many different cancers), people who adopted 5-6 of the recommendations had a 25% lower risk of developing cancer.

What is the take home message? Obviously, if you smoke, then quit. However, as you can see from the above study, adopting other healthy lifestyle choices such as eating a healthy diet, exercising, watching your weight, etc. can make a big impact, not just with respect to heart disease, but with cancer as well. So even if you cannot quit at present, or choose not to, then at least improve your health in other ways.

- Tamir

Why we smoke

A recent survey that I mentioned in a previous blog post regarding how many times the average smoker attempts to quit, sheds some additional insight on the reasons people smoke. Granted this survey was conducted in England, and it’s possible that British smokers have dissimilar characteristics from their American counterparts; still, some fascinating findings emerge.

56% of male smokers versus 48% of female smokers smoke the most when out with friends. This is important to note with respect to trying to quit. If you are considering kicking the habit, but are surrounded by people who smoke, then there’s a real risk of temptation to light up. In addition, having friends who smoke may make you more likely to take up the habit yourself (although this is mere speculation and not a specific conclusion from the survey).

33% of female smokers stated that they smoked the most when under stress. This too we discuss in our book. Often times, people smoke to alleviate stress. However, much of the “anxiety” that is relieved stems from the withdrawal symptoms, which arise if you go too long without a cigarette. Too many people are under the impression that smoking is effective for stress relief even though this has been disproven.

55% of smokers believe that they became addicted to the psychological habits associated with smoking
before becoming addicted to nicotine itself. Again, the environmental triggers and associations that smokers have with cigarettes and the act of smoking may be as important as what actually goes on in the body on a cellular level with respect to becoming addicted and relapsing after successfully quitting.

30% of smokers hide their habit. 37% of those who hid their habit did so out of embarrassment. This is good news as it hints that perhaps smoking is not as “cool,” glamorous, or socially acceptable as in previous generations. 30% of those who kept their habit under wraps did so out of not wanting to worry a loved one.

Over 50% of smokers hated being told how bad smoking is for their health, stating that they already knew how bad it is. This perhaps is valuable with respect to trying to help loved ones to quit. It’s important to offer advice in a non-preachy, non-judgmental manner. I know that in my own practice several of my former and current smoking patients told me that many other doctors and other health care professionals have looked down at them and treated them with disdain and contempt as drug addicts when discussing their smoking habits.

Finally, roughly 25% of smokers stated that financial reasons (i.e. cigarettes cost too much) were the main motivator for quitting rather than health concerns. This perhaps is a tool that can be used to get people to quit. In New York, where I reside, a pack costs roughly $10 due to very high cigarette taxes. This isn’t the forum to discuss the pros and cons of high tobacco taxes, but I can tell you that in my own practice, I have had several patients who have either cut down or quit smoking due to financial concerns.

- Tamir

(Image links to source: Bioethics.net)

What’s the deal with coffee?

There’s a misconception out there that drinking coffee is unhealthy, almost a vice to be thrown together in the same league with smoking cigarettes, boozing, and eating junk food. In fact, several patients of mine over the years were almost embarrassed to tell me that they indulge; their sheepish grin betrayed their belief that I’m somehow disappointed by their habit.

As we mention in our book, for most people, drinking coffee probably has several health benefits, including a decreased risk of liver disease, diabetes, gout, cognitive problems such as dementia, and perhaps certain cancers.

In addition, two recent studies show additional benefits. One, which was published in the American Heart Association journal, Stroke, showed a 20% decreased risk of strokes in those who drank at least one cup a day of coffee.

The second, published in the prestigious New England Journal of Medicine last December, followed roughly 400,000 people ages 51-70 for over a decade and showed that those who drank 2 or more cups a day had a 10-12% decreased risk of dying. Interestingly, for those people who smoked, the benefits were not seen. Coffee only helped former smokers or those who had never smoked.

So is there a down side to coffee? For people prone to heartburn, it’s one of the main triggers. Furthermore, in some people it increases the risk of insomnia and heart palpitations.

The bottom line is that if you currently drink coffee and feel guilty about it, then don’t – you’re likely doing your body a favor. If you don’t already drink coffee, don’t enjoy the taste, or have heartburn or palpitations when you consume it, then don’t worry about it either. Although the scales seem to be tipped towards coffee having health benefits, what you need to focus on is eating a healthy diet, not smoking, and partaking in regular exercise, which are all much more important for one’s health.

- Tamir

SmokersFitness.com

An essential health resource for current and former smokers

Hookah Research Results

Varenicline Update

Preventing worse menopausal symptoms

Killer commutes

Do What You Like

Beyond alcohol – be mindful of what you drink

Blame Your Genes?

Heart-healthy habits can also decrease the risk of cancer

Why we smoke

What’s the deal with coffee?