Effect Measure

Recently a relative was sent home from the hospital with her own oxygen supply. It wasn’t a cylinder of compressed oxygen but an oxygen concentrator, a device that takes room air and removes a lot of the nitrogen by passing the air through a zeolite canister. These devices can supply 50 – 95% oxygen. About 1 million people over the age of 65 are on home based Long Term Oxygen Therapy (LTOH) supported by Medicare. Many of them need oxygen because they have chronic lung disease brought on by their addiction to cigarettes (not the case for my relative, however). Cigarettes. Oxygen. Not a good combination:

At 2:10 a.m. on December 14, 2007, a fire occurred in a public housing project for the elderly in Westbrook, Maine. Approximately 60 residents were evacuated; six were transported to a hospital for smoke inhalation. The fire was caused unintentionally by a woman aged 57 years who was an overnight guest of a relative who lived in the housing project. The visitor had ignited the fire while simultaneously smoking and using an oxygen concentrator. (CDC, Morbidity and Mortality Weekly Reports)

It’s not often we have a YouTube clip of the exact event described in a CDC MMWR report but that’s the case here:

Oxygen doesn’t explode. It is an accelerant, that is, it makes other things burn faster and more fiercely. This includes cigarettes:

Cigarettes on their own are the leading cause of house fires in the US. Unfortunately this event, smoking while oxygen therapy is in use nearby, is not unique or even Darwin Award material. While many people know that enriched oxygen atmospheres and flame are a bad combination, addictive behavior is addictive behavior. CDC cites estimates ranging from 5% to over 40% of people on LTOH continue to smoke. Prior to this case there were five case series in the medical literature involving 79 hospitalizations for burns and five deaths. After the Maine episode a survey was done of four states (Massachusetts, Maine, New Hampshire and Oklahoma) for the eaight years 2000 to 2007:

A total of 38 cases were identified: five in Maine, three in New Hampshire, 11 in Massachusetts, and 19 in Oklahoma. All incidents involved a single fatality except for one fire that resulted in two deaths. The overall fatality rate for the four states was 3.8 deaths per 10 million population per year. The highest fatality rate was in Oklahoma (6.7 per 10 million population), followed by Maine (4.8), New Hampshire (2.9), and Massachusetts (2.1). Decedents ranged in age from 9 to 87 years (median: 67 years); the death of a child aged 9 years was the only fatality involving a minor. Twenty-four (63%) decedents were female. Thirty-four (89%) of the decedents were on LTOT and were smoking at the time the fire began; three (8%) were household members of smokers on LTOT who survived, and one (3%) was a nonsmoker on LTOT who was unintentionally ignited by a smoker who lived in the household and survived. Twenty-two (58%) decedents died on the day of the fire, and seven (18%) died the following day. The remaining nine (24%) decedents survived a median of 15 days (range: 3–41 days). (CDC, MMWR)

Cigarettes cause chronic obstructive lung disease, heart disease and cancer in the smoker and increase the risk of these diseases to by-standers from second hand smoke. The cigarette industry destroys lives through disease and property by fire. Their product ruins countless lives. Cigarettes should be made prohibitively expensive with high taxes. Yes, that tends to penalize the poor more because they smoke more and have less disposable income. It is a regressive tax.

But it doesn’t penalize them as much as cancer or being burned out of their homes.

Comments

#1 PalMD
August 9, 2008

I very vividly remember a patient with lung cancer who snuck a cig into the hospital. He was on a 100% NRB mask.

About an hour after rounds, I was sitting in the cafeteria and heard the PA announce a fire—on his floor.

We went up there and there he sat, with his face blown off, a permanent look of surprise seared in. We transferred him to a burn unit.

With my dying patients, I don’t tell them not to smoke. But if I know someone is going to smoke, and they have O2, I remind them over and over to turn it off before lighting up.
#2 Susan Och
August 9, 2008

Interesting. As a casino dealer I sometimes have had to referee incidents when oxygen users and smokers wanted to play at the same table. Understanding the physics, it looks like I could just tell the nitwit smoker that the oxygen was like to explode the cigarette if he can’t just put it out.
#3 Ren
August 9, 2008

I was going to write about this today, but I didn’t see an infectious disease angle to it. You guys did a great job with this issue!!! On the one hand, I laugh when I see old men with their oxygen tanks and cigarettes… But, on the other hand, I’m scared that they might take out innocent lives.
#4 anon
August 10, 2008

I smoke a pipe, and as with most pipe smokers, I don’t inhale. On the overall scale of health risks & addictive vices, this is about equivalent to coffee. (It’s mostly about the sensory gratification factor: I’d sooner have pipe & tobacco minus nicotine, than nicotine pills minus pipe & tobacco. Compare to the choice of decaffeinated coffee drinks vs. taking plain caffein pills and missing the sensual elements of the actual beverage.)

A couple of years ago, two weeks of 100+ temperatures and high air pollution led to a deep vein thrombosis and pulmonary embolism. Into the hospital I went, barely able to walk. Of course there’s no smoking in intensive care! I was stressed and bitchy for a day or two, which could have been the nicotine wearing off (pipe tobacco is relatively weak in the nicotine department) or could have been something else. Once I was diagnosed I figured that was the end of the pipe smoking for me, but the doc said that as far as tobacco goes, pipes are a minor risk. Either way, I assumed that I’d have to find something else to put in my mouth when I wanted an excuse to shut up and think.

They sent me home with an oxygen concentrator, and I did indeed find something else to put in my mouth: mixed nuts from Whole Foods. After subsequent tests determined I was in the clear, back went the oxygen concentrator. A few weeks later I was asking about diet and a few other things and mentioned pipe smoking, and the doc said yeah go ahead, just don’t smoke cigarettes (I’ve never smoked cigarettes; same comparison to caffein pills vs. decaf coffee beverages: cigarettes are a nicotine delivery system with no redeeming qualities).

So I went back to puffing on my pipe, and that’s where things stand today. And of course I still nibble on the mixed nuts, which as far as I can tell, everyone agrees are a healthy snack with no controversies.

I had no problem doing without my pipes for a few months; and I can’t even begin to wrap my brain around how anyone would smoke or use any kind of open flame in a room where an oxygen concentrator is in use. To my mind there wasn’t even a question about it: oxygen in use, no smoking, no flames, no exceptions.

If cigarette smokers are that hooked, then when they are on oxygen, they need to be given some kind of nicotine replacement for the duration.

I have a hypothesis that a lot of the road rage and office rage today, in both their major forms and in their more minor forms of pandemic petty nastiness, are related to stress that in previous times would have been relieved by smoking. If that’s the case, then a society with tobacco is preferable to a society without. The question is how to reduce the health risks. And if some people get truly hooked on nicotine, the question is how to deal with that constructively.

Puritannical jihads and a “reefer madness” mentality do us no good. The goal of public policy should not be to enforce a moral code, but to create the conditions whereby people can get along in a pluralistic society, with the maximum degree of personal liberty, privacy, and autonomy. If someone needs their nicotine, give it to them, rather than scolding them and ending up with a building on fire. It’s like the war on other drugs: the laws have done more harm than the drugs, so it’s time to be realistic about this. Provide nicotine pills or whatnot to cigarette smokers on oxygen, prevent fires and major burns. What could be simpler?
#5 daedalus2u
August 10, 2008

I went to a talk by Bruce Ames (yes, that Bruce Ames) last Friday where he was talking about micronutrients and health and what constitutes an actual “deficiency”. His hypothesis is that organisms do “triage” on micronutrients and allocate them according to the degree of essentiality of the pathway they are being used in (very similar to my ATP hierarchies hypothesis). For example staying alive is more important than preserving high fidelity DNA (which only gives you cancer but years later). He suggests that some of the degeneration of aging may be due to deficiencies in these trace micronutrients that lead to degraded repair pathways due to “triage” of these nutrients away from those repair pathways.

This is just background, setting the stage for the vignette he mentioned. One of the important nutrients was folate which if there isn’t enough leads to DNA damage and chromosomal breaks and other things too.

He was visiting one of his former PhD students, working at Hershey, shortly after it was understood that more folate in the diet was necessary to prevent neural tube defects, that the ordinary diet didn’t have enough folate and that folate should be added to foods to prevent neural tube defects. His former student had read the research, looked up the price of folate and found that she could put a useful amount into each candy bar that Hershey made for a fraction of a cent. A cost that was invisible compared to everything else. She went to her bosses and they said “sure, but check with the FDA first”. She couldn’t imagine how anyone at the FDA could object, there was no risk of folate overdose, it wouldn’t cost anyone anything, there would be no possible adverse effects. The business people said “that may be all true, but check with the FDA first”. She went to Washington, talked with the FDA and they said “absolutely not.” “It is completely unacceptable to put folate into chocolate bars”. She asked why and they said that there was this rule, that the FDA won’t allow you to put anything that they considered good into something that they considered bad.
#6 PalMD
August 10, 2008

Anon, pipe smoking is not as benign as caffeine. It can lead to very, very nasty head and neck cancers. Very nasty.
#7 Chris
August 11, 2008

Taxing tobacco to cure one addiction leads to another – tax addiction. We already have too much of that in Government now. But it’s certainly time for Government to stop paying farmers to grow the stuff.
#8 revere
August 11, 2008

Chris: You may use the term “addiction” for both but it is just rhetoric. Physiological addiction is one thing. The use of a policy you disagree with is another. I don’t get physiological withdrawal when I am not taxed although I might miss and need the things the taxes would have paid for: health care, police and fire protection, education, a clean environment. I’ll gladly give up our addiction on defense dollars, if you want to talk in those terms.
#9 Chris
August 11, 2008

Yes – my comment was rhetorical. But this article, http://online.wsj.com/article/SB121841215866128319.html?mod=rss_opinion_main, shows what happens when Government taxes tobacco too much. Do you really think that crack, heroin and meth would go away if we just taxed them? People will find a way to get what they crave. Heavy taxes will just drive tobacco underground.

I would agree that defense spending could be reduced – I would not argue for the tack taken by the current administration. In fact, I would have supported reaping the benefits of tax dollars already spent after 9/11. I would have nuked Afghanistan to rubble, then bounced the rubble around for a day or so. I doubt anyone else would have given us trouble after that, saving us a lot of money.
#10 revere
August 11, 2008

Chris: We are doing that with non nuclear weapons now in Afghanistan. And of course Russia is applying overwhelming force in Georgia. Everyone respects them for it, of course. Probably they should have nuked them instead. I also think the Cubans should have nuked Florida because they harbor terrorists. That seems quite reasonable to me. We could also nuke Sudan while we’re at it. You can never get enough respect from the world.

As for taxes driving cigarettes underground, at least there is a way to get at that. We don’t seem to care about that for pot and have the added problem of criminalizing it, which I am not suggesting for tobacco smoking. Let’s just tax pot and decriminalize it. We’d save a lot on prison costs.
#11 daedalus2u
August 11, 2008

Chris, what is the retail price of the drugs of abuse compared to tobacco? If the free market (which is what black markets are) supports a high price for illegal drugs, the illegal premium goes to criminals rather than to taxes or to legal producers, processors, suppliers.

If your objective is to eliminate drug use, making it illegal doesn’t work. The war on drugs has shown that. The only result has been to enrich criminals, foster lots of criminal activity and put lots of users in prison.

The cost to produce an ounce of pot is a few pennies. The difference between the cost of production and the retail price is the gross profit and is the sum of the illegal premium and tax. Since the tax is zero, criminals obtain all of the gross profit, which they use to foster their illegal activities and maintain their illegal business. That includes lobbying to maintain drugs illegal so they retain their illegal monopoly.

A user doesn’t care what fraction of the retail price is tax or is illegal premium. The criminal supplier wants zero tax and as high an illegal premium as possible. Harsh drug use penalties make the illegal premium higher and are a completely effective barrier to entry of all legal entities.

There is a danger that if drugs are legalized and taxed, that the recipient of those taxes will attempt to modify use so as to increase tax revenues. That is already the case with tobacco and alcohol.

Criminals don’t want drugs legalized and taxed because then they lose their illegal premium. Criminals already do act to modify use to increase their illegal premium. They entice people to become addicted, they kill off their competitors, they adulterate their drugs, they use profits from one drug to subsidize another.
#12 Chris
August 11, 2008

Revere – I agree that we should de-criminalize pot. And a lot of other drugs, since it should be none of the Government’s business what you choose to put in your body. Think of it as “a woman’s right to choose” expanded to all adults with respect to their own bodies. Tax them if you wish, but if the tax is too high, it will be avoided. Bottom line – if banning doesn’t work, prohibitive taxes won’t either.

Sorry I brought up the other topic. It is off-topic for this thread.
#13 pauls lane
August 12, 2008

Ahh but Chris the government with the help of all those do-gooders out there (some on these very pages) just love to tell us what to do with our bodies or not to do. Yes a woman has the right to choose to have her unborn child killed, but I must wear a helmet to ride a motorcycle. I must wear a seat belt when driving or riding in a car. Maryland has criminialized carrying two packs of ‘foreign’ cigarettes. Just think of all the criminals Maryland has created in the past couple of months and just what is Maryland going to tax next to make up for the shortfall? NYC has criminialized trans fat! All in the name of looking out for little ol’ me.
#14 revere
August 12, 2008

pauls: Your failure to use a seat belt or a helmet cost me money (taking care of you and paying your insurance claims). Regarding your cigarette claim, do you have a citation for this? I’ve never heard this before. I’m not saying it’s not true, I’d just like to see some documentation that having 2 packs of Gauloises on you is a crime in Maryland.
#15 pauls lane
August 12, 2008

Revere – well if I failed to wear a helmet or seat belt and were killed, you wouldn’t have to worry about taking care of me..I wonder how much it costs you revere, when I’m lying in a bed the rest of my life, totally useless, because a helmet or a seat belt ‘saved’ me. FYI I do wear those things, the fact that not wearing them is a crime is what irks me. Just gives the police another reason to stop you. Sobriety check stops are one thing, but seat-belt check stops?! Please government stop doing me favors!

by ‘foreign’ I meant foreign to Maryland, like Va, or W.Va., or Pa, or Del., or DC. Those states and the District that are a hop, skip, and a jump from Maryland. Read the WSJ article that Chris graciously supplied the link (3rd paragraph) but I wouldn’t be suprised if two packs of Gauloises on my person is a heinous crime in Maryland.