Suicide Rates Linked to Cigarettes, Smoking Policies

Cigarette smokers are more likely to commit suicide than people who don’t smoke, studies have shown. This reality has been attributed to the fact that people with psychiatric disorders, who have higher suicide rates, also tend to smoke. But new research at Washington University School of Medicine in St. Louis finds that smoking itself may increase suicide risk and that policies to limit smoking reduce suicide rates.

washington university school of medicine in st. louis

In a study published online in the journal Nicotine & Tobacco Research, a team led by Richard A. Grucza, PhD, reports that suicide rates declined up to 15 percent, relative to the national average, in states that implemented higher taxes on cigarettes and stricter policies to limit smoking in public places.

“Our analysis showed that each dollar increase in cigarette taxes was associated with a 10 percent decrease in suicide risk,” said Grucza, associate professor of psychiatry. “Indoor smoking bans also were associated with risk reductions.”

Grucza’s team analyzed data compiled as individual states took different approaches to taxing cigarettes and limiting when and where people could smoke. From 1990 to 2004, states that adopted aggressive tobacco-control policies saw their suicide rates decrease, compared with the national average.

The opposite was true in states with lower cigarette taxes and more lax policies toward smoking in public. In those states, suicide rates increased up to 6 percent, relative to the national average, during the same time period. From 1990 to 2004, the average annual suicide rate was about 14 deaths for every 100,000 people.

“States started raising their cigarette taxes, first as a way to raise revenue but then also as a way to improve public health,” Grucza explained. “Higher taxes and more restrictive smoking policies are well-known ways of getting people to smoke less. So it set a natural experiment, which shows that the states with more aggressive policies also had lower rates of smoking. The next thing we wanted to learn was whether those states experienced any changes in suicide rates, relative to the states that didn’t implement these policies as aggressively.”

Suicide is the 10th leading cause of death in the United States, according to the Centers for Disease Control and Prevention. In 2010, nearly 40,000 people died of suicide across the nation.

Every death that occurs in the United States is recorded in a database managed by the National Center for Health Statistics. Grucza’s team classified each suicide death based on the state where the victim had lived, as well as how aggressive that state’s tobacco policies were.

Using statistical methods, the researchers compared rates of suicide in states with stricter tobacco policies to rates in states with more lenient laws and lower taxes. They also determined whether people who had committed suicide were likely to have smoked. They learned that suicide risk among people most likely to smoke was associated with policies related to tobacco taxes and smoking restrictions.

“If you’re not a smoker, or not likely ever to become a smoker, then your suicide risk shouldn’t be influenced by tobacco policies,” Grucza said. “So the fact that we saw this influence among people who likely were smokers provides additional support for our idea that smoking itself is linked to suicide, rather than some other factor related to policy.”

Although scientists have known for years that people who smoke have a higher risk for suicide, they had assumed the risk was related to the psychiatric disorders that affect many smokers. These new findings, however, suggest smoking may increase the risk for psychiatric disorders, or make them more severe, which, in turn, can influence suicide risk.

“We really need to look more closely at the effects of smoking and nicotine, not only on physical health but on mental health, too,” Grucza said. “We don’t know exactly how smoking influences suicide risk. It could be that it affects depression or increases addiction to other substances. We don’t know how smoking exerts these effects, but the numbers show it clearly does something.”

He explained that many states still have low cigarette taxes, while other states haven’t adopted comprehensive smoke-free air policies. Grucza predicts that if these states raise their cigarette taxes and restrict smoking in public, their suicide rates likely would fall.

Grucza suspects nicotine may be an important influence on suicide risk. Based on the study’s results, he said he is concerned that many new restrictions on public smoking don’t cover newer e-cigarettes, which deliver nicotine but release vapor rather than smoke. This mechanism purportedly allows those addicted to nicotine to get a “fix” without affecting the air others breathe.

“Nicotine is a plausible candidate for explaining the link between smoking and suicide risk,” Grucza said. “Like any other addicting drug, people start using nicotine to feel good, but eventually they need it to feel normal. And as with other drugs, that chronic use can contribute to depression or anxiety, and that could help to explain the link to suicide.”

Survival Benefit Appears to Show Increases With Diuretic Dosage

PHILADELPHIA — Researchers from the Perelman School of Medicine at the University of Pennsylvania found that patients taking prescription potassium supplements together with loop diuretics for heart failure have better survival rates than patients taking diuretics without the potassium. Moreover, the degree of benefit increases with higher diuretic doses. The team, including senior author Sean Hennessy, PharmD, PhD, associate professor of epidemiology in Penn’s Center for Clinical Epidemiology and Biostatistics (CCEB), report their findings in a study published recently online in PLOS ONE.

Perelman School of Medicine

Loop diuretics—one type of diuretic or “water pill” named after the part of the kidney it acts on—are commonly used in the treatment of heart failure (and associated lower-limb edema or swelling) to help push out extra fluid that can accumulate when the heart is not working properly. But they also flush out needed potassium, causing many doctors, but not all, to prescribe the supplements. However, its survival benefit has never been studied, and because of this lack of evidence, there is controversy about whether potassium should be prescribed to all patients receiving loop diuretics.

In a retrospective study, the researchers examined existing health care data from Medicaid between 1999 and 2007 to study approximately 180,000 new starters of loop diuretics who were prescribed supplemental potassium and an equal number of people who started a loop diuretic without the potassium supplement. The researchers found that in patients receiving at least 40 mg/day of furosemide (one form of loop diuretic), adding supplemental potassium appeared to reduce mortality by 16 percent, a large and statistically significant reduction.

“Our findings provide evidence that adding potassium supplementation may increase survival rates among patients taking loop diuretics,” said the study’s lead author, Charles E. Leonard, PharmD, MSCE, a senior research investigator in the CCEB and senior manager of the Ambulatory Drug Use & Effects Program at Penn. “Nonetheless, because this is the first such study of this question, we hope that others confirm these results in independent studies.”

They also found that in patients receiving less than 40 mg/day of furosemide, potassium appeared to reduce the mortality rate by seven percent, a suggestive but statistically non-significant finding. (The overall mortality rate was about nine percent per year in the population under examination.)

The use of potassium supplementation under investigation was preventive, as opposed to being prescribed to patients who already had measured reductions in potassium. Only patients receiving supplemental potassium in solid, not liquid form, were studied, the latter possibly being indicative of an inability to swallow and therefore a marker for a possibly complicating corollary medical impairment.

Loop diuretics act at the ascending loop of Henle in the kidney and help the body push out extra fluid that could accumulate in the lungs or legs and ankles when the heart is unable to completely pump blood throughout the body. But they may also cause the body to eliminate excessive amounts of potassium, which might be expected to increase mortality from heart arrhythmias. As a precaution therefore, many doctors prescribe potassium supplements to their patients receiving loop diuretics.

These results appear to support the common (but not universal) practice of using potassium together with loop diuretics. Today, nearly 5.8 million Americans suffer from heart failure.

“Using potassium supplementation for patients receiving loop diuretic therapy may be a relatively inexpensive way to save lives,” said Hennessy. “In today’s climate of seeking cost-effective measures to keep patients healthy, this is a therapy that certainly merits additional consideration.”

- MFP News Services
- 9/10/14

Treating Afib Can Be a Community Effort

BARCELONA – An international survey of cardiologist physicians indicates that it takes a village to successfully treat and manage patients with atrial fibrillation, but those villages are few and far between, researchers are reporting.

“About 84% of cardiologists believe that coordinated care among healthcare professionals is important,” said Hugh Calkins, MD, immediate past president of the Heart Rhythm Society and professor of medicine at Johns Hopkins University. “But only 33% believe that coordinated care is currently adequate in their respective countries.”

John Hopkins University

The need for care coordination was supported most by cardiologists in France, with 89% agreement that it is necessary; Brazilian doctors were least likely to agree, at 75%. U.S. doctors included in the survey supported the concept at an 86% rate.

But in most countries, effective care coordination is not seen as readily available.

About 60% of the doctors in France said there were adequate professionals outside the hospital setting to help coordinate care. Among physicians in other countries, however, only about 30% to 40% said coordinated outpatient care was feasible.

The U.S. came in at the low end, with about 27% of the surveyed cardiologists indicating there were adequate settings for coordinated care in their country.

Calkins reported the results of the survey, conducted by the Harris polling organization, in a press briefing conducted during the annual meeting of the European Society of Cardiology. The survey was sponsored by Daiichi Sankyo and was conducted in a partnership with the Heart Rhythm Society.

Participants included 1,100 cardiologists overall. Countries represented were the U.S. (160), Japan (161), U.K. (157), Germany (156), France (159), Brazil (153), and Spain (154).

“The survey was designed to better understand the perspective of cardiologists regarding patients with nonvalvular atrial fibrillation and complexities surrounding the management of the disease including the diversity of the nonvalvular atrial fibrillation population, the physicians’ perception of unmet needs, and the scientific challenges that can impact how nonvalvular atrial fibrillation is managed,” said John Camm, MD, professor of clinical cardiology at St. George’s University, London.

Among the other key findings of the survey, Calkins said that nearly all cardiologists — about 98% — believe atrial fibrillation patients may experience a delay in diagnosis, primarily because they are asymptomatic, but also due to low awareness among healthcare professionals and the general public.

“The majority of cardiologists agree that there is an opportunity for caregivers to play a more prominent role in helping patients manage nonvalvular atrial fibrillation,” Calkins said. About three-quarters of the cardiologists suggested that caregivers are able to help patients better manage their condition, although only about half believed that their atrial fibrillation patients have a caregiver.

The doctors surveyed said that caregivers can help patients to stay on their medication. About 43% of the cardiologists overall indicated that this function is the most important support a caregiver can provide.

About 84% of cardiologists also saw an important caregiver role in helping patients communicate with all their healthcare providers.

- MFP News Services
- 9/8/14