Well: No Consensus on Plantar Fasciitis

Phys Ed

Gretchen Reynolds on the science of fitness.

There are more charismatic-sounding sports injuries than plantar fasciitis, like tennis elbow, runner’s knee and turf toe. But there aren’t many that are more common. The condition, characterized by stabbing pain in the heel or arch, sidelines up to 10 percent of all runners, as well as countless soccer, baseball, football and basketball players, golfers, walkers and others from both the recreational and professional ranks. The Lakers star Kobe Bryant, the quarterback Eli Manning, the Olympic marathon runner Ryan Hall and the presidential candidate Mitt Romney all have been stricken.

But while plantar fasciitis is democratic in its epidemiology, its underlying cause remains surprisingly enigmatic. In fact, the mysteries of plantar fasciitis underscore how little is understood, medically, about overuse sports injuries in general and why, as a result, they remain so insidiously difficult to treat.

Experts do agree that plantar fasciitis is, essentially, an irritation of the plantar fascia, a long, skinny rope of tissue that runs along the bottom of the foot, attaching the heel bone to the toes and forming your foot’s arch. When that tissue becomes irritated, you develop pain deep within the heel. The pain is usually most pronounced first thing in the morning, since the fascia tightens while you sleep.

But scientific agreement about the condition and its causes ends about there.

For many years, “most of us who treat plantar fasciitis believed that it involved chronic inflammation” of the fascia, said Dr. Terrence M. Philbin, a board-certified orthopedic surgeon at the Orthopedic Foot and Ankle Center in Westerville, Ohio, who specializes in plantar fasciitis.

It was thought that by running or otherwise repetitively pounding their heels against the ground, people strained the plantar fascia, and the body responded with a complex cascade of inflammatory biochemical processes that resulted in extra blood and fluids flowing to the injury site, as well as enhanced pain sensitivity.

But instead of lasting only a few days and then fading, as acute inflammation usually does, the process can become chronic and create its own problems, causing tissue damage and continuing pain.

This progression is also what experts believed was happening when people developed chronic Achilles tendon pain, tennis elbow or other lingering, overuse injuries.

But when scientists actually biopsied fascia tissue from people with chronic plantar fasciitis, “they did not find much if any inflammation,” Dr. Philbin said. There were virtually none of the cellular markers that characterize that condition.

“Plantar fasciitis does not involve inflammatory cells,” said Dr. Karim Khan, a professor of family practice medicine at the University of British Columbia and editor of The British Journal of Sports Medicine, who has written extensively about overuse sports injuries.

Instead, plantar fasciitis more likely is caused by degeneration or weakening of the tissue. This process probably begins with small tears that occur during activity and that, in normal circumstances, the body simply repairs, strengthening the tissue as it does. That is the point of exercise training.

But sometimes, for unknown reasons, this ongoing tissue damage overwhelms the body’s capacity to respond. The small tears don’t heal. They accumulate. The tissue begins subtly to degenerate, even to shred. It hurts.

By and large, most sports medicine experts now believe that this is how we develop other overuse injuries, like tennis elbow or Achilles tendinopathy, which used to be called tendinitis. The suffix “itis” means inflammation. But since the injury isn’t thought to involve chronic inflammation, its name has changed.

This has not yet happened with plantar fasciitis, and may not, given what a mouthful fasciopathy would be.

The evolving medical opinions about plantar fasciitis matter, beyond nomenclature, though, because treatments depend on causes. At the moment, many physicians rely on injections of cortisone, a steroid that is both a pain reliever and anti-inflammatory, to treat plantar fasciitis. And cortisone shots do reduce the soreness. In a study published last year in BMJ, patients who received cortisone injections reported less heel pain after four months than those whose shots had contained a placebo saline solution.

But whether those benefits will last is unknown, especially if plantar fasciitis is, indeed, degenerative. In studies with people suffering from tennis elbow, another injury that is now considered degenerative, cortisone shots actually slowed tissue healing.

We need similar studies in people with plantar fasciitis, Dr. Khan said. “They have not been done.”

Thankfully, most people who develop plantar fasciitis will recover within a few months without injections or other invasive treatments, Dr. Philbin said, if they simply back off their running mileage somewhat or otherwise rest the foot and stretch the affected tissues. Stretching the plantar fascia, as well as the Achilles tendon, which also attaches to the heel bone, and the hamstring muscles seems to result in less strain on the fascia during activity, meaning less ongoing trauma and, eventually, time for the body to catch up with repairs.

To ensure that you are stretching correctly, Dr. Philbin suggests consulting a physical therapist, after, of course, visiting a sports medicine doctor for a diagnosis. Not all heel or arch pain is plantar fasciitis. And comfort yourself if you do have the condition with the knowledge that Kobe Bryant, Eli Manning and Ryan Hall have all returned to competition and Mr. Romney still runs.

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Health insurance rate-setting map would raise costs, official says

A proposal to split California into six zones for setting health insurance rates would drive premiums up as much as 23% for some policyholders next year as part of the federal healthcare overhaul, the state insurance commissioner is warning.

These rating boundaries for the individual insurance market are among several items that state lawmakers are debating during a healthcare special session in Sacramento aimed at implementing the federal Affordable Care Act. In January, most Americans will be required to have health coverage or pay a penalty.

Under the proposal for six regions, the lnsurance Department estimates that premiums for similar coverage would increase as much as 22% in Los Angeles and 23% in the Bay Area.

Insurance Commissioner Dave Jones said he's pushing for an 18-region plan that would cap increases at 8%. That and other alternatives are expected to be discussed at state hearings Wednesday.

Overall, many healthcare experts and consumer advocates have expressed concern about the affordability of premiums next year. Rates are expected to rise because the federal law requires improved benefits, and there will be new limits on how much insurers can vary rates based on age.

Now, state leaders are trying to determine what role geography will play in insurance rates. Health insurers currently set their own rating regions, but the federal law allows states to establish their own map.

"There is a lot of interest in doing this quickly," Jones said. "It's important to get it right as well so we can minimize any rate shock."

A spokeswoman for state Sen. Ed Hernandez (D-West Covina), chairman of the Senate Health Committee, said the proposed legislation seeks to keep California in compliance with federal rules that recommend seven rating regions or fewer.

Two industry trade groups, the California Assn. of Health Plans and the Assn. of California Life & Health Insurance Cos., also oppose the six-region plan. Insurers favor a 19-region map that was adopted by state lawmakers last year for the small-employer health insurance market.

Jones has come out against the 19-region plan as well, saying rates could rise as much as 25% under that system.

chad.terhune@latimes.com

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Tucson arrests unleash anger over Arizona immigration law

TUCSON — It's routine for immigration officials in Arizona to detain people suspected of being in the country illegally.

Monday, however, the detention of two men — an immigrant rights activist and a father of six in Tucson — sparked protests, frustrated local authorities and illustrated the difficulties of complying with SB 1070, the state's controversial immigration enforcement law.

"This is unjust," Alma Hernandez yelled in Spanish to a crowd of about 300 that gathered in front of the Tucson Police Department to protest the detentions. Hernandez, a spokeswoman with the civil rights organization Corazón de Tucson, riled up the crowd by introducing immigrant rights activist Raul Alcaraz Ochoa, who had just been released from immigration detention.

"We need to fight for all those who are detained," Alcaraz Ochoa said.

Immigration officials arrested him Sunday after he positioned himself underneath a U.S. Customs and Border Patrol vehicle in an attempt to stop officials from taking away another man, Rene Meza.

The incident began Sunday afternoon after someone called Tucson police expressing concern for the safety of children in a silver Mercury Cougar, Lt. Fabian Pacheco said.

Officers discovered five children in the vehicle, along with Meza and his girlfriend, Perla Lopez. Four of the children were younger than 5 and were not in proper safety restraints as required by law, Pacheco said.

Meza had a Mexican voter registration card but no valid U.S. driver's license, Pacheco said. Police arrested Meza and called immigration officials after federal records revealed he had prior contact with them.

Meza was charged with being in the country illegally after a previous deportation, Customs and Border Protection spokesman Victor Brabble said. Meza is scheduled to go before an immigration judge Tuesday.

Under SB 1070, Arizona law enforcement officials are compelled in most circumstances to check the status of someone they stop for lawful reasons if they suspect the person is in the country illegally.

Pacheco said the officers were simply enforcing the law.

"The department is stuck in the middle," Pacheco said. "Our discretion is gone."

Soon after Tucson police flagged immigration officials, Border Patrol officers drove up.

Alcaraz Ochoa, who was on his way to a community meeting, saw what was happening and approached the officials.

"They took the father, and the children were crying and asking for their father," Alcaraz Ochoa said.

Alcaraz Ochoa, a legal permanent resident and prominent immigrant rights activist best known for participating in a sit-in at Republican Sen. John McCain's office in 2010, said he began to question the officials. Dissatisfied with their answers, he crawled underneath the Border Patrol vehicle.

He said Border Patrol officials pepper-sprayed him, removed him from beneath the vehicle and handcuffed him.

Brabble said Border Patrol agents arrested Alcaraz Ochoa after he failed to respond to repeated warnings and refused to move from beneath the vehicle.

Meza may also face state charges of driving with a suspended license and of not having the children in proper restraints. Lopez, a U.S. citizen, was not detained.

Lopez's mother, Lydia Lopez, said the children weren't restrained properly because the family had just bought the vehicle from a private owner moments earlier and didn't have the safety seats with them. She said the punishment is too extreme.

"It's not justified," Lopez said in Spanish.

cindy.carcamo@latimes.com

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Fergie, Josh Duhamel expecting their 1st child

NEW YORK (AP) — Her hump, her hump, her lovely lady lump: Fergie is pregnant with her first child.

A representative for the Black Eyed Peas singer confirmed the news Monday. Fergie's actor husband Josh Duhamel tweeted about the news with joy, saying: "Fergie and Me and BABY makes three."

The 37-year-old Fergie and 40-year-old Duhamel married in 2009. She joined the Black Eyed Peas when the group released its third album, "Elephunk," in 2003. The foursome is known for its pop-inspired hip-hop tunes like "My Humps," ''I Gotta Feeling" and "Boom Boom Pow."

Fergie launched her solo debut, "The Duchess," to much success in 2006. It featured five Top 5 hits, including "Fergalicious" and "Big Girls Don't Cry."

Duhamel has appeared in the "Transformer" films and most recently in "Safe Haven."

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National Briefing | South: Abortion Curbs Clear Senate in Arkansas

The State Senate voted 25 to 7 on Monday to ban most abortions 20 weeks into a pregnancy. The measure goes back to the House to consider an amendment that added exceptions for rape and incest. The legislation is based on the belief that fetuses can feel pain 20 weeks into a pregnancy, and is similar to bans in several other states. Opponents say it would require mothers to deliver babies with fatal conditions. Gov. Mike Beebe has said he has constitutional concerns about the proposal but has not said whether he will veto it.

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Audit of Fed's gold finds it's safe, more pure than expected

NEW YORK — Turns out the Federal Reserve's gold is secure and a bit more pure than previously thought — or so the government says.

Auditors spent weeks last year in a vault five stories beneath Manhattan counting, weighing and drilling small holes into gold bars owned by the U.S. Treasury.

It was the first time the Treasury's inspector general had audited the department's gold held by the Federal Reserve Bank of New York, which has captured the imagination of Hollywood as well as government skeptics.

The audit's results are in: The New York Fed's operations and controls are up to snuff, and the U.S. gold on deposit is a bit finer than Treasury records had indicated.

Still, the audit probably will not lay to rest questions over whether the New York Fed has secretly lent the gold or otherwise encumbered it in a swap transaction with another government or bank.

"There's no way to prove there's not a secret agreement," said Ted Truman, a former assistant Treasury secretary and top Fed official.

The audit of the Fed gold came after 2012 presidential contender and former Rep. Ron Paul (R-Texas) questioned the central bank's gold holdings.

While he was in Congress, Paul questioned whether the Fed had lent or otherwise encumbered U.S. gold in financial arrangements. At a congressional hearing in 2011, the Treasury Department's inspector general, Eric Thorson, assured Paul that "not one troy ounce is encumbered."

Paul has called for a full, independent audit and assay of the country's gold reserves. But as part of its audit, the Treasury tested a sample — not all — of the government's 34,021 gold bars in the New York Fed's vault.

In three of the 367 tests, the gold was more pure than Treasury records indicated, according to the inspector general. As a result, the government notched up the value of its gold holdings by approximately 27 fine troy ounces — or about $43,500, based on gold's market price Monday.

The assaying process consumed 10 ounces of gold, and the remaining 69 ounces removed for sampling were returned to the Treasury, according to the inspector general's office.

The U.S. gold at the New York Fed has been placed under so-called Official Joint Seals, attesting to the results of the audit.

"At this point, we do plan to conduct this audit annually," the inspector general's office said in emailed responses to questions. "However, since the gold is now under Official Joint Seal, we would not anticipate weighing, counting and assaying unless the seal shows signs of tampering."

The audit also examined internal controls, security and operations at the New York Fed. "Our audit disclosed no material weaknesses and no instances of reportable noncompliance with laws and regulations," the Treasury's audit report said.

The New York Fed holds 99.98% of the U.S.-owned gold bars and coins in the custody of the Federal Reserve. The rest of the gold is on display at Fed banks in cities such as Richmond, Va.; Kansas City, Mo.; and San Francisco.

As of Sept. 30, when the market price of gold was $1,776 an ounce, the Fed banks held $23.9 billion in U.S. gold. (Gold has since declined in value, and on Monday the precious metal was hovering around $1,610 an ounce.) The vast majority — about 95% — of the country's gold reserves is held elsewhere, in Ft. Knox, Ky.; West Point, N.Y.; and Denver.

Truman, the former Treasury and Fed official, was not surprised by the audit's findings.

"I would be flabbergasted if they found some huge discrepancy or even a substantial discrepancy between what they said they had and what they found," Truman said.

Still, the audit won't end conspiracy theories that involve the government's gold held by the Fed, he said.

"I would surprised if anyone's convinced of anything," he said. "They'll conspire now about whether the audit was aboveboard."

andrew.tangel@latimes.com

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Seawater desalination plant might be just a drop in the bucket

CARLSBAD, Calif. — Dreamers have long looked to the Pacific Ocean as the ultimate answer to California's water needs: an inexhaustible, drought-proof reservoir in the state's backyard. In the last decade, proposals for about 20 desalting plants have been discussed up and down the coast.

But even with construction about to begin on the nation's largest seawater desalination facility, 35 miles north of San Diego, experts say it is doubtful that dream will ever be fully realized.

"While this Poseidon adventure may work out, I don't look for a lot of that," said Henry Vaux Jr., a UC Berkeley professor emeritus of resource economics who contributed to a 2008 National Research Council report on desalination.

The reasons boil down to money and energy. It takes a lot of both to turn ocean water into drinking water, driving the average price of desalinated supplies well above most other sources.

The purified water produced by the Poseidon Resources plant will cost the San Diego County Water Authority more than twice what it now pays the Metropolitan Water District of Southern California for supplies from Northern California and the Colorado River. Over the authority's 30-year contract with Poseidon, San Diego County ratepayers will pay between $3 billion and $4 billion for the desalted water, which is expected to provide no more than a tenth of their overall supply.

Seawater desalination is not new to California. There are number of small coastal plants, used mostly for research or industrial purposes, and a few, such as one on Catalina Island, that provide municipal supplies.

For reasons unique to the region, San Diego County will be the first to stick a big straw into the Pacific. It is at the end of the line for imported water, doesn't have much local groundwater and is perennially battling with Metropolitan, Southern California's wholesaler of imported supplies.

"I do believe it is worth it," said Tom Wornham, board chairman of the county water authority. "I would rather be apologizing to people in 10 years for the rate than the fact they would have no water."

Up the coast, other places have taken a pass on the Pacific. Los Angeles and Long Beach recently shelved seawater desalting plans after concluding that other water sources, such as conservation or recycling, are cheaper and easier to pursue.

Poseidon, a small, privately held company based in Stamford, Conn., started talking about developing a desalination plant in Carlsbad in late 1998. The road to construction has been so long and twisting that Global Water Intelligence, which covers the international water industry, last year listed the project among the "Top 10 Desalination Disasters" of all time.

It took years for the company to get the necessary state and local permits. Environmentalists filed multiple legal challenges, the last of which was only recently resolved in Poseidon's favor. A deal with a number of local water agencies in San Diego County fell apart.

In the end, the Poseidon supplies — up to 56,000 acre-feet a year — will sell for roughly $2,000 an acre-foot, more than double the company's 2004 estimate. (One acre-foot is enough to supply two average homes for a year.) The price will rise with inflation; if energy costs go up, so will the price of water.

On the other side of the Pacific, Australia offers a sobering lesson in the perils of diving too deeply into desalination.

When years of withering drought emptied the country's reservoirs, Australia commissioned six big coastal desalting plants, including some of the world's largest. Then the rains returned. Just as some of the operations were coming on line, they were no longer needed.

Four of the six plants are being idled because cheaper water is available. Australian politicians are bemoaning the desalination binge, complaining that it saddled ratepayers with "hyper-expensive" white elephants they have to pay for regardless of whether the plants are used.

"That's certainly the risk — that we build them when they're not necessary or we build them, frankly, too soon," said Heather Cooley of the Pacific Institute, an Oakland think tank.

Santa Barbara had a similar experience in the early 1990s, when it built a desalination plant during a severe statewide drought that ended before the facility was finished. The $34-million plant, with a tenth of the capacity of the Carlsbad facility, was never used beyond the testing phase, though it could still be brought into service in an emergency.

The $954-million Carlsbad project is being financed with $781 million in tax-exempt construction bonds sold by Poseidon and the water authority. The balance is coming from investors who anticipate a return of about 13%. IDE Americas Inc., the subsidiary of an Israeli firm that runs some of the world's largest coastal desalination facilities in the Middle East, has been hired to design and operate the plant, slated for completion in 2016.

The fresh water will be produced through reverse osmosis, an energy-intensive process that separates salts and contaminants from seawater by forcing it through sand filters and tightly coiled, synthetic membranes peppered with billions of tiny holes a fraction of the width of a human hair. The water will then be pumped inland for distribution — the opposite direction that drinking supplies are usually moved — requiring construction of a 10-mile underground pipeline that the water authority will own and operate.

Poseidon chose the Carlsbad location, next to the Encina Power Station, so it could draw from the power plant's cooling water discharge — thus avoiding the environmental harm of operating its own ocean intake.

But new federal and state environmental regulations are pushing coastal power plants to phase out the use of huge volumes of ocean water for cooling, thwarting that strategy. Poseidon expects the Encina station to be replaced within the decade with a new generating facility employing a different cooling system.

That will mean the desalter will have to pump directly from the ocean, sucking 300 million gallons a day. Of that, 100 million gallons will go through the reverse osmosis process, with half converted to fresh water and half to a concentrated brine. The brine, twice as salty as the sea, will be diluted in a mixing pool with the other 200 million gallons of intake and discharged to the ocean.

Destruction of marine life is a major environmental concern of ocean desalination. Raw seawater is full of tiny organisms, including plankton that form a critical part of the food chain and the young stages of fish and invertebrates. When the water they live in is pumped into a plant, they die.

The Coastal Commission is requiring Poseidon to restore 55 acres of marine wetlands in south San Diego Bay to compensate for the plant's projected effects. The State Water Resources Control Board is also developing new seawater desalination regulations that could force Poseidon to change its intake and discharge systems.

"They took a big risk in building this before the rules are finalized," said Joe Geever of the Surfrider Foundation, which tenaciously fought the Carlsbad proposal in court and argues that water agencies should turn to the ocean only as a last resort — after more environmentally benign sources such as recycling and storm-water capture have been aggressively pursued.

Poseidon, which is trying to line up customers for a similar-size desal plant proposed in Huntington Beach, says it is peddling more than water. "What we're selling is ... a reliability premium that's locally controlled, drought-proof," said Carlos Riva, the company's chief executive.

But even Poseidon doesn't predict that the Pacific will become California's dominant water supply. The state has too many other sources.

"We have quite a bit of water to move around," said Peter MacLaggan, the Poseidon executive who is overseeing the Carlsbad project. "I don't think it's ever going to be a majority of supply or anywhere close to that."

bettina.boxall@latimes.com

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Singer Mindy McCready dies in apparent suicide

HEBER SPRINGS, Ark. (AP) — Mindy McCready, who hit the top of the country charts before personal problems sidetracked her career, died Sunday in Arkansas in an apparent suicide. She was 37.

The Cleburne County Sheriff's Office said in a news release that McCready was found dead at a residence in Heber Springs from what appears to be a single, self-inflicted gunshot to the head. An autopsy is pending.

It wasn't the first suicide attempt for the troubled singer, whose list of problems only continued to grow in 2013.

McCready entered court-ordered rehab earlier this month after her father told a judge she was no longer taking care of herself or her children and was abusing drugs and alcohol. Her sons were put in foster care at the time, but it's not clear where Zander and Zayne were at the time of McCready's death.

McCready's longtime boyfriend David Wilson, the father of her younger son, died last month in Arkansas. Authorities found his body on the same porch where they discovered McCready's on Sunday, and his death also was investigated as a suicide.

The front porch light remained on Sunday night at McCready's home in the wooded lakefront community filled with large homes. Yellow crime-scene tape blocked off the front of the house, and a deputy sat watch over the property, referring questions to the sheriff. A pickup truck remained in the driveway.

Wilson's passing struck McCready hard. She issued a statement last month lamenting his death. She called him her soul mate and a caregiver to her sons in an interview with NBC's "Today." She said she'd never gone through anything as painful as his death.

"I just keep telling myself that the more suffering that I go through, the greater character I'll have," she said, according to a transcript of the interview.

News of McCready's death spread quickly Sunday night on Twitter, with major country stars paying their respects to the onetime Nashville darling.

"Too much tragedy to overcome. R.I.P Mindy McCready," wrote Natalie Maines of The Dixie Chicks.

And Jason Aldean added: "Just heard about Mindy McCready. My thoughts and prayers are with her 2 boys and her family."

Melinda Gayle McCready arrived in Nashville in 1994 still in her teens with tapes of her karaoke vocals and earned a recording contract with BNA Records.

In 1996, her "Guys Do It All the Time" hit No. 1 and its dig at male chauvinism endeared her to females. Her other hits included "Ten Thousand Angels," also in 1996, and her album by that title sold 2 million copies.

She spent the next 15 years chasing another hit as personal problems began plaguing her. Her problems included a custody battle with her mother over one of her sons, an overdose and discord in her love life.

McCready took her older son, Zander, from her mother and the boy's legal guardian, Gayle Inge, in late 2011. She fled to Arkansas without permission over what she called child abuse fears. Authorities eventually found McCready hiding in a residence without permission and took the boy into custody.

She and Wilson had a son, Zayne, in April 2012. The older son's father is McCready's former boyfriend Billy McKnight.

In May 2010, she was hospitalized briefly after police responded to an overdose call at a home in North Fort Myers, Fla., owned by her mother. This followed a stint on "Celebrity Rehab With Dr. Drew," where she declared herself to be clean from drugs. She is the fifth celebrity appearing on that show to have died.

But her troubles began earlier. In 2004, she was charged with obtaining the painkiller OxyContin fraudulently at a pharmacy. She pleaded guilty and was placed on three years' probation.

She violated the probation with a drunken driving arrest in May 2005. A few days after that arrest, she was beaten and her boyfriend at the time was charged with attempted criminal homicide. Then she attempted suicide in July 2005, overdosed in September 2005 and slit her wrists in December 2008.

Also that year, McCready was charged in Arizona with hindering prosecution and unlawful use of transportation. Those charges stemmed from an alleged attempt in June 2005 to purchase two high performance boats, but she claimed she was trying to stop a con man.

In July 2007, she was arrested in her hometown of Fort Myers, Fla., on misdemeanor charges of scratching her mother on the face during a scuffle and resisting sheriff's deputies.

She made headlines again in April 2008 when she claimed a longtime relationship with baseball great Roger Clemens. Published reports at the time said she met the pitcher at a Florida karaoke bar when she was 15 and he was 28 and married.

In June 2008, McCready was arrested and charged with violating her probation by falsifying her community service records relating to the 2004 drug charge. A month later, she entered an extended care facility for undisclosed treatment, and followed that with a 60-day jail sentence in the Williamson County jail.

McCready found some peace after her appearance on "Celebrity Rehab" and told The Associated Press in early 2010 she hoped to get her career restarted, write a book about her experiences and begin production on a reality show. She felt she'd finally gained some control over her life.

"It is a giant whirlwind of chaos all the time," she said. "I call my life a beautiful mess and organized chaos. It's just always been like that. My entire life things have been attracted to me and vice versa that turn into chaotic nightmares or I create the chaos myself. I think that's really the life of a celebrity, of a big, huge, giant personality."

___

Talbott reported from Nashville, Tenn. Associated Press writer Tamara Lush contributed to this report from Tampa, Fla.

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Well: Health Effects of Smoking for Women

The title of a recent report on smoking and health might well have paraphrased the popular ad campaign for Virginia Slims, introduced in 1968 by Philip Morris and aimed at young professional women: “You’ve come a long way, baby.”

Today that slogan should include: “…toward a shorter life.” Ten years shorter, in fact.

The new report is one of two rather shocking analyses of the hazards of smoking and the benefits of quitting published last month in The New England Journal of Medicine. The data show that “women who smoke like men die like men who smoke,” Dr. Steven A. Schroeder, a professor of health and health care at the University of California, San Francisco, wrote in an accompanying editorial.

That was not always the case. Half a century ago, the risk of death from lung cancer among men who smoked was five times higher than that among women smokers. But by the first decade of this century, that risk had equalized: for both men and women who smoked, the risk of death from lung cancer was 25 times greater than for nonsmokers, Dr. Michael J. Thun of the American Cancer Society and his colleagues reported.

Today, women who smoke are even more likely than men who smoke to die of lung cancer. According to a second study in the same journal, women smokers face a 17.8 times greater risk of dying of lung cancer than women who do not smoke; men who smoke are at 14.6 times greater risk to die of lung cancer than men who don’t. Women who smoke now face a risk of death from lung cancer that is 50 percent higher than the estimates reported in the 1980s, according to Dr. Prabhat Jha of the Center for Global Health Research in Toronto and his colleagues.

After controlling for age, body weight, education level and alcohol use, the new analysis found something else: men and women who continue to smoke die on average 10 years sooner than those who never smoked.

Dramatic progress has been made in reducing the prevalence of smoking, which has fallen from 42 percent of adults in 1965 (the year after the first surgeon general’s report on smoking and health) to 19 percent in 2010. Yet smoking still results in nearly 200,000 deaths a year among people 35 to 69 years old in the United States. A quarter of all deaths in this age group would not occur if smokers had the same risk of death as nonsmokers.

The risks are even greater among men 55 to 74 and women 60 to 74. More than two-thirds of all deaths among current smokers in these age groups are related to smoking. Over all, the death rate from all causes combined in these age groups “is now at least three times as high among current smokers as among those who have never smoked,” Dr. Thun’s team found.

While lung cancer is the most infamous hazard linked to smoking, the habit also raises the risk of death from heart disease, stroke, pulmonary disease and other cancers, including breast cancer.

Furthermore, changes in how cigarettes are manufactured may have increased the dangers of smoking. The use of perforated filters, tobacco blends that are less irritating, and paper that is more porous made it easier to inhale smoke and encouraged deeper inhalation to achieve satisfying blood levels of nicotine.

The result of deeper inhalation, Dr. Thun’s report suggests, has been an increased risk of chronic obstructive pulmonary disease, or C.O.P.D., and a shift in the kind of lung cancer linked to smoking. Among nonsmokers, the risk of death from C.O.P.D. has declined by 45 percent in men and has remained stable in women, but the death rate has more than doubled among smokers.

But there is good news, too: it’s never too late to reap the benefits of quitting. The younger you are when you stop smoking, the greater your chances of living a long and healthy life, according to the findings of Dr. Jha’s international team.

The team analyzed smoking and smoking-cessation histories of 113,752 women and 88,496 men 25 and older and linked them to causes of deaths in these groups through 2006.

Those who quit smoking by age 34 lived 10 years longer on average than those who continued to smoke, giving them a life expectancy comparable to people who never smoked. Smokers who quit between ages 35 and 44 lived nine years longer, and those who quit between 45 and 54 lived six years longer. Even quitting smoking between ages 55 and 64 resulted in a four-year gain in life expectancy.

The researchers emphasized, however, that the numbers do not mean it is safe to smoke until age 40 and then stop. Former smokers who quit by 40 still experienced a 20 percent greater risk of death than nonsmokers. About one in six former smokers who died before the age of 80 would not have died if he or she had never smoked, they reported.

Dr. Schroeder believes we can do a lot better to reduce the prevalence of smoking with the tools currently in hand if government agencies, medical insurers and the public cooperate.

Unlike the races, ribbons and fund-raisers for breast cancer, “there’s no public face for lung cancer, even though it kills more women than breast cancer does,” Dr. Schroeder said in an interview. Lung cancer is stigmatized as a disease people bring on themselves, even though many older victims were hooked on nicotine in the 1940s and 1950s, when little was known about the hazards of smoking and doctors appeared in ads assuring the public it was safe to smoke.

Raising taxes on cigarettes can help. The states with the highest prevalence of smoking have the lowest tax rates on cigarettes, Dr. Schroeder said. Also helpful would be prohibiting smoking in more public places like parks and beaches. Some states have criminalized smoking in cars when children are present.

More “countermarketing” of cigarettes is needed, he said, including antismoking public service ads on television and dramatic health warnings on cigarette packs, as is now done in Australia. But two American courts have ruled that the proposed label warnings infringed on the tobacco industry’s right to free speech.

Health insurers, both private and government, could broaden their coverage of stop-smoking aids and better publicize telephone quit lines, and doctors “should do more to stimulate quit attempts,” Dr. Schroeder said.

As Nicola Roxon, a former Australian health minister, put it, “We are killing people by not acting.”

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American Airlines, US Airways merger to alter business travel

In the wake of the deal to merge American Airlines and US Airways, many business travelers are asking themselves the same question: What does this mean for me?

Change is the only certain answer.

And change, according to some airline experts, is not good for business travelers who have grown accustomed to their regular airline routes, connecting hubs and frequent flier programs.

"What I can see is 900 pitfalls," said Joe Brancatelli, a business travel expert who writes a regular online column on the subject. "I don't see an upside."

The $11-billion deal announced last week would create the world's largest airline, employing more than 100,000 workers and serving about 187 million passengers a year.

In announcing the merger, US Airways Chief Executive Doug Parker said the new airline would probably maintain all of the hubs and destinations of the two carriers.

But Brancatelli is doubtful.

"When an airline tells you they are keeping everything, that is a lie," he said.

Although the two airlines have very few routes that overlap, Brancatelli said American and US Airways have several connecting hubs in the same region, some of which would have to be eliminated.

For example, he noted that US Airways operates a major hub in Phoenix, while American operates a connecting hub in Dallas. Brancatelli said he suspects the merged airline will cut flights to Phoenix, making Dallas the primary hub for the region.

"These guys didn't merge to make our lives better," he said. "They merged for their own purposes."

Still, executives from American and US Airways stress that the merger would primarily benefit frequent business travelers because, under the combined resources of the new carrier, they would be able to choose from 6,700 daily flights to 336 destinations in 56 countries.

Travelers who have acquired frequent flier miles with either airline can carry them over and redeem them on the new, larger carrier, they promise.

"There are only upsides," said Thomas Horton, chief executive for AMR Corp., the parent company of American Airlines.

American Airlines' loyalty rewards program, AAdvantage, is the nation's largest and has been ranked by several publications and analysts as one of the best.

AAdvantage is a three-tier system that rewards travelers for accumulating miles with such perks as seat upgrades, free checked bags and early boarding. Each tier represents a higher status level, such as AAdvantage Gold, AAdvantage Platinum and AAdvantage Executive Platinum.

Most other airline loyalty programs, including US Airways' Dividend Miles program, have four tiers and require passengers to accumulate more miles to reach elite status, according to travel experts.

But how American Airlines' AAdvantage and US Airways' Dividend Miles programs will be merged has not been decided.

"At some point we will have to look at that," said John McDonald, a spokesman for US Airways. "What I can say is that we are going to do what is right."

Alicia Jao, vice president of Travelnerd, a website that analyzes travel deals, said she suspects the rewards program for the newly merged airline would shift to a four-tier system to match the rewards programs at other airlines.

The change may upset American's frequent fliers, she said, but they would probably understand that change was inevitable.

hugo.martin@latimes.com

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