Archive for the ‘Uncategorized’ Category

Stem Cell Gamble?

July 7, 2009

The Obama administration issued new NIH guidelines for Human Stem Cell research after scientists had complained about restrictive and extensive consenting proposed for fertilized egg donation.  The head of the NIH, Dr. Raynard Kington, said researchers would be able to use federal funds for some stem cell lines that were previously banned under Bush administration rules.

Many scientific groups welcomed the new rules as a step in the right direction, away from politically-driven policy and toward science-based policy.  The rules permit federally funded research on surplus fertilized eggs from in vitro fertilization clinics, embryos that would have been destroyed.

But some complain the new rules still fall short of “decisions based on facts, not ideology” as President Obama promised on March 9, 2009.

Continuing a ban on embryonic stem cell lines derived from other proven techniques “is a terrible disappointment,” says Stanford University School of Medicine stem cell researcher Dr. Irving Weissman.  He says transferring genetic material from a patient to egg, through somatic cell nuclear transfer (SCNT) has shown promise in many animals including primates, and the failure to include those cell lines for future research restricts important work.

Some who oppose human embryonic stem cell research say advances in adult stem cell research make ethical problems obsolete.  Not so fast, say Weissman and others.  So-called induced pluripotent stem (iPS) cells have caused cancer in lab animals, when genes used to reprogram the cells continue to be active.

The International Society for Stem Cell Research is urging the NIH to allow federal funding for both iPS and SCNT-derived human embryonic stem cells.  The California Institute for Regenerative Medicine says it is also working with the NIH to include broader sources of stem cells, consistent with ethical and professional standards.

“The NIH is gambling,” says Weissman, that adult stem cells and IVF-derived stem cells will be enough.  He says discouraging ethical scientific research on human stem cell sources continues a policy dictated by polls not by science.

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The Flu to Come

July 5, 2009

“For the moment, H1N1 (influenza) is causing the same kind of disease as the regular seasonal flu,” says UC Berkeley School of Public Health professor of epidemiology Dr. Arthur Reingold.  Reingold is a wiry and wry researcher who also advises the World Health Organization on vaccine policy.  We spoke in his living room only hours after he returned from the Cote d’Ivoire.  He also studies AIDS prevention in Africa and Latin America and teaches at UC San Francisco Medical School.

I had asked his opinion on two new studies published in Science on the H1N1 swine flu virus that continued to cause cases and even deaths during the summer.  “True, it’s not the usual flu season in North America, but this is not a usual virus.  It’s new, and there is very little natural immunity to it,” Reingold explained, squinting for effect behind wire-rimmed glasses.  He added there is some evidence of partial immunity among adults older than about 57, presumably who’d been exposed to a similar virus decades ago.

The new studies in Science, one from the US Centers for Disease Control and Prevention, one from the Netherlands, offered details about the molecular structure of the new virus.  In research on ferrets, whose lungs are infected with influenza very much like human lungs, the studies suggest H1N1 may penetrate deeper into lungs and bind more strongly with lung cells than with nose cells “potentially with more severe clinical consequences,” said Dutch researcher Ron Fouchier.  Both studies found the ferrets became sicker with H1N1, and the infections penetrated the gastrointestinal tract.

However, the two studies differed on how infectious the virus may be.  CDC researchers used virus samples from California, Texas and Mexico, where it was first identified, and found the new virus was not as transmissible as ordinary seasonal flu.  The Dutch researchers said their sample, from a patient in Rotterdam, was just as infectious as regular flu.

The new virus, technically called 2009 A(H1N1), may have already mutated in Europe to a slightly more infectious form.  This diabolical evolutionary trick of influenza viruses is called resortment, an ability to recombine genes.  It is why epidemiologists including Reingold are wary of H1N1.  No one knows what it’s going to become.

It is flu season now in the Southern Hemisphere, where cooler temperatures favor the survival of influenza viruses outside the body.  H1N1 resortment is almost certainly going on right now in the bodies of people infected with multiple influenza strains.  This combining genes of various viruses happens randomly, until a particularly strong variant emerges and stabilizes.

“It is worth paying attention to what’s going on in the rest of the world,” says Reingold.  He says whatever virus variant becomes dominant, is the one we’ll have to deal with in the Northern Hemisphere in a few months.

How about a vaccine?  115 million doses of seasonal flu vaccine are normally distributed each year in the US.  A swine flu vaccine would be in addition to that one.  A new swine flu vaccine is now ready for clinical trials, and if all goes well, could be available by November.  But Reingold is cautious.  “It may take two doses per person,” that’s 600 million doses to cover everyone in the United States, he says, and it’s unlikely there will be more than 60 million available.  Some countries, such as Switzerland, likely will have enough for their entire populations.

The good news is not everyone will have to be vaccinated to stop the spread of the virus.  “Herd immunity” is the idea that transmission can be stopped if even a fraction of a population is immunized.  How many people will need to be vaccinated, will depend on how infectious H1N1 becomes.  Even if it is no more infectious than regular seasonal flu, Reingold predicts “we still won’t have nearly enough vaccine this Fall.”

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What Price Satisfaction?

July 1, 2009

“Insane,” she said, her blue eyes reddened with tears, “I can’t believe what I did.”

She’s a trim, blonde 54-year old woman with three children and a heavy burden of dissatisfaction with her looks.  I told her I think she looks a lot like Meg Ryan, with her bangs and pigtail bobbing.  She would, except for the gnarled, puffed and reddened lips and a bright scar across her left cheek.  She had mutilated herself in an attempt at inexpensive beauty.

We agree to call her Mary.  She makes a living in public and wants anonymity.  She confessed she’s always had “issues with self-image” and that’s what drove her to a plastic surgeon a few months ago.  That turned out well, she said, but “It cost over a thousand dollars, and I couldn’t justify the expense of more injections of silicone.  So I went to the internet and bought a bottle of silicone for ten dollars and injected it into myself.”  It was contaminated.

It is difficult to look at the picture of her face taken four days later.  “People thought I was the victim of domestic violence,” she said, adding “I assured them I was not, but it’s embarrassing to talk about.  It’s my worst nightmare.”

She is in the comfortable office of TriValley Plastic Surgery in Dublin, California.  Dr. Steven Williams, an athletic-looking Yale Medical School graduate and new father of a baby boy, gently probed his gloved index finger around Mary’s inflamed face.  “You may need several corrective surgeries, we’ll do the best we can.”   His voice seemed to reassure a very nervous patient.  “Will this scar?” she asked pointing to her gashed cheek.  “We can make the scar very small but you might notice some scarring.”  She attempted a smile.

“We have a practice that’s becoming known for repairing such problems.  We’ve noticed an uptick in people trying to do things like this at home and having problems and having to come in and see us,” says Williams.  He says he thinks it may be the economy and the notion, encouraged by advertising, that plastic surgery is somehow “foolproof.”

In the operating room in his office suite, a monitor beeped tracking Mary’s heart rate as it hovered around 90.  She’s awake with local anesthetic as Dr. Williams moves quickly around her head and neck with blue cloth drapes.  “We don’t know exactly what this material is, but it is actively causing serious problems for her,” Williams selects a small scalpel.  “It’s not something you can just draw out,” he explains, “You actually have to go in surgically and cut it out.”  He repeatedly asks Mary if she feels any pain, she answers no, but under the surgical drapes her feet wag in some discomfort.

“She’ll have some residual scarring, we simply can’t avoid that,” says Williams.  Mary may have more profound scars that will not be visible.  “It’s taken this to realize I should have been satisfied with what I had,” she says and takes a deep breath.

An hour and a half later, Mary left the office and headed home.  She looked at me, seemingly pleading for understanding, “I hope speaking out might help someone avoid doing what I have done.”

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Call it Camp Wonder

June 25, 2009

14 year old Brandi Coil tipped her sunglasses back on her dark brown hair.  She sat in the shade as whoops of excitement erupted from the grassy field nearby.  Her arms and legs were covered by bandages but she smiled broadly and talked excitedly.  “You’re just not paying attention to your wounds and stuff and how sore you are.  You’re just having a great time, you just forget about it, everybody does.”

Brandi has Recessive Dystrophic Epidermolysis Bullosa, known as EB, a rare and severe skin disorder that curls her hands and feet, and causes severe, painful blistering of the skin.  She has to keep her skin covered she says, “to keep flies off it, and protect my open sores.” 

We are relaxing at Camp Wonder near Livermore, California, where on this day 21 of the 80 campers have EB, and all have some kind of severe skin disorder.  Camp Wonder is run by the non-profit Children’s Skin Disease Foundation, which has provided air fare, accommodations and activities for campers from around the United States.  “When we’re in public, people just stare, all you get are stares,” said Brandi, “and it”s really uncomfortable.  Here you don’t get stares.”

16-year old Joseph Pedsmer of Long Island, New York, his voice raspy from cheering on his relay team, said “It’s that we share that common bond that makes us work so well together.”  Joseph’s throat, chin and bare arms are red and scarred from a severe form of eczema.  “This is just one week of fifty-two in the year,” Joseph said, “that these kids get to live away from stares and judgement.”

The nine-year old camp was the brainchild of then-16 year old Francesca Tenconi, of Walnut Creek, California.  She had a painful and disfiguring skin disorder called Pemphigus Foliaceous, and spoke to Drs. Jenny Kim and Stefani Takahashi of UCLA Medical School about her idea.  “It’s a great way to get everyone together for a week and give these kids a sense of normalcy,” said Tenconi, who’s now about to enter medical school herself to pursue a career as a pediatric dermatologist.  Her disease was successfully treated and she now is free of the physical scarring, but the emotional pain stayed with her.  “It’s not something even many doctors understand.”

Spending a week with the campers, swimming, playing ball, riding horseback, rope climbing and hiking, as well as taking care of their medical needs, is an instructive introduction to dermatology for medical student 29 year old Bridgit Hartman, a camp volunteer.  “I think it’s easy to forget how much many of these kids are dealing with emotionally, every single day,” said Hartman who also acknowledged, “This has been a hard week.”

“This makes us better doctors, nurses and people, really,” said 45-year old dermatologist Jenny Kim, who’s been here every day of every camp session since the beginning.  “These young people are so strong, so happy and so beautiful in their ways,” said Kim as she led me into the camp’s “Med Shed” to meet 6 year old Zach Troop.  Zach and his mother, Kadee, are from Bountiful, Utah.  It is Zach’s first camp. 

“It’s great!” Zach grinned as his mother wrapped a bandage on open wounds on his left foot.  Zach also has EB.  Bandages fleck his shoulders and knees as well.  His wounds will likely spread and damage more and more of his skin.  There is no cure.  But there is Camp Wonder.

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Study: Uninsured Not A “Crisis”

June 24, 2009

Conservative economist June O’Neill of  City University of New York and the Employment Policies Institute (EPI) says there’s no “crisis” of the uninsured in the United States.  She says the widely used estimate of 47 million uninsured Americans is misleading.  In a new study, she and co-author David O’Neill also of CUNY, say 18 million uninsured Americans aged 18-64 are actually “voluntarily uninsured,”  and could afford to buy healthcare if they chose.

They also say policy proposals dramatically overestimate the cost of providing affordable health insurance, because policymakers don’t understand the rest of the uninsured.  They add solutions should cost far less than the $1.6 trillion Congressional Budget officials estimated for proposals that would address only two-thirds of the problem.

“We urge policymakers not to rush the healthcare debate,” said June O’Neill in a written statement.  “This new information will (help) policymakers target those truly ‘at risk’ and decrease the cost of covering the uninsured.” 

Using data from a number of surveys, O’Neill says “(t)he uninsured… obtain about half the amount of health services received by the insured population.  The lower health status of the involuntarily uninsured could be attributed to their level of education, income, and even lifestyle habits (such as smoking and obesity), more than the mere fact that they do not carry health insurance.”

This kind of information is crucial to the national debate on healthcare.  As a Democratic Congress and the Obama administration hurry to finish a job President Bill Clinton thought he could accomplish, the true scope and depth of the problem of the uninsured can be manipulated.  News reports regularly characterize the problem of the uninsured as “critical” but a careful analysis of the details has been unavailable until now.

Critics will point out that O’Neill was Director of the Congressional Budget Office herself in the mid-1990’s when Congress and the Clinton White House wrangled over health reform, and never could solve America’s healthcare troubles during the days when it would have been, oh, so much less expensive.

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Get High and Stay High

June 22, 2009

Dawn broke crisply at Crazy Creek, as yellow streams of sunlight brightened crests of the ridge across the field where wild turkeys and pigs ducked through the brush.  This is a small private airport near Middletown, CA, about half an hour drive north of the Napa Valley.  A beautifully restored blue and tan TravelAir biplane and several sleek, bright white sailplanes waited by the runway.

I had camped out, to get an early start on what weather charts had promised would be a good day.  I got in an early morning run, a hearty breakfast with good friends and started preparing my ship.  By nine o’clock the first folks with eager grins climbed into the front two seats of the 83-year old biplane for an open-cockpit thrill.  The throaty purr of its Wright Whirlwind radial engine recalled the early days of barnstorming.  Captain Bob, a 60-year old retired airline pilot, deftly guided the singing craft into a clear blue sky.  A dozen of us, pilots and would be aviators alike, stopped what we were doing to watch and dream a little.  We all imagined ourselves smiling in the slipstream, listening to the hum of the biplane’s wires.

This ideal of simpler flight drew a steady stream of adventurous and enthusiastic people to this valley on this brilliant morning.  Some came for a biplane ride, others to soar on the silent wings of gliders, spectacular, sexy and astonishingly efficient aircraft.

Gliders are the earliest form of winged flight, and from Galileo’s crude wooden and fabric approximation of bird wings, engineers and aerodynamic inventors have created amazing carbon and fiberglass works of art, with impossibly narrow and thin wings that stretch more than 60 feet from tip to tip.  Gliders continuously fall through the air, but by seeking rising air, good pilots have flown more than a thousand miles.  From 5000 feet, the best of these can glide more than 60 miles without any other lift.  My glider is not that efficient, nor am I yet capable of attempting anything like such an all day flight.  But when I fly I feel a mastery of the air that’s hard to describe adequately.

I am very eager on this day to  get my ship up into the warming morning sky.  A little before 11 o’clock, one of us pointed to a ridge west of the airport.  Without a word, it was a signal understood by soaring pilots worldwide.  The first of what would be a sky full of puffy cumulus clouds began its wispy existence.  They are markers of rising air known as thermals, sun-heated mushroom-clouds of air lifting themselves skyward.  It is time to fly.

I help another pilot put the wings on his sailplane.  It is a shiny, white fiberglass single-seater he keeps in a trailer.  It’s a German, factory-made glider with 48-foot wings.  It takes about 20 minutes to pull it out of its earthly home and get it ready to go soaring.

My glider is already assembled.  I pull on my parachute, spray on a little sunscreen and put on my funny hat.  Glider pilots all wear funny hats.  The sun is brutal when you sit under a canopy for hours.  I remove the ropes holding my sailplane to the ground,  and a couple of other pilots walk over and ask if I’m ready.  They help me push it out to the runway and point it into the wind.  I slip into the cockpit, as the towplane idles toward me.  One of the pilots pulls out a 200-foot rope from the towplane’s tail, and connects it to a hook in the nose of my glider.  I do a quick check, lock the canopy, give a thunbs up to the man holding my wingtip off the ground, and hear the towplane’s engine wind up.  We start to move.

In about seven seconds, my glider lifts off the ground, and the towpilot pulls me, climbing steadily, toward a 3800 foot high mountain that’s dead ahead.  Before we get there, rising bubbles of air buffet us both.  They are begging me to release from the towplane and use their energy to lift my glider without connection to an engine.  I pull the release handle and feel the sudden freedom of soaring.  I turn immediately into a strong thermal that takes me 3000 feet higher in about five minutes.

This is what eagles feel.  Indeed, many of us share thermals with eagles, hawks and even pelicans, wheeling upward in these invisible bubbles of air.  It is a very sensual experience.  I can feel the air heaving and roiling around me.  It’s a living, bucking beast booting me in my seat and small of my back.  Every burble, bump and boost from the thermal lifts and rocks the glider.  I grin as I rein in its energy and harness its power for my soaring pleasure.  It’s like surfing a really big wave.

Upward, ever upward I climb and turn, feeling the air, working it, turning tighter then wider, always searching  for the strongest lift in the changing shape of the thermal.  I also feel the hot sun on my face and arms, and hear the wind whoosh as the lift strengthens and then quiet as it eases.  There is the constant beep beep beep of my variometer, a sensitive electronic device that measures changes in my total energy, in other words, my height and speed.  It’s now a satisfyingly rapid ditting, and I glance at the instrument showing seven knots (seven hundred feet per minute) climb.

Directly above me hovered a forming cumulus cloud.  I can feel the moist coolness of the air as it reached its dewpoint and began to condense.  From here, 6500 feet over the ridge near Mount Saint Helena, I clearly see San Francisco, the Bay, Point Reyes and the Pacific Ocean, and into the Central Valley and the Sierra foothills.  I leveled out my turn and dove to gain speed, setting my flaps for high-speed flight, aiming for the next growing cloud about three miles away.

In this way, climbing turns followed by high speed dashes, I covered about 50 miles in two hours.  That is pitifully slow by competition sailplane standards, but I was loafing, drinking in the wonder of motorless flight and the stunning view through my canopy that had me literally sitting on top of the world.  Just me and the eagles, powered by the sun.

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El Nino Coming?

June 20, 2009

Marine Mammal Center veterinarian Bill van Bonn unlatched the gate and stepped into a fenced pen with a yearling sea lion.  You could see outlines of his rib bones through his brown fur.  He made a raspy gargling bark.  Four hours earlier the emaciated pup was on the operating table, and van Bonn was removing a necrotic and infected lymph node.  “He’s about half normal weight,” said van Bonn, “pretty typical for the sick sea lions we’re now seeing so many of.”

The new $32 million Center on a bluff overlooking Rodeo Beach north of San Francisco, “is filled to capacity and beyond,” said van Bonn.  He’s a former veterinarian with the Navy’s Marine Mammal Program in San Diego and wears a stethoscope around his neck as we thread our way betwen pens of barking sea lions.  “We’re not exactly sure why.  We’re not seeing demoic acid poisoning or anything else specific in necropsies (of dead sea lions.)  We know the animals are malnourished, the question is where did the food go?”

A quick look at the animated SST Anomaly from the National Climate Data Center may explain.  US Government climate scientists say the trend is consistent with an El Nino weather pattern.  This means water temperatures are warmer than normal along the California coast;  indeed, buoy data show water temperatures several degrees warmer than usual for this time of year.

“El Nino for this part of the coast is bad news,” said Zeke Grader a San Francisco fisherman who now heads an industry group, The Pacific Coast Federation of Fishermans Associations.  He stood along the Crissy Field shoreline with the Golden Gate Bridge behind him.  “The water’s warmer and the fish generally will head north where the water is deeper and cooler.”

“We’re starting to see a number of seabirds starting to strand from malnutrition,” say Mary Jane Schramm of the Gulf of the Farallons National Marine Sanctuary.  Schramm said a guano-covered promontory called Bird Rock just south of Rodeo Beach had been home to nesting Brandt Cormorants.  Not this year.  She also said there are early indications common murres are not nesting in their regular sites on the Farallons.  “So we know there are some problems with the food chain.”

Grader has seen this before.   In 1982 and 1998 strong El Ninos hit fishermen hard, and lashed California with torrential rains.  El Ninos typically mean increased precipitation on the West Coast.  “Generally (El Ninos) mean wet winters,” said Grader, “which is good for (drought-plagued) California, because we need to get that water into the streams for the salmon, and it’s good for the snowpack.”

If you’re reading this on the West Coast, you likely already know about El Nino’s effects- if not, you may want to visit my friend meteorologist Jan Null’s fine El Nino Resources website and learn a little bit about what the future may hold.

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Health Plan, Health Plan, Who’s Got a Health Plan?

June 17, 2009

Californians are dissatisfied with their health care system.  A new KTVU/Field Poll released today shows more than 2/3rds of Californians want health care reform now.  About a third want the whole system scrapped and to start over

“Our government is just not making the right decisions as far as how important the people are,” said Molly Eaton outside a market in San Francisco’s Mission District.

A block away, a helmetless bike messenger named Marcus, who didn’t want his surname used, said he’d lost his health insurance along with his last job, and his new employer didn’t offer it.  “A lot of countries have free health insurance for everybody.  It’s like included in taxes.”

In San Francisco’s financial district Anthony Byers in an expensive looking suit, said “I do think there needs to be a new plan, and hopefully we’re on that path.”

Director of the Field Poll, Mark DiCamillo ran down results from the third annual health care system survey of California voters.  “By a greater than two to one margin Californians want to procced now with health care reform.”  He said the telephone poll of 1209 California voters during May asked about many of the proposals now circulating in Washington, DC.  Poll results showed people want health care choices, but disagree along party lines about whether to pay for care for the uninsured.  “Democrats are willing to pay for such a tax by a two-to-one margin, but Republicans are not willing, by a three to one margin.”

Tax accountant Paul Bradshaw of suburban Novato said he’s willing to help those who are out of work and looking for a job, but “people who don’t want to work and are riding on the coattails of the taxpayers, I don’t want to support them.”

“I think I’d be willing to pay some,” said Wayne Yee of San Ramon, “but probably not a whole lot.”

43 year old San Franciscan Howard Frazier, who’s now on disability from an on-the-job injury, said “if the economy gets a little better, I wouldn’t mind paying a little extra money for the people that ain’t got (health care), people got kids y’know.”

The poll also found 85% want some kind of a public health care plan to compete with private insurance, 81% want coverage regardless of pre-existing conditions, and 69% want employers to be required to offer health insurance to all workers.  70% oppose a requirement that everyone have health insurance or pay a fine.

Nijua Coleman of Oakland, with her ten year old daughter by the hand, said what’s really important is more coverage.  “More benefits for everybody.  Everybody should be able to get health care.”

Whether this “Summer of Health Care” will yield any meaningful reform depends on how big a dose of change Congress can swallow.

Follow me on Twitter @JohnFowlerTV

Follow Me on Twitter

June 17, 2009

See what stories I’m working on and follow me on Twitter at JohnFowlerTV.

I’ll be keeping my tweets short, but you can tune in to KTVU in the San Francisco Bay Area, or here on ktvu.com, for more.

When is a Smoker Not a Smoker?

June 17, 2009

“I’m a non-smoker,” said Susan Longardino, standing on the sidewalk outside the San Francisco nail salon where she had an appointment.  “I have never bought a pack, but when I’m out with friends, after a nice dinner, or go to a club, I’ll generally have a cigarette.”

“No, I don’t smoke,” said newly-hired waiter Stewart Merritt at the entrance to a San Francisco seafood restaurant that caters to tourists.  “Only when I’m intoxicated or I feel some stress.”

Denial?  Maybe.  Merritt and Longardino are among a rapidly growing segment of tobacco users which scientists call “social smokers.”  It is a group (about 30% of California smokers) only recently identified by health professionals.  But since 1971, they have been targeted by a multimillion dollar cigarette marketing campaign, which did exceptionally detailed and intensive study on these smokers.

“They analyzed them, kind of figured out their demographics, their psychological profiles and know how to market to them.  They even designed products to attract social smokers,” says UC San Francisco pulmonologist and Center for Tobacco Research scientist Dr. Rebecca Schane.  Schane has co-authored an article for the American Journal of Preventive Medicine, based on her extensive review of many of the ten million previously secret documents tobacco companies released in the $205 billion Master Settlement Agreement of 46 states’ litigation.

“(Tobacco companies) hired anthropologists, psychologists and behavioral scientists to figure out what made social smokers tick,” says Schane.  “Their research shows (social smokers) are a unique group, and whether they are really addicted (to nicotine) remains to be determined.  They smoke to gain peer acceptance, they want to be liked by the group.”  Schane, an expert on lung disease, says tobacco companies devised marketing strategies to make smoking appear chic, sexy and glamorous.  “There is nothing glamorous,” she says, “about lung cancer.”

Schane and co-author Prof. Stan Glantz of UCSF’s Medical School, are trying to use the tobacco marketing research to find effective ways to get social smokers to stop lighting up.  “(Big Tobacco) identified this group long before public health did,” says Glantz, a veteran of the tobacco wars.  Now it’s time, he says, to use the psychological profiles to help social smokers avoid cigarettes.

“They are not motivated by their own health risks,” explains Schane, “because they don’t identify themselves as smokers.  They feel they can quit any time, and don’t associate the risks of lung or cardiovascular disease with their behavior.”  Just one to four cigarettes a day, Schane points out, ups the risk of lung cancer five times over that of non-smokers.

“They are motivated by peer-group and social interaction,” she says, “so an effective message might include the risks of second-hand smoke on friends and family.  Social smokers are sensitive to those around them.”  She is preparing another article on health risks and potential smoking cessation strategies for social smokers.

She also says physicians and health workers need to be aware that social smokers will deny they smoke unless pressed.

“I don’t smoke.  Smokers are people who smoke every day,” says Josie Venuto, a twenty-something tourist from Miami having lunch on San Francisco’s Fisherman’s Wharf.  “That’s not me.  I only smoke when I drink.”

“I’m not a smoker either,” says Luc Kanea, a lanky young man from Krakow, Poland.  “I just do this for fun, when I go out with friends, have a beer or go to a bar,” he said as he took a long drag on a Camel cigarette.

They’re blowing smoke, damaging their lungs and making tobacco companies richer.