Thursday, March 15, 2018

Second Hand Tobacco Smoke Kills Now

The final scientific research to establish the killing power of tobacco smoke had to wait for “natural” research opportunities. No one can design scientific research on the large scale effects of tobacco smoke on human beings (unethical and costs) .
Scientific research requires large numbers of participants, divided into never smoked and forced to smoke (control and treatment) groups.
For the last few years about 440,000 died in the US, with 11,000 in Missouri, each year, as the result of Big Tobacco marketing and addiction.
Then progressive communities passed clear air ordinances and watched the change in hospital admissions and deaths from heart attacks and strokes.
Addicted people paid for the cigarettes; no research costs. The lure of charismatic Big Tobacco brought in the “treatment” group; no ethical research decisions were needed.
Pueblo, Colorado, restrict smoking in 2002 with a three year study. A comparison of the number of heart attack hospital admissions before and after the law was passed showed a 27% decrease in the number of heart attacks.
A study, between 2007 to 2014 (published last year) in Indianapolis, Indiana, showed a 25% decrease in hospital admissions for acute heart attacks. “Among people who never smoked there was a 21% decrease in heart attacks.”
[Half way through the study, clean air was extended to bars because of the number of lives being saved during the first years. This is good public health practice.]
There is no safe level of tobacco smoke exposure. This includes third hand tobacco smoke from a smoker’s hair, clothes, and body.
Smokefree legislation saves lives. The stronger the law, the fewer hospitalizations and the lower the health care expenditures for a wide range of diseases. For maximum benefit there should be no exceptions in tobacco smoke exposure laws.
[Frequent exceptions have been prisons, hotel and motel rooms, and residential establishments such as long-term care institutions and rest homes!!! These are all places where there is no need for the effect tobacco smoke has on intensifying many illnesses.] 

Second and third hand tobacco smoke not only kill but kill now; any time that a blood clot is caught in the brain or the heart. That includes memory care residents.

Thursday, March 8, 2018

The Composite Corpse

The Composite Corpse
We normally think of a dead body as one dead body. One thing killed the body: cause of death in the corner’s report. One person is responsible in the case of a crime. Case closed.
The perfect crime is not solved. The person responsible is not found.
How then can thousands of people be killed each year by people who are clearly identified? The killers kill only a little bit of many persons.
Each cigarette shortens a smoker’s life by about 11 minutes. There is no safe level of tobacco smoke exposure. This is a matter for public health.
The result of selling cigarettes to nicotine addicted persons is well enough known that the result is premeditated: 11 minutes lost per cigarette; 10 years off a normal life time.
Now to catch the murderer. We know the time. Take 10 years off the end of a life time. Take 20 years off the start; before a life time smoker gets fully addicted to nicotine.
That leaves a 50-year market in which to sell cigarettes to an addicted person. Addiction now drives the sales. Some 70% of smokers would like to quit.
How many cigarettes are needed to kill the equivalent of one composite body?
Fifty years x 365 days x 24 hours x 60 minutes = 26,280,000 minutes.
Now 26,280,000 minutes/11 minutes =                   2,389,091 cigarettes.
And 2,389,091/20 =                                                    119,454 packs.
And 119,454/10 =                                                         11,945 cartons.
And 11,945/50 =                                                                239 cases.
No one person can smoke that many cigarettes. A pack-a-day smoker would need to buy 365 packs x 50 years = 18,250 packs; 1,825 cartons; 36.50 cases.
Therefore a minimum of 239 cases/36.5 cases or 6.5 (7) pack-a-day smokers would be needed to buy this many cigarettes. Half would be expected to die early enough to result in a composite one-life-time loss of life.
The sale of 239 cases per year kills one equivalent person (20 cases per month).
It takes a lot of cigarettes to kill the equivalent of one person. It is a messy way to kill people. There are over 30 times as many made ill. Tobacco companies can avoid liability until this statistical, composite, public health, view is commonly accepted: Sell 20 cases per month and pre-meditatively kill one equivalent person.   
Until then, half of all life time smokers will continue to die from tobacco related causes.This does not include those who die or are made ill from exposure to their second and third hand smoke.

Wednesday, February 28, 2018

Eliminating Tobacco Smoke

Every city, every business, every residential health care facility, can set clean air quality standards higher than state and national standards.
Every city, every business, every residential health care facility, can enforce clean air quality standards (and state and national standards) more effectively than states or the federal government.
Modern clean air quality standards, therefore, rest, by default, within communities. You do not have to breath second and third hand tobacco smoke.
It only takes one straw to break a camel’s back.  It only takes one exposure to second and third hand tobacco smoke to trigger a blood clot. That blood clot can then cause a stroke or heart attack at any time
Tobacco smoke is the number one preventable cause of illness.
Tobacco smoke is the number one preventable cause of early death (about 10 years on average for life long smokers); plus horrendous medical bills.
Alternative nicotine sources (nicotine lozenges) contain no smoke.
Nicotine addicted people are under stress in their daily lives.
The threat of being forced to quit is one more source of stress, which can decrease the rate of success to quit.
Replacing each cigarette with a nicotine lozenge eliminates tobacco smoke.
Replacing cigarettes with nicotine lozenges eliminates the stress of forced quitting.
Replacing cigarettes with nicotine lozenges allows timing to quit the cult successfully. No need to buy cigarettes. More free productive time.

Smoke Free City, San Antonio, TX, Memory Care Between a Main Entrance and Employee Entrance

Thursday, February 22, 2018


It is time to put falling into perspective. When Margaret fell backwards the other day that scared me. I could see the couple we ate with in the dining hall almost two years age. One fell backwards in their apartment; too far for the spouse to make a catch. Then hospital, then passing; then the spouse, who was very active in the fitness classes, passing.
Margaret’s falls at Provision Living are very different from the falls when we were refugees from the flood, and staying in skilled nursing in South Hampton Place. There she went down in a spiral. Her feet remained in place until her right hip hit the floor and she rolled out onto the tile floor; six times before the overdosing with Xanax was finally discontinued by the house doctor.

Found Under a Heavy Sleave
Three Weeks Later
Here, she has had a series of bruises from unknown causes. They tended to get worse as time passed. They healed well. There have been none over the past two weeks.

The rolling office chairs we have instead of a stuffed couch were suspected when I made the last trip to San Antonio. Then a series of events said something else; weight, her fit into the chair, and getup time. She is sliding, not falling out of the chair?
For two weeks she was up at 8:00 and out of the apartment. Safe and a bit sleepy. She napped. She took little part in exercise activities.
The last two days, she has refused to get up at 8:00. She is up before 10:00 when I go to a fitness class. Yesterday she came to the class with a group from memory care one. I was surprised to see her come in. She sat beside me, holding a two-pound weight the entire class.
I returned to memory care with the group. They wanted to do the ball bounce across the center of a circle of chairs. I immediately set Margaret in the circle as it was forming. She refuses to go to a chair in a completed circle.
We ended up with another person between us. I could now watch her facial expressions. What happened next was totally unexpected.
After the ball was bounced to her a couple of times, she became Maggie of two years ago, at a slower pace. By the time the session ended all of the residents were again taking part; even two, out of memory care, staff joined in; who wandered in checking on things.
Was a fully rested Maggie showing different behavior from a drowsy Margaret?
We know that Margaret is sliding out of the office chair. I happened to have my i-phone near this computer when I heard a weak call, “Richard!” The chair does not move as she twists about
We also know that sliding out of the chair no longer bothers her. This is not a good habit. 
What is in This Box?
Waiting for Rescue
Getting down on the floor to play with her keepsakes is OK, but it takes two caregivers to return her to a chair once or twice a day. OR is the chair sliding out behind her?
So, the rolling chair is locked in an empty apartment. A fairly heavy straight chair, found by a caregiver, is now in place. My concern is that she may push the straight chair back and tip over backwards.
It is 7:06 on Wednesday morning with more things to do than I can take part in: 8:30, stretching; 9:15, swimming that overlaps; 10:00, Morning Movers, 10:30, In The Dust of Rabbi, a CD travel log of the how and where of the disciples of Christ; 3:00, Building Better Balance; 4:00, meditation; and three meals.
I need to be back here by 8:00 and observe what happens next.
8:55 one eye open and then back to sleep.
9:00 the third caregiver check on getting up.
9:43 the fifth caregiver check, morning pills, and easily up to the bathroom.
9:50 time for me to go to fitness class and to get the newspapers.
Up for the Day

9:55 out of the apartment and up for the day with our little memory car dog in escort. He seems to sense when people need help.

11:20 and back from Bible Study. Margaret did not get into the circle of chairs. Today she was already seated in the activity area when the circle was formed.
12:00 the frown is showing. Everyone needs to be on their watch.

6:50 am Thursday Fire drill!!! What a relief!! The alarm was turned off as soon as everyone was out of their apartments, while roll call was taken.
7:00 Margaret is sound asleep again.
Now it is 1:38 after a struggle to get the Mail message list to use a larger font on this MacBook Pro computer (failed). By Jove!!! The Blogger screen is larger now. So, need to look at Mail again.

I ate lunch (noon meal) with Margaret seated in the activity area watching U Tube trivia channel. Margaret was tapping her foot and nodding to Tennesse Ernie Ford.

She has yet to sit in the new straight chair (see previous post).

Tuesday, February 20, 2018

Falling in Memory Care

This morning, Monday, a bit before 9:00 I saw Margaret fall backwards; this time onto the daybed. She may have tripped over her own feet. She may have been a bit dizzy from bending over and picking up a magazine. She may have . . ..
I pulled the call button at 9:00 and returned to reading the morning newspaper. No response by 9:15; some 5 minutes after the system repeats the call. No response by 9:35. I go looking for a reason the system is not working. There were three caregivers on duty in the dining/activity area.
What went wrong this time? First, I was an hour late going to breakfast; I was not  a backup for the 8:00 getup. Second, no one came at 8:00 to get Margaret up, dressed, and out of the apartment, in about five minutes, for a light breakfast. This plan has worked perfectly for over the past two weeks.
There is no explanation of why it works, but getting up late today recreates the performances of the past.
[10:05 I hear the laundry cart rattle. Margaret is pushing it in the bathroom. I wait. I take her left hand at that magic moment when her attention is changing. “Time for breakfast. Let’s go.” Pause. “Let’s go. Let’s go.” And to the apartment door. “Let’s go, let’s go” in a soft chant. And out into the hall.
R____ jumped to one side of the hall near his door. A grin spread across Margaret’s face. They both laughed. She greeted everyone in the activity area with a smile, a head nod, and her I’m OK grin. I return to writing.]
Dressing late is a struggle for all concerned. She is not a happy camper when the eyebrows arch and the vertical lines show between. After being ready for the day, the caregivers know to give her time to outlive the “worries”. 
This time the call system failed because one person did not have a pager but did hear the call in the office. Another said that memory care residents don’t use the system. Their calls are accidental trips.
[What is wrong with this picture? When the cord was not tied up it was near a towel and the handle on the commode. Margaret was pulling the chord more than once a day, at times. The correction was to tie up the cord and keep towels off the towel bar.]
All agreed that the 8:00 getup time was needed to be continued every day. Memory care rooms are visually checked periodically all day and all night.
[A pizza party was held, last week, to celebrate reducing the average call button response time in assisted living to less than four minutes. When problems are identified, they get fixed.]
1:30 and back from church streamed into the 3rd floor theater. Margaret came to our apartment door at 11:05. I asked her if she wanted to go to church. “I don’t know if I do,” as clear as can be!! We walked into the service, 10 minutes late, to a roaring community church rendition of How Great Thou Art. She was attentive all through the service and lunch.

Response Time in Room 133
(Written some time ago but I forgot to post it until it showed up this morning when I opened Word! My 2008 copy of Word selects old pages at random on opening.)
Margaret slowly slid to the floor in front of the windowed bookcase. The dining room table leaf rattled a bit. Her hand, sliding down the edge, may have controlled her soft landing on the floor in a seated position.
I pulled the bedroom call button: 9:17. Margaret seemed totally unflustered by being on the floor. This was a different behavior. I went back to writing while watching her. She went back to playing
I pulled the bathroom call button: 9:29. Margaret remained fully intent on her keepsakes on the bottom two bookcase shelves.
I walked to the office: 9:45. Three people were there. I again inquired, as I have done several times before, “Did you hear the bell?”
“Yes”. “Why did you not come to our room?”
“A--- responded to the call.”
“But no one came.”
“Here. See what the pager shows.”  Room 133.
S--- visits with me as other matters are cared for. Maggie is busy with her keepsakes. I learn that the personal call buttons show the person’s name rather than the room number.
I learn that A--- went to the apartment across the hall from ours: Room 134.
I remember B--- racing into our room twice in the last month to find our call buttons not pulled. She then going across the hall: Room 134.
“I remember to go to Maggie for 134 and to C--- for 133. I don’t know the room numbers.” A new person on the floor did not (rightly) associate call numbers with room numbers in this case.
“It seems the wiring has been corrected in the building but no one informed the caregivers.” The building is now over two years old.
This explains the false calls to our apartment over the past several months.
At the last residents council meeting, the call response time was severely questioned. It became clear that the system is not an emergency response system. An acceptable time was given as four minutes, on average. This makes sense as an, “I need some routine assistance,” system.
Also reported was a delay in responding to our call in memory care one, that was confused with a call, at about the same time, with a call made in memory care two.
The personal call buttons that show the person calling is a step up from the room call buttons. Experienced caregivers know what each resident needs at each time of day.
This works with experienced caregivers. One of our calls last month was not received because the pager was not turned on. Another because only one pager was functioning, so it was left in the office. At other times pagers were either missing or the batteries were dead.  Or people were not familiar with a new pager system.
The building does have an emergency call system. Call 401 on a room phone. Ours is under one of the Sleep Number beds where Maggie leaves it alone. The concierge can rouse who ever is needed, if you know this, and if you have access to a room phone. Also set your cell phone for the concierge (of course memory care residents normally do not have cell phones or room phones.)
11:15 Margaret just got up, flashed a big smile, and left the apartment. An hour’s nap made a complete personality change. The “worries” are gone and she is happy again. She could speak in one and two word sentences all afternoon!
The resident’s council meeting pointed out that a true emergency response system must include a real person and a means of communication (two way conversation). That is 911, for example. In house, such a system confirms the call (if no need for anyone to respond it saves manpower) or distributes the call to the appropriate person to respond in an appropriate time. In an emergency the line of communication would remain open until the responder checks in.
In San Antonio, three years ago, we found two separate systems for routine and emergency calls at one place, and a pendent with two buttons for routine and emergency calls. Maggie is now out in the activity/dining areas most of the day with about a five-minute check if she is not visible.
[The past two days, Margaret has refused to get up at 8:00! This leaves her in the room when no one is at hand. She has again slid onto the floor. We switched chairs (no arms and no wheels) to see what happens.]

Friday, February 16, 2018

The Responsible Use of Nicotine

What was learned at the, 13 February, Resident Council meeting has been summarized in the chart in operational terms: Condition of Employment, Training, and Uniform. The chart was distributed at a, 14 February, meeting at Provision Living with the Central Missouri Area Agency on Aging (CMAAA), Donna Wobbe, Director, 573-443-5823.
A few edits have been made to keep the chart on one page. It will be used in a working paper presentation to the staff at Provision Living, Thursday, 22 February 2018. Other comments:
Conditions of Employment
Employers who hire people with addictions that have a harmful effect on others at the site have a responsibility to minimize or eliminate the effect on smokers and non-smokers. This is the flip side of providing special arrangements for the physically and mentally “challenged”. A well established practice.
There is a counter culture that promotes tobacco smoking. Many states have laws prohibiting “life style” city ordinances. This made some sense at the time we knew little about the immediate effects of tobacco smoke.
Columbia, MO, promotes tobacco smoking by outdoor “smoker stations” in the downtown “The District” area to “protect the wild life” at the other end of the sewer system. This promotion also comforts nicotine addicted and non-addicted persons with the reassuring words, “If you smoke cigarettes, you have every right to do so.”
This is one of the main tobacco company lies. There is no such right (except where smoking has no effect on other people). It is important to the people taking in the money, to say this, so everyone is happy with their operation. The specter of “excess” deaths hanging over the area must be kept out of mind.
[Columbia, MO, City Code 16-231 Littering, states it is a Class A misdemeanor with up to one year in jail and up to $1,000 fine if (cigarette butt) litter escapes from property that permits littering.
This is a perfect example of how laws, that look good to the public, are passed with little if any attempt at enforcement. Owners are not interested in paying $1,000 fine for each night that butts stray into the street.]
Our understanding of when tobacco smoke injures is changing as we learn more about how it injures. Blood platelets become sticky in about 30 minutes; promoting heart attacks and strokes (both tobacco and e-cigarettes). Vascular endothelial function is reduced in seconds; arteries then fail to enlarge when added oxygen is needed.
I measured indoor and outdoor air quality in northwest Missouri for several years. It came as a surprise to find an article, in March, 2017, that compared the fine particulate concentration from tobacco, marihuana, and “vaping”. They have the same concentration of toxic fine particles! It never occurred to me that burning and heating (charring?) would generate the same toxic particles.
It is the fine particulates that contribute to illness and “excess” deaths in smog. Burning tobacco with or without nicotine made no difference in their results. It is the smoke; not the nicotine, that is toxic.
“Vaping” seems to be a truth and another big lie. It can get a person, addicted to nicotine, to switch from tobacco to vaping (for about $60, at one store I visited). It can also get a non-addicted person addicted.
The CDC and FDA have yet to sort this out. Until they do, avoid vaping. Vaping generates a colorful third hand “smoke” with its own drug rituals.
Several people have mentioned the smell of tobacco smoke. That used to be the end of the matter. Now it is a warning, of the presence of third hand tobacco smoke and the immediate results on health; that an addicted person is sharing for lack of knowing how to use, non-smoke containing, nicotine sources.

Thursday, February 15, 2018

Tobacco Smoke Control in Memory Care

The chart relates important parts of effective tobacco smoke control in memory care presented at the Provision Living at Columbia, 13 February 2018, Resident Council meeting.

My trip to a smoke free city last week, San Antonio, Texas, made it very clear that common tobacco smoke control terms are confusing and misleading.
Source: First hand tobacco smoke is taken in by a smoker through the mouth. Second hand tobacco smoke is taken in through the nose. Smokers hold their cigarettes so as to avoid new second hand smoke. Third hand tobacco smoke exposure in memory care comes from the smoke that has settled in hair, clothes and bodies of smokers.
Restriction: Smoke free is an area that is free of smokers. It is not an area free of tobacco smoke. Tobacco free is an area free of smoking and free of tobacco smoke except for third hand tobacco smoke. Smoker free is free of tobacco smoke but can still be invaded by third hand tobacco smoke. These restrictions are not effective in memory care.
Smoker: The non-addicted smoker can honor a request to not smoke on the job and to even wait until after work to enjoy a smoke. Such a person does not carry a risk of tobacco smoke exposure to memory care residents. Addicted smokers must have an appropriate source of nicotine (lozenge) in a timely manner or burn tobacco to take in the needed nicotine in a toxic smoke.
Stage: Smokers who are quitting now find the smoke free environment in Provision Living a safe place to work. One still smokes when with relatives, however she no longer buys cigarettes.
Smokers can be classified by their readiness to quit and the amount they smoke by the Center for Disease Control (CDC) Missouri Quit Line, 1-800-784-8669, along with free counseling and a kit of alternative smokeless nicotine sources.
Alternative safe nicotine sources free of tobacco smoke not only provide help in breaking addiction but also provide an immediate elimination of third hand tobacco smoke in memory care. I found the lozenge is the most popular in local pharmacies.
Addicted caregivers could pick up needed lozenges for the shift when clocking in.
Three residents recited their experiences in quitting “cold turkey”. One left smoking behind when moving to Provision Living. One just quit; health and cost. Another was teased by friends to the point that he gave in. He then found out how much non-smokers “hated smokers”; for over 35 years that he had been smoking. 
A tobacco smoke cessation group was suggested. We now know that this must be done with the encouragement of the entire community to be successful.
The comment that membership would be kept private struck me as very odd. Success in breaking addiction demands a positive cooperative atmosphere. There must a celebration of purpose that overpowers the negative aspects of breaking free from addiction, or a significant emotional event like the three residents had before they moved into Provision Living.
The time has come that the “dirty secret” of exposing residents to third hand tobacco smoke in the residential health care community in Columbia needs to be made public to keep the air clean. Residential property is not a private place for people addicted to nicotine to share their toxic wastes.
The damage tobacco smoke does to the human body is no longer something that takes decades: lung cancer. The heart doctor we had an appointment with, prior to the resident counsel meeting, had the walls decorated with “Stop Smoking” and “Avoid Second Hand Tobacco Smoke.”
The threat to health is now known to be immediate. Blood platelets become sticky within 30 minutes of tobacco smoke exposure. Sticky platelets form clots. Clots cause heart attacks and strokes. Avoid second hand and third hand tobacco smoke.
My travels in the past four years still show Provision Living at Columbia to be the best for our money and for our care by radiant caregivers. Replace tobacco smoke with smokeless nicotine.