First, be ready to quit.  Quitting is often a tough process, and there’s no point in starting if you know it won’t work.  If you’re not ready to quit, figure out why not.  Consider what you enjoy about smoking–an escape from the office, companionship, the comfort of a familiar habit.  Start weighing those factors against what you don’t enjoy–the cost, the health effects, the holier-than-thou attitude from those yuppies in that Prius speeding by you.

Use these to play mindgames with yourself.  Each time you light up, remember how bad it makes you smell.  Or think what you could do instead with all the money you’ve spent in the past month on cigarettes.  Or if you’re inclined to the macabre, follow the advice of one of my patients who quit a pack-a-day habit.  He made a list of twenty diseases linked to smoking (see the end of the article) and mentally labeled each cigarette in the pack with the name of one disease as he smoked it.  If you consistently link smoking to something negative, you’ll be more prepared to give up the habit.

Once you’re ready to quit, learn about your options.  Get information from a health care provider, online, or call 1-800-QUIT-NOW.  Use their support to develop a plan that combines three elements: lifestyle changes, a quit program, and medications.

When it comes to changing your lifestyle, focus on eliminating your triggers and reinforcing a smoke-free life.  Ask friends not to smoke around you.  Avoid places, people, and frothy beverages that make you smoke.  When cravings hit, have sugarfree gum or low calorie snacks in your home, office, and car.  Get support from the people closest to you.  You changed your relationship status on Facebook after your last breakup, why not publicly announce that you’re finally getting out of an abusive relationship with nicotine?  Tweet it to the world.

Next, line up a quit program and start the program before you actually quit smoking.  Options range from a simple one-time phone conversation to multiple intensive sessions with a trained expert.  Two free, easily accessible resources are 1-800-QUIT-NOW and online chats at LiveHelp.  Your community might have a Nicotine Anonymous group or a local health care organization that provides a quit program.  In general, the more intensive the program, the more likely it is to help you succeed.  People pay to have experts design a workout program, a healthy diet, a polished resume.  It makes sense to get an expert on your side when it comes to quitting smoking, especially when it’s free.

In addition to lifestyle changes and quit programs, medications are an effective tool to help you quit.  The three most commonly used medications are nicotine, buproprion, and varenicline.

Nicotine replacement therapy with patches, gum, inhalers, or sprays doubles the success rate of quitting.  Probably the most effective way to use nicotine substitutes is to wear the patch and then have an additional agent, such as the gum, to combat breakthrough cravings.  If you smoke less than 25 cigarettes a day, you should chew the 2mg dose of gum; if you smoke more than that, use the 4mg dose.  The gum is more effective the less you chew it and the more you park it between your gum and cheek, like dipping tobacco.  People sometimes worry that they’re replacing one bad habit (cigarettes) with another (nicotine), but the negative health effects from smoking come primarily from all the other toxins in the smoke, not nicotine.  The patch, gum, and other nicotine products are safe when used as prescribed.

Buproprion, also called Wellbutrin and Zyban, is as effective as nicotine replacement in helping people quit smoking.  The drug acts on multiple neurotransmitters in the brain to decrease the cravings for a cigarette.  It’s usually taken twice a day for three months, starting one week before the quit date.  The most common side effect is insomnia, and the most dangerous side effect is an increase in suicidality, especially in adolescents.

Varenicline, also called Chantix, appears to be more effective than either nicotine or buproprion, tripling the success rate of quitting.  It binds to the nicotine receptors in your brain, decreasing the withdrawal symptoms and blunting any buzz from a cigarette you might smoke during a moment of weakness.   Like buproprion, it is taken twice daily for three months.  While it’s a safe drug, like buproprion, there is a concern for an increased risk of suicidality.  People taking this medication need to do so under a doctor’s supervision, and they and their families should pay attention to any symptoms of depression or unusual behavior.

There’s no clear best method for combining these three medications.  But one medication strategy recommended by experts is to use varenicline and a nicotine patch daily, with an additional nicotine fix–gum or spray–for when a craving really hits you.

Once you’ve determined your best strategy, and lined up medications, counseling, and the support of your friends and family, pick a quit day.  Your odds of quitting smoking are best if you go cold turkey rather than winding down over a period of days to weeks.  Remember that if it’s your first try, it might not be your last.  Don’t be discouraged if you start smoking again, a relapse just puts you one step closer to the day when you finally quit.

Twenty diseases linked to smoking: asthma, blindness, bladder cancer,  breast cancer, chronic bronchitis, congestive heart failure, deep vein thrombosis, diabetes type 2, emphysema (COPD), esophageal cancer, heart attacks, impotence, infertility, lung cancer, pancreatic cancer, pulmonary embolism, oral cancer, osteoporosis, stroke, ulcers.

It might seem surprising that a non-radioactive, tobacco-less, industrial waste-free product could cause cancer.  Sure, it makes you fat and gives you cavities, but cancer?  The theory is that the mega-doses of sugar contained in these beverages trigger our bodies to release higher levels of insulin, the hormone that regulates sugar levels.  Insulin is created in the pancreas and triggers pancreatic cells to divide.  Each time a cell divides, the chances of its offspring developing a cancer-causing mutation increase.  So more sugar causes more mutations in pancreatic cells, which leads to more pancreatic cancer.

That’s the theory, but the research into the link between soft drinks and pancreatic cancer is contradictory–some studies confirm a link, some studies refute it, and some studies go so far as to find that even fruit juices are linked to pancreatic cancer.  This particular Singaporean study was well-designed and its conclusion is believable.  It is not, however, as dire as headlines make it sound.

While the study did find that soft drinks increased the rate of cancer, let’s look at that increase.  The people who didn’t drink soft drinks had a rate of about 3 in 10,000 cases of pancreatic cancer per year.  The 85 percent increased risk this study found means that soft drinks increase the annual rate of pancreatic cancer among soda drinkers to about 5 in 10,000.  Not particularly dramatic.   Furthermore, the researchers did not find that fruit juice, which contains about as much sugar as soft drinks, was linked to pancreatic cancer.

So, should you stop drinking soda?  Yes, but not because of the risk of pancreatic cancer.  You should mostly stop drinking soda, as this video shows, because it’s just incredibly disgusting how much sugar there is in a can of coke.  Don’t let nutrition labels deceive you, “carbohydrates” means sugar, and a “single serving” is sometimes only two-thirds of what’s in the can.  So a Coca-Cola Classic label advertising 27 grams of carbohydrates per serving actually contains about 40 grams of sugar in a 12 ounce can.  That’s the equivalent of ten of the sugar packets you’d put in your coffee.

Replacing sodas with fruit juice doesn’t solve the problem.  Even completely natural fruit juice, made from pesticide-free fruits picked by free-range hippies with the dawn’s pure dew still glistening on their skins, contains about as much sugar as soft drinks.  A single glass of fruit juice combines the sugar from several fruits, usually without the fiber that helps make whole fruit so healthy.  And despite that, manufacturers still add sugar.  Their labeling can be confusing: fruit juice means 100 percent of the contents come from fruit, while fruit drinks, fruit beverages, and fruit cocktails contain added ingredients–usually sugars and fortifiers.  A juice box (8.45 ounces) of unsweetened apple juice contains 25 grams of sugar.  That’s about the same amount in an identical volume of Coca-Cola Classic, 28 grams of sugar.

I was surprised to find the American Academy of Pediatrics has a policy on fruit juice (and on trampolines and ATVs!  Sounds like some fun committee meetings).  They state children under six months shouldn’t drink any fruit juice, children from six months to six years should drink less than six ounces (the volume of half of a can of soda), and children older than six years should drink less than twelve ounces of fruit juice a day (the same volume as a full can of soda).  They worry that the amount of sugar in fruit juices can contribute to childhood obesity, as well as malabsorption syndromes, chronic diarrhea, and cavities.

Ironically, sports drinks and vitamin water, which are marketed specifically for their health benefits, aren’t much better when it comes to sugar content.  That bottle of Gatorade (602g) you drink after kickboxing class contains 32 grams of sugar–about eight of the sugar packets you’d add to your coffee.  No wonder it’s so hard to lose weight at the gym.  For a typical workout, water and a healthy diet give you all the hydration and electrolytes you need. You’re shooting yourself in the foot if you’re trying to lose weight through exercising, and then drink a sports drink afterwards.

Similarly, vitamin water is actually sugar water.  Sure, there are a few sprinkles of additional vitamins, but that’s like the parsley that comes on the side of the jumbo burger deluxe with French fries.  You don’t need those extra vitamins if you’re eating a healthy diet.  While a bottle of vitamin water might only advertise 13 grams of sugar per serving, realize that there are 2.5 servings in a bottle.  That’s as bad as a bottle of sports drink, and almost as bad as a can of soda.

Regardless of your feelings about a slight increase in your risk of pancreatic cancer, there are plenty of good reasons to quit drinking sugary beverages–not just sodas, but fruit juice and other supposedly healthy drinks.  Combine the possible risk of pancreatic cancer with the known negative impacts of sugar on much more common diseases-obesity, diabetes, cavities-and you’ve got a really good reason to put down that bottle.  The real message about soft drinks, fruit juices, and other sugary drinks is that while they might slightly increase your risk of pancreatic cancer, they’re unhealthy for much more common reasons.

Media have widely reported that seasonal flu epidemics kill about 36,000 Americans a year, so I was surprised to see this low death count for the 2009-2010 H1N1 pandemic.  The CDC’s flu-tracking website shows that pediatric death rates from H1N1 are double to triple the rates from seasonal flu earlier this decade, and this year’s number of doctor visits and hospitalizations for flu is higher than it has been in previous years.  While I didn’t expect a huge increase, I certainly wasn’t expecting 25,000 fewer flu deaths this year!

Why is the 2009-2010 H1N1 pandemic less deadly than prior flu pandemics?  Is it a statistical fluke, given how difficult it is to estimate every single person who died from flu and flu-related complications?   Or is the H1N1 pandemic truly less lethal than prior epidemics? 

Some might argue the lower death rate is because the epidemic has not yet run its course, and many more people will die this spring.  However, we have seen a peak and cases are now declining dramatically.  So while early reporting might inaccurately exclude a few thousand later deaths, the CDC’s estimates are not entirely premature for the purpose of comparison to peaks in prior years.

One possible factor lowering the death rate is the surprising finding that H1N1 spares the elderly.  Flu typically strikes people over the age of 65 the hardest, but not this year.  The majority of H1N1 cases are in people younger than 65, and deaths are unusually skewed towards younger patients.  In most years, 90% of flu-related deaths are in people older than 65, but this year, they only account for 10% of the deaths. 

One study found that about a third of people older than 60 already had antibodies to H1N1, compared to only 6% of young adults.  This suggests adults were exposed to a virus similar to H1N1 in the 1950’s and retain lifelong immunity, thus limiting the overall mortality.  A large portion of the missing 25,000 deaths could be immune older adults who survived the flu season without a sniffle. 

Another possibility to explain the lower death count is the vagaries of number-crunching.  It’s difficult to estimate the number of people who die from flu.  There is no accurate and complete nationwide flu-tracking system, the CDC uses data from only ten states to develop their estimates.  Educated guesswork accounts for underreporting, and data from these states is extrapolated the entire nation.

Flu cases and deaths are under-reported, as it’s difficult to define what a flu-related death actually is.  If someone is weak from the flu, falls out of bed striking their head, and dies from a bleed in their brain, does that count as a flu-related death?  What about a person who catches the flu and has a heart attack? (Flu is known to increase the risk of heart attacks, just like everything else.)  A doctor might only record heart attack on the death certificate, unaware that the patient had been suffering from the flu.  Assuming the doctor does report the patient died of flu, this information can be recorded in different places—for example, the death certificate or the patient’s chart.

Given these difficulties, statisticians have access to imperfect data and have to make several assumptions.  The data used and assumptions made will vary from study to study.  The study that determined 36,000 annual deaths from flu used data from the National Center for Health Statistics, which compiles death certificate information from previous years but not the current year.  The current CDC estimate of 11,000 deaths uses rawer data from the Emerging Infections Program.  Given the different methodologies, perhaps comparing these two numbers is like comparing apples to oranges. 

Neti pots are small containers with a nozzle designed for easy insertion into your nostril.  Fill the pot with lukewarm saltwater, made with non-iodized salt instead of table salt–such as pickling salt, or salt sold by neti pot suppliers online or in health stores.  Stand over the sink, tilt your head to the side, and insert the nozzle into the upper nostril.  Pour the saltwater in, and let it drain out of your lower nostril into the sink. Avoid looking at yourself in the mirror if your dignity is important to you.  Check out this link for an entertaining music video starring the neti pot.

Theoretically, rinsing your sinuses breaks up thick mucus and cleans out germs and allergens, thereby improving your health.  Several studies have examined nasal saline irrigation (NSI), as neti pots and similar devices are called in the medical literature. The data do show benefits in people who suffer from sinus-related symptoms such as stuffy nose, cough, and facial pressure.  These studies are small and vary in quality, but generally show that NSI is safe and improves symptoms in many patients who have acute and chronic rhinosinusitis. The research also suggests that NSI reduces the need for steroid nasal sprays.  These findings led this review to conclude that NSI can play a role in the treatment of chronic sinus disease.

However, a more recent study presented last month showed that long-term neti pot use might actually make people sicker.  A team led by Dr. Nsouli, an allergist, followed 68 people with chronic sinus problems who were using neti pots.   The researchers asked them to stop using NSI and counted how many sinus infections they had.  Compared to the prior year, the group suffered 62.5% fewer cases of sinusitis during the year they didn’t use neti pots. Compared to a different group of 24 patients who continued using neti pots into the second year, the group suffered 50% fewer cases of sinusitis.   I asked Dr. Nsouli why he thought neti pots might increase rates of sinusitis.  “NSI will deplete the nose from its immune elements,” he wrote, “resulting in chronic sinus disease.”  By rinsing sinuses every day, not only are you washing out allergens and bacteria, you’re also washing out proteins such as immunoglobulins that help protect the nose and sinuses.   These findings are preliminary and the study has yet to be published in a peer-reviewed journal.  However, they suggest that further research is needed before neti pots should be unreservedly recommended.

So what’s the bottom line?  In the short term, using a neti pot for a few days will probably not do any harm, and it’s likely to help relieve the symptoms of acute sinusitis and nasal congestion.  However, current medical research does not provide a clear answer about long-term use, and it is possible that daily use of a neti pot over several months can do more harm than good.

You might find the calculator useful, but don’t substitute it for common sense.  Remember that most cases of the flu resolve on their own, with or without a doctor’s visit and prescription for Tamiflu, but that rarely people can have serious complications.  Pay attention to what your body is telling you, not an Internet calculator or this website.

I wrote a column about the H1N1 vaccine. And while I’m engaged in blatant self-promotion, check out my column about a cocaine vaccine–I think this is one of the most interesting advances in medicine this year, with fascinating implications for the legal, educational, and public health care systems.

Some of this could soon come true, and unfortunately, it’s not the flying cars.  Researchers just published a study of a new anti-cocaine vaccine, which shows promise that future addicts might be immunized against drugs of abuse.

The researchers gave about 50 cocaine abusers a vaccine against the drug.  About half had a strong immune response, while the remainder only responded weakly to the vaccine.  Those with a strong immune response continued to use cocaine, but at a decreased rate when compared to the weak responders and the placebo group.  Certainly this initial version of the vaccine is no cure for cocaine addiction, but the study is proof of concept that a vaccine can limit drug abuse.

The vaccine itself is a molecule of a cocaine derivative, called succinylnorcocaine, linked to a piece of the bacteria that causes cholera.  The patient’s immune system recognizes the cholera component, and develops antibodies to the cocaine-cholera complex.  The next time the patient uses cocaine, the antibodies recognize the cocaine and neutralize it.  No drug reaches the brain, and the user doesn’t get high.

The concept behind the anti-cocaine vaccine can be applied to other drugs of abuse such as nicotine, meth and heroin.  However, such vaccines will not work against alcohol, which is too simple a molecule.  NicVAX, an investigational anti-nicotine vaccine, shows some promise in reducing smoking rates.  While the anti-nicotine and anti-cocaine vaccines are exciting advances, no anti-drug vaccine will be ready for several years.  Still, it is realistic to expect that vaccines will be a legitimate future treatment option for drug abuse, likely in combination with behavioral counseling.

What will happen once we do have effective vaccines against drugs of abuse?  The implications are fascinating.  People convicted of drug-related crimes might be ordered to go to vaccine clinics instead of prison.  Parents of teenagers abusing drugs might force their children to get the vaccine.  Health care agencies, recognizing that drug abuse burdens society as much as measles, mumps, and rubella, might recommend that you take your two-year old to get an anti-cocaine shot along with those routine immunizations.  Universities seeking to curb recreational drug use might require the vaccine for incoming freshmen. Insurance companies could lower premiums for those who receive the vaccine.  The airline industry or health care industry, recognizing the potential dramatic impact of a coke-snorting pilot or physician, might mandate that their employees get vaccinated.

Once an effective vaccine against drug abuse is here, who should and should not be required to get it?  Share your thoughts below.

To understand the safety issues, here’s a little background.   Common estimates are that at baseline about 1 women in 10,000 will have a blood clot this year; that number increases to about 3 women in 10,000 if they’re taking BCPs.  (Compare this to the fact that more than 50 women in 10,000 will get a blood clot due to pregnancy.)  Since this is true for many BCPs, what’s so special about Yaz and Yasmin?

Like many BCPs, Yaz and Yasmin use both estrogens and progestins to prevent ovulation.  However, unlike other BCPs, Yaz and Yasmin use a new progestin called drospirenone.   The research on drospirenone is contradictory: one study sponsored by the manufacturer found no increased risk in blood clots, while two studies by independent researchers found a slight increase in blood clots from drospirenone.

Let’s take a closer look at these studies that show an increased risk.  A Danish study by Lidegaard, published in the British Medical Journal, examined women taking different types of oral contraceptives.  As expected, they found that the pill increases the risk of blood clots, from an annual rate of 3 per 10,000 women to 6 per 10,000 women.  What did they find specifically about drospirenone?  Comparing drospirenone to levonorgestrel (a progestin found in other BCPs such as Alesse and Nordette), they found that annually, 5.5 women out of 10,000 on levonorgestrel BCPs had blood clots, while about 8 women out of 10,000 on drospirenone had blood clots.  A similar increase was also found when other progestins (desogestrel and gestodene, found in OrthoCept, Mircette, and others) were compared to levonorgestrel.

The second study, done in the Netherlands by van Hylckama Vlieg, found similar results.  Patients taking BCPs had higher rates of blood clots: in patients aged 30-40 years old, the annual rate of blood clots was 2 per 10,000 women in patients who didn’t use BCPs, and 10 per 10,000 women who did use BCPs.  It was lower in women younger than 30 and slightly higher in women older than 40.  While the authors don’t report their results in the same manner as the previous study, extrapolation from their data shows that drospirenone has an annual rate of 12 blood clots per 10,000 women aged 30-40.  Desogestrel BCPs also had similar increased rates compared to baseline.

The bottom line from these studies: Yaz and Yasmin, which use drospirenone,  have a slightly higher risk of blood clots than BCPs using levonorgestrel.  This risk is not dramatically higher.  Furthermore, other BCPs containing desogestrel and gestodene also have a slightly increased risk of blood clots compared to levonorgestrel. 

If you’re weighing the risks and benefits of birth control, remember that BCPs decrease the risk of getting ovarian and endometrial cancer.  Also they definitely decrease the medical risks associated with pregnancy!  To counter those benefits, there are some risks in smokers–people who smoke face increased risks of breast cancer and heart attacks if they use BCPs.  There is debate whether non-smokers have an increased risk of breast cancer and heart attacks while using BCPs, currently there is no consensus on these issues.

So what should you do if  you’re on Yaz or Yasmin?  There’s no immediate cause for serious worry, but please use the information in this post to have an informed conversation with your health care provider about the best option for your individual situation.  There might be a levonorgestrel-based BCP that’s better for you.

A collaboration between the US Military HIV Research Program and the Thai Ministry of Public Health announced that for the first time, a vaccine against HIV has actually been shown decrease your chances of catching HIV.

The trial, which gave about 8,200 people an experimental HIV vaccine called RV144 and 8,200 people a placebo, showed that the vaccine decreased the rate of HIV by about 30%. While the ideal vaccine would have a much higher success rate, this is an important milestone.

Many questions remain to be answered—will the vaccine work as well against HIV strains in Africa, the United States, and other parts of the world as it did against the strain in Thailand? Will it work against HIV transmitted by injection drug use, which delivers a much higher virus load than sex? Was this just a fluke?

Here’s the link to the press report from the US Military, and here’s a link to a good article from the LA Times.

The H1N1 flu vaccine will be available to the US public around October 6. Influenza activity, much of it H1N1, has been increasing the past few weeks in the US, so this is welcome news for all of us: individuals now have an option for protection from an unpleasant illness, health care providers have a new treatment to offer their patients, and anti-vaccine wingnuts finally have some fresh material.  Here’s some answers to common questions about the H1N1 vaccine.

What is the H1N1 flu vaccine and is it different from the seasonal flu vaccine?

The H1N1 vaccine and the seasonal flu vaccine are two separate vaccines against different viruses.  Health care professionals recommend that certain people get both vaccines.

The H1N1 vaccine protects only against the new H1N1 influenza virus, which is the cause of swine flu.  It does not protect against other strains of seasonal flu.  The seasonal flu vaccine, offered every year, provides protection against an additional three common influenza viruses.  Both vaccines are expected to reduce illness, limit hospitalizations, and potentially save lives.

When will the H1N1 flu vaccine and the seasonal flu vaccine be available?

According to the CDC, the first doses of the H1N1 vaccine will ship in early October and be available to the public around October 6. This initial version is the nasal spray. The injectable vaccine will ship soon after.

The seasonal flu vaccine is already available, as a nasal spray and as an injection.

What is the difference between the injected H1N1 vaccine and the nasal spray H1N1 vaccine?

The injected H1N1 vaccine contains viral proteins-it does not contain an actual live virus. The nasal spray contains live, weakened virus.

Due to production issues, the nasal spray vaccine will be available before the injectable vaccine. Unfortunately, since the nasal spray vaccine contains a live virus, it is only recommended in healthy individuals between the ages of 2 and 50. People older than 50 and people with chronic underlying medical conditions should wait for the injectable vaccine.

Who should get the H1N1 flu vaccine?

Vaccine experts recommend that high-risk groups get vaccinated against the illness.  This includes:

● Pregnant women

● Healthcare providers

● People aged 6 months through 24 years

● People who are around infants less than 6 months old

● Anyone with a chronic health condition that increases their risk of severe illness.  Such chronic conditions include but are not limited to asthma, heart disease, emphysema, diabetes, and a weakened immune system.

This includes about 159 million Americans, chances are good you’re one of them.

Though the focus should be on high-risk groups, experts recommend that anyone who wants the vaccine should get it, provided there is enough leftover supply for the general population.

Who should not get the H1N1 flu vaccine?

Anyone with an allergy to eggs should not receive the vaccine, since chicken eggs are used in the manufacturing process for both the nasal spray and the injectable vaccine.  Children less than 6 months should not get the vaccine (instead, people around them should get the vaccine so they are protected).

For adults over 65, the seasonal flu vaccine is highly recommended, but the recommendation for H1N1 vaccine is not as strong.  For reasons that are currently unclear, older adults are less likely to suffer severe illness from H1N1 as compared to younger adults, perhaps due to a certain amount of immunity from prior exposure decades ago.

Who should receive the H1N1 injection vaccine instead of the nasal spray vaccine?

Basically, healthy people between the ages of 2 and 50 can get the nasal spray, anyone else should get the injection. Especially if you have a weakened immune system, you should not receive the live virus nasal spray; get the injection with the killed virus instead. Children who need long term aspirin therapy, such as for conditions like Kawasaki disease, should also receive the injection instead of the nasal spray.

Can I get the H1N1 flu vaccine at the same time as the seasonal flu vaccine?

You can get both injections at the same time. However, if you’re using the nasal spray, you should separate the two by about one month.

How many doses of the H1N1 vaccine do I need?

Adults need just one dose of the vaccine. Children under 10 years need 2 doses separated by a month in order to get a good immune response.

What are the side effects of the H1N1 vaccine?

Similar to the seasonal flu vaccine, the most common side effects of this injectable vaccine are pain at the injection site, muscle aches, headaches, and malaise.  Rarely, patients might suffer severe allergic reactions to the vaccine.

The nasal vaccine’s side effects include runny nose, sore throat, and fevers-symptoms that resemble a very mild case of the flu, but are not nearly as severe or long-lasting as a real influenza infection.

The best data about this vaccine come from two studies recently published in the New England Journal of Medicine. Several hundred adult patients who received the vaccine have been followed for months, and initial data was published several weeks after vaccination.  No serious short-term side effects were found in any of those patients.

Since the nasal spray vaccine is a live virus, can I catch the flu from it?

No. The nasal spray vaccine contains live, attenuated viruses that are cold-adapted. This means that they can live in the relatively cooler temperatures of the nose, but not warmer places deep in the body, such as in the lungs. Because they are limited to the nose, the effects of the virus are mild. Some people do get side effects that resemble a very weak, short-lived flu, but are nowhere near as serious as a real influenza infection.

Will getting the seasonal flu vaccine increase my risk of catching swine flu?

It’s unlikely. Media in Canada are reporting on a study purportedly showing that individuals who got the flu shot in 2008 are more likely to catch H1N1 in 2009. This study has not been published in any scientific journal, so no one knows if it’s accurate. According to Dr. Thomas Freiden from the CDC, investigators have closely looked at data from New York and Australia for similar results, and no increased risk was seen. At this point, all the reliable data and studies that have been published do not show any increased risk of catching swine flu after getting the seasonal flu vaccine.

What is the current status of research on H1N1 vaccine?

As of September 30, several studies of hundreds of healthy adult patients have been published. Research is ongoing in children and pregnant patients.

The H1N1 vaccine is manufactured using the same process as the seasonal flu vaccine, by the same manufacturers in the same factories. Years of research with the seasonal flu vaccine, including research in pregnant patients and children, have shown it to be extremely safe.

What is Guillain Barre Syndrome and why are people talking about it when they’re talking about the H1N1 flu vaccine?

Guillain Barre Syndrome is a rare neurological illness with symptoms ranging from mild muscle weakness to complete paralysis.   While most people recover, some people die from the illness.  Triggers for the disease include infections, most commonly by a bacteria called Campylobacter.

The influenza virus itself can also cause Guillain Barre Syndrome, and there is some debate about whether the seasonal influenza vaccine causes the disease.  If the vaccine does increase the risk, the increase is very slight at about one case per million people vaccinated.  The odds of developing a severe complication such as pneumonia from an influenza infection are higher than that, so even if the vaccine does cause Guillain Barre Syndrome, you’re better off getting the seasonal flu vaccine.

Unlike the controversial link between the Guillain Barre Syndrome and the seasonal influenza vaccine, there is a likely association between the syndrome and a previous swine flu vaccine.  According to the CDC, the 1976 swine flu vaccine caused about one case of Guillain Barre Syndrome for every 100,000 people vaccinated.

The 1976 swine flu vaccine which resulted in an increased risk of Guillain Barre Syndrome was manufactured using different techniques than the current H1N1 vaccine.  Since the current H1N1 vaccine is produced with the same process as the seasonal influenza virus, the risk of Guillain Barre Syndrome is thought to be similar to the very low or negligible risk from the seasonal influenza vaccine.

Is mercury (thimerosal) included in the vaccines?

Some, but not all, of the batches of H1N1 vaccine are thimerosal-free.

Thimerosal is a mercury compound that is added to multi-dose vials of influenza vaccines to prevent bacterial contamination of the medication.  Some groups have questioned whether mercury in vaccines plays a role in the development of autism, but scientific studies have shown no correlation between thimerosal and autism.

Are adjuvants included in the H1N1 vaccines?

No.  None of the current H1N1 vaccines marketed in the US contain adjuvants.

Adjuvants are additional materials that are added to the antigen in a vaccine to make it more effective.  Adding these materials, such as small doses of aluminum, will increase your body’s immune response to the vaccine.

I’ve already had H1N1, should I get the vaccine? If I do, will it harm me?

If you’ve already had H1N1, there’s no point in getting the vaccine. However, if you do get the vaccine, it will not harm you-on the other hand, it won’t help either.

Many people have had flu-like symptoms over the past several months and wonder if it was H1N1, realizing that if it was, there’s no point to getting the H1N1 vaccine. Since most people who have had upper respiratory infections in the past few months did not actually have H1N1, the CDC is recommending that they still get the vaccine against H1N1. This is especially true for people in one of the high-risk groups mentioned above.

H1N1 doesn’t seem to be that lethal, I’m young and healthy, should I really get the H1N1 vaccine?

The CDC recommends that young, healthy people get the vaccine if there is supply available after vaccinating high-risk groups.  Overall, H1N1 does not appear to be particularly more deadly than the seasonal flu, but there is a higher rate of infection in younger people.  It also appears that young, healthy people make up a higher percentage of the deaths from H1N1 than is typical for seasonal flu.  While the chances of you dying from this disease are small, the chances that you will get infected and sick enough to stay home from school or work for a few days is much higher.  The vaccine could prevent both illness and death.

You’ll have to weigh these known benefits from the vaccine versus the unknown risks.  Initial studies of a few hundred adults have shown no danger from the vaccine in the short-term.  In the long-term, since the vaccine is made using the same techniques as the seasonal flu vaccines, the H1N1 vaccine is expected to be equally safe.

Is it possible that these recommendations will change?

Yes.  While the CDC’s recommendations are based on the best evidence available, the H1N1 situation is fluid and new recommendations might be made as more information is known.

Should the virus suddenly become more lethal, the recommendation to vaccinate young, healthy adults will become stronger.  If the rates of H1N1 infection are declining in the US by the time the H1N1 vaccine is introduced, the recommendation to vaccinate might become weaker.  I will continue to update this webpage as more is learned.

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In Your 20’s

Get your blood pressure checked every two years.  Even though high blood pressure is a disease linked to aging, young people can still have hypertension.  High blood pressure causes an increased risk of heart attack, stroke, and heart failure.  Early diagnosis and treatment can substantially reduce your risk of death from those diseases.  A single reading of high blood pressure (the upper number higher than 140 or the lower number higher than 90) is not reliable, and should be repeated at least one week later before making any decisions about changing your lifestyle or starting medications.

Women should get checked for cervical cancer Women should get Pap smears starting at the age of 21, or sooner if you were sexually active before the age of 18 (other experts have slightly different age recommendations from the USPSTF).  Cervical cancer is the second most common cancer in women worldwide.  However, since the introduction of the Pap smear in the 1950’s, the death rate from cervical cancer has plunged as the disease is detected at an early stage while it’s still curable.  In general, experts recommend that Pap smears should be repeated every year for three years, and then if all tests were normal, at least once every three years.

Sexually active women should get screening for sexually transmitted diseases.  The USPSTF recommends that sexually active women under the age of 25 should be checked once for chlamydia and gonorrhea, with future testing depending on sexual behavior and the prevalence of STDs in the area.  Chlamydia and gonorrhea are relatively common STDs that lead to pelvic inflammatory disease, ectopic pregnancies, and infertility.  They often do not cause symptoms in women and can only be detected by medical testing.

Get a complete eye exam by an ophthalmologist once in your twenties.  This exam is more thorough than a simple visual acuity check for glasses.  Read about it in the section for people in their forties.

Visit your dentist, and follow up as recommended.  The American Dental Association does not have a firm recommendations that I could find about how often healthy people should see a dentist.  Recommendations vary from once or twice a year, with follow-ups at intervals recommended by your dentist.  Good preventative oral care at a young age can prevent future oral surgeries and dentures at an old age.

In Your 30’s

Men should get their cholesterol checked around the age of 35.  High cholesterol, like high blood pressure, is a risk for heart attacks and strokes.  Men who are at risk for heart disease-if you smoke, are overweight, have diabetes, have high blood pressure, have a family history of heart disease, or have already had a heart problem-should get this done in their twenties.  You should continue to get your cholesterol checked about once every five years.  If you do have high cholesterol, you will need testing more often based on your health care provider’s recommendations.

Continue screening recommended for people in their twenties.  Get a complete eye exam twice in your thirties, and continue to visit your dentist about once a year for regular checkups and cleanings.  Continue getting your blood pressure checked every two years.  Women should continue regular screening for cervical cancer.

In Your 40’s

Women should start breast cancer screening. Breast cancer is the second most common cause of cancer deaths in women (lung cancer is the most common).  Early detection of breast cancer decreases mortality rates.  The USPSTF, along with the American Medical Association and the American College of Obstetrics and Gynecology, recommends that healthy women start performing mammograms at the age of 40.  Other professional organizations recommend waiting until your 50’s, when the risk of breast cancer is higher.  If you have risk factors for breast cancer, such as a family history for breast cancer, you might want to start screening at a younger age.  Mammograms should be repeated every one to two years.

Women should probably get their cholesterol checked around the age of 45.  There is controversy as to whether all women should get their cholesterol checked, or only women with risk factors for coronary heart disease.  Many experts recommend that all women get screened at the age of 45.  In contrast, the USPSTF recommends that you should only get your cholesterol level tested if you have risk factors.  If you do have risk factors, you should get your cholesterol checked even younger than 45.  You should continue to check your cholesterol every five years, or more frequently if you do have high cholesterol.

Men should start taking aspirin to prevent heart attacks. Heart disease is the leading cause of death in the US.  Aspirin prevents heart attacks, reducing your risk by a quarter to a third.  While aspirin does slightly increase the risk of bleeding stomach ulcers, its benefits outweigh its risks for most men.  Talk with your health care provider to decide whether aspirin is the right choice for you.  To help reduce the risk of intestinal bleeding, the USPSTF recommends taking a low dose of aspirin, known as a “baby aspirin.”  The risk of heart disease is lower in healthy premenopausal women than for healthy men of the same age, which is why this recommendation targets men.

Get checked for diabetes. While the USPSTF does not make any recommendations about screening for diabetes in healthy people, the American Diabetes Association recommends that everyone get a simple blood sugar check around the age of 45.  If you are overweight or have other risk factors for heart disease, including a blood pressure greater than 135/80, then you should get screened for diabetes at a younger age.  The test should be repeated every three years.

Get another complete eye exam at age 40.  Your ophthalmologist will look for diseases such as glaucoma and cataracts, which have no symptoms in their early stages.  Early detection is important to prevent visual loss.  Once many eye diseases develop symptoms, it’s difficult or impossible to regain vision that has already been lost.  People with diabetes will need more frequent eye exams, as the disease is a common cause of blindness.  Based on the results of this exam, your ophthalmologist will recommend when your next eye exam should be.

Continue screening recommended for people in their twenties and thirties.  Get your cholesterol checked every five years.  Continue to visit your dentist about once a year for regular checkups and cleanings, and continue getting your blood pressure checked every two years.  Women should continue regular screening for cervical cancer.

In Your 50’s

Women should start taking aspirin to prevent strokes. After menopause, risk for heart disease and stroke increases.  There is good evidence that aspirin decreases the risk of ischemic stroke.  As with men, the recommendation is to take a “baby aspirin” dose, not a regular strength dose.  Since aspirin does increase the risk of intestinal bleeding, it is important to talk with your health care provider to make sure aspirin’s benefits will outweigh its risks in your specific case.

Get screened for colorectal cancer starting at age 50. The recommendation from the USPSTF is that you get screening with either a fecal occult blood test, which involves giving the lab a stool sample, or with a colonoscopy or sigmoidoscopy, which involves inserting a camera into your large intestine.  Talk to your doctor about the best method for you and the interval which you need it.  In general, fecal occult blood tests are done annually, and sigmoidoscopy and colonoscopy are done every five to ten years.  Colorectal cancer is the second leading cause of cancer death in the US, and early detection of cancerous polyps is estimated to save almost 20,000 lives per year.  People with family members who’ve died of colon cancer or certain intestinal conditions such as Lynch syndrome should get screened at an earlier age.

Additionally, continue screening you’ve already started, including blood pressure, diabetes, and cholesterol checks.  Continue to get complete eye exams at a frequency recommended by your ophthalmologist, usually about once every one to three years.  Continue annual dental checkups and cleanings.  In general, women should continue mammograms and Pap smears, and men should continue daily aspirin.

In Your 60’s

Women should get screened for osteoporosis around the age of 65.  About one-half of post-menopausal women will suffer an osteoporosis-related fracture; many of these could be prevented by taking medications such as bisphosphonates, calcitonin, or hormones.  Screening tests are painless and include an x-ray test called a DXA scan or an ultrasound.  If you have risk factors for osteoporosis, including previous broken bones, excessive alcohol use, or cigarette smoking, you should start your screening at a younger age.  Repeat tests are done every three to five years, perhaps more frequently if you have risk factors.  Though the USPSTF does not make a recommendation for men, other professional societies recommend men consider screening for osteoporosis as well.

Men who have ever smoked should be screened for aortic aneurysms around the age of 65. An aneurysm is a swelling of a blood vessel that is prone to bursting.  When the rupture occurs in your aorta, the largest blood vessel in your body, the results are usually fatal.  The disease is rare in women and non-smokers.  However, the disease is common enough in men who have smoked more than one hundred cigarettes in their life that the USPSTF recommends screening with a simple, painless ultrasound.  If you have a family member with an abdominal aortic aneurysm, you should also consider getting screened for the disease.

Get another complete eye exam around the age of 65 and continue to follow-up at a time period the ophthalmologist recommends, around once every one to two years if no significant problems are detected.

Continue blood pressure checks every two years, diabetes checks every three years, and cholesterol checks every five years, or at a frequency recommended by your health care provider.  Also continue aspirin, mammograms, colorectal cancer checks, and dental checkups and cleanings.

In Your 70’s and Beyond

The USPSTF does not introduce any new screening tests after the age of 65.  At this stage, screening tests are a very individualized decision between you and your health care provider.  It might be appropriate to stop certain screening tests and stop taking aspirin.

As I mentioned in the introduction, these are general guidelines developed in large part by the United States Preventative Services Task Force, whose focus is at the population, not individual, level. These screening test recommendations are designed for healthy people without symptoms of disease.  You have a unique body with unique health care needs, so not all of these recommendations will apply to you.  Further tailoring of recommendations can be done online with this calculator, but it’s no substitute for a conversation with your health care provider about developing a specific plan for your body.