Well: No Consensus on Plantar Fasciitis

Phys Ed

Gretchen Reynolds on the science of fitness.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Boeing Engineers Approve Pact, but Tech Workers Say No

SEATTLE (AP) — The union representing Boeing Co.'s engineers and technical workers delivered a split decision on a new contract Tuesday, with the engineers accepting their offer and the technical workers rejecting theirs and authorizing a future strike.

The union had recommended that both units reject the contract offer because it would not provide pensions to new employees. They would have a 401k retirement plan instead.

The union called that unacceptable, but the Chicago-based airplane-maker said the change was important to the company's future.

The vote came as the company is trying to solve battery problems that have grounded its new 787s. The engineers and technical workers in the union work on plans for new planes and solve problems that arise on the factory floor.

While a strike by the technical workers is not imminent, the vote means the negotiating team can call one at any time, said Bill Dugovich, spokesman for the Society of Professional Engineering Employees in Aerospace.

The engineers' vote means those 15,500 employees have a new four-year contract in place, Dugovich said. Union negotiators hope to resume contract talks soon on behalf of the 7,400 technical workers, he said.

Boeing Commercial Airplanes President and CEO Ray Conner said in a statement that the company was pleased with the engineers' vote but "deeply disappointed" in the technical workers' rejection of what he called the company's "best and final" offer.

"The realities of the market require us to make changes so we can invest in new products and keep winning in this competitive environment ..." Conner said in his statement. "That's why our proposal to move future hires to an enhanced 401(k)-style retirement plan is so important, as we have repeatedly emphasized over the course of these negotiations."

Union members rejected one previous contract offer in October. SPEEA last went on strike for 40 days in 2000.

"With this second rejection by technical workers of Boeing takeaways, it's time for the company to stop wasting resources and improve its offer to reflect the value and contributions technical workers bring to Boeing," SPEEA Executive Director Ray Goforth said in a statement. "That way, we can avoid a strike and focus on fixing the problems of the 787 and restoring customer confidence in Boeing."

The latest labor unrest is happening as U.S. regulators launch an open-ended review of the 787's design and construction. Last month, a battery on a parked 787 caught fire in Boston. On Jan. 16, another 787 made an emergency landing in Japan after another battery problem.

All 50 787s that Boeing had delivered so far are grounded until the issue is resolved.

The union's nearly 23,000 employees are mostly in the Puget Sound region. Union leaders believe a strike would shut down Boeing production lines in Everett, Wash., where its big planes are made, as well as in Renton, Wash., where it cranks out the widely used 737.

The factory-floor assembly work is done by the members of the International Association of Machinists. The Machinists approved a new, four-year contract in December 2011, after a walkout in 2008 that contributed to a 3½-year delay in delivering the first 787.

It was also a factor in Boeing opening a plant in South Carolina, where laws make it more difficult to unionize.

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IHT Rendezvous: Women Killed as 'Witches,' in Papua New Guinea, in 2013

BEIJING — “They’re going to cook the sanguma”, or witchcraft, “mama!”

This terrifying cry by Papua New Guinean children opens “It’s 2013, and They’re Burning ‘Witches’,” a long and eloquent report in The Global Mail, an Australia-based online news site.

It was published last week before news shot around the world on Tuesday that the police in Papua New Guinea, in another case, had charged two people with torturing and killing a 20-year-old mother, Kepari Leniata, whom they accused of being a witch. Ms. Leniata was “stripped, tortured with a hot iron rod, doused in gasoline and set alight on a pile of car tires and trash” earlier this month in front of a crowd of hundreds of people, including young children, The Associated Press reported.

Why?

“Leniata had been accused of sorcery by relatives of a 6-year-old boy who had died in a hospital. Ware and Watea are believed to be the boy’s mother and uncle, police said in a statement,” The A.P. reported.

The year 2013 or not, such violence against women is not that uncommon in Papua New Guinea, where “witches” (in reality just women, often older ones) may be blamed when things go wrong, a reflection of the powerful belief in sorcery in the Pacific nation just north of Australia. A key reason for identifying a woman as a witch and attacking her is when a man, or child, dies unexpectedly.

But there may be other reasons. As the Australian international television station Australia Network reported, in a resource-rich country undergoing a boom, accusing her of being a witch is an easy way to take her land.

Dame Carol Kidu, a Papua New Guinean politician, told the station: “There are other things involved nowadays, like greed, acquisition of people’s properties and land, and all sorts of things might be all tied up in all of this, using – killing the sorcerers as a reason to acquire land. So it needs to be investigated and we need to work out how we can deal with it. It is a very complex issue.”

The United Nations also found that accusations of sorcery can be used to kill women for a range of motives: “The U.N. Human Rights agency says they’ve seen an increase in these types of killings as well as torture and rape. They say the accusations are often used to deprive women of land and property,” U.N. radio reported recently.

What lies behind the ferocity? Traditional beliefs, alcohol and drug use among men, and uneven development in a country that is in the middle of a mining boom where, as The Global Mail wrote, “the wealth bypasses the vast majority.”

It writes: “enduring tradition widely resists the notion that natural causes, disease, accident or recklessness might be responsible for a death. Rather, bad magic is the certain culprit.”

The dead person if often a man; the culprit is a woman. Or, a “witch.”

“When people die, especially men, people start asking ‘Who’s behind it?’ not ‘What’s behind it?’” said Philip Gibbs, a longtime resident, anthropologist, sorcery specialist and Catholic priest who was quoted by The Global Mail.

But in its report, the news site was careful to point out that while many Papua New Guineans believe in sorcery to some degree, that doesn’t mean they support the lynchings.

“In the words of the editor of the national daily Post Courier, Alexander Rheeney, city and country folk alike overwhelmingly ‘recoil in fear and disgust’ at lynch mobs pursuing payback, and at the kind of extremist cruelty that Sister Gaudentia was about to witness,” it wrote, referring to the “cooking” that the children were shouting about.

That’s Sister Gaudentia, a Swiss nun who tries to save “Angela,” a woman accused of witchcraft in the Global Mail article. The article includes powerful photos of accused “witches” (warning – they are graphic, showing machete injuries or healed, hacked-off limbs.)

Hearing the children shout that a witch was about to be cooked, Sister Gaudentia rushed after them. “Two days earlier, she had tried to rescue Angela (not her real name), an accused witch, when she was first seized by a gang of merciless inquisitors looking for someone to blame for the recent deaths of two young men.”

“Angela” was luckier than Ms. Leniata.

She had no male relatives to protect her (a common profile for accused “witches”) and was horribly tortured, but lived, the article says. A “sorcery survivor,” today she is in hiding with her small son.

“Those victims who lived to tell the tale owe their lives either to individual police members or to a strong church leader who intervened for them,” Mr. Gibbs, the anthropologist and priest, told the Global Mail.

“In effect it means that, if sufficiently motivated to act, the power of the police and civil authorities, or the power of the church, can be enough to defend a person who is otherwise powerless,” he said.

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Pistorius charged with murdering girlfriend

PRETORIA, South Africa (AP) — Sobbing softly with his head in his hands, Olympian Oscar Pistorius was charged Tuesday with the premeditated murder of his girlfriend on Valentine's Day. The defense lawyer says it was an accidental shooting.

Prosecutor Gerrie Nel told the court that Pistorius got up from bed, put on his prosthetic legs and walked seven meters (yards) from the bedroom toward the bathroom and shot 29-year-old Reeva Steenkamp several times through the bathroom door, Pretoria. Nel told the court the door was broken open afterward.

The shooting death in the early hours of Valentine's Day of Steenkamp has shocked South Africans and many around the world who idolized Pistorius for overcoming adversity to become a sports champion, competing in the London Olympics last year in track besides being a Paralympian. Steenkamp was a model and budding reality TV show contestant.

Nel said the killing was premeditated because Pistorius had planned to say that he thought he was shooting an intruder. "It was all part of the preplanning. Why would a burglar lock himself inside the bathroom?" Nel said.

Defense lawyer Barry Roux said the shooting was accidental: "We submit it is not even murder. There is no concession this is a murder."

In arguing that Pistorius should be freed on bail, he said there were no other charges outstanding against the 26-year-old double-amputee who last year became the first double-amputee track athlete to run at the Olympics.

As the dramatic court hearing was held in the capital, Steenkamp's body was being driven to a church for a memorial service under gray skies in the south coast city of Port Elizabeth. Six pall bearers carried the coffin draped in white flowers. The family said relatives have gathered from around the world.

June Steenkamp, the mother, said the family wants answers.

"Why? Why my little girl? Why did this happen? Why did he do this?" she said in an interview published Monday in The Times newspaper.

Legal experts say it could take months for the case to be tried.

Pistorius, in a gray suit and tie, nodded after the chief magistrate asked if he was well. And he nodded his appreciation when his brother, Carl, pressed his shoulder in support. Journalists jammed into the courtroom, which was full with almost 100 people, including Pistorius' father, Henke, and the athlete's sister, Aimee.

In an email to The Associated Press on Monday, Pistorius' longtime track coach — who was yet to comment — said he believes the killing was an accident.

"I pray that we can all, in time, come through this challenging situation following the accident and I am looking forward to the day I can get my boy back on the track," Louw wrote in his statement. "I am still in shock following the heart-breaking events that occurred last week and my thoughts and prayers are with both of the families involved."

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National Briefing | South: Abortion Curbs Clear Senate in Arkansas

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

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Japan Finds Swelling in Second Boeing 787 Battery

TOKYO (Reuters) - Cells in a second lithium-ion battery on a Boeing Co 787 Dreamliner forced to make an emergency landing in Japan last month showed slight swelling, a Japan Transport Safety Board (JTSB) official said on Tuesday.

The jet, flown by All Nippon Airways Co, was forced to make the landing after its main battery failed.

"I do not know the exact discussion taken by the research group on the ground, but I heard that it is a slight swelling (in the auxiliary power unit battery cells). I have so far not heard that there was internal damage," Masahiro Kudo, a senior accident investigator at the JTSB said in a briefing in Tokyo.

Kudo said that two out of eight cells in the second battery unit showed some bumps and the JTSB would continue to investigate to determine whether this was irregular or not.

The plane's auxiliary power unit (APU) powers the aircraft's systems when it is on the ground. National Transportation Safety Board investigators in the United States are probing the APU from a Japan Airlines plane that caught fire at Boston's Logan airport when the plane was parked.

The U.S. Federal Aviation Authority grounded all 50 Boeing Dreamliners in commercial service on January 16 after the incidents with the two Japanese owned 787 jets.

The groundings have cost airlines tens of millions of dollars, with no solution yet in sight.

Boeing rival Airbus said last week it had abandoned plans to use lithium-ion batteries in its next passenger jet, the A350, in favor of traditional nickel-cadmium batteries.

Lighter and more powerful than conventional batteries, lithium-ion power packs have been in consumer products such as phones and laptops for years but are relatively new in industrial applications, including back-up batteries for electrical systems in jets.

(Reporting by Mari Saito; Editing by Richard Pullin)

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IHT Rendezvous: Romanian Film Takes Top Prize at the Berlinale

10:46 a.m. | Updated

BERLIN — “Child’s Pose,” a film by the Romanian director Calin Peter Netzer, took the top prize, the Golden Bear, at the 63rd Berlin International Film Festival on Saturday.

The story of a privileged woman whose maternal instincts kick into overdrive when her son kills a teenage boy in a car accident, “Child’s Pose” shares several hallmarks of the recently revitalized Romanian cinema, not least a focus on institutional malaise and corruption. It was written by Mr. Netzer and Razvan Radulescu, who also collaborated on the screenplays of many other acclaimed Romanian films, including “The Death of Mr. Lazarescu” and “4 Months, 3 Weeks, 2 Days.”

The runner-up prize, the Silver Bear, went to another Eastern European social drama, “An Episode in the Life of an Iron Picker.” Directed by the Bosnian filmmaker Danis Tanovic (best known for the Oscar-winning “No Man’s Land”) and based on actual events, the film recounts an impoverished Roma family’s struggles with an unjust health care system, and enlists the real-life couple to re-enact their plight. The male lead, Nazif Mujic, won the best actor prize.

Paulina García, the star of Sebastián Lelio’s “Gloria,” about the romantic reawakening of a Chilean divorcee, won the tightly contested best actress category. David Gordon Green won best director for “Prince Avalanche,” a buddy comedy starring Paul Rudd and Emile Hirsch. And best screenplay went to Jafar Panahi and Kamboziya Partovci for one of the most talked-about films in the competition, “Closed Curtain,” a confessional, self-reflexive drama about an artist and his demons. It is the second movie, after “This Is Not a Film” (2010), that Mr. Panahi has made in defiance of a ban on filmmaking by the Iranian authorities.

The Alfred Bauer Prize for innovation, named for the founder of the Berlinale, went to perhaps the most eccentric film in the competition, the French Canadian director Denis Côté’s “Vic and Flo Saw a Bear,” a darkly comic and melodramatic lesbian love story. The Australian director Kim Mordaunt won the best first feature award for “The Rocket.” And the Teddy Award for best gay-themed film went to the Polish director Malgoska Szumowska’s “In the Name of …,” about a Catholic priest struggling with his homosexuality.

Led by the Hong Kong director Wong Kar-wai, whose new film, “The Grandmaster,” opened the festival, this year’s Berlinale jury included the actor Tim Robbins; the filmmakers Susanne Bier, Andreas Dresen and Athina Rachel Tsangari; the cinematographer Ellen Kuras; and the artist Shirin Neshat.

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Danica Patrick wins pole for NASCAR's Daytona 500

DAYTONA BEACH, Fla. (AP) — Danica Patrick is at her best in the spotlight.

Good thing, too, because she's going to be there all week.

Patrick won the Daytona 500 pole Sunday, becoming the first woman to secure the top spot for any race in NASCAR's premier circuit. It's by far the biggest achievement of her stock-car career. She's braced for the attention that will follow.

"I think when pressure's on and when the spotlight's on, I feel like it ultimately ends up becoming some of my better moments and my better races and better results," Patrick said. "I just understand that if you put the hard work in before you go out there that you can have a little peace and a little peace of mind knowing that you've done everything you can and just let it happen."

Patrick, who taped interviews Sunday with CNN, ESPN and Good Morning America, was the first woman to lead laps in the Indianapolis 500. She finished third in 2009, the highest finish in that illustrious race for a woman. And she became the only woman to win an IndyCar race when she did it in Japan in 2008.

Her latest stamp in the history books came with a lap at 196.434 mph around Daytona International Speedway. Patrick went out eighth in the qualifying session, then had to wait about two hours as 37 fellow drivers tried to take her spot.

Only four-time Cup champion Jeff Gordon even came close to knocking her off the pole. Gordon was the only other driver who topped 196 mph in qualifying. He locked up the other guaranteed spot in next week's season-opening Daytona 500.

"It's great to be a part of history with Danica being on the pole," said Gordon, who joked that at least he was the fastest guy. "I think we all know how popular she is, what this will do for our sport. Congratulations to her. Proud to be on there with her."

The rest of the field will be set in duel qualifying races Thursday.

However the lineup unfolds, all drivers — including boyfriend Ricky Stenhouse Jr. — will line up behind Patrick's No. 10 Chevrolet SS.

"I was brought up to be the fastest driver, not the fastest girl," she said. "That was instilled in me from very young, from the beginning. Then I feel like thriving in those moments, where the pressure's on, has also been a help for me. I also feel like I've been lucky in my career to be with good teams and have good people around me. I don't think any of it would have been possible without that.

"For those reasons, I've been lucky enough to make history, be the first woman to do many things. I really just hope that I don't stop doing that. We have a lot more history to make. We are excited to do it."

Even before her fast lap, Patrick had been the talk of Speedweeks. Not only did she open up about her budding romance with Stenhouse — Patrick officially filed to end her seven-year marriage to 47-year-old Paul Hospenthal in January — but she was considered the front-runner for the pole after leading practice sessions Saturday.

Now, she will garner even more hype.

"That's a huge accomplishment," team owner and fellow driver Tony Stewart said. "It's not like it's been 15 or 20 years she's been trying to do this. It's her second trip to Daytona here in a Cup car. She's made history in the sport. That's stuff that we're proud of being a part of with her. It's something she should have a huge amount of pride in.

"It's never been done. There's only one person that can be the first to do anything. Doesn't matter how many do it after you do, accomplish that same goal. The first one that does always has that little bit more significance to it because you were the first."

The result surely felt good for Patrick, especially considering the former IndyCar driver has mostly struggled in three NASCAR seasons. Her best finish in 10 Cup races is 17th, and she has one top-five in 58 starts in the second-tier Nationwide Series.

She raced part-time in 2010 and 2011 while still driving a full IndyCar slate. She switched solely to stock cars last season and finished 10th in the Nationwide standings.

She made the jump to Sprint Cup this season and will battle Stenhouse for Rookie of the Year honors.

Starting out front in an unpredictable, 500-mile race doesn't guarantee any sort of result, but securing the pole will put her in the limelight for at least the rest of the week.

"I don't think about Danica as a female race-car driver," defending Cup champion Brad Keselowski said. "I think of her as a rookie and someone that hasn't won races or proved that she is competitive."

Patrick won the pole at Daytona for last year's Nationwide race.

But this is considerably different, significantly bigger.

The previous highest female qualifier in a Cup race was Janet Guthrie. She started ninth at Bristol and Talladega in 1977.

"It's obviously a history-making event that will last a long, long time," Guthrie said, praising Patrick's feat. "It's a different era, of course. Different times. I can't imagine what I would do with a spotter or somebody telling me how to drive. It's rather a different sport now. Back then, there was a much greater difference from the front of the field to the back."

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Well: Health Effects of Smoking for Women

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Allure of Self-Insurance Draws Concern Over Costs

WASHINGTON — Federal and state officials and consumer advocates have grown worried that companies with relatively young, healthy employees may opt out of the regular health insurance market to avoid the minimum coverage standards in President Obama’s sweeping law, a move that could drive up costs for workers at other companies.

Companies can avoid many standards in the new law by insuring their own employees, rather than signing up with commercial insurers, because Congress did not want to disrupt self-insurance arrangements that were seen as working well for many large employers.

“The new health care law created powerful incentives for smaller employers to self-insure,” said Deborah J. Chollet, a senior fellow at Mathematica Policy Research who has been studying the insurance industry for more than 25 years. “This trend could destabilize small-group insurance markets and erode protections provided by the Affordable Care Act.”

It is not clear how many companies have already self-insured in response to the law or are planning to do so. Federal and state officials do not keep comprehensive statistics on the practice.

Self-insurance was already growing before Mr. Obama signed the law in 2010, making it difficult to know whether the law is responsible for any recent changes. A study by the nonpartisan Employee Benefit Research Institute found that about 59 percent of private sector workers with health coverage were in self-insured plans in 2011, up from 41 percent in 1998.

But experts say the law makes self-insurance more attractive for smaller employers. When companies are self-insured, they assume most of the financial risk of providing health benefits to employees. Instead of paying premiums to insurers, they pay claims filed by employees and health care providers. To avoid huge losses, they often sign up for a special kind of “stop loss” insurance that protects them against very large or unexpected claims, say $50,000 or $100,000 a person.

Such insurance serves as a financial backstop for the employer if, for example, an employee is found to have cancer, needs an organ transplant or has a premature baby requiring intensive care.

In a report to clients last year, SNR Denton, a law firm, wrote, “Faced with mandates to offer richer benefits with less cost-sharing, small and midsize employers in particular are increasingly considering self-insuring.”

Officials from California, Maine, Minnesota, Utah, Washington and other states expressed concern about the potential proliferation of these arrangements at a recent meeting of the National Association of Insurance Commissioners.

Stop-loss insurers can and do limit the coverage they provide to employers for selected employees with medical problems. As a result, companies with less healthy work forces may find self-insuring more difficult.

Christina L. Goe, the top lawyer for the Montana insurance commissioner, said that stop-loss insurance companies were generally “free to reject less healthy employer groups because they are not subject to the same restrictions as health insurers.”

Insurance regulators worry that commercial insurers — and the insurance exchanges being set up in every state to offer a range of plan options to consumers — will be left with disproportionate numbers of older, sicker people who are more expensive to insure.

That, in turn, could drive up premiums for uninsured people seeking coverage in the exchanges. Since the federal government will subsidize that coverage, it, too, could face higher costs, as would some employees and employers in the traditional insurance market.

Large employers with hundreds or thousands of employees have historically been much more likely to insure themselves because they have cash to pay most claims directly.

Now, employee benefit consultants are promoting self-insurance for employers with as few as 10 or 20 employees.

Raeghn L. Torrie, the chief financial officer of Autonomous Solutions, a developer of robotic equipment based in Petersboro, Utah, said her business started a self-insured health plan for its 44 employees on Jan. 1 as a way to cope with the uncertainties created by the new law.

“We have a pretty young, healthy group of employees,” she said.

In Marshfield, Mo., J. Richard Jones, the president of Label Solutions, an industrial label-printing company with 42 employees, said he switched to a self-insurance plan this year “to hold down costs that were going up because of government regulation under Obamacare.”

The Township of Freehold, N.J., made a similar decision in January to gain more control over benefits and costs for its 260 employees.

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