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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Pistorius Returns to Court Seeking Bail on Murder Charge

PRETORIA, South Africa — Prosecutors accused Oscar Pistorius, the double amputee track star, of premeditated murder on Tuesday, saying he opened fire four times on his girlfriend through a closed bathroom door after putting on his prosthetic legs and walking more than 20 feet from a bedroom.

Prosecutor Gerrie Nel said Reeva Steenkamp, the victim, had been in a tiny room measuring roughly 16 square feet. “It must have been horrific,” he said.

But a lawyer acting for Mr. Pistorius, Barry Roux, said the defense would “submit that this is not a murder.” He said there was no evidence that Mr. Pistorius, 26, and Ms. Steenkamp, 29, had fought and there was no evidence of a motive.

Mr. Pistorius returned to a Pretoria courtroom on Tuesday to seek bail — a step police officials have said they will oppose. It was his second appearance before the same court.

Ms. Steenkamp’s funeral was scheduled for later on Tuesday in the southern coastal city of Port Elizabeth, her hometown.

The police arrived at Mr. Pistorius’s house in a gated community in Pretoria early last Thursday to find Ms. Steenkamp dead from gunshot wounds. Mr. Pistorius, who ran on carbon-fiber blades that earned him the nickname of Blade Runner, has disputed the charge against him.

Early news reports in South Africa said that Mr. Pistorius, a gun enthusiast, had accidentally shot his girlfriend, thinking she was an intruder. But those suggestions gave way to grim police accounts of previous law enforcement complaints about domestic episodes at his home and the charge of premeditated murder.

The development stunned a nation that had elevated Mr. Pistorius as an emblem of the ability to overcome acute adversity and a symbol of South Africa’s ability to project its achievements onto the world stage.

During his first court appearance on Friday, Mr. Pistorius did not enter a formal plea. But a statement released by his agent said that he disputed the charge of premeditated murder “in the strongest terms” and that “our thoughts and prayers today should be” for Ms. Steenkamp, and her family, “regardless of the circumstances of this terrible, terrible tragedy.”

If convicted, Mr. Pistorius would face a mandatory life sentence, though under South African law he would be eligible for parole in 25 years at the latest. South Africa abolished the death penalty in 1995.

Mr. Pistorius was born without fibula bones and both of his legs were amputated below the knee as an infant. But he became a Paralympic champion and became the first Paralympic sprinter to compete against able-bodied athletes at the 2012 London Olympics.

His triumphs made him a global track star but the case has forced him with cancel forthcoming events. Several companies have withdrawn lucrative sponsorships and his case has played into an emotional debate in South Africa about violence against women.

Members of the Women’s League of the ruling African National Congress protested outside the building, waving placards saying: “No Bail for Pistorius,” Reuters reported.

Lydia Polgreen reported from Pretoria, South Africa, and Alan Cowell from London.

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Nudes check out nudes at Austrian museum

VIENNA (AP) — These museum goers didn't just leave their outerwear at the coat check. They handed over their shirts, trousers, underwear — everything, except their shoes and socks.

The occasion Monday at Vienna's Leopold Museum was a special after-hour showing of "Nude Men from 1800 to Today" — an exhibit of 300 paintings, photographs, drawings and sculptures focused on the bare male.

For many, the evening was a goose-bump raising instance of life imitating art.

"I can't say I'm sweating," said office worker Herbert Korvas, as he stood in the atrium with other young men wearing no more than socks and a smile and waiting for the tour to start. Still, he said he was drawn to the idea of naked museum viewing "because it was something different."

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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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Killing Off TV Characters Carries Risk

The shocking ending of this season’s “Downton Abbey” — shocking at least for those who managed to avoid the news when the finale was shown in Britain in December — most likely left thousands of the show’s fans mourning the loss of a beloved character and angry with the show’s creators for erasing him from their lives.

The plot twist, though, was just the latest in a long tradition of television character assassinations, many of which have elicited reactions of shock, pain, sorrow, fury and sometimes laughter from devoted watchers. “Downton’s” leading man, Matthew Crawley, played by Dan Stevens, left the series in a screech of tires on a country road on Sunday, never to return. That is, unless, some other character, perhaps his beloved Mary, steps into a shower at some future time and declares that his death was all a dream. That, of course, was the infamous solution employed by the venerable television family saga “Dallas” in the ill-conceived decision to kill off a central character, Bobby Ewing, in 1985.

Generally, though, the decision to terminate a television character means there is no going back. And while many show creators say the decision to kill off a popular character carries a risk, potentially alienating viewers, in almost every case shows survive. They often thrive, the producers say, because shaking up viewers is almost always a good thing.

The death of Matthew in “Downton” recalls many other plot developments that have taken place in the middle of successful television runs, like the heart-tugging death in 1998 of Bobby Simone, the character played by Jimmy Smits in “NYPD Blue.”

But some deaths have taken place on shows as little recalled as the comedy “The Hogan Family,” which changed names mid-run from “Valerie” after the series lead, Valerie Harper, staged a salary protest. (Her character died, like Matthew, of an auto accident.)

As happened in “Downton,” a character’s exit is often driven by an actor’s decision to pursue other artistic challenges or bigger paychecks. The latter was the case with the demise of Lt. Col. Henry Blake, the character played by McLean Stevenson for the first three seasons of “M*A*S*H” on CBS.

After Stevenson signed a contract with NBC, the “M*A*S*H” producers gave Colonel Blake a send-off episode, in which he said his goodbyes and flew away. Even the cast (other than the star Alan Alda) didn’t know a coda scene would be added, to deliver the news that the colonel had gone down in a plane crash.

Stevenson’s career went with it. His character’s death stirred hostile reactions not only from the fans, who poured in angry letters, but also from CBS, which wasn’t happy its hit comedy had broken viewer’s hearts.

Today, thanks to the Internet and social media, audiences have more immediate ways to voice their fury. When the ABC drama “Lost” had a core character, Charlie, played by Dominic Monaghan, drown trying to save his friends, the show’s top producers were inundated with protests.

“People were really angry,” said Carlton Cuse, who with Damon Lindelof, was a main creative voice on the show. “They proceeded to blast the heck out of Damon and me for this woefully misguided decision. We thought people would be shocked, but we were unprepared for that level of anger.”

Mr. Cuse noted the unexpected extinguishing of characters is a growing — and mostly welcome — trend.  “If you watch ‘CSI Miami’ and someone puts a gun to David Caruso’s head, you know he’s not going to be shot,” he said. In recent years, especially on cable dramas, writers are more willing to blow up such conventions. “Now I think people are reaching further narratively, and maybe those shots of adrenaline are not as unusual as they were in the past,”  Mr. Cuse said, pointing out that “The Walking Dead” on AMC kills off familiar characters almost routinely. “These moments are really good for television, because as a storyteller you want to attack and break up those conventions the audience has in their minds.”

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Singer Mindy McCready dies in apparent suicide

HEBER SPRINGS, Ark. (AP) — Perhaps there was one heartbreak too many for Mindy McCready.

The former country star appears to have taken her own life Sunday afternoon in Heber Springs, Ark. Authorities say McCready died of an apparent self-inflicted gunshot to the head and an autopsy is planned. She was 37, the mother of two young sons.

If confirmed, it was at least her fourth suicide attempt since 2005, ending a series of tumultuous public events that marked much of the singer's adult life.

Speaking to The Associated Press in 2010, McCready smiled wryly while talking about the string of issues she'd dealt with over the last half-decade.

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

This time it seems the whirlwind overwhelmed McCready.

Her death comes a month after that of David Wilson, her longtime boyfriend and the father of her youngest son. He is believed to have shot himself on the same porch of the home they shared in the small wooded community of large lakefront houses about 65 miles north of Little Rock, Ark., and his death also was investigated as a suicide.

It was the most difficult moment in a life full of them. McCready issued a statement last month lamenting his death. And she called him her soul mate and a caregiver to her sons in an interview with NBC's "Today" show.

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

Like so many times before, McCready showed a little toughness in the midst of a personal storm, again endearing herself to her fans. But as usual, the brave face for the camera hid a much more complicated internal struggle that surfaced publicly time and again over the last 10 years.

This time, along with her remembrances of finding Wilson as he lay dying, she also answered questions about whether they'd argued earlier that evening about an affair and if she'd shot him.

"Oh, my God," the "Today" transcript reads. "No. Oh, my God. No. He was my life. We were each other's life."

It's unclear what circumstances led to McCready taking her own life, but it appears she was struggling again with twin issues that have persisted for years — substance abuse and the custody of her children. She checked into court-ordered rehab and gave her children up to foster care earlier this month after her father asked a judge to intervene, saying she'd stopped taking care of herself and her sons and was abusing alcohol and prescription drugs.

It's not clear where her sons, 6-year-old Zander and infant Zayne, were Sunday.

A deputy stationed outside McCready's home Sunday night referred questions to the Cleburne County sheriff, who was unavailable. Yellow crime-scene tape cordoned off the front yard and a dark-colored pickup truck sat in the driveway.

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

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

And Carrie Underwood added: "I grew up listening to Mindy McCready...so sad for her family tonight. Many prayers are going out to them..."

Melinda Gayle McCready arrived in Nashville in 1994 still in her teens with tapes of her karaoke vocals and earned a recording contract with BNA Records. She had a few memorable moments professionally, scoring her first No. 1 hit almost immediately.

"Guys Do It All the Time," a self-assured dig at male chauvinism, endeared her to female fans in 1996. She also scored a hit with "Ten Thousand Angels," and her album of that title sold 2 million copies.

Beyond that, though, she's mostly remembered for a string of dramatic moments as she spent the next 15 years chasing another huge hit. Her problems included a custody battle with her mother over one of her sons, an overdose and discord in her love life.

She made headlines in April 2008 when she claimed a longtime relationship with baseball great Roger Clemens. Published reports at the time said she met the pitcher at a Florida karaoke bar when she was 15 and he was 28 and married. Clemens denied the relationship. A decade earlier she was engaged to actor Dean Cain, but the two never married.

She also had a turbulent relationship with Billy McKnight, a country singer who is the father of her oldest son. McKnight was arrested in 2005 on charges of attempted murder after authorities say he beat and choked her.

During this period she also pleaded guilty to obtaining the painkiller OxyContin fraudulently at a pharmacy and got probation. She violated the probation with a drunken driving arrest in May 2005, a few days before McKnight was arrested. And in July 2007, she was arrested in her hometown of Fort Myers, Fla., on misdemeanor charges of scratching her mother, Gayle Inge, on the face during a scuffle and resisting sheriff's deputies.

Less than a year later, McCready was arrested and charged with violating her probation by falsifying her community service records relating to the 2004 drug charge. A month later, she entered an extended care facility for undisclosed treatment, and followed that with a 60-day jail sentence. Inge took custody of Zander.

There were at least three suicide attempts between July 2005 and December 2008.

She tried to get help in an unusual way, joining the cast of "Celebrity Rehab 3" with Dr. Drew Pinsky. McCready came off as a sympathetic figure during the show's run. Pinsky called her an "angel" and in an interview in 2010 said it appeared McCready was doing "rather well."

Pinsky helped treat McCready for love addiction on the show and said he'd referred her to professionals who could continue to help her afterward.

"A love addict basically is somebody that really didn't have a good model for intimacy in their childhood, often times traumatized in one way or another, thereby intimacy becomes a risk place, becomes an intolerable place," Pinsky said. "And so what they tend to do is attach themselves to idealized, bigger than life, unavailable others, specifically go after some public figure that's married or go after some rock star who is himself a sex addict and not interested in a relationship, and then idealize that person and actively pursue them to the point of obsession."

McCready is the fifth celebrity to pass away since appearing on Pinsky's show and the third from Season 3. Alice in Chains bassist Mike Starr and "Real World" participant Joey Kovar both died due to overdose. In the months after her stint, she said she found some peace and told The Associated Press in early 2010 she hoped to get her career restarted, write a book about her experiences and begin production on a reality show with her brothers. She'd just met Wilson and talked openly about their relationship, though the producer and musician declined to speak on the record.

With a publicist, reporters, cameras, makeup artists and musicians swirling around her during a press day for her last album "I'm Still Here," McCready fended off questions about a sex tape and said she and Wilson started out as friends.

"And I've never had a relationship like that before where we started completely as friends," she said. "It turned into friends really caring about each other and then it turned into love and I've never had that happen before."

At the time, Pinsky thought the relationship was on the right track: "She's an easy person to like and to care about and we hope she does well," Pinsky said. "So far so good as far as I can tell."

McCready said her main goal in 2010 was to pull her family back together: "I would like my son back with me and for my brothers and I and he to be able to go and do this (TV reality show), and I think after that I will be a pretty happy girl."

The new album debuted at No. 71 and failed to gain radio airplay. McCreary's plans never materialized and she soon was in legal trouble again, this time fighting for custody.

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

She and Wilson had their son in April 2012.

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

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Well: Health Effects of Smoking for Women

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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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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