text:
This information is produced and provided by the National Cancer Institute (NCI). The information in this topic may have changed since it was written. For the most current information, contact the National Cancer Institute via the Internet web site at http://cancer.gov or call 1-800-4-CANCER.
This summary briefly covers smoking as a primary risk factor for cancer, but the main focus is on the effect of smoking on recurrence or on diagnosis of a second primary cancer; patterns of quitting and continued smoking in cancer patients; and recommendations for smoking intervention for cancer patients. This information will assist health professionals caring for patients during and after treatment. Substantial material on cancer prevention and smoking cessation in the general population is available elsewhere. Because virtually all the available evidence pertains to cigarettes rather than other forms of tobacco such as snuff or chewing tobacco, reference is made to smoking cigarettes rather than to tobacco use.
In this summary, unless otherwise stated, evidence and practice issues as they relate to adults are discussed. The evidence and application to practice related to children may differ significantly from information related to adults. When specific information about the care of children is available, it is summarized under its own heading.
The relationship between tobacco use and cancers of the lung and head and neck has been established for almost 50 years. Of the estimated 53,000 cases of head and neck cancer diagnosed each year, 85% are associated with tobacco use. The relative attributable risk for morbidity from smoking for lung cancer is more than 90%; it is between 60% and 70% for other smoking-related cancers (larynx, oral cavity, esophagus, bladder, kidney, pancreas, and other urinary cancers).[1] Evidence suggests that smoking before age 30 years is a strong risk for colorectal cancer, with the risk appearing after a very long induction period (>35 years) in both men [2] and women.[3]
Smokers may also be at increased risk of regional and metastatic disease at diagnosis.[4] In one study, smoking worsened the course or outcome of acute myeloid leukemia, particularly in younger patients and those with unfavorable karyotypes.[5] A study of renal cell carcinoma patients suggests that improvement in renal cell carcinoma risk following smoking cessation may be relatively linear but may take more than 20 years to reduce risk to that of a nonsmoker.[6]
Smoking contributes to cancer development by causing mutations in tumor suppressor genes and dominant oncogenes and by impairing mucociliary clearance in the lungs and decreasing immunologic response.[7] (Refer to the PDQ summary on Lung Cancer Prevention for more information.)
Evidence exists for substantial medical advantage to an individual quitting smoking once cancer is diagnosed. There is substantial evidence that continued smoking may reduce the effectiveness of treatment and increase the likelihood of a second cancer. (Refer to the Smoking as a Risk for Second Malignancy section of this summary for more information.) Continued smoking may also worsen side effects of treatment,[1] although the direct evidence for this is surprisingly limited because few studies have evaluated this issue.
If one extrapolates from the extensive evidence of the effects of smoking on cardiovascular disease, pulmonary functioning, immunosuppression, and wound healing due to vasoconstriction and the fairly rapid reduction of some effects following smoking cessation,[2,3] these results might also apply to cancer patients, particularly if surgical management or lung functioning is involved. For example, one study outlined a model of cardiopulmonary toxicities in response to various antineoplastic therapies that may be potentiated by tobacco use. More specifically, smokers treated with bleomycin or carmustine showed higher levels of pulmonary fibrosis and restrictive lung disease, and the anthracyclines led to higher risk of cardiomyopathy in smokers.[4]
In a study of advanced head and neck cancer patients receiving radiation therapy,[5] patients who continued to smoke during radiation therapy suffered mucositis for a longer time (23.4 weeks) than did patients who quit at the time of radiation therapy and remained abstinent (13.6 weeks) or patients who remained abstinent for at least a month after treatment (18.3 weeks). Extended mucositis may be associated with permanent alteration in appearance. In one study, patients receiving induction chemotherapy for acute myeloid leukemia who continued to smoke were more likely to experience severe pulmonary infection (26% vs. 18%), although overall survival rates did not differ in adults older than 60 years.[6] Following radiation therapy for laryngeal carcinoma, patients who continue to smoke may be less likely to regain satisfactory voice quality.[7]
Another area of reasonable concern for patients who continue to smoke is the rate of general complications following any type of surgery. It is documented that wound healing postsurgery is slowed in smokers because both nicotine and carbon monoxide cause vasoconstriction, inhibition of epithelization, and creation of cellular hypoxia.[8,9] In one study of predictors of complications following resection in lung cancer patients, a history of smoking doubled the likelihood of complications, but smoking at the time of admission for surgery did not.[10] However, no detailed information on the time since smoking had ceased was provided.
One study found decreased response rates and survival rates in patients with head and neck cancer who continued to smoke during treatment. Patients who continued to smoke had a significantly lower rate of complete response to radiation therapy (45% vs. 74%) and 2-year survival (39% vs. 66%). Recent quitters were more similar to long-term quitters than to continued smokers in survival likelihood at 18 months.[11]
Another study also showed an effect of continued smoking on survival rates in patients with head and neck cancer.[12] Those who stopped smoking doubled their chance of survival, irrespective of extent of disease at diagnosis; after 2 years, survival of quitters approached that of nonsmokers. Relative risk for recurrence in quitters was about double that in nonsmokers; in those who continued to smoke after diagnosis, relative risk for recurrence quadrupled, regardless of the amount they smoked. One study failed to find significant differences in prognosis in resected stage I non-small cell lung cancer patients on the basis of smoking status; the recurrence and death rates in both former and current smokers did not differ but were double to triple the rates in newer smokers.[13] These differences failed, however, to reach statistical significance because of the small number of newer smokers; in addition, the lack of differences between former versus current smokers was hard to interpret because no definitions were provided.
In another study, a consistent trend was found in patients with small cell cancer: continued smokers had the poorest survival, followed by patients who quit at diagnosis, then by patients who had quit on average 2.5 years before diagnosis.[14] Although survival curves of recent ex-smokers did not differ statistically from continued smokers, perhaps because of small numbers, no continued smokers (n = 57) survived past 131 weeks, whereas six of those who quit at diagnosis (n = 35) were in complete remission at 1 and 2 years.
The relationships between smoking, disease recurrence, and mortality rates for prostate cancer have been examined. Studies have found an association between continued smoking and earlier recurrence [15,16] and increased mortality.[17] In a study of 1,416 men who underwent radical prostatectomy, recurrence occurred after a mean of 7.3 years in 34.3% of current smokers, 14.8% of former smokers, and 12.1% of those who had never smoked.[16] Another study found higher 5-year mortality rates in patients with stage D2 disease (88% vs. 63%) and non–stage A disease (39% vs. 17%).[15] In a prospective observational study of 5,366 men, prostate cancer–specific death rates were 15.3 per 1,000 person-years for current smokers versus 9.6 per 1,000 person-years for those who had never smoked. Prostate cancer patients who quit smoking for 10 years or longer had mortality rates similar to those of nonsmokers.[17]
Persons who initially present with both smoking-related and non–smoking-related malignancy face increased risk of a second malignancy at the same site or another site if they continue to smoke.[1,2] When prognosis is more favorable for the initial cancer, the evidence is even stronger that continued smoking increases the risk of new primary cancers for up to 20 years after original diagnosis. In two studies of survivors of small cell lung cancer (SCLC) (mostly stage I and II),[3,4,5] risk of a second cancer (mostly non-SCLC [NSCLC]) was 3.5-fold to 4.4-fold higher than in the general population. In those who continued to smoke, the risk was far higher, particularly in those who also received chest irradiation (relative risk [RR] = 21.0) and alkylating agents (RR = 19.0).[4] In individuals who stopped smoking at the time of diagnosis, the risk was no higher than in those who had stopped smoking at least 6 months before diagnosis.
In a study of breast cancer survivors who subsequently developed lung cancer,[6] the risk for subsequent lung cancer in those who were treated with thoracic radiation therapy (XRT) alone was negligible, whereas the risk attributable to smoking was substantial (adjusted odds ratio [OR] = 5.6) and even higher for a combination of XRT and smoking (unadjusted OR = 9.0, P < .05; adjusted OR = 8.6, P = .08). Even higher multiplicative risk for subsequent lung cancer from radiation treatment and smoking (RR = 20.2) was identified in a study of Hodgkin lymphoma survivors,[7] which found higher multiplicative effects (RR = 49.1) for a combination of radiation and alkylating agents in moderate to heavy smokers compared with other cases. Another study in Japan confirmed that patients with SCLC who survive at least 2 years greatly reduced their likelihood of a second cancer if they quit smoking.[8]
Patients with oral and pharyngeal cancers who smoke also have an exceptionally high rate of second primary cancers. A follow-up study of more than 1,000 patients with oral cancers found that the risk of a second cancer increased with continued smoking up to almost five times as much (OR = 4.7) for all aerodigestive cancers among long-term heavy smokers (two packs or more per day), even after controlling for alcohol, which carries its own excess risk. No effect was seen for quitting within 2 years, but risk decreased significantly after 5 years' cessation.[9] Another study [10] confirmed this increased risk, though at a somewhat lower level. More than 1,000 patients with early-stage head and neck squamous cell carcinoma were examined for the joint effects of tobacco and alcohol exposure on second primary tumors (SPT) up to 6 years after initial diagnosis. SPT cases were more likely to be current smokers (27.5% vs. 18.8%) who smoked more for a longer period and used forms of tobacco other than cigarettes or in combination with cigarettes. Overall risk for SPT was approximately double for smokers. Most increased risk was associated with continued smoking (RR = 2.1) and alcohol intake (RR = 1.3) after diagnosis, although no interaction effect was evident.
The relationship between smoking and progression of prostate cancer has also been documented. One study found a much higher 5-year tumor-specific mortality rate among smokers with stage D2 disease (88% vs. 63%) or non–stage A disease (39% vs. 17%), which was attributed to immunosuppressive effects of continued smoking.[11] Finally, the impact of smoking on risk of a secondary lung cancer has been demonstrated in survivors of Hodgkin lymphoma.[7,12]
Most patients with a smoking-related cancer stop smoking or make serious efforts to quit at the time of diagnosis.[1,2,3,4] One study reported that approximately half of a group of patients with oral and pharyngeal cancers quit at or after diagnosis;[5] heavier smokers were substantially more likely to quit. Another study found a 12-month abstinence rate of 64.6% among head and neck cancer patients.[2] A quit rate of 52% was reported in 115 head and neck cancer patients just before diagnosis, suggesting that an increase in smoking and cancer-related symptoms drives a substantial part of the decision to quit smoking, in addition to knowledge of the diagnosis.[6]
Even patients who continue to smoke may remain motivated to quit. In a group of stage I small cell lung cancer patients, almost 90% had made one or more attempts to quit smoking, although 60% of survivors still smoked at 2 years.[1] In another study, 84% of the sample had made at least one attempt to quit since surgery, and 69% had made multiple attempts.[3] These studies found that while 80% of larynx and pharynx cancer patients remained abstinent after surgery, only 20% of those with oral cavity cancers did so. Patients who had undergone less intensive treatment (in particular, radiation therapy) were more likely to remain smokers; if they quit, they were 2.46 times more likely to resume tobacco use, even after controlling for severity. Higher relapse rates have also been associated with less radical treatment of head and neck cancers.[7]
Such a relationship between continued smoking and less severe disease has also been found in cardiac patients.[8] Another group in which secondary prevention may be particularly important is survivors of childhood cancer. In pediatric cancer survivors, initiation of smoking may be as high as in a group of healthy peers. An excellent review of the findings and recommendations in addressing smoking in this population has been published.[9]
Surprisingly few smoking intervention studies have been conducted with cancer patients. Many patients report quitting smoking at the time of diagnosis, and many others have comorbidities that prevent enrollment in clinical trials, yet little is known about routine smoking cessation services in an oncology setting. Thus, a smoking cessation feasibility study reported on implementation issues.[1] In this study, 14,514 adult cancer patients were screened as potential participants, with fewer than 2% of patients determined to be eligible. Barriers to enrollment and exclusion criteria included the following:
Eighty-four percent of eligible patients enrolled. Compared to those who enrolled, those who declined were more likely to have advanced disease. Those who enrolled had extensive smoking histories (mean, 38 years), scored very high on measures of nicotine dependence, and averaged about seven drinks per week; about one-quarter of enrollees reported clinical levels of depressive symptoms. Researchers concluded that integrating a smoking cessation program into routine clinical care is feasible, although challenging, and that particular attention should be given to the subpopulation of smokers who also experience depression.[1]
Another study found that when consistent intervention was provided to a group of head and neck cancer patients, about 65% were able to quit and remain abstinent, including about half of those who expressed little interest in quitting at baseline.[2][Level of evidence: I] A large intervention study with head and neck cancer patients used surgeon- or dentist-delivered advice to stop smoking, contracted quit dates, written materials, and booster advice sessions. Partially because of a high drop-out rate, a significant intervention effect was not detected, though differences were in the expected direction.[2] A similar study [3][Level of evidence: I] also failed to find beneficial effects for very brief (<5 minutes) physician-delivered interventions based on the Ask, Advise, Assist, Arrange model outlined below. More than 400 cancer patients with a range of diagnoses were randomly assigned to receive either intervention or usual care. Approximately half had been diagnosed within the previous 6 months, 46.3% had tried to quit in the previous 6 months, and 84% were considering quitting in the following 6 months. Patients randomly assigned to the intervention group acknowledged receiving advice and resources from their physician consistent with the protocol; however, there were no significant differences in quit rates at either 6-month follow-up (11.9% vs. 14.4%) or 12-month follow-up (13.6% vs. 13.3%). Patients were more likely to quit smoking if they had been diagnosed with head and neck cancer or lung cancer, were lighter smokers, expressed a strong desire to quit, and used additional intervention resources. These results suggest that very brief physician counseling for this high-risk group is not adequate to improve quit rates.
A case-controlled retrospective study [4][Level of evidence: III] examined the effects of referral to a nicotine dependence center for more than 200 smokers diagnosed with lung cancer compared with smokers without a lung cancer diagnosis. Most lung cancer patients were less likely to have made previous attempts to quit but expressed higher motivation to quit smoking than did individuals without lung cancer. Although the likelihood of being abstinent at 6 months postintervention was higher among lung cancer patients (22% vs. 14%), after adjusting for demographic variables and level of motivation, there was no statistically significant difference. Patients who were closer to diagnosis at the time of intervention were far more likely to be abstinent at 6 months (27.3% vs. 0% for 3–6 months vs. 7% for >6 months, P = .01). In general, a brief smoking intervention consisting of approximately 1 hour of tailored intervention, including prescription of pharmacologic treatment, showed relatively little impact in this high-risk population. However, referral sooner after diagnosis may increase the likelihood of quitting. This study is limited by the self-selection of patients and lack of a nonintervention comparison group.
Considerable work has been done, however, with other patient groups—particularly cardiac patients—in establishing the valuable role of physicians and other health care providers in providing smoking intervention in the context of medical care. Specific recommendations for intervening in tobacco use have been published in several contexts. On the basis of outcomes from six major clinical trials of physician-delivered smoking intervention conducted in the late 1980s,[5] the Ask, Advise, Assist, Arrange model was developed. In this model, the physician provides a brief intervention that entails asking about smoking status at every visit, advising abstinence, assisting by setting a quit date, providing self-help materials, recommending the use of nicotine replacement therapy, and arranging for a follow-up visit. See the list below for brief and expanded intervention outlines. The Patient-Centered Counseling Key Elements list below provides detailed questions that may be asked in the assist phase in a patient-centered counseling format that is brief enough (5–7 minutes) to be delivered within the context of a usual office visit.[6][Level of evidence: I]
These recommendations form the core of the Public Health Service–sponsored Clinical Practice Guideline [7][Level of evidence: IV];[8] that extended the recommendations by strongly supporting the value of referral to more intensive counseling. Furthermore, in addition to the documented value of nicotine replacement therapy (using gum, lozenge, patch, nasal spray, or inhaler), there is now clear evidence for the value of the antidepressant bupropion HCl (Wellbutrin SR and Zyban), 150 mg twice a day, as an adjunct for treatment;[9] however, these adjunctive pharmacological treatments have not been tested in cancer patients. Individuals should be advised to check with their physicians.
Not all smokers are equally motivated to stop smoking. One of the most useful models for physicians in understanding the motivational issues in stopping smoking and actually quitting is the Stages of Change Model. Most individuals attempting to change a complex behavior such as smoking go through several predictable stages, from precontemplation to contemplation to preparation and, finally, to action. One of the goals of brief physician counseling is to move patients along these stages, until they are more motivated to quit. In addition, especially for first-time quitters, relapsing and cycling through these stages one or more times is common, until the person develops better behavioral skills.
The most common triggers for relapse are stressful situations and social triggers for smoking. One study found that the patterns of relapse in head and neck cancer patients were comparable to patterns of relapse in quitters in the general population.[10][Level of evidence: II] Smokers should be encouraged to anticipate such situations and develop strategies for handling them, as part of developing a new identity as a nonsmoker. It may take more than a year for even motivated smokers to successfully make these changes. The Stages of Change Model is well described and summarized [7] and is outlined as part of the Ask, Advise, Assist, Arrange Key Elements list below. Other important information such as smoking history (e.g., amount smoked or previous attempts to quit) can be efficiently collected by asking patients to complete a brief set of self-assessment forms in the waiting room. Nicotine addiction can be assessed using the Fagerstrom Test for Nicotine Dependence, and behavioral patterns (e.g., tendency to smoke when under stress) can be assessed using the online Quit Guide. When talking to patients about smoking cessation, providers can use a fact sheet available from the Centers for Disease Control and Prevention.
Psychiatric disorders and alcohol abuse may be complicating factors in the treatment of smoking, regardless of the population. Smoking prevalence is notably higher among those with mental or alcohol disorders,[11,12] and response to treatment is poorer.[13,14]
A comprehensive longitudinal study [15] of all patients (N = 1,425) seen over a 3-year period at the MD Anderson Cancer Center Tobacco Treatment Program identified individuals with major depression (n = 194), an anxiety disorder (n = 53), alcohol abuse (n = 92), or combinations of these disorders (n = 255), with the remainder (n = 831) having no psychiatric diagnosis. Across groups, individuals smoked an average of one pack per day. Patients received an individually tailored behavioral intervention, generally consisting of an in-person initial evaluation and an average of eight treatment sessions over 3 to 4 months, either in person or by phone, with follow-up at 6 months. Smoking-related pharmacotherapy was part of treatment for 88% of participants; about 15% also received a consultation with the program's addiction psychiatrist.
Individuals with no psychiatric diagnosis had abstinence rates of 44% at the end of the program and 45.1% at 6 months. Abstinence rates for clinical groups at 6 months varied, as follows:[15]
Regardless of the diagnosis, the best predictor of extended abstinence was the Fagerstrom Test for Nicotine Dependence (FTND) (overall average score, 4.9 [standard deviation, 2.2]; group range, 4.7 [no diagnosis] to 5.4 [major depression]). The overall conclusion is that in an intensive comprehensive program for cancer patients who are smokers, such as the program offered here, individuals with an anxiety disorder are likely to do as well as individuals without any diagnosis, but those with major depression or alcohol abuse may do more poorly, particularly if their FTND scores are higher.
Tailoring intervention for specific populations may also be important, although this has not been examined specifically in cancer patients. A study of the effects of self-help intervention materials designed for an African American population showed higher quit rates (25%) among those receiving the tailored materials than among those receiving the standard materials (15.4%) at 12 months postintervention.[16][Level of evidence: I]
Other investigators have begun to examine intervention approaches specific to patients at high risk for developing lung cancer, through the use of genetic biomarker feedback (presence of the CYP2D6 genetic abnormality, which increases the risk of developing lung cancer twofold to fourfold) in otherwise healthy smokers. Adding information on genetic risk for cancer to the usual counseling approaches increased initial quit rates significantly, but this effect was not maintained; such an approach may be a useful motivational component to add to a more comprehensive intervention but may not be sufficient in itself.[17][Level of evidence: I]
Ask, Advise, Assist, Arrange Key Elements
Patient-Centered Counseling Key Elements
The following information is based on the successful use of pharmacological agents in the cessation of smoking in the general population. None of the following agents have been studied in large placebo-controlled studies in cancer patients for aid in smoking cessation. Dosage adjustments or titrations may be required when administering these agents to oncology patients. (Refer to Tables 1 through 7 for more information.)
Nicotine Replacement Therapies
Nicotine replacement therapies are designed to aid in the treatment of withdrawal symptoms associated with nicotine. Several precautions must be considered before therapy is initiated, but these precautions do not constitute absolute contraindications.
Varenicline (Chantix)
Varenicline is a nicotinic acetylcholine receptor partial agonist and the first U.S. Food and Drug Administration (FDA)-approved prescription pharmacologic agent targeted to these nicotinic receptors.[2][Level of evidence: I] Although specific mechanisms of action are unknown, it is thought that the agonist properties result in reduced craving and withdrawal by stimulating release of dopamine, and the antagonist properties prevent inhaled nicotine from binding at the nicotinic receptor sites.[3]
There have been at least 12 published randomized, controlled trials evaluating varenicline versus placebo (or other approved agents for smoking cessation) for its ability to affect abstinence rates related to smoking or the use of smokeless tobacco.[2,4,5,6,7,8,9,10,11,12,13,14] All studies were relatively large (129–607 patients per arm) and involved multiple sites and countries. In all studies, varenicline was statistically better in achieving abstinence rates by self-report and carbon monoxide measures than was placebo, and was often better than the other approved smoking cessation comparator arm. Abstinence rates at 12 weeks can be expected to range from 44% to 49% for varenicline, compared to 11% to 17% for placebo; longer-term rates (52 weeks) range from 14% to 22% for varenicline versus 4% to 8% for placebo.
Most studies evaluated varenicline 1 mg twice a day, using a 1-week titration of 0.5 mg daily for 3 days, 0.5 mg twice a day for 4 days, and then 1 mg twice a day for 11 weeks. However, a few studies evaluated different doses, such as 0.3 mg or 0.5 mg daily or 0.5 mg twice a day, and one study evaluated a flexible dosing schedule during weeks 2 to 12 after all participants were titrated up to 1 mg twice a day in an open-label fashion. From these data, varenicline 0.5 mg twice a day appears to be the minimum dose required to achieve statistically significantly better abstinence rates over placebo.[9,10]
Most studies included healthy smokers, i.e., those without significant comorbidities such as cardiovascular disease or psychiatric disease. One study evaluated varenicline in patients with chronic obstructive pulmonary disease,[12] and another study focused on patients with stable cardiovascular disease.[11] However, no studies have evaluated varenicline use in cancer populations.
More than 3,000 patients in clinical trials received varenicline 1 mg twice a day for 12 to 24 weeks. The side effect profile across these 12 studies [2,4,5,6,7,8,9,10,11,12,13,14] was very consistent (although incidence varied) and comprised the following:
Cardiovascular events often occurred as frequently in the placebo and nicotine replacement arms as in the varenicline arm and overall were rare.
Only one study evaluated varenicline in patients with stable cardiovascular disease. At week 24, this study demonstrated 7-day abstinence rates of 34.9% for varenicline versus 15.9% for placebo (P < .0001); at week 52, these rates were 27.9% for varenicline and 15.9% for placebo (P = .0001).[11] The prevalence of any adjudicated cardiovascular event was 7.1% in the varenicline arm and 5.7% in the placebo arm, for a difference of 1.4%.[11]
A boxed warning for varenicline addresses the risk of neuropsychiatric events—specifically, suicidal ideation or behavior, agitation or hostility, depressed mood, and uncharacteristic behavior or thinking.[15] For patients with significant comorbidities, the risks of smoking and varenicline use must be weighed against the benefits of smoking cessation. The dose-finding trial and package insert provide evidence that the incidence of adverse events is somewhat dose dependent.[10,15] It is not known, however, whether cardiovascular risks—in particular, in patients with cardiac comorbidities—are dose related because the study evaluating varenicline in patients with stable cardiovascular disease only studied varenicline 1 mg twice a day.[11] This is an area in need of investigation.
In a pooled analysis of two randomized studies (total N = 2,052) in which varenicline was directly tested against bupropion SR and a placebo,[3] results showed continuous abstinence rates of 44% with varenicline, 29.7% with bupropion SR, and 17.7% with placebo at weeks 9 through 12. Abstinence rates were followed through week 52 at study end, with varenicline at 22.4%, bupropion SR at 15.4%, and placebo at 9.3%. Factors found in previous studies to predict better quit rates—such as being older, being male, having a lower level of nicotine dependence, smoking fewer baseline cigarettes, and having the first cigarette of the day at a later time—were not found to be predictive of higher quit rates in this pooled analysis.[3]
In June 2011, the FDA updated the prescribing information label for varenicline to warn that the drug may increase the risk of cardiovascular adverse events in patients who have cardiovascular disease.[16] The change is based on findings from a clinical trial of 700 smokers who had cardiovascular disease.
Bupropion Hydrochloride (HCl)
Also used as an antidepressant, bupropion HCl (Zyban) is a non-nicotine aid to smoking cessation. It is a relatively weak inhibitor of the neuronal uptake of norepinephrine, serotonin, and dopamine and does not inhibit monoamine oxidase. The exact mechanism by which bupropion HCl enhances the ability of patients to abstain from smoking is unknown; however, it is presumed that this action is mediated by noradrenergic or dopaminergic mechanisms.[17] One study [18][Level of evidence: I] failed to find any additional value of bupropion HCl in reducing relapse in individuals using the nicotine patch compared with a placebo either as part of a relapse prevention program (after the end of successful patch therapy) or as a second-level treatment for individuals who were still smoking after nicotine-patch therapy.
There are concerns that varenicline and bupropion HCl may be associated with an increased risk of depression and other neuropsychiatric events, including suicidal behaviors.[15,19] This concern is based on postmarketing reports and post hoc analyses.[15,19] Attempted and completed suicides have also been reported in patients taking these medications.[20] These neuropsychiatric events have been reported in patients with or without preexisting psychiatric illness.
In July 2009, the FDA required the manufacturers of both varenicline and bupropion HCl to add a boxed warning to the product labeling, based on the continued review of postmarketing adverse event reports.[20] The warning describes the risk of the following neuropsychiatric events from postmarketing reports:[15,20]
The warning acknowledges that nicotine withdrawal related to smoking cessation may contribute to these neuropsychiatric events. The warning also acknowledges that causality between the medication exposure and these events cannot be conclusively established and states that the risks of these medications should be weighed against the potential health benefits of quitting smoking.
It is recommended that clinicians closely monitor all patients taking varenicline and bupropion HCl. The premarketing smoking cessation studies of these medications excluded patients with serious psychiatric illness (e.g., schizophrenia, bipolar disorder, and major depressive disorder), suggesting that the safety of these medications for these patients has not been investigated.[15,20] Therefore, during smoking cessation, it is important to especially monitor patients with preexisting psychiatric illness who are receiving varenicline and bupropion HCl for smoking cessation.
Patients can be carefully matched to specific smoking cessation strategies. Some smokers can quit with the help of counseling or psychological interventions, while others might need nicotine replacement therapies. Some smokers might need medications to successfully quit smoking. Given the significant health benefits derived from smoking cessation, medications can be used in these patients with careful monitoring.
Fluoxetine HCl
Although bupropion HCl (Zyban) is the only FDA-approved antidepressant for smoking cessation, fluoxetine HCl (Prozac) has been studied and shown to be effective.[17][Level of evidence: I] However, fluoxetine HCl also carries a boxed warning describing an increased risk of suicidality in adults younger than 25 years.[21] (Refer to the Depression and Suicide section in the PDQ summary on Pediatric Supportive Care for more information.)
Lobeline (Bantron)
Lobeline (Bantron) is classified as a category III agent by the FDA (safe but no proven effectiveness). This product is not recommended for use in any smoking cessation program because of its lack of efficacy.[22]
The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.
This summary was renamed from Smoking Cessation and Continued Risk in Cancer Patients.
This summary is written and maintained by the PDQ Supportive and Palliative Care Editorial Board, which is editorially independent of NCI. The summary reflects an independent review of the literature and does not represent a policy statement of NCI or NIH. More information about summary policies and the role of the PDQ Editorial Boards in maintaining the PDQ summaries can be found on the About This PDQ Summary and PDQ NCI's Comprehensive Cancer Database pages.
If you have questions or comments about this summary, please send them to Cancer.gov through the Web site's Contact Form. We can respond only to email messages written in English.
Purpose of This Summary
This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about the risks of continued smoking in cancer patients and about quitting patterns and cessation intervention in these patients. It is intended as a resource to inform and assist clinicians who care for cancer patients. It does not provide formal guidelines or recommendations for making health care decisions.
Reviewers and Updates
This summary is reviewed regularly and updated as necessary by the PDQ Supportive and Palliative Care Editorial Board, which is editorially independent of the National Cancer Institute (NCI). The summary reflects an independent review of the literature and does not represent a policy statement of NCI or the National Institutes of Health (NIH).
Board members review recently published articles each month to determine whether an article should:
Changes to the summaries are made through a consensus process in which Board members evaluate the strength of the evidence in the published articles and determine how the article should be included in the summary.
Any comments or questions about the summary content should be submitted to Cancer.gov through the Web site's Contact Form. Do not contact the individual Board Members with questions or comments about the summaries. Board members will not respond to individual inquiries.
Levels of Evidence
Some of the reference citations in this summary are accompanied by a level-of-evidence designation. These designations are intended to help readers assess the strength of the evidence supporting the use of specific interventions or approaches. The PDQ Supportive and Palliative Care Editorial Board uses a formal evidence ranking system in developing its level-of-evidence designations.
Permission to Use This Summary
PDQ is a registered trademark. Although the content of PDQ documents can be used freely as text, it cannot be identified as an NCI PDQ cancer information summary unless it is presented in its entirety and is regularly updated. However, an author would be permitted to write a sentence such as "NCI's PDQ cancer information summary about breast cancer prevention states the risks succinctly: [include excerpt from the summary]."
The preferred citation for this PDQ summary is:
National Cancer Institute: PDQ® Smoking in Cancer Care. Bethesda, MD: National Cancer Institute. Date last modified <MM/DD/YYYY>. Available at: http://cancer.gov/cancertopics/pdq/supportivecare/smokingcessation/HealthProfessional. Accessed <MM/DD/YYYY>.
Images in this summary are used with permission of the author(s), artist, and/or publisher for use within the PDQ summaries only. Permission to use images outside the context of PDQ information must be obtained from the owner(s) and cannot be granted by the National Cancer Institute. Information about using the illustrations in this summary, along with many other cancer-related images, is available in Visuals Online, a collection of over 2,000 scientific images.
The information in these summaries should not be used as a basis for insurance reimbursement determinations. More information on insurance coverage is available on Cancer.gov on the Coping with Cancer: Financial, Insurance, and Legal Information page.
Contact Us
More information about contacting us or receiving help with the Cancer.gov Web site can be found on our Contact Us for Help page. Questions can also be submitted to Cancer.gov through the Web site's Contact Form.
Call 1-800-4-CANCER
For more information, U.S. residents may call the National Cancer Institute's (NCI's) Cancer Information Service toll-free at 1-800-4-CANCER (1-800-422-6237) Monday through Friday from 8:00 a.m. to 8:00 p.m., Eastern Time. A trained Cancer Information Specialist is available to answer your questions.
Chat online
The NCI's LiveHelp® online chat service provides Internet users with the ability to chat online with an Information Specialist. The service is available from 8:00 a.m. to 11:00 p.m. Eastern time, Monday through Friday. Information Specialists can help Internet users find information on NCI Web sites and answer questions about cancer.
Write to us
For more information from the NCI, please write to this address:
Search the NCI Web site
The NCI Web site provides online access to information on cancer, clinical trials, and other Web sites and organizations that offer support and resources for cancer patients and their families. For a quick search, use the search box in the upper right corner of each Web page. The results for a wide range of search terms will include a list of "Best Bets," editorially chosen Web pages that are most closely related to the search term entered.
There are also many other places to get materials and information about cancer treatment and services. Hospitals in your area may have information about local and regional agencies that have information on finances, getting to and from treatment, receiving care at home, and dealing with problems related to cancer treatment.
Find Publications
The NCI has booklets and other materials for patients, health professionals, and the public. These publications discuss types of cancer, methods of cancer treatment, coping with cancer, and clinical trials. Some publications provide information on tests for cancer, cancer causes and prevention, cancer statistics, and NCI research activities. NCI materials on these and other topics may be ordered online or printed directly from the NCI Publications Locator. These materials can also be ordered by telephone from the Cancer Information Service toll-free at 1-800-4-CANCER (1-800-422-6237).
Last Revised: 2012-10-23
This information does not replace the advice of a doctor. Healthwise, Incorporated disclaims any warranty or liability for your use of this information. Your use of this information means that you agree to the Terms of Use. How this information was developed to help you make better health decisions.
To learn more visit Healthwise.org
© 1995-2012 Healthwise, Incorporated. Healthwise, Healthwise for every health decision, and the Healthwise logo are trademarks of Healthwise, Incorporated.


text:
A single photo - no words - capturing a moment from the week. A simple, special, extraordinary moment.
A moment I want to pause, savor and remember.
-inspired by SouleMama
That's a content little one for sure. Happy New YearReplyDelete
Looks like you've got a future farmer on your hands! Love it when kids play on their tummy and get right up into their toys. You've captured a great moment.ReplyDelete
How fun! Playing on the floor is the best. Thanks for sharing.
oh how I miss getting toys for Christmas! Love the moment! Happy News Year to you and your family!ReplyDelete

subset: commoncrawl


text:
28 photos
$3,750,000 29 acres Thorne Bay Road, Thorne Bay, Alaska 99919 - Ketchikan Gateway Borough
Location: Located in the lush rainforest of Prince of Wales Island, on the south arm in Thorne Bay just 35 minutes by floatplane from Ketchikan in Southeast Alaska. Parcel Size: 29 Acres subdivided into seven parcels, plus a Tidelands lease with DNR for small island Legal Address: Thorne Bay Subdivision, Block 5, Lots 8,9,10,13,14,15. Buildings: 4,500 sq.ft. original log lodge building completed around 1987, a second 4,000 sq.ft. guests building built around 1996, additional buildings include an office, laundry room, two bunkhouses, fish packing plant, warehouse, and apartment plus 4 other work sheds. The total square footage of all buildings today is approximately 17,000 square feet. Included is a 1,000 foot Boardwa
James Riley J. Riley Realty LLC


text:
BY yollanthe On Jun 08, 2018 Template
Loss and profit statement for self employed free basic. Free profit and lossnt self employed basic for. Profit and loss statement self employed template pics printable financial for.
Templatet and loss statement self employed pics basic free. Profit and loss statement self employed pics inspiration personal sponsorship letter template for. Profit and losst self employed free for basic. Profit and loss statement self employed free for.
Template basic self employed profitd loss statement free for. 7 self employed profit and lossement case 2017 template free basic. Free profit and losstatementelf employed basic for best of 11.
80/100. User Ratings (731 Votes)
318 Facebook Shares
163 Twitter Tweets
264 Pinterest Pins
293 G+ Shares
170 Thumblr Shares
209 Lkdln Shares
Yollanthe is a home editor and is also (naturally) a total homebody. But she'll always venture out for her book club, a heaping bowl of steaming ramen, or the latest Kristen Wiig flick.
Recent Posts
Static Pages
Intellectual Property Policy and Infringement Claims - Privacy Policy - Terms of Use
© 1999-2019 Tientas.com. All rights reserved.


text:
Kannada Packages
Receive the most popular South Asian programming with our Kannada Packages
Select a region to find a package in your language.Change Region
Save with our best deals
Call 877-608-2740 to learn more
Enjoy the latest television programming from South Asian from the comfort of your own home when you sign up with our international Kannada packages offered by DISH. Stay updated with the some of the most popular South Asian TV shows, movies, music, children's programs, documentaries, and more at an everyday low price. The Kannada Package has entertainment the whole family can enjoy from different parts of Kannada and South Asia. Check out the international packages below to see what Kannada channels can be delivered to you in 100% digital quality and sound.
Kannada: Mega
Sign up for the Kannada Mega package from DISH to stay updated with Karnataka, India. Receive the latest South Asian television programming including movies, serials, game-shows, educational programs, and LIVE news from Karnataka. Check out the Kannada package below to see the entertainment you can receive from DISH in 100% digital quality and sound.


text:
Supreme Court shows little sympathy for whales beset by sonar
WASHINGTON — Whales may simply have to pay the price as the Navy prepares for war, Supreme Court justices suggested Wednesday.
In a closely watched environmental case, justices Wednesday morning repeatedly sounded sympathetic to Pentagon officials who want to run large-scale Navy exercises off the Southern California coast. While the resulting underwater sonar storm disturbs marine mammals, it also helps prepare sailors for combat.
"I thought the whole point of the armed forces was to hurt the environment," Associate Justice Stephen Breyer said, half-jokingly. "Of course they're going to do harm."
The Pentagon and environmentalists disagree over exactly how much mid-frequency active sonar injures marine mammals, and justices Wednesday couldn't resolve the conflict. An apparent majority of justices, though, did appear ready to defer to military expertise in matters of national security.
Chief Justice John Roberts raised the specter of an undetected "North Korean diesel submarine to get (closer) to Pearl Harbor" if sailors couldn't train with sonar, and Associate Justice Samuel Alito asked pointedly if a judge could be considered "an expert on anti-submarine warfare." Alito added that there is "something incredibly odd" about a trial judge making a decision "contrary" to the Navy's requirements.
Even Breyer, who at times has been skeptical about other claims of executive authority, suggested that "an admiral (who) comes along with an affidavit that seems plausible" might outrank a "district judge who just says" the training should stop.
"You're asking us (for a decision), who know little about whales and less about the Navy," Breyer told Los Angeles-based attorney Richard Kendall, who's representing environmental groups.
The technical but crucial legal question in Winter v. Natural Resources Defense Council is when a federal agency can sidestep conventional environmental protections by declaring an emergency. A Pentagon victory could make such emergency declarations more common, and on more than just military matters.
Even before the hour-long oral arguments Wednesday, legal scholars were predicting the conservative-led court was likely to defer to military necessity in time of war. The prediction is enhanced by the fact that Winter v. Natural Resources Defense Council arises from the San Francisco-based 9th Circuit Court of Appeals, which the Supreme Court reversed in eight out of 10 cases last year.
It's the conflict between whales and sailors, though, that gives the case its sizzle.
Underscoring the stakes — and perhaps as part of a bit of courtroom staging — an array of uniformed Navy officers sat prominently in the front row of the visitors section Wednesday.
The Navy needs the Southern California Operating Area for training exercises, which prepare naval strike groups for deployment to the Pacific Ocean and Middle East. Sailors use mid-frequency active sonar to detect otherwise hard-to-find submarines.
The Southern California coastal waters are also home to at least 37 species of marine mammals, including pygmy sperm whales, coastal bottlenose dolphins and endangered blue whales.
The Navy's sonar produces piercing underwater sounds that Kendall said was 2,000 times louder than a jet engine. Some scientists say sonar use can cause hearing loss, cranial bleeding, behavioral modifications and mass strandings.
A district court imposed additional safety measures on the Navy, including stopping sonar use when marine mammals were spotted within 2,200 yards and powering down the sonar under certain other conditions.
"The Navy is perfectly able to train under these circumstances," Kendall said.
The Bush administration's Council on Environmental Quality declared "emergency circumstances" existed, which the administration argues should dissolve the district court's training limitations. Administration officials also dispute the extent of harm, noting that Navy exercises have been taking place off the Southern California coast for the past four decades.
"No marine mammals will be killed as a result of these exercises," Solicitor General Gregory Garre told the court. "They hear the (sonar) sound, and they go in the opposition direction. It also has some temporary effect on their feeding patterns."
Associate Justice David Souter pressed Garre vigorously, insisting that the Navy may have brought the emergency circumstances on itself, but Associate Justice Anthony Kennedy added that a presidential declaration of military necessity "certainly must be given great weight."
Kendall predicted the court should rule within two months, prior to the next — and final — training session planned for the Southern California Operating Area.
Supreme Court skeptical about smokers' deception claims
Next president will reshape U.S. courts from top to bottom
Supreme Court's new session to be devoted to business
Plaintiffs, defendants find going slow in federal courts


text:
"Temper your fly fishing with artistry.....put as little as you can between the trout and you..."
From Fishing Small Flies by Ed Engle
Hi, this is Ed Engle. I'm making some exciting changes to my fly fishing. Check out the "What's New" tab below for details.
Copyright © 2018 Ed Engle/EdEngleFlyFishing.com All Rights Reserved


text:
IBM FRU - AC Adapter - 120W TP G40 - 2 Pin - Lite On - No Cable - Requires 13H5264 - Sub 02K7086 - Option 22P9150, IBM 02K7092.
* We have limited quantity of 02K7092 in stock. Our inventory changes constantly and quantities listed are based on available stock. This item comes with our 100% Money-Back Guarantee.
I purchased a battery for my Gateway cx2610 laptop from Code Micro. I was very happy with the produ...
Jason G.
Great NorthWeb
Our department needed two discontinued drive modules for our servers. Code Micro delivered on time. ...
Mark E.
Citi Corp


text:
Now that the Ab Lounge has sold over 4 million units and is making its' manufacturer Fitness Quest piles of money, it was only a matter of time until it was knocked off – enter the Ab Chair.
The Ab Chair makes some pretty bold claims. It says it's easy to get great abs, it's better than the Ab Lounge XL and even has a bicycle attachment for cardio…
Ab Chair Manufacturer Claims:
"With the Ab Chair Deluxe™, you can transform flabby abs into sexy swimsuit abs in just minutes a day, unlike other ab machines such as the Ab Lounge or Ab Lounger, which take a longer time to give you the sexy abs you've always wanted..
The advanced "crunch" system behind the revolutionary Ab Chair Deluxe™ works your abdominal muscles with a fuller range of motion than traditional crunches, sit-ups, or other ab machines like the Ab Lounge or Ab Lounger can provide, with less strain on your back and neck."
Are you freakin' kidding me with these bogus claims? I'll tell you this, the Ab Lounge is a piece of junk (although you wouldn't know it by how many desperate people bought one) so when I see a copy cat machine like the Ab Chair I want to barf.
A bicycle attachment on an ab machine? Yes you read right, they're so desperate to sell them they're trying to fool you into believing this is a good idea (I would call it a solution in search of a problem myself).
If you're a glutton for punishment and want to waste your money, by all means get an Ab Chair. When you get serious about getting in shape and are willing to put some effort into the process read my review of the best ab machine here.


text:
Kicking the Whitney Museum of American Art's trend of blending art and fashion up a notch, the museum's co-chair Adam Lippes last night hosted a laid-back celebration of his collaboration with the institution and online retailer Gilt Groupe.
The elegantly dressed partygoers were feting the July 1 launch of "ADAM for The Whitney Museum of American Art," a collection of four limited edition T-shirts designed by Whitney-selected artists Matthew Brannon, E.V. Day, Phoebe Washburn and Ellen Harvey. Gilt will donate a portion of shirt sales to the museum, although a representative from the company declined to identify a specific percentage. For his part, Lippes plans to make a set donation regardless of sales. "It's not a moneymaking initiative," said the designer.
Jewelry designer Zani Gugelmann, CNN anchor Alina Cho, and fashion writer Derek Blasberg were among the guests admiring the tees, which were individually rolled and tied with a bow at the entrance. The Transom particularly liked E.V. Day's shirt, which featured an image of a fishnet stocking stretched diagonally across the front, outlined in hot pink spray paint.
Host Adam Lippes mentored the artists—most of whom had never designed clothing before—in translating their ideas into wearable designs. According to Lippes, the project had been in the works for almost a year. Artist Matthew Brannon watched as cocktail waiters navigated the crowds in his design, which features an image of measuring tape across the chest and a graphic red shrimp on the back shoulder. "It's the first time I've seen it," he told The Transom. "I'm a little surprised to see it's a man's shirt."
It was hard to tell which was the true star of the party—the T-shirts or Adam Lippes' apartment. "If I lived in an apartment like this, I'd never leave the house," laughed Whitney trustee Joanne Cassulo, taking in the sunset through the wall-to-wall windows of the West Village penthouse. "It's why I had to downsize." Then she tiptoed off to peek at Lippes' art collection, which included two large works by Dash Snow and a small Eric Fischl painting, the host's most recent acquisition.
But who knew fashion heavyweights got all dressed up to celebrate dressing down? The unofficial dress code was glam: Vogue editor Meredith Melling Burke donned a floor-length orange gown and Bergdorf Goodman fashion director Roopal Patel wore a long, gray silk number.
The Gilt project is one of several recent Whitney initiatives to blend fine art and fashion. The museum recently announced a partnership with artist Jenny Holzer to design sneakers for Bloomingdale's as well as a project inviting three M.F.A. students to enact a "live exhibition" inside a Bloomingdale's shop window.
In 2008, the Whitney partnered with the Gap to produce T-shirts designed by artists featured in the Whitney Biennial. But the Lippes T-shirts, which will sell at ADAM boutiques and the Whitney gift shop after a 36-hour presale on Gilt, will run you a bit more than the $28 Gap charged. The discounted prices range from $48 to $68, while the retail prices are $95 to $125.
Chuckled Whitney PR manager Amy Roth, "I can't tell you how many artists of senior stature have asked me, 'Why didn't you ask me to do a T-shirt?'" But when asked which high-profile artists were itching to break into the design business, Roth demurred. Art-inclined fashionistas will just have to wait for another Whitney T-shirt collaboration to see who makes the cut.


text:
You are here
American Society for Gastrointestinal Endoscopy
Since its founding in 1941, the American Society for Gastrointestinal Endoscopy (ASGE) has been dedicated to advancing patient care and digestive health by promoting excellence and innovation in gastrointestinal endoscopy. ASGE, with nearly 12,000 members worldwide, promotes the highest standards for endoscopic training and practice, fosters endoscopic research, recognizes distinguished contributions to endoscopy, and is the foremost resource for endoscopic education.
ASGE physicians have highly specialized training in endoscopic procedures of the digestive tract, including upper gastrointestinal (GI) endoscopy, flexible sigmoidoscopy, colonoscopy, endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS). ASGE is the only medical society that requires documentation of specific training in GI endoscopic procedures.


text:
All of my social media platforms are filled right now with posts about children heading back to school. Many parents are sending their almost grown-up kids to college for the first time. It is a time filled with anxiety for both the child and the parent as the child takes their first steps towards independence and adulthood.
But amongst all of these FaceBook notices, I see another trend emerging. Mothers are proudly proclaiming that their daughters are their best friends and that this split will be exceptionally hard on both of them.
Honestly, I totally don't understand this. I have never had a desire to be the cool, hip mom. And though I am a very open-minded and approachable parent, my children are not and never will be my best friends. To me, it is just the inherit nature of being a parent.
3 Reasons I Will Never Be My Daughter's Best Friend
1. Best Friends Are Equals
As long as my daughter is reliant on me for her emotional growth, career guidance and financial support, there will be an inequality in our relationship. I am, as I should be, on a higher rung on the proverbial ladder.
Yes, best friends can provide those things too but I really don't think any of them will step up to pay for a wedding or help with the down payment on a house.
2. Best Friends Tell Each Other Everything
It is very important to always be available, open and non-judgemental as a parent. It encourages your daughter to come to you to discuss issues and problems with you. Your job as a parent is to affirm your daughter's personal value and worth and meet all of her emotional needs.
This kind of support should always be one-sided and a parent should never use their daughter as their own personal sounding board or built-in therapist. Daughters should not feel responsible for their mother's emotional well-being. Children should not be burdened with their parents' problems.
If you are discussing things of a personal nature with your teenage or young adult daughter, you are being overly dependent on her for your own emotional needs. Find your own friends.
3. Best Friends Don't Make Rules And Set Boundaries
Teenagers test the rules and young adults need to stretch their wings and try to fly on their own under your watchful eye. Your responsibility to your daughter is completely different from that as a best friend. You need to set boundaries and enforce rules. That doesn't sound like a best friend to me and once you cross that line with your daughter, it will be very difficult to reign her back in. How confusing is it for her if you oscillate between best friend and mom?
I have many friends and they have carried me through many dark times. I want my daughter to find those kinds of relationships outside of me. I want her to be able to build close relationships with girlfriends and her future partner. I want to be her mom, not her friend.
I anticipate that once my daughter is out in the world, making her own way and has children of her own, our relationship will change. Maybe I shouldn't say never. Maybe we can be best friends then.
What is your relationship with your adult daughter?
I would love to connect with you!
You can find me on PINTEREST, FACEBOOK, TWITTER, INSTAGRAM or Follow my blog with Bloglovin.
Join my support group for bloggers here. Join my Pinterest group board here.
Start your blog journal and keep track of your progress with these FREE printables!


text:
Pan seared potatoes, onion and red pepper with Yves veggie crumbles and Daiya cheese served on top of an english muffin.I also added little chili powder and some sliced avocado. This was a great brunch, the only thing missing was a mimosa!
Mexican Hash
3tbsp sunflower oil
4 potatoes-peeled and cubed
1/2 onion- small diced
1 red pepper- small diced
1 tsp chili powder
1/4 tsp garlic powder
1/3 cup Yves ground round
1/4 cup Daiya cheese
3 tbsp fresh chopped cilantro or parsley
sea salt
fresh ground pepper
avocado (optional garnish)
Heat oil in pan, add potatoes and saute until they form a golden crust. Add the rest of the ingredients and continue to saute for 3-4 minutes. Serve on top of a toasted english muffin.


text:
Custom College Apparel
|Custom Sports Apparel
Find the right fit for you and the whole family with our vast selection of custom MLB apparel from t shirts and jackets to sweatshirts and batting practice jerseys. Personalize your custom MLB jersey including relpica and authentic MLB jerseys.
All prices are in USD. Copyright 2019 Onthefield.com. Sitemap | Privacy Policy | Hosting by Tierpoint
Onthefield.com 901-B Occidental Ave. S., Seattle Washington 98134 · (206) 624-9569 · 1 (800) 924-9569


text:
NaBloPoMo – Day 30
Yesterday, the fam and I all ventured into Rocky Mountain National Park (RMNP). It was pretty dang cold, but there was a lot of beauty to behold. It's amazing how different the park looks in the winter as opposed to in the summer when we usually visit.
Julian fell asleep in the car, but the rest of us enjoyed seeing a couple large herds of elk. I don't think I've ever seen so many in one spot before. There had to be a few hundred. They were slowly making their way across the road as they migrated down to a lower elevation.
And Ava, Grandma, Grandpa and I took a little walk by a stream and Sprague Lake.
We saw this tree – frozen in time – on our walk.
After RMNP, we had dinner out, then stopped at Safeway where Julian was looking so cute in the shopping cart with his lil hat on, I had to take his picture.
The kids have been enjoying getting into things here at the resort. And when I say getting into things, I mean literally climbing into things. (Well, he had a little help getting into the sink.)
We have one more day to enjoy here, then it's back home for us. We might visit the Stanley Hotel today and do a little shopping in town. Right now I'm missing out on a rousing game of Candyland in the other room, so I'm outta here. 😉


text:
Meet Abrys, a sensitive, romantic young twink with a smooth body, huge blue eyes, and a charming smile. This was our 1st studio shot with this sweetie, so he blushed with that cute shyness at times. He looked amazing though, wandering around the studio, wanking his dick under the cover of that big black umbrella.
Russian confused gay twink creature unveils curves and reaches for the cute dick.
Fascinating yet confused a bit, this fair-haired sweetheart is ready to show off his teenage body despite the perfectly explainable shyness he feels in front of the camera. Give the BOY some support and he will reveal his lovely, almost hairless build with a tummy begging for pleasures. He knows you like him, the tension is getting closer to the limit, and he reaches for his swelling shaft.
NUDE young twinks MOVIE galleries
The hottest dandy-like TWINK exposes assets
Teen well-hung boy hottie flashes gems through stylish clothes.
The YOUNG TWINK looks cool today reminding you about the times of Oscar Wilde when boys were great fashionably dressed, and sexually enthusiastic.
Watch him get rid of his dark and white garments to expose his white royal build, flash budding muscles and finally show off his naked tasty COCK begging for attention.
jerk twink
Uncouth TWINK naughty in the wood
Uncouth TWINK checks out the joys of the summer wood Adrian is truly in his natural position here, among the trees and bushes and the sun-drenched woods. Watch this yard boy bare his cute chest and teasingly play around with green leaves and branches using them as a cover for his seriously sized cute dick – luckily, with little success.
There is nothing sexier than a pair of firm young twink thighs with his much beef in between, soaked in sunshine.
Serious-looking TWINK plays with COCK
Serious-looking BOY bares it all on a bed and fondles dick. Say hello to Aivars, a sturdy, serious-looking young twink with blazing large eyes and a appetizing body you'd love to run your tongue all over. The TWINK looks so serious you may think he's just back from his studies or from his office. Anyway, he's done with business and pleasure time has come. Looking you straight in the eye, he gets rid of his garments piece by piece, and it won't be long before his glorious package will be exposed and fondled.
gay twinks masturbating his penis
Fashionable red head gay twink gets Naked
Lanky carrot-headed TWINK slips out of his fashionable clothes Alex is all hot redhead sex appeal and style. Pay attention to his pants and patterned shirt which go perfect with his bunch of red hair. The gay boy is tall, royal, and very appealing. Check out the dreamy young twink play around the chair and get rid of his clothes uncovering his lovely tender body. This dreamy type appears to have quite a dick!
Muscular TWINK gets naked
Thin muscular TWINK plays and gets naked on a maroon couch. Yet another episode with Alex, a rockstar-like TWINK with a taste in garments, a romantic freckle-splashed face and a smooth figure you'd love to caress non stop.
Deep in his dreams, he does some really beautiful posing showcasing all the hottest bits he got including sweet absolutely nude legs, elegant arms, and a very decent-sized cute cock ready to be launched between his hips.
FREE boy PICS
Sweet TWINK turned into dance queen
Smooth boy poses totally naked becomes a hot dance queen. Whatever the festivity, you would like to celebrate it with Alius, a hot, responsive TWINK who does not mind a bit of perverted play. Look, you must have woken the sweetheart up, he was taking a nap in the middle of the dance! With this bright stuff still on his head, Alius jumps out of his crimson pants, shows off his perfectly shaped naked buttocks and starts fondling his stiffening erection.
GAY boy
gay twink playing with his penis
Lovely towheaded gay boy uncovers white toned skin and masturbate
Andrew is all radiance and prowess. You won't know what he is about to do, cuddle with you or spank your buttocks, hard.
Muscled, tanned, with dyed hair, he is the embodiment of street sex appeal. See him reveal his
divine chest and toned belly, teasingly pulling those underpants down in a single moment. Looks like the gay boy is in need, and he is not shy to feed it!
White twink vids
GAY Teenage Sexy TWINKS
2 TWINKS kiss and Wanking dicks
A towheaded TWINK and a brunette gay twink hug and wanking smooth dicks
Watch as the chemistry bodys up between the 2 very sexy young twinks as they exchange romantic glances and start touching each other. Andrew is definitely more active, embracing his pale TWINK lover, kissing his nipples and undressing him. nude young twinks photo
Soon the very sexy gay twinks are absolutely nude, exchanging kisses, their hardening penises rubbing gently against each other. This is a romantic scene full of kisses.
Towheaded Strok Gay GALLERIES
Tender boy with a really big cock
Tender boy with a really big cock Been missing our hot and sweet twink movies, haven't you? Don't worry, tonight you will get one and it will be totally awesome! Meet Mark – one of them adorable gay twinks that never ever try to hide their nature from the eyes of the people around them. This guy is proud to be gay and you can see it in everything he does!
The way he strips for you, the way he strokes his nice-sized twink cock… All that is absolutely mesmerizing. See this hot teaser here – he can't wait to play with you.
European boy enjoys naked modeling
Even though boy model Kody looks like a real Eastern European pimp, it will be him who's going to get pimped here in this gallery. When you leaf through his twink gallery, you will see him dropping the tough looks and turning into the one he really is.
He's one of them sweet and innocent European twinks! The black pants fall on the floor, followed by his cool leather jacket… Now only his shorts separate you from his yummy dink. But don't fret – soon this annoying obstacle will be removed.
Teenage nerd turns into a gorgeous gay star
Tell me, what do you see when you look at Sacha? Frankly, what we see from the first sight is one of them slightly nerdy skinny twinks. A good college student, a smart and slightly shy one, all that.
However, the way you perceive this amateur boy will most definitely change when you see him stripping. What do we have there? A pierced ear, a tattoo, a nice bushy dick… Yeah, Sacha is a real bad boy hiding under the looks of a typical teen geek! He's one of those erect boys that turn into real stars when they get naked.
Naughty teen baldhead debuting in gay erotica
Xerx is a model for those who got tired of effeminate blonde twinks already. He's that tough guy that you are looking for, word! He's baldheaded, wiry, he's got that homemade tat on his shoulder, he's tanned because he's hanging out in the street all day long…
But hey, he's obviously not trying to escape the attention of those in love with nude teen boys. Look, he's even shaven his cute cock and balls for this shoot. Oh my, he looks so amazing on his first twink pics ever!
Shy twinky first-timer tries to get himself hard
Alright, maybe Arturas is one of them really shy nude boys. Maybe he's having problems getting a hard-on in front of that camera. But doesn't it actually make him look even cuter? Say, wouldn't you just love to come up to him and help him relax?
Wouldn't you give his boy penis the sucking that it seems to need so badly? I bet you would! But let's quit fantasizing at least for a while – and watch Arturas cope with his willy on his own. Mmm, I love skinny twinks beating it hard – what about you?
Ripped boy Akelo and his yummy booty
Ready to get acquainted with another one of them sexy muscle twinks?
Well, this is exactly what I'm here for tonight, sugar! The name of our today's teen gay superstar is Akelo – and he is a totally gorgeous ripped hot man that is simply made for posing on explicit twink pics! Just have a look at his strong and firm glamour muscles – nice, aren't they?
Chest, biceps – it's all there for you to enjoy. And the awesome package is also complemented with a terrific firm ass and a cock to match it.
Handsome hot man and his meaty weapon
Got a bit tired of looking at amateur twink boys here? Well, have a look at today's video then, lover. The one it shows to you doesn't look like another boy-next-door, no doubt. Dark-haired lanky lover Silvester looks like a gorgeous movie star!
That handsome face of a real hot Romeo… It will make you forget about all cute teen boys you have seen before. By the way, Silvester also turns out to be the lucky owner of a very impressing cock. Its big head and thin shaft look so tempting.


text:
Wednesday, March 14, 2012
DIY Style: Super Simple At-Home Shoe Repair
32 comments:
- Karolina B-H said...
almost like new ones ;) good idea
- March 14, 2012 at 9:36 AM
- THE ALTERNATIVE WIFE said...
Great tip! I just broke out my Prada patent leather burgundy kitten heels today for the first time in a while and I noticed some scuffs thinking that I need to take them in to get repaired. Maybe I can find a burgundy pen that works. :) xoxo
- March 14, 2012 at 9:44 AM
- Well... said...
Oooh, simple and easy! I love it :)
Thanks for sharing this tip
Statement Necklace Giveaway
Trendy Teal
- March 14, 2012 at 9:46 AM
- Kultur und Stil said...
great ;-)
I normally do that with nailpolish, because I made the experience that this keeps better on the shoe!
xxx Anita
- March 14, 2012 at 10:08 AM
- Kim (A Very Sweet Blog) said...
HaHa Mary Ann! At first I was like, what's wrong with the shoes? LOL Now that is detail. What a great fix!
- March 14, 2012 at 10:13 AM
- TheTinyHeart said...
I've done this before with my black leather boots! Such an easy little fix :)
The Tiny Heart
- March 14, 2012 at 10:57 AM
- Baby Budget Blog said...
Perfect way to touch up shoes!! I use nail polish sometimes too :)
Vintage Collar Necklace Giveaway
- March 14, 2012 at 11:10 AM
- Minted Magazine said...
Great tips!! We'll have to try it out.
Minted Magazine
- March 14, 2012 at 3:59 PM
- Moon Child said...
Like new - haha, exactly what I did to a pair of my worn in booties that are close to fatality!! X
- March 14, 2012 at 6:11 PM
- littlemissandrea said...
This is definitely an awesome quick fix for when shoes get scuffed up. Thanks for the tip! Also, thanks for stopping by over at my blog - following you now :) Would love if you do the same!
- March 14, 2012 at 7:17 PM
- Allison said...
Magic Erasers remove all sorts of scuffs and marks from shoes and bags. Love them!
- March 14, 2012 at 7:18 PM
- What She Wore said...
Nail polish remover also removes scuffs off patent leather. Google told me so. And I tried it and it was right!
- March 14, 2012 at 7:38 PM
- alison*elle said...
I've used the permanent marker trick before too! Or shoe polish :)
xo, alison*elle
- March 14, 2012 at 9:38 PM
- Am2Pm Chic said...
Great tip, it "hurt" me when i saw a scuff on my shoes, now I can prevent it easily . Thanks for sharing.
- March 14, 2012 at 11:18 PM
- Am2Pm Chic said...
Great tip, it "hurt" me when i saw a scuff on my shoes, now I can prevent it easily . Thanks for sharing.
- March 14, 2012 at 11:18 PM
- Juneli said...
Thanks for your tip! to be honest, I've also done that, only I've used a normal permanent marker!!
- March 15, 2012 at 1:02 AM
- lucia m said...
wow! love it!! perfect!!
- March 15, 2012 at 3:32 AM
- Bravoe Runway said...
This looks almost like new! I'll definitely need to try it out because I'm so hard on my shoes :)
- March 15, 2012 at 8:10 AM
- Viv said...
i totally do this, and it shoes how well it works because i can't tell the difference in the after picture except that it looks fixed!
- March 15, 2012 at 10:39 AM
- Skinny said...
Thanks for the share, I have the same problem with most of my shoes!!
- March 15, 2012 at 11:05 AM
- Skinny said...
Thanks for the share, I have the same problem with most of my shoes!!
- March 15, 2012 at 11:05 AM
- Marion said...
1) I seriously just reached in my desk, pulled out my sharpie and promptly starting touching-up my black heels! Love this easy (and super affordable!) idea.
2) LOVELOVELOVE your yellow peplum blouse in the previous post. You look gorgeous and the cuffed sleeve details are beautiful...great sewing work girl!
Lastly, you should totally do a lil' pop of neon with a cute belt for the "Trend of the Month Challenge!" I am personally terrified of neon...so I will probably only do earrings and a belt. :-)
XO - Marion
- March 15, 2012 at 3:41 PM
- Sunny & Star said...
Looks wonderful. Thanks for the tip. I have some shoes I will definitely be trying this on.
- March 15, 2012 at 3:43 PM
- LINDA said...
Very cool! <3
Linda from www.moonon.com
- March 15, 2012 at 5:04 PM
- Dietingfashions said...
That is awesome, simple, and quick! Thanks for sharing.
For the insides of my shoes, I use baby wipes to clean them.
- March 15, 2012 at 7:30 PM
- Carrie Couch said...
I've done that a bunch of times, too! I've even used sharpie to color bleach spots in clothes. Yeah, its a bit cheap looking but when you're bartending, no one can notice!
- March 15, 2012 at 11:08 PM
- Rakhshanda said...
That's an awesome idea <3 Great post mary <3 Love your blog & outfits!!!!
- March 16, 2012 at 12:50 AM
- Laura said...
Beautiful blog and posts! Would you like us to be friends and follow each other?
Fashionhypnotised girl
- March 16, 2012 at 2:54 AM
- toi said...
such a clever idea :)
- March 16, 2012 at 4:59 PM
- Miss Peregrin said...
What an interesting idea! So simple, but it works so well.
- March 22, 2012 at 6:58 PM
Just came across your blog. I never thought of that..thanks! I thought you and your visitors might be interested in http://www.TheGreatShavingRipOff.com
- April 19, 2012 at 6:55 PM
- jang geun gulk said...
I have some shoes I will definitely be trying this on.But in that some pieces are scratched what is the Best Adhesive for Shoe Repair
and then only i will try these on mine.
- November 18, 2013 at 4:18 AM


text:
- Welterweight
Brook injury puts January fight in doubt
Kell Brook's world title fight with American Devon Alexander may have to be put back a month after the Sheffield fighter rolled an ankle in training.
Brook's IBF welterweight bout is scheduled for January 19 but promoter Eddie Hearn has opened talks with Alexander's camp, and the fight's broadcasters Showtime, about a postponement.
Brook sustained his injury when out running and although Hearn admits that it is not a serious injury, it is affecting his fighter's training regime.
If the original fight date was honoured, Brook would risk going into the ring with the Missouri man at only '60-70%' and at such a disadvantage Hearn believes his charge would almost certainly lose. But he is hopeful of a new date being reached without upsetting British fight fans' preparations to watch the bout.
"It's not a horrific injury but it's hampering him from doing his sprints and doing his runs and also side-to-side movement in the ring and on the pads," Hearn told Sky Sports News. "It's frustrating because it's not an injury that would force you out of a fight.
"We thought we would be up front with everybody and I spoke to Golden Boy (Alexander's promoters) on Tuesday night to say 'look, I think we might have a problem if we go on the original date.' So what I would like to do is potentially to push it back two, maybe three, even four weeks.
"What I don't want to do is let a 60% or 70% Kell Brook go into a fight of that magnitude because we would not do him justice and he would not do himself justice.
"Alexander's only lost one, he's 25 years of age, world champion and deservedly so. You can't play around at this level and if you are not 100%, all the work you have done to get here is going to be wasted. If he went in 60-70% I don't think he would win the fight."


text:
Jim is proud to call WNEP home after joining the team in November 2010 as a reporter covering the always exciting Luzerne County beat.
Jim is a native of Belmar, New Jersey but has already made a mark in the Poconos as a seasoned reporter. Jim began his newscasting career at Blue Ridge Communications News13 in 2007 first as its Carbon County reporter, then as its Monroe County reporter. Jim also dabbled in weather anchoring before making the jump to Newswatch 16.
Jim is a graduate of Villanova University (GO WILDCATS!) where he majored in communications and experimented in comedy talk radio.
Jim's second passion is dirt track modified and sprint car racing. Since 1998, he has been the official track videographer at New Egypt Speedway in New Jersey. He has also filmed and announced at speedways as far away as Florida and Vermont and even Quebec, Canada.
In 2011, Jim became the voice of the Penn Can Speedway in Susquehanna, PA, calling the play-by-play action every Friday night on the microphone.
When not reporting live or getting a rooster tail of mud thrown at him from a 450hp dirt modified, Jim can be found riding the waves at the Jersey Shore, belting out karaoke at the local pub while sipping a lager, and chasing tornadoes and hailstorms on the back roads of NEPA.
Jim is a trained storm spotter for the National Weather Service, and is always on the look out for a good chase.
Jim also enjoys skiing, working out, driving to Florida for February Speedweeks, and listening to his two favorite "buddies" on Sirius XM radio.


text:
Sales Tax (Variation By County)
From ConsumerWiki
Revision as of 20:36, 23 March 2011 by Cicjscribner (Talk | contribs)
Sales tax varies by county.
The basic state tax rate is 7.25% with some districts adding voter approved special taxing jurisdictions or district taxes. Voter approved special taxing often provides revenue for additional city or county projects such as libraries, transit projects, stadiums, etc. For additional explanation, consumers may contact the California Board of Equalization.
Board of Equalization
450 N Street
Sacramento, CA 95814
(800) 400-7115
Consumer Resource & Referral Guide
Directory of State Agencies
Directory of Federal Agencies
Return to DCA Home Page


text:
Girls Personalised Teddy Print - Birth, Christening, Baptism
A new baby Print! A unique and highly personalised print, drawn by hand initially, showing the name and birth details of a new born baby. The name is in the design! A perfectly thoughtful gift to celebrate life, ideal to brighten up a playroom or nursery.
These designs usually take a week to 10 days to produce, but may be a little longer in busy periods. If you are in a hurry for it, please say and we will do our best to meet your requirements.
If you'd like to receive a proof on email, prior to printing, please 'start a convo' but please realise that this may slow the order process down.
At checkout please enter the child's name. There is also the option of adding two short messages or notes at the foot of the design.. Please enter the text carefully as it will be copied exactly, including capital letters and punctuation.
The print comes in three sizes. Please select carefully. This listing is for a print only, no mount or frame is included.
Designs are printed on 235gsm, Satin Photo Paper. The colours Charis uses are sharp and vibrant and stand the test of time, looking great on any wall!
Please be aware that different computers will reproduce the colours slightly differently and therefore the colours on your computer might appear slightly different from the print-out picture.
Prints will be dispatched in a cello sleeve, and mailed flat in sturdy cardboard.
Thanks for looking;)
Payment must be made at the time of purchase! We accept paypal and credit/debit though paypal.
PLEASE NOTE: It is the responsibility of the buyer to pay any and all Customs Charges and/or Duties in his/her country related to their purchase.
Shipping from United Kingdom
All items are dispatched within 10-14 days, but we do endevour to dispatch as soon as possible.
All items are securely packaged and shipped via Royal Mail. You will be notified once the item(s) have been shipped. A proof of postage is obtained. UK postage is Second Class.
We ship internationally.
We do not buy delivery confirmation nor insurance. If you would like either you can convo us for pricing and we will set up a reserved listing for you.
I WILL NOT ship to a 'Third Party' address. This is to comply with Etsy policies and avoid fraud.
Personalised items will not be refunded.
We take great care in ensuring that all of our designs and products are produced to the highest possible standards.
Due to the hand-drawn nature of our personalised designs, the over-all shape of the design may vary - for example a digger may face the opposite way, but it will be as close to the designs featured as possible, whilst making the name clear.
Every care has been taken to ensure that all images and descriptions of our products are as accurate as possible but slight variations may occur.
And lastly, please check personalised information carefully when ordering as we cannot be held responsible for any errors.


text:
Buy UK Charity Gifts Online
Since 2007 we have been the number 1 charity gift site comparing the best gifts from the UK's leading charities.
Browse our site to find the best Charity Gifts and presents in the UK – brilliant for Christmas, but great all year round! Choose from hundreds of Charity Gifts from just £3 or Adopt an Animal – a great gift for animal lovers for just a small fee a month.
Popular gifts include WWF Adopt an Animal where you get a free cuddly toy and Save the Children Wish List which includes a range of virtual gifts. Use our charity gift picker on the right hand side to find the perfect gift for your loved ones and remember each gift will go to those around the world who need help the most.


text:
Internships are the ideal technique for a student to acquire work experience and produce associates in a certain work or market. Locating summer season internships while in high school is not challenging, nevertheless the pupil needs to know where you should seem. It is essential to perform some research and initiate inquiring properly prior to spring season, so that you can safe the career just before college comes to an end. un internships
Some agencies offer formal internship programs for top schoolers. These are typically offered to students residing inside the nearby locality. Businesses such as Microsoft, the Smithsonian, and the Gallery of recent Art have these applications. However, so do small businesses inside less city regions, so pupils ought to ask at local business owners. Students who have a selected career in your mind need to seek advice from an association dedicated to this industry. Although the group may have a non-local countrywide headquarters, it can possibly have community chapters or casual groupings that will link a student with summer season job possibilities in the discipline.
For top schoolers
- Pupils who have a selected region.
- Even firms that do not have conventional internship courses could possibly have sporadic requires for summertime.
Even firms which do not have formal internship courses could have sporadic needs for summer interns. Students should look into the Sites for these firms or place a phone call to their human solutions reps. They should also inquire whether friends and neighborhood friends are aware of anybody looking for interns to the summer season. Word of mouth marketing is the best way to learn about such prospects as well as the man or woman referring each student can serve as a guide. un internship
These firms or place a
Students seeking compensated summertime internships should also consult with local town and region authorities workplaces. They often will need short-term aid in the summer season and the career might include not just forcing pieces of paper. Some metropolis and county zoos offer you students prospects carrying out excursions or educative trainings with regards to the wildlife. College students must also search the web for opportunities and ask on the organization that employs their parents. Companies could favor giving unpaid summertime internships to children of staff as opposed to total strangers. summer internship
Zoos offer you students prospects
Individuals that have a particular section of attention can approach companies and government departments with a proposition to produce their own personal internship option. The group can be so impressed by the time and effort placed into the proposition, they may generate an intern placement for that college student. This might pave how for the creation of a much more professional software in afterwards years.
Intern placement for that college student
Summer time internships is available by using these approaches and also other expert task look for resources. The student must be self-self-confident adequate to inquire with local business owners and govt places of work and never hesitate of denial. The research might just yield an opportunity that sets the training course for that career of the student's ambitions. internship search
Available by using
- Even companies which do not have formal internship courses could possibly have sporadic requires for summer interns..
- Individuals searching for paid out summer season internships should likewise check with nearby area and county government.
- Internships are a fantastic way for students to get work experience and develop associates inside.
- Students that have a specific region of curiosity can approach companies and government agencies having a proposition to generate.


text:
Thursday, 23 January 2014 06:24 PM
One of the most potent outside liberal-oriented political groups announced on Thursday that it would back Hillary Rodham Clinton if she chooses to seek the White House in 2016, the latest sign that senior members of President Barack Obama's team are looking to line up with the former first lady.
Priorities USA brought on board Jim Messina, Obama's 2012 campaign manager and the latest Obama insider to join a pro-Clinton group. With so many Obama veterans lining up to help clear the way for a Clinton campaign, it perhaps adds pressure on Clinton to go forward with another White House bid.
Clinton, a former secretary of state, senator and first lady, says she has not yet decided if she will again seek the White House. But that has not stopped supporters from building a political machine in case she decides to turn the key.
The early alignment for Priorities USA sends a clear signal that high-dollar donors are awaiting a Clinton decision and are ready to fork over millions to promote and defend Clinton from Republican criticism that conservative groups have been leveling for months in attempts to weaken her standing.
Other pro-Clinton outside groups have been forming and working to defend her record in her absence. Correct the Record, for instance, has been trying to debunk Republicans' criticism of her decades in public service while Ready for Hillary has been organizing low-dollar fundraisers for her aimed as much at showing grassroots support as building a list of would-be-volunteers if Clinton joins the race.
But the formal shift for Priorities signals that big-dollar donors were ready to join the Clinton bandwagon. Priorities and its sister super PAC, Priorities USA Action, both can raise unlimited sums of money and share staff members. But Priorities USA operates under a part of the tax code governing nonprofit groups and can keep its donors secret. The super PAC must release the names of its funders.
Priorities helped raise millions for Obama's re-election and ran some of the election's toughest television ads defining Republican nominee Mitt Romney as a heartless corporate raider.
After 2012, the group considered various options, but its donors clamored for Priorities to become the de facto pro-Clinton super PAC.
The addition of Messina and former Michigan Gov. Jennifer Granholm, which had been expected, puts the leadership of the super PAC in the hands of one of Obama's most trusted advisers and a longtime Clinton supporter.
Before directing Obama's re-election campaign, Messina was a top 2008 campaign aide and a White House adviser who played a key role in the passage of the president's health care overhaul. Granholm had previously announced her support of Clinton through a separate super PAC, called Ready for Hillary, and had supported Mrs. Clinton during the 2008 Democratic primary.
"Having played a critical role in 2012, Priorities USA Action has very clearly demonstrated its ability to help elect a Democratic president. We intend to replicate that role and its success again in 2016, defining a clear choice for the American public," Messina said in a statement.
Messina joins a number of top former Obama campaign aides who have backed outside efforts to bolster Clinton's standing should she run for president. Senior campaign aides Jeremy Bird and Mitch Stewart are advising Ready for Hillary. Buffy Wicks, who led the campaign's voter mobilization effort, recently signed on as executive director of Priorities USA Action.
The organization also announced a 14-member board that includes longtime Clinton allies such as Harold Ickes and Maria Echaveste, who both served in the Clinton White House; Randi Weingarten, the president of the American Federation of Teachers; and David Brock, who leads Correct the Record. The board also includes Stephanie Schriock, the president of EMILY's List, which supports female candidates who back abortion rights.
The early efforts have begun to create an impression that Clinton is the favored heir to Obama's White House, as opposed to Vice President Joe Biden, who has kept open the option of a third White House campaign.
The outside groups have formed an early de facto campaign organization to help Clinton compete vigorously against Republican opponents who are already trying to negatively define her tenure as secretary of state. The organizations are building the network without her direct consent but she has not raised any objections, offering a tacit endorsement that has encouraged Democrats to push forward in preparation for a campaign.
The group's alignment had been expected for months but was first confirmed Thursday by The New York Times. Peter Kauffmann, the group's spokesman, confirmed the group would be supporting Clinton if she runs.
© Copyright 2019 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.
Newsmax Comment Policy
Keep discussions on topic, avoid personal attacks and threats of any kind. Links will not be permitted.
Newsmax, Moneynews, Newsmax Health, and Independent. American. are registered trademarks of Newsmax Media, Inc. Newsmax TV, and Newsmax World are trademarks of Newsmax Media, Inc.