Antismoking Outlays Drop Despite Tobacco Revenue





Faced with tight budgets, states have spent less on tobacco prevention over the past two years than in any period since the national tobacco settlement in 1998, despite record high revenues from the settlement and tobacco taxes, according to a report to be released on Thursday.







Paul J. Richards/Agence France-Presse — Getty Images

State antismoking spending is the lowest since the 1998 national tobacco settlement.







States are on track to collect a record $25.7 billion in tobacco taxes and settlement money in the current fiscal year, but they are set to spend less than 2 percent of that on prevention, according to the report, by the Campaign for Tobacco-Free Kids, which compiles the revenue data annually. The figures come from state appropriations for the fiscal year ending in June.


The settlement awarded states an estimated $246 billion over its first 25 years. It gave states complete discretion over the money, and many use it for programs unrelated to tobacco or to plug budget holes. Public health experts say it lacks a mechanism for ensuring that some portion of the money is set aside for tobacco prevention and cessation programs.


“There weren’t even gums, let alone teeth,” Timothy McAfee, the director of the Office on Smoking and Health at the Centers for Disease Control and Prevention, said, referring to the allocation of funds for tobacco prevention and cessation in the terms of the settlement.


Spending on tobacco prevention peaked in 2002 at $749 million, 63 percent above the level this year. After six years of declines, spending ticked up again in 2008, only to fall by 36 percent during the recession, the report said.


Tobacco use is the No. 1 cause of preventable death in the United States, killing more than 400,000 Americans every year, according to the C.D.C.


The report did not count federal money for smoking prevention, which Vince Willmore, the vice president for communications at the Campaign for Tobacco-Free Kids, estimated to be about $522 million for the past four fiscal years. The sum — about $130 million a year — was not enough to bring spending back to earlier levels.


The $500 million a year that states spend on tobacco prevention is a tiny fraction of the $8 billion a year that tobacco companies spend to market their products, according to a Federal Trade Commission report in September.


Nationally, 19 percent of adults smoke, down from over 40 percent in 1965. But rates remain high for less-educated Americans. Twenty-seven percent of Americans with only a high school diploma smoke, compared with just 8 percent of those with a college degree or higher, according to C.D.C. data from 2010. The highest rate — 34 percent — was among black men who did not graduate from high school.


“Smoking used to be the rich man’s habit,” said Danny McGoldrick, the vice president for research at the Campaign for Tobacco-Free Kids, “and now it’s decidedly a poor person’s behavior.”


Aggressive antismoking programs are the main tools that cities and states have to reach the demographic groups in which smoking rates are the highest, making money to finance them even more critical, Mr. McGoldrick said.


The decline in spending comes amid growing certainty among public health officials that antismoking programs, like help lines and counseling, actually work. California went from having a smoking rate above the national average 20 years ago to having the second-lowest rate in the country after modest but consistent spending on programs that help people quit and prevent children from starting, Dr. McAfee said.


An analysis by Washington State, cited in the report, found that it saved $5 in tobacco-related hospitalization costs for every $1 spent during the first 10 years of its program.


Budget cuts have eviscerated some of the most effective tobacco prevention programs, the report said. This year, state financing for North Carolina’s program has been eliminated. Washington State’s program has been cut by about 90 percent in recent years, and for the third year in a row, Ohio has not allocated any state money for what was once a successful program, the report said.


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DealBook: Trail to a Hedge Fund, From a Cluster of Cases

In April 2009, an F.B.I. agent visited the Silicon Valley home of Richard Choo-Beng Lee, a hedge fund manager with deep contacts inside technology companies. The government, the agent said, had overwhelming proof that Mr. Lee had engaged in insider trading. Within weeks, Mr. Lee confessed and began cooperating.

A year and a half later, in the parking lot of a New England prep school, the same agent approached Noah Freeman, a Harvard-educated money manager turned teacher. After the agent played a secretly recorded conversation of Mr. Freeman swapping illegal tips, Mr. Freeman admitted to crimes and started assisting the authorities.

Last winter, another agent confronted Mathew Martoma, a pharmaceutical-industry analyst, at his 8,000-square-foot Florida mansion. As they stood on the front lawn, with Mr. Martoma’s wife and children inside, the agent told him that they had evidence that he had broken the law.

Overcome with stress, Mr. Martoma passed out.

Three criminal defendants — Mr. Lee, Mr. Freeman and Mr. Martoma — have a common denominator: Each had worked for SAC Capital Advisors, the hedge fund run by Steven A. Cohen, one of the most powerful figures in finance. By posting impressive annual returns averaging 30 percent across two decades, Mr. Cohen, a 56-year-old Long Island native, has amassed a fortune estimated at nearly $9 billion.

Mr. Cohen has not been accused of any wrongdoing and he may never be charged, but he has become a central focus of the government’s sprawling investigation into criminal conduct at hedge funds. A picture of the inquiry has emerged from interviews with people involved with the case.

The trail leading to SAC has emerged out of a cluster of cases, many of them connected to the prosecution of the fallen titan Raj Rajaratnam. Investigators heard SAC traders on incriminating wiretaps; in other instances, cooperators and informants accused the fund of misconduct. As the authorities painstakingly pieced together dozens of cases across multiple, overlapping conspiracies, again and again one name kept popping up: Mr. Cohen’s SAC.

Complete Coverage: Insider Trading at a Top Hedge Fund

Investigators have penetrated SAC and other funds by aggressively deploying techniques — wiretaps, cooperators and informants — once reserved for infiltrating the Mafia and narcotics rings. Government lawyers have reviewed millions of pages of documents and taken hundreds of depositions. Securities watchdogs, meanwhile, have developed more sophisticated methods to detect insider trading, which is defined as trading based on material, nonpublic information.

The long-running inquiry has linked six former SAC employees to insider trading while at the fund; three, including Jon Horvath, who has implicated one of Mr. Cohen’s top lieutenants, have pleaded guilty. At least six other former employees have been tied to insider trading after leaving SAC. Several more have received subpoenas, people briefed on the case say.

Since 2002, the financial industry’s self-regulatory groups have referred about 80 instances of suspicious SAC trading activity to federal authorities for further investigation. In 2007, as the citations piled up, the self-regulatory groups took a more aggressive tone, noting that the hedge fund had been “repeatedly” flagged for suspicious trading. (An SAC spokesman has said that the fund trades in thousands of stocks each day, so given its level of activity it is not surprising that the fund would show up in referrals.)

“Government lawyers go where the facts take them,” said H. David Kotz, a former inspector general at the Securities and Exchange Commission now with Berkeley Research, a consulting firm. “With so many disparate strands of the investigation leading to SAC, it makes perfect sense that they would be closely looking at the guy in charge.”

And they are looking very closely. A few years ago, the F.B.I. secretly recorded the telephone line at Mr. Cohen’s Greenwich, Conn., estate, said two people briefed on the investigation. It is unclear what precipitated the wiretapping and whether any evidence was collected. Federal securities regulators have had previous brushes with SAC in 2003 and Mr. Cohen in 1986, but neither inquiry resulted in any action. Last summer, S.E.C. lawyers deposed him.

Speaking to his roughly 1,000 employees last week, Mr. Cohen expressed confidence that he acted appropriately. In defending the fund, SAC cites its strong culture of compliance and says it is “outraged” and “deeply disturbed” by the conduct of former employees.

But with Mr. Martoma’s arrest Nov. 20 — the first case that directly ties Mr. Cohen to questionable trades — the investigation has entered a more serious phase. The S.E.C. warned the fund that it was preparing a civil fraud lawsuit against SAC related to Mr. Martoma’s case. A lawyer for Mr. Martoma, Charles A. Stillman, said that he expected his client to be exonerated.

And just as it did in the investigation of Mr. Rajaratnam and in the landmark 1980s prosecutions of the financial giants of that era, Michael R. Milken and Ivan F. Boesky, the government is pursuing lower-level employees and then seeking their cooperation in the hopes of building a case against the boss.

C. B. Lee

Had he made different career choices, Richard Choo-Beng Lee might have been an engineer at Apple or Intel. Instead, armed with a computer science degree and a knack for numbers, Mr. Lee became a star technology analyst on Wall Street.

Known as C. B., Mr. Lee worked in the 1990s at the brokerage firm Needham & Company alongside Mr. Rajaratnam. In 1999, Mr. Lee landed at SAC, where he earned millions working for a team of tech-stock traders. After five years, he left, and in 2008 started his own California-based hedge fund, Spherix Capital.

That same year, a government informant taped incriminating calls with Mr. Rajaratnam, who by then had become a billionaire running the Galleon Group. On the basis of those calls, prosecutors received a judge’s approval to wiretap Mr. Rajaratnam’s cellphone. They also received permission to eavesdrop on Danielle Chiesi, a close associate of Mr. Rajaratnam. Ms. Chiesi was heard on calls with Mr. Lee passing inside information.

B. J. Kang, an F.B.I. agent, showed up at Mr. Lee’s modest San Jose, Calif., home in 2009. After pleading guilty, he closed Spherix Capital and became a cooperator, recording conversations that helped ensnare several defendants.

Securing Mr. Lee’s cooperation proved to be a major breakthrough because he helped them better understand SAC’s trading practices and culture. As part of Mr. Lee’s plea agreement, he agreed to share information about illegal conduct that he saw while working for Mr. Cohen.

He also provided investigators with detailed insights into expert-network firms, a growing business that connected traders with sources at publicly traded companies. Mr. Lee said SAC and other funds aggressively used these matchmaking firms, some of which were cesspools of inside information.

A few months after Mr. Lee “flipped,” the F.B.I. directed him to try to get rehired by SAC, said a person briefed on the case. Mr. Cohen entertained his request but ultimately rebuffed him, leery that Mr. Lee had abruptly closed his fund, this person said.

Jeffrey Bornstein, a lawyer for Mr. Lee, 56, said that his client continues to cooperate with the government.

Noah Freeman

When Noah Freeman graduated from Harvard in 1999, the stock market was roaring. After a stint in management consulting, Mr. Freeman tried his hand at hedge funds. He started at Brookside Capital, a unit of Bain Capital.

Mr. Freeman joined SAC in 2008, lured by a two-year, $2 million-a-year guarantee. The fund gave him several hundred millions of dollars to manage.

Mr. Freeman routinely shared his best ideas with Mr. Cohen. Unlike hedge funds with one manager making investment decisions, SAC has about 140 teams — each controlling several hundred millions of dollars. The teams give their “high conviction ideas” to Mr. Cohen, who directly manages only about 10 percent of the fund. SAC compensates employees based on a percentage of the winnings they generate for the fund, as well as on profits they make for Mr. Cohen’s portfolio.

An accomplished speed skater and triathlete, Mr. Freeman thrived in the high-stress world of hedge funds. But the pressure to perform was immense. To help gain an edge, Mr. Freeman became a big user of expert networks, especially Primary Global Research. His principal contact at Primary Global was Winifred Jiau.

Mr. Lee and other informants had told government investigators that Primary Global was especially dirty, and investigators began listening to its phone calls. On one call in May 2008, Ms. Jiau was heard giving Mr. Freeman inside tips about Marvell Technology. Mr. Freeman shared the information with another SAC colleague, Donald Longueuil, who used it to earn more than $1 million in profits.

SAC fired Mr. Freeman in 2010 for poor performance, according to a fund spokesman. Disillusioned with Wall Street, Mr. Freeman went into education. He took a job teaching honors economics at the Winsor School, a prestigious all-girls school in Boston. One day, in November 2010, Mr. Kang, the F.B.I. agent, was waiting for Mr. Freeman in the parking lot of Winsor.

As a government cooperator, Mr. Freeman wore a wire and secretly recorded conversations with Mr. Longueuil, who had been the best man at his wedding. Mr. Longueuil is serving a two-and-a-half year sentence.

In a Dec. 16, 2010 interview, Mr. Freeman told investigators that he thought that trafficking in corporate secrets was part of his job description at SAC, according to an F.B.I. agent’s notes of the interview, which were in a court filing and first reported by Bloomberg News.

“Freeman and others at SAC Capital understood that providing Cohen with your best trading ideas involved providing Cohen with inside information,” the agent wrote.

Prosecutors announced charges against Mr. Freeman and Mr. Longueuil in February 2011. Primary Global has closed. Ms. Jiau, who was found guilty at trial, is in prison. At her trial, Mr. Freeman testified that he gave investigators the names of at least a dozen people who he believed were involved in criminal conduct.

Mr. Freeman, 36, who has yet to be sentenced, is currently a stay-at-home father, and his cooperation could spare him prison time. His lawyer, Benjamin E. Rosenberg, declined to comment.

Jon Horvath

In November 2010, the F.B.I. raided two hedge funds that heavily used expert-network firms: Level Global Investors and Diamondback Capital Management. Both had strong ties to Mr. Cohen; each was started by SAC alumni.

Fourteen months after the raid, prosecutors charged seven traders — including two each from Level Global and Diamondback — in what it called a “criminal club” that made nearly $70 million trading on secret information gleaned from sources inside technology companies.

Among those arrested was Jon Horvath, an SAC tech-stock analyst who once worked at Lehman Brothers. Low key and analytic, Mr. Horvath lacked the swagger of many of his peers. For months, he maintained his innocence.

But in September, a month before trial, Mr. Horvath admitted to insider trading while at SAC and agreed to cooperate. In court, Mr. Horvath said that he — along with his SAC manager — traded on confidential financial results. “In each instance I provided the information to the portfolio manager I worked for and we executed trades in the stocks based on that information,” he said.

The portfolio manager is Michael S. Steinberg, according to two people briefed on the inquiry. Prosecutors have not charged him, but have named him an unindicted co-conspirator.

Barry Berke, a lawyer for Mr. Steinberg, 40, and Steven Peikin, a lawyer for Mr. Horvath, 42, declined to comment.

Though recently placed on leave, Mr. Steinberg is one of SAC’s longest-tenured employees. He joined in 1997, when it was just Mr. Cohen and several dozen traders; for years, he sat near Mr. Cohen on the trading floor and the two grew close. When Mr. Steinberg was married in 1999 at the Plaza Hotel, Mr. Cohen attended the black-tie affair.

Mathew Martoma

In 2008, a team of S.E.C. enforcement lawyers in New York, led by Sanjay Wadhwa, noticed a pattern in the “suspicious trading reports.” CR Intrinsic Investors, a unit of SAC Capital, had made an uncanny string of immensely profitable, well-timed trades in technology and health care stocks. Their suspicions raised, the team requested more trading reports from the regulatory arm of the New York Stock Exchange. Huge bets by CR Intrinsic on the pharmaceutical companies Elan and Wyeth, placed just before they announced disappointing results from a drug trial, jumped off the page.

The S.E.C. issued a subpoena requesting that SAC produce documents — e-mails, instant messages, phone and trading records — connected to the unusual trades. As they combed through e-mails, S.E.C. lawyers discovered reams of correspondence between Mathew Martoma, a drug stock specialist at CR Intrinsic, and Dr. Sidney Gilman, a neurologist.

Two days before Thanksgiving, federal agents arrested Mr. Martoma. Prosecutors said that Dr. Gilman had leaked him secret data about clinical trials that he was overseeing for an Alzheimer’s drug being jointly developed by Elan and Wyeth.

The case was a turning point in the investigation of SAC because, for the first time, the government linked Mr. Cohen to trades that it contends were illegal. Mr. Martoma and Mr. Cohen collaborated on the Elan and Wyeth transactions, prosecutors said, earning SAC profits and avoiding losses totaling $276 million. After Mr. Martoma learned from Dr. Gilman — whom he met through an expert network — that there were problems with the trials, he reached out to his boss, the government said.

“Is there a good time to catch up with you this morning? It’s important,” Mr. Martoma e-mailed Mr. Cohen in July 2008, just days before Elan and Wyeth announced their findings.

An hour later, Mr. Martoma and Mr. Cohen had a 20-minute telephone conversation. SAC promptly sold a $700 million position in Elan and Wyeth and then made a big negative bet. After the drug companies released the negative data, their shares plummeted.

An S.E.C. lawyer interviewed Mr. Cohen about the Elan and Wyeth trades this summer, according to a person briefed on the case. In sworn testimony, he said that SAC sold the stocks because Mr. Martoma told him that he had lost conviction in the position, this person said. Otherwise, Mr. Cohen had little recall of their conversation.

Federal agents paid a house call to Mr. Martoma a year ago, pressuring him to “flip” and help build a case against Mr. Cohen. While speaking with the agents in his front yard, Mr. Martoma fainted. After picking himself up, he declined to cooperate. When the S.E.C. deposed him earlier this year, Mr. Martoma refused to answer questions, invoking his Fifth Amendment right against self-incrimination.

The government has said it will not prosecute Dr. Gilman, who has agreed to testify against Mr. Martoma.

SAC continues to operate during the intensifying investigation. The negative attention and controversy aggravates and angers Mr. Cohen, said a friend, but his ability to compartmentalize allows him to maintain a focus on investing.

An SAC spokesman said Wednesday that Mr. Cohen is cooperating with the government’s inquiry.

During market hours, Mr. Cohen can be found at the center of his football field-size trading floor in Stamford, Conn., sitting among his traders, sifting through information, and buying and selling stocks. SAC, which manages $14 billion, is up about 12 percent this year through the end of last month.

“None of this stuff is material to his returns and it’s all just a lot of noise,” said Ed Butowsky, managing partner of Chapwood Investments, a longtime SAC client. “Steve Cohen is the Michael Jordan of the hedge fund business. When people are successful everyone likes to take shots at them.”

Ben Protess contributed reporting.

A version of this article appeared in print on 12/06/2012, on page A1 of the NewYork edition with the headline: Trail to a Hedge Fund, From a Cluster of Cases.
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Typhoon Kills Hundreds in Philippines


Bullit Marquez/Associated Press


A resident hung clothing amid fallen trees and debris on Wednesday, a day after Typhoon Bopha made landfall in the village of Andap, in southern Philippines.







MANILA — Rescue teams were trying to reach isolated villages in the southern Philippines on Wednesday after a powerful out-of-season typhoon tore through the region, leaving more than 270 people dead, officials said.









Erik De Castro/Reuters

Residents transported the body of victim in the southern Philippines on Wednesday.






Karlos Manlupig/Associated Press

Relatives mourned in New Bataan on Wednesday.






Typhoon Bopha packed winds of up to 100 miles per hour when it struck Tuesday, bringing torrential rains that flattened entire villages, leaving thousands homeless, as well as washing out roads and bridges needed by rescue personnel trying to reach stricken regions.


A national disaster official, Benito Ramos, said at a news conference Wednesday afternoon that 274 deaths had been confirmed, with 339 people known to be injured and 279 missing.


The storm was weakening and leaving the Philippines on Wednesday. The Philippines is hit by more than 20 powerful tropical storms per year, but this typhoon struck remote communities off the usual storm path that are not accustomed to such strong storms.


In December of last year, Tropical Storm Washi killed more than 1,200 people and left hundreds of thousands homeless. Officials this year called for mandatory early evacuations of vulnerable communities.


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Jets going with Mark Sanchez as starting QB


NEW YORK (AP) — Rex Ryan is sticking with Mark Sanchez as the New York Jets' starting quarterback.


The team announced Wednesday morning that Sanchez, benched last Sunday against Arizona, will get the start this week over Greg McElroy and Tim Tebow when the Jets play the Jaguars at Jacksonville.


Sanchez was pulled late in the third quarter, and McElroy came in and led the Jets to the only touchdown of the game on his first NFL drive and helped New York to a 7-6 victory. Sanchez was 10 of 21 for 97 and three interceptions, while McElroy was 5 of 7 for 29 yards and the score, and appeared to spark the team.


Ryan, who was scheduled to speak later Wednesday, said Monday that he needed "a little more time" to consult with his staff before making the decision for this week. It was perhaps the biggest call in Ryan's nearly four years as coach of the Jets, considering the sensitivity of the situation and the possible ramifications.


Sanchez, whose confidence was shaken with Sunday's miserable performance, gets a chance to bounce back from the first benching of his NFL career and to regain the trust of his teammates. He has struggled the last several weeks, with two touchdowns and five interceptions in his last four games. He'll likely be on a short leash against Jacksonville — with McElroy possibly ready to go.


"I'll just keep working, go study this film and keep trying to improve," Sanchez said Sunday after the game. "I need to understand where the mistakes came from, keep studying, keep preparing, be ready to play next week and see what happens."


It's uncertain if Tebow will be active against his hometown Jaguars after sustaining two broken ribs. He was medically cleared by team doctors to play, but Ryan chose to keep him active but not play against New England on Thanksgiving night and then made him inactive against Arizona.


If Ryan went with McElroy, a seventh-round pick in 2011 out of Alabama, it would have been a clear message that the franchise is moving on from Sanchez.


However, money could have played a role, too, with Sanchez owed $8.25 million next year in guarantees. The Jets are likely stuck with Sanchez and his contract, so they need to see if he can rebound. If he can't, it will be an intriguing offseason for New York, especially since Tebow has not played much since being acquired from Denver in March and might not be back next year.


It didn't appear that Tebow was much of a factor in Ryan's decision. Ryan said all three quarterbacks would be in the mix, but didn't want to speculate as to whether he would have pulled Sanchez in favor of Tebow last Sunday if he were active.


Tebow was expected to have a major role in the offense, but instead has been just a spare part averaging about seven offensive snaps per game. He has been listed as the No. 2 quarterback on the depth chart, but if the Jets turned to McElroy, it would have meant that the No. 3 guy leapfrogged Tebow to start for the Jets.


Although Ryan said it wouldn't factor into his decision, the fact the team is playing on the road for the next two games should also help Sanchez.


He was booed mercilessly by the MetLife Stadium crowd last Sunday, particularly after each interception, and chants for McElroy were heard throughout the game. McElroy was cheered as he warmed up late in the third quarter, and there was growing sentiment among some fans and media that he earned a start after lifting the team.


The Jets are hoping he also sparked Sanchez, whom they deemed the face of the franchise just a few years ago when they traded up in the draft in 2009 and took him with the fifth overall pick. He helped lead New York to consecutive trips to the AFC championship game for the first time in team history, but it has been a bumpy ride since. Sanchez has been criticized the last two seasons for failing to take the next step in his development, and Ryan has been knocked for sticking with the quarterback for too long.


The two have been joined at the hip, and stand side-by-side during the national anthem before every game. Ryan was seen in the locker room consoling Sanchez after the game, his arm on his shoulder as the two spoke for a few minutes. Until last Sunday, the threat of being benched — even with Tebow on the roster — didn't appear to be a real possibility.


Now, Ryan has sent the message to Sanchez: Perform or else. And, Sanchez gets one more shot to save his job this season — and his status as the Jets' franchise quarterback.


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Extended Use of Breast Cancer Drug Suggested


The widely prescribed drug tamoxifen already plays a major role in reducing the risk of death from breast cancer. But a new study suggests that women should be taking the drug for twice as long as is now customary, a finding that could upend the standard that has been in place for about 15 years.


In the study, patients who continued taking tamoxifen for 10 years were less likely to have the cancer come back or to die from the disease than women who took the drug for only five years, the current standard of care.


“Certainly, the advice to stop in five years should not stand,” said Prof. Richard Peto, a medical statistician at Oxford University and senior author of the study, which was published in The Lancet on Wednesday and presented at the San Antonio Breast Cancer Symposium.


Breast cancer specialists not involved in the study said the results could have the biggest impact on premenopausal women, who account for a fifth to a quarter of new breast cancer cases. Postmenopausal women tend to take different drugs, but some experts said the results suggest that those drugs as well might be taken for a longer duration.


“We’ve been waiting for this result,” said Dr. Robert W. Carlson, a professor of medicine at Stanford University. “I think it is especially practice-changing in premenopausal women because the results do favor a 10-year regimen.”


Dr. Eric P. Winer, chief of women’s cancers at the Dana-Farber Cancer Institute in Boston, said that even women who completed their five years of tamoxifen months or years ago might consider starting on the drug again.


Tamoxifen blocks the effect of the hormone estrogen, which fuels tumor growth in estrogen receptor-positive cancers that account for about 65 percent of cases in premenopausal women. Some small studies in the 1990s suggested that there was no benefit to using tamoxifen longer than five years, so that has been the standard.


About 227,000 cases of breast cancer are diagnosed each year in the United States, and an estimated 30,000 of them would be in premenopausal women with ER-positive cancer and prime candidates for tamoxifen. But postmenopausal women also take tamoxifen if they cannot tolerate the alternative drugs, known as aromatase inhibitors.


The new study, known as Atlas, included nearly 7,000 women with ER-positive disease who had completed five years of tamoxifen. They came from about three dozen countries. Half were chosen at random to take the drug another five years, while the others were told to stop.


In the group assigned to take tamoxifen for 10 years, 21.4 percent had a recurrence of breast cancer in the ensuing ten years, meaning the period 5 to 14 years after their diagnoses. The recurrence rate for those who took only five years of tamoxifen was 25.1 percent.


About 12.2 percent of those in the 10-year treatment group died from breast cancer, compared with 15 percent for those in the control group.


There was virtually no difference in death and recurrence between the two groups during the five years of extra tamoxifen. The difference came in later years, suggesting that tamoxifen has a carry-over effect that lasts long after women stop taking it.


Whether these differences are big enough to cause women to take the drug for twice as long remains to be seen.


“The treatment effect is real, but it’s modest,” said Dr. Paul E. Goss, director of breast cancer research at the Massachusetts General Hospital.


Tamoxifen has side effects, including endometrial cancer, blood clots and hot flashes, which cause many women to stop taking the drug. In the Atlas trial, it appears that roughly 40 percent of the patients assigned to take tamoxifen for the additional five years stopped prematurely.


Some 3.1 percent of those taking the extra five years of tamoxifen got endometrial cancer versus 1.6 percent in the control group. However, only 0.6 percent of those in the longer treatment group died from endometrial cancer or pulmonary blood clots, compared with 0.4 percent in the control group.


“Over all, the benefits of extended tamoxifen seemed to outweigh the risks substantially,” Trevor J. Powles of the Cancer Center London, said in a commentary published by The Lancet.


Dr. Judy E. Garber, director of the Center for Cancer Genetics and Prevention at Dana-Farber, said many women have a love-hate relationship with hormone therapies.


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DealBook: Freeport to Buy Plains Exploration and McMoRan

Freeport-McMoRan Copper and Gold said on Wednesday that it would buy two oil and natural gas companies, Plains Exploration and Production and the McMoRan Exploration Company, in a return to the energy business.

The two transactions will create a natural resources titan worth about $60 billion, including debt, and will formally reunite Freeport with McMoRan, the oil exploration company it spun off in 1994.

Under the terms of the deals, Freeport will pay about $6.9 billion in cash and stock for Plains. That offer consists of $25 a share in cash and 0.6531 of a Freeport share, worth about $50 a share based on Tuesday’s closing prices.

And Freeport will pay $14.75 a share in cash and 1.15 units of a trust that will hold a 5 percent interest in future production of McMoRan’s deepwater exploration operations. Freeport and Plains together already own about 36 percent of the smaller exploration company.

“This transaction will enable us to add assets with exceptional exploration and development potential to a world-class mining company to create a premier minerals and oil and gas business focused on value creation for shareholders,” James R. Moffett, Freeport’s chairman, said in a statement.

JPMorgan Chase is providing $9.5 billion to help pay for the cash portion of the deal and to repay some of Plains’s existing debt.

Freeport was advised by Credit Suisse and the law firm Wachtell, Lipton, Rosen & Katz. Plains was advised by Barclays and the law firm Latham & Watkins. McMoRan was advised by Evercore Partners and the law firm Weil, Gotshal & Manges.

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Assad Suffering Reversals in Fighting and Diplomacy


Thair Al-Khalidieh/Shaam News Network, via Reuters


A Free Syrian Army fighter battled government forces in Homs, Syria, on Monday.







BEIRUT, Lebanon — Fierce fighting on the battlefield and setbacks on the diplomatic front increased pressure on the embattled Syrian government as fresh signs emerged on Tuesday of a sustained battle for control of the capital, Damascus.




News reports quoted activists as saying that fighting was raging in the southern suburbs of Damascus and near the international airport for a fifth straight day as government forces sought to dislodge rebels and reverse their recent gains.


While the government has superior firepower and rebels are reporting heavy losses, loyalist forces have been carrying out a serious counteroffensive in the suburbs without being able to subdue the insurgents.


The latest reports followed developments on Monday when a senior Turkish official said that Russia had agreed to a new diplomatic approach to seek ways to persuade President Bashar al-Assad to relinquish power, a possible weakening in Russia’s steadfast support for the Syrian government.


In Damascus, a prominent Foreign Ministry spokesman was said to have left the country amid reports of his defection, and President Obama and Secretary of State Hillary Rodham Clinton issued warnings that any use of chemical weapons by a desperate government would be met with a strong international response. The NATO secretary general, Anders Fogh Rasmussen, echoed this warning on Tuesday.


“The possible use of chemical weapons would be completely unacceptable to the whole international community,” Mr. Rasmussen said, according to Agence France-Presse.


A Western diplomat confirmed that there were grave concerns in United States intelligence circles that Syrian leaders could resort to the use of the weapons as their position deteriorates.


The Syrian Foreign Ministry, repeating earlier statements, told state television that the government “would not use chemical weapons, if it had them, against its own people under any circumstances.”


The United Nations said it was withdrawing nonessential international staff from Syria, and the European Union said it was reducing activities in Damascus “to a minimum,” as security forces pummeled the suburbs with artillery and airstrikes in a struggle to seal off the city from its restive outskirts and control the airport road. A senior Russian official spoke for the first time in detail about the possibility of evacuating Russian citizens.


The United Nations World Food Program reported on Tuesday that “the recent escalation of violence in Syria is making it more difficult to reach the country’s hardest-hit areas.”


“Food insecurity is on the rise due to bread shortages and higher food prices in many parts of the country. High prices are also affecting neighboring countries hosting Syrian refugees,” the organization said in a statement.


“Road access to and from Damascus has become more dangerous, making it difficult to dispatch food from World Food Program warehouses to some parts of the country, the organization said, adding that there had been increasing indiscriminate attacks on its trucks in different parts of the country.


It also said it would relocate seven nonessential staff members to neighboring Jordan while about “20 international and 100 national W.F.P. staff remain in the country to carry out the emergency operation to feed 1.5 million vulnerable Syrians.” Mr. Assad has held on longer than many had predicted at the start of the 21-month uprising. He still has a strong military advantage and undiminished support from his closest ally, Iran. Military analysts doubt the rebels are capable of taking Damascus by force, and one fighter interviewed on Monday said the government counteroffensive was taking a heavy toll. There were still no firm indications from Russia that it was ready to join Turkey and Western nations in insisting on Mr. Assad’s immediate departure.


But the latest grim developments follow a week of events that suggested the Assad government was being forced to fight harder to keep its grip on power. Rebels threatened its vital control of the skies, using surface-to-air missiles to down a fighter plane and other aircraft. The opposition also gained control of strategic military bases and their arsenals, and forced the government to shut down the Damascus airport periodically. The Internet was off for two days.


A Russian political analyst with contacts at the Foreign Ministry said that “people sent by the Russian leadership” who had contact with Mr. Assad two weeks ago described a man who has lost all hope of victory or escape.


“His mood is that he will be killed anyway,” Fyodor Lukyanov, editor of a Russian foreign affairs journal and the head of an influential policy group, said in an interview in Moscow, adding that only an “extremely bold” diplomatic proposal could possibly convince Mr. Assad that he could leave power and survive.


“If he will try to go, to leave, to exit, he will be killed by his own people,” Mr. Lukyanov said, speculating that security forces dominated by Mr. Assad’s minority Alawite sect would not let him depart and leave them to face revenge. “If he stays, he will be killed by his opponents. He is in a trap. It is not about Russia or anybody else. It is about his physical survival.”


Anne Barnard reported from Beirut, Lebanon, and Ellen Barry from Moscow. Reporting was contributed by Alan Cowell in London, Sebnem Arsu in Istanbul, Peter Baker in Washington, Hwaida Saad, Neil MacFarquhar and Hania Mourtada in Beirut, and Christine Hauser in New York.



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Chiefs had given counseling to Belcher, girlfriend


KANSAS CITY, Mo. (AP) — Kansas City Chiefs officials knew that linebacker Jovan Belcher and his girlfriend were having relationship problems, and the team provided the couple with counseling in an effort to help, a police official said.


Belcher fatally shot Kasandra Perkins, 22, at their Kansas City home Saturday before shooting himself in the head in the Arrowhead Stadium parking lot in front of team officials who were trying to stop him, including general manager Scott Pioli and head coach Romeo Crennel.


Police Sgt. Richard Sharp told The Kansas City Star for a Tuesday story (http://bit.ly/SDwg9m ) that the couple had been arguing over relationship and financial issues for months and that the team had been "bending over backward" trying to help them. Sharp didn't specify how long the couple had been undergoing counseling.


When Belcher arrived at Arrowhead on Saturday, he encountered Pioli in the parking lot and told him the assistance the team had offered hadn't fixed the couple's problems and now "it was too late," Sharp said.


Pioli tried to persuade Belcher to put down his gun as Crennel and linebackers coach Gary Gibbs arrived at the scene.


Belcher thanked the men for everything the team had done for him and asked if Pioli and team owner Clark Hunt would take care of his daughter, The Star reported.


After that, Belcher reportedly said, "Guys, I have to do this."


"I was trying to get him to understand that life is not over," Crennel said Monday. "He still has a chance and let's get this worked out."


When Belcher heard police sirens approaching, he knelt behind a vehicle and shot himself in the head.


Investigators believe Belcher killed himself because he was distraught over shooting Perkins, Sharp said.


"He cared about her," Sharp said. "I don't think he could live with himself."


The night before the killings, Perkins had attended a concert downtown with friends and Belcher had been out at the Power and Light District, police said, while Belcher's mother was watching their 3-month-old baby. Detectives don't know exactly what the couple was arguing about but The Star reported that Belcher was upset that Perkins had stayed out so late.


Autopsies with toxicology tests were performed on both bodies but it could be weeks before results are known, police said.


Police spokesman Darin Snapp said Monday that Belcher's mother was given temporary custody of the couple's daughter.


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National Briefing | New England: New Hampshire: Not Guilty Plea in Hepatitis Case



A traveling hospital technologist accused of stealing drugs and infecting patients with hepatitis C through contaminated syringes pleaded not guilty in federal court on Monday. The technologist, David Kwiatkowski, whom prosecutors described as a “serial infector,” was indicted last week on charges of tampering with a consumer product and illegally obtaining drugs. Until May, Mr. Kwiatkowski worked as a cardiac technologist at Exeter Hospital, where 32 patients were given diagnoses of the same strain of hepatitis C he carries. Before that, he worked in 18 hospitals in seven states, moving from job to job despite having been fired twice over accusations of drug use and theft. In addition to the New Hampshire patients, a handful of patients in Kansas and one in Maryland have been found to carry the strain Mr. Kwiatkowski carries.


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Generic Drug Makers Facing Squeeze on Revenue


They call it the patent cliff.


Brand-name drug makers have feared it for years. And now the makers of generic drugs fear it, too.


This year, more than 40 brand-name drugs — valued at $35 billion in annual sales — lost their patent protection, meaning that generic companies were permitted to make their own lower-priced versions of well-known drugs like Plavix, Lexapro and Seroquel — and share in the profits that had exclusively belonged to the brands.


Next year, the value of drugs scheduled to lose their patents and be sold as generics is expected to decline by more than half, to about $17 billion, according to an analysis by Crédit Agricole Securities.“The patent cliff is over,” said Kim Vukhac, an analyst for Crédit Agricole. “That’s great for large pharma, but that also means the opportunities theoretically have dried up for generics.”


In response, many generic drug makers are scrambling to redefine themselves, whether by specializing in hard-to-make drugs, selling branded products or making large acquisitions. The large generics company Watson acquired a European competitor, Actavis, in October, vaulting it from the fifth- to the third-largest generic drug maker worldwide.


“They are certainly saying either I need to get bigger, or I need to get ‘specialer,’ ” said Michael Kleinrock, director of research development at the IMS Institute for Healthcare Informatics, a health industry research group. “They all want to be special.”


As one consequence of the approaching cliff, executives for generic drug companies say, they will no longer be able to rely as much on the lucrative six-month exclusivity periods that follow the patent expirations of many drugs. During those periods, companies that are the first to file an application with the Food and Drug Administration, successfully challenge a patent and show they can make the drug win the right to sell their version exclusively or with limited competition.


The exclusivity windows can give a quick jolt to companies. During the first nine months of 2012, sales of generic drugs increased by 19 percent over the same period in 2011, to $39.1 billion from $32.8 billion, according to Michael Faerm, an analyst for Credit Suisse. Sales of branded drugs, by contrast, fell 4 percent during the same period, to $174.2 billion from $181.3 billion.


But those exclusive periods also make generic drug makers vulnerable to the fickle cycle of patent expiration. “The only issue is it’s a bubble, too,” said Mr. Kleinrock. He said next year, the generic industry would enter a drought that was expected to last about two years.  Of the drugs that are becoming generic, fewer have exclusivity periods dedicated to a single drug maker.


In 2013, for example, the antidepressant Cymbalta, sold by Eli Lilly, is scheduled to be available in generic form. But more than five companies are expected to share in sales during the first six months, according to a report by Ms. Vukhac.


Heather Bresch, the chief executive of Mylan, the second-largest generics company in the United States, said Wall Street analysts were obsessed with the issue. “I can’t go anywhere without being asked about the patent cliff, the patent cliff, the patent cliff,” she said. “The patent cliff is one aspect of a complex, multilayered landscape, and I think each company is going to face it differently.”


Jeremy M. Levin, the chief executive of Teva Pharmaceuticals, the largest global maker of generic drugs, agreed. “The concept of exclusivity — where only one generic player could actually make money out of the unique moment — has diminished,” he said. “In the absence of that, many companies have had to really ask the question, ‘How do I really play in the generics world?’ ”


For Teva, Mr. Levin said, he believes the answer will be both its reach  — it sells 1,400 products, and one in six generic prescriptions in the United States is filled with a Teva product  — and what he says is a reputation for making quality products. That focus will be increasingly important, he said, given recent statements by the F.D.A. that it intends to take a closer look at the quality of generic drugs. Mr. Levin also said he planned to cut costs, announcing last week that he intended to trim from $1.5 to $2 billion in expenses over the next five years.


This article has been revised to reflect the following correction:

Correction: December 4, 2012

An earlier version of this article misstated the country in which the pharmaceutical company Endo is based. It is an American company, not Japanese.



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