At least 16 hurt in blast and fire at Kansas City restaurant

At least 16 people were hurt and a popular wine bar was destroyed by an apparent natural gas explosion and ensuing fire at an upscale shopping district in Kansas City, Mo., Tuesday evening.

Residents reported smelling natural gas and seeing utility crews in the area before the conflagration. A strong scent of gas hung in the air afterward.

“Early indications are that a contractor doing underground work struck a natural gas line, but the investigation continues,” Missouri Gas Energy, a natural-gas provider, said in a statement.

The Kansas City Fire Department said the incident was under investigation. “It does seem to be an accident,” Fire Chief Paul Berardi said during a late-night news briefing.

JJ's Restaurant and wine bar, just off Country Club Plaza, had apparently been partially evacuated before the blast occurred about 6 p.m.

"This was happy hour at the restaurant. There were patrons in the restaurant," Berardi said.

No fatalities were reported, but officials brought in cadaver dogs to check the rubble. The Kansas City Star reported that one JJ's employee was missing.

The fire raged for two hours, with thick smoke visible for miles. Victims streamed to hospitals; at least four people were in critical condition.

Initially, police said a car had hit a gas main, but officials later discounted that explanation.

Witnesses described a chaotic scene. 

"I was sitting in my living room folding laundry, and felt in my chest -- and heard -- an explosion," said Jamie Lawless, who lives about two blocks from JJ's. "I started freaking out, and I was looking around, and then I saw other people walking outside. You could see giant black smoke billowing up from the plaza area, and nobody really knew what it was."

Sally McVey, who lives across the street from JJ's, said the fire "was growing exponentially, incredibly quickly. It was not like a fire I’ve seen before, where it takes a long time to spread.”

A crowd gathered to watch firefighters battle the blaze. At an apartment building on JJ's block, a woman on a top-floor balcony called down to onlookers.  "'Is my building on fire?' and everybody says, 'Yes, come down!' " McVey said. "She’s like, 'Oh my gosh,' and a lot of people come out of that building with their computers and dogs. She did too.”

JJ's owner, Jimmy Frantze, was out of town, said Kansas City Mayor Sly James, who used to be a fixture at the restaurant. The business, which boasted a selection of 1,800 bottles, had been on the site for 28 years.

“It was 28 years of a great restaurant, and then it has to end like this,” Frantze told the Kansas City Star while driving back from Oklahoma. “I want to make sure to check on my employees to make sure they are all right.”

Kansas City Police Department's bomb squad and officials with the Bureau of Alcohol, Tobacco, Firearms and Explosives were expected to investigate the accident after the search dogs finished looking for victims, Berardi said.

 matt.pearce@latimes.com

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Well: No Consensus on Plantar Fasciitis

Phys Ed

Gretchen Reynolds on the science of fitness.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Civilian deaths in war in Afghanistan drop for first time in 6 years

KABUL, Afghanistan -- Civilian deaths in the war in Afghanistan dropped in 2012 for the first time in six years, a sign of lessening hostilities, but insurgents dramatically expanded their campaign of assassinating government supporters, the United Nations said Tuesday.

The annual U.N. report on civilian casualties in Afghanistan documented a 12% decline in civilian deaths, largely due to fewer ground operations, new limits on airstrikes by U.S.-led coalition forces and fewer suicide bombings by insurgents. Coalition operations resulted in 39% fewer civilian deaths, the report said.

A harsh winter that limited combat operations and insurgent movements also contributed to the drop in casualties as the 11-year conflict shifts to a new phase in which foreign forces step back and Afghan soldiers and police, who possess less deadly weapons, are almost entirely in the lead.

In all, 2,754 civilians died in the war last year, bringing the death toll to 14,728 since 2007, when the U.N. began tracking civilian casualties.

But the report said that targeted killings -- attacks against government employees, tribal and religious leaders and Afghans involved in peace efforts -- resulted in more than twice as many deaths and injuries in 2012, in part because Taliban-led insurgents increased their use of homemade bombs that spread damage over a wider area.

U.N. officials said they were particularly disturbed by a seven-fold increase in casualties among government workers, including the murders of the two top officials in the women’s affairs department in Laghman province, east of Kabul.

"Steep increases in the deliberate targeting of civilians perceived to be supporting the government demonstrates another grave violation of international humanitarian law," Jan Kubis, the U.N. special envoy to Afghanistan, said in a statement. He said the Taliban leaders’ promises to protect civilians so far amounted to "only words."

Insurgents were responsible for 81% of civilian casualties last year, compared to 72% in 2011, the report said, with improvised bombs being the single deadliest weapon.

Civilian deaths and injuries from operations by U.S.-led international forces and Afghan soldiers and police fell by 46%, the U.N. said, due largely to new restrictions by coalition commanders on airstrikes on residential dwellings.

Still, a NATO airstrike last week in eastern Kunar province reportedly killed 10 civilians in addition to four Taliban commanders, provoking fresh ire from President Hamid Karzai. The Afghan leader on Monday ordered his country’s security forces "not to request foreign airstrikes on residential areas" – a move that could further reduce civilian deaths but also hinder Afghan forces that have no air power of their own.

Marine Gen. Joseph F. Dunford, the coalition commander, said this week that his forces would comply with Karzai's order and could continue to operate effectively. The order does not apply to unilateral NATO operations, but experts say that in practice it could give U.S. forces cover for stepping back even further from combat operations as the Obama administration seeks to withdraw half of the remaining 66,000 American troops from Afghanistan by next February.

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Romanian cinema triumphs again with top Berlin award

BERLIN (Reuters) – Romania claimed another major scalp on the European film festival circuit this weekend when “Child’s Pose” won the Golden Bear in Berlin, underlining the country’s emergence as a powerhouse of hard-hitting cinema in the post-Communist era.

The film, directed by Calin Peter Netzer, tells the story of Cornelia, an obsessive mother who uses every trick in the book to prevent her son from going to jail after he kills a boy in a car accident.

It is the latest in a long list of critical hits that have enjoyed startling success at festivals like Berlin and Cannes in recent years, helping to bring Romania‘s cinema to a wider audience.

Some of Romania‘s top directors, who have enjoyed the artistic freedom that flourished after the death of Communist dictator Nicolae Ceausescu in 1989, dismiss talk of a cinematic “new wave”, saying it lumps together very different styles and stories.

But ever since Cristi Puiu’s “The Death of Mr. Lazarescu” hit Cannes in 2005, and two years later his compatriot Cristian Mungiu won the coveted Palme d’Or there for the harrowing abortion drama “4 Months, 3 Weeks and 2 Days”, Romanian cinema has been firmly on the map.

“It is an acknowledgement, I think, that Romanian cinema is still producing good quality cinema and has been for a few years and it is a good endowment that it is still like this,” Netzer told Reuters after receiving the Golden Bear for best film.

UNFLINCHING STORYTELLING

While each film differs, there is a common thread of unflinching storytelling and compelling human drama often laid out against the backdrop of a cold and uncaring society.

Netzer said “Child’s Pose” was not a critique of Romania today, despite its unflattering portrayal of flashy materialism and casual corruption among the nouveau riche.

“I think basically this is about a relationship, a kind of pathological relationship between mother and son,” he told reporters in Berlin after the closing ceremony late on Saturday.

“The rest – the corruption, the framework, the context, all of that is on a separate level and is really only a backdrop.”

Victory in Berlin is likely to give the movie a major boost in terms of distribution in Romania and beyond, although some critics wondered whether the alienating figures of both mother and son might limit its appeal.

“There’s an instant bond the audience has with the two young women in ’4 Months…’ which we are deliberately not supposed to have in ‘Child’s Pose’,” said Jay Weissberg, critic at trade publication Variety.

“The mother is a monstrous figure and her son is even worse.”

However he, like many others, was impressed by Luminita Gheorghiu’s portrayal of Cornelia, one of several standout performances in Berlin-nominated films by mature actresses making the most of the kind of parts rarely written in Hollywood.

Paulina Garcia was the popular winner of the best actress Silver Bear for her turn in Chilean film “Gloria”, in which she plays a 58-year-old divorcee who sets out to live life to the full despite her setbacks.

“We all face crossroads in our lives where we can retreat into ourselves or we can hit the dance floor,” said “Gloria” director Sebastian Lelio of his character.

The biggest surprise at the Berlin awards ceremony was the best actor prize going to Nazif Mujic, a Bosnian Roma who had never acted before and had to be talked into playing himself in a drama based on his real-life ordeal.

“An Episode in the Life of an Iron Picker”, made for just 30,000 euros ($ 40,000), tells the story of how Bosnian hospitals refused to operate on his wife after she miscarried because she was not insured, despite the fact that her life was in danger.

Best director went to U.S. filmmaker David Gordon Green for his quirky road movie “Prince Avalanche” and Iranian entry “Closed Curtain” picked up the best script prize for directors Kamboziya Partovi and Jafar Panahi.

Panahi made the movie in secret in defiance of a 20-year filmmaking ban and was not allowed to travel to Berlin to collect his award.

“Tradition and culture remain, politicians come and go,” Partovi told reporters after receiving the honour.

(Reporting by Mike Collett-White; Editing by Andrew Heavens)

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National Briefing | South: Abortion Curbs Clear Senate in Arkansas

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

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Japan Finds Swelling in Second Boeing 787 Battery

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

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

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

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

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

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

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

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

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

(Reporting by Mari Saito; Editing by Richard Pullin)

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Mary Jo White could face conflicts of interest as SEC chairwoman

NEW YORK — As a lawyer in private practice, Mary Jo White worked for Wall Street all-stars: banking giant JPMorgan Chase & Co., auditor Deloitte & Touche, former Bank of America Corp. chief Ken Lewis.

White, President Obama's pick to lead the U.S. Securities and Exchange Commission, even did legal work for former Goldman Sachs Group Inc. director Rajat Gupta, the highest-profile catch in the federal government's crackdown on insider trading, according to disclosures White filed ahead of her U.S. Senate confirmation hearing.

If she wins approval to lead the country's top financial watchdog, government ethics rules could force White to sit out of some SEC decisions. Potential conflicts of interest — or the appearances of conflicts — could arise from her work at the high-powered New York law firm Debevoise & Plimpton, and that of her husband John White, a partner at the prestigious firm Cravath, Swaine & Moore.

Obama's appointment of White, a former U.S. attorney in Manhattan known for high-profile prosecutions of mobsters and terrorists, was seen as a signal the administration was getting tougher on Wall Street. Her confirmation hearing in the Senate has not yet been scheduled but is expected in the next several weeks.

"She would have quite a minefield to navigate," said Robert Kelner, an attorney who is an expert in government ethics rules at the law firm Covington & Burling in Washington. "But this is not unusual for a senior-level appointee coming out of a law firm."

White could have to abstain from votes on matters involving former clients at a time when the SEC has been struggling to regain investor confidence among regulators and financial markets.

Government ethics rules generally prevent commissioners from participating in matters in which they or their spouses have any financial stake, or have any interest that could raise questions about their impartiality, Kelner said.

These rules generally restrict commissioners from taking part in cases they worked on while in the private sector — whether to bring a securities fraud lawsuit against a former client, for example, Kelner said.

White could still be involved in other matters dealing with former clients, just as long as she hasn't previously worked on the other side of particular cases before the SEC, Kelner said.

What could also complicate White's tenure at the SEC is an ethics pledge Obama has required executive-branch appointees to sign since he took office.

Aiming to limit the effects of the "revolving door" between government officials and the private sectors they regulate, the ethics pledge precludes appointees from participating in any matter involving "specific parties that is directly and substantially related" to their "former employer or former clients." Kelner said the pledge generally would not apply to broad regulations or policies.

The White House could grant White a waiver from the ethics pledge.

White did not respond to an email request for comment. Nominees typically do not speak publicly ahead of their confirmation hearings.

White would take over the SEC at a time when the agency faces major regulatory issues, aside from enforcement issues. The five-member commission, under former Chairwoman Mary Schapiro, failed to pass a sweeping overhaul of money-market funds, which federal officials say remain a weak link in the financial system.

Also before the SEC are rules governing high-speed stock trading and how the increasingly fragmented stock market is structured. The agency still must mete out myriad regulations called for by the Dodd-Frank financial overhaul of 2010.

John Coffee, a securities law expert at Columbia University in New York, said White has no apparent conflicts involving the marquee regulatory matters facing the SEC.

"There is just a forest of bayonets waiting out there if she looked like she was protecting a former client from an enforcement action," Coffee said. "I think she's also too smart to put herself in that kind of position."

andrew.tangel@latimes.com

Times staff writer Jim Puzzanghera in Washington contributed to this report.

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Travis Barker skips Blink-182 Australia tour due to flying fear

(Reuters) – Travis Barker will skip the Australian tour of pop-punk band Blink-182, citing a long-term fear of flying that worsened after he survived a fatal crash nearly five years ago that killed two friends.

“I’m sorry to announce I won’t be joining Blink-182 on this Australian tour,” Barker, 37 and drummer for the group, wrote on Facebook. “I still haven’t gotten over the horrific events that took place the last time I flew when my plane crashed and four people were killed, two being my best friends.”

Barker was one of two survivors of the 2008 crash when a private plane he was on burst into flames during an aborted takeoff. He spent several months in hospital with injuries.

Barker said he had hoped to get to Australia by ship if need be for the tour, which starts on Wednesday in Sydney, but that schedules hadn’t worked out.

“Once again, I’m sorry to all the fans,” he said.

The band, also writing on Facebook, said Barker would be replaced on the tour by Brooks Wackerman from Bad Religion and Tenacious D.

“The band knew the chances of Travis overcoming his fear of flying, which was magnified after the horrible plane crash of 2008, would be a challenge, but we wanted to play for our fans in Australia nonetheless,” they said, adding that cancelling the tour had not been an option.

(Reporting by Elaine Lies; Editing by Paul Tait)

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Well: Health Effects of Smoking for Women

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Allure of Self-Insurance Draws Concern Over Costs

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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