What Physicians Don't Know About Smoking

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As a public health professional, I was appalled by the intensity of the antagonism over the damages in a Californian's lawsuit against Philip Morris U.S.A., decided last June. Sure, the damages $3.5 billion may seem immense. But this record award will barely dent the tobacco giant's profits.

The mantra of those who seemed outraged by the award was "Everyone knows the dangers of smoking." The apparent acceptance of this seeming truism distressed me, especially when acquaintances of mine I considered intelligent and educated displayed such acceptance. Although the conviction that everyone knows the health risks of smoking seems widespread, the medical literature abundantly belies it, with studies that have shown that relatively very few Americans are well informed about the diversity of tobacco-related illness. Evidently, even many of those who suffer such illness (emphysema and heart disease, for example) are ignorant concerning what caused it.

Although the conviction that everyone knows the health risks of smoking seems widespread, the medical literature abundantly belies it . . . .

On the heels of my self-satisfied reaction to the stir over the damages, I realized that only a couple of years before, I myself would have condemned the award. Although I had been an internist for two decades and had treated hundreds of persons with diseases related to cigarette smoking, it was only after I became Medical Director of the American Council on Science and Health (ACSH) that I learned how dangerous the habit is. I should not have felt that the behavior of commentators who are not health professionals should be more informed on this subject than mine had been as an accomplished healthcare practitioner, one who had undergone both an excellent medical education at New York University and thorough training in cardiac, pulmonary, and circulatory diseases at topnotch programs. Despite these credentials, I had been woefully ignorant of how variegated the adverse effects are of introducing tobacco smoke into the human body.

In the United States, tobacco smoke is responsible for about 85 percent of deaths from lung cancer, which is the most common cancer in both men and women and the leading cause of death from cancer. While it is possible that most of the patients I diagnosed with lung cancer had had considerable knowledge of the health risks of smoking, all even longtime smokers seemed devastated when they learned the diagnosis. And those who said they had not smoked in years apparently were dismayed when they learned that lung cancer often emerges in a patient five or more years after he or she has last smoked a cigarette. Some patients protested to the effect of: "But I was only a pack-a-day guy I was never a heavy smoker." But for no smoking-induced ailment has a threshold been ascertained. In other words, no level of exposure to tobacco smoke is on a scientific basis describable as safe.

Of 737 adult cigarette smokers questioned in 1995 in a study published in the March 17, 1999, issue of The Journal of the American Medical Association, evidently (a) less than one third considered their risk of sustaining myocardial infarction larger than average, and (b) only 40 percent considered their risk of getting cancer larger than average. Apparently, less than 50 percent of the heavy smokers (i.e., subjects who smoked at least 40 cigarettes daily) considered their risk of sustaining myocardial infarction or cancer elevated. Among the ex-cigarette-smokers who were subjects in this study many of whom had been smokers for years awareness of having a consequently elevated risk of disease apparently was more deficient than it was among the smokers. But the risk of disease of former smokers may be 10 times larger than that of persons who have never smoked.

American physicians seem similarly under-cognizant of the riskiness of cigarette smoking. Disbelief or an expression of surprise usually follows my telling ostensibly up-to-date colleagues of the magnitude of this riskiness. There is a tremendous difference between simply knowing that cigarette smoking is hazardous and knowing that almost 50 percent of those who use cigarettes in accordance with their manufacturers' intentions consequently die prematurely. In the U.S., cigarette smoking is the underlying cause of death in nearly 50 percent of persons whose age is less than 75 years.

. . . [N]o level of exposure to tobacco smoke is on a scien-tific basis describable as safe.

The crucial facts about smoking I didn't know when I practiced medicine include those stated below.

* Heavy smoking is unessential to a cigarette smoker's developing an elevated risk of disease from smoking. There is a correlation of adverse health effects and smoking as few as four cigarettes a day.
* Some health effects of smoking cannot be undone, even in former smokers.
* In terms of disease, the 10 percent of smokers who develop lung cancer represent the tip of the iceberg. The chances are very great that a smoker will develop a disease in consequence of smoking.
* Cigarette smoking adversely impacts nearly every bodily system. For example, it causes or contributes to blindness, osteoporosis, impotence, and inability to become pregnant (see "Cigarette Smoking and Sexual Health," PfH, Vol. 12, No. 3).
* The risks of exposure to artificial sweeteners, environmental chemicals, and pesticide residues are hypothetical and are not at all comparable to the risks of cigarette smoking, which are proven.
* The health risk from smoking filter-tipped or "light" cigarettes which are heavily marketed, particularly to women is not smaller than, and may exceed, that from smoking non-filter-tipped or non-"light" cigarettes.

As a medical practitioner, I was also not in the least conversant with the tobacco industry's hugely effective campaign of disinformation and intimidation intended to conceal relevant facts from the public. In terms of informativeness, the warnings on cigarette packs are a flagrant triviality; warnings on cigarette lighters are less ambiguous. ACSH's president, Dr. Elizabeth M. Whelan, has stated:

In 1964-1965 . . . the [tobacco] industry faced the threat of individual states' requiring their own, different health-warning labels on cigarette packs. This undoubtedly would have made the interstate packaging and marketing of cigarettes chaotic. So the industry cut a deal in Washington: Congress mandated a wishy-washy national label. With this single masterstroke, the tobacco companies secured a privilege possessed by no other manufacturer: federally granted freedom not to provide consumers with detailed information on the health effects of their products.

Moreover, that the labels of virtually innocuous products (such as foods that contain the noncaloric fat substitute olestra) include warnings analogous to those on cigarette packs diminishes the latter warnings.

Many educated persons claim that cigarette smoking is not addictive. But the rate of would-be nonsmokers terminating their habit of smoking is very low. On average, Americans trying to quit this habit succeed in doing so only after seven attempts and many use anti-smoking pharmaceutical and/or psychological aids.

I hold to the principle that adults aware of the risks of an action should be considered to blame for the consequences of that action. Regrettably, most cases of smoking addiction in adulthood originate from the smoker's having smoked when he or she was a teenager. Thus, addiction to smoking often precedes informedness on the risks of smoking and/or the discernment necessary to use such information healthfully.

In the U.S., cigarette smoking is the underlying cause of death in nearly 50 percent of persons whose age is less than 75 years.

If future juries act on the ample evidence of Big Tobacco's long-term misbehavior particularly evidence of its dissembling the destructiveness of smoking cigarette companies may in consequence widely tell the whole truth about their products and about the health consequences of using them. Only after such companies have done so, and have virtually precluded sales of tobacco products to minors in the U.S., should adult American smokers be considered the sole cause of the consequences of their smoking.

Until such a time, tobacco companies will happily continue to agree with the vox populi that "everyone knows . . . ."

(From Priorities, Vol. 13, No. 3)