Do Americans really know enough about the dangers of smoking to make an "informed" decision to light up? Of course they should. Even Philip Morris, as we now know from a company-funded study in the Czech Republic that caused an international flap last week, was aware of early death rates among smokers. The rates were touted in the study as "indirect positive effects" that netted the country savings on health care, pensions, welfare and housing for the elderly.
Yet still some commentators, disgusted by huge damage awards and government deals with the tobacco industry, trumpet the mantra: "Everyone knows the dangers of smoking!"
Well, that depends on what your definition of "know" is. A recent World Bank report, "Curbing the Epidemic," states: "Many smokers are unaware of their risks, or they simply underestimate or minimize the personal relevance of those risks, even in high-income societies." I received an excellent medical education at New York University, as well as a thorough grounding in lung, heart and circulatory diseases in the finest internal medicine programs in the country in the 1970s. Despite this, and 20 years of practice as an internist, I remained woefully ignorant of the breadth of adverse effects of smoking until 1998, when I became medical director of a national public health organization. As a practicing physician, I "knew" that smoking was risky. But in my second career, as a public health physician, I learned that there is a huge difference between the awareness that cigarettes are "dangerous" and knowing that, when used as intended, they prematurely kill almost half of smokers. Smoking is the underlying cause of almost half of all deaths before age 75.
The difference between what I knew then, when I was a practicing physician, and what I know now, includes these crucial facts:
* You do not have to be a heavy smoker to incur major health risks.
* There is no known "safe" exposure, and as few as four cigarettes daily has been associated with adverse health effects, some irreversible, despite quitting.
* Smokers wade through a minefield of diverse risks; thus, the odds are overwhelming that a smoker will prematurely develop some cigarette-related disease. The 10% who get lung cancer are just the tip of the morbidity iceberg.
* Smoking has a devastating impact on nearly every system in the body, causing blindness, infertility, impotence and osteoporosis, among a spectrum of other maladies. The proven risks of smoking are in another statistical universe compared to more publicized yet hypothetical risks, such as exposure to artificial sweeteners, pesticide residues and environmental chemicals.
* Heavily marketed filter-tips and "lite" cigarettes, often aimed at women, not only fail to reduce risk but may actually increase it.
I recall patients, newly diagnosed with cigarette-induced disease, being shocked that it was happening to them. They almost always revealed the same dim understanding of smoking and disease that I had.
But beyond not knowing the specifics of cigarette-related risks, I also was ignorant of the details of the 50-year history of the tobacco industry's hugely successful campaign of disinformation, intimidation, conspiracy and just plain fraud in concealing the facts about smoking. I did not know that they used the clout of their advertising dollar to keep the bad news about smoking out of popular magazines--and paid film stars to smoke their brands in movies. It was news to me that they had enough power in 1959 to get the New York City Transit Authority to order Reader's Digest ads removed from the subways when the magazine was promoting an article titled "The Growing Horror of Lung Cancer."
Why haven't the tobacco companies fully informed us?
Because they have been getting away with not doing so. The industry has repeatedly cited the government-mandated warning label as "preempting" its duty to warn smokers about the dangers they face.
Only after the tobacco industry provides complete disclosure, including that of addiction, and stops selling to kids, should adult smokers bear the full responsibility for the consequences of their habit.
Until that time, the industry will remain only too happy to agree with the vox populi : "Everyone knows."