American College of Physicians: Internal Medicine — Doctors for Adults ®

Friday, March 1, 2013

Newsflash: Smoking is still very unhealthy

I have shocking news. Smoking is very, very bad for you.

In 1964 the U.S. Surgeon General issued a report summarizing the known adverse health effects of smoking. At that time about 40% of American adults smoked. A widespread campaign followed informing Americans about the link between smoking and lung cancer, emphysema, stroke and heart attacks. Federal law required the placement of health warnings on cigarette packages, and school children all learned about the adverse health effects of smoking.

By 2010 the prevalence of smoking decreased to 19% of American adults, mostly because of more people quitting (rather than fewer people starting). But from 2004 to 2010 the prevalence of smoking has changed little. We seem to have reached a steady state, a nadir of smoking despite the now well-known health hazards. And while smokers were much more representative of the general population in the 1960s, they are now disproportionately poor and less educated. Current smokers are also on average younger than non-smokers, since so many smokers quit as they get older.

This week the New England Journal of Medicine (NEJM) published two studies that attempted to quantify the differences in longevity between smokers and non-smokers. The studies followed hundreds of thousands of men and women and compared the information about their smoking status to their longevity and cause of death.

The results were fairly dramatic. On average, those who never smoked live over 10 years longer than those who continue to smoke their whole lives. For those between 25 and 79 years old, the death rate for smokers is three times that of those who never smoked. Those who quit also did much better than those who didn't. Those who quit between the ages of 25 and 34 lived 10 years longer than those who continued smoking, almost reaching the longevity of those who never smoked. The benefit of quitting decreased with increasing age, but never disappeared. Smokers who quit between the ages of 55 and 64 still lived 4 years longer than those who kept smoking.

My regular readers will recognize that these are not randomized studies, and they therefore deserve some skepticism. That's true. One study was controlled for alcohol use, educational level, and body mass index, but one can easily imagine other confounding factors (poverty, poor access to health care) that may be more prevalent among smokers and independently increase the risk of death. So we can't be certain that the effect of smoking is as large as the study suggests. Still, the studies add to a mountain of evidence that has already established the risk of smoking. And a randomized study will never be done, so we will never be able to measure the risk exactly.

The bottom line is that smoking is likely to cut your life short. Quitting at any age has benefits. Sooner is better.

The author of an accompanying editorial in the same NEJM issue concludes with this concern: "Because smoking has become a stigmatized behavior concentrated among persons of low social status, it risks becoming invisible to those who set health policies and research priorities. Yet, the need for greater attention to the policies known to reduce the prevalence of smoking remains urgent. As former Australian Health Minister Nicola Roxon has said, 'We are killing people by not acting.'"

But the increasing "invisibility" and disenfranchisement of smokers seems to me inevitable. For half a century we have very successfully educated people about the risks of smoking. We have waged a campaign that has made it clear that smoking is hazardous and we have tried to make it uncool. We cannot simultaneously applaud our important success while being surprised that those most resistant to the message are those whom information and solid judgment are least likely to reach.

All diseases that are predominantly acquired through behaviors, like HIV or cervical cancer, follow the same pattern over time. As education about prevention of the disease spreads, those who have access to information and value their health will stop contracting the disease. A generation later those who are still engaging in the risky behaviors are very difficult to reach. Few problems are more intractable than people in free societies choosing to harm themselves.

Further progress in decreasing the prevalence of smoking is likely to be incremental and slow. I suspect further attempts at addressing this problem through policy will involve tradeoffs, not solutions.

Learn more:
Smokers Lose 10-Plus Years of Life, Studies Find (Wall Street Journal)
Quitting smoking prolongs life at any age (LA Times)
Putting a Number on Smoking's Toll (NY Times)
21st-Century Hazards of Smoking and Benefits of Cessation in the United States (NEJM article)
50-Year Trends in Smoking-Related Mortality in the United States (NEJM article)
New Evidence That Cigarette Smoking Remains the Most Important Health Hazard (NEJM editorial)

Tangential Miscellany
Seven years and over 300 posts ago I decided to start writing a weekly health news blog. Since then my posts have been republished in half a dozen publications, started some fascinating debates, and I hope educated and stimulated you. Thank you for reading. I promise to try not to bore you in the next seven years.

Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000. Holding privileges at Cedars-Sinai Medical Center, he is also an assistant clinical professor at UCLA's Department of Medicine. This post originally appeared at his blog.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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