Wednesday, February 12, 2014
Smoking: A half century of knowing we should quit
In 1950, Ernst Wynder, MD, and colleagues began to produce convincing data that cigarette smoking caused lung cancer. Over the ensuing many years evidence has arisen linking cigarette smoking to many different cancers and conditions, chronic lung disease and heart attacks. In 1964, the Surgeon General reported that cigarette smoking was the most important risk factor for development of lung cancer and that quitting smoking reduced that risk. Since that time a concerted effort to reduce tobacco smoking has been one of the most important public health agenda items for the medical profession. Since this is the 50th anniversary of organized tobacco control, the Journal of the American Medical Association has devoted an entire issue to the subject of tobacco and health.
Articles include a survey of smoking prevalence around the world: U.S. residents smoke less than people in Europe, especially Eastern Europe. Although many Africans smoke, they don’t smoke much. Women generally don’t smoke as much as men, except possibly in Eastern Europe.
There were a pair of articles discussing eCigarettes, the nicotine delivery devices that look vaguely like cigarettes but don’t burn tobacco. One article expressed the strong conviction that eCigarettes should be regulated by the Food and Drug Administration (FDA) because their long term safety has not been studied, especially in adolescents, their public use makes people accept a smoking-like activity in public places where it is now prohibited and many people who smoke eCigarettes also smoke tobacco so perhaps the delivery of nicotine allows ongoing addiction. The other article suggested that eCigarettes might be a “disruptive technology” and might entirely replace burning tobacco, with its associated health risks. Digital photography was a similar disruptive technology and has successfully nearly replaced film photography due to its competitive cost and improved convenience and adaptability. The authors felt that increased regulation of eCigarettes might serve to bolster the market share of the tobacco industry, with significant negative impact on the health of the smokers who are likely to abandon tobacco for a cheaper and more convenient alternative.
Other articles looked at the usefulness of two drugs, bupropion and varenicline, to promote and support cigarette abstinence. These drugs have been available for years, along with nicotine replacement, to help smokers quit and have been moderately helpful.
The most thought provoking article of the collection was written by two authors, Andrea L. Smith and Simon Chapman, of the Public Health School of the University of Sydney in Australia. They point out that the vast majority of patients who have quit smoking have done so entirely unassisted. No support groups, no drugs, no counseling. In a 2013 Gallup poll, 48% of successful quitters stopped “cold turkey” because they decided it was time, 5% used nicotine replacement and only 3% used drugs. The authors noted that the Australian government spends a vast amount more money on the drugs prescribed to help patients quit than on social marketing campaigns which would make them want to quit. Apparently the U.S. is not alone in its belief that we need pharmaceuticals to make us well. Buying drugs which don’t work and require that patients visit doctors for prescriptions and counseling is revenue generating. Successfully quitting “cold turkey” is not.
In 1964, Americans first got the message from the Surgeon General that they should quit smoking to reduce their risk of lung cancer. The response to this message was huge. In 1964 42.7% of adults smoked and today that number is 18.1%. Average daily cigarette consumption among smokers has also dropped, from 20 to 13. We have seen a significant reduction in death rates associated with smoking related diseases. The vast majority of smokers consider themselves to be addicted and would like to quit. The huge number of patients who have successfully quit have reduced their risk of heart attack, stroke, cancer and lung disease significantly.
A group out of Yale University modeled the number of premature deaths prevented by tobacco cessation since 1964 and they estimate that 8 million lives were saved. These were people who didn’t get cancer, didn’t need oxygen tanks, didn’t have to undergo radiation treatment or chemotherapy, have bypass operations, struggle to walk up hills due to shortness of breath or heart pain. A lot of people need thanks for this: doctors who diligently nagged patients, researchers who followed up leads conscientiously, advocates who countered tobacco company rhetoric, public health specialists who made the story interesting, and most of all smokers who decided to quit, because it was time.
Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.
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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:
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.
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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, 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
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.
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.
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.
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.
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.
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David Katz, MD
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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.
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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.
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Other blogs of note:
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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.
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The Public Library of Science's open access materials include a blog.
One of the most popular anonymous blogs written by an emergency room physician.