Blog | 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.