What I Didn’t learn in Medical School: Cigarette Smoking
Sure, I learned that smoking and tobacco use were bad for you. And I learned that there were more than 100 chemicals in cigarette smoke besides tar and nicotine. But here a few facts that we never learned, and if we did, they certainly weren’t emphasized.
Tobacco is the single largest preventable cause of morbidity and mortality in the U.S. (Obesity, according to some, might have overtaken tobacco, but more of that in a later posting)
Tobacco products kill one of every two people who use them.
Compared to people who never smoked, smokers lose, on average, about 10 years of life!
About 480,000 deaths each year in the US are smoking-related.
Smoking leads to or worsens many other conditions, including, but not limited to, diabetes, rheumatoid arthritis, wound healing, reproduction capabilities in both men and women, erectile dysfunction, age related macular degeneration, and bone fractures.
Seventy chemicals in in cigarette smoke are known carcinogens.
Filtered cigarettes allow smokers to inhale these chemicals even deeper into their lungs than unfiltered cigarettes.
Smoking causes:
almost 90% of lung cancer deaths (we all know people who never smoked who got lung cancer, but the fact remains that most people with lung cancers are or were smokers)
about one-third of coronary heart disease deaths
about 80% of deaths from COPD (chronic obstructive lung disease). (I’m not even going to talk about all those people walking around—if they can still walk—on oxygen due to COPD).
By the way, remember the slogan by one tobacco company in the 1960’s aimed at women, “You’ve come a long way baby”. Well, they were sure right about that. When I was in medical school, lung cancer was the number one cause of cancer death in men, but wasn’t near the top of the list for women (we used to have to memorize lists like this all the time!). Today, and for at least the last 10 years, lung cancer is the leading cause of cancer deaths in BOTH men and women. The risk of lung cancer in women rose about six-fold between 1950-2010. You’ve come a long way, indeed!
Smoking and cancer
More than 40 different cancers are related to tobacco use, including lung, mouth, throat, larynx, esophagus, stomach, kidney, pancreas, liver, bladder, colon and rectum. Even one form of leukemia, acute myeloid leukemia, is linked to tobacco use)
According to the CDC, about 40% of all cancers have a link to tobacco use
If no one smoked or used tobacco products, one in three cancer deaths would not happen.
Nicotine and addiction: Nicotine is the most common form of chemical dependence in the U.S. (In my own experience, I was able to get pregnant heroin users to stop using heroin but couldn’t get them to quit smoking!)
Despite all the above, every day, about 2500 children under 18 years of age try their first cigarette. About 400 of them will become regular users and half of these will ultimately die of their habit.
Now, for the good news (yes, there is some)
Fewer adults smoke today than ever before. (In large part this is due to public policy and a very broad educational campaign including warning labels and high taxes on tobacco products). Smoking incidence has declined from about 21% to 14% (about 1 in 7 adults) today. There are more former smokers than current smokers in the world.
Most tobacco users—about two-thirds—want to quit completely, but only 5% of these will be able to by themselves quitting “cold turkey”.
With a supportive physician, prescriptions for the drugs approved to reduce the cravings associated with nicotine withdrawal and some nicotine substitutes (patch, gum, etc.), a support group as found in a smoking cessation program, along with a supportive family, about 50% can and will be tobacco-free 3 months after their “quit date”. This compares to the 75% who will be smoking again within 30 days, when they try it on their own.
The benefits of smoking cessation are immediate.
After 1 year, the risk of heart disease is reduced by 50%
After 2-5 years, the risk of a stroke is about the same as a non-smoker
After 10 years, the risk of lung cancer is reduced by 50%
Quitting by 30 years of age gains about 10 years of life expectancy
It’s never too late to quit; quitting by 60 years of age gains three years of life expectancy. That’s three more years (more than 1000 days) with the grandkids!
I am not opposed to programs that promote using low dose CT scans to identify early lung cancer among current and former smokers, but I think it would be far more cost-effective to educate children about the harmful effects of smoking, nudge them and other smokers (and all tobacco users) back to non-tobacco status before they are 30, and continue to assess a smoker’s willingness to change their behavior (see Part 1 of this blog regarding the transtheoretical model of behavior change) at EACH VISIT, gently nudging them into the active state of behavior change and them help them achieve their goal. Providers must also be aware of the potential triggers that might result in relapse and be prepared to respond appropriately. All physicians should be trained on how to conduct a motivational interview, including the 5 R’s: Relevance, i.e. help the patient identify the negative consequences of smoking, Risks of smoking, Rewards of quitting, Roadblocks to quitting, Repetition (at every visit). Physicians might not be the cause of chronic health conditions in the US, but they can and must be an important part of chronic disease prevention.
