Articles

Smoking: The Good News and the Bad News

The principles we espouse on Science-Based Medicine are vitally important, but some of the subjects we address are not so important in the big scheme of things. Homeopathy and electrodermal diagnostic devices don’t actually harm very many people. For today’s post, I’m going to follow the Willie Sutton rule and go where the money is, so to speak.

Smoking is the leading preventable cause of death. No prospective double blind randomized controlled studies have been done, or ever could be done; but a mountain of evidence converging from many avenues has established the health dangers of smoking beyond any doubt. Hill’s criteria of causation have been amply fulfilled.  Smoking causes 90% of all deaths from lung cancer and chronic obstructive pulmonary disease (COPD). It increases the risk of coronary heart disease, stroke, several types of cancer, infertility, stillbirth, sudden infant death syndrome (SIDS), osteoporosis, and premature skin aging (wrinkles). The dangers of second-hand smoke have been amply documented, and where smoke-free laws have been passed there has been a drop in the incidence of heart attacks and of emergency room visits for children with asthma.

Two new studies published in The New England Journal of Medicine reinforce what we already knew and offer both good news and bad news. 

Historical Notes

Back in 1604, King James I of England had a poor opinion of smoking. He said it was:

A custom loathsome to the eye, hateful to the nose, harmful to the brain, dangerous to the lungs, and in the black, stinking fume thereof, nearest resembling the horrible Stygian smoke of the pit that is bottomless.

He didn’t have any scientific evidence to go on, and neither did scientists until well into the 20th century. In the early 1900s, doctors promoted cigarette smoking. Ads featured doctor endorsements like “good for your health” and “more doctors smoke Camels.”  Celebrities, Santa, even babies appeared in tobacco ads. The evidence of harm gradually accumulated, and the tide turned in 1964 with the Surgeon General’s report on smoking and health. Public attitudes changed, and the health hazards of smoking are now widely recognized, but the allure of cigarettes and the addictive properties of nicotine have kept the custom alive.

One New Study

A new study by Jha et al.  found that smoking causes 25% of deaths among both men and women smokers between the ages of 35 and 69. Three times as many smokers die compared to nonsmokers. Smokers lose at least one decade of life expectancy. It’s hard to understand why anyone would knowingly begin using an addictive drug that would cut their life short by 10 years, but there’s something attractive about cigarettes that apparently overrides better judgment. Between 1965 and 2010 the prevalence of cigarette smoking in the US dropped from 42% to 19%, but it changed little from 2004 to 2010.

It’s a global problem. Most of the world’s smokers live in low- and middle-income countries. It is estimated that smoking will kill about 1 billion people in the course of the 21st century. That’s bad news.

The good news is that if smokers stop smoking before the age of 40, their risk of death will drop by 90% compared to those who continue to smoke. [Clarification: smokers' life expectancy is 10 years less than that of non-smokers. If they stop smoking before the age of 40, their life expectancy will improve to only one year less than that of never-smokers.]   It’s never too late to stop, but the benefits diminish with age. Smokers who stop at age 45-54 gain 6 years of life, and those who stop at age 55-64 gain 4 years of life.

Another New Study

A second study by Thun et al.  looked at trends in smoking-related mortality over different time periods and found that:

The risk of death from cigarette smoking continues to increase among women and the increased risks are now nearly identical for men and women, as compared with persons who have never smoked. Among men, the risks associated with smoking have plateaued at the high levels seen in the 1980s, except for a continuing, unexplained increase in mortality from COPD.

For women, the relative and absolute risks of death from smoking have risen to parity with men for lung cancer, COPD, ischemic heart disease, and stroke. “You’ve come a long way, baby” but now maybe you will wish you hadn’t. As the authors point out, “women who smoke like men die like men.” And it appears that women have more difficulty quitting than men.

They corroborated the findings of the Jha study that smokers are 3 times as likely to die. [Clarification: over the 10 year period studied, all-cause mortality was at least three times as high among current smokers as among those who had never smoked.] More than two thirds of all deaths among current smokers in the older age groups are associated with smoking. The rate of COPD in nonsmokers has declined, but it continues to rise in smokers.  The reason for that rise is not clear. They speculate that changes in cigarette design (less irritating tobacco blends, paper that dilutes the smoke, etc.) may have led to easier and deeper inhalation.

What Can Be Done?

Smoking is the leading preventable cause of death. What can we do about it? Prohibition wouldn’t work any better than it did for alcohol. But legislation to raise taxes on cigarettes, prohibit sales to minors, and restrict smoking in public places can have an impact. Warning labels on cigarette packages increase public awareness but don’t persuade many smokers to quit. Smoking cessation programs using nicotine replacement, drugs, hypnosis, incentives, and social interventions don’t have a very high long-term success rate. But there is hope: three-quarters of ex-smokers report having quit on their own without assistance of any kind.

Over 68% of smokers say they want to stop. . Advice from a health professional increases quit attempts and increases use of effective medications which can nearly double to triple rates of successful cessation. The US Preventive Services Task Force (USPSTF) recommends (Grade A recommendation) that clinicians ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products.   But less than half of smokers who saw a health professional in the last year reported receiving advice to quit. That’s shameful. It means doctors were treating lesser problems while ignoring the greatest modifiable threat to their patients’ health. Surely we can do better.

Posted in: Public Health

Leave a Comment (65) ↓

65 thoughts on “Smoking: The Good News and the Bad News

  1. dbe says:

    “But legislation to raise taxes on cigarettes, prohibit sales to minors, and restrict smoking in public places can have an impact.”

    Done, done, and done (at least where I live).

    I’m not sure how I feel about the taxation issue unless the money is solely used for the health costs related to smoking, which is probably not true.

  2. BillyJoe says:

    HH: “Warning labels on cigarette packages increase public awareness but don’t persuade many smokers to quit”

    How about these:
    https://www.google.com.au/search?q=plain+packaging+images&hl=en&client=safari&source=lnms&tbm=isch&sa=X&ei=LRY_UfWCL62YiAefpICgBA&ved=0CAkQ_AUoAQ&biw=1024&bih=672#

  3. cervantes says:

    “But less than half of smokers who saw a health professional in the last year reported receiving advice to quit. ”

    Maybe so, but other research also shows that in general, people only remember about half of what happens in a typical physician visit. If you don’t want to hear it, you won’t. Also, “seeing a health professional” could mean an orthopedist or some other specialist who has a narrow agenda. Primary care providers are probably more likely to discuss this.

    But . . . Doctors aren’t generally trained in behavior change counseling, and don’t necessarily realize that a brief mention isn’t going to accomplish very much. This is a very long story, but I’ll just say for now that you need to have a conversation with the person that doesn’t consist of just threatening them with death or scolding them, but engages their own motivations and goals. You want to activate the reasons why they might want to stop smoking, and get them thinking about it.

  4. Scott says:

    I’m not sure how I feel about the taxation issue unless the money is solely used for the health costs related to smoking, which is probably not true.

    Ultimately, money is fungible. Which particular bits of spending are said to correspond to which particular bits of revenue is just accounting sleight-of-hand with no real meaning.

    Concretely, say we’ve got $80 from income tax and $20 from cigarette tax. And $30 of spending on “health costs related to smoking” plus $70 of other spending. Does it make any difference whatsoever if we say that the former costs are coming from the cigarette tax plus $10 of the income tax, versus just putting them together into pools of $100 each? No it does not.

    I suppose you might have a bit of an argument if the money raised from cigarette taxes were substantially greater than the health costs… but since the health costs are so huge, I very much doubt that’s the case.

  5. PJH says:

    Sorry, but something that gets on my nerves, and I know I’m being pedantic, but:

    “The good news is that if smokers stop smoking before the age of 40, their risk of death will drop by 90%”

    implies, but does not actually mean, that they have a 90% chance of living forever. Ditto for every other use of the phrase “risk of death.’

  6. Chirez says:

    I realise that there is a whole other half to the sentence which is unwritten and assumed, but it really irks me when I read things like ‘smokers are 3 times as likely to die’.

    It’s clearly a false statement without those invisible qualifiers and reflects the absence of quality of life judgement.

    Healthcare is not about making people live forever. Everyone dies. That’s not likely to change any time soon, though average lifespan increases steadily. So far as smoking is concerned, the choice hinges on whether you would like a shorter life in which you smoke tobacco, or a longer life without it.

    I don’t smoke, never have, but I have difficulty seeing how anyone could raise an argument for the former choice being any more or less valid than the latter. People do a lot of things which are unhealthy, all the time. The relevant question is not ‘should you be doing this?’, but ‘are you aware of the consequences of doing this?’

    Second hand smoke is a separate issue, and revolves around the effect of one person’s choices upon the choices of those affected by it. Whether you should be allowed to do something which has been proven to harm people nearby is a question of personal liberty vs public welfare.

  7. mousethatroared says:

    My mom (a non-smokker) had asthma, one of the triggers being cigarette smoke. When she went college back in the 60s and 70s she said that the classrooms were sometimes filled with smoke. I still remember hearing her coughing and struggling to inhale some evenings. Her asthma symptoms got much better when she finished college, started working in elementary schools and my dad stopped smoking. My asthma does not give me as much trouble, but when it’s flaring up, being in a smoke filled room is very difficult. Even if the smoking bans don’t encourage smoker to quite, I’m so grateful for them. It makes life much better for those of us who are affected by the second hand smoke.

  8. tgobbi says:

    A recent tax increase on tobacco products in Cook County, IL (includes Chicago) has raised the price of cigarets to about $12.00 per pack. One wonders if this will have a measurable impact on the smoking rate.

  9. mousethatroared says:

    Regarding the “risk of death” thing. I wonder if there is a set time that the phrase refers too? Less risk of death over a 10 year period, 20 year period? I’m not particularly bothered by the phrase, but maybe it would have more impact if it was more concrete.

  10. Cervantes – so-called motivational interviewing does help, but only a little. 15-45 minutes of smoking cessation counseling using this technique were only modestly more effective than “brief advice.” http://www.thecochranelibrary.com/userfiles/ccoch/file/World%20No%20Tobacco%20Day/CD006936.pdf

    It’s probably worth it, but it’s a lot of extra time for a little extra benefit.

    We definitely need to keep researching more effective, and more cost effective, measures.

    There has been some encouraging research on online methods, for example.

  11. “risk of death” is usually either annual risk of death, or risk of death over the specified period of the study.

    I agree, it would be best to state it explicitly.

  12. Harriet Hall says:

    Re “risk of death”
    I inserted this clarification: [Clarification: smokers' life expectancy is 10 years less than that of non-smokers. If they stop smoking before the age of 40, their life expectancy will improve to only one year less than that of never-smokers.]

  13. cervantes says:

    That’s true Dr. Novella — primary care docs really don’t have the time to do serious behavior change counseling, let alone the training. What we really need is a reorganization of the system so that behavioral health services are co-located, and linked with, primary care. (Along with other specialty services.) That way the doc could do a brief intervention to assess and activate the patient’s interest, and refer them to a cessation service. While quit rates aren’t all that great no matter what we do, even a modest rate per year, over several years, adds up to a substantial effect.

    I don’t think anybody would claim that a single MI session is going to do much for any problem — it takes time.

  14. evilrobotxoxo says:

    As a psychiatrist and addiction researcher, I have a couple of minor disagreements with this post and some of the previous comments.

    @HH: Smoking is often referred to as a “preventable” cause of death. My problem with this is that it encourages people to think about smoking the wrong way, as though it is somehow in a separate category from all other chronic diseases. Smoking is an action. Nicotine addiction is the disease, and it’s a chronic psychiatric disorder with a high mortality rate. You can prevent addiction from occurring, but once a person is addicted there’s really nothing more “preventable” about it than there is about most other chronic diseases.

    @Chirez: your post states several times that smoking is a choice. There’s a grain of truth in that, but for the most part it’s not true, and it’s certainly not the right way to think about the problem. People don’t smoke because they choose to, they smoke because they’re addicts. Addiction is a disorder that affects the brain’s decision-making circuitry, resulting in an impairment of free will. As Dr. Hall states, over 2/3 of smokers want to quit, i.e. they choose not to smoke, but their brain overrides that choice. Addicts certainly need to take responsibility for their actions if they want to get better, but saying that smoking is a choice is missing the entire point of what the problem actually is.

    @Steven Novella: You imply that more aggressive behavioral approaches for smoking cessation are not cost effective, but I suspect that if someone really crunched all the numbers, they would compare favorably to many of the treatments for other chronic diseases. For example, I find it really hard to believe that smoking cessation counseling is not more cost effective than hemodialysis. I think people just don’t look at the problem objectively. For example, Dr. Hall points out that smokers lose a decade of life expectancy. Imagine your doctor told you that you had a tumor that was going to take ten years off of your life. What would you do, and how much would you be willing to spend, in order to have that tumor removed?

  15. evil – I did not mean to imply that cessation interventions are not cost effective. Just that they are not a panacea, and they do involve a lot of time. It’s not as if we just need to get doctors to tell patients to stop smoking. We don’t have the infrastructure to add all the time it would take to do it effectively (just for the small, but worthwhile, gains).

    I agree we likely need to use physician extenders for this kind of counseling. Insurance companies should pay for it – that will create a huge incentive to do it, and probably save them money.

  16. Harriet Hall says:

    @evilrobotxoxo,

    I don’t see it as just a problem of nicotine addiction, but as a problem of a disease-inducing environmental factor. Yes, there is addiction, but there are also the many medical harms of tobacco smoke, including second-hand smoke exposure. All harms from smoking, psychiatric and physical, can be prevented by never smoking that first cigarette.

    You say “once a person is addicted there’s really nothing more “preventable” about it than there is about most other chronic diseases.” That goes without saying. Nothing is preventable if it has already occurred.

  17. DugganSC says:

    @Scott:
    Having lived in a few states that have raised taxes on cigarettes with the promise of spending some portion of it on smoking cessation plans, it’s less a matter of “is the money from the cigarette taxes going directly into smoking cessation programs?” and more “that’s all very pretty, but what assurance do we have that you won’t increase smoking cessation program funding at all and instead blow the money on upgrades on the local stadium and pork barrel projects?”

    I’ve heard in multiple places, but never in a context other than “I heard someone say this”, that the addiction to smoking is as much or more mental than it is physical. It’s not the nicotine that’s addictive so much as it’s the social ritual of having something in your hands and in your mouth at all times, sometimes cited as the reason why many smokers take up toothpicks, chewing gum, over-eating, etc as a substitute.

  18. Harriet Hall says:

    I also inserted this clarification for the “3 times as likely to die” statement. [Clarification: over the 10 year period studied, all-cause mortality was at least three times as high among current smokers as among those who had never smoked.]

  19. kb says:

    While no one in their right mind would argue today that smoking is good for you as the evidence for the damaging effect of cigarettes is beyond doubt, I do have some misgivings about the post. First, I was somewhat baffled by the leading sentence in the second paragraph, because I thought the leading preventable cause of death was hypertension , not smoking. Second, as legislation prohibiting smoking in public places and other measures have managed to reduce smoking rates in recent years, it seems that obesity is now the leading preventable cause of death in the US. Could it be that we are exchanging one cause of death for another?

    Dr. Hall writes:

    It’s hard to understand why anyone would knowingly begin using an addictive drug that would cut their life short by 10 years, but there’s something attractive about cigarettes that apparently overrides better judgment.

    .
    I will have to quote Kurt Vonnegut here: “The public health authorities never mention the main reason many Americans have for smoking heavily, which is that smoking is a fairly sure, fairly honorable form of suicide.”
    He also said:
    “I am going to sue the Brown & Williamson Tobacco Company, manufacturers of Pall Mall cigarettes, for a billion bucks! Starting when I was only twelve years old, I have never chain-smoked anything but unfiltered Pall Malls. And for many years now, right on the package, Brown & Williamson have promised to kill me.
    But I am eighty-two. Thanks a lot, you dirty rats. The last thing I ever wanted was to be alive when the three most powerful people on the whole planet would be named Bush, Dick and Colon.”
    He died at the age of 84, from a fall down the stairs of his house.

    I tend to agree with evilrobot: the discussion of this issue often borders on a crusade against smokers and is very off-putting.

  20. Harriet Hall says:

    Some cases of hypertension and obesity are caused by genetic conditions, tumors, and diseases. HBP and obesity are treatable, and some of the deaths due to them are preventable, but the conditions themselves are not entirely preventable. I would argue that it is still correct to say smoking is the leading preventable cause of death because it is “absolutely” preventable in every case by simply not starting to smoke.

  21. phiend says:

    What are your thoughts on e-cig’s? I switched from regular cigarettes to electronic about a year ago and haven’t touched a real cigarette since. I however have never looked at it as a way to quit nicotine but just as a way to quit smoking tobacco. I still use the e-cig every day and really enjoy it and have real plans to stop, unless I find that it too is very dangerous, which really I worry about but have yet to find any evidence that it is. I would really like to see more research done with these things as I believe they are an amazing way to get away from cigarettes as they cover, at least for me, all of the addictive parts of smoking. The nicotine, the social aspect of it and the need to have something in your hand/mouth. I do think though that trying to sell them as a way to quit is the wrong approach, as you’re not actually quitting the addiction but transferring it to something else, and I think that needs to be acknowledged and maybe even made its selling point.

  22. DugganSC says:

    @phiend:

    :-/ That vaguely reminds me of how heroin was invented to wean people off of morphine and Oxycontin was invented to wean people off of heroin. Substitution of vices very seldom helps unless you can ensure that the new vice is significantly less harmful and/or more easily quittable.

    Heh, of course, that brings to mind Quitters, Inc. and their methods.

  23. mousethatroared says:

    HH “It’s hard to understand why anyone would knowingly begin using an addictive drug that would cut their life short by 10 years, but there’s something attractive about cigarettes that apparently overrides better judgment.”

    Just an observation. Not sure if it’s still the case, but in the 80′s people mostly started smoking in their late teens, maybe early twenties. Since you are immortal in your late teens and early twenties, the thought of cutting off ten years of your life (when you are elderly, and like, you know, don’t have much to live for anyway) hardly seems relevant. This is one reason that I’m a proponent of a high cig tax. The high cost of starting a smoking habit seems like it would be more inhibiting than health concerns for the age bracket most at risk for starting smoking.

    Speculation, of course.

  24. Jan Willem Nienhuys says:

    the tide turned in 1964 with the Surgeon General’s report on smoking and health

    in this connection two earlier investigations should be mentioned:

    foremost the British Doctors Study by Doll and Peto, who showes as early as 1954 that smoking causes

  25. mousethatroared says:

    DugganSC – I’m sorry to nitpick, but I’m pretty sure that oxycontin was invented to be a painkiller. Maybe you are thinking of methadone, which has been used as a replacement in heroin addiction. Although I’m not really sure how, why or if that’s effective or still done today.

  26. David Gorski says:

    and I know I’m being pedantic,

    Then don’t be.

  27. Jan Willem Nienhuys says:

    Oops! hit the wrong button. I meant to refer to

    http://en.wikipedia.org/wiki/British_Doctors_Study

    to show that in 1954 smoking as cause of lung cancer was known already

    and 14 years before that the German physician Müller had done the same thing

    http://link.springer.com/article/10.1007%2FBF01633114

    and in 1943 a similar study was done:

    Schairer E, Schöniger E. Lungenkrebs und Tabakverbrauch [Lung cancer and tobacco consumption].
    Zeitschrift für Krebsforschung 1943;54:261

    to which Robert N. Proctor drew attention around 1999.

  28. Chris says:

    kb:

    I thought the leading preventable cause of death was hypertension , not smoking.

    I am related by marriage to a family with a genetic form of hypertension. I think it has something to do with some genetic makeup of their kidneys (or liver, I forgot which). Until the 1950s they typically died a long painful death in their 40s.

    When the first diuretics came out, their average age lengthened into the 80s. Even for those who smoked. Though the one brother who did not smoke died in his mid-90s. The one who married a Christian Scientist did make it to 70, but that included no smoking, alcohol or caffeine (some evidence lifestyle really helps).

    Your sentence should be “leading treatable cause of death.”

    Having seen my step-mother struggle to stop smoking for over twenty years: I know the best way to stop smoking is to never start.

    We were also influenced by my dad, who quit smoking in the 1960s after a dentist found the beginnings of mouth cancer. One thing worse than someone who has never smoked, is an ex-smoker. He could not stand being around them after a while, which is why my step-mother worked so hard to quit.

  29. BKsea says:

    In defense, I don’t think PJH was being pedantic. The original post had some sloppy statements (Sorry Dr. Hall, I am generally a great fan). I have seen the bloggers from SBM criticize the press for sloppy interpretations of studies. I think it is important to be precise here and the original statements could have been interpreted to mean just about anything. Thanks for the clarifications.

  30. Janet says:

    @BKsea

    HH was not interpreting studies–that was done already–she was reporting and summarizing, to my mind anyway. I think your criticism is unwarranted and that PJH is beyond pedantic and downright silly. Blog writing is not being done for submission to journals or for print publication and is not subjected to much editing. I think I’m a competent writer, but I knock these comments out very quickly while doing other things usually, and I’d hate to have them subjected to the grammar police. I value good use (usage?) of language, but am not going to sit here with a style manual and other references to make a comment and I don’t expect to be told about minor errors. HH’s posts are very “clean” and well-structured, yet she seems to get “picked at” (can’t think of anything more dignified to call it) over the tiniest nuances of perception.

    Personally, I am very happy to know that having quit before 40 was a good thing–also I didn’t start until my mid-twenties (all my professors smoked and I took it up in self-defense so I could stand to be in their offices!), so I found this post edifying, reassuring, and well-written.

  31. Chris says:

    Janet:

    Personally, I am very happy to know that having quit before 40 was a good thing–also I didn’t start until my mid-twenties (all my professors smoked and I took it up in self-defense so I could stand to be in their offices!), so I found this post edifying, reassuring, and well-written.

    My self-defense was to pick up a large computer printout (back when they were 17″ wide!), and wave them in the direction of the engineering supervisors who were talking and smoking near my desk to push the smoke away from me. They got the hint.

    A couple of years later the company made all building interiors non-smoking.

    (one guy in the office with asthma could occasionally where a gas mask with a filter to keep the smoke out, he got rid of it when the buildings were smoke free)

  32. WilliamLawrenceUtridge says:

    @phiend

    What are your thoughts on e-cig’s? I switched from regular cigarettes to electronic about a year ago and haven’t touched a real cigarette since. I however have never looked at it as a way to quit nicotine but just as a way to quit smoking tobacco. I still use the e-cig every day and really enjoy it and have real plans to stop, unless I find that it too is very dangerous, which really I worry about but have yet to find any evidence that it is. I would really like to see more research done with these things as I believe they are an amazing way to get away from cigarettes as they cover, at least for me, all of the addictive parts of smoking. The nicotine, the social aspect of it and the need to have something in your hand/mouth. I do think though that trying to sell them as a way to quit is the wrong approach, as you’re not actually quitting the addiction but transferring it to something else, and I think that needs to be acknowledged and maybe even made its selling point.

    I remember a discussion on Doctor Radio (Sirius) about this, the docs were trying to convince the smoker to quit e-cigs as well. As far as I know (correct me if I’m wrong, please), most of the harms are due to tar and other chemicals, not the nicotine itself.

    @Duggan

    :-/ That vaguely reminds me of how heroin was invented to wean people off of morphine and Oxycontin was invented to wean people off of heroin. Substitution of vices very seldom helps unless you can ensure that the new vice is significantly less harmful and/or more easily quittable.

    I don’t think this is an appropriate comparison due to specific effects. Nicotine is not a hallucinogen, it does not cause the kinds of cravings, highs or lows of heroin, and given its legality and availability (and cost), it seems like it would fit into the category of being significantly less harmful than even alcohol.

    I’d really like to know if any health effects have been associated with e-cigarettes. Aside from costs, I’m not aware of any (having looked into it NOT AT ALL, so my opinion is essentially worthless). Nicotine is a peripheral vasodilator, isn’t it? Which would lower blood pressure? Health effects of e-cigarettes would be a really interesting post IMO.

    @MTR

    Since you are immortal in your late teens and early twenties, the thought of cutting off ten years of your life (when you are elderly, and like, you know, don’t have much to live for anyway) hardly seems relevant.

    As Denis Leary once said, yes it cuts of ten years at the end of your life – but they’re the bad ones at the end :)

  33. fxh says:

    # cervantes said:: “But . . . Doctors aren’t generally trained in behavior change counseling, and don’t necessarily realize that a brief mention isn’t going to accomplish very much. ”

    I’m pretty sure I’ve seen studies here (oz) that showed that a simple mention of giving up smoking, taking around 10 seconds, by GPs was in fact very useful and relatively painless both for GP and patient.

  34. Davdoodles says:

    “Nicotine addiction is the disease, and it’s a chronic psychiatric disorder with a high mortality rate. You can prevent addiction from occurring, but once a person is addicted there’s really nothing more “preventable” about it than there is about most other chronic diseases.”

    I get the point, to a degree, but I suspect it may result from a case of “if you have a hammer, everything starts to look like a nail”.

    I’m a “nicotine addict”, but I haven’t smoked for over ten years. I feel completely fine and not even slightly in the grippe of a “chronic disease”, nor a “psychiatric disorder”.

    To my mind, it’s smoking itself, ie the act of inhaling the smoke of multiple smouldering cigarettes, and not the nicotine addiction, that is the cause of any and all negative health effects.

    I’d be interested, for example, if its possible to identify the symptoms of the “chronic psychiatric disorder” that is “nicotine addiction”, in the absence of an active smoking habit.
    .

  35. Davdoodles says:

    “Symptoms” in my last sentence above should probably be “clinical features”…
    .

  36. BillyJoe says:

    WLU,

    “As Denis Leary once said, yes it cuts of ten years at the end of your life – but they’re the bad ones at the end”

    Except that you still get those bad ones at the end – years of not being able to breathe, of wasting away because of lung cancer, of trying to get around without legs to walk on.
    I did notice your smily of course.

  37. BillyJoe says:

    BTW, I don’t think that poster was being pedantic and, it seems to me neither did Harriet because she seemed to have no problem making adding a clarification. It reminded me of when I read that 1200 people each year die in car accidents. Did they mean in the USA or the entire world. It’s important, not pedantic

  38. evilrobotxoxo says:

    @Davdoodles: Congratulations on quitting, and I hope you don’t start up again. However, if you went and smoked a pack of cigarettes, you probably would start smoking again. If I went and smoked a pack of cigarettes, I probably wouldn’t ever smoke again because I’ve never been a smoker. There’s something different about my brain from yours, and that difference hasn’t gone away just because you’ve stopped smoking for ten years. That difference puts you at an increased risk of morbidity and early death relative to me, so yes, it is a chronic disease that you have and I don’t.

    I think the larger point that you’re trying to make is that nicotine dependence (the DSM term) is a bit of a convenient fiction. It’s not like syphilis, where you either have it or you don’t. Some people smoke more than others, some smoke only when they drink, some can quit more easily than others, and there is a clear difference between active smokers and former smokers. I acknowledge all of these things. However, my point is that people trivialize nicotine dependence because it seems like a lifestyle choice, but not only is it a psychiatric disorder by any imaginable criteria, it is the deadliest psychiatric disorder on the population level. If any other disease were responsible for 18% of all death in the US, or killed more than twice as many people worldwide as HIV and malaria combined, there would be Manhattan project-scale efforts to stop it. There would be entire scientific institutes dedicated to fighting that terrible malady.

  39. evilrobotxoxo says:

    @Davdoodles: one other point – you put “nicotine addiction” in quotes to indicate that you don’t accept the term, but that’s part of the point I’m trying to make, that people think of smoking differently than they think of other disease states or even other types of addiction. We talk about people as heroin addicts, cocaine addicts, oxycontin addicts, or alcoholics (which essentially means alcohol addict). But nicotine addicts are called “smokers.” They have a “habit.” That’s like calling alcoholics “drinkers.” Well, I’m a drinker, and you could even say that I have a drinking habit, but I’m not an alcoholic. Why do you conceptualize nicotine addiction differently when it’s fundamentally the same thing?

    @Harriet Hall: that’s a good point, it is also an environmental factor. I actually interpret the meaning of “preventable” differently from you, meaning that smokers’ deaths are preventable even after they start smoking because you can get them to stop smoking. My point is that the whole concept of “preventable” death is not a very rigorous one, and in this case I think it’s not a very helpful one.

  40. kathy says:

    @BillyJoe : “It reminded me of when I read that 1200 people each year die in car accidents. Did they mean in the USA or the entire world.” Must be USA … in South Africa we get more than that over the (so-called) Festive Period. OK, OK, I know that wasn’t the point of your post!

    @cervantes “Doctors aren’t generally trained in behavior change counseling, and don’t necessarily realize that a brief mention isn’t going to accomplish very much.” Anecdote warning! A close friend, who happens to also be a doctor, said to me – once – that my smoking was not good and he wished I’d stop, then reassured me that he would not mention the matter again. A couple of years later I gave it up without stress, on my own, and I’ve been off it for nearly 2 years now. I wrote to him to thank him for not pressuring me … The thing is, he knows me pretty well and had the nous to realise that putting pressure on would only make me stubborn.

    Why I say this is, that a brief mention MAY work, and lengthy counseling may not, it depends on the individual. This is one area where “individualised treatment”, so touted by CAM in theory if not in practice, could be usefully applied.

  41. kb says:

    Delving deeper, I realize there are two concepts of “preventable cause of death” that are being mixed up. The first refers to the statistics provided by the WHO, and includes things such as lower respiratory infection, ischaemic heart disease, HIV/AIDS and so on, and are based on actual numbers (although many developing countries lack systems for assessing causes of death in the population, and the numbers of deaths from specific causes have to be estimated from incomplete data).
    The other concept of “preventable cause of death” is, as evilrobot says, far less rigorous. It is an estimation of the number of deaths attributable to risk factors, and the most quoted study is that by the Harvard School of Public Health. I can’t say I understand all the details of what they did, but to quote the Editor’s Summary: This approach estimates the number of deaths that would be prevented if current distributions of risk factor exposures were changed to hypothetical optimal distributions.

    Don’t get me wrong, I am not arguing that smoking is not a risk factor. But this approach, and someone please correct me if I am mistaken, is binary: you either smoke or you don’t. Whether you chain smoke or just have one cigarette after dinner is not factored in.
    My point is that this scare-mongering and witch-hunting of smokers is counterproductive. It is a fact that the majority of teenagers will try smoking at some point (as well as alcohol and possibly cannabis), yet only a minority will become addicts. How to further minimize this group is an immense challenge. More evidence for the damaging effects of smoking is not going to help us in that.

  42. Chris says:

    kb:

    It is a fact that the majority of teenagers will try smoking at some point (as well as alcohol and possibly cannabis), yet only a minority will become addicts.

    [citation needed]

  43. Davdoodles says:

    “Why do you conceptualize nicotine addiction differently when it’s fundamentally the same thing? ”

    I guess because, unlike your list (heroin, oxycontin, etc), it’s not an intoxicant (ok a very mild, short-acting one possibly), doesn’t have any particular social or family impact, it doesn’t gradually subsume one’s life like alcoholism et al. An alcoholic is typically drinking to mask some serious issue (or ten), which surfaces upon sobriety, and usually needs to be dealt with via psychiatric or other psycho-social intervention, if the person’s life is to return to something approaching normal.

    Nicotine addiction, in contrast, is more akin to chewing one’s fingernails, or drinking tea, except smoking long enough can cause cancer and death. Stop doing it, and no terrible repressed secrets emerge into the light. You’re mildly grumpy for a week, smell better, and have more money in you pocket. That’s it.

    In short, I never encountered and psychiatric component to my nicotine addiction, other the compulsion to smoke, and cravings which passed relatively quickly when I stopped smoking the things.

    “you put “nicotine addiction” in quotes to indicate that you don’t accept the term, but that’s part of the point I’m trying to make, that people think of smoking differently than they think of other disease states or even other types of addiction.”

    I was only meaning to separate the concept of addiction from the smoking behavior itself. I’ve no issue with the concept of nicotine addiction per se. You’re quite right that, even after ten years, I’d probably start smoking easier than you. I’m a nicotine addict. I do have a quibble however with the characterization of that addiction (as distinct from the act of smoking) as a chronic illness, psychiatric or otherwise.

    My point is that the harm from smoking comes from actually smoking, not from being addicted.
    .

  44. kb says:

    @chris

    kb:
    It is a fact that the majority of teenagers will try smoking at some point (as well as alcohol and possibly cannabis), yet only a minority will become addicts.
    [citation needed]

    You are right, my statement was lacking nuance. The prevalence of smoking varies between regions, socioeconomic status, sex etc… In general adolescents smoking precentages are are declining in industrialised countries. Still, overall, about a third to a half of 17-18 year olds report that they have never tried smoking, which means that about half to two thirds have, yet the percentage that smokes is far lower. For example, in Canada, which has adopted several tobacco control measures, 48% of youth in grades 10-12 have ever tried a cigarette, while only 11% are current smokers. . Admittedly, 48% is not the majority, as I said (in Europe the percentage is higher). My point was not this, but rather that of those that have tried smoking, only a minority continue.

  45. kb says:

    @chris

    kb:
    It is a fact that the majority of teenagers will try smoking at some point (as well as alcohol and possibly cannabis), yet only a minority will become addicts.
    [citation needed]

    You are right, my statement was lacking nuance. The prevalence of smoking varies between regions, socioeconomic status, sex etc… In general adolescents smoking precentages are are declining in industrialised countries. Still, overall, about a third to a half of 17-18 year olds report that they have never tried smoking, which means that about half to two thirds have, yet the percentage that smokes is far lower. For example, in Canada, which has adopted several tobacco control measures, 48% of youth in grades 10-12 have ever tried a cigarette, while only 11% are current smokers. . Admittedly, 48% is not the majority, as I said (in Europe the percentage is higher). My point was not this, but rather that of those that have tried smoking, only a minority continue.

  46. evilrobotxoxo says:

    @Davdoodles: I’m not sure how much experience you have dealing with people addicted to alcohol or “hard” drugs, but there are plenty of people who are basically just like you or me once they’re clean, and they’re not using drugs to “self-medicate” or mask some severe underlying pathology. Conversely, people with all sorts of psychiatric issues are significantly more likely to smoke. You’re right that the effects on one’s life that arise with tobacco use aren’t the same ones that come up with cocaine use, for example, but the underlying clinical features of the disorder and the pathophysiology are basically the same.

    I’m a little baffled by your statement that nicotine addiction is like chewing one’s fingernails. Have you ever looked at the sidewalk outside a cancer hospital, where the bald people in hospital gowns huddle together to smoke through their tracheostomies?

    We seem to agree about the concept of nicotine addiction, and I don’t personally care if it’s called a disorder, illness, condition, or whatever. My point is that it’s not a preference or a lifestyle choice, it’s a physical condition of the brain that predisposes people to illness and death. Whether you accept it or not, that state of addiction is considered a psychiatric disorder. The damage caused by the act of smoking is not primarily neuropsychiatric, BTW; the primary manifestations are vascular and pulmonary disease, and to a lesser extent cancer. You’re correct that it’s the smoking, not the propensity to smoke, that causes the harm, but that’s the case for cocaine and heroin as well. However, looking at it that way completely misses the point of what the real problem is. Cigarettes kill lots of people because they’re addictive. Rat poison and bleach are not addictive, and they don’t kill very many people. If cigarettes weren’t addictive, they wouldn’t kill very many people either. Addiction is the issue, not the toxicity of the substance itself.

  47. Chris says:

    kb:

    Still, overall, about a third to a half of 17-18 year olds report that they have never tried smoking, which means that about half to two thirds have, yet the percentage that smokes is far lower.

    [citation needed]

    (hint do not make statements that include quantitative assertions without citing the source)

  48. Narad says:

    And it appears that women have more difficulty quitting than men.

    Anecdotally, that comes a quite a surprise to me. The vast majority of my female friends seem to have had very little trouble dropping the habit. Does it depend on the extant level of consumption?

  49. Narad says:

    A recent tax increase on tobacco products in Cook County, IL (includes Chicago) has raised the price of cigarets to about $12.00 per pack. One wonders if this will have a measurable impact on the smoking rate.

    Being in Chicago, I sorely doubt it among established smokers. Those with the means to have a vehicle will simply travel to Indiana or otherwise outside of Cook County. Those without them will either buy at retail or resort to the black market (which has existed since at least 2009, to my knowledge; you can get cheap Newports if you know the right part of Washington Park to look in). I’m even dubious about the effect on youth, given the ubiquity of the habit among the urban poor, but it will take a while for that effect to materialize. There is of course also Drum or Kite to fall back on, or the still cheap, nasty dollar-store cigars.

    It’s just a regressive tax. The earliest data to come in will be whether it actually increases revenue (in an area known for fiscal irresponsibility).

  50. kb says:

    @chris

    You must think you’re awfully clever.
    As I said rates vary by region, so I am not going to cite each and every survey for each and every country. For European countries, in the ESPAD survey (pdf!) for 2011, on average, 54% of the students reported that they had smoked cigarettes at least once, and 28% that they had used cigarettes during the past 30 days. For the USA, numbers are rather similar if you combine the rates for cigarettes with those of smokeless tobacco. In any case, I will repeat my point that the majority of those who try smoking do not become addicted, and unless you have something to say about my point, instead of nitpicking without saying anything, I will stop responding to you.

  51. mousethatroared says:

    evilrobotxoxo “I’m a little baffled by your statement that nicotine addiction is like chewing one’s fingernails. ”

    I would be curious to hear your observations on the similarities OR differences between addictions, such as cigarettes, alcohol, medications and activities generally considered compulsions, like shopping, gambling, hoarding, even nail chewing, etc.

    I understand if you don’t have time in this thread, but I’ve always been curious and you do such a good job of explaining things.

  52. Narad says:

    @evilrobotxoxo

    I’m not sure how much experience you have dealing with people addicted to alcohol or “hard” drugs, but there are plenty of people who are basically just like you or me once they’re clean, and they’re not using drugs to “self-medicate” or mask some severe underlying pathology. Conversely, people with all sorts of psychiatric issues are significantly more likely to smoke.

    Let’s take EtOH alone. Could you quantify this “plenty of people” who are not using it to “self-medicate”? That are “basically just like you or me once they’re clean”? No psych follow-up or further medication required (e.g., antidepressant or anxiolytic), just detox them and they’re good to go? Or are you proposing tobacco use as an additional marker of underlying psychiatic issues?

  53. Chris says:

    kb:

    You must think you’re awfully clever.

    No, it has to do with the observations in the first story of this podcast. George Hrab says over and over that it is an observation.

    Plus, my youngest just graduated from high school last year, and by my anecdote, I really did not see it as more than half. But, granted, that is just an anecdotal observation and not data (plus my volunteer time was in the science department). Though, I appreciate that you came up with data dependent on country.

    Now, for my own anecdotal observation about Europe: When I first visited Europe almost thirty years ago it was hard to get away from tobacco smoke. But the last time, about four years ago, we noticed that there was lots less tobacco smoke (both times involved going to the Netherlands). It seems that all of those numbers are subject to change over the years.

  54. evilrobotxoxo says:

    @Narad: here’s a link from NAMI:

    http://www.nami.org/Template.cfm?Section=By_Illness&Template=/TaggedPage/TaggedPageDisplay.cfm&TPLID=54&ContentID=23049

    Let me quote the relevant sentence, which summarizes data from the ECA and NCS surveys: “42.7 percent of individuals with a 12-month addictive disorder had at least one 12-month mental disorder.”

    If you take that at face value, the majority of people with addictive disorders do not have comorbid non-substance-related psychiatric disorders. I think the reality is a little more complicated than that. Part of it is that alcohol use frequently causes depression, anxiety (during mild withdrawal), etc, creating a self-perpetuating cycle that can resolve with sobriety. So the substance use creates the psychiatric syndrome, rather than the other way around. A similar phenomenon occurs with people who have soft psychotic signs at baseline that are exacerbated with cocaine or amphetamine use. The point is that causality can go in both directions. On the other hand, it’s also true that substance abusers do tend to have more cluster B personality traits that might fall short of a diagnosable personality disorder. Nevertheless, the typical layperson’s idea that all addicts are weak-willed pathetic souls self-medicating away their traumatic childhoods or whatever really isn’t true. It certainly is true that many, if not most, addicts fall within the range of “normal” psychiatrically, or at least there are many, many people with more severe psychiatric pathology who are not addicts.

    Whether or not addicts require psychiatric follow-up, that’s complicated, in part because relapse prevention is the most important and most difficult part of substance abuse treatment. There are certainly a number of alcoholics and other substance abusers/addicts where if you could give them a magical injection that would prevent them from ever using again, they would never require psychiatric follow-up. All of us know people like that, regardless of whether or not we’re aware of it. But because of the risk of relapse, follow-up is always required.

    @MTR: it’s a complicated question, and it’s not fully understood, but I’ll tell you my opinion. The way I see it, there are several different major symptom clusters within psychiatry that correspond to different neural circuits, and one of those clusters could be called something like “disorders of impulse control and decision making,” most likely mediated by abnormal basal ganglia function. The basal ganglia are believed to control “action selection,” essentially deciding which part of the brain has control over final motor pathways based on prior experience of what worked and didn’t work in the past. The simplified idea is that the more dorsal parts control voluntary movement based on success or failure of prior motor outputs, while more ventral parts mediate things like motivation and reward-seeking based on prior reward vs. punishment. The idea is that the underlying computations are believed to be analogous. This leads to different manifestations of when different parts of these circuits malfunction. For example, you have things like tic disorders, which are on a continuum with movement disorders and involve circuit loops through dorsal striatum, while things like OCD or trichotillomania (and probably nail-biting) are on a continuum with anxiety disorders and involve more ventral areas. There are also things like anorexia nervosa and binge eating, as well as addiction, sexual paraphilias, etc. The point is that these are literally disorders of the parts of your brain that make decisions about what actions you perform.

    To attempt to answer your question, I would say that things like compulsions of any sort, gambling addiction, drug addiction, etc. all share certain clinical features, and I think that once they’ve developed, they probably share a lot of pathophysiological mechanisms. However, the mechanism by which they develop has to be somewhat different because drug addiction involves molecules entering your brain and directly modulating activity in these circuits, while in something like gambling addiction, that activity has to be modulated through other means. It’s worth pointing out that things like gambling or shopping involve a reward structure that is non-physiological in the sense that it didn’t exist in the conditions under which humans evolved. Additionally, cocaine is objectively more addictive than shopping or gambling, in the sense that a much higher percentage of people who try cocaine get addicted than people who shop. So I think that once those things have developed, they have more similarities than differences, even though the mechanism by which they develop must have important differences.

  55. Narad says:

    @evilrobotxoxo

    @Narad: here’s a link from NAMI

    OK, thanks for the pointer. I’ll try to take a look at the underlying data over the weekend. I certainly understand that to some extent, with EtOH it’s a chicken-and-egg situation. I’m still unclear whether you were suggesting concomitant tobacco use as a marker.

  56. Chris says:

    Myself to kb:

    both times involved going to the Netherlands

    We did visit other countries. It is just that we have relatives in the Netherlands that we need to connect with in person each time we go over.

    And here is a weird thing: both of our then teenage children disliked the smell of marijuana they encountered in Amsterdam. Plus our daughter refused to tour Copenhagen’s Christiana’s Freetown. I asked her what was wrong, and she countered with “You should be asking what you did right!” Okay, I had honestly told them about my one experience with weed, and that I did not like that it made me more dumb.

    Yes, I was honest to my children.

  57. Chris says:

    Davdoodles:

    Nicotine addiction, in contrast, is more akin to chewing one’s fingernails, or drinking tea, except smoking long enough can cause cancer and death.

    That is too simplistic. I do not have data, but just anecdotes.

    My dad could quit smoking on a dime, and could still carry the carton of smokes in his pocket. But both my mother and step-mother suffered if they were denied nicotine. There had to to something more.

    Though, I do not know why someone chews their fingernails. I once tutored math to someone in high school. She admired my fingernails, and I told I did not chew on them. It is what she did, and she never mentioned it again.

    As it turns out (as I read A Cabinet of Medical Curiosties, after reading The Violinist’s Thumb ), we are all genetically unique. While my siblings are both tall, slim and have hazel eyes… their hair started to turn gray in their twenties. My short rotund body is still mistaken to be ten years younger because my reddish blond hair has no gray, plus there are very few wrinkles on my blue eyed freckled face. I got all of the recessive genes. It is only after middle age that I appreciate my genetic dice roll. Both of my siblings have totally white hair. You just can’t tell with my sister due to the bottle of hair dye in the bathroom cabinet.

  58. Narad says:

    My dad could quit smoking on a dime, and could still carry the carton of smokes in his pocket.

    Big pocket. (A carton is 10 packs, at least hereabouts.) I have heard reports from people who required having them on hand in order to quit, viz., avoiding the associated anxiety of not having any squares and making a conscious choice from moment to moment. It’s not surprising that individual cues vary. The cigarettes don’t smoke themselves, after all.

  59. Jan Willem Nienhuys says:

    when I read that 1200 people each year die in car accidents. Did they mean in the USA or the entire world

    this number was roughly the annual number of US traffic deaths per 10 million population (or per 100 billion miles traveled) in 2008. It might have been one of the states, for example Georgia or Ohio. Or a large city. That number is somewhat less that the number of traffic related deaths in Australia (pop. 22 million).

    With three extra zeroes (1,230,000) it was the estimated world total for 2007.

  60. evilrobotxoxo says:

    @Narad: It’s true that tobacco use is strongly correlated with a bunch of other psychiatric pathology, but I don’t consider it a useful clinical indicator of anything because there are so many smokers who aren’t otherwise mentally ill.

  61. evilrobotxoxo says:

    @Narad: let me clarify that. The point I was originally trying to make is that addiction of all types, including tobacco, is strongly correlated with other mental illness. However, there are plenty of smokers and other types of addicts who aren’t otherwise mentally ill. I was trying to make the point that nicotine addiction has more similarities with other types of addiction than it has differences.

  62. mousethatroared says:

    evilrobotxoxo – Thanks so much for a very informative answer. I’ve always wondered if there was a relationship between the substance abuse and compulsions, OCD, tics, etc. But it seems like one usually sees them discussed separately.

  63. Chris says:

    Narad:

    Big pocket. (A carton is 10 packs, at least hereabouts.)

    Oops. I meant “pack.” Obviously I have not been around tobacco products for a very very long time.

    Perhaps one of the biggest reasons our kids never picked up smoking is that a cousin of their dad died in his early forties from mouth cancer due to smoking about ten years ago. It spread even after most of his jaw was removed (and I think replaced), and he was dead less than a couple of years after being diagnosed.

    This morning there was an article in the local paper on the results of a “Healthy Youth Survey.” It failed to quote the actual numbers for tobacco, other than to note it went down. But I found the one for my county (the tobacco bit is at the very bottom):
    http://adai.uw.edu/WAstate/HYS/king_hys.pdf

    The most telling thing is that the last graphic says: “Statewide, 12th graders who smoke cigarettes are more likely to get lower grades in school (C’s, D’s or F’s) compared to non-smokers.”

  64. Jesus_McMurphy says:

    @William
    [quote]I don’t think this is an appropriate comparison due to specific effects. Nicotine is not a hallucinogen, it does not cause the kinds of cravings, highs or lows of heroin, and given its legality and availability (and cost), it seems like it would fit into the category of being significantly less harmful than even alcohol. [/quote]

    Just a nitpick. Heroin is not a hallucinogen, it’s a semi-synthetic opiate.

    “Hallucinogens” can refer to psychedelics (LSD, DMT, etc.), dissociatives (dextromethorphan, ketamine, etc.), and deliriants (jimsonweed, diphenhydramine, etc.), of which only dissociatives have any appreciable risk of dependence and habituation. Classic psychedelics are not only not desirable to use constantly, the tachyphylaxis makes it near impossible to dose serotonergics back to back or even a few days later.

    Interestingly enough, nicotine was used traditionally in religious ceremonies as an entheogen, and was used to bring about a sort of psychedelic state. This required large doses of nicotine and I don’t need to tell anyone how toxic nicotine is (LD50 wise.)

Comments are closed.