Chapter two
ost smokers want to quit smoking, generally for health-related
reasons. So far, it seems that this is the only way of taming
the risks of smoking. Quitting stops most of the harmful effects
from developing further. As most damage is reversible, quitting
may restore health.
Taming the risks of continuous smoking--a wishful way of thinking shared by smokers, health promoters, society and the tobacco industry. Could we as people and as a society find ways to do so? There are efforts but little success. Health information has certainly improved, new approaches to tame the cigarette explored. At this stage combating smoking remains the only realistic option.
When you want to support the quitter, you need to change the culture, where the smoker lives. For instance, in my home country Finland, it seems to me, we have had success in this target: after a very long-lasting comprehensive effort we now have a vast and steady non-smoking majority, which doesn't want to hear disinformation from the tobacco industry. The industry have chosen to keep silent and tame knowing that every move from their side annoys this majority. Representing the smokers's interests has no clear visibility in Finland, and the Smokepeace movement is dead.
Also, the more educated politicians become--as they do--the easier they find it to understand that killing people with cigarettes is not good for the state economy. This is a result of a long-lasting taming of those decision-makers whose task is to guard finances.
In the field of prevention, true and measurable successes are actually few. That being the case, health promoters can sometimes loose their motivation. Also, whenever news from a "less hazardous" cigarette, "safe ways of smoking" or the like come up, people are motivated to turn to them. This wishful thinking is understandable on the basis of strong nicotine dependence and, more generally, people's will to cope with the fact of continuing smoking.
But the tobacco industry must everywhere win new age-groups, and of course, new countries in the world. Their best clients, like the Malboro Man, die early, and new smokers have to be hooked. To replace the dying and the quitters must be a big task now in the USA and western and northern Europe, where the anti-tobacco movement is growing ever stronger and where court cases and various settlements with the state narrow the industry's growth potential. Also, much of the industry's once secret material is now available to outside readers. This material shows that the industry was the first to know about the hazards of smoking and nicotine dependence. Knowing that one single approach is not enough, the industry always posited mere health promotion as means of reducing smoking in the youth. This approach gave a very positive impression and tamed the decision-makers.
The industry has had a tremendous success and there are still billions of regular smokers in the world. Maybe some 30-40% will be able to stop smoking, and non-smoking generations will be born. Smoking will gradually loose its social status. But that will take time. In the near future, approximately 500 million of the world's population today can expect to be killed by tobacco, 250 million of these being premature and occurring in middle age. Following any decrease in smoking prevalence there will be a period of time which will elapse before any decrease in the incidence of tobacco-related diseases is apparent. In front of these figures any taming of the risks would be very welcome.
For those whose task is to follow tobacco-related scientific information the flow of newly discovered health consequences of smoking is hard to keep up with. Even now, lots of new evidence is published.
For instance, not only is cigarette smoking known to be deleterious to patients with coronary artery disease but, also patients who continue to smoke after successful percutaneous coronary revascularization are at greater risk of infarction and death than non-smokers. And already in adolescents, cigarette smoking is associated with evidence of mild airway obstruction and slowed growth of lung function. More recent studies have tended to find cigarette smokers to be at a higher risk of colorectal cancer and even colorectal adenomas, precursors of cancers. The prognosis of breast cancer patients seems to been poorer in smokers, and the risk of cervical cancer higher in smokers than non-smokers. The role of a sex partner's smoking or passive smoking on cervical cancer has been a matter of debate. The risk is brought either via inhalation of environmental tobacco smoke or exposure to tobacco-related mutagens/carcinogens in semen of the partner. Paternal and maternal smoking may be associated with an increased risk of childhood cancer.
Changing from cigarettes to snuff is no good way of taming the risk. Moist snuff is a potent carcinogen and has been proven to be a cause of cancer in humans.
Newly revealed hazards will continue to be published, tobacco being a greater cause of death and disability than any single disease. The only message from this almost unbelievable variety of risks is that quitting smoking is the only real means of abolishing the dangers.
There is much literature about the benefits of quitting smoking available to motivate the smokers, health promoters and maybe some of those working for the industry. I often wonder how the tobacco industry employees can cope these days. For their sake, not to mention that of current smokers, it would be nice to be able to promote realistic ways of diluting the risks of smoking considerably. n
Philip Morris had launched a six-week advertising campaign in June the same year which, the company said, was designed more to protect smokers' rights than advance commercial interests. These rights were upheld by a range of ad slogans claiming that eating cookies, putting pepper on food, and drinking chlorinated water or milk is more likely to cause lung cancer than inhaling second-hand smoke. The ads also took on board the fashionable issue of risk. "Life always involves some risks," ran one slogan. "You need to decide which ones are important."
The health experts' declaration, which didn't appear on billboards or in the print media, countered that risks "must be balanced with benefits, and their voluntary or involuntary condition have to be taken into account." The problem is, it continued, "ETS entails only involuntary risks without any benefit."
Chlorinated water brings benefits with negligible risks, but passive smoking brings risk without benefits, the experts argued. Neither is it a matter of choice, because passive smokers, especially children, often cannot avoid ETS and so remain "involuntarily exposed to its hazardous components."
The statement pointed out that well-established facts about passive smoking confirm that ETS contains the same toxic compounds present in uninhaled tobacco smoke. "People exposed to ETS in hale the toxic compounds which are detected in their blood and urine." It also refers to the findings of the US Environmental Protection Agency that ETS causes lung cancer in adults, and is associated with a range of health risks in children."
According to Philip Morris, though, it's all a question of what people want. Kids can therefore choose from a range of ETS risks, including:
* Roberto Masironi (Switzerland), European Medical Assoc. on Smoking or Health; Manel Nebot (Spain) Health Department of Barcelona City Council; Helios Pardell (Spain), Advisory Council on Smoking--Dept. of Health and Social Security, Autonomous Government of Catalonia; Tapani Piha (Finland), Ministry of Social Affairs and Health; Esteve Saltó (Spain) Dept. of Health and Social Security, Autonomous Government of Catalonia; Ricard Tresserras (Spain), Dept. of Health and Social Security, Autonomous Government of Catalonia; Jean Trédaniel (France) European network for Smoking Prevention; Patti White (UK), International Union Against Cancer. The subject of the seminar was the Risks of Environmental Tobacco Smoke: A Scientific Update.
Studies dating from the 1970s have consistently shown that children and infants exposed to ETS in the home have significantly elevated rates of respiratory symptoms and respiratory tract infections. Over 50 recently published US studies confirm key conclusions.
ETS exposure to parental smoking contributes to between 150,000 and 3,000 cases of lower respiratory tract infection (including pneumonia and bronchitis) each year in infants and children. It is associated with increased respiratory irritation, and the severity of asthma in an estimated 200,000 to 1 million children. ETS exposure 'in utero' and in infancy can alter lung function and structure and create other changes that are known to predispose children to long-term pulmonary risks.
In the US sudden infant death syndrome (SIDS) is the major cause of deaths in infants under a year old, and has been linked to maternal smoking. The risk to infants of SIDS increases with exposure to ETS. This is independent of other known SIDS risk factors, including low birth weight and low gestational age, both of which are associated with active smoking during pregnancy. Additional studies are needed to determine whether the increased risk is related to in utero or postnatal exposure to tobacco smoke, or to both.
Sources: National Cancer Institute, GLOBAlink
That, at least, is the image of the low-high strength debate among smokers. It would seem to come down to a deceptive interplay between knowledge and risk, the feeling that small interventions and precautions can stave off the worst. Put a seat belt on and you can drive faster. Smoking cigarettes with lower tar and nicotine yields has apparently found a comfortable niche in the common sense of smokers, and it is no wonder that non-smokers find this logic of consolation laughable. Who, after all, is being duped the most by the lite and ultra-lite ruse?
Many smokers, though, are not so easily taken in, and the reason is obvious. No matter what strength of tobacco they use, they smoke in such a way that they get about as much out of it as they are used to. If this means that they prefer lighter brands, it is because they are the chosen means to get the desired hit.
Such observations can be gleaned from the findings of painstaking studies, but also from the remarks of smokers that are so common as to be banal. The extent of information and messages about the problems of smoking that circulate in west European and north American societies, in particular, have established a conventional wisdom about tobacco on two key fronts: its killing potential and the addictive nature of nicotine. People trying to kick the habit are increasingly resorting to nicotine patches, inhalants and gum because the addictive quality of nicotine is all too plain.
Perhaps part of the problem lies in the way questions are asked and the inferences drawn from the answers they elicit. If you were to ask people to say which is more dangerous: a cigarette that contains less tar and nicotine or one that holds more of these ingredients, it would be surprising if they chose the latter. It might have been better if Gallup had tried to find out whether smokers of light cigarettes felt less threatened by smoking-related illness because they smoked these brands, or whether they felt they smoke more intensively when they use light tobacco, or whether smoking light brands make any discernable difference to the way they smoke.
What if the majority of smokers were to answer 'no, yes, no' to each of these questions respectively? Would that mean that the association of lowered tar and nicotine levels in cigarettes with diminished risk is essentially meaningless?
Smokers who want to get a clear picture of their plight may know their individual situation fairly well, but they still have to cut through a false notion of lesser risk to reach the true level of uncompromising risk they face.
Mark Waller
Zekhauser and Viscusi, Risk within Reason. Science 1990.
This is the epigraph to a Swedish study published by Department of Finance of risk mitigation and the costs they entail. The study looked at the financial implications of risk reduction in society in eight areas: spillages and exposure to volatile organic compounds (VOCs), drowning incidence of children in domestic wells, hospital fire safety, rail level-crossing safety, bone marrow transplants, radon risk reduction, hard plastics and occupational safety, and smoking prevention. An odd mixture of risk problems, one might think.
But the study throws a revealing light on the relationship between problem areas and risk cutting costs in terms of the amount of human life saved by intervention measures. The costs of human life are calculated by dividing the amount of money needed to mitigate a risk Interestingly enough, the hazards to people and the environment posed by VOCs are the most costly (over 200 million Kroner) to curtail--costly in proportion to the numbers of lives they save. Drowning incidence in domestic wells (a common form of water supply in Nordic rural areas) also figures as expensive, and all other risk areas are counted in the millions. All, that is, except tobacco control, the costs of which in relation to life saved is measured at most as a few thousand Kroner.
The study highlighted the key role of four facets of risk management: moral culpability, societal change, economic self-interest as an issue preventing risk mitigation, and risk denial on the part of people.