Research Shows Increasing Health Risks of Smoking
Maintaining Your Health
on Mackinac
By Yvan Silva, M.D.

There is scarcely a week that goes by without new information on the health risks of smoking. In March, a group of British scientists published evidence on the harmful effects on smoking during pregnancy, not only on the children to be born, but their children as well, the grandchildren. Scientific research is quickly examined and reported by media nationwide and internationally. Societal reaction is rapidly leading to changes in public safety regulations, curtailing the sites where smoking is permitted and where second-hand smoke may affect others. At this point, there is little doubt that smoking is harmful, and in a variety of ways, and that most smokers would like to quit.

Last year, cigarette sales dropped 50 percent in New York City as additional taxes raised the price of a pack to more than $7.50. Several media reports suggested that most cigarette smokers in the city were buying their cigarettes elsewhere. In Michigan, state cigarette taxes increased the price of each pack by 50¢ on August 1, 2003. In July, the sale of cigarettes to convenience stores increased by 30 percent in anticipation of the tax increase. There was a rapid rush to buy and stores sold out stocks before the tax went into effect.

Convenience stores sold more than half of the 787 million packs of cigarettes purchased in the state in 2001.

The price of cigarettes in Michigan has gone up again; one of my patients told me he pays about $6 per pack. He and his wife each smoke a pack a day. Some days they go over a pack. And they’re really concerned about the current high price of gas.

Twenty-four percent of adults in Michigan smoke cigarettes. The tax increase is expected to raise state revenues by about $343.2 million. On one hand, it is thought that this increase in cost will influence some 40,000 smokers to quit. On the other hand, there is the specter of a proportionate increase in illegal peddling of cigarettes smuggled from other states with lower taxes, or from Canada. The business is huge, and the annual loss to the US tax structure is estimated at $2 billion, with global traffic in contraband cigarettes in the $16 billion range. Penalties are less than for trafficking in illegal drugs.

Smoking is the leading cause of preventable death and disease in the United States. Smoking accounts for $50 to $73 billion in annual medical care expenditures, or six percent to 12 percent of all U.S. medical costs. It was Thomas R. Marshall who, while presiding over the U.S. Senate in 1920, made the notorious statement, “What this country needs is a really good five-cent cigar.” The U.S. government response to that statement has been belated, but surely, since the 1998 report by the National Cancer Institute, this country has seen its share of the ubiquitous “No Smoking” signs.

In 1964, when the landmark Report on Smoking and Health was issued by then-U.S. Surgeon General Luther Terry, 53 percent of adult American men smoked cigarettes. Since then, 46 million Americans have kicked the habit and now 25 percent of the men in this country smoke, but the decline has been slow, and it has been even slower for women and minority groups. Three thousand American kids take up the habit every day, a steady supply of customers for the tobacco industry and a steady supply of patients for our health care systems.

The statistics on cigars are even worse. The complacency over cigars is phenomenal. Cigar consumption rose nearly 50 percent between 1993 and 1997, and the trend shows no signs of abating. In all, Americans smoked 3.6 billion cigars in 1997, an increase of 18 percent from 1996, with large cigars and premium brands accounting for most of the rise. This nouveau trend has 300,000 women smoking cigars; 25 percent of all teenagers smoked at least one cigar in 1996 and the tobacco industry’s billboards asking, “Why do politicians who smoke cigars try to tax cigarettes?” were catalysts for defeat of tobacco control legislation in 1998. While a cigarette contains less than one gram of tobacco, a typical cigar has five to 17 grams. A cigar has more nicotine (13.3 vs. 1.1 mg), tar (44 vs. 16mg) and it generates far more carbon monoxide (97 vs. 14 mg) than a cigarette. Go on and add the bad news on pipe smoking and smokeless tobacco and it’s clear that tobacco is harmful in all its forms, many of which, unlike cigarettes, are not widely known.

We can move on to the business of addiction. Nicotine is addictive, yet some people seem to get away with smoking just a few cigarettes. A Canadian study recently showed that many casual smokers have a gene that reduces their ability to break down nicotine by the liver. Because they get more of a punch from each puff, they smoke less. That may explain the difference. The risks remain.

Why not smoke? Smoking has been incriminated in diseases affecting virtually every system in the body – the skin, mouth and larynx, lung, heart and blood vessels, stomach, pancreas, bones, and urinary bladder. This litany has recently extended to diminished sperm counts, impotence, and hearing loss. One by one, as research has gone on to show, an accumulation of these seemingly drastic reports continues to leave millions in denial. How much more information would anybody need to make a decision to quit?

Everybody knows how difficult quitting really can be.

And there has been a tremendous surge in quitters. A federal government report a few months ago stated that Americans are trying to kick the smoking habit four times more often than they did in the years before the introduction of nicotine gum, patches, and other stop-smoking products. Analysis of data from pharmacies and over-the-counter purchases of smoking cessation products led the Centers for Disease Control and Prevention (CDC) to conclude that Americans made more than 8 million attempts to quit smoking in 1997 and 1998, up from 2 million in 1991, before the introduction of the nicotine patch. In 1998, the nicotine patch accounted for 49 percent of the drug-assisted attempts to quit, nicotine gum 28 percent, and prescription non-nicotine medication 21 percent. The nicotine inhaler and nasal spray accounted for less than three percent.

The CDC report stated that 48 million U.S. adults currently smoke. The study may have overestimated the actual number of attempts to quit since personal surveys were not conducted. It was not possible to determine whether the sales reflected purchases used to quit or to substitute for smoking where it’s banned. It is common for smokers to go through several cycles of attempting to quit, relapsing, and trying again. Importantly, the CDC recommended that smoking cessation products be included as a health insurance benefit. The report also suggested that decreasing the costs of treatment could increase the number of people trying to quit.

When to quit? A U.S. Public Health Service report in June stated that there is now an unprecedented opportunity to reduce tobacco use rates because of an unusual confluence of circumstances: 70 percent of smokers now want to quit smoking completely, and 46 percent try to quit each year; more than 70 percent of smokers visit a health care setting each year with health problems and most importantly, effective treatments now exist.

The conclusions: tobacco dependence is a chronic condition, which should be treated repeatedly until long-term, or permanent abstinence is achieved. All users should be offered treatments, depending on the intensity of the dependence. Counseling can be effective, practical counseling, social support as part of and outside of treatment. At least one of the nicotine-based and non-nicotine medication treatments should be prescribed in the absence of contraindications. All health insurance plans should include as a reimbursed benefit the counseling and medication treatments.

Nicotine replacement therapy is generally used for smokers who smoke more than 10 cigarettes per day. The therapy helps the smoker deal with physical withdrawal by providing enough nicotine without the other harmful substances found in tobacco products. It also eases the cravings associated with withdrawal. You should not smoke or chew tobacco when using a nicotine replacement. By itself, nicotine is a powerful stimulant and the additive effect may put you at serious risk.

Several forms of nicotine replacement are available. The nicotine patch provides a steady and controlled supply across the skin. A new patch is applied daily. Nicotine gum is chewed as needed, when an urge is felt. Nasal spray provides nicotine through a solution sprayed into the nose. A nicotine inhaler contains a cartridge in a plastic cylinder that provides nicotine when inhaled.

If you have heart or blood vessel disease or are pregnant, your doctor will be careful about the amount of nicotine replacement you should have. You should report problems or side effects promptly. Bupropion hydrochloride is a prescription drug that may help some people who are quitting cope with nicotine cravings. It can be used in conjunction with nicotine replacement therapy. Social and psychological counseling sessions help some people quit. Local programs should be available to you. Your doctor, your local hospital, or a local chapter of the American Lung Association may help you identify programs in your community. When your doctor prescribes medications, be sure to provide your personal list of all medications and herbal supplements you’re taking so you can avoid drug interactions.

Long-time smokers sometimes rationalize that there is no use in quitting now because they’re addicted and the damage has been done. Not true. Although damage is not reversed overnight, there is plenty of evidence of reversal of these effects, and getting regular exercise, avoiding second-hand smoke, and proper nutrition may help the repair processes. The benefits of quitting only get better with time. The reasons for quitting are multitudinous; the time is now. To try and succeed is wonderful. To relapse is human - try again. To continue to smoke is decidedly unwise.

Dr. Silva is a professor of surgery at Wayne State University and a resident of Woodbluff on Mackinac Island.