Blowing Smoke Despite Progress, Cigarettes Continue to Be a Major Public Health Problem

For generations, Americans have heard the risks of smoking trumpeted in public-service announcements and read them right on cigarette packages.

Many have seen family members die from lung cancer or emphysema. Some have read that more than 438,000 people die annually from tobacco-related disease, making it the leading cause of preventable death, according to the American Lung Assoc. (ALA).

And today, they live in a society that officially frowns on smoking, and bans it in workplaces, restaurants, even in many outdoor locations. Cigarette prices have soared in recent years, with legislators adding more burdensome taxes on top of that cost.

You’d think that all this would be a successful recipe for phasing smoking out of our culture altogether. But that’s not happening. Not even close.

In fact, the ALA claims, each day more than 1,000 children and teenagers become regular, daily smokers — half of whom will eventually die as a direct or indirect result of their addiction. And many of them, said Dr. Francis Podbielski, are victims of marketing.

“The Joe Camel ads speak to kids 8, 10 years old, even though they might not buy their first pack of cigarettes until they’re 14 or 15,” said Podbielski, a thoracic surgeon who heads the lung-cancer program at Mercy Medical Center. “It becomes something in their lexicon. They see the ads, they buy candy cigarettes, and they graduate to the real thing.”

Michele Hart, a pulmonary nurse clinician with Baystate Health, said seen the rise in teen smoking, too, and noted that girls are starting younger than boys — many of them, perhaps, getting messages that have nothing to do with TV ads or billboards.

“We do a lot of outreach in schools to discourage kids from starting smoking, but in a lot of cases, people they know, parents and grandparents, are smoking,” she said. “And for a lot of kids, smoking still has that glamorous look. That perception is less than it used to be years ago, when everyone smoked in movies, but a lot of girls still think it’s cool. Or else, they smoke as a way to stay skinny — which is a myth; a lot of overweight people smoke.”

What all this means is that another generation will grow up to face the long-term health hazards of smoking — or grasp at treatments designed to help them quit. This month, The Healthcare News looks at what doctors and lawmakers alike are doing to clear away the smoke for good.

Cracking Down

The addictive qualities of cigarettes, long accepted as fact, should lend weight to ongoing advocacy efforts to transfer tobacco-industry oversight from the Federal Trade Commission to the U.S. Food and Drug Administration, said Podbielski.

The ALA is pushing hard for that that eventuality, arguing that tobacco products are among the only ingestible products that are not regulated by the federal government.

Currently, two bills have been introduced in the U.S. Congress that aim to give the FDA authority to oversee the manufacture, marketing, and distribution of tobacco products. One of those, the Family Smoking Prevention and Tobacco Control Act, recently cleared the House Energy & Commerce Committee by a 38-12 vote and, at press time, was awaiting a full House vote.

“This legislation will finally provide the U.S. Food and Drug Administration with the authority it needs to regulate the production and marketing of tobacco products, which have been historically exempt from the most basic oversight,” said Bernadette Toomey, ALA president and CEO. “It would require tobacco companies, for example, to stop using misleading or inaccurate health claims, to inform consumers of tobacco product ingredients, to make products less harmful and addictive if possible, and to limit marketing to young people. We cannot allow this to continue.”

The ALA isn’t stopping there, however. Two years ago, it issued its Smokefree Air 2010 Challenge, setting that date as a goal for all states and municipalities to ban smoking in workplaces. To date, 22 states have gone that route, with Massachusetts passing its own ban in 2004.

The ALA is also pushing for higher state excise taxes on cigarettes — the average is currently $1.11 per pack — and calling for funding increases for state-run tobacco prevention and cessation programs. The Centers for Disease Control and Prevention (CDC) recommends minimum levels of funding per capita, but currently, only six states (Massachusetts not among them) spend the recommended amount.

As for the smoking-cessation aids that are medically available, nicotine patches and gums are still extensively used; all of them are intended to wean smokers off their nicotine cravings gradually. Only two nicotine-free drugs have been approved by the FDA: Zyban, about a decade ago, which is also sold as an antidepressant under the Wellbutrin name; and, more recently Chantix.

“Chantix is the newest product on the market,” said Podbielski. The drug’s active ingredient is varenicline, which works in two ways: cutting the pleasure of smoking and reducing the withdrawal symptoms that lead smokers to light up again and again. But there are some drawbacks.

“Initially people were doing really well on it, but it has some common side effects that in some people can be really serious,” Hart said, among them nausea, vomiting, headaches, and insomnia. “So they have to make a choice whether to deal with the side effects or try a different product.”

More seriously, she noted, the FDA warned of possible suicidal thoughts in some users of Chantix, “so we advise patients who are taking that medication, if their mood changes, they should be in touch with a doctor as soon as possible to discuss those effects.”

In addition, Chantix isn’t a magic pill, said Podbielski; it works in concert with the smoker’s own willpower. “Chantix removes the physical craving, but you have to want to stop.”

That applies to any type of quitting regimen, Hart said. “You have to want to quit, but you also need to plan some coping strategies, plan how you’re going to deal with stressful situations.”

That might involve changing one’s entire lifestyle, to escape routines that have always been associated with smoking in the past, she said. And it might simply involve replacing the oral habit, perhaps by chewing gum — or even chewing on a straw.

Put It Down

Anti-smoking advocates are grasping at straws when it comes to convincing people that any product that leads to coughing, burning sensations in the chest, increased heart rate, and a higher risk of cancer is not a good idea.

Addiction is powerful, Hart said, but reason can be a useful tool. “We tell patients that they can reduce their risk for heart attacks and heart and lung disease by stopping smoking, and if they do already have damage done to their lungs as a result of smoking, that damage doesn’t go away, but stopping smoking will slow the progression of diseases.”

The best-case scenario, Podbielski said, would be for people to understand, as early in life as possible, the damage smoking can do, which is why many hospitals and health systems have intervention programs targeted to elementary schools.

He understands the economics of the situation, and knows that banning cigarettes outright might lead to a black market. But he smirks at the “duplicity” of lawmakers who speechify against smoking but don’t mind the tax revenues.

“When we talk about the evils of smoking,” he said, “we have to ask — if smoking is so bad, why do we allow it to be sold at all?”

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