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Wednesday, December 15, 2010

Smoking is Still Really, Really Bad for You

Long before I entered medical school, the harms of smoking were drilled into me.  For better or worse, as an elementary school kid, I stood by cigarette vending machines and told people not to smoke.  At the risk of confusing correlation with causation, I must have been awfully successful, because smoking rates in the U.S. fell from 44% in the 1950s to 32% to the 1980s, all the way down to 21% in 2008.  Or perhaps it had something to do with legislation, taxes, restrictions on advertising, class action lawsuits, and public health outreach campaigns.

At any rate, if I spent my childhood learning that cigarettes were bad for you, medical school has shown me that they are even worse.  Cigarettes are the cause of death in 33% to 50% of smokers.  And smokers die an average of 10 (or more) years earlier than non-smokers.  Every American schoolchild should know that smoking causes lung cancer.  Emphysema and heart disease get some attention too, though probably not enough.  But did you know that smoking also causes bladder cancer?  Pancreatic cancer?  Gangrene?  Erectile dysfunction?  Osteoporosis?  The list goes on.  I won’t even get into the fact that secondhand smoke accounts for 600,000 deaths annually, a third of those in children.

Seriously, why would you even do that?

Smoking has gone from being a problem of rich countries to a problem of the developing world.  Of the over 5 million smoking-related deaths per year, about half are in the developing world.  In India alone, almost 1 million people a year die from smoking-related causes.  All told, tobacco kills two to three times as many people a year as HIV.

These figures don’t take into account the staggering morbidity of smoking- patients living with chronic disease, unable to breath due to emphysema or demented secondary tobacco-related strokes.  All of this occurs in the context of strained health systems that lack the capacity to aid those living with disease; smoking-related illness simply taxes an already inadequate primary care infrastructure.  (If health systems in the developing world were stronger, doctors and nurses at local clinics could educate and counsel people on the harms of smoking and the benefits of quitting.)

Why is this shift happening?  Largely because of economics.  The harder it is to sell cigarettes in America or Europe, the more appealing it is for tobacco companies to set up shop in countries with more lax regulations.  Deficiencies in education and lack of knowledge of the adverse effects of smoking also help: in a survey conducted in China, 60% of people were unaware that smoking causes lung cancer and 96% of those surveyed did not know smoking causes heart disease.  To wit, heart disease accounts for a third of smoking deaths, lung cancer for 17%, and emphysema for 20%.  (As an aside, I think it merits noting that heart disease kills more smokers than lung cancer and that people may "recognize" the effects of smoking in themselves and their friends/family more readily if they connect tobacco and cardiovascular disease.)

And while it’s more than fair to attack tobacco companies, did you know that the largest producer of tobacco in the world is the Chinese government?  It’s true: the China National Tobacco Corporation peddles more cigarettes than our good friends over at Phillip Morris or R.J. Reynolds.

It’s easy to point out a problem, but much harder to solve it.  Smoking deaths are preventable, but only if the international community makes a concerted effort to curb tobacco use.  First, we need to recognize smoking as a global health problem, like HIV, cholera, and malaria.  Then, we need to enact international regulations like those we put into place in the U.S.  It won’t be easy—standing up to American corporations AND the Chinese government is a tall task—but the benefits are painfully clear.  Not without a struggle, the U.S. has decided that smoking prevention and cessation is vital to its national interests.  It’s time we take that same view on smoking in the developing world.  With the myriad health problems industrializing nations have to face, why should we tolerate millions of more deaths caused by a preventable, man-made product?


  1. Maybe China sees it as another form of population control, supplementing its one-child policy...

  2. Adam, in doing research on people's overestimates of HIV risks I came across the fact that the true lifetime lung cancer risk of smoking was ~3%, whereas people think the risk is 1/2 or above. I'm having trouble reconciling that with the fact that as many as half of smokers die from smoking. What do they die of? How many of the deaths are due to exacerbating the risk of other more common causes of death?

    You're right to highlight economics but I think you're missing a key component of our anti-smoking efforts: cigarette taxes, which are insanely high and which directly fund the media campaigns.

    On a lighter but simultaneously much darker note here is a video of Ardi Rizal, a chain-smoking Indonesian 2-year-old:

  3. Hey Kerwin- thanks for the comments.

    1) The most common cause of death in smokers is heart disease, but that increased risk can be estimated by comparing the rate in smokers to non-smokers. That gets back to my point that a lot of heart attacks and strokes are caused by smoking, but the public may not perceive it as such because we are all focused on lung cancer and don't appreciate the effect of cigarettes on cardiovascular disease. As for emphysema, another driver of mortality in smokers, you don't see much of it outside of smokers except in a few niches (e.g., miners).

    2) I agree with you on taxes, but they are a double-edged sword. Tobacco taxes can be a driver of state revenue and poor governments may be loath to oppose smoking too aggressively at the risk of losing the cash. Also, my understanding of tobacco taxes it that they don't usually encourage smokers to quit (they are addicted and will pay more for cigarettes, which is good news for governments reliant on tobacco taxes). BUT, tobacco taxes can provide a financial barrier to youths who may be considering smoking, thus averting future addictions.

    3) After reading your comment on my post, my sister emailed me: "oooh... jason took you to town..." Sigh...

  4. In general increasing tobacco taxes increases revenue for the state, rather than decreasing it. The smaller amount of people smoking does not offset the increased funds.

    The thing that annoys me most is the WTO strong arming lesser developed countries into accepting lax cigarette laws. Countries that want really intense pack laws can get forced to decrease their requirements. WTF?

    Interestingly, heard today that more 12th graders in the US are smoking marijuana than smoking cigarettes. What do you think of this?


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