No country has ever been able to rid itself of tobacco -- even when tobacco use has been a capital crime. With widespread smoking of cigarets (today's preferred spelling of "cigarettes"), ultra-rare diseases such as lung cancer and emphysema became common.

Cigaret smoking is now a major problem both in industrial societies and in the Third World. Red China has the world's highest cigaret consumption per capita. The role of the U.S. in all this is troubling: Thorax 46: 153, 1991. In Singapore, they're apparently now caning anybody under 18 caught doing tobacco ("Good" says Ed; Br. Med. J. 313: 636, 1996).

Today, tobacco smoke is the most widespread of the known pollutants. In developed countries, ethanol and tobacco are the two principal causes of avoidable death. Surgeon General Koop calls cigaret smoking "the chief, single, avoidable cause of death in our society and the most important public health problem of our time." (I'd have voted for alcoholism on the second point, but it's close....) Tobacco smoking kills 1000 people in the US each day. Mortality rates for young and middle-aged cigaret smokers is 1.7 x that of nonsmokers. By taking up smoking, a person cuts his or her life expectancy by 15 years (JAMA 258: 2080, 1987); the estimate of "5 minutes of life lost for every cigaret" is probably low.

Tobacco smoke is a complex mixture that contains nicotine (the addictive component) and many other harmful substances, including carbon monoxide, benzopyrene (* mutates ras codon 12 G-->T; Cancer 72: 432, 1993), nickel, polonium, and radon. "Low-tar" and "low nicotine" cigarets are not measurably less dangerous than the regular kind (Am. J. Pub. Health 77: 546 & 685, 1987). Smoking without inhaling (pipes, cigars) is less addictive and easier on the lungs, but the risk of mouth and throat cancer is high. "Smokeless tobacco" is as addictive as cigarets and causes mouth cancer; the average age at which an American begins "chewing tobacco" is now ten (JAMA 266: 3143, 1991).

Cigaret smoke contains nearly 4.000 chemical matters. Click here for see 50 major chemicals in cigaret smoke

What happens to tobacco smokers? You will learn about the anatomic lung pathology of uncomplicated cigaret smoking later in the course. After high serum cholesterol, cigaret smoking is the most important risk factor for coronary heart disease (heart attacks, sudden death, angina pectoris -- see Chest 94: 449, 1988) and other complications of atherosclerosis (including ruptured aortic aneurysms and strokes -- for the latter, see Lancet 2: 643, 1989). Chronic bronchitis and emphysema (together, COPD "chronic obstructive pulmonary disease") kill 150,000 people in the US each year. Lung cancer kills 140,000 people in the US each year. Cures are rare. The vast majority of these cancers are caused by cigaret smoking. Mouth cancer, throat cancer, larynx cancer, and esophageal cancer are all strongly associated with tobacco smoking.

Bladder cancer rates are roughly tripled for cigaret smokers. Pancreatic cancer and kidney cancer rates are at least doubled for cigaret smokers. Leukemia and plasma cell myeloma are also probably increased in smokers. We are now zeroing in on the molecular biology on oncogenesis on these cancers, which seem to result, at least in part, from mutations which carcinogens in tobacco cause. Smoking and cancer: Am. J. Med. 93(1A): 13S-17S, 1992. Tobacco mutates p53 (duh NEJM 332: 712, 1995).

Peptic ulcer disease is especially common in cigaret smokers. Cigaret smoking accounts for an extra 15,700 cases of stroke among U.S. men each year (NEJM 316: 628, 1987; also Am. J. Med. 149: 2053, 1989). Buerger's disease is a (fortunately rare) disease of young male smokers, who develop gangrene of their hands and feet. If we're to believe a new claim, mild brain-damage to the fetus is the rule rather than the exception in women who smoke (Ped. 93: 221 & 228, 1994, definitely stay tuned).

Osteoporosis in women is also exacerbated by smoking, and tobacco will rob a woman of 5-10% of her total bone mass over a lifetime (NEJM 330: 387, 1994). It increases your risk for rheumatoid arthritis, probably (Arth. Rheum. 39: 732, 1996).

The majority of household fires are caused by cigaret smoking. In Cuban epidemic neuropathy (1991-1993), tobacco combined with malnutrition to cause a grisly disease, and tobacco amblyopia (i.e., going blind from it) is probably a sporadic variant.

Rear-end collisions often result from "acts of smoking" (i.e., fumbling for your tobacco, lighting, flicking, etc.: JAMA 273: 1334, 1995). And smoking causes gum disease, bad breath, and stained teeth. (An unusually candid RJR dealer once acknowledged on TV that tobacco smoking "may" cause stained teeth "in predisposed individuals".) In a study with an obvious flaw ("it's dumb to smoke, and being dumb could be hereditary"), mothers who smoked during pregnancy gave birth to kids with persistently lower IQ's (Pediatrics 93:221, 1994). And we now know it greatly accelerates wrinkling of the skin (Ann. Int. Med. 114: 840 & 900, 1991).

There is no longer any reasonable doubt that passive smoking (inhaling someone else's cigaret smoke) is dangerous. Passive smoking probably causes around 5000 cancers yearly in the US (Am. Rev. Resp. Dis. 133: 1, 1986; JAMA 259: 2821, 1988; Am. Fam. Phys. May '88, p. 212; histopathologists see JAMA 268: 1697. 1992). Parents' smoking and children's health: Am. Rev. Resp. Dis. 133: 959, 1986; spouses' health: Am. J. Pub. Health 77: 548, 1987. The EPA (Am. J. Med. 93(1A): 38-S, 1992) decided that second-hand smoke kills 53,000 Americans yearly (which is clearly ridiculous, like many other government pronouncements), but the push to a smoke-free workplace is laudable. In the mid-1990's, a sideshow in the ethics circus involved a proposed ban on smokers adopting babies.

It is very difficult to quit, and people have done so deserve our congratulations. Quitting smoking greatly and quickly improves one's chance of a long and healthy life. The risk of sudden cardiac death drops almost to baseline immediately, while the risk of heart attack and lung cancer return to baseline over the next several years (NEJM 322: 213, 1990). Only the changes of emphysema are known to be irreversible.

Defenses of tobacco smoking are ingenious but flawed, and closely resemble other forms of pseudoscience. (See, for example, "Dr. Oat Cell"'s letter, JAMA 255: 1016, 1986.) Even the scientists who get their grant money from the tobacco companies ("The Council on Tobacco Research") are pretty much unanimous in agreeing that smoking obviously causes disease (Am. J. Pub. Health. 81: 894, 1991).

People don't smoke "because they like the taste" -- if they did, you could buy tobacco-flavored ice cream at "31 Flavors". People smoke because they are physically addicted to nicotine (see Chest 93(2S), 1988; the withdrawal syndrome is as severe as drugs that actually give pleasure, see JAMA 261: 898, 1989). Most addicts started smoking as teenagers, in order to assert their "independence" and as a sign of "maturity". The majority are never able to quit. Addicts cannot really exercise "freedom of choice". There is not a shred of evidence for "a gene to like cigarets" that also causes all cigaret-related diseases. There is no evidence, either, that smokers are self-medicating for a primary deficiency in certain neurotransmitters.

In spite of all this, however, most adults today know that tobacco is highly addictive and lethal. U.S. men are smoking less, and the incidence of lung cancer in men is finally starting to go down. Cigaret smoking, once macho, is now a teenaged girl's vice. The most successful stop-smoking campaigns are run by industry. Each smoking worker costs industry several hundred dollars extra per year.

The most effective anti-smoking ads directed for young people are the ones which remind them "The tobacco companies are playing you for a fool" (JAMA 279: 772, 1998).

Health care professionals are natural leaders in the fight against tobacco. Today only around 20% of physicians and 20% of nurses are tobacco smokers -- way down from previous decades. There are many packages to help your patients quit. The skin patch is now over-the-counter, and nicotine (though of course "evil") itself does not seem to be a problem for heart patients, who can use the patch safely (NEJM 337: 1230, 1997). Doxepin and clonidine both ease withdrawal, and "Zyban" became a sensation in 1998. There's also "Nicotrol" nicotine nasal spray (Mayo Clin. Proc. 73: 118, 1998).

If you believe that a physician's job is to improve the health of his or her patients, you will want to talk to them about smoking. If you take two minutes to urge a patient to stop smoking, he or she is around 50% likely to eventually quit. (See also Am. J. Pub. Health 77: 313 & 782, 1987; JAMA 259: 2882 & 2883, 1988). Comparisons of three stop-smoking clinics: Am. J. Pub. Health. 80: 554, 1990. To quantitate tobacco smoke exposure in your research, measure urinary conitine (Thorax 45: 356, 1990). To measure oxidative damage to a person, measure serum F₂-isoprostane: yes, cigarets greatly increase it (NEJM 332, 1995).