Secondhand smoke signals

Public opinion is finally starting to catch up with medical research and physicians can play a crucial role in lowering the societal burden.

Issue: October 1, 2006

ByJoseph Aisner, MD

The recent U.S. Surgeon General report about secondhand smoke helped us to focus our attention again on the health implications and the growing intolerance, finally, to tobacco smoke exposure in a progressively more informed population. We know this both by the decreased incidence of smoking in some segments of the population, and the decreased number of visible smokers who stand outside of buildings to partake of their addiction. Yet we walk passively by the clouds of smoke, and we tolerate this secondhand exposure in many settings where innocent bystanders are affected.

How many of us would willingly walk into an old building with asbestos flaking and falling off the ceiling pipes? Likewise, who would willingly walk into a room or other site labeled as a “radiation exposure” hazard without adequate protection? Not only would most people actively shun such situations, but they also do not tolerate such exposures when they are involuntary or even when they occur on a voluntary basis. This observation is clear both from the avoidance of these exposures, and the high success rates of tort litigation resulting from such exposures. We only need to recognize the magnitude of the asbestos tort litigation industry to confirm this observation. Why are these exposures so intolerable to us as a society, yet secondhand smoke so much less so? What cultural and scientific information define our responses to cigarette exposure? How many times do we need to be warned?

Old standard

In 1964, the U.S. Surgeon General published the now famous report titled “Smoking and Health: Report of the Advisory Committee to the Surgeon general of the Public Health Service,” which clearly and unambiguously linked cigarette smoking with chronic obstructive pulmonary disease, lung cancer, heart disease, arteriosclerotic cardiovascular disease and stroke. This report and its three successors in 1967 to 1969 resulted in a warning label on cigarettes. Nevertheless, the warning label on the cigarettes produced little effect on smoking incidence. Through very clever marketing, tobacco companies stimulated smoking in youths with an “it’s cool to smoke” campaign, with product placement ads and by spiking cigarettes with more addictive levels of nicotine. In some markets, the tobacco companies “dumped” the so-called “spiked” cigarettes to overwhelm the local brands, or gave away samples, reminiscent of the “old dope peddler” referred to in the Tom Lehrer song of the same name.

Joseph Aisner, MD [photo]
Joseph Aisner

That first report was followed by 29 additional reports from surgeon generals over the next 35 years. These reports progressively added more evidence to the causal relationship between cigarette smoke, cancer and other diseases. Nevertheless, the effect on smoking incidence remained relatively minor until recently when smoking incidence finally began to decrease, first among white males, and more recently in other minority (mostly male) populations. The tobacco companies responded to these reports by refining their campaigns to target various ethnic groups. The tobacco lobbying effort spent exorbitant sums to prevent legislation or to undermine local legislation designed to reduce public use and exposure to tobacco smoke.

Legal landmark

A major legal breakthrough occurred when state governments tried to offset the cost of tobacco-related diseases, which burdened the state budgets through retiree state Medicaid and similar state-supported programs. State attorney generals eventually reached a multibillion dollar settlement with the tobacco companies.

Response to these settlements was most interesting to watch. With the assistance of the tobacco lobby, most of the money went to offset state budgets, rather than education efforts to stop smoking habits before they formed. Tobacco companies simply added the cost of the settlement to the price of cigarettes, and the health care burden (greater than $2.70/pack in hospital costs alone in 1992) remains uncollected. This is also a burden to taxpayers. Several states used these funds for smoking education and reduction, but this was fiercely opposed (and successfully in California) by the tobacco lobby.

Burden of evidence

In 1993, the Environmental Protection Agency issued a report titled “Respiratory Health Effects of Passive Smoking: Lung Cancer and Other Disorders,” which labeled cigarette smoke as a class-A carcinogen, similar to asbestos, radon gas and benzene. This classification should have prompted the Occupational Safety and Health Administration of the U.S. Department of Labor to restrict secondhand smoke exposure.

The tobacco lobby was able to prevent major legislative action but a national response began to slowly trickle down. It began in local municipalities where legislators enacted smoking restrictions. The tobacco lobby responded to this by advocating far less restrictive legislation at the state level, which would preclude the local restrictions. Rather than enact legislation, the state of Maryland, led by the state’s health department and the state’s OSHA equivalent, held hearings to develop smoking regulations to protect indoor workers. These efforts were vigorously opposed by the tobacco lobby, but resulted in restrictions that required ventilation sufficient to handle any class-A carcinogen in all indoor smoking areas except for bars and restaurants (an obvious compromise). The most striking aspect of these issues is that they heralded the recognition of risk associated with secondhand smoke both by proximity and exposure. Shortly thereafter came increasing estimates of the effect of secondhand smoke on lung cancer, childhood asthma, and other diseases as evidenced in the recent Surgeon General’s report.

Sea change

The effect of these warnings, the actions of the anti-smoking activists and the growing litigation against the tobacco companies finally induced a societal change in attitudes. The change is just beginning, but it is gaining momentum. Even tobacco companies have recognized this fact and rapidly positioned themselves as “good guys” by sponsoring high-profile anti-smoking campaigns. Not only are we letting the fox guard the hen house, but also, these national campaigns place the tobacco companies in the public eye; specifically, the campaigns place them in front of their youthful target audience.

Larger municipalities like New York City have restricted all indoor smoking. This movement is growing steadily but faces tobacco lobby opposition at every step of the way, which usually offers obscure alternatives and weaker proposals. There are significant smoking restrictions in public buildings and hotel rooms, along with the long-accepted smoking ban on airlines, which was originally enacted to protect the cabin crew. These restrictions need more effort and must expand beyond affluent communities.

Up in smoke

The new Surgeon General’s report should have an extraordinary effect on these efforts. Once again, we hear the warning about secondhand smoke, but now we know how it affects other populations. How can anyone ignore a report that says there is no safe level of secondhand smoke exposure? Now is the time to act, regardless of the billions of dollars that the tobacco lobby will spend.

First, we must make a concerted effort at education. As oncologists, professionals who see the decimation of a lifetime of smoking, we must add our voices to reduce smoking among youth, to reduce secondhand exposure among all individuals and to reduce the terrible burden on health and quality of life.

Although tobacco companies are already looking to increase profits by targeting individuals outside of the United States, we can feel some pride that in the area of public health, the United States is ahead of most of the world. We have recognized the threat of firsthand and secondhand cigarette smoke exposure, and we are now witnessing society move away from smoking despite the huge influx of tobacco company lobbying. We must not relax our vigilance on this front, and we must actively work to change our society’s tolerance of smoking. Despite all of the recognition of the problem, tobacco use still remains the largest and most preventable cause of disease in this country and most other countries worldwide.

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Joseph Aisner, MD, is a Professor of Medicine and the Chief of Oncology at the Cancer Institute of New Jersey in New Brunswick, N.J. He is also the lung cancer section editor for Hem/Onc Today.