Tough on Tobacco
Samet Recounts Progress Toward Eradicating Smoking
Decades of research on the health risks of cigarette smoking have really cleared the air, prompting a dramatic, steady decline in tobacco use. Yet despite the plethora of indisputable evidence, millions of Americans still smoke.
“With no smoking [allowed] indoors, you walk by bars and restaurants and outside…people, who are probably well educated, are smoking or they’re vaping. It’s amazing, isn’t it?” said Dr. Jonathan Samet, a pulmonary physician who is dean of the Colorado School of Public Health. He spoke recently in Natcher Bldg. at the fifth in a series of lectures celebrating NHLBI’s 70th anniversary.
Over the last century, adult cigarette consumption rose steadily, then began a consistent decline in the early 1960s, as successive studies linked cigarette smoking to heart disease, chronic respiratory diseases, lung cancer and to rising mortality rates.
“I think critical in shaping those research directions has been NHLBI, in terms of this volume of science and targeting critical issues and making sure the right answers were coming forth,” said Samet. Progress was bolstered nearly 50 years ago when the lung division was added to what was then called the National Heart Institute.
But now a new phenomenon is complicating the current smoky landscape—the popularity of e-cigarettes, particularly among teens and young adults. So much remains unknown about the respiratory and other effects of the toxic chemicals in these e-liquids.
“If a child starts using e-cigarettes while the lungs are still developing and growing—at age 13, 14 or 15, inhaling this vapor, what are the risks?” asked Samet.
E-cigarettes typically contain fewer toxicants and should reduce the disease risk for cigarette smokers who switch to them, but they renormalize nicotine, warned Samet. Nothing, of course, reduces the health risks more than complete smoking cessation.
“It’s a complicated risk trade-off between adults and children,” said Samet. “How many children is it okay to start being exposed to nicotine to protect one 60-year-old smoker? My answer is no children and that’s where we need comprehensive policy.”
In today’s fast-paced world, where social media is instant, we need to circulate information much quicker than in the time it takes to publish results from a protracted study, Samet said in a post-lecture discussion with Dr. James Kiley, director of NHLBI’s Division of Lung Diseases.
“This is not just the old tobacco epidemic; that was easy,” said Samet. “A brand got rolled out, came on the market, mostly stayed on the market.” Now, makers of e-cigarettes keep changing how and what chemicals they deliver, said Samet, so we need real-time information targeting vulnerable populations about short-term and cumulative effects.
Back when conventional cigarette smoking hit its peak, around 1960, the average sales across all adults was more than 4,000 cigarettes annually, or more than 200 packs per year. In those days, many smoked a pack a day or more. Marketing tactics then often blew smoke, said Samet, as the tobacco industry tried to undermine the science. These tactics continue today, but conventional cigarettes have not become safer, Samet emphasized.
A major turning point in the war on smoking came with the first surgeon general’s report in 1964 that compiled thousands of studies on the toxic health effects of cigarettes. The report’s release coincided with a national downturn in cigarette consumption.
“I think it represents one of the first examples of a true comprehensive, systematic review,” said Samet.
Successive surgeon general reports would update the health consequences, including a 1984 report that identified cigarette smoking as the major cause of chronic obstructive pulmonary disease in American men and women. Samet began contributing to the surgeon general’s reports that year.
“They’re a great example of science policy translation,” he said. “Pull all the evidence together, review it and come to conclusions that mean something.”
The 50th anniversary surgeon general’s report in 2014 was triple the size of the first report.
“In terms of the need to not smoke for the health of the lung, we have an incredible foundation,” said Samet. The 2014 report connected smoking not only with a vast number of respiratory outcomes, but also with other chronic diseases including rheumatoid arthritis and diabetes.
An ongoing challenge in battling the smoking epidemic, Samet said, is addressing health disparities—by education, socio-economic indicators, racial and ethnic populations and other susceptible populations such as the mentally ill—that drive different mortality patterns across the country.
As individual and population studies continue, “I would say who’s at risk goes beyond susceptibility; [consider] who’s being marketed to,” said Samet. Trying to prevent smoking-related diseases, he concluded, “will be the never-ending story.”
But that story could end, he admitted, if cigarette consumption one day goes down to zero. “That’s what we’re aiming for.”