Physicians and cigarette smoking

In a recent popular motion picture thereis a line which seems to indicate the point towhich popular thinking has now progressedwith respect to the cigarette problem. Theunheroic hero of the play is offered a cigaretteby the similarly equivocal heroine and, believing it is marijuana, he declines. She insists,reassuring him with the line, “¿�Don'tworry;this kind just gives you cancer.―

Surveys indicate that the American publichas in general accepted the evidence, in spiteof the objections of a few die-hards, that lungcancer tends to follow cigarette smoking.Nevertheless, judging from the reported annual sales of cigarettes, the individual smokerdoes not relate the hazard to himself, eitherbecause the extent of the risk is not comprehended or the day of reckoning seems too remote. The number of deaths from lung cancer,therefore, continues to rise.

The evidence implicating cigarette smokingseems complete enough, far more precise, infact, than that which has been accepted byphysicians as adequate to take action againstthe causes of other plagues. There is theknown presence in cigarette smoke of carcinogenic substances, the production of skin cancerin laboratory animals by smoke condensates,the predilection of precancerous lesions forthe lungs of heavy smokers, and the numerousepidemiological and statistical studies showinga consistent parallelism between the numberof cigarettes habitually smoked and the chanceof developing lung cancer. The evidence canbe summarized perhaps in two simple statements: cigarette smoke contains carcinogens;statistics confirm the fact that what mightbe predicted does in fact occur.

Acceptance of the relationship of cigarettesmoking to lung cancer has been announcedby a long list of scientific societies and otheragencies, and steps to curtail cigarette smoking have been taken by a number of foreigngovernments. The most recent and sweepingindictment of the cigarette, with a consideration of preventive measures, has been published by The Royal College of Physicians ofLondon in a booklet entitled “¿�SmokingandHealth.―The United States government seemsnow ready to examine the problem, and anadvisory committee to the Surgeon Generalof the Public Health Service on the healthhazards involved in the use of tobacco is tobe set up.

Aside from the all too evident distaste of

Dr. Taylor is Professor and Chairman of theDepartment of Obstetrics and Uynecology at theCollege of Physicians and Surgeons of ColumbiaUniversity in New York City.

*Reprinted from the Journal of the AmericanMedical Association 181: 777-778, September 1,

certain elements of the “¿�Americaneconomy―for anything which might disturb the cigarette market, there seem to be two factorswhich stand in the way of positive action. Oneis the failure to recognize the full extent ofthe damage to the nation's health; the other,the refusal of individuals and groups in oursociety to accept the responsibility to do something about the situation. [At the request ofthe Board of Trustees of the American Medical Association, the Council on Drugs willconduct a year-long study of the relationshipbetween cigarette smoking and disease.]

The magnitude of the problem can be expressed in minimal and maximal terms. Tostart with, there are almost 40,000 annualdeaths from lung cancer. Students of theproblem estimate that 75 per cent to 90 percent (30,000 to 36,000) of these may be attributed to the smoking habit. This is moredeaths than occurred from combat among theUnited States Armed Forces in more thanthree years of fighting in Korea, and it isapproximately equal to the total annual deathsfrom motor vehicle traffic accidents (37,000per year), about which so much justifiablehorror is constantly expressed in our dailypress.

The relative difference in mortality ratesbetween smokers and nonsmokers is considerably less for heart disease than for lungcancer. Nevertheless, cardiac deaths are somuch more numerous than deaths from lungcancer that the net excess of deaths fromcoronary artery disease in heavy smokersover nonsmokers is approximately four timesas large as the number of excess deaths fromlung cancer. Higher death rates for smokersthan for nonsmokers have been reported alsofor cancers of the oral cavity, larynx,esophagus, and urinary bladder, from pepticulcer, from bronchiectasis and chronic bi-onchitis, and from certain forms of vasculardisease.

There is definite evidence that the life expectancy of men who are cigarette smokersis less than that of nonsmokers. ProfessorRaymond Pearl of Johns Hopkins Universityprepared life tables almost a quarter of acentury ago which showed this.

Recent data compiled from various studiesexpress this in another way: viz., of Americanmen 35 years of age, 23 per cent of nonsmokersmay expect to die before age 65 as comparedto 41 per cent of men who smoke two or morepackages of cigarettes a day. In other words,the risk of dying in the “¿�primeof life― isalmost twice as great for American men whoare heavy cigarette smokers as for nonsmokers. Furthermore, among American menbetween the ages of 50 and 70, the death ratefrom all causes over a period of three yearswas 34 per cent higher for those who smoked

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Physicians and Cigarette Smoking*Howard C. Taylor, Jr., M.D.

less than half a pack a day than for nonsmokers and 123 per cent higher for thosewho smoked more than two packs a day thanfor nonsmokers.

The nonacceptance or the noncomprehension of these figures seems to be the firstreason for inaction. The second reason issurely the existent dispersion of responsibility,making it possible for those with potentialinfluence to “¿�washtheir hands― of the problemand to remain unconcerned with the judgmentof the future.

Perhaps, understandably, those who profitfrom the production and marketing of cigarettes do not accept the evidence, and theirconsciences may in consequence be untroubled.The national expenditures of the six largesttobacco companies for advertising cigarettesare reported to be in excess of $150,000,000annually, and this provides valuable, if notessential, support for our so-called mass mediaof communication. Government agencies arecaught in cross currents of political pressuresand move with caution or not at all.

However, the physician, both as an individual and as a member of professional organizations, cannot remain free of criticism.Health is his subject, which he is dedicatedto promote. He will lose self-respect as wellas professional and social stature if he flinchesbefore a health problem simply because it hasnew facets, social and economic, instead ofthe familiar aspects of, for instance, infectionor neoplasia.

The example of The Royal College of Physicians is a shining one. We should not haveallowed our British colleagues to be ahead ofus, but plenty remains to be done. There isnobody in America to whose pronouncementson health matters more heed is given thanthe American physican. The collection of further data is not required. Those on recordare adequate and are available for reevalua

tion if that is needed. What should be askedfor is a firm expression of opinion on theevidence, a public recognition of the extentof the problem, and proposals for at leastthe beginning of a program by which America may eventually find its way out of thisunexpected medical, economic, and moralpredicament.

Finally, there is the individual physicianhimself and his individual patient. This isindeed the heart of the problem and one whichwe have to meet from two standpoints, that ofcounsel and that of example.

There is evidence that the smoking of cigarettes has declined substantially among physicians over the past several years. Thissuggests that at least some physicians, betterinformed than the people in general, are protecting themselves or possibly acting on theconviction that their public conduct will havea favorable influence on their patients' habits.

The vast majority of physicians, however,have with respect to this problem claimed thelayman's privilege of ignorance. “¿�Weare notcancer researchers or specialists in the diseases of the heart or chest.― “¿�Wedo not haveany opinion because we haven't bothered tostudy the evidence.―

This claim to the layman's status providesa comfortable means of avoiding the issuewhen we advise our patients, and of continuing, by example, to indicate our indifferenceor contempt for the evidence on the damagebeing done to the public health. Yet, howeverhard we try to pose as such, we are not yetlaymen in the public image because, for mostAmericans, the physician is the final accessible authority on all matters of health. Thephysician has then an obligation to acceptor to reexamine if he wishes- -the facts on theeffect of smoking upon health and then to actpersonally and to advise his patients in accordance with the implication of these facts.

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