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Cleveland, OH
Dr. Mazzone is Co-Director of the Fellowship Program and Dr. Arroliga is Professor of Medicine, Cleveland Clinic Lerner College of Medicine and the Department of Pulmonary, Allergy, and Critical Care Medicine, The Cleveland Clinic Foundation, Cleveland, OH.
Correspondence to: Alejandro C. Arroliga, MD, FCCP, Department of Pulmonary, Allergy, and Critical Care Medicine, The Cleveland Clinic Foundation, 9500 Euclid Ave, G 62, Cleveland, OH; e-mail: arrolia{at}ccf.org
How many different ways are there to say that cigarette smoking is bad for you? Smoking is an epidemic that affects one in three adults in the world, 23% of adults and 28% of high school students in the United States.1 Nearly 450,000 persons will die every year of a disease attributable to tobacco use.2 In the United States, tobacco use kills more people each year than AIDS, suicide, murder, car accidents, and illicit drugs combined. The economic impact of the diseases caused by smoking is significant. It is estimated that 8% of all annual health-care expenditures in the United States are used in the treatment of smoking-related diseases.2 The loss of productivity is more difficult to define.
It has long been known that smoking causes lung cancer.3 Recent evidence has strengthened the view that current smoking is an independent predictor of shortened lung cancer survival.4 In this issue of CHEST (see page 1733), Garces et al provide evidence that smoking also affects the quality of life (QOL) of lung cancer survivors. They report the results of a cross-sectional study in which 1,028 survivors of lung cancer responded to a lung cancer QOL survey, with the results analyzed to determine the impact of tobacco use on the QOL of these patients. The findings of the study are straightforward and disturbing. As expected, the QOL was better for the survivors who never smoked and for former smokers when compared with survivors that were currently smoking. Never-smokers and former smokers had better appetite; less fatigue, cough, and dyspnea; and less distress. Unfortunately, 30% of patients who were smoking at the time of their lung cancer diagnosis continued to smoke afterwards, and 5% who were former smokers restarted the deadly habit.
Tobacco use has been known to decrease the QOL in other settings (nicely outlined in the article by Garces et al). Whether this study provides novel information or not is not entirely clear. As there was no baseline (at the time of diagnosis) survey administered, it is possible that the tobacco-related reduction in QOL was present well before lung cancer was known to be present. Nonetheless, we have been provided with yet another reason why smoking is bad.
So with all of this evidence available, why do so many continue to smoke, even in circumstances in which it is hard to imagine that they would want to do so? Some of the fault must lie with the individual, some with the tobacco industry, and perhaps some with the health-care profession.
The individual must bear some of the responsibility. The vast majority of tobacco users become addicted at an early age. Adolescent smokers who use the drug (nicotine) frequently experience symptoms of nicotine dependence with increased smoking.5 Genetic and behavioral factors certainly play a significant role in nicotine addiction.678910 Is this enough to excuse one from their responsibility to their own health?
The tobacco industry must bear some of the responsibility. The tobacco industry is powerful. It has major political and economic clout with strong lobbying forces. The industry has marketed their product successfully through the years, misleading the public for decades. They have altered cigarette designs and composition to be more appealing to specific consumer groups.11 Contrary to other industries that produce harmful products, the tobacco industry has escaped almost untouched over the years. Can you imagine producing a product today that is as harmful and costly as tobacco, with no beneficial effects, and seeing it be approved by the Food and Drug Administration? It is clear that this powerful industry is not going to change and will continue to make strong efforts to sell their deadly product in the United States and abroad. Certainly, the tobacco industry should bear some of the blame and burden from this epidemic.
Does the health-care industry play a role? Our best medical therapy for smoking cessation may have a 35% cessation rate at 12 months.1213 Some of us smoke. Many smoking cessation clinics are not covered by insurance. Is there more that we can do?
First, we have to recognize that smoking in the lung cancer survivor is common, despite its affects on mortality and QOL. We must recognize that cancer survivors have specific characteristics that impact their ability to quit smoking. They have depressive symptoms, low quitting self efficacy, as well as a low perceived risk of smoking and benefit from quitting.1415 We need to develop interventions specific to these characteristics. We think that the measures suggested by the American Society of Clinical Oncology16 and other professional societies need to be implemented. These include increased efforts to discourage tobacco use in the young, increasing the price of cigarettes by raising federal taxes, ensuring tobacco settlement funds are devoted to health-related projects, reforming third-party payment for tobacco cessation efforts, further restriction of second-hand smoke in public places, supporting research into tobacco addiction, and implementing a halt of US government promotion of tobacco products.16 We do not believe that regulation of tobacco products17 to decrease the lethality of the product will work. We believe that all health-care professionals, including nurses, pharmacist, social workers, physicians, and respiratory therapists, etc.,118 should be involved in advising our cancer survivors about smoking cessation. Finally, we think that pulmonary physicians, oncologists, and other professionals involved in the care of cancer survivors should be working with a multidisciplinary group of professionals who should evaluate the cancer survivors during each visit to the physician to establish pharmacologic, behavioral, and other types of therapies that have been shown to be effective in tobacco use cessation. We don’t need to find new reasons to tell people that smoking is bad; we have enough.
References
This article has been cited by other articles:
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  E. R. Gritz, C. Dresler, and L. Sarna Smoking, The Missing Drug Interaction in Clinical Trials: Ignoring the Obvious Cancer Epidemiol. Biomarkers Prev., October 1, 2005; 14(10): 2287 - 2293. [Abstract] [Full Text] [PDF]
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