My truth is a tale of smoke and cynicism, power and death, and a glimmer of fiery, fragile hope.
I tripped up the stairs, clutching a clipboard and breathlessly reciting the signs of chronic obstructive pulmonary disease (COPD)- tar staining, cyanosis, hyperinflated chest, wheeze. Suddenly my train of thought was derailed. There was a cigarette butt wilfully loitering on the steps. Even here. I felt a stinging slap of hopelessness- my little nicotine nemesis was so beloved that it was able to sit bold as brass on the steps to our respiratory ward. I gave it a vicious look, trudged onwards and started a new list. Bed 4, end stage COPD- clutching a Venturi mask to her face, every inch of her body exhausted by the effort of gas exchange, breathing as hard as a marathon runner, knowing it wouldn't stop until she died. Bed 7, query lung cancer- his awake bronchoalveolar lavage the single most horrific procedure I'd ever seen. A sort of iatrogenic water boarding that had failed to provide any information on the large mass dominating his chest X-ray. My list, and most of the people on our ward, were testimony to the power and horror of tobacco.
The tendrils of tobacco's power reached beyond the respiratory ward. I could take a history anywhere in any hospital and when someone described themselves as a smoker, my heart would sink a little at their increased risk of heart disease, hypertension, stroke and cancer. As a medical student my inner optimist would enquire about smoking cessation, but the barrage of polite declines slowly eroded this optimism and by the time I was qualified the question was almost a formality.
Sadly, my blossoming cynicism followed me out of the hospital and all the way home. One of my friends was a smoker and philosopher who somersaulted his way through arguments. We debated life, the universe and smoking. As a scientist I would hurl statistics at him- 100,000 people die every year in the UK from smoking related illnesses. 8 in 10 non-smokers live beyond age 70, but only half of long term smokers do (1). I'd outline the dangers of second hand smoke and give graphic descriptions of how people suffocate over weeks and months thanks to emphysema. Nothing phased him. He knew the risks, it was his choice. He felt my desire to dissuade him bordered on the unethical because it insulted his autonomy. The reality was I had no real ability to change it. And perhaps I was being a dictator to even try. Certainly my friend wasn't alone, British society accepted smoking, what right did I have to disagree? People have free will, let them exercise it.
Then two events shifted my perspective: the death of a loved one and a political triumph.
Coffins are small. They house a body, but they can never hold a person. My cousin baked the most amazing biscuits I'll ever eat, she loved music and had unending patience for jigsaws. She was kind and generous and irreplaceable. These things, the things that made her who she was, live in my heart and in every person who was lucky enough to know her. She died in her forties from lung cancer.
34,859 families stood over coffins because of lung cancer in 2010 (2). Being one of those families has completely dissolved any qualms I had about impinging on people's ability to smoke. My philosopher friend may want his autonomy, but on balance I think the world would be a better place with fewer cigarettes and fewer coffins. Sod your right to inhale tar and cyanide and die gasping.
I realise my opinions may offend, so let us turn to a safer subject: politics. I come from Scotland, a wild country that is famed for its whisky and which offers a plethora of pubs to drink it in. I never hoped we would be able to ban smoking in these pubs, yet in March 2006 Scotland did exactly that with a ban on smoking in enclosed public places (3). In 2007 Wales, Northern Ireland and England followed. The positive impact on health has been notable- air quality in pubs has improved, bar workers have better respiratory health and hospital admissions for acute coronary syndrome are down (4). Whilst I expected improvements in health, I didn't expect it to be popular. A recent survey of 12,000 British adults found that 78% supported the ban (5) .This societal support and the political will to ban smoking, stirred my comatose optimist and gave me a glimmer of hope.
This year, my optimist was brought back fighting by the Australian government. 2012 was the year that Australia passed a plain packaging law to standardise cigarette packets (6). Goodbye camels and cowboys, hello disease addled eyes and cancer ridden lungs on a murky green background. Lest we forget who is responsible for selling these deadly wares, companies can put their name on the packet in a dull, diminutive font. It has been said this will have no impact on smoking, but the tobacco companies' reactions tell a different story. British American Tobacco, Imperial Tobacco, Philip Morris and Japan Tobacco all took legal action against the Australian government, claiming the law violated the companies' intellectual property rights. Philip Morris also asserted the law would contravene a bilateral trade agreement with Hong Kong that would leave the government liable to pay Philip Morris huge amounts in compensation (7). Thankfully the Australian High Court ruled that the laws were sound and they will come into force in December 2012. The perfect Christmas present for Australian hearts and lungs.
With the return of my fiery, fragile hope, I've come to find my truth. Trying to stop people smoking wasn't thinking too big, it wasn't thinking big enough. We can't take on tobacco one smoker at a time, it's like trying to stop malaria by catching every mosquito in the world with a pair of chopsticks. We need to be murderously ambitious. We need to suffocate the tobacco industry. The World Health Organisation (WHO) have defined the elimination of leprosy as a prevalence of less than 1 case per 10,000 of the population (8). Using this definition, I believe it's realistic to eliminate tobacco smoking in the UK in my lifetime. Given longer I think we can eliminate it worldwide.
You may say I'm a dreamer, but if you look at the statistics of smoking we really have no choice but to make it happen. In the Lancet earlier this year, Giovino et al reported the results of the Global Adult Tobacco Survey of 14 low and middle income countries. 40.7% of men in the survey smoked a tobacco product, ranging from 21.6% in Brazil to 60.2% in Russia (9). These high demand rates are readily met by the tobacco industry with cigarettes being manufactured faster and cheaper than ever before. One of the most formidable accounts of this mass production of death was penned by Proctor this year (10). He uses the assumption that one death is caused by every million cigarettes smoked, to provide some sickening statistics.
“…the 6 trillion smoked in 1990 will cause about 6 million deaths in 2015. That's one death every 5 seconds.”
“Cigarette companies make about a penny in profit for every cigarette sold...a tobacco manufacturer will make about US$10 000 for every death caused by their products.”
We can even make our own relatable statistics. Philip Morris' Richmond plant in Virginia, USA made 146 billion cigarettes in 2010. That's 146,000 deaths. The Kunming Cigarette Factory in China made just 71 billion that year, a paltry 71,000 deaths (10). Between these two factories, in a single year's production they will kill the equivalent of every man woman and child in the town I was born in. 54 times over. Don't feel left out, its a game we can all play.
Hopefully you're now asking yourself “how do we end it”? Some suggestions are well known, such as plain packaging, high taxes, restricted advertising and accessible cessation. But ours is an ambitious aim, which will require daring and innovation. Borland (11) has proposed a regulated market model, which would take mass marketing away from the tobacco companies and hand it to an agency with a harm reduction charter. Advantages of this approach would include brand control, price control and the ability to incentivise manufacturers reducing the harmfulness of the products. An equally bold idea is Daynard's suggestion that reducing nicotine levels in cigarettes to non-addictive levels could secure a smoke free future (12). While I think both of these ideas are compelling, I also find a certain radical appeal to Tasmania's “2000 Smoke Free Generation” idea, which would ban the sale of cigarettes to anyone born after the year 2000 (13).
All of these ideas are big and brave and massively problematic, much like taking on the tobacco industry. Together, the biggest tobacco firms make more than $1,100 of profit a second (14), so they have much to lose if smoking declines. This fact was felt by the Australian health department when they were passing the plain packaging bill through parliament. The team were “swamped” by 63 freedom of information requests, 52 of which were courtesy of tobacco companies in what has been described by commentators as “a specific and deliberate attempt to divert resources” (15). Disappointingly, tobacco companies are being aided in their efforts to maintain power and profit by the policies of some countries. The WHO Framework Convention on Tobacco Control came into force in 2005 and was a landmark achievement in international public health. It sets minimum standards for tobacco control which are legally binding in 176 countries, covering every aspect of the industry from production to marketing and taxation. Yet, even under a Democratic President with a vocal commitment to healthcare the United States has not ratified the convention (16). Clearly there is a long way to go before my hopes are realised.
The tobacco industry has the audacity to make millions of dollars selling an addictive product which causes millions of deaths. We must be as smart, as ambitious, as bold as they are. If ever there was a man who captured all of these qualities it was Apple's visionary leader Steve Jobs. In 2005 at Stanford University he delivered the most moving and inspiring piece of public speaking I've ever heard. His advice was to “Stay hungry. Stay foolish.” This is the mantra public health needs- from smoking to obesity, from malaria to HIV, it is imperative we think big. When devising solutions we shouldn't just accept our limitations, instead we must push them, shove them, shatter them. Stay hungry. Stay foolish. That's my truth, now tell me yours.
- Smoking- The Facts. http://www.patient.co.uk/health/Smoking-The-Facts.htm Accessed 06/10/12
- Lung cancer mortality statistics. http://www.cancerresearchuk.org/cancer-info/cancerstats/types/lung/mortality/uk-lung-cancer-mortality-statistics Accessed 06/10/12
- Smoke free legislation. http://www.healthscotland.com/scotlands-health/evidence/smokefreelegislation.aspx Accessed 06/10/12