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Tobacco
tobacco ardly a newspaper or magazine these days is devoid of a piece on tobacco. Several states are H suing tobacco companies to recoup huge medical costs resulting from consumption of tobacco. The federal government has just issued new regulations on tobacco. Two books on tobacco, each appearing this year, provide perspective on the industry and the ironies and paradoxes about this problem. One is entitled Smokescreen: The Truth Behind the Tobacco Industry Covet-up by Philip J. Hilts, Addison-Wesley, 288 pp, $22. The other is Ashes to Ashes, America’s Hundred-Year Cigarette War, the Public Health, and the Unabashed Triumph of Philip Morris by Richard Kluger, Knopf, 807 pp, $35. Some observations; the downside: (1) About 46 million Americans smoke cigarettes; each averages 25 cigarettes a day which means 70,000 nicotine “hits” a year. (2) Tobacco kills about 420,000 Americans each year or about 1,160 Americans each day. That is the equivalent of 3 jumbo jet crashes 365 days a year. Worldwide, tobacco kills 3 million people each year or 6 people every minute. If current smoking patterns persist, when the young smokers of today reach adulthood, there will be 10 million deaths a year from tobacco or 1 every 3 seconds worldwide. (3) Cigarette consumption in the USA is no longer decreasing. Although the percentage of Americans aged 18 and over who smoke is down to 25% (from 50% in the early 197Os), there has been essentially no decrease in numbers of cigarettes smoked in the USA since 1993. In 1995 it was 487 billion cigarettes, a 2 billion increase over 1994. (In 1981, 640 billion cigarettes were smoked in the USA.) Per capita consumption in 1995 was 2,515 cigarettes per American aged 18 years and older. The percentage of high school seniors who smoke is now 22%, the highest since 1979. (Most smokers of course take up the habit before age 18.) (4) Tobacco is addictive. Tobacco fulfills the recognized definition of addiction: it controls the users behavior; its use is continued despite harm, and it causes the user to seek out the substance and puts that substance ahead of other priorities. Mark Twain said that “quitting smoking is one of the easiest things to do. He had done it a 1000 times.” But quitting isn’t easy as we all know. Only 75% percent of smokers, according to a recent Gallup poll (for SmithKline Beecham), say that they have tried to quit. But only 32% were smokefree for >3 months, 22% for 1 to 3 months, and 44% for < 1 month. (5) Although cigarette smoking is stable in the USA or increasing only slightly, in Europe, Asia, and the developing countries, it is increasing at astounding rates. In Europe the smoking sections of restaurants in the large cities are crammed with adults and teenagers, while the nonsmoking areas are small isolated corners of restaurants. 1084
01996 by Excerpta Medico, All rights reserved.
Inc.
(6) The direct costs of cigarette smoking in the USA are estimated to be $50 billion a year. (7) Cigarette butts litter our land. Of the nearly one-half trillion cigarettes smoked a year in the USA, 97% of them have cellulase acetate filters which have an after-smoke life of 5 to 7 years. These filter-tip cigarette butts now languish in every conceivable crammy, from cemetery statuary to bellies of whales. Several trillion are out there at any given time-in landfills, park trails, storm sewers, beaches, etc. (8) Cigarettes are probably the most common cause of residential fires. (9) Cigarette smokers have more nonfatal illnesses than do nonsmokers, and lost productivity is greater among smokers than nonsmokers. (10) Federal subsidies to tobacco farmers increase the taxes to nonsmokers as well as smokers. (11) The federal, state, and local governments subsidize the costs of treatment of illnesses produced by tobacco. (12) Cigarette smoking is a major cause of miscarriages and underweight newborns. (13) Tobacco makes for untruthfulness in both advertisers and politicians. This summer Philip Morris Europe ran full-page newspaper ads in major cities in Europe urging nonsmokers to be tolerant of smokers. The ads indicated that second-hand smoke was less dangerous than drinking 1 or 2 glasses of milk (1.62), or eating 1 biscuit (1.49), or drinking chlorinated water (1.38), or eating pepper (1.30). Second-hand smoke had a relative risk of 1.19. The tobacco industry has been a major contributor to congressional candidates and to both the Democratic and Republican parties. Dole, who had a terrible time ending his cigarette smoking habit 50 years ago, has recently stated, “There is a mixed view among scientists and doctors whether it is addictive or not. I’m not certain whether it’s addictive. It is to some people.” And this man is running for the presidency of the USA. Tobacco money alters the thought processes. (14) Cigar smoking is also increasing rapidly. About $1 billion worth of cigars were sold in the USA in 1995,98% to men and 2% to women. About 10 million persons in the USA smoke cigars, up from 100,000 a decade ago. It has become fashionable since the glossy, celebrity-studded Cigar Ajicionado magazine appeared in 1992. (15) Smokeless or spit tobacco sales also are increasing rapidly. About 40% of the nearly 700 major league baseball players use it. In Texas, 26% of 0002-9 149/96/Q 15.00 PII SOOO2-9 149(96)0066 l-3
eighth graders have chewed spit tobacco. Nationally, about 1 million adolescents, including nearly 20% of all high school boys, use spit tobacco according to the U.S. Department of Health and Human Services, and chewing tobacco increases the frequency of cancers of the mouth and pharynx about 6 times compared to nonusers. Although the downside for tobacco is much greater than the upside, here are some positives: (1) The tobacco industry provides jobs for about 700,000 Americans in farming, manufacturing, and retailing. The numbers of lawyers and lobbyists supported by the industry is unclear but obviously large. There are 124,000 tobacco farms in the USA and they produce 1.6 billion pounds of tobacco, a 25% reduction compared to 1975. A total of 674 million acres grew tobacco in the USA in 1995. Farmers in North Carolina gross about $3,400 per acre of tobacco compared with $210 per acre of soybeans and $700 per acre of cotton. (2) Tobacco provides about $21 billion a year in revenue from its agriculture and manufacturing. The tobacco crop itself in the USA is valued at $3 billion a year. Advertising expenditures in the USA exceed $6 billion a year. Fees for lawyers and lobbyists are in the multimillion dollar range. (3) The tobacco industry provides about $13 billion to federal, state, and local governments in tax revenue. Cigarettes are the world’s most heavily taxed consumer product! In the USA, the tax is 8 1.5 cents a pack (20 cigarettes), but in 20 other industrialized countries the taxes are even higher, sometimes 5 times higher. (4) Tobacco reduces the expenditures on Medicare and Social Security as a result of the premature deaths of smoking victims. If every cigarette smoker quit today, there would be a crisis for Social Security and all pension plans that incorporate actuarial assumptions about millions of smokers dying before they can receive benefits they otherwise would collect. (5) Tobacco is beneficial to the USA’s balance of trade. (The tobacco industry, of course, is pushing cigarette sales in overseas markets to help make up for the loss of customers at home.) (6) Because the tobacco companies have plenty of money, they are beginning to use it more to support some research endeavors unrelated to tobacco and also various charities. (7) Smoking is banned in more and more sites in the USA including, most recently, prisons. The peer pressure to smoke is not as great as in years past.
(8) Some stores have discontinued selling tobacco products (Target for example). (9) New regulations on tobacco. What are they? (a) declare nicotine an addictive drug, giving the Food and Drug Administration authority to control its sale and distribution; (b) require all tobacco advertising in magazines read by a significant number of teenagers to be in black and white and text only; (c) ban cigarette brand name sponsorship of sporting events, teams, and race cars, although corporate sponsorship could continue; (d) bar brand names on products such as hats and T-shirts; (e) prohibit single-cigarette sales, “kiddie packs,” and other gimmicks; (f) require tobacco sales to occur in face-toface transactions with photo identification showing proof of age for all sales unless they are by mail or from self-service displays in places where only adults are allowed; (g) require tobacco billboards to be in black and white and text only, and ban them within 1,000 feet of schools and playgrounds; and (h) bar cigarette vending machines from places where minors have access. Will they work? Who knows? They will probably have little effect on the 46 million present cigarette smokers in the USA. But 3,000 teenagers take up smoking in the USA every day! It’s these 1,095,OOO new teenage smokers each year in the USA to whom these regulations are directed. It is important that tobacco be ruled an addictive substance and controlled by the FDA. Here’s why. The U.S. Supreme Court in May 1996 ruled that talk about a product, even one considered a vice, cannot be banned if the product is legal. The actual case occurred in 1956 when Rhode Island banned advertising on liquor prices. It took 40 years but the Supreme Court ruled that unconstitutional. The same would presumably occur with tobacco if it was not declared an addictive drug. Cigarette smoking is the number 1 preventable cause of death in the USA. Humans were not made to smoke, chimneys were.
William Clifford Roberts, MD Editor in Chief Baylor University Medical Center Dallas, Texas 75246
FROM THE EDITOR
1085
01996 by Excerpta Medico, All rights reserved.
Inc.
(6) The direct costs of cigarette smoking in the USA are estimated to be $50 billion a year. (7) Cigarette butts litter our land. Of the nearly one-half trillion cigarettes smoked a year in the USA, 97% of them have cellulase acetate filters which have an after-smoke life of 5 to 7 years. These filter-tip cigarette butts now languish in every conceivable crammy, from cemetery statuary to bellies of whales. Several trillion are out there at any given time-in landfills, park trails, storm sewers, beaches, etc. (8) Cigarettes are probably the most common cause of residential fires. (9) Cigarette smokers have more nonfatal illnesses than do nonsmokers, and lost productivity is greater among smokers than nonsmokers. (10) Federal subsidies to tobacco farmers increase the taxes to nonsmokers as well as smokers. (11) The federal, state, and local governments subsidize the costs of treatment of illnesses produced by tobacco. (12) Cigarette smoking is a major cause of miscarriages and underweight newborns. (13) Tobacco makes for untruthfulness in both advertisers and politicians. This summer Philip Morris Europe ran full-page newspaper ads in major cities in Europe urging nonsmokers to be tolerant of smokers. The ads indicated that second-hand smoke was less dangerous than drinking 1 or 2 glasses of milk (1.62), or eating 1 biscuit (1.49), or drinking chlorinated water (1.38), or eating pepper (1.30). Second-hand smoke had a relative risk of 1.19. The tobacco industry has been a major contributor to congressional candidates and to both the Democratic and Republican parties. Dole, who had a terrible time ending his cigarette smoking habit 50 years ago, has recently stated, “There is a mixed view among scientists and doctors whether it is addictive or not. I’m not certain whether it’s addictive. It is to some people.” And this man is running for the presidency of the USA. Tobacco money alters the thought processes. (14) Cigar smoking is also increasing rapidly. About $1 billion worth of cigars were sold in the USA in 1995,98% to men and 2% to women. About 10 million persons in the USA smoke cigars, up from 100,000 a decade ago. It has become fashionable since the glossy, celebrity-studded Cigar Ajicionado magazine appeared in 1992. (15) Smokeless or spit tobacco sales also are increasing rapidly. About 40% of the nearly 700 major league baseball players use it. In Texas, 26% of 0002-9 149/96/Q 15.00 PII SOOO2-9 149(96)0066 l-3
eighth graders have chewed spit tobacco. Nationally, about 1 million adolescents, including nearly 20% of all high school boys, use spit tobacco according to the U.S. Department of Health and Human Services, and chewing tobacco increases the frequency of cancers of the mouth and pharynx about 6 times compared to nonusers. Although the downside for tobacco is much greater than the upside, here are some positives: (1) The tobacco industry provides jobs for about 700,000 Americans in farming, manufacturing, and retailing. The numbers of lawyers and lobbyists supported by the industry is unclear but obviously large. There are 124,000 tobacco farms in the USA and they produce 1.6 billion pounds of tobacco, a 25% reduction compared to 1975. A total of 674 million acres grew tobacco in the USA in 1995. Farmers in North Carolina gross about $3,400 per acre of tobacco compared with $210 per acre of soybeans and $700 per acre of cotton. (2) Tobacco provides about $21 billion a year in revenue from its agriculture and manufacturing. The tobacco crop itself in the USA is valued at $3 billion a year. Advertising expenditures in the USA exceed $6 billion a year. Fees for lawyers and lobbyists are in the multimillion dollar range. (3) The tobacco industry provides about $13 billion to federal, state, and local governments in tax revenue. Cigarettes are the world’s most heavily taxed consumer product! In the USA, the tax is 8 1.5 cents a pack (20 cigarettes), but in 20 other industrialized countries the taxes are even higher, sometimes 5 times higher. (4) Tobacco reduces the expenditures on Medicare and Social Security as a result of the premature deaths of smoking victims. If every cigarette smoker quit today, there would be a crisis for Social Security and all pension plans that incorporate actuarial assumptions about millions of smokers dying before they can receive benefits they otherwise would collect. (5) Tobacco is beneficial to the USA’s balance of trade. (The tobacco industry, of course, is pushing cigarette sales in overseas markets to help make up for the loss of customers at home.) (6) Because the tobacco companies have plenty of money, they are beginning to use it more to support some research endeavors unrelated to tobacco and also various charities. (7) Smoking is banned in more and more sites in the USA including, most recently, prisons. The peer pressure to smoke is not as great as in years past.
(8) Some stores have discontinued selling tobacco products (Target for example). (9) New regulations on tobacco. What are they? (a) declare nicotine an addictive drug, giving the Food and Drug Administration authority to control its sale and distribution; (b) require all tobacco advertising in magazines read by a significant number of teenagers to be in black and white and text only; (c) ban cigarette brand name sponsorship of sporting events, teams, and race cars, although corporate sponsorship could continue; (d) bar brand names on products such as hats and T-shirts; (e) prohibit single-cigarette sales, “kiddie packs,” and other gimmicks; (f) require tobacco sales to occur in face-toface transactions with photo identification showing proof of age for all sales unless they are by mail or from self-service displays in places where only adults are allowed; (g) require tobacco billboards to be in black and white and text only, and ban them within 1,000 feet of schools and playgrounds; and (h) bar cigarette vending machines from places where minors have access. Will they work? Who knows? They will probably have little effect on the 46 million present cigarette smokers in the USA. But 3,000 teenagers take up smoking in the USA every day! It’s these 1,095,OOO new teenage smokers each year in the USA to whom these regulations are directed. It is important that tobacco be ruled an addictive substance and controlled by the FDA. Here’s why. The U.S. Supreme Court in May 1996 ruled that talk about a product, even one considered a vice, cannot be banned if the product is legal. The actual case occurred in 1956 when Rhode Island banned advertising on liquor prices. It took 40 years but the Supreme Court ruled that unconstitutional. The same would presumably occur with tobacco if it was not declared an addictive drug. Cigarette smoking is the number 1 preventable cause of death in the USA. Humans were not made to smoke, chimneys were.
William Clifford Roberts, MD Editor in Chief Baylor University Medical Center Dallas, Texas 75246
FROM THE EDITOR
1085