Smoking, cancer, heart disease, and the oral-systemic link: Where we are with research

Author: Richard H. Nagelberg, DDS

Dr. Richard Nagelberg examines the links between smoking, lung cancer, and heart disease, as well as the types of research and studies that established the strength of their credibility over time. Likewise, he considers where we are today with the link between oral health and overall health as he evaluates the current state of oral-systemic research.

Perhaps the most universally accepted facts in health care are the detrimental effects of tobacco, particularly cigarette smoking, for nearly every part of the body. It is safe to say that no one disputes the direct causal links between cigarette smoking, lung cancer, and heart disease. Listed below are only two statements regarding the state of this knowledge.

✔️The scientific evidence is incontrovertible: inhaling tobacco smoke, particularly from cigarettes, is deadly. Since the first Surgeon General’s Report in 1964, evidence has linked smoking to diseases of nearly all organs of the body. ( June 21, 2018)

✔️Smoking is by far the biggest preventable cause of cancer. Thanks to years of research, the links between smoking and cancer are now very clear. Smoking accounts for more than 1 in 4 UK cancer deaths, and 3 in 20 cancer cases. (

There is a boatload of research supporting this link. However, there has never been one large-scale double-blinded interventional study demonstrating that smoking causes lung cancer and heart disease. The fact that this link exists is based on the cumulative results of numerous smaller studies over a long period of time.

The reasons are the same for the lack of large-scale interventional studies investigating the link between smoking, lung cancer, and heart disease, among others, as well as that between the mouth and the body. These studies are too costly and full of variables that are difficult to control in a study spanning 20 years or more. It is the cumulative results of research that will demonstrate the strength of the link between oral health and overall health, rather than one definitive piece of research.

While the risks of smoking were being investigated, there were naysayers who doubted the emerging results. In fact, there was substantial skepticism within the medical community about whether the apparent increase in cancer deaths was real or the result of better diagnosis. The study that is credited with the beginning of the stop-smoking movement was published in 1954 by Hammond and Horn. Their paper ended with: “[we are of the opinion that the associations found between regular cigarette smoking and death rates from diseases of the coronary arteries and between regular cigarette smoking and death rates from lung cancer reflect cause and effect relationships.]” (1)

At present, we are in the middle of the oral-systemic research, waiting until a sufficient body of research provides incontrovertible evidence one way or the other.

1. Hammond EC, Horn D, The relationship between human smoking habits and death rates: a follow-up study of 187,766 men. J Am Med Assoc. 1954;155(15):1316-1328.

We Now Know Exactly How Many DNA Mutations Smoking Causes

Every 50 cigarettes you smoke gives you one extra DNA mutation per lung cell.


Source: The Verge
Author: James Vincent

A common tactic for people trying to give up smoking is to quantify exactly how much damage — financial or physical — each cigarette or pack of cigarette does. How much does smoking cost you per month, for example, or how much shorter is your life going to be for each drag you take? Well, a new study into the dangers of smoking now lets us measure this damage right down to the number of mutations in your DNA.

A research team led by scientists from Los Alamos National Laboratory compared tissue samples from 1,063 non-smokers and 2,490 smokers, examining each individual’s DNA to look for mutations. They found that for every 50 cigarettes smoked, there is one extra DNA mutation for each cell in the lungs. Over the course of a year, this means that someone who smokes a pack a day (20 cigarettes) has 150 extra mutations per cell in the lung, 97 per larynx cell, 23 per mouth cell, 18 per bladder cell, and six per liver cell.

These changes to the cells aren’t dangerous in themselves, but each one has the potential to turn into a cancerous growth. “Smoking is like playing Russian roulette: the more you play, the higher the chance the mutations will hit the right genes and you will develop cancer,” Ludmil Alexandrov, the co-lead author of the study, told the New Scientist. “However, there will always be people who smoke a lot but the mutations do not hit the right genes.”

The reason for all these extra mutations is found in tobacco smoke — a substance that contains some 7,000 different chemicals, over 70 of which are known to cause cancer. How exactly different types of cell mutations lead to cancer is less clear, and the team from Los Alamos are hoping next to drill down further into this line of research and find out the probabilities that any individual DNA mutation will turn into cancer.

The good news for smokers, though, is that it’s never too late to quit. Although smoking causes regular DNA mutations, as soon as people give up cigarettes, the mutations stop too. One UK study from 2004 found that those who quit smoking at age 30 nearly eliminate the risk of dying prematurely, while those who quit at 50 halve it. For people trying to give up, those are certainly some more comforting odds.


This news story was resourced by the Oral Cancer Foundation, and vetted for appropriateness and accuracy.

2016-11-04T09:43:28-07:00November, 2016|Oral Cancer News|

Depressed Head and Neck Cancer Patients Have Lower Survival and Higher Recurrence Risk

Author: Kathy Boltz, PhD

Depression is a significant predictor of 5-year survival and recurrence in patients with head and neck cancer, according to a new study published in Pyschosomatic Medicine (doi: 10.1097/PSY.0000000000000256). These findings represent one of the largest studies to report on the impact of depression on cancer survival.

Although depression can have obvious detrimental effects on a person’s quality of life, its impact on cancer patients is more apparent, explained lead author Eileen Shinn, PhD, assistant professor of Behavioral Science at The University of Texas MD Anderson Cancer Center, in Houston. Increasing evidence shows modest associations between elevated symptoms of depression and greater risk for mortality among patients with lung, breast, ovarian, and kidney cancers.

The research team sought to clarify the influence of depression on survival, focusing their analysis on a single cancer type. By limiting the sample set and adjusting for factors known to affect outcome, such as age, tumor size, and previous chemotherapy, they were able to uncover a more profound impact of depression.

The researchers followed 130 patients at MD Anderson with newly diagnosed oropharyngeal squamous cell carcinoma (OSCC), a type of cancer in which the tumor originates at the back of the throat and base of the tongue.

At the beginning of their radiation therapy, Patients completed a validated questionnaire at the beginning of their radiation therapy to identify symptoms of clinical depression. Researchers monitored the participants, all of whom completed treatment, until their last clinic visit or death, a median period of 5 years.

“The results of this study were quite intriguing, showing depression was a significant factor predicting survival at 5 years, even after controlling for commonly accepted prognostic factors,” said senior author Adam Garden, MD, professor, Radiation Oncology. Furthermore, depression was the only factor shown to have a significant impact on survival.

Patients who scored as depressed on the questionnaire were 3.5 times less likely to have survived to the 5-year interval compared with those who did not score as depressed. The degree of depression was also found to be significant, as every unit increase on this scale indicated a 10% higher risk for reduced survival.

The results were replicated with a different psychological health survey and were not influenced by how soon following diagnosis the depression assessment was done.

OSCC is diagnosed in 10 000 to 15 000 Americans each year. Major risk factors known to be associated with OSCC include smoking and tobacco use, alcohol consumption, and human papillomavirus (HPV) infection. Incidence of OSCC has doubled in the last 20 years due to increasing HPV infection rates, noted Shinn.

Neither alcohol nor tobacco use, also surveyed in this group, had a significant impact on survival. HPV infection status, when available, also did not appear correlated.

Despite a high cure rate, normally 60% to 80%, recurrence rate of disease is unusually high in these patients (approximately 30%). The researchers also investigated a potential link between depression and disease recurrence.

“When we controlled for all variables, depression was linked with a nearly 4 times higher risk of recurrence,” said Shinn. In addition, never smokers had a 73% lower chance of recurrence, compared with current smokers. Those were the only two factors associated with cancer recurrence.

This news story was resourced by the Oral Cancer Foundation, and vetted for appropriateness and accuracy.

2015-12-30T18:15:58-07:00December, 2015|Oral Cancer News|

SA Developed Melanoma Drug Now Seen Effective in Fighting Lung Cancer

Author: News Radio 1200 WOAI Staff


1229_1264794779Keytruda, a cancer drug developed largely at San Antonio’s START Center, has already proven to be effective in treating advanced melanoma to the point that it is the major part of former President Jimmy Carter’s treatment.  Now, News Radio 1200 WOAI reports Keytruda has been given ‘fast track’ approval by the FDA for use in treating lung cancer, the leading cause of cancer deaths in the United States.

Dr. Amita Patnaik, a researcher and oncologist at START who helped develop the drug, says the impact of Keytruda on lung cancer patients has been amazing.

“Close to 40% of those patients will receive a response,” she said.  “And of those patients who receive a response, about 80% of those patients will have a long term response.”

The life saving potential of Keytruda in fighting non small cell lung tumors is obvious.  An estimated 221,000 Americans are diagnosed with lung cancer each year, and 158,000 die of the disease annually.

Dr. Patnaik says Keytruda is becoming the most successful of what are known as ‘targeted therapies,’ drugs which trigger the body to take action to fight the cancer.  She says both melanoma and lung cancer work essentially the same way to undermine the body’s defenses.

“The commonality between melanoma and lung cancer is there is a supressive effect of the cancer on the immune system.”

She says Keytruda essentially overrides that supressive effect, prompting the body to restart its natural immune defenses and fight the cancer.

That means the treatment takes place without chemotherapy.

“Thus avoiding some of the toxicities associated with chemotherapy including hair loss, fatigue, a drop in counts, nausea and vomiting, and the spectrum of negative side effects you get with chemo.”

Dr. Patnaik says several other types of cancers work the same way, ‘turning off’ the body’s natural immune systems, and she says there are indications that Keytruda will work for those cancers as well.

“Keytruda is showing activity in about ten or more other cancers, including liver cancer, head and neck cancer, and in a rare form of breast cancer.”

The FDA granted Keytruda ‘breakthrough therapy designation’ because of demonstrated preliminary clinical evidence that the drug may ‘offer a substantial improvement over available therapies.’

*This news story was resourced by the Oral Cancer Foundation, and vetted for appropriateness and accuracy.

2015-10-06T11:11:27-07:00October, 2015|Oral Cancer News|

Current tobacco reports show 50 years of progress

Author: Jef Akst


In 1964, the U.S. Surgeon General released the first report on the effect that cigarettes and other forms of tobacco have on human health, presenting strong evidence of the link between smoking and lung cancer, among other adverse consequences. During the last 50 years, significant progress has been made in terms of understanding how smoking causes various diseases and how to treat them, and educational campaigns have contributed to a drop in smoking rates from 42 percent to 18 percent of US adults. Nevertheless, more than 480,000 Americans still die from tobacco-related diseases each year, and additional health consequences continue to be linked to smoking.

“Between now and mid-century, nearly 18 million Americans will die preventable avoidable deaths if we don’t do something to alter that trajectory,” Mitchell Zeller, the director of the Center for Tobacco Products of the Food and Drug Administration (FDA), said during a press conference held today here at the American Association for Cancer Research (AACR) meeting in San Diego, California.

To this end, the AACR released a compilation of peer-reviewed research and review articles, published across seven of its journals, covering basic scientific research on the molecular mechanisms of tobacco carcinogenesis, tools for the diagnosis of lung cancer and other tobacco-related diseases, and the impact of the original Surgeon General’s report on tobacco control. Ellen Gritz from the University of Texas MD Anderson Cancer Center helped put the new report together. “Together, these reports add to the broad reach of important tobacco-related research at the forefront of cancer research and policy, and shine a light on both the challenges and opportunities ahead,” Gritz said.

“[The report] drives home the need for action, citing this large burden of smoking-attributed premature death and morbidity, . . . [and] ends with a call for more action,” added Jonathan Samet, a pulmonary physician and epidemiologist at the University of Southern California.

In addition to the special report, AACR today hosted speakers from the FDA, the National Cancer Institute (NCI), and other groups to discuss the way forward for tobacco-related research, education, and regulation. “Clearly, if you think about other domains of health and risk, if a consumer product were to be introduced onto the market which caused a few dozen deaths it would easily make national news, and produce a public outrage, 60 Minutes reports, headlines,” said Robert Croyle, who directs the Division of Cancer Control and Population Sciences at NCI. “But we’re in a bizarre situation where we have a legal product on the market that’s responsible for about half a million deaths [each year].”

Zeller pointed to several recent FDA initiatives aimed at reducing tobacco-related deaths, including education campaigns targeting young people. Like the other panelists, Zeller praised the progress that has been made, noting the “remarkable denormalization of tobacco use” since a time when his parents would put out bowls of loose cigarettes at parties, and when he and his classmates would make ashtrays in arts and crafts class. But he emphasized that the fight is far from over. “As we pause to acknowledge all of that progress, we also have to take stock of the work that lies ahead of us,” Zeller said.

 *This news story was resourced by the Oral Cancer Foundation, and vetted for appropriateness and accuracy.

Nearly 6 Percent Of Lung Cancer Tissue Samples From Non-Smokers Show Signs That HPV May Have Triggered The Tumors

Article Date: 12 Apr 2013 – 1:00 PDT
Source: Medical News Today


A common virus known to cause cervical and head and neck cancers may also trigger some cases of lung cancer, according to new research presented by Fox Chase Cancer Center at the AACR Annual Meeting 2013.

Examining tissue samples from lung cancer patients, the researchers found that nearly 6% showed signs they may have been driven by a strain of human papillomavirus (HPV) known to cause cancer.

If HPV indeed plays a role in lung cancer in some patients, the next step is to better understand those tumors so they can be treated more effectively. “The ultimate goal,” says study author Ranee Mehra, MD, attending physician in medical oncology at Fox Chase, “is to determine if we can target our therapies to the specific characteristics of these tumors.”

Studies from Asia have shown that lung tumors are frequently infected with HPV. The pattern makes sense, explains Mehra – the lungs are located very near the head and neck, which are known to be at risk of tumors upon exposure to some strains of HPV.

To investigate, she and her colleagues examined 36 tissue samples from people diagnosed with non-small cell lung cancer who had never smoked, part of the Fox Chase Cancer Center Biosample Repository. The reason they chose non-smokers, Mehra explains, is that smoking is a major cause of lung cancer – but in non-smokers, the explanation is often less obvious.

The researchers found that 4 out of 36 samples had signs of infection from two strains of HPV known to cause cancer, 16 and 18. Looking more closely at the two samples infected by HPV 16, Mehra and her team saw signs the virus had integrated into the tumor’s DNA – which is even more suggestive that the infection caused the tumor. They presented their findings at the annual meeting of the American Association for Cancer Research.

Although this suggests that HPV drives lung cancer in less than 6% of non-smoker patients, making it a relatively rare occurrence, lung cancer is very common, Mehra notes – killing more than 1 million people every year. Approximately 10 percent of cases occur in non-smokers. “Given how many patients develop lung cancer, if even a small percentage of those tumors stem from HPV, that ends up being a large number of patients,” she says.

It’s not clear how HPV reaches the lung, she says; patients may simply breathe it in. And just because these patients have evidence of an HPV infection that does not necessarily mean the infection caused their tumors, Mehra cautions. “It could simply be a coincidence that they had both lung cancer and HPV,” she notes. “But the presence of both simultaneously, and the integration of the virus into the tumor’s DNA, fuels the hypothesis that they are related.”

Although the majority of people are exposed to HPV, these results are largely not cause for concern, assures Mehra. “In my practice, I treat many people with head and neck cancers who are infected with HPV. Some fear that they are ‘contagious’, and could somehow pass the cancer onto their families,” she says. “Mostly, I reassure them – even though most people have been exposed to HPV, it’s rare for someone to develop cancer as a result.”

And people who have lung cancer but never smoked need not rush to their doctors to determine if they also have HPV, since doctors don’t know yet if they should treat these tumors differently, or if the presence of the virus has any impact on prognosis. “These results are very preliminary and not a reason to run to your doctor to find out if you are infected, or panic if you are,” she states.

As such, researchers need to investigate what factors drive some people to develop cancer after exposure to HPV, so they can better treat those types of tumors, says Mehra. “Hopefully, this research will fuel some discussion or further studies,” she notes. “What we need is a better understanding of why does cancer develop in some patients and not in others.”


* This news story was resourced by the Oral Cancer Foundation, and vetted for appropriateness and accuracy.


HPV linked to certain lung cancers; is oral sex to blame?

Author: Jonathan Weiss

By now, it’s a given that smoking causes lung cancer. The American Lung Association reports that 80 to 90 percent of all cases of lung cancer are smoking-related. The remaining 10 to 20 percent, though, has been more of a mystery — until now. A new line of research has implicated thye sexually transmitted infection human papillomavirus, or HPV, in lung cancers that were found in non-smokers.

HPV is the leading cause of all cervical cancer cases in the world. It’s a well-known disease that’s gottena lot of press in recent years; an effective vaccine was recently developed that can prevent the viral infection and subsequent cervical cancer development. Whether or not the vaccine should be required for teenage girls has become a hot-button political issue.

Adding fuel to the fire, a research team from the Fox Chase Cancer Center recently looked at tissue samples from lung cancer patients who had no history of smoking and saw that close to 6 percent showed evidence that they had been driven by HPV infection. Four out of 36 lung samples had signs of infection from two strains of HPV known to cause cancer. Looking more closely at the two samples infected by one strain of HPV, Dr. Ranee Mehra, MD, attending physician in medical oncology at Fox Chase and her team saw signs the virus had integrated into the tumor’s DNA — which is even more suggestive that the infection had caused the tumor in the first place.

Dr. Mehra noted that non-smoking related lung cancers kill 100,000 people a year, so 6 percent of those cases having a known and preventable cause could save lives.
It is not known how the virus could travel down to the lungs. However, Dr. Mehra notes that there is highly convincing data indicating that HPV had directly caused the tumors rather than the person just having cancer and an unrelated HPV infection. “The presence of both simultaneously, and the integration of the virus into the tumor’s DNA, fuels the hypothesis that they are related,” stated Dr. Mehra.

HPV is widely known to cause a range of cancers, including cervixal, throat, head, and neck cancer. The virus has also been implicated in a drastic rise in the number of throat and oral cancers related to oral sex. There was no comment from the research article indicating that oral sex may be associated with the risk of HPV related lung cancer.

Mount Sinai Hospital, in New York City, has an interesting infographic that explains the risk of cancer from oral sex. The current research was presened at the American Association for Cancer Research Annual Meeting 2013 on Wednesday, April 10.

$27 Million Verdict Against R.J. Reynolds for Cancer Victim


A Florida man was awarded $27 million in compensatory and punitive damages against tobacco company R.J.

Reynolds last month after doctors told him that 44 years of smoking caused his lung cancer.

  • Plaintiff had lung removed due to cigarette addiction
  • Thousands of lawsuits pending against big tobacco companies
  • First payouts by big tobacco expected to be made today

Addictive Habits

Emmon Smith, a minister in Mariana, Florida, started smoking when he was a 13-year-old boy in 1944. Despite numerous attempts to quit, he couldn’t kick the addictive habit until he was forced to in 1992 by a cancer diagnosis and subsequent removal of one of his lungs.

Smith sued tobacco company R.J. Reynolds in 2008, and in March of this year a jury awarded him $10 million in compensatory damages and $20 million in punitive damages; however, they found the plaintiff 30 percent at fault so he will receive only $7 million of the compensatory award, for a total of $27 million.

Smith’s suit was led by attorney Richard Diaz  as well as a team of attorneys from Crabtree & Associates and Ratzan Law Group.

The Smith case was just one of more than 8,000 lawsuits against tobacco companies stemming from a 1990s class action known as the Engle case. In 2000, a Florida jury awarded class members a stunning $145 billion in punitive damages, finding that cigarettes are dangerous, addictive, carcinogenic, and most importantly, that tobacco companies knew all this and lied about it. “They found that tobacco was a defective product, that the companies were negligent, guilty of fraud, caused various diseases including lung cancer, were involved in conspiracy to defraud the American people and on and on,” says Stuart Ratzan of the Ratzan Law Group.

Justice at Last

Among the diseases found to be caused by smoking were aortic aneurysm, bladder cancer, cerebral vascular disease, cervical cancer, chronic obstructive pulmonary disease, coronary heart disease, esophageal cancer, kidney cancer, laryngeal cancer, lung cancer, complications of pregnancy, oral cavity/tongue cancer, pancreatic cancer, peripheral vascular disease, pharyngeal cancer and stomach cancer.

However, the Florida Supreme Court overturned the $145 billion punitive part of the Engle award in 2006. “The Supreme Court ruled that individual plaintiffs would have to file suit for damages individually,” Ratzan explains. “Punitive damages had to be reversed and each member of the class had to file a case to prove how much damages they were entitled to.”

Today thousands of suits are still pending. “Plaintiffs have to prove they were addicted to cigarettes, that cigarettes caused them lung cancer, or pulmonary disease, or one of the other diseases,” says Ratzan.

Earlier this month the United States Supreme Court declined to hear an appeal filed by R.J. Reynolds over a $28.3 million award, and today the company is expected to finally pay out the damages it owes in the first two Engle progeny cases, with thousands left to go. “Maybe one day the class will get its justice,” Ratzan says.

Declines in Smoking and Lung Cancer Mortality in the U.S.: 1975–2000

Source: Oxford Journals

Although changing smoking behaviors have had a major impact on lung cancer mortality in the U.S., the numbers of lung cancer deaths averted are only a small fraction of deaths that could have been avoided had all smoking ceased following the 1964 Surgeon General’s Report. Further efforts to control tobacco use are needed to decrease the impact of the disease, according to a study published March 14 in the Journal of the National Cancer Institute.

The restrictions on smoking in public places, escalations in cigarette taxes, reduced access to cigarettes, and an increased public awareness on the health issues related to smoking have all helped steadily decrease the number of smokers in the U.S. since the mid 1950’s; however, little measurable information exists in regards to the amount lung cancer deaths have diminished in association with the decline in smoking. In order to determine the effect that reduced tobacco smoking has had on lung cancer mortality in the U.S., Suresh H. Moolgavkar, M.D., Ph.D., of the Program in Biostatistics and Biomathematics at the Fred Hutchinson Cancer Research Center in Seattle, Washington and colleagues built independent models based on cohort, case-control, or registry data and adjusted to overall mortality to estimate the number of lung cancer deaths prevented between 1975–2000. The data were distinguished by sex and birth decade (1890–1970), and the prevalence of smoking and lung cancer deaths were considered based on actual tobacco control (ATC), historical changes in smoking rates, no tobacco control (NTC), predicted smoking rates had there been no tobacco control, and complete tobacco control (CTC), which estimates the effects of what may have happened if all smoking had stopped in 1965.

The researchers found that between 1975 and 2000, there were 2,067,775 lung cancer deaths among men and 1,051,978 lung cancer deaths among women. The models predicted that 550,000 lung cancer deaths among men and 240,000 among women were averted by tobacco control efforts. “The results of this article show the dramatic impact of the reduction in smoking associated with tobacco control efforts in the second half of the 20th century on lung cancer mortality during the period 1975–2000,” the researchers write. The researchers note the limitations of the study, namely that the numbers don’t reflect the effects of non-cigarette forms of tobacco use. Despite this, they feel that, “continued implementation of evidence-based tobacco control policies, programs, and services remains the most promising approach to reducing the burden of lung cancer.”

In an accompanying editorial, Thomas J. Glynn, Ph.D., Director of Cancer Science and Trends and International Cancer Control at the American Cancer Society, writes that we may be dawning on a new era for tobacco control, citing the Affordable Care Act and the Family Smoking Prevention and Tobacco Control Act as major components of the avoidance of lung cancer deaths. “Tobacco taxes have been raised substantially at the federal, state, and local level,” he writes. Glynn also notes that smoke-free laws and regulations have protected millions against secondhand smoke at workplaces, public spaces, and even at home, not to mention new treatments developed to combat the smoking habit. Still, he feels that the tobacco industry is aggressive in combatting the tobacco control laws, saying that many state governments have lowered their support for tobacco control. However, he writes that, “We should use all of the tools at our disposal to rein in the rogue tobacco industry, and assiduously apply all of our political, research, advocacy, public health, and clinical skills to end tobacco’s century of death, disease, and disability.”

This news story was resourced by the Oral Cancer Foundation, and vetted for appropriateness and accuracy.

The 795 Thousand and Ending a Century of Tobacco

Source: Oxford Journals

Tonight, a grandfather will read his grandson a soothing bedtime story. Yesterday, a mother saw her son perform a brilliant violin solo. Tomorrow, a grandfather will see his granddaughter complete the first unassisted triple play in their community’s t-ball league history.

What do these vignettes have in common? They represent just three of the 795 851 people––the 795 thousand––whose premature deaths from lung cancer were averted in the United States through aggressive tobacco control policies and interventions between 1975 and 2000, as determined by a series of consortium-based sophisticated modeling techniques and reported by Moolgavkar et al. (1) in this issue of the Journal.

Sometimes, we become inured to the sheer number of deaths caused by tobacco—for example, a predicted 1 billion tobacco-caused deaths this century, 100 million people killed by tobacco in the 20th century, 6 million deaths per year globally, 443 000 deaths per year in the United States, etc. But, despite these enormous, and even numbing, numbers, we need to remember that every one of these 1 billion, 100 million, 6 million, or 443 000, was a father, mother, brother, sister, son, or daughter who, if tobacco had not intervened, would have enjoyed, and shared, a longer, healthier, and more fulfilling life.

How did this happen? How did we allow tobacco, over the past 100 years, to kill and cause disease with such abandon? And, more important, how have we begun to turn the tide against the tobacco tsunami and how can we continue to learn from our experience? To best address these questions, we need to take a step back and briefly put tobacco in historical context.

In his Booker Prize–winning novel, The Sense of an Ending, Julian Barnes’ central character defines history as “… that certainty produced at the point where the imperfections of memory meet the inadequacies of documentation” (2). Fortunately, regarding tobacco, our often inadequate memories are offset by extensive documentation, provided––ironically enough––by the tobacco industry itself (3) and by superb historians (4,5). They remind us that tobacco has long had a revered place in America—witness the tobacco leaves blended into the columns of the US Capitol, our cinema industry’s affection for cigarettes, and the nearly 100 years that have passed since manufactured cigarettes began to take their deadly toll in this country.

This reverence for tobacco has only begun to change in the last half century with the publication of the UK Report of the Royal College of Physicians in 1962 (6) and the US Surgeon General’s Report on Tobacco and Health in 1964 (7). Both of these landmark reports concluded, for the first time and with solid scientific evidence, that cigarette smoking is a cause of lung cancer and other diseases. Continuing in this historical vein, and focusing specifically on the 1975–2000 period, Moolgavkar et al. (1) provide us with three scenarios, each predicting the number of lung cancer deaths in the US during that time if: 1) we had done nothing about tobacco use—3 908 048 lung cancer deaths; 2) we did what we have done about tobacco use—3 119 753 lung cancer deaths; and 3) tobacco control efforts had been completely effective—1 397 540 lung cancer deaths.

These data were arrived at through a painstaking collaborative process that should serve as a model for future analyses in public health more broadly. They are tantalizing—especially in the “what could have been” scenario—but, more important, they give us a clear view to what should be the future of tobacco control in the United States. We have known for some time what “works” in tobacco control, that is, a science-based comprehensive approach (8). That approach includes broad-stroke issues such as the promotion of smoke-free environments, increased tobacco taxes, wide availability of tobacco dependence treatment, and aggressive public information campaigns. This comprehensive approach works best if, additionally, more specific interventions are included, such as litigation against the tobacco industry, omitting tobacco protectionism from trade agreements, or, as reported by Primack et al. (9) in this issue of the Journal, limiting the exposure of youth to tobacco imagery in films, which the authors show to be an important contributor to adolescent smoking behaviors.

Yet, despite knowing what “works” and having the science to back that up, we have often lacked the political and financial will to do what is necessary to take full advantage of our knowledge and put an end to the scourge of tobacco in our society. Although we have been quite successful in reducing tobacco use—from prevalence rates of more than 40% in the early 1960s to slightly less than 20% today—and in saving lives, for example, the 795 thousand—Moolgavkar et al. (1) nevertheless show us that, had we been more aggressive, an additional 2.5 million lung cancer deaths could have been avoided.

The good news is that we have become more aggressive in our tobacco control efforts and, there, again, Moolgavkar et al. (1) provide data to back up that contention. Of the 795 811 lung cancer deaths averted mostly because of tobacco control actions between 1975 and 2000, 70 218 of those deaths were in the year 2000 alone, suggesting an accelerated protective effect.

Also, since 2000, the pace of US tobacco control has accelerated. For example, the Affordable Care Act has opened up tobacco dependence treatment to millions more of the 70% of smokers who wish to quit. The Family Smoking Prevention and Tobacco Control Act has given the US Food and Drug Administration authority to regulate tobacco products and protect both youth and adults from their use. The United States, with the planned addition of graphic warning labels on cigarette packs later this year, has fully embraced, if not ratified, the provisions of the world’s first global public health treaty, the Framework Convention on Tobacco Control. Genetic research on the causes and maintenance of nicotine dependence has had a number of breakthroughs, which may translate to more effective treatment. Tobacco taxes have been raised substantially at the federal, state, and local level. Smoke-free laws and regulations protect millions more smokers and nonsmokers against deadly secondhand smoke at workplaces, in public spaces, and, increasingly, at home. Last, new medications for, and approaches to, tobacco dependence treatment have been developed.

These developments suggest that we may be entering a new era for tobacco control. This era is not without its dangers and potential pitfalls. The tobacco industry remains an aggressive purveyor of cigarettes and other tobacco products within the United States and globally (10); many state governments have reduced their support for tobacco control (11); smoking prevalence rates have stalled at around 20% for the past several years (12); and there remain disagreements within the tobacco control community regarding harm reduction issues (13). Nevertheless, this era has the potential to reinvigorate and expand tobacco control, and, in so doing, bring us closer to the deaths-averted scenario drawn by Moolgavkar et al.

Incidentally, it was my father who, after decades of smoking, died of lung cancer before he was able to see his granddaughter complete that triple play. He was not one of the 795 thousand, but seeing it would have brought tears to his eyes, and thinking of him, and what he missed due to tobacco, brings tears to mine. The data that Moolgavkar et al. (1) provide should, however, give us greater resolve to wipe our tears away, put science to work, and see to it that the 795 thousand grows to many millions of lives saved in the coming decades. We should use all of the tools at our disposal to rein in the rogue tobacco industry, and assiduously apply all of our political, research, advocacy, public health, and clinical skills to end tobacco’s century of death, disease, and disability.

This news story was resourced by the Oral Cancer Foundation, and vetted for appropriateness and accuracy.

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