Source: San Francisco Chronicle

For all the debate and pain and money expended on our ongoing “drug war’ – which is too much a failing, endless one – the worst drug of all is too often unmentioned, but kills and maims more than the rest of them put together. And it’s legal.

Tobacco abuse is projected to cause a billion premature deaths in this century; To put it another way, until and unless we have a nuclear war, the tobacco industry will continue killing more people than any other man-made cause. This true in just about any region, but here in California, there are nearly four million smokers, and as the American Lung Association reminds us, “Tobacco-related illness remains the number one preventable cause of death in the state, responsible for more than 36,000 deaths each year – that’s more people lost to tobacco than alcohol, HIV/AIDS, car crashes, illegal drugs, murders, and suicides combined.” The national toll is about 438,000 deaths per year. One of them was my dad, but I hated tobacco long before it claimed him.

In any event, the annual UCSF Center for Tobacco Control Research and Education symposium again keyed off on the “billion lives” estimate and showcased ongoing efforts to apply research to decreasing that daunting figure. This year, American Cancer Society CEO John Seffrin. PhD said that the 12 million cigarettes smoked each minute meant an ever-increasing morbidity and mortality, despite whatever progress, with a tripling of disease and death in the developing world – “a tsunami of tumors” and other disease.

The majority of smokers start while quite young – and not coincidentally, that is where marketing of tobacco is concentrated. An illuminating talk on “The Mind of the Adolescent Smoker” by Bonnie Halpern-Felsher PhD, UCSF Professor of Pediatrics, highlighted the prevalence of denial, social norms and peer pressure, and the tobacco industry’s ongoing efforts to promote so-called “light” cigarettes and “chew” to kids – with an imperative not to try to scare young people, but to show them they can’t trust the manipulative marking approaches. Other talks regarding tobacco treatment in addiction treatment and the race-based targeted marketing and risks of menthol in tobacco were reminders of how tricky the industry can be – a timely talk, as the FDA is being urged to ban menthol altogether.

For all the good science produced, the war remains profoundly political as well. The tobacco industry goes all out to convince people that smoking isn’t all that bad, that they don’t market to young people, that secondhand smoke is not a hazard, and so on. Nobody with an educated brain believes them anymore, unless they are somehow corrupted by cash themselves. This is a battle with many fronts, and the American Lung Association issues progress reports, with grades. Seffrin noted that California was once a pioneer in tobacco control, but has slipped in some respects. Most recently, California earned an “A” for smoke-free air policies, but an “F” in funding tobacco control, including a “D” for a low cigarette tax – we rank 33rd of states in that regard. More locally, San Francisco earned an overall “B”, an improvement over a previous “D” mostly due to our comprehensive environmental tobacco smoke ordinance.

The most recent (December 2010) U.S. Surgeon General‘s report on tobacco is titled “How Tobacco Smoke Causes Disease,” with six primary conclusions:

1. There is no safe level of exposure to tobacco smoke

2. Damage from tobacco smoke is immediate.

3. Smoking longer means more damage.

4. Cigarettes are designed for addiction.

5. There is no safe cigarette.

6. The only proven strategy for reducing the risk of tobacco-related disease and death is to never smoke, and if you do smoke, to quit.

Most of this should seem obvious to most of us by now. So, what else to do? As many physicians know too well, clinically, the tough job is to encourage and help patients quit. That’s crucial and some improvements in helping smokers quit are underway. On a public health/policy front, there is the proposed California Cancer research Act (CRCA) [ http://www.californiansforacure.org ], which would increase cigarette taxes by $1/pack, with the funds going for tobacco cessation, research and control. As the previous 5 cent tax hike instituted in 1988 is only worth 2 cents now, this would go a long way towards restoring our state’s status as a leader in tobacco control. We are all paying for the costs of smoking already, and it’s time for smokers, and the industry, to shoulder more of the burden.

There is room for at least some evidence-based optimism regarding the tobacco wars. At the UCSF seminar, the ACS’s Seffrin also said we are saving 350 more lives daily than twenty years ago. California’s smoking rate is about 12%, as compared to a national rate of 21% – and that latter has been halved over the past couple of generations. Many of those still smoking are “light smokers” more amenable to stopping. As UCSF’s longtime leading foe of the tobacco industry professor Stanton Glantz PhD noted, it is possible that if California again pushed hard, as before, smoking could be virtually eliminated in this decade. And that’s not necessarily a pipe dream.

An infamous example of tobacco marketing in Catholic nations.An infamous example of tobacco marketing in Catholic nations.