Documento(s) 11 de 37

An unparalleled epidemic

The tragedy of the stories about Roger, Julie, George, and Julieta is that their experiences are repeated thousands of times each year. Although many people believe that smoking is harmful, few appreciate just how much damage it really does. Annually, more than 45 000 Canadians suffer early deaths because of tobacco use.^[161,467] This frighteningly large total exceeds the 42 000 Canadian deaths in all the years of World War II. The total also exceeds the number of annual deaths from car accidents, suicide, murder, AIDS, and illicit drug use combined.^[380] For AIDS, the total number of deaths reported in 1993 was 998, lower than the 1992 record of 1 116. During the entire period 1979–93, the total number of reported deaths from AIDS in Canada was 6 439.^[233] In 1993, the total number of fatalities from traffic accidents, including those caused by drinking, was 3 601.^[595] It has been estimated that for the period 1955–2005, a total of 12.3 million Canadians will have died prematurely from tobacco use.^[467]

The Canadian Medical Association (CMA) has strong words regarding tobacco and health. As long ago as 1969, the CMA said that

the story of the health hazards created by cigarette smoking represents an unrivalled tale of illness, disability and death. The potential benefits to be derived from the cessation of smoking place it at a level of importance in preventive medicine with pasteurization of milk, the purification and chlorination of water, and immunization.^{[76, p. 689]}

The total number of smoking-related deaths per year has increased in this century as smoking has increased. The total, when adjusted for an aging population, is now leveling off among men but continues to increase among women, because increases in smoking among women took place later than in men. It normally takes several decades before smoking results in death, so there is a delay before higher smoking rates translate into higher death rates. Similarly, it takes time before lower smoking rates translate into lower death rates.^[369] Even with lower smoking rates, though, the total number of smoking-related deaths will increase in future years because of Canada’s growing population and aging baby boomers. Of all smokers who die prematurely, half will die before age 70 and lose an average of 23 years of life.^[467] The half who die after age 70 lose an average of 8 years of life.^[467]

The rise in the health consequences due to tobacco is partially illustrated by Figure 1, which shows the rise in lung cancer since 1950. More than 80% of lung cancer deaths and about 30% of cancer deaths are caused by tobacco use. Unlike some other forms of cancer, lung cancer is usually lethal. Within 1 year of diagnosis, 66% of men and 62% of women are dead; within 5 years, 85% of men and 80% of women are dead.^[427] Smoking also causes cancer of the throat, mouth, tongue, lip, larynx, pharynx, bladder, kidney, and pancreas. It has been associated with several other cancers, including cancer of the stomach and cervix.

As important as smoking is as a cause of cancer deaths, it is responsible for an even greater number of deaths due to heart attacks, stroke, and other forms of heart disease. American research indicates that of all tobacco-related deaths, 46% are due to cardiovascular disease, 26% to lung cancer, 14.3% to chronic bronchitis and emphysema, 7% to other cancers, and 6.7% to other causes.^[602] Of all heart disease deaths, about 30% are

Figure 1. Age-standardized lung cancer death rate for males and for females, 1950–96.^[428,567]

attributable to smoking. Smoking also causes 80%–90% of chronic obstructive lung disease and is the major cause of emphysema and chronic bronchitis. Smoking can cause and aggravate asthma.

Employees exposed to chemicals in certain types of workplaces have an increased risk of certain diseases. If an employee smokes, the risk increases dramatically and is far greater than if just risks from smoking and from workplace chemicals were added together. For example, lung cancer death rates (per 100 000 people) for cigarette smokers exposed to asbestos dust has been reported at 602, compared with 123 for cigarette smokers not exposed to asbestos dust, 58 for nonsmokers exposed to asbestos dust, and 11 for non-smokers not exposed to asbestos dust.^[541]

Smoking during pregnancy increases the risk of complications, low birth weight, miscarriages, stillbirths, premature births, bleeding during pregnancy, and sudden infant death syndrome. Smoking has been linked to lowered immunity, early menopause, reduced fertility, and peptic ulcers. In men, smoking has been associated with a higher risk of impotence. Smoking can cause gum disease and tooth loss.

Quitting smoking can have a tremendous effect on reducing health risks and on improving life expectancy, especially if quitting occurs early in life. The benefits of quitting can be immediate, and within days or weeks some of the effects of smoking are reversible, including some respiratory problems. After 3 years, on average, the risk of sudden cardiac death approaches that of never smokers. However, increased risks still remain compared with the never smoker. For example, after 10 years of not smoking, the risk of lung cancer remains at 30%–50% of that for continuing smokers^[236] and considerably higher than that for never smokers. And the greater the number of years a person smoked and the higher the number of cigarettes smoked daily, the greater the risks.

One of the most important studies ever done on the health consequences of smoking was carried out in the United Kingdom starting in 1951.^[148] The study involved 40 000 doctors and followed them over the next 40 years, monitoring their smoking and, when applicable, their age at and cause of death. The study, released in 1994, concluded that “half of all regular cigarette smokers will eventually be killed by their habit.”^{[148, p. 901]} The study also concluded that earlier studies “substantially underestimated the hazards of long term use of tobacco.”^{[148, p. 901]} Smoking was significantly associated with 24 different causes of death. Interestingly, smokers were less likely to die from Parkinson’s disease, although no explanation is offered. Partway through the study, in 1978, the alcohol consumption patterns of the doctors were monitored. In contrast with smoking, the study found that moderate consumption of alcohol actually increased life expectancy. However, heavier drinking (more than three units a day) led to increased death rates.¹

Cigarette smoke contains more than 4 000 chemicals. At least 43 of these have been identified as carcinogenic in humans or animals, and others have been identified as toxic, so it is no surprise that smoking is so harmful. The substances in smoke include carbon

¹ One pint of beer = 2 units; one glass of wine = 1 unit; 25 mL of liquor = 1 unit.

monoxide (found in car exhaust), acetone (used in paint strippers), hydrogen cyanide (used in gas chambers), ammonia (used in fertilizers and bathroom cleaners), mercury, lead, benzene, cadmium (used in car batteries), formaldehyde, arsenic, and toluene (used in industrial solvents).^[61,231] Unburnt tobacco has more than 2 500 chemical compounds, including pesticides applied during growing and sometimes substances added during the manufacturing process.^[606] Nicotine itself is a potent toxin that has been used in insecticides and rat poison. Indeed, nicotine has been around as a poison since at least the 19th century. For humans, a lethal dose when swallowed has been estimated at only 40–60 milligrams (mg).^[618] That’s a mere drop, next to nothing. A smoker may consume more nicotine than that in two packages of cigarettes, but of course the dose is spread out.

There is no such thing as a safe cigarette, including so-called light cigarettes. Tobacco products are the only products legally available on the market that are harmful when used exactly as the manufacturer intends. The industry kills its best customers.

Apart from the health consequences, smoking can yellow fingers, yellow teeth, and speed the onset of facial wrinkles. It can cause clothes and hair to stink and as the saying goes, make kissing a smoker taste like kissing an ashtray.

For most new smokers, the taste of smoking a cigarette is awful. Smoking is an activity that has to be learned, but once learned, it may be extremely difficult to stop. Just ask an ex-smoker. Smokers often fail in attempts to quit because of intense cravings for nicotine and because of withdrawal symptoms. It is not unusual for smokers to need a cigarette in the morning, their body having gone without a fix for 8 hours. In the most extreme and unusual cases, smokers cannot even get through the night without a cigarette. In 1988, the US Surgeon General concluded that nicotine is the drug in tobacco that causes addiction and that the pharmacologic and behavioural processes that determine tobacco addiction are similar to those that determine addiction to drugs such as heroin and cocaine.^[605] Data from Imperial Tobacco indicate that in 1989, 43% of smokers attempted to quit in the previous six months but only 1.8% of the total population did so,^[290] strong evidence of the power of nicotine. Even after surgery for lung cancer, nearly half of smokers resume smoking. One study found that 40% of smokers who had their larynx removed tried smoking again.^[248]

Tobacco is considered by many to be a gateway substance to illicit drug use. Research indicates that preventing tobacco use may help reduce the potential for use of illicit drugs.^[605]

The harm caused by smoking is not limited to smokers. Nonsmokers are harmed by second-hand smoke, technically known as environmental tobacco smoke (ETS) but sometimes referred to as passive smoking or involuntary smoking. ETS includes both the smoke emitted from the lit end of the cigarette and the mainstream smoke exhaled by a smoker. ETS can cause fatal lung cancer in otherwise healthy nonsmokers and has a particularly harmful impact on children’s respiratory systems.

Cigarettes are not the only harmful tobacco product. Cigars, pipes, and smokeless tobacco (chewing tobacco, snuff) are not safe alternatives to cigarettes. All of these products can cause cancer in the mouth area, including cancer of the lip and tongue.

No one should assume that he or she is immune to the risks of smoking. Those whose deaths are attributable to smoking include King George VI, musician Nat King Cole, actor Humphrey Bogart, actress Betty Grable, film maker Walt Disney, “Marlboro Man” Wayne McLaren, tobacco company head R.J. Reynolds, as well as descendants R.J. Reynolds, Jr and R.J. Reynolds III.

Economic and other nonhealth consequences

Nonsmokers as taxpayers have to pay for the medical costs resulting from smoking-related disease. Health Canada estimates that the direct health-care costs attributable to smoking in 1993 totaled $3 billion. If lost productivity, including foregone household income, is added, the total rises to $11 billion.^[237] In the United States, researchers have estimated that smoking-related health-care costs in 1993 totaled US $52 billion. When lost productivity was taken into account, the total economic burden rose to more than US $100 billion.^[643]

Cigarettes are the cause of preventable fires. These fires cause millions of dollars of property and environmental damage, result in the injury and death of innocent victims, risk the safety of fire fighters, and generally increase fire insurance premiums.

The economic consequences of tobacco use are staggering, but there are also significant intangible costs. Nothing can place a value on the pain and suffering caused by disease, the grief of losing a friend or loved one, or the financial crisis created by the death of a family’s wage earner.

Tobacco is harmful to the environment. In addition to the damage from forest fires, the outdoors has to deal with about 2 billion empty cigarette packages annually, several billion plastic and metallic foil overwraps (used to keep the product fresh), and about 50 billion discarded cigarette butts. The butts are often made with cellulose acetate tow, a substance with poor biodegradability. A vast number of trees are cut down each year to produce cigarette paper, packages, cartons, shipping boxes, matches, and matchbooks.

The industry’s position

In the face of the avalanche of knowledge about tobacco and health, the tobacco industry still denies that smoking is harmful to anyone. The industry denies that smoking has been proven to cause lung cancer or any other disease, that anyone has ever died from smoking, that nicotine is addictive, or that ETS is harmful. The transnational (multinational) industry maintains a united stand, regardless of the company or the country.

From the 1950s through the 1960s, and even later, the industry in Canada argued strenuously that smoking did not cause lung cancer. It offered alternative explanations for the rise in lung cancer, such as genetics, a virus, diet, or air pollution. Although the industry has long acknowledged a statistical association (sometimes referred to as risk) between smoking and lung cancer, it has argued that statistics do not prove causation. The industry’s position is that although it is true that smokers are statistically more likely than non-smokers to get cancer and heart disease, the cause of the diseases might be explained by other factors. Today the position is unchanged, but now the industry does everything possible to avoid speaking about smoking and health questions. The industry knows that when it says “smoking is not a proven cause of lung cancer,” all credibility is lost.

On the question of ETS, however, industry representatives put on their best face, go on the offensive, and deny the dangers of ETS just as vigorously as they once did with direct smoking, saying there is no “scientific consensus.” They seek to create the impression that the debate remains open, a decade after the US Surgeon General concluded in his 1986 report that ETS could cause lung cancer.

Because many people find it difficult to believe that the industry still denies that smoking causes any harm to health, a few examples are worth citing. In 1987, Jean-Louis Mercier, then President of Imperial Tobacco, appeared before a House of Commons Committee and was asked whether he believed that any Canadians die of smoking-related diseases. He replied “No, I do not.”^{[401, p. 13:29]} He also stated that the “role, if any, that tobacco or smoking plays in the initiation and the development of these diseases is still very uncertain. The issue is still unresolved.”^{[401, p. 13:22]} Patrick Fennell, the President of Rothmans, Benson & Hedges Inc. (RBH), asserted that “science has not established that there is a causal relationship between smoking and illness.”^{[171, p. 13:23]}

The following is an exchange aired in 1994 on the Canadian Broadcasting Corporation (CBC) Sunday Morning radio program between journalist Lynn Glazier and Rob Parker, the industry’s chief lobbyist, in his capacity as President of the Canadian Tobacco Manufacturers’ Council (CTMC):

Q: Do cigarettes cause cancer?

A: It’s an impossible question for me to answer. I’m not a scientist. I can certainly tell you that the industry’s view is that there is a statistical link between tobacco consumption and a long list of health ill effects. Cause cancer? That’s a scientific question. I’m not qualified to answer it. But I don’t believe that there is an established scientific causal link. The risk is clear.

Q: Are cigarettes addictive?

A: What are you planning to do here?

Q: Is nicotine the substance that addicts people to cigarettes?

A: I can’t answer the question. I’m not qualified to.^[97]

On another occasion in 1994, Rob Parker stormed off a CBC Midday television set in midinterview when David Sweanor of the Non-Smokers’ Rights Association (NSRA) asked him a smoking and health question. Parker said that this was violating an agreement made before coming on the show. Also in 1994, Imperial Tobacco spokesperson Michel

Descôteaux told CTV National News that “we don’t say that smoking is good for you, we don’t say that smoking is bad for you. All we are saying is that in the state of current knowledge we do not know.”^[129]

At the 1994 annual meeting of Imasco, the parent company of Imperial Tobacco, Chairman Purdy Crawford, was asked how many deaths were caused by tobacco use. “We have no view on that,” he replied.^{[242, p. D2]} When another questioner asked how the company would respond if it was ever proven that smoking caused lung cancer, Crawford avoided the question and stopped the person from asking further questions, all to a crescendo of applause from shareholders assembled in Montreal’s plush Monument national.

In the November/December 1994 issue of The Leaflet, an Imperial Tobacco publication for employees and their families, an article entitled “Clearing the Air: Smoking and Health, The Scientific Controversy” contained this excerpt:

The facts are that researchers have been studying the effects of tobacco on health for more than 40 years now, but are still unable to provide undisputed scientific proof that smoking causes lung cancer, lung disease and heart disease . . . . ‘The fact is nobody knows yet how diseases such as cancer and heart disease start, or what factors affect the way they develop. We do not know whether or not smoking could cause these diseases because we do not understand the disease process’.^{[30, p. 2]}

For decades, the industry has tried to muddy the waters. It has sought to create doubt about the health risks when no such doubt was justified. With a slick, sustained public relations (PR) campaign, the industry has used misinformation to help remove the stain from its products and to protect enormous corporate profits. If consumers do not believe smoking is harmful, their motivation to quit is reduced. If politicians underestimate or do not accept the health consequences of smoking, their motivation to pass tobacco control laws is decreased.

In 1994, Imperial Tobacco commissioned a study by economist Jean-Pierre Vidal in response to other studies showing tobacco to be a net loss to the economy. Vidal stated that tobacco-caused deaths are economically beneficial, in part because people are killed off before becoming a burden to society.^[617] Naturally, this report touched off a storm of criticism. Should children’s hospitals be closed because this would save money? Should all Canadians aged 55+ be denied medical care? Imperial Tobacco quickly responded that it did not agree with the study (of course not, because the company denies that cigarettes kill) and claimed that the study was not supposed to be made public.

Canadian trends in smoking

According to data from Imperial Tobacco, the proportion of Canadians aged 15 and over who smoke declined from 47% in 1971 to 29% in 1993.^[290] Figure 2 shows the overall trend. Prevalence among men peaked at 62% in 1960. Among women, prevalence peaked at 40% in 1974. However, per capita consumption (age 15+) — the average number of

Figure 2. Prevalence of smokers among adults (age 15+) for men, for women, and for men and women, 1958–93. Source: 1958–70, derived from Rose (1981);^[508] 1971–89, Imperial Tobacco (1989);^[290] 1990–93, Imasco (1993, 1994),^[278,279] and derivations from these.

cigarettes (including roll-your-own) smoked per person — may be a better measure of smoking because it takes into consideration both the number of smokers and the amount smoked. These rates peaked in 1966, declined slowly with some ups and downs until 1982, and then began a dramatic decline that lasted until 1993 before rising somewhat in 1994 as lower taxes made smoking more affordable. Figure 3 shows the historical trend.

Even though smoking rates were declining, a growing population meant that tobacco companies enjoyed increased overall sales until 1982. This was the peak year for total tobacco sales in Canada, with 73 billion cigarettes, including roll-your-own, sold. In 1995, the comparable figure, including contraband, was about 51 billion cigarettes, although exact figures are impossible to obtain because of smuggling.

Smoking patterns vary greatly. A Health Canada survey in 1994 found that although 31% of Canadians aged 15+ were smokers (6.6 million smokers), prevalence varied from a low of 25% in British Columbia to a very high 38% in Quebec. Thirty-two percent of men were smokers, compared with 29% of women. Men reported that they smoked an average of 21 cigarettes a day and women reported 17, although actual numbers are somewhat higher than obtained from self-reporting. Of the 31% of the population who were smokers, 25% were daily smokers and 6% were nondaily smokers. Prevalence generally decreased with age, reflecting both successful quitting and early death: 38% of those 20–24 years old smoked, compared with 34% of those 25–44 years old, 29% of those 45–64 years

Figure 3. Canadian per capita (age 15+) cigarette consumption (including roll-your-own), 1921–95. Consumption during 1990s includes contraband estimates, and as a result there is some uncertainty. Imports, which are typcially very low, have not been included. Source: For legal sales, Goodyear (1994);^[203] Statistics Canada (1995–96);^[566] for contraband, Canadian Tobacco Manufacturers’ Council (1993),^[90] Lindquist Avey Macdonald Baskerville Inc. (1993, 1994),^[364–366] Imasco Ltd (1996),^[284] and personal calculations.

old, and 16% of those aged 65+. Among those 15 to 19 years old, 29% smoked.^[235] A 1991 study found exceptionally high rates of smoking among indigenous people: 56% of Indians and 72% of Inuit were smokers,^[241] rates among the highest anywhere in the world. Smoking decreases with education: 33% of people with less than high school education smoke, compared with 19% of people with university education. Among men, 4% smoke cigars, 2% smoke pipes, and 1% use chewing tobacco or other forms of smokeless tobacco.^[235]

Trends in youth smoking are shown in Figure 4. There was a particularly large decline in smoking among teenagers during the 1980s.

A total of 5.9 million Canadians are former smokers (27% of the population aged 15+). Of the 6.6 million current smokers, 4.9 million (74%) have made a serious attempt to quit by giving up smoking for at least 1 week.^[234] Among current smokers, younger people are more likely to have attempted to quit in the previous 3 months than older people: 29% for those aged 15–19, 22% for those aged 20–24, and about 10% for those aged 25+. Older smokers may be less likely to try quitting because of previous failed attempts; if they had been able to quit, they would no longer be smokers. Thirty percent of smokers smoking 1–10 cigarettes per day attempted to quit in the previous 3 months, compared with 5% smoking 11–25 cigarettes.^[235]

Figure 4. Smoking prevalence reported by 15–19 year old Canadians, 1965–1994, according to government surveys. Source: National Clearinghouse on Tobacco and Health.^[429] Note that the 1994 Youth Smoking Survey found a smoking prevalence among 15–19 year olds of 23% for males and 24% for females,^[240] lower than the results from the Survey on Smoking in Canada illustrated in the graph.

Overall, the good news is that the number of smokers has been going down. The bad news is that some 6.6 million Canadians still continue to smoke. The bad news is made worse by the fact that tens of thousands of teenagers start smoking each year. Apart from the addictiveness of nicotine, why do so many people continue to smoke and so many teens begin smoking? The answer lies largely with the wealth, power, and skill of the tobacco companies — the merchants of death.

Documento(s) 11 de 37