Almost 50 years ago, I was in the front row when the Surgeon General of the United States, Luther Terry, made the first official announcement that cigarette smoking was harmful to health. I was an overly eager high school reporter on my 14th birthday having won a contest to report on the American Association for the Advancement of Science convention in Philadelphia.
It is now hard for young people to believe, but that was an earthshattering announcement. Although my parents did not smoke, I grew up in a corner grocery that sold more cigarettes and other tobacco products than it sold anything else. People smoked everywhere. Doctors smoked in their offices. Other doctors (or actors playing doctors) were in television commercials that told us filters or menthol flavor actually improved our health. I returned to my school and made an impassioned speech to a general assembly. Many years later, I found out that one sixth grader was so inspired by it that it led him to become a cancer surgeon.
Did that speech stop me from smoking? Not completely. I could get cigarettes for free, many of the “cool” kids smoked, and I did smoke one package of Marlboros in the 11th grade, but I could never figure out what was appealing about cigarettes. More importantly, almost nobody around me smoked.
This personal history is consistent with why young people do smoke or use smokeless tobacco. They use it because people around them smoke. A recent study shows that 8 percent of children of non-smoking families will smoke, but over 25 percent of children will smoke if they have a parent or older siblings who smoke. Other studies show that young people also use tobacco because their friends do or because actors they admire use tobacco in movies or on television.
In addition to social cues, young people continue to use tobacco because it satisfies oral needs (some people have to have something in their mouth whether it be their thumb, food, or a cigarette). If they start using tobacco, many people become addicted to the nicotine and get withdrawal if they try to stop.
I tell my patients that nothing is better for their health than not smoking and not hanging out with people who do smoke. Both because social proximity to smokers encourages smoking and second hand smoke has many of the dire consequences of smoking oneself.
But once my patients are smoking, quitting is difficult. Statistically, even people who successfully stopped using tobacco had failed on at least two previous serious attempts to stop before they were successful. So along with counseling and peer group support, several new products have appeared that are “safer” forms of tobacco or are meant to ease the withdrawal from nicotine once a person is addicted. Unfortunately, there has been little scientific testing in adolescents or even in adults.
There is one “old” product, nicotine patches that are now being use more in adolescents and two new products, e-cigarettes and snus, which are new to the U.S.
Nicotine patches can work well if the reason the adolescent cannot stop smoking is physical addiction to nicotine. But nicotine is quite an impressive poison in overdose. Young children have died from neuromuscular blockade from eating a single cigarette. If someone wears a nicotine patch that is too large for their body weight or wears a patch and also smokes, they can first become very stimulated and then can lose control of their autonomic nervous system (including forgetting to breathe). These devices need to be use in adolescents under close medical supervision with good awareness of side effects. But they do help the nicotine addicted to stop using tobacco.
The World Health Organization states that as of July 2013, no rigorous studies have been conducted to determine if electronic cigarettes are a useful method for helping people to stop smoking. The U.S. Food and Drug Administration says that most of these devices are being imported illegally. The manufacturers say that they are safer because the e-cigarettes deliver nicotine without the over 300 bioactive by-products of combustion that smoking a real cigarette produces and then are inhaled. No one really knows, but over 1 percent of American adolescents have already used them. The data is confusing, most is by people being paid by manufacturers to prove their products safe, and yet people are using them. I would advise everyone not use them until we know if they are safe.
Snus is a moist ground tobacco popular in Scandinavia and related to snuff and dip. It is placed under the upper lip and can be swallowed. It is banned in the European Union (with some exceptions) and was banned in Russia this year. It is not clear that the product available in the U.S. is exactly the same as the product used in Sweden for the last 150 years. Nevertheless, about one in 50 American adolescents have tried it at least once and about 1 percent use it regularly (remember about 5 percent of adolescents report using snuff or other forms of non-smoking tobacco regularly).
Finally, a much lower percent of Americans are smoking. Over 30 years it has gone from over 50 percent to less than 20 percent. There are two reasons for this drop: all the unfavorable publicity and a vast increase in price. Let us keep up the pressure. The best way to get people to stop smoking is that they never start.
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