Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Mr
- James M Dickerson (23 June 2004)
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Pipe Smoking
- Hugh M Humphreys (23 June 2004)
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Smoking and lung cancer.
- Gareth Lloyd (25 June 2004)
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Teenagers smoking
- Dr.Naseem A. Qureshi (27 June 2004)
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The Importance of Young Adult Cessation Efforts
- Stanton A Glantz (1 July 2004)
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Lung Cancer and Physicians: Where are we at? Where are we going? How are we going to get there?
- Jay R. Schrand (8 July 2004)
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Imporance of age of initiation
- Ron Borland (8 July 2004)
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Parental smoking under age 30 can harm children
- Ellen CG Grant (8 July 2004)
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Declaration of Opposition to Smoking by the Japanese Respiratory Society
- Hiroshi Kawane, 1-2 Ajinadai-higashi, Hatsukaichi City, 738-0052, Japan (15 July 2004)
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Re: Lung Cancer and Physicians: Where are we at? Where are we going? How are we going to get there?
- Jay R. Schrand (25 July 2004)
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Re: The Importance of Young Adult Cessation Efforts
- David W Kuneman (27 July 2004)
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Do smokers actually die "about 10 years younger than non-smokers"?
- Mundi I. Josephson (24 March 2005)
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This Study's Lung Cancer Statistics
- Mundi I Josephson (31 March 2005)
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James M Dickerson, Marketing Consultant Lexington, Kentucky USA 40515
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I only quit this year at age 67 but I only averaged about 20-40 cigarettes a week for 30 years. I have no heart disease and 94% lung capacity per recent extensive examinations, tests, and CAT Scans. How do I fit into this mortality table re loss of life expectancy? Thank you. Competing interests: None declared |
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Hugh M Humphreys, None Home TA3 5PP
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This article refers exclusivley to cigarette smokers and emphasises that pipe and other smokers are not included. Indeed it says that in the early years people abandoned pipes for manufactured cigarettes and this is when the mortality rates started to increase. However the Press never makes this distinction and therefore the publicity from the Media always implies that the results also apply to pipe smokers, when they do not. There was time, five or ten years ago, when this distinction was made by the life insurance industry. Then pipe smokers were classified as a "non smokers" on application forms. But recently the distintion seems to have slipped and application forms ask "do you smoke?" rather than "do you smoke cigarettes?". This seems to have happened by default rather than because there is evidence that pipe smoking is harmful, or as harmful, as cigarette smoking. So it seems that all smokers are tarred (sorry) with the same brush. Is this justied? What is the evidence on pipe smoking. The difference between cigarette and pipe smoking is , of course, that pipe smoking is not directly inhaled into the lungs. (Just try doing it if you do not believe me). I am inclined to infer that pipe smoking is not very harmful. This may be a dangerous inference? Also any one reading Dr Doll's latest paper may be encouraged to decide that pipe smoking is harmless, give up cigarettes and take up a pipe. What studies have been done into the effects of life-long pipe smoking? What are the results? Competing interests: A life-long pipe smoker |
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Gareth Lloyd, retired Manchester M23 1PY
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The article by Doll is interesting. For almost 50 years Doll has trumpeted a causal relationship between smoking and lung cancer. The present article shows that there were 1062 deaths due to lung cancer among 25,346 doctors or 5.2%. If the 17% lifelong non-smokers is excluided the percentage of cancer deaths among smokers is still only 5%. This hardly amounts to a causal relationship. The statisticsl difference between smokers and non-smokers within this 5% has very little relevance in terms of cause since 95% of smokers escaped lung cancer. The relationship is more likely to be casual or, at best, enforcing a real and as yet unknown cause. Competing interests: None declared |
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Dr.Naseem A. Qureshi, Locum Psychiatrist Prince Sultan Bin Abdulaziz City for Humanitarian Services, Riyadh
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Sir: Smoking is a dangerous life style habit of people. Following continuing extensive campaigns against smoking worldwide, the prevalence of smoking is decreasing across western nations but this epidemiological trend is less obvious in developing world including Middle East countries, where smoking is rather increasing. Despite serious adverse effects of smoking on the body systems, people smoke and die as a result of smokeing- related diseases which include cardiovascular disorders, cancers, respiratory diseases and many other diseases. Now, the most alarming development as regard smoking is that teenagers due to multiple complex biopsychosocial reasons began to smoke heavily globally. It is not known that how many of them may possibly die before reaching age 30. International medical community must focus to address the teenagers smoking and should also device strategies to prevent smoking in this particular population of vulnerable age. The study by Doll et al among British doctors presents certain important findings. One may beg a question, "can these findings be generalized to world population other than doctors at large?" Finally, smoking is a bad habit coupled with preventable millions of deaths globally each year and hence people should quit it as early as possible before age 25 or 30. Reference: Richard Doll, Richard Peto, Jillian Boreham, and Isabelle Sutherland. Mortality in relation to smoking: 50 years' observations on male British doctors.BMJ 2004; 328: 1519-0 Competing interests: Non-smoker |
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Stanton A Glantz, Professor of Medicine University of California San Francisco 94143
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The study by Doll, et al (1) reinforces the fact that physicians and public health officials should invest more energy in smoking cessation and prevention for young adults because helping someone stop smoking before age 30 avoids most of the long term damage. While most cessation efforts are directed at people in middle age, the highest spontaneous quit rates are actually among young adults (2). While people generally begin experimenting with cigarettes as teenagers, it is during the period of young adulthood that most people make the transition from experimentation to consistent addicted cigarette consumption. This transition is characterized by stopping and starting smoking, and the tobacco industry invests considerable resources in creating a social environment to recapture these transient quitters (2). Cessation efforts directed at this group should capitalize on the fact that many young adults transiently quit and seek to maintain their smoke-free status. In addition to focusing clinical resources on this subpopulation, public health interventions such as smoke-free pubs would make it more difficult for the tobacco industry to recapture these victims (3). References 1. Doll R, Peto R, Boreham J, Sutherland I. Mortality in Relation to Smoking: 50 Years' Observations on Male British Doctors. Bmj 2004;328(7455):1519. 2. Ling PM, Glantz SA. Tobacco Industry Research on Smoking Cessation. Recapturing Young Adults and Other Recent Quitters. J Gen Intern Med 2004;19(5 Pt 1):419-26. 3. Sepe E, Ling PM, Glantz SA. Smooth Moves: Bar and Nightclub Tobacco Promotions That Target Young Adults. Am J Public Health 2002;92(3):414-9. Competing interests: None declared |
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Jay R. Schrand, Independant Researcher Port Hueneme, CA 93041
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I recognize the courageous efforts of the distinguished Sir Richard Doll, in persisting against such insurmountable odds. After 50 years, smoking should be considered a major causative factor in Lung Cancer(LC)(1). Theoretically there is always a possibility for an unknown confounder. However, to dispute the large odds ratio(RR=24) would be as difficult as trying to prove causation for ETS with its’ low odds ratio(RR=1.2) and numerous potential confounders. I would question why the mortality risk increased and the differential in survival rates for smokers VS never smokers increased from 7 to 10? Traumatic and chronic stress have a serious effect on the human system. Anda et al report that tobacco initiation and use has a strong and graded relationship with the number of Adverse Childhood Experiences (ACE)(2); being exposed to the stress of child abuse or coming from a dysfunctional family. Nicotine reduces the effects of stress. From the same 1996 survey (Dube et al table 4)(3), it appears that the risk between smoking and ACE's $ 3 increased in the latest 1962-1978 relative to previous birth cohorts. While not yet significant, this suspicious trend may indicate that those exposed to ACE's are recently under even more stress, which encourages tobacco use in the first place. Stress does not appear to influence the risk for LC incidence. However, the stigma that patients report(4) certainly does effect treatment, survival and eventually mortality. The helping professions(5) and the military/veteran populations have an attraction for those with ACE's, and are now exposed to occupational sleep disruption and stress. In the past few decades, it is likely that Physicians who smoke, encountered enormous stress from their peers, especially if still in practice. How much professional courtesy, much less empathy, is a physician with LC going to receive from his peers? This recent stigma may explain the large increase in the percentage of surveyed physicians in this study who requested no further questionnaires after 1991(1). Yes, tobacco is a causative factor in LC. But, how much of the mortality, especially in the healing and peacekeeping occupations is due to childhood, adult or tobacco control program related stress? Neither the increased mortality risk nor differential in survival rates in Physicians may generalize to the general population. Who is responsible and to blame? In 1998, the average age of death from LC was 71 compared to 78(6) for all causes. In 1900 life expectancy was 47 years(7). It takes around 70 pack/years to develop LC. It was not apparent until the 1930's when advances in medicine and health care increased life-span. It would be tempting to blame health care, as patients tend to do. However, Physicians healing talents in particular, improve life. Yes, the tobacco companies' aggressive marketing has increased consumption of this legal product. However, there is no indication that they introduced a specific cancerous agent or process that increased this particular risk. It's likely been there all along. Those who smoke are easy targets. However, they are simply using a 2000 year old product that, as compulsive as it is, has utility. But, just who owns the problem? Prevention only deters the easy ones, and is a dismal failure. It is health care’s advancement in treatment that has made the greatest improvements in other areas. However, the amount of money spent on research for treatment of LC has been a paltry $1,740 compared to the $4-13,000 per death for designer cancers. If the money wasted on prevention was spent on honest treatment research, LC would not be a problem. It would also help the 13% of LC patients who do not smoke. We all own the problem and need to work together. Pudgy former smokers produced by the tobacco control efforts, and are now targets of the anti-obesity campaign. Can the program to prevent the scourge of poor penmanship be far behind? One would think that Physicians who enjoyed smoking for 50 years would be especially interested in more research for better LC treatment. Medice cura te ipsum. Jay R. Schrand References: 1. Doll R, Peto R, Boreham J, Sutherland I. 2. Anda RF, Croft JB, Felitti VJ, Nordenberg D, Giles WH, et al. 3. Dube SR, Felitti VJ, Dong M, Giles WH, Anda RF. 4. Nuttall R, Jackson H 5. Chapple A, Ziebland S, McPherson A. 6. Computed from: 7. U.S. Bureau of the Census. Competing interests: The author is a Systems Engineer, Independent Researcher, and Veteran, and has no financial interest in the tobacco, food or pharmaceutical industries other than as a consumer of their products. |
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Ron Borland, Nigel Gray Distinguished Fellow in Cancer Prevention The Cancer Council Victoria, Carlton Victoria, Australia, 3053
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The new findings from the UK doctors study are of great importance. There is one aspect of the findings where there are grounds for caution in generalising to the current population of smokers. That is the finding that there was no net loss of life in those who quit smoking before 30 (25 -34). The average age of initiation in the doctors study is reported as 18. Depending on how age of initiation is defined, this is probably about 3 years older than is the case today for many countries. 1,2 If it is years smoked that is critical to when years of life begin to be lost, then the critical age will be lower. Further, if there is potential for smoking to do greater damage when it occurs during the growth phase of adolescence, then there might be an even greater reduction in the age to no damage. Research is needed on health outcomes as a result of age of uptake and of years smoked before firm conclusions can be reached about the size of any relative safe period for smoking. Safe in this context, is if the person quits, something the addictive nature of nicotine makes problematic even for those who may start out with such intentions. References: 1 Hill D, Borland R. Adults' accounts of Onset of Regular Smoking: Influences of School, Work, and Other Settings. Public Health Reports 1991; 106(2): 181-186 2 Giovino GA Epidemiology of tobacco use among US adolescents. Nicotine and Tobacco Research 1999, 1,S31-S40 Competing interests: None declared |
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Ellen CG Grant, physician and medical gynaecologist 20 Coombe Ridings, kingston-upon-Thames, KT2 7JU, UK
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It would be a mistake to believe that stopping smoking at age 30 prevents most excess deaths from smoking. The Doll study did not include the effects of parental smoking on the doctors' children. It is well established that tobacco smoking increases the risk of unexplained infertility, recurrent miscarriages, premature births, pre-eclampsia and stillbirths. Damage to the health of the future generations may be the most harmful and important effect of smoking. Competing interests: None declared |
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Hiroshi Kawane, professor The Japanese Red Cross Hiroshima College of Nursing, 1-2 Ajinadai-higashi, Hatsukaichi City, 738-0052, Japan
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Sir John Crofton's picture on the cover of 26 June issue reminds me of his lecture in Japan. He attended the 6th World Conference on Smoking and Health held in Tokyo in 1987. I was deeply impressed with the anti- smoking activities in the United Kingdom. British doctors got to know the hazards of cigarette smoking by their own findings. Sixteen years later in 2003, as a member of the committee on smoking problems in the Japanese Respiratory Society, I could take part in making a declaration of opposition to smoking[1]. The Japanese Respiratory Society has drawn up a set of principles and guidelines on the elimination of smoking. We aim to reduce the number of not only smoking-related disease cases but also premature deaths in Japan. Hiroshi Kawane
Reference [1]The Japanese Respiratory Society. Declaration of Opposition to Smoking. http://www.jrs.or.jp/citizen/topics/sengen_e.html(accessed 14 July) Competing interests: None declared |
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Jay R. Schrand, Independent Researcher Port Hueneme, CA 93041
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In my previous response I suggested that with the large odds ratio(RR=24) that smoking has on Lung Cancer (LC), that it would be as difficult to disprove smoking as a causative factor. However, Silva’s(1) recently published analysis of asthma and Chronic Obstructive Pulmonary Disease (COPD) found that when asthma was included in the model, the relative risk for smokings' influence on COPD dropped from the usual large ratio of 6-12 reported in previous studies to a still significant but meager 3. From Santillan’s(2) meta-analysis, asthma is also an independent risk factor(RR=1.8) for LC. And while I still suspect that smoking is still a considerable causative risk factor, we would indeed need to include asthma (as well as the stress of ACE’s) in the model in order to accurately assess the true effect, and of course, the population attributable risk (PAR). Jay R. Schrand References: Santillan AA, Camargo CA Jr, Colditz GA. Competing interests: : The author is a Systems Engineer, Independent Researcher, and Veteran, and has no financial interest in the tobacco, food or pharmaceutical industries other than as a consumer of their products. |
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David W Kuneman, retired retired
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Good grief!, Dr Glantz advocates elimination of public smoking to reduce teen's exposure to Big Tobacco's efforts to retain them as customers. Right in his own backyard, www.lao.ca.gov/cup0396.html, Legislative Analyst's office, Mar 1996 the State of California found despite tax hikes, teen smoking increased. Of course, many public smoking bans had also already been passed by various legislative authorities within the state which, according to Dr Glantz should also have cut teen smoking. Same thing in the USA overall, despite the price hike due to the Tobacco Settlement, and various excise tax increases, and many public smoking bans, it is a well known fact teen smoking increased up to approximately 1999. Education, and respect for authority ( laws that don't allow teens to smoke) are the only ways to cut teen smoking. Try to use the force of law to cut teen smoking results in rebellion, and actually hikes teen smoking. Lets not use this paper as a platform to promote more persecution of adults in the name of cutting teen smoking. Competing interests: None declared |
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Mundi I. Josephson, Professor of English, retired University of Saskatchewan, Saskatoon, Canada, S7N 0L2
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I find this 10 year average difference difficult to believe, especially since Cuyler Hammond's earlier study--and no-control-of- variables study--purported a much smaller approximate 5 year average difference. I'm also concerned about the use of the word "about" in "about 10 years." Does this mean 9 years or 8 years or 11 years or 12 years? This does not sound very scientific. Therefore, if 25,346 doctors died during the 50 years of this study, why didn't Doll et al report the actual average ages at death of the non- smokers vs. the smokers? For example, if the non-smokers lived to be on average 81.5 years and the smokers lived to be on average 71.4 years, then why not publish these figures in the study and say, precisely, that "cigarette smokers die 10.1 years younger than non-smokers"? Moreover, even though I've read the article several times, I can't find any table to substantiate the sweeping statement that there is an "average" loss of life of 10 years, a loss that applies to all 25,346 now- deceased doctors. Have I missed something? Competing interests: None declared |
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Mundi I Josephson, Professor of English, retired University of Saskatchewan, Saskatoon, Canada, S7N 0L2
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Could someone tell me if my analysis of the BDS lung cancer statistics is correct or incorrect? My e-mail is jjosephson@shaw.ca. Table 1 reports that 2.49 current male smokers out of "1000 men/year" die of lung cancer. My interpretation, therefore, is that 997.51 smokers per 1000 men/year do not contract lung cancer. In terms of percentages, this suggests to me that 99.751% of current male smokers per year do not get lung cancer. Am I correct in concluding that 99.751% of smokers never contract lung cancer? Or, does the "per year" of the "1000 men/year" make a difference? If so, can someone tell me precisely what percentage of smokers actually develop lung cancer? Thanks and sincerely, M.I. (Joe) Josephson, Ph.D. Competing interests: None declared |
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