I am physician and much of what we do is smoking related disease. Treatment of emphysema and the diagnosis of lung cancer is a regular occurrence. In the 10 days before New Year's Day I diagnosed lung cancer three separate times--all were incurable at the time of discovery-- and on Christmas Eve we could do nothing to stop a woman from dying because of unrelenting bleeding in her windpipe, possibly an undiscovered tumor, bleeding into her lungs—may be it was tuberculosis but that is less prevalent and less likely. So, I hope you can see why this season, more than ever, I am troubled by the multiple and overwhelming costs of the addiction to tobacco products. So let me ramble a bit today about disease, cost, politics, and smoking cessation efforts.
There is the burden of chronic obstructive pulmonary disease (COPD) which often manifests itself as a late-life asthma and is better known as emphysema. Autopsy studies have shown that 100% of smokers at age 65 had some evidence of emphysema on her lungs. So, it seems to be a contradiction to hear that only 1 and 5 individuals who smoke for two decades one pack each day--or the equivalent exposure which is called 20 pack years--develop COPD. The confusion is resolved by the fact that emphysema is an anatomic change in the lung observed on imaging and on the pathology slide whereas obstructive pulmonary disease is a loss of function as measured with a lung function test, the “blow as hard as you can test” commonly known as spirometry. (If you cannot picture this test, this was the same test that is made familiar to individuals growing up in coal country. Black lung disease presents with a different pattern on that same test. Many of us who grew up in Pennsylvania who have relatives who smoked and worked in the mines and unfortunately are individuals who had both patterns on the test.)
There is also lung cancer. That too is a high risk for smokers. For a smoker who has kept with the routine of one pack each day for ten years, that individual has once gained a 1 in 5 chance in their lifetime of developing and dying from one form of lung cancer. There are five separate lung cancers each of different grades of aggression associated with tobacco smoke, but treatment if given early is often not early enough and is not a cure. These are not a good cancers to have. A sardonic reality encapsulated by an oncologist is that most who receive the diagnosis eventually die of the disease rather than with the disease as it is with less virulent cancers. My eighty year old uncle just died from a lung cancer due to smoking for a time in the remote past, the nineteen fifties and sixties. Happily and surprisingly he did live with this for five years after the initial resection and diagnosis.
Tobacco, though, affects every organ system. Cardiac disease, which is part of the larger category of vascular disease, is a blood vessel disease that brings on heart attacks, strokes, and loss of circulation to the limbs when disease and roughed vessel clot off suddenly. People have angina, dementia, lose feet and legs, rarely hands in the chronic form of vessel disease. Loss of bone mineral density, loss of teeth, and wrinkles are lesser-known consequences of tobacco use. There are other cancers of the aerodigestive tract including esophageal cancer, head and neck cancer and laryngeal cancer all which contribute to the more horrifying salvage surgeries that eliminate the ability to speak, larygectomies and removals of jaws and tongues. Bladder cancer and kidney cancer, other diseases which lead to salvage surgery and rerouting of the urinary tract, are not to be forgotten.
I’ve seen this tragedy for years without a sense of the total national cost. It seems like it ought to be not just a big number but a big portion of total health care costs. I guess about half the patients at any given time in the hospitals I work at are being treated for a smoking related disease. However, according to the CDC the financial costs in yearly death attributable to smoking related illness is $90 billion. (A large chunk of that number is not the illness but the loss of productivity.) The financial costs for long-term care due to smoking related illness is a similar number per year. Total health expenditures each year are one sixth of GDP—a much higher number than smoking related costs—1-2 Trillion dollars. Consequently, I find the CDC in whole numbers and proportionally a number surprisingly low compared to what the consequences of tobacco use I see on a day-to-day basis. November for instance was a difficult month and each call night I ended my shift by signing a death certificate. Question 35 the New Hampshire State death certificate asks whether a death was attributable to tobacco. Half of those individuals died of a smoking related disease. Not to be ignored then is that from this day-to-day experience the monetary costs and our discussion here are merely a very visible tip of a great iceberg of immeasurable social costs.
This CDC estimate is quoted often and comes from the health and human services (HHS). Is this figure corroborated by other studies? Well . . .although there are numerous studies for the cost to regions, cities and other countries, in my ongoing search I repeated find this single report as an aggregate estimate of the burden of smoking on the United States. So, let me answer a set of similar questions. I'll begin with the 2010 surgeon generals report derived from the HHS report:
"More than 1,000 people are killed every day by cigarettes, and one-half of all long-term smokers are killed by smoking-related diseases. A large proportion of these deaths are from early heart attacks, chronic lung diseases, and cancers. For every person who dies from tobacco use, another 20 Americans continue to suffer with at least one serious tobacco-related illness. But the harmful effects of smoking do not end with the smoker. Every year, thousands of nonsmokers die from heart disease and lung cancer, and hundreds of thousands of children suffer from respiratory infections because of exposure to secondhand smoke. There is no risk-free level of exposure to tobacco smoke, and there is no safe tobacco product."
http://www.surgeongeneral.gov/...
page 6
http://www.cdc.gov/...
Several claims are frequently quoted from the book The Price of Smoking by Frank A. Sloan, Jan Ostermann, Christopher Conover, Donald H. Taylor, Jr. and Gabriel Picone This is from MIT Press and is available in ebook form and one of the authors posted a summary at
“We further estimated that the social cost of smoking in 2000 was around $40/pack of cigarettes, distributed as follows:
•$33 private cost: borne by the individual, primarily through a substantially shortened lifespan
•$5.50 quasi-external cost: borne by the smokers’ family through increased health costs, slightly lower wages and other factors
•$1.50 external cost: borne by society, and representing the net effect of things like taxes paid, Medicaid and Medicare payments, and Social Security received”
http://theincidentaleconomist.com/...
This per pack estimate is matched here:
http://www.tobaccofreekids.org/...
The point of bringing all this up is to showcase the controversy that smoking still manages to create. It is a Rorschach test of our times—to borrow a phrase from Bill Maher. Do we help or punish? Do we let the government control or the free market play out? Should we believe it costs us anything? Leave it to the Cato institute to advocate that heavy smokers generally don't live long enough to develop the costly and chronic illnesses that affect the elderly, and as a result smoking actually reduces society's healthcare burden. Even though all of us have seen friends and relatives suffer a smoking related disease, and would be hard pressed to say this has neutral or even positive social costs, there is another side to the argument. The author Van Doren extends this thought with the following quote:
“So why are politicians going after smokers and tobacco companies? For the same reason that Willie Sutton robbed banks: there's a lot of money there. The 25 percent of the population that smokes is a convenient unorganized source from which the rest of the population can extract revenue. Taxing smokers because we can take their money easily is theft (more often than not from people who can ill afford to be robbed) dressed up in good intentions.”
http://www.cato.org/...
http://www.cato.org/...
Holy smoke, dude! In my experience this line of thinking has it all wrong. If you follow me for a day, a year, or two you will see these folks are not dying young, they are dying slowly and horribly. They die on ventilators. They die in operating rooms. They burn their faces when they light up cigarette while using oxygen. They die in nursing homes. They die after amputations or with suppurating wounds. They die with cancer and die after multiple pneumonias. Are we to believe for every one I see there are numbers of sudden deaths out there equal or exceeding these events that are somehow financially helpful, I suppose you dare to say? Back up a conclusion like this with evidence of higher rates of sudden death among smokers. If smoking is so virtuous, why not go further and advocate early smoking exposure?
Even the cigarette industry apologizes for this line of thinking. Here is a statement from Phillip Morris about a Czech study the company funded that reached a convenient conclusion.
"The funding and public release of this study which, among other things, detailed purported cost savings to the Czech Republic due to premature deaths of smokers, exhibited terrible judgment as well as a complete and unacceptable disregard of basic human values. For one of our tobacco companies to commission this study was not just a terrible mistake, it was wrong. All of us at Philip Morris, no matter where we work, are extremely sorry for this. No one benefits from the very real, serious and significant diseases caused by smoking."
http://en.wikipedia.org/...
http://www.mindfully.org/...
As a culture we are comfortable with accepting some deferred cost if it is an illness that is not by the individuals own bad judgment. In an infamous debate moment this fall, Wolf Blitzer posed an analogous question about deferred costs of healthcare to candidate Ron Paul. An injured youth remains in an ICU for six months. Who should bear the cost if he does not have health insurance? That the congressman had no real answer is not surprising and should be telling. One member of the audience shouted for a death to be permitted—an accidentally injured youthful adult, not a smoking related illness. I take from the poor reception the outburst received, that the cost of this accident was something acceptable for the larger society to bear. May be the accident was from the poor youth's own poor judgemen?
Because I feel most of us would extend this sentiment to people who develop a cigarette related illness—we do already, I do not really expect the law of Kharma will rise as a popular or practical response for those who have contracted a smoking related illness. I have never seen a punishing policy applied to those who clearly have a tobacco related illness. We have not set as a policy turning anyone with asmoking related illness away from an ER. The few instances we put limits on care because of smoking are in the context of extraordinary treatments. The only one that comes to mind is organ transplantation. (I suspect some centers for bariatric surgery include smoking cessation as a prerequisite for obesity surgery.) Instead, what we agree again and again in councils and legislatures is that taxation on cigarette smoking should increased—with the interesting exception of here in New Hampshire—in large part due to our understanding of late life disease and in small part due to second hand disease.
Also, despite the perspective embodied in the Cato reports, I do feel a strong majority of us would like to see fewer smokers. Is it too strong to conclude what they write about is really just a license to smoke guilt free?
I will end this diary and the speculative musings with a mention of a real world solution. New York City has recorded a dramatic change in smoking rates since passage of the Smoke-Free Air Act (SFAA) in 2002. “Concurrent with the Tobacco Control Program’s 5 point plan, smoking prevalence in NYC decreased 27%, from 21.5% in 2002 to 15.8% in 2009, while in years before 2002, the smoking prevalence was virtually flat.” I read this as neither the culture or the market reduced smoking rates until government intervention provided the mechanism and motivation. I should mention these ordinances were matched with greater smoking cessation efforts. Although we promote smoking cessation each and every day, a Pigovian taxation—a sin tax—or other government intervention is effective for creating a culture of cessation and abstinence.
http://www.nyc.gov/...