Chapter 27. A program for the future

It is possible to argue, of course, that all is going well on the cigarette front. The number of cigarettes smoked per capita is down a little, the number of smokers is down a little, the number of ex-smokers is up, perhaps substantially, and the number of cigarettes smoked is not rising very rapidly. If the antismoking campaigns are just continued on the present pattern, stressing voluntary abstinence, the figures may continue to improve.

It is also possible to argue, however, that sooner or later, however reluctantly, society may have to face the bankruptcy of anticigarette programs based on voluntary abstinence–– that is, on a denial that cigarettes are addicting. If there are still tens of millions of cigarette smokers a generation hence, including millions of fresh teen-age recruits, along with tens of thousands of lung-cancer deaths annually and hundreds of thousands of premature deaths from cardiovascular disease, chronic bronchitis, and emphysema, all cigarette-associated, despite increasing unanimity of agreement among smokers themselves that smoking is a major health menace, even those who deny that cigarette smoking is an addiction to nicotine may have to concede, however reluctantly, that the time is ripe for a change in national policy. (Some readers may even conclude that the time is already overripe.)

Without prejudging the issue of  when public health policies toward cigarette smoking should change, let us explore for a moment three directions that a new policy might take when and if the time comes to recognize openly and officially that cigarette smoking is an addiction and that voluntary abstinence is not the solution.

First, efforts should be made to popularize ways of delivering frequent doses of nicotine to addicts without filling their lungs with smoke, or to minimize smoke delivery to the lungs. This will reduce or eliminate the lung-cancer hazard. Here are some of the ways in which this might be accomplished:

• Develop a short cigarette with  high nicotine content, capable of delivering a maximum of nicotine to the bloodstream with a minimum of smoke to the lungs.

• Convert smokers from cigarettes to cigars or pipes.

• Develop a cigarette with noninhalable smoke.

• Develop smoke-free ways of delivering nicotine to the lungs–– for example, nicotine inhalers.

• Popularize chewing tobacco and snuff.

• Develop ways of taking nicotine by mouth, perhaps in pill form. (Dr. Murray Jarvik of the Albert Einstein College of Medicine in New York is currently exploring this possibility, with a grant from the American Cancer Society. In Sweden, trials of a nicotine chewing gum are under way.)

FIGURE 12. Death Rates by Degree of Inhalation, Male Smokers and
Nonsmokers, per 100,000 Person-Years

The results that can be expected from keeping cigarette smoke  out of the lungs, even among smokers who continue to smoke, are quite impressive. The overall death rate per 100,000 person-years among male smokers aged forty-five to fifty-four falls from 1,021 among those who inhale deeply to 824 among those who do not inhale at all. Between the ages of sixty-five and seventy-four, the drop is even more impressive from 6,411 among those who inhale deeply to 3,994 among those who do not inhale at all. Figure 12 gives the details.

Keeping carcinogenic smoke out of the lungs, however, is only a partial solution. Switching to cigars, pipes, and chewing tobacco does not eliminate the risk of cancers of the oral cavity. Moreover, the bulk of the damage suffered by smokers is due to diseases of the heart and circulatory system–– and it is the nicotine itself that has adverse effects on the heart. The second direction in which future policy must move, accordingly, is to find a  nicotine substitute.

Such a substance should have no adverse effects (or significantly less disastrous effects), on the heart or other organs, but should satisfy the craving for nicotine.

Can such a substance be found?

The odds in favor are good. Literally scores of nicotine "congeners" molecules closely related to nicotine chemically–– are known; and many of these are also known to have no effects on heart action. What is not known is which of them will satisfy the nicotine craving.

With scores of chemical candidates for the role of a safe nicotine substitute already available, and with additional scores or perhaps hundreds waiting to be synthesized by chemists, why are no tests of these nicotine congeners being run? The answer appears to be essentially a moral one.

Few Americans recognize that nicotine is an addicting drug. Most people, therefore, feel that smokers should stop smoking voluntarily that is, by an "effort of will"–– rather than depending on a "chemical crutch," a nicotine substitute. The attitude toward nicotine thus parallels the attitude of some who oppose the methadone treatment for heroin addiction (see Part I), arguing that heroin addicts should stop by an "effort of will."

This is perhaps a worthy moral stand. But it has not, to date, proved successful. For while highly moral efforts have for seven years been concentrated on persuading smokers to stop smoking, and teaching them how to stop smoking, smokers have gone right on smoking–– more than 500 billion cigarettes per year–– and from 250,000 to 300,000 smokers a year go right on dying prematurely as a result of their smoking.

A third fresh direction for anticigarette public-health campaigns to take is to  tell people the facts about nicotine addiction. It should be shocking to the conscience of the country that such facts have been kept a secret from young people.

Messages about nicotine  addiction should be woven into the school curriculum. When children first study American Indians, they should learn that Indians were so addicted to tobacco that they could not do without it. When children learn the routes of the great explorers, they should be informed that the mariners were so addicted to tobacco they had to take supplies with them, and planted tobacco seeds along their routes. The sad plight of nicotine addicts cut off from their supplies–– "Tobacco, sir, strong tobacco," and "We die, sir, if we have no tobacco!"–– should be understood at a very early age. Full meaning should be restored to the word "addicting," which anticigarette and antiheroin campaigns have debased to the role of a paper tiger.

Footnotes
Chapter 27

1. James L. Hedrick,  Smoking, Tobacco and Health, prepared for National Clearinghouse for Smoking and Health, U.S. Department of Health, Education, and Welfare, Public Health Service, March 1969 (revised), Figure 13, p. 27.