“I cannot emphasise too much the importance of adolescents to the survival of the tobacco industry”

Modern tobacco smoking, i.e. the sixty a day addiction, is a recent phenomenon. The ancient “civilised” use of tobacco like that of the American Indians’ practice of smoking a ceremonial pipe to reinforce the peace, and even the cigar and a brandy after a meal, do not have the addictive effect produced by the modern cigarette. It has been scientifically designed to enhance addiction and advertising has been directly aimed at children to get them started young. The modern smoking epidemic kills 400,000 Americans per year - more than AIDS, RTA, alcohol, homicides, drugs suicides COMBINED. And Northern Ireland figures are worse.

Smoking - a paediatric disease

The tobacco companies know the importance of the teenage smoker and the imperative of starting the addiction in childhood. They study their smoking habits and their market preferences. 82% of adults with any history of smoking had their first cigarette before the age of 18 and more than half were regular smokers by that age. In the USA 1 million children start to smoke each year; that is 3000 every day of the year.

The Clinton administration is the first to take on the tobacco industry head to head and it is on the level of the teenager that they are concentrating their campaign. The new advertising bans give an insight into the techniques used by the tobacco companies. Advertising aimed specifically at children is to be banned - the “Joe Camel” character is the most famous. The plan in the USA is to prohibit sales to under 18 year olds and require ID for tobacco purchase. Vending machines are to be banned as are free samples, kiddie packs and sales of single cigarettes. Media advertising for cigarrettes will only be allowed in a black and white text only format, eliminating colourful imagery. Outdoor advertising is to be banned within 1000 feet of schools or playgrounds.

Tobacco company support for action events such as skiing and Formula 1 racing have been shown to influence teenagers. The Marlboro insignias on our own Eddie Irvine’s Ferrari are there for a good reason ... and Northern Ireland with the highest death rate from coronary heart disease in the world. Don’t worry about the Ulster Fry, just stop smoking!

If the Clinton government has its way Virginia Slims, with its subliminal message to girls that these cigarretes will keep them slim, will not be able to support festival of athletic girls in skimpy clothes that is the Virginia Slims tennis tournament - the main warm-up tournament for female players in the American Open Tennis tournament. The Marlboro man riding a fine steed in the hills of Wyoming will no longer be the ideal macho man. And the ubiquitous T-shirts, caps and sporting goods that carry a brand name or logo of a tobacco product will no longer penetrate every walk of life.

But how does one discourage teenagers from taking up a “cool” addiction which will have no effect on them till they are old. There is no use telling a 15 year old that he will die of cancer. Old people die, they are supposed to die. To a 15 year old you are old when you are thirty and if you are reading this magazine then thirty is only around the corner! There is probably some merit in attacking the social consequences of the dirty habit i.e. the foul smelling, smoke-affected hair, the smell of smoke off the clothes, the bad skin. It is no harm to remind them that “kissing a smoker is like kissing an ash tray”.

Nicotine is a chemical addiction

Nicotine is an addictive drug. The method of chemical addiction is akin to that for cocaine and heroin and withdrawal has the same effects as “going cold turkey”. 77% to 92% of smokers are addicted to the nicotine in cigarettes and the evidence establishes that consumers use these products almost exclusively for pharmaceutical purposes. Despite the desire of most smokers to quit smoking, fewer than 3% succeed each year. Tobacco products do not exist without nicotine. Tobacco manufacturers claim publicly that taste provides an independent reason for tobacco use, but they have been unsuccessful in their attempts to sell non-addictive, low-nicotine products that provide tobacco “taste”. Tobacco company documents confirm the industry’s knowledge that consumers will not smoke cigarettes that fail to produce the necessary “physiological response” and satisfy the “nicotine need”.

This was known to the board of Philip Morris in 1969. In 1972 the assistant director of research at R.J. Reynolds wrote that nicotine is “a potent drug with a variety of physiological effects” and “a habit-forming alkaloid”. The major cigarette manufacturers have conducted extensive research to understand precisely how nicotine affects the brain, the CNS and other systems of the body and have developed the modern cigarette to exploit these effects.

The modern cigarette - “the ultimate delivery system for nicotine”

You thought that a cigarette was just a tube of paper that held a stash of the weed with a cotton wool filter in the end to maintain the illusion that it kept the tar out of your lungs. Just take a look at all the techniques that they admit to developing to maximise the nicotine delivered by a modern cigarette:

1.     The paper itself is specially impregnated to keep the cigarette burning.

2.     Tobacco blends are adjusted using high-nicotine tobaccos to raise the nicotine concentration in lower-tar cigarettes. The top leaves of the plants have a higher nicotine content and are favoured for cigarette manufacture.

3.     However the tobacco stems, lower leaves and other scrap materials are not wasted. They are processed into “reconstituted tobacco” with extraneous, chemically derived nicotine being added to make cigarettes for the cheaper end of the market.

4.     Adding ammonia compounds to the tobacco increases the delivery of  “free nicotine” to smokers by raising the alkalinity or pH of tobacco smoke. This is akin to adding bicarbonate to cocaine to make “crack”. When you’re smoking a cigarette you are basically “free-basing” nicotine.

5.     Filters and ventilation systems are designed to remove a higher percentage of tar than nicotine.

6.     Genetically engineered hybrid tobacco plants have been developed to increase nicotine content. In 1991 Brown and Williamson patented a new variety of tobacco which delivered a higher level of nicotine. Such tobaccos are used as blending tools.

7.     Nicotine “analogues” that retain nicotine’s reinforcing characteristic have been developed and added to low nicotine cigarettes.

8.     Chemicals such as acetaldehyde are employed to strengthen nicotine’s pharmacological effects.

Don’t underestimate the power of the tobacco companies.  They regard themselves as a specialised segment of the pharmaceutical industry and have made the design and promotion of tobacco products an art form.

Stop blaming the patients

Smokers are the highest at-risk group for all the major killer diseases in Northern Ireland. The  EHSSB figures regularly show that coronary heart disease, respiratory disease, lung cancer, cerebro-vascular disease and gastro-oesophageal cancer have the highest mortality figures. Even breast cancer has its links with smoking.

We doctors have a policy of blaming patients for their “habit”, not recognising it as an addiction. Smokers are afraid to come and see us because they know they will get just another lecture on goving up but not much help to give up. We are only too happy to have well woman clinics, healthy living clinics, the business man’s regular health overhaul and other trendy health fads but we drive away the most at-risk patients. And you’d be surprised how some people started smoking. Meet a few of my patients:

·       Jack, an air force pilot during the war (that’s the second world war for those who can only remember back as far as the Falklands). “It was normal then; everyone smoked; no one new the dangers. In fact the air force encouraged all of us fighter pilots to smoke. You can see it in all the movies about the war. They said it stirred up the adrenaline and made us better fighters.”  Jack gave up smoking many years ago when he realised the dangers but that was not enough to prevent his lung cancer developing.

·       Willie is a farmer from up Ballymena way. When he was a young fellow he always had a tremor. His GP suggested he take a wee drink to steady his nerves but he said he didn’t like to drink. So the G.P. said to smoke instead. He found it worked and continued for many years. Fortunately his oesophageal cancer was picked up during an OGD for heartburn and I hope he has had a curative operation.

·       Pat was a nurse at Foster Green, the TB hospital as it was in the 1950’s and 60’s. At the end of every shift the charge nurse would take all the nurses into the office and make them smoke a cigarette. “It’ll make you cough up all the germs you get from the patients around here.” Pat became addicted. We were not able to offer Pat an operation and after palliative treatment she passed away a few years ago.

It is now fashionable for teenage girls to smoke. Unless it can be made unfashionable, the current epidemic of smoking related diseases in young women will continue. I say “young women” because a women of 45, with three teenage children, who is dying of cancer is a young woman who is needed by her family.

What can a young doctor do?

1.     First and foremost, do whatever you can to help your patients to give up smoking.

2.     Realise that smoking is an addiction as strong as cocaine or heroin. Most people are unintentional addicts having been convinced to take it up by slick advertising to promote this legalised addiction.

3.     Realise that smokers are the highest risk group for disease in our community.

4.     Rather than blaming smokers and putting up brick walls, welcome them into our clinics, educate them on early disease symptoms and let them know they are welcome to discuss their addiction - maybe with a nurse rather than the daunting experience of facing a doctor.

5.     Be suspicious for early disease symptoms in this high risk group. Remember that by the time the text-book symptoms of lung, gastric and oesophageal cancer appear, the disease is usually incurable.

6.     Realise that many young patients have been smoking for a lot longer than we think. A thirty year old may have been smoking for twenty years and already have substantial lung, laryngeal, stomach or oesophageal damage. Many “primary” pneumothoraces in 20 and 30 year olds are found at thoracoscopy in fact to be due to extensive emphysematous bullous disease. That 28 year old who has had heartburn since infancy, helicobacter since childhood and has been smoking since the age of 10 has a high risk for gastro-oesophageal  cancer.

7.     Lobby politicians to penalise the tobacco companies.

This last statment sounds like the crass exhortation of all do-good campaigners. But, believe me, the tobacco companies are lobbying hard against medical opinion to try to maintain this modern epidemic which is crippling National Health Services. Only politicians can make big inroads into the tobacco industry. To their credit the EC does spend about £12million a year on anti-smoking campaigns. But that pales into insignificance when you realise that they spend £800million in subsidies to tobacco growers. The message has only started to get through and has a long way to go. Wouldn’t it be nice if our successors were able to look back on the late twentieth century with curiosity and, having overcome this epidemic, wonder how we ever let such a weed cause so much human hardship.