IN-DEPTH FEATURES
New US Report Links More Diseases to Smoking

U.S. Surgeon General Richard H. Carmona released a new comprehensive report on smoking and health last Thursday May 27, revealing that smoking causes diseases in nearly every organ of the body. Published 40 years after the US Surgeon General's first report on smoking -- which concluded that smoking was a definite cause of three serious diseases -- this newest report finds that cigarette smoking is conclusively linked to diseases such as leukemia, cataracts, pneumonia and cancers of the cervix, kidney, pancreas and stomach.

"We've known for decades that smoking is bad for your health, but this report shows that it's even worse than we knew," Dr. Carmona said. "The toxins from cigarette smoke go everywhere the blood flows. I'm hoping this new information will help motivate people to quit smoking and convince young people not to start in the first place."

According to the report, smoking kills an estimated 440,000 Americans each year. On average, men who smoke cut their lives short by 13.2 years, and female smokers lose 14.5 years. For smokers who die young, the loss is an average of 22 years compared to their original life expectancy.

The economic toll exceeds $157 billion each year in the United States -- $75 billion in direct medical costs and $82 billion in lost productivity.

Around the world, almost 5 million people are said to die each year from smoking. World Health authorities say that if the current rates of smoking persist, some 10 million will die yearly by 2030.

The Israel Cancer Society says that 10,000 a year die in Israel from smoking, and of these 15 percent were only passive smokers.

"We need to cut smoking in this country and around the world," Health and Human Services Secretary Tommy G. Thompson said. "Smoking is the leading preventable cause of death and disease, costing us too many lives, too many dollars and too many tears. If we are going to be serious about improving health and preventing disease we must continue to drive down tobacco use. And we must prevent our youth from taking up this dangerous habit."

In 1964, the Surgeon General's report announced medical research showing that smoking was a definite cause of cancers of the lung and larynx (voice box) in men and chronic bronchitis in both men and women. Later reports concluded that smoking causes a number of other diseases such as cancers of the bladder, esophagus, mouth and throat; cardiovascular diseases; and reproductive effects.

The news report, "The Health Consequences of Smoking: A Report of the Surgeon General," expands the list of illness and conditions linked to smoking. The new illnesses and diseases are cataracts, pneumonia, acute myeloid leukemia, abdominal aortic aneurysm, stomach cancer, pancreatic cancer, cervical cancer, kidney cancer and periodontitis.

Statistics indicate that more than 12 million Americans have died from smoking since the 1964 report of the surgeon general, and another 25 million Americans alive today will most likely die of a smoking-related illness.

The report's release came in advance of World No Tobacco Day, an annual event on May 31 that focuses global attention on the health hazards of tobacco use. The goals of World No Tobacco Day are to raise awareness about the dangers of tobacco use, encourage people not to use tobacco, motivate users to quit and encourage countries to implement comprehensive tobacco control programs.

The report concludes that smoking reduces the overall health of smokers, contributing to such conditions as hip fractures, complications from diabetes, increased wound infections following surgery, and a wide range of reproductive complications. For every premature death caused each year by smoking, there are at least 20 smokers living with a serious smoking-related illness.

Another major conclusion, consistent with recent findings of other scientific studies, is that smoking so-called low-tar or low-nicotine cigarettes does not offer a heath benefit over smoking regular or "full-flavor" cigarettes.

"There is no safe cigarette, whether it is called `light,' `ultra-light,' or any other name," Dr. Carmona said. "The science is clear: the only way to avoid the health hazards of smoking is to quit completely or to never start smoking."

The report concludes that quitting smoking has immediate and long-term benefits, reducing risks for diseases caused by smoking and improving health in general. "Within minutes and hours after smokers inhale that last cigarette, their bodies begin a series of changes that continue for years," Dr. Carmona said. "Among these health improvements are a drop in heart rate, improved circulation, and reduced risk of heart attack, lung cancer and stroke. By quitting smoking today, a smoker can assure a healthier tomorrow."

Dr. Carmona said it is never too late to stop smoking. Quitting smoking at age 65 or older reduces by nearly 50 percent a person's risk of dying of a smoking- related disease.

Other Health-Related Effects

In addition to causing disease, smoking has many other effects that come from the generally reduced state of health that smokers experience.

Smokers are more likely to be absent from work than nonsmokers, and their illnesses last longer. Smokers also tend to incur more medical costs, to see physicians more often in the outpatient setting, and to be admitted to the hospital more often and for longer periods than nonsmokers.

Because of damage to the body's host defenses, delayed wound healing, and reduced immune response, smokers have a lower survival rate after surgery compared to that of nonsmokers. Similarly, smokers are at greater risk for complications following surgery, including wound infections, postoperative pneumonia, and other respiratory complications.

According to the standards set by the US Surgeon General, smoking is causally related to periodontitis. The reason is not understood. It may be because smoking affects the body's ability to fight infection and repair tissue. Periodontitis is a serious gum disease that can result in the loss of teeth and bone loss.

Peptic ulcers, which are located in the digestive tract (stomach and duodenum), usually occur in people with an infection caused by the Helicobacter pylori bacterium. Among persons with this infection, smokers are more likely to develop peptic ulcers than nonsmokers. In severe cases, peptic ulcers can lead to death.

Women and Smoking

Women who smoke are at an increased risk for infertility. Studies have shown that smoking makes it more difficult for women to become pregnant. Research also has shown that smoking during pregnancy causes health problems for both mothers and babies, such as pregnancy complications, premature birth, low-birth-weight infants, stillbirth, and infant death. Low birth weight is a leading cause of infant deaths, resulting in more than 300,000 deaths annually in the United States.

How Does Smoke Damage the Smoker?

Some people think that the main problem is the presence of carcinogens in the smoke, but the truth is that smoking causes damage in a variety of ways.

When a person inhales the smoke into his lungs, the toxic ingredients in the smoke enter the bloodstream and travel throughout the body, causing damage in several different ways. Nicotine reaches the brain within 10 seconds after smoke is inhaled. It has been found in every part of the body and in breast milk.

Carbon monoxide, a product of all fires, binds to hemoglobin in red blood cells, preventing affected cells from carrying a full load of oxygen.

Cancer-causing agents (carcinogens) in tobacco smoke damage important genes that control the growth of cells, causing them to grow abnormally or to reproduce too rapidly. The carcinogen benzo[a]pyrene binds to cells in the airways and major organs of smokers.

In addition, smoking affects the function of the immune system and may increase the risk for respiratory and other infections.

Another way that cigarette smoke does its damage is by the oxidative stress that mutates DNA, promotes atherosclerosis, and leads to chronic lung injury. Oxidative stress is thought to be the general mechanism behind the aging process, contributing to the development of cancer, cardiovascular disease, and COPD.

Usually, the body produces antioxidants to help repair damaged cells. Smokers have lower levels of antioxidants in their blood than do nonsmokers. In fact, smoking is associated with higher levels of chronic inflammation, another damaging process that may result from oxidative stress.

Horrendouse Overall Figures

Of overall deaths from cancer, 30 percent are caused by smoking. According to the Israel Cancer Association, 90 percent of all lung cancer deaths are due to smoking. The risk of getting lung cancer is two to three times as great among smokers as among nonsmokers.

For heart disease the situation is similar. Some 30 percent of all deaths due to heart disease are attributed to smoking. For younger people the figures are worse. About 75 percent of all heart attacks to people younger than 45 are among smokers.

How Did the US Surgeon General Conclude that a Condition was Caused by Smoking?

The 28 reports issued by the US Surgeon General since the first one in 1964 assembled the scientific data on smoking and many related diseases and then evaluated the data to assess whether or not smoking could be classified as the cause of a particular disease. Using this approach, almost every report has expanded the list of diseases caused by tobacco use.

Overall, the US Surgeon General concluded that tobacco use is the single most avoidable cause of disease, disability, and death in the United States.

Since the first causal conclusions in 1964, there has been increasing evidence to support those earlier conclusions.

Using terminology already in use by the Institute of Medicine and the International Agency for Research on Cancer, the Surgeon General was very careful in how each condition and its relationship to smoking was classified.

The causal relationship between smoking and diseases were classified in the following way:

When there is evidence that is sufficient to infer a causal relationship, the report says that smoking is proven to cause the disease. If the evidence is suggestive but not sufficient to infer a causal relationship, the report only said that smoking may cause the disease. In other cases, the available evidence is inadequate to infer anything about a causal relationship. In this case the report writes that there is not enough proof that smoking does or does not cause the disease. Finally, if the evidence is suggestive of no causal relationship the report states that smoking probably does not cause the disease.

For the Surgeon General to conclude that smoking is proven to cause a particular disease, the strongest conclusion, there must be specific scientific evidence that smoking either increases the overall number of cases of the disease or else makes the disease occur earlier than it otherwise would.

The reports use a number of questions to guide their judgment: * Do multiple high-quality studies show a consistent association between smoking and disease? * Are the measured effects large enough and statistically strong? * Does the evidence show that smoking occurs before the disease occurs (a temporal association)? * Is the relationship between smoking and disease coherent or plausible in terms of known scientific principles, biologic mechanisms, and observed patterns of disease? * Is there a dose-response relationship between smoking and disease? * Is the risk of disease reduced after quitting smoking?

It can be seen that the methods used to approach and evaluate the data were very strict and that the conclusions are not based on superficial associations.

For More Information

In addition to the 960-page printed report, "The Health Consequences of Smoking," the U.S. Department of Health and Human Services released a new interactive scientific database of more than 1,600 key articles cited in the report. The database can be used to find detailed information on the specific health effects of smoking as well as to develop customized analyses, tables and figures.

The database will be continually updated as new critical studies are published, allowing the Surgeon General to determine on a regular basis whether the evidence supports a new definitive conclusion about smoking-caused disease. "Using this technology, once a threshold of danger is met, we can quickly alert the American people of new information related to smoking," Dr. Carmona said.

The report found that for a number of diseases and conditions associated with smoking, the evidence is not yet conclusive to establish a causal link. For these illnesses, which include colorectal cancer, liver cancer, prostate cancer, and dysfunction in men, additional studies are needed to reach the threshold of evidence required by the Surgeon General's strict causal criteria to declare that they are causally related to smoking. These criteria were introduced in the 1964 report and have been updated in the 2004 report using new uniform standards (See below).

For breast cancer, the evidence suggests that there is no causal relationship overall to smoking. However, the report notes that on a genetic basis, some women may be at increased risk if they smoke. More research is required to clarify the role of smoking in the cause and progression of breast cancer.

To help communicate the report findings as widely as possible, Surgeon General Carmona also unveiled new resources in the electronic media for the public showing the hazards of smoking and the benefits of quitting. In addition, a full- color, easy-to-read summary of the report has been developed for the public. Ordering information is given below.

"The media site and public summary of the smoking report are something that I am really proud of," Dr. Carmona said. "By preparing materials that people who don't have a medical degree can understand, we effectively bring the science to people in a way they can use. Improving the health literacy of Americans by closing the gap between what health professionals know and the public understands will have a lasting positive health impact."

Copies of the full 960 page report "The Health Consequences of Smoking: A Report of the Surgeon General" and related materials are available from the Centers for Disease Control and Prevention, Office on Smoking and Health, and from the US Surgeon General.

To order the summary or the full report contact: CDC's Office on Smoking and Health Publications, Mail Stop K-50, 4770 Buford Highway, NE, Atlanta, GA 30341- 3717. Telephone: 1-800- CDC-1311.

The four major conclusions of the new report are: -- Smoking harms nearly every organ of the body, causing many diseases and reducing the health of smokers in general. -- Quitting smoking has immediate as well as long-term benefits, reducing risks for diseases caused by smoking and improving health in general. -- Smoking cigarettes with lower machine-measured yields of tar and nicotine provides no clear benefit to health. -- The list of diseases caused by smoking has been expanded to include abdominal aortic aneurysm, acute myeloid leukemia, cataract, cervical cancer, kidney cancer, pancreatic cancer, pneumonia, periodontitis, and stomach cancer. These are in addition to diseases previously known to be caused by smoking, including bladder, esophageal, laryngeal, lung, oral, and throat cancers, chronic lung diseases, coronary heart and cardiovascular diseases, as well as reproductive effects and sudden infant death syndrome.

Smoking Problems of the Elderly Particular problems that are found among elderly people who smoke include: * Smoking reduces bone density among postmenopausal women. * Smoking is causally related to an increased risk for hip fractures in men and women. * Of the 850,000 fractures among those over age 65 in the United States each year, 300,000 are hip fractures. Persons with a hip fracture are 12-20 percent more likely to die than those without a hip fracture. Estimated costs related to hip fractures range from $7 billion to $10 billion each year. * Smoking is related to nuclear cataracts of the lens of the eye, the most common type of cataract in the United States. Cataracts are the leading cause of blindness worldwide and a leading cause of visual loss in the United States. Smokers have two to three times the risk of developing cataracts as nonsmokers. * Chronic obstructive pulmonary disease (COPD) is consistently among the top 10 most common chronic health conditions and among the top 10 conditions that limit daily activities. Prevalence of COPD is highest in men and women 65 years of age and older (16.7 percent among men and 12.6 percent among women). * Smoking causes abdominal aortic aneurysm.

Tips on Quitting The US Center for Disease Control has compiled a number of aids to stopping. This is a summary of what they have found. Nicotine is a Powerful Addiction If you have tried to quit smoking, you know how hard it can be. It is hard because nicotine is a very addictive drug. For some people, it can be as addictive as heroin or cocaine. Quitting is hard. Usually people make 2 or 3 tries, or more, before finally being able to quit. Quitting takes hard work and a lot of effort, but you can quit smoking. Reasons for Quitting Quitting smoking is one of the most important things you will ever do. * You will live longer and live better. * Quitting will lower your chance of having a heart attack, stroke, or cancer. * The people you live with, especially your children, will be healthier. * You will have extra money to spend on things other than cigarettes. Five Keys for Quitting Studies have shown that these five steps will help you quit and quit for good. You have the best chances of quitting if you use them together. 1. Get ready. * Set a quit date. * Get rid of ALL cigarettes and ashtrays in your home, car, and place of work. * Don't let people smoke in your home. * Review your past attempts to quit. Think about what worked and what did not. * Once you quit, don't smoke--NOT EVEN A PUFF! 2. Get support. Tell your family, friends, and co-workers that you are going to quit and want their support. Ask them not to smoke around you or leave cigarettes out. Programs are given at local hospitals and health centers to help you quit and not go back. 3. Learn new behaviors. Try to distract yourself from urges to smoke. Talk to someone, go for a walk, or get busy with a task. When you first try to quit, change your routine. Use a different route to your regular places. Drink tea instead of coffee. Eat breakfast in a different place. Do something to reduce stress from not smoking which is especially strong at the beginning. Take a hot bath, exercise, or read a book. Plan something enjoyable to do every day. Drink a lot of water and other fluids. 4. Get medication and use it correctly. Medications can help you stop smoking and lessen the urge to smoke. The U.S. Food and Drug Administration (FDA) has approved five medications to help you quit smoking: 1. Bupropion SR--Available only by prescription. 2. Nicotine gum--Available over-the-counter. 3. Nicotine inhaler--Available by prescription. 4. Nicotine nasal spray--Available by prescription. 5. Nicotine patch-- Available by prescription and over-the- counter. Ask your health care provider for advice and carefully read the information on the package. These medications will more or less double your chances of quitting and quitting for good. The CDC says that everyone who is trying to quit may benefit from using a medication. If you are pregnant or trying to become pregnant, nursing, under age 18, smoking fewer than 10 cigarettes per day, or have a medical condition, talk to your doctor or other health care provider before taking medications. 5. Be prepared for relapse or difficult situations. Most relapses occur within the first three months after quitting. Don't be discouraged if you start smoking again. Remember, most people try several times before they finally quit. Here are some difficult situations to watch for: Alcohol. Drinking lowers your chances of success. Being around smoking can make you want to smoke. Many smokers will gain weight when they quit, usually less than 10 pounds. Eat a healthy diet and stay active. Don't let weight gain distract you from your main goal--quitting smoking. Some quit-smoking medications may help delay weight gain. Bad Mood or Depression. There are a lot of ways to improve your mood other than smoking. Studies suggest that everyone can quit smoking. Your situation or condition can give you a special reason to quit. Questions to Think About Think about the following questions before you try to stop smoking. You may want to talk about your answers with your health care provider or with a rov or other counselor. 1. Why do you want to quit? 2. When you tried to quit in the past, what helped and what didn't? 3. What will be the most difficult situations for you after you quit? How will you plan to handle them? 4. Who can help you through the tough times? Your family? Friends? Health care provider? 5. What pleasures do you get from smoking? What ways can you still get pleasure if you quit? The information here was taken and adapted from "Treating Tobacco Use and Dependence," a U.S. Public Health Service- sponsored Clinical Practice Guideline. For information about the guideline or to get more copies of this booklet, call toll free: 001-800-358-9295, or write: Publications Clearinghouse P.O. Box 8547 Silver Spring, MD 20907 U.S. Department of Health and Human Services Public Health Service Current as of June 2000

Benefits of Stopping Within 20 minutes after you smoke that last cigarette, your body begins a seris of changes that continue for years. 20 Minutes After Quitting Your heart rate drops. 12 hours After Quitting -- Carbon monoxide level in your blood drops to normal. 2 Weeks to 3 Months After Quitting -- Your heart attack risk begins to drop. Your lung function begins to improve. 1 to 9 Months After Quitting -- Your Coughing and shortness of breath decrease. 1 Year After Quitting -- Your added risk of coronary heart disease is half that of a smoker's. 5 Years After Quitting -- 5-15 years after quitting your stroke risk is reduced to that of a non-smoker's. 10 Years After Quitting -- Your lung cancer death rate is about half that of a smoker's. Your risk of cancers of the mouth, throat, esophagus, bladder, kidney, and pancreas decreases. 15 Years After Quitting -- Your risk of coronary heart disease is back to that of a non-smoker's.

The Letters of Gedolei Yisroel About Smoking Letter of Gedolei Yisroel Against Smoking We hereby appeal to our precious, beloved young folk who are not yet addicted to smoking, the bad habit whose end result can be very bitter: Please, dear brothers, do not do harm to yourselves and do not contaminate your surroundings by taking up this evil habit. Our holy Torah is a code of life which we must live by. Hashem wants us to guard our health so that we will be able to serve Him. Far be it from us to take this matter of health lightly, all the more so in an area which doctors are convinced is very damaging. Whoever can avoid smoking and prevent others from doing so, is obligated therein. Whoever has already succumbed to this habit is obligated to try to the best of his ability to wean himself from it. He must surely refrain from smoking in a public place where others can inhale the smoke. Yosef Sholom Eliashiv Aharon Yehuda Leib Steinman Moshe Shmuel Shapiro Michel Yehuda Lefkowitz S. Nissim Karelitz Shmuel Auerbach * * * Letter from HaRav Shmuel Wosner About Smoking Wednesday, parshas Bo, 5760 (4 Shevat, 5760 -- January 11, 2000) People have asked me what is my humble opinion, daas Torah, about smoking cigars, cigarettes, and the like, which are well known to be exceptionally damaging to one's health. I will comply with their wish and answer in brief. 1) "The Chachomim have prohibited many things because they are life- endangering. Anyone who disobeys and says, `I am willing to endanger myself and it is no one else's affair what I do in these matters,' or `I am not careful about these matters,' is to be punished with makkos mardus" (Rambam, Mishneh Torah, Hilchos Rotzei'ach, 11:5). 2) The Rambam includes in this issur various sorts of food and drink that are dangerous to life, as he enumerates in the cited perek (halochos 6-16). The Ritvo (on Shavuos 27a) writes that the Torah forbids eating food which damages one's health when it writes, "Only take heed to yourself and greatly beware for your nefesh" (Devorim 4:9). 3) After the Chasam Sofer (Chidushei Chasam Sofer, Avoda Zorah 30) cites the above-mentioned halocho of the Rambam's, he writes, "The duty of the Sages to see to it [that we do not endanger ourselves] is inferred, according to the gemora (Mo'ed Koton 5a) from the posuk `blood will be upon you' (Devorim 19:10). According to the gemora, if the Chachomim do not take care to eliminate the hazards listed in the gemora (and similar ones), and as a result a person's blood is spilt, the Torah considers the Chachomim as having spilt that blood. 4) We learn from the above that the Sages of today have the responsibility to warn the public about the enormous danger of smoking cigarettes and similar acts, which have been proven [dangerous] beyond doubt in extensive medical research, and because of which hundreds of thousands of people die prematurely. Likewise, medical reports from all over the world substantially confirm that smoking is a major cause of lung cancer, heart disorders, and many other diseases. 5) The halocho is therefore obvious. It is completely forbidden to begin smoking when one is an adolescent or when one is young. The Torah definitely requires parents, teachers, and educators to prevent young people from smoking. 6) Anyone who has already acquired this bad habit should make efforts to gradually wean himself from it, for the sake of his future and his [present] benefit. 7) One may not, cholila, smoke in public places, since research has shown that the smoke [when breathed in by others] damages others' health too. 8) Since this bad habit is tremendously damaging, those who publish advertisements in newspapers and other publications have a part in harming others. 9) In light of the grave matter written above, according to the Torah, anyone who can prevent himself from smoking or help others not smoke is obligated to do so. May everyone who listens to what we have written enjoy a serene and secure life. May he merit long life by guarding his own life, that of his family, and that of those around him, according to the Torah's demands. He will be zoche to what the Torah promises: "I will put none of these diseases upon you, which I brought upon Egypt, for I am Hashem Who heals you" (Shemos 15:26). "For through Me your days shall be multiplied and the years of your life shall be increased" (Mishlei 9:11). I sign for the benefit of our holy nation, awaiting Divine mercy. (signed) Shmuel HaLevi Wosner HaRav Wosner is rav and av beis din of Zichron Meir and rosh yeshiva of Yeshivas Chachmei Lublin, Bnei Brak

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