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Ann Thorac Surg 1998;66:694-696
© 1998 The Society of Thoracic Surgeons
a Section of Thoracic Surgery, City of Hope National Medical Center, Duarte, California, USA
Address reprint requests to Dr Grannis, Section of Thoracic Surgery, Department of General Oncologic Surgery, City of Hope National Medical Center, 1500 E Duarte Rd, Duarte CA 91010
e-mail: (fgrannis{at}smtplink.coh.org)
Abstract
Thoracic surgeons play a major role in the treatment of tobacco-caused disease. Historically, thoracic surgeons have been committed investigators of tobacco-caused disease and activists for tobacco control reform. This editorial reviews and comments on the current activity of American thoracic surgeons, thoracic surgical societies, and journals in these areas. Thoracic surgeons have been remiss in their individual and collective public health responsibility to inform the public and advocate tobacco control reforms. We must commit to a more energetic effort.
On February 16, 1998, Former Surgeon General Everett Koop, MD, Food and Drug Administration Chief David Kessler, MD, and American Medical Association representative George Lundberg, MD, issued a clarion call-to-arms to American physicians in an editorial in the Journal of the American Medical Association and in a letter to Congress: "Surely there cannot be a physician who believes that it is professionally, ethical or socially responsible to be silent as Congress begins to consider how the tobacco industry (TI) should do business in the future. It is time to volunteer, to learn, and to speak out" [1]. "We believe each physician has a responsibility to seize this moment in history and to use every means at his or her disposal to convince members of Congress to enact meaningful tobacco legislation" [1].
If one searches the pages of the two major thoracic surgical journals, The Annals of Thoracic Surgery and The Journal of Thoracic and Cardiovascular Surgery, over the past 32 years, one finds precious few articles, editorials, and letters on the important topic of tobacco-caused human disease and the public health measures necessary for its control. It is critically important that we reexamine this problem and commit to a more energetic participation in tobacco control (TC) efforts at this time, a critical cusp in the national debate now ongoing over the possible "global settlement" between Congress and the tobacco industry (TI).
Historically, thoracic surgeons were among the first to recognize the fact that tobacco causes lung cancer and other disease, and to advocate TC public health measures. Alton Ochsner noted an obvious association between a sudden increase in the incidence of cases of lung cancer and cigarette smoking in the 1930s, and was a TC activist throughout his life. Evarts Graham, who himself died of lung cancer, provided early epidemiologic data of the strong association between cigarette smoking and lung cancer in 1950. William Cahan instigated early laboratory experiments into the carcinogenesis of cigarette smoke in animals, and remains an active TC advocate today. Doctor Richard Overholt was a lifelong crusader for TC. I have personal memories of hospital workers (myself included) at the New England Baptist Hospital hurriedly hiding cigarettes when Dr Overholt entered the hospital cafeteria, because of his rumored penchant for tearing up cigarette packs. Dwight Harken, also of Boston, was another early antitobacco activist, who together with Ochsner and Overholt advocated litigation by lung cancer patients against tobacco companies.
That was then; this is now. A search of The Annals of Thoracic Surgery and The Journal of Thoracic and Cardiovascular Surgery in the National Library of Medicine for the years 1966 to 1998, on the text words "smoking," "tobacco" or "cigarette," retrieves a striking dearth of published material on these topics. Furthermore, the search retrieves no position statement by either The Society of Thoracic Surgeons or The American Association for Thoracic Surgery on tobacco-related disease or control measures. This represents evidence of a lamentable failure of our profession in the interests of public health. This situation must change, and change now.
It is important for each thoracic surgeon to understand that he or she represents the major hope of treatment and possible cure to patients suffering with tobacco-caused diseases, including coronary artery disease, lung cancer, emphysema, and esophageal cancer. Furthermore, because many thoracic surgeons perform vascular surgical procedures, they also make a significant contribution toward reducing mortality and morbidity from stroke, aortic aneurysm, and peripheral vascular disease.
Cigarette smoking is the single most important correctable risk factor for mortality in the United States. There are currently about 50 million smokers in this country, and approximately the same number of ex-smokers. From these two groups, 430,000 die each year of smoking-related diseases. Another fifty thousand die of disease caused by environmental tobacco smoke. Approximately 30% of smokers will ultimately die of a tobacco-related disease. These deaths comprise about 25% of all deaths, far exceeding mortality due to acquired immunodeficiency syndrome, alcohol, drug abuse, accident, murder, and suicide combined. These diseases include coronary artery disease, chronic obstructive lung disease, peripheral and cerebrovascular disease, and cancers of the lung, oropharynx, larynx, esophagus, pancreas, kidney, bladder, colon, and cervix. Lung cancer alone causes 160,100 deaths each year [2].
There is also considerable morbidity caused by tobacco products, with a striking increase in premature and low birth rate among neonates, and increases in sudden infant death syndrome and upper respiratory and ear infections in children. Children and nonsmoking spouses in smoking households suffer damage from environmental tobacco smoke and have a higher prevalence of the smoking habit, respiratory illness, and neoplasms. Cigarette smoking is related to major disability secondary to chronic obstructive lung disease, cerebrovascular accidents, myocardial infarction, amputations secondary to peripheral vascular disease, and macular degeneration.
This tobacco-associated morbidity and mortality also results in a staggering economic loss to our society of approximately $120 billion/year, including a $32 billion annual cost to Medicare and Medicaid [3]. Thus, each of the 24 billion packs of cigarettes sold costs our government $1.25. Former Surgeon General Joseph Califano has estimated that tobacco-related disease will have depleted the Medicare system alone $800 billion by the year 2010.
Almost all new smokers come from the age group under 21 years. Three thousand children and adolescents begin smoking daily in response to a $5.1 billion annual bombardment of marketing directed toward them by the TI [4]. Despite all efforts, the prevalence of smoking is again on the rise in teens. Recent Congressional actions seem to offer some hope that our society is finally going to take effective action in primary prevention.
Even if these efforts were a perfect success, with no further new smokers, we would still face the daunting problem of shepherding approximately 50 million current smokers to abstinence. There is good evidence that cessation of the smoking habit will reverse the increase in mortality associated with coronary artery disease, that progressive decrements in pulmonary function will cease, and that the risk of development of a bronchogenic carcinoma will decrease by about 50% over the ensuing decade. Smoking cessation is, therefore, a high national priority. The powerful addictive nature of nicotine has only been widely recognized during the past decade, although it is now apparent that TI research labs had documented this addictive potency years earlier. Allegations have been made that tobacco companies have deliberately manipulated nicotine levels in cigarettes.
We are currently exporting this terrible epidemic around the world, because 80% of sales by our TI are to foreign markets. The Global Burden of Disease Study has estimated that tobacco-attributable mortality will reach 8.4 million deaths/year in the year 2020 [5].
It is clearly time to take effective action to correct this intolerable situation. Thoracic surgeons must shake off 30 years of apathy. Long hours of work on a virtual assembly line, treating millions of patients with tobacco-caused disease, does not fulfill our obligation to society. We must also help to shut down the conveyor belt. We must become more involved in primary prevention efforts in our communities and help our patients with smoking cessation. We must demand that our elected representatives, both medical and political do the following:
After failure of social-political change after the 1964 Surgeon General’s report, Dr Overholt stated, with remarkable prescience, that "In the war of attrition which is going to last at least a generation, the medical profession must be the leader, the emancipator. We must take the initiative now and we must not lose it" [6]. Our generation ignored Overholt’s sage advice and lost the war of attrition. We have accomplished little progress against tobacco-related disease in the past four decades because of the ruthless use of the wealth and power of the TI, the weakness of our political institutions, and the inertia of American medicine. The TI has repeatedly hoodwinked and out-maneuvered our leaders. No meaningful TC has been achieved. The result has been a national and international public health disaster.
Finally, 34 years later, public revelations of internal TI documents have provided alleged evidence of cover-ups and conspiracy, and these have catalyzed our political and legal institutions into action, in a myriad of state attorneys-general and class-action suits against the TI. The June 16, 1997, "global tobacco settlement" between the TI and a few attorneys-general is a stopgap measure, concocted by a badly frightened tobacco cartel uncertain of its ability to survive protracted legal assaults. Its preemption, cap, and immunity provisions would save the TI from regulation, disclosure, and liability, and would allow it to continue to prosper in its predatory activities. Neither this bailout deal nor the equally weak McCain-Hollings bill S.1405 can be allowed to pass into law.*
Thoracic surgeons in general and thoracic surgical societies, specifically The Society of Thoracic Surgeons and The American Association for Thoracic Surgery, as well as their official journals, The Annals of Thoracic Surgery and The Journal of Thoracic and Cardiovascular Surgery, have been remiss in their individual and collective public health responsibility to inform the populace and to advocate TC reforms. We must commit to a more energetic effort. We have failed in our duty to our patients and to our society in the past; we must not fail again, now or in the future.
Footnotes
* An evaluation of the global tobacco settlement of June 16, 1997, by Stanton Glantz and his colleagues at the University of California San Francisco can be accessed on the Internet at URL http://www. library.ucsf.edu/tobacco/ustl/. An evaluation of the McCain bill S.1405 can be accessed on the Internet at URL http://ourworld.compuserve.com/homepages/lungcancer/koop1415.htm. The full text of S.1415 is not presently available. 
References
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