20 myths about smoking that will not die

Originally published as two columns on The Conversation, we bring you the definitive list of 20 myths about smoking that will not die by Simon Chapman, University of Sydney

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Across forty years I’ve come to recognise many factoid-driven myths about smoking that just won’t die. If I asked for a dollar each time I had to refute these statements, I’d have accumulated a small fortune.

Their persistence owes much to their being a vehicle for those who utter them to express unvoiced but clear sub-texts that reflect deeply held beliefs about women, the disadvantaged, mental illness, government health campaigns and the “natural”.

Let’s drive a stake through the heart of ten of the most common myths.

1. Women and girls smoke more than men and boys

Women have never smoked more than men. Occasionally, a survey will show one age band where it’s the other way around, but from the earliest mass uptake of smoking in the first decades of last century, men streaked out way ahead of women.

In 1945 in Australia, 72% of men and 26% of women smoked. By 1976, men had fallen to 43% and women had risen to 33%.

As a result, men’s tobacco-caused death rates have always been much higher than those of women. Women’s lung cancer rates, for example, seem unlikely to reach even half the peak rates that we saw among men in the 1970s.

Currently in Australia, 15% of men and 12% of women smoke daily.

But what about all the “young girls” you can see smoking, I’m always being told. In 2014, 13% of 17-year-old male high school students and 11% of females smoked. In two younger age bands, girls smoked more (by a single percentage point).

Those who keep on insisting girls smoke more are probably just letting their sexist outrage show about noticing girls’ smoking than their ignorance about the data.

2. Quit campaigns don’t work on low socioeconomic smokers

In Australia, 11% of those in the highest quintile of economic advantage smoke, compared with 27.6% in the lowest quintile. More than double.

So does this mean that our quit campaigns “don’t work” on the least well-off?

Smoking prevalence data reflect two things: the proportion of people who ever smoked, and the proportion who quit.

If we look at the most disadvantaged group, we find that a far higher proportion take up smoking than in their more well-to-do counterparts. Only 39.5% have never smoked compared with 50.4% of the most advantaged – see table 9.2.6).

When it comes to quitting, 46% of the most disadvantaged have quit compared to 66% of the least disadvantaged (see table 9.2.9).

There is a higher percentage of the disadvantaged who smoke mainly because more take it up, not because disadvantaged smokers can’t or won’t quit. With 27.6% of the most disadvantaged smoking today, the good news is that nearly three-quarters don’t. Smoking and disadvantage are hardly inseparable.

3. Scare campaigns ‘don’t work’

Countless studies have asked ex-smokers why they stopped and current smokers about why they are trying to stop. I have never seen such a study when there was not daylight between the first reason cited (worry about health consequences) and the second most nominated reason (usually cost).

For example, this national US study covering 13 years showed “concern for your own current or future health” was nominated by 91.6% of ex-smokers as the main reason they quit, compared with 58.7% naming expense and 55.7% being concerned about the impact of their smoking on others.

If information and warnings about the dire consequences of smoking “don’t work”, then from where do all these ex-smokers ever get these top-of-mind concerns? They don’t pop into their heads by magic. They encounter them via anti-smoking campaigns, pack warnings, news stories about research and personal experiences with dying family and friends. The scare campaigns work.

4. Roll-your-own tobacco is more ‘natural’ than factory made

People who smoke rollies often look you in the eye and tell you that factory made cigarettes are full of chemical additives, while roll-your-own tobacco is “natural” – it’s just tobacco. The reasoning here that we are supposed to understand is that it’s these chemicals that are the problem, while the tobacco, being “natural”, is somehow OK.

This myth was first turned very unceremoniously on its head when New Zealand authorities ordered the tobacco companies to provide them with data on the total weight of additives in factory made cigarettes, roll-your-own and pipe tobacco.

For example, data from 1991 supplied by WD & HO Wills showed that in 879,219kg of cigarettes, there was 1,803kg of additives (0.2%). While in 366,036kg of roll-your-own tobacco, there was 82,456kg of additives (22.5%)!

Roll-your-own tobacco is pickled in flavouring and humectant chemicals, the latter being used to keep the tobacco from drying out when smokers expose the tobacco to the air 20 or more times a day when they remove tobacco to roll up a cigarette.

5. Nearly all people with schizophrenia smoke

It’s true that people with mental health problems are much more likely to smoke than those without diagnosed mental health conditions. A meta-analysis of 42 studies on tobacco smoking by those with schizophrenia found an average 62% smoking prevalence (range 14%-88%). But guess which study in these 42 gets cited and quoted far more than any of the others?

If you said the one reporting 88% smoking prevalence you’d be correct. This small 1986 US study of just 277 outpatients with schizophrenia has today been cited a remarkable 1,135 times. With colleagues, I investigated this flagrant example of citation bias (where startling but atypical results stand out in literature searches and get high citations – “wow! This one’s got a high number, let’s quote that one!”).

By googling “How many schizophrenics smoke”, we showed how this percolates into the community via media reports where figures are rounded up in statements such as, “As many as 90% of schizophrenic patients smoke.”

Endlessly repeating that “90%” of those with schizophrenia smoke does these people a real disservice. We would not tolerate such inaccuracy about any other group.

6. Everyone knows the risks of smoking

Knowledge about the risks of smoking can exist at four levels:

  • Level 1: having heard that smoking increases health risks.
  • Level 2: being aware that specific diseases are caused by smoking.
  • Level 3: accurately appreciating the meaning, severity, and probabilities of developing tobacco related diseases.

Level 4: personally accepting that the risks inherent in levels 1–3 apply to one’s own risk of contracting such diseases.

Level 1 knowledge is very high, but as you move up the levels, knowledge and understanding greatly diminish. Very few people, for example, are likely to know that two in three long term smokers will die of a smoking caused disease, nor the average number of years that smokers lose off normal life expectancy.

7. You can reduce the health risks of smoking by just cutting down

It’s true that if you smoke five cigarettes a day rather than 20, your lifetime risk of early death is less (although check the risks for one to four cigarettes a day here).

But trying to “reverse engineer” the risk by just cutting down rather than quitting has been shown in at least four large cohort studies such as this one to confer no harm reduction.

If you want to reduce risk, quitting altogether should be your goal.

8. Air pollution is the real cause of lung cancer

Air pollution is unequivocally a major health risk. By “pollution”, those who make this argument don’t mean natural particulate matter such as pollen and soil dusts, they mean nasty industrial and vehicle pollution.

The most polluted areas of Australia are cities where pollution from industry and motor vehicle emissions are most concentrated. Remote regions of the country are the least polluted, so if we wanted to consider the relative contributions of air pollution and smoking to smoking-caused diseases, an obvious question to ask would be “does the incidence of lung cancer differ between heavily polluted cities and very unpolluted remote areas?”

Yes it does. Lung cancer incidence is highest in Australia in (wait for this …) in the least polluted very remote regions of the country, where smoking prevalence happens also to be highest.

9. Smokers should not try to quit without professional help or drugs

If you ask 100 ex-smokers how they quit, between two-thirds and three-quarters will tell you they quit unaided: on their final successful quit attempt, they did not use nicotine replacement therapy, prescribed drugs, or go to some dedicated smoking cessation clinic or experience the laying on of hands from some alternative medicine therapist. They quit unaided.

So if you ask the question: “What method is used by most successful quitters when they quit?” The answer is cold turkey.

Fine print on this English National Health Service poster states a bald-faced lie by saying that “There are some people who can go cold turkey and stop. But there aren’t many of them.” In the years before nicotine-replacement threapy and other drugs were available, many millions – including heavy smokers – quit smoking without any assistance. That’s a message that the pharmaceutical industry was rather not megaphoned.

Not true.
NHS poster.

10. Many smokers live into very old age: so it can’t be that harmful

In just the way that five out of six participants in a round of deadly Russian roulette might proclaim that putting a loaded gun to their head and pulling the trigger caused no harm, those who use this argument are just ignorant of risks and probability.

Many probably buy lottery tickets with the same deep knowing that they have a good chance of winning.

Ten more myths about smoking that will not die

There’s plainly a big appetite for smoking myth busting, so here are 10 more.

1. Today’s smokers are all hard core, addicted smokers who can’t or won’t give up

This claim is the essence of what is known as the “hardening hypothesis”: the idea that decades of effort to motivate smokers to quit has seen all the low-hanging fruit fall from the tree, leaving only deeply addicted, heavy smokers today.

The key index of addicted smoking is the number of cigarettes smoked per day. This creates a small problem for the hardening hypothesis: in nations and states where smoking has reduced most, the average number of cigarettes smoked daily by continuing smokers has gone down, not up. This is exactly the opposite of what the hardening hypothesis would predict if remaining smokers were mostly hard core.

2. Smoking is pleasurable

Repeated studies have found that around 90% of smokers regret having started, and some 40% make an attempt to quit each year. There’s no other product with even a fraction of such customer disloyalty.

But I’m always amused at some die-hard smokers’ efforts explain that they smoke for pleasure and so efforts to persuade them to stop are essentially just anti-hedonistic tirades.
Many studies have documented that the “pleasure” of smoking centres around the relief smokers get when they have not smoked for a while. The next nicotine hit takes away the discomfort and craving they have been experiencing.

This argument is a bit like saying that being beaten up every day is something you want to continue with, because hey, it feels so good when the beating stops for a while.

3. Light and mild cigarettes deliver far less tar and nicotine to the smoker than standard varieties

Several nations have outlawed cigarette descriptors such as “light” and “mild” because of evidence that such products do not deliver lower amounts of tar and nicotine to smokers, and so are deceptive.

The allegedly lower yields from cigarettes labelled this way resulted from a massive consumer fraud.

Cigarette manufacturers obtained these low readings by laboratory smoking machine protocols which took a standardized number of puffs, at a standardized puff velocity. The smoke inhaled by the machine was then collected in glass “lungs” behind the machine and the tar and nicotine weighed to give the readings per cigarette.

But the companies didn’t tell smokers two things. So-called light or mild cigarettes had tiny, near-invisible pin-prick perforations just on the filter (see picture). These holes are not covered by the “lips” or “fingers” of the laboratory smoking machine, allowing extra air to be inhaled and thus diluting the dose of tar and nicotine being collected.

But when smokers use these products, two things happen. Their lips and fingers partially occlude the tiny ventilation holes, thus allowing more smoke to be inhaled. Smokers unconsciously “titrate” their smoking to obtain the dose of nicotine that their brain’s addiction centres demand: they can take more puffs, inhale more deeply, leave shorter butt lengths or smoke more cigarettes.

Today, where use of these descriptors has been stopped, the consumer deception continues with the companies using pack colours to loudly hint to smokers about which varieties are “safer”.

Magnification and location of filter ventilation holes.
Author collection

4. Filters on cigarettes remove most of the nasty stuff from cigarettes

We’ve all seen the brown stain in a discarded cigarette butt. But what few have seen is how much of that same muck enters the lungs and how much stays there.

This utterly compelling video demonstration shows how ineffective filters are in removing this deadly sludge. A smoker demonstrates holding the smoke in his mouth and then exhales it through a tissue paper, leaving a tell-tale brown stain. He then inhales a drag deep into his lungs, and exhales it into a tissue. The residue is still there, but in a much reduced amount. So where has the remainder gone? It’s still in the lungs!

5. Governments don’t want smoking to fall because they are addicted to tobacco tax and don’t want to kill a goose that lays golden eggs

This is perhaps the silliest and most fiscally illiterate argument we hear about smoking. If governments really want to maximise smoking and tax receipts, they are doing a shockingly bad job of it. Smoking in Australia has fallen almost continuously since the early 1960s. In five of the 11 years to 2011, the Australian government received less tobacco tax receipts than it did the year before (see Table 13.6.6).

Plainly, as smoking continues to decline, diminishing tax returns will occur, although this will be cushioned by the rising population which will include some smokers.

In the meantime, tobacco tax is a win-win for governments and the community. It reduces smoking like nothing else, and it provides substantial transfer of funds from smokers to government for public expenditure.

Those of us who don’t smoke do not squirrel away what we would have otherwise spent on smoking in a jam jar under the bed. We spend it on other goods and services, benefiting the economy too.

6. Most smokers die from smoking caused diseases late in life, and we’ve all got to die from something

Smoking increases the risk of many different diseases, and collectively these take about ten years off normal life expectancy from those who get them.

Smoking is by far the greatest risk factor for lung cancer. In Australia, the average age of death for people with lung cancer is 71.4 (see Table 4.2), while life expectancy is currently 80.1 for men and 84.3 for women.

This means that, on average, men diagnosed with lung cancer lose 8.7 years and women 12.9 years (mean 10.8 years). Of course, some lose many more (Beatle George Harrison died at just 58, Nat King Cole at 45).

If a 20-a-day smoker starts at 17 and dies at 71, 54 years of smoking would see 394,470 cigarettes smoked. At ten puffs per cigarette, that’s some 3.94 million point-blank lung bastings.

It takes about six minutes to smoke a cigarette. So at 20 a day, smokers smoke for two hours each day. Across 54 years, that’s a cumulative 1,644 days of smoking (4.5 years of continual smoking if you put it all together).

So by losing ten years off life expectancy, each cigarette smoked takes about 2.2 times the time it takes to smoke it off the life expectancy that might otherwise have been enjoyed.

7. Smokers cost the health system far more than the government receives from tobacco tax

In June 2015, a senior staff member of Australian libertarian Senator David Leyonhjelm, Helen Dale tweeted:

In Australia, a now old report looking at 2004/05 data estimated the gross health care costs attributable to smoking “before adjustment for savings due to premature death” were $A1.836 billion. In that financial year, the government received $A7,816.35 billion in customs and excise duty and GST on tobacco.

Someone who thought that the fiscal ledger was all that mattered in good government might conclude from this that smokers easily pay their way and perhaps we should even encourage smoking as a citizen’s patriotic duty.

With smokers being considerate enough to die early, these noble citizens lay down their lives early and thus contribute “savings due to premature death” like failing to draw a state pension or needing aged care services late in life. Philip Morris notoriously gave this advice to the new Czech government in 1999.

Other assessments, though, might well point to the values inherent in such assessments. History’s worst regimes have often seen economically non-productive people as human detritus deserving death. Primo Levi’s unforgettable witnessing of this mentality in Auschwitz comes to mind.

8. Big Tobacco is starting to invade low-income nations, now that smoking is on the wane in the wealthiest nations

Sorry, but US and British manufacturers have been aggressively marketing cigarettes in places such as China since the early years of last century. These collectable posters show many featuring Chinese women.

The large populations, the often lax tobacco-control policies and the higher corruption indexes of many low- and middle-income nations makes many of these nirvanas for Big Tobacco.

There are fewer more nauseating experiences than reading the corporate social responsibility reports of tobacco transnationals and then seeing how they operate in smokers’ paradises such as Indonesia. This documentary says it all.

9. Millions of cigarette butts on the world’s beaches leach lots of toxic chemicals into oceans

Cigarette butts are the most discarded items in all litter. Every year uncounted millions if not billions are washed down gutters in storm water and find their way into rivers, harbours and oceans. Cigarette filters and butts contain toxic residue and experiments have shown that placing laboratory fish in containers for 48 hours with leachate extracted from used cigarette butts, 50% of the fish die. From this, we sometimes hear people exclaim that cigarette butts are not just unsightly, but they “poison the oceans”.

But a confined laboratory container does not remotely mirror real life exposures in oceans or rivers. There are some 1,338,000,000 cubic kilometers of water in the world oceans, so the contribution of cigarette butts to the toxification of all this could only excite a homeopath.

If we want to reduce tobacco litter, we need not wander into such dubious justifications. The best way by far is to keep reducing smoking. Industry attempts at portraying themselves as corporately responsible by running dinky little clean-up campaigns or distributing personal butt disposal canisters avoids their efforts to keep as many smoking as possible.

10. Tobacco companies care deeply about their best customers dying early

Naturally, all businesses would rather their customers lived as long as possible so that the cash registers can keep ringing out long and loud. Tobacco companies wish their products didn’t kill so many, but worship the god nicotine for its iron grip on so many.

Visit any tobacco transnational’s website and you will find lots of earnest and caring talk about the companies’ dedication to doing all they can to reduce the terrible harm caused by their products. All the major companies have now invested heavily in electronic cigarettes, so isn’t this a sign that they taking harm reduction seriously?

It might be if the same companies were showing any sign of taking their feet off the turbo-drive accelerator of opposing effective tobacco control policies. But they are doing nothing of the sort. All continue to aggressively attack and delay any policy like tax hikes, graphic health warnings, plain packaging and advertising bans wherever in the world these are planned for introduction.

For all their unctuous hand-wringing about their mission to reduce harm, they are all utterly determined to keep as many smoking as possible. Big Tobacco’s business plan is not smoking or ecigarettes. It’s smoking and ecigarettes. Smoke when you are able to, vape when you can’t. It’s called dual use and some 70% of vapers are doing just that. The tragedy now playing out in some nations is that too many gormless tobacco control experts are blind to this big picture.

Simon Chapman, Emeritus Professor in Public Health, University of Sydney

These articles were originally published on The Conversation. Read the original article  and the other original article.