Chapter 3

Taking Tobacco’s Health Costs into Account

IN THIS CHAPTER

Bullet Seeing what smoking does to lifestyle

Bullet Counting up the health costs of smoking

Bullet Glancing at the health benefits of quitting

A group of friends, camping together, join around the campfire after the sun sets and the night turns cooler. The group finishes eating their s’mores, sings a couple of folk songs, and relaxes around the brightly burning fire. The hostess reaches into her backpack and brings out paper straws that she passes to her guests.

Most guests take a straw, lean into the fire and then suck up the gritty smoke, breathing deeply in and out. Plumes of smoke rise through the trees into the star-filled sky. A couple of guests pluck bunches of leaves from nearby plants and start chewing them — while spitting out the residue. Others gather dead leaves, crush them into a powder and snuff it up their noses. A satisfying end to a lovely evening.

Does this sound like your vision of an idyllic camping adventure? Yuck. Probably not. But ask yourself how different this scene is from what people do when they smoke, chew, or sniff tobacco, whether indoors or out. Why would anyone do that? As Chapter 2 notes, it’s largely about addiction, of which nicotine is a prime culprit.

In this chapter, we review the consequences of smoking or ingesting tobacco products. First, we describe how consuming tobacco affects a person’s life. Then, we delve into the longer-term consequences of smoking cigarettes, pipes, and cigars, or using smokeless tobacco products.

Warning Research tells us that scare messages about tobacco just don’t work very well to help people stop smoking. For some, such messages seem to even make things worse. We report this information not with the intent of scaring you. Just realize that in order to make good decisions, it helps to know the truth about the risks of tobacco.

How Smoking Affects Everyday Life

In this section, we primarily address how smoking affects day-to-day living. That’s because, to date, more people smoke than use smokeless methods of tobacco ingestion. Plus, a vast body of research on the effects of smoking exists for us to draw upon.

There are limited studies on pipe smoking, cigar smoking, low-tar and low-nicotine cigarettes, so-called “all-natural cigarettes,” and filtered versus unfiltered cigarettes. Smokeless tobacco (such as chewing tobacco and snuff) has also been researched. We note this information when it’s available and where it’s applicable.

However, there is much less research to draw upon regarding heated tobacco products (HTPs). In fact, to date, research on HTPs has been done primarily by the very companies that are selling the devices — and that’s not exactly unbiased research. It will take multiple long-term studies to answer the questions about the safety of HTPs.

Warning There is no verifiably safe tobacco product available today. You may hear claims to the contrary, but the evidence fails to support that idea. Whether you smoke, inhale, chew, or sniff, tobacco is hazardous to your health.

Examining exercise

Smoking makes it much harder to exercise. That’s unfortunate because the benefits of exercise on overall physical health and well-being are hard to deny. The following is just a partial list of health benefits you can expect from frequent, consistent exercise, whether you smoke or not. Specifically, exercise

  • Normalizes blood pressure
  • Improves overall cardiovascular health
  • Decreases the risk of diabetes
  • Reduces some cancer risks
  • Improves muscle and joint function
  • Reduces inflammation
  • Strengthens bones
  • Improves memory and brain functioning

Regular exercise also improves mental health. Frequent exercisers have less depression and anxiety. They also have better focus and handle stress more effectively. Find a drug that can do all that for both mental and physical health, and you’ll become rich and famous!

So, if you smoke, it’s even more important to exercise. That’s because smoking damages many of the things that exercise at least ameliorates. Unfortunately, smoking also makes exercise more challenging because smoking

  • Narrows the arteries, reducing blood flow
  • Increases resting heart rate
  • Decreases lung capacity
  • Increases carbon monoxide in the bloodstream
  • Increases the body’s production of phlegm
  • Decreases the body’s ability to use oxygen

These effects of smoking obviously decrease your stamina and aerobic capacity. Smoking also damages muscles and their capacity for growth because of impaired circulation. That doesn’t mean you shouldn’t exercise, but you need to proceed with care. Exercise seems to mitigate some, but not by any means all, of the risks from smoking. Quitting is best.

Warning If you smoke and plan to start an exercise routine, be sure to check with your primary-care provider first. Your health may already be compromised, and you may have to adhere to a graduated, careful regimen.

The nearby sidebar, “Getting moving,” illustrates how a smoker can benefit from exercise.

Tip Some regular smokers who exercise claim that smoking doesn’t impact their health. This belief involves denial and wishful thinking. Smoking may not have fully caught up with them or, more likely, they’re experiencing some effects that will worsen with time.

But how about smokeless tobacco? See Chapter 2 for information about the types of smokeless tobacco. Given that it’s not inhaled, you could be tempted to think it’s benign. In fact, smokeless tobacco has been widely used in sports. Because of the stimulant effects of nicotine, many athletes have believed that chewing or snuffing tobacco could improve their performance.

Indeed, smokeless tobacco does appear to have a few short-term, positive effects on athletic performance. It seems to improve concentration, decrease performance anxiety, and temporarily improve aerobic capacity.

But what may help a bit in the short run, can bite you in the long run. Data tell us that smokeless tobacco has been associated with increased rates of mouth, tongue, gum, and cheek cancer. Caffeine has many of the positive effects of nicotine and much less downside risk. Consider having a cup of coffee instead.

Eating and smoking

Many teens, especially girls, start smoking because they want to lose weight. In fact, merely desiring to diet increases the chances that a teen will turn to smoking. And, perhaps unfortunately, there is some truth that smoking, and nicotine help control weight. Nicotine appears to have many impacts on the body, including increasing metabolism and suppressing appetite. In addition, smokers sometimes claim that they reach for a cigarette rather than a cookie or a donut.

However, smoking negatively affects nutrition. For example, tobacco smoke has the potential to decrease absorption of calcium and vitamins C, B, and E. Furthermore, smokers are less likely to eat a healthy diet full of fruits and vegetables.

Smokers who quit tend to gain weight. The amounts are typically moderate, but significant. Sometimes smokers who previously had normal body mass indexes move into the overweight category after quitting smoking.

Technical stuff The body mass index (BMI) is a measure of body fat that is based on your height and weight. Your BMI indicates to what degree your weight is on target, underweight, or overweight. You can find your BMI at www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm.

Warning Concerns about weight gain are important. However, it’s important to remember that the negative health effects of smoking far outweigh the costs of gaining weight. See Chapter 20 for dealing with weight gain when trying to quit smoking.

Smelling and smoking

When it comes to the sense of smell, you get hit with two problems from smoking:

  • Smokers are six times more likely to have a diminished sense of smell than nonsmokers. Those who smoke more lose even more of their sense of smell. Loss of smell can make food less appetizing. Loss of smell even poses some danger: You may not be able to detect gas leaks or smoke and fire. You may not know your house has some horrible odor — not a good thing when having company over.
  • Smokers, well, um, they tend to smell like disgusting smoke and cigarettes to nonsmokers. Cigarette smell is notorious for permeating curtains, furniture, bedding, cars, clothes, and even your hair. You may wonder why you don’t smell it. Did we mention you lose your sense of smell?

Perhaps surprisingly, smokeless tobacco appears to affect sense of smell and taste as well. No easy out here.

Looking in the mirror

Smoking affects the youthfulness and health of your skin. Several studies have been conducted in which identical twins (one a smoker and one not) were evaluated by researchers who did not know their smoking history. Overall, nonsmoking twins were judged as more attractive and had fewer signs of facial aging than their smoking counterparts.

So, if you want healthier, more vibrant skin, giving up smoking may be your next miracle beauty cream. And instead of having to pay over $100 an ounce for it, you get paid by not having to buy cigarettes!

Smoking also affects appearance by causing

  • Yellowing of the fingers and fingernails
  • Thinning hair and hair loss
  • Acne breakouts
  • Stained teeth
  • Patches on the tongue (especially ugly if your tongue is pierced)
  • Belly fat
  • Increased risk of psoriasis
  • Sagging skin

Tip Smokeless tobacco products don’t cause as many of these problems, although they aren’t entirely benign, as evidenced particularly by oral effects such as stained teeth and periodontal disease.

Reproducing and smoking

If you’re thinking about having a baby, there’s no better time than now to stop smoking. Fertility in both men and women decreases with smoking. Sperm quality, density, count, and motility decline. Eggs are exposed to the toxins and appear to be damaged by smoking.

Warning Men who smoke are at risk for erectile dysfunction. We’re pretty sure that could make getting pregnant a bit more challenging and possibly less rewarding.

Worse are the effects of smoke on the unborn child. Smoke, whether from the mother, or secondhand, goes directly to the developing fetus. Smoking is associated with

  • Increased rate of miscarriages and stillbirths
  • Increased incidence of birth defects
  • Prematurity
  • Sudden infant death syndrome (SIDS)
  • Low birth weight
  • Lung and respiratory problems

In effect, the baby becomes a smoker right along with both mom and dad. Most advice in books and on the Internet implore you to stop smoking if you’re planning to become pregnant. Prospective parents already know that. We simply suggest that this is a time future parents don’t go it alone. See your healthcare provider to coordinate your pregnancy, or your partner’s pregnancy, with an effective stop-smoking plan such as the one outlined in this book. You don’t need to try harder, just smarter.

Khloe’s story (in the nearby sidebar, “Getting the help you need”) describes how a healthcare provider can help or hinder a pregnant woman’s desire to quit smoking.

Tip If you’re a smoker and become pregnant, beating yourself up will not help. We know you care about your baby, and feeling guilty won’t make things better. You need to find someone who can support you and help you develop a solid game plan for quitting and preparing yourself for the birth of your baby.

Getting Seriously Sick from Smoking

Unfortunately, ingesting poison into your system daily for many years takes a toll. We say that not to shame or scare you. Mercifully, we’re keeping some of the gory details limited. The reason it’s important to know about these issues is that it may help give you additional motivation for quitting.

Tip If you feel you grasp the overall health risks of smoking or just find the information too gruesome and upsetting, you can certainly skip right to Parts 3 and 4. Those parts focus on quitting strategies and developing your personal plan for doing so.

The good news is that quitting smoking confers substantial health benefits no matter when you do it. The bad news is that you actually have to quit to get these benefits.

So, exactly what can you expect in the relatively near term when you quit smoking? Here are a few of the benefits:

  • If you’re an exerciser, your lung function starts to improve after just a few weeks of not smoking.
  • Fertility returns to normal quickly after quitting.
  • The risk of babies born with low birth weight is the same as nonsmokers upon quitting.
  • Your smell and taste will gradually return after six months or less.
  • You won’t cough as much in the first year or so.
  • Your heart disease risk reduces after the first year and improves to that of a nonsmoker after 15 years.
  • Cancer risk reduction takes longer but declines after five years.
  • Your risk of a stroke declines substantially after five years.

In the following sections, we detail the major health risks of smoking. Smoking continues to be the most preventable cause of death in the United States and most of the world.

Examining the vascular system

The circulatory system includes the heart, arteries and veins and is responsible for delivering oxygen-rich nutrients and removing waste from all areas in the body. In a healthy body, the process of circulation is effortless. Smoking interferes with that process.

Cardiovascular disease

Heart disease is the leading cause of death for men and women in the United States. About 20 percent of all deaths from heart disease can be directly attributed to smoking. In addition, smokers who have heart disease are more likely to die younger than nonsmokers.

Warning Every single cigarette a smoker consumes increases the risk of heart disease. In other words, the more you smoke, the more likely you’ll die of heart disease.

What does smoking do to the cardiovascular system? If your health care provider tells you that you suffer from one of the following health issues, you can bet that smoking has contributed to these interrelated diseases:

  • Hypertension (high blood pressure): Smoking increases blood pressure immediately and over the long term. Hypertension causes the heart to pump harder. It damages blood vessels, causing them to narrow, weaken, or rupture. That damage, in turn, can lead to stroke or heart attack.
  • Arteriosclerosis: This disease involves plaque buildup in the arteries, which can result in a serious blockage resulting in stroke or heart attack.
  • Heart disease: When the plaque buildup affects the blood supply to the heart or the coronary arteries, it can cause chest pain, shortness of breath, or a heart attack. When a heart is weakened, it can lead to what’s known as heart failure. Heart failure occurs gradually, and symptoms include shortness of breath, weakness, fatigue, wheezing, and retention of fluids, resulting in swollen feet and ankles.

Warning Although many pipe and cigar smokers claim that they don’t inhale, some do, and all of them ingest secondhand smoke close up. Smoking cigars and pipes increases both the risk of heart disease and stroke.

Cerebrovascular disease

Strokes occur when the blood supply to the brain is impeded by a blockage or leakage. The more you smoke, the higher your risk for stroke. In fact, strokes are the top cause of serious long-term disability in the United States. The acronym FAST can help you remember the symptoms of a stroke. Here’s what the acronym stands for:

  • Face: Numbness or weakness as evidenced by a droopy or asymmetrical smile.
  • Arms: Weakness or paralysis on one side of the body, which can be determined by trying to raise both arms at the same time. With a stroke, one arm may not function the way the other one does.
  • Speech: Confusion or difficulty speaking, or understanding may show themselves.
  • Time: If these symptoms appear, call a doctor immediately. Urgent, prompt attention can improve the outcome greatly.

Smoking leads to a host of cerebrovascular problems. It also hijacks the mind, body, and soul. Ted’s story, in the nearby sidebar, “Dying for a smoke,” shows how powerfully addiction leads to deterioration in health, but also impedes recovery.

Checking for peripheral artery disease

With peripheral artery disease (PAD), plaque builds up in the arteries of the outer (or peripheral) part of the body, most commonly the legs. PAD results in pain, cramping, weakness, and numbness in the extremities. If the blood flow is sufficiently restricted, it can also lead to a high risk of infection, which is difficult to treat. Those with severe PAD, can develop gangrene in the affected tissues, which can lead to amputation or even death. Smoking and diabetes are both risk factors for PAD.

Looking at lungs even if you don’t want to

From the moment a smoker inhales for the first time, the lungs rebel. Most first-timers choke and cough as part of this rebellion. But the lungs adapt after a while and seem just fine again — until they’re not so fine.

Warning In addition to lung problems directly caused by smoking, smoking exacerbates preexisting asthma, makes recovery from colds or flu slower, and can increase the risk of pneumonia.

Warning See your doctor for any cough that lasts for three weeks or more or immediately if you’re coughing up blood.

Confronting coughs

Most smokers develop a smokers’ cough. It’s caused by toxins setting up shop in your lungs, which the body tries to eliminate by coughing. In the beginning, it’s a dry, unproductive cough without phlegm. As time passes, it becomes more frequent, gets worse in the morning, and starts producing phlegm. Treatments designed for typical coughs are not particularly effective for smoker’s cough. Eventually, smoker’s cough often leads to more serious conditions.

Taking a turn for the worse

Many people fear lung cancer as the worst outcome of long-term smoking, and for good reason. However, chronic obstructive pulmonary disease (COPD) ranks pretty high on the list, too. In fact, the U.S. Centers for Disease Control and Prevention (CDC) ranks COPD the fourth leading cause of death in the United States. As COPD progresses, the lungs struggle to function properly. The lung tissues thicken, which makes it more difficult to inhale and exhale. More mucus is also produced as the disease progresses.

Again, our intention is not to scare you, but people with end-stage COPD have great difficult breathing and become cognitively impaired due to the lack of oxygen. Most experience substantial anxiety because of being unable to catch their breath, which can turn into feelings of drowning. Although there are medications for easing symptoms for a while, there is no cure for COPD. Smoking causes at least 75 percent of all cases of COPD.

Technical stuff COPD is often used as an umbrella term encompassing both chronic bronchitis and emphysema. Chronic bronchitis is bronchitis that persists for months, often recurring over years. Symptoms of chronic bronchitis include

  • Shortness of breath
  • Unusually low energy
  • Cough
  • Overproduction of mucus or phlegm
  • Sometimes fever

The most severe symptom of emphysema is shortness of breath. That shortness of breath may appear when going for a long walk at first. However, as the disease progresses, shortness of breath becomes much worse and can be evoked by almost doing nothing, even when sitting. Also, people with advanced emphysema suffer chronic fatigue, poor alertness, and blue or gray fingernails.

Confronting lung cancer

Eighty percent to 90 percent of all lung cancers appear to be caused by smoking. Most lung cancers are not diagnosed in the early stages, which is why about half of all patients die in the first year following diagnosis. The five-year survival rate is just under 20 percent. We should note that a few new, targeted medications and immunotherapy hold some promise for future improvements in these outcomes.

Warning Smoking light or menthol cigarettes does not reduce a smoker’s risk of lung cancer compared to regular cigarettes. However, smoking unfiltered cigarettes doubles the risk of lung cancer for smokers. Filters do not make cigarettes safe in any way, shape, or form. But if you’re going to smoke something, come hell or high water, at least consider avoiding unfiltered cigarettes.

Tip Early detection greatly improves survival rates. If you’re a smoker, consider going to www.lung.org for a free quiz that you can use to determine if you’re eligible for a low-dose CT screening exam that could save your life.

Normally, the first sign of lung cancer is a cough that doesn’t go away. Hoarseness, shortness of breath, chest pain, coughing up blood, weight loss, and frequent lung infections represent more concerning symptoms. Don’t wait; if you think you’re at high risk or you have some of these symptoms, see your healthcare professional right away.

Warning When it comes to your risk of heart disease, stroke, and especially COPD and lung cancer, you may think you’ve succeeded at dodging the bullet if you use smokeless tobacco. Although your risk of lung cancer and COPD may be lower as a smokeless tobacco user, that’s not necessarily the case for many other forms of cancer. In the next section, we look at some of the health risks faced by smokeless tobacco users.

Warning HTPs have not yet been linked to lung cancer. And tobacco companies claim that they’re safer than cigarettes. We have two problems with this claim:

  • There have not been any long-term studies of the safety of HTPs compared to cigarettes.
  • You’re inhaling the vapor of the entire tobacco product. Indeed, HTPs don’t involve the range of carcinogenic materials and chemicals of burned tobacco, but they do contain some of the same toxins.

Scanning for other cancers

Smoking not only devastates the lungs and circulatory system but also is responsible for many otherwise preventable cancers. Cancer involves cells going wild dividing and invading healthy tissue. Cancer cells move stealthily through the blood and lymphatic system. Toxic chemicals from tobacco make emerging cancer cells more likely and stopping cancer cells more difficult. Warning signs of cancer include

  • Unexplained weight loss
  • Persistent cough or hoarseness
  • Sores that take too long to heal
  • Unexplained lumps that appear anywhere on the body
  • Bleeding or discharge
  • Fatigue

Warning If you have any of the troubling signs above, or significant changes in appetite, bowel or bladder routine, or unexplained pain, see your healthcare provider for a checkup.

The more cigarettes you smoke and the more years you smoke them, the greater your risk of cancer of most types. Sending toxic chemicals throughout your body has consequences including a higher risk of the following:

  • Mouth and throat cancer
  • Esophageal cancer
  • Cancer of the larynx
  • Cancer of the trachea
  • Pancreatic cancer
  • Stomach cancer
  • Bladder cancer
  • Kidney cancer
  • Liver cancer
  • Cervical cancer
  • Colon and rectum cancer
  • Leukemia

Warning Whether smoky or smokeless, using tobacco causes cancer. For those who smoke pipes or cigars, chew tobacco, or use snuff, the resulting cancer is mainly found in areas that have been directly exposed to the tobacco, such as the mouth, throat, nose, and sinuses. In addition, smokeless tobacco is associated with a higher risk of pancreatic cancer.

Eroding overall health

Ingesting poison into your body day after day, not only causes cancer, heart disease, and stroke, but a whole lot of other heartache. Smoking negatively impacts every part of your body. Smoking increases the risk for a variety of disorders, from loss of hearing to loss of bone mass. The following problems have been linked to smoking:

  • Hearing loss: Smoking decreases oxygen levels, which negatively effects the blood vessels that keep the critical hair cells in the inner ear healthy.
  • Cataracts and macular degeneration: Smoking tobacco substantially increases the risk of eye problems. Some studies have found that smokeless tobacco also increases risk.
  • Crohn’s disease: Crohn’s disease is a type of inflammatory bowel disease that causes pain, diarrhea, weight loss, and malnutrition. Smoking is a risk factor, and it can lead to more disease.
  • Periodontal disease: This disease involves chronic infections of the gums around the teeth. Tobacco use makes it worse, and chewing tobacco is a particular risk.
  • Type 2 diabetes: This chronic disease impacts health negatively across a variety of domains and is 30 percent to 40 percent more likely to occur for smokers as compared to nonsmokers.
  • Rheumatoid arthritis (RA): RA is a chronic, autoimmune disease, and smoking has been shown to increase its risk and severity.
  • Osteoarthritis: It’s unknown exactly why, but smoking actually seems to confer some small benefit for reducing this disease of the cartilage that protects the ends of bones. Given all the other problems smoking causes, it hardly seems worth going for this mild benefit.
  • Osteoporosis: This disease involves a deterioration of bone density. The more cigarettes you smoke, the more likely you’ll have osteoporosis and break bones. And if you do break a few bones, they’ll heal more slowly.
  • Ulcers: Evidence suggests that ingesting tobacco increases the risk of stomach ulcers and slows healing.

You could almost get the impression that the human body just isn’t designed to handle cigarette smoke or tobacco products.