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Blogs by the online BMJ respiratory medicine champion
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Smoking, lies and statistics
Last week I gave a short presentation to a group of nurses out in rural Angus. They had asked for a general update on respiratory services within the region, so I was happy to oblige. As ever, part of any update in respiratory services has to include something on lung cancer, and smoking cessation.
You'd think, in 2011, that everyone would accept that smoking causes lung cancer; smoking causes COPD; and is generally "not very good for you". But one of the girls was not convinced. "My mother smoked until she was 86, and my aunt smoked until she was 90" This is a standard sort of response to the suggestion that smoking is not the best idea. And we all know someone who smoked until they were xx, or even yyy, and they die from "old age". Of course we do, but as chest physicians we see hundreds of people every year who die from lung cancer, in their 80s, 70s, 60s, 50s, 40s, and even 30s. I've diagnosed lung cancer in two men in their 20s in the past 5 years. Both had strong famliy histories of lung cancer, and both were heavy smokers - they could not quote that their family lived long and happy smoking lives. So what to say to the person who tells me that their family members lived as smoking octagenarians? It's about statistics, probability, and risk. Every day we're exposed to risk, some risk we can't avoid (background radiation, for example), and other risk we inflict on ourselves. So what risk is acceptable? We can only make reasonable decisions on what is accpetable if we understand what the risk actually is. If all a smoker knows is long lived relatives, their perceived risk is small. As chest doctors we see so much lung cancer/COPD/IHD that we *know* the risk is too great. I showed a slide, freely available on the Cancer Research website, which show the lifetime risk of lung cancer death by age 75 in a lifelong smoker is 16%, or about 1 in 12. The same risk for a lifelong non smoker is 0.2 %, or about 1 in 500. And stopping smoking at 60 reduces this risk from 16 % to 8 %. It was only when I told them this that the sole smoker in the room accepted that I might be on to something. Why don't we get this sort of information accross to the public? If nurses don't know this, then how can we expect members of the public to know? Smoking is prevalent, over 20% of the population smoke, more up here in Scotland. We don't do enough to dispell the lies they tell themselves to keep them smoking. And statistics are powerful, so we should share them.
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There is another way I explain people about cancer risk.
We all fill out a TOTO form of our life, daily, weekly, monthly, yearly....When it is a simple form your chances to win first prize are low. But some of us are going to add double or triple x on some games and do it on permanent basis, you increase the chances to "win" the prize many times. Between first prize and nothing there are other notable "prizes" such as COPD, IHD, etc. Now, some of us are born with forms that have already double and triple x marked on some games. That mean that we are more "prone " to first prize. Adding some more triples and doubles to the form with smoking will surely hasten the arrival of "first prize"...
Then some of us are born with a way not to be able to fill in the triples and doubles at some games. That means that those of us have a lesser chance.But we don't know who is who...
We all know there are some slow acetylators in the population so these will be less prone to develop lung cancer associated with smoking, however, these usually smoke less, since the need for nicotine is lower( less nicotine is metabolised to the not active cotinine) and we do not test for CYP polymorphisms yet.
This is where the tobacco industry has succeeded. They are diverting the attention from what should have been a fairly easy decision given the evidence to a debate about artistic freedom and expression of art. There, even with all the statistics we can get, it is difficult to convince people.
Dry statistics loses every-time when pitted against a smoking rockstar.
I find that doing lung function on smokers is useful. When I can tell them there is already early COAD, they sit up and listen. When I then tell them that a reduction in lung function means a reduction in life expectancy (I do this is medico-legal reports all the time), they listen. I tell asthmatics this too; ie that reduced lung function from lack of compliance means a shorter life. It is not a matter of pleasing me but of giving them better lungs for their old. I also tell them they have the lung function of an eighty year old (eg if they are fifty). This shocks them (vanity??).
Finally, I tell them that the multinational company which makes fags doesn't give a toss about them and they are just useful cannon fodder for shareholders. They usually take this on board.
The greatest determinant of smoking cessation is the cost of a packet. We are going to generic packaging and we have had no smoking adverts for years unlike Greece which has or had billboards when I was last there eg selling Virginia Slims to slim, attractive young women. COAD and cancer keep you slim.
In other words, whether people smoke or drink, is not really offending me. Indeed it is great for business. It is not a good idea surely and I tell them that you get away with nothing and that they may not make old bones.
Nonchalance often gets under their skin.
When people come back and tell me they have not used their CPAP pumps and I know there is no alternative in severe cases (except weight loss), the mere fact that I am not going to scold them and it really isn't my job to make the world perfect and there is no Plan B, C and D, they looked a little surprised.
Some go away and reconsider as they were looking to me as the parent figure to do my block. It is easier for a smoker to go through the eye of a needle...
In cases of sleep apnoea, I tell them if they want to drive a car...bla...bla and how they could end up in jail for five years if there are no skid marks on the road and that the cops will sub poena my medical notes.....bla, bla.....the ball bounces off old Stone Wall Odysseus and back into their court.
I know this is a bit off topic but the principle is the same. The more "Super-parent" you are, in my experience, the more they turn off.
How they'll be convinced since many patients say "look at your stuff doctor" or "if doctors smoke,why not me?"
We have some of the strictest laws on smoking and it is working. Smoking is regarded as surrogate for low IQ. It is a social statement. I know no doctors who smoke. We have no cigarette advertising anywhere.
We have a long way to go with its brother, alcohol but the random breath test is changing behaviour for the better (0.05% limit).