THE COSTS OF TOBACCO IN BOTH HEALTH AND ECOnomic terms are enormous. Cigarette smoking causes approximately 5 million premature deaths each year around the world secondary to cardiovascular disease, chronic obstructive pulmonary disease, and lung cancer. In the United States, lung cancer is the leading cause of cancer-related deaths for both men and women. More than 170 000 new cases of lung cancer (13% of all cancer diagnoses) will be diagnosed this year, and more than 160 000 deaths from lung cancer will occur (28% of all cancer deaths). The 5-year survival for all patients who receive a diagnosis of lung cancer is an abysmal 14%, and even those who are diagnosed and definitively treated at the earliest stage (IA) have only a 67% 5-year survival. In the United States, direct medical costs for the treatment of lung cancer alone are approximately $5 billion annually. Years of research and innovative treatment for lung cancer have yielded improved amelioration of symptoms but little increase in overall survival. Clearly, the best treatment for lung cancer is prevention. Since smoking is responsible for 87% of deaths from lung cancer, tobacco avoidance or cessation is absolutely crucial for making any real progress in fighting this disease. Fortunately, it is never too early or too late to stop smoking; there is always a health benefit to be gained by quitting. Peto et al reported that a lifelong male smoker who lived to age 75 years had a 16% cumulative risk (ie, a 1 in 6 chance) of getting lung cancer. However, if that individual had stopped smoking at age 60 years, the cumulative risk for cancer decreased to 10%. Stopping smoking at age 50 years would reduce the risk to 6.0%; at age 40 years, to 3.0%; and at age 30 years, to 1.7%. For never smokers, the cumulative risk would be 0.4%. Therefore, if individuals who have been smoking for many years stop, even well into middle age, they will dramatically reduce their risk for lung cancer. If they stop smoking before middle age, they can cut their risk of getting lung cancer by at least 90%. More than two thirds of smokers say they want to quit the habit, making it essential to find better ways of helping them to do so. Certainly, real progress in assisting patients to quit smoking has been made with intensive smoking cessation programs. Those programs that involve a combination of intensive behavioral support and pharmacological therapy have been shown to have the greatest success rate. But how should clinicians advise patients who continue to smoke, either because such patients just cannot seem to quit despite their best efforts or have no intention of doing so simply because they enjoy smoking too much to stop? Is there anything physicians can offer besides more lectures, stern admonitions, and grim statistics? Two articles in this issue of JAMA demonstrate that there is something a smoker can do to decrease his or her risk of lung cancer. The study by Godtfredsen et al answers an important question: can smoking reduction, rather than cessation, decrease the risk of lung cancer? In their prospective cohort study involving more than 19 000 Danish men and women, the authors found a dose-response relationship between smoking intensity and incidence rates of lung cancer. Reducing smoking from an average of approximately 20 cigarettes per day to fewer than 10 cigarettes per day reduced the relative risk of developing lung cancer by 27% compared with unchanged heavy smoking. The reduction in risk probably would have been greater except for the practice of “compensatory smoking,” that is, getting the maximum number of puffs out of the limited number of cigarettes allowed. The authors are quick to point out that smoking cessation, rather than smoking reduction, should still be advocated as the best method for reducing harm from tobacco and that other tobacco-related diseases such as chronic obstructive pulmonary disease and myocardial infarction have not shown any reductions in risks after smoking reduction. Nonetheless, because only a minority of smokers are able to quit smoking completely, it is important to inform them that the more they can reduce the number of cigarettes they smoke, the more they will decrease their risk of lung cancer. They should stop smoking completely, but cutting down is clearly beneficial.
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Open Access
Aug 2, 2023
Anna-Marie Marshall + 2
