30 July 2021
Written by Testimony Olajire
Tobacco is one of the leading causes of death in the world today. With over 8 million people a year dying prematurely from smoking[i], the activity remains a threat of global interest. There are different methods that tobacco can be ingested, the most popular being cigarette smoking, cigars, and water-pipe tobacco. It has been scientifically established that tobacco taken in any form is unsafe and dangerously addictive[ii].
One of the ways tobacco smoking adversely affects its user is by causing lung cancer. Although not every smoker may develop lung cancer, persons who smoke are 15 to 30 times more likely to develop lung cancer than non-smokers[iii]. As of now, smoking accounts for the highest number of recorded lung cancer cases all over the world[iv].
When people smoke, they inhale dangerous chemicals into their lungs. These chemicals have the capacity to react with the DNA in lung cells and damage them. The body system automatically reacts to repair any damage caused by the dangerous chemicals. However, as more and more damage is caused, the body’s immunity becomes weak and there is more damage than can be repaired. This may trigger the formation of cancerous cells in the lungs[v].
Smoking can increase the risk of both Small Cell Lung Cancer (SCLC) and Non-Small Cell Lung Cancer (NSCLC), which are the two types of lung cancer. SCLC poses a higher risk of death and is found mostly in persons who have a smoking history. Since the early 1900s, when cases of lung cancer became more popular, more than enough facts and figures have closely associated this health condition with the long term effects of smoking.
Smoking tobacco exposes the body to about 7,000 different types of chemicals, out of which 70 are known to be cancer-causing[vi].
Tobacco use is responsible for 22% of all cancer deaths[vii].
An estimated 90% of lung cancer cases are thought to be caused by smoking[viii].
Smoking will increase the risk of both SCLC and NSCLC. 80 to 85% of lung cancers are NSCLC[ix] and 95% of persons with SCLC have a history of smoking[x].
Tobacco smoking is also responsible for many other health conditions[xi] such as chronic obstructive pulmonary disease[xii]. This is a condition caused by damage from tobacco smoke to the alveoli of the lungs. Bronchitis, which is an example of obstructive pulmonary disease, is usually common among tobacco smokers with or without them knowing it. Pulmonary disorders associated with tobacco smoking are characterized by a chronic cough, shortness of breath, wheezing, excess sputum, and other respiratory tract infections[xiii].
Because tobacco smoking is highly addictive, smokers are bound to smoke more than when they first started smoking and the rate of smoking increases progressively. This multiplies the risk of adverse health outcomes and the immune system may never be able to fight against these intruders since they keep increasing exponentially.
Smoking tobacco on its own is very harsh on the respiratory tract. A cigarette is therefore designed to contain other components that make smoking more pleasant. Wrapped around the tobacco are additives such as menthol, sugars, levulinic acid and other flavourings so the harmful tobacco smoke can be inhaled more smoothly.
Tobacco contains addictive levels of nicotine. Some cigarette brands infuse more nicotine in their cigarettes so addiction is stronger and smokers can keep buying more. Over time, the high level of nicotine inhaled from constant smoking makes it so addictive that many smokers are not willing to quit despite knowing the adverse effects.
The holding end of a cigarette is made up of filters that limit the amount of smoke inhaled. Modern-day cigarettes will also contain ventilators that help smokers inhale tobacco smoke more deeply without having to draw hard. The ventilator (which is usually found wrapped around the holding end) is also designed to allow fresh air to mix with inhaled smoke.
The change in attitude towards smoking began when the deadly effects of tobacco smoking were made public. As studies linking smoking to lung cancer began to mount, government and independent organisations started launching campaigns to bring awareness to the adverse health effects of smoking.
While developed countries were faster to embrace non-smoking policies than developing and underdeveloped countries, over time, it was clear that efforts to curb smoking were making an impact globally[xiv]. Although smoking has not been eradicated, awareness about the negative effects of smoking have reached regions all around the world.
Since the late 1990s, the US has seen a reduction in cigarette sales from 10-11 cigarettes per adult per day to ~3 cigarettes per adult per day. The number of deaths from lung cancer followed a similar trend, reducing from about 55 out of 100,000 men in the early 1990s to less than 30 by the end of 2010[xv].
The various health campaigns reinforce each other in a virtuous cycle: once smoking becomes less common, the peer pressure to smoke disappears. Instead, as cigarettes become less popular, the pressure from peers turns against smoking.
While the global effort against smoking has been effective, authorities have done little to regulate how tobacco products are made and what is in them. As a consequence, in recent decades, tobacco companies have purposely designed cigarettes to make tobacco smoke smoother, less harsh and more appealing to new users.
Although the number of people that smoke has significantly reduced, it may be harder now more than ever for those who are still smoking to quit. Frequent rebranding and strategising by tobacco producing companies have made tobacco products not only appealing but also harder to quit. Research conducted on cigarettes smoked from 1998 to 2012 showed a significant increase in the amount of nicotine present per cigarette from 1.65 milligrams to 1.85 milligrams[xvi]. This increase is likely to create and sustain an addiction to nicotine.
Ammonia additives are newer components of cigarettes and other tobacco products. They make tobacco smoke more comfortable to inhale. In addition to this, ammonia and other ammonia compounds accelerates the speed with which nicotine reaches the brain, such that the addictive psychoactive sensation of smoking can be experienced faster. This has only worked to increase addiction to nicotine[xvii].
Sugars and flavourings are the order of the day in today's smoking world. Unlike 50-60 years ago, smokers can comfortably inhale tobacco smoke from cigarettes without feeling the discomfort of the smoke travelling down the throat into the lungs. Flavours give the smoke a more appealing taste while the higher levels of sugar used work alongside nicotine to make tobacco smoking more addictive[xviii].
Branding and repackaging have made the methods of inhaling tobacco products even more diversified. The use of Heated Tobacco Products (HTPs) using vaporisers (vapes) is a common example. Usually, this method of smoking is advertised to be neater, more modern and with lesser health risks. The use of vapes is also often promoted as capable of helping people come out of addictive tobacco cigarette smoking. However, the active components of vaping devices still contain nicotine, the highly addictive substance that would cause unwanted health effects with long term use.
Electronic Nicotine Delivery Systems (ENDS), commonly referred to as e-cigarettes are a way of inhaling nicotine products using electronic devices that transform liquid directly to aerosols. These devices are often used by celebrities and are perceived to be a trendier way of smoking. They are made in a variety of flavours and often endorsed by celebrities and other public figures. To say the least, it is much easier for teenagers and young adults to pick up e-cigarettes and vapes compared to cigarettes, tobacco pipes, or cigars. Yet, the negative health effects of tobacco are still sustained across all the smoking methods.
Not much research has been made into the use of Electronic non-nicotine delivery systems and their effect on health. However, what is known is that, e-cigarettes, which contain nicotine, are not healthy irrespective of the medium of ingestion into the body. Inhaling of smoke from e-cigarettes and vapes can also cause just as much harm as those caused by conventional cigarette smoking.
Health campaigns against smoking are being conducted on a global scale, with the WHO leading the pace on measures that help people in both developed and developing countries quit smoking[xix].
In 2007, WHO launched MPOWER, an acronym that embraces practical steps contained in the WHO Framework Convention on Tobacco Control (WHO FCTC). The MPOWER measures are summarised below:
Using different surveillance and fact-finding mechanisms, WHO has consistently monitored the success of public smoking campaigns and their impact on the behaviours of smokers and non-smokers across the world.
Exposure to harmful chemicals in passive smoke is responsible for a significant number of lung cancer deaths. WHO FCTC has taken measures to provide cleaner and safer environments for people to live in. This has been implemented in some countries by bans on smoking in public areas.
Offering people help to quit tobacco smoking is one of the most important measures to FCTC since it can help to improve the life expectancy of smokers. This measure will only be effective when combined with all other MPOWER measures[xx]. Help to quit tobacco smoking includes the use of cessation programs, and several other supports, including active counselling.
People who are coming out of tobacco smoking are very vulnerable since tobacco is highly addictive. They require all the care, love, and understanding they can get to ensure they do not go back to the addiction. Those affected will also require medical attention to manage withdrawal symptoms which they will experience during the initial stages of quitting.
Different measures such as pack warnings, TV and radio sensitisation, and the use of other mass media have helped to broadcast the dangers of tobacco use. In the early days of cigarette smoking, most cigarette packs were heavily covered in branding. Today, cigarette packs are covered with several warnings on the dangers of smoking and jarring images of the damaged gums, lung cancer and more. In Australia, since the use of warnings on cigarette packages, the country has recorded about 100,000 fewer smokers[xxi].
Since its inception, WHO FCTC has worked on effecting the placement of comprehensive bans on all forms of sponsorships and promotions for tobacco. This will include cigarettes, cigars, and modern tobacco smoking devices.
Increasing taxes on tobacco could be one of the most effective measures for reducing tobacco smoking across the globe[xxii].
At least one of the MPOWER policies has been implemented in 136 countries as of 2018, totalling the number of persons protected from the dangers of smoking to about 5 billion[xxiii]. The 2019 WHO report on the global tobacco epidemic indicates how about 65% of the world's population is covered by at least one of the MPOWER tobacco control measures. This is a significant improvement to 2007 when only 15% of the world's population was covered by the FCTC provisions[xxiv].
Even though the prevalence of smoking is higher in high-income and developed countries, the adverse effects of smoking are disproportionately high in developing nations. As of 2020, the prevalence of smoking in low-income countries was found to be about 10%, whereas the prevalence of smoking in high-income countries is estimated to be about 20%[xxv].
Poverty and poor living conditions have made the health effects of smoking in low-income countries much more prominent. Tobacco use increases the financial burden in many families as funds that would have been spent on providing basic needs are diverted to buying tobacco products.
There are many health burdens smokers of tobacco products can inflict on themselves. Yet, smoking does not affect active smokers alone. For every 8 smokers who die from a smoking-related disease, 1 non-smoker dies from second-hand smoke exposure[xxvi].
The American Cancer Agency has found that passive second-hand smoking is responsible for about 7,000 deaths from lung cancer each year in the USA[xxvii]. Another study by the National Institute of Health has revealed that passive smoking will not only increase the risk of lung cancer but can also lead to the development of breast cancer, particularly in women[xxviii].
Quitting smoking can prevent premature death. The risk of developing cancer can be reduced by 30 to 50% after quitting smoking for 10 years[xxix].
Quitting tobacco smoking can improve health conditions by:
Lowering heart rate and blood pressure
Improving blood circulation and the lung function
Eliminating carbon monoxide from the body
Reducing the risk of cough, shortness of breath, and other respiratory tract conditions.
Within 5 to 15 years of quitting smoking, a person will have reduced the risk of death, lung cancer, heart disease, stroke, throat and mouth cancer by significant figures.
Since it became popular in the early 1900s, smoking has done more harm than good, causing addiction, lung cancer, and reinforcing the cycle of poverty in low-income countries. However, campaigns against tobacco smoking have seen success over the years. More and more people are quitting tobacco smoking and have also joined the campaigns against it. This has led to improvement in quality of life and a notable decrease in the number of deaths caused by smoking-related conditions. By rightly deploying all the MPOWER measures and improving sensitisation across the globe, tobacco smoking can be brought to the barest minimum.
[i] The World Health Organization in 2020 tobacco estimated the number of deaths caused by tobacco across the world to be way above 8 million. https://www.who.int/news-room/fact-sheets/detail/tobacco
[ii] 2020 WHO tobacco fact sheet states "All forms of tobacco are harmful, and there is no safe level of exposure to tobacco…smokeless tobacco use is highly addictive and damaging to health.” https://www.who.int/news-room/fact-sheets/detail/tobacco
[iii] According to the CDC. There is no denying that tobacco smoking is the leading causative factor for lung cancer. The chances of being diagnosed with lung cancer increases as a person continues to smoke and the addiction heightens. See the CDC’s take on smoking and lung cancer: https://www.cdc.gov/cancer/lung/basic_info/risk_factors.htm#:~:text=People%20who%20smoke%20cigarettes%20are,the%20risk%20of%20lung%20cancer.
[iv] The World Health Organization records that lung cancer accounts for 1.76 million deaths globally in 2020 and is responsible for the most deaths caused by cancer. WHO also recognizes that tobacco smoking is the leading cause of lung cancer. https://www.who.int/news-room/fact-sheets/detail/cancer
[v] The connection between smoking and lung cancer: https://www.healthline.com/health/lung-cancer/smoking-lung-cancer#fact-sheet
[vi] The National Institutes of Health: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6164459/
[vii] The National Institutes of Health: https://www.ncbi.nlm.nih.gov/books/NBK482357/
[viii] The National Institutes of Health: https://www.ncbi.nlm.nih.gov/books/NBK482357/
[ix] The American Cancer Society on Lung Cancer: https://www.cancer.org/cancer/lung-cancer/about/what-is.html
[x] The National Institutes of Health: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4758961/
[xi] According to the CDC, cigarette smoking is the leading cause of preventable disease, disability, and death in America. https://www.cdc.gov/tobacco/data_statistics/fact_sheets/index.htm
[xii] The connection between smoking and lung cancer: https://www.healthline.com/health/lung-cancer/smoking-lung-cancer
[xiii] Chronic Obstructive Pulmonary Disease: https://www.healthline.com/health/copd
[xiv] Smoking: How large of a problem is it? https://ourworldindata.org/smoking-big-problem-in-brief
[xv] Smoking: How large of a problem is it? https://ourworldindata.org/smoking-big-problem-in-brief
[xvi] https://puu.sh/HXU11/8b7a8edf7b.png Nicotine is the active ingredient in tobacco. It is psychoactive and has the ability to cause mild stimulation and relaxation when inhaled. It is however highly addictive, making persons who smoke needing to come back for more. Long term effects of nicotine include blindness, cataracts, pneumonia, asthma, heart disease, emotional and psychological imbalance, among others.
[xvii] Tobacco companies have made cigarettes deadlier than ever: https://www.vox.com/2014/6/23/5835158/tobacco-companies-have-made-cigarettes-deadlier-than-ever
[xviii] Designed for addiction: How the tobacco industry has made cigarettes more addictive and even more deadly: https://www.tobaccofreekids.org/assets/content/what_we_do/industry_watch/product_manipulation/2014_06_19_DesignedforAddiction_web.pdf
[xix] In 2003, member states of the World Health Organization adopted the WHO Framework Convention on Tobacco Control (WHO FCTC). In 2005, FCTC was fully adopted. Today, more than 90% of the world’s population have adopted FCTC. See https://www.who.int/news-room/fact-sheets/detail/tobacco
[xx] According to the WHO, increasing taxes on cigarettes has been the least implemented MPOWER measure. However, it can cause a significant reduction in tobacco smoking among youths and persons in low-income countries, especially when taxes are raised well above the average income standards. https://www.who.int/news-room/fact-sheets/detail/tobacco
[xxi] A decade on from plain packaging, what is the result? https://www.smh.com.au/politics/federal/a-decade-on-from-plain-packaging-what-is-the-result-20210709-p588e7.html
[xxii] WHO Tobacco Fact Sheet: https://www.who.int/news-room/fact-sheets/detail/tobacco
[xxiii] This brings the number of persons who the FCTC has covered globally as of 2019 to 5 billion. Source: https://www.who.int/teams/health-promotion/tobacco-control/who-report-on-the-global-tobacco-epidemic-2019
[xxiv] WHO Report on the Global Tobacco Epidemic: https://www.who.int/teams/health-promotion/tobacco-control/who-report-on-the-global-tobacco-epidemic-2019
[xxvi] WHO Tobacco Fact Sheet: https://www.who.int/news-room/fact-sheets/detail/tobacco
[xxvii][xxvii] Lung Cancer Risk Factors: https://www.cancer.org/cancer/lung-cancer/causes-risks-prevention/risk-factors.html
[xxviii] National Institutes of Health: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6164459/
[xxix] WHO Report on the Global Tobacco Epidemic: https://www.who.int/teams/health-promotion/tobacco-control/who-report-on-the-global-tobacco-epidemic-2019
Testimony Olajire is a medical writer and holds a Bachelor's degree Medicine and Surgery (M.B.B.S).