Physician Leadership In Tobacco Control:The Physician’s Perspective

By Peter Dehnel, M.D.Medical Director, Children’s Physician Network

IF SARS, OR SMALLPOX, OR FOOD BORNE illnesses, or motor vehicle accidents were prema­turely killing 400,000 Americans a year, the physi­cian community would be mobilized in a second to combat these very important health threats to the public. If personal decisions like consuming alcohol or carrying a handgun were killing 50,000 to 60,000 innocent bystanders each year, again, the physician community would be up in arms (no pun intended) about “secondhand alcohol deaths” or “secondhand gunshot deaths.”

Then we come to tobacco. Tobacco is associated with over 400,000 premature deaths each year in this country among tobacco users, including 125,000 lung cancer deaths. In light of its very poor progno­sis, the only effective “treatment” for lung cancer is tobacco prevention. Secondhand smoke causes the premature death of 50,000 to 60,000 people each year who have decided not to use tobacco products. In spite of these figures, the medical community continues to tolerate the harm tobacco does to the health of many of our patients and families. Why should this situation exist?

There are several plausible reasons why physicians have traditionally not been more active in tobacco reduction efforts, which include tobacco use pre­vention, tobacco cessation, and secondhand smoke reduction. These include:

• Intense efforts on the part of tobacco companies to “normalize” tobacco use;

• A well-organized “disinformation” campaign to discredit the scientific evidence regarding the harm caused by tobacco;

• Lack of physician training in effective tobacco reduction;

• Lack of resources for physicians and clinics to help in tobacco reduction;

• The misconception that this is a “personal choice” issue and not a health issue;

• Not knowing that up to 70 percent of current smokers want to quit, but would benefit from physi­cian guidance to be successful;

• No awareness that 90 percent

of current adult smokers started before they were adults and unable to make a fully informed decision about using tobacco in the first place; and

• No awareness that teenagers are highly targeted by the manufacturers of tobacco products.

Tobacco use is all about nicotine addiction. Ciga­rettes are nothing more than a “highly refined nico­tine delivery system.” Our patients who continue to use tobacco are, for the most part, addicted to nicotine and need our help to end this dependency. They most likely started using tobacco as a teenager, at a time when their developing neuropathways were more susceptible to the powerful influence of inhaled nicotine. For most smokers, tobacco use stopped being a “personal choice” a long time ago, and now they have to continue using it to prevent withdrawal symptoms.

A related issue is the harm caused by secondhand smoke. Tobacco is a complex mixture of 4,000 chemicals, including 200 toxins and 40 to 50 car­cinogens. Eighty-five percent of the smoke generated b y a given cigarette is released into the air around a smoker. While there is a dose-related effect, there is no “safe” level of secondhand smoke exposure—it is in the EPA's “Class A Carcinogen” category. Second­hand smoke exposure has a variety of health prob­lems associated with it—heart disease, stroke, lung and other cancers, asthma, pneumonia, bronchitis, sinusitis, and otitis media. Prenatal exposure to to­bacco smoke leads to prematurity, low birth weight, the subsequent development of asthma, and infants subsequently dying of SIDS. In this regard, 2001 marked the first year when tobacco-related SIDS deaths equaled the number of childhood motor vehicle deaths—both about 2,500 infants.

What is needed now is for physicians to “step up to the plate” and lead efforts to reduce tobacco use and secondhand smoke exposure. This starts with first leading efforts in your own clinic with all your patients, regardless of age. It then extends to leading efforts in your community. This may mean plac­ing one or two calls or e-mails to your city council members or supporting local groups that are work­ing on tobacco reduction. A number of communities have begun the process of considering ordinances for smoke-free restaurants and other workplaces. These initiatives have stalled for the most part. New physi­cian engagement would go a long way to reinvigo­rate these efforts.

In terms of leading efforts at the state level, it is extremely easy to e-mail your state senator and repre­sentative on issues related to tobacco reduction such as the $1 tobacco tax increase that was considered during the most recent session. A relatively small number of physicians are needed to be on the “front line,” interfacing with the media, testifying at city council meetings, writing letters to the editor and other similar activities. For these physicians, the importance of this issue is compelling enough for them to leave the safety and security of their clinic settings.

There are numerous groups, resources and organiza­tions that can help practitioners lead their office-based tobacco cessation efforts. The U.S. Public Health Services' “Treating Tobacco Use and Depen­dency” is an evidence-based approach to tobacco cessation, and is available to all physicians free of charge. The Minnesota QUITPLAN (1-888-354-PLAN, www.quitplan.com), sponsored by MPAAT (Minnesota Partnership for Action Against Tobacco), can direct smokers to telephone-based resources for tobacco cessation. Each of the health plans have their own resources for helping subscribers reduce and stop their tobacco use. Cessation treatment is neither easy nor quick, and physicians need to ap­proach it like you would manage any other long-term or chronic condition.

Tobacco is first and foremost a health issue, and phy­sicians are the logical candidates for leadership in the efforts to reduce the harm caused by tobacco. Please decide what your “next steps” will be in terms of leading efforts in your clinic and/or community. If you are looking for opportunities for involvement or resources to carry this out, please contact me at 612-813-8098 or e-mail peter.dehnel@childrenshc.org.

 

* Resources are taken from the “Tools for Eliminating Secondhand Smoke in Your Community” Sponsored by Blue Cross and Blue Shield of Minnesota and the Minnesota Medical Association