Important message: don’t trust tobacco companies.  They are marketing “Safe” tobacco products, advertised as tobacco harm reduction (THR) items. They are unregulated and not subject to testing by governmental agencies such as the USA Food and Drug Administration.  The goal of the tobacco companies is to attract young persons and turn them into new users. They also target developing countries where there is a huge market waiting to be exploited.  

The conduct of the industry has led Dr. Fiore to list what he has called, The Seven Pillars of Fraud.2

Over the years, tobacco companies have:

-        Denied any harm from direct and indirect smoke inhalation

-        Claimed that tobacco-sponsored “research” was independent

-        Suppressed unfavorable results

-        Denied that nicotine is addictive

-        Manipulated nicotine levels in cigarettes to create addiction

-        Marketed products with misleading labels; e.g., “light” cigarettes

-        Focused on youth

The focus on youth is especially ominous for childhood cancer survivors, many of whom are just past childhood.  They are vulnerable to added damage to organs that may already be impaired from prior Chemo- (CT) &/or Radiation Therapy (RT); especially the lungs. They also are at increased risk of developing a second malignant or paramalignant condition, such as Langerhans cell histiocytosis (LCH).3   LCH and childhood cancer follow each other like shadows.3

Moreover, LCH of the lungs is strongly linked to tobacco smoking.4

A whole issue of The European Journal of Cancer recently was devoted recently to Cancer Chemo-prevention5.   All those concerned with the well-being of the patient cured of childhood cancer – family, friends and physicians – can help prevent cancer and disability much more simply and directly. They can do this by helping to guide the health habits of young survivors. Perhaps the least intrusive site and most objective four walls are those of the long-term follow-up clinic. There, many questions relevant to health status are asked. When it comes to smoking, staff members can and should ask probing questions after making the 3 key statements:

-        DON’T SMOKE

-        STOP SMOKING IF YOU’VE STARTED

-        STAY OUT OF SMOKE-FILLED ROOMS

Close questioning must go deeper. Has there been any thought of trying a flavored cigarette? Some have enticing names like, “Twista Lime” and “Warm Winter Toffee”. Has the person been tempted to try a non-inhalation, nicotine-containing item such as tobacco “candies” (flavored compressed tobacco leaves), or nicotine-containing waters and juices?6

There is danger in starting in going down that road.  These cigarette substitutes may prevent smokers who wish to kick the habit from doing so by keeping them satisfied in a smoke-free work-place or school until they go home where they can smoke. The hazards to themselves and to those near them are thus perpetuated. In both men and women, the link between smoking cigarettes to lung cancer, heart disease and debilitating pulmonary diseases such as emphysema are widely known. 

Cigarette smoking kills > 400,000 Americans/year, most from lung cancer, with heart and lung disease next. More die from smoking than automobile accidents, gun shot wounds, AIDS, fire, and drug and alcohol abuse combined.1 Most of the deaths are secondary to lung cancer, with lung-related disability; e.g., emphysema, and heart disease next.

More than 1/3 of all deaths for the middle age group, and more than 1/6 deaths overall in America are attributable to smoking. For every such death, there are 20 patients chronically ill, mostly from pulmonary and cardiac problems.

Not so well appreciated is the fact that the risk of breast cancer in pre-menopausal women is higher in smokers and in those subjected to second-hand smoke.7  Recently, evidence of an increased risk of cervical cancer in smokers has been published.8

There are more than 6000 compounds in cigarette smoke. There has been no health advantage from filters (more tobacco was put in cigarettes to make up for lost “taste”), or from low tar, nitrosamine and catechol blends. Moreover, interventions to restrict cigarette sales have had no effect on ‘teenage smoking.9 

Thus, while there are relatively safe smoking substitutes like those pioneered by the Scandinavian nations, notably the Swedish product, “snus,” it is a better strategy to say there is no safe tobacco.

Summary

All those close to the patient can help prevent avoidable illnesses by discouraging the use of tobacco products.  The staffs of late follow-up clinics can add prophylaxis, which is the backbone of pediatrics, to surveillance as an important part of their mission. It would be tragic indeed should a child survive the rigors of cancer and its treatments only to succumb as a young adult to a preventable lethal disease caused by smoking

Giulio J. D’Angio, M.D.

University of Pennsylvania.  Philadelphia, Pennsylvania 19104, U. S A.

References

1 K.E. Warner JPH/O 2005;27:543 ff.

2 M C Fiore et al. NEJM 2005; 353; 972 ff.

3 M Egeler et al. Hemat Oncol Clin North Am 1998; 12: 369 ff.

4 R Vasallo et al. NEJM 2000;342:1969 ff.

5 EJC 2005; 41: 1831 ff.

6 C Carpenter et al. Health Affairs, 2005; 24: 1601 ff.

7 KC Johnson Int J Cancer 2005;117: 619 ff.

8 Study Committee report Int J Cancer 2006; 118: 1481 ff.

9 CM Fichtenberg, SA Glantz BMJ 2002;325:188 ff.