Monday, January 31, 2011

IN MY VIEW: Surgeon General's "One Puff Can Cause Heart Attack" Approach Will Backfire

According to the United States Surgeon General, a single puff on a cigarette is enough to kill you. In her media interviews and press materials accompanying the release of the 2010 Surgeon General's report on smoking, Dr. Regina Benjamin made it a point of communicating to the public that a single puff of cigarette is all that it takes to trigger a heart attack.

This scientific "fact" was disseminated widely throughout the media, with headlines such as:

"Surgeon General: One Cigarette Could Kill You"

"Just One Puff of a Cigarette is Enough to Trigger a Heart Attack"

"Even One Puff of Cigarette May Cause Heart Attack"

"A Puff of Ciggie Enough to Cause Heart Attack"

"Heart Attack One Cigarette Puff Away"

"Just One Cigarette Puff Can Trigger a Heart Attack"

"One Puff Can Kill You, HHS Says"

The Rest of the Story

It is tautologically true that one puff of a cigarette can trigger a heart attack, but only in an individual who has heart disease so severe that he or she is just one puff away from a heart attack.

However, the Surgeon General was not particularly careful to qualify her statement to refer only to people with severe, pre-existing coronary artery disease. Thus, the statement was misleading and I believe, intentionally so.

I have already pointed out that Surgeon General's office lied blatantly to the American public by claiming that even brief exposure to secondhand smoke can cause cardiovascular disease and that inhaling even the smallest amount of tobacco smoke causes cancer.

But even the tautologically correct assertion that one puff of a cigarette can trigger a heart attack (in someone who is already a puff away from a heart attack) is, I believe, a damaging statement that does more public health harm than good.

Why? For two reasons.

First, I believe that such a statement undermines the public's appreciation of the important dose-response relationship between cigarette smoke exposure and disease. By making people believe that a puff of cigarette smoke is enough to kill them, the Surgeon General has removed much of the incentive for people to quit smoking. Why quit if you have already smoked for many years? If only a puff is required to kill you, then aren't you already a goner? What would be the point of quitting?

There is even less rationale for quitting among people who are around smokers. They are going to continue to inhale a puff or two of tobacco smoke, no doubt, and since that is enough to kill them, why bother worrying about their own active smoking?

Similarly, there is little reason for people to reduce their exposure to secondhand smoke. Almost everyone is going to occasionally inhale a puff or two of secondhand smoke. If that's enough to kill you, then why go through all the trouble of limiting your exposure?

In other words, what the Surgeon General has done is to decimate the public's appreciation that there exists a dose-response relationship between the amount of cigarette smoke exposure and the magnitude of disease risk. Unfortunately, it is the understanding that such a relationship exists that forms the basis of the rationale for someone quitting smoking or reducing their exposure to secondhand smoke.

The Surgeon General would have us believe that there is a threshold relationship between smoke exposure and disease risk, by which once you reach the threshold (one puff), you are already at a high risk of dropping dead from a heart attack. Beyond that, there seems to be little reason to worry about limiting your exposure. After all, you've already reached that all-important threshold.

Second, I believe that the Surgeon General's hyperbole threatens to undermine the credibility not only of her own office but also of public health and anti-smoking groups in general. When the public comes to realize that we are exaggerating the truth - by claiming that a single puff is enough to trigger a heart attack - they are not going to merely dismiss that isolated claim, but they will likely dismiss a host of other claims about the hazards of tobacco smoke, including ones that are true. The public is going to throw the baby out with the bath water, so to speak. It is the Boy Who Cried Wolf revisited.

The tactic of trying to scare people into believing that cigarette smoke is so toxic that just a single puff can kill them is not going to work in the first place. It is based on a blind adherence to the Health Belief Model, which posits that the reason why people are smoking is because they are simply not aware enough of the dangers of smoking. This assumption is heavily flawed, especially in 2011. Educating people about the hazards of cigarette smoking is hardly going to influence smoking uptake and cessation. People understand that it is bad for them. The reason they are not quitting in greater numbers has little to do with their understanding of cigarette's hazards, and everything to do with their inability to successfully counter the addiction to smoking, which is an exceedingly strong one. But the Surgeon General's office is doing nothing to actually help smokers quit.

Quite to the contrary. Ironically, the Department of Health and Human Services is doing everything it can to take effective options away from smokers to help them quit smoking. The Department's threatened ban on electronic cigarettes is a perfect example. If the Department truly believes that even a single puff on a cigarette could kill a smoker, then why would it want to ban a product which has already proven effective in helping thousands of ex-smokers quit smoking?

Unfortunately, the Department of Health and Human Services has made it clear that it would prefer smokers to continue to risk their lives by puffing on cigarettes than by switching to non-tobacco electronic cigarettes which could greatly reduce their risk of disease. And the Department would rather that ex-smokers who have already quit smoking (via use of electronic cigarettes) return to smoking, rather than maintaining themselves tobacco-free by the use of electronic cigarettes.

Apparently, then, even the Department of Health and Human Services itself does not believe its own hyperbole. If cigarette smoking were so bad that even one more puff is likely to be enough to kill many people, the Department would certainly not want to risk ex-smokers going back to cigarette smoking by taking electronic cigarettes off the market. But that very Department has seized multiple shipments of electronic cigarettes, not allowing them to enter the United States.

Cigarette smokers may be the ones puffing away, but the federal government is truly blowing smoke.