Clearing the air

First Lady Nechama Rivlin came out publicly against smoking and volunteered to help anti-smoking efforts at a clinical conference held recently at Shaare Zedek Medical Center.

By JUDY SIEGEL-ITZKOVICH
NECHAMA RIVLIN and PROF. GABRIEL IZBICKI. (photo credit: SZMC)
NECHAMA RIVLIN and PROF. GABRIEL IZBICKI.
(photo credit: SZMC)
In the bad old days, high-caliber journalist Edward R. Murrow warmly endorsed cigarette smoking and the tobacco company that sponsored his famous See It Now program. A three-pack-a-day smoker, Murrow died of lung cancer at the age of 57, followed a year later by his older brother – a decorated US Air Force brigadier general who was a heavy smoker as well. Senior physicians paid by tobacco companies appeared on TV endorsing their products and claimed that the toxic products promoted concentration and relaxation.
Some famous people who frittered their lives away smoking admitted their mistake.
Actor Yul Brynner of King and I fame who 30 years ago, at the age of 65, died of lung cancer, pre-recorded a few days before his passing an unforgettable American Cancer Society public service announcement that was shown in the US and around the world. He looked directly into the camera for 30 seconds and said, “Now that I’m gone, I tell you: Don’t smoke! Whatever you do, just don’t smoke! If I could take back that smoking, we wouldn’t be talking about any cancer. I’m convinced of that.”
Israel has not had many celebrities who spoke out publicly against smoking. Shinui Party environment minister Prof. Yehudit Naot – a biologist at the Technion-Israel Institute of Technology and a lifelong smoker, declined to speak out against tobacco before she died of throat cancer at the age of 60.
ISRAEL’S FIRST Lady Nechama Rivlin, a former chronic smoker, disclosed last year in an interview that she suffers from pulmonary fibrosis – a rare genetic condition in which lung tissue becomes thick, stiff or scarred and causes shortness of breath.
“My disease is not caused by smoking,” she said then, but according to experts, it can be exacerbated by tobacco.
Unpretentious, modest and forthright, Rivlin accepted an invitation from Jerusalem’s Shaare Zedek Medical Center and took time out from her busy schedule to speak out against tobacco at a clinical conference held there earlier this month. Arriving with a mobile oxygen machine and a nasal tube that she removes when on camera, she apologized for being unable to climb the stairs to the stage and spoke from the floor of the auditorium to the audience of doctors, nurses and other hospital staffers.
“We are not born with a cigarette in our mouth. It’s a habit that can be changed. We are bound to educate our children to ensure that they don’t smoke. I grew up in an era when there was no awareness of harm from smoking. We smoked at work, in cafes, near our children and in buses. I was a heavy smoker, and I even enjoyed it. Today,” the First Lady continued, “it’s clear that smoking is harmful, and I support the smoking-cessation at Shaare Zedek’s pulmonary diseases institute. I will be happy to help in the war against smoking. The struggle against tobacco and its ill effects is significant and important, and I welcome the activity and the initiative.”
The clinical conference was initiated by Prof. Gabriel Izbicki, the Swiss-born head of the pulmonary institute – a staunch opponent of tobacco. The event present the latest findings on smoking epidemiology, damage to health and ways of kicking the habit.
The World Health Organization declared that smoking is the number-one preventable cause of death around the globe, causing much harm to the health of adults of all ages and youngsters. It predicts that by 2020, 10 million people in the world will die of smoking if the number of smokers is not reduced, he said.
“It causes many lung diseases including chronic obstructive pulmonary disease (COPD); damage to blood vessels throughout the body; cardiac disorders; impotence; harm to vision an fertility; and cancer of the lungs [78% of all cases, the majority of them incurable], mouth and tongue, kidney, bladder, stomach, pancreas, esophagus, larynx and cervix,” Izbicki noted. About a fifth of the population smoke regularly – which means a million Israelis.
The American Cancer Society announced last month that smoking may be linked to more diseases – and more deaths – than previously estimated, according to a new ACS study published online in the New England Journal of Medicine. Despite estimates that the annual death toll of active and passing smoking in the US alone at 480,000, it is now believed that the dirty habit causes death from 21 diseases established by research as being related to tobacco.
These includes 12 types of cancer (including breast and prostate malignancies), six categories of cardiovascular disease including stroke and aneurysms, diabetes, COPD and pneumonia resulting from flu complications.
“In particular, smoking was associated with at least a doubling of risk of death from several causes,” which include kidney failure, reduced blood flow to the intestines, high blood pressure, infections and various respiratory diseases other than COPD, according to the NEJM study. The authors also assessed deaths among former smokers and found that the excess risk of dying from each of these causes declined as the number of years since quitting increased.
Lead author and epidemiologist Brian Carter wrote: “In our study, smokers had higher death rates from many diseases not currently established as caused by smoking, and we think there is strong evidence that smoking is likely to cause some of these diseases. If our results hold true for the US as a whole, about 60,000 more Americans than we thought may be killed each year by cigarette smoking.
For perspective, this additional number of deaths outnumbers deaths from motor vehicle accidents, influenza or liver cirrhosis,” Carter added.
DR. EYAL Romem, a SZMC epidemiologist, said that according to estimates, if the world’s smoking rate continues as it is today, one billion people will die of smoking in the 21st century. While residents of Western countries are increasingly aware of the dangers, the tobacco manufacturers are especially targeting the developing world, including Russia, China, the Far East and other regions.
“The companies are working very hard to introduce their products there to get more customers,” said Romem. “Smoking is the leading cause of death in China and the second in Russia. Two-fifths of men in Turkey smoke. In Israel, 8,100 people die from smoking, and this includes 850 non-smokers who die from passive smoking by inhaling the smoke of others.” The tobacco companies here invest NIS 61 million a year advertising their products. Smoking families spent NIS 7.5 billion annually on their tobacco habit – which is more than the state’s entire welfare budget. The yearly cost to the economy for healthcare due to smoking is NIS 3.7b.
DR. HAVA Azulai, who lectured on tobacco damage, said that according to recent studies, tobacco shortens the life of smokers by an average of 12 years. Discussing some of the hundreds of toxic components in tobacco smoke, she listed nicotine, tar, acetone, methanol, pyrene, ammonia, arsenic, urethane, toluene, DDT and vinyl chloride. Water pipes (nargilas), she said, contain more toxins than conventional cigarettes, and smoking such a pipe for an hour is equivalent to lighting up a whole pack of cigarettes; it can also transmit diseases from one user to the next.
Photos were shown of several pairs of identical twins – one a smoker and the other not – with the former looking much older, wrinkled and with browned-tinged teeth compared to the much younger- and healthier- looking sibling.
Dr. Chen Chen-Shuali began by describing a case of a 52-year-old, overweight mother of four who suffered from COPD resulting from smoking.
“She has constantly complained of being choked and was hospitalized in our hospital twice the past year. She long wanted to stop smoking, but she was not successful. Her son, who serves in the Israel Defense Forces, refused to come home on his leaves from service because he couldn’t stand the smoke.
All her other children smoke. But she finally joined our smoking-cessation group and was helped to kick the habit. Now her army son comes home, she feels better, and she has not been hospitalized this year.
Dr. Avraham Buadana, who is involved in the pulmonary diseases institute’s clinic for smoking cessation, explained that learning how to stop smoking either in groups and/ or with medications in included free in the basket of health services.
“We offer three double meetings in small groups of three to eight smokers and support between and after meetings. In the first, a pulmonologist conducts lung-function, oxygen saturation and carbon monoxide tests, and patients are asked to fill our questionnaires to determine how addicted, physically and behaviorally, they are to tobacco. The smokers are asked to write down when they smoke each cigarette, what induced them to do so and whether it gave them any satisfaction.
“In the second session, participants are encouraged to tell family and friends that they are quitting and presented with an explanation of nicotine replacement devices and drugs to help them quit. Each patient decides on an official day on which he or she stops smoking.
“In the third, we discuss the financial benefits of cessation and how to prevent ‘slip ups.’ They are advised not to smoke when they drink a cup of coffee. Drinking a glass of cold water in the morning is helpful, and one should brush one’s teeth after every meal.”
If they are present in a room with someone who lights up, they should leave the room to avoid temptation. There is a summation meeting with a pulmonologist. The Jerusalem hospital’s clinic boasts a higher longterm cessation rate – over 50% – than most other facilities.
IZBICKI SURVEYED what can help achieve cessation and what can’t. Studies show that hypnotism and acupuncture are of no help at all. Support through the Internet and smartphones has the potential to help.
“If one’s family doctor, in every consultation, would spend a minute or two urging their patients to quiet, it would be very effective.
This simple advice could result in many thousands of people kicking the habit.” Nurses’ advice, he added, can be as effective as a word from doctors.
Nicotine is so addictive, said Dr. Nessim Arish, because it bonds with a receptor that causes the neurotransmitter dopamine to be released. This binding results in calming and pleasure, but it causes the natural level of dopamine to drop, so one feels the need for yet another cigarette. When one kicks the habit, he said, in the short term there can be mood changes, reduced concentration, impatience and increased appetite and anxiety, but these phenomena decline as time passes.
Aside for nicotine gum and patches, smokers who want to quit may be prescribed Zyban (bupoprion), an oral antidepressant, and Champix (varenicline), a pill specially designed to bind with the nicotine receptor.
“Varenicline helps fight the side effects of giving up smoking, but it doesn’t always help. Children and pregnant women may not take it. But both drugs may cause side effects,” he said.
Electronic cigarettes (e-cigs) were surveyed by Dr. Ariel Rokah, who noted that these have been marketed aggressively by manufacturers in the past decade after they were developed by a Chinese pharmacist in 2003.
“They are simulators of smoking, but there is absolutely no supervision of their contents or manufacture. Nicotine and other essences are not burned but rather evaporated. They are as dangerous as conventional cigarettes,” he said. There have been over 900 published studies of e-cigs, said Rokah.
“They have been found to contain carcinogens and chemicals that cause inflammation and brochospams in the lungs. The longterm damage is not known. The US Food and Drug Administration came out against them, with orders not to import or manufacture them, but a US court halted the limitations, arguing that they are not a food and thus cannot be controlled by the FDA. Their import to Israel was also banned, but the Supreme Court ruled similarly and angered the Health Ministry, which is very worried about their dangers, including the risk that they will encourage young people to start smoking.”
BUT YOUNG people should not think about kicking the habit; they should concentrate on not starting to smoke. Take Yul Brynner’s and Nechama Rivlin’s advice.