It is back-to-school time again. As the University of Michigan students begin their re-immigration to Ann Arbor, some will be presented with a surprise: the U of M has become a smoke-free campus. The University of Michigan – as of July 1, 2011 – has initiated its Smoke-Free University Initiative. Robert Winfield, M.D., the Chief Health Officer of U of M and the Director of the University Health Service, has requested that all students and staff show “patience, respect, and professionalism” in the act of transitioning to a smoke-free environment. I think what he meant by this was to avoid treating the members of our community who smoke like criminals. Perhaps, it is good for a community such as ours, a community in which we all know what is best, to be reminded to act with civility even towards those who do things we spend our whole life fighting against.
It is a tough time to be a tobacco smoker, or a tobacco company for that matter. Big tobacco cannot advertize on racecars anymore, much less on television or in print media. And, in addition to the Surgeon General warnings, they have to put those “scary” pictures on their packs now. The effects of the Family Smoking Prevention and Tobacco Control Act are still settling in. But, for the smokers themselves, I feel that our society may have crossed the final checkpoint on the path towards universal cessation: smoking has become completely and irretrievably stigmatized as a “bad and dirty habit” and perhaps even an “evil habit.” No longer do people have to sit in a restaurant or workplace or even their apartment and be forced to breathe in the results of burning tobacco (if modern day cigarettes can even be said to be “tobacco” anymore, it is kind of like saying a hot dog is made of meat – if you are curious you should Google “cigarette components”). Non-smokers have decided that we do not have to put ourselves at risk to avoid hurting someone’s feelings.
It has been a long struggle. “[We’ve] come a long way, baby!” From the era of Lucky Strikes being given to our soldiers in World War II (smoking as patriotism), to a period where 60-80% of adult males smoked (smoking as societal norm), to the first big movements toward quitting in the 1960s and 1970s (smoking as dangerous to health), to now (smoking as evil). Currently, about 20% of our country’s adult citizens are smokers. The decreasing trends that began in the 1960s flatlined in the 2000s (George W. Bush was a friend of big tobacco), but hopefully they will begin to head southward again. However, the smokers in our country are now overrepresented by the “uneducated poor,” thus giving us an epoch where one social problem runs smack into another.
Regardless, strides have been made and battles have been won. The war is not yet over, however. Despite tobacco smoking being the most extensively researched cause of disease and death in the history of science, tobacco is still legal and readily available. Cigarettes are still being marketed to children. Nicotine is still crossing millions of blood-brain barriers. Prohibition as a concept still scares people, but it is likely that millions of lives would be saved. My personal recommendation would be for the United States Department of Health and Human Services, through the Food and Drug Administration, to give the pharmaceutical companies the Letters of Marque needed to get into the nicotine delivery business. That is, the U.S. government should start a war between competing corporations. (“Win-win,” anyone?)
However, in my time studying, discussing, and thinking about these issues, I came across a new horn of the dilemma. I discovered that the severely mentally ill members of our country are smokers in massive numbers. For example, more than 80% of schizophrenics are smokers (some studies show numbers as high as 95%). The self-reported reasons for smoking by schizophrenics are the same as those for the general population: relaxation and habit. However, there has been a growing body of evidence, which many have now termed proof, that schizophrenics are using cigarette smoking as a means of self-medication.
I will not go into all of the current knowledge about schizophrenia etiology and symptoms, but I will say that smoking does have effects on dopaminergic pathways and has positive effects on cognition. Schizophrenics often have auditory hallucinations, paranoia, delusions, and disorganized thinking. These symptoms are predominantly caused by the inability of the brains of schizophrenics to differentiate, sort, and focus on the multitude of stimuli that go on around us. Think of being in a busy restaurant. Imagine that instead of being able to block out all the noises, conversations, and movements around you, every single piece of sensory information is as important as the interesting things said by the attractive person sitting across from you. The effects of cigarette smoking and nicotine help schizophrenics through increased selective attention.
“They should use other forms of medication,” I hear you say. Great idea, except for the fact that anti-psychotic drugs are very expensive, do not work very well for most people, and have extreme side effects. Tardive dyskinesia is the most common side effect. This makes it very hard for the body to move in normal ways at normal speeds. Also, there are common metabolic side effects that are quite similar to an individual having diabetes. (Just what someone with a severe mental illness needs!) Thus, the cheapness, effectiveness, and availability of cigarettes offer most schizophrenics some succor. Smoking leads to schizophrenics having a 30-60% increased risk of respiratory disorders and heart disease, but is this a risk that is worth taking?
It is a type of tragedy when ideals come into conflict. Free expression, free choice, and freedom of action can all lead to injury, disease, and death. Yet, I would never give them up. Public health professionals want to help people and society to make better decisions about health and wellbeing. And, after all, there is nothing worse for an individual’s health than smoking with the possible exception of sedentary life style. If we could get everyone in the country to give up smoking and to start exercising seven days a week, the morbidity and mortality rates would drop precipitously. However, I do not want to live in a nanny state that can determine what I can and cannot do. Once smoking and exercise as social problems are solved, public health would move on to banning motorcycles and theme parks, or something.
We should continue on our path of eliminating tobacco smoke from our society. However, we should keep in mind that there are minority groups out there who perhaps benefit from the effects of smoking much more than they are harmed by the risks. Minorities should be protected from the tyranny of the majority. And, we should all be protected from the “tyranny of health promotion.” Even at the risk of being hung up on the horns of a dilemma, we should remember our ideals. It is easy to have ideals when nothing is at stake.
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