We Have Not ‘Come a Long Way, Baby’: Dr. Alan Blum on Smoking Cessation and Prevention

To mark World Lung Cancer Day on August 1st, Cancer Network spoke with Dr. Alan Blum, Professor and Gerald Leon Wallace, MD, Endowed Chair of Family Medicine at the University of Alabama School of Medicine, where he also directs the University’s Center for the Study of Tobacco and Society, which he founded in 1999. Dr. Blum is an expert on the history of tobacco use, tobacco industry marketing, and the anti-smoking movement. He is a renowned pioneer in creative physician-led public advocacy initiatives to counter the promotion of unhealthy products and lethal lifestyles.

-Interviewed by Anna Azvolinsky

Cancer Network: You’ve studied the marketing tactics used by the tobacco industry to target consumers for a long time [over four decades]-and have organized clinicians to promote health among patients, to prevent [young people] from taking up smoking [and to help them] get off it. Can you talk about some of your recent efforts against smoking and the tobacco industry?

Dr. Blum: Here we are on World Lung Cancer Day, and it is sort of a bittersweet moment in that we have to have a day like this. In fact, I don't understand why we don’t have 364 days for this and maybe give the tobacco industry 1 day a year to blow smoke. It is truly astounding that we need a day to raise awareness of the leading cause of cancer deaths.

I don’t know what to say more than that our medical profession, our oncology societies, our pharmaceutical companies, our insurance companies, [and] our hospitals have not [done] a sufficient job in ending this terrible pandemic. We have pretty much ceded the battlefield to the tobacco industry.

Cigarette advertising has been out of sight for really the past 20 years, since a master settlement agreement in the United States was signed to end cigarette billboards and, for all practical purposes, to remove tobacco advertising from television and from the sponsorship of sports [events].

However, the industry has maintained its grasp on the next generation: There is still internet [-based] promotion, supposedly to those over 21 years old, and there are bar nights and all sorts of clever gimmicks in the Far East and in Central and Eastern Europe, where lung cancer is still extremely prevalent.

Our complacency in the United States is the most important concern that I have. We have Stand Up 2 Cancer, which purports to be working toward a cure for everything, but some of its leading sponsors include those that are still part of the cigarette fuel chain, or the cigarette supply chain, you might say.

Siemens, for example, makes a great deal of the laboratory equipment that we use, but still makes the fastest cigarette-making machines in the world. Then there is Condé Nast (the publisher of The New Yorker), which still has cigarette advertisements in Vanity Fair and other [of its] magazines. There are [also] examples [of companies] like Safeway supermarkets, which still sells cigarettes [and] are sponsors of Stand Up 2 Cancer.

We need to stop the hypocrisy, at the very least. Our own pension funds (such as TIAA) are investing in tobacco stocks. Every university I know has an endowment that is still invested in tobacco stocks. So, you could say that we have met the enemy and he is us; it’s not just the tobacco industry.

Cancer Network: As a clinician, what techniques have you found to be particularly effective in helping your patients stop smoking and preventing them from relapsing? I imagine that the process is very individualized.

Dr. Blum: The issue of smoking cessation has not greatly advanced. We’ve known for a long time that the best way [to stop-I don’t use the negative word ”quit”] is to go cold turkey. In the 1970s, we knew that even a few extra words and personal attention on the part of a physician meant more than just about anything; it improved the cessation rate by 5% [per year] just by saying, “[I care about you and really want you to please] consider this.”

[It would be helpful] if every oncologist who works with a lung cancer patient can also look around and talk to family members and say, “Although we don’t have a foolproof cure for lung cancer yet, we can prevent this, as upwards of 90% of lung cancer is entirely preventable-so I am sure that your dad or your mom would want you to stop smoking and never have any of your children smoke.”

Those are the things that are probably going to do more to immunize the next generation than all of the “Opdivos” and “Keytrudas” that we have [that claim in ubiquitous TV ads to] extend the life of a patient with lung cancer.

If you break down smoking cessation, one of the problems is that medical schools do not teach this. They talk about asking patients [about “quitting”] and “assisting” them and “arranging for follow-up,” but they don’t really look at the words and don’t even ask what brand of cigarettes their patients buy.

I think every physician needs to know what brand of cigarettes their patient buys, because that tells you a lot-if they are buying a budget brand, or whether they think they are getting a benefit from menthol, which is just an anesthetic that deadens the throat. Or whether the patient is buying a cigarette with a filter. No physician asks, “Why do you buy cigarettes with a filter?” Patients assume that since 99% of cigarettes have filters, those must be safer, but that is just not true.

The filter is probably the leading myth that physicians can explode. Filters actually make you inhale more deeply and probably more frequently, to compensate for having to get the nicotine through that filter. That is quite a striking myth that physicians can debunk for their patients.

The filter is essentially a fraud-and the early cigarette filters were made out of asbestos! I think that “low tar” is another example of this; this just means “low poison,” and there is no safe level of it. If [physicians] switch gears from finger-wagging [and preaching about] how dangerous smoking is, to making it a consumer product that is a “rip-off”-that is roughly $5 to $7 a pack in the US, except in New York City, where it’s upwards of $14 or $15 a pack.

Buying cigarettes is like spending $100 for a pack of hot dogs. It is a total rip-off. After all, it’s just dead leaves that you are inhaling the burning product of, and that has upwards of several thousand chemicals that nobody would want to take in if they knew about [].          

Cancer Network: You’ve constantly been vocal about some of the overlooked aspects of smoking, like the filter that you mentioned, and many [factors] that many [people], including oncologists, don’t know about. Could you highlight some more of these?

Dr. Blum: I think the key thing is that there are many ways to go about appealing to the individualized preferences of someone who smokes. First of all, I don’t call anyone a “smoker.” I don’t use the term “alcoholic,” just as I don’t say a person with the flu is a “flu-ic.”

If we personalize to the point where here is a person who smokes and you are a physician who wants to help that person, it automatically becomes a partnership, as opposed to a kind of lording over someone and finger-wagging. Developing that personal tie, and touching that person and saying “I care” is probably the best thing that one can do. Then, shifting the focus away from the guilt and the anxiety of having a physician talk at you, to [a frank discussion about] the “rip-off” nature of the product itself.

Why does a cigarette burn in a 50-mile-per hour wind? Because there are chemicals in there to keep it burning, so that you keep buying more and more because they keep burning up. Why are 20 cigarettes in a pack? It has to do with taxes. Most patients don’t know that.

We really don’t need to be talking on rounds about the number of cigarettes or the number of packs per day. Med students like to say “Oh, he has a 50-pack-year history,” but [that] is a totally meaningless term. Instead, why not talk about the number of inhalations? It’s about 10 inhalations per cigarette, and there are 20 cigarettes per pack; that is 200 inhalations per day, which is more than 70,000 inhalations per year.

It’s like going up to a bus in Manhattan and breathing in from the exhaust pipe. You would never do that, but that is exactly what you are doing when you are taking a hit from a cigarette. It’s a combination of terrible poisons that add up.

I had a patient who was a Marine, and we counted how much money he had spent, and he said, “Gee, I smoked a Porsche!” He could have bought himself a luxury automobile with the money he spent on smoking.

Anything to shift the focus from the guilt and anxiety [toward] getting people angry about the product and the manufacturer and all of those organizations that haven’t helped them stop smoking.

Cancer Network: You've been a major advocate of lung cancer prevention through education of consumers so that they never take up smoking, and helping patients quit smoking as soon as possible. Pharmaceutical companies are obviously developing therapies to treat lung cancer; you mentioned Opdivo and Keytruda. Do you think [these companies] should have a more active role in prevention of this disease rather than its treatment?

Dr. Blum: I am ambivalent about the pharmaceutical industry. They missed their chance. They could have helped many, many decades ago in preventing lung cancer. The Metropolitan Life Insurance Company had advertisements on preventing illnesses. I’ve never seen the pharmaceutical industry do anything that is not in its self-interest.

That is not to say that the industry has not made some great advances. I prescribe pharmaceutical products every day. I think that some of these humanized monoclonal antibodies that are now being used to treat patients are incredible. But when we talk about commercials that are incessant, even on televised baseball and football games-and everywhere you look “For a chance at extra life,” I think it is a cynical gambit.

These drugs are absurdly expensive, and the return is whatever the patient’s family wants to make of it. I am sure that the valued extra time these products promise is good. I haven’t seen that enormous benefit, but I am not an oncologist and can’t judge what would be best for a patient. If you want to look at a cost factor, however, a better investment would be in primary prevention.

Cancer Network: Lastly, on lung cancer screening, guidelines generally recommend low-dose CT scans for individuals at a higher risk for lung cancer. What is your perspective on the effectiveness of lung cancer screening? Should there be more of an effort to make such screening more widespread?

Dr. Blum: Lung cancer screening has been a major controversy. The United States Preventive Task Force [USPSTF] recommends low-dose CT screening.

I guess I am really unhappy that [in 2018] we are in the 100th anniversary of World War I, where many men got their start smoking cigarettes-and they got their start smoking cigarettes because the Red Cross and the women’s auxiliaries of medical societies passed the can around in movie theaters to raise money to send cigarettes to the boys overseas.

The origin of this epidemic is ourselves; we have helped promote this. Here we are, 100 years later, [with an advance] of maybe diagnosing something a little bit earlier. I think that it is certainly a proven technique when it works. But you have to screen, as I understand it, upwards of 300 individuals to diagnose a [single patient with] cancer. Then you have false-positives and the invasive testing that goes along with that. And I am told that, for every 900 patients, you give 1 [patient] cancer because of the dosage of radiation. So, I personally don’t recommend low-dose CT screening for the indications that [USPSTF] recommends. I recently ordered one on an otherwise healthy individual that I thought would possibly benefit were cancer detected. But I really think that we are in this technological age where we have abandoned our own words and our own confidence in prevention for the lure of technology and pharmaceutical products.

Cancer Network: Anything else you would like to add on these topics?

Dr. Blum: It’s funny, because I happened to [come across] a copy of the Osler textbook. Sir William Osler wrote this great textbook in the golden age of medicine (from 1890s to the 1920s), and there was one mention of tobacco in the book; it was called “tobacco heart.”

I fear that the focus on lung cancer solely when it comes to smoking and the supposed cures that we are coming across with newer therapies are overlooking the fact that the leading cause of smoking-related diseases is heart disease. So, we can’t forget that even if we had a foolproof immunization for lung cancer, this wouldn’t necessarily result in any decrease of heart disease-and it might even increase heart disease and emphysema because people might gain a false sense of security.

There was also one page on lung cancer in Osler’s textbook [including] a comment that the causes are entirely unknown. We’ve come a long way to understanding that upwards of 90% of lung cancers are due to cigarette smoking. Lung cancer is a man-made epidemic, and we really need to do a better job [of preventing it]. I hope that we can do a better job in the future, using lung cancer as the example of the modern day Black Plague that never had to happen.