Jan 24 2013

Man or Woman – Smoking Is Still Bad For You

By now it should hardly be a news flash that smoking is bad for your health. What is interesting, however, is that the risks associated with smoking are getting worse over the last half century. For most of this time the health risks from smoking were greater among men than women – because men smoked more. However, a new study published in the New England Journal of Medicine, indicates that women have essentially caught up to men in this regard (probably not a form of equality they were hoping for).

The article traces trends in smoking-related health risks over the last 50 years. To summarize the finding – smoking increases the risk of developing heart disease, lung cancer, strokes, and chronic obstructive pulmonary disease (COPD). Those first three conditions are the number one, two, and three causes of death respectively (well, cancer in general, not specifically lung cancer). The new study tracks the relative risk of dying from all causes among current smokers and those who have never smoked. For lung cancer specifically they found:

For women who were current smokers, as compared with women who had never smoked, the relative risks of death from lung cancer were 2.73, 12.65, and 25.66 in the 1960s, 1980s, and contemporary cohorts, respectively; corresponding relative risks for male current smokers, as compared with men who had never smoked, were 12.22, 23.81, and 24.97.

So the relative risk for women lagged behind that for men. This risk peaked for men in the 1980s, but women have now caught up. To put the current relative risk into better perspective – those people who are lifelong smokers live on average one decade less than those who have never smoked – 10 years of lost life. This, of course, is an average. You may get lucky and beat the odds, or you may die in your 40s and lose 30-40 years of life. That’s a game I would rather not play.

Why is smoking more risky now than it was in the 1950s? It likely has to do with smoking behavior and trends in the formulation of cigarettes. Smokers over the years have generally started smoking earlier and smoke more.

More interesting, however, is the fact that cigarettes now are often formulated to be low tar, “light” or “mild.” This has two potential effects. The first is to lull smokers into a false sense of security. It’s like overeating fat free ice cream. They think they are smoking less dangerous cigarettes so they smoke more. This, it turns out, is a bad idea. But further, the milder tobacco smoke is less irritation, which means that smokers can inhale the smoke more deeply into their lungs. Further, they have to inhale the smoke more deeply in order to absorb the same amount of addictive nicotine. So light cigarettes may in fact be more dangerous.

One curious fact to come out of this data is that male smokers continue to have a rising risk of COPD. The exact cause is unknown, but it may be related to the deeper inhalation of smoke with current types of cigarettes.

There is a carrot to this stick, however. Quitting smoking, at any age, is beneficial. If you quit smoking before age 30 all of the relative risk of dying essentially goes away. If you quit before age 40 you only lose, on average, one year of life (instead of 10). The later you quit the lower the benefit, of course, but at any age quitting smoking reduces the relative risk of dying. So if you are a smoker – quit now.

Further, laws to discourage smoking are actually working. I remember back in the 1980s there was vigorous debate about laws restricting the places where people could smoke, and smokers were complaining about their rights. I never bought such arguments – I always felt that my right not to be exposed to smoke in public was greater. When data started coming out on the risks of second hand smoke this tipped the scales, and suddenly restrictive laws started popping up.

There is still debate about the relative risk of second hand smoke (it’s real, the question is one of magnitude) but meanwhile that debate has been rendered moot as data comes in showing that restrictive laws help smokers and those around them. A recent study out of the UK, for example, showed a 12% drop in asthma hospital admissions among children following laws to restrict smoking in enclosed public places. In response to such laws smokers are smoking less at home as well, it seems.

Also, laws restricting smoking in the work place have resulted in fewer admissions for myocardial infarctions (heart attacks), including among non-smokers, suggesting a second-hand smoke effect. Such laws reduce public smoking, public exposure to second-hand smoke, and also private smoking. The immediate result is fewer heart attacks and fewer asthma admissions, but we should also expect long term benefits to reduced smoking-related health risks.


If you are a smoker – quit. Seriously, what are you waiting for?

Laws restricting public smoking are a good thing.

And finally, to quote the NEJM article: ““women who smoke like men die like men.”

35 responses so far

35 thoughts on “Man or Woman – Smoking Is Still Bad For You”

  1. nybgrus says:

    I never bought such arguments – I always felt that my right not to be exposed to smoke in public was greater.

    And by what objective standard did you determine that your right was greater? Red vs blue.

    Sorry, I couldn’t resist.

    But thanks for the article. I knew most of this already, but it is always good to approach smoking cessastion counceling with actual numbers like this that people can take to the bank (so to speak).

    One thing I would add though is that I recall reading somewhere a couple of years ago that one of the reasons for increased morbidity and specifically increased incidence of peripherally located bronchogenic adenocarcinoma is because of the advent of filters. The distribution used to be primarily centrally located sqaumous cell carcinoma because the large particle size of the inhaled smoke settled out into the large bronchi. The cigaratte filter (the first one was made of asbestos!!) made the smoke predominantly composed of smaller particulates that made it deeper into the respiratory tree and thus triggered the peripherally located adenocarcinomas we tend to see more (relatively) than before.

  2. nybrus – that’s right, the article does also mention the effect of filters on allowing the smoke to be more widely distributed within the lungs.

  3. champenoise says:

    Well apparently you can wait until you’re 40, good news!

  4. Brant says:

    “indicates that women have essentially caught up to men in this regard (probably not a form of equality they were hoping for).”

    Registered just to tell you how brilliant that quote is.

  5. ccbowers says:

    “The cigaratte filter (the first one was made of asbestos!!) made the smoke predominantly composed of smaller particulates that made it deeper into the respiratory tree and thus triggered the peripherally located adenocarcinomas we tend to see more (relatively) than before.”

    I have heard this before, but it seems to me that in order for this to be true it is not enough that the fillters change the ratio of small to large particles, but the filters would need to actually have to increase the total number of the smaller particles that travel further/deeper. Is this what occurs, or am I missing something?

  6. I disagree – the point made in the article is that the finer air particles allow for deeper inhalation and deeper penetration of the lungs. Also – deeper inhalation is required to absorb the same amount of nicotine.

    So – the smoke that is inhaled has a greater percentage of smaller particles, and more of that smoke is inhaled.

  7. Murmur says:

    When smoking was banned here in the UK it not only improved the air quality due to lack of smoke in pubs, it forced many pubs I went to to clean up their acts in general as the smell of smoke no longer masked any number of smells caused by bad hygeine practices.

  8. ccbowers says:

    “I disagree – the point made in the article is that the finer air particles allow for deeper inhalation and deeper penetration of the lungs. Also – deeper inhalation is required to absorb the same amount of nicotine.

    So – the smoke that is inhaled has a greater percentage of smaller particles, and more of that smoke is inhaled.”

    With what did you disagree?

    My point was in reaction to nygrbus’s comment, and was that the ratio of fine particles does not seem to be as relevant as the amount of finer particles inhaled. Apparently the filters also cause more of the finer particles to be inhaled more deeply, which could explain how the filters are relevant. This would have to be related to the inhaling more deeply and needing more inhalations for the same amount of nicotine rather than due to the filter’s blocking of the larger particles (and the changing of the ratios)

  9. ChrisH says:


    Well apparently you can wait until you’re 40, good news!

    I know by watching my stepmother’s several attempts to stop smoking after marrying my non-smoking father that it is not easy. It took her close to twenty years. It may have been helped along by my father restricting her from first smoking in the car, and then the house and finally anytime he was around (even if it was outside). She was so disappointed that she was unable to quit after trying so hard to be a non-smoker while he was stationed in Korea (we lived in Minnesota that year).

    My father actually quit smoking rather quickly. In the mid-1960s an Army dentist told him he had the beginnings of mouth cancer. So that afternoon my dad tossed out all of his cigars and never smoked again. He was quite delighted that he found after a while he could taste food again.

    My stepmother did die of lung cancer about twenty years after quitting when she was a bit over eighty years old. (my mother also smoked, but she died in a vehicular accident about a year after my dad quit smoking)

    The best thing is to never start smoking.

    And I am delighted at the restrictions on smoking. I remember when I was in college in the late 1970s some people would still smoke in movie theaters. It was a great day when a bunch of us from the dorm went to see a movie together and our entire row told the guy in front of us to put out his cigarette. That was about the last time I saw someone light up in a theater.

  10. mindme says:

    RE smoking and asthma

    Oddly just as I was about to read this, a FB friend posted this link on her wall:


    No idea if the author has his own axe to grind, although the subheadline “The claim that the smoking ban has reduced asthma rates is a case study in using ‘research’ to justify coercive policy.” makes it seem that way.

    Regarding women catching up. I do recall reading in the early 2000s or late 1990s that young women were the last remaining growth market for smoking. Their customers were dying and they had reached about all the novice male smokers who were ever going to pick up the habit. I can see now that “investment” in bringing in more young women 10-20 years ago is now showing tangible results.

  11. nybgrus says:


    I believe the answer to your question is multifactorial. I have no direct peer reviewed data to show you at the moment, and much of what I am about to say is pieced together from things I recall reading as well as my basic understanding of the physics and physiology involved.

    The filter itself would actually alter the ratio of large:small particles. This is because large particles are formed as smaller particles coalesce after smoke is generated. With a filter this coalescence is prevented long enough for at least some of the particles to cool to the point where they will no longer coalesce, thus less total particles are emitted and the ratio shifts to favor smaller. Whether this yields a higher absolute number of smaller particles is not something I know, though it is plausible at least.

    Next you would have differences in exposure. As Dr. Novella pointed out, the filterless cigarettes lend themselves to shallower breathing because they are more irritating to airways and they deliver more nicotine with shallower breaths. Thus, we would expect SCC to develop before adenocarcinoma, though hypothetically if the patient were to somehow survive the SCC and continue smoking it is likely that their OR for adeno is still higher as well.

    Lastly is one that I would have to ask my fiance about – the turbulence. The upper respiratory tree has evolved specifically to create turbulent airflow. This is to allow opportunity for bacteria, viruses, and detritus to stick to the mucous and be removed via the mucociliary elevator (which is an interesting reason why smokers say they start to cough when they stop smoking and starting again fixes it. More on that if you are curious). From my very rudimentary understanding, having turbulent flow with mixed large and small particles would mean more of the small particles stick to the walls secondary to the large particles acting on the small. Less large would mean the smalls could flow deeper with less risk of running into the walls of the upper respiratory tree. This is not something I am certain of from a physics perspective, but seems to make sense vis-a-vis exposure to asbestos. We know that asbestos is extremely small particulate and that it increases the risk of adenocarcinoma and mesothelioma indicating that it penetrates extremely deeply into the airway simply by virtue of its physical properties (another side note, for the medical boards they like to try and trick us; asbestos exposure most increases the risk of peripheral adenocarcinoma – they throw in mesothelioma as a distractor).

    All of these are small effects, most likely. But they add up. And there is still plenty of SCC secondary to smoking. It is just that SCC has dropped and peripheral adeno has gone up.

  12. ccbowers says:

    nybgrus –

    I think your elaboration is pretty good, and I largely agree with your explanations. I’m a bit paranoid about being misunderstood (this is true in general): All I was saying is that in order for filters to be contributing to increased morbidity, their effects would have to extend beyond manipulating the ratios of particle size:

    There would need to be increased deposition in the relevant parts of the lung by 1. increasing the number of certain-sized particles that would deposit there (likely smaller ones – but there is likely an optimum range of sizes) and/or 2. altering the inhalation process in a way that increased the deposition of the particles in the relevant areas. The low tar and “milder taste” effect also could contribute by further increasing the strength of inhalations. I’m not trying to be opinionated on the topic, I’m just trying to make sure it all makes sense.

  13. nybgrus says:

    Perfectly reasonable and eminently respectable ccbowers.

    Of course, goddidit is just as good an explanation :-p

    But yes, I agree. And I believe the explanations I gave give a reasonable account of the necessary changes to induce the difference in cancer incidences.

    I would add one refinement to your thoughts that is an extension of what I had written above. You needn’t necessarily have an increase in the deposition of particles to the requisite areas of the lung. A decrease in deposition of particles to the centrally located SCC generating areas could stave off SCC development long enough for accumulated deposition in the peripheral lung to lead to oncogenesis there. Which, as I write this, is an increase in deposition as you stated, but merely a different mechanism. So I suppose you actually were still correct. LOL. Sorry, I’m pretty tired. But in any event, all of these factors combined are likely contributers to the overall picture.

  14. eiskrystal says:


    The article is probably correct that the government wants to prove that the ban was useful and has gone beyond the science. Thing is, I can’t get excited about that as banning smoking has helped in so many other ways. It’s almost annoying that they even thought they had to do pull such a stunt.

  15. ccbowers says:

    “Of course, goddidit is just as good an explanation :-p”

    Or “godsditit.” Sorry, I’m a few years behind- in Battlestar Galactica mode, still in 2007 I think.

  16. nybgrus says:

    Godsdamnit ccbowers. You’re a fracking thorn in my side. 😉

  17. BillyJoe7 says:

    The argument in Australia is about whether plain packaging helps to reduce smoking over and above what has already been achieved with other measures introduced over the last couple of decades. Some say that the money spent getting this measure through was not worth the small reduction in smoking that could be achieved considering that smoking rates are already at very low level due to all those other measures. I don’t think it matters, though. If I have to see a packet of cigarettes, I’m happy to see it covered in pictures of people dying of lung cancer, or lungs filled with holes and tar…


    As you can see, “plain packaging” is actually a misnomer.

  18. Bronze Dog says:


    If you are a smoker – quit. Seriously, what are you waiting for?

    Believe me, my brother has tried on multiple occasions.

  19. ChrisH says:

    Bronze Dog, witnessing a person struggle to quit smoking was one reason I never started.

    Plus, one thing that is worse than a never smoking person about second hand smoke, is a former smoker, like my dad. He definitely made it clear life without tobacco was better, and he really did not want smell the stuff!

  20. BillyJoe7 says:


    “Believe me, my brother has tried on multiple occasions”

    Most smokers who eventually give up make several attempts before being successful. Encourage him with that news. My wife comes from a family of six, all of whom smoke, all of whom enjoy smoking and have no intention of giving up. So count yourself lucky, your brother may yet succeed, whilst mine are a lost cause. Their denial extends to criticising the value of measures taken by our government to reduce smoking – especially the ugly/plain packaging – and complaining about the taxes levied on cigarettes. For the sake of my sanity, I have given up arguing with them.

  21. nybgrus says:

    I count myself as one of a lucky few – I simply cannot start smoking.

    My parents both smoked all throughout my childhood. In my college years I was the “social smoker” – partaking in a cigarette after a few adult beverages with the crowd. Then after college I worked as a waiter for about half a year in a city where smoking in public and in restaurants was still quite legal and everyone smoked. My colleagues all smoked and after shifts would go outside for a smoke. To join in and make friends I joined. I hated bumming cigs off of them so often so I would buy my own packs (which was always quite comical since I didn’t have a brand and would try something new each time and the cashier would always look at me like I was crazy). I even established a ritual of my own. I would come home late, put on my “smoking jacket,” go downstairs to a bench out in front of my place, and smoke 2-3 cigarettes whilst making calls back home (the time difference helped) or just listening to music. I did this every single night. After a week or so, I would do the whole ritual, but after 1 puff I would be disgusted with it, and just not smoke. After 3-4 days of the ritual without smoking, I would try again and manage another week. I did this for almost 5 months straight. At the end, when I left the city and moved home where smoking is banned, I didn’t miss it in the slightest, and though I was still that “social smoker” I would only inhale 1 or 2 puffs and then Bill Clinton the rest to hang out with the group. Finally, two years ago, I even got sick of that and have only had 1 cigarette since. After 2-3 puffs I was high as a kite and felt so nauseated I retched, put it out, and haven’t touched ’em since.

    So yeah, for whatever reason – despite my best efforts – I simply could not start smoking.

  22. DevoutCatalyst says:

    Join the U.S. military, nybgrus, maybe they can help get you started. Lotsa smokers there. Good luck on your journey.

  23. ChrisH says:

    DevoutCatalyst, funny it was an Army dentist that told my dad to quit about forty five years ago. And there is a more concerted effort to reduce smoking: Report Urges Timeline for Tobacco-free Military, and there is still a higher level of tobacco use versus civilians it is a health criteria:

    Woodson said he will announce a new multi-year program this year to help service members deal with tobacco use and obesity.

    “Our service members are using tobacco and tobacco products at a much higher rate than their peers in the civilian sector,” he said, and entry-level service members and retirees tend to develop weight problems.

  24. tmac57 says:

    I’ll add my own anecdote if I may.
    I was raised in a family of chain smokers,and did much the same as nybgrus,as far as ‘trying’ to become a smoker,but it just didn’t take,which was a blessing in disguise.
    Then I became quite bothered by the ubiquitous presence of smoke filled breakrooms,cars,restaurants and bars,you name it…it was the 60’s and 70’s then…before more enlightened minds could gain a hold.
    Fast forward to the 90’s,and I find myself in a telecom school for ATT on some now forgotten new piece of technology,talking to a young man 20 years my junior,who was simultaneously cursing the new smoking ban in the breakrooms,and his own inability to quit.
    While being empathetic to his struggle, I pointed out to him that my own mother was then suffering from emphysema,and my wife’s mother was in the final stages of lung cancer,and about to die.
    But he,like many smokers, had a glib reply of “Well I’ve got to die from something,Right?” I thought about this a moment,and then remembered that the day before he had been going on about his very young kids,and how much they meant to him and his wife,and I said, “You know,if I had people in my life who meant that much to me,I don’t think I would be so careless with my life.I think I would do all that I could to see them grow up,get educated,maybe have children,and maybe I and my wife could enjoy them,my grand kids,and our retired years together.”
    The next day he came into class,and said “I will never pick up a cigarette again”. I hope he meant that,and I believe he did.

  25. nybgrus says:


    I am now pretty bothered by places where you can still smoke inside. I currently live in a city where that is the norm and smoke free bars are an exception. I can manage – certainly better than my fiance who absolutely cannot stand smoke – but it does get to me, especially in the winter when all the doors and windows are closed and it gets really smokey.

    And indeed, one of the recommended tactics for smoking cessation counseling is to get people to make a list of pros and cons they find from smoking and see if they don’t decide that the cons outweigh the pros. Reminding them about being around longer for loved ones tends to weigh heavily on the cons side of the equation.

  26. ChrisH says:

    One method I don’t recommend as a way to quit smoking:

    When I filled out my form for a college dorm room in 1975 I requested a non-smoking roommate.

    Unfortunately so did my roommate, who did it as a way to force herself to quit smoking. More than once I caught her attempting to smoke, and then a friend of hers was smoking in the room. Despite it being the middle of winter I opened the window and sat next to it explaining it wasn’t his company but that I gag when I smell the stuff.

    I think my roommate finally did quit smoking. I just wish I was not the one who had to breathe it.

  27. ChrisH says:

    By the way, I should also add that one incentive for not smoking was the cost. Just a couple years before starting college I quit buying comic books because they started to cost more than twenty five cents, and I was shocked to see one of my friends pay what to me was too much for a package of cigarettes, it was more than several comics! I am just too cheap (frugal, penny-wise?).

    (which is perhaps why we can pay the tuition for three kids)

  28. BillyJoe7 says:

    Seeing as we’re into anecdotes…

    I was never a serious smoker, but I did spend a few years smoking a few cigarettes every night while studying. However, it didn’t sit well with running, especially when I started training for marathons, so I decided to give it up. Surprisingly I found that hard to do, and even after having given it away for a few years, I couldn’t resist taking a drag from my wife’s cigarette every now and then. That is now past history as well. Unfortunately, my wife continues to smoke and she will never give it away. Her grandfather was a heavy smoker and lived into his eighties so that tack doesn’t work on her. That’s an unreliable anecdote, yes, but she’s a “feely” type, not a “sciencey” type.

    Another thing: I can’t stand the taste of beer. Scotch and red wine are fine, but I can’t get the beer past my tongue. I don’t think I’ve met anyone else with such an aversion, but I wonder how common that is and what the basis for it might be.

  29. DevoutCatalyst says:

    Foster’s isn’t beer.

  30. nybgrus says:

    An ex girlfriend of mine hated beer. Just one of the many reasons she is ex status.

  31. tmac57 says:

    I hated the taste of beer for the first several years after I started drinking it as a means to get buzzed. Then on my 21st birthday,my friends took me out for pizza and beer,and the combination clicked,and from that moment on I really enjoyed the taste.The same thing happened with wine a few years later.

  32. BillyJoe7 says:

    DC: “Foster’s isn’t beer”

    Oh, is that the problem?
    How about XXXX?




    “pizza and beer”

    Makes me shake just thinking about it.
    Surely, it’s pizza and coke.

  33. DevoutCatalyst says:

    All beers put you off? I’d be sorry to hear that, and if so it’s too bad, because I was thinking we could fly you to Belgium for one of our Skeptics in the Monastery events, drink Chimay, diss God, appreciate the good life, pious monks serving us manna from heaven. As the saying goes, build a better Trappist and the world will beat a path to your abbey — Belgian monks make great beer. Will you join us BillyJoe?

  34. nybgrus says:

    Belgian beer with Belgian chocolate is as close to proof of the existence of a loving god we will ever have.

  35. BillyJoe7 says:

    Perhaps I do need to expand my horizons.

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