The Public’s Health: Smoking and Salt

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People pretty much know that smoking is bad for you. You, the smoker, and you, the person exposed to secondhand smoke. Smoking accounts for over 450,000 deaths a year in the US, more than alcohol, accidents, homicides, suicides, and illegal drugs. It is good for people’s health – both the smokers and those who are exposed to that smoke in their homes, workplaces and places of recreation – that people are smoking less; fewer people are smoking and those who do are, on average, smoking fewer cigarettes. Most of the people who have quit have done it on their own, rarely the first time that they tried (“Quitting smoking is easy,” said Mark Twain, “I’ve done it hundreds of times.”) Others have had help – from support groups, physicians, therapists, drugs.

But more important than individual efforts to change individual behavior is the positive impact public policy can have on public health. Mandatory immunizations for school, seat-belt laws, laws governing the safety of manufactured automobiles, helmet laws etc., have all had measurable and significant impact on our health. The two most common and important public policy initiatives regarding smoking are taxing tobacco and banning smoking in public places. In the January 27, 2010 JAMA, Mohammed K. Ali and Jeffrey P. Koplan look at “Promoting health through tobacco taxation”.[1] They show that increasing tobacco taxes decreases tobacco use, especially in young people, and thus the morbidity and mortality that comes from tobacco.

The beneficial effect of smoking bans is so enormous it suprises even tobacco control advocates. “Cardiovascular effect of bans on smoking in public places: a systematic review and meta-analysis”, published by David G. Meyers, John S. Neuberger, and Jianghua He in the Journal of the American College of Cardiology, September 29, 2009,[2] examined 11 studies of smoking bans done in 10 different locations and found that there was a 17% overall reduction in acute myocardial infarction (AMI = heart attack) when these bans were implemented, and that the risk incrementally decreased 26% for each year that the ban was in place. In Helena, MT a smoking ban instituted in June 2002 and resulted in a 40% decrease in AMI by the time the ban was suspended by a court order in December. After the ban was lifted, the AMI rate returned to baseline within 6 months. The impact on AMI is in addition to any effect on other diseases, such as cancers, which were not examined in this study (and would take many more years to have an effect). While much of this improvement in the public’s health comes from reducing the impact from second hand smoke on non-smokers, such bans also unquestionably encourage smokers, especially younger ones, to stop smoking. This is particularly true when quitting is something that the smoker had wanted and planned to do, with the smoking ban or increase in the tobacco tax acting as the “final straw”.

Ronald Bayer and Matthew Kelly, in the New England Journal of Medicine January 28, 2010 discuss “Tobacco control and free speech”[3] and look at how the courts are likely to decide on cases brought to them on tobacco control. While not, so far, opposing tobacco bans, the American Civil Liberties Union is supporting objections to limits on tobacco advertising on the basis of their restriction of free speech: “Burt Neuborne of the New York Civil Liberties Union told Congress that the proposed bans represented ‘a vote of no confidence in the capacity of ordinary Americans to judge for themselves how to react to tobacco advertising”. Bayer and Kelly cite the Posadas decision, written by former Chief Justice Rehnquist in 1986, that limited the advertising for a casino. The quote his opinion “It would surely…be a strange constitutional doctrine which would concede to the legislature the authority to totally ban a product or activity [such as gambling] but deny to the legislature the authority to forbid the stimulation of demand for the product or activity [advertising]”. I would argue that it is unreasonable to suggest that we can outlaw products (such as heroin, marijuana) or activities (gambling) but not restrict others (e.g., smoking in public places) and thus most often bans have been supported.

However, the Supreme Court is moving away from the Posadas position, Bayer and Kelly tell us, in the 2001 case of Lorillard Tobacco Company v. Reilly, and given the 2010 Citizens United decision in which the Court has made the bizarre declaration that corporations have First Amendment rights to give money directly to political candidates, it is far from certain that they would support tobacco bans, taxes, or restrictions on advertising in the future. Clearly, these justices who have previously styled themselves as “strict constructionists” looking at original intent”, have clearly demonstrated that they have no such belief, radically making new law and reading their own beliefs into the Constitution. But what is certain is that all these restrictions, without directly forbidding any adult from smoking, have a dramatic positive impact on the public’s health.

Another article in the New England Journal of Medcine, published on-line January 20, 2010, by Kristen Bibbins-Domingo, et. al., looks at the “Projected effect of dietary salt reductions on future cardiovascular disease”, and notes that reducing dietary salt by 3g per day (or about 1/3) would reduce the annual number of deaths from all causes by 44,000 to 92,000, and new cases of coronary heart disease by 60,000 to 120,000, stroke by 32,000 to 66,000 and AMI by 54,000 to 99,000. This is important, because in recent years the emphasis on salt reduction as a method of treating hypertension (high blood pressure), one of the big vehicles for these bad outcomes, has diminished with the marketing of large numbers of anti-hypertensive drugs. We, as physicians and the public, need reminders of the dramatic efficacy of this sort of dietary change.

The article does not address how that reduction might be accomplished; clearly, as with smoking, the effect could occur if people as individuals just reduce their salt intake. But the probability of this happening is again low. Programs such as labeling the salt/sodium content on foods in both grocery stores and restaurants, especially “fast-food” restaurants, have been implemented in a number of cities. Further regulation, actually requiring lowering of the amount of salt in these foods, would have an even greater impact. Unlike smoking bans, which have a great part of their effect through elimination of exposure of non-smokers to secondhand smoke, the benefit of salt restriction is mostly to the individual consumer. However, this does not mean that societal impetus for this change is not a critical part of changing people’s behavior. Indeed, as noted by Mark Doescher, Director of the Rural Health Research Center and the Center for Health Workforce Studies at the University of Washington in his comments on the important new textbook Community Based Health Interventions [4], “…environmental factors, such as safe streets, healthy food choices, and smoke-free establishments govern individual behavior.”

Experts in occupational safety have long recognized that changing individual behavior is the least effective way of increasing safety. If we want to prevent people from slipping on a factory floor and going through a plate glass window, the first choice is architectural (don’t put a plate glass window next to a shop floor where substances may be spilled that people can slip on). The second choice is engineering, or retrofitting (put a steel mesh over the window). The least effective choice is changing human behavior (telling people to be careful!). The dramatic reduction in deaths from car accidents over the last 30 years has had virtually nothing to do with people driving more safely, and everything to do with car manufacture (engines that collapse down instead of into your lap, air bags, etc., all of which were resisted by the automobile industry) and safer road construction. With regard to the health of the public, the same rules apply. Tobacco bans, tobacco taxes, and efforts to reduce salt intake by honest labeling are much more likely to have a salubrious impact than efforts to get people to change their behavior individual by individual. We need to encourage the latter, but because Doescher is correct, we must also implement the policy changes. We must no longer allow the economic benefit to special interests to continue to endanger the public’s health.

[1] Ali MK, Koplan JP, “Promoting health through tobacco taxation”, JAMA 27Jan10;303(4)357-8.
[2] Meyers DG, Neuberger JS, He J, “Cardiovascular effect of bans on smoking in public places: a systematic review and meta-analysis”, J Amer Coll Card 29Sep09;54(14):1249-55.
[3] Bayer R, Kelly M, “Tobacco control and free speech”, NEJM 28Jan10; 262(4):281-3.
[4] Guttmacher S, Kelly PJ, Ruiz-Janecko Y, eds., Community-based health interventions, Jossey-Bass, San Francisco, 2010.