TCS Daily

Second Hand Joke

By Sydney Smith - May 7, 2004 12:00 AM

Smoking is a filthy habit. It causes bad breath. It stains the fingers and the teeth. It rots the lungs and it takes the breath away. Spend a day in any doctor's office and you can quickly spot the long time smokers, such is its impact on the body. And death by tobacco is a truly horrible death, with the final days spent gasping for breath and drowning in ones own secretions while the doctors look on helplessly.

And yet, as loathsome as smoking is, it's hard not to feel sorry for smokers. Every morning I pass small clusters of them in front of the hospital, just around the corner from the "No Smoking" sign, like high school hoodlums who smoke just a step away from school property. Some of them are hospital employees, puffing off job stress during their breaks. Others are patients, with nothing but flimsy hospital gowns and robes to protect them against the elements while they seek solace in tobacco. It seems cruel to make them smoke outside. The hospital has a special room for prayer. Couldn't they have a special room for smoking?

But then, the world has become a cruel place for smokers. Not only must they huddle outside at work to indulge, they increasingly must also huddle outside when they're enjoying a night on the town. Over a hundred cities in the U.S. have banned smoking in public places such as bars and nightclubs. Last month, Ireland banned smoking in pubs. Now Scotland is under pressure to do the same, and the EU is flirting with its own ban.

The rationale for these bans is that smoking in public is not only a nuisance for non-smokers, but a health threat. While it's true that an asthmatic non-smoker may have problems working or relaxing in a smokey bar, anti-smoking advocates have lately drastically stepped up their claims regarding the dangers of second hand smoke. A CDC official, writing in the British Medical Journal warned people with heart disease to avoid all buildings that allowed any smoking, claiming that just thirty minutes of inhaling second hand smoke could cause heart attacks. Apparently, even miniscule amounts of tobacco smoke can turn your coronary arteries from this into this.

The basis of this latest second-hand smoke hysteria is a study in the same issue of the British Medical Journal which purported to find a forty-percent decrease in heart attacks in Helena, Montana, during the six months that the city banned smoking in public places. The data come from St. Peter's Hospital, the one hospital that serves the Helena area, population 68,000. Most of the time, between the months of June and November, St. Peter's gets anywhere from thirty-four to fifty patients with heart attacks. During the six months of the smoking ban, they had only twenty-four. Obviously, the drop in heart attacks must be due to the smoking ban.

Or maybe not. First of all, the number of patients that St. Peter's serves is very small, and the smaller the patient population the more likely disease rates will fluctuate just by chance. Take, for example, my own medical practice. I have around two thousand active patients. Most of the time, I have one or two people in the hospital on any given day. But for the past month, for some reason, I've been averaging four to six patients a day. Is it something about the way I'm practicing medicine? No. I'm practicing the same way I do when I have no patients in the hospital. It's just the nature of illness and populations. Every doctor experiences good months and bad months that are more or less random, (except for bad viral seasons, when patient influx is predictable.) It's not far fetched to think that the same thing is going on at St. Peter's, and if the study had compared heart attacks year to year, rather than six-month period to six-month period, there might not have been such a large difference.

Another problem with the study is that during the six months of the smoking ban, the hospital changed the way it diagnosed heart attacks. Before the smoking ban, heart attacks were diagnosed by testing for an enzyme called creatine phosphokinase. When the heart is damaged, this enzyme leaks into the blood. However, other muscles can leak this enzyme, too, so relying on it exclusively can result in a certain degree of false positives. During the smoking ban, the hospital began testing for another enzyme, called troponin, and enzyme which is specific to heart muscle, and which improves diagnostic accuracy considerably.

It's quite a stretch to look at the data from Helena and conclude that thirty minutes of second hand smoke exposure will kill your heart. It's just too small a sample to make such sweeping conclusions. If banning public smoking really reduced heart attack rates by forty-percent, wouldn't New York city cardiologists have noticed by now? A forty-percent decrease in business is hard to overlook. And wouldn't the city's health department, which believes strongly in the benefits of smoking bans, have noticed, too?

Smoking is bad and smoking around non-smokers without their permission is rude. But exaggerating the dangers that smokers pose to non-smokers is not wise. For one thing, it undermines the credibility of the medical profession. For another, it promotes an attitude of intolerance that should give us pause in a free society. The way things are going, it will be only a matter of time before a smoker is charged with manslaughter for his co-worker's heart attack.

Sydney Smith is a family physician who has been in private practice since 1991. She is board certified by the American Board of Family Practice, and is a Fellow of the American Academy of Family Practice. She is the publisher of MedPundit. She wrote recently for TCS about the Human Rorschach Test.


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