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How Many Diseases Does It Take?

It is not a secret that I dislike tobacco companies. Intensely. I do not see the point of allowing them to sell a product whose value is all in the negative. I am appalled that we are looking for expensive ways to diminish lung cancer mortality before considering a complete ban on this disease promotion apparatus. Yet this story in the LA Times got my goat. Briefly, a woman who has smoked for years and has had smoking-related obstructive lung disease since 1989 decided to sue tobacco companies after developing lung cancer in 2003. The suit has been making the rounds in various levels of courts, since the defendants asserted that she had exceeded the 2-year statute of limitations following the onset of her smoking-caused disease, referring to the 1989 COPD diagnosis. However, the California State Supreme Court has ruled that she can still sue the manufacturers, since she filed her suit within two years of the lung cancer diagnosis. So, why am I bothered?

Well, here is the thing: once you develop lung disease, followed by periodontal disease, as this woman did, had she really remained unaware that cigarettes are bad? That they cause problems? Is it really possible to live in our world and NOT be aware that tobacco kills? And if she was aware and continued to smoke, whose responsibility is it that she developed lung cancer, hers or the manufacturer’s? Well, you say, but the tobacco companies are unethical and lied about making cigarettes more addictive by adding undisclosed ingredients. So, how are we, the consumers, to know? Well, this is pretty simple: We have free will, don’t we? And if you have the free will, you have to exercise some will power, no? Is this not what the human condition is all about?

Consider what would happen if we just let all of our desires run rampant. At the simplest level, who would want to get up early and do back-breaking work to produce food for our communities? And why contain anger at town hall meetings, when my humanity tells me to get into a brawl? These are basic ways in which we conquer our instincts and do what we need to do to live in a society with human beings and other organisms. But what is peculiar is that we have not extended these exercises of will to the area of consumerism. In other words, it seems to me that whichever way the market, and more importantly marketing, goes, so goes the perceived need for personal will and responsibility. Ergo, smoking despite warnings of its dire effects is OK, since the poor soul is addicted, and she can always sue on the back end, while the murderous tobacco CEOs and investors walk away with the profits. I don’t know, I think it is embarrassing to give up your will that way personally.

There are two nuances to this view that I want to express. First, I do believe that cigarette companies are unethical, cruel and in debt to us, but the debt that needs to be paid is to the society, not to individuals. It is a debt to our public health that requires complete withdrawal of their product from the market and a large monetary compensation to promote healthy habits among human beings. Second, I believe that there are shades of this personal vs. societal responsibility balance that are important. Take, for example, food options for an inner city youth who lives in poverty. He may want to exercise his free will to get better nutrition than a $1.25 meal at McDonald’s offers, or spend his $1.25 on an apple instead of a bag of potato chips, but for this he has to go across town, a trip that he does not have the means to undertake. This, folks, is where this young man’s personal responsibility needs to be supplemented with societal commitment to equity.

So, should this unfortunate smoker with severe and life-threatening sequelae of tobacco abuse be able to sue the producer of the poison, even if she knowingly took the poison? I guess as a society we have decided that this is OK, but as an individual I am dubious. Yet it really is in the interest of our common health and wealth to punish and eliminate producers of such poisons as a society. Relying on individuals to do this job is just a perpetuation of the idea that we are not responsible for our actions. And furthermore, this becomes but a small pimple on this giant’s ass, a nuisance, and not a necrotizing fasciitis that is required to kill it once and for all.

Marya Zilberberg, MD, MPH, is a physician health services researcher with a specific interest in healthcare-associated complications and a broad interest in the state of our healthcare system. She is the Founder and President of EviMed Research Group, LLC, a consultancy specializing in epidemiology, health services and outcomes research. She is also a professor of Epidemiology at the University of Massachusetts, Amherst. She blogs at Healthcare, etc.

4 replies »

  1. I am a big opponent of smoking and tobacco factories, and I think that this is currently the largest and most serious disease that exists. In my family, all smokers except me, and I’m sick to look at how to poison every day. Perhaps there is no current solution but on http://www.oohoi.com can find plenty of useful information.

  2. “We have free will, don’t we? And if you have the free will, you have to exercise some will power, no? Is this not what the human condition is all about?”

    I can’t say that I’m not disappointed in your limited thinking for an MD. I would have expected deeper thought on this subject.

    90% or more of smokers became addicted to nicotine while they were all under the legal age to make rational decisions for themselves. The other 10% or so are very young adults, who still are easily deceived and manipulated.

    I’m sure that you know that once someone becomes addicted to nicotine, the choice to quit becomes extremely difficult, and the tobacco industry now basically controls their lives.

    To put it in better perspective, consider the following scenario.

    I slept with your 14-year old daughter because she was looking for an older guy and she is capable of making her own decisions about sex. She has free will and is able to exercise some will power, so there should be nothing wrong with her choosing to sleep with an adult, right?

    Of course not. If that really happened, you’d be totally outraged and looking to prosecute me to the fullest extent of the law for child rape, right?

    So why do you think your 14-year old daughter has the free will and capability to choose to smoke or not? That’s what the human condition is all about.

    See what I mean? Don’t buy into this “free will” bullshit the tobacco industry is trying to hand you. They put addictive chemicals in their products in order to line their pockets at smokers’ expense.

    They deserve to lose every single lawsuit brought against them.

  3. I am not a zealot when it comes to the sale and use of tobacco.

    There are many ways we abuse our bodies. And there are other values as humans that we have that compete with maximizing our biologic well being alone.

    Many of our greatest American writers, for example, were/are highly addicted to nicotine

    But as the old cliche goes “ultimately everyone stops smoking”

  4. So in answer to your questions:

    “Well, here is the thing: once you develop lung disease, followed by periodontal disease, as this woman did, had she really remained unaware that cigarettes are bad? That they cause problems? Is it really possible to live in our world and NOT be aware that tobacco kills? And if she was aware and continued to smoke, whose responsibility is it that she developed lung cancer, hers or the manufacturer’s? Well, you say, but the tobacco companies are unethical and lied about making cigarettes more addictive by adding undisclosed ingredients. So, how are we, the consumers, to know? Well, this is pretty simple: We have free will, don’t we? And if you have the free will, you have to exercise some will power, no? Is this not what the human condition is all about?”

    I’m surprised that you, well versed in the effects of tobacco consumption on carcinogensis and other disease processes, are not acknowledging the cognitive effects of addiction.

    Nicotine changes the structure of the human brain itself. I have personally observed how nicotine addiction deprives individuals not only of their “will power”, but even causes them to construct elaborate intellectual justifications for the smoking, elaborate dismissals of the effects of tobacco on their bodies, and so on.

    I think a strong case can be made that tobacco addicts, like, for example, crack addicts, are not in their right minds (to speak colloquially) particularly regarding their ability to reason about their addiction and its consequences.

    Tobacco addiction, nicotine addiction, is insidious because it subtracts from people’s very humanity by depriving them, by degrees, of their ability to exercise their free will.

    This is in turn should have legal consequences. Much as statutes of limitation on childhood sexual abuse have changed to reflect the fact that people may find the ability to speak only later in life due to the nature of the crime and the age at which they were wounded, so also the law should recognize that nicotine addiction physically alters the human brain, and in so doing impairs the very humanity of the victim.

    If you insist on constituting the tobacco addict as a person with the same level of free will as a normal non addicted person, you are doing a disservice to the reality of the disease, and to the evil perpetrated on the individual by the purveyors of tobacco.

    Therapy should of course attempt to instill in the addict a sense of free will and empowerment, but the therapist should also recognize the reality that the tobacco addict is, at root, a person with impaired free will, due to the physiological changes that the toxin has caused in the brain. The law should be similarly wise.