CHAPTER XVII

EFFECTS OF TOBACCO SMOKING ON THE HUMAN SYSTEM

PHYSICAL EFFECTS. OPINIONS OF MEDICAL MEN QUOTED AND DISCUSSED.

EFFECTS OF TOBACCO SMOKING ON THE HUMAN SYSTEM

It is a matter of very great importance for the user of tobacco that he should have clear information regarding the beneficial and harmful effects of tobacco on the human mind and body. There are very few matters which have been the subject of such varied opinions; such exaggeration and misconception. Those who are opposed to the use of tobacco have not hesitated to ascribe to it every form of evil, physical, mental and moral. Insanity, epilepsy, cancer, malignant throat disease, blindness, heart disease and a host of other diseased conditions are traced to tobacco smoking by its enemies. On the other hand the users of tobacco are scarcely less vehement in holding that no harmful effects follow, but ascribing all kinds of virtue as resulting from its use. It is not our object in this chapter to justify or recommend the use, or to advise the avoidance of tobacco; we think it is a matter that the individual should decide for himself. Moreover, we think that no general rules governing all cases can be laid down, but that each individual must judge for himself whether the use of tobacco is justified in his own particular case or not, taking into consideration all the circumstances that affect him. The important thing is that he should possess clear and correct information with regard to the effects of tobacco as far as such have been scientifically determined; and from the observation of its effects on his own organism to determine whether in his own case the practice is beneficial or otherwise and to what extent it may be pursued if he desires to smoke.

We, therefore, purpose to submit the facts which have been determined by the most careful scientific investigators and others of high standing, who, from their experience in the investigation of the causes of disease, are best qualified to offer opinions which may be accepted as authoritative.

A perusal of the vast amount of literature both for and against the use of tobacco brings out certain points very largely. First, in the case of the opponents, the most sweeping statements are made without a particle of scientific proof in support of them, by persons who are in no way qualified to make such statements. Statistics are quoted most recklessly and accepted as conclusive, although in most cases there is no logical connection between the matter of the statistics and the absolute effects of tobacco. If there is a question of a certain condition, it is not sufficient to show that the person suffering from it was a user of tobacco and to allege, therefore, that tobacco was the cause of the condition. It must be shown conclusively that no other circumstances than the use of tobacco could have caused this condition. Dr. T. W. Jenkins, of Albany, N. Y., (New York _Medical Journal_, 1915, V. 102, p. 355), who was awarded a prize by this leading medical journal for his essay on tobacco smoking says: "The first thing to bear in mind is that considering the large amount of tobacco used very little harm results, and care should be taken not to incriminate tobacco when the troubles under observation may be due to other causes."

Secondly, among the investigators themselves who have made impartial inquiries about the effects of tobacco, there is sometimes a wide difference of opinion in the interpretation of results and in the relation of cause and effect. Thus most varied opinions exist on the subject of nicotine. The result is that it is difficult for the average man to come to a satisfactory conclusion on the subject; for it cannot be said that the scientific knowledge of the effects of tobacco smoking on the human system as presented to us today is final or sufficiently well determined to enable definite and true conclusions to be arrived at.

Thirdly, there is the widespread error of ascribing the evils of the _abuses_ of tobacco to the _use_ of tobacco. This matter of the _use_ and _abuse_ of tobacco cannot be put too clearly. Most medical investigators have based their results clearly on the _excessive_ use of tobacco. It is a very rare thing to find a medical investigator drawing attention to any harmful results following the moderate use of tobacco, and it appears a just statement to make that the majority of men use tobacco in moderation. It appears to be true that excessive smoking is harmful and is capable of producing deleterious effects on the respiratory and nervous systems in man, but it has never been scientifically proved that the moderate use of tobacco has any particularly harmful effects. Moreover, it is well-known to the medical profession and so stated constantly that in many cases where the use of tobacco has produced bad effects on the eye, nerves, etc., its use is contra-indicated, owing to the condition of the subject due to other causes and that such results would not occur in a normally healthy subject. Therefore, because tobacco when used excessively or when used by persons who are not constitutionally fitted for it, produces bad effects, it is not logical to argue, as many opponents of tobacco smoking do, that the use of tobacco is universally harmful.

Fourthly, the conclusions arrived at by some investigators, are based on experiments made on animals, and it appears quite open to criticism, and is in fact disproved by common experience, that such results will follow when applied to man. Hinging on this is the question of immunity and toleration. The human system will easily after use tolerate effects which at first it rebels against. This may easily be seen in muscular and other efforts. Let a man who is constantly leading a sedentary life suddenly walk 10 miles. The result is almost prostration and he will not recover from it for a considerable time. Let him, however, commence by walking a mile or two and gradually at each walk increase the distance, and in a short while he will be able to walk 10 miles without feeling any fatigue. Similarly running or other rapid exercise to a person not used to it will produce such rapid disturbances in the respiration and circulation as even to be fatal, while the seasoned athlete may perform such feats without the least ill effects.

To take animals or persons who have never before used tobacco and to argue or conclude that the effects of tobacco smoke on them are the effects of tobacco on smokers generally is absurd. Yet such experimental results are very often made the basis of denunciation of tobacco smoking.

Finally most investigators have made their inquiries for the exclusive purpose of discovering the evil effects of tobacco smoking. They proceed to their work with a biassed mind. They have already assumed that the habit is harmful and they simply want to find out how much harm they can discover. They are prejudiced from the beginning. It is to this class of investigator that Dr. John Aikman refers to (New York _Medical Journal_, Oct. 30, 1915), when he says: "In reading the literature on the use of tobacco we are impressed by the fact that much of it is written by persons greatly opposed to the use of the plant, and naturally prejudiced." It is quite conceivable that a man may investigate the evil effects which follow from wearing clothes and shoes and he could undoubtedly find some evil effects; but the users of such articles could very justly say that the beneficial results of such habits more than outweighed the demonstrated harm that might occur. And then the user of tobacco might say that the beneficial effects of smoking more than compensated for any slight harm that may happen. For tobacco has undoubtedly many excellent effects, and no one knows this better than the smoker himself. He will readily admit that excess is bad. He will readily admit that the use of tobacco is not suitable to immature persons, or in fact to many other persons, but he insist that in the majority of cases, it is not only practically harmless but that it has many desirable qualities, for that is proved by his own experience and the experience of millions of other smokers in all ages and under all conditions.

We will now proceed to consider some of the effects which have been ascribed to tobacco smoking and give expressed opinions concerning them.

PHYSICAL EFFECTS OF TOBACCO SMOKING

The principal deleterious effects on the human system ascribed to the use of tobacco are:

(a) Throat diseases.

(b) Disturbance of vision.

(c) Heart troubles (smokers' heart).

(d) Disturbance of the digestive organs (dyspepsia, etc.).

(e) Disturbance of the nervous system.

(f) Disturbance of nutrition.

As regards (a) throat diseases, the following is the opinion of Dr. H. Reik of the Johns Hopkins University, surgeon to the Baltimore Eye, Ear and Throat Hospital, as expressed by him in the Boston _Medical and Surgical Journal_, Vol. 162, p. 856, 1910:

"There is not one scintilla of evidence that malignant disease of the throat is due in any way to the use of tobacco; and if it be admitted that carcinoma (cancer) of the lip or tongue has been produced by smoking, it is clearly _not tobacco_, but traumatism (i. e., injury) from the stems of the pipe or other tobacco container that is responsible.

"It does not appear or at least has not been proven that tobacco causes any definite characteristic lesions of the nose, throat or ear."

Dr. Reik is a man of high standing in the medical profession. His opinion is clear and unmistakable and it is presumed he has seen thousands of cases of nose and throat diseases and knows what he is talking about.

Dr. Reik refers to the question of so-called smokers' cancer. Cancer is a disease which attacks all kinds of people and may occur in widely different parts of the body. The causation of this disease is not known to the medical profession but what is known about it is that it usually occurs on the site of some previous injury. Thus cancer may occur on the tongue as the result of the constant irritation of a jagged broken tooth.

Dr. I. C. Bloodgood (Boston _Medical and Surgical Journal_, No. 2, 1914), who has examined 200 cases of lip cancer says that smoking is a common factor, the disease when occurring being usually on the site of a neglected and ulcerated smoker's burn. The burn may be a charring of the skin due to a very hot pipe stem or burning cigar stem. He says, moreover, that if the burn is not continued and there is no other injury, this defect may heal without evidence of ulceration.

Similarly a cancer may be the result of continual use of a broken or rough pipe stem or from using a dirty pipe stem on a broken skin. All these are clearly matters which the average smoker easily and usually avoids. It is, however, clear that tobacco itself is in no way responsible for cancer, and no responsible medical writer on the subject alleges that it is.

Most of the medical writers who have inscribed injurious physical effects on the nervous system, heart and sense organs, to excessive tobacco smoking have stated that these effects are due to the toxic action of the alkaloid nicotine known to exist in tobacco. There is a wide difference, however, in the results obtained by different writers as to the amount of the nicotine in tobacco which finds its way with the tobacco smoke. Moreover, some of the investigators who have done very careful work do not consider that nicotine is the toxic element, but the substance called pyridine which is derived from it.

Dr. Bush (quoted below) referring to this matter says:

"From a review of the literature it would appear that extensive studies had been made as to the effects on living organisms of the alkaloid, nicotine. From such studies a great number of writers, especially laymen, have adopted the hasty conclusion that tobacco smoking entailed like results.

"Comparatively few studies have been made of the effects of tobacco smoking on human beings; and such as have been made fail to state if the tobacco used or the smoke produced was examined for nicotine or its congeners. The absence of an examination necessarily causes some doubt in the causative faction of the phenomena. Some authors are rather inclined to conclude that nicotine alone is the pathogenic factor in tobacco smoking, but since the presence of nicotine _per se_ in tobacco smoke is debatable and since other toxic substances are demonstrable, it would seem as if the whole subject still remained open for investigation."

The nicotine contained in ordinary tobacco, according to many authors, ranges from about 1 to 8 or 9 per cent. Lee's investigation (_Journal of Physiology_, 1908, p. 335) found that about half of the total nicotine was present in the smoke--according to Lee the pyridin seemed to be entirely without influence.

Lehmann (_Archiv für Hygiene_, 1909, p. 319) found that from 80 to 90% of the total nicotine in a cigar or cigarette was to be found in the smoke. He found also that in the case of cigars about 10 to 18% of the nicotine in the smoke is absorbed by the smoker and that cigarette smoke absorbed by the smoker contains a less proportion of the nicotine in the tobacco than is the case with cigars. The general opinion is, however, that about one-seventh of the nicotine in the tobacco will be found in the smoke.

Entirely at variance with these results are those obtained recently by A. D. Bush, M.D., Instructor of Physiology in the University of Vermont (New York _Medical Journal_, March 14, 1914), and those obtained in the laboratory investigation by the London _Laucet_. Bush made long and extensive investigations on the effects of tobacco smoking and criticised the results of previous workers. He shows very clearly that in many cases the conclusions drawn by them as regards nicotine contained in tobacco smoke are either entirely erroneous or that the deductions made from the investigations were not warranted by the facts observed. He points out the fact that most writers on the subject have overlooked the fact of the great discrepancy between the possible effects arising from the administration of the amount of nicotine in a cigar and the actual effect produced on the smoker of the cigar. He asks this pertinent question: "If a cigar contains 0.085 grains nicotine, and if one-seventh of the nicotine of the tobacco is present in the smoke and if but .004 grains is capable of causing death, why does the smoker not absorb enough nicotine to cause his demise?"

As a result of his careful experiments, Bush found that although nicotine was present in all the samples of tobacco tested there was no nicotine whatever found in the smoke, except in the case of cigarettes and in this case only traces were found. The reason of this is given as due to the rapid burning of the cigarette which did not allow sufficient time for the complete decomposition of the nicotine. Pyridine was, however, found in the smoke of all tobacco burned. Pyridine is only one-twentieth as toxic as nicotine. Bush concluded, therefore, that pyridine and not nicotine is the toxic factor in tobacco smoke. The same fact was stated several years ago by Rideal (_Disinfection and Preservation of Food_, London and New York, 1903, p. 254), who says: "Tobacco smoke, contrary to popular belief, does not contain nicotine, which is decomposed by the heat; but pyridine and its homologues and the beneficial effects of tobacco in many cases of asthma must be attributed to this latter."

The _Lancet_ investigation (see _Lancet_, Ap. 6, 1912, pp. 944-947) was made because "a recent review of numerous analysis of tobacco which have been published from time to time raises some doubt as to whether the results given correctly represent the actual alkaloidal contents of the tobacco." Moreover, to find the relationship of the true amount of nicotine in any tobacco to that in the smoke produced by the combustion of that tobacco, and any modification caused by the method of smoking.

The investigation was conducted under the strictest conditions, the most recent methods of chemical research being employed.

The following table (given by the _Lancet_) shows the nicotine contents of various tobacco samples and the percentage of nicotine in the smoke:

Description of Tobacco. Per Cent Per Cent Per Cent Nicotine Nicotine Nicotine in Tobacco in Smoke in Smoke (Pipe). (Cigarette).

Virginian Cigarettes (Sample 1) 1.40 0.74 0.12 Virginian Cigarettes (Sample 2) 1.60 0.60 0.06 Caporal (French) Tobacco 2.60 2.20 0.95 Turkish Cigarettes 1.38 0.51 Egyptian Cigarettes 1.74 0.21 Pipe Smoking Mixture (1) 2.85 2.20 2.25 Pipe Smoking Mixture (2) 2.81 1.53 Pipe Smoking Mixture (3) 2.04 0.23 Perique Tobacco 5.30 1.27 0.57 Cavendish Tobacco 4.15 3.85 Latakia Tobacco 2.35 1.20 Havana Cigar 0.64 0.20

From this analysis it appears that pipe mixtures contain the largest amount of nicotine in the tobacco (2.04-2.85%). Egyptian and Turkish cigarette tobaccos come next (1.38-1.74%). Virginian cigarette tobacco shows similar figures (1.40-1.60%). French tobacco (Caporal) contains 2.60%, and Perique 5.30%. For all practical purposes the tobaccos consumed by the public according to this report seldom contain more than 3% of nicotine and generally less, the average being about 2%, which is much lower than previous writers lead us to expect.

The cigarette, whether Egyptian, Turkish or American, yields the least amount of its total nicotine to the smoke formed, while the pipe yields a very large portion (in some cases between 70 and 80%) of its nicotine to the smoke. Analysis of cigar smoke gives figures midway between the two.

With the results of Bush and the _Lancet_ before him the user of tobacco will be better able to judge of the opinions of those who describe the effects of nicotine on the vision, heart, digestive organs, etc., as likely to be the results of tobacco smoking.

Thus the disturbance of vision ascribed to tobacco smoking is called tobacco amblyopia.

Dr. W. S. Franklin of San Francisco (_Calif. State Jour. of Med._, 1909, V. 7, p. 85), says that to produce this disease it is necessary to smoke daily from .75 to 1.0 gms. of pure nicotine. If 17% of the nicotine of tobacco is carried in the smoke, in order to absorb that quantity 7 or 8 cheap domestic cigars, 10 or 11 Cubans or 60 cigarettes should be smoked. Now very few smokers consume this amount and according to Bush, and the _Lancet_, and others there is no such percentage of nicotine in the smoke.

To the use of tobacco is ascribed an acid dyspepsia--this, however, is noticed more particularly in habitual chewers and in this case the nicotine not being burnt has no chance of being decomposed. All writers have agreed that chewing is the worst way that tobacco can be used. Dr. R. V. Dolbey says: (_Northwest Medicine_, 1909, V. 1 p. 99).

"In chewing, quantities of watery extract of tobacco are swallowed and taken down with the food containing a large percentage of nicotine and causing severe dyspepsia. While tobacco juice solution in the laboratory kills intestinal bacteria, excessive tobacco chewing does not have this effect on the human body owing to the fact that the gastric and pancreatic juices act on it and alter it."

Dr. I. S. Gilfilian discusses the effects of tobacco on the heart in the St. Paul _Medical Journal_, July, 1912, p. 338. He says that the important part whether organic changes in the cardio-vascular system may be produced by tobacco is still doubtful, and that it has never been shown that smokers suffer more from organic heart disease than nonsmokers.

General opinion is that smoking lessens the pulse rate and slightly increases the blood pressure, and that it is a cause of arterio-sclerosis.

With regard to arterio-sclerosis, Dr. A. Lorand of Carlsbad who is a world-wide authority on the effects of toxic substances on the blood, says in his book, _Old Age Deferred_ (English translation, 1910, p. 367):

"Clinically we have observed the great frequency of arterio-sclerosis in _great_ smokers, but we do not think that two or three light cigars a day, but never before meals, can do any harm save in exceptional cases. Indeed there are a few instances of persons living to be over 100, notwithstanding the fact that they were smokers--a fact contrary to the observation of Hufeland who pretends that he never heard of such a case. The famous English painter, Frith, who died in October, 1909, used to smoke 6 cigars a day, and Mr. F. of Chartres, in France, passed last year his 100th birthday in spite of his having taken snuff all his life."

If there were any serious lesions caused in the human system by the continued use of tobacco we might naturally expect that life insurance companies would take notice of it, but hear what they have to say (_Medical Record_, New York, July 12, 1913):

Dr. H. G. Turney, at the meeting of Life Insurance Medical Officers Association, London, January, 1913, said that as far as observation and study of the literature went he did not consider that there was much evidence that the habit of smoking can be convicted of any serious effect on the mortality table. One must confess rather to a feeling of surprise that the life-long absorption of so potent a drug as nicotine by a large proportion of the male population should not be accompanied by more obvious results in the way of serious injury to the cardiac muscle than appears to be the case.

Dr. A. Marvin of the Department of Pharmacology, Vermont University, made numerous experiments on the effects produced by tobacco. In the cases of the respiratory system, he states that in rapid smoking the respiratory rate is increased, due more to the effort than to the drug. In deliberate smoking there is very little effect. In the digestive system the effects produced were, increased flow of saliva and stimulation of the mucous membrane of the stomach and intestines. Marvin did not find any important symptoms of systemic irregularities except where there was excessive use of tobacco. He says: "Tobacco produces, _when used to excess_, symptoms in a very small per cent and often it is only one factor in producing the conditions observed." A very cautiously expressed and noncommittal opinion.

It is to be remembered that of the percentage of nicotine in tobacco smoke only a small portion is drawn into the smoker's system. The greater part passes off again in the smoke passed out; also that the products of combustion of tobacco include acqueous solution as well as smoke; it will not probably be questioned that some of this watery solution is drawn into the mouth as well as the smoke and probably contains minute quantities of nicotine or its derivatives.

The smoker may obviate any slight harmful effects of these substances by care. If he is a cigar smoker he must avoid chewing or sucking the butt end of the cigar in which the acqueous solution finally gathers, and he would find it better to smoke long thin cigars which afford a small area behind the burning point for the collection of acqueous vapor and give a better combustion. Judged from these viewpoints the best and most expensive thick cigar is likely to be more harmful than the very worst kind of a cigarette, for although there may be a much smaller percentage of nicotine in the cigar tobacco, a much larger proportion of it may reach the mouth of the smoker through the water produced by combustion, in the case of the cigar than in the case of the cigarette.

Every cigar and cigarette smoker should use a holder for the reason stated. The cigarette from the nicotine point of view is the least objectionable form of smoking. In fact expert opinion is recognizing that unless where the smoke is inhaled cigarette smoking if not excessive is probably harmless. It is hard, of course, to kill a popular prejudice, but we have to deal with demonstrated facts not prejudices. In the case of inhalation of cigarette smoke the danger is from carbon monoxide gas and not from nicotine.

When the difference of opinion amongst authoritative investigators are discounted their general results will be found to agree very well with the general facts observed by all users of tobacco. What they see is that probably seventy per cent of the adult male population under all conditions and circumstances use tobacco within limits of moderation. They see around them men who have for many years used it, and they do not observe any particular harmful results in the user of tobacco compared with the nonuser. Men as a rule are not more nervous, more subject to heart troubles or age troubles than women, who as a sex, do not use tobacco. Smokers do not deny and never have denied that the abuse of tobacco is harmful.

The general view that both scientific investigators and popular observation is able to support is well expressed by Clouston, who is a world known authority on nervous and mental disease. (See _Hygiene of Mind_, 3rd Ed. London, 1906, p. 260.)

"If its use is restricted to full grown men, if only good tobacco is used not of too great strength, and if it is not used to excess, then there are no scientific proofs that it has any injurious effects, if there is no idiosyncracy against it.... Speaking generally, it exercises a soothing influence when the nervous system is in any way irritable. It tends to calm and continuous thinking and in many men promotes the digestion of food.

"Tobacco, properly used may, in some cases, undoubtedly be made a mental hygienie."

Mann (_Brit. Med. Journal_, 1908, V. II, p. 1673), expresses a similar opinion thus: "Most men if they choose to smoke can do so within certain limits without injury to health. Some men can exceed such limits with apparent impunity. The extent of the limitation must be determined by each man for himself."