"Everything in moderation."
It's a common justification made for behaviors that may fall outside the realm of healthy. Whether it's a drink or two or indulging in a favorite dessert, consuming small quantities, rather than abject abstinence, is a more palatable and acceptable option for most people.
The less-is-more approach may be sound when applied to many aspects of our frenzied daily lives, but when it comes to smoking, the same rationale cannot apply.
A new study that I conducted with other nursing and health services researchers has found that those who enjoy the occasional cigarette in social situations are risking their health just as much as the person who smokes a pack or more a day.
Ours is the first population health study to compare the blood pressure and cholesterol levels of people who self-identify as current versus social smokers.
To eliminate risks of cardiovascular disease, the only answer is not to ever start smoking or stop it completely. This needs to be a priority for health providers and policymakers.
An on-ramp... to a dead end
A study of nearly 40,000 people conducted over a four-year period as part of The Ohio State University's Million Hearts educational program identified nonsmokers, current regular smokers and those who said they were "social smokers," meaning they didn't have a cigarette every day. The "social smokers" in our study tended to be younger, male and were disproportionately Hispanic. Social smokers have been identified in previous studies as those who smoke in nightclubs and bars. Also, social smoking has been shown, in previous studies, to be associated on college campuses with alcohol consumption.
Our study defined a social smoker as "an individual who does not smoke cigarettes on a daily basis but who smokes in certain social situations on a regular basis."
The researchers collected deidentified data from volunteers who completed Million Hearts cardiovascular screenings. After taking into account demographic and physical differences between the regular and social smokers, we found that there was virtually no difference in their risk of experiencing hypertension or high cholesterol, conditions that frequently lead to heart disease.
The study did not measure outcomes on cancer, but we know that smoking has been linked to 30 different types of cancer.
I believe that this is one of the most important findings in tobacco-related health in years, and it brings to light an issue, like e-cigarettes and secondhand smoke, that we in the health care field must address with urgency. We now know that once people start opening packs of cigarettes, whether it's for daily use or just to socialize at a party, they're entering the same on-ramp toward serious health problems.
When moderation becomes a vice
This knowledge carries significant ramifications for the medical profession and the way nurse practitioners, doctors, nurses and physician assistants communicate with patients. It's routine for clinicians to ask patients whether or not they are smokers during a checkup or exam. The social smokers will frequently respond negatively to that question because they don't think of themselves in those terms and, thus, a significant health threat goes undetected.
Given these findings, it makes more sense for clinicians to reframe their questions. For example, "Do you ever use tobacco in social situations with friends or work colleagues?" or "When was the last time you had a cigarette or used tobacco?"
High levels of bad cholesterol, the type measured in our study, and high blood pressure are risk factors for heart attack and stroke. Knowing that these health risks for occasional smokers are the same as those who light up frequently, clinicians must become more precise in collecting this information from their patients.
This study should also affect the advice that patients receive in the examination room. In terms of heart health, it's simply not sufficient for clinicians to advise patients to cut back on their smoking.
The societal impact of this new study could be enormous. It concluded that more than one of every 10 Americans identifies as social smokers, compared to the 17 percent who smoke regularly. Extrapolate those numbers to the country as a whole and it means that millions of people are placing their heart health at risk by occasionally indulging in cigarettes. We can't ignore this problem.
Over the last few decades, the United States has done a commendable job in raising public awareness of the dangers of smoking and properly stigmatizing tobacco use as a pervasive and deadly health threat. Armed with this new knowledge regarding the dangers of social smoking, public health officials, anti-smoking advocates and the medical community need to focus their messaging on those who mistakenly believe the occasional cigarette leaves them exempt from the warnings directed toward heavier users. Moderation, in this case, is most definitely a vice from a health perspective, and a potentially life-shortening approach.