Cigarette smoking--A paradox. (Editorial).

An alien from another planet landing in the United States is bound to be impressed by the health-conscious population. Speed limits and traffic signs are posted on most roads to reduce the number of accidents. Food products have their nutritional value and composition, including micronutrients and additives, clearly displayed. Even a bottle of distilled water has a label to show that it contains nothing--but water. A multitude of vitamins, nutritional supplements, and health "aids" can be purchased. A number of magazines meet various health needs, and many web sites provide detailed information on virtually any health topic.

Children are educated about various health issues. In many public restrooms there are signs encouraging users to wash their hands. Health fitness clubs are plentiful, and health-conscious joggers can be seen at all hours of the day--and night. Patient education is an essential function of clinicians, and before recommending accreditation, surveyors of the Joint Commission for the Accreditation of Health Care Organizations want to see clear documentation that patients have been educated about their health problems. Prevention is a major issue, and many screening programs are available, such as those for hypertension, hyperlipidemia, breast cancer, colorectal cancer, and osteoporosis.

The alien thinks: These people do not spare themselves any effort when their health is at stake!

But something draws his attention. He is puzzled by a habit of a fairly large segment of the population. These people repeatedly take small cylinders, 3 to 4 inches in length and about a quarter-inch in diameter, place one end in their mouth, and amazingly set fire to the other end! Incredibly, they then inhale the smoke, and a few seconds later exhale it. Although some take small puffs and quickly exhale, many inhale deeply, as if to ensure that a maximum amount of the smoke reaches the alveoli. They hold the smoke internally for a few seconds, and then exhale it slowly, as if with regret.

The alien cannot understand this behavior. He notices that "smokers" are obsessed by their habit. They are always concerned about having enough of these cylinders, although there are quite a few dispensers available in most places. When deprived of their habit, many become anxious, nervous, and even irritable. In many public places, smokers converge eagerly to specially designated congregation areas to join others with similar habits. Many furtively leave their warm and comfortable workplace to brave inclement weather conditions just to indulge in their habit.

The alien notices that many of the smokers are in poor health. They often cough, get short of breath easily, and are afflicted by many other diseases. The alien ponders: And all of these complications arise due to smoking? How can such a health-conscious population indulge in such an unhealthy practice?

The intrigued alien decides to investigate matters further. He examines the container where the cylinders come from, reads the health warning issued by the government, and is even more puzzled: People know that it is bad for their health, and yet they still do it! He goes to the factory where these cylinders are prepared. There he can hardly contain his amazement. Dried plant leaves are finely shredded, a number of other clearly toxic substances are added, and the mixture is rolled into small cylinders. He is amused to see a "filter" placed at one end. He peruses documents in the factory and sees clear evidence that smoking is associated with many health problems. Why do these people do it?

Perplexed, and somewhat disappointed, the alien begins to compose his final report: Humans are very complex and definitely paradoxical beings in whom the forces of self-preservation are battling those of self-destruction.

Ronald C. Hamdy, MD, FRCP, FACP 

Editor