SECTION V. Notes on Tobacco

NOTES ON TOBACCO

It is the purpose of this section to present as fairly as possible the evidence relating to the effects of tobacco on the human body, so that those who smoke may correctly measure the probable physical cost of the indulgence. The extremes of opinion on this subject are well expressed in the following verses:

"Hail! Social Pipe--Thou foe to care, Companion of my elbow chair; As forth thy curling fumes arise, They seem an evening sacrifice-- An offering to my Maker's praise For all His benefits and grace." DR. GARTH.

"A custom loathsome to the eye, hateful to the nose, harmful to the brain, dangerous to the lungs, and the black stinking fume thereof nearest resembling the horrible Stygian smoke of the pit that is bottomless." JAMES I.

Tobacco is a plant, Nicotiana Tabacum of the order Solanaceæ, which includes Atropa Belladonna, or "Deadly Nightshade," Hyoscyamus, or "Henbane," Solanum Dulcamara, or "Bitter Sweet," all powerful poisons, and likewise the common potato and tomato, which are wholesome foods. The cured leaves are used for smoking and chewing, or when powdered, as snuff.

Prior to the middle of the 16th Century, the use of tobacco was confined to the American Indians. In 1560 the Spaniards began to cultivate tobacco as an ornamental plant, and Jean Nicot, the French Ambassador at Lisbon, introduced it at the court of Catherine de Medici in the form of snuff. Smoking subsequently became a custom which spread rapidly throughout the world, although often vigorously opposed by Governments. In the 17th Century, smoker's noses were cut off in Russia.

Tobacco contains a powerful narcotic poison, nicotin, which resembles prussic acid in the rapidity of its action, when a fatal dose is taken.

The percentage of nicotin present varies according to the brand and the conditions under which it is cultured.

The following figures have been given by the various authorities.

London Lancet .64 to 5.3 per cent. French Dept. of Agriculture .22 to 10.5 " " Connecticut Agricultural Experiment Station 2.89 " " (Home grown--after fermentation.) U. S. Dept. of Agriculture .94 to 5. " " (Domestic.)

Aside from nicotin it also contains small quantities of related substances--nicotellin, nicotein, a camphoraceous substance termed nicotianin, said to give tobacco its characteristic flavor, and likewise a volatile oil developed during the process preparation. On heating, pyridin (a substance often used to denature alcohol), picolin, collidin, and other bases are formed, as well as carbolic acid, ammonia, marsh gas, cyanogen and hydrocyanic acid, carbon monoxide (coal gas) and furfural. Furfural is a constituent of fusel oil, which is so much dreaded in poor whisky. The smoke of a single cigaret may contain as much furfural as two ounces of whisky.

The complex constitution of tobacco and the smoke from its combustion has caused much debate as to the substances that are responsible for its charm and its ill effects, which are to be described. No one can doubt the serious injurious effects from such a powerful poison as nicotin if taken in any but the most minute quantities (one to three milligrams have produced profound poisoning in man).

It has been maintained by some that nicotin is practically destroyed in the process of smoking, and that the effects of tobacco are limited to the decomposition products resulting from the burning tobacco, especially pyridin. But pyridin is also formed in the burning of cabbage leaves, and cabbage leaves do not possess any attractions for smokers, neither do they produce the well-known effects that smoking and chewing tobacco produce. No doubt pyridin and furfural are factors in the drug effects of tobacco, but recent painstaking experiments by high authorities have shown the presence of nicotin in tobacco smoke, and when we reflect that there is sometimes sufficient nicotin in an ordinary cigar to kill two men, it is not strange that enough of it may be absorbed from the smoke passing over the mucous membranes of the nose, throat and lungs to produce a distinct physiological effect.

Investigators who claim to show by experiments the absence of nicotin from tobacco smoke must explain why the palpable effects of smoking, in those who have not established a "tolerance," are those of nicotin poisoning, and why the symptoms produced by chewing tobacco are identical with those following the smoking of tobacco, which are: mild collapse, pallor of the skin, nausea, sweating, and perhaps vomiting, diarrhea, muscular weakness, faintness, dizziness, and rise in blood pressure followed by lowered blood pressure.

Nicotin is undoubtedly decomposed by burning, but it may become volatilized by heat and a certain amount absorbed before decomposition takes place.

Lehmann, in 1908, found in tobacco smoke the following percentages of the nicotin contained in the tobacco:

Cigaret smoke 82 per cent. Cigar smoke 85 to 97 " "

The London Lancet (1912) gives the following figures:

Cigaret smoke 3.75 to 84 per cent. Pipe mixture smoke, smoked as cigarets 79 " " Pipe smoke 77 to 92 " " Cigar smoke 31 to 63 " "

The United States Department of Agriculture found in tobacco smoke about 30 per cent. of the nicotin originally present in the tobacco.

Contrary to general opinion, Havana cigars contain less nicotin than the cheaper brands, which augurs ill for the large class of people who cannot afford to smoke higher priced brands. Many of the cheaper grades do, however, show a low percentage of nicotin.

By means of an ingenious apparatus, Zhebrovski, a Russian investigator, compelled rabbits to smoke cigaret tobacco for a period of 6 to 8 hours daily. Some died within a month, and showed changes in the nerve-ganglia of the heart. Others established a tolerance similar to that exhibited by habitual smokers, but upon being killed at the end of five months, degenerative changes similar to those produced by the injection of nicotin were found, viz., hardening of the blood vessels. There is, indeed, no difficulty in producing the characteristic effects of nicotin by administering tobacco smoke, either in man or in animals.

Nicotin causes brief stimulation of brain and spinal cord, followed by depression. There is an increased flow of saliva, followed by a decrease (large doses diminish it at once) and often nausea, vomiting and diarrhea. The heart action is at first slowed and the blood pressure increased. Subsequently there is a depression of the circulation, with rapid heart action and lowered blood pressure. In habitual smokers, this preliminary stimulation may not occur. The stimulating effect on the brain is so brief that tobacco can not properly be termed a stimulant. Its effect is narcotic or deadening. Those who fancy that their thoughts flow more readily under the use of tobacco are in the same case with any other habitué whose thoughts can not flow serenely except under his accustomed indulgence. That a sound healthy man, who has never been accustomed to the use of tobacco, can do better mental or physical work with tobacco than without it has never been shown. Indeed, such experiments as have been made on students and others show to the contrary.

The statistics presented by Prof. Fred. J. Pack are of interest in this connection.

In six educational institutions the students competing for places on the football team were grouped as follows:

------------------------+-----------+-----------+------------ | Number | Number | Per Cent. Institution. | Competing |Successful.|Successful. |for Places.| | ------------------------+-----------+-----------+------------ Institution A. | | | Smokers | 11 | 2 | 18.2 Non-smokers | 19 | 11 | 57.9 Institution B. | | | Smokers | 10 | 4 | 40 Non-smokers | 25 | 17 | 68 Institution C. | | | Smokers | 28 | 7 | 25 Non-Smokers | 17 | 14 | 82 Institution D. | | | Smokers | 28 | 11 | 39.3 Non-smokers | 15 | 10 | 66.6 Institution E. | | | Smokers | 10 | 7 | 70 Non-smokers | 15 | 12 | 80 Institution F. | | | Smokers | 6 | 0 | 0 Non-smokers | 26 | 15 | 57.7 ------------------------+-----------+-----------+------------

SCHOLASTIC STANDING

---------+-------+-------++--------+-------+-------- Institu-|Smoker.| Non- ||Institu-|Smoker.| Non- tion. | |smoker.|| tion. | |smoker. ---------+-------+-------||--------+-------+-------- A | 65.2 | 69.8 || G | 74.0 | 75.0 B | 64.7 | 74.6 || H | 75.2 | 79.4 C | 78.8 | 81.1 || I | 81.6 | 88.4 D | 75.8 | 77.6 || J | 78.5 | 81.3 E | 84.6 | 84.8 || K | 74.0 | 84.6 F | 69.6 | 71.3 || L | 77.3 | 77.6 ---------+-------+-------++--------+-------+--------

The following table shows the relative scholastic standing of smokers and non-smokers:

------------+--------------+-----------+------------- | Number | Total | Average | of Men. | Mark. | Mark. ------------+--------------+-----------+------------- Smokers | 81 | 6,034 | 74.5 Non-smokers| 101 | 8,021 | 79.4 ------------+--------------+-----------+-------------

Twelve institutions reporting:

------------+--------------+-----------+------------- | Number | Highest | Lowest | of Men. | Marks. | Marks. ------------+--------------+-----------+------------- Smokers | 81 | 4 | 12 Non-smokers| 101 | 11 | 6 ------------+--------------+-----------+-------------

---------------------------+-----------+------------- Number of | Highest | Lowest Men. | Marks. | Marks. ---------------------------+-----------+------------- 101 non-smokers furnish | 11 | 6 101 smokers would furnish | 5 | 15 ---------------------------+-----------+-------------

------------+------------+----------------+---------- | Number | Total | | of Men. | Conditions | Average. | | and Failures. | ------------+------------+----------------+---------- Smokers | 82 | 70 | .853 Non-smokers| 98 | 48 | .439 ------------+------------+----------------+----------

Prof. Pack's conclusions were as follows:

1. Only half as many smokers as non-smokers are successful in the "try outs" for football squads.

2. In the case of able-bodied men smoking is associated with loss of lung capacity amounting to practically 10 per cent.

3. Smoking is invariably associated with low scholarship.

There have of course been many notable instances of high scholarship and prodigious mental achievement by heavy smokers. Such exceptions, however, do not affect conclusions derived from the study of average groups.

Hitherto figures on smoking and athletics have been open to question because comparisons were made between groups that are not of necessity of the same physical and mental type, having no important difference except in the use of tobacco. But Prof. Pack has sought to avoid this objection. As he points out, the football squad is probably as nearly a homogeneous group as it is possible to find. It seems reasonable to account for the inferior physical and mental work of these particular groups of smokers on the theory that in the main the well known toxic effects of tobacco are sufficient to create this difference.

Dr. George J. Fisher, in a series of careful tests found:

1. Cigaret smoking caused an increase in the heart rate.

2. Cigaret smoking maintained a blood pressure which, under the circumstances of the experiment, would otherwise have dropped.

3. Cigar smoking caused a considerable increase in heart rate and blood pressure.

4. In a number of instances, in the cigar test, the heart was unable to maintain, with a vertical position, the increased blood pressure found in the horizontal position, showing a disturbance of the control of the blood vessels. This latter effect was more pronounced in tests taken on non-smokers.

5. It was also noted that smoking was not conducive to concentration upon the reading, which the men attempted during the tests.

Bush, in a series of tests on each of 15 men in several different psychic fields found the following conditions among smoking students immediately after the period of smoking was completed:

1. A 10½ per cent. decrease in mental efficiency.

2. The greatest actual loss was in the field of imagery, 22 per cent.

3. The three greatest losses were in the fields of imagery, perception and association.

4. The greatest loss, in these experiments, occurred with cigarets.

Bush ascribed these effects to pyridin, claiming that his experiments failed to reveal nicotin in the tobacco smoke, except in a very small proportion in that of cigarets.

Tests for nicotin in smoke are beset with many difficulties and possible fallacies which have in the past misled investigators into apparently determining that tobacco smoke contained no nicotin, but simply decomposition products.

Pyridin is unquestionably present in tobacco smoke, and is a poisonous substance, although less so than nicotin. It is not found, however, in chewing tobacco, and as the clinical effects of chewing tobacco are apparently identical with those of smoking tobacco, very strong and universally accepted chemical proof of the absence of nicotin from tobacco smoke must be awaited before accepting such a conclusion. (See(), (), () in bibliography.)

Cigaret smoking is a time waster; that is, it breaks up the power of attention, as few smokers are satisfied with one cigaret and the mere physical act of lighting a fresh cigaret disturbs the continuity of thought and work. Dr. W. J. Mayo calls attention to the fact that according to his observations research scholars who smoke cigarets have not done well.

Only one insurance company, the New England Mutual, has published any experience on tobacco users. This covered a period of 60 years and a body of 180,000 policyholders, as follows:

RATIO OF ACTUAL TO EXPECTED MORTALITY.

------------------------------------------------------- ABSTAINERS. | RARELY USE. | TEMPERATE. | MODERATE. --------------|-------------|------------|------------- Tobacco, 59% | 71% | 84% | 93% Alcohol, 57% | 72% | 84% | 125% -------------------------------------------------------

The standard here used is the American Experience Table, which is largely an artificial table upon which premiums are based, but which provides for a much higher mortality than the average companies sustain. For example, the actual mortality of the New England Mutual in 1913 was 57 per cent. of the expected.

Fifty-nine per cent. of the expected mortality means that where, according to the premium tables, 100 were expected to die, only 59 actually died.

The general class of risks in this company were of excellent quality, as the figures show. Nevertheless, the abstainers exhibited a far lower mortality than that experienced by the general class.

Dr. Edwin Wells Dwight, who presented the figures, urged caution in their interpretation, suggesting that the low mortality among abstainers, both from alcohol and tobacco, might well be due to a more conservative habit of living. Furthermore, as the abstainers from alcohol were not separated from the abstainers from tobacco in this analysis a perfect comparison can not be made; but our knowledge of the toxic effects of both these narcotics and the preceding statistics of Doctor Pack justify us in assigning to tobacco a positively unfavorable effect.

Experiments on animals with nicotin extracts from tobacco and inhalation of tobacco smoke have produced hardening of the large arteries. Clinical observation by some of the world's best authorities indicates that the same conditions are brought about in man by heavy smoking.

Disturbance of the blood pressure, rapid heart action, shortness of breath, palpitation of the heart, pain in the region of the heart, are important effects. Tobacco heart is often lightly spoken of because the abandonment of the habit will often restore the heart to its normal condition, but tobacco heart sometimes causes death, especially under severe physical strain or in the course of acute disease, such as typhoid or pneumonia. Surgeons have noted failure to rally after operation in tobacco users, who are, of course, deprived of their accustomed indulgence immediately before and after operation. It is probable that many such cases pass unrecognized, although the alcoholic is usually supplied the narcotic his system demands.

Cannon, Aub, and Binger have also shown that nicotin stimulates the adrenal glands, small organs adjacent to the kidneys, which secrete a substance that in excess powerfully affects the blood vessels, constricting them and temporarily increasing the blood pressure. This influence may be partly responsible for the change in the blood vessels noted in heavy smokers.

Excessive smoking is often an important factor in causing insomnia.

Blindness or tobacco amblyopia, a form of neuritis, is not an uncommon affection among smokers. There is also often an irritant effect on the mucous membranes of eyes from the direct effect of the smoke.

Catarrhal conditions of the nose, throat and ear have also been noted.

Acid dyspepsia is a common affection among smokers.

Few people realize that so many ingredients in tobacco and tobacco smoke are deadly poisons. Few people know that one drop of nicotin on the unbroken skin of a rabbit will produce death. Two drops on the tongue of a dog or cat will prove fatal; moreover, fatal poisonings have occurred in man from swallowing tobacco and even from external application of strong solutions. A case was recently reported from New Haven of fatal poisoning in a baby, who had been fed from a milk bottle and milk-mixture in which some tobacco had been accidentally spilled.

SUMMARY

From the mass of evidence and opinion with which medical literature is loaded, a few salient facts stand out:

First: Tobacco and its smoke contain powerful narcotic poisons.

Second: It has never been shown to exert any beneficial influence on the human body in health, and it is not even included in the United States Pharmacopoeia as a remedy for disease, notwithstanding the claims that are made for its sedative effects and its value as a solace to mankind. If these benefits are real and dependable, they should be made available in exact dosage and applied therapeutically. If they are not real and dependable in a medical sense, they are not real and safe as a mere drug indulgence.

Third: The symptoms following tobacco-smoking are identical with the effects of tobacco-chewing among those not accustomed to its use; hence, any collateral psychic effect, such as the sight of smoke, the surrounding, etc., are of minor importance in establishing the habit. The main charm to the smoker is the drug effect, as in any other similar indulgence. Nicotinless tobacco is not popular, notwithstanding the efforts of the French and Austrian Governments to make it so.

Fourth: Fortunately, the sedative drug effect is so slight, as compared to that of other narcotics--opium, alcohol, cocaine, etc.--that the tobacco habit is less seductive and may be broken with comparative ease and is therefore less harmful morally. Men who have smoked or chewed steadily for 40 years have been known to give up the habit without experiencing much physical discomfort. Like any other habit, however, there is a tendency to increasing indulgence, and this is a risk that the smoker takes, just as does the alcohol user or the opium habitué who begins with so-called moderate indulgence.

Fifth: The well-known effects of tobacco on the heart and circulation should lead one to pause and consider the possible cost of this indulgence, especially as--

Sixth: It is difficult to determine, years in advance, whether or not one is endowed with sufficient resistance to render so-called moderate smoking comparatively harmless.

Seventh: The vital statistics show that diseases of the heart and circulation are rapidly increasing in this country in which--

Eighth: The per capita consumption has rapidly increased in recent years, while--

Ninth: In the United Kingdom, where these diseases are decreasing, there has been no material increase in the use of tobacco, and the per capita consumption is less than one-third that of the United States.

In 1880 the annual per capita consumption of tobacco in the United States was about 5 lbs., while in 1914 it had risen to more than 7 lbs. In the United Kingdom the per capita consumption is about 2 lbs., and there has been no material increase in recent years.

The cigaret bill, in particular, has grown enormously, having more than doubled in the past five years, while there has been a slight increase in the consumption of cigars, smoking tobacco, chewing tobacco and snuff, as shown in the following table:

------------------------------------------------------------------------ Fiscal | | | Tobacco, | Year | Cigars | Cigarets | Chewing and | Snuff | | | Smoking | --------+----------------+----------------+---------------+------------- 1910 | 8,213,356,504 | 7,884,748,515 | 436,608,898 | 31,969,111 1911 | 8,474,962,786 | 9,254,351,722 | 380,794,673 | 28,146,833 1912 | 8,350,119,103 | 11,239,536,803 | 393,785,146 | 30,079,482 1913 | 8,732,815,703 | 14,294,895,471 | 404,362,620 | 33,209,468 1914 | 8,707,625,230 | 16,427,086,016 | 412,505,213 | 32,766,741 |----------------+----------------+---------------+------------- Total | 42,478,879,326 | 59,100,618,527 | 2,028,056,550 | 156,171,635 ------------------------------------------------------------------------

Tenth: The poetic effusions of the lovers of the weed are no safer guide than the exaggerated and intemperate denouncements of people who have idiosyncrasies against tobacco and simply hate it.

Eleventh: Those who now smoke should have a thorough physical examination to determine the condition of the heart and blood vessels. This examination should be repeated at least annually, in order to detect any adverse influence on the circulation.

REFERENCES

The Toxic Factor in Tobacco, The Lancet (London), 1912, I, p. 944.

French Department of Agriculture, Compt. Rend. Acad. de Science, CLI, p. 23.

Garner, W. W.: The Relation of Nicotin to the Burning Quality of Tobacco, U. S. Department of Agriculture, Bureau of Plant Industry, Bulletin No. 141, Sept. 30, 1909, p. 15; A New Method for the Determination of Nicotin in Tobacco, U. S. Department of Agriculture, Bureau of Plant Industry, Bulletin No. 102, July 6, 1907, p. 12.

Lehmann, K. B.: Untersuchungen über das Tabakrauchen, Munchen, med. Wchnschr., 1908, LV, pp. 723-25; The Physiological Action of Tobacco Smoke, Med. Rec., 1908, LXXIII, pp. 738, 739.

The Toxic Factor in Tobacco, The Lancet (London), 1912, II, pp. 944-947.

Garner, W. W.: The Relation of Nicotin to the Burning Quality of Tobacco, U. S. Department of Agriculture, Bureau of Plant Industry, Bulletin No. 141, Sept. 30, 1909, p. 15.

Zhebrovsky, E. A.: The Effect of Tobacco Smoke upon the Blood Vessels of Animals, Russky Vratch, 1907, VI, p. 189; 1908, VII, pp. 429-431; Med. Rec, 1908, LXXXIV, pp. 408, 409.

John, H.: Editorial, Jour. A. M. A., 1914, LXII, pp. 461-2; Ueber die Beeinflussung des systolischen und diastolischen Blutdrucks durch Tabakrauchen, Ztschr. f. exper. Path. u. Therap., 1913, XIV, pp. 352-365; Pawinski, J.: Ueber den Einfluss unmassigen Rauchens (des Nikotins) auf die Gefässe und das Herz, Ztsch. f. klin. Med., Berl., 1914, LXXX, pp. 284-305.

Pack, Frederick J.: Smoking and Football Men, Popular Science Monthly, 1912, LXXXI, p. 336.

Fisher, George J. [Monograph not yet published.]

Bush, Arthur D.: Tobacco Smoking and Mental Efficiency, N. Y. Med. Jour., 1914, XCIX, pp. 519, 529.

Mayo, Wm. J.: Personal communication.

Dwight, Edwin Wells: Proc. Assoc. Life Ins. Med. Dir., Oct., 1911, II, p. 474.

Favarger, Heinrich: Experimentelle und klinische Beiträge zur chronischen Tabakvergiftung, Wien. klin. Wchnschr., 1914, XXVII, pp. 497-501; Experimental and Clinical Study of Chronic Tobacco Poisoning, Jour. A. M. A., 1914, LXII, p. 1764; Pekanovits. Effects of Tobacco Smoking, Jour. A. M. A., 1914, LXXII, p. 1907.

Bangs, L. Bolton: Some Observations on the Effects of Tobacco in Surgical Practice, Medical Record, LXXIII, March 4, 1908, pp. 421-23-51.

Cannon, Aub. Binger: Effect of Nicotin Injection on Adrenal Secretion, Jour. Pharm. and Exper. Therap., 1912, p. 381; Editorial, Nicotin and Adrenals, Jour. A. M. A., 1912, LXIII, p. 1287.

Hare, Hobart Amory: Fiske Prize Dissertation, No. 34, p. 1884. Dixon, A. S.: Proceedings of the Academy of Natural Sciences, Philadelphia, Nov. 11, 1884.

Reynolds, H. S.: Jour. A. M. A., May 30, 1914, LXII, p. 1723.

Annual Report of the Commissioner of Internal Revenue, 1914, p. 34, Government Printing Office, Washington, D. C.

* * * * *

Bamberger, J.: Hygiene of Cigar Smoking, Abstr. Jour. A. M. A., 1904, XLIII, p. 706; Zur Hygienie des Rauchens, Munchen. med. Wchnschr., 1904, LI, pp. 1344-1345.

Current Comment: Some New Evidence on the Tobacco Question, Jour. A. M. A., 1912, LIX, p. 1798.

Editorial: The Pharmacology of Tobacco Smoke, Jour. A. M. A.. 1909, LII, p. 386.

Editorial: The Use of Tobacco, Jour. A. M. A., 1910, LX, p. 32.

Editorial: Tobacco-Smoking and Circulation, Jour. A. M. A., 1914, XLII, p. 461.

Hochwart, L. Von Frankl: Die Nervösen, Erkrankungen der Tabakraucher, Deutsch. med. Wchnschr., 1911, XXXVII, pp. 2273, 2321.

Index Catalogue of the Library of the Surgeon-General's Office, second series, XVIII, pp. 297-306.

Larrabee, R. C.: Tobacco and the Heart, Abstr. Jour. A. M. A., 1903, XLI, p. 50. Read before the Massachusetts Medical Society, June, 1903.

Pel: Un cas de psychose tabagique, Ann. med. Chir., 1911, XIX, p. 171.