The man next to you reaches into his pocket and pulls out a gun. He looks around, first at you and then into his lap while his hand slowly goes up as he brings the gun closer to his face. Bang, that’s it; it’s all over, the act has been done!

But would you let that happen? Would you be willing to sit silently and let him kill himself? After all, he is someone’s son, brother, husband or father. No! Perhaps, you would try to take the gun away and stop him from committing suicide. Why? Because killing oneself is a sin; it is an act against nature; an act against God!

However, we let this happen every day; in our drawing rooms, in the restaurants and at the bus stops. We let people kill themselves, slowly, very slowly. Only this time, the weapon is much smaller and socially acceptable. It is a cigarette!

Smoking kills. Period!

Its modus operandi may involve targeting the lungs, the heart, the brain, you name it, but one thing is for sure: it kills! It can harden the blood vessels and cause a stroke, a heart attack or make one incapable of walking without pain. It can cause mouth, lung, pancreatic or bladder cancers. A simple act like breathing can be turned into an ordeal by smoking once it causes COPD or the worsening of asthma. It is easy to get pneumonias and tuberculosis (TB) - check; diabetes, osteoporosis, cataracts, blindness - yes sir! Abortions, low birth weight babies, complicated pregnancies, you name it. Sadly, the list goes on!

In the 1950s, however, it was realised that smoking played a major role in the development of lung cancer, followed by a sharp increase its (the disease) ratio in the 1960s.

Compared to non-smokers, a 14 to 20 fold increase in the risk of lung cancer is seen in tobacco abusers. Over 85 percent of the lung cancers are attributed to smoking. The number of cigarettes smoked in a day, the duration one has smoked for and the age one started smoking at - all determine the risk of developing lung cancer later in life. The longer you smoke for and the earlier you start, greater is the risk of developing the disease. This is because tobacco causes damage to the DNA.

What makes lung cancer a silent killer is the relative nature of the disease. Very few people are diagnosed in its early stages. This is because there is no global screening for lung cancer and its symptoms, i.e. cough, shortness of breath, weight loss, spitting up blood, chest pain and hoarseness of voice usually occur when the disease is far advanced.

Moreover, about 5 percent of the people with a normal chest X-ray and a history of smoking may harbour lung cancer. And by the time it is diagnosed, it is already too late! At best, if diagnosed early, one has a 73 percent chance of surviving for another five years; a figure that drops sharply as the disease progresses.

Not just restricted to cancer, smoking is the most important preventable cause of respiratory diseases. In fact, there is a 33 percent chance that a lifelong smoker will die prematurely of a smoking-related complication. This translates into an 8.8 percent contribution by smoking to the total global morality burden; a trend that alarmingly has increased by 45 percent since 1990. If left unchecked, it will double by the end of this decade.

While the prevalence of smoking seems to have plateaued in the developed world, it continues to increase in the developing countries. For instance, it is estimated that around 60 percent of the men in China are smokers.

Interestingly, history notes that smoking cigarettes was seen as a means to prevent the spread of TB. It was supposedly a sophisticated alternative to chewing tobacco; an act that necessitated the spitting of tobacco juice. Most people start smoking as children and adolescents. The reasons may be peer pressure, parental influences, behavioural problems, poverty, depression or a desire to look mature and sophisticated. Further glamorised by the movies where smoking has been a sign of masculinity for men and social independence for women, the trend continued to rise throughout most of the 20th century.

Nevertheless, it is not just the smokers who are at risk. The people around them, commonly known as passive smokers, are also vulnerable to develop smoking-related diseases. Marriage to a smoker is associated with a 20 percent increase in risk and working in tobacco-friendly environments can increase it to as high as 50 percent. This means that smokers, while endangering their own lives, put the lives of their children, families and friends at risk as well. This is supported by an increase in the rate of respiratory tract infections, asthma and sudden infant deaths seen in the children of active or chain smokers.

Smoking is an addiction. While most of the smokers agree, they ignore the fact that they are also addicted to tobacco. They rationalise, as observed in  other addictions, it to smoking only when with their friends or under social or psychological stress. Also, as exhibited by other addicts, denial is strong in cigarette smokers as over half of them do not believe they are at risk of developing cancer or heart disease.

While they may continue to smoke, three out of four smokers would express the desire to quit and slightly less than half of them would try to do so. Praiseworthy as the attempt may be, the success rate of those who try to quit smoking is almost one percent each year. This is because of the addictive nature of nicotine, among other compounds in tobacco smoke, which releases endorphins in the brain, giving a sense of happiness and calm to the smokers. Furthermore, while attempting to quit, they go through periods of severe anxiety that can cause dysfunction in their daily lives.

The success ratio in quitting smoking increases only when the smokers are advised by their physicians to do so or when they are enrolled in support groups and/or healthcare programmes. The realisation that the benefits of quitting smoking start almost immediately adds to the success rate. Smokers should be told about the improvements in lung functions, followed by a reduction in the risk of a heart attack to the level of a non-smoker within two years of smoking cessation. The risk of lung cancer decreases significantly, but does not drop to the level of a non-smoker.

As such prevention is the best way to combat this evil. Medication and behaviour therapy can complement one another as therapies used for smoking cessation. However, a strong willpower is the most important determinant of the success of quitting smoking.

Meanwhile, a strong anti-smoking media campaign to create awareness is a good platform to start with. Including anti-smoking education in schools where children are easily influenced is highly recommended. Changing the social norms by banning smoking in our homes, parks, cinemas, restaurants, public transports, projecting that tobacco use is an addiction worthy of contempt may result in a decrease in this practice. We owe it to ourselves, our country and our future generations. After all, you won’t allow a homicide to use bullets, so why allow it any other way?

n    The writer is a consultant pulmonologist and critical care physician. He holds postgraduate degrees in Diplomate American Board of Internal Medicine (2008) and Diplomate American Board of Pulmonary Medicine (2010).

    Email: Irtazak@skm.org.pk