The standard answer from a doctor is simply never have a single cigarette. Never bring your phone to bed, never have unprotected sex, never sit for eight hours at a time. Never is the directive for a lot of things that a lot of people will do more times than never.
This is a new reader-question-and-answer column that focuses on social determinants of health, and how we assess risk and make decisions. Cigarette filters are an interesting place to start because they were created and sold as a mind game. A mind game of death. I’ll start by saying clearly that no amount of inhaled smoke in any form is advisable. But the interesting thing is that smoking filtered cigarettes could actually be worse than smoking unfiltered.
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That’s the opposite of the message that a generation of young smokers grew up hearing. Particularly women, to whom “light” and “ultralight” cigarettes were marketed in body-conscious terms. The approach was so successful that Marlboro had to compensate by creating the Marlboro Man, who was a cowboy who likes cigarettes. His primary mission was to convince men that the filter did not change the “man-sized taste of honest tobacco.”
It remains unclear what man-sized taste means, but it really seemed like filters could have made smoking healthier. Consider how filtered cigarettes work.
The thing is not a complex machine. All you have to do to operate is suck on it. That sucking pulls air through little holes in the filter, and that air dilutes the smoke generated by the burning tobacco.
The end effect is supposed to be like watering down a drink. If an alcoholic person goes from drinking a bottle of wine every day to drinking a bottle that’s been half replaced with coffee, that would seem like an improvement. A weird improvement, but an improvement. Wouldn’t it?
Or would it?
A simple diagram of a cigarette omits the rest of the machine, the part to which the cigarette has to be attached (temporarily) in order to function: the human respiratory system. And even a cigarette-to-lung model omits the rest of the machine, the brain and also the world in which this smoking person operates.
A scientist who has been assembling the entire picture is Peter Shields, an oncologist and professor of medicine at Ohio State University who specializes in lung cancer. He and a team of colleagues in both medical and behavioral science have done extensive research on how smoke enters our bodies. That includes considering how the smoothness and lightness of a cigarette changes our behaviors and attitudes toward smoking.
“As people switch to cigarettes that have more holes, they take bigger puffs, longer puffs, and they smoke more cigarettes per day,” Shields explained to me. “So the way it works is, the old-style cigarettes had about 10 percent ventilation. And light cigarettes had about 20 percent, and then ultralight cigarettes had anywhere between 50 and 70 percent. Our view is that those 10 percent ventilation-rate cigarettes are probably more dangerous than zero percent.”
When filters were becoming popular in the mid-20th century, tobacco companies touted lab experiments—done on “smoking machines” that are meant to simulate human inhalation—that found that filters decrease the amount of tar per breath. But didn’t actually account for the way people behave differently with the filtered smoke. To carry over the coffee-wine example, it’s like if we forget to consider the effect of coffee on the human body. Maybe the person ends up wired and anxious, and so desires only more wine, and ends up drinking three bottles of this horrible coffee-wine concoction.
Since 2009 it has been illegal to market cigarettes as “low” or “light” or “mild.” There are ongoing class-action lawsuits in multiple states awarding money to people who bought these products under the belief that they were less detrimental to the body. But it has taken decades for the effects of these products to come to light.
“There’s evidence that the tobacco industry understood back in the 1970s that they were making a more dangerous product,” said Shields. “The products would fool the smoking machines, and so they could be advertised as healthier. Smokers would get a ‘smoother’ smoke and believe it. And the public-health community would endorse it—at least a step in the right direction—because they had a lower tar yield.”
Tar yield is a term d’art in cigarette research that rarely makes it to consumer marketing. (If it did it might say something like, “Low tar yield! Nice!”) A group of researchers at the Massachusetts Institute of Technology and Massachusetts General Hospital found no difference in cancer rates between people who smoked medium-tar, low-tar, and very low-tar cigarettes. People who smoked cigarettes with very high tar yields did have higher rates of lung cancer than other smokers, though the scientists concluded that “may reflect unmeasured differences between smokers of non-filter and filter cigarettes,” and that introducing filtered cigarettes to people who are already smoking a lot of unfiltered cigarettes would likely have “limited public-health benefits.”
I asked some friends who smoke constantly if there is a belief in the young-smoker community that filtered cigarettes are healthier, and the consensus was nah. “Nah, just less gross/wet/prone to tobacco in the teeth,” Amy Rose Spiegel wrote to me. “Most normals find unfiltered a little bleck, but there are exceptions if you roll your own and/or are a young but weathered rancher/caballero.”
By wet she was referring to the fact that filters are made to withstand dissolving in saliva—which means they linger on city streets and pile up on highways even while the rest of the cigarettes quickly dissolve and disintegrate. The global landscape would look dramatically different if cigarette filters fell out of use. The money saved cleaning them up could be put to other use in bettering communities, the benefits of which are incalculable.
Where was I? Oh yes. Even if the industry-generated health halo were totally dissolved by now, given the choice between smoking ten filtered cigarettes per day or ten unfiltered, Shields believes people would probably be better off with the filterless. This is in part because he’s been tracking a curious rise in lung cancer that correlates well with the rise of filtered cigarettes. A 2014 report from U.S. Surgeon General Vivek Murthy on smoking concluded that changing cigarette designs have caused an increase in lung adenocarcinomas, and Murthy implicated cigarette filters.
Shields and many others believe that because the smoothness of the smoke means people tend to take deeper breaths and hold them longer, and this pulls the smoke deeper into the lungs, this really changes the exposure to the compounds in the smoke. It’s not just a different dose of carcinogenic exposure; it’s a different dose being delivered to a different part of the lungs for a different amount of time. And the effects of this can’t be really well predicted by lab studies done on smoking machines. Even a small change in these exposures could mean a huge difference when played out over the lifetimes of millions of people who smoke thousands of cigarettes every year.
So to the question at hand, what are real human people—and the health professionals who advise them—to do? The marketing messages have made all of this very confusing, and I’m not sure how much I’ve done to help. But Shields sees a clear way forward for everyone, and it involves assigning no blame, and laying on no one the psychic burden of choosing between two ways of giving oneself cancer.
“It doesn’t matter so much if you want to say that the tobacco companies knew something or didn't know something, or if they were at fault or not, or if they need to be moral or socially responsible or not,” he said. “The FDA has the authority to make tobacco companies take the holes off. There’s no public-health value to the holes. There’s at least some harm to the holes—even if you don't buy the whole adenocarcinoma thing.”
There is some debate among scientists on the role of filters in the rise of these cancers, with others pegging it to increasing amounts of substances called nitrosamines in tobacco. According to Shields, beliefs vary depending on what they’ve been studying for the last 20 or 30 years. “The tobacco-specific nitrosamines people think it’s all about nitrosamines, and the ventilation people thing is all about ventilation”
“But the fact is it doesn't matter. If the FDA has evidence for either one of them or both they can regulate both. They don’t have to make a choice.” After a pause, he reconsidered. “I guess maybe with the Trump administration, where for every regulation you pass you have to take out two, maybe you do have to make a choice.”
Have a health question, “for a friend?” Please email AskJim@TheAtlantic.com.