Chapter 13: Smoking and Emphysema

On July 13, 1994, an obituary in the Washington Post reported the death, at age 60, of Richard Joshua Reynolds, III, an heir to the founder of the R.J. Reynolds tobacco company. The headline and an accompanying photograph showed the deceased smoking a cigarette and implied that Reynolds died from emphysema, caused by smoking. Reading the obituary in detail, however, it turned out that he had quit smoking eight years prior to his death; and that there was a family history of emphysema, the deceased's own father having died from the disease at the age of 58. Furthermore, the obituary disclosed that the deceased's own doctor was unable to state the "immediate cause" of his death.

Medical opinion concerning emphysema has had an interesting history. My 1973 edition of "Diagnosis and Treatment" (a standard medical textbook), states that emphysema is a disease which involves destruction of the alveolar (lung) tissue but that the cause is unknown, although "many doctors" think it is caused by "cigarette smoking". In 1973, Chromic Pulmonary Obstructive Disease (COPD) had not yet been invented. COPD, while now discussed at length in modern medical textbooks, did not exist in 1973.

Some time subsequent to 1973, a genetic cause of emphysema was discovered. In an article in the latest on-line edition of Grolier's Encyclopedia, Howard Buechner, M.D., explains that a significant number of the people with the disease lack a gene that controls the liver's production of a protein called alpha-1 antitrypsin (AAT). This protein controls or degrades an enzyme called neutrophilelastase, produced by the white blood cells. When the enzyme is left unchecked, it destroys alveolar tissue.

Evidently, the Reynolds, father and son, had genetic cases of emphysema, which may or may not have killed the younger Reynolds, even thought he had not smoked for eight years prior to his death. But this raises the question: if there any proof that there is any cause of emphysema other than genetics?

The politically correct medical establishment dances around that question with all of the skill of a lawyer. In the Merck Manual, 14th Edition (1982), we are introduced to a new disease, Chronic Onstructive Pulmonary Disease, or COPD, and, at page 629, we are shown a diagram, showing that the disease is combination of emphysema and bronchitis, and that some patients may have one disease and some the other, but many will have both. Cigarette smoking is said to "presumably" play a role in COPD. At page 630, we told about AAT deficiency, but this is described as a "rare condition"; it is not clear whether the authors mean that AAT is a "rare condition" that causes emphysema, or that emphysema is rarely caused by AAT deficiency. The language is, I think, deliberate vague.

By 1992, it becomes still more politically imperative to blame smoking for COPD and emphysema. In the 16th Edition of the Manual (1992), it is explained that, yes, emphysema is caused by destruction of lung tissue, caused by an unchecked enzyme. We are told, however, that smoking lowers the body's defenses to the enzyme. No evidence or authority is cited for that proposition.

Thus, we are left with confusing conclusions. We have a new disease, COPD, the exact cause of which is unknown (indeed, the definition of the disease is vague; it seems to be a case of "this patient has something wrong with his lungs, but we don't know exactly what"). Cigarette smoking is thought to play a role; yet the 16th Edition makes it clear that many cigarette smokers never develop the disease, and the authors do not know why. I submit that the reason is very simple: smoking does not cause emphysema.