Dr. Len's Cancer Blog

Expert perspective, insight and discussion

Dr. Len's Cancer Blog

The American Cancer Society


by Dr. Len March 27, 2006

I am taking a week off to spend some time with my family. 

I won't have internet access during that time, so there won't be any new entries until the middle or latter part of next week.

Thanks to everyone for your support and interest, and I look forward to resuming my blog when I return.

Filed Under:

More Sad News for Smokers

by Dr. Len March 24, 2006

Several years ago I read an article in a medical journal that estimated the survival probabilities of people who smoked.


What struck me about the data in that article was the percentage of smokers who lived into their 80’s and 90’s.  It approached zero.


The graph from that article still hangs on a board next to my desk (As I write this, I am traveling, so I can’t provide the reference.  I will try to update that information at a later date.)


In this week’s issue of the Annals of Internal Medicine there is another article that again demonstrates how lethal smoking can be.  It also shows that it is never too late to quit smoking.


The authors were able to take advantage of the excellent health records and data typical of Scandinavian countries to monitor the smoking histories and causes of death of about 50,000 people in 3 counties in Norway.  In addition, they were fortunate to have folks who for the most part stayed in the communities where they lived, and were willing to get the check-ups required for the study over many years.


The study reports the number of deaths that occurred in these 25,034 men and 24,505 women from ages 40 to 70.  It also determined the impact of smoking and smoking cessation on the risk of dying.


I wish I could show you copies of the graphs that appear in the article.  They are dramatic in their presentation of how smoking increases the risk of death over this period of time.


Here are the bottom line numbers:


  • If you were a man, and smoked a pack a day or more, the chance you will die before your 70th birthday is 41%. 


  • If you are a woman, the chance you will die before age 70 is 26%.


Those are incredible numbers.


The majority of these deaths (60%) occurred between ages 60 and 69.


There was some good news in this tragic report, and that is if you stop smoking at ANY age, you will live longer.  The earlier you stop, the better.  But even if you wait until your 50’s or 60’s, there is still a benefit in terms of survival.


Another observation made by the authors is particularly pertinent to the discussion currently going on about the differences in lung cancer between men and women, triggered by the recent death of Dana Reeve.


The authors report that they did not observe a difference in the rates of death from lung cancer between men and women, when they looked carefully for the amount of cigarette smoking and the number or years smoked.


From their research, they conclude that unfortunately cigarette smoking is an equal opportunity killer for men and women when it comes to lung cancer.


Two final statistics:


  • If you are a male smoker, you have a little over 2 to 3 1/2 times the risk of dying between ages 40 and 70 compared to a non-smoker, depending on the amount you smoke. 


  • The increased risk of dying for “low dose” male smokers of 1-9 cigarettes per day is over 2 times that of a non-smoker. 


(This further reinforces another recent study that demonstrated there is no such thing as a safe level of smoking, and makes me wonder about how this might translate for people exposed to cigarette smoking in bars, restaurants and other locations.  Getting to this level of exposure in a smoky bar on a Friday night isn’t difficult to achieve.)


For those of us familiar with the statistics, there aren’t many surprises here.  What this study does in a detailed way, with the advantage of outstanding long term follow-up and health records is clearly demonstrate the impact of smoking on the duration of life.


Numbers can be dry and boring.  But when you consider the real-life impact of the deaths reported in this study, you can begin to appreciate the impact cigarettes have on everyday folks.


Scare tactics don’t work often, but maybe if you have someone you love who is a smoker you should show them these numbers.


Maybe if they are 30 or 40 or 50 years old and realize they only have a 60% chance of seeing their 70th birthday if they are a man and smoke a pack a day, and only a 75% chance if they are a woman will help them make the decision to stop today.


At least it’s worth a try.

Filed Under:

Genetic Tests and Breast Cancer Risk: Not Perfect

by Dr. Len March 21, 2006

We have known there are families with increased risks of developing certain cancers due to genetic abnormalities.  This has been particularly true in the case of women with breast cancer.


For years, we struggled with the knowledge that women in some families were highly susceptible to developing breast cancer.  Counseling these women was difficult, because we had no clear roadmap to provide us evidence-based recommendations as to what was best for a particular patient.


We did the best we could, and when the family history was very strong we would occasionally recommend that the woman consulting us have prophylactic mastectomies.  This was a difficult decision for many of our patients to make, in no small part because they were usually young, and responding to a case of breast cancer in a sister or mother.


As time went on, and we learned more about various genetic syndromes, we became more confident that we were honing in on better tests which would provide us the evidence and information about genetic abnormalities that we had previously lacked. 


We began to understand and then map the human genome.  Increasingly sophisticated and complex tests were developed which could help us answer the mysteries of familial disease.


Our ability to counsel our patients, especially those with a family history of breast and/or ovarian cancer, improved considerably about 10 years ago when testing for mutations in the genes called BRCA1 and BRCA2 became available.


Inherited abnormalities of these genes may explain 5-10% of breast cancer cases and 10-15% of ovarian cancer cases in this country every year.


Today, the usual scenario for a woman with a strong family history of breast and/or ovarian cancer is to consult her physician and possibly a genetic counselor to determine if she is a candidate for genetic testing. 


If testing is appropriate, the ideal circumstance is for the woman with the cancer to be tested, since she has the greatest chance of having the genetic mutation. 


If that test is positive, then the female relative who is at risk of developing the cancer needs to make a decision as to whether or not she wants to be tested.


If that test is negative, or if the relative with the cancer declines to take the test or is unable to get the test, then the relative who is at risk of developing the cancer can decide if she wants to proceed with testing after discussing the situation with her doctor and the counselor.


After a thorough explanation of the possible risks and benefits of testing, the woman can obtain a commercially available test.  (The benefits are that several preventive options are available which significantly reduce the risk of cancer, including more frequent screening, prophylactic mastectomy and/or oophorectomy, and tamoxifen; the risks are the anxiety associated with the knowledge that the mutation increases one’s risk of breast and ovarian cancer substantially, and potential employment and insurance discrimination.)


Once the test results are returned, if positive, various surveillance and treatment options can be discussed.  If negative, the woman may feel reassured that she is not at an increased risk from this form of inherited cancer.


But that reassurance may not be as sound as it appears at first glance.  And that is the problem with the limits of our knowledge, our skills, and the application of our science in this particular situation. 


I have followed the literature on this topic for several years.  Scientists know that there are a number of areas on the BRCA genes where defects can occur.  The problem is that current testing that is available to most women only checks for a limited number of mutations, and does not “scan” the entire gene.


The result is that women, particularly those of Ashkenazi (European) Jewish descent who have a specific “founder” mutation (that is, one that has been established for a long time and can be passed from mother OR father to daughter) have a better chance of being found with the current test than women who develop a spontaneous mutation in the gene and pass it on to their families.


But our genes are constantly undergoing mutations that are passed from generation to generation.  Those “spontaneous” mutations can occur in the BRCA genes as well, and can be passed on.  However, they are unique in certain families and will not show up on the test ordered by the doctor.


The other problem with genetic testing is that there are other genes besides BRCA1 and BRCA2 where mutations can occur and be passed from generation to generation.  Frequently, even those that are known to be fairly common are not currently tested for in most circumstances.


Beyond that, there are probably many other places in our genetic material where mutations can occur that haven’t yet been discovered, but once again they too can become embedded in our familial genetic libraries.


An article that appears today in the Journal of the American Medical Association helps clear the clutter and clarifies the current status and limitations of our knowledge and testing for genetic abnormalities in breast and ovarian cancer (there are certainly other genetic abnormalities that can lead to increased incidence of cancers within families, but today’s blog is concentrating only on breast and ovarian cancers).


The researchers in this study went to great lengths to get a truer picture of what the real rate of mutation is in several different genes (including BRCA 1, BRCA2, CHEK2, TP53, and PTEN.  Because of complexity, I don’t have the opportunity to go into each of these in detail).  They wanted to know how many women with a strong family history really are at risk of breast cancer if the best available tests were offered to detect these abnormalities.


They defined women at high risk as those with breast cancer who had at least 4 cases of female breast cancer, ovarian cancer, and/or male breast cancer in their families.  They then studied genetic material from 300 of these women using sophisticated testing to find out whether or not there were genetic abnormalities not picked up on previous testing.  All of these women had been previously reported as having no evidence of BRCA1 or BRCA2 abnormalities.


Of the 300 families, 17% had a genetic abnormality that provided a familial basis for their breast cancer.


Among those tested for BRCA1 and BRCA2, 35 of the 300 were positive (recall that these women had previously been tested and were “negative”).


The science is too complicated for me to explain here, plus its sophistication is in fact beyond my limited knowledge.


But the practical implications are obvious:  Using currently available testing in the United States, we are missing a significant number of inherited breast cancers. As a result, we cannot provide women in these families the information they need to make the best decisions for their individual health and their individual risk.


We clearly need to improve our testing paradigms to provide the best information possible to these families and these women.


The authors, from the University of Washington, pose and answer the question this way: “The clinical dilemma is what to offer to women with a high probability of carrying a mutation in BRCA1 or BRCA2 but with negative commercial test results.  Technically, the answer is at hand.  The mutations identified in our study that were missed by commercial testing are detectable using other approaches that are currently available…Therefore; a genetic method should be used to detect them.”


The authors go on to provide additional information, particularly regarding a test called MLPA. 


They note, “All genomic alterations in our series were identified by MLPA, which allows rapid and cost-effective analysis of rearrangements across the entire BRCA1 and BRCA2 genes.  We believe that for families testing negative (wild type) for BRCA1 and BRCA2 by conventional sequencing, MLPA followed by sequence confirmation of breakpoints in patients’ genomic DNA is the current best choice for evaluating the wide range of genomic rearrangements in BRCA1 and BRCA2.”


The problem, though, is that clinical testing using MLPA is not available in the United States.


I am not certain why that is the case, although I do know that several folks are looking into the question as I write this.


So here is the bottom line: If you have a strong family history of breast cancer and want to understand your own risk and what to do about it, see your physician and do your best to get a consultation with a genetic counselor if one is available in your community.


If your BRCA1 or BRCA2 test is positive, as I noted previously, there are certain options available for discussion. 


But if it is negative, don’t stop there.  Talk to your doctor and your counselor about possible additional testing.


The reality is that what we are doing today for most of our patients in this situation is not sufficient, and you need to be aware of that.


Hopefully, in the not too distant future, this issue will be remedied so that we can provide the best information available to women at risk.


And, remember that the search goes on to continue to look for other genetic abnormalities that will help us better understand who as at greatest risk for which cancers.


We still have much to learn.

Filed Under:

For Smokers, Help Is Just A Phone Call Away

by Dr. Len March 15, 2006

An article in the current issue of the Archives of Internal Medicine reports that telephone counseling services do better than routine medical approaches in helping people stop smoking.


Basically, what the authors did was invite a large number of veterans treated at 5 Veterans’ Administration Medical Centers in the Midwest to participate in a smoking cessation program.


Almost 69,000 mostly male VAMC patients were invited.  Of that group, 1831 responded and 838 people decided to participate.


The groups were divided in two, with the “study” group receiving telephone counseling to support their efforts at quitting smoking, while the other half formed the “control” group that received some information on smoking cessation by mail, routine medical care and other medications and services as offered by the VA system.


The study is important because it demonstrates that an intervention such as telephone counseling for smoking cessation can significantly improve quit rates at one year.


Based on follow-up phone calls at one year after starting their participation in the study, 13% of the folks who were offered telephone counseling had not smoked for the previous six months.  For the control group, the comparable number was about 4%.


By other measures, telephone counseling was also helpful. 


More of the telephone participants took advantage of using medications to help them quit, which has been shown in other studies to improve the odds a quit attempt will be successful. 


The telephone group also made more efforts to quit, which is important since long term, committed smokers rarely succeed on their first try.  “Keeping at it” is the key to success with smoking cessation as it is with other medical issues such as obesity, and lack of exercise.


A success ratio of almost 1:8 may not seem like much, but by several measures these participants were pretty hard core smokers.  In addition, success in smoking cessation comes one small step at a time, but as we know from other studies the returns on the investment are enormous.


As I mentioned above, the mantra here has to be: “If at first you don’t succeed, try again.”


As pointed out by one of our own American Cancer Society experts, every time you try to quit smoking—even if you don’t succeed—you learn something new that is helpful in your next attempt.  The bottom line is don’t give up.


As the authors noted in the article, the VA system does an excellent job of recording a person’s smoking history, and chart reviews have shown that 75% of VA patients who are smokers are advised to quit.


Why is that important?  Because studies show that when it comes to preventive medical behaviors, such as smoking cessation, a doctor or other health care provider’s recommendation is the major motivating factor to encourage someone to change a particular unhealthy behavior or get a screening test for cancer.


But another comment in the study also caught my eye. 


In the control group, almost every one of the participants had a discussion with their health care provider about the need to stop smoking.  Three quarters of those discussions lasted less than 5 minutes.  That is simply not enough time to get the job done.


Part of my professional life was spent as a primary care physician.  I believed in prevention, and worked hard with my patients to get them to change their habits.  Sometimes I succeeded; more often I did not (although I must admit that I suspect more of my patients stopped smoking than lost weight or changed their diet in response to a high cholesterol or diabetes).  It was very frustrating.


I left practice 10 years ago.  In the “good old days” as an internist, I had about 15 minutes with a routine follow-up patient.  I had some time to talk about smoking and other health habits as part of those visits.


Today, for the routine follow-up patient visit, my hunch is that most doctors have a lot less time to spend with their patients.  More primary care doctors have to focus only on the problem of the moment, and don’t have the time to do all of the things that everyone would like them to do.


Smoking cessation is probably one of the most important messages that a doctor or other health care professional can deliver to their patients.   The return on investment of the advice to quit smoking can be huge, if the patient is able to follow through.


But, smoking is a terribly powerful addiction. 


What is clear is that the primary care clinicians caring for patients throughout the country simply don’t have enough time to help their patients through a smoking cessation program, which at best is a difficult time for the person who is trying to quit.


Doctors can recommend and/or prescribe medications, which can be very helpful.  But there isn’t much time for them to counsel patients, and there is no time for them to follow up with the patient after they leave the office to continue their encouragement.


To me, that is one of the most important implications of the study.


We are entering an era where there is going to be a fundamental change in how we deliver our health care.


The “old” (and current) model of one doctor taking care of one patient is going to become extinct.  The shear pressures on practice from an economic and quality standpoint are going to force this change.


Primary care as a specialty is under increasing pressure to provide services.  Medical students don’t want to become primary care doctors.  The pay isn’t great, and the lifestyle can be difficult.  (By the same token, the personal rewards can be incredible.  Nonetheless, there simply won’t be enough primary care doctors to care for an expanding and aging population.)


As we move forward, primary care doctors’ offices are going to become more of a “medical home” for patients.  Care is not going to be “one on one.” 


There are going to be innovations, some of which people will like, some of which they will not. 


For example, group visits where several people with similar medical problems are seen as a group, with individual examinations as appropriate are becoming a feature of medical practice that is growing in usage and popularity.


Primary care doctors will increasingly become team leaders, working hand-in-hand with other primary care clinicians such as nurse practitioners and physician’s assistants to provide needed medical care.


As we enter this era of change, we are going to be redesigning our practices, and we will have to redesign our training.


That brings us to the importance of telephone counseling services such as the one described in this article and what role they will have in the future of medicine.


Properly used, these services can help clinicians extend their influence in a way that doctors simply cannot do on their own.


Doctors don’t have the time to do the counseling, but that doesn’t mean they don’t recognize the importance of the service.   Studies like this one will provide more evidence that doctors can improve the odds their patients will be able to quit smoking.


In other words, it can become an effective team effort.


Imagine the power of the doctor saying not only that you need to quit smoking, but here is the phone number for a service where you can get help that will increase the chances you will be successful in your effort.


If we could make this model work, the results would be well worth the effort.




The American Cancer Society provides information on smoking cessation on our website. 


You can get information on the Society’s Quitline program and other telephone counseling services that are available in your community by calling 800-ACS-2345 anytime, 24 hours a day.






Filed Under:

Governor Richards

by Dr. Len March 09, 2006

Our thoughts and prayers go out to Governor Richards as she begins her course of treatment for her cancer of the esophagus.


We do not have specific information on her condition, and respect her privacy as she faces this difficult challenge in her life.


We can provide some general background information that may be useful in answering questions about the disease, although this does not apply necessarily to her specific situation. 


The facts about the disease, the statistics and the treatment are dry and objective.


We must always remember that behind these facts there are many personal stories of those who have had this disease.  They too have had to struggle with the same news that the Governor has just received.


Cancer of the esophagus is an uncommon cancer in women.  The American Cancer Society estimates that there will be 3,290 cases of the disease diagnosed in women in the United States in 2006.


Symptoms of this cancer can be very subtle, and usually involve difficulty swallowing, heartburn, a change in dietary habits (more liquids, less solids) and unexplained weight loss.  Patients can also have chest discomfort.  Occasionally, the first sign of this cancer is the presence of a swelling in the neck due to the spread of the cancer to a lymph node.


There are two types of esophageal cancer: Squamous cell, which is located in the upper esophagus, and adenocarcinoma which is diagnosed in the lower part of the esophagus, frequently near the junction where the esophagus and stomach join.


Cigarette smoking and alcohol are risk factors for squamous cell cancer, and the Governor has publicly stated in the past that she was addicted to both at one time in her life.


For adenocarcinoma of the esophagus, which originates in the gland-like cells which line the distant part of the esophagus, current thinking is that the primary risk factors are obesiety and the increased incidence of gastroesophageal reflux disease, commonly known as GERD.  Smoking also increases the risk of this disease, but alcohol does not.


There is also a condition of the esopohagus called Barrett’s esophagus, which is diagnosed in patients who usually have chronic and severe heartburn.  This disease probably results from stomach acid getting into the esophagus and causing the lining of the esophagus to change its appearance.


There is no consensus currently that routine screening of asymptomatic men or women for cancer of the esophagus using endoscopy is appropriate.  Patients with Barrett’s esophagus, on the other hand, do undergo regular examination to determine if there is any malignant change.


Treatment for cancer of the esophagus first requires an assessment of how far the cancer has spread locally or beyond.  If local, then surgery, radiation therapy and chemotherapy in various combinations and protocols will be recommended.  If the disease has spread, then radiation and/or chemotherapy would be appropriate.


Over the past several years, because of what appears to be earlier diagnosis and improved treatment approaches, there has been a significant improvement in the five year survival for this cancer.  However, it is not usually diagnosed at an early stage.


Governor Richards has faced many challenges in her life, and has obviously been successful in many of them.  She is a woman with presence and charisma, and is much admired by many.  She has faced personal challenges, and provided a public face for those challenges, as well as encouragement to many folks who shared her problems.


These qualities have served her well in the past, and undoubtedly will serve her once again as she faces this difficult challenge in her life. 


We wish her well.

Filed Under:

More Thoughts About Dana Reeve

by Dr. Len March 07, 2006

This has been a difficult day.

The American Cancer Society lost a friend who was recently honored by our Eastern Division as Mother of the Year, in recognition of her devotion to her son and step-children. (You can read the American Cancer Society tribute to Dana Reeve on our website.)

As I traveled from Atlanta to Toronto, I could not escape the frequent media pieces showing a beautiful, vibrant, optimistic women who would be taken from this earth long before her time.

Ms. Reeve's death was a reminder for me personally about the loss of a parent when I was young.  My heart goes out to her son and step-children, and I hope they will find strengh in the memories of their parents, who were loved, admired and respected by so many.

Today was also a reminder of what it was like to be a doctor, unable to provide a cure for a young person afflicted with cancer. Each loss was a personal one, and served as a reminder of how much we needed to accomplish to prevent those tragic deaths.

It was also a reminder of my young, beatiful and talented cousin who was taken from this earth at the age of 46 from lung cancer.  How helpless I felt not being able to suggest anything that would stem the tide of the scourge that gripped her body.

A colleague of mine brought be back to focus this afternoon as he reminded me of the message Ms. Reeve's death should send to us all.

Lung cancer is viewed by many as a disease that is caused by the person whom it afflicts.  That is not appropriate.  For many, this is a disease that is the result of an addiction that is as powerful as it can be, that grips their bodies and prevents them from being able to break free.

And it is a disease that in many cases has no known cause, as was the situation for Ms. Reeve.

We need to move beyond "victimization" of lung cancer and increase our research efforts into its cause and treatment.  We need to better fund our efforts at tobacco control, so fewer of us will have to deal with the horrible effects of this toxin.

Dana Reeve showed us the way to help people with spinal cord injuries. 

In her death, may we see the way to reduce the tragedy of this terrible disease that took her from this earth so prematurely.

Filed Under:

In Memoriam: Dana Reeve

by Dr. Len March 07, 2006

My colleagues and I at the American Cancer Society were saddened to learn this morning of the tragic death of Dana Reeve from lung cancer.


Our heartfelt sympathies go out to Ms. Reeve’s family and friends in their moment of loss and sorrow.


Ms. Reeve was a noble woman, who through her example and support for her husband during his time of need gave light to the problems and hopes of people with spinal cord injuries.  She set an example to all of us of what can be accomplished through love, devotion and perseverance. 


She will always be remembered for showing so many what can be done in times of the greatest need.  She was a vital and brave woman.


Her death highlights the fact that not every case of lung cancer is caused by cigarette smoke.  We will never know what actually caused this disease to occur in this woman, and her death highlights the need for us to better understand the causes of lung cancer in people who have no known exposures to toxic agents like cigarettes.


We also need to reflect at a moment such as this on the hundreds of thousands of families that are affected every year by the loss of a loved one to cancer.  Their lives, their loves, their hopes and their accomplishments are all important, and they too are missed.


Celebrity puts some of us in the spotlight of the public.  Their lives and their deaths are magnified in our conscience and awareness.  When tragedy occurs, it makes all of us acutely aware of our own mortality and vulnerability.  It also makes us more aware of what we don’t know, and what we need to learn to diminish that tragedy for others.


A phrase that is part of my life is etched on my parents' gravestone.  It says, “In thy light shall we see light.”


In Ms. Reeve’s light, may many others see the light as well.

Filed Under:

Honey, What Happened to the Haze?

by Dr. Len March 06, 2006

Today’s story is a short one, but nonetheless instructive to me and I hope to you.


Like other states considering smoke-free restaurant laws, Georgia went through a considerable amount of debate, angst and anguish last year as the legislature debated whether or not to pass a smoke-free ordinance.


You can only imagine how politically charged the issue was, not only because the restaurant and bar owners were concerned about their potential loss of business, but also because of the long heritage of tobacco as a staple product and income producer for this state for many years (in fact, my wife—who is a physician—talks frequently of what it was like to help her family pick tobacco when she was a child).


But the bill was passed, in no small part as a result of the intense efforts of American Cancer Society Georgia volunteers and staff.


That didn’t end the suspense, for it took the Governor until the very last minute to decide to sign the bill.


Now Georgia has no smoking in restaurants that permit people 18 and under on their premises.  If you are an establishment that doesn’t let young folks in, then you don’t have to comply.  I guess that means if you are an employee of a bar or restaurant where they serve only adults, your health doesn’t matter much. But that is not the central theme of today’s discussion.


Saturday a week ago, my wife and I had an interesting experience in one of our local eateries that has been on my mind since it occurred, and I thought would be worthwhile to share with you.


Not far from our home in Atlanta is one of those “clubby” steak house types of restaurants that is very popular among Atlantans and those who visit the city and are on generous expense accounts.


We go there infrequently, in part because of the expense and in part because there are only so many times we can eat steak (we do try to follow the Cancer Society guidelines in that regard).


Then Saturday night a week ago we found ourselves in Atlanta (we are usually elsewhere on weekends) and wanted to go out to have some time at a place we enjoy.


We were sitting in the bar enjoying a cocktail while waiting for our dinner table when my wife turned to me and told me there was something different about the place.  After a couple of minutes of thought, she realized what it was: no cigar or cigarette smoke.


We enjoyed our dinner that night, and realized what a positive change it was to be able to have dinner in a place we liked, and enjoy the experience even more than we had in the past (forget about the fact that our clothes won’t have to be dry-cleaned the next day!!!).

I shared the experience with my Society colleagues, and they made an interesting suggestion: why not thank the restaurant when you go back?  I thought that was a great idea.  It seems so obvious, but I wonder how many of us ever do just that—say thank you for making something more pleasant. 


After all, it was (and in many places, remains) the restaurant and bar owners who are against this legislation, claiming that it will reduce their revenues and possibly destroy their businesses.


It turns out, for whatever reason, that my wife and I decided to pay a second visit to the same restaurant this past Wednesday.


And, as suggested by my colleagues, I sought out the manager and told him our experience from the past Saturday night, and how I had shared it with my colleagues.


Almost immediately, a large smile came across his face.


He told us how nice it was to hear something positive for a change, since he had had so many complaints from other customers.


However, he noted, the reality was that the restaurant had found their bar revenues had increased considerably, with some of the biggest gains coming from the significant increase in the number of folks who were now ordering and eating dinner in the bar area.


This was not what they had expected, he admitted.  They were not in favor of going smoke free but have learned that it was in fact, from a business standpoint, a positive experience.  After all, he said, smoking (especially cigar smoking) was very much a part of their atmosphere and identity as a restaurant.  (I guess that should be atmosphere as in “milieu” and ATMOSPHERE as in the air we would breathe as patrons of the restaurant).


In any event, I suspect this one positive story is not the only one.  And we never would have heard the story had we not taken a moment to say thank you to the management.


Which brings me to my next recommendation:


Can you imagine the positive impact it would have if all of us took a moment to say thank you?  The people who own these restaurants need to hear that again and again.


There are many similar stories that I have read in the press talking about increased revenues and patronage as a result of smoke-free legislation.  I have been told by countless people how much more they enjoy going out for dinner now that they don’t have to cut their way through a cloud of smoke to get to their food.


What we need now is some continuing positive reinforcement so others will take the bold step of moving forward into the smoke-free world, and send their patrons and their owners the message that this really works—for everyone.  Well almost everyone except the smokers, that is.


And that’s OK by me and my wife and I suspect many of you as well.





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About Dr. Len

Dr. Len

J. Leonard Lichtenfeld, MD, MACP - Dr. Lichtenfeld is Deputy Chief Medical Officer for the national office of the American Cancer Society.