In Malaysia where I reside, the government introduced an ambitious bill last year proposing that smoking be banned for everyone born after 2007. To be clear, this is a blanket ban with no exceptions: if you are born after 2007, cigarette smoking will no longer be an option. 

Although there have been concerns about whether this bill would end up criminalizing children and inadvertently create an underground market for cigarette smoking, the goals of this bill are laudable and well-supported by dozens of charities. The idea is that the dangers of smoking are such settled science that the only conscionable action would be to end smoking, one generation at a time, until it is completely eradicated. 

This is a far cry from the mood during the younger decades of the 20th century, when smoking was in vogue and practiced everywhere, indoors and outdoors. It is difficult to imagine such a scenario playing out today, with warning labels on cigarette boxes and constant health campaigns reminding the public about the horrors of smoking. What was once a carefree activity is now correctly seen as dangerous and wrong. 

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Doctors will be familiar with the experience of examining the chest of a patient and hearing much noise during auscultation, only for the patient notes to later reveal that the patient was a heavy smoker. I used to have a medical superior who would tell off patients for smoking then and there. 

When smoking starts to deteriorate lung function, it triggers a chain reaction of biological events that prompt further such deterioration. Emphysema, chronic obstructive pulmonary disease (COPD), increased susceptibility to infection—these conditions complement each other and worsen the condition of the patient. As smoking decimates the lungs of patients, many spend their last days gasping, coughing, and feeling like they never have enough oxygen. 

Smoking, AATD, and Lung Cancer 

Lung disease is characteristic of 2 other conditions: alpha-1 antitrypsin deficiency (AATD) and lung cancer. AATD predisposes a patient to emphysema, especially if they are exposed to tobacco smoke. Lung cancer is a leading cause of death globally for both men and women. It has an abysmal prognosis, with around one-fifth of patients dying within 5 years of receiving a diagnosis. 

AATD is a genetic disease while lung cancer presumably is not. This begs the question: does a diagnosis of AATD predispose a person to develop lung cancer later in life?

Read more about AATD etiology 

A systematic review involving more than 4000 patients suggests that AATD does not increase the risk of developing lung cancer—unless an individual has a clear history of cigarette smoking.

The authors of the study recruited 2 groups of patients: never-smoker patients diagnosed with lung cancer (n=457) and never-smokers undergoing non-cancer-related surgery (n=631). Controls were sex- and age-matched. They were both then screened for AATD. 

The results were clear. “No higher risk of lung cancer was found among individuals who were homozygous or heterozygous carriers of the most frequent AAT deficiency alleles (PI*S, PI*Z) as compared to carriers of the normal genotype (PI*MM). Similarly, no effect was observed for subjects by sex or age group,” the authors of the study wrote. 

In other words, AATD did not influence the development of lung cancer in this cohort of patients. The research team proposed that AATD may play a role in the carcinogenesis of lung cancer in smokers/ex-smokers but have no influence in individuals who are never-smokers. This theory implies that tobacco use is in effect a modifier in how AATD relates to the genesis of lung cancer, even though the chief aim of this study was not to assess the link between smoking and lung cancer.

Achieving Smoking Cessation

The good news is that public health campaigns against smoking are working. According to a study conducted by Bernstein and colleagues published in Frontiers in Medicine, many patients who smoke do have a desire to stop — if only they have the right resources to do so. 

Read more about AATD treatment 

To achieve smoking cessation among our patients, it is inevitable that we tell them about the dangers of cigarette smoking. However, the story does not end there: today, there are high-quality smoking cessation programs that offer research-based techniques to help patients to quit. In terms of smoking cessation, we must remind our patients of that great maxim: “If there is a will, there is a way.” 

“Lung cancer screening visits, follow-ups, and result letters represent an enormous opportunity to connect these patients with smoking cessation resources and deliver tailored cessation interventions,” Bernstein and colleagues concluded. 


Tubío-Pérez RA, Torres-Durán M, García-Rodríguez ME, et al. Alpha-1 antitrypsin deficiency and risk of lung cancer in never-smokers: a multicentre case-control studyBMC Cancer. 2022;22(1):81. doi:10.1186/s12885-022-09190-3

Bernstein MH, Baird GL, Oueidat K, et al. Heavy smoking patients receiving a lung cancer screen want to quit: a call for tailored cessation interventionsFront Med (Lausanne). 2022;9:816694. doi:10.3389/fmed.2022.816694