Cigarettes vs Alcohol: Comparing Physical, Psychological & Social Harm

The cigarette and alcohol industries combined are worth almost $160 billion.^1,2 Products from either industry are responsible for hundreds of thousands of jobs, millions of dollars in advertising, and cultural legacies that have become hallmarks of American history. But cigarettes and alcohol have also caused an untold number of cases of physical, psychological, and social harm, completely changing the way we think about substance abuse and public health.

Alcohol vs. Cigarettes

Columbia University’s Go Ask Alice! website notes that from a biological perspective, there is no single way to determine whether alcohol or cigarette consumption is worse for a person’s health. There are dozens of different factors that can decide the ultimate health effects, such as gender, age, lifestyle, family history, mental health, presence of other chemical substances, stress, environment, etc. However, the relative danger of either alcohol or cigarettes is without question, “especially when used in unsafe contexts and in large quantities.”³

The discussion of comparing the potential harm of alcohol use to cigarettes can get challenging because consuming moderate amounts of alcohol does not necessarily cause harm. In fact, there may be notable health benefits, such as lowering the risk of a heart attack.⁴ On the other hand, any degree of tobacco use is harmful, even through the inhalation of other people’s smoke, a fact that was controversially covered up by cigarette manufacturers for decades.⁵

Part of the problem regarding alcohol is that moderate consumption is not a risk, while excessive alcohol consumption is widely understood to cause (or develop) serious health issues.  This can be confusing to discuss because the distinction between “moderate consumption” and “excessive consumption” is very easily blurred. Excessive drinking has been implicated in the formation of at least 60 major types of disease, and more than 2.5 million people die every year because of it; that number is more than the people who die from HIV or tuberculosis.⁶

Is Alcohol Worse Than Smoking?

The National Institute on Alcohol Abuse and Alcoholism notes that alcohol is the third-leading cause of preventable death in the United States. Globally, it is the fifth-leading risk factor for premature death and disability.⁷ A big factor in the prevalence of this high mortality rate is that alcohol impairs people’s decision-making and judgment abilities. Alcohol’s ability to lower inhibitions is what makes it a very popular drink, but is also what causes people to engage in unsafe sexual practices. This can lead to contracting/spreading any number of sexually transmitted diseases, as well as putting people at risk for sexual assault or rape. According to Journal of American College Health, more than 80 percent of sexual assaults on college campuses involve alcohol. This report suggests men use their intoxicated status to justify their behavior, and women develop deep feelings of guilt or shame because their own intoxication may have led them to make decisions that they would not have made while sober.⁸

What makes the problem worse is that alcohol is an addictive substance, which increases exposure to these risks. People who are more likely to develop a dependence on alcohol may continue drinking even though their use of alcohol has harmed their well-being, which in turn creates additional health and psychological issues. People with alcohol use disorder may require alcohol rehab to achieve long-term recovery.

Dangers of Smoking Cigarettes vs Drinking Alcohol

Cigarettes are not psychoactive like alcohol (that is, they do not affect perception, mood, consciousness, cognition, or behavior), but they are very addictive. There are over 4,000 chemical substances found in a single cigarette; some of them, like nicotine, are what make cigarettes as addictive as they are. Medical News Today explains that when a cigarette is smoked, the nicotine reaches the brain within 15 seconds of the first inhalation. Nicotine is so important in how cigarettes work that it is responsible for the success of the entire tobacco industry. It is one of the most addictive drugs in the world, coming in third after heroin and cocaine and above alcohol.^9,10

But most of the other chemicals in a single cigarette are deadly. Some, like acetone, damage the eyes, nose, and throat, and long-term exposure can harm the liver and the kidneys; cadmium is a carcinogen that affects the brain, kidneys, and liver; cresol can damage the respiratory system; and nickel can cause bronchial asthma.⁹

In November 2007, the American Journal of Public Health reported that an investigation into the tobacco industry found that over 100 of the 599 analyzed chemicals in cigarettes had “pharmacological actions” that are meant to mask the smell of tobacco smoke, improve the delivery of the nicotine, increase the addictiveness of cigarettes, and “mask symptoms and illnesses associated with smoking behaviors.”¹¹

As with most addictive substances, there is also a genetic component to cigarette smoking that contributes to the likelihood of whether a person will become dependent on the habit. The South Dakota Medicine journal writes of twin and family studies that have shown that there are “several genes that cause an individual to become more susceptible to being addicted to nicotine.” The genes in question determine how many receptors the brain produces to metabolize the nicotine in an inhalation. The genes are also responsible for the production of chemical messengers that communicate the feelings of pleasure and reward that come with smoking, which are what compel a smoker to persist with the habit, even past the physically harmful effects of smoking.¹²

Dangers of Smoking Cigarettes

DISEASES AND CONDITIONS

The high number of carcinogens present in a typical cigarette is responsible for many diseases and conditions, some of which are associated with alcohol consumption. Examples include:

• Lung cancer.
• Asthma, bronchitis, and emphysema.
• Cardiovascular diseases such as heart disease and stroke.
• Colon, rectal, and liver cancers.
• Weakened immune system.
• Diabetes.
• Poor response to arthritis treatment.
• Erectile dysfunction.
• Tuberculosis.¹³

Smoking is the leading cause of preventable death in the United States, killing about 443,000 Americans every year, says Voice of America News.¹³ This reality is indicative of “the potent toxicity of tobacco smoke inhaled by smokers for decades,” says the Thoracic Surgery Clinicsjournal.¹⁴ A joint study by the World Health Organization and the U.S. National Cancer Institute published in January 2017 predicted that 8 million people around the world would die from smoking each year by 2030, and the global economy would lose $1 trillion annually as a result.¹⁵

A study published in the Lancet journal noted that despite smoking being responsible for at least 10 percent of the world’s deaths, especially in developing/poorer countries, public health education and outreach efforts have been successful in reducing the overall smoking mortality rate, and fewer people are smoking today than in generations past.¹⁶ The Centers for Disease Control reported that a 2012 national anti-smoking campaign “was highly successful and cost-effective,” leading 1.6 million people to try and quit their habit. The program was estimated to save $50,000 per year of life saved.¹⁷

The Landmark Report

In 1964, the Surgeon General’s Advisory Committee on Smoking and Health published a landmark report that almost entirely addressed the negative health effects of cigarette smoking. Amid the uproar from tobacco companies, the report detailed that cigarette smoke was the main cause of chronic bronchitis, and that there was a significant correlation between smoking, emphysema, and heart disease. The report also detailed a causative link between smoking and a 20 percent chance of developing lung cancer, and that there was a correlation between pregnant women who smoked and premature and underweight births.¹⁸

CIGARETTE SMOKE WAS THE MAIN CAUSE OF CHRONIC BRONCHITIS

The publication of the report became one of the major news stories of 1964 and led to the Federal Cigarette Label and Advertising Act (1965) and the Public Health Cigarette Smoking Act of 1969, which banned the broadcast of cigarette advertisements on television and radio, many of which used cartoon mascots to make cigarettes of interest to parents, young adults, and even children.¹⁹ The laws also required that manufacturers place the now ubiquitous warning labels on their tobacco products.

In 2010, the Food and Drug Administration was granted sweeping powers by Congress to regulate the tobacco industry, which manifested in “[severe restrictions] on the way the industry can advertise and sell cigarettes and smokeless tobacco products, especially marketing efforts designed to appeal to children and teenagers.”²⁰

The dangers of smoking are well understood and documented, but as far back as 1987, a writer in The New York Times lamented that “despite [the] overwhelming evidence,” 53 million Americans smoked 570 billion cigarettes a year, enough to make the cigarette business in the United States a formidable force; “against all odds,” says the Wall Street Journal, “the US tobacco industry is rolling in money,” thanks to Americans spending $117 billion in 2016, buying more cigarettes than they did soda and beer combined.^21,22

Alcohol’s Psychological and Social Harm

For some in public health, however, the cigarette lobby is not the real problem. Chris Hawkey, a gastroenterologist, writes in The Guardian that research predicts alcohol will be responsible for the deaths of over 90,000 people by 2019, meaning the bigger danger is in the bottle, not the cigarette pack. Rates of alcohol consumption have increased throughout all levels of society and given way to an “epidemic of alcohol liver disease.”²⁴

Hawkey writes that while both cigarettes and alcohol claim thousands of lives every year, alcohol’s effects are significantly worse because, unlike cigarettes, alcoholism ruins lives and the drinker’s sense of self-worth before actually bringing about death. Hawkey notes that this “personal degradation,” and the destruction of family, friends, and other social circles does not usually happen with tobacco.²⁴ Yet, while the tobacco industry’s marketing is tightly regulated by the government, the University of Texas at Austin found that spending on alcohol ads has increased by 400 percent over the last 40 years. This comes even as the overall drinking rate has not appreciably changed, suggesting that alcohol manufacturers are spending literally hundreds of millions of dollars to convince Americans to drink more.²⁵

Chris Hawkey notes that the limitations on how tobacco companies can promote their products has “markedly reduced smoking and smoking-related illness.” ²⁴ Imposing similar restrictions on the alcohol lobby could save tens of thousands of lives from preventable death every year.

Unsurprisingly, the alcohol lobby has pushed back at any suggestion that they should cut down on their marketing. Companies have pointed to pre-existing codes that require advertising to not feature actors who appear to be under 25 years of age as proof that they are already toeing the line when it comes to responsible promotion of their products.²⁶

But Hawkey counters that in order to reach a wider and deeper audience, alcohol ads often enhance personal qualities, such as masculinity, sexual attractiveness, or general popularity. Whether in print, on television, or on the radio, alcohol marketing commonly presents alcohol as “the gateway to social and sexual success,” and the content of the ads is aimed directly at teenagers and young adults.²⁴

Binge Drinking and Drinking Delusions

There may be a temptation to think that excessive alcohol consumption is only a problem on the fringes, but a Guardian survey found that “52 percent of respondents drank above safe limits.” The Substance Abuse and Mental Health Services Administration reported in June 2017 that binge drinking rates among American teens and young adults is down, but at least 14 percent of people aged 12-20 still report having drunk too much alcohol too quickly in the past month. The director of the administration’s Center for Substance Abuse Prevention stated that binge drinking is still a “serious public health issue for young people, their families and communities.”²⁷

Chris Hawkey concludes in his Guardian piece that while alcohol enjoys greater cultural tolerance than smoking, both vices present health problems that are too important to gloss over. In order to reduce social harm caused by the widespread encouragement to drink, everything from sports sponsorships to happy hours will have to be re-evaluated. Hawkey specifically mentions the practice of underage drinking around the family table as a form of introduction to responsible consumption as a “delusion.” The cultural practice is widespread in continental Europe, where teenagers as young as 16 are often given wine at dinner, and studies have suggested that children who are introduced to alcohol as a normal part of life are less likely to engage in binge drinking when they grow up.²⁸

There is a double standard that exists in how cigarettes and alcohol are accepted and regarded. “Any policy that treats alcohol differently to tobacco cannot be defended,” argues Hawkey, a point echoed in a 2015 report published in MySanAntonio.com.²⁴ Covering figures published in a National Institute on Drug Abuse survey, MySanAntonio.com noted that the drug mortality rate in the country is “overwhelmingly dominated by […] the two most popularly used and legally accessible drugs on the market” – namely, tobacco and alcohol. While tobacco was responsible for the deaths of 480,000 Americans in 2013, and alcohol for 29,001 deaths in the same year, heroin, prescription drugs, and cocaine combined to kill a notably smaller number of people: 4,202, according to figures released by the Centers for Disease Control. Even with moderate decreases in rates of dangerous alcohol consumption and smoking, the two vices are still the deadliest drugs commonly available.²⁹

Social Smoking and Drinking

For many people, the vices tend to be enjoyed together. Even though the rate of regular tobacco users has gone down,¹³ more people (most of them young women) are coming forward as “social smokers.” That is, they do not smoke on their own, but they will tend to smoke in the company of friends and usually when consuming alcohol. A 2015 study published in the Journal of Neurochemistry found that a number of drinkers crave the stimulant effect of nicotine, which helps offset the sleepiness that alcohol induces.³⁰ Other research has also noted that the nicotine in cigarettes can augment the pleasurable effects of alcohol, increasing the desire to drink more and then smoke more to counteract the depressant effects of the alcohol.³¹

Prospective Memory

The part of memory most jeopardized by too much alcohol and nicotine is prospective memory, which involves planning and recalling future activities. Remembering to take medication at a specific time, or remembering to meet with friends at a prearranged place and time, is prospective memory at work.

Alcohol’s effects on prospective memory have been well documented. The Drug and Alcohol Dependence journal found that binge drinkers could remember to carry out fewer actions based on cues and timing than people who didn’t binge drink.³² People who smoke regularly experience similar issues. Another study in Drug and Alcohol Dependence noted that daily smokers struggle to remember to perform fewer actions based on prospective memory compared with people who have never smoked.³³

Wine Drinkers and Smoking

Unsurprisingly, people who drink and smoke at the same time (and in dangerous amounts) suffer greater setbacks to their prospective memory. Additionally, people who consume alcohol and nicotine in combination have difficulty thinking quickly and efficiently, and score worse on problem-solving tests than people who don’t drink or smoke together. Perhaps most worryingly, the Addiction Biology journal reported that people who are psychologically dependent on alcohol, and who also smoke cigarettes, are at a greater risk for brain damage. People who fall into this category display more cortical thinning in the frontal region of the brain, which is important for the retention and use of memory.³⁴

As dangerous and unhealthy as combined cigarette and alcohol consumption is, the relationship provides an unexpected way for the vices to be controlled. While there is abundant evidence that increasing state taxes on cigarette sales reduces smoking and helps people wean off the habit, the same move also lowers the drinking rate among people who drink too much and smoke. That’s according to research published in Alcoholism: Clinical & Experimental Research in 2014. A surprising find was that this effect only applied to beer and spirits; wine drinkers, according to the authors at the Washington University School of Medicine, “are more likely to have healthier lifestyle habits” than other drinkers and would therefore not be affected by an increase in cigarette taxes. Simply put, people who drink beer or hard liquor are more likely to be smokers, whereas “wine drinkers are less likely to smoke.” Wine drinkers may also be better educated than people who favor other forms of alcohol and may therefore be warier of the health risks of smoking.^35,36

Controlling Tobacco and Reducing Drinking

The study’s authors theorized that “reduced drinking may be yet another health benefit related to tobacco-control policies.” Examples of such policies include the average price of a pack of cigarettes going from $1.91 to $8.54 in New York, a state that exercises some of the highest taxes on cigarettes in the country. Another policy is the ban on smoking in public spaces; again, New York has one of the strictest such bans in the country. Perhaps not coincidentally, researchers discovered that per capita alcohol consumption in New York dropped from 2.91 gallons per person to 2.06. States like Missouri, which have lower cigarette taxes and weaker smoking bans, experienced much smaller declines in per capita alcohol consumption (2.44 gallons at the start of the study period to 2.42 gallons when the study period ended).³⁷

The analysis carried out by the Washington University researchers suggests that a 20 percent increase in cigarette prices could potentially reduce per capita alcohol consumption by 2 percent. A comprehensive smoking ban in bars and restaurants would also reduce alcohol consumption by up to 7 percent.³⁷

Even taking into account that an increase in cigarette taxes would not significantly affect wine drinkers, the total per capita alcohol consumption was nonetheless reduced when states made smoking less convenient and more expensive. The researchers believe that this could lead to an overall benefit in public health where rates of cirrhosis, high blood pressure, depression, and injuries and fatalities linked to risky alcohol consumption would inevitably drop.

Killing Two Public Health Birds

In conclusion, the lead author of the study said that the only other drug that keeps alcohol off the list of deadliest substances in the United States is tobacco. Attempts to raise taxes on alcohol to control excessive alcohol consumption have been universally unpopular. After the spectacular failure of Prohibition in the early 20th century, and with the hundreds of millions of dollars the alcohol industry brings in, no politician would risk their future by suggesting a tax increase on beer or wine.

However, the cigarette lobby presents a much easier target, and it might be possible to kill two public health birds with one stone. An increase in cigarette taxes and stronger laws on smoking in public places would not only reduce the harm done to smokers and the people around them, it might also clamp down on the danger of excessive alcohol consumption by compelling people to drink less.³⁷

What Do Americans Think about Smoking and Drinking?

In 2014, Gallup’s annual Consumption poll revealed a number of insights into how the American public view smoking and drinking. For example, 58 percent said it is acceptable to charge smokers more for health insurance, but only 14 percent were all right with businesses refusing to hire smokers because of their habit. Even when hospitals make the argument that they have a legal right to refuse employment to smokers, “the average American does not agree with the policy,” but since charging smokers more for life insurance is a well-established practice, there is less concern.³⁸

Similarly, only 19 percent of people believe that smoking should be made completely illegal in the United States. This again stems from American antipathy toward totally banning anything, a skepticism borne from the failure of Prohibition in the 1920s.³⁸

While wine is strongly associated with highly educated Americans, “smoking follows the exact opposite pattern.” Only 6 percent of Americans with a postgraduate degree reported smoking compared with 27 percent of Americans with a high school degree or less. Gallup theorizes that having more levels of education brings with it the knowledge that smoking is not worth the health cost. Additionally, Americans who are less educated tend to associate with other people who are less educated; smoking, therefore, becomes more of an acceptable social behavior. Likewise, Americans who are better educated will associate with other people of a similar educational standing, which further reduces the likelihood that anyone in that particular group will smoke.³⁸

When smokers are asked by a survey interviewer about how harmful their habit is, the smokers admit that there is an element of self-damage in what they are doing, but they tend to downplay the degree of that damage (“a classic case of cognitive dissonance,” says Gallup). The way the question is worded allows 41 percent of smokers to agree that the practice is merely “somewhat” harmful while 88 percent of nonsmokers said that smoking is “very” harmful to health.³⁸

The “cognitive dissonance” at work allows the smokers room to confess to the obvious, that smoking is bad for their health, but it also gives them hope that the negative health effects are not as bad as they are made out to be or even that the smoker will somehow dodge the avalanche of health consequences that affect other smokers (a cognitive bias known as the “optimism bias”).

In reality of course, smoking is universally and extremely harmful for health; and no amount of optimism, cognitive bias, or alcohol will change that.