attached to the HDL has been referred to as the "good cholesterol", since high levels of HDL cholesterol decrease the risk of heart disease. High levels of VLDL and LDL cholesterol are associated with increased deposition of "bad cholesterol" and other fatty substances in the arteries.

Non-Lipid Risk Factors
Cigarette Smoking As A Risk Factor
Smoking is an activity most people agree is harmful to health. The government has recognized this by requiring a warning label on every pack of cigarettes sold, and in every advertisement for cigarettes. Compared to non-smokers, cigarette smokers experience increased death rate, more frequent illness and disability, decreased physical capacity, and increased use of medical services. It has been accurately reported that cigarette smoking is the foremost preventable cause of death and chronic disease in this country. In spite of such general knowledge, and undeniable statistics (which will be discussed subsequently) smoking is still more prevalent than it should be. There does appear to be some progress. One study in 1980 compared the number of smokers then with a similar study done in 1965. The proportion of smokers decreased from 41.7 percent in 1965, to 32.6 percent in 1980. This trend, hopefully, is continuing.

Patients, relatives, and health care workers can all attest to the difficulty in giving up the addiction of nicotine in tobacco smoking. Here is an example from my own clinical practice: A woman, in her early 70's was hospitalized for congestive heart failure and severe shortness of breath. She had chronic obstructive lung disease and emphysema in its final stages. She could hardly walk, tired easily, and coughed constantly. She required assistance with most activities from her nurses. Still, against hospital rules and good sense, she would laboriously make her way to the bathroom to smoke, discontinuing her oxygen therapy to do so.

While visiting her one day, I noted the smell of cigarette smoke in the room, and saw cigarettes (mentholated, of course!) on her table. "Have you been smoking?", I asked, aghast at the idea. "Yes…", she replied, nonchalantly. "Why do you still do that?", I asked. "Because I like it", she said. "Do you like to cough and wheeze, too?", I asked. She looked at me calmly and said, "I don't mind". What more could I say? With such an attitude, no wonder we have health problems.

This woman was completely disabled by her disease. She was almost totally bed and chair confined, and on continuous oxygen therapy. Other women her age are still active, driving their car, having an active social and family life, traveling, and even working full-time. I didn't ask my patient if she minded not having those things. What a price this woman paid for "liking" to smoke, and "not minding" the cough, wheezing, and shortness of breath.

Other patients have answered my concerns about their smoking by saying, "You have to die of something", or "If I die, I die". Unfortunately, dying may not be the worst thing that can happen to a smoker. The disability, financial losses, the physical suffering of illness, the stroke or heart attack that leaves one an invalid… these can be worse things.

Mayan stone carvings dated at about A.D. 600 to 900 appear to show that humans began sampling tobacco at that time. Physicians did not suspect for sure that tobacco could cause ill effects until the 19th century. Benjamin Rush, a famous colonial physician condemned tobacco in his writings as early as 1798. By the mid- to late 1800's, many medical authorities were expressing concern about the development of medical problems connected with tobacco. They suggested a relation between smoking and coronary artery disease, even recognizing the potential association between passive smoking and heart problems. They also noted a correlation with lip and nasal cancer. Since individuals consumed only small amounts of tobacco, mostly tin the form of snuff, cigars, chewing tobacco and pipe tobacco, it did not produce the widespread illnesses it does today. Cigarette smoking was relatively rare until the invention of the cigarette-rolling machine in 1881, followed by the development of "safety matches". Smokers increased their average of 40 cigarettes a year in 1880 to an average of 12,854 cigarettes per smoker per year in 1977, which was the peak of American tobacco consumption.

While "smoker's cough", emphysema, and bronchitis have long been associated with smoking cigarettes, definitive evidence for its effect on health comes from the famous Framingham Study. Smokers have been shown to have significantly increased risk of heart attack, stroke, and other arteriosclerotic diseases. There are, of course, other studies that show increased risk of lung disease and cancer.

 What Does Smoking Do to You?
Many studies have been done to determine exactly how cigarette smoking exerts its harmful effect. The Framingham Study statistics were unequivocal in showing that cigarette smoking was associated with increased risk. This did not tell us, though, whether the cigarettes were the primary risk, or if they simply influence the effect of other known risk factors. It has been shown that smoking is an independent risk