The story I am about to tell you was triggered by a very famous clinical trial, back in the ‘80s – the ATBC trial. As you very well expect, I had NO IDEA what was going on back at the time. All I knew was that my mom was a heavy smoker. By heavy I mean 2-3 packs of cigarettes per day! Not any cigarettes, but the ones without filter. To give you a vague idea about the amount of cigarettes in our house, here is how I would estimate it. If you started at the entrance door and checked every single drawer, every single pocket and every single exposed opening that could accommodate something about the size of a cigarette pack, from left circling to the right around the whole house, you would have found cigarettes pretty much EVERYWHERE in that house. Should the Apocalypse have come and there be no way of getting cigarettes, my mom would have still been set to keep on smoking, at the same rate of 2-3 packs daily, for at least 6 more months! That house had so many cigarettes that even now, more than 3 decades later and several years after she died, if I find a box that went unopened for any reason, I still expect to find a pack of cigarettes there!
Now, with that said, about when I started middle school and moved over from my grandmother’s to my mom’s, people had already began talking that smoking wouldn’t be good for you…and obviously, for a 12 year old kiddo reading fish books to provide the best possible care for her guppies, the update about what people thought of smoking was terrifying, to say the least! I didn’t say anything, but I started watching carefully every smoker and every non-smoker I met. I was kind of tempted to smoke myself to see how that was. My mom looked darn sexy holding a cigarette…however, before I make that a positive, let me tell you that the woman looked so darn good because she was a volleyball player most of her entire life. She was a very talented and highly sought after player with countless training sessions on-board on a regular basis. How she could do all that performance while smoking that much, don’t ask me! Several decades post factum I can tell you that if she wouldn’t have smoked she might have very well written history in that sport – but she did not. Because she smoked? …Very likely. However, this is my biased opinion and I could be wrong.
In this given smoking landscape, despite my determined mini-study of watching smokers and non-smokers on a regular basis, I could put no logic together. To put it in the ever present and popular current jargon of scientific literature: “more studies were needed”! Heck with it! Was it BAD?? If it was, why wasn’t it straight-forward enough for all to quit?? Of course, you know now what I did not know then and you understand now what I surely did not understand then. People I trusted (because they seemed smart to me) smoked as much as those who I did not trust. People that were sick – I mean very-very sick – smoked to the same extent some of the healthiest people did. Physicians and nurses I knew, they all smoked like chimneys! Gossip about smoking just did not add up! Who was wrong and who was right?! All I could tell for sure was that my grandmother was THE MONUMENT of integrity, correctness and discipline one could imagine and, well, she did not smoke. In fact, she was loudly against it and would always run into a great argument with my mother for this very reason.
That fact inclined the balance for me: smoking must have been bad! Nonetheless, I loved the smell of it! A preference that stuck with me forever. I know that not because I am a smoker (I quit, very long ago), but because every single perfume I like enough to decide to buy turns out to contain nicotine – no exception! If I like it, it does have nicotine! That will make a great topic on day, let me know if you want to hear about it.
It turns out, however, that despite her complete disregard to her mother’s advice to quit smoking, my mom – deep in her heart – she knew that smoking was wrong. The day she acknowledged that was the day when she decided to increase her vitamin A intake by eating more carrots. My assumption today, after reading and studying, and then reading and studying again several thousand times over, is that she must have heard about the ATBC clinical trial. How? I don’t know. My gut is wrenching though and I believe that I am right. What she heard and what she did for sure shortened her life rather than lengthen it. But she did not know what she was doing. I didn’t know either. Nobody knew. Let me explain:
It was 1985-ish and people thought that smoking may cause lung cancer. It was also clearly established that Finns (as in the people of Finland) were the heaviest smokers in the world. To be honest with you, whoever put that in writing surely did not study Romanians, but that will be another topic for another time! Just take this: Romanians did not prohibit smoking in public areas until last year (that is 2016)!!!!! Anyway, back to the 1980-1985 time-frame: the vitamin A research was booming, and so was vitamin E research. Scientists thought that vitamins A & E could be valuable cancer prevention agents. If you go check my drug files, do take a look at all the knowledge to date files I made available for vitamins. Look carefully at the number of publications on each vitamin A and vitamin E during the decade 1980-1990. You will notice a very interesting fact: the research on vitamin A and E had a faster pace than research on other vitamins (check here vitamin B, vitamin C and vitamin D for a comparison). More papers were published over a shorter interval on A&E as compared to each other single vitamin! That is what allowed the happening of one of the most interesting, well intended, but very unfortunate studies in humans – the ATBC study. Go read more about it for yourself! Briefly, between 1985 and 1988, the ATBC study enrolled just under thirty thousand Finns with ages between 50 and 69 who had smoked at least five cigarettes per day. Since the study was about to give them either alpha-tocopherol or beta-carotene (hence the ATBC name), the individuals already taking vitamin A or E were been excluded. The rest were assigned by chance (a.k.a. randomized) to receive 50mg of alpha-tocopherol or 20mg of beta-carotene or both combined, or neither (placebo) for 5 to 8 years, or until they died, or until the study closed (1993).
Please don’t get me wrong: I DO NOT pick on neither the scientists nor the study! This clinical trial followed every ethical approval requirement. As with any clinical trial, it was conducted because evidence was needed to see whether one clinical approach or another was better for the patients. When we clinicians plan and conduct a clinical trial we are always well intentioned and wholeheartedly want nothing more than to help people. Sadly, we are many times defeated. Luckily, the impressive brains designing such clinical studies do know how to go about planning so that, even if the hypothesis fails, man-kind STILL learns something of value from that experience and move forward, taking decisions about that specific action on a better track from then on. That was quite what was about to happen with the ATBC study. Imagine having such a superb hypothesis “abundantly available antioxidant vitamins to prevent lung cancer” (this is an oversimplification of the reasoning behind the trial, but nonetheless the implication if the hypothesis were to be proven true)! Anything along these lines would have made its way into the mass media and would have disseminated like crazy by word of mouth. This was likely how the hypothesis made it to my mother and many like her. That must have been what nudged her decision to get on the “carrot diet”. At first look, the plan was by all measures harmless. Or should I say by all the measures known of at that time?
My mom did start the carrot diet with a stubbornness that I rarely saw in her. That is not because she wasn’t stubborn (she was very stubborn and I do take after her…!), but because she was more scrupulous about eating the damn raw carrots at breakfast, lunch and dinner than doing anything else! Looking back now, I am horrified. I didn’t know to stop her. If I knew that it would hurt her, I swear I would have found a way to stop her!!!! She tried to make me eat them too. I couldn’t. I just could not shovel down my throat this many carrots! She must have eaten easily 4-5lbs daily for a good ten days, maybe two weeks. As per my forecast, just like the fish I read about, she DID turn orange. Looked pretty funny to say the least! No makeup of any kind would help her natural beauty. Her dark olive skin tone, much-much darker than mine, together with the beta-carotene she stored everywhere ON HER, gave her an overall orangeish to light-caramel tone. I am really sorry that I have no pictures, but you can imagine that she had no intent what-so-ever to immortalize that image! I was in a way intrigued and in another concerned. Vitamin A definitely did change something. Whether that was for the good or for the bad, only time could have told us. Nobody yet asked the fish how they felt about eating vitamin A and we eat them anyway! Their meat sold faster and so did their caviar, all because they looked so perfect and joyful, a pink-orange that any wife dreamed of serving! Jeez…, was this right?? I could only advocate in my mind that fish eat phytoplankton (fish diet made of water plants), thus their natural diet may have included colored water plants and they may have had that special enzyme to cut beta-carotene and make retinol. The supplement did not kill the fish, but was that only because we eat the fish? What happened to the fish we did not eat? No data. We did eat all the fish that eat beta-carotene! We still do that.
You know that I proceeded at studying this in my fish tank, don’t you? Well, it is better said that I attempted. My fish tank was too small and could not separate beta-carotene eaters from non-eaters. My guppies also got to a point when they multiplied so much that they started dying because of over-crowding. More studies were needed. But I was suspicious. I ate my veggies while deciding not to abuse any of them, I certainly did not want to turn orange like my mom!
To put an end to this story, I want to tell you what we learned as clinicians and scientists from the ATBC study. A morale I still teach and preach today to my students, friends, neighbors and anyone who cares listening. The longest healthiest life among the participants was reserved to the placebo group, the individuals who did not receive either of the drugs. With regard to lung cancer, the subjects taking beta-carotene ultimately developed 18% more lung cancer. The participants also had a higher incidence of cardiovascular death. In parallel with the ATBC study, or soon after the end of its enrollment, another study was launched: the CARET study (read as in “carrot”). The beta-carotene and retinol efficacy study (e.g. CARET) enrolled a little over 18,000 participants to receive 30mg beta-carotene or 25,000 international units of retinol, the active form of vitamin A, or placebo. The study was stopped early, around 1996, due to the fact that the supplemented patients were found to have a 28% increase in the incidence of lung cancer and 17% higher incidence of death than non-users. Everyone was requested to discontinue treatment as a result and all were continued to be followed and evaluated. They donated blood samples at the time of the study closing and regularly afterwards. Investigations of their health status and changes in their blood samples continued for a very long time. Some data is still published today after investigations with methods and procedures that were not available back at the time.
The problem is complicated. To begin with, these individuals were the heaviest smokers – thus none of them were healthy to begin with. They were also relatively old, so if the carcinogenic process was already ongoing, one could not blame the vitamin A alone. But, still! At the time of enrollment, those that wound up in the placebo arms were equally sick, equally old, equally-equally everything as those that got vitamin A. Still, the placebo group died less and developed less lung cancer! Clearly vitamin A did something bad. What was that? You can picture the research landscape back then. If this bugs you – this bugged every scientist regardless of being involved or not decades ago. Everyone wanted to get to the bottom of this! I’ll make sure to prepare a topic specifically on these two studies and what followed. The blood of the study participants revealed a wealth of evidence… Stay tuned and I will tell you what that was about!
What happened to my mom? She eventually recovered and went back to her beautiful Egyptian-like skin tone. It took several weeks until she lost “her orange“.
I recall no symptoms or complaints other than her skin color change. The young age (she was in her 30s), her exceptional physical condition and athletic physique must have helped her a lot in counteracting any possible negative effects of that awfule carrot-diet. Yet, I will never forget that I lost her way too early, soon after her 63rd birthday, to something nobody, not even myself, has been able to elucidate to-date…
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