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In a world that has irrefutably established that cigarette smoking causes significant health problems, why do millions of people continue to smoke? Despite a decades-old public health battle to get out the word that smoking kills, there may still be people out there who manage to filter out public service announcements from the alluring mass media images of smoking. Although there will continue to be a need for anti-smoking messages to compete for unconverted hearts and minds, many smokers know that cigarettes are unhealthy and continue to smoke anyway. Nicotine is addictive, addictions are very hard to stop, and the result is an entrenched threat to public health.  Smoking is still far-and-away the heavyweight champion preventable cause of death in the US, amounting to 443,000 deaths per year according to CDC calculations. The expense of a smoking habit, tobacco bans in most public areas, and the indignity of being packed into designated smoking areas have not caused a significant reduction in the ranks of smokers. A significant number of the scientists at my institute, people who study cancer, hike across a parking lot in the Texas heat to smoke in an alley (true, some are French). I’m mystified when I see young physicians smoking.

The US required tobacco manufactures to add labels to packaging which read “Caution: Cigarette smoking may be hazardous to your health” in 1966, the world’s first official warning to consumers. The previous year, 42% of Americans were smokers. Today, about 20% of Americans smoke. Efforts to regulate tobacco marketing have certainly contributed to the decline but the number of Americans exposed to the risks of tobacco and the societal cost of smoking-related illness remain unacceptable.

Since 1985, one of four warning labels has appeared on packaging in the US, each with the heading, “SURGEON GENERAL’S WARNING”. The most arresting of the four is probably, “Smoking Causes Lung Cancer, Heart Disease, Emphysema, and May Complicate Pregnancy.”  It is easy to see that for many, particularly those at risk for chronic illnesses due to educational disparities and difficult socioeconomics, this dispassionate list of diseases may not be particularly meaningful. In the intervening years, the US has fallen behind the 39 countries which have developed more graphic warning labels, including images of smoking-related pathologies.

This week, the Department of Health and Human Services unveiled 9 new graphic warnings labels that will cover the upper half of the front and back of cigarette packages starting in September, 2012. The labels are the result of The Family Smoking Prevention and Tobacco Control Act that gave the FDA a mandate to regulate tobacco products. President Obama signed the bill in the early days of his administration in 2009. That it will take 3 years to go from law to enhanced warning labels is another example of the glacial pace of change in federal public health.

The images are interesting. They have the feel of the “This is your brain, This is your brain on drugs” style of public service announcements that many of us grew up with in the ‘80s. The most powerful image shows a man holding a cigarette with a plume of exhaled smoke emanating from a gaping hole, a tracheotomy stoma, in his neck. The text reads, “WARNING: Cigarettes are addictive.” There are rotting teeth and gum lesions, a wired-up chest scar, a stylized cartoon of a baby in a NICU incubator, lungs before and after smoking, a woman in tears, and a man proudly wearing an “I Quit” shirt. Some of the labels could more realistically depict the effect of smoking on patients, but there is significant shock value on display.

The new warning labels look like they will be bad for those in the cancer stick business. The four tobacco giants have all threatened legal action alleging violated property and free speech rights.  The government has already won a general challenge to larger warnings labels with images in a Kentucky federal court. The specific proposed labels will be closely scrutinized when the case is argued in the Sixth Circuit Court of Appeals.

Let’s be sure to note that the story is not only of progress in the public health effort to regulate tobacco. The Tobacco Products Safety Advisory Committee of the FDA released recommendations on menthol-containing cigarettes (such as the Newport brand) in March, 2011. As detailed by Dr. Michael Siegel in a June 9th New England Journal of Medicine editorial, the expert panel found that although menthol does not increase the toxicity of cigarettes, it does mask the harshness of tobacco. Convincing data show that menthol-containing cigarettes are more appealing to young people and the modified taste is less of a barrier to initiating the habit. Studies have also shown that menthol smokers have a harder time quitting than smokers of non-menthol containing cigarettes. Newport cigarettes are specifically marketed to African Americans, troubling given the findings on youth smoking. The expert panel concluded, “Removal of menthol cigarettes from the marketplace would benefit public health in the United States.” It did not go further to recommend specific action to the FDA, such as a ban of menthol cigarettes. This is a huge victory for Lorillard, the maker of Newport, who used an absurd argument that a menthol ban would lead to creation of a black market in menthol cigarettes to influence the debate. The committee, the FDA, and congress bowed to Big Tobacco pressure and as a result, cigarettes with increased addictive potential will continue to be marketed to a population at risk.

There will continue to be smokers who established an addiction before they were in a position to hear and process the message that smoking kills. There will also be the self-injurious users who start or persist with the full knowledge that smoking might hasten their death. These particularly intransigent smokers must constitute less than 20% of the general population. If a forced look at a gruesome image can have more impact than boxed warnings and the pleas of friends and family members, we may reach a point where our society can move on to pressing health problems that are not so clearly preventable.

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