Kenneth Warner is the Avedis Donabedian Distinguished University Professor of Public Health at the University of Michigan.
One of the nation’s leading researchers on tobacco concerns, he served as Senior Scientific Editor of the 25th anniversary Surgeon General's report on smoking and health, published in 1989. He chairs the board of the international journal Tobacco Control, and was a founding member of the board of directors of the American Legacy Foundation. From 2001-2002 he served as the World Bank's representative to negotiations on the Framework Convention on Tobacco Control. He is an elected member of the Institute of Medicine of the National Academy of Sciences.
I caught up with Warner last week for a conversation about the current challenge of tobacco control, and why the American public seems bored and jaded about our single largest public health problem.
Harold Pollack: When did cigarettes really become a public health concern?
Kenneth Warner: Cigarette smoking itself got going in a big way during World War I. The industry had recently perfected cigarette mass production. Manufacturers provided cigarettes for free for the dough boys, and that got it all going. The health problems probably began in a big way ten-to-thirty years later.
There's actually a famous anecdote about a prominent surgeon named Alton Ochsner. When he was a medical student in 1919, he was called in to observe a lung cancer surgery. He was told at the time he might never see another case of lung cancer, it was so rare. He actually didn’t for another seventeen years. Then he started seeing bunches--among men who had begun smoking during the war.
Public awareness of these problems probably dates back to the 1930s, although the linkages between tobacco and health were not rigorously documented until later. The earliest careful documentation began to appear around 1950.
The first really solid epidemiological research was published in JAMA in 1950 by Wynder and Graham. It was a case-control study of 684 lung cancer cases. Wynder and Graham found that 96.5% of the lung cancer patients had been moderate or heavy smokers—a much higher proportion than found among patients hospitalized for other things. It was the first really strong statistical evidence that smoking was associated with lung cancer.
Within a couple of years, the Doll and Hill cohort studies of British physicians concluded that smoking was strongly related to lung cancer. There was an American cohort study, a lot going on at the same time. From then on, it was clear that smoking caused many health problems.
Pollack: It’s remarkable how much credible evidence emerged so quickly from so many sources and populations. It’s useful to remember that history when listening to the latest dramatic claim that wheat germ causes cancer or whatever.
Warner: That’s right. Smoking was considered a risk factor by a lot of people for decades before the formal evidence was in. Cigarettes were often semi-jokingly referred to as “coffin nails” decades before the real evidence started to come in.
One of the great successes of the tobacco industry was to defuse the issue, to make people think it might be a minor problem, not as big as the experts said. Many people felt that smoking couldn’t be as bad as the government said it was. After all, the government hadn’t banned it.
The mass public reaction to this research dates back to December 1952, and the publication of an incredibly influential article by Ray Norr, “Cancer by the Carton,” in Reader’s Digest. When you look at a curve of adult per capita cigarette consumption in the U.S., you see it going up steadily and then it drops sharply in 1953 and 1954 immediately following Norr’s piece.
Back in those pre-TV days, Reader's Digest was the American public's principal source of information about health and medicine. So the piece had an enormous impact.
Then cigarette companies started advertising filtered cigarettes as taking out the bad stuff that caused the problems and letting the flavor through. The public bought into these arguments because they wanted to buy the product.
The 1964 Surgeon General’s Report on Smoking and Health
Pollack: We just celebrated the 50th anniversary of the Surgeon General's report on smoking and health. Why was that 1964 report such a big deal and how many lives were saved by the tobacco control efforts that that report kicked into motion?
Warner: That Surgeon General's report was truly one of the great documents in the history of public health. It’s recognized as such by pretty much everybody. They decided to issue the report on a Saturday because they were afraid of the effects it would have on the stock market.
It was actually released to the press in a secured State Department conference room where President Kennedy had given his press conferences. The reporters were allowed in the room and given the report for 45 minutes beforehand. They were locked in. They had no telephones. They were not allowed to contact anybody.
Then they had the press conference. The news about the Surgeon General's report was actually one of the lead news stories of all of 1964. Unfortunately, President Kennedy wasn't around for the release of the report that he had authorized.
Pollack: How did that report come about?
Warner: It came into being because there were several health organizations urging President Kennedy to appoint a panel to study the evidence on smoking. They were frustrated because the previous Surgeon General, Leroy Burney, had issued a 1957 statement that smoking was expected to be the cause of lung cancer and other diseases and that this needed to be attended to. Nothing was happening.
The health organizations badgered President Kennedy and he did what any good president would do: He set up a committee, figuring basically that nothing would come of this, at least that's the rumor that he didn't think much would come of it in particular.
The committee consisted of physicians and scientists who were vetted by the major health organizations and the tobacco industry. The tobacco industry could veto any of the people it didn't like. The committee ended up with a group, none of whom had specifically researched tobacco, none of whom had taken a public position on smoking, and several of whom were themselves smokers. It really was a very fair group.
They spent 2 years in their study. Looked at over 7000 documents, which was the extent of the available literature at that time, and then came out with this report that really was a wallop to the American public and indeed to the tobacco industry. The committee said that smoking was the cause of lung cancer in men. There was not sufficient data about women in those days, though the committee suspected a link for women, too.
They also associated smoking with a number of other diseases, and said that it was causally related to some of them. They came up with the off-quoted statement that “cigarette smoking is a health hazard of sufficient importance in the United States to warrant appropriate remedial action.”
They didn't say what the remedial action was. That had to follow from whatever government and the private sector decided to make of it.
Eight million lives, 157 million life-years saved
Pollack: It's been 50 years now. How many lives have been saved by the various measures we've done to try to reduce smoking?
Warner: First, I think it's important to say what we mean by the term tobacco control. I'm using it to cover all of the efforts of the private, voluntary, and public sectors to reduce the toll of smoking: trying to prevent kids from starting to smoke, helping smokers to quit, avoiding exposure to second-hand smoke, all of that combined.
This January, some colleagues and I published a paper in JAMA that estimated the cumulative health effects of tobacco control. We found that between 1964 and 2012, eight million premature deaths were avoided as a result of tobacco control. We did not include second-hand smoke deaths, nor the years 2013 and 2014, so probably the best figure today would be about 10 million premature deaths avoided.
Tobacco control, broadly construed, accounts for fully 30 percent of the gain in adult life expectancy since 1964. Nothing—no medical intervention or any other public health development - has contributed anything close to that.
Moreover, each of those deaths on average involved an increase in life of 20 years. Most people have heard that smoking reduces life expectancy by something on the order of eight to ten years. That figure applies to all smokers including those who die of something else.
It’s amazing the death toll isn't higher. The typical pack-a-day smoker takes 10 to 12 sucks per cigarette, on twenty cigarettes a day. We need to call a spade a spade: smokers don’t “puff” on cigarettes – blowing out – they suck on them. Over the course of a year, they're smoking more than 7,000 cigarettes. The average lifetime smoker smokes for about fifty years. These men and women are consuming more than 300,000 cigarettes over their lifetimes. They are inhaling 7000 chemicals more than 3 million times, include seventy known human carcinogens.
It’s rather surprising that about half of smokers survive that 50-year chemical assault on their bodies. Even within this group, however, many are suffering from smoking-produced diseases like emphysema and heart disease, and many of them are chained to oxygen tanks, can't walk up stairs, or whatever.
It's all pretty devastating. Over the same period that those 10 million lives were saved, about 20 million lives were lost to tobacco. It's astonishing to think of a death toll like that for something that we just don't seem to take as seriously as we ought to.
Tobacco control: The current challenge
Pollack: We still have an estimated 480,000 people a year who are dying in America from tobacco-related causes. And it does seem to me that we don't hear quite as much about that as we did 10 or 20 years ago and people seemed a little bored and jaded with the topic. At least that's my perception. Do you think that's accurate?
Warner: Definitely. The public’s attention span is only so long. And for the public and policymakers to care about an issue, it seems to have to have genuine personal salience for them. Too many among the voting public, and certainly the nation’s legislators, the smoking problem has been “solved.” Smoking is prohibited in most public places and workplaces. Those people don’t smoke. Their friends don’t smoke. They don’t see it. The most influential segments of the voting public seem blissfully ignorant of the magnitude of the problem.
To give one example, if you ask women – educated women – what the leading cause of cancer death among women in the US is, the vast majority will answer breast cancer. Very few are aware that lung cancer now kills 72% more women than does breast cancer.
The pink ribbon campaign for breast cancer has greatly raised awareness and funding for breast cancer research. That came about in no small part because there were so many articulate, educated women who were getting breast cancer and wanted to see something done about it. The male-dominated research establishment wasn't paying adequate attention. So there was a need for action. They've done a marvelous job with the pink ribbon campaign.
But where’s the brown ribbon campaign for the much larger group of women who are dying of lung cancer? I fear the answer is that they are the wrong people. They're less visible, less vocal, less organized. They are, in many instances, embarrassed that they're smoking and feel that they are personally responsible for having caused their disease. Somehow society is neglecting this disease. The deaths of one out of five Americans are produced by smoking. This is a shocking number.
One out of every five deaths of Americans is caused by smoking today. Think about that: Fully a fifth of all deaths are completely avoidable! And yet the American public seems bored and passive about this. It’s amazing, and tragic.
Smoking today is concentrated in people with low educations and incomes. Increasingly, and frighteningly, smoking is also concentrated among people who suffer from some mental health concern. Some forty-to-fifty percent of all current smokers experience some comorbid mental illness ranging from anxiety to schizophrenia to substance use disorders. Nobody thinks about this when they talk about smoking, but right now, and increasingly over the years, smoking is becoming a problem associated with people who have mental health concerns.
Pollack: Just to clarify, that’s not just people with severe mental illness, necessarily. You mean people with some other sort of mental health concern.
Warner: Exactly. Anything from anxiety or manageable depression up to severe mental illness. Smoking rates are very high among individuals with schizophrenia: about 60% compared to 18% overall in the population….
These men and women have a harder time quitting than do people who are not experiencing mental health problems. This doesn’t mean they can't quit--because they can--but they have a harder time.
For years, the approach to people with mental health problems--especially those who were hospitalized--was that you shouldn’t to touch smoking: Deal with their most severe immediate mental health problem. You would exacerbate it if you tried to get them to quit smoking. It turns out that's not true. Often you're better off trying to help people in those situations to quit smoking while they're being treated for other mental health conditions.
People with serious mental illness experience a loss of life expectancy of about 25 years, which is an extraordinary number. Smoking is responsible for a very large part of that. We need to address this group much better than we have to date.
The stigma of smoking
Pollack: The stigma associated with smoking (and the marginalization of smokers as a political constituency) makes it easier to enact painful measures such as increased tobacco taxes. It opens possibilities to save lives through measures that would have been politically impossible thirty years ago. On the other hand it leads us to neglect many people who are smokers and to disparage many people who really need assistance rather than to be penalized. We penalize smokers, for example, in health reform. We don't charge people more for other risk behaviors. In one way, this is a good thing because it encourages people to quit smoking. But there's a disturbing flip side to that that we have to somehow address.
Warner: We have clearly stigmatized smokers. Smokers feel it, they know it. It's important that people understand that smoking is not this freely chosen behavior that adults pick up because they're doing it because they are pleased by it and get pleasure out of it.
Do they get something out of it? Of course. The nicotine itself may actually be helping them in concentrating on their work or whatever it may be. Yet the fact is that smoking is by and large an addiction that is initiated during childhood when kids have no concept of what addiction is, and for that matter they have no conception of their own personal mortality.
I also suspect that physicians today are not nearly as sympathetic with their smoking patients as physicians were a generation ago. Physicians today haven't ever smoked. They don't understand addiction. They’ve read about it, but you have to have been there to really understand it. As a former smoker who tried quitting 4 times before I finally succeeded, I have a real appreciation of what the addiction is all about.
It’s important for people to appreciate the brain chemistry associated with smoking. Smoking is not just this pleasurable activity. As with other addictions, your brain is fundamentally altered by smoking. It requires nicotine to be satisfied. If laboratory animals are given the choice between food and water on the one hand or a drug to which they are addicted, many of them will choose the drug, to the point that they die for lack of sufficient nourishment. It's a powerful phenomenon.
The penalties that we are imposing on smokers are considerable. I'm one of the people who was responsible in the 1980s for getting the idea out that cigarette taxation is an effective way to reduce smoking. We know that if you raise taxes substantially, you will reduce smoking considerably. At the same time, you're obviously raising revenue for the legislature. There’s a real win-win aspect to this, but I worry about the low-income smokers who just aren't going to quit.
Now it's true that when you raise the price, more poor people will quit. If you look at the disparity in health between rich and poor, the life expectancy difference is about 5 years or so. Smoking is probably the single most important factor in that disparity. In that sense, tobacco taxes can have a progressive impact on health.
However, the vast majority of smokers, poor and rich, are not going to quit. Suppose you're charging $2 or $3 per-pack in taxes, which is fairly typical. Multiply that by 365 packs per year, and you're looking at a significant percent of many people's total income. That has an element of inequity to it.
It's something that we in tobacco control don't address adequately. The answer we always give is, "Well let's take the revenues and dedicate them to helping low-income people with smoking cessation, help them to pay for their smoking cessation pharmaceuticals, counseling, and so on." That's a nice answer for those who can quit that way and want to quit. It's not a good answer for those who either don't want to quit or are unsuccessful trying.
Tobacco harm reduction (THR)
Pollack: This brings us to the contentious issue of “tobacco harm reduction (THR)”-- the search for other ways we could help people who smoke to either stop smoking or to reduce the harm that they will experience from their smoking. It seems like such a sensible idea to reduce people's risk, but the public health community seems split down the middle over this. Why is this such a controversial issue?
Warner: Some smokers either cannot or will not give up their nicotine. That’s what keeps them smoking, and dying. The idea underlying THR is that some of these inveterate smokers might be receptive to alternative forms of nicotine delivery that are much less dangerous. The principal examples are low-nitrosamine versions of smokeless tobacco and, more recently, electronic or e-cigarettes. E-cigarettes in particular have split the public health community. Some believe that their promotion as substitutes for smoking could do a great deal of good – getting inveterate smokers to switch to them – while many in the community fear that e-cigarettes will hook more kids on nicotine and “renormalize” smoking.
I don't think I'd agree with you that the public health community is split down the middle. The public health community is very split, but the vast majority are opposed to the very idea of harm reduction. The idea that anybody would use anything with nicotine or tobacco offends most people in public health, especially most people at the grassroots in tobacco control.
If you take the leadership or the intelligencia within tobacco control, it's fair to say there is a split pretty much down the middle. There's a long history of harm reduction in public health dating to methadone treatment and syringe exchange for heroin users to condom distribution in many Chicago public schools. Of course those are all very controversial measures.
As I mentioned, THR reflects the notion that we need to do more for people who will not quit smoking because they want the nicotine or who cannot quit. If you provide people with some alternative method of getting their nicotine that's less dirty, less hazardous, their risk will be substantially reduced. People using low nitrosamine smokeless products, which are the most recent generation of smokeless tobacco products, are probably risking a minimal amount of disease compared to cigarettes. There’s just a gigantic difference. People who are vaping, using e-cigarettes, are almost certainly greatly reducing their risk compared to cigarette smoking a lot.
There is reason to believe that the e-cigarettes could be a good harm reduction technology. But we must remember that the public health community, the tobacco control community, has been burned by the idea of harm reduction. The first two generations of harm reduction were brought to us by tobacco industry.
In the early 1950s they started advertising filtered cigarettes aggressively as taking the dangerous stuff out of smoke and allowing the flavor through. This was right after the cancer scare exemplified by that Readers’ Digest story. Filtered cigarettes were about 1% of the market in 1950. By 1960 they were the dominant product. It was 57% of the market. They were no safer.
Then there were the low-tar, low-nicotine cigarettes. A prominent ad campaign for True cigarettes showed this very intelligent-looking business woman. She said: "I've heard all that stuff they're saying about smoking. I decided I would either quit or smoke True. I smoke True." In other words it was a tempting alternative to quitting.
In point of fact, it was a deception. We've had a chance to look at industry documents thanks to all the lawsuits. We now know that both filtered cigarettes and low-tar nicotine cigarettes were never considered by the industry to be health enhancing or risk reducing. Rather, they were public relations devices, methods of getting people to smoke more rather than quit.
The cost has been enormous. Nobody knows how many millions of people have died as a result of those deceptions. That's important background to understanding why the tobacco control and public health communities look so askance at the idea of harm reduction.
There are a large number of people, including some very important people in this community, who worry that e-cigarettes in particular are going to get many more young people, children, addicted to smoking. They worry about the notion that we're going to see people who have quit smoking resume their habit: They try vaping; they get addicted to the nicotine or get the nicotine taste. They end up back on cigarettes.
There is also the worry that we are re-normalizing smoking, something we've spent so many years trying to denormalize. People will walk around in public vaping and it looks like smoking. It looks glamorous. Advertising for the predominant product, Blu, which is sold by Lorillard, a cigarette company, looks just like the glamorous and sex appeal ads for cigarettes that we saw three or four decades ago. So there are a lot of reasons to be worried about it.
Having said that, there is real potential in these products, too. We need regulation that's going to make that work properly. Unfortunately, you run into a political morass. The FDA has that authority under the Family Smoking Prevention and Tobacco Control Act of 2009. They can do the regulating, but the surrounding politics is terrifying, and it makes it very difficult for FDA to do what it needs to do.
Pollack: It's terrifying because of the influence of the industry or it's terrifying because of the intolerance of the basic idea of these products?
Warner: Because of the direct and indirect influence of the industry. The indirect influence of the industry is on Congress and frankly the administration. This administration has not been friendly to tobacco regulation. That may seem odd since President Obama signed the law in 2009, but they haven't been very friendly since then.
They’ve had the opportunity with this new law to really accomplish something. It's just been revealed recently, just the last couple of days, that OMB has been involved in what regulation FDA can do. They have apparently removed language from FDA’s proposed deeming regulation that pertained to the regulation of electronic cigarettes and what's called premium cigars. Who likes to smoke premium cigars? The very influential and affluent population.
At every level of the politics this is ugly. Any time FDA proposes a regulation from the Center for Tobacco Products, if it has any potential to reduce cigarette smoking there will be industry lawsuits. It doesn't much matter to the industry whether these suits have ultimate legal merit. The main goal is to simply delay implementation of a regulation that cuts into industry cigarette sales. It's extremely difficult for FDA to do what, in an ideal public health world, it would do right away.
The Obama administration and tobacco control
Pollack: Let’s come back to something you just mentioned. Why do you think the Obama administration has been less of a friend to tobacco control than one might have expected?
Warner: There is little pressure on the administration to do anything with regard to tobacco. There is a lot of pressure on the administration not to do anything with regard to tobacco. That's a powerful influence.
I'll just give you an example that I find personally appalling. There's something that most people in the United States are completely unaware of called the Framework Convention on Tobacco Control. It is the world's first global public health treaty.
It has been ratified at this point by 178 countries out of the 193 countries that are members of the World Health Organization. Only a few significant countries have not ratified this treaty, which by the way is being implemented around the world as we speak. The United States is the most important of those countries that have yet to ratify this treaty.
Almost 90% of the world's population lives in countries that have ratified it. Americans don't even know about it. The Obama administration and previous administrations have not even brought it to the Senate for consideration. That's a powerful statement of how little influence the tobacco control and public health communities have on the administration today.
Pollack: It also speaks to the structure of the US Senate. Maybe that they haven't brought it forward because the framework convention has very little chance of getting the required super majority.
Warner: That's absolutely correct, it's certainly a problem with the Senate, but you're not hearing anybody talking about this in either the Senate or the administration. It's a very important treaty and it's been adopted more widely and more rapidly than almost any other treaty in history. We're not a part of it. It's just a sad commentary on where the country is in that regard.
Pollack: There's also the question of how aggressively the US government assists the tobacco industry in international trade negotiations involving their product.
Warner: It's going on right now with the trans-Pacific trade negotiations. It's a huge issue. It's true every time there's a treaty.
Pollack: If we continue on our present course how many people do you think are likely to die of smoking-related ailments over the coming decades.
Warner: Sadly, we can say quite confidently that the 480,000 deaths-per-year figure we're looking at now will continue for a long time. My colleague David Mendez and I have been researching trends in smoking prevalence since the early 1990s. Our forecasts have proved very accurate since then. We forecast what smoking trends will be at the rate we're going now using the evidence-based measures that we know work: Increasing price through taxation, smoke free laws, media campaigns, restricting advertising. If we simply do more of the same, we're going to be looking at a smoking prevalence rate in excess of 10% of the adult population by the year 2050. The implication is that we will experience hundreds of thousands of completely avoidable deaths every year for many decades into the foreseeable future. That's an appalling toll from any perspective. It’s unacceptable.
We need to do more than what we have done to this point. I actually believe there is an answer. We can reduce smoking-related deaths dramatically. Can we get rid of them entirely? Probably not, but we have the potential to reduce the toll to a relatively minor problem rather than a major one, which is it will remain through at least the middle of this century.
The most important element lies in FDA regulation. What are now described as “end-game” proposals are emerging from the tobacco control community that go beyond the traditional tobacco control measures. I hope we can discuss those in some future conversation. These require unprecedented political will and bureaucratic tenacity, the latter on the part of the FDA’s Center for Tobacco Products.
Good policies in this area would prevent more death and illness than any other medical or public health intervention in the coming decades. All these require is for people – important people – to care more about public health than they do about making a buck or getting and staying elected.
That “all,” however, is an imposing barrier. The American public must also keep the pressure on, so that our government and our entire society aggressively and humanely confront a scourge that will kill 480,000 of our fellow citizens once again this year.