War on Tobacco: The Anti-Smoking Battle Continues
Dr. Michael Eriksen sees public health workers and tobacco companies as locked in a fight for the “hearts and lungs of the world.”
Smoking has declined dramatically in the U.S. since the first Surgeon General’s Report, nearly a half century ago, concluded that smoking causes lung cancer.
But the front lines of the battle are now in developing countries, and the problem is growing. If trends continue, there will be one billion tobacco-related deaths in the 21st century, compared to the 100 million tobacco-related deaths in the previous century, says Eriksen, Dean of the School of Public Health at Georgia State University.
Eriksen, an expert on tobacco control, has been leading the war against smoking in the United States and globally for decades. In this interview with Georgia State writer LaTina Emerson, he discusses why he’s stayed engaged in the fight, his view that tobacco companies are on the rebound with new products and why hookahs are a lot more dangerous than people think.
Q: How are we doing on the war on tobacco? Where are the key fronts in this battle?
A: It’s considered by many to be a victory, but in reality, it’s only half won. While rates have been cut in half, there are still 45 million smokers in the United States, and it’s still the leading cause of death in the U.S. Most smokers want to quit, but can’t or haven’t. Why has it taken 50 years to achieve progress and why are there still tens of millions of users in this country? The answer is there is an industry that makes money at the expense of other people’s health. It’s a very profitable industry, not only here, but globally. In China, the tobacco industry is a government-owned monopoly that generates revenue from both taxes and sales.
Q: A lot of people don’t smoke. Why should they care about this issue?
A: It’s a public health burden. It costs everybody money. A select group of people are profiting at the expense of others. We’re dealing with an addiction that’s deadly, and the people who become addicted are typically 13 or 14 years old — 85 percent of smokers start before they’re 18. By the time they graduate from high school, they want to quit but cannot. You’re addicting the youth to a drug that will kill one out of two lifetime users.
Q: What is working in the fight against smoking? What isn’t?
A: Generally, the consensus about what works is that raising the price of tobacco products through tax policy discourages and reduces consumption. Clean indoor air laws that restrict where people can smoke protect non-smokers, reduce smoking and change social norms. Banning or restricting advertising and marketing takes the glamour out of smoking. The newest area would be considered graphic warning labels and using the package to communicate the harm of smoking as opposed to the glamour. There have been advances in smoking cessation, in terms of pharmaceuticals and nicotine replacement and other types of drugs, but despite that advance, the reality is that most people quit on their own.
Q: Can you talk about the trends in setting up smoke-free zones in the United States and globally?
A: Fifty percent of the U.S. population lives in places where there is no indoor smoking allowed, period. The South is not as progressive. Here, people can smoke in certain restaurants and bars. The smoke-free zone idea started in the U.S. in the early 1980s in California and has diffused throughout the U.S. and now the world. But there isn’t anywhere, in my opinion, that has cleaner air than in the United States. The areas now that are contentious are outdoor areas – like parks, stadiums and beaches – and whether or not smoking should be banned there. Cars with children present are another contentious area. Multi-family dwellings have started to go smoke-free. The home is obviously the hardest to regulate because it’s your home, but it’s also where children are present. It’s not clear what’s going to happen around homes.
Q: Are there other possible solutions?
A: Whatever we can do to the point of banning smoking. It’s so bad and so harmful that it should be taxed to the sky. It should not be allowed anywhere in public. It shouldn’t be advertised anywhere.
Q: How did you get so passionate about this topic?
A: When I was smoking, I was in my early 20s. I was in graduate school, and my mother had three bachelor brothers who lived together. The youngest of the brothers was very industrious, never smoke or drank and worked hard to save his money for early retirement. He developed cancer of the stomach, unrelated to smoking, but died from it. I was in public health school, and on his deathbed he said to me, “If there’s anything you ever do in your life, do something about cancer.” I heard him say that, but then I also had a pack of cigarettes in my pocket. I felt I was just being disrespectful to him by playing with my health when he was losing his life. That was 40 years ago, and a cigarette has not touched my lips since that day at his deathbed.
Q: Is the death of the tobacco industry in sight?
A: If anything, I see they’ll be able to better survive and thrive in the future because they’re invested in alternative products. I would venture to say that in 10 years there will be no combusted cigarettes in this country. It will all be e-cigarettes, oral tobacco, nicotine patches, water and suppositories. It’s more likely that the scenario for tobacco companies will improve because they will no longer be referred to as tobacco companies. They’ll be referred to as nicotine companies. They’ll be providing a product that people want that isn’t as harmful as it was in the past. Their public image will improve, and they’ll be able to be more corporate citizens. I think they’ve weathered the storm, and they’re on the way up.
Q: Tell us more about smokeless tobacco products.
A: The tobacco companies have been coming up with ways of delivering nicotine to the brain without smoke. The biggest thing is called electronic cigarettes, or e-cigarettes. They’re plastic cylinders that have a nicotine capsule in it and use a battery to heat the capsule. They create a nicotine vapor that’s inhaled. Within the last year or two, this has become a multi-billion dollar business. In many ways, the whole issue of second-hand smoke in 10 years is going to be kind of a moot issue because fewer people are going to be actually burning tobacco to get nicotine through smoke. They’re going to be using e-cigarettes, candies or water.
Q: You’ve been called upon by some of the world’s largest emerging economies (for example, China and Brazil) to collaborate on efforts to reduce smoking. What advice have you given these countries?
A: Part of it is recognizing the seriousness of the problem and that there’s something that can be done about it. This needs to be acted on urgently. We know what’s going to happen. People start smoking, it increases over decades and people start dying decades later. The issue is either stopping it and preventing the illness and death or accelerating the reduction and acting boldly, as opposed to what countries tend to do, which is tolerate it because of the industry. What’s the most effective strategy for tobacco control? Increase the price.
Q: Tobacco use is the most preventable cause of death, but you say it will increase worldwide. Why?
A: It will increase worldwide because it is being promoted and marketed in developing countries where the populations are young, have lots of kids and they don’t have strong governments. There’s a great concern about Southeast Asia and Africa. There’s a battle between public health workers and tobacco companies about the hearts and lungs of the world. I think we’ve learned that you make progress by having public policies, taxes and restrictions on sale, labeling and advertising. Weak governments don’t do that. Tobacco control requires government action.
Q: Is reducing the amount of tobacco grown worldwide a reality?
A: I think it is possible to get people into alternative crops and to have it less commonly grown, but I don’t think you’re ever going to eliminate it as a crop. The fewer people who grow it, the less vested interest there is in supporting the use of tobacco. Here’s my pet peeve. Tobacco is fundamentally a worthless crop from a human standpoint. It just kills people. Countries that grow tobacco often have food crises. I’d like to see less tobacco grown and more food grown in its place that has some social benefit.
Q: Do you think other countries should model the restrictions on tobacco advertising, promotion and sponsorship that we have in the U.S.?
A: I think the U.S. is weak. I think most other countries are already stronger than the U.S., and the U.S. shouldn’t serve as a model at all.
Q: Georgia State has a smoke-free campus, along with many other universities nationwide. Is smoking on the decline among college students?
A: High school students have the lowest rate of smoking on record going back to the ‘70s, which is great, and I think that carries over into college age. The problem with college students is that they are fair game for the tobacco companies. You can go to a bar, and there could be someone in there employed by a tobacco company who will give you free cigarettes. They’ll get your driver’s license to capture your identity, put you on a mailing list and send you coupons. That’s totally legal and fair, and students around college campuses are exposed to aggressive marketing of cigarettes because it’s legal. But it doesn’t make it any less deadly or wrong.
Q: In recent years, hookah bars have become a popular trend in the U.S. Is smoking a hookah harmful compared to cigarettes?
A: The smoke from a hookah is water cooled, so it doesn’t feel as harsh, but it’s not filtered, so the smoke still has the same toxins in it. Basically, while you think it’s not as harmful, it actually could be more harmful because it’s easier to inhale and not cough. The second thing is, in the hookah, they put the tobacco in the bowl and place a piece of charcoal on top of it to keep the tobacco lit. So not only are you inhaling the tobacco, you’re inhaling the charcoal fumes directly into your lungs. In some countries, like in India or Egypt, where the hookah pipe is shared, smoking the hookah is associated with tuberculosis because people are passing TB from one to another on the mouthpiece.
Eriksen was senior adviser to the World Health Organization and the longest-serving director of the Centers for Disease Control and Prevention’s Office on Smoking and Health. He has published extensively on tobacco prevention and control and is co-author of The Tobacco Atlas, Fourth Edition, which focuses on the global tobacco industry. He recently created and launched the Tobacco Portal, a web-based resource for tobacco-related facts and data.
This interview has been edited and condensed.