Smoking Cessation: Still Looking for a Miracle
Am Fam Physician. 2001 Feb 15;63(4):626-631.
My first attempt at instigating smoking cessation was in 1959, when at age nine I tried to convince my mother to quit. Despite our “good rapport” and “repeated visits,” and despite exhausting every known smoking cessation strategy I could muster over the next 36 years, my mother died of lung cancer from smoking.
While well-intended and basically true, much smoking cessation advice in the literature serves to further promote what I believe are myths:
“People must be ready to quit.” (I believe anyone will quit at any time when given an adequate reason).
“Nicotine replacement has a central role in cessation.” (I believe it facilitates smoking, prolongs cessation and may increase initiation by kids).
“A physician must acquire specialty training in smoking cessation to be effective.” (I believe honesty, sincerity and frequency of message are more important.)
“Smoking is a medical problem.” (I believe it is an economic problem with medical consequences.)
“We need more smoking cessation and addiction research.” (I do not believe it will likely make a whit of difference.)
Probably hundreds of millions of dollars have been spent and thousands of articles have been written on these topics, yet in our lifetime, all medicine's efforts have at best made a minimal impact on global tobacco consumption. I would not want to be misunderstood; the one-on-one encounter in the physician's office has been vital to what little progress has been made. However, I believe the change agent is the physician, not a protocol, a drug or a technique.
Although countless dollars have been spent in the effort to understand how smoking causes disease, why people smoke, and the best way to get them to “cessate,” we must stop, think and ask, “So what?” More diseases than ever have been associated with smoking. Children are still smoking in record numbers, and the average age at which a smoker has that first cigarette creeps lower each year. Has anything happened or new information been acquired as a result of these activities that would change the imperative to halt the use of tobacco? Hardly.
It is pathetic to see success being defined as a slight down tick in an upward projection of smoking trends. Our goal should not be to more cleverly slice the data, “slow down the increase,” “minimize the impact,” “reverse the trend,” or “find a magic bullet.” At least 30 million Americans have died while we have pursued these as our goals. We have more people spending more money, doing more research and conducting more education about tobacco than at any time in history. Yet, about 60 million Americans still smoke.
The answer isn't smoking cessation. If, on the first day of the new millennium, research had revealed a wonder drug or counseling technique that resulted in one half of all smokers “cessating,” we still will have 250,000 deaths each year related to smoking. Fifty years from now, we still will have spent $3 trillion on smoking-related health care and watched 15 million Americans die. Who in their right mind would call that success?
Had medicine and government done what they should have 50 years ago, smoking would be a thing only seen in museums and old movies. What's so tragic is that the technology to achieve this goal was available then. The willingness to use it wasn't and perhaps still isn't.
About every decade since 1920, there has been a groundswell of public opinion against smoking and the tobacco industry. We are just beyond the crest of a cycle now. This is primarily because there is a false sense of victory over the revelations of the tobacco industry's nefarious actions, because lawyers extracted large amounts of money from smokers, because there is a misperception that the settlement and recent legislation will actually do something to decrease smoking among kids and because the tobacco industry—as they do in every cycle—has agreed to mend its evil ways.
As a result, medicine continues down the same path, making the same honest, well-intended mistakes, while the tobacco companies continue to hook the next generation.
Simply put, if we continue to do what we are doing, history should have taught us that kids will continue to start smoking, the average age that they have their first cigarette will creep lower each year and millions more Americans will die. Only now, the co-profiteers are the states, who in partnership with the tobacco industry through the recent settlement, are not about to jeopardize the hundreds of billions of dollars they are scheduled to receive over the next 25 years.
Let's be realistic. Why do kids smoke? Because the tobacco industry wants them to smoke. Why? Because cigarettes are profitable. Results happen because a system is designed to achieve those results. It really is this simple.
The tobacco industry's arguments regarding reasons why kids smoke—all of their arguments—vanish when one asks: if smoking by kids is a result of (whatever they are blaming it on currently), why weren't kids smoking 100 years ago? When there were no cigarettes, kids did not smoke cigarettes. If there were no profit in selling cigarettes, there would be no cigarettes; and, thus, there would be no kids smoking them. Kids will continue to smoke as long as individuals, corporations and government profit from this behavior. It really is this simple.
Consider this. The profit from a pack of cigarettes is about $1. Each year, 1.1 million kids begin smoking. At one pack per day, the profit from kids smoking is $401 million per year. The Life Time Value (LTV) to tobacco company shareholders of each cohort of hooked kids over an average lifetime is $24 billion.
In the long-term view of the tobacco industry, every year that a new cohort of kids starts smoking is worth $24 billion in profit. Said another way, if a miracle occurred and no new kids started smoking, the tobacco industry's profit over the next 50 years would drop by more than $1.25 trillion (and this is only one profiteer in the “food chain”).
There are but a few options if one's goal truly is smoking cessation, and these have nothing to do with what the physician does in the office.
(1) Make cigarettes illegal.
(2) Remove nicotine from tobacco products (gradually?).
(3) Government could purchase tobacco companies in order to shut them down (gradually?).
While these are tempting, they are unlikely to happen without compelling incentives for legislators. So far, the premature death of 500,000 Americans a year has not been compelling enough.
(4) Continue to operate under the illusion that some researcher will discover a miracle drug or counseling technique. This is the choice we've made for the past five decades.
(5) The Justice Department could enforce the legislation that anyone who knowingly sells a product that carries a 50 percent mortality would be held criminally accountable.
(6) Pay the kids to not smoke. When I was about 12, my parents promised to pay me $500 not to smoke or drink until I was 21. On my 21st birthday, I collected. Why?
This was a lot of money to a 12-year-old. More importantly, it was a very, very good excuse to thwart peer pressure. The usual responses when I used this excuse were, “Wow! I'd do that,” and “I wish my parents would make me that offer.” Why not do the same thing with every kid?
Thanks to the settlement, we could. The settlement was allegedly to pay the states back for the health care costs of its smokers. Logic should then dictate that the states would turn around and refund to its citizens the money it originally collected from them in taxes to pay these costs. Instead, it appears that the proceeds will be used for roads, bridges, future health care and other pet projects. The settlement belongs to the taxpayers. If the states are not willing to give it to the rightful owners, then they should at least use it to prevent kids from smoking, another stated purpose of the lawsuits. If we shifted the money being used on tobacco research to the pot, we would have even more incentive funds to inspire kids not to smoke—not to mention, likely with better results.
(7) Take away the profit. To completely remove the profit motive, we could enact legislation so that for every cohort of 10-year-olds that begins smoking, the tobacco industry must deposit an amount equivalent to 125 percent of their profit on this cohort to a Health Security Trust. To further insure that the tobacco industry remains committed to their publicly stated effort to prevent kids from smoking, this contribution of 125 percent of their profit would continue for the life of the cohort.
Each child would have a Health Security Account (HSA). At age 10, they would have an opportunity to sign a pledge not to smoke until age 21. If they adhered to this pledge, they would annually receive a prorated share of the funds collected from the tobacco industry. If they did not, they would lose all their funding. After a year of abstinence, they could be reinstated. After age 21, the funds could be used for educational debt, health care, first home purchase or as a basis for a retirement plan. At 3 million kids per cohort and $24 billion profit, the fund would equal $10,000 per kid per year, and investment at an annual rate of 7 percent would yield $160,000 per kid at 21 years of age.
Some kids would still choose to smoke. Money collected on this cohort over the next 50 years would continue to fund the HSA. However, the net effect would be that the tobacco industry would be forced to get serious about preventing kids from starting smoking. They, along with tobacco workers, farmers, advertisers and retailers, would have 30 years to wean themselves from the addicting profits.
Legislators would have an opportunity through the HSA to take credit for the funding of universal education, universal health care, adequate housing and universal retirement for everyone regardless of the socioeconomics of their family without raising taxes. Moreover, with the savings on health care and research costs, legislators could bail out the rest of the government and/or lower taxes.
Kids would have a tangible incentive not to smoke.
Will we wait for another decade-long cycle for public opinion to once again crescendo and then after much gnashing of teeth, shouting in outrage and funding of still further research, pat ourselves on the back for another decade? Remember how good we all felt when “Smokefree by the Year 2000,” COMMIT and ASSIST were announced?
Smoking by kids is greater now than when C. Everett Koop, M.D., and the National Cancer Institute first announced these multimillion dollar, well-intended efforts. The tobacco industry is probably still laughing.
Doing nothing is a choice. Continuing to do something that does not work is a choice. Doing the same thing over and over again all the while expecting a different outcome the next time—a working definition of insanity—is a choice. Helping the tobacco industry free themselves of their addiction to profit is the choice we should make. After all, they can't help it, profit is addicting; and incredible profit is incredibly addicting. We have the power to calm, the power to comfort, the power to help them quit. Let's wean them one step at a time by doing something new: I suggest we combine 6 and 7—not a patch, but a cure.
Announcing a new three step smoking cessation program: Step 1: Give the kids a real incentive; Step 2: Take away the profit; Step 3: Stop the killing.
We could do this, you know.
Address correspondence to John W. Richards, Jr., M.D., 4210 Columbia Rd., Suite 7-A, Martinez, GA 30907.
Copyright © 2001 by the American Academy of Family Physicians.
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