Blog | Tuesday, January 24, 2012

Is the fight over cigarette pack warnings the right one?

Cigarettes help keep me employed. They contribute to about one in five deaths in the U.S., and their effects on health are broader than most people realize. Lung cancer is bad, but not as common as struggling to breath with emphysema-ravaged lungs, trying to walk on legs rotting from loss of their blood supply, or waiting for a heart transplant.

The good news (and I'm happy to lose the business) is that cigarette smoking has diminished significantly over the last few decades, although not equally in all populations. It would be hard to deny that the 1964 Surgeon General's report on smoking helped begin this decline.

But smoking rates in the U.S. have leveled off at about 20% (once again, dependent on the segment of the population you look at). No one can rationally deny that ill-effects of smoking, so why is anyone still doing it?

Everyone knows the answer, but few acknowledge the implications. Nicotine addiction is powerful, therefore prevention efforts focus on both prevention of starting smoking and on helping people quit. Smoking usually starts in the young, and the more smokers adolescents are surrounded by, the more likely they are to smoke. We traditionally think of adolescents as being a group particularly difficult to influence, but if they are influenced to smoke, the can be influenced not to. For example, states with stricter smoking laws help prevent cigarette use. Once they start, getting them to stop is an uphill battle.

Exposure to advertising is a risk factor for starting smoking. Theoretically, regulating advertising should help modify smoking habits, and evidence supports this.

The current battle over cigarette package warnings should be seen in this context. If more graphic ads help prevent people from starting to smoke, great, let's do it. That's an important part of the battle. But since peers and family have such a strong correlation with cigarette smoking, we need to take the fight to the smallest levels of society, especially targeting communities with higher smoking rates.

A recent study of blood pressure screening in African-American barber shops had encouraging results. We need wide-spread community-level interventions. We have to take into account that many smokers have a lower level of education than non-smokers. Ads have to be aimed at proper education levels, but ads that speak down to people probably won't be taken well.

The ad industry is pretty damned smart. If they can get poor kids to spend their hard-earned cash on an expensive and deadly habit, they can probably help prevent it.

But once people start to smoke, we have a problem. Most of my patients who smoke want to quit, but it's not a matter of willpower. More insurance companies are starting to pay for smoking cessation programs, although most don't pay for the drugs that are usually required to help people fight the tenacious neurochemistry that keeps them smoking in the first place. A typical prescription for Chantix costs about as much as one month of a pack-per-day habit, but has to be paid up front, unlike 30 packs of cigarettes.

I'm all for graphic cigarette ads. I'm all for draconian smoking regulations that prevent people from smoking in public and at work. But we need a comprehensive national smoking policy, one that any physician can guide people to, one that targets prevention and cessation in every community, one that makes it harder to start and easier to quit.

Peter A. Lipson, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. After graduating from Rush Medical College in Chicago, he completed his internal medicine residency at Northwestern Memorial Hospital. This post first appeared at his blog, White Coat Underground. The blog, which has been around in various forms since 2007, offers "musings on the intersection of science, medicine, and culture." His writing focuses on the difference between science-based medicine and "everything else," but also speaks to the day-to-day practice of medicine, fatherhood, and whatever else migrates from his head to his keyboard.