Public Health Tools Used to Lower Smoking Rates

The Campaign to Discourage Smoking
A Public Health Success Story?
Can we use the same tools against COVID-19?
Mask Up, Get
Vaccinated!
Robert J Miller MD
August 2021

Your beauty up in
smoke
The Ugh
The Ugly Truth
In the campaign to
reduce smoking we
pulled out all of the
stops and went after
smokers
Is it time to push back
against the no-mask
and no-vaccine
crowd?

How did we push
cigarette smoking
rates back down?

How critical was trust in our success in
lowering cigarette smoking?

Change in Percent Smokers from 1965 to 2018
52%
15.8%
34.1%
12.2%
Success?
After 50
years should
this be
better?

https://www.hhs.gov/sites/default/files/2020-cessation-sgr-full-report.pdf
Men: current smokers from 52% to 15.8% and Women: 34.1% to 12.2%
but in 2018 13.7% (34 million) still smoke costing $Billions in
health care costs
Success?

Tobacco use has been documented for over 8,000 years. Tobacco
cultivation likely began in 5000 BC with the development of maize-
based agriculture in Central Mexico. It was originally used by Native
Americans in religious ceremonies and for medical purposes.
In the late 15th century, Christopher Columbus was given tobacco as a
gift from the Native Americans. It gained instant popularity in Europe, for
they believed that tobacco had magical healing powers. Soon, the
smoking of tobacco was promoted as a viable way to get your “daily
dose of tobacco.”

Research has shown that the most potent demand-reducing influences on tobacco
use have been interventions that impact virtually all smokers repeatedly, such as
- higher taxes on tobacco products
- comprehensive advertising bans
- graphic pack warnings
- mass media campaigns
- smoke-free policies

Best Practices for Comprehensive
Tobacco Control Programs—2014
https://www.cdc.gov/tobacco/stateandcommunity/best_practices/index.htm

This comprehensive approach combines educational, clinical, regulatory,
economic, and social strategies.
Research has documented the effectiveness of laws and policies in a
comprehensive tobacco control effort to protect the public from secondhand
smoke exposure, promote cessation, and prevent initiation, including:
- increasing the unit price of tobacco products
- implementing comprehensive smoke free laws that prohibit smoking in all
indoor areas of worksites, restaurants, and bars, and encouraging smoke free
private settings such as multiunit housing
- providing insurance coverage of evidence-based tobacco cessation treatments
- limiting minors’ access to tobacco products.

Smoking Cessation: A Report of the
Surgeon General
2020
U.S. DEPARTMENT OF HEALTH AND
HUMAN SERVICES Public Health Service
Office of the Surgeon General Rockville,
MD
https://www.hhs.gov/sites/default/files/2020-cessation-sgr-
full-report.pdf

https://www.hhs.gov/sites/default/files/2020-cessation-sgr-full-report.pdf

https://www.cdc.gov/tobacco/data_statistics/fact_sheets/economics/econ_facts/index.htm
Economic Trends in Tobacco
(CDC)
By state, the average retail price of a pack of 20 cigarettes including federal and state excise taxes,
ranged from
$4.62 in Missouri to a high of $10.67 in New York, as of November 2017.
On average, federal and state excise taxes account for 44.3% of the retail price of cigarettes.
Increasing the price of tobacco products is the single most effective way to reduce
reduce consumption.

Simply educating smokers about the dangers
of smoking is not on the list of most effective
ways to reduce smoking!

Cigarette smoking is linked to about 80% to 90% of lung cancer deaths.
People who smoke cigarettes are 15 to 30 times more likely to get lung cancer or die from lung cancer than people who do not smoke.
About 10 to 15 percent of smokers develop lung cancer - 21% survival at 5 Years
67 percent of smokers perished from smoking-related illness.
https://www.cdc.gov/cancer/lu
ng/basic_info/risk_factors.htm
Lung Cancer in Smokers and Nonsmokers

How Many People Survive 5 Years Or More after
Being Diagnosed with Lung and Bronchus Cancer?

Cigarette Consumption in the US and Health Events

N
X
doubl
es
US enters
WWI
Depression
begins
US enters
WWII
Evidence
links
smoking
and cancer
1964 Surgeon
General Report
Synar amendment
Fairness
doctrine on
advertising
Non-
smokers
rights
Fed cig tax
doubles
Secondhand
smoke report
Broadcast ad
ban
Nicotine gum
Master settlement
agreement
Family smoking
protection act
Fed tax increase
Cig price
drop
FDA rule
Updates
Secondhand
smoke report

Benefits of lowering
smoking showed up
Lower lung cancer
deaths in men
Lower lung cancer
deaths in women

0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2020
Men
Women
Smoking in the US
Humphrey Bogart
Dead at 57 from esophagus cancer in
1957
Men

0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2020
Men
Women
Smoking in the US
Lauren Becall lived to be 89 and died
in 2014 of a stroke
Women

0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2020
Men
Women
Steeper decline in smoking
among men and started
coming down sooner
More shallow decline in smoking among
women and started coming down later
Smoking Decline in the US

AUGUST 25, 2021
Study suggests women find it more difficult to quit smoking
than men
by European Society of Cardiology
despite smoking fewer cigarettes and being less
nicotine dependent than men, women find it more
difficult to quit.
Possible contributors could be the higher prevalence
of anxiety, depression and overweight or obesity
among women.
Women face different barriers to smoking cessation
related to fear of weight gain, sex hormones, and
mood.

https://seer.cancer.gov/explorer
Men peak was 1984
Women peak at 2005

So, who still smokes and why?
Is it educated, wealthy and successful people?
Is it poor, unsuccessful, uneducated and
unhappy people?

Percentage of adults aged ≥18 years who reported cigarette use “every day” or “some days,” by selected characteristics —
National Health Interview Survey, United States, 2019
https://www.cdc.gov/tobacco

Smoking by Level of
Education in 2019
“I love the poorly educated!”

Smoking by Income or
Health Insurance in 2019

Changing Social Norms about Smoking…then

Changing Social Norms about Smoking…now

Smoking By State in 2018
Utah 8.9%
California 11.3%
New York 14.1%
Texas 15.7%
Florida 16.1%
US 17.1%
Alabama 20.9%
Mississippi 22.2%
Kentucky 24.6%
West Virginia 26.0%

Lung Cancer Mortality by County in the US in 2014

Lung Cancer Incidence Rates by State for 2017

Lung Cancer Death Rates by State for 2017
https://gis.cdc.gov/Cancer/USCS/DataViz.html

Authority Task Trust
Government raise cost/restrict access and advertising Yes
Science educate public Yes
Media stop ads Yes
Culture/Politics de-glamorize smokers Yes
War against smoking (only villain was big tobacco)
Failures are people in distress or prone to addiction (and obviously
people who don’t care). Disease of despair?

Most smokers use tobacco regularly because they are addicted to nicotine.
Most smokers would like to stop smoking, and each year about half try to quit
permanently. Yet, only about 6 percent of smokers can quit each year.
https://www.drugabuse.gov/publications/research-
reports/tobacco-nicotine-e-cigarettes/nicotine-addictive

Aug 7, 2021
How’s it
going with
COVID?

The poor US response to Covid-19 has exposed multiple weakness in
our society including:
a malfunctioning public health system
a nonexistent national health system
a broken information system
such extreme cultural-political polarization that it raises
questions about the effectiveness of a democracy in
making equitable and coherent policy decisions.

The lowest levels of vaccine confidence were
found in countries with the highest education
levels and the best health-care systems
Successful vaccination effort requires the public
to trust the scientists who create the vaccine,
the companies that manufacture it, the health-
care workers who inject it, and the governments
that oversee the process.
That trust chain is a far more important lever of
acceptance than any piece of information,

Public Trust in Government: 1958-2021/
Public trust in government near historic
lows
https://www.pewresearch.org/politics/2021/05/17/public-trust-in-government-1958-2021/
Only about one-quarter of Americans say they can trust the government in Washington to do what is right “just
about always” (2%) or “most of the time” (22%).

Amid coronavirus threat, Americans
generally have a high level of trust in
medical doctors MARCH 13, 2020
Have a great deal or a fair amount of confidence
Medical Doctors 74%
Medical Research Scientists 68%
News Media 47%
Elected Officials 35%
https://www.pewresearch.org/fact-tank/2020/03/13/amid-coronavirus-threat-americans-generally-have-a-high-
level-of-trust-in-medical-doctors/

PROPORTION THAT
TRUSTS MOST NEWS
MOST OF THE TIME
https://reutersinstitute.politics.ox.ac.uk/sites/default/
files/2021-06/Digital_News_Report_2021_FINAL.pdf
US Lowest Trust
in Digital News
in the World in
2021
The Reuters Institute Digital
News Report 2021

https://news.gallup.com/poll/1597/confidence-institutions.aspx
Confidence in Institutions… list of institutions in American society. Please tell me how much
confidence you, yourself, have in each one -- a great deal, quite a lot, some or very little? 2020 Gallup Survey
The Military 72%
The Medical System 51%
Organized Religion 42%
The Presidency 39%
Newspapers 24%
Big Business 19%
Television News 18%
Congress 13%
Percent who answered: Great deal/ Quite a lot
We depend on the
‘Fourth Estate’ to
help us watch over
the government and
we have a broken
information system

https://www.nytimes.com/interactive/202
1/04/17/us/vaccine-hesitancy-
politics.html?smid=em-share
Trump voters more
vaccine hesitancy…
how did COVID
become political

https://www.pewresearch.org/science/2
021/03/05/growing-share-of-americans-
say-they-plan-to-get-a-covid-19-vaccine-
or-already-have/
Trump decided to minimize the
seriousness of COVID his
messaging often came into
conflict with public health
This forced his supporters to
show their loyalty by
denigrating the input from
public health
Public Health didn’t help itself
with faulty messaging

https://www.pewresearch.org/science/2021/03/05/growing-share-of-americans-say-they-plan-to-get-a-covid-19-vaccine-or-already-have/
The risk to the economy they
could see with their own eyes,
the health risks required trust in
“experts”

Biggest jump in
deaths in a
century!

Between 2018 and 2020, life expectancy in the US decreased by 1.87
years (to 76.87 years), 8.5 times the average decrease in peer
countries (0.22 years), widening the gap to 4.69 years.
Life expectancy in the US decreased disproportionately among racial
and ethnic minority groups between
https://www.bmj.com/content/373/bmj.n1343
Historic Drop in Life Expectancy in the United States

https://morningconsult.com/views-on-the-pandemic/
Democrats and Health
Republicans and Health

https://morningconsult.com/views-on-the-pandemic/
Republicans and Economy

Cases
Cases
Hospitalizations
Hospitalizations
Deaths
Deaths
Not Going Well in the US

Despite overwhelming medical information about the
gravity of this pandemic, some people promote resistance
to mitigation efforts

How to behave if you are a
true patriot
The best way to protect every one’s freedom is to oppose any
effort by the government to limit your personal freedom,
unless…
We are in a once in a century public health crisis that
threatens the health and economy of all Americans

With smoking, information (science based) had an impact but needed
government and regulatory participation to make it more expensive, illegal
and inconvenient to smoke and
the media cooperated in making it less sexy or desirable to smoke and
cancelling tobacco advertising.
There was no organized opposition to this other than the limited false
advertising from big tobacco and a dwindling number of angry smokers.

With COVID the science has been challenged almost from the beginning and
there was been organized opposition to mitigation and vaccination
strategies on a political basis, and government restrictions have been
challenged in the courts and by state legislators.
The media has been polarized as well as discredited by obvious bias and
over-reach along with outrageous misinformation!
Makes you wonder If the virus has
a secret advocate rooting for its
success!

Authority Task Trust
Government shut down cities and require masks NO
Science does mitigation work/vaccines safe NO
Media media provide accurate information NO
Culture/Politics encourage responsible behavior NO
War against COVID
The villain was us!

Look Familiar?
Smokers Low Vaccine

Survey: Misinformation affects vaccine hesitancy
Tampa Bay Times June 19, 2021
- Main reasons cited were based on misinformation about the scientific
facts
- Most people trust advice from their personal physician
- But most people no longer have a relationship with a personal physician

https://www.nytimes.com/2021/07/31/us/virus-unvaccinated-
americans.html?referringSource=articleShare

Almost
nothing
will
convince
these
people

“In God we trust…everyone else bring data!”
People need more than impersonal ‘data’ they need a relationship with a
health care provisor based on trust

Countering antivaccination attitudes
Proc Natl Acad Sci U S A. 2015 Aug 18; 112(33): 10321–10324.
https://www.ncbi.nlm.nih.gov/pmc/articles/PM
C4547299/
Randomized trial on the best way to deal with anti-vaccer parent who claims
vaccines cause autism they tried two different approaches:
Giving them new info about the harm of getting sick was
most effective
Confronting them about their mistaken beliefs about
autism was not effective

Does use of the expression
“out of an abundance of
caution…” justify ignoring
science?
If you’re a doctor be honest,
don’t say you are following
the science when you aren’t

Is it in your best interest to behave honestly with transparency?
Politician: No….they want power (stay in office and hide their sources
of campaign contributions, a gaffe : accidently telling the truth)
Media and Social Media: Maybe….they want ratings (conspiracy and
polarization are good for ratings, some have reputations to preserve)
Big Pharma: No…they want block buster drugs (whether they work or
not so the least scrutiny the better)
Physicians and Scientists: Hopefully Yes (if reputation,
legacy and influence are more important than
fame and fortune)

Before you
start
pontificating or
arguing with
others, stop
and challenge
your own
beliefs.

when we ponder and speak, we often do so with the mindset of three different
professions
The preacher let me emphasize why I know I’m right.
The prosecutor let me point out why I’m sure you’re
wrong
The politician, I guess we’re all right.

To be successful think like a scientist.
Treat your position as a working hypothesis that may
turn out to be wrong as new information comes
along, show a little humility.

Isaac Newton
Hypotheses non fingo
“I do not feign hypotheses”
It’s OK to say, “I don’t know.”
When pushed to explain not just
how gravity worked but why it
worked, he said:

Richard Feynman
the physicist Richard Feynman discussing
scientific integrity:
“The first principle is that you must
not fool yourself—and you are the
easiest person to fool.”
The default position in testing your hypothesis is the null hypothesis
(i.e. assume you are wrong and have proved nothing) to try to avoid
confirmation bias.

How the medical experts should have presented their
advice on COVID
1. It’s a new (novel) virus, but since we’re in an emergency, we will start out treating this
like other Corona viruses that we know about until we have more information
2. We will start collecting reliable information by urgently setting up widespread
surveillance testing and high-quality randomized trials
3. All the high-quality data will be presented in real time as it comes in and be widely
shared with the public and scientific community
4. Guidelines on management will be continuously updated by expert panels with
expertise in public health and infectious disease and shared widely along with the data
and rationale for any changes made

Coach: “Son, I don’t know if
your problem is ignorance or
apathy?”
Player: “Well coach, I don’t
know, and I don’t care!”
Ignorance or Apathy…the public

The public needs to feel an obligation to be
educated and to keep informed.

Like Moore’s Law Information Technology (and information)
has been growing exponentially for over a century!
Soon this
will exceed
human
brain
power

Thank You for Being Late | Thomas L. Friedman
We are all (almost all) now too stupid
to understand what’s going on
Most people are comfortable in
their ignorance
A few people (polymaths
and scholars) are trying to
keep up
And Information

34% 13.6% 2.1% 0.13%
What if you now need an IQ
of at least 130 to understand
nuance and complexity
How best to run a
democracy (100% or 16%
to make decisions)

Democracy is a pathetic
belief in the collective
wisdom of individual
ignorance.
A newspaper is a device for
making the ignorant more
ignorant and the crazy
crazier. HL Mencken

And finally, to consider how their behavior benefits
society rather than themselves
We don’t
just have
cognitive
failure we
have a
spiritual
failure

Why So Many Tennis Players Don’t Want the Covid Vaccine
Despite the possible consequences of not being vaccinated — illness and
the loss of income and opportunity to play — tennis players have been
stubbornly slow to get the vaccine.
“Whether someone wants
to get a vaccine or not,
that’s completely up to
them,” Djokovic said. “I
hope that it stays that way.”
New York Times / Aug. 30, 2021

N
X
doubl
es
US enters
WWI
Depression
begins
US enters
WWII
Evidence
links
smoking
and cancer
1964 Surgeon
General Report
Synar amendment
Fairness
doctrine on
advertising
Non-
smokers
rights
Fed cig tax
doubles
Secondhand
smoke report
Broadcast ad
ban
Nicotine gum
Master settlement
agreement
Family smoking
protection act
Fed tax increase
Cig price
drop
FDA rule
Updates
Secondhand
smoke report
Non-smokers rights,
do the vaccinated
have any rights?

Public:
1.need to be less selfish
2. work to be better informed and less credulous
(or gullible)
3.Need to put pressure to force accountability
and transparency from all the bad actors (media,
government, industry)

Experts (authority):
the honest ones need to realize that
the avalanche of new information
does not automatically turn into public knowledge
unless…
the experts maintain (or earn) public trust
(competent/unbiased/honest) and …
present this new information in a format explicable
(accessible) to the general public

So, what strategy makes sense?
1. Advice for the Public
2. Advice for Experts/Authorities
3. Policy makers: appealing to the ‘good sense’ and altruism
of your fellow Americans won’t get the job done (in time) ,
so you need to move ahead with mandates that limit access
to people not vaccinated or not practicing proper mitigation
strategies

In 1905 the Supreme Court confirmed a Massachusetts law that
empowered cities’ boards of health to mandate smallpox vaccination of all
residents
reciting the principle that individual liberty is not absolute in the face of
“the common good,” and that “real liberty for all” depends on restraining
individual exercises of liberty that harm others.
The pre-COVID legal landscape is quite clear: a state can require
vaccinations to protect public health, even imposing criminal penalties for
noncompliance and vaccination as a condition of attending school or of
government employment

Sept. 2, 2021
We Work at the A.C.L.U. Here’s What We Think About
Vaccine Mandates. David Cole and Daniel Mach
We see no civil liberties problem with requiring Covid-19
vaccines in most circumstances. The disease is highly
transmissible, serious and often lethal; the vaccines are safe
and effective; and crucially there is no equally effective
alternative available to protect public health.
In fact, far from compromising civil liberties, vaccine mandates
actually further civil liberties

Opposed to Vaccine mandates Approve Mandates
https://www.medrxiv.org
/content/10.1101/2021.0
1.31.21250866v1.full.pdf
Survey 15,536 adults in
13 countries
How the
people of
various
countries think
about their
government
imposing these
mandates

How many people
think we should
continue to save
lives?
How Is this even
controversial?

Public Health Tools Used to Lower Smoking Rates

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