The book brings together an interdisciplinary group of scholars — including Stanford editors Matthew Kohrman, PhD, a professor of anthropology, and Robert Proctor, PhD, a professor of history. Together the team has investigated how transnational tobacco companies have worked to triple the world’s annual cigarette consumption since the 1960s. They focus on the China National Tobacco Corporation, which currently produces forty percent of cigarettes sold globally.
In a recent Freeman Spolgi Institute Q&A, Kohrman discusses how he got involved in this work. “When I began my ethnographic fieldwork on tobacco in China, I initially studied mostly consumer behavior. But I quickly realized that focusing solely on cigarette consumption, without considering the relationship between supply and demand, was like studying obesity while ignoring food,” he says.
Kohrman explains that cigarettes have become the single greatest cause of preventable death in the world today and the problem is getting worse. “Instead of declining as we would expect based on our impressions living here in California, the number of daily cigarette smokers around the world is projected to continue climbing,” he says. In particular, he explains the big tobacco companies are targeting less-educated people from lower- and middle-income countries.
Kohrman does offer some hope in light of the Chinese government’s recent initiatives to restrict tobacco advertising and smoking in public places. But he says that there is a lot more work to do.
“The road towards comprehensive tobacco prevention in China is going to be a long one,” Kohrman concludes.
This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.
The public’s opinion of tobacco use has dramatically changed over time. Gone are the days when cigarette companies advertise using slogans like “fresh as mountain air” or “more doctors smoke Camels than any other cigarette.” We now know that cigarettes cause blindness and tuberculosis, among many other conditions, and are highly addictive.
But in the era of nicotine e-cigarettes that are touted as cool and harmless, have we really changed our ways? I spoke with Robert Proctor, PhD, a professor of history at Stanford, to learn about his work.
What inspired you to research the history of cigarette design?
“Cigarettes are the world’s leading preventable cause of death, killing about 6 million people worldwide every year. A physician might hope to heal a thousand or perhaps ten thousand people over a career, but what if we could save these 6 million people annually? It was this hope of saving lives that led to my exploring how cigarettes have been designed, and how they might be stopped.”
Where do you find your research materials?
“The Legacy Tobacco Documents Library is a real treasure. I use it to explore the industry’s myriad secret projects — like Project Subculture Urban Marketing, a secret Reynolds campaign from the 1990s to target gays and the homeless in San Francisco. I also use it to find out what they’ve been adding to cigarettes—like diammonium phosphate, a free-basing agent used to boost the potency of the nicotine molecule. I also use it to find out who has been working for the industry, as grantees or expert witnesses. Historically that included dozens of Stanford professors, but I don’t know any still working in that capacity today.”
What do you think about the FDA’s plan to reduce nicotine in cigarettes?
“As I explained in a recent op-ed for the New York Times, the Food and Drug Administration will try to mandate the reduction of nicotine in cigarettes to a sub-addictive level. However, they will encounter ferocious resistance from the industry, which sees nicotine as the indispensable ingredient of their business. For beginning smokers, nicotine is actually a negative in the smoking experience. Once addicted, most smokers regret having started. It will be crucial for the FDA to reduce nicotine sufficiently to make sure new users don’t become addicted. De-nicotinization is easy. Multiple techniques are available to achieve this, including genetic technologies and some of the same techniques used to de-caffeinate coffee.”
Have you also studied e-cigarettes?
“I have studied e-cigarettes but not as intensively. Many of the same techniques once used to market traditional cigarettes have been revived for e-cigarettes and other vaping devices, as Robert Jackler, MD, and his colleagues have shown so beautifully. E-cigarettes may help some smokers quit, but they are more likely to renormalize smoking and act as gateways to regular cigarettes. They also serve as bridge products to keep smokers from quitting nicotine entirely, which is why the big cigarette makers have all launched new vaping devices.”
What more can be done?
“Physicians often know the right thing to do, but may not have the power to make that happen — that is medical impotence. A third of all cancer deaths, for example, are caused by cigarettes. Just knowing that, though, isn’t enough to do any good, since there are powerful forces dedicated to making sure we keep pulling smoke into our lungs. Much more could be done to solve such problems — the new age minima for purchasing cigarettes should help. I also believe we need to explore what I call ‘the causes of causes.’ Cigarette smoking causes disease, but what causes cigarette smoking? Too often we end with the individual, rather than going upstream to the source of the problem in the first place. Stop the manufacture of cigarettes, for example, and you stop having to yank out tumors from lungs or putting people on oxygen. We need more upstream thinking in the practice of medicine.
We also need to think more about health in our own community. For instance, Stanford got a failing grade from the Santa Clara County Public Health Department in 2011 as the most cigarette-friendly campus in the Bay area — for allowing the sale and use of cigarettes on campus. We did finally manage get the sale of cigarettes in the student union stopped, after years of painful protest.”
Editor’s note: Stanford has a smoke-free environmentpolicythat prohibits smoking in all buildings, facilities, vehicles, covered walkways and during indoor or outdoor athletic events. Smoking has been banned on the School of Medicine campus for a decade.
This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.
Smoking used to be portrayed as being glamorous in advertisements and movies. In old films, actors constantly smoked cigarettes and a tough guy usually had one hanging out the side of his mouth. It’s debatable whether smoking still makes you look cool though, especially since there are fewer and fewer public places you’re even allowed to smoke. Plus we now better understand the health risks of tobacco products.
Tobacco use is the single largest preventable cause of disease and premature death in the United States, but nearly 44 million Americans still smoke cigarettes – 1 in every 5 adults. There are also 14 million cigar smokers and 2 million pipe smokers.
Tobacco use is not quite as widespread in California, where just over 1 in every 7 adults smokes cigarettes. In the past year, 61 percent of these smokers attempted to quit.
There are many good reasons to quit smoking, and health concerns usually top the list. Half of all smokers who keep smoking die from a smoking-related illness, including lung cancer, other types of cancer, heart attack, stroke, or lung disease. Women who smoke are also more likely to miscarry or have a baby with a low birth-weight.
20 minutes, your heart rate and blood pressure drop.
12 hours, the carbon monoxide level in your blood drops to normal.
2 weeks – 3 months, your circulation improves and lung function increases.
1 – 9 months, your coughing and shortness of breath decrease.
1 year, your risk of heart disease due to smoking cuts in half.
5 years, your risk of various cancers (mouth, throat, esophagus, and bladder) is cut in half.
15 years, your risk of heart disease is the same as a non-smoker.
Cigarettes are also expensive. You can use a savings calculator to see how much money you would save if you quit smoking. For example, a pack of cigarettes costs $6.77 on average in California. If you smoke a half pack (10 cigarettes) per day, this adds up $24 per week or $1220 per year.
Of course, the nicotine in tobacco is very addictive so quitting can be difficult, but the chance of success is increased with help. There are many treatment options used to help smokers quit and many of these treatments are covered by health insurance.
The most effective quitting method is a combination of counseling, social support and the use of cessation medication. The most common form of counseling is through telephone-quit lines, which provide free support and advice from an experienced cessation counselor. The counselor can provide a personalized quit plan, self-help materials, the latest information on cessation medications, and social support. For instance, 1-800-QUIT-NOW is a free national counseling service. Many clinics and hospitals also have counselors and support groups that you can meet with face-to-face. Counseling and support groups are also available online.
There are a variety of cessation medications that are available either over the counter or with a prescription. Nicotine replacement therapies deliver nicotine to help reduce the severity of nicotine withdrawal symptoms. The nicotine dose is gradually reduced over time. Nicotine gum, lozenges and patches can be purchased over the counter, whereas nicotine inhalers or nasal sprays require a doctor’s prescription.
Bupropioin SR (Wellbutrin or Zyban) is a non-nicotine prescription medication that acts on the chemicals in the brain that are related to nicotine craving. It can be used alone or with nicotine replacement products. Verenicline (Chantix) is a non-nicotine prescription medication that blocks the effects of nicotine, so it should not be used in combination with nicotine replacement products.
It is important for smokers to speak with their doctor and/or a cessation counselor to make a personalized quit plan that is right for them. And this week is a good time to get started, just in time to take part in the Great American Smokeout on November 21. Smokers across the nation will use this Thursday to make a quit plan, or plan in advance and quit smoking.
The Great American Smokeout happens every year on the third Thursday of November. It started in California back in 1976 when nearly 1 million smokers quit for the day, then the American Cancer Society expanded the program nationwide the following year. It has drawn attention to the deaths and chronic diseases caused by smoking, resulting in laws that ban smoking in restaurants and other public places.
The Great American Smokeout is celebrated with rallies, parades, stunts, quit programs, and “cold turkey” menu items. For instance, the community is invited to receive up-to-date cessation information, resources and giveaways at UCSF Medical Center’s Great American Smokeout event from 9-10 am and 12-1 pm on the Parnassus, Laurel Heights, Mission Bay and Mount Zion campuses. UC Berkeley is also celebrating the event with a “cold turkey” give-away – get a free cold turkey sandwich in exchange for a pack of cigarettes from 11 am – 2 pm at Sproul plaza.
A friend once told me that it was 100 times harder for him to quit smoking cigarettes than to quit drinking alcohol. He was successful and hasn’t smoked a cigarette for over 10 years, but he’s a lucky minority. I have several other friends who still struggle with smoking cigarettes – willpower, counseling, exercising, nicotine replacement patches and antidepressants like Zyban haven’t been enough.
Clearly nicotine is highly addictive. About 45 million people in the U.S. smoke cigarettes, even though cigarette smoking leads to 1 of every 5 deaths each year. In a National Health Interview Survey, over half of the smokers reported trying to quit in the past year without success.
In the future, these smokers may get a vaccine to help protect them from nicotine addiction.
Researchers from Weill Cornell Medical College and Scripps Research Institute have developed a new vaccine that may treat nicotine addiction, by blocking the pleasurable sensations that nicotine creates in the brain. Dr. Ronald Crystal and his colleagues have demonstrated that they can prevent nicotine from reaching the brain in mice using a single injection of vaccine. If these findings are confirmed in people, this vaccine could be an effective therapy to help prevent nicotine addiction.