Published OnlineFirst February 20, 2014; DOI: 10.1158/2159-8290.CD-ND2014-002
Q&A: Howard Koh on Smoking Cessation and Policy Comprehensive tobacco-control efforts save lives and help young people avoid nicotine addiction As a young physician in Boston, MA, Howard Koh, MD, MPH, witnessed many patients with smoking-related conditions suffer and die. “I saw the devastation tobacco addiction imposes on people’s health,” he recalls. “It really motivated me to move toward prevention and public health policy.” Koh soon went from primarily caring for patients at Boston City Hospital and Massachusetts General Hospital to becoming the commissioner of public health in Massachusetts in 1997. In 2009, he became the assistant secretary for health in the U.S. Department of Health and Human Services, overseeing 12 public health offices, including the Office of the Surgeon General. To mark the 50th anniversary of the Surgeon General’s first report on smoking and health and to promote the release of this year’s report, Koh spoke with Cancer Discovery’s Suzanne Rose about the continued urgency of tobacco-control efforts. Why didn’t being diagnosed with cancer motivate your patients to quit? Addiction is so powerful. I clearly remember a patient who had surgery for lung cancer who was told that he might have been cured. In a follow-up visit with me—I was a young resident at the time—he told me he resumed smoking. I remember being astonished, but that’s evidence of how powerful and overwhelming this addiction can be. Is eliminating smoking an achievable goal, given that smoking rates have plateaued around 18%? We must make it achievable, and we have no other choice if we’re committed to a healthier future. We know what strategies work, and we must reinforce those strategies: hard-hitting media campaigns, higher cigarette prices, access to cessation assistance, statewide programs funded at levels recommended by the Centers for Disease Control and Prevention [CDC], and comprehensive smoke-free indoor protection for the entire country. Because smoking rates have been cut by more than half since 1964, there’s a misperception that the smoking problem has somehow been solved. Nothing could be further from the truth. Tobacco use remains a public health catastrophe. My message on this 50th anniversary is that we must end the tobacco epidemic as soon as possible, and it shouldn’t take another 50 years. One proposed strategy is raising the age to buy tobacco products from 18 to 21 nationwide. Is that feasible? That’s an innovative strategy that needs careful evaluation. We know that young people often get their cigarettes from friends who are 18 or older. Raising the legal age to buy tobacco products to 21 could potentially greatly limit youth access.
Needham, Massachusetts, was the first town in the country to do this. A recent report in The New England Journal of Medicine noted that rates of youth smoking declined three times faster there than in surrounding communities as a result [N Engl J Med 2014;370:295–7]. New York City, seven towns in Massachusetts, and a county in Hawaii now have a similar policy; three states are considering one. What’s your perspective on raising cigarette taxes?
U.S. Department of Health and Human Services
NEWS IN DEPTH
“There’s a misperception that the smoking problem has somehow been solved,” says Howard Koh. “Nothing could be further from the truth.”
Cigarette taxes can be raised at the city and state level, not just the federal level. In the last decade, just about every state has raised its cigarette tax, regardless of the governor’s political affi liation. At the federal level, there was a 62¢ perpack increase in 2009 to fund children’s health insurance. In the president’s fiscal year 2014 budget, there was a proposed per-pack increase of 94¢ to fund early childhood education. This latest proposal wasn’t adopted, but this is one way to raise revenue and decrease consumption. When you increase the price by 10%, you decrease consumption by 4%, a phenomenon well documented by health economists. Do states have to spend a set amount on smoking prevention or cessation efforts? No. It’s up to the legislature of each state to decide how much to spend on tobacco control efforts. There is a CDC-recommended level; unfortunately, almost no states meet that level. Billions of dollars are going to the states from the tobacco industry thanks to the Master Settlement Agreement in 1998, but less than 3% of those funds and other tobacco tax revenues are used for tobacco control. We need to change that dynamic and emphasize funding prevention to save lives. How is the government encouraging smoking cessation? The Affordable Care Act expands access to smoking cessation and counseling services, and removes cost as a barrier for people who need those services. Health reform created a prevention fund that is channeling millions of dollars to the CDC for community grants to address issues like tobacco control. In the fall of 2012, we launched a tobacco-free college campus initiative with the goal of making all 5,000 college campuses across the country smoke- and tobacco-free; about 1,200 have signed on. This sends the message that the social norm should be one that is tobaccofree, not one that glamorizes tobacco dependence. We’ve had a tremendous commitment to hard-hitting mass-media campaigns, and the U.S. Food and Drug Administration just launched the “Real Cost,” a new mass-media campaign to prevent tobacco addiction among our youth. Go to www. therealcost.gov to learn more. ■
This article is part of the AACR’s commemoration of the 50th anniversary of the Surgeon General’s report Smoking and Health. Please visit http://www.aacr.org for information on additional AACR publications and activities related to the recognition of this milestone.
MARCH 2014CANCER DISCOVERY | 265
Downloaded from cancerdiscovery.aacrjournals.org on March 9, 2015. © 2014 American Association for Cancer Research.
Published OnlineFirst February 20, 2014; DOI: 10.1158/2159-8290.CD-ND2014-002
Q&A: Howard Koh on Smoking Cessation and Policy Cancer Discovery 2014;4:265. Published OnlineFirst February 20, 2014.
Updated version
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Downloaded from cancerdiscovery.aacrjournals.org on March 9, 2015. © 2014 American Association for Cancer Research.
Q&A: Howard Koh on Smoking Cessation and Policy Comprehensive tobacco-control efforts save lives and help young people avoid nicotine addiction As a young physician in Boston, MA, Howard Koh, MD, MPH, witnessed many patients with smoking-related conditions suffer and die. “I saw the devastation tobacco addiction imposes on people’s health,” he recalls. “It really motivated me to move toward prevention and public health policy.” Koh soon went from primarily caring for patients at Boston City Hospital and Massachusetts General Hospital to becoming the commissioner of public health in Massachusetts in 1997. In 2009, he became the assistant secretary for health in the U.S. Department of Health and Human Services, overseeing 12 public health offices, including the Office of the Surgeon General. To mark the 50th anniversary of the Surgeon General’s first report on smoking and health and to promote the release of this year’s report, Koh spoke with Cancer Discovery’s Suzanne Rose about the continued urgency of tobacco-control efforts. Why didn’t being diagnosed with cancer motivate your patients to quit? Addiction is so powerful. I clearly remember a patient who had surgery for lung cancer who was told that he might have been cured. In a follow-up visit with me—I was a young resident at the time—he told me he resumed smoking. I remember being astonished, but that’s evidence of how powerful and overwhelming this addiction can be. Is eliminating smoking an achievable goal, given that smoking rates have plateaued around 18%? We must make it achievable, and we have no other choice if we’re committed to a healthier future. We know what strategies work, and we must reinforce those strategies: hard-hitting media campaigns, higher cigarette prices, access to cessation assistance, statewide programs funded at levels recommended by the Centers for Disease Control and Prevention [CDC], and comprehensive smoke-free indoor protection for the entire country. Because smoking rates have been cut by more than half since 1964, there’s a misperception that the smoking problem has somehow been solved. Nothing could be further from the truth. Tobacco use remains a public health catastrophe. My message on this 50th anniversary is that we must end the tobacco epidemic as soon as possible, and it shouldn’t take another 50 years. One proposed strategy is raising the age to buy tobacco products from 18 to 21 nationwide. Is that feasible? That’s an innovative strategy that needs careful evaluation. We know that young people often get their cigarettes from friends who are 18 or older. Raising the legal age to buy tobacco products to 21 could potentially greatly limit youth access.
Needham, Massachusetts, was the first town in the country to do this. A recent report in The New England Journal of Medicine noted that rates of youth smoking declined three times faster there than in surrounding communities as a result [N Engl J Med 2014;370:295–7]. New York City, seven towns in Massachusetts, and a county in Hawaii now have a similar policy; three states are considering one. What’s your perspective on raising cigarette taxes?
U.S. Department of Health and Human Services
NEWS IN DEPTH
“There’s a misperception that the smoking problem has somehow been solved,” says Howard Koh. “Nothing could be further from the truth.”
Cigarette taxes can be raised at the city and state level, not just the federal level. In the last decade, just about every state has raised its cigarette tax, regardless of the governor’s political affi liation. At the federal level, there was a 62¢ perpack increase in 2009 to fund children’s health insurance. In the president’s fiscal year 2014 budget, there was a proposed per-pack increase of 94¢ to fund early childhood education. This latest proposal wasn’t adopted, but this is one way to raise revenue and decrease consumption. When you increase the price by 10%, you decrease consumption by 4%, a phenomenon well documented by health economists. Do states have to spend a set amount on smoking prevention or cessation efforts? No. It’s up to the legislature of each state to decide how much to spend on tobacco control efforts. There is a CDC-recommended level; unfortunately, almost no states meet that level. Billions of dollars are going to the states from the tobacco industry thanks to the Master Settlement Agreement in 1998, but less than 3% of those funds and other tobacco tax revenues are used for tobacco control. We need to change that dynamic and emphasize funding prevention to save lives. How is the government encouraging smoking cessation? The Affordable Care Act expands access to smoking cessation and counseling services, and removes cost as a barrier for people who need those services. Health reform created a prevention fund that is channeling millions of dollars to the CDC for community grants to address issues like tobacco control. In the fall of 2012, we launched a tobacco-free college campus initiative with the goal of making all 5,000 college campuses across the country smoke- and tobacco-free; about 1,200 have signed on. This sends the message that the social norm should be one that is tobaccofree, not one that glamorizes tobacco dependence. We’ve had a tremendous commitment to hard-hitting mass-media campaigns, and the U.S. Food and Drug Administration just launched the “Real Cost,” a new mass-media campaign to prevent tobacco addiction among our youth. Go to www. therealcost.gov to learn more. ■
This article is part of the AACR’s commemoration of the 50th anniversary of the Surgeon General’s report Smoking and Health. Please visit http://www.aacr.org for information on additional AACR publications and activities related to the recognition of this milestone.
MARCH 2014CANCER DISCOVERY | 265
Downloaded from cancerdiscovery.aacrjournals.org on March 9, 2015. © 2014 American Association for Cancer Research.
Published OnlineFirst February 20, 2014; DOI: 10.1158/2159-8290.CD-ND2014-002
Q&A: Howard Koh on Smoking Cessation and Policy Cancer Discovery 2014;4:265. Published OnlineFirst February 20, 2014.
Updated version
E-mail alerts Reprints and Subscriptions Permissions
Access the most recent version of this article at: doi:10.1158/2159-8290.CD-ND2014-002
Sign up to receive free email-alerts related to this article or journal. To order reprints of this article or to subscribe to the journal, contact the AACR Publications Department at [email protected]. To request permission to re-use all or part of this article, contact the AACR Publications Department at [email protected].
Downloaded from cancerdiscovery.aacrjournals.org on March 9, 2015. © 2014 American Association for Cancer Research.
