Feb. 26, 2001 -- Michelle Globerson started smoking when she was just 15 years old. Now 45, she's quit smoking four times, each time cold turkey, but never for good.
Recently, she's been seeing more and more public service announcements on TV, including one spot that calls smoking "puking (and) disgusting." She agrees. But she's still not ready to give up her pack-a-day habit.
"I know it's wrong -- I'm hurting myself," says Globerson, a supervisor for a pool building company in Mesa, Ariz. "Something is going to make me want to quit. I just don't know what it will be."
At first glance, the nationwide numbers seem to favor females. Just 20.9% of adult women smoke, compared with 24.2% of men, according to the latest CDC data. But the data mask a remarkable drop of nearly 47% in male smoking rates between 1965 and 1995, compared to a more modest decline of 35% for women.
More worrisome is the increase in lung cancer cases. Among women, they've more than doubled since 1973, according to the American Lung Association. Lung cancer mortality fell by 3.2% for men between 1992 and 1997, but among women the rate was essentially unchanged.
There's also concern about teens. While youth smoking rates appear to have steadied after years of increases, an important new study raises serious questions about the effectiveness of school-based programs, a mainstay of teen education efforts.
The study, by researchers at the Fred Hutchinson Cancer Research Center in Seattle, appeared in the December 2000 issue of the Journal of the National Cancer Institute. It surveyed smoking rates among 8,400 students in Washington state, half of whom had been exposed to an intensive, grade 3-to-12 program.
The program was based on the popular "social influences" approach, which teaches kids how to resist TV ads and peer pressure through media literacy classes, role-playing, and other behavioral exercises.
The results were surprising: Researchers found "no significant difference" in tobacco use between students who had gone through the program and those who hadn't; the smoking rate among 12th grade girls who took antismoking classes, for example, was 24.4%, compared with 24.7% for those who didn't.
"It was disappointing, because the social influences approach has been such an attractive one," says Arthur V. Peterson Jr., PhD, a Hutchinson researcher and professor of biostatistics at the University of Washington. "We had high hopes."
A leading cause of cancer deaths
Lung cancer is America's No. 1 cancer killer, claiming more lives than any other type. The CDC estimates that 164,100 new cases were diagnosed last year; each year, more than 156,900 men and women die from lung cancer, representing nearly 28% of all cancer deaths.
Perhaps the only good thing about lung cancer is that the usual cause is easy to identify: cigarette smoking, which causes up to 90% of all such cases, according to the National Cancer Institute (NCI).
Increasingly, states such as Arizona, California, Oregon, Massachusetts, and Florida have turned to public service ads, clean air laws, and taxes on cigarettes, in their bids to drive down smoking and cancer rates. Last year saw the debut of more statewide tobacco control laws than ever before, according to the American Lung Association, including 113 new laws in 43 states.
Controversial and costly as they may be, evidence indicates that tobacco control programs work, particularly for women. California, which launched its program in 1988, saw smoking drop from 22.4% to 18% between 1988 and 1997, according to a December report by the CDC. Lung cancer cases plunged by 14%, compared to a decline of 2.7% in a sample that included five states and three cities. Among women, the impact was even more striking: A 4.8% drop in lung cancer incidence within California, compared with an increase of 13.2% elsewhere.
Critics point out that smoking rates were already on their way down by the time California took aim at tobacco. "But the rate of decline has accelerated -- it's two to three times as rapid as the declines around the country," says Terry Pechacek, PhD, associate director for science in the CDC's Office of Smoking and Health.
And while it will take 10 to 15 years to see the full effect of lower smoking on lung cancer, heart disease is another story: "More than half [of the risk] is gone within one or two years of quitting," Pechacek says. Heart disease is the leading cause of death among women; lung cancer is second.
TV, taxes and treatment
Experts agree that what makes the California model work is that it's comprehensive and doesn't rely on any one approach, a lesson hammered home in the Hutchinson study.
Creative as it was -- 10th graders even re-enacted testimony given by tobacco executives before Congress, just to get a sense of the issues -- the Hutchinson program provided kids with a total of just 46.75 hours of instruction over nine years of schooling. Compare that, Peterson says, to the estimated $7 billion spent each year by tobacco companies on advertising and marketing.
"It's like a raft on a raging sea," Peterson says, of school-based education. "From the results of this study, we would conclude that this raft has no chance. So more and different things must be done."
What should they be? Increasingly, states are turning to a triad of TV ads, taxes, and treatment.
In California, Arizona, Florida, and Massachusetts, aggressive TV and print campaigns portray smoking not only as unhealthy but uncool. In Florida, TV spots crafted with the help of teens hit hard at tobacco companies, with ads that featured images of corrupt executives and corpses in body bags. Edgy and sometimes gritty, the ad campaign, called "Truth," is credited with a 40% reduction in teen smoking between 1998 and 2000.
Taxes on tobacco are another strategy: Over the past decade, all 50 states have adopted them, from a high of $1 per pack in Alaska to 35 cents in Nevada. Some suggest they could be raised even more.
Youth smokers "are somewhere between two and four times as responsive" to price hikes as adults, says David Levy, PhD, senior scientist at the Pacific Institute for Research and Evaluation in Rockville, Md., and a professor of economics at the University of Baltimore. African-American adolescents are particularly sensitive to price swings, he says.
That fact alone could be a powerful weapon: A study in the December 2000 issue of the Journal of the National Medical Association reported that black teenagers who smoke are more likely to develop lung cancer and other long-term problems, even though black teens as a group smoke less than their white peers. Researchers believe racial differences in the way nicotine is metabolized could make tobacco more lethal for blacks.
"You could say it's regressive," says Levy, of taxes that disproportionately affect black youth. "But death is regressive."
Improving treatment options is the third approach. For many smokers, the worst thing about quitting is that it's expensive; the CDC estimates that it can cost as much as $400 for a three-month "quit attempt" using the nicotine patch. Unfortunately, insurance rarely pays.
Some states may force the issue. In Maryland, a coalition of state officials and advocacy groups intends to introduce what would be the nation's first law requiring private insurers to pay for prescription antismoking drugs. "This is a hard sell, believe me," says Joan Stine, director of Maryland's Office of Health Promotion, adding that an earlier version of the bill was torpedoed last year by the state's HMOs.
"In the long run, you save money on these folks if they stop smoking," Stine says. "But [HMOs] don't operate in the long run."
Not quitting, but still watching
One reason for the focus on smoking is that unlike breast or prostate cancer, there is no widely available, effective screening test for early stage lung cancer.
Currently, the NCI is in the midst of a yearlong study of 3,000 patients, to determine whether low-dose CT (computed tomography) scans are safer and more effective than chest X-rays. Indeed, a review article in the Nov. 30, 2000, issue of The New England Journal of Medicine cautions against "compromise or shortcuts in the rigorous scientific process required to determine whether this practice is justified," finding from their review of literature to date, "there does not appear to be a dramatic impact on survival." They further note: "Too often, presumed solutions prematurely become standard medical care before the appropriate studies have been completed."
So prevention remains key. For Globerson, that probably means more TV ads. Some of them make her flinch, but she forces herself to watch.
"Because it does make me think," she says. "Maybe the next time I see the commercial, that will be the time I stop."
Beatrice Motamedi is a health and medical writer based in Oakland, Calif., who has written for Hippocrates, Newsweek, Wired, and many other national publications.