Dr. Schroeder's Final Director’s Corner

When we started the Smoking Cessation Leadership Center in Jan. 2003, I never thought I would stay so long as its director. This is my final Director’s Corner column, because in January, 2022, the talented tobacco control expert Pamela Ling, MD, Professor of Medicine at UCSF and head of its Center for Tobacco Control Research and Education, will become Acting Director of the SCLC.

Over the past 19 years the SCLC has worked with a variety of partners, including professional clinical societies, federal and state governments, voluntary organizations, and corporations to advance our twin goals of increasing the rate at which people who smoke try to quit and improving their odds of success. When we started in 2003, there were about 45 million people who smoked, accounting for about 21.6 percent of the adult population. The most recent estimates (2019) of those numbers are 34 million people who smoke (despite a population growth of 44 million in the interval) accounting for 14 percent of the population. In addition, fewer people who smoke do so on a daily basis, thereby further reducing the risk from death and disease. Assuming that half the people who smoke die from tobacco use, that decline of 11 million smokers over the past two decades means that 5.5 million premature deaths have been prevented. While this progress is cause for celebration, it is also a reminder of how much still remains to be done. In this column, I will not summarize the accomplishments of the SCLC. But those interested in reviewing that work can read two articles: Helping Smokers Quit: New Partners and New Strategies from the UCSF Smoking Cessation Leadership Center (JPD 2018;50:3-11); Helping Smokers Quit: The Smoking Cessation Leadership Center Engages Behavioral Health by Challenging Old Myths and Traditions (JPD 2018;50:151-158). What I will do is offer some observations and thank those who have been involved in our efforts.

Perhaps the most striking aspect of the tobacco control landscape today is the gap between smoking’s enormous public health toll and the lack of resultant urgency and political will. Why is that so? It stems, in my view, from a combination of factors. Despite the fact that still about 500,000 Americans die each and every year from smoking, the problem has been with us for so long that it has become almost invisible, a sort of tobacco fatigue. Another reason why smoking seems invisible is that—in contrast to several decades ago--it is now concentrated among the less fortunate and more vulnerable. Today’s smokers are less educated, more likely to be low-income, to have mental illnesses and/or substance disorders, to be incarcerated, or homeless. Factors such as race, LGBTQ status, geography, and childhood trauma also influence the risk of starting to smoke and the ability to quit. The marginalized status of people who smoke means that in the competition for action and resources, they have relatively little power or influence. Compounding that political impotence is the stigma attached to smoking, where there is often the assumption that by making a bad choice someone who smokes deserves less support and empathy. Yet we know that virtually all adult smokers began in their teens, when judgment is notoriously faulty, and that nicotine is one of the most addictive substances. Another reason for relative inaction, in addition to tobacco fatigue and political invisibility, is that acute crises tend to overwhelm chronic issues in the news cycles and the political arena. Most recently we have seen this with the rise in adolescent vaping, the EVALI epidemic, and—of course— COVID-19. When a new threat appears, it stimulates concern and action in a way that lingering problems do not. Finally, at a time when large segments of our population are suspicious of government, there is less support for national, state, and local governmental efforts to address problems such as smoking. Thus, the public health agencies tasked with reducing tobacco use face an uphill battle.

Does this mean that further efforts at reducing tobacco use are futile? Not at all! There is now widespread public understanding about the harms from smoking and exposure to second-hand smoke, as well as the role of the tobacco industry in causing those harms. Despite industry efforts opposing tobacco control, those public attitudes translate into broad support for the well-proven tobacco control strategies of taxing cigarettes, creating clean indoor air spaces, counter-marketing, and supporting smoking cessation programs such as quitlines. Some parts of the country have made great progress with taxation and clean indoor air laws, while others lag behind, thus highlighting the opportunity for aggressive regional strategies. Regarding tobacco cessation, while clinicians are good at identifying which of their patients smoke and advising them to quit, they do poorly in actually implementing smoking cessation plans. Surprisingly, those specialties that see patients most damaged by smoking—cardiology, oncology, and pulmonary—tend to perform the poorest. Yet, improvement is possible. Our Center has been involved in a culture change in behavioral health where attitudes and behaviors of clinicians actually did evolve, proving that increased attention to smoking cessation can occur. The trick is to find champions within a specialty who can advocate that clinicians are obligated to take some action—either directly or by referral—to help smokers quit and to establish and promote specialty expectations of responsive smoking cessation stewardship. I think it is possible to continue making progress, and in fact over the past decade there has been a steady—though not dramatic--increase in smoking cessation. How to accelerate that trend will continue to be the job of the SCLC and its partners. Whether new technologies--such as the potential availability of the smoking cessation drug cytisine or the use of vaping--can help is yet to be determined. In the absence of dramatic breakthroughs, however, progress will depend upon sustained, relentless efforts on as many fronts as possible.

Finally, I want to close with words of thanks. We have been fortunate in attracting generous sponsors: The Robert Wood Johnson Foundation; The American Legacy Foundation (now Truth Initiative); the Substance Abuse and Mental Health Services Administration (SAMHSA); the California Department of Health; and the American Cancer Society. At each of these institutions we have been blessed to work with dedicated officers who understood and supported our mission. In addition to our funders, the opportunity to work with so many partners has enriched our lives. It has been gratifying to support dedicated health professionals and public health workers who have served their lives to improve the health of others. At a time when it is easy to be cynical, these people have inspired us and enriched our lives. They help to make our country a better place.

Last, but not least, I want to salute the SCLC staff, current and past. In order of seniority at SCLC, our current high-performing staff include: Deputy Director Catherine Saucedo (18 years); Christine Cheng (14 years); Jennifer Matekuare (10 years); Brian Clark (10 years); Jessica Safier (4 years); Maria Pamatmat (3 years); Aria Yow (2 years); and Anita Browning (1 year). It has been so wonderful working with this talented group, who are mission-driven, customer-friendly, and highly professional! Former SCLC staff, who embodied similar qualities include: founding deputy director Connie Revell, Jon Jovi Bodestyne, Brian Eule, Brent Hutchinson, Kristen Kekich, Elissa Keszler, Jennifer Lucero, Lucia Marques, Margaret Meriwether, Reason Reyes, William Rypcinski, Roxanna Said, Jeff Sierra, and Tanjira Wilawanchit.

So, I say goodbye with a heart full of gratitude for the privilege of working on such an important topic with such amazing collaborators. Thanks to all of you, and keep up your efforts to reduce the toll from the most important public health hazard.