9UNP0187SD_Michael_Fiore_WordPress

- Welcome everybody to Wednesday Nite at the Lab. I'm Tom Zinnen. I work here at the Biotechnology Center, and for UW-Extension Cooperative Extension. And on behalf of the Wisconsin Alumni Association, welcome to Wednesday Nite at the Lab. We do this every Wednesday night, 50 times a years. Delighted to have you all here tonight. Tonight is kind of special for me, because the presenter is also a person who used to be my doctor. I'm trying to figure a funny way to say he gave me my 50-year, uh, review. And then he left the practice. 
(laughter)

 So I don't know if that's cause and effect or not. Michael Fiore is a Professor of Medicine here at UW-Madison. And he founded, and has served as the director of the University of Wisconsin Center for Tobacco Research and Intervention since it was established in 1992. He graduated from Boden College in Maine, then completed medical school at Northwestern University in Chicago, and his internal medicine training at Boston City Hospital. His post-graduate education included a Masters of Public Health from Harvard University. He has received additional training as an Epidemic Intelligence Service Officer in the United States Center for Disease Control, where he also completed a preventive medicine residency program at the United States Office on Smoking and Health before coming to the University of Wisconsin-Madison. My personal interest in this topic, besides the fact that Dr. Fiore used to be my doctor, is my mom's dad died of lung cancer after smoking for almost all his life. It was a very impressionable thing to watch your grandpa go through that rather unpleasant way to go, and die. So I think that anything we can do. 

It's also the 401st year since the founding of Jamestown. And it's ironic that this country was built so much and so early in its history on the tobacco trade. It's a pervasive part of our history. I think the kinds of things that we'll hear today are not only the physiology of this, but also the public policy, and a wide range of interesting topics. Please join me in welcoming Dr. Fiore to Wednesday Nite at the Lab. 
(applause)

- About 50 years ago, in the mid-1950s, America confronted a public health challenge that endangered the health of millions, and caused fear of such magnitude that as a nation, the United States mobilized to overcome this epidemic. In the mid-1950s, in an unprecedented and rapid medical response, the polio vaccine was developed. 

And millions were vaccinated against this disease that had crippled a generation. This extraordinary achievement, truly the moving of a mountain, stands as an historic pinnacle among public health success stories. Little did the world realize that at the same moment, a new and even greater challenge loomed. An epidemic of tobacco use in the United States that was rapidly spreading through the vector of tobacco industry marketing and profits. As we moved the mountain of polio, we were confronting a more dogged challenge. Tobacco use in America had become normative. And almost half of all Americans smoked. Since the time that this epidemic peaked in the 1950s, we have lost more than 20 million dead in the United States, making this the most devastating public health challenge of our time. Tobacco continues to be deadly in an unparalleled way. I'm here today to make the case that as with polio in the 1950s, we have begun to move the mountain of addiction, illness and death that results from tobacco use. 

Over the next few moments, what I'd like to do is describe how I believe, as with Polio, we can move the mountain and make tobacco use history. Well, good evening everyone. Thank you so much for inviting me to join you for Wednesday Nite at the Lab. Tom asked me to do this, I think now almost two years ago, when I still was his doctor. And we had a long relationship. And that meant a lot that he asked me and invited me to do this. And I'm really honored to be here with you tonight. What I'd like to do is to give you a picture of the landscape of tobacco use in America, and focus in on what I believe are some of the specific points where we can make a difference, as we move to move the mountain of tobacco dependence in our society. In the spirit of disclosure, I'd like to let you know at the beginning of my lecture that among the work we do at the UW Center for Tobacco Research and Intervention, some of it is partially funded by research from the pharmaceutical industry. And I sit in a name chair made possible by a grant to the university in 1998 by Glaxo, a pharmaceutical company. 

All right. Here's the first slide that I'd like to share with you. And it really is a success story. It is letting us know that since, the dates are missing here, but this represents 1964. Tobacco use rates were over 40%, about 42% of adults. Just last week, the newest data were released representing adult tobacco use in 2007. And it had fallen to less than 20%. In fact, the rate had fallen to 19.7%, an incredible decline. A decline of more than half. But it still represents about 45 million Americans who smoke. 

And to put this in some context. If we are unsuccessful in assisting them in successfully quitting, half of them, more than 20 million Americans are going to die prematurely by a disease directly caused by their tobacco use. As a physician, there are few diseases that I confront that kill prematurely half of the patients who have that disease. And we now think about tobacco dependence as a chronic disease. Not only does it kill people prematurely, but it on average robs them of ten to 14 years of life. So that's how much it takes, on average, off the life of an individual who suffers from a tobacco caused disease. This next slide shows the statistics about the toll of tobacco dependence. In fact, it's almost half a million Americans who are killed each year, killed prematurely from diseases like lung cancer, that Tom's grandfather had, chronic obstructive pulmonary disease, that many of us know as emphysema, heart attack, secondhand smoke, other cancers. Literally the diseases that fill up our clinics and hospitals are caused, or exacerbated by tobacco use. I'm always concerned when I show statistics like this that we become inured to the numbers, that there are so many people that are struck down by tobacco use that it almost doesn't mean anything anymore, because it's statistic after statistic. 

But I want to make the point passionately here tonight that these represent individuals. Fathers, aunts, children, grandparents, one person at a time, one family at a time, that are struck down by a preventable cause of illness. And that is tobacco dependence. I'm going to focus in on three levers, three levers where I believe we can make a real difference in reducing tobacco use. I'm going to be talking about treating smokers already addicted to tobacco. I'm going to be talking about protecting our children from becoming addicted to this drug. And finally, I'm going to talk about the incredible power of policy changes to drive people to think about quitting and preventing kids from starting to smoke. Let's start with treatment. And I'm going to only touch upon treatment, because I know I'm not speaking to a group of physicians who need to know the ins and outs of how to use each and every treatment. But the fundamental suggestion that we have recognized is that we have to create universal access to evidenced based treatments to tobacco users. 

Isn't it a paradox that we have clinics that address the outcomes of smoking. They treat the emphysema. They treat the cancer. They treat the heart attacks. But so infrequently, do they treat the cause of those illnesses, which is tobacco dependence. Well, what do we know about smokers and their interest in quitting? We know that most smokers today tell us they want to quit. You know, I see smokers literally every day, or talk to them on the phone. And there are very few that I meet who say, "I smoke and I love it. " Instead, they say, "I smoke and I'm addicted. 

It's costing my family money. It's hurting my kids. It makes me smell bad. I'm embarrassed. I feel like a failure. " These are people addicted to a drug who so desperately want to quit. And that represents, in fact, one-third of them, trying to quit every year. The problem is, most of them try to quit on their own, cold turkey, without the benefit of the counseling we know makes a difference, or the medicines we know make a difference. And very few of them succeed, less than five percent. If we channel those individuals into using the treatments, the counseling and the medicine we know make a difference, we can jack up those success rates from 5% to 20%, 30% or even 40%. 

And that's what we're trying to do by re-engineering clinics across America, so that they more consistently address tobacco use. There's a little bit of a time delay. 
(inaudible)

 I'm going to come to that, ma'am, thanks for the question. Here's an example of the overview of what treatments are effective. And these were published by the United States Public Health Service in 1996, 2000, and most recently in 2008, just a month ago. We at the University of Wisconsin lead the federal effort to write these. And it is a science based document. It reviewed more than 8,000 articles. All the recommendations are based on statistical analysis of those articles. 

Here's what it found. Counseling is very helpful to people who want to quit. And we give very specific counseling advice that is based on evidence. We know that a lot of people who try to quit, say they want to cut down, or that they'll do it at some point in the future. We know that we need to nail individuals down to a specific quit date, ideally in the next two weeks. We need to review what they've tried in the past and build on that. We need them to identify upcoming challenges to the quit attempt. We need them to deal with the fact that if they're married or living with another smoker, it's going to be very hard to quit. Try to quit as a family. And finally, alcohol is such a factor that leads people to relapse. 

They need to address their alcohol. I'm going to talk a little bit later about 1-800-QUIT-NOW, which is the national quit line. It's free, telephone based counseling to help you quit. So here's the first part of treatment, that is counseling. The second part is medicine. And the medicines are developed and approved by the FDA. These are the seven currently recommended medicines. Two that are non-nicotine, Burproprion and Varenicline, and five that are nicotine. We also know that in addition to counseling and medicines, as I mentioned earlier, we need to re-engineer the clinical encounter. About 80% of smokers visit a primary care doctor every year. 

If we can somehow seize that moment, and identify that individual is a smoker, and offer them the evidence based treatments we know make a difference, we can dramatically increase the likelihood that more Americans will quit smoking We also need to provide insurance coverage. We know that if you put barriers in the way to this, if you say your doctor can't provide counseling to you because he will not be reimbursed, or the medicines aren't part of your medication plan, you're much less likely to make a quit attempt. One really simple way to re-engineer the healthcare encounter is to make this a universal part of every clinic visit. So we've actually advocated, and this has been adopted nationally, that the vital signs be expanded. You know when you go to the doctor and you get your blood pressure and your pulse checked? Your temperature. That's typical vital signs. We have now asked that you add a simple question, are you a current, former or never smoker. Because what that then leads to is the physician, when I pick up the chart, if I see the vital sign indicates that you're a smoker, I'm much more likely to talk to you about quitting, and discussing effective treatments with you. So we talked about treatment. 

I'm going to switch gears for just a moment and talk about children. And there's a lot of information out there of protecting kids from starting to smoke. I've never met a single person, smoker or non-smoker alike, who wants their own kids to become smokers. And we know certain things make a difference. Here's what doesn't help, as much as we'd love it to. School-based programs aren't terribly effective in preventing kids from starting to smoke. You may have seen the tobacco industry advertisements, where they say smoking is only for adults, kids shouldn't do it. And of course, that actually serves to prompt kids to think about using tobacco. What does make a difference is big picture policy changes. And I'll be talking about a couple of those in a few moments, things like increasing tax rates. 

And preventing kids from buying at the local 7/11. And parents quitting themselves is a really powerful level. So policies make a difference. And let's talk a little bit more about policies. Because three of them dramatically change the way, and the percentage of adults that smoke. The first is price. Even though cigarettes are addictive, and they're very addictive, we know that there's something called price elasticity. That is, you increase the price, you decrease the demand, even for addictive substances. Now in Wisconsin, just a few months ago on January 1, the price of cigarettes went up a dollar a pack, because of a dollar per pack excise tax increase. So think about that. 

The tax used to be 77 cents. Overnight, it went up to $1.77 a pack, resulting in cigarettes that cost now about $5 a pack. What we found is that people who weren't even thinking about quitting, because of that, took some dramatic steps to try to quit. I'm going to share that information with you in a few moments. The second big policy change we know makes a difference is making indoor environments smoke-free. Here's a really unusual thing. Most states in America now are smoke free. About 60% of Americans live in states that are entirely smoke free. And by smoke free, I mean every place that people work indoors has to be smoke free. And that includes factories. 

It includes office buildings. It includes restaurants. It includes taverns. Sixty percent of Americans live in states like that. Minnesota is smoke free. Illinois is smoke free. But Wisconsin is one of the few states that is still not smoke free. And it's because of, in my view, unfortunately a lack of political will to take this important step to make every indoor environment smoke free. And a lot of people bring up the issue of free choice, particularly for businesses. I think that's an important question to address. 

But this is not about free choice. It's really about health and safety. And I often use this analogy. If I owned a business and I said I wanted to sprinkle a little asbestos dust around, because it was my choice to do that, and put both my employees and my patrons at risk. Of course you'd say you can't do that, asbestos causes lung cancer. Well, secondhand smoke is much more dangerous, in terms of a risk of lung cancer. And for that reason, I think it's really time for Wisconsin to join the rest of the nation and become a smoke free state. In fact, now about 60% of Americans live in states that are smoke free. And as I said earlier, it includes Illinois and Minnesota. So again, the question, when will Wisconsin join the rest of America and become smoke free. 

I want to talk a little bit about some of the economic consequences of smoking. Because we often focus on the critically important health issues, and not, sometimes, on the economic issues that increasingly drive employers to encourage their employees to successfully quit. Here's a statistic that I find very powerful. A smoker, compared to a non-smoker, is 8% less productive. And why is that? Well, she spends about 20-30 minutes each 8-hour shift dealing with her smoking habit. She often has extra illnesses that require more healthcare expenditures. So think about we can now offer a business owner. That business owner can increase their employees' productivity by 8%, by helping their employees to quit. And increasingly, employers are doing that, particularly since smokers cost healthcare systems so much more than non-smokers, on average, about $1600 extra in healthcare costs every year. 

I want to talk about a really incredibly powerful thing that happened in Wisconsin just a couple months ago. I mentioned already that on January 1, there was a dollar per pack cigarette excise tax increase. On that same day, because we felt we can't just raise the tax without helping smokers who want to quit to do that better, the Wisconsin Tobacco Quit Line, which is a free counseling program to help you to quit. And I'll give you the number to call in a few moments if you have somebody you want to recommend it to. In the past, it used to just provide coaching, counseling, free advice, working with you every step of the way, calling you back three or four times. And it was effective. But we knew it would be even more effective if it could provide free medicine in the way of over-the-counter nicotine medicine patches or gum or lozenges. So we convinced the health department that in addition to having that tax increase, you've got to provide, when people call the Quit Line, free medicine. So everybody now gets two weeks free supply of medicine mailed to their home. It's over-the-counter medicine. 

Of course, New Year's resolutions were happening on January 1. And finally, we went all over the state and publicized this. New ways for smokers to quit. Well, what happened? In a typical year, the Wisconsin Tobacco Quit Line, which again, is that service that provides free telephone coaching. In a typical year, we get 8,000 smokers calling for help. In the first three months of this year, we've had more than 25,000 smokers call. And so many of them say they were moved by both the tax increase and the increased availability of services through the Wisconsin Tobacco Quit Line. Here is the number for the Wisconsin Tobacco Quit Line. It's 1-800-QUIT-NOW. 

Anyone, anywhere in Wisconsin can call that and get free counseling, coaching services over the phone. They take about a half-hour to find out about you as a smoker. They help you develop a quit plan. They mail you two free weeks of medicine. And they call you back three or four times over the next couple weeks. Here's one other really cool thing that they do. Any time that you're having a rough moment, you can call up and say talk me down, I'm really having a strong urge to have a smoke. And so many of them get benefit, every day that they're going through this process. It's open 7am to 11pm, seven days a week. 1-800-QUIT-NOW a free service to Wisconsin smokers who want to quit. 

I want to turn, for just a couple moments and emphasize some of the science that makes the case that secondhand smoke is so dangerous. We now know that there are 50 cancer causing agents in secondhand smoke. Fifty, that we know that it causes about 50,000 cardiovascular deaths and 5,000 lung cancer deaths. And many of these are in people who are exposed to it at the work site. I'm having a little lag time with this. Okay, here we go. I'll go back one. The recognition of secondhand smoke as a cause of lung cancer actually came back in the 1980s. Does anybody recognize this guy? C. 

Everett Koop, exactly. C. Everett Koop is my personal hero. In the 1980s, he really nailed the fact that smoking was so dangerous. He went out front, took personal risks to say we've got to do more to prevent kids from starting to smoke. We've got to do more to help adults who want to quit, to do that successfully. He's an extraordinary man. And just to let you know, he's now about to turn 92. He lives and works, still. He goes to work every day at Dartmouth College in Hanover, New Hampshire. 

He is who I first worked with in Washington back in the 1980s. And I see him every two months or so. I'll be going there in August, just to check in and work together as we've done now for the last 20+ years, on helping people to quit. What his report from 1986 said is that secondhand smoke is a cause of disease, including lung cancer, in healthy non-smokers. Children of smokers get sick. And it's not enough to have a smoking and a non-smoking section in a restaurant, work place or tavern, because the deadly components of tobacco smoke cross those areas, and everybody ends up getting exposed. So that report was from 1986. And it's been updated. We have a new report, which is 2006. And that is shown here, which was an update of all the science we know about how to help people quit. 

This report had six recommendations. And I'm not going to go through each of them. But suffice it to say that it even emphasized it more. Secondhand smoke is deadly in any amount. And that kids are damaged by secondhand smoke. And that there's no safe lower limit of secondhand smoke that's okay and safe. I want to end my talk by sharing with you some of the special programs that we've developed here on campus and across Wisconsin to help people to quit. The Center for Tobacco Research and Intervention that I've directed since 1992 has a really simple message. And that is, we want to help anybody who wants to quit, to do that successfully. And the way we do that is by doing research to develop new treatments and new counseling approaches. 

But we also spend a lot of time taking those treatments and putting them into practice, putting them into practice in clinics and health settings, in community centers across Wisconsin. This is one program we have at the hospital. And it's for the 7,000 or so UW Hospital employees, many of whom still smoke, particularly those who work in housekeeping and in the kitchen, the staff that parks cars, and some of the nurses even, that still smoke. So the hospital provides free treatment to anyone. We run that program for them. The program on the left here, is a program designed when kids go to see their pediatrician and they're having an illness caused by smoking, to empower the pediatrician to help the parents to quit. So that's a program directed at pediatricians to help parents. The middle program is one I'm really proud of. It's called Operation Quit Tobacco. We've done it now for about three years. 

It targets Wisconsin Veterans, Wisconsin active duty military personnel, Wisconsin National Guard. And what we do is provide free treatment to them. You just call up and say you're a Vet or a National Guard, or Reservist, Active Duty, and we'll provide free, extensive treatment through the Wisconsin Tobacco Quit Line. And the last program, to your right, is a program for people on Medicaid in the state. The tag line is in Spanish here, "Medicaid Covers It," which means that we now have treatment for Medicaid recipients to help them to quit. At the start of this presentation, I shared a slide that looked very much like this one. And in that slide, I said that the smoking rates back in the 1950s and '60s, which were about 43%, have fallen to in fact, less than 20% today. So it's taken about 50 years to half the smoking rates in America. And as I've thought about this, I sort of think about it as a hundred years war. A hundred years to eliminate tobacco dependence from our society. 

And as a physician who is fully engaged in this war, what I think about is how we can accelerate progress, so we don't take another 50 years, to truly eliminate tobacco use and prevent those half a million deaths that we see each year. The way we do it at the University of Wisconsin Center for Tobacco Research and Prevention is literally one smoker at a time. Individuals like Dawn Berger, Reggie Taylor, Michelle Naff, all of these people have come through our program, James Lortz, each of them with children and parents, and families, Connie Peterson, and Dan Schwoegler, all of them who came with one goal, and that is to remove deadly tobacco from their lives. I'm an optimist by nature. And I believe we are going to succeed in eliminating tobacco use from our society. It may take 50 years, but my hope is that in fact it will take much less than that. When we achieve that goal, when we truly eliminate tobacco dependence from our society, what I hope all of us can share, whether physician or citizen, whether it's a restaurant owner or a legislator, we can all share the public health success story that removed this deadly harm from our society. Smokers die one person at a time, not one statistic at a time, one person at a time. And we now have it in our power to truly eliminate that illness and death. And I believe we're going to do that and succeed. 

So with that, I'm going to end, and tell you thank you for allowing me to share with you a little bit about how we can move the mountain and remove tobacco dependence from our society. Thank you very much. And I'm very happy to answer questions. 
(applause)

 This is the Web site for our Center: www.ctri.wisc.edu and all the information I shared with you tonight is available on that Web site. 

- Are state and federal governments still subsidizing tobacco farmers? How is that justifiable? 

- The question is, does the state and federal government still subsidize tobacco farmers. Well, the way they did in the past, was a really complicated way that the federal government subsidized tobacco farmers. That's actually been phased out. 

There's very little to none, federal subsidies of tobacco products. Some states may, I can't answer that one definitively. But the federal government no longer does. And it was a crazy program that government is paying money to produce a product that's killing half the people who use it. It doesn't make sense. But here's an important thing to remember, not to defend it, but an important thing to remember. The tobacco farmers get a really small piece of the pie when you look at tobacco industry profits. It's the companies, Phillip Morris, and the others, RJ Reynolds, that are making billions and billions of dollars. And in fact, so much that they can spend $15 billion to advertise and promote their tobacco products to smokers across America. This is a very lucrative product that they sell. 

And that's why they're so invested in keeping people hooked. Ma'am? 

- In 1950, my sister was diagnosed with breast cancer. Four of us in the family all young adults, had smoked for 20 years. My older sister quit, the four of us quit. We all quit cold turkey, and it was not a problem. Talk about the genetics. 

- Well, that was a great story, ma'am. Four sisters who together quit. 

- Sisters and brothers. 

- Sisters and brothers motivated by one of your siblings developing breast cancer. So two points about that. We are increasingly studying the genetic predisposition to becoming addicted to tobacco. And what we're finding, and we're early in this work, and we're doing some of it here on this Madison campus, is that there is a predisposition to becoming addicted to tobacco. That certain individuals, about 40% of the population, carry a genetic code that puts them at increased risk of becoming dependent. But here is the key finding from that research. That's a fluid risk that if the person gets through age 18 and doesn't start smoking, their likelihood of starting smoking returns to a person who doesn't have that genetic predisposition. What that tells us is that if we did a better job of protecting kids from becoming addicted, we might be able to protect most people from becoming addicted. We know, for example, that half of smokers become addicted before the age of 16. And 90% of smokers become addicted before the age of 20. 

So kids are becoming addicted before it's even legal to buy cigarettes, which is age 18. We need to do a better job protecting our kids from becoming addicted. That was a great story, ma'am. 

- My father, an orthopedic surgeon, continued to smoke throughout his life, and died at 86. 

- And for those of you who didn't hear, her father, an orthopedic surgeon, lived to 86 and smoked probably every day of his life. And I can't tell you how many stories I've heard. And I just say, isn't it wonderful your father was blessed in that way. What we know, though, is that for most people, tobacco injures their health. Everybody has a story of somebody who lived an incredibly long and even healthy life smoking. But they're the exception. 

They're the exception. And I sometimes think about it as almost playing Russian Roulette. I kind of envision the pistol that you swing to move the bullets around, but instead of bullets, there are cigarettes in there. And those cigarettes are killing us. They're killing us. Not all of us, but they're killing us. Everybody doesn't get killed by tobacco smoke, but half of the people who use it, do. In the back. 

- How many chemicals are added to cigarettes, say 50 years ago and now? 

- The question is how many chemicals are added to cigarettes. 

Well, there's all sorts of laws that protect the tobacco industry. And one of them is that they don't have to disclose their ingredients. Isn't that unbelievable? The most deadly product sold in America does not have to disclose its ingredients. We do know about some of the chemicals that are added. And let me just start, though, by telling you, tobacco by itself is deadly. People love to say to me that they smoke Free Spirits, you know, the ones that are organic, Indian tobacco. That kills you, too. It may kill you a little less, but it still kills you. So, tobacco by itself is deadly. 

But you're right, that adding chemicals can make it worse. Here's one example. It was shown in an exposé that the tobacco industry was adding ammonia to cigarettes. The reason being the ammonia allowed us to absorb more of the nicotine and make the cigarettes more addictive. And while they never admitted to it, it seemed to be the only purpose of adding that ammonia, was to make tobacco more addictive. That's one of just a slough of chemicals that are added, most of which, I have know idea what they are. Sir? 

- On the slide that you showed with the hundred year time span, it looked like the slope for the first 25 years of data that you had was a little steeper, and then it leveled off for the last 25. So that really may not end up at 100 years. Is there a reason why there might be a change in that slope after 25 years? 

- You know, what wasn't on there was the data for 2007, when it went below 20, and that's going to help bring that down. The slope has been remarkably consistent. And I've done analyses of different pieces of that. But if you look at the broad span, there was a concern in the '90s that it was happening, but actually, it's been remarkably consistent, to the point of about half a percentage point decline per year, since the early 1960s, when it was about 43% or so. If you look at it, it's about a half a percentage point per year, remarkably consistent over the 50 years, about a 25 point drop. Ma'am? 

- Do you have any experience with the kind of person who vehemently denies smoking to the extent that some of us feel that consciously she's not lying, and yet there's all kinds of other evidence that she is smoking. There's like a profound disassociation denial. Have you had any experience with that kind of situation? 

- I've been doing this for 20 years. 

And the one thing I've learned more than anything else. So the question is, have I had any experience with people who say emphatically that they don't smoke, but there's other evidence that they do. And you even believe they believe they don't smoke, but there's evidence that they do. And I was about to say that one thing I've learned in the 20-plus years that I've been doing this, is that smokers are people first. They're individual and they're very different. I think one of the challenges to addressing tobacco dependence is we've been looking for sort of a one size fits all approach to smokers, and it just doesn't exist. People go from being not addicted at all to incredibly addicted. They go from smoking one cigarette a day or a week, to five packs in a day. They're remarkably diverse as a population of 45 million Americans. The second thing I've learned, quite powerfully, is to respect that it has to come from the smoker, that I can't shove down anybody's throat, and I don't think any of us can. 

If a person is just not ready to quit, it just ain't going to happen. We can encourage them. We can support them. We can motivate them. But it ultimately has to come from the person. Here's the good news. Most people want to quit. Some deny they do, and probably are. Some deny they even smoke. Where we see that clinically, is pregnant women who continue to smoke. 

That's the one group in society that really consistently misrepresents their smoking if they do use tobacco. Because as a society, we've gotten so intolerant of a pregnant woman smoking, because we know it damages the baby. So that's the only group that consistently, not always, but consistently misrepresents their tobacco use. There was a question from a lady in the back. 

- Most of our farm crops have dual purposes. Does the tobacco plant have a dual purpose? 

- That's a great question. Most products have dual purposes, and does the tobacco plant have a dual purpose. Well, it's a big money maker, I don't know if you call that dual purpose, besides using it for smoking. But it makes money because it's used for smoking. 

I am not aware of an alternative mass use of tobacco. Of course, Native Americans, long before we came to America, used it ceremoniously, and continue to do so, but in a much different way, not daily, not inhaling, not a pack a day. So I don't know of one. The reason I paused for a second is that a gift once, a friend gave us a platter, that my wife and I still have, that was tobacco leaves with sort of glass on either side of it. So we still have that at the house. But that's not mass produced, so I don't think it's a regular use of tobacco leaves. Sir? 

- Are there ways of ingesting nicotine in such a way that you're not combusting it, so you're not having this cardiovascular development, and what are the consequences? 

- The question is, is there a way of ingesting nicotine, or are you asking even tobacco, without some of the cardiovascular and other health risks. Of course, there's smokeless tobacco, what we call chewing tobacco. 

And what we know about chewing tobacco is that it's surely not as dangerous as smoking, but it does cause mouth cancer in some people who use it. So it's not a safe alternative. It's probably much, much less dangerous than smoking, but it's not a safe alternative. What is available, though, and we use it as a bridge from deadly tobacco to neither nicotine or tobacco, to use the nicotine medicines for a couple months, as you move from smoking to dealing with your addiction while you're breaking your habit, to then giving up the addictive nicotine. People are often able to do that. It's not a magic bullet, but they're often able to do that. 

- Does nicotine reduce stress, is that why, you know, it seems like everybody is smoking. Does it improve short-term memory? Some of those people out there are throwing a whole bunch of stuff around about this, you know, they have a zillion different things going on at one time. It seems like it's supposed to improve short-term memory. 

- So the question is, does nicotine have any physiological benefits, like improving short-term memory, or relaxation. In fact, nicotine is a very complex drug. But we always have to remember that nicotine is one of 4,000 chemicals in tobacco. And so that's the first thing. When we talk about nicotine, we don't mean tobacco. It's really just one chemical. But there have been studies that have shown that, for some individuals, it does, in certain tests, improve short-term memory. And for some individuals, it does have a combination of relaxation, as well as stimulation, an unusual combination. With that said, what most smokers say is that I smoke to relax. What in fact they're doing, if we examine their blood nicotine level, when it gets low, and gets out of that comfort range, they're in low-level nicotine withdrawal. 

So they have a smoke, they get that blood level back up and they feel calm again. But all they've done is to give themselves another injection of nicotine through their lungs to get back up into a safe physiological range. Tom? 

- As the percentage goes from 45% to under 20%, how does the demographics of smokers change, and how does your research keep up if the demographics do change? I'm assuming that it's probably going to be more people tending to be more lower income. 

- That's a great question, what's happening to the demographics of smoking as we've gone from 45% down to 20%. Has anybody seen the TV show "Madmen"? It's a TV show that's on some cable network. It's kind of back on in the end of July. We just love it, my wife and I, because it shows the early 1960s, and it's Madison Avenue advertising executive, and kind of the life they lived back in the early '60s. 

And what's really striking about that TV show is that everybody's smoking and drinking, usually at the same time, while at work. So they're all having drinks, and they're having smokes, and they're hitting on the secretaries. It's just unbelievable. And it's all happening while they're being advertising executives on Madison Avenue in New York City. Why did I mention that? Because that is a good microcosm of the way life was back in the '50s and '60s. I mean, many of us in this room can remember everybody smoked then, or it seemed like it. In 1960, more than half of men smoked, much more than half of men smoked. So it was sort of an equal opportunity killer back then. Where are we now? 

We've gone down to 20%. You're right, Tom, it's the poor. It's the least educated. It's certain racial and ethnic groups, Native Americans in particular. Paradoxically, the ones who used to use it only ceremoniously now smoke at the highest rate of any racial and ethnic group. But it's also people who use alcohol, alcoholics. It's people who have chronic medical conditions, depression, anxiety, schizophrenia. And it's people who use illegal substances, drugs. So we've been challenged as we have worked to develop new treatments and new counseling approaches in particular, to more effectively reach the changing demographics of tobacco use in America. I'm going to take this lady, and then I'll go back to you, sir. 

- In 1980, in Wisconsin, we finally got limited legislation through providing a place in restaurants where you could sit without having smokers around you. Fred Risser had put in seven different laws before that. It was only when a large coalition of at least 30 or 40 organizations that agreed to help advertise for that legislation that caused it to happen. That really started a lot of kind of systematic effort to expand that. What is going on right now in the political arena to advance cigarette and other kinds of smoking cessation? 

- Well, to repeat the question, you very kindly filled us in on the fact that the story of reducing tobacco use and creating clean indoor environments started back with Senator Fred Risser's work in the early 1980s. 

- Earlier, he had seven times put in legislation that didn't go anywhere. 

- He's still one of the nation's champions, and the state's champions around this issue. He has a bill currently before the legislature that would make Wisconsin entirely smoke free, all restaurants, all bars, all places of work. So that anybody who works in an environment can go there, can not be injured as a result of that exposure. 

I would say the biggest policy challenge on the horizon for Wisconsin, is whether we're able to make our state safe and smoke free. There's been progress, enormous progress. But it didn't reach the tipping point in the last legislative session. It got close, but it didn't get there. But just in the last three years, Eau Claire, the city, has gone smoke free. Marshfield has gone smoke free. Monona, the city of Monona, has gone smoke free. So increasingly, towns across Wisconsin are taking this action, city by city, town by town. And at some point, there's going to be enough momentum. I'm hoping it's in the next legislative session to tip the balance and make this an entirely safe and smoke free state, which then makes it fair to all the businesses in this state. 

You want to add a point, ma'am? 

- Does the Center provide some guidance to various individual communities if they want to go in that direction? Where is the impetus coming from? 

- Our Center does provide, our focus primarily is understanding and treating tobacco dependence. But we know one way to do that is creating policies. So if a community like Eau Claire, which we did recently, is going smoke free, which it did I believe in June, we then take the time to go and help them to make that work well. In particular, to help people who smoke use that as an opportunity to quit. So we do do that in a small way. There's something called Smoke-Free Wisconsin, which is not associated with the university and thus can lobby the legislature in a way that faculty or university personnel cannot. And they're working statewide to help make Wisconsin a safe and smoke-free state. 

It's called Smoke-Free Wisconsin. The executive director is a really impressive woman, Maureen Busalaci. Sir, you were next. 

- I think a couple years ago, I heard on the radio that the cigarette companies have agreed to cool it with pushing cigarettes here, but they're encouraging it overseas, places like China, trying to get those people hooked early as kids. You know, what they did here back in the '50s and '60s, it sounds like what they're trying to do overseas. 

- The question is, has the tobacco industry cooled it in America in pushing tobacco, and instead moved overseas. Well, that's half right. They've definitely moved overseas, but they still push it here, to the tune of billions and billions of dollars. They've gotten more sophisticated in their marketing, but they've not stopped. And it's a battle, a battle that about a thousand kids lose every day, when they become addicted to smoking. 

A thousand kids in America become addicted every day. With that said, overseas tobacco is a giant, growing problem. Take China for example. China has 350 million smokers. More smokers in China than people in America. About 60% of men in China smoke. I visited there to help in a small way with their efforts to help physicians about a year ago, in August of last year. And I was invited by a hospital. When I was greeted by the pulmonologist who ran that hospital, he had a pack of Marlboros in his pocket. So the head of that hospital, who invited me there, was addicted himself. 

And it just said to me what a challenge it is to reduce the harms of tobacco internationally. It's a major problem. Ma'am? 

- I am interested in the issue of a will in more detail. What are the barriers of our legislators to allow smoking? Isn't that the tavern's or tobacco people are saying we'll give you money for your campaign? Is that one of these things? What are the pressures of the legislators not to go with smoke-free? 

- So the question is, I've presented a lot of evidence to to make an environment smoke-free, why hasn't the legislature signed onboard. It's a complicated issue, and I sure can't speak for those couple hundred individuals who are up at the state house. 

But I think some of the forces are economic ones. The Tavern League, for example, is a powerful political force in our state, both in terms of contributions, but also in terms of letter writing and phone calling that they can mobilize. I think part of it is just fear. And it's fear that the local businesses in their communities will suffer. When state after state, community after community, when this does happen, businesses actually end up doing better. It makes sense, when 80% of people don't smoke, you've got a good chance of increasing your business by getting some of the people who weren't going in there because they didn't want to be exposed to smoke. 

- So what's the fear? 

- There is a fear that tavern owners, particularly in the periphery of a city, are going to lose their family business. That's not all of it. But I hear it over and over again. 

And I think it's a real fear, not justified, but it's a real one. I'll take maybe one or two more questions. 

- You mentioned smokeless tobacco, there's also stuff called snuff. Is that not a type of tobacco. I only read about it in Victorian novels. Can you tell me more about what snuff is, how it was used, and why it's fallen from favor? Is there anything we can learn from that, or how other uses of tobacco might fall from favor. 

- The question is, what about the other forms of tobacco. And I didn't emphasize them a lot because they're so uncommonly used. Less than five percent of people use non-cigarettes. 

As we all know, pipes have sort of fallen out of the wayside, and even cigars are decreasingly popular. There's a whole variety of smokeless tobacco products, from just raw tobacco that people literally put in their mouth. We've all seen the baseball games when the baseball players have a big wad of stuff and they're spitting continuously. It's really quite gross. But there are some more sophisticated kinds, little pouches that people put in their mouths. You know, there's a lot of debate about if some are less dangerous than others, endless debate about this. There are certain forms, snoos, for example that's sold in Sweden, that's often touted as a safe form of this. When I hear all that, I guess what I think is why use any tobacco. If it's deadly, why not just work to get rid of the addiction to all tobacco products? That makes more sense to me. 

Maybe I'll take two last questions. Sir? 

- I heard on the news that I think that smoking is going to be banned soon, but it's all right to smoke marijuana. And you can't mix the tobacco in with the marijuana. Is marijuana smoking hard on your heart and lungs, and cause cancer, as much as tobacco? What's the deal with that? 

- The question is what about marijuana. And we don't have a lot of information on the health effects of marijuana for two reasons. One, there are few people that smoke 20 joints a day, which is the equivalent of a pack of cigarettes a day. And people who smoke marijuana don't want to be in a federally funded study for obvious reasons, so it's really hard to measure. 

And what we know about smoking is what's called a dose response risk factor. The more you smoke, the greater the risk of all these conditions. And in general, people smoke fewer joints, even people who smoke marijuana every day, than the average smoker would smoke cigarettes. We don't have any easy answers. But we do know that marijuana burnt is toxic at least to the lungs. The other issues, like cancer and heart disease are less well understood. There was a question up here by this gentleman. 

- Do you have programs through your institute to help smokeless tobacco users to stop? 

- The question is do we have programs through the Center for Tobacco Research and Intervention, as I mentioned, you can go on this Web site and get access to all the programs we have, to help smokeless tobacco users. In fact, the Quitline, 1-800-QUIT-NOW, has a separate coaching program to help smokeless tobacco users quit. 

And we know coaching helps them. And on the Web site, we have some information specifically for smokeless tobacco users. And all the information on our Web site is in the public domain, it's part of the university, so you can just take it, copy it and share it. There's no cost or permission, or anything needed. 

- One other question, after you stop smoking, how long does it take before the health benefits, for the health consequences to reverse? 

- So the question is, when you quit smoking, how soon do you get benefits from that. And I love to say to smokers, it'll start literally the day you quit and will continue for the rest of your life. Let me give you a couple of examples. Your sense of breathlessness, which every smoker who's smoked for 20 or 30 years, they're out of breath. They'll begin to have more air and they'll say they can exercise more within a month. 

Your risk of a heart attack when you quit smoking declines by 50%, within one year of quitting. Your risk of a stroke declines by 50% within five years of quitting. Your risk of lung cancer, which never returns to that of a never-smoker, approaches that 15-20 years out from quitting. Do all of the health risks disappear? No, the emphysema is literally you've destroyed your lungs, so that's somewhat irreversible. But all of the others that don't do permanent damage to the lungs, virtually all of them get better, or are fully eliminated. Thank you for inviting me to join you here tonight. 
(applause)