Why telling smokers to quit didn’t work - and what actually did
The reduction in cigarette smoking in the U.S. is one of the biggest public health success stories in our lifetime.
How did we get here?
I’ll give you a hint: it wasn’t by telling smokers to just quit already.
An individual smoker, who’s smoking a cigarette painstakingly designed to keep them hooked, vs. a giant multinational corporation with billions of dollars, policymakers in its pocket, and a legion of scientists being paid good money to design the product to be increasingly addictive and get it placed and marketed in highly appealing ways - that’s a losing proposition.
Over decades, tobacco control organizations (including the Truth Initiative, where I worked for several years), state attorney generals, community advocates and others in the U.S. came together with coordinated strategies to push for solutions that actually put a dent in smoking rates.
So, what actually worked?
Prevention > After-the-Fact Treatment
Once you’ve started smoking, quitting is hard. Nicotine is physiologically addictive. Even though almost 70% of adults who smoke say they want to quit, and more than 50% try in a given year, fewer than 10% are actually able to quit each year.
What works better? Preventing people - especially young people - from smoking in the first place. Among daily adult smokers, 87% tried their first cigarette by age 18 and 95% by age 21.
And what works to prevent young people from smoking? Changing systems (what’s available and visible and where, how expensive it is, and so forth) and social norms (i.e., what their peers and others they care about think is okay). Which brings us to the next two lessons learned from what worked to bring smoking rates in the U.S. down.
Changing the system > Changing the individual
You can try to get each young person to ignore the temptation of shelling out a couple dollars to try a cigarette that they see front-and-center every time they pop into a shop, advertised all over the place with appealing flavors and colors - OR you can make cigarettes harder to get, more expensive, less advertised, and less appealing for all young people. The evidence is clear on what works to reduce smoking: tobacco taxes work; restricting advertising where cigarettes are sold works; banning menthol and other flavors in cigarettes works.
Another key approach to changing the system that worked to bring smoking rates down in the U.S. is a joint legal challenge. Tobacco companies were forced to settle in court in 1998 through a Master Settlement Agreement (MSA) with 52 state and territory attorney generals, which has directed billions of industry dollars towards preventing smoking and contributed to a significant drop in smoking in the U.S.
Population-level solution > single-person solution
All those systems changes are powerful because they apply to all people in a community, all at once. Another thing that applies to all people in a community, all at once? Changing the unspoken rules about what’s okay to do - aka social norms. How did smoking cigarettes go from being cool and rebellious to lame and icky? A combination of things, including laws making restaurants, bars, and other places smoke-free and effective nationwide media campaigns (like the truth campaign’s anti-industry messaging, and the FDA’s Real Cost campaign, focused on the cosmetic effects and other costs of smoking).
This is what public health is all about, as I explained in a TEDx talk a few years ago with the help of my daughters:
Like jamming a square peg into a round hole, there is a fundamental mismatch between the individual level at which we think about and try to improve health and the population level at which health is actually determined.
So often, we get the message that if you’re not healthy - blame yourself. And if someone else isn’t healthy - shame on them.
But that ignores the reality of the policies and systems that shape our choices and the increasing degree to which corporations mold those policies and systems to favor their profits over our well-being.
So we need to put down the square peg and pick up the round peg:
- Put down single-person solutions & pursue population level solutions instead.
- Put down efforts to change individuals & change systems instead.
- Put down after-the-fact treatments & pursue prevention instead.
And yes, making the shift to prevention, to systems changes, to population-level solutions will be challenging. But together, we can do it - look no further than the graph at the top of this post for proof.