 Good afternoon and welcome. My name is Barry Rave. I'm a member of the Ford School of Faculty and I'm the Director of Close-Up, the Center for Local, State and Urban Policy. We are very pleased to close up to be able to partner in sponsoring this event with the Domestic Policy Corps of the Ford School. Two of its leaders, Aaron Sullivan and CJ Lobasi are here and we're delighted to have them and do want to point out that the format that we'll be using after the presentation be thinking even now about questions that you might want to raise for the latter Q&A conversation. What we'll do is you have opportunities to fill out questions on cards. Toward the end of the presentation we'll begin collecting those. Aaron and CJ will be reviewing those and going back and forth raising questions of our speakers. So please begin to give thought to that now and engage in the conversation that will follow. That said, let me turn to the topic for today. When Rebecca Blank was the Dean of this school before she went on to become the Commerce Secretary and now the Chancellor of the University of Wisconsin-Madison, she often said you could define how excited a person was about introducing someone by the words that they used. In short, it's common to say things like I am pleased to introduce, I am delighted to introduce, but as Becky put it, and many of you know her, when you begin to pile up adjectives before those words you really get the sense that someone doing the introduction is excited. Let me begin by saying I am very, very, very pleased to introduce Ken Warner and actually welcome him back to the Ford School where if I understand it correctly and how timely that Paul Corant would walk in just as I'm beginning, that he began his academic odyssey at this university and was then the Institute for Public Policy Studies. I'm so pleased to be able to have this conversation for several reasons. One is that this is such an intriguing topic, a question of public policy that has evolved in ways that we might not have anticipated 15, 20, or 25 years ago, given the political economy of tobacco. I say that as the son of a retired cigar salesman. I sort of know a little bit about tobacco politics and the amazing changes that have taken place with some significant demonstrable results, some of which we will probably be talking about in a few moments. And so as a School of Public Policy, as we think about those areas where it is possible to kind of move the needle in a positive direction through policy engagement, tobacco really does become an intriguing one and yet with much, much more work to be done. In turn, my great pleasure stems from the fact that we have the chance to welcome Ken Warner and hear his reflections on this issue. It is no secret that Ken is a defining figure in the economics of disease prevention and the application of the tools of economics to the issue of tobacco control throughout the course of his career. I don't even know where to begin in outlining some of the highlights, the awards, the honors, and the superlatives that can be stated. But certainly as this school approaches its centennial next year and we increasingly and while Hall raised the question of how does one constructively apply and engage the social sciences, the policy sciences to some of the most pressing issues of our time and do so in a way with real rigor and integrity and have impact, Ken really is the gold standard. He is a model for all of us for thinking about that kind of application and long-term career and long-term impact. Finally, on a personal note, Ken was one of the two first faculty I met when I came to this campus. The other, John Romani, has seated in the third row. I want to just say a word about it. I can certainly speak to both of them, but I want to introduce Ken at this point. Ken has been just an absolute remarkable mentor for me. An advisor, someone whose thoughts I've sought on many occasions. The advice has always been on target and an incredible, incredible act to try to at least begin to emulate someone who has just been a great, great friend and advisor in every possible way. Given that, to go back to the Becky Blank construction, let me just say I am very, very delighted to welcome Ken Warner to give our remarks today on this fascinating title and this fascinating topic. Ken, welcome. Thank you, Barry. That was very, very, very kind of you. I was going to say I've done a lot at this university. I've been here for over 40 years, and I think one of the most important things I ever did was hire Barry. As I recall, I was department chair at the time. I think when you got here, and he was certainly the best hire one could ever hope to make. And in turn, he mentioned John Romani, who was my first department chair. And I see lots of friends in here from the old days. We're going to engage in sort of a journey of nostalgia for those of you who have a little gray in your hair like I do. I guess a lot of gray in my case. A little nostalgia, go back a little ways, and then move forward into the future. So we're going to cover a lot of territory during this talk. And it's going to be, where is Paul Caronte? Oh, there you are. Paul will remember bumming cigarettes from me when we were both new faculty here. I probably bummed some from him occasionally. And I was just commenting to Bonnie that it's really hard for our students today to realize that when we started out here, I was in the School of Public Health, also public policy, but started out in the School of Public Health. And probably half the faculty in the School of Public Health were cigarette smokers, and we were smoking in our offices. So we have come a long way. Things have changed. And I'm going to talk about a number of things here. I don't need to read this to you, but we're going to end up looking into the future. Not to say we're going to be able to predict the future, but think about that future. So I want to start out with some of the dramatic changes that everybody's aware of that have occurred with attitudes and norms concerning smoking over the last, actually, it's 50 years on January 11. That will be the 50th anniversary of the very first Surgeon General's report on smoking and health, which the New York Library, Public Library declared was one of the 10 most important books in the realm of science in the last century. So this is for the nostalgia part. I actually like showing these slides in front of my students, but I've stopped doing it because they have no idea who any of these people are. But some of you will know who they are. So we started out with Humphrey Bogart on your left. Humphrey Bogart, as you know, if you're old enough to know who he is or was, was the most prominent actor of his day. He was considered the sexiest male alive. He was smoking in virtually every scene in every movie that he ever made. Unfortunately, he died of lung cancer in his 50s. Who's the next one over? Well, yeah, Lauren Bacoff. Go beyond one beyond. I'm skipping pictures here. John Wayne, the Duke who made lots and lots of movies, he bragged by the way that he beat the big C when he had a cancerous lung removed. Unfortunately, he succumbed to cancer shortly after that. How about the third picture? Who's somebody just said it over here? Babe Ruth, the Bambino, the Sultan of Swat. Interestingly, Babe Ruth never smoked cigarettes, but he was inveterate cigar and pipe smoker. And what nobody knows about him is this very large man, and he was a very big man, weighed about 90 pounds when he died and was missing half of his face from oral cancer. But he wouldn't let anybody take a picture of him because of that. How about next to him? Good. Edward R. Murrow, who is the most respected man of his generation. He's the guy who essentially put an end to the communist baiting issues that Eugene McCarthy was not Eugene Joe McCarthy. That, by the way, is a great political science story. So this talk is going to go a little bit longer than I thought. I had a buddy in college. He predicted Eugene McCarthy's total vote in the primary, the Democratic primary back in what was at 68. He predicted it closer than any of the national polls. He was much closer than any of the national polls. And he found out something nobody else knew. Why did Eugene McCarthy do so well in the New Hampshire vote? A lot of people thought they were voting for Joe. Very interesting. On the other end, I'm not sure if there's a Betty Grable or Greta Garbo, somebody like that. But it's one of those sort of symbols of, again, the sex appeal of somebody associated with smoke. And in particular, it was the period of women's liberation when women were now allowed to smoke, starting probably in the 30s, 40s and 50s. And start to see that. I've got three more images I wanted to show you as well, because they put some things into perspective. So who's that? Yeah, former President Ronald Reagan. I have to give him credit. He was one of the few men of his generation who never smoked. He just advertised. And point of fact, for his generation, the peak smoking rate was something in the order of about 80% of men were smokers. He was not one of them, but he was an advertiser. And here, you could name all of them probably if you're a real good baseball fan. This is just a typical ad. I've got dozens of these things of baseball players and other athletes advertising cigarettes. So we've got Bob Elliott, Ted Williams, Stan Musial, Joe DiMaggio, etc. And I don't know how many of them really smoked, but they did a lot of advertising. And of course, you can understand the appeal of that as a model. And here's the quintessential image of cigarette smoking, of course. Anybody know who that is? I think the last time that I looked at the night before Christmas, he was smoking a pipe. But somehow here he's transformed into a cigarette smoker. So that was then and this is now. And obviously, the imagery is just dramatically different than it used to be. And that reflects how we think about smoking in our society. So the change in smoking behavior, smoking prevalence is much more than halved. Since the mid 1960s, total cigarette consumption in the US was 633 billion. In 1981, when it peaked, it's under 300 billion now. This is one of my favorite graphs. I actually developed this for the 25th anniversary, certain general's report. And here we are coming up to the 50th anniversary. It's adult per capita cigarette consumption over the course of the 20th century into the 21st. And it's why if you look at it, it tells you why Alan Brandt at Harvard named his book about this, The Cigarette Century. I think when 21st century historians look back on this, they're going to say it's the most interesting and certainly the most important public health story in the developed world, not necessarily in the developing countries, but in the developed world. I'm not going to go over the various events, tobacco control events that occurred, but lots of them are associated with pretty significant blips. Now you will note, we have here the first certain general's report that comes the year after the peak level of adult per capita cigarette consumption, which was, I think, what was it done, 4,300 or 4,400 cigarettes per adult. And it's just it's an odd measure in some ways, but it takes total cigarettes, divides them by the population over the age of 17. That doesn't really show you what's happened. I asked Don, because Don Sexton has been working with me, one of our doctoral students has been working with me and some other colleagues at some other universities on a paper that will be coming out in American general public health, where we basically took the smoking experience up through 1963, and essentially said what would have happened if nobody ever started talking about the dangers of smoking. And basically, this is where we would have been, and that's a level almost 6,000 that is now five times higher than where we are today. Keep in mind, this measure combines two measures. It's number of cigarettes per smoker per day, along with smoking prevalence. That's why that gap is so huge. But it's an incredible story. So how did this all come into being? Well, basically, I characterize it as five decades of tobacco control. We started out with an era of persuasion and information. Believe it or not, the first public health people thought that if you simply inform people about the dangers of smoking, they all would quit. Maybe not all of them, but most of them. So in the mid-1960s, that was the thought, that was the philosophy. Inform people, they're rational, they will stop. Phase two is what I call the first incarnation of the non-smokers rights movement. I'll be more specific about that in a moment. Phase three is an era when everybody was promoting the notion of comprehensive tobacco control, trying to go at it from all angles together. And then phase four is the second incarnation of the non-smokers rights movement. So I'm about to commit an academic heresy. I'm going to commit sociology. I'm an economist. I'm not a sociologist, so please forgive me for this. And if there are sociologists in here who find this of sufficient interest and want to work on it with me, I'd love to do this right. I'm going to talk to you about how I view what has happened. This is sort of my characterization of it. The information and education campaign early on was understood and acted upon by a socioeconomic educational elite. They're the ones who quit smoking. We have very good data on that. I'll show you some a little bit later. They're the ones who first quit smoking. And of course, they're the politically engaged people. So they lobbied for policy changes, partly because they were interested in public health, and that was a nice thing to do for public health, partly because it was awful easy to do, and it was a little selfish in a way. It's easy to say you want to see increases in cigarette taxes when you're not going to be paying them. And in fact, it turns out that people are going to be paying them now, or poor people in large part. How about the ban on smoking in airlines? That was the first workplace where smoking was ever banned. Why? What do you think? Why was it on airlines first? That's where they traveled. Pardon? That's where they traveled. Who traveled? The elite. Well, the elite. And specifically, there's a group of frequent fliers who are more important. Actually, these days are well, they're important. They're just Congress, right? Congress was the biggest group of frequent fliers in the country. They flew all the time and they didn't smoke. Most of them just like everybody else in their education class. So get it out of the airplanes because it was be blown in their faces. So it was a very natural first place to see a smoke-free workplace. So the middle and lower socioeconomic and educational groups responded to the social pressures and the environmental changes around them. And that, in turn, the norms changes that occurred led to more and stronger policy change. And you have this virtuous cycle that's been going on ever since the early days of this. Health consequence. This is also the results here from a paper we're working on right now going to submit later this month probably. Since 1964, it's actually just a little bit less than 10 million premature deaths have been either averted completely or postponed as a result of people's decisions not to continue smoking or not to start smoking because of what is going on in tobacco control. On average, on average, each of those people has gained 20 years of life expectancy. Think about that. That's a gigantic change. If you could get rid of smoking, by the way, all smoking, it's the same as if you get rid of all cancer in terms of what it would do to life expectancy in the United States. I think this is without a question of a doubt the greatest public health success story in the U.S. and certainly in other developed nations in the last half century. But it's also the greatest remaining problem we have when you look at it surely from the point of view of mortality. Now, why do I say that? There are probably people in this audience today who think that obesity and physical inactivity are the major behavioral killers of our time. They don't even come close to smoking at this stage. You can take the highest estimates and the estimates for the behavioral as well for the obesity and physical activity range from about 100,000 deaths a year up to 350, 360,000 deaths. And I don't think much of anybody believes the upper end at this stage. For smoking, the figure that's going to come out in the New Certain Generals report is going to be about 485,000. So it's possible that we'll see the two of them cross at some point as smoking continues down and if obesity goes up it looks like it's leveling off fortunately. But this is this is the big problem if you're simply talking about what causes death. All right, what can you do about it? Well, there are three basic categories of policy interventions. This is sort of calls to Newcastle for people that in public policy you know this. For anything, you can take information and education strategies, you can provide economic incentives, or you can have laws and regulations. We have a huge body of research in tobacco control that allows us to say we have a real genuine evidence-based policy field here. This shows you the categories of what works, what doesn't work, and what we're not so certain about. I'm going to talk about several of them individually. So I'm going to start out with the early years of the anti-smoking campaign, the information in public education. It's hard for people to imagine today, but in that first certain general's report came out in 1964 it was one of the biggest media stories of the year. It came out remember in the beginning of the year in January 11th. It was held, the conference was held on Saturday. It was in a secured State Department conference room. Why on Saturday? Because they were afraid of the effects on the stock market when the report came out. The reporters were given copies of the report to take a look at. They were locked inside the room, literally locked inside the room for 45 minutes before the Q&A with the surgeon general and the committee that had established that smoking was a cause of cancer. 15% decline in cigarette sales in the very first three months following issuance of the report. By the end of the year as people lapsed back to smoking it had dropped to about 5%. But never again would we be as high as we were the year before 1963. The Fairness Doctrine Ads. How many people here remember, probably don't even know by name. Anybody remember Fairness Doctrine Ads? Okay, a couple of you. Fairness Doctrine Ads was a fascinating story. So the federal communications established a rule called the Fairness Doctrine that said if you were a broadcaster, radio or TV, and you were broadcasting about something controversial that you had to donate airtime to the other side of the controversy because we didn't have all the media we did today. There were about three or four networks and there was a monopoly basically. So they had to agree to donate airtime. It was designed to cover political issues. But a 25-year old brand new law school graduate went to the FCC and said smoking is controversial. The cigarette advertising on television and radio is pervasive and nobody gets to hear the other side. And the FCC agreed with him and ended up requiring the broadcasters to donate airtime. It was never nearly as much as the pro smoking ads. It wasn't in prime time like the pro smoking ads. But for the first time in history we saw that per capita consumption drop for consecutive years. First time since smoking, cigarette smoking started at the beginning of the 20th century. The other thing that was going on then was cigarette tax increases at the state level. Lots of them. Now who knows whether this was people in state legislature saying smoking is awful. We ought to do something good for public health. Or whether they're saying that's now acceptable. We can raise our taxes and get some revenue brought in. It did both. The tax will raise revenue. It will also get some people to quit smoking. So it's a chance to do good while you're doing well at the same time. That spate of tax increases stopped in 1971. Doesn't mean there were none. But it slowed up dramatically when all of a sudden the states got aware of interstate smuggling that was going on because of these large gaps in state tax rates. Started up again around 1981 and went up in its cycle kind of up and down over the years. What differences it make? So this is the area that's probably best documented of all the areas of tobacco control, tobacco policy. The price elasticity of demands about minus 0.3 to 0.5. That means a 10 percent price increase decreased the cigarette demand by 3 to 5 percent. Roughly half of it is prevalence. The other half is cigarettes per day. Which actually is much less important from a health point of view. Low-income smokers are much more price responsive than high-income smokers. So this means that we have the opportunity to address significant health disparities simply by raising a tax. It fascinates me as someone in public health where the major theme in public health for the last decade is health disparities. Black, white, rich, poor, you name it, and nobody ever talks about the fact that the single most important cause of the difference in death rates between the poor and the rich in the United States is smoking. The study I said we're just completing now, we're estimating it accounts for probably something in the order of 30 to 40 percent of those health disparities. Now you could say that's all true but what about the regressivity of the tax and it is a very regressive tax. If we have time later we can come back and talk about that. Something I'm very concerned about. Very importantly children are two to three times more price responsive than adults. This is the single most important thing you can do if you want to reduce youth smoking. Unglamorous but the single most effective thing you can do. So the first incarnation of non-smokers rights law. These are 1973 to 2000 it's non-smoking areas and sections and a lot of you will remember those. I remember waiting in a restaurant in Toronto after they had adopted their first one and we were told we're going to have a long wait if we waited for the non-smoking section and we said we'll wait. I think it was about 15 minutes or something by the time we actually got inside and we're seated there. Every single table had a sign up on the wall you know the no smoking symbol. Every single table had an ashtray and our table is the only one where nobody was smoking. So this all starts out Arizona in 73. Minnesota comes up with the first considered model law. Michigan joined the group in 1986. The second incarnation is a fascinating one this is completely smoke-free workplaces including all restaurants and bars started out in several municipalities primarily in California. Davis was the first in 1993 and by the way since it's a close-up seminar I should point out that the federal government has done some significant things in tobacco control but this is predominantly a state and local policy story. It is predominantly what the states and localities have chosen to do and it's frankly where the locus of action is for the advocates. Really because of a divide and conquer strategy. It's easy for the tobacco lobby to control Congress and they've controlled it really forever. It's somewhat easy to control 50 state legislatures. I don't know what it is now but I remember years ago four of the top five lobbying firms in Lansing had tobacco as one of their clients. I don't know what it is today. It's harder when it gets down to the local level and that's where a lot of the grassroots action has taken place. But it's also occurred at a national level as you can see here Ireland went smoke-free in 2004. March of 2004. Jim and Ann Duterstat were over in Ireland the next month and I don't know how I must have gotten four or five emails from them while it was over there. They love to go pub hopping and just raving about the clean air in the pubs. Nobody's smoking inside. You had to go through a haze to get into the pub but that's another story. So today more than 30 countries smoke-free includes the UK, France, Italy. You think about French restaurants. You know what were the defining characteristics of French restaurant? Great food, really good wine, dogs and smoke. You know that's a French restaurant and today you got the first three and the other one is gone. Smoke-free air laws are well studied. We know that workers exposure to the toxins in smoke is reduced by about 80 to 95 percent. Obviously they're exposed some of them at home and so on. It increases quitting rates and compared to workplaces that allow smoking. Decreases daily consumption reduces employer costs. Not only you've probably seen it when you go into a hotel which frequently by the way is just their choice to be smoke-free. And I'll say $250 cleaning fee if you smoke in the room, something like that. They save huge amounts of money not allowing people to smoke in those rooms. Anybody who's in a restaurant or a bar that used to have cash registers and presumably computerized equipment now, it gets gunked up just as people's lungs do when there's a lot of smoke in the air and they had to be replaced more frequently. The most important outcome however is the most recent. We have over 100 studies worldwide. If you have a non-smoking workplace compared to one that allows working you will see a significant decrease in acute myocardial infarctions and deaths from myocardial infarctions. We don't know the exact number. It's probably in the order of 10 to 15 percent. I would ask you this question. Do you know of anything in the world of medicine or public health that could begin to have that kind of health impact simply because a governor or some other official signs his or her name to a piece of legislation saying, thou shalt not smoke at the workplace? I can't. Nobody's ever been able to suggest one to me. Advertising and counter advertising, there's less good evidence on the effects of advertising. The consensus view is that it does cause some smoking. The best single study based on international comparisons suggests if you get rid of all forms of advertising and promotion compared to no ban whatsoever, you reduce smoking by about 6 percent. You know, your first reaction might be 6 percent. That's not much. But then you say 6 percent of almost 500,000 deaths in the United States or 6 million deaths worldwide. Smoking is the leading cause of death worldwide. Those are big numbers. So this is a real consequence. Counter advertising, I mentioned the campaign during the late 60s to 1970 with the Fairness Doctrine. Some of you probably are aware of the ad campaign that was mounted by Truth through the American Legacy Foundation. They're coming back. I just learned this one. I was in Washington last week and no, Washington was not closed. But it should, it might probably should have been, but the Truth campaign, which is the second most effective thing after taxes for reducing youth smoking, is going to come back in its full glory, which I'm very pleased to hear about. So what doesn't work so well? School health education, unfortunately, it's a public policy audience. I won't get any trouble here. When I, when I say this in front of my colleagues that health behavior, and they start throwing rotten tomatoes at me, they don't like that because school health education is kind of motherhood and apple pie. And it probably should be at some level, but it doesn't work. Why do I say that? It's not that there aren't well designed programs that if they're implemented according to the way they're designed, they would have some impact. But think about the, the, you know, what, what, what did school boards care about? What did teachers care about? You know, they got to worry about the three Rs and a few other things. This is not a high priority for them. They're not given the resources or training to do it. They don't do booster programs. It just doesn't work. It's kind of like the old dare program. I don't know if the new dare program is working, but the old dare program, there were what, 30-some-odd studies of it. And the only one that showed any statistically significant impact concluded that the people, the kids who had gone through the dare program were more likely to start smoking marijuana earlier than the kids who hadn't gone through it. And as my wife will remember our, our younger son came home from, and I was the second grade or something like that, fifth grade, I don't know. He said, it makes me mad. It makes me want to use drugs. And he was right. Sales to minors' laws don't work unless they're incredibly well-enforced. Nobody wants to put the resources into it. Pup laws don't work. That's possession use and purchase by minors. Most minors and their parents aren't even aware that there's a law against doing that. What may or may not work? Well, we know the current warning labels don't. If you ever around a pack of cigarettes try to find it. It's on the side. It's usually in sort of a gold script on, on a white background such can't read it. And if you did, they're old. So we have these new warning labels that were tied up in the courts and the FDA, which I'll come to later, is probably going to reintroduce them. They'll be 50% of the front and back of the pack, which by the way, is no longer even the international standard. It's probably the standard, but there are many countries that are ahead of this now. And I'll mention that. The other thing about the U.S. ones that I don't like at all is their drawings. Most countries have photographs. They're much more graphic. And I think much more effective. We'll see what happens when that comes back and whether it will matter. The evidence suggests it does encourage some people to quit. So we're hopeful that that will happen. So what's happened in total here? We've had a dramatic impact, but it has taken decades. And the problem isn't solved. So think about this. We got about a fifth of all adults who continue to smoke today on survey 70% tell us they want to quit. Half make a sincere effort every year. A quit attempt is defined as quitting for 24 hours with the intent of quitting permanently. 50% of smokers try to do that. And here's the unfortunate punchline. We end up with about 2.5% succeeding. Ultimately, it takes about 10 quit attempts for the average person today. 10 serious quit attempts, too quick. Why do we have this problem? Well, the people who are smoking today are not the same as Paul Carrot and myself. And the others who were smoking in the 70s or the 80s or even the 90s. Some of them, it looks, are very heavily addicted. Some of them may be what's called hard core. These are smokers who either can't quit or won't quit, choose not to. Their low socioeconomic status. Think about this. College graduates today is smoking rate is 7.5%. For people who have only nine to 11 years of high school, the smoking rate is 36%. More than a four fold difference. If you go back to 1966, which is unfortunately the first year where you have data, it's after the certain general's report, there was about a 10 percentage point gap. 40 somewhere in the 40s for the lower education and somewhere in the mid 30s. 34, 35% for people who are college graduates. So we've had enormous success in this campaign, but it's highly concentrated among the kinds of people who are sitting here today. And now I'm going to show you what I think is the single most important fact about smoking today and most people in giving talks about tobacco control or planning policy mention it and then go on about their business and forget about it and I'm as guilty as the rest. It is probably the case that close to half of all current smokers in the United States have a diagnosable mental illness or comorbid substance abuse problem within the last 30 days. They are dosing themselves. They're treating themselves. Schizophrenics smoke at an incredibly high rate. Something like 60% in the general population and those who are institutionalized where they can smoke it's more like 80%. They are giving themselves something they need to take care of keep themselves in some sense of stasis. And then of course there's this one. Some people simply don't want to quit smoking. The other side of the coin from 70% of people telling us they want to quit is that 30% saying they don't want to quit. And what's the politically correct answer when a surveyer asks you if you want to quit? You say, oh sure, I want to quit. So it's probably at least a third of smokers really aren't the least bit interested in smoking. When I ever talk about that in tobacco control we just assume they want to. Not right. So I'm going to tell you just a bit about a model that I've been working on with David Mendez my colleagues since the early 1990s. And the reason for doing this is to say please believe what you see on the next three slides. This is to show you why you ought to believe this. Okay. And I have to say in fairness I'm not really bragging here because David is both the brains and the brawn behind this. He just let me put my name on it with him which is very nice. So we have this dynamic smoking simulation model that basically tracks the smoking population. It looks at the percentage of 18-year-olds who come in who are smokers. It looks at people who leave because they die or quit and it looks at the denominator for each age group is the population at that age and it figure out smoking prevalence. Okay. When we calibrated the model with data through 1995 only and projected ahead we hit the NHIS estimate in 2005 to the tenth of a percentage point. We got it exactly. We missed the 15-year projection for 2010 by six tenths of a point when we recalibrated to data through 2000 we were two tenths of a point too low on the other side. The fact is this model works it's not a brilliant model it's just logic and it works. So this is what it tells us and this is a very concerning story. It says to us if nothing changes so smoking initiation remains roughly where it is today this is actually a little bit higher than it is today and smoking cessation rates don't change and it appears they haven't changed for three to four decades the actual rate of quitting. This is what we're going to be looking at through the middle of the century 2050 and it's telling us by 2050 we'll get down to 14 percent. That's scary and that is plainly and simply unacceptable. Suppose we could reduce initiation by 25 percent and increase cessation by 25 percent. That's where we go. Year 2050 we're down to about 10 percent smokers. In other words we will have halved where we are now and by 2050 another long period of time. It's a little frightening. If we could reduce initiation by half and increase the cessation rate by half we end up here. That gets us down to about seven percent by mid-century and obviously we're still falling at a relatively steep slope there. But the point is the federal goal of 12 percent by 2020 the only reason a federal goal is 12 percent in 2020 is because that's what they set it for in 2010 and when they missed it by a mile they said we can't raise it for 2020. They're going to miss it for 2020. Not going to hit it then. Actually what I suggest to them is they keep their goal at 12 percent every decade and we'll get there. Eventually they will be right. Eventually they will be right. Now take a look at this and think about the implications of this because this is a scary story and by the way when I said the status quo here which is the top line that doesn't mean we don't do more tobacco control it just means we continue doing what we've been doing at the same rate and get the same results. So it's not like you're stopping anything you're just not doing anything exceptional. All right where are we going to go from here? Well I think I'm pretty confident more states will go smoke-free. Within about five years I expect most states not all but most of them to have a smoke-free workplace law. There'll be cigarette excise taxes increased in the states we can be sure of that. Maybe the federal government but probably not soon because we had a pretty big increase in 2009 and they haven't shown a lot of tendency to increase the federal tax frequently. More media campaigns I have to tell you this I was so excited to be invited to speak here I started working on this talk probably two months ago it also shows you I have nothing else to do. That's true that I put this together initially two months ago I have revised a little bit I put this question mark on here about more media campaigns turns out I learned in Washington last week there are going to be lots more media campaigns and they're expensive so that's kind of cool that's going to happen. Truth campaign which was over a hundred million dollars a year when it started out which is the size of a pretty decent size advertising campaign not Coke or Chevrolet but a pretty good advertising campaign they're going to go back up to a hundred million from about 35 or 40 so that's good. The CDC has been running a program called TIPS TIPS from people who have quit or whatever that is going to come back that's about a 40 million dollar effort and I understand that the HHS at a different level is also going to put some number of tens of millions of dollars in this so we're going to see some more media campaigns and that's a very good thing. What happens if we stick to what we know the evidence-based interventions? Well you can only go so far with smoke-free once it's done it's done you can't get extra out of having smoke-free workplaces once the warning labels are phased in they may have a positive impact but people will get used to them and that will wear off there's no question about that. There are serious equity issues about how high you can raise cigarette prices and cigarette taxes given that most of the people smoking are in very low-income groups and that even though they're more price responsive than high-income smokers any reasonable tax increase is going to get only a small minority of them to quit so they're going to have stuck paying for that media campaigns are expensive they're difficult to make them effective we'll see where it goes so here's a prediction hope nobody will hold me to it we're going to be seeing in 2020 smoking prevalence optimistically 14 and a half maybe as high as 17 percent it depends partly on what you think it is today because the federal surveys are not very consistent one of them NHIS is 18 percent national survey and drug use and health is 20 percent or 21 percent but it's in that range and here's kind of the punchline that I think is most upsetting when you think about this we're looking at literally hundreds of thousands of deaths per year for decades to come from a cause that is 100 percent preventable that just seems completely ludicrous and unacceptable to me that's what it is so here's what we're going to see at the state local and institutional level we're definitely going to see more novel outdoor smoking restrictions there are about 6,000 public beaches and parks where smoking is not permitted that number will go up University of Michigan was not the first campus to go smoke free by any means it was one of the first major universities to go smoke free and we're now seeing lots of others follow I forget what state but there's another state that just adopted the law that says you cannot smoke in a car if there is a kid in it who's under the age of 18 so these are kinds of things that for sure we will see more of over time and then we're going to continue to see all these novel products and if you're not interested in tobacco per se you're probably not very familiar with some of them snooze if there's time during the Q&A we can talk about snooze the most interesting natural experiment in health behavior probably ever anywhere the dissolvables brand new products called orb sticks and strips just stick them in your mouth and they dissolve you don't have to spit e-cigarettes everybody heard of electronic cigarettes and e-cigarettes that's kind of a hot issue these days they're all around so this is sort of bred a discussion about tobacco harm reduction whether it's good or bad and the idea here is there are a lot of people who just aren't quitting cigarettes maybe what they need is something else that gives them nicotine something else perhaps that gives them some tobacco but is less hazardous and anything that is not combusted is dramatically less hazardous there are some forms of smokeless tobacco in Sudan and India that are very dangerous and kill literally millions of people but if you look at the products that are available in the United States particularly low nitrosamine which most of them are it's not clear that they're very hazardous at all I can't say this kind of publicly but there's certainly maybe one percent of the danger associated with smoking should they be out there as substitutes how should we deal with that in a regulatory sense what about e-cigarettes if e-cigarettes were used by inveterate cigarette smokers to switch they'd be a good thing if they're used by cigarette smokers to tide themselves over during the work day because they can puff on these things inside their workplace but they get people to keep smoking cigarettes outside the workplace and they're a bad thing so it's hard to figure out exactly where to take it I mentioned here the true pulmonary nicotine inhaler now you're probably if you know anything about this field you're probably saying we've got a pulmonary inhaler you can get it by prescription you get a prescription from your doc you go and they give you an inhaler it's not a pulmonary inhaler when you suck on it the particles with the nicotine go into your mouth they're stuck on the linings of your mouth the oral mucosa and the linings of the throat they don't get down into the lung most e-cigarettes are probably delivering very little nicotine to the lung it turns out it is really hard to get nicotine into the lung there is one optimized form of delivery for nicotine into the lung and that's cigarettes okay so Philip Morris International not the Philip Morris we know and love here but Philip Morris International separate company now bought the patent from a nicotine scientist to a true pulmonary inhaler a very hard thing to do but he's created a device where you can hail this stuff without it burning like it would if you were trying to do it otherwise and they have promised that in 2015 they're going to bring out a new new device that sounds very much like it's going to be this pulmonary inhaler it'll be highly addictive but if it gives you the feeling like the electronic cigarette that you're smoking it gives you sort of the physical aspect so people think it's so awful some people about electronic cigarettes you know my response is we want you know the major approach we have taken to dealing pharmaceutically with smoking is to give people the drug and take away the behavior why not give them the behavior and largely take away the drug give them something they can hold between their fingers anybody here who's a smoker remembers how important that was to him being able to hold it in the field and the whole thing electronic cigarettes you can blow smoke out of your mouth like fire you know breathing dragon or something it's going to be really interesting to see what happens with that one so now we have something altogether new this is the potential for federal regulation 2009 cigarette smoking act and tobacco control act whatever it was called which President Obama signed gave FDA the authority to regulate cigarettes and smokeless tobacco products and they may use their deeming authority to declare all other tobacco products and e-cigarettes under their jurisdiction as well we're waiting to see about that what can they do they may ban menthol I will have to wait and see that's an extremely controversial issue politically anybody know why who smokes mentholated cigarettes in very large numbers African Americans about 70% of African Americans who smoke use mentholated cigarettes for whites it's a very small percentage so this is kind of race related it's very difficult politically but it's an issue they've got to deal with the graphic warning labels plain packaging what you're looking at here is a mock-up of Australia's new cigarette packs and they're actually out now plain packaging means that that first of all they did all kinds of studies they brought people in for focus groups and they said let's figure out what the ugliest single ugliest most unappealing color is and it turns out it's this dark olive green that you see on here and if you see here it says brand and whatever else the size and type of font are identical for all brands of cigarettes so the only way you distinguish them is if you can read you can't use a logo or anything like that and in their case I think it's 75% of the front and a smaller percentage on the back are warning labels that's out that's happening now Uruguay has 85% of the front and back with graphic warning labels FDA could conceivably conceivably require something like that they could restrict the marketing of new products or approve others the how they handle e-cigarettes is going to be really interesting and these novel smokeless products they can establish performance standards somebody put out a cigarette called Omni the company was named Vector Tobacco by the way I love the name for a tobacco company it was Vector Tobacco they put out a cigarette called Omni which reduced the PAH's catacols and nitrosamine levels by about 80% those are the three things that are believed to be the principal causes of lung cancer in smokers okay so that's a big decrease nobody bought the product but FDA could require it they could tell everybody you got to do that the technology is there you got to do it if regulation is in fact pursued aggressively I think the potential is probably quite terrific because they could do things quickly you can change marketing rules quickly product constituents quickly product availability there's nothing that has more potential to really impact smoking than FDA regulation a group like this one has got to appreciate the barriers to this the industry obviously opposes any form of regulation that congress opposes it see above because the industry opposes it lots of money involved legal issues doesn't matter what FDA does it will be sued this happened with the warning labels and they go to court and they are confronting deep pockets legally the legal the money that Phillip Morris alone spends on its legal affairs every year dwarfs what FDA spends on all of the issues that it deals with obvious black market concerns or our legitimate philosophical issues about how far one should go and there's simple fact that this is a very low priority of society and government today by the way the Obama administration bless their souls for other purposes is one of the real barriers here the Obama administration is telling FDA to go slow they don't want noise coming out of FDA on cigarettes opportunities the public health community is getting very impatient and is going to be applying political pressure political pressure from the public health community in $1.70 you'll get your cup of Starbucks but somebody at least is paying some attention to this we have a new director of FDA center for tobacco products Mitch Zeller who is a long time tobacco control advocate he worked for Dr. Kessler when he was a commissioner of FDA and Mitch was responsible for Kessler's tobacco activities he's heavily invested in this and he really cares about it I have to say with regard to barriers in Washington last week I saw a slide that was put together apparently by the FDA that shows hurdles that they've got to jump over so that something can become a policy go through their whole process there are about 16 to 20 of them it was one of the most intimidating looking figures I've ever seen that's not going to stop them necessarily but it is very intimidating so this has led to this idea of a discussion of an end game and the idea of trying to figure out how you can do something more people are concerned and frustrated with the slowness of progress we understand now that business as usual is not a solution it's continued improvement if we don't do something more we have this problem of this ongoing slaughter of people that's completely avoidable so people are saying let's find something different something out of the box looking toward the future so what are the ideas and where are they coming from they're coming from all over the world from Canada and Australia we have proposals for not-for-profit regulated supply take it out of the industry and have a harm reduction mandate so it's not a matter simply of selling more cigarettes because that's your agency's job your agency is to sell fewer cigarettes and figure out how to reduce harm we have this idea of a sinking lid in New Zealand and the idea there is very simple one whatever the supply of cigarettes is today reduce it by 10% each year for 10 years until you don't allow the sale of cigarettes easier for New Zealand to do as an island for the rest of us but a very interesting thing to watch and the New Zealand government has committed to a tobacco-free society maybe it's smoke-free I don't remember which I think by the year 2025 and maybe 2030 but they're one of the few national level governments that's actually done that an idea from Singapore is to prohibit possession of tobacco for people born after a given year they usually mention 2000 so this is a smoke-free generation concept that's a slow process of moving toward prohibition basically the idea that people have latched on to in the US is this one reducing nicotine to non-addicting levels and if there's time afterward I can tell you a story about how this really is catching on there are a lot of people including a lot of feds when they're at work who are paying attention to this notion and the interesting thing is that the law that established FDA's authority to regulate cigarettes and tobacco other in smokeless tobacco products says specifically you cannot require the removal of all nicotine from cigarettes without an act of Congress however you can require a reduction in the level of nicotine to whatever you want so long as it's not removed think about decaffeinated coffee it still has a little caffeine in it think about no alcohol beer almost all no alcohol beer has a little bit of alcohol in it so the experts in the field think we could easily require a reduction of nicotine levels to levels that could not possibly sustain addiction and they say this is the idea that most people in this country are kicking around right now and there's even discussion of prohibition or as Robert Proctor calls it in his book abolition the book is called what's it golden holocaust I forget the subtitle but he's making the case for abolition and it's he's a historian at Stanford it's a really powerful book I recommend it to you one of the ideas some of the rest of us are kicking around we call prohibition light and that's the idea of banning only combusted tobacco products at least as a first major step toward trying to be tobacco free but give people tobacco products if they want as long as they're not burning burning generates six to seven thousand chemical compounds 70 to 80 of which are known human carcinogens those are not present in large part in the smokeless products so these end game ideas could dramatically reduce the toll of smoking the barriers to doing anything like this are obviously enormous and the likelihood of seeing something happen the near term is very low but I point out to you we got New Zealand that's made its own commitment we have the state of Tasmania and Australia which is seriously entertaining the notion of the smoke free generation the smoke free 2000 generation Uruguay is way ahead of most of the world an aggressive tobacco control policy they're being sued by Philip Morris and others for their policies and bless his soul the I guess he's still the mayor of New York Bloomberg is funding their lawsuits since their country can't afford it and then we have Australia which has been taking a lot of dramatic steps as well and here's of course a critical point don't ever underestimate what's going to happen in tobacco control so I've been in this field for a long time if you had told me 10 years ago 2003 that I'd be standing here in 2013 10 years later and that there would be 30 countries that had prohibited smoking in all restaurants bars and workplaces it would have started out with Ireland and its pubs and it would include France and Italy and England and Scotland I would have said you were out of your mind I would not have thought that possible and yet we're here so what's going to happen again I don't know near term where I hope we will see more aggressive use of evidence-based interventions we're certainly going to see more expansion of smoke free laws to outdoor areas we are seeing marketing of these tobacco harm reduction products for better or worse and some tentative regulatory steps by FDA it is important to watch what they do with menthol and the warning labels so here's a problem that we haven't dealt with and we're we started talking about this in Washington interestingly last week first time I've ever heard this really discussing what's ultimate success does it mean reducing prevalence if it means reducing prevalence of what we're talking about cigarettes combusted tobacco products all tobacco products when do we declare victory and go home when we hit 10 percent 5 percent zero we're not going to hit zero we might hit 5 percent and 10 percent is going to leave us with this legacy of hundreds of thousands of deaths a year maybe we want to eliminate nicotine addiction why would you want to do that do we care about nicotine addiction per se nobody cares about caffeine addiction they have the same effect on blood pressure and pulse virtually identical they set off on receptors the same way that caffeine does and nicotine does we may be more dangerous but we don't really know caffeine per se we have no evidence it's dangerous and it may even be good for you I say that as a decaffeinated person and it may be hard to believe watching me dance around here but you should have seen me when I was on caffeine maybe we should just get realistic and talk about minimizing harm from tobacco use and not trying to be so global and you know excited about big goals and then of course is the question when we will get down to 10% smoking prevalence in United States there's no question in my mind about that that will happen but will it happen 10 years from now or 35 years from now or 50 that we don't know so what's it going to take to make some substantial progress we've had all the elements you see here and we've been pretty successful with tobacco control what we're really lacking right now and the resources have kind of tailed off we had more money than we do these days but we still have some we have more in any other country in the world we don't have any public interest which is clearly a problem and we don't have much by way of upcoming leadership one of the interesting features of tobacco control is a lot of people kind of got into it at the time that I did and the leadership of tobacco control looks like me old white men okay we need to have younger people we need to have more diversity to feel we need to have more women for sure and we're seeing that internationally we're still looking for it domestically we need more good leadership and I've got this sort of blank face because maybe that leadership will come from here it's tough to get students of this generation interested in this subject because like most Americans they think it's been solved they don't see it as a problem because not in their face it's other people who are dealing with the problem thank you well maybe I'll ask myself a question is there anything else to talk loudly well we'll start with this mic you want this thing first thank you so much for coming and talking to us today and we had quite a few questions that were addressing differences in smoking rates based on a variety of factors but a few focused on smoking and gender differences and the questions were if you could comment on gender differences in smoking rates how they have changed over time and whether this has any practical implication in terms of policy effectiveness whether some policies work specifically on some genders or not yeah actually it's a great question and we have observed it's a very interesting difference in stories right now female smoking rates are probably 15 16 percent male smoking rates 21 too so they're close but they're not identical and there's been a gap like that for for many years now but if you go back to the time of the certain general report right before it what you observe was the male smoking rate was coming down already because of what had been going on about smoking in the 1950s and it was about prevalence was a little over 50 probably 52 53 percent of men smoking then women's smoking was in the 30s because they started up about three or four decades after men and if you look at the curves of smoking rates for men and women it's fascinating they absolutely parallel each other with the three to four decade lag the women's smoking was still on the upswing men had kind of peaked women's smoking was on the upswing when the the certain general's report comes out and it kind of puts a halt to it so you see men go down fairly quickly early on and women sort of level out so since then probably for the last 20 30 years they've kind of gone down in tandem of course it was very heavy marketing toward women the Virginia Slims campaign you've come a long way baby which started in 1967 I think was targeting women there have been there have been campaigns that have targeted lots of groups women were heavily targeted for a good decade or more at that time speaking of what's by the way the single group of people in the world who make the tobacco companies drool more than any other are Chinese females because there's so many of them and they don't smoke so they're trying really hard to get Asian women to smoke they were succeeding with Japanese but they've not been as successful they hope and so far they haven't made inroads with Chinese women I don't know that there are policy difference there probably are some policy differences the literature is not very good on that I've seen some studies with price that say that men respond and women don't I've seen others say women respond and men don't I don't believe either of them I mean rats respond to price women and men both have to respond to price but I don't know if research would indicate big differences we have another question that's more focused towards socioeconomic status this person asked that if socioeconomic status is such an important factor and especially on the last 20% being sort of a different class of smoker and the rest this person asked does that suggest that it would be better to move upstream and work on factors that affect socioeconomic status such as income or education disparities to that sort of indirectly affect smoking habits there's a real answer easy answer that sure I mean if I could wave my magic wand and come up with a desired policy it would be some policy that would get the poor out of poverty the uneducated educated and we could not you know we wouldn't have a whole lot we had to worry about if we could do that we could find things to tinker on in the fringes but sure that would be the ideal policy absolutely somebody knows how to do that I would love to hear we seem to be moving in the opposite direction another question that came from the audience was about how smoking policies are interacting with marijuana policies and this question is Uruguay just legalized marijuana how do you reconcile this with harsher controls on tobacco and are they just trading tobacco for something else well that's of course fascinating to watch we now have a couple of states which have legalized marijuana not just for medicinal purposes but in general I don't think it's I mean I know it's not a trade in the in the sense that nicotine is you know is a far more addictive substance and it has the advantage by the way this is some the tobacco companies used to say when we were first talking about addiction they used to say smoking is not addictive people aren't you know rolled up in little balls giggling and you know stuffing food in their face or doing something silly because you know they're high from it they just go about their daily living and my answer is that's why smoking is so very addictive because you could go about your daily living doing that it is harder to be stoned and functioning well and in some jobs I mean we had a painter once who he was a real artist and he was always very stoned but I don't think they're substitutes for each other and of course the really critical thing to think about here is they're two extremes there's completely unregulated legality which is in large part what smoking has been and then there's complete ill legality which is what we've had with marijuana and heroin and cocaine and so on the public health response is to try and come up with policy measures that make it a little difficult to use this stuff but if somebody gets into trouble with it give them a way out you know other than prison you know give them education give them cessation programs give them some kind of residential program if they're addicted to drugs or whatever so I don't think they're the same by any means although I think it's fascinating to watch the opposite directions in which they are moving right now but I mean marijuana most everybody I think who knows much of anything about it I think would argue that it's ridiculous that we make it as illegal as we do and that we send people to prison for it now what a waste of human resources and other resources to stick people in prison for drugs another question we had was about the role of state public health departments and what role they play in smoking reductions well as I said earlier the most of what has gone on in tobacco control is a state and local phenomenon so you have a few things at the federal level like the federal communications commission the fairness doctrine occasional federal tax increases there are not many of them but most of it if you look at smoke free laws you look at state-based media campaigns you look at tax increases they come from the state and local level you know the old story about if something starts out in California that you know it sort of diffuses to other states there are what for Jack Walker used to be the director of public policy studies here used to look at the politics of diffusion of political innovation among the states and there are certain states that in their regions are sort of the leaders that will get you to figure out where you know where things are going and California of course is the leader and look at what happened with smoke free environments smoke free workplaces it started out in Davis in 1993 there were a huge number of California cities that were smoke free before any state was so it's basically this is a state and local activity it's unfortunate in some ways that the feds can't take more steps stronger steps they have the potential now with the FDA regulation we'll see if that amounts to anything so another question that we had focused on the generational gap in interest you were talking about so the new truth campaign makes use of Twitter and do you think that the use of social media will have a significant impact on smoking cessation in the generation that heavily uses social media and what are their policies do you think can galvanize interest among a younger group well social media is obviously where it's at for younger groups and I think there's no question that it has to be used truth has been doing that for a long time now I don't know what the new campaign is going to be a hundred million dollars I don't know how much of it's going on to TV ads and how much it's going to be placed elsewhere but you got to use social media for certainly for younger people one of the problems with younger people this is very interesting there's a lot of people a lot of students at University of Michigan smoke on the weekends or a little smoke when there was some friends having a beer or something they don't think they're smokers if you ask you know you ask people if they smoke no no I'm not a smoker I'm not a smoker and then you ask them about specific occasions oh yeah I'll do it then we have a situation now that we never used to think was possible we've got about 20 percent of all smokers nationwide who don't smoke on a daily basis we used to think if you were a smoker you had to smoke about a half pack a day at least or you wouldn't be able to sustain your habit now we have people who are doing it on a non-daily basis and actually Paul will know whom I'm talking about here we had a guy in our poker game who while he ran the one I think it was the first non-smoking vegetarian restaurant in Ann Arbor because he saw an opportunity a financial opportunity he was a smoker his wife wouldn't let him smoke at home he couldn't smoke at work because he'd said there was no smoking in his workplace and he'd come to our poker games and in the dead of winter since we didn't allow smoking around the table he was the only smoker he'd go outside and stand in the snow and smoke a cigarette by one pack for a while he was at the poker game now anybody here who's ever played poker you will appreciate you don't want to get up to go to the bathroom you don't want to miss one hand and this guy was standing out in the cold to smoke and that was the first time everybody started thinking about it there are different ways in which you can be addicted and it turns out there's loads of literature on this that addiction is very much socially conditioned socially defined we've now defined it as unacceptable in the workplace it's something that people you know in Ann Arbor you don't see many people smoke at all but there are other places where you do it just depends on sort of the social background but the non-daily smoking phenomenon has us perplexed we have a couple questions about the nature of tobacco products and the way they've changed over the years one is specifically how nicotine levels have changed in cigarettes and then the other is how the development of sort of the electronic cigarettes news things like that has affected the control of smoking okay well the first thing to say and this is something that people don't appreciate is the modern cigarette is one of the most heavily engineered products in the world incredibly sophisticated engineering of them so have they increased the addictiveness level of them yes is it always through increasing nicotine no some of it is through increasing ammonia as an additive which actually heightens the effect of the nicotine there's all kinds of other substances that may contribute that we don't know whether or not they contribute to addiction and the product this I'll be great as well here's a fat cigarette okay no but nobody appreciated this when they first came out but when we came out with light cigarettes remember in the sort of late 60s early 70s they came out with the new light cigarettes much lower tar nicotine delivery well it turns out the way they were made this is actually a very simple technology the vast majority of them if this is the filter end of it had a series of microscopic perforations around the filter okay and the cigarette smoking machine that the FDA used to assess nicotine and and tar yield which was published on the PACS by requirement then held the filter tip like this at the very end of the the cigarette it pulled on it a fixed number of times with a fixed intensity okay and that's how they measured they took a look at what was in the filter and what was coming out of the filter and see what they were getting and that's how they measured tar nicotine well it turns out that smokers would hold the cigarette like this what are they doing when they do that they're occluding half of the holes the holes were there so that when the machine smokes it it pulls air in and dilutes the smoke when you're going like this you're blocking half of the holes if you happen to have large lips you're what we call in the trade a congenital hole blocker you block a hundred percent of the holes and there's no more air flowing in and you're getting more tar nicotine and in addition you suck on it harder when it's got a tough yield anybody who remembers the old Kent filtered cigarettes the original filtered cigarette they were tough to get anything out of so you'd really suck on them hard the machine sucks exactly the same on every cigarette that it's measuring so that was a way to fool the machines which they were very good at for any number of years so they're highly engineered the other products the smokeless products that they're producing today are in general very low nitrosamine and as I said very frankly I mean I would not encourage anybody to start using them perish the thought but if somebody's using them I'm gonna go on to it if everybody's using those I'm going to a different field I don't care I'm not real worried about them so I will take advantage of this time to mention snooze how many of you even know the word snooze okay just a handful of you snooze is a low nitrosamine smokeless product that has been used by Swedish males for about four decades now it turns out that originally its nitrosamine level is considerably higher than the new products in the US but it was still relative to other smokeless it was low nitrosamine because largely they didn't tax snooze very heavily and they did tax cigarettes very heavily so it's $14-$15 a pack or something Swedish males started using snooze in large numbers so approximately 30% of Swedish males have been snooze users for four decades now turns out Sweden has the lowest male smoking rate of any country in Europe and I think probably of any country in the world and they have the lowest lung cancer rate of any country in the world sir I shouldn't say that in Europe we know that we know it's Europe 50 some odd countries in Europe and this has been just a natural experiment basically set off by price interestingly women have not adopted snooze in large numbers but so it's 30% of men use snooze and maybe 14 or 15% of them smoke some of them use both the interesting thing is that the Swedish health ministry has studied this product if you'll pardon the expression to death they've done I don't know how many studies two of them have suggested a risk one of them suggested it could increase the risk of diabetes which makes sense because it has sugars in it I mean the smokeless products have lots of sugars in them the other one suggested an increased risk of heart disease but there have been two or three other studies that have not found that no study has ever found any association of the use of snooze with any form of cancer none so frankly as I say these low nitrosamine products now they're not nearly as addictive as smoke and they're not as much fun this is going to be real hard to sell them and so far these strips and orbs and sticks nobody's buying them these cigarettes they're buying they've got some cachet and some people are putting money into them you've seen the ads the complaint that a lot of the activists in tobacco control have is they're using exactly the same advertising themes that the cigarette companies use you know 20 30 years ago sexy models you know this is cool let's do this this is a neat thing this is a modern thing to do same theme same models but again we don't know to what effect at this point did I talk long enough that I managed to avoid answering the question they can't remember the question okay an additional question we had is about the expansion of bands beyond like specific spaces to outdoor bands and how effective they've been and also struggles with enforcement when you're taking it outside of confined spaces yeah it's probably harder when you're doing it outdoors and when you're doing indoors one of the remarkable things about the indoor bands is enforcement has been almost non-existent and unnecessary because compliance is pretty high people can see when you're smoking and you get such dirty looks people tend to comply there have been a few countries that have had problems early on when they've introduced these laws but almost all of them as far as I know have been completely successful with them outdoors a little bit more difficult I don't know what's your observation around U of M you know it's the policy that's not particularly well advertised to people who are not here on campus but my sense is that smoking has reduced significantly on campus from what I've observed but I'm not particularly good official judge of that but people are going to do it and it's going to be hard to enforce it and the question is whether you want to spend a lot of resources on enforcing it I don't know I probably wouldn't another person asked if you would comment on the effect of litigation on reducing smoking yeah that's actually a real important area litigation has done lots of things and it's in the news every single day I mean every single day I get at least one email on new lawsuits or old lawsuits and what they're doing with regard to smoking the single most important one was the MSA the master settlement agreement how many of you have heard of the MSA okay quite a few of you this was the settlement of the lawsuits by the states against the tobacco companies by a very original legal theory it started out in Mississippi there were four states that did their cases individually and were successful before all of them got together to work as a group and the legal theory was you cigarette companies are imposing costs on us the state because we've got to pay for Medicaid victims of lung cancer and heart disease and so on and the burden goes on the innocent victim the taxpayer so it removed the base of most of the lawsuit which is somebody decided to smoke you know the company's always saying they could have quit they just chose to smoke as their decision it wasn't the taxpayer's decision that Medicaid smokers should get lung cancer and they have to pay for it so these lawsuits were very successful and we ended up with the MSA which depending on which side of the issue you happen to be on was good or bad it sent many billions of dollars to the states it did not do much for tobacco control I happened to be on the very first board of directors of the American Legacy Foundation which is one of the spin offs of the lawsuit was created by the lawsuit it's the one that put together the truth campaign our first chair of the board was Chris Gregoire who some of you will know is the immediate past governor of the state of Washington at the time she was the AG for Washington and was the one who led the negotiations for the attorneys general so I came up to her I'll never forget this the very first meeting and I said you know Chris why is there nothing in here that says you've got to devote five percent ten percent of your state resources to public health or tobacco control the money just went to the states and she looked me straight in the face this is a great politician looked me straight in the face and said oh we just assumed that everybody would do that because it was the right thing to do the other thing they did that was a real misfortune in that particular the money's great for the states you know we had those ridiculous scholarships in the state of Michigan that subsidized the rich the kids who went to school their parents got a subsidy and it was just a stupid way to use the money but that's what we chose to do with it but the one that really got me was the 99.05 clause that was in the MSA the 99.05 clause says the various participating manufacturers all the big tobacco companies will pay to the states at whatever the rate was it was hundreds of millions of dollars a year billions of dollars excuse me a year I think it was eight billion dollars a year or something like that for 25 years and they would pay I think it was 300 million a year roughly based on sales to the American Legacy Foundation which was mounting this truth campaign which ended up working but the truth campaign and the Legacy Foundation was only going to get their money for five years unless they are after the participating manufacturers constituted at least 99.05 percent of the market the cigarette market so I said what is this nonsense this is ridiculous and she said oh our actuaries and our accountants everybody looked at this real closely they said there's no possibility it'll ever be less than 99.05 and I said that's ridiculous it's got to be less than 99.05 already you know right now in the beginning of the thing and of course I think it was 97 at that time and it's probably down to about 95 percent now or something so that was an opportunity it was really missed in the MSA the other lawsuits are ongoing I saw an email today a discussion about the Florida case which was the class action lawsuit I'm trying to remember the name of it now but the question is whether the benefits or whether the rights of suing pass along to the children of people who were deceased because they were members of the lawsuits so there's just lots of discussion about these things a lot of the lawsuits have been settled but not for nearly the money that was originally awarded for it because the companies can drag these cases out forever and do but I think the lawsuits have been important they're increasingly important around the world right now particularly unfortunately because the tobacco industry is suing the countries that are trying to adopt tobacco control policies we could obviously continue this conversation for some time given the nature of issues and certainly Ken's expertise I do want though to invite you to continue the conversation out in the great hall where we have refreshments we didn't think to order snooze and alternative products of that sort but appropriate refreshments for a fall afternoon before we do that please join me in thanking Ken for a very illuminating talk thank you