The end game

Aiming to extinguish tobacco’s harms for good

Americans’ love affair with the cigarette hit a peak in the early 1960s. With major marketing efforts and few regulations, it was fashionable to light up everywhere — in restaurants, movie theaters, airplanes, even hospitals. Back then, half of all American men and a third of women were smokers, lured by advertising featuring movie starlets, elite athletes, revered astronauts, rugged cowboys and even Santa Claus with cigarettes in hand.

But the smoke started to clear in 1964 with the first of 30 reports by the U.S. Surgeon General on the dangers of tobacco and the addictive nature of nicotine. The following decades saw sweeping government bans on smoking in restaurants, bars and workplaces; higher tobacco taxes; and the biggest hit against tobacco companies: a 1999 federal racketeering charge that resulted in billions of dollars in penalties, strict limits on tobacco advertising and an anti-tobacco media campaign. These steps led to a significant decline in smoking prevalence and reductions in deaths from lung cancer, heart disease and other smoking-related illnesses.

Yet tobacco still holds many Americans in its grip, with deadly effects. More than 40 million adults light up every day, and over 500,000 people die each year of diseases caused by smoking. And while cigarette use is declining among children and adolescents, exposure of young people’s brains to nicotine is climbing for the first time in decades. A recent report from the federal Centers for Disease Control and Prevention documented that use of electronic cigarettes among youth has skyrocketed in the past four years, with prevalence climbing from 1.6 percent to 16 percent among high-school students.

“Millions of kids are being introduced to nicotine every year, a new generation hooked on a highly addictive chemical,” U.S. Secretary of Health and Human Services Sylvia Burwell said recently while announcing a new federal ban on e-cigarette sales to youth.

These disturbing trends have inspired a new generation of scientists, including several at the Stanford Prevention Research Center, to turn to innovative technologies, including social media and telemedicine, and new policy approaches to end the use of what some call the world’s deadliest consumer product. They are reaching out to particularly vulnerable groups, such as young people, in an effort to stop tobacco consumption, which accounts for $170 billion a year in direct health-care spending, according to a 2015 study in the American Journal of Preventive Medicine.

“There is still no bigger killer, and this is a totally unnecessary health burden,” says Michelle Mello, MD, PhD, a Stanford professor of law and of health research and policy who has been promoting anti-smoking policies. “We have made enormous progress in reducing tobacco’s use, but it’s time for the end game.”

The seduction of tobacco

Nicotine, the addictive substance in tobacco products, can enslave users; some smokers say nicotine addiction is harder to kick than heroin or cocaine addiction in part because the drug remains so pervasively available. When nicotine is inhaled, it goes directly to the brain within 10 seconds, where it binds to receptors that stimulate the release of the neuro­transmitter dopamine, which signals pleasure. But the feeling is transient, and the brain adapts so that more and more of the drug is needed to maintain normal brain function. In the absence of the drug, users go through a withdrawal process that can make them irritable, anxious and depressed and cause disturbances in concentration and sleep as well as weight gain.

For years, behavioral scientists and pharmacologists have been trying to develop better ways to help smokers quit. The traditional method involves cognitive behavioral therapy, in which smokers are coached on ways to distract themselves from intense tobacco cravings, such as going for a walk or visiting a supportive friend. That is usually combined with nicotine replacement drugs, such as over-the-counter patches, gums and lozenges or prescription inhalers and nasal sprays, which help reduce cravings. Some drugs, such as the antidepressant bupropion (Zyban) and the stop-smoking drug varenicline (Chantix), also help greatly. Yet even with medication and counseling, only about 30 percent of smokers are able to successfully quit smoking over the long term.

Clinical psychologist Judith Prochaska, PhD, associate professor of medicine at the Stanford Prevention Research Center, says advances in behavioral approaches are much needed, both to improve success rates and to reach more people. Further, she says if scientists can find more effective methods for helping smokers quit, these principles can be applied to many other behavioral issues, such as overeating or alcohol addiction.

“Tobacco is a fantastic model for better understanding how to optimize health outcomes via effective behavior change,” says Prochaska, who is the president-elect of the Society for Research on Nicotine and Tobacco, the leading professional society in the field.

She and her team are exploring new ways to tackle tobacco addiction, capitalizing on technologies such as social media tools, computer-assisted interventions and telemedicine. She says these technology-based treatments are more personalized and less costly, and can reach large numbers of smokers over vast distances — particularly young people, who are especially hard to engage.

In a recent trial with 160 smokers, Prochaska and her colleagues combined standard interventions with a virtual, peer-​to-peer support group using Twitter. In the study, called Tweet2Quit, half of the participants were randomized to private support groups of 20 individuals. These individuals received twice-daily, automated prompt questions to keep them engaged, such as, “How are you rewarding yourself for quitting?” and “How are you organizing your life to avoid tobacco smoke?” All participants received a nicotine patch and were referred to the National Cancer Institute’s smokefree.gov​ website for information on quitting.

The results were impressive, with 40 percent of those in a Tweet2Quit support group free from smoking for more than two months, compared with 20 percent of those exposed to traditional methods. The study, supported by the National Institutes of Health, was published in February in the journal Tobacco Control.

Prochaska and her colleague Connie Pechmann, PhD, a professor of marketing at UC-Irvine, were able to “listen in” on the lively private Twitter chats. “I wasn’t surprised when I saw the results because I could see people were really working at it,” Pechmann says. “They were really attached to one another, were committed to quitting and felt an obligation to quit — that they would let the group down if they didn’t. It was like a sports team. They wanted the group to win.”

‘There is still no bigger killer, and this is a totally unnecessary health burden.’

Those in the private Twitter groups developed online friendships. “They knew they could text each other any time of the day or night if they felt a craving and needed help fighting it off,” Prochaska says. “We saw group members sharing openly that they slipped and had a cigarette and their fellow group members responding, ‘Don’t give up — we are there for you.' This concept of a peer-to-peer support group where we encourage online engagement is novel, and the findings are highly encouraging. It has been powerful observing our participants supporting each other with breaking free from their addiction to nicotine.”

With a new, $2.5 million NIH grant, the researchers are expanding the study to more than 1,000 people who will each be matched with a “buddy” who can cheer them on. The researchers will follow the participants for six months to see whether they are able to stop smoking.

Prochaska and her colleagues also are using online tools to reach out to a particularly vulnerable group: unemployed smokers. In a recent study published in JAMA Internal Medicine, the researchers found that smokers have a much harder time finding work, and when they do get a job, they are paid $5 less per hour on average than nonsmokers. It is well-​documented that employees who smoke cost employers more than nonsmoking employees, due to higher health costs, greater absenteeism and working while sick.

With funding from the California Tobacco-Related Disease Research Program, the team is recruiting smokers at local unemployment centers to test a first-of-its kind online program focused on job seekers who smoke. The study is unusual in that it meets smokers where they are — both physically and psychologically. Participants don’t have to travel to a distant site for counseling, and they receive guidance based on their readiness and drive to quit. The trial, which also uses mobile texting, will help participants identify the barriers to change and strategies for overcoming those obstacles.

The researchers will examine, over a six-month follow-up period, whether the participants stop smoking, find jobs, and experience improved health and financial well-being.

“If it works, it could be an argument for clustering other health-related programs in the same location,” as many people at these unemployment centers have limited access to health care, says Cati Brown-Johnson, PhD, a postdoctoral scholar at the Stanford Prevention Research Center collaborating on the project.

Reaching out to Alaska

When it comes to smoking and health, probably one of the most at-risk — and under­studied — groups in the country is people of Alaska Native heritage.

Nicole Jeffery, a clinical research coordinator at the Stanford Prevention Research Center, knows this all too well. Part Yup’ik, Jeffery grew up in Barrow, Alaska, and is among the few of her high school classmates to attend college; she graduated from Stanford in 2009.

Tragically, about 10 percent of her high school classmates are already dead, she says, victims of alcoholism, drug abuse and suicide.
She and her colleagues are recruiting participants for a novel telemedicine project — a long-distance counseling program — that they hope will combat some of the health problems that have plagued Alaska Native people and serve as a model for how to change health behaviors, including smoking, among underserved groups. Prochaska is the principal investigator for the NIH-funded project, which focuses on smoking and other risk factors for heart disease.

“If this can be shown to be effective, that’s a new tool available to community members in the villages,” Jeffery says. “That is huge.”

Jeffery lost her grandmother, a longtime smoker, to lung cancer. She says Alaska Native people suffer from disproportionately high rates of heart disease, cancer and chronic health problems in major part because of lifestyle behaviors: 42 percent smoke, and many are sedentary and have given up healthy, native diets for processed Western foods that are high in calories and sodium and low on nutrition. They also feel abandoned by a health-care system with few doctors to treat the most basic ailments and with specialty care that is a costly plane ride away.

“I often think about the people at home — of going there for Christmas and hearing people in church tell me, ‘They don’t know what’s wrong with me, and they don’t care.’ This is the community I love and the people I know, and it hurts when you see them not get the care they deserve,” says Jeffery, who is starting medical school this fall at the University of Washington with the goal of becoming among the first native physicians to practice in Alaska.

Through the telemedicine trial, she counsels individuals in remote villages via video hook-up from her Palo Alto-based office. During the weekly, 45-minute sessions, she and her colleagues encourage study participants to adopt better diets, exercise more and reduce smoking. She acknowledges there are challenges to doing research in rural Alaska, including weather disruptions, dropped calls due to poor internet connections, and heavily burdened community health workers. It also takes time to build trust and to demonstrate that the research is not on the community, but rather, with and for the community.

“Rural Alaska does have unique barriers. So I think it needs a unique solution,” Jeffery says, smiling. “I think our team has rolled with the challenges. But what we are doing is so needed. And people are so grateful.”

The researchers, based at Stanford and in Anchorage, have recruited more than 80 individuals with a goal of enrolling 300 participants, all daily smokers and of Alaska Native heritage. Participants do not have to commit to stop smoking when they join, though the counselors encourage them in that direction.

“People have different motivations for quitting smoking,” Jeffery said. “People will tell me, ‘I want to be here for my kids. I don’t want to have heart problems.’ Others just aren’t ready yet.”

A generation on the line

At age 16, Prit Pandya is an anti-smoking crusader of a different sort. A junior at Milpitas High School in California, he has been spending his weekends visiting local outlets that sell tobacco and helping document their sales strategies, logging what he finds on his iPad. He’s part of a team of Santa Clara County interns on a project with Stanford to collect data on tobacco marketing, with an eye to influencing state and local tobacco policy.

“I want to create more awareness in teens,” says Pandya, who’s a member of his school’s tobacco prevention club. “I want them to make better judgments — to see how small judgments you make may harm you in the future. One cigarette right now might make you happy, but you don’t know how it is damaging to your lungs in the future.”

Reaching teens is crucial, experts say, as 88 percent of adult smokers got hooked before the age of 18.

“The best way to keep a 50-year-old from smoking is to keep a 15-year-old from smoking,” says Robert Jackler, MD, professor and chair of otolaryngology — head and neck surgery, who has done extensive studies on tobacco advertising.

Teens are particularly susceptible to nicotine, as the brain’s frontal lobe — the area involved in reward, planning, attention and motivation — is still developing. When it is exposed to the dopamine surge of the drug, it readily adapts and learns to value this reward over other pleasurable activities, Prochaska says. This sets up the teen for a lifetime of addiction. Yet teens tend to see themselves as invulnerable, immune to the lure of the drug, says developmental psychologist Bonnie Halpern-Felsher, PhD, a professor of pediatrics and adolescent medicine at Stanford who studies teen and young adult attitudes about tobacco, alcohol and other health risks.

“When you ask adolescents, ‘Can you become addicted?’ they will say yes,” Halpern-Felsher says. “When you ask them, ‘Can you quit tomorrow?’ they say yes. They don’t understand that you don’t have control over the product.”

That has made teens a favorite target of the tobacco industry, whose products are ubiquitous and readily accessible to youth, even in states like California that have waged long anti-smoking campaigns, says Lisa Henriksen, PhD, a senior research scientist at the Stanford Prevention Research Center.

“Everybody complains that there are so many fast-food restaurants, but in California there are 28 tobacco retailers for every McDonald’s,” she says. “These retailers are literally omnipresent.”

That is key because teens who frequent retail outlets with widespread tobacco advertising, such as convenience stores and small markets, are significantly more likely to start smoking than those who are less exposed to this advertising, she found in a 2010 study, published in the journal Pediatrics.

“You can walk up to pay for soda or a snack on the way home from school and when you go up to a cash register, you are confronted with a very large display of cigarettes and tobacco products. They are placed in every store so they are maximally visible,” she says.

‘I had one middle-schooler tell me, “I’m mad. I don’t want to be a replacement smoker.” ’

She and her colleagues have been documenting the latest trends in tobacco marketing, sometimes enlisting the help of students, like Pandya, to visit tobacco sellers and report back on what they observe. The biggest trend is the surging popularity of so-called electronic nicotine delivery systems, often displayed on the front counter in convenience stores, liquor stores and other retail outlets. These are battery-powered devices in the shape of a conventional cigarette or palm-sized box that can be filled with “e-liquids” containing various levels of nicotine. The user presses a button that ignites a coil inside the device to heat the liquid and create a puff of vapor that is inhaled. These products, available in vape shops as well as general retail stores, are sold in thousands of different flavors, including apple pie, chocolate and caramel frappe, making them appealing to youth.

In the past four years, the number of high-school students using these electronic devices has skyrocketed while cigarette smoking among these youth has declined from 15.8 percent to 9.3 percent, according to a recent report from the CDC.

“Cigarette smoking is passé. What’s new is vaping and marijuana. Kids think it’s less dangerous than smoking,” Pandya says, based on what he’s observed among his peers. The safety of the relatively new — and until recently unregulated — electronic nicotine products remains highly controversial, as there are no long-term studies to document their risks.

In two recently published studies, Halpern-Felsher and her colleagues showed that youth harbor misperceptions about e-cigarettes. E-cigarettes lack the lung-damaging tar and the carbon monoxide of combustible cigarettes and most deliver nicotine more slowly to the brain. But Jackler and other experts say they contain enough of the drug to form an addictive habit. Moreover, studies show that American teens who start with e-cigarettes are more likely than nonusers to begin smoking conventional cigarettes, Halpern-Felsher says.

She says young people get very little information about the health risks of e-cigarettes from schools, parents, health educators, health-care providers and others. For that reason, she is teaching youth about the dangers of these nicotine offerings through a new online tool kit she plans to distribute to school districts across the state and hopes to make a national model. She says using “scare tactics” with kids — simply telling them a product is unsafe or that they’re likely to develop lung cancer years down the road — isn’t very effective.

What is effective is stirring outrage among teens about how they are being manipulated and lied to, as the tobacco industry did in the early days when it claimed cigarette smoking was perfectly safe. That is the model established by the Truth Campaign, created in 1999 by the nonprofit American Legacy Foundation to provide honest information to young people about the behavior of the tobacco industry.

“I tell kids that industry leaders have been dishonest before. Can you trust them? And I point out that over 500,000 people die every year from smoking. So the industry needs replacement smokers,” Halpern-Felsher says. “I had one middle-schooler tell me, ‘I’m mad. I don’t want to be a replacement smoker.’ ”

Henriksen also hopes that documenting tobacco marketing practices will help inform widespread policy changes that will discourage tobacco use in teens. These would include a ban on menthol and other flavored tobacco products, limits on who can sell tobacco, restrictions on tobacco displays and tobacco-free policies on college campuses, among other changes.

Some of these efforts already have paid off: In May, California Gov. Jerry Brown signed legislation to raise the legal age for buying tobacco from 18 to 21, making California the second state in the nation, after Hawaii, to raise its age limit. New legislation also expanded tobacco-free laws to cover school property at all times, regulated e-cigarettes like traditional tobacco products and increased licensing fees for tobacco distribution and sale.

Tobacco-control forces in California also announced recently they have enough signatures for a fall ballot initiative that would increase the state’s tobacco tax by $2 a pack, the first increase since 1988. Raising the price of cigarettes is a proven strategy for discouraging young people from buying tobacco products, as youth are particularly sensitive to price, Jackler says.

There have been steps at the federal level as well, with the Food and Drug Administration enacting sweeping new rules that include a ban on sales of electronic nicotine products to anyone under age 18. The new regulations, which go into effect in August, also require e-cigarette makers to apply to the FDA to sell their products and to provide details on the ingredients and how the products were made.

Prochaska says the state’s new tobacco initiatives are certain to help California reduce its smoking rates, just as regulations against lighting up on airplanes, in restaurants and in hospitals did in the ’80s and ’90s. Recently, she and Henriksen received funding from California’s Tobacco-Related Disease Research Program to study the impact of closing the loopholes in the state’s 1994 smoke-free workplace laws to include owner-operated businesses with no employees; hotel lobbies, meeting and banquet rooms; warehouse facilities; employee break rooms; and workplaces with five or fewer employees — one of the new laws just signed by Gov. Brown.

She says restrictions on public smoking make it less socially acceptable and have contributed to significant declines in tobacco use and in smoking-related diseases and death. Today, 19 percent of men and 15 percent of women nationwide are regular smokers, far less than the heyday of the early 1960s.

“Although it has been an uphill battle against a behemoth of an industry, with widespread influence and financial means,” Prochaska says, “I am optimistic about the future.”

Ruthann Richter is the director of media relations for the medical school's Office of Communication & Public Affairs. Email her at richter1@stanford.edu.

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