COMPARING SMOKING BEHAVIORS BETWEEN FRANCE AND THE UNITED STATES: A HISTORICAL AND CULTURAL ANALYSIS
by
CHRISTINE DANG
DISSERTATION
Presented to the Faculty of the Medical School The University of Texas Southwestern Medical Center In Partial Fulfillment of the Requirements For the Degree of
DOCTOR OF MEDICINE WITH DISTINCTION IN GLOBAL HEALTH
The University of Texas Southwestern Medical Center Dallas, TX
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ACKNOWLEDGMENTS
I would like to thank Dr. Angela Mihalic, my chief thesis mentor and advisor during the International Medical Exchange Program. I would also like to thank Dr.
Adriane Dela Cruz and Dr. Mary Chang for the guidance during their thesis writing process and perspectives on smoking behavior from an addiction psychiatry and global health standpoint.
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ABSTRACT COMPARING SMOKING BEHAVIORS BETWEEN FRANCE AND THE UNITED STATES: A HISTORICAL AND CULTURAL ANALYSIS
CHRISTINE DANG The University of Texas Southwestern Medical Center, 2021 Supervising Professor: Angela Mihalic, M.D.
BACKGROUND: The early 20th century represented a time of remarkable growth for the tobacco industry. After the link between smoking and lung cancer was solidified in the mid 20th century, smoking prevalence in developed countries has largely decreased. However, a subset of developed countries has not seen as large a decrease in smoking rates. The reasons for this divergence in smoking prevalence patterns have not been fully explored in the literature. France is one of the countries that has shown a decrease in smoking prevalence, yet their smoking prevalence is still much higher at 30% when compared to other developed countries such as the United States at 16%. These high rates of smoking in the general public also coincide with high rates amongst health professionals. Smoking status in health professionals has real effects on patient care namely through decreased likelihood to engage in cessation counseling and less favorable perceptions of the importance of counseling.
OBJECTIVE: This thesis will explore the effects of American and French government regulations on the usage of tobacco cigarettes in two time periods (1964-2009, and 2009- present day), the cultural ties to smoking and their change over time, prevalence of smoking amongst healthcare professionals, and the public health implications tied with physician smoking status.
METHODS: Historical analysis was performed on legislation passed by the American and French government from 1964 present day, different forms of media promoting tobacco usage, and physician smoking patterns and counseling practices. Sources in both the French and English language were used, and included but were not limited to research articles, book chapters, newspaper articles, and official government reports.
RESULTS: The findings of this literature review suggest that compared to the United States, France has higher rates of smoking due to delayed government action at the height of the tobacco epidemic and cultural attachment to cigarette use.
Both France and the U.S. have cultural ties to cigarette smoking. However, in France, the association of smoking with national identity through cigarette marketing tactics and the birth of café culture in the 1960s are large reasons why high smoking rates persist. The U.S. s success in decreasing smoking rates over the latter half of the 20th century could largely be attributed to the stigma created around smoking and tobacco use, increasing the awareness of the medical complications of smoking by cultural icons, and mass public health campaigns.
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Though more prevalent in France, physician smoking remains an issue in both countries and is associated with decreased rates of cessation counseling and negative perceptions regarding the utility of cessation counseling. However, French patients are more likely to experience these negative downstream effects as France has higher smoking rates amongst physicians.
CONCLUSION: This review provides a different perspective from previous literature in that it not only compares French and American government action, but it also analyzes the cultural underpinnings of tobacco use as well as its public health implications. Furthermore, it has revealed many areas in which both the United States and France could improve their public health strategies in combatting the tobacco epidemic as well as reasons why high smoking rates continue to persist in France.
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TABLE OF CONTENTS
Foreword 7
Chapter 1: Historical Background 20th century prior to 1964: The growth of the cigarette industry 10
Chapter 2: Government Involvement 1964 2009: The rise of government regulations on the tobacco 15 industry 2009 Present day: FDA regulations and Future Movements 21
Chapter 3: Cultural Ties 28
Chapter 4: Health Professionals & Smoking 32
Chapter 5: Conclusion 35
Afterword 41
References 42
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FOREWORD
My love of languages began one sixth grade study hall where I decided to take beginning French the following year. Little did I know that this one French class would
ead a e , a bac e deg ee F e c a g age a d c e, a e research internship, and after starting medical school, six months of rotations in various
a a d Pa , F a ce a a f UT S e e I e a a Med ca
Exchange Program.
Those six months of rotations were full of learning experiences, both medical and cultural. My first rotation was emergency medicine at St. Joseph, a small private hospital in the 14th arrondissement. Every afternoon after lunch, all the residents and medical students would congregate outside the entrance of the emergency room in the cold Paris weather to light a cigarette. The first time this happened, I was quietly surprised, but noticed this pattern as well in the older physicians. In my previous visits to Paris, I had always been taken aback by the higher rates of smoking compared to the United States; however, I expected differently at the hospital. When shadowing an intern (who also happened to smoke), we took a substance use history from a patient, and he informed the patient about the negative effects of smoking. The knowledge about the dangers of smoking and the need to discuss these dangers with patients was the same in both the
U.S. and France, yet smoking behaviors were so drastically different between the two countries. This situation made me wonder why the rates of smoking were so different in the United States compared to France, how tobacco use in healthcare providers can affect patient care, and what events in history have molded the stigma of smoking in the field of medicine and in daily life.
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Smoking prevalence in developed countries has largely decreased over the course of the 20th century, yet a subset of developed countries has not seen as large a decrease in smoking rates [1] . The reasons for this divergence in smoking prevalence patterns have not been fully explored in the literature. France is one of the countries that has shown a decrease in smoking prevalence, yet their smoking prevalence is still much higher at 30% when compared to other developed countries such as the United States at 16% [2]. These high rates of smoking in the general public also coincide with high rates amongst health professionals. Smoking status in health professionals has real effects on patient care namely through decreased likelihood to engage in cessation counseling and less favorable perceptions of the importance of counseling [3-5].
The tobacco epidemic is one of the largest global public health threats, killing more than 8 million people globally each year. Seven million of these deaths are attributable to direct tobacco use, and 1.2 million are the result of nonsmokers being exposed to secondhand smoke [6]. As smoking disproportionately affects those of lower socioeconomic status, reducing tobacco use would be the first step to addressing health disparities, thereby decreasing tobacco-related health complications and achieving a healthier international community. Since the link between lung cancer and smoking was established, French and American public health advocates have been relentlessly lobbying the government for stricter legislation against tobacco companies and have led several public health campaigns aiming to prevent youth from smoking. By comparing and contrasting the French and American strategies of combatting the tobacco epidemic and their efficacies, we can better understand which methods are most useful in curtailing smoking rates and why smoking rates are higher in France.
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In this thesis, I hypothesize that smoking prevalence in France is higher than in the United States due to cultural ties to smoking and the delayed enforcement of tobacco restrictions by the French government. I seek to explore the effects of government regulations on the usage of tobacco cigarettes in two time periods (1964-2009, and 2009- present day), the cultural ties to smoking and their change over time, prevalence of smoking amongst healthcare professionals, and the public health implications tied with physician smoking status. By taking a more in-depth look into each country s history in terms of its political actions and cultural attachments to smoking, we can better understand present-day differences in smoking behavior.
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HISTORICAL BACKGROUND
20th century prior to 1964: The growth of the cigarette industry
In the early 20th century, cigarette smoking became more common in the United
States. Annual per capita cigarette consumption skyrocketed from 54 cigarettes in 1900 to 4345 cigarettes in 1963, just 2 years prior to the release of the 1st Surgeon General s
Report [7, 8]. By 1953, approximately 47% of American adults and half of all physicians smoked cigarettes [9]. Cigarette usage rapidly grew despite fierce opposition of religious leaders and temperance advocates who feared that cigarettes were a gateway drug to narcotic drugs and alcohol [10, 11]. Advertising was a powerful tool for cigarette companies to garner current and potential consumers. During this period in time, little was known about the deleterious health effects of tobacco use, and many advertising campaigns used explicit yet unfounded health claims to appeal to consumers. For instance, They don t get your wind (Camel 1935), gentle on my throat (Lucky Strike,
1937), play safe with your throat (Philip Morris, 1941) [10, 12]. It was also quite common to see advertisements using physician and celebrity endorsements to add validity to these health claims and to attract consumers (Figure 1).
Similar to the U.S., France experienced a rise in cigarette consumption from the beginning of the 20th century up until the mid 1970s with sales increasing an average of
4% annually [13]. Much of these sales directly benefitted the government as France had a state-run monopoly on the tobacco industry. known as Societé d exploitation industrielle des tabacs et des allumettes (SEITA). SEITA, which was created in 1910 then later privatized in the 1990s, oversaw the fabrication and distribution of tobacco products in
France. The two major cigarette brands, Gauloises and Gitanes, branded themselves as
10 something uniquely French and appealed to national pride, often using their national colors of red, white, and blue on their packaging and advertisements (Figure 2). The distribution of free Gauloises cigarettes known as le tabac de troupe to soldiers during
World War I further associated the brand with French patriotism and contributed to the surge in popularity of the brand such that after the war, SEITA helped pay off the debts of the French government through its sales [14].
In both the U.S. and France, the rising popularity of cigarettes was facilitated by three major factors: (1) national advertising campaigns; (2) the industrial revolution which transformed the means of transport and mass production, leading to widespread distribution of cigarettes, (3) and the rise of feminism which led to the increasing acceptance of females smoking cigarettes [10, 15-17]. Between the two countries, marketing tactics differed in that the French relied more heavily on boosting national pride whereas American companies employed physicians or actors as the faces of their product to boost its popularity. The usage of national pride by French companies may have contributed to the eventual incorporation of smoking into French cultural practices which could be potentially difficult to address in public health efforts. On the other hand, the employment of actors and physicians in American tobacco advertisements was easier to reverse as increasing amounts of scientific evidence linking smoking with lung cancer surfaced. Physicians changed their stance on smoking, and several actors involved in marketing campaigns would later publicize the negative effects of smoking.
Consequently, the usage of patriotism in marketing tactics may have led to the entrenchment of smoking as a cultural practice in France, contributing to its persistently high national prevalence.
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Figure 1: American cigarette advertisements from the 1930s featuring physician and celebrity (Ronald Reagan) endorsements [18]
Figure 2: French advertisements from Gauloises and Gitanes, the two largest cigarette brands from the early 20th century, featuring the national colors [18]
An increasing number of cases of lung cancer
Lung cancer was a rare diagnosis in the 19th century, yet numbers were increasing during the first 2 decades of the 20th century [19]. In 1929, Fritz Lickint performed the first study statistically evaluating the link between lung cancer and tobacco in Dresden,
Germany and was the first to coin the term passivrauchen, or passive smoking, in 1936
[20]. By the mid 1950s, the association between cigarette consumption and lung cancer was solidified by several scientific studies [21-23], leading the US Public Health Service
12 to release an official statement that the weight of the evidence is increasingly pointing in one direction: that excessive cigarette smoking is one of the causative factors in lung cancer [24].
Many cigarette companies refuted these health claims by conducting their own scientific research to disprove this association. They also challenged the evidence of previous studies, stating they relied on animal evidence [25]. Companies went on to popularize the filtered cigarette, claiming that the filter would prevent inhalation of potentially carcinogenic materials even though the industry had recognized as early as the
1930s that filtered cigarettes did not reduce the amount of inhaled substances [10].
However, the advertising campaigns claiming purity with a filter were so successful in swaying the public to believe these cigarettes were safer that sales dramatically began to shift from unfiltered to filtered cigarettes. In 1952, filtered cigarettes accounted for less than 2% of cigarette sales, yet by 1957, it would grow to account for 40% of sales [26,
27].
The landmark 1964 Surgeon General Report
In January 1964, Dr. Luther L. Terry released the first Surgeon General s report on smoking and its impact on health. This 387-page report reviewed over 7,000 research articles on smoking and disease. Many of these articles came from the mid-20th century; however, the earliest dated from even the early 1900s. This report concluded that smoking was associated with higher all-cause mortality amongst men, that it was a cause of laryngeal and lung cancer in men and probable cause of lung cancer in women, and that smoking was the most important cause of bronchitis [28]. The release of this report ignited a series of policies aimed to diminish the usage of cigarettes amongst the
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American population [29]. The report hit the country like a bombshell, according to Dr.
Luther L. Terry, and prompted an international conversation regarding the negative health effects of tobacco use [30].
In the years following, both the French and American government moved to pass a series of policies aimed to diminish the usage of cigarettes amongst the general population by restricting marketing campaigns by the tobacco industry and promoting awareness of the entire gambit of health problems associated with cigarette smoking. The next section will discuss in detail the most important American and French policies that were passed and their effects on the national consumption of cigarettes.
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GOVERNMENT INVOLVEMENT
1964 – 2009: The rise of government regulations on the tobacco industry
United States
Following the release of the 1964 Surgeon General report, the U.S. Congress quickly adopted the Federal Cigarette and Advertising Act of 1965, which required that all cigarette packaging carry a health warning: Caution cigarette smoking may be hazardous to your health. The Public Health Service, in partnership with several health organizations, has supported successful state and community campaigns, disseminated research findings related to the negative health effects of tobacco, and ensured public visibility to antismoking messages [29]. With a heightened general awareness of the detrimental health effects of smoking, public health advocates were able to put much pressure on President Richard Nixon, an avid pipe smoker himself, to sign the Public
Health Cigarette Smoking Act of 1970 (also known as the Broadcast Ban). This law banned cigarette ads on television and radio, a monumental feat as cigarette companies were one of the largest product advertisers on television in the 1960s [31]. Per capita cigarette usage began to drop following passage of this law (Figure 3), suggesting that restricting cigarette advertising can produce real decreases in consumption.
Anti-smoking legislation not only came from the national level but also from individual states. In 1975, Minnesota passed the Minnesota Clean Indoor Air Act, the first statewide law in the U.S. requiring separate smoking areas in public places.
Comprehensive anti-smoking laws came in piecemeal throughout the nation beginning with Aspen, CO mandating smoke-free areas in restaurants in 1987 and then California
15 becoming the first state in 1998 to pass a comprehensive statewide law banning smoking in restaurants, bars, and public places [32].
Heavily taxing tobacco products has become a strategy commonly used in other developed countries such as Denmark and Canada to dissuade consumers from smoking.
The United States also has used this strategy since the 1980s, but rates of taxation did not fully keep up with the rate of inflation and rise of income in the 1990s. In 1993, the most expensive city to buy cigarettes was Washington DC, where the state tax was 63 cents, in addition to the 24-cent federal tax [33]. However, in the 1990s, cigarettes were 60% more affordable than in 1955 [34]. Despite the relative affordability of cigarettes, smoking rates continued to drop in the 1990s with a per capita annual cigarette consumption dropping to approximately 2500 compared to approximately 4300 in the 1960s (Figure
3).
In the early 2000s, the U.S. Department of Justice sued several major tobacco companies on the grounds of misinforming the public of the dangers of cigarette use.
Several large public health groups such as the American Heart Association and the
American Cancer Society provided testimonials for the lawsuit which tobacco companies ultimately lost [35]. Appeals to overturn the decision were not granted with the court stating that the defendants knew of their falsity at the time and made the statements with the intent to deceive. Thus, we are not dealing with accidental falsehoods, or sincere attempts to persuade [36]. As a result, tobacco companies issued corrective statements admitting to the adverse health effects of smoking and secondhand smoke, addictiveness of nicotine, manipulation of cigarette design and composition to enhance nicotine delivery, and the lack of health benefit from smoking low tar or mild cigarettes.
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Statements were published as full-page ads in more than 50 newspapers across the country and were broadcast during primetime slots on major television networks [37].
This lawsuit represented a major public health victory and prompted several other class action, individual, and third party reimbursement lawsuits both in and outside of the U.S against large tobacco companies [38].
Figure 3: Changes in per capita cigarette consumption during the 20th century [39]
France
Compared to their American compatriots, France was late to create anti-smoking legislation. This could partially be attributed to France s state-wide monopoly on tobacco through SEITA. The revolving door culture of tobacco executives moving in and out of the government made strict anti-smoking legislation difficult to pass as many politicians were stakeholders in the tobacco business [40].
It was not until the 1970s that France passed its first significant piece of legislation aimed to restrict the spread of smoking and tobacco use. The French health
17 minister at the time, Simone Veil, helped draft the Veil law, which passed in 1976. Its major accomplishment was the implementation of written warnings of abus dangereux or the risk of addiction on all cigarette packaging [41]. It also attempted to establish nonsmoking areas in public spaces; however, the law specified that nonsmoking areas must be more than half of the total establishment, a requirement so extreme that many places were unable to comply with these guidelines. As a result, this portion of the law was poorly enforced [42]. Compared to the United States where antismoking legislation was largely passed on a state level with the exception of a few national laws which curbed tobacco advertising, France attempted to accomplish a lot (establishing non- smoking areas, printing warnings on packaging) in one large national law but was unable to fulfill all of its goals.
The Evin law of 1991 was created to expand on the pre-existing Veil law.
Whereas the United States passed its Broadcast ban in 1970, the Evin law of 1991 was the first French law attempting to control tobacco advertising. It outlawed any advertising portraying tobacco use in a positive light, replaced the previous message of abus dangereux (risk of addiction) on cigarette packages with a larger, more explicit warning of nuit gravement à la santé (serious harm to health) and instated taxation on tobacco products. Similar to its predecessor, the Veil law, it attempted to mandate smoke-free sections in cafes and restaurants, but was so loosely worded that it was not enforced well
[42]. For instance, establishments such as restaurants and cafés had smoking and nonsmoking sections that were often not well separated.
Viewing tobacco use as a still pertinent problem in France during the early 2000s,
President Jacques Chirac, declared la priorité: la guerre contre le tabac, (a priority: the
18 war against tobacco) in 2002 as part of Plan Cancer I (2003-2007) [41]. As part of Plan
Cancer, taxes were imposed on tobacco products to help dissuade French citizens from buying and using these products, a move which proved to be effective. After an increase in 37% in price, per capita cigarette sales dropped 34% within 2 years (2002-2004) [43].
With the increase in taxes, prices for cigarettes steadily grew, and France became one of the most expensive countries in which to buy cigarettes [44].
The Bertrand decree of November 15, 2006 modified the Evin law and extended smoking restrictions in its first wave in 2007 to enclosed or covered public or work spaces, health establishments, public transport, and schools, and in its second wave in
2008 to places of social gathering such as bars, clubs, hotels, and restaurants. It also created more specific restrictions for designated smoke rooms reserved for smokers; for instance, such spaces had to be enclosed and ventilated [45]. As the construction of these rooms were difficult for regular establishments, customers would resort to smoking at outdoor tables. Despite these harsher restrictions, compliance (97%) and support (88% amongst smokers) for this law has been very high amongst the French people [46].
The overall prevalence of smoking in France has slightly decreased throughout the latter half of the 20th century and remained stable in recent years (Figure 4). This decrease in prevalence appears to be closely correlated to the increase in price over time
(Figure 5). From 1950 to 1976 (the year the Veil law was passed), per capita cigarette consumption doubled from 2.9 cigarettes/day/adult in 1950 to 5.8 in 1976. This number remained stable until 1991, the year which marked the passage of the Evin law. The Evin law, which increased taxation on cigarettes, preceded a slight decrease in per capita cigarette consumption to approximately 5 cigarettes/day/adult in 2002 [43]. The passage
19 of Plan Cancer by Chirac also added even more taxation to cigarettes in France, and by
2010, per capita cigarette consumption dived down to less than 3, which 60 years later, was approximately the same number as in 1950.
Overall, the French strategy for tackling the tobacco epidemic was different from that of the U.S. in that legislation was passed on a national level, and successive laws built on top of each other. On the other hand, the U.S. used state-level legislation to address tobacco usage. Though the French approach was more unified, its laws required several iterations to put forth attainable requirements for non-smoking areas for establishments to abide by and properly enforce these laws. In all, this delayed complete enforcement, for instance of advertising restrictions, compared to the U.S.
Figure 4: Graph depicting prevalence of smoking by sex (top-most line (blue): men, middle (gray): overall, bottom-most (green): women) [47]
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Figure 5: Change in sales of cigarettes and relative price of cigarettes over time. Black line depicting sales in terms of cigarettes/adult/day, gray line depicting price of cigarettes in terms of price index [48]
2009 – Present day: FDA regulations and Future Movements
United States
Since the 1990s, the Food and Drug Association (FDA) has been trying to claim jurisdiction over the tobacco market by asserting nicotine is a drug. In 2009, President
Barack Obama signed the Family Smoking Prevention and Tobacco Control Act which gave FDA the authority to regulate the manufacture, distribution and marketing of tobacco products. Under this act, the FDA was required to come up with new warning labels for cigarette packaging and advertisements. In 2012, the FDA was unable to get their new warning labels approved after the U.S. Court of Appeals cited that the harsher proposed graphic warnings were unconstitutional as the images were not needed to prevent cigarette companies from misleading consumers, and thus infringed on corporations right to free speech [49, 50]. One of the rejected proposed warnings depicted a man smoking through a tracheostomy, and another showed a corpse with staples on the chest on an autopsy table. Under the new Required rule for cigarette
21 packages and advertisements issued in 2019, 13 different images realistically depicting lesser known health side effects of tobacco use were proposed. An example of these images can be seen in Figure 6. These changes are set to take place in 2021 and would provide a much-needed update to the current set of warnings which were first instated in
1984.
Figure 6: New warnings which will be incorporated on cigarette packaging throughout the United States beginning 2021 [50]
The Family Smoking Prevention and Tobacco Control Act also helped implement new rules to curb youth access and use of tobacco products. Some of the most notable restrictions include prohibiting the sale of cigarettes in packs less than 20 (known as
kiddie packs ) that make cigarettes more affordable to minors, restricting cigarette sales by vending machine and mandating products be placed behind the counter, restricting tobacco advertising near schools and playgrounds, and reducing tobacco ads to black- and-white text in publications with significant teen readership [51]. Furthermore, the passage of the Tobacco 21 law in 2019 raised the federal minimum age for sale of tobacco products from 18 to 21 years old.
Access to medical treatment for smoking cessation was facilitated by the
Affordable Care Act, passed by the Obama administration in 2010. This act required all state Medicaid programs and most private insurances to cover tobacco cessation
22 treatment and established the Prevention and Public Health Fund which provides funds to prevent and reduce tobacco use [52].
National public health campaigns have been instrumental in helping raise awareness of the negative health effects of smoking and in encouraging smokers to quit.
In March 2012, the Center for Disease Control and Prevention (CDC) launched the first- ever federally paid national tobacco education campaign: Tips from Former Smokers.
This campaign consisted of televised commercials featuring the stories of real people living with serious medical complications from smoking and the emotional stories of the toll smoking-related conditions have taken on their family members, and was associated with an increased number of quit attempts amongst viewers [53]. Every Try Counts, an
FDA-driven antismoking campaign, aims to encourage adults 25-34 years old to stop smoking through message bulletins underscoring the benefits of quitting; these messages are placed around gas stations and convenience stores where smokers typically smoking advertisements and may face triggers to smoke [54]. Both campaigns provide websites featuring telephone quitlines and smartphone applications in several languages to link smokers with cessation counseling. Since 2012, approximately one million people who smoke have successfully quit from the Tips from Former Smokers campaign alone [55].
France
Despite the efforts of the French government to curb smoking, a large portion of the public still smokes. In fact, a national survey conducted by the national health department, Santé Publique France, noted that in 2016, 34.5% of 15-75 year olds smoked cigarettes, and 28.7% smoked daily. These rates have remained stable since 2010 [56].
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One of the most influential policies passed since the Bertrand decree in 2006 was the 2016 ordonnance. This established that 65% (was previously 30-40%) of all cigarette packaging must be neutral, characterized only by one color regardless of type or brand, with visual and text health warnings. When comparing the changes in cigarette packaging in France over time, the emphasis of neutrality and bold warnings has become more apparent. Figure 7 prominently displays the barely visible abus dangereux warning implemented by the Veil law in 1976, the larger, more visible nuit gravement à la santé from the 1990s, and finally the neutral packaging displaying graphic images of medical complications from smoking which recently took effect in 2016. Due to the recency of this ordonnance, limited data is available on its effects on public cigarette consumption.
Figure 7: The change of French cigarette packaging warnings over time
Similar to the United States, anti-tobacco campaigns have been instrumental in engaging the French people in discussions about smoking. Many of the present anti- tobacco campaigns have been spearheaded by the national agency of public health, known as Santé Publique France. Since 2016, the Tabac Info Service, an anti-smoking subgroup of Santé Publique France, has sponsored the mois sans tabac (no smoking month) campaign (Figure 8). This campaign aims to help smokers take the first step to
24 quit smoking every November. Mois sans tabac has grown into a mass media campaign using television, radio, advertisements and the internet, and has recruited over 909,000 participants since 2016. Through a series of cessation workshops, one-on-one telephone counseling, sports challenges, and flashmobs, it creates a sense of community while also challenging participants to stop smoking for a month [57]. Their website is filled with inspiring testimonials from participants who maintained their smoking abstinence after the challenge. One participant thought it was a lost cause, and too late for [her] to quit after multiple failures at 64 years old. However, she was able to scream victory! when she and her husband successfully quit the same day and have continued to not smoke for
11 months [58].
Figure 8: An advertisement for the Mois sans tabac (No smoking month) campaign, reading Because 1 month without smoking is 5 times more of a likelihood to quit. [57]
From a prevention standpoint, the French government has been trying to reduce the number of teenagers who begin to smoke. France raised the minimum age to legally purchase cigarettes from 16 to 18 years old in 2009, a strategy similar used in the U.S.
(though the age will be raised from 18 to 21 years old in 2021 in the U.S.) [59]. Santé publique also began a peer mentoring program aiming to educate middle and high schoolers about the negative effects of smoking. This program was inspired by other peer-mentoring programs in the United Kingdom which were shown to be efficacious in
25 reducing smoking rates amongst adolescents. Another program contains a series of workshops for parents and their children which uses role-playing and situational exercises aiming to begin conversations early about the negative effects of substance use while creating a positive familial environment. Campaigns such as these are vital in helping children understand early on the harms of tobacco use and build a stronger support system through their peers and parents which may serve to be a protective factor in the future [60].
Socioeconomic disparities
In the 1960s, when the link between lung cancer and smoking became scientifically established, the vast majority of American smokers who decided to quit smoking were professional, affluent men [61]. In the recent years, these socioeconomic disparities have widened amongst smokers in France and the United States. As seen in
Figure 9, a large portion of French smokers are of lower education level and are unemployed. Rates of smoking have risen from 35.2% to 37.5% in 2005 to 2010 in those of lowest socioeconomic status (SES) whereas it decreased from 23.5 to 20.9% in those of highest socioeconomic status [56]. These disparities have real health outcomes in the
United States, people living in poverty have been shown to smoke more heavily and are more likely to be affected by lung cancer than those of more affluent status [62, 63].
Furthermore, those of lower SES are less likely to have access to healthcare, and thus are more likely to be diagnosed in the later stages of disease [64].
Health literacy is one of the main reasons why these disparities exist. In both
France and the United States, studies have shown that lower health literacy is associated with higher nicotine dependence, less knowledge about health risks, and lower risk
26 awareness [65, 66]. In one French telephone survey, a number of consumers outright denied the risk of smoking, some citing that exercising would clean [their] lungs, or that breathing city air is as bad as smoking cigarettes. Others were against the anti- smoking movement which they deem to be an infringement on their individual freedom
[67, 68].
Figure 9: Graph depicting the breakdown of regular smokers by education level and employment status
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CULTURAL TIES
France
In the streets of France, seeing a busy café with patrons smoking, chatting, and having a drink is commonplace. Many foreigners are struck by the amount of smoking they witness when first visiting France, yet the reasons for these differences in smoking behavior are multifaceted. A combination of cigarette branding tactics used to appeal to national identity, the rise of café culture, and cigarette consumption by cultural icons are reasons that could explain why smoking remains prevalent in France to this day, and why smoking is inextricably linked to French culture.
One of the most well-known cigarette brands is the Gauloises, named after the original Celtic tribe that settled in modern day France. The brand grew in popularity between the two World Wars, after it was popularized by the poilu, slang for the French soldiers fighting in the trenches. Smoking Gauloises was considered patriotic and representative of the heartland values, and their slogan, Liberté toujours, or freedom forever evoked a sense of national pride that became a trademark of their brand [69].
The appeal to nationalism through marketing tactics leading to a surge in popularity of the brand could be part of the explanation as to why smoking rates remain persistently high in France.
French cultural icons also played a large role in the creation of café culture and the promotion of smoking. Famous artists such as Maurice Ravel and Pablo Picasso and authors such as Jean-Paul Sartre and Albert Camus were avid smokers and frequented cafés which became a gathering place for intellectuals to debate philosophical issues, and for artists to exchange ideas and display their works. The association between these
28 cultural icons and the café is forever immortalized and respected to this day; in Paris, cafés such as Café de Flore or Les Deux Magots have name plates showing where famous figures such as Hemingway, Sartre and Picasso sat [70]. In both the U.S. and
France, social triggers (ie: smoking cigarettes with a drink or a meal or being with friends who smoke) can make it difficult for smokers to quit [71, 72]. However, in France where café culture is so popular, this social aspect is a major obstacle for many to quit smoking and for France to achieve lower smoking rates.
The cigarette has become a part of the French national identity and a symbol of individual freedom. Even with stricter legislation on advertising and permitted smoking places, the connection between smoking and French culture remains apparent to this day.
For instance, tobacco product placement still persists in films due to lack of enforcement of tobacco placement restrictions in the media and claims of artistic freedom by filmmakers. A review by the National League against Cancer found that 80% of French films between 2005 and 2010 had smoking present, representing the equivalent of five tobacco commercials per movie [73]. Though a number of French citizens disprove of stricter tobacco legislation, viewing it as an infringement on individual freedom, the majority of French citizens are in favor of these stricter tobacco laws, a possible indication that French cultural attachment to smoking is beginning to weaken [74].
United States
The United States also has cultural attachments to smoking rooted in its own history. Since the 1930s, cigarettes were celebrated and glamourized by Hollywood stars like Humphrey Bogart, Gertrude Lawrence, and Ronald Reagan who could often be seen clutching a cigarette on the large movie screens (Figure 10) and were often under
29 cigarette advertising contracts (Figure 1). While the image of sophistication and elegance was propagated by Hollywood, some tobacco companies used advertising to help create iconic images unique to their brand. For instance, the Marlboro man, depicted as a cowboy, engendered an image of rugged masculinity that followed the brand all over the world. The Marlboro man campaign was wildly successful, and in just two short years,
Marlboro s sales grew from $5 billion in 1955 when the campaign first launched to $20 billion in 1957 [75].
The U.S. cultural attachment to smoking appears to be limited to films and advertisements from the tobacco golden age, the early 20th century, and has not been ritualized into daily social routines as it has in France. The cultural attachments the U.S. from this golden age have been fiercely combatted by public health advocates as well as state and federal governments. For instance, several of the Marlboro men who developed smoking-related health complications such as lung cancer and chronic obstructive pulmonary disease (COPD) went on to aid the anti-smoking movement by testifying in favor of anti-smoking legislation and appearing on televised segments to educate the public on the negative effects of smoking [76]. Antismoking legislation was also instrumental in deglamorizing tobacco. The Broadcast Ban of 1970 dropped smoking within television dramas by 70%, and the Master Settler Agreement in 1998 which banned tobacco companies from paying to place their products in films led to a sharp decline in the number of films featuring tobacco products [77]. The American Motion
Picture Association (MPA) has attempted to regulate the depiction of smoking in films through ratings and a smoking label for movies containing smoking, though this
smoking label has not yet been widely applied [78].
30
Figure 10: An example of the glamorization of cigarettes in American Hollywood films Noel Coward and Gertrude Lawrence in Private Lives (1930) [61]
31
HEALTH PROFESSIONALS & SMOKING
Prevalence of cigarette smoking and changes over time
Patients generally view their physicians as trusted health advisors, and to some extent, role models for a healthy lifestyle [79]. When physicians themselves struggle with the health practices that they advise for patients, the trust and credibility within the patient-physician relationship can begin to fade. For instance, patients who perceive their provider to be overweight or obese may be less likely to follow medical advice and more likely to change providers [80]. Physicians have also reported difficulty in counseling patients on practices such as dietary fat intake, sunscreen use, and smoking cessation that they too struggle with [81]. Recognizing the potential of physician behaviors to impact patient care is the first step to understanding why smoking amongst health providers must be addressed.
Smoking remains an important issue in the medical profession, and physicians play a key role in smoking cessation in the community as well as in the development of public health policy [82]. Research has shown that medical interventions have proven to be a vital tool in helping patients quit smoking [83]. This puts physicians, particularly those engaged in primary care, at the forefront of smoking cessation counseling and highlights the importance of a physician s ability to broach cessation counseling and treatment options with patients. However, when physicians themselves engage in smoking, this responsibility may become muddled.
Though most developed countries have experienced a steady decline in physician smoke rates, a subset of these developed countries still have fairly high physician smoking rates [84]. France is among the few countries which have consistently
32 documented smoking rates over 25% amongst physicians [85, 86]. Generally speaking, the prevalence of smoking physicians has closely mirrored the prevalence of the general population over the course of time. In the United States, up to 40% of physicians smoked in 1959, a number which dramatically decreased over the course of time to 21% in the mid 1970s then 3.3% in the 1990s [87, 88]. Conversely, in 2015, smoking prevalence was
16% amongst French general medicine physicians down from 29% in 2003 [89].
Perceptions & public health implications
Smoking cessation counseling provides an important opportunity for healthcare providers to assess a patient s desire to quit and to provide cessation resources. These types of office-based interventions can influence national smoking rates little by little as many smokers visit their physicians annually. Physician smoking status and the perceived benefit of counseling are two major factors that govern the likelihood that a patient is to receive counseling.
Smoking status in physicians has been repeatedly shown in several studies to have negative downstream effects on patient care, namely through decreased likelihood of cessation counseling. In one study conducted in the U.S. by Tong and colleagues, the
5A s model was used to assess thoroughness of smoking cessation counseling: asking, advising, assessing, assisting or arranging follow-up about smoking. Current smoking status was found to be a factor negatively associated with performing the 5A s [4]. One
French study similarly found that cardiologists who were current smokers were less likely to routinely assess smoking status and were less likely to offer counseling and provide assistance to patients who smoked [3] (Figure 11). Altogether, these findings suggest that
33 physicians who are also smokers are less sensitive to smoking as a major health risk factor and are less aggressive in its management.
The perceived utility of counseling by physicians is also an important factor to assess when looking at the difference rates of counseling amongst smoking and nonsmoking physicians, and smoking status plays a large role in these perceptions.
Physicians who smoke have a tendency to minimize the consequences of smoking as well as their perceived responsibility to connect smokers with cessation resources [86, 90].
Several studies in both the U.S. and France alike have demonstrated that positive beliefs regarding the importance of cessation counseling were positively associated with increased rates of counseling, patient-reported cessation, and referral to specialized cessation resources [3, 4, 91, 92]. Furthermore, physicians in both countries have cited that competing priorities during patient encounters, not being a primary care provider, and discomfort asking patients about smoking status as major barriers to engaging in cessation counseling [4, 5].
Figure 11: French cardiologist smoking status and behaviors towards offering patients smoking cessation counseling (Aboyans 2008)
34
CONCLUSION
The findings of this literature review suggest that compared to the United States,
France has higher rates of smoking due to delayed government action at the height of the tobacco epidemic and cultural attachment to cigarette use. Though more prevalent in
France, physician smoking remains an issue in both countries and is associated with decreased rates of cessation counseling and negative perceptions regarding the utility of cessation counseling.
Political action
This literature review demonstrates that American and French policies are closely aligned with MPOWER (M: Monitor tobacco use and prevention policies, P: Protect people from tobacco smoke, O: Offer help to quit tobacco, W: Warn about the dangers of tobacco, E: Enforce bans on tobacco advertising/promotion, R: Raise taxes on tobacco), guidelines set forth by the World Health Organization in 2004 as part of the Framework
Convention on Tobacco Control.
Overall, France s political reaction to the tobacco epidemic could be characterized as delayed, largely due to France s national monopoly on the tobacco industry. Compared to the U.S. which took legislative action on a state and national level, France s policies were primarily done on the national level and took several iterations to be effective due to unclear wording and lack of enforcement. However, France has been more forceful than the U.S. in changing cigarette packaging to neutral colors with plain font and placing heavier taxation on tobacco products. These both comprise of areas where the U.S. could improve. It may be difficult to implement plain packaging, as the first amendment has proven to be an obstacle unique to the U.S. Over the recent years, the Supreme Court of
35 the United States and district courts have increasingly sympathized with the corporations right to free speech over the government s ability to regulate this speech in the favor of public health [93]. Moving forward, this may become a barrier in effectively informing the public of the negative health effects of smoking.
In terms of offering help for consumers to quit smoking, the O of MPOWER, both countries have successfully led anti-tobacco campaigns publicizing available cessation resources. Access to nicotine replacement therapy has also eased in the recent years through increased coverage of treatment costs by insurance companies and assurance maladie (insurance funded by French taxpayers through the government). In the U.S., the passage of the Affordable Care Act in 2010 was monumental in increasing treatment coverage, and in 2017, the French government began reimbursing up to 65% of treatment costs through its assurance maladie. These public health campaigns can cast a wider net in linking more people with tobacco cessation resources, and the increased treatment coverage can reduce financial barriers and encourage consumers contemplating quitting smoking to finally quit.
Cultural ties
Both France and the U.S. have cultural ties to cigarette smoking; however, the ritualization of smoking into daily social practices such as enjoying a cigarette with coffee or gathering with friends at a café is a large reason why high smoking rates persist in France. The two major cigarette brands in France, Gauloises and Gitanes, built their brand around French nationalism and led to the association of smoking with national identity. In addition, renowned artists and authors such as Picasso and Sartre contributed to the glamorization of cigarette smoking in France during the early 20th century. French
36 café culture was born when these cultural icons frequented street cafés which acted as gathering places for art showcases, philosophical discussions, and smoking which represented youth and rebellion. Even with the stricter antismoking laws which have moved smoking patrons outdoors to the café terraces, smoking still remains engrained in
French social practices.
Though the U.S., like France, has had cultural icons promote smoking through advertising campaigns or appearances in movies, the U.S. has been more successful in decreasing smoking rates over the latter half of the 20th century. This could largely be attributed to the stigma created around smoking and tobacco use, increasing the awareness of the medical complications of smoking by aforementioned cultural icons, and mass public health campaigns. Stricter bans on public smoking may have weakened the role of smoking in daily practices and have also been associated with an increased number of total and successful attempts to quit smoking [94].
Physician smoking and effects on patient care
Despite physician smoking rates dropping since the 20th century, physician smoking remains an issue in both the U.S. and France and can negatively impact patient care. Studies conducted in both countries have similarly shown that physicians who smoke are less likely to counsel patients on the negative effects of smoking and are more likely to hold negative perceptions regarding the utility of counseling [4, 5]. However,
French patients are more likely to experience these negative downstream effects as
France has higher smoking rates amongst physicians. Approaching the issue of physician smoking, especially in the early stages of training, and encouraging healthy habits amongst trainees have been associated with healthier lifestyles including decreased
37 smoking rates at the end of training [79]. Furthermore, the literature has revealed a gap of knowledge about cessation counseling amongst non-primary care physicians [3, 4].
Incorporating education on cessation counseling techniques into the standard medical school and/or residency curricula could be useful in increasing counseling rates, particularly amongst specialists who typically deem these conversations to be beyond their scope of practice and the responsibility of primary care physicians.
E-cigarettes: a future challenge
After the rise of smoking in the first half of the 20th century, U.S. public health advocates have been largely successful in deglamorizing cigarettes with smoking rates at an all-time low of 7.6% in high school students [95, 96] . However, another threat is on the horizon. In both France and the U.S., electronic cigarettes (also known as e- cigarettes) threaten to undo the many decades of work by public health officials. E- cigarrettes contain nicotine and thus people who use are at risk for developing nicotine use disorder; the addition of flavors (which has been outlawed in traditional cigarettes) increases the allure to the younger population [97].
Many of the challenges faced by public health officials in the beginnings of the tobacco epidemic are resurfacing with e-cigarettes [98]. Misinformation in particular has been more prevalent and difficult to control with the advent of social media. From a content analysis of 1068 tobacco-related messages on Twitter, a popular global social media platform, up to 10% contained health claims, 18% of which were explicitly false and the majority of which contained unverified health consequences or cessation techniques that were not evidence-based [99]. As a result of this misinformation, many
38 consumers may believe the risks of e-cigarette use to be minimal and may be more likely to continue using e-cigarettes.
The U.S. and France have adopted similar stances on e-cigarettes. Both acknowledge their risk of acting as a gateway drug for youth [100, 101], but also view them as a potential tool to quitting traditional cigarettes as the amount of scientific evidence increases that users of traditional cigarettes are more likely to cut back on smoking by switching over to e-cigarettes [102]. In national surveys reported by the
French national public health department, Santé Publique, in 2017, e-cigarettes helped
700,000 people stop smoking from 2010 to 2017 [100].
Both the U.S. and France have already taken measures to prevent e-cigarettes becoming a gateway drug for many minors by making it illegal to sell e-cigarettes to persons under 21 years old in the U.S. and 18 years old in France and banning the sale of flavored cartridges in some states of the U.S. Though e-cigarettes are still a relatively new product, scientists have begun to uncover its health complications, most notably e- cigarette or vaping use-associated lung injury (or EVALI) which is suspected to be due to vitamin E acetate, an additive of tetrahydrocannabinol containing e-cigarettes [103]. It will be interesting to see how both the French and U.S. approach regulation of these products in the coming years, and whether they will learn from their lessons in broaching the tobacco epidemic.
The tobacco epidemic has been a longstanding problem in both the U.S. and
France, and there has been much progress by public health officials in advocating for stricter antismoking laws. However, there is still work to be done in continuing the battle
39 against tobacco companies, and in addressing the rise of popularity in e-cigarettes. This literature review has revealed many areas in which both the United States and France could improve their public health strategies in combatting the tobacco epidemic as well as reasons why high smoking rates continue to persist in France. Higher taxation and neutral packaging are among the next steps needed to curb tobacco use amongst the general public moving forward. In terms of preparing physicians to be better able to counsel patients in smoking cessation, addressing the implications of physician smoking early on in medical training and education of physicians in cessation counseling techniques are of the utmost importance.
40
AFTERWORD
During my one year abroad as part of the International Medical Exchange
Program, I was confronted with cultural and language differences on daily basis; however, the difference in smoking behaviors between France and the U.S. was one that struck me the most. My time dedicated to this thesis has reminded me to look beyond the unassuming cultural differences and has helped me understand the wealth of political and cultural history explaining the differences in smoking behavior in these two countries. As a future internal medicine physician, I will undoubtedly have difficult conversations with my patients regarding smoking status and smoking cessation, and I will strive to become a proper physician role model and confidante for my patients.
41
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