Howard Koh on Smoking Cessation and Policy

Published OnlineFirst February 20, 2014; DOI: 10.1158/2159-8290.CD-ND2014-002

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Needham, Massachusetts, Q&A: Howard Koh on Smoking was the ﬁ rst town in the country to do this. A recent report Cessation and Policy in The New England Journal of Medicine noted that rates Comprehensive tobacco-control efforts save lives and of youth smoking declined help young people avoid nicotine addiction three times faster there than in surrounding communi- As a young physician in Boston, MA, Howard Koh, MD, ties as a result [N Engl J Med MPH, witnessed many patients with smoking-related condi- 2014;370:295–7]. New York tions suffer and die. “I saw the devastation tobacco addiction City, seven towns in Massachu-

imposes on people’s health,” he recalls. “It really motivated setts, and a county in Hawaii U.S. Department of Health and Human Services me to move toward prevention and public health policy.” now have a similar policy; three “There’s a misperception that the Koh soon went from primarily caring for patients at Boston states are considering one. smoking problem has somehow been City Hospital and Massachusetts General Hospital to becom- solved,” says Howard Koh. “Nothing could be further from the truth.” ing the commissioner of public health in Massachusetts in What’s your perspective on 1997. In 2009, he became the assistant secretary for health in raising cigarette taxes? the U.S. Department of Health and Human Services, overseeing Cigarette taxes can be raised at the city and state level, not 12 public health offi ces, including the Offi ce of the Surgeon just the federal level. In the last decade, just about every General. To mark the 50th anniversary of the Surgeon General’s state has raised its cigarette tax, regardless of the governor’s fi rst report on smoking and health and to promote the release political affi liation. At the federal level, there was a 62¢ per- of this year’s report, Koh spoke with Cancer Discovery’s Suzanne pack increase in 2009 to fund children’s health insurance. In Rose about the continued urgency of tobacco-control efforts. the president’s fi scal year 2014 budget, there was a proposed per-pack increase of 94¢ to fund early childhood education. Why didn’t being diagnosed with cancer motivate your This latest proposal wasn’t adopted, but this is one way to patients to quit? raise revenue and decrease consumption. When you increase Addiction is so powerful. I clearly remember a patient who the price by 10%, you decrease consumption by 4%, a phe- had surgery for lung cancer who was told that he might nomenon well documented by health economists. have been cured. In a follow-up visit with me—I was a young resident at the time—he told me he resumed smoking. I Do states have to spend a set amount on smoking pre- remember being astonished, but that’s evidence of how vention or cessation efforts? powerful and overwhelming this addiction can be. No. It’s up to the legislature of each state to decide how much to spend on tobacco control efforts. There is a CDC-recom- Is eliminating smoking an achievable goal, given that mended level; unfortunately, almost no states meet that level. smoking rates have plateaued around 18%? Billions of dollars are going to the states from the tobacco We must make it achievable, and we have no other choice industry thanks to the Master Settlement Agreement in if we’re committed to a healthier future. We know what 1998, but less than 3% of those funds and other tobacco tax strategies work, and we must reinforce those strategies: revenues are used for tobacco control. We need to change that hard-hitting media campaigns, higher cigarette prices, dynamic and emphasize funding prevention to save lives. access to cessation assistance, statewide programs funded at levels recommended by the Centers for Disease Control and How is the government encouraging smoking cessation? Prevention [CDC], and comprehensive smoke-free indoor The Affordable Care Act expands access to smoking cessa- protection for the entire country. tion and counseling services, and removes cost as a barrier Because smoking rates have been cut by more than for people who need those services. Health reform created a half since 1964, there’s a misperception that the smok- prevention fund that is channeling millions of dollars to the ing problem has somehow been solved. Nothing could be CDC for community grants to address issues like tobacco further from the truth. Tobacco use remains a public health control. In the fall of 2012, we launched a tobacco-free catastrophe. My message on this 50th anniversary is that we college campus initiative with the goal of making all must end the tobacco epidemic as soon as possible, and it 5,000 college campuses across the country smoke- and shouldn’t take another 50 years. tobacco-free; about 1,200 have signed on. This sends the message that the social norm should be one that is tobacco- One proposed strategy is raising the age to buy tobacco free, not one that glamorizes tobacco dependence. We’ve products from 18 to 21 nationwide. Is that feasible? had a tremendous commitment to hard-hitting mass-media That’s an innovative strategy that needs careful evaluation. We campaigns, and the U.S. Food and Drug Administration just know that young people often get their cigarettes from friends launched the “Real Cost,” a new mass-media campaign to who are 18 or older. Raising the legal age to buy tobacco prod- prevent tobacco addiction among our youth. Go to www. ucts to 21 could potentially greatly limit youth access. therealcost.gov to learn more. ■

This article is part of the AACR’s commemoration of the 50th anniversary of the Surgeon General’s report Smoking and Health. Please visit http://www.aacr.org for information on additional AACR publications and activities related to the recognition of this milestone.

MARCH 2014CANCER DISCOVERY | 265

Q&A: Howard Koh on Smoking Cessation and Policy

Cancer Discovery 2014;4:265. Published OnlineFirst February 20, 2014.

Updated version Access the most recent version of this article at: doi:10.1158/2159-8290.CD-ND2014-002

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