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 2 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. 3 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. 4 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. 5 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 6 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 lead to many others, a bachelor’s degree in French language and culture, a summer research internship, and after starting medical school, six months of rotations in various hospitals around Paris, France as part of UT Southwestern’s International Medical 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. 7 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. 8 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. 9 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