Curbing smoking means changing norms

“The best bang for your buck is not going into schools. We’ve done it for years and we’ve seen the tobacco initiation rate stalled,” women smoking a cigarettesaid Theresa Knox, her voice taking on the tone of someone telling you a trade secret. “The best bang for your buck is these system-wide changes — but it takes time.”

Grand Forks Public Health’s tobacco prevention coordinator was explaining why her department wasn’t putting as much emphasis on going out and talking to people about the dangers of tobacco as it seems to do in encouraging various powers that be to impose indoor and even outdoor smoking bans.

Her point was that public health has reached a point of diminishing returns when it comes to educating children about tobacco. That is, less education might mean more kids smoking, but more education won’t necessarily mean more kids not smoking. Now, public health wants schools to ban smoking everywhere on campus, including outside in the parking lot, so kids don’t see any parent or teacher smoking and think that smoking is in any way a normal, everyday activity, even if only a few do it.

The difference between the two is that the former is persuasive and the latter leverages the coercive power of local government and employers. And it may explain a little why tobacco control policy, while it may be winning the war of public opinion, seems to get a lot of grief in the process.

It took the Grand Forks City Council almost five years and two separate pieces of legislation to ban smoking in all public places, mostly because of loud opposition from bar owners, many of whose customers lit up, and from some members of the public. Some council members thought city government was overreaching in trying to protect consenting adults from doing what is still a legal act. Nobody’s making anyone go into a smoky bar, they said.

More recently, the state House decided to cut some tobacco control funding in favor of battling chronic diseases. This follows an attempt to eviscerate the state’s voter-approved tobacco program, saying the money would be better spent expanding UND’s School of Medicine and Health Sciences. How to best spend the money made up a lot of the discussion, said Rep. Curt Kreun, R-Grand Forks, who’s also one of the council members that supported the smoking ban, but he said there were a number of lawmakers who felt that tobacco control efforts may have gone too far.

“We all know smoking is bad, but how far do you go?” he said, describing the sentiment.

If the goal is to change society and affect individual behavior, you can go pretty far.

Changing norms

North Dakota spends about $9.3 million a year on its tobacco control program, the money coming from a portion of the settlement the Big Tobacco companies made with the attorneys general of several states.

This state is one of just two that actually spend as much on tobacco control as the Centers for Disease Control and Prevention recommends, mostly because Measure 3, which voters approved in 2008, required it.

It’s an aggressive program that aims to do just about everything but ban smoking itself.

Reading through the CDC’s “best practices” recommendations is like going through a laundry list. Ban smoking in public places. Check. Target kids with anti-tobacco ads. Check. Help smokers quit. Check. But take the best practices in their totality and it’s clear that they form a multi-prong, multi-layer offensive against an idea: The idea that tobacco use is just a normal, everyday thing.

In the social sciences, this is called a “norm,” meaning it’s a behavior that a large majority of society considers normal and acceptable.

“Of course, it changes social norms; it’s the most important reason for it,” said psychologist Terry Pechacek of the best practices. An associate director in the CDC’s smoking and health office, he wrote those recommendations after studying the effectiveness of various anti-tobacco policies in states such as California and Massachusetts that were early adopters of those policies. He stressed that these are proven policies.

The total cost nationwide of changing norms, if each state followed the best practices, is $3.7 billion a year, though that’s an amount that would drop as tobacco use drops. “The tobacco industry spends billions of dollars annually to make tobacco use appear to be attractive as well as an accepted and established part of American culture,” the best practices say. It takes billions more to counter that message.

Aggressive tactics

Norms have already changed drastically. Decades ago, no one would’ve raised an eyebrow if a smoker lit up in the supermarket or even in a hospital waiting room. Today, it’s almost unthinkable.

In many places, though, smoking outside a building on the sidewalk or in a bar is still seen as normal. The best practices aim to change that.

To get smokers to quit, they recommend states offer phone counseling — it’s called the “Quitline” in North Dakota — and free nicotine patches. They enlist doctors and nurses, some of the most persuasive people in our lives when it comes to our health, to remind tobacco users they need to quit. They call for advertising targeted at different kinds of smokers and would-be smokers — teens, considered the most vulnerable to advertising, are a particular focus.

But best practices also recommend more than persuasion: They call for raising the tobacco tax to around $2 a pack — North Dakota charges 44 cents — and banning smoking in public places. While smoking ban proponents often talk about protecting nonsmokers from secondhand smoke, the goal of a ban is also to help quitters avoid temptation.

To get legislation of that kind passed, best practices recommend enlisting the aid of local public health departments and anti-tobacco volunteer groups. It was one such group, the Grand Forks Tobacco Free Coalition, which got the city’s smoking ban passed. Statewide, similar advocacy efforts got more than three dozen school districts and two universities to ban smoking on campus and two other cities to ban smoking in all public places.

As an indicator of how important local advocacy can be, half of the $9.3 million spent on tobacco control in North Dakota goes to such efforts. A quarter goes to helping smokers quit, 13 percent goes to advertising, 5 percent goes to administration and 8 percent goes to gathering data to ensure the campaign is working.

It appears to be.

In North Dakota, since Measure 3 was implemented in July 2009, the number of cigarettes packs sold has dropped from 47 million to 45.2 million in fiscal year 2010, according to the state’s Center for Tobacco Prevention and Control Policy. The number of calls to the Quitline seeking nicotine patches has increased from 1,271 to 3,374.

The best practices might be just the start. Anti-tobacco advocates at the national Institute of Medicine suggest the tobacco industry be required to reduce the amount of nicotine in cigarettes, meaning the cigarettes would be less addictive and less pleasurable over time. They suggest state and local governments reduce the number of stores allowed to sell cigarettes and persuade developers to prohibit tobacco use as a condition of a lease of an apartment or sale of a condo.

That’s social engineering on a pretty grand scale, all in the name of prevention.

Price of prevention

Jeanne Prom, executive director of the state’s tobacco control center, doesn’t see anything wrong with that. Her office estimates that North Dakota pays $247 million a year in medical costs and lost productivity because of smoking, or $567 for every North Dakotan.

Most people can agree that preventing a problem is better than having to fix it and she sees tobacco control as no different. In Bismarck, when the city commission banned smoking in bars, bar owners treated it like some sort of infringement of rights, she said. But when the commission restricted texting while driving, she said, there was no such backlash.

Prom suspects the hand of Big Tobacco, which she said has perpetuated the myth that connects smoking with freedom and rights. To her, the aim of public health isn’t to curtail choices, but to make certain choices more likely. “Primarily public health is about making an environment where people can be healthy and the default is a healthy choice.”

That feeling that people are being forced into something by public health policy isn’t necessarily limited to tobacco.

Knox said there were similar reactions when water treatment plants around the nation began adding fluoride to water, or when, in Grand Forks, the city decided to fine stores for selling tobacco to minors, or when public health push to require parents to put young children in child car seats.

“What people focus on at a cusp of a change like that is regulation. ‘Don’t tell me what to do,’” she said. She used a canoe analogy: If you were in a canoe with a hole in it and she said she can patch it, would you say “Leave me alone?”

In the end, after public health policies come into effect, they often become the norm. After all, few if any person complains about fluoridated water.

It appears anti-tobacco policies are also well on their way to becoming a norm. When Grand Forks bar owners attempted to gather signature to put the smoking ban on the ballot — it’d been decided by the council without a public vote — they couldn’t get enough of their customers to sign. In Bismarck, after much discussion, the state House didn’t even vote to end the tobacco control program; that section of the med school bill was eliminated in committee.

By Reach Tran; (701) 780-1248, (800) 477-6572, ext. 248; or send e-mail to [email protected]

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