Smokers: Will Gruesome Pictures Make You Quit?
NEAL CONAN, host: This is TALK OF THE NATION. I'm Neal Conan, in Washington. Starting next year, cigarette packages and ads must include vivid pictures of rotted teeth, diseased lungs and a corpse on a slab after an autopsy. The Food and Drug Administration unveiled nine images yesterday that will take up the top half of every cigarette pack.
If you're a smoker, take a look at those on our website. Go to npr.org. Click on TALK OF THE NATION. Would these labels make you think more about quitting? If not, what would? Give us a call: 800-989-8255. Email us: email@example.com. And you can also join the conversation on our website. Go to npr.org. Click on TALK OF THE NATION.
Later in the program, the story of a foul ball and a scapegoat in Chicago - Alex Gibney on his new documentary "Catching Hell." But first, the new cigarette labels. And let's begin with a caller. Tom's on the line, calling from Circleville in Ohio.
TOM: Hi. Thanks for having me on.
CONAN: And have you seen these new images?
TOM: Yeah. They won't make me quit, and they can put them on the packs, because I just take my cigarettes and put them in my own case, anyhow. I enjoy a cigarette. I don't smoke in my house. I don't smoke in my car. If I do smoke, I smoke outside. I also enjoy cigars and pipes. And I really am tired, because the people that smoke know what cigarette smoking does to you.
Okay, I'm just tired of the government getting in my life, and all these self-righteous people that are almost making it illegal for you to even smoke outside, where it'll affect no one because it's out in the open air. And, you know, it won't stop me, simple as that.
CONAN: And Tom, it sounds like there'd be nothing that would make you stop.
TOM: You know, I enjoy it. You know, I've quit other things in my life. I don't drink alcohol. You know, why don't they go after the people with alcohol? How many people get killed by drunk drivers, cirrhoses of the liver and the other diseases, the wife-beating, the child abuse? You don't see a cigarette smoker doing that.
CONAN: There are warning labels on liquor bottles and beer bottles.
TOM: Well, yeah, but do they show - do they show what a liver is? Do they show an abused child? Do they show a beaten wife on them?
CONAN: The - I think the difference is that the FDA was - there was a law passed requiring it to regulate tobacco, and specifically to use these images.
TOM: Well, you know, maybe they should pass a law on alcohol, too. Why don't show all the stuff, you know?
CONAN: All right, Tom.
TOM: You know, I'm just tired of self-righteous people, people that, you know, because they don't like something and they don't like the smell. You know, I'll go out of my way not to offend somebody, but I'm tired of them attacking me all the time.
TOM: Like I said, I go out of my way not to offend somebody. I don't smoke in my house, don't smoke in my car. I don't smoke where they say no smoking.
CONAN: We've got you, Tom. Thanks very much for the call. Appreciate it.
TOM: All right, you're welcome.
CONAN: Let's turn next to Dr. Margaret Hamburg, the commissioner at the Food and Drug Administration, who joins us from her office in Silver Spring, Maryland. Nice to have you with us today.
Dr. MARGARET HAMBURG: Thank you very much. Glad to be here.
CONAN: And people like Tom, is that who you're trying to get through to?
HAMBURG: Well, we think that we really do have to address the problem of smoking in our nation. It is the leading cause of preventable death. Every year, almost half-a-million people die from smoking and tobacco use, and it also causes enormous amount of disease and disability, not to mention avoidable costs to our health care system and to the economy, more broadly.
We are clearly trying to provide the public with information that they need about the serious health consequences of smoking. We are also, as you mentioned, implementing a law that Congress passed in a very bipartisan way, with an overwhelming majority two years ago, and the president signed into law.
That law is very specific about these graphic health warning labels, the nine text warnings that were to be used on the warning labels and the requirement for color, graphic warning images that would take up 50 percent of the package front and back. So we are implementing the law, and we are trying to have additional impact on a very, very serious public health problem for our nation.
CONAN: How much difference do you expect that these images are going to make?
HAMBURG: Well, we hope that they will make a very significant difference. We know from the experience of other countries that have already implemented graphic health warning labels, that they do very much get the consumer's attention. They increase awareness about the health risks of smoking, that they actually do have an impact on the intent of smokers to quit.
And importantly, we're trying to reach kids that haven't yet taken up smoking, but are at risk if they do start smoking of the addiction and a lifelong habit with deadly consequences. And so for many kids, smoking seems cool and glamorous, but when they pick up a package to try that cigarette and they see the real-world consequences of smoking, they won't think it's quite so sexy, and that's part of what we're trying to convey.
CONAN: I've read based on the experience of Canada, probably the closest analogy to the United States, that the expectation is that something like over 200,000 people would quit on this - would stop smoking over the next couple of years, that at least the projection.
HAMBURG: Well, there have been estimates. And, of course, they're only estimates. But it's been projected that with the introduction of these graphic health warning labels in this country, some 213,000 individuals would stop smoking.
CONAN: That's out of a population, I think, of smokers on the order of 46 million.
HAMBURG: Yeah, so it's not the answer to the entire problem, and as a nation, we really need to have a comprehensive, integrated strategy to address the public health challenge of smoking and tobacco use.
Over the last four decades, we saw steady declines in smoking rates, but in the last five to seven years, since 2004, I believe, the numbers have leveled off, and about 20 percent of the American population is smoking now, adults and young people. And we need to see those numbers to continue to decline. We really do have to recognize that we are suffering - individuals, families, communities and our nation - from preventable disease. And if we can bring down those rates of smoking, we can dramatically improve health for all.
CONAN: Let's get another caller on the line. Corey's(ph) calling us from St. Louis.
COREY: Hi. Thanks for taking my call.
COREY: I wanted to say, you know, last week, my sister was visiting from Switzerland, and she told me that in Switzerland, they have those images on the packs of cigarettes, and they just flip them over. Now, I looked at the images on your website, and the fact that it would cover both front and back on the packages here I think is a wonderful idea.
I want to say, you know, I'm 34 years old. Both my husband and I have been smoking over 20 years. I have tried everything under the sun to quit smoking. And once I looked at those pictures, my thought was if I had to look at this every time I wanted a cigarette, I wouldn't be able to smoke.
CONAN: Well, Corey, I think you are a poster child - hopefully not on the cigarette pack, but I think Dr. Hamburg would applaud your reaction.
COREY: And, you know, I hope that it goes through and that the appeals that the cigarette - the tobacco companies are talking about and going against First Amendment rights, you know, I think that's bogus. And this should be on our cigarette packs, because I have two young children, and while I do smoke, I don't smoke around them, and I would be absolutely furious if either one of them ever picked up a cigarette.
And I know that with those images, I absolutely would quit smoking. That would be the one thing that would do it for me.
CONAN: Corey, good luck.
COREY: Thank you. Thank you very much.
HAMBURG: The other thing I might mention is that on these graphic warning labels, we also do include a toll-free quit line, 1-800-QUIT-NOW, so that people that do want to explore ways to quit smoking - which isn't always easy, as everyone knows - they will have access to a number that can link them in to services in their state, in their community to help them quit.
CONAN: There will be a court case. As Corey mentioned, the tobacco companies say this regulation is a violation of their First Amendment rights, and they're going to take that to case, and we'll have to see how well they do there.
But there is a sense of aggrievement that we heard earlier from that first caller, the feeling smokers have that they're being persecuted by the government. They're being told what to do, and they're grown-ups, and they can make their own decisions.
HAMBURG: Well, you know, as an adult, he clearly is making his own decision to continue to smoke. He sounds like a very responsible smoker in terms of trying to avoid producing second-hand smoke exposure to people around him.
What we're trying to do with these graphic health warning labels is to provide, admittedly, a very vivid illustration of the actual health risks of smoking. It's one thing to understand a statistic on paper. It's another, I think, to get that powerful image. As they say, a picture can be worth 1,000 words.
I think it is very important. He deserves the information that he - the best information that's available to make a considered choice. If he chooses to keep smoking, that is his choice.
I think when it comes to kids, it becomes a more complex question. And just as the last caller indicated, even though she's been a smoker herself, she'd be very upset if her children started to smoke, and I think that we have to recognize that most smokers in this country today starting smoking before they were the age of 18.
A lot of what we're doing is trying to address the problem of youth smoking, and that these images can have a very important effect reminding individuals who already may know the statistics about what the real consequences look like and helping young people to really understand that smoking has risks.
CONAN: We just have a few seconds left with you. What is the next step after these images?
HAMBURG: Well, these images have now been made available to the companies that produce cigarettes. They will be required to begin to put these images on their products, both the cigarette packages and also on print tobacco - print cigarette advertisements. It's required to take up 20 percent of the top portion of those advertisements. And 15 months from now, as the law indicated, all of those products will have to have these warning labels.
CONAN: Dr. Hamburger(ph) , thanks very much for your time today, appreciate it.
HAMBURG: Thank you.
HAMBURG: ..TEXT: CONAN: This is TALK OF THE NATION from NPR News. I'm Neal Conan in Washington. If you haven't seen the new images that will be soon printed on cigarette packages and ads. You'll find them at our website, npr.org. Click on TALK OF THE NATION. They are graphic: ravaged lungs, a diseased mouth, a corpse. And the FDA hopes they will prompt more than 200,000 people to kick the habit in 2013.
In a few minutes, we'll talk with one writer who doubts that. If you're a smoker, would these labels make you think more about quitting? If not, what would? Our phone number, 800-989-8255. Email firstname.lastname@example.org. You can also join the conversation on our website. That's at npr.org. Click on TALK OF THE NATION.
Danny McGoldrick is the president for research at the Campaign for Tobacco-Free Kids, and he joins us here in Studio 3A. Danny, nice to have you with us.
DANNY MCGOLDRICK: Neal, thanks for having me.
CONAN: So you grab smokers' attention with these pictures. Is that enough? I mean, there is information about quit lines.
MCGOLDRICK: There is information about quit lines, and that was a very important decision by the FDA to include that. We of course encourage them to do so in our comments and our partners' comments to the FDA.
I think the research tells us that when you combine an emotional, graphic appeal, sometimes fear-arousing, but back that up with some help, that that's the most effective way to communicate with smokers.
CONAN: Who funds those quit lines? Where are they located? Are they state or federal?
MCGOLDRICK: The 800-QUIT-NOW number gets you to your state quit line. Every state now, fortunately, has a quit line. And so you call that number, and by virtue of where you call from, you are routed to the appropriate quit line.
And they provide services such as, you know, telephone counseling services, where you can call them at various times, or they'll even proactively call you. Some states, depending on how well they're funded, also offer free or reduced-price medications that help people smoke. So it's actually getting people to the evidence-based interventions that enhance the probability that they'll succeed in quitting. It's very important that that's a part of these warning labels.
CONAN: And how successful - the United States has been late into this game. There are many other countries that have very graphic and even more graphic images than the ones that are going to be on the U.S. cigarette packs next year. How well have these campaigns worked elsewhere?
MCGOLDRICK: Well, there's been a fair amount of evaluation, a growing literature on the effectiveness of graphic health warnings. And what the data show consistently, when we surveyed people before the graphic warnings go on the packs and after and compare those to countries where that didn't happen, what we see is increases in knowledge about the health effects of smoking.
We think everybody knows it, but they don't. But increases in intentions to quit, as well. And so they've shown that they do reach smokers and affect them in a positive way. And it's not going to get every smoker to quit. Like your caller earlier might not be the absolute target audience for this, but we do know from a large amount of research that smokers do notice them certainly more than the warning labels that are currently on American cigarettes and do respond to them possibly.
CONAN: Let's get another caller in. This is John(ph), John with us from Salisbury in Maryland.
JOHN: Hi, I lived in Canada from '97 to 2001, and my circle and friends and so on all heavy smokers, you know, multigenerational. And the graphic pictures have been in effect there for at least 12 years. It never seemed to bother them. They've had loved ones die of lung cancer, you know, esophageal cancer, and they're still smoking strong.
It's just, you know, I think that once you're so dedicated to it, you know and so on, it's - some people are going to smoke, they're going to smoke, and the ones that are, you know, inclined to not won't.
CONAN: And what about you, John?
JOHN: I smoked up until a couple of years ago, off and on, never was a dedicated smoker. You know, I'd bum other, you know, cigarettes from other people and so on. But, you know, I decided, you know, to stop because I really didn't, you know, like it anyway. So - I chew nicotine gum, though, probably too much, but...
CONAN: Is that to keep off the cigarettes?
JOHN: Yeah, I think it's more of a habit no. I think, you know, the lesser of the two evils, I suppose. But it's just that, you know, I think people that are, you know, that - like this gentleman that you were talking to earlier that, you know, if you're a die-hard smoker, then you're probably going to remain a die-hard smoker, so...
CONAN: An unfortunate choice of phrase there.
JOHN: Yes, unfortunately.
CONAN: John, thanks very much for the call, good luck.
JOHN: Thank you, bye-bye.
CONAN: Bye-bye. And is there research that suggests that for some smokers, these morbid images might increase the likelihood of smoking?
MCGOLDRICK: I'm not aware of any evidence to that effect. I think if that were the case, the tobacco industry would probably be putting on them voluntarily rather than suing to try to keep them off. But I think - you know, John raises some really important points.
We know here in the U.S., and I assume it's the case in Canada, too. Seventy percent of smokers would like to quit, and it's nicotine that's the key. The companies have known this for years. They manipulate levels. They add ammonia to get it to your brain faster. And not every smoker is going to respond to the same trigger.
You know, for some people, these graphic warning labels, it may not be a - it's not going to be the first time they see them. It may just be when they're in a particular mood and for some other reason are feeling inclined to quit, they pick that pack, they look at it. They call that 1-800-QUIT-NOW number and get it.
For another smoker, it might be because their workplace went smoke-free or another smoker because price went up. So the tobacco companies don't rely on one avenue to hook - you know, to get 4,000 kids to try their cigarette every day and keep smokers smoking. They have a comprehensive marketing approach.
And as Dr. Hamburg said, we have to have a comprehensive approach, as well.
CONAN: Here's an email from Kelly(ph) in San Francisco: I'm 27 years old, quit smoking six months ago. I think the picture are great. They alone would not have made me quit. They're a positive step in the right direction; however, the decision to quit is so subjective. I ultimately quit because I was afraid of the damage I was inflicting on my health. There are so many things that can harm and kill you at any given time, I decided I should probably not actively, knowingly contribute to my own demise.
Again, that's a rational decision. Sometimes rationality does not play a big role in this. Betsy(ph) in Ann Arbor: While, yes, adults can choose to want to do - choose what they want to do with their bodies, I do not think that people have the right to expect their fellow citizens will pay the big price of the consequences of their choice.
And that gets onto the questions not just of secondhand smoke, questions of exposing children to smoking.
MCGOLDRICK: Right, it's - you know, 90 percent of smokers start as kids. And so that's when - virtually no one starts as an adult. But it's - secondhand smoke affects nonsmokers, but also we spend about $100 billion a year in this country treating tobacco-related disease, much of that paid for with public dollars through our Medicaid and Medicare program and other government programs.
So we all have a stake in reducing smoking, but it's really about saving lives. You know, for every two people we stop from smoking, we save a life. There aren't too many interventions that are quite that effective, and I think we have to keep that in mind and the 443,000 who die every year. That's really what this is all about. 1
CONAN: Let's go next to Frederick(ph) and Frederick with us from Leawood in Kansas.
FREDERICK: Yes, good evening. Or good afternoon, sir.
CONAN: Good afternoon.
FREDERICK: Yes, now years ago, I remember - this is nothing new, by the way. I mean, we were shown images of this in high schools and immediately upon being released for, you know, after-school program or lunch, I would see people light up after viewing images of, you know, death and disease.
Similarly with sexually transmitted diseases. You know, they would show the very same thing. I don't know how much that did to curb people's activities. I do not believe it will be effective.
I have been smoking. I'm currently on nicotine replacement therapy. But what caused me to quit is rather the price and the effect it was having on those around me, people on whom I should be spending my money.
CONAN: Well, that's another part of the program, Danny McGoldrick.
FREDERICK: Correct. Now, I have been on hold for a substantial amount of time, and I managed to think of something that would make me quit.
CONAN: And what is that.
FREDERICK: That would be if the managed to - and I can't see this occurring practically, it doesn't seem to be reasonable, but I think if they managed to put a photo of a nude congressman on the pack. That would be disgusting enough.
(SOUNDBITE OF LAUGHTER)
CONAN: Let's hope they don't go down that road.
MCGOLDRICK: Yeah, we - one important point to make, though, is that the FDA does have the authority to alter the warning labels moving forward based on evidence of new harms caused by tobacco or new science on what works best on the warning labels.
So it won't take an act of Congress next time to change the warning labels. We know how difficult that is. And so it's very important. But the caller again makes the point that it's not one thing that's going to change something that's so A, ingrained in our culture but B, the power of nicotine. It's going to take educational efforts like on the packs but also broader than that. It's going to take increasing price and other efforts. It's really that comprehensive approach.
You know, the companies spend $12 billion a year trying to get people to smoke, and so it's going to take a comprehensive effort. These warning labels are a huge step forward over where we were but just one piece of a larger puzzle.
CONAN: Linda(ph) in French Settlement, Louisiana, writes: I've seen these kinds of pictures when my friends would bring me cigarettes from Taiwan, where they have this program. It did not stop me at all. What stopped me was my dear husband's diagnosis of lung cancer last year. If these pictures stop even one person from taking up the habit or scare somebody into stopping, they're worth it.
My husband's cancer is only seen in people who have smoked at least 20 years, and it is terminal. It's just so hard to scare people out of bad and dangerous habits, but we must continue to try.
The FDA announced their plan back in November, when Daniel Foster, a news editor for the National Review, first heard about it. He responded with a blog post that said: The message is clear. Your government believes you are an idiot and a child. And Daniel Foster joins us now from his office in New York. Nice to have you on the program today.
DANIEL FOSTER: Thanks a lot, Neal.
CONAN: And when you wrote that, you'd recently quit smoking cold turkey. After the warning labels were announced, you wrote now I'm thinking about starting up again just in response to what, the nanny state?
thinking about starting up just in response to, what, the nanny state?
FOSTER: Yeah, that was - I mean, that was mostly facetious, but I think my visceral reaction of these labels is primarily a function of - they're just gratuitous. And as you've said before, we're talking about pictures of corpses with toe tags and stapled up chest cavities, mothers blowing smoke full on in the faces of crying babies, extreme close-ups of rotting cancers mouths.
Mr. McGoldrick, you know, admitted he called it an emotional fear-inducing tack, and I would call it a kind of B horror movie production value that implied nothing more than a profound contempt for the public's intelligence and for its ability to make its own choices. I think that's what we're getting into this.
CONAN: Did you manage to stay away from cigarettes though?
FOSTER: You know, I quit as a regular smoker. Yes, I'm an occasional social smoker and I did so for the familiar reasons - health concerns and things like that. I certainly didn't do so because the government told me that I wasn't smart enough to make my own decisions.
CONAN: Doesn't the government - as Danny McGoldrick also mentioned, we spend a lot of money treating cancers through Medicaid and Medicare. Doesn't government have an obligation to try to reduce those expenditures too?
FOSTER: Well, I want to say two things about that. It would be one thing if we were having that argument, about whether individual choices to smoke collectively impose a substantial enough burdens on the freedoms of nonsmokers to justify government intervention. That's - I'd be fine having that argument. But, frankly, that's not the argument that we're having. The argument we're having basically begins and ends on whether or not smoking is bad for you, and whether or not these signs will work, and I think that's entirely besides the point.
You know, the logical - not to be the slippery slope guy, but the logical extreme of this kind of thinking is a society where everything that's imprudent is illegal. And that's not the kind of society that anyone wants to live in.
And I mean, also, just in its own terms, though, will this program be efficacious? I think the optimistic - rather optimistic projection that 200,000 smokers out of 46 million will quit, I mean, that's less than one percent. And further consider that the stimulus bill, the infamous stimulus bill set aside $225 million to state and local governments to pursue this kind of campaign. I mean, does that the best use of those funds? It's less than one percent change in the number of active smokers, really the most efficient way at allocating federal taxpayer dollars?
I think that the group that this lower roll down to the benefit of most is manufacturers of cigarette cases, and I think that we'll see a, perhaps, a return to a more elegant time where people walk around with silver cigarette cases instead of cardboard packs.
CONAN: What do you make of the argument of the tobacco companies about the infringement of their free speech?
FOSTER: I'm not sure it's a free speech issue. I think the question is - begins and ends on whether or not governments can and should be in the business of trying to affect our leisure habits. I'm not entirely convinced it's a free speech issue, though, I'm willing to sort of entertain that argument. To me, the question is whether or not it's an appropriate use of taxpayer dollars, and whether or not it's an appropriate exercise of government power. And I realize that, at this point, my argument has become so unpopular and so out of vogue that people just sort of shrug and say, but smoking is bad for you, as if that were an answer to the question of whether or not this is an appropriate use of state power. It's like the old debate about seatbelt laws...
CONAN: Or motorcycle helmets, yeah.
FOSTER: ...or motorcycle helmets. Exactly. You sort of tell somebody that - ask somebody to justify in terms of the legitimate powers of the government those sorts of things, and they kind of shrug and say, well, you know, riding a motorcycle without a helmet is bad for you, as if that were an answer to the question. I mean, the sort of thinking that I'm - the sort of argument that I'm making is for better or worse - and I would say worse - just out of vogue.
CONAN: Well, just like smoking, riding without a motorcycle helmet can wind you up in the hospital at vast expense.
FOSTER: Sure. And as I said, that's - that could be a legitimate argument to have about this. As a conservative who leans Libertarian, I think the standard there has to be set fairly high. You know, for instance, we might set one standard for the harms done by something like heroin and another standard for the harms done by something like marijuana. I think that's a real conversation that we can have. But I'm obviously going to have standards for what counts as societal costs that come down on the side of individual liberty.
CONAN: Daniel Foster, thanks very much for your time today.
FOSTER: Thank you too.
CONAN: Daniel Foster, a news editor for the National Review. You're listening to TALK OF THE NATION from NPR News. And let's see if we can go next to - this is Ryan, Ryan with us from Bend, Oregon.
RYAN: Yes. Hi.
RYAN: I'm, like, a younger person. I'm 23 years old. And we've had a lot of people - or I've had a lot of friends that have come down from Canada and shown - and like some of your other callers have stated, they have their images, sort of, like, what's going on here? But most of us just laughed at them. They carried it around as, sort of, like a macabre souvenirs.
CONAN: Like our last guest mentioned, B movie - B horror movie clips.
RYAN: Exactly, exactly. And a lot of them would come down and, you know, they take them out of their pockets and say, look what Canada is doing or whatever and they'd show, you know, rotting gums and whatever. And for a person like, I don't think that that would actually end up helping me to quit. I think it's actually - you know, it's more of a funny thing than anything. I mean, we're - people that are smoking, and especially young people that are smoking, are determined to do it, and they know the risks. I mean, we've all saw that in high school and we're pretty much - we know what we're doing.
(SOUNDBITE OF LAUGHTER)
CONAN: All right, Ryan. Thanks very much for the call. Appreciate it.
CONAN: That's the counterproductive argument. It's - people are - young people are rebels and this makes them more rebellious.
MCGOLDRICK: Right. I think that it's not one exposure to these things, from seeing a visitor from another country or anything that's going to make a difference. And I think our callers reflect also that people are going to react to them differently, and some are saying that we'll help them quit. So we're not suggesting that the warning labels are going to get all 45 million American smokers to quit tomorrow.
MCGOLDRICK: But for, like I said, for every two people who don't start smoking, we save a life. So what if we say these warning labels got 1,000 people not to smoke, then that would mean we save 500 lives at no cost to the U.S. government, and that's I point that I really wanted to make.
MCGOLDRICK: The entire Center for Tobacco Products, the new center to regulate tobacco products under the FDA law, including the warning labels, are paid for by user fees on the tobacco companies. And so these are not taxpayer dollars that are being used to fund this, and in fact, it's just having the companies put the images on there. So this is one of the lower cost interventions. I would, of course, argue that it's a worthy investment to invest public dollars in getting people to not start smoking and get them to quit, because it will not only save lives, it will save health care dollars. It is a proven investment that works to save dollars and lives.
CONAN: Danny McGoldrick, vice president of research at the Campaign for Tobacco-Free Kids. He joined us here in Studio 3A. Danny, nice to see you again.
MCGOLDRICK: Great to see you, Neal. Thank so much.
CONAN: Up next, the story of the Chicago Cubs fan who reached for a foul ball and shouldered the blame for the team's heartbreaking loss in the playoffs. We'll talk with the directory of the new documentary "Catching Hell."
I'm Neal Conan. Stay with us. It's the TALK OF THE NATION from NPR News.
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