Clearing the Air

Though she doesn’t take credit for it, Joanna Cohen may have prevented her first tobacco-related death at age 5. As she and her sister climbed on their grandfather who was lying on a couch, they broke one of his ribs. His doctor did a chest x-ray and detected lung cancer. The discovery—and subsequent surgery—helped her grandfather live another three decades. Today, Cohen is taking a more conventional approach to preventing tobacco deaths. She is the new director of the Institute for Global Tobacco Control (IGTC) at the Bloomberg School. Cohen, who previously led research at the University of Toronto’s tobacco research unit, brings a scientist’s zeal for data: “Evidence is key to moving forward in tobacco control, and that’s what our role is.” During a March interview with Johns Hopkins Public Health editor Brian W. Simpson, Cohen touched on global tobacco control trends, smoke-free cigarettes, “nanny-state” accusations and her priorities for IGTC.

Where are we in terms of tobacco use globally?

It’s actually not such a pretty picture, and if current trends continue it’s just going to get a lot worse. Right now we estimate about 1.1 billion smokers in the world. The trends are for 1.6 billion by 2025. What’s more, 80 percent of those smokers would be in lower- and middle-income countries.

Why the surge in developing countries while prevalence is falling in developed countries?

Good question. The fuel of this pandemic is the tobacco companies. They have realized that the market is not growing in developed countries so they’ve really turned their attention to lower- and middle-income countries. They see them as untapped markets, and they get very excited about those markets.

Does this dramatic increase in smokers mean the WHO Framework Convention on Tobacco Control (FCTC) is a failure?

No, definitely not. It just came into force in 2005, and it requires that countries start implementing some of the protocols. They’re built around protecting people from secondhand smoke, helping people quit and preventing people from starting to smoke. We see particular support for the Framework Convention in lower- and middle-income countries because they really want to stop the spread of this scourge.

How long will it take for the FCTC to have a real impact?

It really depends on how quickly countries can implement best practice interventions. I just came back from a few days in Vietnam talking about their draft legislation to enact smoke-free public places. They’re also talking about raising taxes on tobacco and putting picture warnings on their cigarette packs. But that’s a country where the government also owns the tobacco company and so there are lots of political pressures to go slowly.

Since 1965, the U.S. has cut smoking prevalence in half. Are more regulations really necessary?

It is remarkable what we’ve been able to accomplish in the last 50 years. Who would have thought even 10 years ago that you would be able to go into smoke-free bars? The challenge in front of us is that we still have millions of smokers in this country, and there’s still the pipeline of children turning into adolescents, turning into young adults—that doesn’t stop. So there’s still more things we can do in this country.

How do you respond to people who say these are “nanny-state” regulations that limit individual choice?

I think it’s a challenging question and a fair question. I don’t think anyone would like to go into a restaurant and not have public health officials who make sure that raw chicken is kept at cold enough temperatures in the refrigerators or that you have good food-handling practices in restaurants. The government does have a responsibility to protect its citizens. We have pounds of evidence dating back to the 1950s that [cigarettes are] a toxic and defective product that kills half of long-term users. It’s just unacceptable.

What are your priorities for the Institute?

The Institute has a tremendous history. It was led by Jon Samet, who is a giant in tobacco control. As we move forward, we want to provide the evidence base for the most effective and efficient tobacco control policies, programs and activities. Building leadership capacity in countries around the world is also a key focus. Every year, we bring 100 people from lower- and middle-income countries here to Hopkins for a two-week summer institute where they are exposed to some of the best and brightest, and learn leadership skills and the evidence to be able to push tobacco control forward in their countries.

What’s the Institute’s connection with the Bloomberg Initiative to Reduce Tobacco Use?

We’re one of five partners in the Bloomberg Initiative; we are really the academic arm of this partnership. And we’re here to generate the evidence, synthesize it and translate it so that other partners can really do what they’re good at, which is advocating for change at the political level.

What do you think about smoke-free cigarettes?

These products are new, and it’s unclear actually what level of nicotine someone would get from these cigarettes. Theoretically it might be really helpful in supporting people in quitting. In practice, though, I don’t think we’re there yet.

Were you ever a smoker?

I tried smoking (laughs) almost behind the barn sort of thing, but you know those pictures of black lungs just scared me enough that I didn’t want to continue. But my parents smoked when I was growing up. There were still ashtrays in the house. They actually quit in the late ’60s, soon after the Surgeon General’s report. My Dad had an awful night, sort of a smoker’s cough, felt he was going to die and said, “If I wake up in the morning I’m not going to smoke anymore,” and he was able to do that.

If you could change one thing in the tobacco environment in the U.S., what would it be?

I’m sorry I can’t answer “one thing” because human behavior is so complex and there’s no silver bullet. You need a physical environment where these products are much harder to get than they are now, that they’re not available 24/7 on every corner. You also need an environment where you don’t see tobacco advertising and promotion wherever you go, and you need an economic environment where these are costly products. And you need a political environment where our leaders can really take this problem seriously and do something good for public health. Tobacco control in particular is an area where we really can save lives millions at a time. We really have the tools at our disposal. We now know what we need to do. We just have to do it.