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Introductory remarks
  1. Thomas C Schelling
  1. School of Public Affairs, University of Maryland, College Park, Maryland, USA

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It is just ten years since David Hamburg and I convened a group at Harvard to think about setting up an institute concerned with smoking. John Pinney and several others here today participated in the group. The response was positive; we did set up an Institute. I remembered that conference this morning as I selected the tie I would wear today; at the end of the conference Julius Richmond, former US Surgeon General, presented David with the blue version, and me with the red, of the No-Smoking tie. From the audience it may look like any small pattern, but up close you would see that the pattern is the universal no-smoking logo.

What I like about today’s conference is that we are all here because we sympathise with people who smoke. They are not the enemy; we are not trying to harass them, we are trying to help. That attitude has become uncommon at conferences on smoking; for many it is hard to be anti-smoking without being anti-smoker. We know it is hard to stop smoking, and we are here because we’d like to make it easier if we can.

This conference may also be unusual because it occurs at a time when we may actually have a White House that will, for the first time, be willing to take a stand against the most dangerous drug of all, nicotine. We had the Califano experience, with little help from the White House; we had the Everett Koop experience, with no help from the White House. Things may be due for a change. We are also facing the prospect of a major reform in health care, which possibly –I can only say possibly – will take a new approach to prevention.

The stunning changes in behaviour that have occurred in the last 30 years – the decline in the incidence of smoking, the increase in cessation, the decrease in the uptake of smoking – may be levelling off. Have the people for whom it was easy already stopped smoking, leaving the hard core for whom it is especially difficult? My interpretation is that if we are coming down to a hard core, it is not a hard core in terms of addiction and the difficulty of giving up smoking, that was difficult enough for the 50 million or so who already stopped. But they may be a hard core in terms of motivation and of our ability to reach them and recruit them to the ranks of those who try, and keep trying, to stop.

Let me point to an economic anomaly. One thing that anyone who deals with the economics of smoking should recognise – and I include smokers among those who deal with the economics of smoking – is that if someone succeeds in giving up cigarettes, through almost any kind of expensive therapy, stopping smoking will still save money. Maybe not for a $20 000 in-patient treatment, but for almost any smoking therapy that I know of, you break even before the end of the first year of abstinence.

So why do people need financial assistance in order to quit? Why is it important that health care and health insurance and corporate health programmes provide part or all of the costs of giving up smoking?

I think there is an answer to this question, but the answer is not that people can’t afford it on their own. The answer is that there is a marketing job to be done, and the health care financing of smoking cessation is part of that marketing campaign. It is not a campaign to save people money and to help them afford the help they may need. It is to reach out and surround people with an ambience in which smoking is increasingly recognised as unhealthy and unpopular. It is a campaign to make people more self-conscious about their smoking. I call it the ‘ soft coercion ’ of surrounding smokers with continual reminders, not only that they shouldn’t smoke but that, sooner or later, they are going to recognise they have to stop and they may as well start now.

I think much the same is true of the increasing restrictions on smoking in public places and in the workplace. The most important effect may not be that it reduces where, when and how much smokers can smoke, but that it surrounds smokers with a social environment that continually reminds them that sooner or later they are going to have to stop.

I think we are here today to talk not about the ‘ microeconomics ’ of financing the quitting of smoking but about the macroeconomics of a holistic marketing campaign in which we use all the ways we know to reach out to people to remind them that there is help when they need it, that sooner or later they are going to want to stop smoking, and that sooner is much better than later.

This is the process of continuing to change the social norms that govern the ways that people eat, drink, exercise, smoke, and otherwise take (or don’t take) care of themselves. It is important not to get too focused on the details of who quits and who pays, but to stay with the larger issue of how we generate a social mood through a marketing campaign that brings people into the quitting process.

I recently agreed to serve on a committee of the Institute of Medicine concerned with prevention of smoking among young people, and was asked to think about one or two points that I would make at the first meeting. My first point will be that we are probably better at helping people stop who want to stop than at preventing smoking in the first place; and it is fortunate that when young people take up smoking they have a decade or two in which to stop before the dangers become too severe. (The 45- to 50- year-old who has been smoking for 30 years is in immediate danger if she or he doesn’t quit pretty soon.) Campaigns to prevent smoking among children need to be accompanied by campaigns to help them stop smoking. It always stuns me that in surveys of smokers in the youngest adult age group, 20-24 years of age, more than half, both men and women, say they have tried seriously, and unsuccessfully, to stop smoking within the past 12 months. It is crucial not to rely wholly on prevention, but to recognise that a great many of today’s children who smoke will quickly become young adults who want to stop and may need help.

The other point I plan to make is that one of the best ways to keep children from smoking is to surround them with adults who do not smoke. In a long-run effort to get children to smoke less it is important that their parents, and other adults whom they may emulate, succeed in stopping smoking if they smoke. While we tend to focus on the adult smoker at a conference like this, we should recognise that inducing adult smokers to try to stop, and helping them to succeed, is one of the best ways to influence children not to smoke.

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