Road Kill/Tobacco Kill

GUEST: Dr. Kelly Henning
AIR DATE: 12/19/09

I’m Richard Heffner, your host on The Open Mind. And our conversation today is about two foundation initiatives designed to save lives … ultimately, of course, yours and mine … and those of untold others around the globe.

Medical doctor Kelly Henning is my guest. Formerly a Division Director at the New York City Department of Health and Mental Hygiene, today Dr. Henning heads all of the Bloomberg Philanthropies’ massive public health Initiatives, including one to reduce tobacco use around the world and, of course, its Global Road Safety Initiative.

Now, today, first I want to ask Dr. Henning just what progress she has to report on these Bloomberg initiatives — and I do know that they are directed primarily overseas — but also I would ask her as a physician just why we seem so hell-bent on killing ourselves with tobacco … and on the road. What is there about the human being that makes us want to kill ourselves seemingly?

HENNING: Well, you know, we have, we have a lot of information about persons in low and middle income countries around the world. And we know that in many cases they don’t realize that smoking tobacco, or chewing tobacco results in, in adverse health affects.

Unlike the United States where, at this point … what many of our citizens are well aware of how dangerous it is to smoke. In many parts of the developing world that’s not the case. People are unaware to this, right to this moment … they think that it’s completely safe to smoke cigarettes or to chew tobacco or to use other forms of tobacco.

Similarly with global road safety, most people aren’t aware that it’s such an important thing to wear a seat belt inside a car or to wear a helmet when they’re riding on a motorcycle. Or to be very cognizant and aware of pedestrians when they are driving at very high speeds. So there’s a big problem with awareness around the world. And, and that’s one of things that we’re trying to address with the Initiative.

HEFFNER: So then your task then is educational?

HENNING: Partly educational. Certainly raising awareness among populations about these dangers is part, part of the struggle, part of the fight, part of what we’re, we’re engaged in.

We do a lot of other things as well. We try to work with governments to improve the knowledge and the technical capacity of governments to protect their citizens against tobacco. As well as against these, these safety harms on the roads, on the world’s roads.

As you know, almost … well, over a million … one point two million people a year are killed on roads, globally. It’s an enormous number.

Over five million a year killed from tobacco, globally. And in both cases more than 80% of those deaths are occurring in low and middle income countries. So, the scope of the problem is truly enormous.

HEFFNER: That really is a war that you’re waging.

HENNING: We think of it as an epidemic. Particularly tobacco. We talk about the tobacco epidemic and the fact that we’re really trying to intervene and reduce those, those death figures.

We know that in the 21st century it could be as much as a billion people killed by tobacco and the diseases caused by tobacco. So, if we intervene we think we can reduce those numbers, we think we can bring them down. But it’s a big, it’s a big fight. It’s a hard work.

HEFFNER: The intervention. Describe it.

HENNING: For tobacco?

HEFFNER: MmmHmm.

HENNING: We have the global initiative that the Bloomberg Philanthropies supports is very much in, in line or in step with the World Health Organization suggests.

As you know, there’s a global treaty that countries have signed up for to try to reduce tobacco use and most countries around the world have signed on.

But now it’s a problem of implementing all those strategies and really getting them out there in the country … making them work.

WHO. came out a year and a half ago, or so with an “Empower package”. The Empower Package stands for interventions. Monitoring tobacco use, protecting people from second hand smoke, by making public places smoke free. Warning about the dangers of tobacco. Enforcing ad bans, banning all that advertising that you see all over television and on billboards internationally for tobacco products.

HEFFNER: Overseas, too?

HENNING: Overseas. Very, very prominent overseas. And raising the price of tobacco, which is incredibly important, too. As an intervention.

HEFFNER: How do you go about that?

HENNING: Well …

HEFFNER: Taxes?

HENNING: Taxes. Taxes are the most effective way to reduce tobacco use. So as you raise the price of tobacco products children, particularly, and, and teenagers become unable to purchase tobacco products because of the price increases and it really reduces their initiation of smoking and use of tobacco.

It’s been shown quite clearly that raising price through taxes is extremely effective.

HEFFNER: The enemy. How do you identify the enemy?

HENNING: Well, the tobacco industry is strongly at work in the, in the low and middle income countries around the world. Particularly through their advertising methods.

These can be very subtle … things like holding parties where they give away free cigarettes. Or giving out coupons to reduce the price, to try to counteract increases in taxes.

There are a number of tactics that very much relate to promotion and advertising that we’re very aware of, W.H.O. is very aware of and our partners on the ground are really trying to overcome.

HEFFNER: And with what success?

HENNING: We are seeing successes. We are seeing some early, some early wins if you will.

I can just name a few. Mexico City, a very enormous metropolis in Mexico, of course, has gone 100% smoke free in the last year and a half.

HEFFNER: What do you mean by that?

HENNING: That means that like New York City all of the public places and spaces in the … in Mexico City … ban smoking. So one cannot smoke inside a government building, inside a restaurant, inside a bar … any enclosed places. And it’s been quite effective. They’ve really, they’ve really taken this very seriously. The government of Mexico City has promoted and enforced this law and it’s really been a big success.

HEFFNER: Now when you say … when I ask you who the enemy is … because we always need to personalize that way … and you say “the tobacco companies, essentially, and their advertising”. These tobacco companies are they mostly American?

HENNING: There are international tobacco companies … some are American, some are British, some are Japanese. There are a number of different, large tobacco companies out there that are working to promote their products.

And what we’d like to do through the interventions that W.H.O. has promoted and through out work on the ground, to really raise awareness and try to make the environment safer for, for the population so that they realize that it’s not a good thing to start smoking. It’s important to quit. And so that they’re not exposed to second hand smoke, which is what a lot of these smoke free public place laws are about.

HEFFNER: Is that the way you think you can sneak into the public consciousness … the second hand smoke?

HENNING: Second hand smoke is a, is an important issue. Another one that many people are unaware of … so, it’s often … people don’t realize that a person sitting at the table next to them in a restaurant smoking is really endangering their own health.

In some cities in the world people would ask that person who’s smoking to please put out their cigarette or to go outside. In other cultures, that would be unheard of. People aren’t aware that there’s a danger. And they couldn’t consider that a problem. So we’re really trying to work on that.

HEFFNER: Is there any historical precedent for this kind of killer part of our society. Has there been anything like tobacco in the past? In the history of mankind that is as dangerous?

HENNING: Well, we know that tobacco is the leading agent of death in the world today. So it’s magnitudes above many other health effects that we worry about. Tobacco’s been around for a very long time. Our understanding of the dangers, our understanding of its relationship to early death, premature death, death among adults during their most productive years is relatively recent in the history of mankind. Fifties … forties, fifties, sixties … so it’s, it’s a battle that we’re, in some ways, just beginning. Particularly in these low and middle income countries.

HEFFNER: I, I’m aware of the fact that the Bloomberg Philanthropies have put in hundreds of millions of dollars into this battle. It’s an astonishing sum. And how effective do you think money can be?

You look like a very optimistic, with-it person. Do you feel in the time that you’ve spent at this, that it’s working?

HENNING: We … we, we work very hard to try to measure our, our effects.

HEFFNER: MmmHmm.

HENNING: We feel that we have to measure it in order to control it.

HEFFNER: Right.

HENNING: So we are doing a global adult tobacco survey right now in 15 low and middle income countries around the world where the most smokers live. Two-thirds of the world’s smokers live in these countries.

HEFFNER: Are these also poverty countries?

HENNING: They are. They’re low income countries, or middle income countries … China, India, Indonesia, Bangladesh … for example … Russia … a number of others.

We’ll be doing 14 of those surveys around the world. They’re in the field right now. In fact they’re almost finished. We should have some data very soon. And we will be able to measure, actually whether the number of smokers in these low income, high burden countries is actually coming down over time. And whether we’re having an effect.

HEFFNER: Prelim … preliminarily … I can say it … do you have any sense of what you’re going to … of what the figures will indicate?

HENNING: We’re … the figures that we’re collecting right now are our baseline figures …

HEFFNER: (Head shakes “yes”)

HENNING: … so in a couple of years we’ll have follow up figures …

HEFFNER: I see.

HENNING: … we’ll have a better idea. We do know, though, that these interventions work. From experiences in higher income countries and we do know that as the laws and the regulations and the enforcement of those for smoke free places, for ad bans, for hard hitting advertisements, for pack warnings on cigarettes, as those laws go into effect we expect we’ll see a reduction. We have every reason to believe we will.

HEFFNER: In high income countries … take our own … how successful has the battle against tobacco been?

HENNING: It’s, it’s … things are going well in the US. There’s a lot more work to do, always. But our smoking rates have come down over the last several decades.

We have increasing numbers of states and large municipalities that are smoke free. That is, have smoke free public places.

We’ve had success with the raising price of tobacco. Recently there’s been a Federal increase in the price of tobacco in the United States. So we’ve had some real successes in the U.S.

I wouldn’t say that it’s over, that we’ve made all the progress that we can make. I think there is more progress to be made. But the experiences have been very positive.

HEFFNER: There was a time, if I remember correctly … that the tobacco industry understood that the … what had been the Fairness Doctrine requirement that if there were tobacco, cigarette smoking ads on television … they had to be countered in part by some representation of anti-smoking commercials.

That those were so effective, the anti-smoking commercials, that the tobacco industry was happy to suggest that tobacco be banned on television. Is there any counterpart now to those successful anti-smoking commercials? They were pretty gruesome.

HENNING: They continue to exist, actually. There are anti-smoking campaigns. Public campaigns that include television, radio, billboards and so forth … in the United States that are on-going. There are a number of those campaigns now being aired in low and middle income countries. Somewhat … to some degree supported through the Bloomberg Initiative. There have been campaigns in India now. Campaigns in China, even. Campaigns in a number of countries, Mexico … around the world … and those campaigns are quite hard-hitting.

They really promote the idea that, that … what we’d like to have is smokers viewing those campaigns and thinking about quitting … really, really … really moving the, the, the, the tick forward, if you will, about trying to change behavior with those campaigns.

HEFFNER: Wouldn’t you prefer and I’m not putting words in your mouth … and your answer maybe “no”. But I would think you would prefer and your objective would be to ban tobacco.

HENNING: Well, that’s a very common question that is asked about tobacco control. Tobacco exists, it’s out there … it’s widely prevalent and banning it outright is fraught with difficult. So, in, in the … at the moment, the, the strategy is to really try to implement control measures to reduce the demand.

Demand reduction, if you will, for tobacco. And those are the ones that I mentioned earlier that W.H.O. is promoting.

HEFFNER: I know … I understand that demand reduction, as with illicit drugs … is, is a key. But we also have laws against the illicit drugs … that’s why I can use the word “illicit”. Do you feel that it’s such a lost cause that making an effort toward banning the killer … cigarette … would be fruitless?

HENNING: I think it’s … all strategies are on the table, I think. I think that this is an enormous public health …

HEFFNER: It’s a very diplomatic thing to say …

HENNING: … it’s an enormous public health problem. And I think that we, we, we always consider all the options. As you know, in the United States, the FDA’s been given increasing, jurisdiction …

HEFFNER: MmmHmm.

HENNING: … over tobacco … the use of tobacco and how it’s used and what needs to be in place in order to make claims about its safety. And those are steps toward what you’re suggesting. But again we have to live in the current reality and I think we’re very anxious to reduce young people from starting smoking and encouraging people to quit.

HEFFNER: You talk about current reality and I understand that’s a euphemism for political awareness. But I would think that the major element here would be the statistic that you used before … I hope you’ll repeat it … about the assumption of the numbers of deaths due to tobacco. What is that number?

HENNING: So, the … I think perhaps one of the most astonishing figures in public health is this concept that in the 21st century … with current models … it could be that a billion people would die of tobacco related disease, if we don’t intervene.

And that’s one of the urgencies around intervening as soon as possible. 80 plus percent of those deaths would occur in low and middle income countries. So we feel that it’s important to begin to bring those low and middle income countries on board to try to give them the tools to work toward reduction in tobacco use, in line with the W.H.O. recommendations and that’s what the initiative is really supporting.

HEFFNER: In our own country you suggested before that we’re … I’ll let you restate it so that I don’t mistakenly say more than you mean to say … that we’re fairly aware of the dangers of tobacco. Is that what you … do I get …

HENNING: I think compare …

HEFFNER: … that right.

HENNING: I think compared to many other cultures around the world it’s true. That the, the level of awareness is better in the United States than in many places.

HEFFNER: Okay. Better in the United States. But let me pin you down to … how good is the awareness … how high is the awareness in our own country? And I ask that because I know that in my family, among my friends … very high awareness. I have a suspicion that it couldn’t be that high in many other parts of the country, levels of society because of the numbers of cigarettes that are smoked.

HENNING: It’s true that, that cigarette smoking is related to other factors. There are regional differences, there are socio-economic differences. Age group differences in terms of smoking rates in the United States. And, and, and along with that levels of awareness about the harms.

Tobacco is an addictive product. So once people begin smoking it’s difficult to quit. And so there’s also cohort effects, if you will. People who’ve started smoking in the past, who continue to smoke even though they may wish to quit.

So it is true that there are certainly still too many smokers in the United States. No question about that.

HEFFNER: And the kids?

HENNING: Children’s smoking rates have declined … teenagers which is monitored in the U.S. New York City has a very low teenage smoking rate. They report single digit smoking rates among teenagers.

HEFFNER: As contrasted with a dozen years ago?

HENNING: Where they were probably double, at least what they are today. So, so there are, there are improvements in teenage smoking rates. But it’s an area that’s monitored carefully. Nationally there have been a little … there have been a couple blips upward a bit in recent years. So I know that the, the Federal government is very concerned and very, very worried about that.

In developing countries the teenage smoking rate is high in many places. And the average age of onset of smoking is very low. So in some cultures the average age of beginning to smoke could be as low as ten years of age, or 12 years of age. Very low.

HEFFNER: Well, I was nine when my brother took me out to the garage …

HENNING: (Sigh)

HEFFNER: … in the back … and taught me how to smoke. Ahemm … is your target overseas … and this goes back to what I was asking you at the beginning and I think I was mistaken in my assumptions. Is your target overseas government there more than widespread public information?

HENNING: So maybe, maybe it’s important to mention that we, we think that it requires a multi-prong approach. So we support governments to assist them with technical assistance and other means to try to develop tobacco control policies. We also support non-governmental organizations who work hard to help governments do the right thing.

HEFFNER: MmmHmm.

HENNING: We also support some academic institutions to do … to provide the information that’s needed in order to really have a, an evidence base for how important it is in those countries to do tobacco control.

So, and we do these surveys that I mentioned just a bit ago. So there’s … there, there are multiple areas that are incorporated into the Initiative that we support currently.

HEFFNER: And how well are you doing? If I may switch the subject for a moment … to that other death dealer … the driving mechanism.

HENNING: The Road Safety Initiative is newer. We’ve been working on that for a little less than two years and we did … we supported the World Health Organization’s programs … pilot programs in Vietnam and in Mexico.

The interventions were different. In Vietnam where most people drive with motorized two wheelers, that is …

HEFFNER: MmmHmm.

HENNING: … motorcycles … the initiative focused very much on motorcycle helmets, as well as reducing drunk driving.

In Mexico where cars are much more prevalent, the program was to focus on seat belt wearing, as well as, again, reductions in drunk driving.

So in both cases there have been some successes. Vietnam has had an amazing transformation, if you will, in the last year and a half, where a national level law was put into place requiring all motorcycle users to wear standardized, acceptable motorcycle helmets. Not just drivers, but everyone on the motorcycle. And that law went into effect and very quickly the population took it up. We’ve had a series of observational studies done in Vietnam through our program which have shown more than 90% helmet wearing rates, which are very high.

In Mexico we’re beginning to see a, a very big increase in looking for drunk driving intercepts by police, sobriety checks, random checking in, in those areas where we’re working and those have led to reductions in hospitalizations for serious crashes.

So we think that there is a lot … a lot more to do, but it’s a good start.

HEFFNER: As a physician you must be … you heart must be warmed by the decrease in the mortality statistics from both tobacco and driving.

HENNING: That’s our goal. We’d like to see a real, concrete reduction in deaths. That’s what we try to measure, that’s what we’d like to see. And certainly any time we see any, any evidence that that’s happening, we’re very, we’re very happy about that. And that’s what we’d like to promote.

HEFFNER: How goes it in the US?

HENNING: On road safety?

HEFFNER: MmmHmm.

HENNING: The US track record on road safety has historically been good, but we are … we do have higher fatality rates than many industrialized countries around the world. So there is, there is room to improve …

HEFFNER: We do have higher rates than other industrialized …

HENNING: Than many. Yes. Yes. And we also have … as you probably are aware … some states who have rolled back or repealed their motorcycle helmet laws … so there is room to improve in the US on road safety, for sure.

HEFFNER: So you have an enemy there, too. As in tobacco, you have the tobacco manufacturers, the cigarette manufacturers. Where is the enemy with driving?

HENNING: Well, I think with road safety we have actually layers of interventions that, that relate to different things.

So, for instance, we would like to change people’s behavior. We’d like them to fasten their seat belt, we’d like them to put on their helmet appropriately, when they’re riding their motorcycle. We’d like them to reduce their speed when they’re driving. And obviously not to drive when they’ve been drinking.

So those are behavioral changes that we work on. There are also infrastructure issues. So, in the developing world, for instance, in low and middle income countries about half of death are among not in cars … people walking, people on bicycles …

HEFFNER: MmmHmm.

HENNING: … etc. … and frequently there’s no sidewalk available. There’s no berm or edge to the road. There’s no safe way to cross the road; there may not be safe intersections. So there are infrastructure issues as well. And then there are transport issues. Many countries have no public transit that is safe or, or in good enough condition for their population.

HEFFNER: Well, I certainly shouldn’t have left it until we have 2 minutes or less left. But, coming back home …what about the damn cell phone? And the computer, while driving. What’s that situation like?

HENNING: That’s about distracted driving. So drivers are distracted by a number of things, but most … among the most important are cell phone use and that’s both cell phones that are handheld as well as cell phones that are hands free. As well as texting and that’s both looking at messages as well as typing messages. There, there’s increasing data that all of that, all of those are very dangerous for drivers. That drivers need to be really concentrating on the road, not on anything else. They can’t be distracted or their likelihood of, of having a crash and a fatal crash goes up.

HEFFNER: Statistically, is that demonstrated?

HENNING: Yes. That’s been shown. And it, it really does appear that this cell phone issue is, is … because people are on cell phones for such a long period, they tend to talk for several minutes … repeated calls. It really is causing a danger.

HEFFNER: And that’s the distraction?

HENNING: The drivers are distracted.

HEFFNER: Despite the youthful belief that you can multitask …

HENNING: Not when driving.

HEFFNER: Not when driving? What about laws in that area are they enforced?

HENNING: Well, there, there are a few states that have cell phone bans. But that’s an issue under active consideration right now, as you know, in the US and the, the President just asked for or demanded the Federal employees not be texting when driving. And the expectation is that this will gain momentum and there will be other groups and additional legislation in this area, as it’s becoming more and more evident that it’s a major problem.

HEFFNER: So you and the Bloomberg Philanthropies have your work cut out for you.

HENNING: (Laughter) Indeed.

HEFFNER: Dr. Henning thank you so much for joining me today on The Open Mind.

And thanks, too, to you in the audience. I hope you join us again next time. Meanwhile, as an old friend used to say, “Good night and good luck.”

N.B. Every effort has been made to ensure the accuracy of this transcript. It may not, however, be a verbatim copy of the program.