A Quest for Quitters

Michael Fiore has a plan that could lengthen the lives of 3 million Americans and save billions in health care costs. It’s the most ambitious campaign against cigarettes in our lifetime — and it could all go up in smoke.

By Jenny Price ’96

Michael Fiore’s first case at the UW Medical School was both a success and a numbing failure. Not long after arriving on campus in 1988, he began working with a middle-aged woman who smoked a pack of cigarettes a day and had tried to quit at least a dozen times. She told Fiore she had a new reason to kick the habit: her first grandchild was on the way.

Fiore counseled the woman and supplied her with nicotine gum — the only medicine then available to help people quit smoking — and she indeed gave up cigarettes for good. But soon after, doctors found an orange-sized tumor in one of her lungs. She died within eight months.

“It really drove home for me the personal tragedy of tobacco dependence in our society and in our state,” Fiore says.
Now fifty-one, Fiore directs UW-Madison’s Center for Tobacco Research and Intervention, an agency that enlists seventy staff in the effort to curb tobacco use. In the nearly twenty years that he’s been fighting his war on cigarettes, he has helped thousands of smokers give up tobacco, conducted research that has led to better strategies for those who want to quit, and pushed his fellow doctors to take tobacco use seriously as a health risk.

Considered by many to be the nation’s leading authority on beating nicotine addiction, Fiore was asked three years ago to lead the development of a $130 billion plan to dramatically cut tobacco use in the United States during the next twenty-five years. The position has put him at the helm of the federal government’s most ambitious attempt to end smoking, and squarely at the center of a legal squabble that may put that very plan in jeopardy.

But when he thinks about the 46 million Americans who smoke — and the estimated 70 percent of them who wish they didn’t — Fiore sees more than just a pressing public-health issue. He vividly remembers that first patient, for whom his advice was too late. It’s personal for him, and it will remain so until every smoker who wants to quit can do so.

“We want it to be as easy to get smoking cessation treatment as it is to walk down to the corner store and buy a pack of Marlboros,” Fiore says.
Fiore’s campaign to halt tobacco use was launched when he began work as a medical epidemiologist in the U.S. Office on Smoking and Health, under then-U.S. Surgeon General C. Everett Koop. Fiore arrived with a medical degree and a master’s degree in public health from Harvard University, and he was fresh off a residency at the Centers for Disease Control and Prevention, where his work had included studies of the health effects of groundwater pesticide contamination and of living in homes with mold or allergen growth.

“The things I remember about him were his unbelievable energy and his passion against tobacco, and they were evident almost immediately ... I felt that anybody who had those two virtues really belonged in the tobacco-control business,” Koop says.

Koop put Fiore to work examining the public-health implications of Americans’ tobacco use. Scrutinizing surveys dating from the 1960s, Fiore concluded that smoking was more prevalent among less-educated populations as well as racial and ethnic minorities. He also found that most smokers who tried to quit gave up cold turkey, without any support or medication to wean them from the addictive effects of nicotine.

“There’s a powerful misconception that tobacco use is just some bad habit that smokers should be able to overcome on their own,” Fiore says.
That realization helped ignite a period of unparalleled intervention, as doctors and public-health agencies began to do more to help smokers shake the addiction. After he arrived at UW-Madison, Fiore began pushing for policy reforms that would prompt clinicians and health care systems to ask patients about their tobacco use, and, beginning in 1991, he argued that whether patients smoke should be one of the vital signs that doctors routinely monitor, along with pulse, respiration, blood pressure, and temperature. Today Fiore’s influence on the day-to-day interaction between doctors and their patients is palpable: 70 percent of doctors now ask their patients about smoking, a dramatic shift away from the passive attitudes of old. Many states have since initiated support centers and phone banks to help smokers quit. In Wisconsin, Fiore’s staff organizes the state quit line (see sidebar, page 61).

In 2002, former U.S. Health and Human Services Secretary Tommy Thompson ’63, JD’66 asked Fiore to lead a group of experts in developing a national strategy to help Americans beat nicotine addiction. The sixteen-member committee came up with a twenty-five-year, $130 billion plan that Thompson says will become the “cornerstone of the controlling and the limitation of tobacco use in this country.” Among the plan’s features are a twenty-four-hour national quit line providing counseling and free nicotine-replacement drugs, a massive media campaign, and millions of dollars for research to find better treatments for smokers who want to quit.
The plan — based on expert testimony, published articles, and scientific data — is at the center of the U.S. Justice Department’s racketeering case against six cigarette makers. The lawsuit claims that the companies conspired to mislead the public about the health effects of smoking and to market cigarettes to children, and most observers believe that Fiore’s plan forms the core of what the government would seek as remediation if it wins a judgment against the industry. And that has put the plan’s proposals under intense scrutiny, both from industry lawyers and some smokers themselves, who feel the government’s case is an affront to their rights.

In May, Fiore was called by the government as an expert witness and subsequently endured more than eight hours of cross-examination by Philip Morris lawyer Ted Wells, who at times crowded the witness stand and suggested the plan’s projections for how many smokers it could reach were overstated. Wells also pointed out that the plan was so sweeping it would allow a billionaire such as Warren Buffet to get free medication and counseling if he were a smoker. In later interviews, he derided the plan as “fatally flawed,” arguing that the government has no legal grounds to ask tobacco companies to pay for such a broad approach.
Tobacco appears to have the courts on its side on that issue. Both a federal appeals court and the U.S. Supreme Court have ruled that racketeering laws limit the scope of damages that the government can seek in the case. Because of those restrictions, any judgment against the tobacco companies is likely to be for far less money than Fiore’s plan costs. In their closing arguments, justice department lawyers suprised many observers by asking the judge to approve a five-year program that would cost just $10 billion. Complaints from health advocates and some Democratic members of Congress prompted an internal investigation into whether government lawyers were pressured to seek lower damages. The judge also allowed anti-smoking groups to present arguments that the government failed to represent the public interest in the case.

Regardless of the outcome of the case, Fiore maintains that the plan’s cost is reasonable, especially relative to the price of smoking, which he tabulates as $150 billion a year in health care costs tied to tobacco use and $180 billion in lost productivity and absenteeism.

“This program — for twenty-five years — costs $130 billion. We’re spending three times that amount every year in costs from tobacco,” he says. “When put in that context, it’s really a pretty modest investment.”
“I think anybody that’s looking at this on a rational basis would say this is a hell of a buy,” adds Thompson. “I think we’ve got to be much more aggressive.”

Some smokers take issue with that kind of thinking. A shrinking, but increasingly defiant group, hard-core smokers are growing resistant to the ramped-up efforts to get them to quit. Many argue that a national stop-smoking campaign, while well-intentioned, is unrealistic and would result in far fewer smokers quitting than Fiore predicts.

“I was considering quitting myself eight or ten years ago, and all this started up and I thought, ‘I’m going to smoke. Nobody’s going to tell me not to,’ ” says Garnet Dawn, who serves as Midwest regional director for The Smokers Club, Inc., a nationwide group that promotes smokers’ rights.

Dawn says that the mass-marketing campaigns by anti-tobacco groups have “become so extreme that people are almost beginning to laugh at it.” She also sees those efforts as driven by the influence of large pharmaceutical companies that would benefit from mass distribution of nicotine replacement medications.

Fiore’s center, she notes, is partially funded by the Robert Wood Johnson Foundation, the nation’s largest philanthropy devoted to public health. She and other smokers’ rights advocates say that the foundation’s stock in Johnson & Johnson, whose subsidiaries manufacture and market nicotine patches and inhalers, represents a conflict of interest.
Even in Madison, where Fiore works, not everyone has adopted his vision of a smoke-free society. After the city passed an ordinance outlawing smoking in bars, Fiore joined a group of doctors, nurses, and health care workers at a press conference supporting the ban, while at the same time, a crowd of bar owners and smokers protested across town, demanding the city repeal the ban to restore lost business.

Recent figures from the federal government show that the rate at which smokers are quitting has slowed, suggesting that some people will continue to smoke despite knowing the health threat it poses. Just 3 percent of U.S. smokers quit between 1990 and 2003.

To Fiore, statistics such as these underscore the need for more activity, not less. “Most smokers have periods of quitting, when [nicotine addiction] goes into remission but then relapses when they go back to smoking,” Fiore says. “It’s the nature of the chronic disease that some people [will] relapse.”
Helping smokers quit has been the primary mission of Fiore’s campus center, which he founded in 1992, the same year he was honorably discharged after serving in the U.S. Army Reserves in the Persian Gulf War. Its headquarters are tucked away on the second floor of a modest office building a few blocks from Camp Randall Stadium. The center gets two-thirds of its $6.3 million annual budget from the federal and state governments, with the remainder coming from pharmaceutical clinical trials and nonprofit organizations. Its staff has grown from five to seventy people.

Fiore’s research focuses mainly on the role doctors and other clinicians play in motivating smokers to quit, as well as an analysis of the nature of tobacco dependence. His studies have shown that tobacco withdrawal symptoms last much longer than previously thought, with some patients exhibiting more severe symptoms two to three months after quitting than in the first week after they stopped smoking. The center also conducted some of the first research on nicotine replacement drugs.

Nothing he or anyone else has learned suggests quitting is easy, and neither is telling someone to quit. “When you are in the business of public health, you really are telling people to say no to a lot of things they like to do,” says Koop. “And it takes a special person to say no and not sound judgmental.” That’s where Fiore succeeds, Koop says, noting that his warmth and passion for helping people are enough to outlast the powers of addiction.
“He’s always really upbeat about it,” says Larry Meiller PhD’77, whom Fiore helped quit smoking thirteen years ago. “He congratulates you for every day that you’re not smoking, and he’s a great cheerleader, along with knowing a whole lot about why we need to quit and how we can quit.”

In Meiller’s case, it took a combination of counseling sessions and nicotine gum, which he says he still chews from time to time. A professor of agricultural journalism and host of a daily talk show on Wisconsin Public Radio, Meiller says that sharing his attempt to quit with listeners helped, but talking with Fiore and his staff about what triggered his smoking made the biggest difference. That meant giving up coffee, which he always paired with cigarettes, and taking note of when he lit up, such as when he got off the air or finished teaching a class.

Now sixty-one, Meiller says that his previous attempts at quitting on his own left him a “basket case.” One colleague who didn’t smoke even asked him, “Would you please start smoking again?” Still, when he came to Fiore for help, the doctor was brutally frank about how hard it is to quit, telling him it usually takes smokers multiple attempts to succeed.
Persistence, Fiore says, is what will make the national plan effective. The idea is that the more access smokers have to support, the more often they’ll give quitting a shot. Based on the increased number of attempts, the proposal promises that 5 million Americans will stop smoking within one year — thus preventing 3 million premature deaths.

“If we really want to control the disease and help every individual with the disease to put it in remission, we’ve got to give them the evidence-based treatments we know make a difference,” he says.

One of the plan’s key components is a $3.2 billion-a-year, twenty-four-hour-a-day national quit line. The toll-free number would do more than just serve as a place for smokers to call for counsel and advice; it also would be a vehicle for providing free nicotine replacement therapies to smokers who want to quit. Those who call the quit line, which would incorporate existing state-operated lines, would get at least four follow-up calls to help them stay on track.
Based on the plan’s recommendation, Thompson helped secure a $25 million annual budget to get a national quit line operating. But while the current line provides over-the-phone counseling, it does not offer medications. Although he describes the existing line as a critical first step, Fiore says that a new line will remove barriers to treatment by reaching segments of the population in which the prevalence of smoking is higher and people often can’t afford treatment.

“If we look at how smoking has evolved over the last fifty years, it’s increasingly concentrated in the least-advantaged members of our society,” Fiore says.

The national plan calls for a $1 billion-a-year media campaign to educate the public about the quit line and the dangers of smoking, an amount, Fiore says, that is needed to counter the $10 billion to $12 billion the tobacco industry spends on advertising and promotion each year.

Another element is $500 million a year dedicated to researching new treatments for tobacco dependency. Current treatments result in only 10 to 30 percent of smokers being able to quit for the long term, Fiore says, and putting more money into research could raise that rate to 50 percent. The plan would establish more research centers, like the one at UW-Madison, to work on the problem and spend a half-billion dollars a year to train and educate doctors, nurses, and other health care professionals to intervene with patients who smoke. Fiore says that seven of ten smokers visit a doctor each year, but few are offered treatment options.
That’s the same number of smokers who say they want to quit. Fiore says twenty-five years is a reasonable time frame for making that happen, because 40 percent of smokers who want to quit will try in any given year, but just 6 percent of them will succeed. Yet, none of these proposals will come to pass if the plan continues to sit on the shelf.

“In the future, smokers are either going to have access to treatments to help them to quit or they’re not,” Fiore says. “And to have a plan over the next twenty-five years that helps people quit, to me, is an incredibly appropriate forward- looking remedy. Now, I don’t say a remedy in a legal sense; I mean in a real practical, real-world sense.”

Although Fiore is often asked to testify in a court case against the tobacco industry, he rarely accepts, aside from a class action case in New York ten years ago. The federal case was different, he says, because of its potential for making a dent in tobacco use.

“For the first time, we’re having a dialogue about how important it is to help smokers quit,” he says.
And that’s a thrilling prospect not only for Fiore, but also for his former boss, Koop. Fiore keeps a photo of the two in his office, which Koop signed, “No disappointment, yet. Our expectations are still high.” Koop says he wrote that because a lot of young people who go into public service “have great expectations and then they just sort of fizzle out.”

Fiore and Koop still speak every two weeks and see one another every couple of months. The former surgeon general, who now heads up his own heath institute at Dartmouth College, says they have a father-son relationship. And Fiore enthusiastically cites Koop as hero, mentor, and friend.

“It was sort of prophetic that this youngster who came and was so excited and doing something about tobacco eventually did the best thing anybody’s ever done about tobacco,” Koop says. “What remains to be seen now is whether the government has the guts to act on it.”

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