CDC Director Talks About the Nation's Biggest (and Winnable?) Health Battles

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http://www.medscape.com/viewarticle/731362?src=ptalk&uac=139759CJ

Eli Y. Adashi, MD: Hello, I am Eli Adashi, Professor of Medical Science at Brown University and host of Medscape One-on-One.

Joining me today is Tom Frieden, Director of the Centers for Disease Control and Prevention, whose earlier tenure as the Commissioner of New York City's Health Department was marked by visionary accomplishments. Our topic is winnable public health battles. Welcome.

Thomas R. Frieden, MD, MPH: Thank you.

Dr. Adashi: It's wonderful to have you with us today. Let's begin with tobacco. How does one account for the fact that 1 in every 5 adults still smokes and that progress has stalled over the last 4 years? Is it that we're now up against the true hardcore smokers or is there much more to it than that?

Dr. Frieden: Well, tobacco is addictive, and most smokers began smoking as kids. Most smokers want to quit. In fact, we're not up against the hardcore smokers overall. What we see is that places in the United States that implement effective policies continue to see big declines in tobacco use, so the things that worked before, continue to work. We have to implement them and implement them more effectively.

Dr. Adashi: So the packages and the know-how are here. The secret is applying them effectively and conscientiously.

Dr. Frieden: Absolutely. We've seen a lot of progress with smoke-free public places. We're not seeing good developments with running hard-hitting ads. It's expensive to do that, but they work. But there's good news with coverage of cessation treatment and with more options for people who want to quit. Every doctor should be an advocate for tobacco cessation.

Dr. Adashi: Speaking of smoke-free spaces, where would you say we are on the whole towards becoming a smoke-free nation, as appears to be the norm in New York City.

Dr. Frieden: Well, the glass is far more than half full, but it's still partly empty. We've seen a steady expansion in smoke-free places around the country and in fact, around the world. But still, last year 90 million Americans were regularly exposed to second-hand smoke and, shockingly, most children are exposed to second-hand smoke. For parents who smoke, they should be aware that 98% of kids with a parent or guardian who smokes have measurable levels of tobacco toxins in their bodies.

So don't kid yourself, if you smoke, quit, and if you think your kids don't notice, well, they're twice as likely to become smokers themselves, and they're virtually certain to be exposed to toxic chemicals.

Dr. Adashi: My last read of the figures suggests that due to first- and second-hand smoking exposure, 1 individual dies every minute in the United States. Is that a correct and up-to-date figure?

Dr. Frieden: There are more than 400,000 deaths per year from tobacco. That's more than a thousand each and every day of the year. It remains the leading preventable cause of death in this country and, in fact, globally. Therefore everyone in the health field really should be advocates for tobacco control. That means control in the community through measures such as hard-hitting ads, smoke-free places, and increasing the price of tobacco; and prevention in the healthcare setting: helping smokers to quit, advising each and every smoker with personalized, forceful, specific information, and advice to quit. It makes a big difference. It can be discouraging for doctors, because most people whom we encourage to quit don't, but what an individual clinician may not recognize, is that 3-5 minutes of personalized advice doubles the likelihood that a smoker will quit.

Dr. Adashi: So it sounds as if a whole series of individually important but complementary measures really are ultimately what makes a difference.

Dr. Frieden: Absolutely. And, in parts of the country and parts of the world where they've been applied, we've seen smoking rates fall and fall rapidly.

Dr. Adashi: Looking forward, can one point to recent pharmacological or technological innovations that would perhaps add to our set of tools as we seek to promote smoking cessation. Is there anything on the horizon that is quasi-revolutionary or at least a game changer?

Dr. Frieden: Well, first, there are great tools today, and there are an increasing number of options for smokers who want to quit: medication, different forms of nicotine, and different combinations. Personally, I think that every smoker who tries to quit and sees a healthcare professional should get cessation assistance medications. Currently, only about 1 in 10 does. So better use of existing tools is very important. It's encouraging that we have more medications that are available, more forms of nicotine replacement that are available, and more ways to potentially use combinations of medications. In the future, we would be very excited by some things on the horizon like more effective medications, or maybe even a vaccine, but that's theoretical. Right now what's practical is that smoking is killing people and we can help them quit.

Dr. Adashi: So really, pragmatism and the utilization of existing approaches seem to be the way to go.

Dr. Frieden: In fact, for the first time over the past few years, the trend has been that now, most Americans who've ever smoked, have already quit. So, if you've got a patient who thinks they can't quit, you can tell them that, "Most smokers already have, and you can too."

Dr. Adashi: That's a significant message. Let's move on now to obesity -- another hopefully winnable battle. Drawing on your experience in New York City, has menu labeling had the desired impact on food choices that adults make for themselves, but perhaps even more importantly, for their children?

Dr. Frieden: Menu labeling is an important intervention. It empowers people. It gives them information. It also is important, because it gets the restaurants to think twice before they put up a 1500-calorie breakfast. So it both makes the choices healthier, and it makes the options healthier by getting some reformulation on the part of the restaurant industry. I think we would say that it's a modestly effective intervention. The data from New York City suggest that people did reduce the amount of calories they consume as a result of menu labeling by and large. However, for example, one restaurant chain had a price discount, where they had an inexpensive foot long, 5-dollar sandwich, and that foot long, 5-dollar sandwich resulted in a big increase in calories consumed per customer.

So, informational efforts like menu labeling are important. They empower people, they hold restaurants accountable to an extent to what they're doing, but they can be overwhelmed by other factors, such as price. Now as you may know, in 2012, menu labeling becomes the law of the land, and every restaurant throughout the United States, if they're a chain restaurant, will need to have the calories prominently displayed.

Dr. Adashi: That is being articulated by the Affordable Care Act that was signed into law not all that long ago, 6 months ago, to be precise. Where do trans fat reducing initiatives fit into the mix? Do you think of it in the context of anti-obesity regimens or more simply as a wellness-promoting regimen?

Dr. Frieden: Elimination of artificial trans fat is a specific improvement in nutrition that's possible. It will definitely reduce heart attacks. Whether it reduces obesity is really not proven. There's some evidence that suggests it might, but, whether or not it does, it will drive down heart attacks substantially. The estimates are in the tens of thousands per year. What we've seen nationally is real progress, with a substantial reduction in the amount of artificial trans fat that is in the food supply. We now need to take stock of what's left, and how we can further reduce it. Trans fat is a real success story, and I think the food industry, although they were reluctant at first, now sees that it didn't cost money. It wasn't complicated by and large (some products took some reformulation). It didn't reduce the availability, and in fact it's quite feasible.

Dr. Adashi: Let's extend that line of thinking now and move to sodas, which I know you have had significant interest in. Has a meaningful soda tax convincingly shown to be an effective anti-obesity measure, and in that context, has any municipality or state actually been able to accomplish this feat?

Dr. Frieden: The first thing we know is that Americans drink far too much soda, and -- not just soda -- but other sugar-sweetened beverages, sugary drinks. We consume about 250 or 300 calories more per day, per person, than we did a few decades ago, and nearly half of that increase is in sugar-sweetened beverages. So I don't think there's any debate that we need to reduce the amount of sugar-sweetened beverages that we consume. That's why we're getting them out of schools, we're getting them out of daycares, and we're getting them out of the vending machines that are in schools. We've seen actually real progress from the industry in advertising less to young children, at least. So there's widespread consensus that we need to reduce the amount of sugar drinks that we consume.

Learning from the tobacco industry, there are a few things that work. Marketing restrictions work, having access to water and healthy drinks works as an alternative, and price is very important. So, when we see in the supermarket 5 or 10 liters for just a couple of dollars, we know that that's going to drive up consumption. The data on the price responsiveness in soda is quite strong, and it's largely from the industry, so the lower the prices, the higher the consumption, and the higher prices, the lower the consumption. There has not yet been anywhere in the country a community that has gotten a soda tax implemented that is at a level high enough that we would expect it to possibly reduce consumption.

It is really up to each community to decide how they want to address the obesity epidemic.

Dr. Adashi: Would it be fair to say that, by all accounts, this is a very sensible measure, but that the ultimate experiment has not as yet been done in terms of seeing the impact of such on obesity? Would that be a fair statement?

Dr. Frieden: No community has reversed the obesity epidemic. So we're seeing now communities throughout the United States and throughout the world considering, debating, and trying to apply new strategies. And whatever is done, what's essential is that we rigorously evaluate it so we can learn from it.

Dr. Adashi: Finally, you are taking on the all-important challenge of healthcare-associated infections. What is the battle plan?

Dr. Frieden: First, understand that these are unacceptable. We now have the technology to eliminate a large proportion of healthcare-associated infections, and we need to do that not just in the short term, but sustainably, and there are very encouraging data (from around the United States) of systems that have driven down rates of healthcare-associated infections by 70% or 80% and kept them at a low level.

The next level of battle has to be to look hard at the ambulatory surgery centers, at long-term care facilities, at the outpatient settings such as dialysis centers, and drive numbers down more.

I remember when I was in training as a medical resident, we thought that line infections were just par for the course; they happened. We now know that they don't need to happen, and because they don't need to happen, we have a responsibility to prevent them.

Dr. Adashi: Finally, taking the broadest view possible, would you care to predict where the nation might be in 2015 in its multiple public health battles?

Dr. Frieden: I'm optimistic that we're going to be in a much better place on prevention. We're going to have a more widespread recognition that prevention saves lives and saves money. We'll have fewer smokers. We'll have examples from communities around the United States of places that have reversed at least childhood obesity. We'll have a big decrease in infections associated with the healthcare setting. We're going to have prevention on a standard footing, so that we understand that prevention is a core component of our health system. Not only is it good, but we need it. We need to ensure that we have the money and the productivity and the life to be the healthiest community and country we can be.

Dr. Adashi: If I may say so, I personally believe the nation's public health is in good hands. On that note, sincere thanks to Dr. Frieden and to you, our viewers for joining Medscape One-on-One. Until next time, I am Eli Adashi.

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Authors and DisclosuresInterviewerEli Y. Adashi, MDProfessor of Medical Science, Warren Alpert Medical School of Brown University, Providence, Rhode Island

Disclosure: Eli Y. Adashi, MD, has disclosed no relevant financial relationships.
IntervieweeThomas R. Frieden, MD, MPHDirector, US Centers for Disease Control and Prevention Administrator, Agency for Toxic Substances and Disease Registry, Atlanta, Georgia

Disclosure: Thomas R. Frieden, MD, MPH, has disclosed no relevant financial relationships.