Kicking Tobacco's Butts

Physician Involvement Key to Antismoking Campaigns

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Public Health Feature - July 2005  

By  Erin Prather

Houston radiologist Joel Dunnington, MD, despises smoking. Having witnessed one-third of his patients at The University of Texas M.D. Anderson Cancer Center die from cigarettes, Dr. Dunnington has been involved in antismoking campaigns for 27 years and has conducted research on tobacco for the past 16 years. His reasoning is simple: Cigarette smoke kills the most people.

As a result, he believes physicians must participate in antitobacco movements to help convince cities to pass antismoking ordinances. That's why he joined other Houston physicians to convince the Houston City Council to make his hometown smoke-free. It worked. In March, Houston joined a growing list of Texas cities to ban smoking in restaurants without bars. (See "Austin Voters Approve Stricter Smoking Ordinance.")

Smoking is still permitted in Houston restaurant bars and stand-alone bars, something that troubles Dr. Dunnington. He believes the ordinance is not as inclusive as it should be.

"Every reputable scientific organization in the world that has looked at tobacco smoke pollution has concluded that it kills people. Millions of Americans are exposed to secondhand smoke everyday. At a restaurant, I prefer to have my food  smoked, not me."

The physicians had an ally on the council - Councilwoman Shelley Sekula-Gibbs, MD. She's been trying to limit the harm caused by secondhand smoke since she saw its effect on children, especially those with asthma, during her family medicine residency.

"I recognized then that it would take policy changes to really help protect innocent people from the harm of secondhand smoke," she said. "Many think of it as an inconvenience. They forget that thousands of people die every year from secondhand smoke. If those numbers were related to a terrorist attack or an epidemic, we would be moving quickly to address the issue and to make preventative changes."

She credits the Houston medical community, led by Harris County Medical Society President Robert C. Vanzant, MD, for persuading the council to pass the ordinance. Houston will revisit the ordinance next year to determine if additional establishments, such as bars, should also become smoke-free. 

Tobacco Remains No. 1  

While obesity is marching up the list of the causes of preventable deaths in Texas, it doesn't match tobacco's numbers. The U.S. Centers for Disease Control and Prevention says illnesses attributable to smoking take the lives of more Texans than AIDS, heroin, cocaine, alcohol, car accidents, fire, and murder combined.

Furthermore, the U.S. Environmental Protection Agency estimates that passive smoking causes 3,000 lung cancer deaths of nonsmokers annually, and the American Cancer Society (ACS) says 35,000 to 40,000 other nonsmokers die from heart disease after exposure to secondhand smoke.

Smoking caused Philip P. Huang, MD, MPH, chief of the Bureau of Chronic Disease and Tobacco Prevention of the Texas Department of State Health Services, to get involved in public health issues as a medical student.

"I realized this was the No. 1 preventable cause of death and disease that physicians face," he said. "Cancer. Heart disease. So much of it is smoking related."

He urges physicians to get involved in antismoking campaigns. "Physicians can have a tremendous impact on their community if they choose to become involved in addressing tobacco use. Physicians can make a real difference." 

OpeningLubbock 's Airways  

In the summer of 2000, Lubbock sixth-grader Amit Bushan started a campaign to stop smoking in local restaurants and bowling alleys because allergies and asthma prevented him from going places where smoking was allowed. Amit, whose father is rheumatologist Naga Bushan, MD, contacted ACS and the American Heart Association (AHA) for campaign assistance.

AHA board member Donna Bacchi, MD, MPH, used her experience in working to pass an antismoking ordinance in Austin in 1995 to help organize the Smokeless Lubbock Coalition to lobby the Lubbock City Council for a stricter smoking ordinance.

Dr. Bacchi provided medical expertise and lined up 25 physicians who treated patients affected by secondhand smoke to testify at a council hearing in March 2001. They were joined by 10 patients, two of whom had lung cancer but didn't smoke.

The coalition mounted a media campaign to educate the public about the issue, and after months of deliberation and controversy, the Lubbock City Council approved an antismoking ordinance in 2002. One year later, voters rejected a ballot measure to overturn that ordinance. Although smoking is not banned completely, it is limited to bars and sports grills.

Dr. Bacchi says physicians should be involved in smoke-free campaigns because they see patients who are affected by secondhand smoke every day. "Physicians have the medical expertise to talk with people who are in power to make changes," she said.   

The El Paso Proof  

The usual argument against antismoking ordinances by the tobacco industry and its front groups is that businesses will suffer economically. However, the success of the El Paso no-smoking ordinance proves that reasoning is weak.

In January 2002, El Paso banned smoking in restaurants, bars, workplaces, and other public places. The Smoke-Free Paso Del Norte Coalition is credited with introducing the ordinance and conducting a grassroots campaign that won its passage.

A year later, a DSHS study concluded that antismoking ordinances do not affect restaurant revenues. The data were drawn from quarterly sales tax reports and monthly mixed-beverage tax receipts from the state comptroller's office. The study's findings were consistent with research conducted in other smoke-free cities.

"The only industry that will lose money is the tobacco industry," Dr. Dunnington said. "They know that when smoke-free ordinances pass, smokers quit at a higher rate and many smoke fewer cigarettes. Every legitimate economic survey done with valid research methods shows there is no economic change in the community or there is even an improvement after workplaces go smoke-free. It's ironic that all workplaces must have handicapped access, but citizens with asthma cannot go into certain areas because of tobacco smoke pollution."

Kelly Headrick, ACS vice president for government relations, says it would like to emulate California and make Texas a smoke-free state. Physicians can be instrumental in doing so.

"It's easier to pass smoke-free ordinances locally. Ideally, when there is enough support and cities covered by smoke-free ordinances, this will create a momentum to have some degree of continuity at the state level. It simply comes down to the fact that everyone has a right to breathe clean air."

Erin Prather can be reached at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by email at  Erin Prather.  


How You Can Help Fight Tobacco

  • Be role models by not using tobacco and promoting a tobacco-free culture.
  • Work within professional organizations to monitor tobacco-consumption patterns and attitudes.
  • Promote tobacco-free events and premises.
  • Promote tobacco control on the agenda of all professional meetings.
  • Routinely ask patients about tobacco consumption and exposure to tobacco smoke.
  • Use evidence-based practices to advise patients on how to quit smoking.
  • Promote tobacco control in professional development curricula.
  • Participate in World No Tobacco Day events.
  • Refrain from accepting any kind of tobacco industry support.
  • Prohibit the sale or promotion of tobacco products on your premises.
  • Dedicate resources to tobacco control.
  • Participate in tobacco-control activities of your professional network.
  • Support campaigns for tobacco-free public places.

Adapted from World Health Organi z ation Meeting on Health Professions and Tobacco Control; Code of Practice on Tobacco Control for Health Professional Organizations,Jan. 28-30, 2004 ; Geneva , Switzerland.  



The 5 A's

The "5 A's" -  A sk, A dvise, A ssess, A ssist,   and A rrange - are designed to be used with the smoker who is willing to quit.

Ask -  Systematically identify all tobacco users at every visit.

Advise  - Your advice should be:

  • Clear.  "I think it is important for you to quit smoking now, and I can help you," or "Cutting down while you are ill is not enough."
  • Strong.  "As your clinician, I need you to know that quitting smoking is the most important thing you can do to protect your health now and in the future. The clinic staff and I will help you."
  • Personalized.  Tie tobacco use to current health or illness, and/or its social and economic costs, motivation level/readiness to quit, and/or the impact of tobacco use on children and others in the household. 

Assess  - Determine the patient's willingness to attempt to quit smoking.     

Assist -  Aid the patient in quitting with these four suggestions:

  • Set a quit date - ideally, the quit date should be within two weeks.
  • Tell family, friends, and coworkers about quitting and request understanding and support.
  • Anticipate challenges to planned quit attempt, particularly during the critical first few weeks.
  • Remove tobacco products from your environment. 

Arrange  - Schedule a follow-up contact with the patient. 


The 5 R's

Approximately 46 percent of Americans try to stop smoking each year. Most try to quit "cold turkey." Of those, only about 5 percent succeed. Most smokers make several quit attempts before they successfully quit for good. Patients not ready to try may respond to a motivational intervention. You can motivate patients to consider quitting with the "5 R's" -  R elevance, R isks, R ewards, R oadblocks, and R epetition. 

  • Relevance -  Encourage the patient to indicate why quitting is personally relevant.
  • Risks -  Ask the patient to identify potential negative consequences of tobacco use. 
  • Rewards -  Ask the patient to identify potential benefits of stopping tobacco use. 
  • Roadblocks -  Ask the patient to identify barriers or impediments to quitting. 
  • Repetition  - The motivational intervention should be repeated every time an unmotivated patient has an interaction with a clinician. Tobacco users who have failed in previous quit attempts should be told that most people make repeated quit attempts before they are successful. 

This information is included in the Clinician's Packet: Treating Tobacco Use and Dependence -A How-To Guide For Implementing the Public Health Service Clinical Practice Guideline , a March 2003 publication of the U.S. Public Health Service. It is available online at

To access A Clinical Toolkit for Treating Tobacco Dependence , from the Texas Department of State Health Services, visit


Support or Start a Smoking Ordinance Campaign

Many communities in Texas are considering smoke-free ordinances. Although the science stands clearly behind smoke-free laws, these are still difficult campaigns to wage and win.

Contact your local American Cancer Society office if you hear about or would like to start a no-smoking ordinance campaign in your community.

For more information, log on to


Tar Wars: Get Involved!

The Texas Department of State Health Services and the Texas Academy of Family Physicians invite family physicians and other health professionals and educators to become involved as presenters in the Tar Wars campaign, a tobacco-free education and prevention program for fifth-grade classrooms.

The curriculum is consistent with the Centers for Disease Control and Prevention Guidelines for School Health Programs to Prevent Tobacco Use. The program was developed in 1988 by Doctors Ought to Care and Hall of Life, a division of the Denver Museum of National History. In June 2000, the American Academy of Family Physicians (AAFP) took over the program. Since then, AAFP has made Tar Wars available in all 50 states and other countries, reaching more than 2.5 million children.

If you have questions or comments regarding Texas Tar Wars, contact Janie Dykes, Tar Wars coordinator, at (512) 458-7402, or send an email to janie.dykes[at]dshs[dot]state[dot]tx[dot]us


Texas Smoke-Free Ordinance Database

Studies continue to demonstrate that exposure to secondhand smoke is linked to cancer and other serious health consequences. Placing restrictions on smoking in public places is a key strategy to limit the public's exposure.

As part of the research team brought together to plan and evaluate the Texas Tobacco Preventative Initiative, the University of Houston has developed the Texas Smoke-Free Ordinance Database. In addition to providing a collection of ordinances from cities across the state, university researchers have analyzed the strengths and weaknesses of ordinances included in the database.

This is accomplished by defining key aspects of collected ordinances, then providing a descriptive scoring system for evaluation. Key aspects described or evaluated include:

  • Places where smoking is restricted,
  • Level of restrictions,
  • Level of exemption of bar coverage based on percentage of gross annual sales of alcoholic beverages, and
  • Enforcement and sanctions.

The database Web site ( ) allows users to download text of local ordinances and view corresponding summary profiles evaluating the ordinance for each city. Users can generate customized reports that compare ordinances at the state, public health region, and county levels. These reports can be further customized by the user specification of population size range and percentage of minority population coverage of interest. 


Austin Voters Approve Stricter Smoking Ordinance

On May 7, Austin voters passed a smoking ordinance that requires restaurants, bars, indoor music venues, bowling alleys, and billiard parlors to become smoke-free. Effective Sept. 1, smokers will be required to stand at least 15 feet away from establishment entrances when choosing to light up. Bingo parlors, fraternal organizations, and a small number of restaurants with restricted permits are exempt from the ban.

In February, Onward Austin - a coalition of antismoking organizations - collected 41,499 signatures on a petition to have the smoking referendum added to the May 7 ballot. Of those, more than 37,500 were verified. Onward Austin includes organizations such as the Travis County Medical Society, American Cancer Society, and Lance Armstrong Foundation. Guadalupe "Pete" Zamora, MD, Thomas S. McHorse, MD, and William M. Ramsdell, MD, all served on Onward Austin's steering committee.

The ordinance's passage was a long and hard-fought battle. Opponents, mainly a coalition of local bar and restaurant owners known as Keep Austin Free, fought the ban and mounted a crusade to have it defeated. Onward Austin countered with its own campaign, which proved more successful. The ordinance passed with 52 percent of the vote.

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Last Updated On

June 10, 2016

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