In a school auditorium, a thirteen-year-old student stares at the raw gaping hole in Wade Hampton’s throat. Wide-eyed, the boy leans in. Hampton covers the hole with a beige antiseptic patch, presses two fingers over it, and says in a strained, gravelly voice, “This is what smoking cigarettes did to me.”

He lifts his fingers to breathe; then presses back down.

“And I wasn’t much older than all of you when I started smoking.”

The boy finally blinks, looks at a friend, and doesn’t say a word.

Click to read photo caption. ©2007 Endeavors magazine

The auditorium full of seventh graders falls silent as the sixty-year-old Hampton tells students at North Asheboro Middle School that he smoked a pack and a half to three packs of cigarettes a day for thirty years before he got a sore throat that wouldn’t go away. It was cancer, he tells students, and doctors had to remove his larynx and give him radiation treatments that permanently scarred and narrowed his esophagus.

“I tried to stop smoking many times,” Hampton tells them. “But I just couldn’t. Nicotine addiction got me.”

Now, every winter, he inhales freezing cold air straight into his chest through a hole in his throat called a stoma, which gets raw if he talks too much. He has no vocal cords. He speaks with the aid of a prosthesis and vibrations of the esophagus wall. And because of his pencil-thin esophagus, he often chokes on food, which he can barely smell or taste.

“I wanted to be cool,” Hampton tells the kids. “Does this seem cool to you?”

Hampton is president of SAVESurvivors and Victims of Tobacco Empowerment — a nonprofit organization of twenty volunteers who speak about their tragic experiences to North Carolina middle and high school students. UNC professor of medicine Adam Goldstein started SAVE with friend Sheila Pratt in 1997 because one out of every five deaths in North Carolina is related to tobacco, and 80 percent of American smokers started smoking as teenagers.

The elephant in the room

When Goldstein came to UNC as an assistant professor in 1993, not much was happening in tobacco-related policy research.

“People told me, ‘you can’t do community advocacy or policy research work in tobacco here,’” Goldstein says. “‘We’re a tobacco-producing state. Be very careful what you do.’” A faculty member said Goldstein wouldn’t get tenure. Others said tobacco-use-prevention research wasn’t sexy enough. Funding would be hard to come by. “Warnings came from people with policy connections, who said, ‘this isn’t a long-term career,’” Goldstein says.

But patients’ stories and sickening statistics overwhelmed him.

More than 33 percent of sixth graders and over 50 percent of seventh graders have tried cigarettes. More than two hundred thousand North Carolinians under eighteen right now will someday die prematurely because of tobacco-related illnesses. Seventy percent of teen smokers say they wish they had never started. In one study, 95 percent of teenage smokers said they would quit within five years, but eight years later, only 25 percent had succeeded. Every day, four thousand American kids try smoking for the first time.

Goldstein realized that doctors wouldn’t make a dent in preventing lung cancer without preventing smoking, especially youth smoking. But how do you do that in North Carolina? First, he organized a seminar on the future of tobacco farming, during which several researchers showed that one of the main reasons the tobacco-farming population is decreasing rapidly everywhere in the United States is that the industry is shifting cigarette production overseas. “This is the trend that hurts North Carolina farmers most,” Goldstein says, “and this trend won’t change.”

He joined other researchers in forming coalitions with farmers interested in shifting away from tobacco, and such work helped Goldstein open a few more doors.

“We know how to stop the smoking epidemic,” he says. “What’s been missing is the political will.”

Research shows that higher taxes on cigarettes, comprehensive indoor air laws, and smoke-free school campuses drastically reduce smoking and prevent deaths in the United States. Restricting youth from buying tobacco, enforcing existing laws, and effectively designing and implementing mass media campaigns also help a lot.

“Those data are out there,” Goldstein says. But he had to figure out more effective ways to make people listen.

“I remember when I went to the state legislature ten years ago to testify for a bill, and I started talking about a patient who had just been diagnosed with lung cancer. After thirty seconds, I was thanked for coming and cut off because I was supposed to be talking only about a bill to make buying tobacco products more difficult and not the reasons for the bill.”

This made Goldstein wonder who could advocate for patients if he couldn’t. “We looked at AIDS advocacy groups and breast cancer groups that used survivors as spokespersons. We thought about why this isn’t the case with tobacco.”

One reason is that people with lung cancer often die, and emphysema patients are usually too sick, he says. “But people with laryngectomies and heart attacks can speak out. Question was — would they want to speak out? Their lives had changed irrevocably. People with laryngectomies are severely disfigured, and a lot of this happened because of a lifetime of addiction.”

According to several studies, nicotine is more addictive than heroin. From 1998 to 2004, the amount of nicotine in cigarettes increased by an average of 10 percent, according to a 2006 study by the Massachusetts Department of Public Health, though it’s not clear why or even if such an increase makes cigarettes more addictive. But this much is certain: in 2000, Phillip Morris International admitted to lacing cigarettes with ammonia so that smokers would absorb nicotine more quickly, thus making cigarettes potentially more addictive.

Free will

Wade Hampton was fourteen years old when he began smoking in 1961. He didn’t think much about it because most people he knew smoked cigarettes. Actors and news anchors smoked on television. Favorite sports stars and television personalities smoked. Ads were everywhere. But as medical evidence piled up against smoking, Hampton tried to quit.

“You think you’ll be able to just stop smoking one day,” he says. “You think, as a kid, that you’re invincible. But you’re not.”

Today’s kids, you’d think, know better. But teenagers still pressure each other. They rebel. And Goldstein found that trotting out health professionals who spout off cancer statistics doesn’t get the kids’ attention as well as real-life North Carolinians telling their stories.

Do the kids really hear them?

“When their eyes light up, you know they hear your message,” Hampton says.

“I think young people relate to what I’m saying because it’s real and heartfelt. I think kids know that I’m not underselling it or overselling it. I’m telling them the truth.”

One student, twelve-year-old Stephanie Watson, says, “Seeing Mr. Hampton with a hole in his throat, you know, I can see what smoking did to him. I think I’ll remember that.”

Goldstein says it’s difficult to quantify SAVE’s direct impact, but it seems to work. Officials from many school districts that adopted a 100 percent tobacco-free policy said that hearing a SAVE member speak helped influence them to pass the legislation. Youth, who said they were inspired by SAVE members, successfully petitioned a bowling-alley manager to make his alley smoke-free. North Carolina’s media campaign prominently features stories about SAVE volunteers and their health problems. And most significantly, the largest reduction in youth smoking rates in the United States occurred in 2005 in North Carolina.

“Now, there are lots of reasons for that,” Goldstein says. “We’re convinced SAVE is one of them, based on how it fits together conceptually with the media program and how it fits politically statewide.”

Click to read photo caption. Tobacco.Reality.Unfiltered., ©2007 Endeavors magazine

Lieutenant Governor Beverly Perdue gave SAVE volunteer Terrie Hall the Distinguished Service Award in Preventive Health in 2005. That’s one measure of success — political viability in a tobacco-friendly state. Another, Goldstein says, is that schools keep asking SAVE volunteers back every year, not to mention the hundreds of testimonials from kids, teachers, and school administrators.

Last fall, UNC’s Tobacco Prevention and Evaluation Program, which Goldstein directs, released a report detailing the success of SAVE and multiple other local and state programs that comprise the Teen Tobacco Use Prevention and Cessation Initiative, which is funded by the North Carolina Heath and Wellness Trust Fund. The report states that cigarette use in North Carolina declined from 27.3 percent in 2003 to 20.3 percent in 2005 among high school students, and from 15.8 percent to 5.8 percent among middle schoolers; both are now below the national average. Among African American youth, tobacco use declined 36 percent. And awareness of the Tobacco.Reality.Unfiltered. (T.R.U.) media campaign rose from 45 percent in 2004 to 54 percent in 2006.

Click to read photo caption. Tobacco.Reality.Unfiltered., ©2007 Endeavors magazine

Goldstein’s research associate, Shelley Summerlin-Long, helped lead the conceptual design for T.R.U., and if you’ve ever seen one of these commercials, chances are you haven’t forgotten it. In one, SAVE volunteer Terrie Hall speaks through an artificial voice box, asking teens to think twice about using tobacco products. In another commercial, a young man named Gruen von Behrens says he was diagnosed with oral cancer after chewing tobacco for just four teenage years. Doctors had to remove parts of his jaw, tongue, and neck during thirty-five surgeries. Students squirm in their seats when von Behrens speaks at assemblies. Some wipe tears from their eyes. Some just look away.

These real-life testimonials from tobacco survivors are tough to watch, and that’s the point. Goldstein’s team studied communications theory and found that SAVE presentations and television commercials should have a negative emotional tone to elicit a response from kids. Hampton’s talk, for instance, makes the kids feel uncomfortable. And although such presentations and TV spots might seem like scare tactics, their true purpose is to counterbalance the myth that smoking is cool and fun, which is what magazine ads and movies often portray, Don Cole says. Cole, a SAVE volunteer, had a lung removed due to cancer; his cancer is now in remission.

“In every magazine kids pick up they see superstars advertising cigarettes and beer,” he says. “These products are sold like a come-on; like it’s okay to smoke.” Kool Cigarettes ran an ad campaign featuring hip-hop artists on cigarette packs and in magazines.

Kids see these ads, Cole says. They see cigarettes not as negative, but as positive. Maybe even as beautiful or funny.

Joe Camel vs. Mickey Mouse

In the 1990s, Goldstein helped conduct research that found that 90 percent of six-year-olds could look at a picture and identify Joe Camel, the cigarette-puffing cartoon spokesman for Camel Cigarettes.The same percentage recognized Mickey Mouse.

“So our conclusion was that RJ Reynolds reached six-year-olds as effectively as Walt Disney,” Goldstein says. He also found that even three-year-olds were well aware of tobacco ads. This got people’s attention, and, along with other research, fueled a national campaign to rid cartoon figures from cigarette ads. As other evidence came out — such as industry memos about hooking teenage smokers for the sake of long-term profit — the industry was forced to remove billboards that featured the Marlboro Man and Joe Camel. Significant steps, but were they enough?

“We did another study that showed that 60 percent of all G-rated animated films have characters using tobacco and alcohol,” Goldstein says, “and there was not a single mention of a negative health consequence. Not one.”

Kurt Ribisl, an associate professor in the School of Public Health who researches tobacco control policy, says that cigarette manufacturers still try to attract child smokers. Cigarette companies spend most of their advertising budgets — some $15.2 billion — on ads for retail outlets. And often, ads are placed below the cash register. “Joe Camel used to hang out down there and that’s why kids knew Joe Camel so well,” Ribisl says. “Most adults don’t know that this is going on.”

Today, instead of a Joe Camel poster, cigarette manufacturers plaster large colorful brand names down there. Goldstein says, “Cigarettes are sold in the same place as candy, right at the eye level of children. We assume as adults that this is just part of the cultural landscape.”

Adults, meanwhile, are even easier targets. Cigarette companies place ads in certain retail stores depending on the make-up of the community, Ribisl says. In Chapel Hill, a mini-mart on West Rosemary Street — close to a black neighborhood — has more ads and discounts for Kool Cigarettes because African Americans are much more likely than white smokers to smoke menthol cigarettes. A block away at a Franklin Street mini-mart, product placement, ads, and discount offers cater to college students.

Tobacco companies now target college-age adults more than any other group. It’s legal, young adults frequent bars and nightclubs more than any other group, and cigarette companies can easily advertise and sell their products at bars. Right now, 18-to-24-year-olds have the highest smoking rate of any adult subgroup. In fact, they’re the only subgroup with a smoking rate that’s increasing. To address this, Goldstein’s evaluation helped secure a $1.6 million grant from the N.C. Health and Wellness Trust Fund in 2005 to establish the N.C. Tobacco-Free College Initiative, a group of twenty organizations whose goal is to prevent smoking and promote cessation — including the N.C. Quitline — at sixty colleges across the state.

But Ribisl says that the industry hasn’t forgotten about the rest of us. The manufacturers of Kool Cigarettes, for instance, designed a cigarette package with a picture of waterfalls because their research found that most people consider running water soothing. And many people say that smoking calms their nerves.

Does such advertising go too far? Could the government actually regulate product placement and package design?

“Sure it could,” Ribisl says. “The FDA proposed restricting all retail outlet advertising to be black and white and text only — so-called tombstone advertising. That’s legal.” The government can pass such laws because of high health-care costs associated with smoking, but so far Congress hasn’t acted. “The science is clear. If you regulate advertising and package design, then there will be a major health benefit. The FDA went through testimony and evidence about all of this.”

Ribisl says that cigarettes should be sold at their own special locations, as liquor is at ABC stores across the state. “But these are ambitious proposals,” he says. “Right now, I’m just trying to help with basic things: we should not expose children to secondary-smoke pollution in school environments. It should be against federal law to sell cigarettes to children over the internet.”


In 2003, Ribisl found that eleven- to fifteen-year-olds could successfully buy cigarettes online 91 percent of the time. (See Endeavors, Winter 2004, “Kids Buy Smokes Online.”) The Journal of the American Medical Association published his results, and then Massachusetts Congressman Martin Meehan proposed a bill to further regulate cigarette sales to minors. What’s happened since then?

“Nothing,” Ribisl says. “Not at the federal level. About half the states regulate mail-order and internet cigarette sales.”

Ribisl briefed congressional aides in Washington last summer, but there’s no pending legislation. And aside from some state-level lawsuits dealing with taxable internet sales, only one noteworthy thing changed: state attorneys general, the Federal Bureau of Alcohol, Tobacco and Firearms, major credit card companies, and delivery companies such as Federal Express, DHL, and UPS, all signed an agreement to prevent people from buying tobacco products online with credit cards or PayPal.

Yet in January of 2006, Ribisl identified over eight hundred internet cigarette vendors compared to the eighty-eight he found in January 2000. He says we need consistent federal laws that prevent children from buying cigarettes online and laws that help states collect taxes that Ribisl says should help fund tobacco prevention efforts.

“Access to these cheaper cigarettes undermines peoples’ quit attempts,” he says. “When prices increase, smokers are more likely to cut back or quit. And early studies suggest that when people have access to cheap internet cigarettes, people will smoke more and be less likely to quit. This could undermine some of the gains we’ve made in tobacco control in recent years.”

Those gains include promoting smoke-free school campuses. When Ribisl first came to Carolina in 1999, some school districts were building smoking sheds so students sixteen and older could smoke on school grounds.

“Schools did this because parents were upset that their kids who liked to smoke were getting wet in the rain,” Ribisl recalls. Today, the sheds are gone. Instead, eighty-three of North Carolina’s one hundred and fifteen school districts are completely smoke-free. That means no one — teachers, visitors, or students — can light up on school grounds, not even at a school bus garage. Ribisl gathered disparate research, linked it with his own, and helped create the web page for N.C. Tobacco-Free Schools, a group of citizens who push for tobacco-free school districts across the state.

“When we started this work five years ago, about a dozen school districts had campus-wide smoke-free policies,” he says. “When teachers and other role models smoke around children, kids are more likely to experiment with smoking.”

Funding health and wellness

Tobacco-Free Schools, T.R.U., and SAVE are just three of the many nonprofit programs that the N.C. Health and Wellness Trust Fund Commission helps finance. North Carolina’s General Assembly created the trust fund in 2002 after the 1998 Tobacco Master Settlement Agreement — a $206 billion agreement between forty-six states that had previously sued the four main cigarette manufacturers for medical liability and an alleged cover-up of harmful health effects from smoking. Twenty-five percent of that settlement’s $4.6 billion for North Carolina goes into a trust fund that promotes health issues, including those related to tobacco use. Prior to 2002, the state spent only federal funds on tobacco-use prevention. So as fate would have it, money from tobacco companies now funds research that is then used to prevent smoking and help people quit. Ironically, such research informs the same politicians that tobacco lobbyists try to influence.

The trust fund commissioners are guided by sound science, Goldstein says, and politicians can be, too. “We found that one of the greatest predictors of how a legislator will vote on tobacco issues is the extent to which they believe that secondhand smoke is a major cause of disease — which it is.”

Secondhand smoke contains four thousand different chemicals, fifty of which are known carcinogens. Surprisingly, secondhand smoke contains twice as much nicotine and tar as smoke inhaled directly from cigarettes. It has five times the carbon monoxide, which decreases the amount of oxygen in blood. Inhaling secondhand smoke for twenty minutes — the same as smoking one pack of cigarettes — activates blood platelets that cause blood clotting, thus increasing the chance of heart attack.

Armed with these facts, the Surgeon General of the United States released a major statement in 2006 saying that secondhand smoke is carcinogenic, period. There is no safe threshold.

“So this means that we can eliminate smoking outside of buildings for public health reasons founded on solid science,” Goldstein says. And sure enough, the dominoes began to fall. The campaign for smoke-free schools is based on this science, as are the mandates that will make sixty-seven of the state’s one hundred and ten hospital campuses completely smoke-free. On July 1, 2007, UNC Hospitals, the School of Medicine campus, Duke University Medical Center in Durham, and WakeMed in Raleigh will have 100 percent smoke-free campuses.

It’s a quiet revolution that will make North Carolina a national leader, Goldstein says. “Most states have one, two, three hospitals that may have done this.”

And this can happen, Goldstein says, “because the duty of a health-care institution is to promote health, not to enable poor health. We can give employees nicotine-replacement products if they need to get through the day. We can encourage and promote cessation, and in doing so, eliminate secondhand smoke.”

Preemptive control

Yet these hospitals had to get a special exemption from the state before implementing their own policies because an existing state law — called preemption — mandates that public buildings must allow 20 percent of their space for smoking. This state law preempts local communities from drafting their own smoking ordinances, although individual business owners can. Also, local governments can restrict smoking in buildings used for health purposes.

Ribisl says, “For a state that prides itself on allowing local control and decisions, I think it’s really appalling that we have a preemption law that restricts any local community from regulating smoking on a municipal level.”

He says that the tobacco industry has much more power at the federal and state levels. Locally, city councils are more likely to listen to doctors, parents, teachers, and community advocates than to tobacco lobbyists. “That’s why laws like this are passed at the state level,” Ribisl says.

Advocacy groups have been trying to chip away at the preemption law ever since it was enacted in 1993. Ribisl points to Charlotte, where city leaders are asking the state for the right to restrict secondhand smoke pollution in restaurants. N.C. Prevention Partners, a nonprofit that focuses on proper nutrition, physical inactivity, and tobacco use, was one of the first to work against the law. The organization spoke with hospital administrators to enact smoke-free campus policies while hospitals began taking up the cause themselves. And now faculty, staff, and students at UNC’s School of Public Health are asking how the school can be perceived as a model of health when smoking is permitted on the grounds of its three-building campus.

Barbara K. Rimer, dean of the school, says, “We know that secondhand smoke kills. It’s also harmful in the shorter term.”

Some people might argue that restricting smoking outside of buildings would go too far, that people have a right to smoke, especially right outside a building. But Rimer and Ribisl disagree.

“There’s an epidemic of asthma in this country,” Rimer says, “and a number of our faculty, staff, and students have asthma and other respiratory conditions that are aggravated by tobacco smoke.”

And Ribisl says that banning smoking outside of buildings is just the next step in our ever-evolving social norms.

“It used to be rude not to offer someone a cigarette. Then it was rude to not ask if it’s okay to smoke in front of someone. Now, it’s pretty much rude if you smoke around people.”

He points to the huge outcry when smoking was banned on airplanes, schools, and workplaces. New York smokers complained when the city banned smoking in bars and restaurants. Each time, Ribisl says, smokers and the tobacco industry prophesied that such policies would hurt the businesses, but each time they were wrong. Can you imagine the guy next to you lighting up on an airplane now?

“So I think there’s an irreversible norm change,” Ribisl says. “I think further social acceptability will dramatically change over time.” Soon, he says, smoking around children will be considered utterly offensive.

“People talk about the right to smoke, but there’s nothing in the Bill of Rights about that,” Ribisl says. “I think the right to breathe clean air is a little more valid. Nobody is saying that people cannot smoke. Smokers can choose when and where they smoke, but our students, employees, and patients cannot choose when and where they breathe.”

Adam Goldstein is a professor of family medicine in the School of Medicine and director of UNC’s Tobacco Prevention and Evaluation Program, which receives funding from the N.C. Health and Wellness Trust Fund, the Centers for Disease Control and Prevention, the N.C. Tobacco Prevention and Control Branch, the N.C. Division of Alcohol and Law Enforcement, and the Louisiana Office of Public Health. Kurt Ribisl is an associate professor of health behavior and health education in the School of Public Health. Barbara K. Rimer is the Dean of the School of Public Health.

The N.C. Health and Wellness Trust Fund Commission funds the N.C. Tobacco-free College Initiative, as well as the Teen Tobacco Use Prevention and Cessation Initiative, which includes SAVE and Tobacco.Reality.Unfiltered. This year, the trust fund commission tripled the media campaign budget to $5 million. To volunteer with SAVE or to find out more, go to