Fit for Duty podcast: Episode 4.

Hello and welcome to Fit for Duty — the Aetna International podcast.

Because we know that organisations — large and small — recognise that their future growth and success depend on their people, Fit for Duty brings you insights on some of the biggest health and well-being challenges and forces shaping the corporate health landscape today. We’re here to help you build a healthy, happy, productive workforce.

I’m Lorien Norden, global content marketing lead for Aetna International. I’ve spent years having conversations with some of the most fascinating and well-informed clinical, well-being and health care experts out there. And now, in this new podcast, we’re bringing the latest thought leading market insights directly to you, along with strategies you can put into place today to help your employees flourish. Because when your people thrive, your business does too. 

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Today, I’m joined by Dr Sneh Khemka, Vice President, Population Health Solutions and vHealth here at Aetna. We caught up ahead of World No Tobacco Day, which is on 31^st May. Tobacco and smoking is an area of particular focus for us because tobacco usage is the single largest cause of preventable deaths around the world — and is a concern for the majority of our customers worldwide. Along with personal responsibility and lifestyle choices, I wanted to examine the roles that health-based leadership, regulatory controls and public health campaigns have played in recent history in bringing down tobacco usage in developed countries, and the learnings that could be adopted by developing nations. At the time of recording, we were in the thick of the COVID-19 pandemic in Europe and the U.S., and I asked Sneh whether he thought the disease would impact attitudes towards smoking. Sneh provides insights into the role of society and family groups on smoking cessation before going on to outline how employers can tackle smoking cessation in the workplace. I would also urge you to listen to Sneh’s view on turning the tide on youth vaping. And how much hope does Sneh hold for technology that’s emerging to help people in their quest to kick the tobacco habit? Find out in this 30-minute episode.  

So hello and welcome to today’s podcast. Joining me this morning is Dr Sneh Khemka. Hello Sneh. It’s a pleasure to have you here.

It’s a pleasure to be here. Thank you for having me.

Would you please mind introducing yourself and giving our listeners a bit of background?

Yes, my name is Dr Sneh Khemka. I’m a cancer surgeon by background. I trained in the UK and I have been working with Aetna International for the last six years as head of Population Health, which really has a bent at looking a population health trends, public health trends and putting in interventions that make people’s health better. I’m also a radio doctor on a radio station called LBC and I give people live advice on real life medical issues. And I’ve been looking at health systems around the world for many years now and I’ve got a fairly good view on global health trends, and I know that smoking and the use of tobacco is a very, very relevant topic especially in today’s state and it’s an interesting topic for us to talk about.

Fantastic, so if anybody hasn’t had an opportunity to tune in to LBC, I know that everybody is listening from an international basis but if you get the opportunity to have a listen to Sneh, it’s well worth your time. So in terms of tobacco usage trends, as you mentioned, it’s incredibly relevant but before we get in to the current COVID-19 pandemic, I’d really like to take a step back and take a look at this historically. So for example the WHO has estimated that tobacco is still responsible for approximately 7 million adults across the world every year. And research has found that on average in developed, smoking countries that people die about 14 years before their time, and lose 23 years of quality life. So it also continues to have an incredibly high economic cost — so $300 billion a year according to the CDC as far as the U.S. is concerned.

So, Sneh, from your perspective, is tobacco use still the single largest cause of preventable deaths in the world or has it been recently?

So the statistics that you talk about there, Lorien, are shocking. And it’s a little difficult to digest for most people. They’re such big stats that it’s difficult to know what it actually means, but the quick answer to your question is yes. It’s actually still the biggest public health issue that we know about. Much more than COVID or any other current condition that we’re talking about. Tobacco is still one of the leading causes of death around the world. And just to put it into to digestible statistics, about 1 out of every 6 people who die around the earth, around the globe in any one year, their death will be caused directly by smoking. So out of every six people who die, one of them will die as a result of smoking. And that’s an astounding statistic. Now in some countries, especially low- to middle-income countries, developing countries more recently they have been attributing the higher rates from smoking. So some countries, it’s even more than 1 in 5 deaths, so 20% of deaths that happen are as a direct relation to smoking. Because, as we know, smoking causes a whole range of issues from heart disease, to cancer, to high blood pressure to all sorts of things. And the multi-factorial element that comes from smoking means that death rates are still very high among smokers.

They are absolutely astounding and thank you for putting that into context. In terms of how we are tackling this from a science perspective, from a health-based leadership perspective, you know I think that the current climate that we’re all living through is really seeing a return to faith in serious medical experts.

So when it comes to tobacco use, what roles to health-based leadership, regulatory controls and public health crises play on tobacco usage trends globally?

So it’s quite a complex question that you ask me there, Lorien, so let me try and break it down into some bite-sized chunks. So the first thing I’d say is that tobacco usage has decreased around the world. Since the 1950s, there has been quite a significant global decrease and now we’ve got about just over a fifth of the world’s population smokes now. But if you go back to the 1950s it was probably about double that. So now we’ve got about 1.1 or 1.2 billion people are smoking. Let’s just take some UK statistics, if we go back to the 1950s, about 60% of men were smoking and about 45% of women were smoking. And that has dropped right down over the last few decades so that we are now averaging around 15-17% of UK adults smoking. Still slightly more men than women. There have been some significant things that have happened in the natural course of things but also and more importantly from government policy which have made some serious differences. So in the 1950s, the first research started coming out — from Cancer Research UK actually — showing that there was a link between smoking and lung cancer and lung cancer death. And that started hitting the mark and decreasing the number of men smoking. In 1965, in the UK, we put in some advertising bans for cigarettes on the TV and that had a significant impact. But what had the most impact was in the ‘80s there were significant tax rises from the government for tobacco-based products, and that drove it down further. So between 1960 and 1980 we dropped from around 60% smoking to around 42% and that continued to drop into the 2000s when we really ramped up activity. And that dropped the percentage from around 35% to today’s current 17% and that came in the way of smoke-free policies around the country. We all know about smoking bans in pubs and restaurants and all that sort of stuff that happened in around 2007. Vending machines were banned in 2011. Tobacco displays were banned in 2015. Tax increases were happening throughout that time and media advertising from governments and institutions began to have an impact. And so many countries around the world have reflected those statistics from the UK, but not every country. There are still lots of developing economies in low- to middle-income countries that have not put these things into place and that have not made the pushes required, and they still have quite high rates of cigarette smoking.

So I mean, really, you’re talking about the government actually taking a very proactive role in some countries and in some countries it’s a very reactive role if any real role at all.

Are there any examples of countries that you can think of where the government has started to turn the tide on that tobacco usage in the developing world? Are they starting to look at policies being put in place by European countries and by countries around the world, and starting to wake up to the changes that can be wrought by these policies and regulations?

The first thing I’d say is that smoking is that decreasing the rates of smoking is actually very significantly driven by government activity. So while personal responsibility must be there and we must take, individuals must stop themselves, actually what the government does to regulate against it, tax against it, advertise against it and put public health campaigns makes a significant difference. I don’t want to pick on any particular countries but big culprits for lack of change, and I call them culprits for a reason, are countries across Asia and across Eastern Europe in particular. Those are where the World Health Organization is pointing us towards as areas that haven’t put in these government changes that are required. And those are the countries that need further encouragement and further support. And actually the World Health Organization has quite a useful mantra, which is called MPOWER. And MPOWER stands for ‘M’ for the monitoring of tobacco usage and prevention policies, ‘P’ protecting people from tobacco use, ‘O’ offering help to quit tobacco use for government funded programs for smoking cessation, ‘W’ warn people about the dangers of tobacco, public advertising campaigns and things like that, ‘E’ enforce bans on smoking so actually regulation and ‘R’ raise taxes on tobacco. So those are the six MPOWER measures that governments that are struggling can really take on and they can get support from the World Health Organization and other international bodies to try and do something about the smoking issues in their countries.

So what impact do you think then that the current COVID-19 pandemic will have at an individual level, at a government level, because clearly as a health expert you will know better than anyone that smoking and vaping weaken the function of the lungs, could leave people more susceptible to the coronavirus?

So what do you think the pandemic will do to individuals’ behaviours and attitudes and also to governments as we battle together against this outbreak?

So what I’d say to you, Lorien, is what I’d like it to do and the sceptical Dr Sneh approach to what I think it will actually do. So let’s talk about what I’d like it to do. What we know is with COVID you are much more likely to get serious lung problems if you are a smoker and that’s because your lungs are in not such good health. You’re much more susceptible to the COVID virus, you are much more likely to get pneumonia and require some sort of ventilatory support if you’re a smoker. And for anyone listening to this now and as we’re recording this, we’re right in the crunch of the pandemic, now is your chance to stop smoking. If there’s ever an occasion for you to say enough is enough and stop, now is that occasion. And what I would like to see if that people will prick up their ears, they would take responsibility, they would say that something like this is coming along to test us and it’s time for us to take personal responsibility. What I fear may happen is that is that social isolation, quarantine, those sorts of things will cause mental health issues among individuals and often to revert to smoking to manage stress levels. People being at home not being allowed out in the open. I don’t know actually this is just anecdotally that people are smoking more than usual and the shame is that if people respond in that way, that we have exactly the opposite of the situation we want to have. At a government level, is what I would like to see is that post the COVID crisis, that we use the same principles of pandemic management that we’ve used for COVID that we put towards things like smoking. We have been effectively able to ban people from going out of their homes, doing their jobs, we’ve caused huge economic turmoil by putting in a lockdown and we’ve done that to prevent something which is causing from a handful of deaths to tens of thousands of deaths. Smoking causes millions of deaths and yet no government has ever taken such draconian measures to stop smoking. And what I would like to see is that governments can then show the same innovative response to epidemics and pandemics like smoking as they have to the COVID crisis. Unfortunately, Dr Sneh’s scepticism suggests that we will take a more moderated approach once the COVID crisis is over. Some governments will listen, some governments will make incremental changes but I fear that we won’t see the wholesale change about tobacco use that we really should be.

I was having exactly the same discussion with colleagues the other day, excuse me, about how this gives an exact example of how organisations, society can really pull together. And if, as you say, we put this much energy into changing behaviours, to galvanising public action against diseases and conditions and negative behaviours such as smoking, such as addiction, that could really start to change the economic impact and really start to have an impact on the death rate related to tobacco smoking, to a whole range of lifestyle-related diseases and conditions. So yes, I completely take your point. I’m with you, optimistic Lorien would really hope for the same, but yes, the sceptical side of everybody’s personality is going to say actually is it really could lead to the complete opposite as you’ve said. So really looking at big lessons that we have learned in our efforts to prevent and control tobacco use. You’ve called out a couple there.

Are there other specific learnings that you can see that we could apply to other public health and lifestyle areas, such as dietary behaviours, levels of activity. Are there any particular examples that you could call out that we can apply?

One thing I would say, particularly regarding any type of lifestyle associated disease, whether that’s tobacco use and the end effects of that or whether it’s about obesity and other lifestyle related conditions. We, as human beings, do things in groups. So there was a very large study that was published about 10 years ago by the New England Journal of Medicine that talked about smoking cessation and how we get people to stop smoking. And what that study showed quite emphatically is that if you live with another smoker, your chances of stopping are reduced to almost 3% of success if the person your fellow cohabitant continues to smoke. If you are married and your husband or wife smokes and they don’t try to stop smoking without you, you have a very, very reduced chance of stopping smoking. So if you’re going to do it, do it as a family, do it in pairs. That really makes a big difference. Two, they found that children have a very big influence. If children advocate to parents to stop smoking, you are 30% more likely to stop smoking. So use your family, especially your children as a big boon to your smoking cessation initiative. Or getting fitter initiative or whatever. Three, is that social media can make a big different. If you advertise on social media that you are stopping smoking and you look for groups of people who are stopping smoking, or just friendly support, and put it out into a public forum so that you are monitored by your friends. And a lot of people do this with how they share their running activity or their fitness activity. And smoking is particularly successful. About 70% more chance of stopping if you share it in a public social media sense because then you’re being observed and you are measured by your success. So those things do make a difference, they do help in stopping smoking. I think the ones that I’d highlight that have made a particular difference around the world are the more recent initiatives around very high taxes on tobacco, lack of advertising, lack of labelling, complete white labelling of tobacco products and hiding them behind shelves, mostly so that new smokers are not being attracted to them, with attractive packaging, and three, the banning of smoking in public places. There are many countries around the world that still allow people to smoke in bars and pubs and restaurants. The fact that that has stopped has had a significant decrease, not only on existing smokers, but also on new smokers, on teenagers coming into their adult years who would have otherwise thought about taking it up and who are not thanks to those public health initiatives.

You know, I’d really like to talk about that in a bit more detail actually. The teen vaping, but I also wanted to talk about CVS health. You know, Aetna being a CVS company, we really look to CVS Health as an example, and they obviously exited the tobacco market and stopped selling cigarettes and tobacco products in all CVS pharmacy locations. And within 12 months of ending those sales, consumers purchased 100 million fewer packs of cigarettes. So again, looking at that herd mentality, if you like, your social support groups and really looking at the responsible organisations like CVS and the attitude that they take. And citing a CVS Health research study 39% of respondents said that they or a family member or a friend have struggled with nicotine use either in form of cigarettes or vaping in the past five years. So again, the company has looked to expand its remit to include vaping products, to include e-cigarettes. But after years of decline in youth smoking rates in the U.S. today, young adults who use e-cigarettes are four times more likely to start smoking traditional cigarettes. And that’s according to the Truth Initiative.

So coming back to teen vaping. It’s been called a national health epidemic in the U.S.. What can we be doing about this? First of all, what is the latest medical thinking on the health risks of vaping and e-cigarettes. We understand it a little bit from a U.S. perspective — we’ve just covered it a little bit there. But what about globally? And secondly, how can governments, and schools, and the health care sector tackle youth vaping and tobacco use to protect our youngsters and future generations?

Well the first thing I’d say, and not just because I work for CVS, but I really do have to take my hat off to the CVS decision makers who made those brave decisions for CVS those years ago, because, there’s no doubt that selling cigarettes is a wonderful revenue-making activity. And to lose that much revenue, for a CEO to make that decision to stop selling cigarette products overnight and to lose that on their top line, that’s a big decision for someone to make. But what we do know is that it makes a huge difference to people’s health, and if you’re a health care company, that’s absolutely the right thing to do.  And as you’ve quoted, it reduced cigarette purchasing in the tens of millions. And that’s because we as human beings tend to do what’s available to us and what’s convenient to us. So if you ran into a CVS store on a street corner and purchase a pack of cigarettes, you’re much more likely to do that. If you can’t access it, then you’re much less likely to buy cigarettes and smoke them. So what I’d then say is that I’d encourage CVS competitors and like organisations to do exactly the same. Frankly, I don’t why they haven’t. It should have been done a long time ago. The fact that you can go into a pharmacy still and buy a packet of cigarettes, it’s such a paradox to me that I just simply can’t understand it. Well, I do understand it, it’s because of commercials. So hats off CVS and not just because I work for CVS. About your question regarding vaping. I think what my view is on this is that we just don’t know at the moment. There is not enough study, there is not enough evidence at the moment to be able to inform us properly about vaping in particular. Now, vaping as you’ll know takes a number of different forms. There are heated tobacco products, which we know are some of the worst out there. They actually heat tobacco with aerosols, and it’s got nicotine and toxic chemicals. You’ve got electronic nicotine delivery systems — E.N.D.S.. Those E.N.D.S do not have tobacco in them but they do have nicotine in them so they’re thought to be slightly safer. There’s lots of different types out there. So what we need is better research into the different types. There’s been a lot of furore around flavoured vaping and a lot of chemicals going into the flavoured vapes in particular that cause lung disease. What I will say to you, Lorien, is that as a doctor, I can tell you is that inhaling things into your lungs that’s not natural is probably not a good idea. It’s goes back very long into our history. As a human society and a homo-sapien probably since our early evolutionary times we have tried to smoke. Smoking is a deeply social thing. Think of Native Americans and the passing of the pipe and the peace being around that. Culturally, it’s quite a deep rooted thing, so I don’t think we’re suddenly going to stop inhaling things into our lungs as a human race and as society. I think we’re going to continue to do it in one shape or another. But what we need to do is to find what is safe. And I have hope for vaping, especially for the products that don’t have tobacco.  But there is some really nasty emerging evidence that it’s causing even worse lung issues in young people than even cigarettes themselves. So I think at this point in time, I think what we need to is to tread with caution, advise not to take on vaping. Try and do whatever we can to stop teenagers getting into the vaping thing, and we can talk more about that. But do really good research into understanding what does have health consequences and what doesn’t have health consequences so we can provide society with a safe alternative to dangerous vaping or dangerous cigarette smoking.

Absolutely and then in terms of how we specifically potentially target youngsters with positive messages, you know obviously making them aware of the dangers, making their parents aware so that they can help their youngers and teenagers to make those informed decisions.

Where do you see society and public health policy, governments, where do you see the influencers being effective in that type of environment with the youth and generations that will be coming through?

So it’s going to be exactly the same as with the tobacco story. So the first thing I’d say is that you’re talking about the teen vaping issue, is definitely peer group related. And breaking up peer groups especially in those younger adults and teenagers where often they will start vaping as a group of people. Getting into those groups and trying to break those social norms is one of the most effective, but also one of the most difficult things to effect. So if you can do it, if you can get into young social groups who are thinking about vaping, and you can almost have a champion as a listened to voice within those social groups who can take an active stance against it. And that has to be at a very local level. That has to be by local community champions, local adults, responsible individuals in the community. And I think big industry, such as CVS, plays a role, doing that. The government has a role to play in doing that. So I think that’s the first place to hit. The second is regulation. Making sure that those really dangerous manufacturers out there — and there are quite a few — are not able to manufacture and distribute their dangerous product. And then to regulate even the safer producers to make sure they are producing safer materials and have got good evidence about it. Three is taxing it. Always making it more expensive, makes it even less accessible, especially for younger people. And four is banning it in public places so that it doesn’t become so much of a social activity and break that social norm. Five is public health education programmes. Posters in bus stops, television and all that sort of stuff does make an impact. All of those things that we’ve talked about previously for tobacco still apply, but with vaping there is very much more that social, peer-group element than there has been than cigarette smoking. 

And you mentioned there having a champion within teen groups within those peer groups that can really promote positive messages about giving up smoking and the benefits of that. So if I could turn our focus slightly more into a corporate environment, so from a corporate employee population health management. Looking at how we can incentivise and encourage and empower and support individuals within that environment to give up smoking. From an employer’s perspective, they’re obviously trying to ensure that they have the healthiest, happiest, and most productive and robust workforce that they possibly can, and I was wondering if there are any examples that you can give as you just have done for that youth group in terms of what organisations can do in the short-term and in the long-term to help their employees adopt healthier behaviours and quit smoking and quit tobacco use?

You ask a really good question there, Lorien. The role of employers in helping people to stop smoking is becoming more and more important. And that’s because society is moving into this phase, especially in the United States and also in other countries where employers pay for employees’ health insurance and benefits. Employers are taking an increasing role in managing and looking after the health of their employees. So one is the financial responsibility that comes. Two is the social responsibility that comes. Increasingly as we spend vast amounts of our working lives or our daily lives at work, there is a social responsibility that companies are taking on, understanding they are responsible for the health and well-being of their employees. Much more than say 10 or 15 years ago. Three is that peer group mentality, essentially translated from teenagers into adults that goes into the workplace. So rather than being at school, or college or university, if your co-workers are smoking, you’re much more likely to smoke. So having effective smoking cessation policies in the workplace and stopping smoking there really makes a difference in breaking up that peer-based activity there as well. And the last thing is the economic impact. Smoking related diseases cause so much problem including absence from work, need for early retirement, early death, lack of productivity, employee absenteeism, that there is an economic imperative for employers to do something about smoking. And so what’s happening and I won’t choose any particular company, but I’ll choose a trend, is that employers are now investing a lot more money into smoking cessation programs, which are run by health care companies like CVS Aetna, which make a big difference.  So you can then start breaking up the peer group, which we know from what we’ve discussed is really effective. They’re putting in regulation and banning smoking in campuses, so you look at hospitals, and there are complete smoking bans throughout the campus, which can be quite a large geographical area. There’s public information campaigns, advertising in the workplace, putting posters up in workplaces and put messages in emails about smoking cessation and so forth. There is a bit of naming and shaming that goes on as well. I don’t know about you, but there’s a sort of a small cargo of people that we know are the smokers. And they’re sort of the social pariahs when they go out for their cigarette break and come back smelling of smoke. And treating them like social pariahs is actually very effective because it does start to change behaviours as well. So you see all of these things coming through in the workplace and I see the employer being more and more responsible over time to help people with smoking cessation.

And there’s obviously a lot of tools and resources out there that employers can provide as well. So from a digital health perspective, you know there are apps such as Smoke Free, for example, that employers can make available to their employees either through their health benefits programs or by subsidising access. Aside from that, what other advances in digital health tech and let’s even talk about augmented intelligence and the looking at the collection and sharing of big data in condition management and tobacco-related comorbidities.

How do you see the future of health tech advancing our fight against tobacco use at a societal level?

That’s a great question. So first is knowing where your problem is. So now our ability to monitor and get data on where smoking is happening, where cigarettes are being sold, what age groups are accessing them, where you have particularly focussed smoking groups, knowing where diseases are being caused. That allows us to have much more of an insight at a local, and national and an international level. So our ability now to understand how people are smoking, why people are smoking, what gets them to stop and what diseases they’re getting has got much better. So our campaigns can be much more targeted. Two is the advance in digital therapeutics around this. So 10 years ago, you had to read a text book or live classes if you wanted to go to smoking cessation course. Now we don’t do any of that. There are a plethora of apps and digital tools that are out there. And some of the more advanced ones are using the more augmented intelligence that you’re talking about. So what they are doing is that they know when you’re much more likely to want to have a cigarette. And they can send you a notification on your iPhone saying, “I bet you feel like a cigarette now. Let’s talk through this. Let’s not have a cigarette.” So something that really helps you with that journey in stopping smoking on a much more targeted basis because it understands your behaviours and uses augmented intelligence. And so digital tools have advanced. They’re quite prevalent now, they’re quite easy to access, they’re often free or they’re sponsored by your employer. So you can do this as part of your daily life. You don’t need to take time off work or take time out to read a book or go to a course. And you integrate it into part of your normal activity and because it’s on your phone, which is always with you, you can use it as a constant support thing to help you through. And so what we are seeing is that people who use digital tools to stop smoking are far more successful at stopping smoking. So I have great hope in this realm.

Yes, that’s certainly an exciting area to keep an eye on. So you know, before we draw this conversation to a close, is there anything else you would want to say to add to the conversation about giving up smoking?

You mentioned earlier that now is the time, so is there anything else you want to close with?

I’d say never stop stopping. For those smokers out there who are listening to this, giving up is the wrong term, because you’re not giving up anything. Stop. And if you don’t stop, don’t stop trying to stop. That’s a very important message that does get through to people. The COVID crisis will be a catalyst for many of you, I hope. And behaviour change is one of the most difficult things. So if you are taking it on, find a buddy either real-time or digital, to help you to do it. And get all the support you can to do it and best of luck with your smoking cessation journey.

Dr Sneh Khemka, thank you ever so much for time today, and I have lots of other topics that I would like to bring to and discuss with you in the coming weeks. So hopefully we can find some time to do that. So thank you again.

Thanks very much, Lorien.

For those who don’t know us, Aetna International is a global health and wellness benefits provider. But, we’re more than just an insurance safety net; our skill lies in delivering the tools, services and resources that help drive health care costs down and people’s physical and mental health and well-being up. This is something that’s important to our corporate clients and self-funded members alike. That’s why we currently serve almost 900,000 members around the world — from Shanghai to Seattle. Ultimately, we believe that when people thrive, their work and personal endeavours thrive too. For more information about us, you can visit AetnaInternational.com.

Join us for episode 5 of the Fit for Duty podcast when we’ll be looking at the digital health dilemma facing employers today. Technology has a profound impact on the way we communicate, behave, interact, work and live. We delve into the insights uncovered by research we conducted with 4,000 workers across Singapore, UAE, UK and US in March 2020. The research explores the link between the use of technology and its impact on mental and physical health. What do employees think employers need to do to harness the positives and diminish the negatives of technology to help them achieve good health outcomes and all-round well-being? Listen in as we find out and talk to subject matter experts to find out about the opportunities available to employers today as they focus on creating healthy, happy, productive workforces.