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Scared of legal pot? Hold on. Let’s talk about tobacco.

What’s ailing us? Many serious illnesses we face are embarrassingly simple to avoid. Ezra Klein talks with Center for Disease Control director Tom Frieden.

Tom FriedenWe could do so much more to help people live longer, healthier and more productive lives. Tobacco remains the leading preventable cause of death in this country. It still kills more than a thousand Americans everyday. And yet, if you look at the communities that have done the right things, they've driven rates way down by 20, 30%. Teen smoking rates down by 50% or more. We could drive those numbers down dramatically if we focus on it.

Take blood pressure control. Heart attacks and strokes kill more Americans than any other cause, in fact, cause more inequalities in health and any other disease. Two million Americans a year get a heart attack or a stroke and yet many, maybe even most of those could be prevented by simple things like controlling your blood pressure. Taking an aspirin a day if you're at risk. Getting your cholesterol under control and not smoking.

Vaccine-preventable diseases are still too common. We're seeing, for example, outbreaks of measles now in communities that haven't vaccinated well. We're seeing cervical cancer that's going to continue if we don't get our HPV vaccination rates up. When we see thousands of people going to hospitals every year who don't have to if they just got a flu shot every year.

Ezra KleinWhat is the single biggest opportunity out there in health?

Tom Frieden I would start with tobacco control. You know what, people sometimes think, "Oh, tobacco. That's yesterday's issue." It still kills more people than anything else in this country and around the world. And there's a lot more that we can do about it. It doesn't just kill people, it disables, disfigures, causes diseases. It increases our health care cost. Tobacco is really the number one enemy of health in this country and around the world.

Ezra KleinWhen you say that a lot of people think that tobacco is yesterday's news, what is the next step on policy? At this point you're dealing with taxes in New York that are high enough that one out of three packs is basically smuggled into the state. When you say there's a lot more to do, what is there more to do?

Tom FriedenFirst off, there are a lot of places that haven't yet implemented the things that we know will work, whether that's protecting people from second-hand smoke at work or increasing tax or reducing smuggling, which there are ways to do. Or running hard hitting ads, which we know make a major impact – they save lives and save money. These are some of the things that work.

Health care system can do much better at helping people quit. Medications will double or triple the chances that you'll succeed. But the things that are going to make the biggest impact are price, hard hitting ads and smoke-free laws.


Still dangerous. Flickr/Azrasta.

Ezra KleinWhat do you think about e-cigarettes?

Tom FriedenE-cigarettes may help in some ways but they are definitely harmful in many ways as well. If they get kids hooked on tobacco and nicotine, which they are doing. If they get smokers to continue smoking rather than quit. If they get smokers who quit to come back to smoking.

Ezra KleinWhat's your view of the evidence on whether they actually help people quit?

If they re-glamorize the act of smoking or confuse smokers at what works to quit. These are all real problems with only at this point potential benefits from e-cigarettes.

Tom FriedenThere's one small well-done study that they helped a little bit. The patches helped a little bit in that study too. The two weren't statistically different. We do know that people who are using e-cigarettes are not quitting at higher rates than people who aren't using them now. As we learn more, I have no doubt that an individual here or there can be helped by them, that they might be helpful to some people. As a societal issue, they're only going to be helpful if they're well-regulated and if cigarettes are well-regulated.

Ezra KleinI'm a dedicated reader of the CDC's Vital Signs newsletter. Most of us think of the drug problem as a problem of illegal drugs. But your data often focuses on legal drugs. It's about tobacco, it's about alcohol, and it's about opiates and prescription drugs. I think there's been, according to you guys, a 400% increase in female deaths from prescription drug overdose in the last couple of years.

Then also it's about antibiotics and overuse of antibiotics in the rise of superbugs. You guys have scared the hell out of me about things that are supposedly, if not safe, at least safe for adults to consume and reasonably regulated ways.

Tom FriedenIn health care, there's something that's sometimes called the inverse care law. People who get care the most needed the least and vice versa. That's also sometimes true in terms of medications. We overuse a lot of medications but we also underuse important medications. We don't get it right.

One of the most striking weeks I've had as CDC Director in my five years there was when I had, in the course of one week alone, looked at the increase in prescription opiate overdoses in death numbers, in babies born addicted to opiates because their mother was taking an opiate during pregnancy, in distracted or drugged driving, in hepatitis-c from kids who started out using pills and graduated to heroin because it was cheaper, and in HIV among that same population. This is in the course of one week. It's every age group, from babies to seniors. There are enough opiates prescribed in this country for every single adult to get 75 pills every year.

Ezra KleinReally?

Tom FriedenWe're awash in these. One of the things that we need to do as a society, of course we need to improve the prescribing practices. We need to improve what States do on opiate monitoring. We need to improve what medical boards do. We need to ensure that there's a good collaboration between law enforcement for that tiny number of people who are breaking a law and treatment and public health programs to support people who need help and support.


Oxycontin is a popular opiate. Getty images / Steve Russell.

What we also need to do is start looking at what we think about as a society because some of the things that are going to help our health most isn't going to be taking another pill. It may be getting physical activity. It may be eating healthier. Maybe joining a book club and maybe building linkages in society that are getting eroded by some of the things in our society.

Ezra KleinThis will be a really basic medical question, so forgive it. What does it mean when an infant is born addicted to opiates?

Tom FriedenIt is horrific. Opiates change the way your body works and develop dependency or addiction. If you remove the opiates then the opposite of what the opiate causes happens at a very high rate and you can get rapid heartbeat, you can get sweating, you can get profuse problems, you can get hyperactivity and you can actually get death. Infants who are born opiate addicted need to be very carefully detoxified from that in a way that will not harm them.

Ezra KleinI want to talk through antibiotics and superbugs because when I sit around thinking about what should I be neurotic about, that's typically what I come to. When I've spoken to people who really study those issues they sound almost apocalyptic. You hear people say we are entering a post-antibiotic world because we're not coming up with them fast enough and the ones we have are rapidly losing their effectiveness. How worried are you or how worried should I be about the rise of superbugs and the constricting pipeline of antibiotics?

Tom FriedenYou should be worried enough to make sure that we have the resources at CDC to reverse this problem and slow it.

Ezra KleinI don't think I have as much money as you think I have.

Tom FriedenWell, first off, I'll just tell you two stories. It's not often that top scientists at CDC come to me and say, "We have problem. We need you to sound the alarm." That happened here. That happened here with a class of organisms called CRE or Carbapenem-Resistant Enterobacteriaceae. They are gram-negative organisms which tend to be pretty deadly, particularly to people in the hospitals. They have developed resistance to virtually all or in some cases all of our antibiotics.


A 3d-rendering of the deadly, drug-resistent CRE bacteria. CDC/ Melissa Brower

The good news is that we know how to control them. We've now recommended that every single hospital in this country have an antibiotic stewardship program and we'll help them to set those up. We recommend that every hospital tracks what their resistance patterns are and what their prescribing patterns are. We're focusing on hospitals because half of all hospitalized patients get an antibiotic in their course of treatment but maybe a third of those antibiotics are either inappropriate or unnecessary. They're given too long, they're too broad a spectrum, they're not necessary.

The result of that kind of problem with antibiotic prescribing is that we have more than 23,000 deaths a year from resistant organism and, in addition to that, we're at about 14,000 deaths a year from what's called C. diff or Clostridium difficile which is an organism you get if you take antibiotics.

It's a serious problem. We do have the risk of being in a post-antibiotic era. I'm trained as an infectious disease physician. I think back to my years of training and my care of patients with tuberculosis and HIV where we had patients who we had no treatment for and you really do feel like you're in a post-antibiotic era. You're back to doing things like removing parts of lungs and trying experimental therapies and hoping that the patient's own immune system kicks back in.

C.Diff - Clostridium difficile

Clostridium difficile, or C.Diff. CDC / Lois S. Wiggs.

We can make a big difference. We think that with a modest investment we'll be able to cut drug resistant organisms, particularly CRE, by 50% in 5 years and C-Diff by 50% in 5 years. We can do this. We can make a big difference.

Ezra KleinWhat about the other side of the equation? What do we need to do to reopen the antibiotics pipeline? When you talk to folks, they don't seem to think we've hit a point where the human race cannot discover or create new antibiotics. They seem to think that the economics of doing so is simply are not advantageous for the drug companies.

Tom FriedenWe don't know how long it's going to be and how likely it will be that we'll be able to succeed in making new antibiotics, but we've got to try. There are a few different moves afoot in Congress to make it more economically advantageous for companies to develop new antibiotics. We want to make sure that when new antibiotics come on to market they're used well so that companies can both make a good profit or reasonable profit and also we don't abuse the medications and lose them in a couple of years. If we don't improve our system for using antibiotics, the new ones are going to be lost just as quickly as we're losing the ones we have today.

Ezra KleinThere is this study, you probably saw it, that came out of Oregon on whether Medicaid - and perhaps any health insurance - makes you healthy. When they looked at things like blood pressure and cholesterol, things that should have been brought under control within two years, they didn't see a huge difference. Our system actually does not reliably translate all that money we're spending on tier and on coverage into actual health.

Tom FriedenYou have to say that having coverage, a way to get care without going broke, is a necessary but not a sufficient condition for a big health improvement. We published an article a few years ago about the Massachusetts experience. Initially, they had a big increase in coverage but not a big increase in access because they had a gap in primary care availability. That's fundamentally because we don't pay primary care providers enough.

You also have to look at the time horizon. We need to be able to look 10 or 20 years down the line. If I get your blood pressure from 160/100 down to 130/80 with a couple of medications, that's going to substantially reduce your risk of all sorts of problems but it may take 5, 10 even 20 years for that prevention to happen. Getting the quality and then waiting to see the results is important.

Ezra KleinI'm the kind of person who literally will not go see a movie about a disease outbreak because it will activate my ancient lineage of complete terror around disease. You sit around and you marinate in what appears to me to be the most horrifying data that mankind can produce everyday. How does your family act differently as a consequence? What do you have them do that is different than what most folks do to protect them from whatever you come to perceive as high risk?

Tom FriedenVery little is different really. It's basic. Wash your hands regularly. Get regular physical activity. Eat foods you love that are healthy. That's one of the things that's so challenging. Take physical activity as an example. You don't have to have much, 30 minutes a day. Doing that, which can be three 10-minute walks, is going to make a huge difference in your life. You'll feel better even if you don't lose an ounce. You will be much less likely to have high blood pressure, high cholesterol, cancer, arthritis, depression. You'll sleep better. And it doesn't cost a cent.

There's a lot a of things that can be done that are not very difficult and can make a really big difference. Of course, get your shots, get vaccination, get a flu shot every year and see the doctor regularly and if you have a problem make sure to get follow up.

Ezra KleinDo you remember the old Michael Pollan line, "Eat food. Not too much. Mostly plants"?

Tom FriedenYes.

Ezra KleinIt sounds like if you were doing that you would say, "Eat real food. Walk 30 minutes and wash your hands."

Tom FriedenDon't smoke. Alcohol in moderation.

Ezra KleinIt sounds like, from this conversation, the big stuff you could probably fit into less than 15 words. Compose the sentence for me.

Tom FriedenEat right. Get physical activity. Don't smoke. Alcohol in moderation. Spend time with friends.

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