Chapter 10: Anatomy of a Change Movement: What the Movement to Ban Public Smoking Has to Teach Healthcare Leaders About Culture Change

INTRODUCTION

One of the most important lessons we have learned about cultural transformation is that culture does not change unless and until people change. Because culture is shaped by the collective attitudes and behaviors of the people who work in the organization, until a critical mass of individuals are willing to make the commitment to positive personal change, no “culture change initiative” will achieve a long-term impact. But a corollary lesson is that people will not change unless they perceive a meaningful personal benefit to doing so.

One of the most profound cultural changes in the history of the world has been the rapid alteration of perceptions about the acceptability of smoking in public places and of tobacco companies using television advertising featuring macho cowboys, glamourous (and anorexically thin) women, and cartoon characters to promote a deadly addiction. We no longer hear about “smokers’ rights” being promoted by multimillion-dollar advertising campaigns; cigarette vending machines have been relegated to museums, and cigarette companies are no longer allowed to give out free samples, including (though they denied doing it) to children; and tobacco companies are no longer allowed to deny what science had long ago proven.

When former US Surgeon General Dr. C. Everett Koop called for a smoke-free society in 1986, people wondered what he was smoking. Back then, people smoked everywhere: in restaurants, in offices and hospitals, in taxicabs, and even in airplanes. We could hardly escape the ambient stench of cigarette smoke—not even in a hospital. In many outdoor locales, such as football stadiums on a Saturday afternoon, a pervasive cloud of cigarette smoke hung in the air. Regardless of how health-conscious we were, we were unable to protect our health, or the health of our children, when out in public.

Today, of course, Koop’s dream of a smoke-free society has substantially been achieved. From the bars of New York City to hotel rooms in North Carolina and Kentucky (home of the tobacco industry), smoking has been increasingly relegated to the back alley, next to the trash bin. Anyone lighting a cigarette on an airplane now would most likely be escorted off the plane in handcuffs—that is, if they survive being attacked by other passengers. Most recently, Congress has raised the legal age for buying cigarettes from 18 to 21. The world has changed dramatically, profoundly, and permanently. It is worth examining how this has happened, because the antismoking movement offers many lessons for the challenge of cultural transformation in healthcare organizations. Here are 10 key lessons for culture change drawn from this most powerful historical example.

1. Start With an Uncompromising Goal