MRFIT (Multiple Risk Factor Intervention Trial Research Group, 1982, 1990, 1996). However, changes were modest, and control groups showed similar outcomes (Cutler, 2004; Syme, 2002).

In contrast, some health risk behaviors have changed over time, and public interventions seem to have played an important role: an example is smoking. National cigarette consumption per capita reached its peak in the early 1960s. Since the 1964 Surgeon General’s report on the dangers of smoking (U.S. Department of Health, Education, and Welfare, 1964), consumption has steadily dropped to less than half the peak level, declining roughly in parallel among whites and blacks. Standing by itself, the Surgeon General’s report would probably not have generated such a wide-ranging and sustained response. But the report did not stand by itself. It mobilized public opinion and eventually generated a variety of legislative responses, including taxes on cigarettes, restrictions on broadcast advertising, antitobacco advertising campaigns, limits on access to cigarettes, and bans on smoking in various establishments and public places.

Antismoking policies have been extensively studied (Chaloupka and Warner, 2000; U.S. Department of Health and Human Services, 2000); as summarized by Cutler (2004), many of them are effective. Generally, a 10 percent increase in prices (through taxation, for instance) reduces consumption of cigarettes by 4 percent, with young men affected more than young women (Chaloupka and Pacula, 1998) and the poor affected substantially more than the rich (Gruber and Kosygi, 2002). Antitobacco advertising can have large effects: California’s $26 million media campaign of the early 1990s reduced smoking by an average (per year) of eight packs per person. Workplace smoking bans reduce the number of workers smoking by 5 percent and also reduce consumption among workers who continue to smoke (Cutler, 2004). Such policy changes, while effective, are nevertheless insufficient to account for the overall historical reduction in smoking, which must reflect, in addition, a broad-based movement away from smoking among millions of people. Somehow, in the late 20th century, the political timing was right for antitobacco measures, and growing public approval helped make them effective.

Blacks have benefited as much or slightly more than whites from smoking declines over the last four decades. The same cannot be said across education groups. Smokers among high school dropouts were 6 percentage points more numerous than among college graduates in 1966, and 19 percentage points more numerous in 1995.

When promotion of health behavior becomes part of a broad social movement, involving and mobilizing a range of social actors—national and local legislators, the media, private business, volunteer groups, etc.—wide-ranging effects such as those from antismoking campaigns are possible. Cutler (2004) refers to this phenomenon as permeation, the saturation of



The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement