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3
Containing the Tobacco Problem

The trends in cigarette smoking charted in Chapter 1 reflect the push and pull of social forces that tend to promote tobacco use and those that tend to reduce it. Tobacco use in the United States dates back to before colonization, and it has probably had its detractors almost as long. This chapter reviews public health efforts to contain tobacco use over the past four decades. It is not meant to present a nuanced account of the economic, political, and social forces that have shaped the nation’s response to tobacco use over this period. Fortunately, interested readers can find the full story in recent books by Richard Kluger and Allan Brandt (Brandt 2007; Kluger 1997). The brief review presented below is designed to highlight key features of the story as seen through the lens of public health.

The introduction of mass-produced, finished cigarettes in the 1880s was followed by mass marketing campaigns that have made cigarettes one of the most highly promoted products in the nation’s history. As the appeal of cigarette smoking grew, however, so did the strength and vehemence of the antitobacco activists. Some opponents had moral or religious objections to smoking, and they and others decried its presumed health dangers in the context of a contemporary populist health and hygiene movement. Cigarettes were called a “poison” and even “coffin nails” during those anti-tobacco campaigns (Burnham 1989; DHHS 2000; Tate 1999).

The antitobacco activists claimed some victories in the early 20th century, including the passage of laws in several states that prohibited tobacco use by both adults and minors (DHHS 2000; Outlook 1901). Their gains, however, were short-lived. Smoking was becoming embedded in the American culture. Cigarette use among soldiers in the Civil War—as in



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Ending the Tobacco Problem: A Blueprint for the Nation 3 Containing the Tobacco Problem The trends in cigarette smoking charted in Chapter 1 reflect the push and pull of social forces that tend to promote tobacco use and those that tend to reduce it. Tobacco use in the United States dates back to before colonization, and it has probably had its detractors almost as long. This chapter reviews public health efforts to contain tobacco use over the past four decades. It is not meant to present a nuanced account of the economic, political, and social forces that have shaped the nation’s response to tobacco use over this period. Fortunately, interested readers can find the full story in recent books by Richard Kluger and Allan Brandt (Brandt 2007; Kluger 1997). The brief review presented below is designed to highlight key features of the story as seen through the lens of public health. The introduction of mass-produced, finished cigarettes in the 1880s was followed by mass marketing campaigns that have made cigarettes one of the most highly promoted products in the nation’s history. As the appeal of cigarette smoking grew, however, so did the strength and vehemence of the antitobacco activists. Some opponents had moral or religious objections to smoking, and they and others decried its presumed health dangers in the context of a contemporary populist health and hygiene movement. Cigarettes were called a “poison” and even “coffin nails” during those anti-tobacco campaigns (Burnham 1989; DHHS 2000; Tate 1999). The antitobacco activists claimed some victories in the early 20th century, including the passage of laws in several states that prohibited tobacco use by both adults and minors (DHHS 2000; Outlook 1901). Their gains, however, were short-lived. Smoking was becoming embedded in the American culture. Cigarette use among soldiers in the Civil War—as in

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Ending the Tobacco Problem: A Blueprint for the Nation wars to follow—helped promote its popularity and respectability (DHHS 2000). There was no medical consensus regarding health dangers; in fact, many physicians openly smoked and sometimes even promoted the product (DHHS 2000; Walsh 1937). The anti-tobacco forces were unable to stem the growing popularity of cigarettes over the first half of the next century (DHHS 2000; Schudson 1984). By the middle of the 20th century, researchers were studying the health effects of smoking. In 1952, an article in Reader’s Digest reporting on the emerging evidence linking smoking and cancer aroused public concern (Norr 1952). More than 10 years later, publication of the 1964 Surgeon General’s report (HEW 1964) was widely regarded as a turning point in the history of smoking in the United States and the point of departure for the modern tobacco control movement (DHHS 2000). The 1964 report consolidated the growing body of research that linked smoking to lung cancer, chronic bronchitis, and emphysema, disseminating the emerging data on tobacco’s adverse effects to a wide audience (HEW 1964). The report’s authoritative voice—the Surgeon General is the country’s top health officer—and compelling documentation were impossible to ignore. The steady growth in smoking prevalence that had begun in 1920s came to a halt. After publication of the report, public debate over smoking could never again be divorced from its documented adverse health effects. Smoking could no longer be viewed exclusively as a matter of consumer choice based on the idea that tobacco is an ordinary consumer good. Smoking had officially become a medical problem and a public health challenge. As the 1964 report stated, “cigarette smoking is a health hazard of sufficient importance in the United States to warrant appropriate remedial action” (HEW 1964). The Surgeon General’s report stimulated a significant change in public attitudes about smoking and new public health and public policy responses. The story of the past four decades, however, is not one of unmitigated public health success. The decades following the report’s release can be divided into two periods. The first phase, which lasted through the late 1980s, was characterized by largely unsuccessful efforts by those involved in the antismoking movement to gain political footing against the tobacco industry, a commercial giant with many tools at its disposal. Beginning in the mid-1980s, however, the understanding of the tobacco problem and the tools used to combat it underwent dramatic transformations. Smoking came to be recognized as a form of drug addiction, one that typically begins by the age of 18 years and that is fostered by the marketing and other actions of cigarette companies. In addition, the harms that smoking causes to nonsmokers, as well as smokers, also changed the political landscape of tobacco control efforts.

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Ending the Tobacco Problem: A Blueprint for the Nation PUBLIC HEALTH TAKES ON THE TOBACCO INDUSTRY: 1964–1988 The initial declines in smoking following the release of the 1964 Surgeon General’s report came largely from motivated smokers quitting in response to the highly publicized and frightening findings about tobacco’s dangers. With some 70 million tobacco users in the country and with so many Americans—from farmers, factory workers, and cigarette manufacturers to retailers, advertising agencies, and the media—tied economically to smoking, however, dramatic political change did not occur overnight. Moreover, in the turbulent 1960s, the country’s attention was focused on such pressing political issues as civil rights, Vietnam, and the War on Poverty (Kluger 1996). Educational Initiatives Public education was the first line “remedial action” taken in response to the Surgeon General’s call. The American Cancer Society was an early leader. Other voluntary health groups, such as the American Lung Association and the American Heart Association, with their core missions of public education, were also well positioned to take early leadership roles. The three groups worked independently of one another until 1981, when they formed the Coalition on Smoking OR Health. State and local leaders of these organizations began to form similar coalitions in their areas, extending the antismoking effort in states and local communities (DHHS 2000). The American Medical Association (AMA) did not become an advocate for tobacco control until the mid-1980s, when Board of Trustees member Ronald Davis urged the AMA to testify before Congress (Kluger 1996). New programs to aid in smoking cessation and prevention were developed and implemented. The 1960s saw a rapid introduction of new behavioral approaches to smoking cessation, with novel ideas appearing almost every year. By the 1980s, pharmacological approaches were attracting attention. The National Cancer Institute’s Smoking and Tobacco Control Program was a major source of research funding (Shiffman 1993). School-based prevention programs were also developed and introduced in the 1970s and 1980s, sometimes as a part of alcohol or other substance abuse programs. These programs used a variety of approaches, which varied on the basis of local preferences. Later, the Centers for Disease Control and Prevention issued its Guidelines for School Health Programs to Prevent Tobacco Use and Addiction to provide a national framework and impetus for these programs (CDC 1994). It took time for antismoking coalitions to coalesce, but anti-tobacco advocacy and grassroots efforts came to play a key role in containing the

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Ending the Tobacco Problem: A Blueprint for the Nation tobacco problem. A notable early development came in 1966 when John F. Banzhaf successfully petitioned the Federal Communications Commission (FCC) to invoke the Fairness Doctrine and mandate reply time on television and radio for the cigarette commercials glamorizing smoking. This action ultimately led to an FCC requirement, beginning in 1967, that stations run one free counter advertisement from health groups for every three cigarette commercials that they aired. The American Cancer Society, working with top advertising agencies that donated their time, took the lead in producing graphic and compelling counter advertisements. Banzhaf went on to form Action on Smoking and Health, a national antismoking consumer organization that was reported to have 60,000 members by 1979 (Kluger 1996). Congressional initiatives gave some support to the public education efforts, giving what seemed to be at least a symbolic win to the nascent tobacco control movement. Within a year of the publication of the Surgeon General’s report, the U.S. Congress passed the Cigarette Labeling and Advertising Act of 1965, which required cigarettes packages to contain the message “Warning: Cigarette Smoking May Be Hazardous To Your Health” (CDC 2005). As additional scientific evidence documenting the dangers of smoking continued to emerge, the 1969 Public Health Cigarette Smoking Act upgraded the warning to read “Warning: The Surgeon General Has Determined That Cigarette Smoking Is Dangerous To Your Health” (CDC 2005). The law also banned all cigarette advertising on television and radio, effective January 1, 1971 (Borio 1993). By 1981 a Federal Trade Commission (FTC) staff report had concluded that the health warning on packages was “worn out” and was having little impact on public knowledge and attitudes about smoking. The warning was too abstract and difficult to remember, and it was not seen as personally relevant (Hinds 1982). Congress responded with the Comprehensive Smoking Education Act of 1984, which required the use of four, more specific, labels on cigarette packages and cigarette advertisements that would be rotated on a regular basis (CDC 2005). The new warnings reflected the steady flow of research findings tying smoking to increasing numbers of serious conditions. By the time that the 1989 Surgeon General’s report was released, the list of conditions that scientific studies had linked to smoking included various cancers—including lung, laryngeal, oral, and esophageal cancers—as well as pulmonary disease, heart disease, and fetal growth retardation. This growing body of research helped power the tobacco control movement. The Tobacco Industry’s Response Even as public health forces were coalescing and making policy inroads, the tobacco industry was fully engaged as a formidable opponent. Tobacco

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Ending the Tobacco Problem: A Blueprint for the Nation has been entrenched in American society for so long that it is extremely difficult to sort out the precise roles of various commercial, medical, social, and cultural forces in sustaining the tobacco problem. The tobacco industry’s forceful strategies, however, have provided a powerful counterforce to the public health effort. As the 2000 Surgeon General’s report would later state, in admittedly simplified terms: “The history of tobacco use can be thought of as a conflict between tobacco as an agent of economic gain and tobacco as an agent of human harm” (DHHS 2000). The medical establishment was initially slow to embrace the imperatives of the growing findings about smoking and heath. The tobacco industry, on the other hand, quickly sprung into action in the early 1950s to counter the studies connecting smoking to higher mortality rates. In the late 1950s, cigarette manufacturers created the Tobacco Institute, which claimed to represent not only cigarette producers and distributors but also hundreds of thousands of farmers and others with economic interests in tobacco (Kluger 1996). The Tobacco Institute was the driver of the industry’s extensive public relations and lobbying campaigns for decades. It sought to underscore the economic importance of tobacco and, together with the industry’s Council for Tobacco Research (initially called the Tobacco Industry Research Council), to undermine the scientific evidence identifying the risks of smoking and documenting its effects on health. By disputing the scientific findings about the dangers of smoking, the industry sought to reassure its customers and to obscure the public’s understanding of the risks. The industry also assertively sought to counter and displace the message about the dangers of smoking with a message tapping into the American spirit of individualism, freedom, and unease with government paternalism. The industry’s message was simple: Smoking is an individual’s free choice and no one else’s business and certainly not the government’s business. Although the voluntary health organizations leading the early public education effort tended to avoid controversy and politics, tobacco interests built a powerful presence on Capitol Hill. They sustained their influence by lobbying, making campaign contributions, and building allegiances with members from tobacco growing states, many of whom held key leadership positions (Kluger 1996). Through their efforts, tobacco industry advocates were able to influence key legislation. For example, Congress denied the Consumer Product Safety Commission jurisdiction over cigarettes, reversing the position taken by the agency’s first chairman, who said that the commission had authority to regulate or even ban cigarettes. Tobacco was also expressly exempted from regulation under the Toxic Substances Control Act (1976), even though the law was intended to regulate chemical substances which present “unreasonable risk of injury to health of the environment.” Although the nicotine in tobacco is highly addictive, tobacco is also explicitly exempted

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Ending the Tobacco Problem: A Blueprint for the Nation from regulation under the Controlled Substances Act (1970). Without these congressionally enacted exemptions, tobacco products would have been subject to strong regulation—indeed, they theoretically could have been removed from the market under these statutes if the applicable regulatory agency had been so inclined (Kluger 1996). As they sought protection from potentially damaging legislation, tobacco companies also spent billions of dollars marketing cigarettes to ensure a steady stream of customers. Their products were killing some 400,000 people a year and causing widespread morbidity, while the public health community scrambled to stem the damage. The major companies, aggressively competing for market share and for new smokers, hired top public relations companies to reshape the image of old brands and draw in new populations of smokers (Kluger 1996). With women accounting for an increasing proportion of smokers and with the women’s liberation movement advocating for female freedom and independence, women became a ready target for tobacco industry marketing. In 1967, companies rapidly increased their advertising in women’s magazines and Philip Morris launched its Virginia Slims cigarette featuring the memorable slogan “You’ve Come a Long Way Baby.” The rate of smoking initiation among girls younger than age 18 years rose abruptly in 1967, the year that the Virginia Slims campaign began, peaking in 1973 at more than double the rate in 1967 (Pierce et al. 1994). By the late 1980s, the R.J. Reynolds Company recast its Camel cigarette brand with a cartoon figure, Joe Camel, and initiated a marketing effort that would prove especially popular with young people. Following this image redesign, Camel’s youth market share ballooned. Although the tobacco companies insisted for decades that they were not targeting underage smokers, industry papers that would later become public indicated otherwise (Kluger 1996). The tobacco companies also competed for smokers who were concerned about the dangers of smoking by marketing a succession of new low-tar and “light” cigarettes that offered smokers an alternative to quitting. These products emit lower levels of tar, carbon monoxide, and nicotine than other cigarettes, as measured by the standard FTC machine testing method. The implication that low-tar cigarettes would therefore reduce the dangers of smoking made these products the choice of increasingly large numbers of customers. Research later showed, however, that the benefits of low-tar products are not what the FTC figures might suggest, because smokers alter their smoking patterns to compensate for the reduced nicotine delivery and because the standard smoking machine used by the FTC does not accurately simulate how smokers smoke. Therefore, people who switched to these brands did not significantly lower their health risks (Harris et al. 2004; IOM 2001; NCI 2001).

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Ending the Tobacco Problem: A Blueprint for the Nation Companies also turned their attentions internationally, as free trade agreements and the collapse of communism in the late 1980s opened markets in Asia and Eastern Europe that previously were controlled by local monopolies. The big international tobacco companies introduced marketing campaigns in countries that until then had not seen extravagant cigarette advertisements, due to the state previously controlling all tobacco sales. The introduction of more varied and better-tasting American cigarettes, sometimes cheaper thanks to market competition, exported the tobacco problem to developing countries, even as rates were declining in the United States (Sugarman 2001). As a result, more than 95 percent of the world’s smokers now live outside the United States. According to World Health Organization projections, by the year 2020, 10 million people will die annually from tobacco-related illnesses, and 70 percent of these individuals will be in developing countries (WHO 2005). Even when Congress passed legislation that seemed to promote the tobacco control effort, the public health gains often turned out to be illusory. The 1965 health warning legislation, for example, actually represented an important success for tobacco interests. Without it, a much tougher FTC proposal would have taken effect, putting in place a stronger warning on packages and also on advertisements. Congress temporarily blocked a warning on advertisements, a requirement that the industry was eager to avoid. Preemption language in the bill also stripped states of the authority to impose tougher requirements on packages or advertisements. The legislation kept regulatory action centered in Congress, where tobacco interests were most powerful (DHHS 2000). The industry also recognized—though it presented a contrary message to the public—that the mild warnings that Congress required in the 1965 and 1969 acts might prove helpful in suits by smokers who claimed that the companies had not informed them of the dangers of smoking. Indeed, in 1992, the U.S. Supreme Court ruled in a case brought on behalf of a smoker, Rose Cipollone, that the 1969 act preempts state tort suits based on negligent failure to warn of the dangers of smoking, to the extent that such suits were based on a claim that the manufacturers’ and sellers’ post-1969 advertising ought to have included additional or more clearly stated warnings about the health consequences of cigarette smoking (Rabin 2001a). The trade-offs involved in the labeling legislation, as well as doubts about the impact of the product warnings, have led some public health experts to question whether the legislation was a public health victory (IOM 1994). Surgeon General Luther Terry, who issued the 1964 report, would later go so far as to call the 1965 law, “a hoax on the American people” (DHHS 2000). The broadcast ban on tobacco advertising was probably also a net benefit to the industry. Between 1967 and 1970, when public health advocates aired counter advertisements as part of the Fairness Doctrine, cigarette

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Ending the Tobacco Problem: A Blueprint for the Nation consumption dropped at a much faster rate than either before or after this period (DHHS 1989). Several studies have found that the ads were driving at least some of the downturn in smoking (Farrelly et al. 2003; Hamilton 1972; O’Keefe 1971; Warner 1989). When the congressional broadcast ban took effect (without much industry resistance), those advertisements disappeared from the nation’s living rooms, and the tobacco control movement lost one of its more effective tools for reducing tobacco use. Whatever the public health benefits of banning broadcast tobacco advertising, it was to the industry’s advantage to get the counter advertisements off the air. After the television advertising ban, tobacco companies vastly increased their marketing budgets, shifting a large portion of advertising dollars into promotional activities aimed at (1) putting cigarettes in the hands of prospective users; (2) positioning cigarettes in prominent and accessible places at points of sale; and (3) creating good will for the companies with the public, community leaders, and politicians (IOM 1994). In 1975, the tobacco industry spent $491 million on all types of cigarette advertising and promotion in the United States. By 1985 that figure had nearly quintupled to $2.48 billon, and it continues to multiply (FTC 2005). The industry prevailed in the courts as well. Of more than 200 tort claims filed on behalf of individual smokers between the mid-1950s and the early 1990s, not a single lawsuit succeeded. Tort litigation against the tobacco industry seemed to be dead. In a first wave of litigation, which began in the 1950s, the companies successfully argued that, absent a foreseeable risk of harm, consumers must bear the risks of using nondefective products. In the second wave, which began in the early 1980s, the industry successfully argued that smokers continued to smoke even with knowledge of the associated health risks (Rabin 1993). The industry message that smoking was an individual choice—indeed, a right—and that others had no business depriving smokers of that pleasure resonated powerfully within American society. Even as antismoking forces were gathering steam and public knowledge of the dangers of smoking was high, smoking was widely seen as a personal decision, even if it was a self-destructive one. For those who were not smokers or tied to the tobacco industry, it could be a justification for steering clear of the controversy over smoking. As the remainder of this chapter reveals, however, new and increasing concerns about the health consequences of tobacco use would soon begin to reshape public opinion regarding smoking. The Campaign Against Secondhand Smoke Research about the harmful effects of secondhand smoke began to emerge in the 1970s. As nonsmokers sought to assert their right to a smoke-free environment, they introduced a new justification for tobacco control.

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Ending the Tobacco Problem: A Blueprint for the Nation Eventually, this movement would weaken the claims of smokers’ rights and transform public perceptions and the tobacco policy debate. In the end, this shift also played a major role in reducing smoking altogether by changing social norms and helping smokers quit or reduce smoking. Early research on secondhand smoke left many uncertainties about the nature and scope of the risk that tobacco smoke posed to nonsmokers, and specific scientific findings supporting nonsmokers’ rights claims did not emerge until the late 1980s. However, public health officials and grassroots antismoking groups—particularly the Group Against Smokers’ Pollution, or GASP, founded in 1971—did not wait. They embraced the early indications that smoking could harm nonsmokers, while locating their campaign for smoke-free environments in the context of a broader environmental protection movement along with a growing consumer health consciousness (Bayer and Colgrove 2002). The 1972 Surgeon General’s report (HEW 1972) noted the potential hazards of secondhand smoke. By the mid-1970s, government at all levels and private companies were beginning to respond to calls for smoke-free areas. In 1973, domestic airlines were required to have a no-smoking section, and a year later smoking was restricted on interstate buses. Much of the action was taking place at the state and local levels. In 1973, Arizona became the first state to create smoke-free public places; in 1974, Connecticut became the first state with a law restricting smoking in restaurants; and in 1975, Minnesota became the first state to have a comprehensive workplace smoking ban (DHHS 2000). The tobacco industry tried to focus attention on the lack of definitive data about the risks of secondhand smoke, but the threat to nonsmokers had caught the attention of the media and the public. By the late 1970s, a Roper poll commissioned by the Tobacco Institute found that almost 60 percent of respondents believed that smoking was probably harmful to nonsmokers, and even 40 percent of smokers agreed that their smoking probably endangered others (The Roper Organization Inc. 1978). The campaign against secondhand smoke continued to gain momentum in the 1980s, with states and localities passing a variety of restrictions on smoking in public places. By 1986, 41 states and the District of Columbia had statutes restricting smoking (Bayer and Colgrove 2002). That year, reports from the National Academy of Sciences and the Surgeon General contributed to the sense of urgency about secondhand smoke. The report by the National Academy’s National Research Council stated that secondhand tobacco smoke increases the risk of lung cancer in nonsmokers by 30 percent and is harmful to children (NRC 1986). Surgeon General C. Everett Koop’s 1986 report (DHHS 1986), Health Consequences of Involuntary Smoking, acknowledged the limitations of the data but called for immediate measures to protect nonsmokers.

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Ending the Tobacco Problem: A Blueprint for the Nation Congress banned smoking on all airline flights of 2 hours or less in 1987, and 3 years later effectively extended that prohibition to all domestic flights. Smoking was also banned in federal buildings and in child care facilities that received federal funds. The 1992 release of the Environmental Protection Agency’s landmark report, Respiratory Health Effects of Passive Smoking: Lung Cancer and Other Disorders, added to the momentum for smoke-free spaces (EPA 1992). The report concluded that secondhand smoke is a Class A carcinogen, meaning that it is a definite cause of human cancer. According to the Environmental Protection Agency report, secondhand smoke causes some 3,000 deaths from lung cancer a year among nonsmokers. Secondhand smoke gave new momentum to the efforts of tobacco control advocates, setting the stage for a fundamental shift in the political dynamic of tobacco control and in the public discourse and understanding of tobacco control efforts during the last decade of the 20th century. ADVANCES IN TOBACCO CONTROL: 1988–2005 The tobacco control movement coalesced around the secondhand smoke issue, which turned out to be only the first of several issues to pose unprecedented challenges to commercial tobacco interests. While the science on the adverse effects of secondhand smoke continued to emerge, a second scientific front opened to counter the industry focus on freedom of choice: advances in neuroscience demonstrated that nicotine is a highly addictive drug. This finding permanently transformed the debate about smoking and reshaped the public policy agenda. The emphasis on addiction also cast smoking among adolescents and youth in a new light and stimulated a third front in the tobacco wars. Nicotine: An Addictive Drug Historically, the term addiction has been associated with stereotypical images of compulsive drug use, deviance, and criminality; heroin has been viewed as the prototypical addictive drug in the United States (HEW 1964). Beginning in the mid-1960s, however, scientific criteria for addiction (often labeled “drug dependence”) have emphasized the hallmark behavioral features of drug use, including a loss of control, and experts in the field have attempted to disassociate the clinical condition itself from the social and moral connotations and images traditionally linked with the term addiction. Equally important have been the major advances in neuroscience research that have identified the neurobiological substrates of addiction (IOM 1996) (see Chapter 2). By the early 1980s, researchers reported that laboratory animals worked to acquire nicotine; this behavior is a hallmark of addiction to a substance.

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Ending the Tobacco Problem: A Blueprint for the Nation Studies also demonstrated nicotine’s psychoactive effects, another component of addiction. Brain mechanisms for behavioral reinforcement and compulsive use were characterized (IOM 2001). Epidemiological studies showing that large majorities of smokers had tried and failed to quit added to the evidence of addiction. The 1988 Surgeon General’s report (DHHS 1988), Health Consequences of Smoking: Nicotine Addiction, detailed how nicotine meets the criteria for an addictive drug, concluding that smokers smoke because they are addicted and that nicotine is the addictive agent. A growing number of scientific and medical organizations, including the World Health Organization, the American Medical Association, and the American Psychiatric Association, declared nicotine addictive or dependence producing. The medical consensus that nicotine is an addictive drug transformed the concept of smoking from a bad habit of weak-willed people to a patho-physiological process that produces compulsive behavior. Increasingly, scientific studies have documented the pharmacological and structural effects of nicotine on the nervous system, which ultimately leads to specifiable changes in the brain. The highly addictive nature of nicotine undermines the tobacco industry’s longstanding position that smoking is a “free choice” and, by drawing attention to the similarities between tobacco addiction and addiction to other psychoactive drugs, establishes the empirical and ethical foundation for more aggressive regulation. Although the FDA regulates nicotine patches and other nicotine-containing products used as aids for smoking cessation, FDA commissioners had traditionally declined to assert any jurisdiction over cigarettes. In the late 1980s, Scott Ballin, director of the Coalition on Smoking OR Health, petitioned the FDA to regulate low-tar cigarettes and the new smokeless brand Premier on the basis of their implied health claims that these products are less harmful than ordinary cigarettes (Kessler 2000). In response to the petition, FDA Commissioner David Kessler decided to explore a broader regulatory approach than one based on the “implied health claims” associated with low-tar cigarettes. In 1991, he created a team of FDA lawyers, scientists, and policy makers to study the policy implications of the finding that nicotine is an addictive drug. In particular, they explored whether the FDA could regulate nicotine under the Federal Food, Drug, and Cosmetic Act (Kessler 2000). The statutory definition of drugs under the FDA law refers to “articles (other than food) intended to affect the structure or any function of the body.” Kessler’s team would spend the next several years documenting both that nicotine affects the structure or function of the body and that the tobacco industry intends it to have that effect. The phrase “intended to” required evidence that nicotine was not merely an unavoidable component of tobacco but was also an ingredient that cigarette makers intended to

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Ending the Tobacco Problem: A Blueprint for the Nation Figure 3-3). Although the momentum generated by the last four decades of tobacco control is unlikely to be erased altogether, these projections do show that a weakened commitment to tobacco control will affect millions of lives; and the model does not take into account new smoking fads, other changes in demand, or industry innovations. In Chapter 1, the committee observed that the patterns and trends of tobacco use differ substantially in different regions and states and that these differences arise to some extent from differences in the nature and the intensity of tobacco control activities. To depict the range of possible outcomes, the System Dynamic Model was used to project what would happen to smoking prevalence if, over the next 4 years (by 2010), the entire country’s smoking initiation rates rose and smoking cessation rates fell to match those prevailing in Kentucky, the state with highest smoking prevalence, in 2005. If this were to occur, national smoking prevalence could rise—and could rise substantially, to 23.5 percent by 2025, an increase of approximately 11 million smokers. It is unlikely that tobacco control initiatives throughout the country would lose ground so quickly, but this calculation graphically makes the point that the inertial continuation of past trends should not be taken for granted. The committee also used the System Dynamic Model to estimate the changes in smoking prevalence that would occur if the country were to reach Kentucky’s 2005 smoking initiation and smoking cessation levels in 2015 and 2020, scenarios that are more realistic. As shown in Figure 3-4, the results were equally disturbing: even imagining that it would take 15 years for smoking initiation and smoking cessation rates to reach Kentucky’s levels, the model predicts that there would be more than 17 million more smokers by 2025 than under the status quo scenario displayed in Figure 3-5. FIGURE 3-3 Comparison of SimSmoke Model estimates of adult smoking prevalence (2005 to 2025) under the status quo and worst-case scenarios.

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Ending the Tobacco Problem: A Blueprint for the Nation FIGURE 3-4 System Dynamic Model estimated adult smoking prevalence assuming the U.S. matched the 2004 initiation and cessation rates of Kentucky by 2010, 2015, and 2020. Conversely, the committee wondered what would happen to overall national tobacco use prevalence if, over the next few years, tobacco control efforts intensified to the point that the entire country had initiation and cessation rates by 2010 that matched those of California in 2004. California was selected for this purpose because it is, to some extent, a model state with respect to both tobacco control policies and tobacco use. The projected trajectory is parallel to the national projection, but it plateaus at substantially lower levels, eventually reaching the 10 percent target of Healthy People 2010—albeit in 2050, almost two generations later than the 2010 milestone (Figure 3-6). Accordingly, there would appear to be substantial room for advances in tobacco control efforts to make a positive FIGURE 3-5 System Dynamic Model estimated adult smoking prevalence comparing Kentucky 2020 scenario with the status quo scenario.

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Ending the Tobacco Problem: A Blueprint for the Nation FIGURE 3-6 System Dynamic Model estimated adult smoking prevalence assuming the U.S. reaches California’s 2004 initiation and cessation rates by 2010. difference. The effects of intensified tobacco control activities are explored in Chapter 5. SUMMARY This chapter has documented the progress in building a strong foundation for state tobacco control activities that has been made over the last decade. However, there are genuine reasons for concern that the infrastructure for tobacco control is eroding while the tobacco industry’s efforts to promote and maintain demand are continuing to increase. The committee has tried to project the likely public health consequences of intensified or weakened investments in tobacco control compared with those of standing still. The good news is that even if tobacco control activities remain at present levels, smoking prevalence is likely to decline from 2006’s estimated 20.9 percent to a little less than 16 percent in 2025. As noted above, this continued decline will occur because of the system’s inertia: There are currently more middle-aged and older smokers than there would have been had their birth cohorts passed through the ages of tobacco initiation under higher tobacco prices and stronger tobacco controls. Over time, as those birth cohorts are replaced by aging younger cohorts who had lower rates of initiation, the prevalence of tobacco use will continue to decline. Shortly after 2025, however, the decline in prevalence appears likely to plateau at about 15 percent, well above the Healthy People 2010 target of 12 percent. This steady-state scenario should be compared with a worst-case scenario, based on a weakening of tobacco control policies and programs.

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Ending the Tobacco Problem: A Blueprint for the Nation If a significant retrenchment occurred, the projected smoking prevalence in 2025 would be about 17 percent, resulting in approximately 4 million more people smoking than would otherwise occur. Although the momentum generated by the last four decades of tobacco control is unlikely to be erased altogether, these projections do show that a weakened commitment to tobacco control will affect millions of lives; and the model does not take into account new smoking fads, other changes in demand, or industry innovations. Finally, the committee projected the likely effect on overall national tobacco use prevalence if, over the next few years, tobacco control efforts intensified to the point that the initiation and cessation rates for the entire country were equivalent to those for California in 2004. The projected trajectory is parallel to the national projection, but it plateaus at substantially lower levels, eventually reaching 10 percent—albeit in 2050, almost two generations from now. With these projections in mind, the committee considered what steps should be taken, not only to solidify progress already achieved and prevent backsliding, but also to set the country on a sure course for reducing tobacco use substantially by 2025. Part Two of the report presents the committee’s “Blueprint for the Nation.” REFERENCES Aguinaga-Bialous S, Glantz SA. 1999. Arizona’s tobacco control initiative illustrates the need for continuing oversight by tobacco control advocates. Tobacco Control 8(2):141-151. ALA (American Lung Association). 2005. State of Tobacco Control: 2005. New York: American Lung Association. ALA. 2006. American Lung Association Says More State Taking Strong Action to Protect Citizens From Tobacco Use. Web Page. Available at: http://www.lungusa.org/site/apps/nl/content3.asp?c=dvLUK9O0E&b=40408&ct=2059325; accessed July 24, 2006. American Legacy Foundation. 2003. American Legacy Foundation Calls Lorillard Plan to Tie Up Funding Unwarranted And Harmful. Web Page. Available at: http://www.americanlegacy.org/americanlegacy/skins/alf/display.aspx?CategoryID=160386b2-d43a-4f67-890a-98e135a8ee6c&ObjectID=ab6fa256-833a-4d26-9f57-a3d8019874a8&Action=display_user_object&Mode=user&ModuleID=ad3a024a-b2d6-4593-874f9-b66136bc614; accessed July 21, 2006. ANR (Americans for Nonsmokers’ Rights). 2004. Preemption: Tobacco Control’s #1 Enemy. Berkeley, CA: Americans for Nonsmokers’ Rights Foundation. AP (Associated Press). 2000, February 29. Phillip Morris open to tobacco regulation. USA Today. AP. 2005, July 27. Vermont: State Files Suit Against Tobacco Company. The New York Times. Bayer R, Colgrove J. 2002. Science, politics, and ideology in the campaign against environmental tobacco smoke. American Journal of Public Health 92(6):949-954. Borio G. 1993. Tobacco Timeline. Web Page. Available at: http://www.tobacco.org/resources/history/Tobacco_Historynotes.html; accessed August 4, 2006.

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Ending the Tobacco Problem: A Blueprint for the Nation PART II A BLUEPRINT FOR REDUCING TOBACCO USE

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