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The phenomenal increase in tobacco use over the course of the 20th century was finally reversed in the wake of the publication of the Surgeon General’s important report in 1964. The data reviewed in this chapter suggest that the gradual decline in tobacco use since 1965 can be divided into two phases, the first running from 1965 to about 1980 and the second running from 1980 to the present. During the initial period, there was a sharp decline in smoking prevalence, accompanied by a modest increase in the average number of cigarettes smoked per day by smokers. Since then, however, the continued decline in smoking prevalence has been accompanied by a substantial decline in cigarettes smoked per day among those who smoke. As will be explained in Chapters 3 and 5, the committee believes that a substantial portion of the declines in smoking prevalence and smoking intensity over the past 25 years is attributable to tobacco control interventions, especially price increases and the emergence of a strong antismoking social norm.

In the committee’s opinion, the data suggest that the Surgeon General’s 1964 report and the dissemination of information on the adverse health effects of smoking had a strong impact on smoking prevalence. However, industry efforts to respond to the health threat of smoking by promoting filtered and so-called “light” cigarettes tended to counteract the effects of antismoking messages and to sustain smoking by those who smoked the most heavily. This interpretation would explain the increase in smoking intensity during this initial phase of tobacco control activity. During the second phase of tobacco control efforts, however, the tobacco industry’s dominance of the playing field was finally challenged by strong advocacy at the local and state levels and by significant increases in price. These efforts not only sustained the downward trend in prevalence but also helped to cut down on the intensity of smoking among a significant portion of smokers.

If this overall interpretation is correct, it suggests that continued implementation of strong tobacco control interventions will be needed to sustain progress. However, it also tends to highlight some important warning signs. First, tobacco control efforts will need to address the needs of a residual population of smokers who are particularly difficult to influence (e.g., smokers with mental illness). Second, a disturbing increase in later-onset, less frequent smoking by 18- to 25-year-olds could portend a growing cohort of new smokers who may be overlooked by traditional prevention programs for teens and by traditional cessation programs developed for older smokers. Finally, the volatile and frequently high rate of initiation of smoking among teens poses a continuing obstacle to society’s long-term goal of reducing the public health burden of tobacco use.

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