Promoting Health Intervention Strategies from Social and Behavioral Research (2000) / Chapter Skim
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Paper Contribution K: The Need for, and Value of, a Multi-Level Approach to Disease Prevention: The Case of Tobacco Control
Paper Contribution K: The Need for, and Value of, a Multi-Level Approach to Disease Prevention: The Case of Tobacco Control
Pages 417-449
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From page 417... ...
2Throughout this paper, phrases such as "cigarette smoking" and "tobacco consumption" are used reasonably interchangeably. Unless the context dictates otherwise, the reader should interpret references to smoking as applying generally to other forms of tobacco consumption as well.
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From page 418... ...
Despite a rising population, total cigarette consumption in the United States has fallen from 633 billion cigarettes in 1981 to 479 billion in 1997. Adult per capita cigarette consumption a common measure of consumption that adjusts for population growth has fallen almost annually since 1973 (Tobacco Institute, 1998~.
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From page 419... ...
In the absence of the then-new knowledge about the dangers of smoking, and the publicizing of this knowledge that constituted the heart of the early antismoking campaign, smoking prevalence almost certainly would have continued to climb, reflecting the rapid rise of smoking rates among women. It is certainly plausible, even probable, that total smoking prevalence would have exceeded 50% by the end of the 1960s or early 1970s.
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From page 420... ...
Rarely inhaled deeply and frequently, these forms of tobacco consumption, although hazardous to health, posed only a minor risk compared to that which would become associated with cigarette smoking. In 1913, Camel cigarettes introduced the "American blend" of tobaccos, a combination of flavorful tobaccos imported from Turkey and Egypt with milder American tobaccos that permitted deep inhalation for the first time.
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From page 421... ...
By the 1940s, women were beginning to smoke in large numbers. Indeed, it is striking to note that four 10-year birth cohorts of women, those born from 1901 to 1940, all reached their rates of peak smoking prevalence within the single five-year period 1958-1963.
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From page 422... ...
, the gap between the two genders has declined gradually over time. Racial and ethnic differences in smoking prevalence are substantial, ranging from 16.9% for Asians and Pacific Islanders to twice as much, 34.1%, for American Indians and Alaskan Natives.
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From page 423... ...
In the older ages, differential death rates for smokers and nonsmokers account for a significant fraction of the prominent decrease in smoking prevalence (Harris, 1983~. Smoking cessation, the principal determinant of the decline in prevalence with age, rises significantly with age.
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From page 424... ...
The NHIS data indicate that close to a fifth of all smokers do not smoke every day. Although multiple possible explanations come to mind, there is widespread agreement that the "clean indoor air" movement, prohibiting smoking in many public places and workplaces, likely has redefined smoking for a subset of smokers.
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From page 425... ...
. The youth prevention orientation has evolved in large part as a political strategy: preventing smoking by kids is a nearly universally lauded objective, even the tobacco industry pays lip service to this goal (Brown and Williamson, 2000, Philip Morris, 2000, R.J.
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From page 426... ...
Federal cigarette excise tax increase proposals are labeled, successfully, as ruinous and unfair "tax-and-spend" government "business as usual." Restrictions on cigarette advertising are an affront to First Amendment protections of commercial speech. Clean indoor air laws assault Americans' basic liberty rights, and the right and obligation to give "common courtesy" a chance to work first (Advocacy Institute, 1998~.
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From page 427... ...
These experts are pondering the possibility of finding effective harm reduction strategies that fall short of smokers' completely renouncing their dependence on nicotine. The interest in harm reduction derives from frustration with the slow pace of smoking cessation only 3% of smokers quit each year and the emergence of a plethora of new nicotine delivery technologies, produced by both the tobacco and the pharmaceutical industries.
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From page 428... ...
Tax increases clearly discourage children from smoking and reduce smoking by adults as well. Prohibitions on smoking in public places clean the air for nonsmokers, decrease smoking prevalence and daily consumption among ongoing smokers, and help to establish and reinforce a nonsmoking social norm.
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From page 429... ...
Warning labels on cigarette packs and ads are intended to inform about dangers and, implicitly, to discourage use.
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From page 430... ...
Education and persuasion remain a core approach in youth prevention, as reflected in the new multimillion-dollar media campaign launched by the American Legacy Foundation in January 2000. Raising cigarette excise taxes, Good general references on this subject are the TOM report Growing Up Tobacco Free (Lynch and Bonnie, 1994)
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From page 431... ...
More encouraging, at least in the short run, have been media counteradvertising campaigns. In California, Massachusetts, Arizona, and Florida, well-funded media campaigns have caught the attention of young people and been followed by youth smoking rates that either declined or failed to rise at the rate experiencednationally through much of the l990s (Popham et al., 1994, Florida Dept.
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From page 432... ...
Despite these uncertainties, the overall strength of the evidence supporting the proposition that higher prices reduce youth smoking led a group of economists who had substantial experience working on tobacco economic issues to call for increased cigarette taxation primarily to reduce youth smoking (Warner et al., 1995~.9 Interest in taxation as a means of combating youth tobacco use followed the early emphasis on education. The latest addition to the youth prevention armamentarium is policy oriented toward reducing youth access to tobacco products at retail outlets.
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From page 433... ...
In concluding this examination of youth prevention efforts, and as a natural segue into the next section's discussion of adult smoking cessation, it is important to recognize a new frontier in tobacco control, one so new that there is insufficient literature to review: youth smoking cessation. Traditionally, youth and adult smoking concerns have been neatly distinguished as prevention and cessation, respectively (excluding, of course, exposure to environmental tobacco smoke an issue for all age groups)
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From page 434... ...
Adult Smoking Cessation If preventing youth smoking is necessary to breaking the generational transmission of nicotine addiction, speeding up the pace of adult smoking cessation is vital to reducing the disease toll of smoking in the foreseeable future. Even if prevention of youth smoking succeeded completely, in all countries of the world, starting today that is, not another child ever started to smoke the tragic milestone of 10 million annual global tobacco-produced deaths three decades from now will still be realized.
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From page 435... ...
That is the hope and expectation of Canadian tobacco control activists who have worked long and hard for plain packaging and large warning labels (Kennedy, 2000~. Judging intervention effectiveness by the percentage of those exposed who succeed in quitting, one must rank many formal smoking cessation programs, including medically directed treatments, as among the most effective weapons in the cessation arsenal (U.S.
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From page 436... ...
Unlike the case for youth prevention, however, for which all categories of interventions are intended to reduce youth smoking, neither of the principal incentive and regulation interventions is explicitly intended to affect smoking rates among adults. Or at least proponents of these measures do not explicitly acknowledge reduction in adult smoking as their objective, although one suspects that many proponents harbor the hope and expectation that smoking prevalence will fall when the interventions are adopted.
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From page 437... ...
Evidence on the impacts of comprehensive tobacco control interventions on adult smoking prevalence is modest in quantity. Again, a major source of insight is provided by analyses of the experiences in California and Massachusetts, each of which has documented significant declines in smoking prevalence attributable to these states' campaigns (Harris et al., 1996, Goldman and Glantz, 1998~.
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From page 438... ...
In concluding consideration of the objective of adult smoking cessation, it seems critical to comment on the evidence on the changing demographic patterns of smoking since the inception of the antismoking campaign in 1964, because the numbers tell a compelling tale. Most notable is the change in smoking prevalence by education class.
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From page 439... ...
More than two decades ago, the tobacco industry was warned by its polling consultant, the Roper organization, that the issue of ETS, and the nonsmokers' rights movement it had spawned, posed the single greatest threat to the economic vitality of the industry (Roper, 1978~. In subsequent years, grassroots activists succeeded in getting numerous and increasingly strong clean indoor air policies adopted, initially at the state level and then, increasingly, at the level of local government.
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From page 440... ...
, and even control of gun violence (taxing guns and bullets, as proposed by Senator Moynihan tTax Treatment, 19943~. Research on the effects of clean indoor air laws, smoking cessation interventions, and other measures
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From page 441... ...
When confronting large and urgent public health problems, the lack of definitive science should never paralyze action. As discussed throughout this paper, the evidence on the impacts of many individual tobacco control interventions and on comprehensive programs as well falls short of the kinds of definitive insights that constitute the lifeblood of science.
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From page 442... ...
To take but one, adult smoking cessation has resulted from dissemination of information about the dangers of smoking, from increased excise taxes, from responses to media antismoking campaigns, and from participation in formal smoking cessation programs. Two important observations verge on truisms.
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From page 443... ...
A cigarette tax increase may push the smoker "over the top" toward successful quitting. And the elimination of tobacco billboards in 1999 may aid that former smoker's resolve to stay "quit." More generally, through specific interventions (such as clean indoor air laws)
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From page 444... ...
Lessons about the effectiveness of taxation in discouraging youth smoking, the potential of state-based lawsuits to generate tobacco control action, and the need for comprehensive multilevel tobacco control programs are shared, learned, and put into play with increasing regularity. The challenges posed by tobacco worldwide are immense and urgent.
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From page 445... ...
Putting out the f res: will higher cigarette taxes reduce youth smoking? Presented at the Annual Meetings of the American Economic Association, 1998.
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From page 446... ...
Harris JE, Connolly ON, Brooks D, et al. Cigarette smoking before and after an excise tax increase and an antismoking media campaign: Massachusetts, 1990-1996.
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From page 447... ...
A Study of Public Attitudes toward Cigarette Smoking and the Tobacco Industry in 1978.
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From page 448... ...
Cigarette smoking by socioeconomic group, sex, and age: effects of price, income, and health publicity. British Medical Journal 1994;309: 923-926.
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From page 449... ...
Warner KE, Murt HA. Impact of the antismoking campaign on smoking prevalence: a cohort analysis.
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