Chapter 1
Issues in Reducing Tobacco Use, Summary,
and Conclusions

Introduction 5

Development of the Report  5
Major Conclusions 6

Issues in Reducing Tobacco Use  6
Eliminating Disparities Related to Tobacco Use and Its Effects  12

Summary and Implications 22

Historical Review (Chapter 2)  12
Educational Strategies (Chapter 3)  12
Management of Nicotine Addiction (Chapter 4)  23
Regulatory Efforts (Chapter 5)  14
Advertising and Promotion 14
Product Regulation 15
Clean Indoor Air Regulation  16
Minors' Access to Tobacco  16
Litigation Approaches 17
Overview and Implications 28
Economic Approaches (Chapter 6)  18
Comprehensive Programs (Chapter 7)  20
A Vision for the Future-Reducing Tobacco Use in the New Millennium (Chapter 8)  2

Chapter Conclusions 22
Chapter 2. Historical Review 22
Chapter 3. Educational Strategies 22
Chapter 4. Management of Nicotine Addiction  22
Chapter 5. Regulatory Efforts 22
Advertising and Promotion 22
Product Regulation 23
Clean Indoor Air Regulation  23
Minors' Access to Tobacco  23
Litigation Approaches 23
Chapter 6. Economic Approaches 24
Chapter 7. Comprehensive Programs 24

References 25


Reducing Tobacco Use

Introduction

What works?

  It would be a boon if the answer were as easy to
state as the question. Programs to reduce the use of
tobacco have a long history in the United States and in
other countries, and the accumulated experience has
provided considerable empirical understanding of the
prospects and pitfalls of such efforts. Rigorous answers
to formal evaluation questions are difficult to obtain,
however, in part because of the wide variety of influ-
ences that are brought to bear on the use of tobacco.
Researchers have little control over many of these
influences and are only beginning to learn how to
measure some of them.

  Nonetheless, a substantial body of literature
exists on attempts to reduce the use of tobacco. This
report provides an overview of the major modalities
that have been studied and used intensively, and it at-
tempts, where possible, to differentiate their techniques
and outcomes. The report also attempts a more diffi-
cult task: to provide some qualitative observations
about how these efforts interact. The report is thus a
prologue to the development of a coherent, long-term
policy that would permit these modalities to be used
as effectively as possible.

Development of the Report

  This report of the Surgeon General was prepared
by the Office on Smoking and Health, National Cen-
ter for Chronic Disease Prevention and Health Promo-
tion, Centers for Disease Control and Prevention
(CDC), U.S. Department of Health and Human Ser-
vices, to report current information on the health ef-
fects of cigarette smoking and smokeless tobacco use.
Previous reports have dealt with some of the issues
included in this report, but a composite assessment of
efforts to reduce tobacco use is a new topic for this
series. However, the current report must acknowledge
the considerable contributions of three prior mono-
graphs: Growing Up Tobacco Free, a report of the Insti-
tute of Medicine (Lynch and Bonnie 1994), Healthy
People 2000: National Health Promotion and Disease Pre-
vention Objectives, and Healthy People 2010, an ongoing
work of the Office of Health Promotion and Disease
Prevention (U.S. Department of Health and Human
Services [USDHHS] 1991,200O).

  The current report is the result of the work of
16 experts in the field of reducing tobacco use who
contributed initial drafts in major chapter areas. The
chapters were reviewed separately by some 60 re-
searchers and public health workers whose expertise
was specific to particular subject areas. After revision,
a preliminary draft volume was reviewed by an addi-
tional 40 experts, including representatives of the in-
stitutes and agencies within the Department of Health
and Human Services that have special interests in re-
ducing tobacco use.

  Several concerns guided preparation of the re-
port. First, it was clear that the primary countervailing
influence against reducing tobacco use is the effort of
the tobacco industry to promote the use of tobacco
products. Although this report was not conceived as
a documentation of such industry efforts, repeated
reference to them is necessary to underscore the diffi-
culties both in achieving desired outcomes and in
evaluating the effectiveness of efforts to reduce the use
of the industry's products. Second, the report has at-
tempted to present the wide variety of techniques and
methods used for tobacco control, but the disparate
methods make comparisons difficult. The result is
more a menu than a cookbook-a set of activities, as
outlined in Chapter 7, whose combination depends on
specific circumstances and the context in which they
are undertaken. Third, a result of this methodological
diversity is that rigorous evaluation of the ways in
which tobacco reduction efforts interact remains part
of the unfinished research agenda. Although interac-
tion of interventive efforts is noted several places in
the report (see, for example, the discussion of the in-
teraction of school education with community-based
programs in Chapter 31, such demonstration of syn-
ergy has been elusive.

  Finally, during the report's preparation, a cascade
of legal and legislative events substantially changed
the landscape where the diverse efforts to reduce to-
bacco use take place. Several legal rulings, still under
adjudication, and the Master Settlement Agreement
between states and the tobacco industry to recover
costs of government programs have altered prospects
for reducing tobacco use through large-scale social
maneuvers. Many of these issues are still unresolved,
and they are likely to influence activities in the com-
ing years.

issues in Reducing Tobacco Use  5


Major Conclusions

1.  Efforts to prevent the onset or continuance of to-
  bacco use face the pervasive, countervailing in-
  fluence of tobacco promotion by the tobacco
  industry, a promotion that takes place despite
  overwhelming evidence of adverse health effects
   from tobacco use.

2.  The available approaches to reducing tobacco
  use-educational, clinical, regulatory, economic,
  and comprehensive-differ substantially in their
  techniques and in the metric by which success
  can be measured. A hierarchy of effectiveness is
   difficult to construct.

3.  Approaches with the largest span of impact (eco-
  nomic, regulatory, and comprehensive) are likely
  to have the greatest long-term, population im-
  pact. Those with a smaller span of impact (edu-
  cational and clinical) are of greater importance
  in helping individuals resist or abandon the use
   of tobacco.

4.  Each of the modalities reviewed provides evi-
   dence of effectiveness:

. Educational strategies, conducted in conjunc-
tion with community- and media-based
activities, can postpone or prevent smoking
onset in 20 to 40 percent of adolescents.

o Pharmacologic treatment of nicotine addic-
tion, combined with behavioral support, will
enable 20 to 25 percent of users to remain ab-
stinent at one year posttreatment. Even less
intense measures, such as physicians advising
their patients to quit smoking, can produce
cessation proportions of 5 to 10 percent.

o Regulation of advertising and promotion, par-
ticularly that directed at young people, is very
likely to reduce both prevalence and uptake
of smoking.

o Clean air regulations and restriction of minors'
access to tobacco products contribute to a
changing social norm with regard to smoking
and may influence prevalence directly.

o An optimal level of excise taxation on tobacco
products will reduce the prevalence of smok-
ing, the consumption of tobacco, and the long-
term health consequences of tobacco use.

6 Chapter 1

The impact of these various efforts, as measured
with a variety of techniques, is likely to be un-
derestimated because of the synergistic effect of
these modalities. The potential for combined
effects underscores the need for comprehensive
approaches.

State tobacco control programs, funded by excise
taxes on tobacco products and settlements with
the tobacco industry, have produced early, en-
couraging evidence of the efficacy of the com-
prehensive approach to reducing tobacco use.

Issues in Reducing Tobacco Use

  Two themes have permeated the history of to-
bacco use in the United States. First, and most obvi-
ously, tobacco is an extraordinary economic fuel, and
its powerful economic impact comes into direct con-
flict with its vast social costs. Second, antitobacco ac-
tivity has a continuous history characterized by waxing
and waning and by a changing mix of motivations and
strategies. These two themes are inextricably linked,
and their interaction provides a backdrop for current
efforts to reduce tobacco use.

  Such efforts take place in a complicated context.
Chronic diseases have largely replaced infectious pro-
cesses as the leading causes of death during the 20th
century (Rothenberg and Koplan 1990). But this re-
placement has occurred during a period of remark-
able gains in life expectancy. Mortality is now less than
half of what it was in 1900. The single most important
risk associated with the leading chronic diseases is
cigarette smoking; the evidence for that statement fills
volumes of Surgeon General's reports on smoking and
health, and these volumes are merely summaries of a
massive literature. Since the first of these reports in
1964, the prevalence of smoking has declined by nearly
half, and it is clear that the declining use of tobacco
has contributed to the observed decline in mortality.
But paradoxically, as life expectancy increases, an in-
creasing proportion of deaths are caused by the chronic
diseases associated with smoking-primarily cancer,
cardiovascular disease, and emphysema. This inter-
play raises key questions.

  First, does the current smoking prevalence of
about 25 percent represent a remarkable public health
success, or is it evidence of continuing failure? The
answer is yes to both questions. Health advocates can
be both pleased with overall trends and loathe to de-
clare success for a job unfinished, because goals and
standards change with evolving efforts to reduce to-


bacco use. If the worldwide public health response to
smallpox can be used as an analogy, the control pro-
gram reached a point at which a single case was
deemed unacceptable.

  Second, why has the decline in smoking preva-
lence been slow? In the face of voluminous evidence
about adverse health effects, prevalence has declined
sluggishly (an average of about 0.5 percent per year
since the mid-1960s). Currently, the decline exhibits
epidemiologic signs of pausing in its downward tra-
jectory, and it has even reversed in some population
subgroups. There is no single, facile explanation for
the persisting practice of tobacco use. If rationality
were the only force at work, tobacco use would have
been abandoned long ago. But as is shown in Figure
1.1, the forces that can be brought to bear on current
or potential smokers are more complex and subtle than
the mere awareness that smoking is harmful to one's
health. A young person on the threshold of deciding to
smoke may be subject to various influences, including
the existence or nonexistence of targeted health educa-
tion programs that discourage smoking, as well as of
restrictions on access to cigarettes and a variety of regu-
lations that determine the content and packaging of the
product. Widespread and local norms, affecting this
young person in the form of peer pressure, perceived
smoking prevalence, and the commercial presentation
of tobacco products, can affect the decision either way.
The cost of cigarettes is likely to have significant influ-
ence on a young person, and other economic policies-
largely unseen by the potential smoker-can affect the
outcome. Personal psychosocial factors undoubtedly

Figure 1.1. Influences on the decision to use tobacco

Antitobacco                                     Protobacco

Health education
Economic policy
Minors' access
Product regulation

Reducing Tobacco Use

play a role and are likely to interact with these other
influences. Arrayed among and against such factors
are the variety of conduits-also largely unseen by
the current or potential smoker-through which the
influences of the tobacco industry are manifested: use
of advertising and promotion to alter perceived social
norms, alteration or prevention of legislation that
would inhibit smoking, legal mechanisms to influence
regulation, political mechanisms to influence economic
policy, and countereducation that can serve to encour-
age the uptake of smoking.

  Whatever the precise interplay of these influences,
the net result has been a slower decline than would be
warranted by awareness of the well-publicized public
health threat that smoking poses. The forces that have
tried to accelerate the decline may be thought of col-
lectively as "interventions," although the term, in a
more narrow sense, is often reserved for circumscribed,
planned, and measurable activities. Many of the ma-
neuvers described in this report do not meet the nar-
rower definition, but all share the common
characteristic of being directed toward a reduction in
tobacco use. With a broader definition in mind,
Ramstrom (1995) has classified tobacco interventions
by the point they affect on the spectrum of tobacco
use. These classifications, depicted in Figure 1.2, are
creating a nonsmoking norm, reducing stimuli to
smoke, strengthening motivation to quit, and reduc-
ing impediments to quitting. Although the conceptu-
alization is useful, a line could legitimately be drawn
from each box to any other box in Figure 1.2, as these
activities are all intimately tied to each other in both

Clean indoor air regulation
Social advocacy
Personal litigation
Advertising restrictions
Promotional restrictions

__-----------
A current !
   smoker  :-
             I
I------------a

_____--------

Widespread social norms             A former
Local community norms t+   smoker / :-
Behavioral treatment                 I ____ -- ------ 2

Pharmacologic treatment  I

I

Psychosocial factors
Peer pressure
Industry influence
Perceived social norms
Advertising
Promotion
Legislation
Regulation
Economic policy
Education


Surgeon General's Report

process and outcome. To borrow from the language
of statistics, the main effects of these efforts may be
much less important than their interactions, both with
each other and with the counterinfluences of the to-
bacco industry.

  The result is a considerable challenge for evalua-
tion. Suppose the young person in Figure 1.1 "decides"
not to smoke, or the current smoker quits. Attribution
of cause to this outcome in individual cases is highly
unlikely. The totality of such decisions-which leads
to a decline in prevalence-poses similar problems of
attribution. Although the epidemiologic methods ex-
ist, data are rarely available to make attributive judg-

Figure 1.2. Overview of relationships among interventions

men&. The challenge of evaluating these separate ef-
forts and strategies results from their disparate   na-
ture and the type of metric that may be appropriate to
their evaluation (Table 1 .l).

  Management of nicotine addiction (Chapter 4),
for example, is usually studied by using standard
epidemiologic study design-often a prospective
comparison of a study group and a control group-
and the effect is measured by some form of the rela-
tive or attributable risk statistic. Educational strategies
(Chapter 3), like other behavioral studies, may use
similar statistics but usually invoke a different set of
confounding factors to be considered; sorting out

Reduce morbidity
and mortality

Protect nonsmokers'
health and rights

Manage nicotine
Manage nicotine            Create a smoke-free
                     Create a smoke-free
addiction
addiction                   environment
                          environment

Prevent smoking
Prevent smoking
  uptake
  uptake

      Chapter
Health education 3,4
Economic policy 6
Smoke-free policy 5
Comprehensive 7
programs

      Chapter
Pharmacologic Rx 4
Behavioral Rx     4
Knowledge Rx     4
Attitude Rx      4

      Chapter
Health education 3
Economic policy 6
Product regulation 5
Smoke-free policy 5
Comprehensive 7
programs
Personal litigation 5

       Chapter
Advertising restrictions 5
Promotion restrictions 5
Sales restrictions      4
Comprehensive       7
programs

Source: Adapted from RamstrGm 1995.

8 Chapter 1


Reducing Tobacco Use

Table 1.1. Characteristics of interventions

Type of
intervention

Targets

Tools

Study approaches

Outcome
measurements

Educational

Clinical

Regulatory

Economic

Social/Com-
prehensive

Children and adoles-
cents, usually in school
Administrative groups
(e.g., members of
health maintenance
organizations)
General population
Health care providers

Persons who smoke,
usually in a health care
setting

General population
of smokers in a
commercial or quasi-
commercial setting

Product manufacture

Product sale

Vendors and buyers

Public venues

Public transportation

Worksites

Health care sites

Taxes

Tariffs and trade

Price supports

Legislators

Media

Communication
networks

Case-by-case strategy
State/local programs

School curricula

Interactive training
Targeted services

Mass media

Pharmacologic     Epidemiologic and
methods          behavioral:

Behavioral
modification

Reinforcing
environment

o Usually a comparison
of "treatment" and "no
treatment" groups
o Control of confounding
by behavioral and
demographic variables

Local ordinance

State regulation
Federal regulation

Federal law

Nongovernment
action (e.g., joint
commission
accreditation of
hospital organization)

Local ordinance

State regulation
Federal regulation

Federal law

International
agreements

Media advocacy
Direct advocacy
Community
interventions
Countermarketing
Regulation
Policy formation

Epidemiologic and
behavioral:

o Usually a comparison
of "treatment" and "no
treatment" groups

o Control of confounding
by behavioral and
social variables

Observational
Knowledge/attitude/
practice studies

Surveillance

Case study

Econometric analysis
Trend analysis

Multivariate models

Relative risk

Attributable
risk

Effect size
(absolute or
relative)

Relative risk

Attributable
risk

Effect size
(absolute or
relative)

Linear trend

Cross-sectional
comparison of
proportions
Case analysis
results

Linear trend

Parameter
estimates (e.g.,
elasticities)

Observational

Case study
General epidemiologic
methods

Trend analysis
Knowledge/attitude/
practice studies

Linear trends

Case study
analysis

Cross-sectional
comparisons

Issues in Reducing Tobacco Use  9


Surgem Gelreral's Report

the relative influence of such factors often requires
complex multivariate procedures. Regulatory efforts
(Chapter 5) are frequently evaluated after the effect
(with a pre- and post-type of study design) or are
evaluated according to ecological correlations with
changes in epidemiologic trends. Economic measures
(Chapter 6) depend for their evaluation on economet-
ric information-that is, on administrative data sets
and survey results that are subjected to correlation and
trend analysis. Finally, comprehensive program strat-
egies are often evaluated using surveillance data sys-
tems, trend analyses, and case studies.

  In each instance, some form of evaluation is pos-
sible, but the ability to connect the intervention to the
outcome differs greatly among these efforts, as does
the ability to estimate impact. Theoretically, it might
be possible to associate each effort with some pre-
sumed number of persons who start smoking or some
number who quit, but to do so would usually require
numerous assertions and assumptions. For example,
to estimate the number of persons who would benefit,
through prevention or cessation of smoking, from an
educational strategy, assumptions would be needed
about its generalizability to the U.S. population, the
variability of its impact, the use-effectiveness to which
it is put, the proportion of the population reached, and
the permanence of its effect. It is even more difficult
to create a set of assumptions for the impact of a regu-
lation that is promulgated in an environment of de-
clining prevalence and whose existence may depend
on the prior emergence of the very changes it wishes
to create. For example, a ban on smoking during
airline flights, a measure intended not only to protect
nonsmokers from environmental tobacco smoke (ETS)
but also to promote a norm of nonsmoking, was pos-
sible only in an era when the dangers of ETS were
widely known and when the danger and discomfort
experienced by nonsmokers had begun to outweigh
the inconvenience, discomfort, and even social ostra-
cism experienced by smokers being subjected to such
restrictions. It is virtually impossible to link a social
strategy to a direct effect on prevalence, however suc-
cessful by other criteria. (Many would argue, quite
justly, that the impact measure of reducing prevalence
by reducing uptake and increasing cessation is not the
only outcome of interest. Unfortunately, proximal
process measures are even more variable among the dif-
ferent strategies, and the ultimate outcome measures-
morbidity and mortality-are too distal to easily
consider.)

  Without a common metric, the various types of
efforts to reduce tobacco use are difficult to compare
quantitatively, although several attempts have been

made (USDHHS 1998a; U.S. Department of the Treasury,
Office of Economic Policy, unpublished report, 1998). Per-
haps a more qualitative approach could be used. One
approach, illustrated in Table 1.2, would be to consider
the potential span of impact (the proportion of the
population, or population sectors) that the particular
effort can exercise in the context of a qualitative esti-
mate of its potential impact. Several examples of each
type of effort are presented, and a qualitative assess-
ment is made based on the data provided in the re-
port. The assessments in Table 1.2 are by no means
meant to be definitive but are meant to provide a
framework for approaching the difficult issue of rela-
tive effectiveness. Although some observers would
urge a more quantitative approach (e.g., using only
randomized controlled trials as a measure of effective-
ness), a number of effective modalities would likely
be falsely discredited. For example, advocacy activity
played a critical role in the formulation of the Food
and Drug Administration's (FDA's) policy regarding
regulation of tobacco products (see "Product Regula-
tion" in Chapter 5), yet linking that policy, or anteced-
ent advocacy work, directly to changing prevalence
would be difficult.

  In a qualitative assessment of relative impact, the
examples provide a basis for a hierarchy of activities,
but that hierarchy requires still another framework:
consideration of the entity conducting the activity (in-
dividual, nongovernment citizens group, nongovern-
ment agency, or government agency) and the
organizational level at which the activity is conducted
(local, state, national, or international). Thus, no single
set of rules is available for invoking these efforts to
reduce tobacco use, and relative efficacy depends on
the context in which an effort takes place. For example,
local efforts to reduce tobacco use might include regu-
latory ordinances (with potentially large impact on
many people), education programs in schools (smaller
impact on fewer people), and promotion of treatment
for nicotine addiction (targeting a still smaller group).
Specific local circumstances would dictate the specific
activities. The federal government would more likely
act to put in place economic measures and a variety of
regulatory efforts (both types of interventions having
very large span and size of impact), depending on the
specific political context.

  In summary, then, these efforts to reduce tobacco
use line up side by side and not in relative order. Their
use is predicated on the particular context in which
they are to operate. Because they all face the same
counterinfluence of the industry's tobacco promotion
(the right-hand side of Figure l.l), a reasonable case
can be made that the large-scale strategies (economic

10 Chapter 1


Reducing Tobncco Use

Table 1.2. Examples of a qualitative assessment of intervention impact

Type of intervention    Specific modality

Span of impact

Size of impact

Educational          School curriculum        Large              Moderate

                Mass media           Large              Small

Clinical         Pharmacologic             Small              Moderate

              Behavioral (alone)           Small          Very small

Regulatory          Product manufacture       Very large         Very large
                Product sale           Large           Large
                 Public venues           Large              Moderate

                Worksites            Large              Small

Economic           Taxation            Very large        Very large
                Tariffs and trade         Very large         Very large
Comprehensive programs Statewide programs       Large           Large
           Case-by-case strategy      Unpredictable       Unpredictable
Note: Examples use a five-point ordinal scale (very small, small, moderate, large, very large), with the additional
use of "unpredictable." (See text for the context for such assessment.)

and regulatory) have the greatest direct impact on that
barrier. But the context necessary for those large-scale
efforts to work depends on public attitudes and social
norms that must be influenced by other means.

  In the 199Os, it became increasingly apparent that
a public health success in reducing tobacco use requires
activity on all fronts. A comprehensive approach-one
that optimizes synergy from a mix of strategies-has
emerged as the guiding principle for future efforts to
reduce tobacco use. Such an approach makes moot the
issue of a hierarchy of interventions, since a compre-
hensive approach presupposes an interdependence of
the available strategies. A coordinated, cohesive in-
frastructure makes intuitive sense, since it permits a
modular approach to the interventions themselves, but
has been challenged on analytic grounds. In such a
framework, attribution of success to particular pro-
gram elements is difficult, and there is no experimen-
tal evidence (nor is there likely to be) that an approach
that is comprehensive is superior to one that is not.
Nonetheless, the 20th century's difficult experience
with tobacco control (as described in Chapter 2) and
the previous decade's success in changing social norms
and generating assets (as discussed in Chapter 7) lend

empirical credibility to the comprehensive approach.

Eliminating Disparities Related to Tobacco
Use and Its Effects

  The elimination of health disparities related to
tobacco use poses a great challenge to this nation. This
was not a main focus of the current report, because two
other recent, important publications have emphasized
the issue. The 1998 Surgeon General's report Tobacco
Use Among U.S. Racial/Ethnic Minority Groups (USDHHS
1998b) was the first to address the diverse tobacco con-
trol needs of the four major U.S. racial/ethnic minor-
ity groups-African Americans, American Indians and
Alaska Natives, Asian Americans and Pacific Island-
ers, and Hispanics. Hedthy People 2020 (USDHHS
2000) presents two overarching goals: increase qual-
ity and years of healthy life and eliminate health dis-
parities among different segments of the U.S.
population. Evidence reviewed in these two publica-
tions highlights the significant disparities that exist in
the United States. These publications also discuss the
critical need for a greater focus on this issue, both in
research and in public health action.

Issues ill Reducirlg Tobm-o Use  2 1


Summary and Implications

  In fact, each of the approaches described in this
report shows evidence of effectiveness. In some in-
stances, the synergism that might be expected through
interaction among these various efforts has been docu-
mented. The remainder of this chapter describes the
major findings and implications for each type of activ-
ity and presents the conclusions of the other chapters.

Historical Review (Chapter 2)

  The forces that have shaped the movement to
reduce tobacco use over the past 100 years are com-
plex and intertwined. In the early years (1880-1920),
antitobacco activity-some of it quite successful-was
motivated by moral and hygienic principles. After
important medical and epidemiologic observations of
the midcentury linked smoking to lung cancer and
other diseases, and after the subsequent appearance
of the 1964 report of the advisory committee to the
Surgeon General on smoking and health (USDHEW
1964), the movement to reduce tobacco use was fu-
eled by knowledge of the health risks that tobacco use
poses and by reaction against the continued promo-
tion of tobacco in the face of such known risks. De-
spite overwhelming evidence of adverse health
consequences of smoking, the stubborn norm of smok-
ing in the United States has receded slowly, in part
because of such continued promotion that works syn-
ergistically with tobacco addiction. Although strate-
gies have varied, health advocates have focused in
recent years on the prevention of harm to nonsmokers
and on the concept of smoking as a pediatric disease,
with the consequent need for protecting young per-
sons from forces influencing them to smoke.

Educational Strategies (Chapter 3)

  The design of educational programs for tobacco
use prevention and the methods used to evaluate them
have become increasingly refined over the past two
decades. Early studies tended to be confined to the
school context, to have short duration, and to be of
low intensity. Studies tended to focus on a single mo-
dality and to ignore the larger context in which pre-
vention takes place. The reported size, scope, and
duration of program effects have become larger in re-
cent reports. In particular, several large programs have
attempted a multifaceted approach that incorporates

22 Chapfu 1

other than school-based modalities. Improvements in
evaluation designs have increased confidence in the
validity of these reports. The pattern of consistency
across this group of large studies also provides assur-
ance that these effects can be achieved in a variety of
circumstances when programs include the critical
multiple elements that have been defined by this re-
search literature.

  To summarize the major findings, school-based
social influences programs have significant and sub-
stantial short-term impacts on smoking behavior.
Those programs with more frequent educational con-
tacts during the critical years for smoking adoption
are more likely to be effective, as are programs that
address a broad range of educational needs. These
effects have been demonstrated in a range of imple-
mentation models and student populations. The smok-
ing prevention effects of strong school programs can
be extended through the end of high school or longer
when combined with relatively intensive efforts di-
rected through other powerful channels, such as strat-
egies that vigorously engage the influences of parents,
the mass media, and other community resources.
These conclusions have been codified in national
guidelines for school programs to prevent tobacco use.

  Thus, an extensive body of research findings
document the most effective educational programs for
preventing tobacco use. This research has produced a
wide array of curricula, protocols, and recommenda-
tions that have been codified into national guidelines
for schools. Implementing guidelines could postpone
or prevent smoking onset in 20 to 40 percent of U.S.
adolescents. Unfortunately, existing data suggest that
evidence-based curricula and national guidelines have
not been widely adopted. By one set of criteria, less
than 5 percent of schools nationwide are implement-
ing the major components of CDC's Guidelines for
School Health Programs to Preveuf Tobacco Use and Ad-
dicfioir (CDC 1994). Almost two-thirds of schools (62.8
percent) had smoke-free building policies in 1994, but
significantly fewer (36.5 percent) reported such poli-
cies that included the entire school environment.

  Schools, however, should not bear the sole respon-
sibility for implementing educational strategies to
prevent tobacco use. Research findings, as noted, indi-
cate that school-based programs are more effective
when combined with mass media programs and with
community-based efforts involving parents and other
community resources. In addition, CDC's school health


Reducing Tobacco Use

guidelines and numerous Healthy People 2020 objectives
recognize the critical role of implementing tobacco-free
policies involving faculty, staff, and students and relat-
ing to all school facilities, property, vehicles, and events.
Although significant progress is still required, the cur-
rent evaluation base provides clear direction for the
amalgamation of school-based programs with other
modalities for reducing tobacco use.

Management of Nicotine Addiction
(Chapter 4)

  The management of nicotine addiction is a com-
plex field that continues to broaden its understanding
of the determinants of smoking cessation. Current lit-
erature suggests that several modalities are effective
in helping smokers quit. Although the overall effect
of such intervention is modest if measured by each
attempt to quit, the process of overcoming addiction
is a cyclic one, and many who wish to quit are eventu-
ally able to do so. The available approaches to man-
agement of addiction differ in their results.

  Self-help manuals and minimal clinical interventions.
Although self-help manuals have had only modest and
inconsistent success at helping smokers quit, manuals can
be easily distributed to the vast population of smokers
who try to quit on their own each year. Adjuvant be-
havioral interventions, particularly proactive telephone
counseling, may significantly increase the effect of self-
help materials. Process measures are not routinely in-
corporated into self-help investigations, but the available
process data suggest that persons who not only have a
self-help manual but also perform the exercises recom-
mended in the manual are more likely to quit smoking
than are persons who try to quit smoking without them.

  Substantial evidence suggests that minimal clini-
cal interventions (e.g., a health care provider's repeated
advice to quit) foster smoking cessation and that the
more multifactorial or intensive interventions produce
the best outcomes. These findings highlight the impor-
tance of cessation assistance from clinicians, who have
access to more than 70 percent of smokers each year.
Moreover, minimal clinical interventions have been
found to be effective in increasing smokers' motivation
to quit and are cost-effective (see "Cost-Effectiveness"
in Chapter 4). However, research has not fully clarified
the specific elements of minimal interventions that are
most important to clinical success nor the specific
changes they produce in smokers that lead to abstinence.

  Intensive clinical interventions. Intensive pro-
grams-more formally systematic services to help
people quit smoking-serve an important function in

the nation's efforts to reduce smoking, despite the re-
sources the programs demand and the relatively small
population of smokers who use them. Such programs
may be particularly useful in treating those smokers
who find it most difficult to quit. Because intensive
smoking cessation programs differ in structure and
content, evaluation is often hampered by variation in
methodology and by a lack of research addressing spe-
cific treatment techniques. Because few studies have
chosen to isolate single treatments, assessment of the
effectiveness of specific approaches is difficult. None-
theless, skills training, rapid smoking, and both intra-
treatment and extra-treatment social support have all
been associated with successful smoking cessation.
When such treatments are shown to be effective, they
are usually part of a multifactorial intervention. Little
clear evidence has implicated particular psychologi-
cal, behavioral, or cognitive mechanisms as the agents
of change. The specific impact of intensive interven-
tions may be masked by the efficacy of several multi-
component programs, some of which have achieved
cessation proportions of 30 to 50 percent. Thus, in their
positive effect on smoking cessation and long-term
abstinence rates, intensive interventions seem little
different from other forms of counseling or psycho-
therapy. With intensive interventions, as with coun-
seling, it is difficult to attribute the efficacy to specific
characteristics of the interventions or to specific change
mechanisms.

  Pharmacologic infemenfions. Abundant evidence
confirms that nicotine gum and the nicotine patch are
effective aids to smoking cessation. The efficacy of
nicotine gum may depend on the amount of behav-
ioral counseling with which it is paired. The 4-mg dose
(rather than the 2-mg dose) may be the better phar-
macologic treatment for heavy smokers or for those
highly dependent on nicotine. The nicotine patch ap-
pears to exert an effect independent of behavioral sup-
port, but absolute abstinence rates increase as more
counseling is added to patch therapy. Nicotine inhal-
ers and nicotine nasal spray are effective aids for smok-
ing cessation, although their mechanisms of action are
not entirely clear. All nicotine replacement therapies
produce side effects, but these are rarely so severe that
patients must discontinue use. Nicotine nasal spray
appears to have greater potential for inappropriate use
than other nicotine replacement therapies. Nicotine
replacement therapies, especially the gum and the
patch, have been shown to delay but not prevent
weight gain following smoking cessation. All nico-
tine replacement therapies are thought to work in part
by reducing withdrawal severity. The available evi-
dence suggests that they do ameliorate some elements

issues in Reducing Tobacco Use  13


Surgeon Gerzeral's Report

of withdrawal, but the relationship between withdrawal
suppression and clinical outcome is inconsistent.
  Bupropion is the first nonnicotine pharmaco-
therapy for smoking cessation to be studied in large-
scale clinical trials. Results suggest that it is an effective
aid to smoking cessation. In addition, bupropion has
been demonstrated to be safe when used in conjunc-
tion with nicotine replacement therapy. In the only
direct comparison with a nicotine replacement prod-
uct, bupropion achieved quit rates about double those
achieved with the nicotine patch. Bupropion appears
to delay but not prevent postcessation weight gain, and
available literature contains inconsistent evidence
about bupropion-mediated withdrawal relief.
Bupropion does not appear to work by reducing
postcessation symptoms of depression, but its mecha-
nism of action in smoking cessation remains unknown.
  Evidence suggests that clonidine is also capable
of improving smoking cessation rates. Clonidine is
hypothesized to work by alleviating withdrawal symp-
toms. Although clonidine may reduce the craving for
cigarettes after cessation, it does not consistently ame-
liorate other withdrawal symptoms, and its effect on
weight gain is unknown. Unpleasant side effects are
common with clonidine use.

  Antidepressants and anxiolytics are potentially
useful agents for smoking cessation. At present, only
nortriptylene appears to have consistent empirical
evidence of smoking cessation efficacy. However, tri-
cyclic antidepressants produce a number of side ef-
fects, including sedation and various anticholinergic
effects, such as dry mouth.

  In summary, research on methods to treat nico-
tine addiction has documented the efficacy of a wide
array of strategies. The broad implementation of these
effective treatment methods could produce a more
rapid and probably larger short-term impact on
tobacco-related health statistics than any other com-
ponent of a comprehensive tobacco control effort. It
has been estimated that smoking cessation is more cost-
effective than other commonly provided clinical pre-
ventive services, including Pap tests, mammography,
colon cancer screening, treatment of mild to moderate
hypertension, and treatment of high levels of serum
cholesterol.

  Contemporaneously with the appearance of this
report, research advances in managing nicotine ad-
diction have been summarized in evidence-based
clinical practice guidelines by the Centers for Disease
Control and Prevention (CDC). That document con-
firms that less intensive interventions, such as brief
physician advice to quit smoking, could produce ces-
sation rates of 5 to 10 percent per year. More intensive

interventions, combining behavioral counseling and
pharmacologic treatment of nicotine addiction, can
produce 20 to 25 percent quit rates at one year. Thus,
the universal provision of even less intensive interven-
tions to smokers at all clinical encounters could each
year help millions of U.S. smokers quit (Fiore et al.
2000).

  Progress has been made in recent years in dissemi-
nating clinical practice guidelines on smoking cessation.
Healthy People 2010 Objective 27-8 calls for universal
insurance coverage of evidence-based treatment for
nicotine dependency by both public and private pay-
ers. Similarly, CDC's Best Practices for Comprehensive
Tobacco Control Programs advises states that tobacco-
use treatment initiatives should include

o Establishing population-based counseling and
treatment programs, such as cessation help lines.

o  Making the system changes recommended by the
CDC-sponsored cessation guidelines.

o  Covering treatment for tobacco use under both
public and private insurance.

o  Eliminating cost barriers to treatment for under-
served populations, particularly the uninsured
(CDC 1999, p. 24).

Regulatory Efforts (Chapter 5)

Advertising and Promotion

  Attempts to regulate advertising and promotion
of tobacco products were initiated in the United States
almost immediately after the appearance of the 1964
report to the Surgeon General on the health conse-
quences of smoking. Underlying these attempts is the
hypothesis that advertising and promotion recruit new
smokers and retain current ones, thereby perpetuat-
ing a great risk to public health. The tobacco industry
asserts that the purpose of marketing is to maintain
brand loyalty. Considerable evidence has accumulated
showing that advertising and promotion are perhaps
the main motivators for adopting and maintaining to-
bacco use. Attempts to regulate tobacco marketing
continue to take place in a markedly adversarial and
litigious atmosphere.

  The initial regulatory action, promulgated in 1965,
provided for a general health warning on cigarette pack-
ages but effectively preempted any further federal, state,
or local requirements for health messages. In 1969, a
successful court action invoked the Fairness Doctrine


Reducing Tobacco Use

(not previously applied to advertising) to require
broadcast media to air antitobacco advertising to
counter the paid tobacco advertising then running on
television and radio. Indirect evidence suggests that
such counteradvertising had considerable impact on
the public's perception of smoking. Not surprisingly,
the tobacco industry supported new legislation
(adopted in 1971) prohibiting the advertising of to-
bacco products on broadcast media, because such leg-
islation also removed the no-cost broadcasting of
antitobacco advertising. Adecade later, a Federal Trade
Commission (FTC) staff report asserted that the domi-
nant themes of remaining (nonbroadcast) cigarette
advertising associated smoking with "youthful vigor,
good health, good looks and personal, social and pro-
fessional acceptance and success" (Myers et al. 1981,
p. 2-13). A nonpublic version of the report detailed
some of the alleged marketing strategy employed by
the industry; the industry denied the allegation that
the source material for the report represented indus-
try policy. Nonetheless, some of these concerns led to
the enactment of the Comprehensive Smoking Educa-
tion Act of 1984 (Public Law 98-474), which required a
set of four rotating warnings on cigarette packages.
The law did not, however, adopt other FTC recommen-
dations that product packages should bear informa-
tion about associated risks of addiction and
miscarriage, as well as information on toxic compo-
nents of cigarettes. In fact, many FTC-recommended
requirements for packaging information that have been
enacted in other industrialized nations have not been
enacted in the United States.

  The role of advertising is perhaps best epitomized
by R.J. Reynolds Tobacco Company's Camel brand
campaign (initiated in 1988) using the cartoon charac-
ter "Joe Camel." Considerable research has demon-
strated the appeal of this character to young people
and the influence that the advertising campaign has
had on minors' understanding of tobacco use and on
their decision to smoke. In 1997, the FTC brought a
complaint asserting that by inducing minors to smoke,
R.J. Reynolds' advertising practices violated the Fed-
eral Trade Commission Act Public Law 96-252). The
tobacco company subsequently agreed to cease using
the Joe Camel campaign. Although the FTC's act
grants no private right of enforcement, a private law-
suit in California resulted in a settlement whereby the
tobacco company agreed to cease its Joe Camel cam-
paign; notably, the Supreme Court of California re-
jected R.J. Reynolds' argument that the Comprehensive
Smoking Education Act of 1984 preempted the suit's
attempt to further regulate tobacco advertising.

Product Regulation

  Current tobacco product regulation requires that
cigarette advertising disclose levels of "tar" (an all-
purpose term for particulate-phase constituents of to-
bacco smoke, many of which are carcinogenic or
otherwise toxic) and nicotine (the psychoactive drug
in tobacco products that causes addiction) in the smoke
of manufactured cigarettes and that warning labels
appear on packages and on some (but not all) adver-
tising for manufactured cigarettes and smokeless to-
bacco. The current federal laws preempt, in part, states
and localities from imposing other labeling regulations
on cigarettes and smokeless tobacco. Federal law (the
Comprehensive Smokeless Tobacco Health Education
Act of 1986 and the Comprehensive Smoking Educa-
tion Act of 1984) requires cigarette and smokeless to-
bacco product manufacturers to submit a list of
additives to the Secretary of Health and Human Ser-
vices; attorneys for the manufacturers released such
lists in 1994 to the general public. Smokeless tobacco
manufacturers are required to report the total nicotine
content of their products, but these data may not be
released to the public. Tobacco products are explic-
itly protected from regulation in various federal con-
sumer safety laws. No federal public health laws or
regulations apply to cigars, pipe tobaccos, or fine-cut
cigarette tobaccos (for "roll-your-own" cigarettes).

  Although much effort has been devoted to con-
sidering the need for regulating nicotine delivery, tar
content, and the use of additives, until recently no regu-
lation had directly broached the issue of whether to-
bacco should be subject to federal regulation as an
addictive product. Responding in part to several pe-
titions filed by the Coalition on Smoking OR Health
in 1988 and 1992, the FDA began serious consideration
of the need for product regulation. Motivated by the
notion that the cigarette is a nicotine delivery system,
by allegations of product manipulation of nicotine lev-
els, and by the concept that smoking is a pediatric dis-
ease and that young people are especially susceptible
to cigarette advertising and promotion, in August 1995
the FDA issued in the Federal Register (1) a proposed
rule of regulations restricting the sale and distribution
of cigarettes and smokeless tobacco products to pro-
tect children and adolescents and (2) an analysis of the
FDA's jurisdiction over cigarettes and smokeless to-
bacco. The final regulations published by the FDA on
August 28, 1996, differed only slightly from the pro-
posed regulation. The announcement prompted
immediate legal action on the part of the tobacco in-
dustry, advertising interests, and the convenience store
industry, which challenged the FDA's jurisdiction over

Issues irz Reducitlg Tobacco Use  15


Surgeon Grrleral's Report

tobacco products. In April 1997, a federal district court
upheld the FDA's jurisdiction over tobacco products,
but held that it lacked authority under the statutory
provision relied on to regulate tobacco product
advertising.

  Although many of the FDA's regulations on to-
bacco sales and distribution were incorporated, to
some extent, in the June 20,1997, proposed settlement
of lawsuits between 41 state attorneys general and the
tobacco industry, the settlement presupposed congres-
sional legislation that would uphold the FDA's as-
serted jurisdiction. After considerable congressional
negotiation, no such legislation emerged. In August
1998, a three-judge panel of the United States Court of
Appeals for the Fourth Circuit held that the FDAlacked
jurisdiction to regulate tobacco products. In Novem-
ber 1998, the full Court of Appeals rejected the
government's request for rehearing by the entire court.
On March 21, 2000, in a 5 to 4 decision, the United
States Supreme Court affirmed the decision of the
United States Court of Appeals for the Fourth Circuit
and held that the FDA lacks jurisdiction under the Fed-
eral Food, Drug, and Cosmetic Act to regulate tobacco
products as customarily marketed. As a result of
this decision, the FDA's August 1996 assertion of ju-
risdiction over cigarettes and smokeless tobacco and
regulations restricting the sale and distribution of ciga-
rettes and smokeless tobacco to protect children and
adolescents (principally codified at 21 Code of Fed-
eral Regulations Part 897) are invalid.

Clean Indoor Air Regulation

  Unlike the regulation of tobacco products per se
and of their advertising and promotion, regulation of
exposure to ETS has encountered less resistance. This
course is probably the result of (1) long-standing
grassroots efforts to diminish exposure to ambient to-
bacco smoke and (2) consistent epidemiologic evidence
of adverse health effects of ETS. Since 197l, a series of
rules, regulations, and laws have created smoke-free
environments in an increasing number of settings:
government offices, public places, eating establish-
ments, worksites, military establishments, and domes-
tic airline flights. As of December 31, 1999, smoking
was restricted in public places in 45 states and the Dis-
trict of Columbia. Currently, some 820 local ordi-
nances, encompassing a variety of enforcement
mechanisms, are in place.

   The effectiveness of clean indoor air restrictions
is under intensive study. Most studies have concluded
that even among smokers, support for smoking restric-
tions and smoke-free environments is high. Research

has also verified that the institution of smoke-free
workplaces effectively reduces nonsmokers' exposure
to ETS. Although most studies indicate that smoke-
free environments have not reduced smoking preva-
lence, such environments have been shown to decrease
daily tobacco consumption and to increase smoking
cessation among smokers.

Minors' Access to Tobacco

  There is widespread approval for restricting the
access of minors to tobacco products. Recent research,
however, has demonstrated that a substantial propor-
tion of teenagers who smoke purchase their own
tobacco, and the proportion varies with age, social
class, amount smoked, and factors related to local
availability. In addition, research has shown that most
minors can easily purchase tobacco from a variety of
retail outlets. It has been suggested that a reduction
in commercial availability may result in a reduced
prevalence of tobacco use among minors.

  Several approaches have been taken to limiting
minors' access to tobacco. All states prohibit sale or
distribution of tobacco to minors. More than two-thirds
of states regulate the means of sale through restrictions
on minors' use of vending machines, but many of these
restrictions are weak, and only two states have total
bans on vending machines. Restrictions on vending
machines are a subclass of the larger category of regu-
lation of self-service cigarette sales; in general, such
regulation requires that cigarettes be obtained from a
salesperson and not be directly accessible to custom-
ers Such policies can reduce shoplifting as well, an
important source of cigarettes for some`minors.

  Regulations directed at the seller include the
specification of a minimum age for sale (18, in all but
two states and Puerto Rico), a minimum age for the
seller, and the prominent in-store announcement of
such policy. Providing merchant education and train-
ing is an important component of comprehensive mi- ..
nors' access-programs. Penalties for sales to minors
vary considerably; in general, civil penalties have been
found to be more effective than criminal ones, Requir-
ing licensure of tobacco retailers has been found to
provide a funding source for compliance checks and
to serve as an incentive to obey the law when revoca-
tion of the license is a provision of the law. Applying
penalties to business owners, instead of to clerks only,
is considered essential to preventing sales to minors.
Tobacco retail outlets and the tobacco industry have
vigorously opposed this policy. An increasing num-
ber of states and local jurisdictions are imposing sanc-
tions against minors who purchase, possess, or use

26 Chapter 1


Reducing Tobacco Use

tobacco products. Sanctions against both buyers and
sellers are enforced by a variety of agencies and mecha-
nisms. Because regulations in general may be more
effective if generated and enforced at the local level,
considerable energy is devoted to the issue of oppos-
ing or repealing preemption of local authority by states.
Public health analyses have resulted in strong recom-
mendations that state laws not preempt local action to
curb minors' access to tobacco.

Litigation Approaches

  Private litigation shifts enforcement of public
health remedies from the enterprise or the government
to the private individual-typically, victims or their
surrogates. In the tort system, the coalescence of in-
stances in which injurers are forced to compensate the
injured can create a force that generates preventive
effects. Although relatively inefficient as a system for
compensating specific classes of injuries, the tort sys-
tem is justified by its generation of preventive actions
and by its flexibility. Tobacco represents an atypical
pattern of litigation and product modification, because
private law remedies have not yet succeeded in insti-
tutionalizing recovery for tobacco injuries or have not
yet generated significant preventive effects. In the case
of tobacco, regulation has been the predominant
control, and such regulation has been distinctive in re-
lying primarily on notification requirements rather
than safety requirements.

  Private litigation against tobacco has occurred in
several distinct waves. The first wave was launched
in 1954 and typically used one or both of two legal
theories: negligence and implied warranty. Courts
proved unreceptive to both these arguments, and this
approach had receded by the mid-1970s. In many of
these and subsequent cases, legal devices and exhaus-
tion of plaintiff resources figured prominently in the
defendants' strategy. A second wave began in 1983
and ended in 1992. In these cases, the legal theory
shifted from warranty to strict liability. The tobacco
industry based its defense on smokers' awareness of
risks and so-called freedom of choice. For example,
plaintiffs argued that the addictive nature of nicotine
limited free choice; defense counsel rebutted by point-
ing to the large number of former smokers who suc-
cessfully quit. Taking freedom-of-choice defense even
further, counsel argued that the claimant's lifestyle was
overly risky by choice or was in some way immoral.
The case that symbolized the second-wave litigation
was that filed by Rose Cipollone, a dying smoker, in
1983. The Supreme Court accepted the tobacco
industry's defense that federal law requiring warning

labels on product packages had preempted claims
under state law that imposed liability for failure to
warn. The Supreme Court left open several other ap-
proaches, but the likelihood of recovery seemed small,
and counsel for the Cipollone estate withdrew.

  In the third wave, begun soon after the Cipollone
decision and still ongoing, diverse legal arguments
have been invoked. This third wave of litigation dif-
fers from its predecessors by enlarging the field of
plaintiffs, focusing on a range of legal issues, using
the class action device, and making greater attempts
to use private law for public policy purposes. These
new claims have been based on theories of intentional
misrepresentation, concealment, and failure to dis-
close, and such arguments have been joined to a new
emphasis on addiction. For example, in one case that
ended as a mistrial, plaintiffs were barred from pre-
senting evidence that the tobacco companies may have
manipulated nicotine levels. The class action device
has figured prominently in these new cases, which
have included claims of smokers as well as claims of
those who asserted that they have been injured by ETS.
Arguably the most notable series of third-wave claims
brought against tobacco companies is the proposed
1997 settlement of suits brought by 41 state attorneys
general attempting to recover the states' Medicaid ex-
penditures for treating tobacco-related illnesses. In the
absence of congressional legislation needed to give that
settlement the force of law, four states made indepen-
dent settlements with the tobacco industry. Notably,
each state obtained a concession guaranteeing that it
would benefit from any more favorable agreement that
another state might later obtain from the tobacco in-
dustry. Subsequently, a multistate Master Settlement
Agreement was negotiated in November 1998 cover-
ing the remaining 46 states, the District of Columbia,
and five commonwealths and territories. Another
notable recent development is the filing of large claims
by other third-party payers, such as large health care
plans.

  Perhaps in partial response, the level of litiga-
tion initiated by the tobacco industry itself has in-
creased in recent years and has included a number of
well-publicized cases, including a threatened suit
against the media to prevent airing of a program that
accused a tobacco company of manipulating nicotine
levels. The company was successful in making the
network withdraw the program, even though similar
information was later made public in other contexts.
Although the industry continues aggressive legal pur-
suit of its interests on a number of fronts, litigation
against the industry has had undoubted impact on

Issues in Reducing Tobacco Use  17


tobacco regulation and is likely to continue to play a
key role in efforts to reduce tobacco use.

Overview and Implications

  Tobacco products are far less regulated in the
United States than they are in many other developed
countries. This level of regulation applies to the manu-
factured tobacco product; to the advertising, promo-
tion, and sales of these products; and to the protection
of nonsmokers from the involuntary exposure to ETS
from the use of these products. As with all other con-
sumer products, adult users of tobacco should be fully
informed of the products' ingredients and additives
and of any known toxicity when used as intended.
Additionally, as with other consumer products, the
manufactured tobacco product should be no more
harmful than necessary given available technology.
The sale, distribution, and promotion of tobacco prod-
ucts need to be sufficiently regulated to protect un-
derage youth from influences to take up smoking.
Finally, involuntary exposure to ETS remains a com-
mon public health hazard that is entirely preventable
by appropriate regulatory policies.
  Such are the basic, reasonable regulatory issues
related to tobacco products. Yet these issues remain
unresolved as the new millennium begins. When con-
sumers purchase a tobacco product, they receive little
information regarding the ingredients, additives, or
chemical composition in the product. Although public
knowledge about the potential toxicity of most of these
constituents is negligible, findings in this report con-
clude that the warning labels on cigarette packages in
this country are weaker and less conspicuous than in
other countries. Further, the popularity of "low tar and
nicotine" brands of cigarettes has shown that consum-
ers may be misled by another, carefully crafted kind of
information-that is, by the implied promise of reduced
toxicity underlying the marketing of these products.
  Current regulation of the advertising and pro-
motion of tobacco products in this country is consid-
erably less restrictive than in several other countries,
notably Canada and New Zealand. The review of cur-
rent case law in this report supports the contention
that greater restrictions of tobacco product advertis-
ing and promotion could be legally justified. In fact,
the report concludes that regulation of the sale and
promotion of tobacco products is needed to protect
young people from smoking initiation.
   ETS contains more than 4,000 chemicals; of
these, at least 43 are known carcinogens (Environmen-
tal Protection Agency 1992). Exposure to ETS has
serious health effects (USDHHS 2000b). Despite this

documented risk, research has demonstrated that
more than 88 percent of nonsmokers in this country
aged 4 years and older had detectable levels of se-
rum cotinine, a marker for exposure to ETS (Pirkle et
al. 1996). The research reviewed in this report indi-
cates that smoking bans are the most effective method
for reducing ETS exposure. Four Heulthy People 2020
objectives address this issue and seek optimal pro-
tection of nonsmokers through policies, regulations,
and laws requiring smoke-free environments in all
schools, worksites, and public places.

  Despite the widespread support among the gen-
eral public, policymakers, and the tobacco industry for
restricting the access of minors to tobacco products, a
high proportion of underage youth smokers across
this country continue to be able to purchase their own
tobacco. National efforts by the Substance Abuse and
Mental Health Services Administration to increase the
enforcement of state laws to comply with the Synar
Amendment and by the FDA to implement the access
restrictions defined in their 1996 rule have reduced the
percentage of retailers in many states who sell to mi-
nors. Unfortunately, nine states failed to attain their
Synar Amendment targets in 1999. Additionally, the
March 2000 Supreme Court ruling that the FDA lacks
jurisdiction to regulate tobacco products has suspended
all enforcement of the agency's 1996 regulations.
Although several states have increased emphasis on
this issue as part of their state-funded program efforts,
the loss of the FDA's program removes a major
infrastructure in support of these state efforts. The
current regulatory environment poses considerable
challenges for the interweaving of regulation into a
comprehensive, multicomponent approach to tobacco
use control and prevention.

Economic Approaches (Chapter 6)

  The argument for using economic policy for re-
ducing tobacco use requires considerable technical and
analytic understanding of economic theory and data.
Because experiments and controlled trials-in the
usual sense-are not available to the economist, judg-
ment and forecasting depend on the results of com-
plex analysis of administrative and survey data. Such
analyses have led to a number of conclusions regard-
ing the importance of the tobacco industry in the U.S.
economy and regarding the role of policies that might
affect the supply of tobacco, affect the demand for to-
bacco, and use different forms of taxation as a pos-
sible mechanism for reducing tobacco use.


Reducing Tobacco Use

  Sup@y. The tobacco support program has success-
fully limited the supply of tobacco and raised the price
of tobacco and tobacco products. However, the princi-
pal beneficiaries of this program are not only the
farmers whose income is supported but also the own-
ers of the tobacco allotments. If policies were initiated
to ameliorate some short-run effects, the tobacco sup-
port program could be removed without imposing
substantial losses for many tobacco farmers. Elimi-
nating the tobacco support program would lead to a
small reduction in the prices of cigarettes and other
tobacco products, which would lead to slight increases
in the use of these products. However, because the
support program has created a strong political con-
stituency that has successfully impeded stronger leg-
islation to reduce tobacco use, removing the support
program could make it easier to enact stronger policies
that would more than offset the impact that the result-
ing small reductions in price would have on demand.

  Throughout the 1980s and 199Os, competition
within the tobacco industry appeared to have de-
creased as a result of the favorable deregulatory busi-
ness climate and an apparent increase in collusive
behavior. This reduction in competition, coupled with
the addictive nature of cigarette smoking, has magni-
fied the impact that higher cigarette taxes and stronger
smoking reduction policies would have on demand.

  The recent expansion of U.S. trade in tobacco and
tobacco products through multinational agreements,
together with the U.S. threat of retaliatory trade sanc-
tions were other countries to impede this expansion,
is nearly certain to have increased the use of tobacco
products worldwide. Such an increase would result
in a consequent global rise in morbidity and mortality
related to cigarette smoking and other tobacco use.
These international trade policy efforts conflict with
current domestic policies (and the support of compa-
rable international efforts) that aim to reduce the use
of tobacco products because of their harmful effects
on health.

  Industry importance. Although employment in the
tobacco industry is substantial, the industry greatly
overstates the importance of tobacco to the U.S.
economy. Indeed, most regions would likely benefit-
for example, through redistribution of spending and
changes in types of job-from the elimination of rev-
enues derived from tobacco products. Moreover, as
the economies of tobacco-growing regions have be-
come more diversified, the economic importance of
tobacco in these areas has fallen. Higher tobacco taxes
and stronger prevention policies could be joined to
other efforts to further ease the transition from tobacco
in major tobacco-producing regions. Finally, trading

lives for jobs is an ill-considered strategy, particularly
with the availability of stronger policies for reducing
tobacco use.

  Demand. Increases in the price of cigarettes will
lead to reductions in both smoking prevalence and ciga-
rette consumption among smokers; relatively large re-
ductions are likely to occur among adolescents and
young adults. Limited research indicates that increases
in smokeless tobacco prices will similarly reduce the
use of these products. More research is needed to clarify
the impact of cigarette and other tobacco prices on the
use of these products in specific sociodemographic
groups, particularly adolescents and young adults.
Additional research also is needed to address the po-
tential substitution among cigarettes and other tobacco
products as their relative prices change.

   T~xntion. After the effects of inflation are ac-
counted for, federal and average state excise taxes on
cigarettes are well below their past levels. Similarly,
average cigarette excise taxes in the United States are
well below those imposed in most other industrialized
countries. Moreover, U.S. taxes on smokeless tobacco
products are well below cigarette taxes. Studies of the
economic costs of smoking report a wide range of es-
timates for the optimal tax on cigarettes. However,
when recent estimates of the costs of ETS (including
the long-term costs of fetal and perinatal exposure to
ETS) are considered, and when the premature death
of smokers is not considered an economic benefit, a
tax that would generate sufficient revenues to cover
the external costs of smoking is almost certainly well
above current cigarette taxes. The health benefits of
higher cigarette taxes are substantial. By reducing
smoking, particularly among youth and young adults,
past tax increases have significantly reduced smoking-
related morbidity and mortality. Further increases in
taxes, indexed to account for the effects of inflation,
would lead to substantial long-run improvements in
health.

  The revenue potential of higher cigarette and
other tobacco taxes-obviously not in itself a goal-is
considerable; significant increases in these taxes would
lead to sizable increases in revenues for many years.
However, because of the greater price responsiveness
of adolescents and young adults and the addictive
nature of tobacco use, the long-run increase in revenues
is likely to be less than the short-run gain. Neverthe-
less, current federal and most state tobacco taxes are
well below their long-run revenue-maximizing levels.

  In short, the research reviewed in this report sup-
ports the position that raising tobacco prices is good
public health policy. Further, raising tobacco excise
taxes is widely regarded as one of the most effective

Issues in Reducing Tobacco Use  19


tobacco prevention and control strategies. Research
indicates that increasing the price of tobacco products
would decrease the prevalence of tobacco use, particu-
larly among minors and young adults. As noted, how-
ever, this report finds that both the average price of
cigarettes and the average cigarette excise tax in this
country are well below those in most other industrial-
ized countries and that the taxes on smokeless tobacco
products are well below those on cigarettes. Making
optimal use of economic strategies in a comprehen-
sive program poses special problems because of the
complexity of government and private controls over
tobacco economics and the need for a concerted, mul-
tilevel, political approach.

Comprehensive Programs (Chapter 7)

  Community-based interventions were originally
developed as research projects that tested the efficacy
of a communitywide approach to risk reduction. A
number of national and international efforts to con-
trol cardiovascular disease (in the United States, nota-
bly the Minnesota, Stanford, and Pawtucket studies)
used controlled designs. The results from these and
other studies were largely disappointing, particularly
regarding prevention and control of tobacco use. Other
large-scale research efforts, such as the Community In-
tervention Trial (COMMIT) for Smoking Cessation,
also failed to meet their primary goals for smoking re-
duction and cessation. Similarly, the results to date
from numerous worksite-based cessation projects sug-
gest either no impact or a small net effect (summarized
in Chapter 4).

  As these studies were under way in the 1970s and
198Os, health promotion-an organized approach to
changing social, economic, and regulatory environ-
ments-emerged as a more effective mechanism for
population behavior change than traditional health
education. Although the aforementioned community-
based research projects used a health promotion per-
spective, they lacked the reach and penetration required
for effective social change. In any event, the results
made clear the distinction between a specific program
(even one using multiple modalities) and a comprehen-
sive multimessage, multichannel approach that used
some or all of the modalities described in Chapters 3
through 6. The legal and economic events of the 199Os-
most notably large excise tax increases and the settle-
ments with the tobacco industry for reimbursement of
Medicaid costs incurred by caring for smokers-have
provided those states with the resources necessary to
mount such a comprehensive approach. The early

results are encouraging, as exemplified by results from
California, Massachusetts, Oregon, and Florida. The
well-funded, coherent, and organized approach to to-
bacco prevention and control provides a credible coun-
terweight to the advertising and promotional efforts of
the tobacco industry and fosters a powerful nonsmok-
ing norm.

  On a broader scale, other social initiatives can also
serve some of these same purposes through means that
are not directly related to changing population behav-
ior. For example, direct advocacy-the presentation
of information to decision makers to encourage their
support for nonsmoking policies-has been pursued
vigorously by health advocates since the organization
of grassroots movements for nonsmokers' rights in the
early 1970s. Much of the clean air legislation now in
place may be attributed in part to such direct advo-
cacy. An interesting observation that supports the logic
behind comprehensive programs is that initial short-
comings in direct advocacy activity may have been
related to a failure of coordination among grassroots
groups and professional organizations. In recent years,
in part as the result of electronic networking and me-
diating by the Advocacy Institute, a more unified ap-
proach to reducing tobacco use has been achieved
among the participating organizations.
  Media advocacy-the use of mass media to ad-
vance public policy initiatives-has also been effective
in placing smoking issues in the public eye and main-
taining a continued impetus for reducing tobacco use.
Case analysis cf several instances of such activity-
advocacy opposing the promotion of the "X" cigarette,
the marketing of "Dakota" cigarettes, the Philip
Morris-sponsored Bill of Rights tour, and the attempted
marketing of "Uptown" cigarettes-highlights several
successes but also indicates that such activities do not
always achieve their immediate aims. Nonetheless,
considerable experience has been gained in seizing
such opportunities.

  Countermarketing activities can promote smok-
ing cessation and decrease the likelihood of initiation.
Countermarketing campaigns also can have a power-
ful influence on public support for tobacco control ac-
tivities and provide an educational climate that can
enhance the efficacy of school- and community-based
efforts. For youth, the CDC has estimated that the
average l&year-old has been exposed to more than
$20 billion in imagery advertising and promotions
since age 6, creating a "friendly familiarity" for tobacco
products. The recent increase in movie depictions of
tobacco use further enhances the image of tobacco use
as glamorous, socially acceptable, and normal. In light

20 Cllnpter 1


Reducing Tobacco Use

of the ubiquitous and sustained protobacco messages,
countermarketing campaigns need to be of comparable
intensity and duration to alter the general social and
environmental atmosphere supporting tobacco use.

  In sum, the comprehensive approach that has
been developed-within the statewide tobacco control
programs has produced results that led the Institute
of Medicine (2000) to conclude that "multifaceted state
tobacco control programs are effective in reducing to-
bacco use" (p. 4). Although these initial results are
encouraging, they need to be considered from the per-
spective of the less favorable results from the commu-
nity trials. Nevertheless, although our knowledge
about the mechanisms by which these new compre-
hensive tobacco control efforts function is imperfect,
the results are sufficiently favorable to support the con-
tinued application of this model. But, accountability
and program evaluation must be emphasized in these
new statewide tobacco control programs to improve
our understanding of how the various components of
the comprehensive programs work.

  Perhaps the most important aspect of comprehen-
sive programs has been the emergence of statewide to-
bacco control efforts as a laboratory for their development
and evaluation. The number of states with such pro-
grams grew slowly in the early and mid-1990s, but in
recent years there has been a surge in funding for such
efforts fueled by the state settlements with the tobacco
industry. Although the data on the impact of these pro-
grams on per capita consumption, adult prevalence,
and youth prevalence are generally favorable, the uni-
fo:m data systems needed to conduct more controlled
evaluations of these efforts are still emerging. The chal-
lenge for the new millennium will be to ensure that these
ever increasing comprehensive statewide tobacco con-
trol programs are as efficient and effective as possible.

  The review of statewide tobacco control programs
indicates that reducing the broad cultural acceptability
of tobacco use necessitates changing many facets of the
social environment. In addition, this report stresses-
as does the Best Practices (CDC 1999) document-that
these individual components must work together to
produce the synergistic effects of a comprehensive

program. However, both of these findings highlight
the complexity involved in evaluating these types of
programs.

  Within the current statewide tobacco control pro-
grams, each of these various modalities discussed in
this report is represented with varying degrees of in-
tensity. As noted above, some of the recommendations
for actions within these modalities could most effec-
tively be done at the national rather than the state level.
Thus, the overall efficacy of these emerging statewide
programs will depend in some ways on public health
advances at the national level. Again, this synergy
between the statewide and national efforts adds greater
complexity to the evaluation issue.

  Finally, this report concludes that the span of
impact of these educational, clinical, regulatory, eco-
nomic, and social approaches indicates the importance
of their sustained and long-term implementation. Pro-
gram evaluation and research efforts are needed to
improve our understanding of how these various ele-
ments work. Although knowledge about the efficacy
of comprehensive programs is imperfect, evidence
points to early optimism for their continuance. With
the expansion of tobacco control surveillance and
evaluation systems and increases in the number and
diversity of statewide tobacco control programs, criti-
cal questions can be answered about how to make these
efforts more efficient and effective.

A Vision for the Future-Reducing
Tobacco Use in the New Millennium
(Chapter 8)

  Chapter 8 outlines broad strategies and courses
of action for tobacco control in the future. Six future
challenges are outlined: continuing to build the scien-
tific base, responding to the changing tobacco indus-
try, using a comprehensive approach in reducing
tobacco use, eliminating health disparities, improving
dissemination of state-of-the-art interventions, and
influencing tobacco use in developing nations.


Surgeorl Gerwal's Rr,vorf

Chapter Conclusions

  Following are the specific conclusions for each
chapter of the report. Note that Chapters 1 and 8 have
no conclusions.

Chapter 2. Historical Review

1.

2.

3.

In the years preceding the development of the
modern cigarette, and for some time thereafter,
antismoking activity was largely motivated by
moralistic and hygienic concerns. Health con-
cerns played a lesser role.

In contrast, in the second half of the 20th cen-
tury, the impetus for reducing tobacco use was
largely medical and social. The resulting plat-
form has been a more secure one for efforts to
reduce smoking.

Despite the growing scientific evidence for ad-
verse health effects, smoking norms and habits
have yielded slowly and incompletely. The rea-
sons are complex but attributable in part to the
industry's continuing stimulus to consumption.

Chapter 3. Educational Strategies

Educational strategies, conducted in conjunction
with community- and media-based activities, can
postpone or prevent smoking onset in 20 to 40
percent of adolescents.

Although most U.S. schools have tobacco use pre-
vention policies and programs in place, current
practice is not optimal.

More consistent implementation of effective edu-
cational strategies to prevent tobacco use will re-
quire continuing efforts to build strong, multiyear
prevention units into school health education cur-
ricula and expanded efforts to make use of the
influence of parents, the mass media, and other
community resources.

Chapter 4. Management of Nicotine
Addiction

1.

2.

3.

4.

5.

Tobacco dependence is best viewed as a chronic
disease with remission and relapse. Even though
both minimal and intensive interventions in-
crease smoking cessation, most people who quit
smoking with the aid of such interventions will
eventually relapse and may require repeated at-
tempts before achieving long-term abstinence.
Moreover, there is little understanding of how
such treatments produce their therapeutic effects.

There is mixed evidence that self-help manuals
are an efficacious aid to smoking cessation. Be-
cause these materials can be widely distributed,
such strategies may have a significant public
health impact and warrant further investigation.

Programs using advice and counseling-whether
minimal or more intensive-have helped a sub-
stantial proportion of people quit smoking.

The success of counseling and advice increases
with the intensity of the program and may be im-
proved by increasing the frequency and duration
of contact.

The evidence is strong and consistent that phar-
macologic treatments for smoking cessation
(nicotine replacement therapies and bupropion,
in particular) can help people quit smoking.
Clonidine and nortriptylene may have some util-
ity as second-line treatments for smoking cessa-
tion, although they have not been approved by
the FDA for this indication.

Chapter 5. Regulatory Efforts
Advertising and Promotion

1.  Since 1964, numerous attempts to regulate ad-
  vertising and promotion of tobacco products
  have had only modest success in restricting such
  activity.

22 Chnptu 1


Current regulation in the United States is con-
siderably less restrictive than that in several other
countries, notably Canada and New Zealand.

Current case law supports the contention that ad-
vertising does not receive the protections of free
speech under the First Amendment to the Con-
stitution that noncommercial speech does.

Product Regulation

1.

2.

3.

4.

5.

Warning labels on cigarette packages in the
United States are weaker and less conspicuous
than those of other countries.

Smokers receive very little information regard-
ing chemical constituents when they purchase a
tobacco product. Without information about
toxic constituents in tobacco smoke, the use of
terms such as "light" and "ultra light" on pack-
aging and in advertising may be misleading to
smokers.

Because cigarettes with low tar and nicotine con-
tents are not substantially less hazardous than
higher-yield brands, consumers may be misled
by the implied promise of reduced toxicity un-
derlying the marketing of such brands.

Additives to tobacco products are of uncertain
safety when used in tobacco. Knowledge about the
impact of additives is negligible and will remain
so as long as brand-specific information on the
identity and quantity of additives is unavailable.

Regulation of tobacco product sale and promo-
tion is required to protect young people from in-
fluences to take up smoking.

Clean Indoor Air Regulation

1.  Although population-based data show declining
  ETS exposure in the workplace over time, ETS
  exposure remains a common public health haz-
  ard that is entirely preventable.

Reducing Tobacco Use

3.  Beyond eliminating ETS exposure among non-
  smokers, smoking bans have additional benefits,
  including reduced smoking intensity and poten-
  tial cost savings to employers. Optimal protec-
  tion of nonsmokers and smokers requires a
   smoke-free environment.

Minors' Access to Tobacco

1.

2.

Measures that have had some success in reduc-
ing minors' access include restricting distribu-
tion, regulating the mechanisms of sale, enforcing
minimum age laws, having civil rather than
criminal penalties, and providing merchant edu-
cation and training. Requiring licensure of to-
bacco retailers provides both a funding source
for enforcement and an incentive to obey the law
when revocation of the license is a provision of
the law.

The effect of reducing minors' access to tobacco
products on smoking prevalence requires further
evaluation.

Litigation Approaches

1.  Two historic waves of tobacco litigation were ini-
  tiated by private citizens, were based largely on
  theories of negligence and implied warranty, and
   were unsuccessful.

2.  A third wave has brought in new types of claim-
  ants, making statutory as well as common-law
  claims and using more efficient judicial proce-
  dures. Although several cases have been settled
  for substantial money and have yielded public
  health provisions, many other cases remain
   unresolved.

3.  Private law initiative is a diffuse, uncentralized
  activity, and the sum of such efforts is unlikely
  to produce optimal results for a larger policy to
  reduce tobacco use. On the other hand, the liti-
  gation actions of individuals are likely to be a
  valuable component in some larger context of
  strategies to make tobacco use less prevalent.

2.   Most state and local laws for clean indoor air re-
  duce but do not eliminate nonsmokers' exposure
  to ETS; smoking bans are the most effective
  method for reducing ETS exposure.

Issurs irz Reduci?rg Tobacco Use  23


Surxeotl General's Report

Chapter 6. Economic Approaches

The price of tobacco has an important influence
on the demand for tobacco products, particularly
among young people.

Substantial increases in the excise taxes on ciga-
rettes would have considerable impact on the
prevalence of smoking and, in the long term, re-
duce the adverse health effects caused by tobacco.

Policies that influence the supply of tobacco, par-
ticularly those that regulate international com-
merce, can have important effects on tobacco use.

Although employment in the tobacco sector is
substantial, the importance of tobacco to the U.S.
economy has been overstated. Judicious policies
can be joined to higher tobacco taxes and stron-
ger prevention policies to ease economic diver-
sification in tobacco-producing areas.

Chapter 7. Comprehensive Programs

The large-scale interventions conducted in com-
munity trials have not demonstrated a conclu-
sive impact on preventing and reducing tobacco
use.

Statewide programs have emerged as the new
laboratory for developing and evaluating com-
prehensive plans to reduce tobacco use.

Initial results from the statewide tobacco control
programs are favorable, especially regarding
declines in per capita consumption of tobacco
products.

Results of statewide tobacco control programs
suggest that youth behaviors regarding tobacco
use are more difficult to change than adult ones,
but initial results of these programs are gener-
ally favorable.

24 Chapter 2


Reducirrg Tobacco Use

References

Centers for Disease Control and Prevention. Besf Prac-
tices for Comprehensive Tobacco Collfrol Proxra1Tzs-
August 1999. Atlanta: Centers for Disease Control and
Prevention, National Center for Chronic Disease Pre-
vention and Health Promotion, Office on Smoking and
Health, 1999.

Fiore M, Bailey W, Bennett G, Bennett H, Cohen S,
Dorfman SF, Fox B, Goldstein M, Gritz E, Hasselblad
V, Heishman S, Heyman R, Husten C, Jaen CR, Jorenby
D, Kamerow D, Kottke T, Lando H, Mecklenburg R,
Melvin C, Morgan G, Mullen I'D, Murray E, Nett L,
Orleans CT, Robinson L, Stitzer M, Tommasello A,
Villejo L, Wewers ME, Baker T. Trdy Tob~~cco Use ord
Deyelzdence. Clinical Practice Guideline. Rockville
(MD): US Department of Health and Human Services,
Public Health Service, 2000.

Lynch BS, Bonnie RJ, editors. Growillg Up Tobacco Free.
Preventing Nicotilze Addiction irz Children alld Youths.
Washington: National Academy Press, 1994.

Myers ML, Iscoe C, Jennings C, Lenox W, Minsky E,
Sacks A. Staff Report on the Cigarette Adzlerfisilzg lnves-
figafion. Washington: Federal Trade Commission, 1981.

Ramstrijm LM. Consequences of tobacco dependence-
a conceptual reappraisal of tobacco control policies.
Paper presented at the 37th International Congress
on Alcohol and Drug Dependence; Aug 22,1995; San
Diego (CA).

Rothenberg RB, Koplan Jl'. Chronic disease in the
1990s. Amual Reuiew of Public Health 1990;11:267-96.

US Department of Health and Human Services. Healthy
People 2000: Nafiollal Health Promotion and Disease Pre-
zle,ztiorl Objectizjes. Washington: US Department of
Health and Human Services, Public Health Service,
1991. DHHS Publication No. (PHS) 91-50212.

US Department of Health and Human Services. Guide
to Community Preventme Services [brochure]. Atlanta:
US Department of Health and Human Services, Cen-
ters for Disease Control and Prevention, 1998a.

US Department of Health and Human Services. Tobacco
Use A\?IOIZ~ U.S. Racial/Ethnic Minority Groups-
AfricaI? Americans, American lndiam and Alaska Natives,
Asiarl Americnns and Pacific Islanders, and Hispanics: A
Report of the Surgeon General. Atlanta: US Department
of Health and Human Services, Centers for Disease
Control and Prevention, National Center for Chronic
Disease Prevention and Health Promotion, Office on
Smoking and Health, 1998b.

US Department of Health and Human Services. Healthy
Peoyle 2010 (Conference edition, in two volumes).
Washington: US Department of Health and Human
Services, 2000.

US Department of Health, Education, and Welfare.
Smoking and Health: Report of the Advisory Committee to
the Surgeorz General of the Public Health Service. Wash-
ington: US Department of Health, Education, and
Welfare, Public Health Service, 1964. PHS Publication
No. 1103.

issues ~JI Rrduci,lg Tobacco Use  25