Reducing Tobacco Use

A Report of the Surgeon General

DEPARTMENTOFHEALTHANDHUMANSERVICES
U.S. Public Health Service


CDC
CENTERS FOR DISEASE CONTROL
    AND PREVENTION

Suggested Citation

U.S. Department of Health and Human Services. Reducing Tobacco Use: A Report of the Surgeon
General. Atlanta, Georgia: U.S. 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, 2000.

For sale by the Superintendent of Documents, U.S. Government Printing Office, Washington,
DC. 20402, S/N 017-001-00544-4.

Use of trade names is for identification only and does not constitute endorsement by the
U.S. Department of Health and Human Services.


Message From Donna E. Shalala

Secretary of Health and Human Services

  This nation is faced with many challenges in its efforts to improve the health
status of all people living in the United States. One of the biggest challenges is to
remedy the fact that approximately one-fourth of our adults continue to smoke
and that tobacco use rates among our youth have increased since the early 1990s.
Tobacco use, particularly cigarette smoking, remains the leading cause of prevent-
able illness and death in this country Our overall success in improving the health
status of the U.S. population thus depends greatly on achieving dramatic reduc-
tions in the rate of tobacco use among both adults and young people.

  Reducing tobacco use is a key component of Healthy People 2020, the national
action plan for improving the health of all Americans for the first decade of the
21st century. No fewer than 21 specific national health objectives related to to-
bacco are listed, including a goal to more than halve the current rates of tobacco
use among young people and adults. Attaining all of the Healthy People 2010 to-
bacco use objectives will require significant commitment and progress in numer-
ous areas.

  This Surgeon General's report provides a major resource in our national ef-
forts to achieve the Healthy People 2020 tobacco use objectives. The research find-
ings reviewed indicate that many strategies and approaches have been shown to
be effective in preventing tobacco use among young people and in helping to-
bacco users end their addiction. The challenge to public health professionals, health
care systems, and other partners in our national prevention effort is to implement
these proven approaches.

  Through the Secretary's Initiative to Prevent Tobacco Use Among Teens and
Preteens, the Department works with federal and nonfederal efforts to reduce young
people's demand for tobacco products. This Surgeon General's report highlights
additional strategies and approaches that this initiative can expand upon. Only by
a coordinated national effort will the tobacco use rates among our young people
be reduced. Each day that we delay in developing a comprehensive national re-
sponse to this problem, 3,000 additional teens and preteens become regular smok-
ers. That statistic poses an urgent public health challenge and-given that we
have at hand numerous strategies proven to be effective-a moral imperative.


Foreword

  For more than three decades, the Surgeon General of the U.S. Public Health
Service has released reports focused on tobacco use and the health of the Ameri-
can people. The tone and content of these reports have changed over the years.
Early on, there was a need for critical review of the epidemiologic and biologic
aspects of tobacco use. Today, the deleterious effects are well documented, and
the reports have begun to investigate the social, economic, and cultural conse-
quences of these effects and what can be done to address them. The present
report assesses past and current efforts to reduce the use of tobacco in this country
and thereby ameliorate its disastrous health effects.

  Tobacco use is an extraordinary phenomenon. Although substantial progress
has been made since the initial report of the Surgeon General's Ad Hoc Committee
in 1964, approximately a quarter of the U.S. adult population smokes, and the
percentage of high school youth who smoke has steadily increased throughout the
1990s.

  Results from community-based interventions and statewide programs show
that a comprehensive approach to tobacco control is needed to curtail the epidemic.
This report summarizes several effective approaches to reducing tobacco use and
presents the considerable evidence-as well as the attendant controversies-
supporting their application. Multifaceted school-based education programs that
are performed in conjunction with community-based campaigns have met with
substantial success. The management of nicotine addiction in persons who al-
ready smoke has the benefit of clinical tools, that is, systems for weaning persons
from nicotine, the efficacy of which is clearly demonstrated. Product regulation,
enforcement of clean indoor air standards, and protecting young people from the
supposed attractiveness of cigarettes all promise substantial impact. By analyzing
the economics of tobacco and by examining models that assess the effect of eco-
nomic policies, we find that various approaches can mitigate the adverse outcomes
associated with tobacco use-and can do so without the dire economic conse-
quences claimed by those who profit from tobacco use.

  But if the evidence is clear that tobacco use is harmful and if the tools are
available to reduce its use, why has the reduction in prevalence been less than
would be expected ? The answer is very complex. As described in Chapter 1 of
this report, numerous forces influence a person's decision to smoke, or if that per-
son is a smoker, the forces that drive continued use. The most important force for
smoking is the totality of industry activity, including advertising, promotion,
organizational activity, support for ancillary issues, and political action, which
maintains marketability and profitability of the product. Efforts to reduce tobacco
use face a more than $5 billion annual budget that the tobacco industry dedicates


to advertising and promotion aimed at sustaining or increasing tobacco use. None-
theless, there is cause for optimism based on considerable public support for ef-
forts to prevent children from becoming addicted to tobacco. If the recent pattern
of increases in youth tobacco use can be reversed, we can make progress toward
tobacco-free generations in the future.

Jeffrey I? Koplan, M.D., M.P.H.
Director
Centers for Disease Control and Prevention
and
Administrator
Agency for Toxic Substances and Disease Registry

ii


Preface

    from the Surgeon General,
U.S. Department of Health and Human Services

Almost 50 years ago, evidence began to accumulate that cigarette smoking
poses an enormous threat to human health. More than 30 years ago, an initial
report from the Surgeon General's office made an unqualified announcement of
tobacco's harm. Beginning in 1969, the series of Surgeon General's reports began
meticulous documentation of the biologic, epidemiologic, behavioral, pharmaco-
logic, and cultural aspects of tobacco use. The present report, an examination of
the methods and tools available to reduce tobacco use, is being issued at a time of
considerable foment. The past several years have witnessed major initiatives in
the legislative, regulatory, and legal arenas, with a complex set of results still not
entirely resolved.

This report shows that a variety of efforts aimed at reducing tobacco use,
particularly by children, would have a heightened impact in the absence of
countervailing pressures to smoke. Besides providing extensive background and
detail on historical, social, economic, clinical, educational, and regulatory efforts
to reduce tobacco use, the report indicates some clear avenues for future research
and implementation. It is of special concern to derive a greater understanding of
cultural differences in response to tobacco control measures. Since racial and eth-
nic groups are differentially affected by tobacco, elimination of disparities among
these groups is a major priority.

Perhaps the most pressing need for future research is to evaluate multifocal,
multichannel programs that bring a variety of modalities together. For example,
as Chapter 3 demonstrates, school-based education programs are more effective
when coupled with community-based initiatives that involve mass media and other
techniques. As pointed out in Chapter 4, a combination of behavioral and phar-
macologic methods improves the success rate when managing nicotine addiction.
Synergy among economic, regulatory, and social approaches has not been fully
explored, but may offer some of the most fruitful efforts for the future. Chapter 7
provides the preliminary data on new statewide, comprehensive tobacco control
programs, which offer great promise as new models for tobacco control and com-
bine multiple intervention modalities. Although all aspects-social, economic,
educational, and regulatory-have not been combined into a fully comprehensive
effort, it is exciting to contemplate the potential impact of such an undertaking to
eventually ensure that children are protected from the social and cultural influ-
ences that lead to tobacco addiction, that all smokers are encouraged to quit as
soon as possible, and that nonsmokers are protected from environmental tobacco
smoke.

David Satcher, M.D., Ph.D.
Surgeon General and
Assistant Secretary for Health


Reducing Tobacco Use

Acknowledgments

This report was prepared by the U.S. Department of
Health and Human Services under the general direc-
tion of the Centers for Disease Control and Preven-
tion, National Center for Chronic Disease Prevention
and Health Promotion, Office on Smoking and Health.

Jeffrey l? Koplan, M.D., M.P.H., Director, Centers for
Disease Control and Prevention, Atlanta, Georgia.

James S. Marks, M.D., M.P.H., Director, National Cen-
ter for Chronic Disease Prevention and Health Promo-
tion, Centers for Disease Control and Prevention,
Atlanta, Georgia.

Michael I'. Eriksen, Sc.D., Director, Office on Smoking
and Health, National Center for Chronic Disease Pre-
vention and Health Promotion, Centers for Disease
Control and Prevention, Atlanta, Georgia.

The editors of the report were

Richard B. Rothenberg, M.D., M.P.H., Senior Scientific
Editor, Professor, Department of Family and Preven-
tive Medicine, Emory University School of Medicine,
Atlanta, Georgia.

Terry F. Pechacek, Ph.D., Associate Scientific Editor,
Associate Director for Science, Office on Smoking and
Health, National Center for Chronic Disease Preven-
tion and Health Promotion, Centers for Disease Con-
trol and Prevention, Atlanta, Georgia.

Frank J. Chaloupka, IV, Ph.D., Consulting Scientific
Editor, Professor, Department of Economics, Univer-
sity of Illinois, Chicago, Illinois.

Michael C. Fiore, M.D., M.P.H., Consulting Editor, Pro-
fessor, Department of Medicine, and Director, Center
for Tobacco Research and Intervention, University of
Wisconsin Medical School, Madison, Wisconsin.

Gayle Lloyd, M.A., Managing Editor, Office on Smok-
ing and Health, National Center for Chronic Disease
Prevention and Health Promotion, Centers for Disease
Control and Prevention, Atlanta, Georgia.

Frederick L. Hull, Ph.D., Technical Editor, Technical
Information and Editorial Services Branch, National
Center for Chronic Disease Prevention and Health Pro-
motion, Centers for Disease Control and Prevention,
Atlanta, Georgia.

Contributing authors were

Timothy B. Baker, Ph.D., Professor of Psychology,
Associate Director, Center for Tobacco Research and
Intervention, University of Wisconsin Medical School,
Madison, Wisconsin.

Michele Bloch, M.D., Ph.D., Health Policy Consultant,
Rockville, Maryland.

Ross C. Brownson, Ph.D., Professor and Chair, Depart-
ment of Community Health, School of Public Health,
Saint Louis University, St. Louis, Missouri.

Frank J. Chaloupka, IV, Ph.D., Professor, Department
of Economics, University of Illinois, Chicago, Illinois.

Patricia Davidson, J.D., Staff Attorney, Tobacco
Control Resource Center, Boston, Massachusetts.

Richard A. Daynard, J.D., Ph.D., Chair, Tobacco Prod-
ucts Liability Project, and Professor, Northeastern
University School of Law, Boston, Massachusetts.

Clifford E. Douglas, J.D., President, Tobacco Control
Law and Policy Consulting, Ann Arbor, Michigan.

Brian S. Flynn, Sc.D., Professor and Director, Office of
Health Promotion Research, College of Medicine, Uni-
versity of Vermont, Burlington, Vermont.

Jean L. Forster, Ph.D., M.P.H., Associate Professor,
Division of Epidemiology, School of Public Health,
University of Minnesota, Minneapolis, Minnesota.

Marc Galanter, J.D., John and Rylla Bosshard Profes-
sor of Law, University of Wisconsin Law School, Madi-
son, Wisconsin.

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Surgeon General's Report

Lawrence 0. Gostin, J.D., Professor of Law, Georgetown
University Law Center, and Co-Director, Georgetown/
Johns Hopkins Program on Law and Public Health,
Washington, D.C.

Mark Gottlieb, J.D., Staff Attorney, Tobacco Control
Resource Center, Boston, Massachusetts.

Douglas E. Jorenby, Ph.D., Assistant Professor, Center
for Tobacco Research and Intervention, University of
Wisconsin Medical School, Madison, Wisconsin.

Graham Kelder, J.D., Managing Attorney, Tobacco
Control Resource Center, Boston, Massachusetts.

Robert Kline, J.D., Staff Attorney, Tobacco Control
Resource Center, Boston, Massachusetts.

Jeff McKenna, M.S., Chief, Health Communications
Branch, Office on Smoking and Health, National Cen-
ter for Chronic Disease Prevention and Health Promo-
tion, Centers for Disease Control and Prevention,
Atlanta, Georgia.

Thomas M. Piasecki, MS., Research Associate, Center
for Tobacco Research and Intervention, University of
Wisconsin Medical School, Madison, Wisconsin.

Raymond Porfiri, J.D., Staff Attorney, Tobacco Control
Resource Center, Boston, Massachusetts.

Michael Schudson, Ph.D., Professor, Department of
Communication, University of California, San Diego,
La Jolla, California.

Donald Sharp, M.D., Medical Officer, Office on Smok-
ing and Health, National Center for Chronic Disease
Prevention and Health Promotion, Centers for Disease
Control and Prevention, Atlanta, Georgia.

John Slade, M.D., Professor, New Jersey School of
Public Health, University of Medicine and Dentistry
of New Jersey, New Brunswick, New Jersey.

David T. Sweanor, LL.B., Senior Legal Counsel, Non-
Smokers' Rights Association, Ottawa, Ontario, Canada.

Edward L. Sweda, Jr., J.D., Senior Attorney, Tobacco
Control Resource Center, Boston, Massachusetts.

Gerald J. Thain, J.D., Consumer Law Professor,
University of Wisconsin Law School, Madison,
Wisconsin.

David W. Wetter, Ph.D., Assistant Professor, M.D.
Anderson Cancer Center, University of Texas, Hous-
ton, Texas.

John K. Worden, Ph.D., Research Professor, Office
of Health Promotion Research, College of Medicine,
University of Vermont, Burlington, Vermont.

Reviewers were

David G. Altman, Ph.D., Professor, Department of
Public Health Sciences, Wake Forest University School
of Medicine, Winston-Salem, North Carolina.

Dileep G. Bal, M.D., Chief, Cancer Control Branch,
California Department of Health Services, Sacramento,
California.

Scott D. Ballin, J.D., Vice President and Legislative
Counsel, Office of Public Affairs, American Heart
Association, Washington, D.C.

Glen Bennett, M.P.H., Coordinator, Advanced Tech-
nologies Applications in Health Education Programs,
Office of Prevention, Education, and Control, National
Heart, Lung, and Blood Institute, National Institutes
of Health, Bethesda, Maryland.

Neil Bracht, M.A., M.P.H., Professor Emeritus, School
of Social Work and School of Public Health, Univer-
sity of Minnesota, Minneapolis, Minnesota.

Allan M. Brandt, Ph.D., Professor Emeritus, Depart-
ment of Social Medicine, Harvard Medical School,
Boston, Massachusetts.

Jesse W. Brown, Jr., M. Div., President, National Asso-
ciation of African Americans for Positive Imagery,
Philadelphia, Pennsylvania.

John C. Burnham, Ph.D., Professor of History and Pro-
fessor of Psychiatry, Ohio State University, Columbus,
Ohio.

David M. Burns, M.D., Professor of Medicine, Depart-
ment of Medicine, University of California, San Diego,
California.

Joseph A. Califano, Jr., President and Chairman, The
National Center on Addiction and Substance Abuse,
Columbia University, New York, New York.

Julia Carol, Co-Director, Americans for Nonsmokers'
Rights, Berkeley, California.

vi


Nelba Chavez, Ph.D., Administrator, Substance Abuse
and Mental Health Services Administration, Rockville,
Maryland.

Moon S. Chen, Jr., Ph.D., M.P.H., Professor and Chair,
Division of Health Behavior and Health Promotion,
School of Public Health, Ohio State University, and
Editor-in-Chief, Asian American and Pacific Islander
Journal of Health, Columbus, Ohio.

Gregory Connolly, D.M.D., M.P.H., Director, Massa-
chusetts Tobacco Control Program, Massachusetts
Department of Public Health, Boston, Massachusetts.

Stephen B. Corbin, D.D.S., M.P.H., Chief of Staff, Of-
fice of the Surgeon General, and Chief Dental Officer,
Public Health Service, Rockville, Maryland.

Linda S. Crossett, R.D.H., Health Intervention Scien-
tist, Division of Adolescent and School Health,
National Center for Chronic Disease Prevention and
Health Promotion, Centers for Disease Control and
Prevention, Atlanta, Georgia.

K. Michael Cummings, Ph.D., M.P.H., Senior Research
Scientist and Chair, Department of Cancer Control and
Epidemiology, Roswell Park Cancer Institute, Buffalo,
New York.

Lisa Daily, Associate Director for Planning, Evaluation,
and Legislation, National Center for Chronic Disease
Prevention and Health Promotion, Centers for Disease
Control and Prevention, Atlanta, Georgia.

Ronald M. Davis, M.D., Director, Center for Health
Promotion and Disease Prevention, Henry Ford Health
System, Detroit, Michigan.

Joseph R. DiFranza, M.D., Professor of Family and
Community Medicine, University of Massachusetts,
Worcester, Massachusetts.

Fran Du Melle, Deputy Managing Director, American
Lung Association, Washington, D.C.

John I? Elder, Ph.D., M.P.H., Professor and Head,
Division of Health Promotion, Graduate School of
Public Health, San Diego State University, San Diego,
California.

Ellen Feighery, R.N., M.S., Research Associate, Stanford
Center for Research in Disease Prevention, School of
Medicine, Stanford University, Palo Alto, California.

Reducing Tobacco Use

Burke Fishburn, M.P.P., Health Policy Analyst, Office
on Smoking and Health, National Center for Chronic
Disease Prevention and Health Promotion, Centers for
Disease Control and Prevention, Atlanta, Georgia.

Julie Fishman, M.P.H., Lead Health Policy Analyst,
Office on Smoking and Health, National Center for
Chronic Disease Prevention and Health Promotion,
Centers for Disease Control and Prevention, Atlanta,
Georgia.

Brian R. Flay, D. Phil., Director, Health Research and
Policy Centers, University of Illinois, Chicago, Illinois.

Adele L. Franks, M.D., Associate Director for Science,
Division of Nutrition and Physical Activity, National
Center for Chronic Disease Prevention and Health Pro-
motion, Centers for Disease Control and Prevention,
Atlanta, Georgia.

John A. Gardiner, Ph.D., LL.B., Director of the Office
of Social Science Research, University of Illinois, Chi-
cago, Illinois.

Gary A. Giovino, Ph.D., MS., Senior Research Scien-
tist, Department of Cancer Prevention, Epidemiology,
and Biostatistics, Roswell Park Cancer Institute, Buf-
falo, New York.

Stanton Glantz, Ph.D., Professor of Medicine, Division
of Cardiology, University of California, San Francisco,
California.

Mark M. Hager, J.D., Ph.D., Professor, Washington
College of Law, American University, Washington,
D.C.

William Hansen, Ph.D., President, Tanglewood Re-
search, Clemmons, North Carolina.

James A. Harrell, Commissioner, Administration on
Children, Youth and Families, Administration for Chil-
dren and Families, Washington, D.C.

Jeffrey E. Harris, M.D., Ph.D., Professor, Department
of Economics, Massachusetts Institute of Technology,
and primary care physician, Massachusetts General
Hospital, Boston, Massachusetts.

Sandra W. Headen, Ph.D., Assistant Professor, Depart-
ment of Health Behavior and Health Education, School
of Public Health, University of North Carolina, Chapel
Hill, North Carolina.

vii


Slqeorl Gerleral `s Report

Jack E. Henningfield, Ph.D., Associate Professor of
Behavioral Biology, Department of Psychiatry and
Behavioral Sciences, The Johns Hopkins University
School of Medicine, Baltimore, Maryland, and Vice
President, Research and Health Policy, Pinney Associ-
ates, Bethesda, Maryland.

Thomas l? Houston, M.D., Director of Preventive Medi-
cine and Environmental Health, American Medical
Association, Chicago, Illinois.

Teh-wei Hu, Ph.D., Professor, School of Public Health,
University of California, Berkeley, California.

John R. Hughes, M.D., Professor, Departments of Psy-
chiatry, Psychology, and Family Practice, University
of Vermont, Burlington, Vermont.

Corinne Husten, M.D., M.P.H., Chief, Epidemiology
Branch, Office on Smoking and Health, National Cen-
ter for Chronic Disease Prevention and Health Promo-
tion, Centers for Disease Control and Prevention,
Atlanta, Georgia.

Jonathan B. Imber, Ph.D., Professor, Department of
Sociology, Wellesley College, Wellesley, Massachusetts.

Murray J. Kaiserman, Ph.D., M.B.A., Coordinator,
Research and Surveillance, Office of Tobacco Control,
Health Protection Branch, Health Canada, Ottawa,
Ontario, Canada.

Laura K. Kann, Ph.D., Chief, Surveillance Research
Section, Division of Adolescent and School Health,
National Center for Chronic Disease Prevention and
Health Promotion, Centers for Disease Control and
Prevention, Atlanta, Georgia.

Nancy J. Kaufman, R.N., M.S., Vice President, The
Robert Wood Johnson Foundation, Princeton, New
Jersey.

Beverly Kingsley, Ph.D., M.P.H., Epidemiologist, Of-
fice on Smoking and Health, National Center for
Chronic Disease Prevention and Health Promotion,
Centers for Disease Control and Prevention, Atlanta,
Georgia.

Norman A. Krasnegor, Ph.D., Chief, Human Learning
and Behavior Branch, Center for Research for Moth-
ers and Children, National Institute of Child Health
and Human Development, National Institutes of
Health, Bethesda, Maryland.

Rick Kropp, Executive Director, Tobacco Prevention
and Policy Resources Center, Stop Tobacco Access for
Minors Project and Stop Tobacco Advertising Aimed
at Minors Project, Santa Rosa, California.

Harry Lando, Ph.D., Professor, Division of Epidemi-
ology, School of Public Health, University of Minne-
sota, Minneapolis, Minnesota.

Murray Laugesen, F.F.P.H.M., F.R.C.S., Public Health
Physician, Health New Zealand, Auckland, New
Zealand.

Edward Lichtenstein, Ph.D., Research Scientist, Oregon
Research Institute, Eugene, Oregon.

Douglas S. Lloyd, M.D., M.P.H., Director, Center for
Public Health Practice, Health Resources and Services
Administration, Rockville, Maryland.

Alan D. Lopez, Ph.D., Epidemiologist, Programme on
Substance Abuse, World Health Organization, Geneva,
Switzerland.

Barbara S. Lynch, Ph.D., Consultant, Rockville,
Maryland.

Willard Manning, Ph.D., Professor, Department of
Health Studies, Graduate School of Public Policy Stud-
ies, University of Chicago, Chicago, Illinois.

Paul Marantz, M.D., M.P.H., Associate Professor and
Head, Division of Preventive Medicine, Department
of Epidemiology and Social Medicine, Albert Einstein
College of Medicine, Bronx, New York.

Kristen L. McCall, MXA., Health Communications
Specialist, Office on Smoking and Health, National
Center for Chronic Disease Prevention and Health Pro-
motion, Centers for Disease Control and Prevention,
Atlanta, Georgia.

Sharon Natanblut, Deputy Director, Office of Tobacco
Programs, Food and Drug Administration, Rockville,
Maryland.

Constance A. Nathanson, Ph.D., Professor, Department
of Population and Family Sciences, School of Hygiene
and Public Health, The Johns Hopkins University, Bal-
timore, Maryland.

Thomas E. Novotny, M.D., M.P.H., Centers for Disease
Control and Prevention Liaison, Office of Global
Health, World Bank, Washington, D.C.

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Reducing Tobacco Use

Judith K. Ockene, Ph.D., Professor of Medicine, Depart-
ment of Medicine, and Director, Division of Preventive
and Behavioral Medicine, University of Massachusetts
Medical School, Worcester, Massachusetts.

C. Tracy Orleans, Ph.D., Senior Program Officer,
The Robert Wood Johnson Foundation, Princeton, New
Jersey.

Guy S. Parcel, Ph.D., Professor and Director, Center
for Health Promotion Research and Development, Uni-
versity of Texas Health Science Center, Houston, Texas.

Cheryl L. Perry, Ph.D., Professor, Division of Epide-
miology, School of Public Health, University of Min-
nesota, Minneapolis, Minnesota.

Michael Pertschuk, J.D., Co-Director, Advocacy Insti-
tute, Washington, D.C.

Richard Pollay, Ph.D., Professor of Marketing and
Curator, History of Advertising Archives, Faculty of
Commerce, University of British Columbia, Vancouver,
British Columbia, Canada.

Robert L. Rabin, Ph.D., J.D., A. Calder Mackay Profes-
sor of Law, Stanford University, Stanford, California.

Lars M. Ramstrom, Ph.D., Director, Institute for Tobacco
Studies, Stockholm, Sweden.

Nancy A. Rigotti, M.D., Director, Tobacco Research and
Treatment Center, Massachusetts General Hospital,
and Assistant Professor of Medicine, Harvard Medi-
cal School, Boston, Massachusetts.

Diane Rowley, M.D., M.P.H., Associate Director for Sci-
ence, National Center for Chronic Disease Prevention
and Health Promotion, Centers for Disease Control and
Prevention, Atlanta, Georgia.

Jonathan M. Samet, M.D., Professor and Chairman,
Department of Epidemiology, School of Hygiene and
Public Health, The Johns Hopkins University, Balti-
more, Maryland.

Joseph Sanders, Professor, University of Houston Law
Center, Houston, Texas.

Thomas C. Schelling, Ph.D., Professor, School of Pub-
lic Affairs, University of Maryland, College Park,
Maryland.

Steven A. Schroeder, M.D., President, The Robert Wood
Johnson Foundation, Princeton, New Jersey.

Gary Schwartz, Professor, School of Law, University
of California, Los Angeles, California.

Heather Selin, M.A., Health Policy Analyst, Office on
Smoking and Health, National Center for Chronic Dis-
ease Prevention and Health Promotion, Centers for
Disease Control and Prevention, Atlanta, Georgia.

Donald R. Shopland, Coordinator, Smoking and
Tobacco Control Program, National Cancer Institute,
National Institutes of Health, Rockville, Maryland.

Jesse L. Steinfeld, M.D., Surgeon General, U.S. Public
Health Service, 1969-1973, San Diego, California.

Charyn D. Sutton, President, The Onyx Group, Bala
Cynwyd, Pennsylvania.

Scott L. Tomar, D.M.D., Dr.l?H., Epidemiologist, Divi-
sion of Oral Health, National Center for Chronic Dis-
ease Prevention and Health Promotion, Centers for
Disease Control and Prevention, Atlanta, Georgia.

Kenneth E. Warner, Ph.D., Richard D. Remington Col-
legiate Professor of Public Health, Department of
Health Management and Policy, School of Public
Health, University of Michigan, Ann Arbor, Michigan.

Judith Wilkenfeld, J.D., Senior Advisor for Tobacco
Policy, Food and Drug Administration, Rockville,
Maryland.

Ernst L. Wynder, M.D., President, American Health
Foundation, New York, New York.

Mitchell R. Zeller, J.D., Director, Office of Tobacco Pro-
grams, Food and Drug Administration, Rockville,
Maryland.

Other contributors were

Milonne Ambroise, Program Assistant, Department of
Family and Preventive Medicine, Emory University
School of Medicine, Atlanta, Georgia.

Ruth Atchison, Proofreader, Cygnus Corporation,
Rockville, Maryland.

Mary Bedford, Proofreader, Cygnus Corporation,
Rockville, Maryland.


Surgeon General's Report

Maureen Berg, Desktop Publishing Specialist, Market
Experts, Silver Spring, Maryland.

Brenda Mazzocchi, M.L.S., Technical Information
Specialist, Technical Information and Editorial Services
Branch, National Center for Chronic Disease Preven-

Elizabeth A. Cooper, Program Assistant, University of   tion and Health Promotion, Centers for Disease Con-
Wisconsin Law School, Madison, Wisconsin.       trol and Prevention, Atlanta, Georgia.

Judith A. Corr, Research Assistant, Office of Health
Promotion Research, College of Medicine, University
of Vermont, Burlington, Vermont.

James H. Davis, Research Assistant, Institute for
Legal Studies, University of Wisconsin Law School,
Madison, Wisconsin.

Susan R. Derrick, Program Analyst, Office on Smok-
ing and Health, National Center for Chronic Disease
Prevention and Health Promotion, Centers for Disease
Control and Prevention, Atlanta, Georgia.

Ellen C. Dreyer, R.N., M.S., Project Director, Cygnus
Corporation, Rockville, Maryland.

Jeffrey L. Fellows, Ph.D., Health Economist, Office on
Smoking and Health, National Center for Chronic Dis-
ease Prevention and Health Promotion, Centers for
Disease Control and Prevention, Atlanta, Georgia.

Sue Frank, Technical Specialist, Tobacco Control
Resource Center, Boston, Massachusetts.

Maritta Perry Grau, M.A., Copy Editor, The Write
Touch: Editorial Services, Frederick, Maryland.

Lucy G. Gritzmacher, MS., Librarian, Cygnus Corpo-
ration, Rockville, Maryland.

Laura Hermer, J.D., Staff Attorney, Tobacco Control
Resource Center, Boston, Massachusetts.

Elizabeth Hess, Editor, Cygnus Corporation; Rockville,
Maryland.

Janis B. Hubbard, MS., Indexer, Fredericksburg,
Virginia.

Paulette Clark McGee, Proofreader, Editus, Kearneys-
ville, West Virginia.

Linda A. McLaughlin, Word Processing Specialist,
Cygnus Corporation, Rockville, Maryland.

Robert H. Miller, Ph.D., Director, Tobacco and Peanut
Analysis Division, Agricultural Stabilization and Con-
servation Service, U.S. Department of Agriculture,
Washington, D.C.

Michael D. Morneault, J.D., Morgan, Lewis, and
Bockius Law Firm, Pittsburgh, Pennsylvania.

Paulette Murphy, M.L.I.S., Technical Information
Specialist, Office on Smoking and Health, National
Center for Chronic Disease Prevention and Health Pro-
motion, Centers for Disease Control and Prevention,
Atlanta, Georgia.

Leslie A. Norman; Public Affairs Specialist, Office
on Smoking and Health, National Center for Chronic
Disease Prevention and Health Promotion, Centers for
Disease Control and Prevention, Atlanta, Georgia.

Ward C. Nyholm, Desktop Publishing Specialist,
Cygnus Corporation, Rockville, Maryland.

Lisa Rogers, Administrative Program Manager, Cen-
ter for Tobacco Research and Intervention, University
of Wisconsin Medical School, Madison, Wisconsin.

Ann E. Schensky, Education and Outreach Program
Manager, Center for Tobacco Research and Interven-
tion, University of Wisconsin Medical School, Madi-
son, Wisconsin.

Peggy E. Williams, M.S., Proofreader, Marietta, Georgia.

Patricia L. Mallin, Director of Electronic Advocacy,
Advocacy Institute, Washington, D.C.

William T. Marx, M.L.I.S., Technical Information
Specialist, Office on Smoking and Health, National
Center for Chronic Disease Prevention and Health Pro-
motion, Centers for Disease Control and Prevention,
Atlanta, Georgia.

Trevor A. Woollery, Ph.D., Health Economist, Office
on Smoking and Health, National Center for Chronic
Disease Prevention and Health Promotion, Centers for
Disease Control and Prevention, Atlanta; Georgia.


Reducing Tobacco Use

Chapter 1. Issues in Reducing Tobacco Use, Summary, and Conclusions  3

Introduction 5
Summary and Implications 2.2
Chapter Conclusions 22
References 25

Chapter 2. A Historical Review of Efforts to Reduce Smoking in the United States  27

Introduction 29
Early Events 29

The Rise of the Cigarette  30
Medical Warnings 38
Turning Point: The Surgeon General's Report  40
The Diverse Momentum of the Movement to Reduce Smoking  43
From Antismoking to Nonsmokers' Rights  46
The Impact of the Movement to Reduce Smoking  48
Conclusions 52
References 52

Chapter 3. Effective Educational Strategies to Prevent Tobacco Use Among Young
     People 59

Introduction 62

Recent Research on Educational Strategies for Smoking Prevention  64
Diffusing Programs to Prevent Tobacco Use  80
Conclusions 8.5
References 86

Chapter 4. Management of Nicotine Addiction  95

Introduction 97
Methods for Managing Nicotine Addiction  100
Contemporary Issues in Research on Tobacco Addiction  228
Conclusions 234
References 235

Chapter 5. Regulatory Efforts 157

Introduction 259
Advertising and Promotion 262
Product Regulation 178
Clean Indoor Air Regulation  2 93
Minors` Access to Tobacco  207
Litigation Approaches 223
Conclusions 260
References 262


:urgeon GetTeral's Report

Chapter 6. Economic Approaches 293
Introduction 295
Supply of Tobacco and Tobacco Products  295
Effect of Price on Demand for Tobacco Products  322
Taxation of Tobacco Products  337
Conclusions 359
References 360

Chapter 7. Comprehensive Programs 371

Introduction 373
Conceptual Frameworks 373
Description of Comprehensive Programs  374
Community Intervention Trials 376
Statewide Interventions 382
Components of Community Programs  403
Summary 416
Conclusions 42 7
References 418

Chapter 8.  A Vision for the Future -Reducing Tobacco Use in the New
       Millennium 431

Introduction 433
Continuing to Build the Scientific Base  433
The Changing Tobacco Industry  434
The Need for a Comprehensive Approach  435
Identifying and Eliminating Disparities  436
Improving the Dissemination of State-of-the-Art Interventions  436
Tobacco Use in Developing Nations  437
Tobacco Control in the New Millennium  438
References 439

Abbreviations 441

List of Tables and Figures  443

Index 445


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


Chapter 2
A Historical Review of Efforts to Reduce
Smoking in the United States

Introduction 29

Early Events 29

The Rise of the Cigarette  30

Popularity and Protest 30
The Attraction of Cigarettes  31
Women and Cigarettes 36
Winds of Change 37

Medical Warnings 38

Public Dissemination 38
Toward a Medical Consensus  39

Turning Point: The Surgeon General's Report  40

A Stubborn Norm 40
Economic and Social Impedance  41
Delayed Effects and Delayed Actions  47
From Disease Treatment to Risk Management  42

The Diverse Momentum of the Movement to Reduce Smoking  43

Support From Business 43
The Attack on Advertising  45
Toward a National Policy to Reduce Smoking  4.5

From Antismoking to Nonsmokers' Rights  46

Regulations, Legislation, and Lobbying for Nonsmokers  46
ETS: From Annoyance to Carcinogen  47

The Impact of the Movement to Reduce Smoking  48

Conclusions 51

References 52


Reducillg Tobacco Use

Introduction

  Like many other social phenomena, the use of
tobacco has created a tapestry of themes, motivations,
and social forces, woven together with a complexity
that has begun to capture the interest of social histori-
ans (Brandt 1990; Burnham 1993; Klein 1993; Tate
1999). Tobacco has economic, social, and political
reverberations and is intimately tied to collective im-
ages and attitudes. Nonetheless, some simplification
is possible: the history of tobacco use can be thought
of as the conflict between tobacco as an agent of eco-
nomic gain and tobacco as an agent of human harm.
An exhaustive history would not be content with such
a simple contrast, but it serves the purpose of this chap-
ter. The chief barrier to reducing tobacco use-the path
of most resistance-is a powerful industry whose
efforts to promote tobacco have continued to shape
public opinion and social norms. Against this back-
ground, the chapter considers the underlying forces

Early Events

that have motivated the movement to reduce smok-
ing. Many recent events that are of critical historical
importance for nonsmoking are considered in other
segments of the report (e.g., social advocacy actions
[Chapter 71; taxation-based initiatives in states [Chap-
ter 71; Food and Drug Administration regulations re-
garding minors as the target of tobacco advertising
{Chapter 51; and proposed national legislation, settle-
ment and attempted settlement of various lawsuits
against the tobacco companies, and criminal proceed-
ings against tobacco companies [Chapter 51). As noted
in Chapter 1, some of the most dynamic changes in the
history of smoking control efforts are currently taking
place, and we are not sufficiently distanced from these
events to evaluate them fully. This chapter will con-
sider, rather, the changing thematic content-religious,
hygienic, medical, and social-of the movement to
reduce smoking that has presaged the current events.

  In North America, the history of tobacco use pre-
cedes written records. After American Indians intro-
duced tobacco to the European colonists, tobacco was
transported from the colonies to Europe, where it
quickly became a widely used consumer item. Just as
quickly, however, the use of tobacco became contro-
versial. Critics of the day attacked tobacco use as
morally irresponsible, extravagant, and a habit of
people of base condition (Best 1979). In England, King
James I published an antitobacco tract in 1604 that,
among other things, offered an early critique of sec-
ondhand smoke: the royal author expressed his con-
cerns that a husband who smoked might "reduce
thereby his delicate, wholesome, and cleane complex-
ioned wife to that extremitie, that either shee must also
corrupt her sweete breath therewith, or else resolve to
live in a perpetual1 stinking torment" (quoted in
Apperson 1916, p. 206). In many countries of north-
ern Europe, tobacco use was criminalized (Best 1979).
Part of the objection in England and elsewhere was
that trading gold to Spain for tobacco-the best tobacco

came from Spain's colonies--was dangerous to the
state economy. But with the English colonization of
Virginia and the growing need in England, and else-
where in Europe, for more state revenue, governments
turned their policies around, despite continued moral
objections to tobacco use. King James I himself set
aside his previous objections and sought ways for the
crown to profit from the tobacco trade (Morgan 1975;
Best 1979).

  Of all the novel consumer goods the New World
made available to the Old World, "tobacco enjoyed the
most rapid diffusion" (Shammas 1990, p. 801 among
people of different income levels, who bought it on
a fairly regular basis.  Closer to the source, mass
consumption was even more pronounced: in the
American colonies during the 18th century, yearly con-
sumption averaged between 2 and 5 pounds per capita
(Shammas 1990). When used medicinally, tobacco was
favorably regarded; but in its widespread use for plea-
sure, "it was considered harmful and faintly immoral"
(Morgan 1975, p. 91; see also Stewart 1967).


Sw~eorz Gerzrral's Rqmrt

  Although that reputation for immorality never   one historian reports, "helped to buy American inde-
entirely vanished, by 1776, tobacco was not only a val-   pendence" (Morgan 1975, p. 6). Thomas Jefferson
ued consumer good but also the economic foundation   thought well enough of tobacco to propose that its
of the colonies' independence movement. "King   leaves be carved into the pillars in one of the Capitol
Tobacco Diplomacy" was a central element in gaining   rotundas in Washington (U.S. House of Representa-
French support for the struggling colonies; tobacco,    tives 1969).

The Rise of the Cigarette

  Before the 20th century, tobacco was used pre-
dominantly for chewing, pipe smoking, inhaling (as
snuff), and cigar smoking. The cigarette was an inno-
vation that appeared sometime early in the 19th cen-
tury. The term "cigarette" first made its appearance
in English in the 1840s (Apperson 1916). For reasons
including cost and ease of use (discussed later in this
chapter), the product quickly caught on among tobacco
users. In the United States, cigarette smoking increased
enough during the Civil War for cigarettes to become
subject to federal tax in 1864 (Tennant 1950). But it
was not until its manufacture was mechanized that the
cigarette became a major tobacco product.

  James Albert Bonsack patented a cigarette roll-
ing machine in 1881 that, by the late 188Os, produced
cigarettes at 40 times the rate of a skilled hand worker
(Tennant 1950; Chandler 1977). The mechanization of
cigarette manufacture, like that of a number of other
products in the late 19th century (such as prepared
cereals, photographic film, matches, flour, and canned
food products such as soup), precipitated a marketing
revolution. Industries that developed "continuous
process" production (Chandler 1977, p. 249) could
increase unit production without increasing produc-
tion costs-the main production problem of the day.
The cigarette industry, like these others, could now pro-
duce almost unlimited quantities of product at mini-
mal cost per additional unit. When James Buchanan
Duke installed two Bonsack machines in 1884 and
arranged the next year an advantageous leasing ar-
rangement with Bonsack, his cigarette output soared.
Within a decade, his unit cost of producing cigarettes
dropped to one-sixth of what it had been (Chandler
1977). In 1890, following a series of price wars made
feasible by these cost savings, Duke merged with
several competitors to form The American Tobacco
Company. With the production problem solved and
competition reduced, the focus of business thinking

shifted to marketing. At a time when national adver-
tising of many products was in its infancy, The Ameri-
can Tobacco Company was innovative and expansive
in its promotional efforts (U.S. Department of Health
and Human Services [USDHHSI 1994).

Popularity and Protest

  The growing popularity of cigarette smoking
coincided with the years of populist health reform in
the 19th century. Antitobaccoism was a standard fea-
ture of various writings on personal health, which held
that any "stimulant" was unhealthy (Nissenbaum
1980). Some of these health beliefs were tied to a reli-
gious orientation. Ellen Gould Harmon White, the
prophetess who founded the Seventh-day Adventists,
spoke out strongly against tobacco. In 1848, her first
vision concerning healthful living taught her the reli-
gious duty of abstaining from tobacco, tea, and coffee.
She attacked these products for the money squandered
on them and for their dangers to health. White may
have picked up these views from Captain Joseph Bates,
a Millerite (follower of William Miller, whose
millenarian group believed that the Second Coming
of Christ would occur in 1843). Not until 1855, how-
ever, did tobacco abstention become a larger theme
among the Adventists. In that year, the group's
Reuirzu a& Herald printed two lead articles attacking
"the filthy, health-destroying, God-dishonoring
practice of using tobacco" (quoted in Numbers 1976,
p. 40).

  This protest was an integral part of the complex
antitobacco crusading at the time. In addition to the
religious motif, there was the considerable influence
of the hygiene movement, which branded "tobacco-
ism" a disease, tobacco a poison (Burnham 1989, p. 6),
and dubbed cigarettes "coffin nails" (Tate 1999, p. 24).

30 Chapter 2


Reducing Tobacco Use

Spearheaded by the American Anti-Tobacco Society,
which was founded in 1849, antitobacco critics found
tobacco a cause of ailments ranging from insanity to
cancer. During this time, cigarettes were often con-
sidered narcotics because they seemed to have addict-
ing qualities (Tate 1999). This litany of physiological
ills ascribed to tobacco use did not prove to have the
social power of the announcement, a century later, that
numerous medical studies had found a direct link be-
tween smoking and specific diseases that, as was un-
derstood only in that later century, often took decades
to manifest themselves. Between 1857 and 1872, George
Trask published the Anti-Tobacco Jozmal in Fitchburg,
Massachusetts, attacking the filth (especially of chew-
ing tobacco), the dangers to health, and the costliness
of tobacco (Tennant 1971). Early 19th century popular
health movements tended to ally themselves with
"nature" and "natural" remedies in opposition to pro-
fessional medicine; by the late 19th century, health
movements were more likely to take medical profes-
sionals as their spokesmen (Burnham 1987).

  One such professional was Dr. John Harvey
Kellogg, Seventh-day Adventist and director of the
famous Adventist-founded Battle Creek (Michigan)
Sanitarium, whose main concern was improving diet.
Kellogg argued that tobacco was a principal cause of
heart disease and other illnesses and that it adversely
affected both judgment and morals (Schwarz 1970).
Along with Ellen Gould Harmon White and her hus-
band, a Millerite preacher, Kellogg organized the
American Health and Temperance Association in 1878,
which opposed the use of alcohol, tea, coffee, and
tobacco. Later, Kellogg served as president of the
Michigan Anti-Cigarette Society and, after World War I,
as a member of the Committee of Fifty to Study the
Tobacco Problem.

  Other organizational efforts directed specifically
at cigarettes began in the last two decades of the 19th
century. These efforts were generally directed at sav-
ing boys and young men from the dangers of cigarette
smoking. In New York City, the president of the board
of education, a smoker himself, set up the Consolidated
Anti-Cigarette League and won the pledges of 25,000
schoolboys not to smoke until they turned 21 (Troyer
and Markle 1983).

  The first to call for cigarette prohibition was the
National Woman's Christian Temperance Union
(WCTU) (Tate 1999). Led by Frances Willard, a friend
of Harvey Kellogg, who was further inspired by her
brother's death from smoking-related illnesses, the
WCTU as early as 1875 made plans to instruct mem-
bers of its youth affiliate, the Juvenile Work, about the
dangers of tobacco, as well as the hazards of alcohol.

In 1883, the WCTU established the Department for
Overthrow of Tobacco Habit, which was renamed the
Department of Narcotics in 1885 (Lander 1885; Tate
1999).

  The campaign against tobacco became a perma-
nent part of the WCTU. Reports from their annual
meetings documented the accomplishments of state
and local chapters in combating smoking. In 1884, the
superintendent of the Department for Overthrow of
Tobacco Habit acknowledged the difficulty of the task
before her: "With a spittoon in the pulpit and the vis-
ible trail of the vice in countless churches, with its
entrenchments bearing the seal of respectability, its for-
tifications so long impregnable will yield slowly and
unwillingly to the mightiest opposing forces" (WCTU
1884, p. v). She noted that tobacco was a habit costing
people "more than the support of all [their] ministers
of the gospel" or than the price of educating their chil-
dren; that it caused disease, "especially the loss of sight,
paralysis, prostration, and scores of ailments hitherto
credited to other sources"; and that it "lower[ed] the
standard of morality" (WCTU 1884, p. v).

  The WCTU was one group that pressed with
some success for legislation to prohibit the sale of
tobacco to minors.' By 1890, such laws had been passed
in 23 states. Connecticut and New York enacted pen-
alties for both the underaged smoker and the merchant
who sold to the minor (WCTU 1890). In New York,
the strengthened law arose out of WCTU lobbying.
"We found so many evasions of the law as it stood,"
the WCTU reported at its annual meeting in 1890, "that
we decided our only way to save the boys was to
amend the law, so as to punish the boy who was found
using tobacco in any public place, street or resort"
(WCTU 1890, p. 185). The Department of Narcotics
organized a letter-writing campaign that mobilized
women, educators, and ministers (p. 185). By 1897,
the Department of Narcotics report could proudly
claim, "everything points to the death of the little cof-
fin nail, if our women will only continue faithful"
(WCTLJ 1897, p. 343).

`The laws prohibiting sales to minors began in New Jersey
and Washington as early as 1883, Nebraska in 1885, and
Maryland in 1886. By 1940, all states except Texas had
laws of this sort on the books (Gottsegen 1940). By 1964,
Texas had joined the list, but Louisiana and Wisconsin had
repealed their laws as unenforceable (LJSDHHS 1989).
The legality of the laws was confirmed by the United
States Supreme Court (Austi~~ zl. Ennessre, 179 US. 343,21
S. Ct. 132 [19001), and a Federal Court of Appeals ruled in
1937 to uphold the authority of local jurisdictions to ban
vending machine sales of cigarettes in the effort to protect
minors (USDHHS 1989).

Historical Reuiezu 31


Surgeor Gcrwrd `s` Report

  Announcements of tobacco's death were prema-
ture, but cigarette sales declined in the last years of
the 19th century. Most likely, the decline was precipi-
tated by the "Plug War," in which The American
Tobacco Company bought several plug tobacco pro-
ducers and sharply cut prices, attracting cigarette us-
ers back to other tobacco products. Moreover, as the
country came out of the depression of the 189Os, cigar
smokers who had shifted to the cheaper cigarettes
moved back to their preferred smoke (Sobel1978). But
the campaign against the cigarette certainly had a leg-
islative impact. Cigarettes were prohibited for both
adults and minors by law-if only temporarily-in
North Dakota in 1895, Iowa in 1896, Tennessee in 1897,
and Oklahoma in 1901. Eleven states had some gen-
eral anticigarette legislation by 1901, and almost all
state legislatures had considered curbs on cigarette
sales (Outlook 1901).

  In 1899, Lucy Page Gaston, a WCTU activist, set
up the Chicago Anti-Cigarette League (changed to the
National Anti-Cigarette League in 1901 and to the Anti-
Cigarette League of America in 1911). The league
focused on the dangers of cigarettes to boys. Gaston
sponsored frequent rallies, at which a chorus of young
nonsmoking men provided the music (Duis 1983; Tate
1999). One of the innovations of Gaston's crusade was
the establishment of a smoking cessation clinic in Chi-
cago (Troyer and Markle 1983). Gaston, whose long
career against tobacco would culminate with her bid
for the Republican presidential nomination in 1920 on
an antitobacco platform (New York Times 1920), worked
tirelessly lobbying for antitobacco legislation.

  Such legislation continued to pass, particularly
in midwestern and some western states-Indiana,
Nebraska, and Wisconsin in 1905; Arkansas in 1907;
and Kansas, Minnesota, South Dakota, and Washing-
ton in 1909. But evasion of the laws was apparently
easy. Cigarette "makings" (e.g., cigarette papers and
cigarette tobacco) were sold even if cigarettes were not,
and some retailers sold matches for a higher-than-
usual price and gave away cigarettes with them
(Warfield 1930; Sobell978). Other retailers and smok-
ers evaded the law through a product wrapped in a
tobacco leaf rather than paper (New York Times 1905).

   The WCTU was not alone in its efforts. Several
businesses and prominent individuals were outspo-
ken in the crusade against tobacco use, some going so
far as to support Gaston's proposed (and defeated)
20th amendment to the Constitution that would have
outlawed the manufacture and shipment of tobacco
products (Junod 1997). Henry Ford attacked the habit
of cigarette smoking and enlisted Thomas Edison to
investigate its dangers (Brandt 1990). According to

Harper's Weekly (1910), many railroads and other firms
would not hire smokers. Sears, Roebuck and Com-
pany and Montgomery Ward Holding Corporation
refused to employ smokers (Porter 1947-48). The Non-
Smokers' Protective League of America was estab-
lished in 1911 with a distinguished board of directors,
including Harvey W. Wiley, chief chemist of the U.S.
Department of Agriculture and father of the (1906)
Pure Food and Drug Act; James Roscoe Day, chancel-
lor of Syracuse University; and David Starr Jordan,
president of Stanford University (New York Times
1911). Dr. Charles G. Pease, a physician and dentist,
was the leader of this group. "Almost single-handed,"
according to a New York Times report (1928, p. 71, Pease
won a 1909 prohibition against smoking in the sub-
ways. In 1917, he opposed sending tobacco to Ameri-
can soldiers in Europe.

  But the New York Times reported in 1928 that "little
has been heard from Dr. Pease since" (p. 7). Indeed,
the anticigarette movement by then was waning.
Cigarette prohibition was repealed in Indiana in
1909; Washington in 1911; Minnesota in 1913; Okla-
homa and Wisconsin in 1915; South Dakota in 1917;
Nebraska in 1919; Arkansas, Idaho, Iowa, and Tennes-
see in 1921; Utah in 1923; North Dakota in 1925; and
Kansas in 1927 (Gottsegen 1940). Legislatures in other
states-including Lucy Page Gaston's home state of
Illinois-considered but did not enact anticigarette bills
(Duis 1983). Even the WCTU, at the time judged "the
most powerful and the most formidable organization
which is actively opposing the use of tobacco" (Brown
1920, p. 4471, in 1919 voted against supporting tobacco
prohibition. The organization pledged to keep to an
educational rather than a legislative campaign (New
York Times 1919).

  A major weapon against the tobacco prohibition
movement was the American soldier. Cigarettes had
been popular among the armed forces since the Civil
War. By 1918, during World War I, cigarettes were part
of the army's daily ration (Dillow 1981); soldiers used
cigarettes for relief during the extremes of tedium and
tension characteristic of the profession. General John
Joseph Pershing himself is supposed to have said, "You
ask me what we need to win this war. I answer
tobacco, as much as bullets" (quoted in Sobel 1978,
p. 84).  "The soldiers, we are told, must have their
tobacco," a newspaper editorialized in 1915: "The ciga-
rette is the handiest form in which this can be sent"
(Lymr [Mass.] Ewr7iq News 1915, p. 4). Even the Young
Men's Christian Association altered its antitobacco
stance and, along with the International Red Cross and
other charitable and patriotic organizations, sent ciga-
rettes off to the soldiers in the field (Schudson 1984).


Reducing Tobacco Use

This outspoken, soldier-directed sentiment in favor
of the cigarette was thus a large-scale factor in the
reversal of anticigarette laws. A representative ques-
tion that fueled the repeal effort in Kansas in 1927 was,
"If cigaret[te]s were good enough for us while we were
fighting in France, why aren't they good enough for
us in our own homes?" (Literary Digest 1927, p. 12; see
also Smith 1973).

  Weakened but not vanquished by these legisla-
tive setbacks, the war on tobacco persevered. In 1921,
the Loyal Temperance Legion reported holding anti-
cigarette essay contests, distributing antitobacco blot-
ters in schools, and stubbing out 125,000 cigars and
cigarettes (WCTU 1921). The Department of Narcot-
ics held up its own end; in 1929, for instance, it held
poster contests, cooperated in antitobacco work with

other civic organizations, sponsored 214 debates on
tobacco, and ran essay contests producing more than
50,000 essays against tobacco use (WCTU 1929). Reli-
gious denominations, including the Presbyterians,
Methodists, and Baptists, also took a stand against
tobacco (Troyer and Markle 1983). The antitobacco
position was especially strong among the Mormons
(Latter-day Saints). A motto of the Mormon youth or-
ganization in 1920, "We stand for the non-use and non-
sale of tobacco" (quoted in Smith 1973, p. 3601, seems
to have presaged the current low prevalence of tobacco
use in Utah.

  Such dedicated opponents did not prevent the
popularity of the cigarette-an inexpensive, easy-to-
use form of tobacco product-from increasing in the
1920s (Figure 2.1; the demographic and epidemiologic

Figure 2.1. Adult per capita cigarette consumption and major smoking and health events, United States,
       1900-1999

1964 Surgeon
General's report
1 r Broadcast ad ban
                 Coalescence of

u.3. entry
into WWII

modern advocacy
  movement

First modern

Fairness Doctrine
messages on
broadcast media

Great Depression

1940    1950    1960    1970    1980    1990

  Year

Note: The 1999 data are preliminary.
Sources: Adapted from Warner 1985; U.S. Department of Health and Human Services 1989; Creek et al. 1994;
U.S. Department of Agriculture 2000.

Historical Rezkw 33


Surgeon Getzcrtll's Report

details of cigarette consumption have been docu-
mented in detail in prior reports [USDHHS 1989,1994]
and will not be repeated here). Men in substantial
numbers either switched from other tobacco forms or
took up smoking, and women in smaller but visible
numbers began taking up tobacco use-in the form of
cigarette smoking-for the first time, even as the fre-
quently women-led antitobacco efforts continued. By
the 193Os, cigarettes accounted for more than one-half
of all tobacco consumption (Schudson 1984).
  In response to these trends, the WCTU cam-
paigned for strict enforcement of laws forbidding the
sale of tobacco to minors, attacked advertising that
claimed or suggested health benefits, and criticized
smoking among women. In 1927, the Department of
Narcotics reported that chapters across the country had
sponsored thousands of antismoking events and strat-
egies. For example, the Portland, Oregon, chapter suc-
cessfully protested a leading department store's use
of a female mannequin holding a cigarette. Members
stubbed out 219,560 cigarettes and 39,713 cigars. The
WCTU also lobbied for laws prohibiting smoking in
places where food was displayed for sale and reported
that 21 states had enacted such laws (Schudson 1993).
  As the cigarette's popularity increased, so did
concerns about its health consequences. Serious rt'-
search of the day sought to link tobacco with a variety
of conditions (Burnham 1989), but uncovered little new
ground (Tate 1999), while sobering results were often
lost amid a welter of overblown charges. For example,
the common observation at the time that cigarette
smokers seemed more dependent on their habits than
other tobacco users, now explained by increased blood
nicotine levels (`rate 1999), led one writer in 1912 to
warn that users would naturally progress from tobacco
to alcohol to morphine (Sinclair 1962). Similar unsub-
stantiated charges have often made better headlines
than the results of serious scientific studies over the
years. In 1930, one doctor claimed that 60 percent of
all babies born to mothers who smoked died before
reaching the age of two (Sinclair 1962). Smoking was
said to depress intelligence and academic achievement
(Troyer and Markle 1983). One historian writing in
1931 recalled a widely distributed antismoking poster
that wordlessly voiced these concerns by showing a
woman who had a cigarette in her mouth and was
holding a baby; the poster bore "no words-the mere
presentment, it was hoped, would have a deterrent
effect" (Corti 1931, p. 266).

  That image of mother and child projected an anti-
smoking message that, typical of its time, contained
both a moral and a medical objection to smoking. His-
torian Allan M. Brandt has observed that antitobacco

crusaders early in the century "saw no tension in see-
ing the cigarette as ungodly and unhealthy; they
equated moral dangers and health risks" (Brandt 1990,
p. 159). A 1925 WCTU pamphlet held that because the
brain's higher functions develop last, youthful smok-
ers would have "impaired morals, weak will, lack of
religious and spiritual development, and a shocking
incapacity for unselfishness and consideration of the
rights of others" (p. 9). One of the moral dangers that
remained a theme in anticigarette propaganda was the
danger smoking posed to thrift, as cigarettes were a
needless expense, especially among the poor (Brown
1920).

  Although anticigarette crusaders had medical
objections to smoking, they did not have any medical
consensus behind them. Medical opinion was gener-
ally noncommittal. Most physicians counseled that
tobacco in moderation was not harmful (Hygeia 1928;
Tobey 1930; Johnson 1932). Media reports even located
medical research that suggested that smoking had
health benefits. During World War I, army surgeons
praised cigarettes for providing the wounded relax-
ation and relief from pain (Nez(~ York Times 1918); a Paris
physician claimed that tobacco use might prevent the
development of microbial infections (Nezc, York Times
1923); and a famous mountain climber said that smok-
ing helped breathing at high altitudes (NL>ZO York Times
1922).

  Without a strong medical component, the objec-
tion against tobacco use was scarcely distinguished
from any number of other protest targets of the reform
movement early in the century. Lacking as strong an
opponent as, for example, the alcohol temperance
movement, tobacco use continued unabated. In the
instance of cigarettes, use proliferated.

The Attraction of Cigarettes

  Throughout its boom period, from the 1920s un-
til the mid-1960s, cigarette smoking was generally
regarded as a consumer activity rather than as a medi-
cal problem. In its commercial essence, the cigarette
is simply a "package," as a Philip Morris Companies
Inc. memorandum has suggested, for a "product"
(Cipollone u. Liggett Group, Inc., 505 U.S. 504, 112 S. Ct.
2608 [1992], cited in Lynch and Bonnie 1994, p. 60). In
fact, the cigarette is by far the most commercially suc-
cessful package for the product-tobacco, itself a
delivery device for nicotine-yet devised. Such think-
ing fits well with the notion that consumption is an
act of imagination-that is, that one buys not the prod-
uct but rather the attributes for which the product is
merely the vehicle (Fox and Lears 1983).

34 Clraptrr 2


Reducing Tobacco Use

  Each vehicle for nicotine delivery has different
social propensities. The unique qualities of the cigarette
as a tobacco form were critical in its role as the agent
through which tobacco use was made both available
and acceptable to all social classes. Put simply, ciga-
rettes not only made tobacco cheaper (through auto-
mated production) but also easier to use. This utility
stemmed from several distinctive features that sepa-
rated cigarettes from other modes of tobacco use and
fueled the spread of the smoking habit.

  The first distinctive feature of the cigarette is its
mildness. This attribute, along with its inexpensive
unit cost, made the cigarette especially appealing to
boys. Before the cigarette became popular, adolescent
males were likely to first try smoking by using cigars,
a practice that required a degree of skill to draw in but
not inhale the strong smoke. The unpleasant side
effects resulting from failing this tobacco rite of pas-
sage were largely avoided when new smokers tried
cigarettes, which used a milder form of tobacco that
was meant to be inhaled. Many of the legislative ef-
forts during the 1890s and after were directed not at
tobacco use generally but at cigarettes exclusively be-
cause they were so accessible to boys and young men
and because they were inhaled (Ol~tlook 1901). A 1907
Wisconsin court decision used this issue of adolescent
accessibility to justify a regulatory distinction between
cigarettes and other forms of tobacco. The cigarette,
the decision stated, was able ". . . to remove the pro-
tection which nature placed in the way of acquiring
habits of use of the more vigorous tobacco commonly
used in cigars. Before the day of the cigarette, mas-
tery of the tobacco habit was obstructed by agonies of
nausea usually sufficient to postpone it to a period of
at least reasonable maturity" (State u. Goodrich, 113
N.W. 388, p. 390 [Wis. 19071).

  Mildness was especially characteristic of ciga-
rettes smoked after the 187Os, when cigarette tobacco
was made milder by being flue-cured rather than fire-
cured. Moreover, the stronger Turkish tobaccos that
were popular in the early 20th century became unavail-
able with the interruption of trade during World War I;
thus, blended American tobaccos came into wider use,
making the cigarette an even milder product than be-
fore (Tennant 1950).

  The inhalability of the milder tobaccos used in
cigarettes is the source of a second important distinc-
tion between cigarettes and other forms of tobacco.
Because the smoke of pipes, cigars, and dark tobacco
is relatively alkaline, its nicotine dose is absorbed
through the linings of the mouth and nose. Flue-cured
"blond" or light-colored tobacco, from which Ameri-
can cigarettes are normally blended, produces slightly

acidic tobacco smoke; the nicotine dose thus must be
inhaled to be absorbed. Drawn into the lungs through
cigarette smoking, nicotine is absorbed into the sys-
temic circulation more quickly than in other forms of
smoking-hence the greater potential for nicotine
addiction (Lynch and Bonnie 1994).

  A third distinctive feature of the cigarette is its
relative convenience and disposability. This mild and
quickly consumed tobacco product seemed to contem-
poraries "peculiarly adaptable to the temperament of
the American people in an age when things are done
hurriedly and yet with greater efficiency than at any
previous time" (Young 1916, p. 119). The New York
Tinles editorialized in 1925 that the cigarette was "short,
snappy, easily attempted, easily completed or just as
easily discarded before completion-the cigarette is the
symbol of a machine age in which the ultimate cogs
and wheels and levers are human nerves" (New York
Tir~rs 1925, p. 24). Facility of use was further aug-
mented by the introduction of the safety match just
before World War I (Burnham 1989).

  In short, cigarettes had a "natural adaptability"
to the rhythms of urban life (Tennant 1950, p. 142).
Cigarettes fit more easily than other forms of tobacco
into brief moments of relaxation, they were more
readily used while working, and they were more eas-
ily managed without the use of one's hands. Ciga-
rettes helped combat the tedium of industrial work.
Particularly before workplace smoking restrictions
were widespread, cigarettes could, in the words of one
commentator, "not only help pace out a day-on the
production line, in the typing pool, behind a lunch
counter or waiting on a welfare line-but they could
give you a steady flow of small rewards to keep on
trucking" (Blair 1979, p. 33). Cigarettes organized and
controlled the passage of time; a cigarette, writes Ri-
chard Klein, is "a clock" (Klein 1993, p. 24).

  After World War I, cigarettes, which were less
costly to use than cigars or pipe tobacco, became part
of a more general "throwaway ethic" reflected in other
consumer developments of the day (Busch 1983). The
disposable razor blade came into widespread use dur-
ing and after World War I (Schudson 1984); in 1927,
U.S. wristwatch production surpassed pocket watch
production, as the more conveniently consulted wrist-
watch had won favor among soldiers (Busch 1983).

  Changing attitudes about hygiene also stimu-
lated this predilection for convenience and disposa-
bility. Between 1909 and 193645 states banned the
common drinking cup used in public facilities such
as railroads; the railroads became the first principal
customers for the paper cup and paper cup dispens-
ers (Busch 1983). Disposable sanitary napkins and

Historical Reuieul 35


Kleenex tissues also became mass-market items for the
first time in the 1920s (Busch 1983). From a strictly
hygienic perspective, the cigarette appeared to give a
cleaner smoke than the cigar. A Lucky Strike adver-
tisement directly contrasted the neatness of cigarettes
to the messiness of cigars, which require more oral
manipulation: "Spit Is an Ugly Word, but It's Worse
on the End of Your Cigar" (Tennant 1950, p. 286). This
advertisement also played on an earlier scandal in
which cigar makers were purported to have used spit
to seal the cigar's leaf wrapper (John C. Burnham, tele-
phone conversation with Richard B. Rothenberg, May
25, 1995). For a generation working in offices and
riding to work in subways, streetcars, and automobiles,
milder smoke was less irritating to others. Both the
strong fumes of cigar and pipe smokers and the
unsightly by-products of snuff and chewing tobacco
users were generally more objectionable than the
smoke and ashes of cigarette smokers. Historian
Cassandra Tate has concluded that one of the lessons
of the first antismoking campaign is that "any success-
ful social reform movement carries within it the seeds
of a backlash" while "incessant warnings can fade into
the ozone of the commonplace" (Tate 1999, p. 155).
  An important part of the cigarette's convenience
was its readiness of use. Some smokers still rolled their
own cigarettes in the 1920s and 193Os, but these con-
sumers were a small segment of the market (Tennant
1950). By far, most smokers during these key decades
of rising cigarette popularity used cigarettes prerolled
by the manufacturer. (Cigars were also prerolled, but
by hand rather than by machine, and thus at consider-
able expense to the buyer.) The cigarette's ready-made
convenience was immediately apparent when com-
pared with, for example, the care required to load a
pipe so that it burned neither too quickly (thereby over-
heating the bowl) nor too slowly (thereby requiring
frequent relighting). The cigarette was far more easily
lit and drawn than other smoked tobacco products.
  One final distinctive feature of the cigarette is
its cultural connotation as a minor moral transgres-
sion. Smoking cigarettes is-and has always been-
considered slightly illicit. A practice that "looked so
strange, felt so pleasant, accomplished so little, and
cost so much [although less than cigar or pipe smok-
ing] could not be unopposed" (Tennant 1950, p. 115).
The pleasure it offers is culturally mediated-that is,
part of the pleasure of smoking is the guilt connected
with it. None of the marketing efforts of the tobacco
giants ever fully legitimized the image of smoking-
and there is some suspicion that they never meant to
(Burnham 1993). As one sympathetic cultural observer
has put it, part of the seductive quality of the cigarette

is "beauty [that] has never been understood or repre-
sented as unequivocally positive; the smoking of ciga-
rettes, from its inception in the nineteenth century, has
always been associated with distaste, transgression,
and death" (Klein 1993, p. xi). A modern parallel is
the recent cachet of smoking as a sexual fetish, with
images available on the Internet (Hwang 1996, p. 5).
Culturally, in fact, interviews have shown that ciga-
rettes became a generational marker for the transform-
ing generation that had come of age during World War I,
as well as for the reform-minded generation of the Viet-
nam War era (Tate 1999).

Women and Cigarettes

  Several features of the cigarette helped make it a
particularly suitable product for, and symbol of, the
liberation of women, who came to smoking in grow-
ing numbers beginning in the 1920s. Just as the ciga-
rette "fairly leaped" into its rightful position as "the
smoke of manly men" with the aid of stories and pic-
tures from the World War I front ([New York] Tobacco
Leaf 1914, p. 6, quoted in Young 1916, p. 228), so for
young women after the war smoking was "perhaps
the one most potent symbol" of the new sense of free-
dom and equality (Fass 1977, p. 292). For the growing
number of women who attended college in the 192Os,
smoking was "a welcome form of notoriety" (p. 293).
Objections to women's smoking betrayed a traditional
double standard, for such opposition arose from the
twin cultural perceptions that cigarettes were not moral
and were not feminine. Smoking "implied a promis-
cuous equality between men and women and was
an indication that women could enjoy the same vul-
gar habits and ultimately also the same vices as men"
(p. 294). But while they were tokens of equality with
men, cigarettes were also amorphic, making men ap-
pear more manly and women more womanly (Tate
1999).

  Aware of (and perhaps sharing) these objections,
cigarette manufacturers were initially cautious about
targeting this potential new market. As late as 1924,
the editor of a tobacco trade journal wrote that "all
responsible tobacco opinion [found the idea of women
smoking so] novel.. . that it would not be in good taste
for tobacco men as parties in interest to stir a particle
toward or against a condition with whose beginnings
they had nothing to do and whose end, if any, no one
can foresee" (Wessell924, p. 6). Even advertisements
with women in mind did not dare picture them actu-
ally smoking.

36 Chnpter 2


Reducing Tobacco Use

  This initial caution was dictated by canny atten-
tion to the political environment. Cigarette manufac-
turers feared a backlash in legislation or public
opinion if they too aggressively sought female
consumers (Tennant 1950). In light of anticigarette leg-
islation arising during the 192Os, and particularly in
light of the ongoing experiment in alcohol prohibition,
this anxiety was reasonable.

  The cigarette industry's caution was short-lived.
As the 1920s advanced, appeals to women through
tobacco marketing were increasingly direct. In 1926,
the Chesterfield brand ran a then-controversial
advertisement wherein a woman urged a male com-
panion to "Blow Some My Way" (Ernster 1985, p. 336).
In 1927, Lucky Strike advertisements showed a famous
female opera star recommending Luckies as soothing
to the throat and a famous actress assuring readers that
Luckies did not irritate the throat (Schudson 1984).
And in 1928, Luckies were advertised with the diet-
conscious slogan, "Reach for a Lucky Instead of a
Sweet" (Ernster 1985, p. 336).

Winds of Change

  The industry's direct appeal to the new market
of female smokers likely reflected less boldness than
it did a recognition of a prevailing wind of cultural
change, of which the women's movement was only a
single component. In the 192Os, on the heels of the
19th Amendment, women's growing assertion of their
equality with men was part of a larger shift in Ameri-
car. culture, the move to a more modern culture from
the somewhat puritanical milieu that supported the
populist reform movement. In the language of one
observer, the change was from a culture of middle-class
respectability to one of "lower-order parochialism"
sponsored and encouraged by industries that catered
to the minor vices (Burnham 1993, p. 16). The 1920s
saw the triumph of "a new behavioral ethic" (Brandt
1990, p. 157), one of consumerism and self-indulgence
rather than the self-denial that had been, for example,
the traditional lot of women. Through the marketing
of cigarettes, the tobacco companies strategically ex-
ploited this development among the less puritanical
and self-recriminating members of both sexes.

  Even at the time, opinion was divided on whether
the massive marketing efforts of the cigarette giants
motivated the change toward a society of smokers
or only took advantage of a cultural and behavioral
shift already under way. In 1940, by which time the

cigarette had clearly triumphed over other forms of
tobacco, one study of the tobacco industry concluded,
"how much of increased cigarette consumption is due
to advertising and how much to fashion is impossible
to determine. The latter influence is still imponder-
able" (Gottsegen 1940, p. 204).

  Fashion and advertising were not the only two
factors. Three other matters were potentially impor-
tant: (1) the physical product itself was not a constant,
(2) the price was variable, and (3) society changed in
ways that influenced consumption. For example,
before the explosion of cigarette marketing in 1914
(Burnham 1989), men smoked more than women, the
rich smoked more than the poor, and urban dwellers
smoked more than rural inhabitants. (For a more com-
prehensive account of the demographic dynamics, see
USDHHS 1989.) With growth in the movement for
women's equality, a rising per capita income in real
dollars, and the long-term trend toward urbanization,
there would likely have been an increase in cigarette
sales even if tobacco companies had not marketed the
product aggressively.

  Regardless of what directed the impetus, per
capita consumption of all forms of tobacco was remark-
ably steady from 1913 to 1945 (Figure 2.11, rising when
real income per capita rose, falling when real income
fell (Tennant 1950). The spectacular growth in ciga-
rette consumption reflected not only the introduction
into the tobacco market of new consumer groups (such
as women) but also, as was previously noted, a major
shift among existing male smokers from other forms
of tobacco use to the cigarette. Annual per capita con-
sumption of tobacco hovered at 7 pounds from 1915
through the late 193Os, except for a transient decline
in the early 1930s that was coincident with a drop in
per capita income in the early years of the Great De-
pression (Tennant 1950). It is possible, however, that
actual consumption of tobacco per unit of weight in-
creased because of less work in both the manufactur-
ing and the use of the increasingly popular cigarette.
World War II, like World War I, served to increase and
promote cigarette smoking, to which numerous war
novels, movies, and other public images testify (Klein
1993). A 1943 treatise observed that the cigarette
achieved a heroic standing from its association with
soldiers during World War II (Gehman 1943). In short,
between about 1920 and 1950, "cigarettes became an
acceptable and noncontroversial part of U.S. life"
(Troyer and Markle 1983, p. 124).

Historical Review 37


Surgeorl Grrwal's Report

Medical Warnings

  Medical opinion at first took little heed of the
growing popularity of cigarettes. Physicians tended
to take an ambivalent or qualified position on the ciga-
rette phenomenon. For instance, although Dr. James
J. Walsh wrote in 1937, "We physicians of the older
generation who have seen the smoking of cigarettes
grow from what seemed scarcely more than a toy into
what is now one of the most significant of social insti-
tutions are under an obligation to the rising genera-
tion to warn them of the serious dangers associated
with the abuse of cigarettes in our day" (Walsh 1937,
p. 665), even Walsh admitted to smoking an occasional
cigarette himself. He further attested that many doc-
tors he knew smoked 20 or 30 cigarettes a day and yet
were "as healthy as the proverbial trout" (p. 665). He
held that "not the cigarette smoke so much as the ex-
cess of it" (p. 665) brought about serious conditions
like Buerger's disease.

  The Puritan temperament that had fueled anticiga-
rette activity early in the century was on the defensive.
Antipathy to Puritan moralism was strong enough to
weaken faith in any research tainted by it. For example,
Alton Ochsner's suggestions in the 1930s and 1940s of
a connection between cigarette smoking and lung can-
cer were discounted by his colleagues because he was
known to be "an anti-smoking enthusiast" (Burnham
1989, p. 18). During these crucial times when cigarette
smoking became widespread, "physicians tended to
absorb the common sense of the general population"
(p. 11). By the 193Os, common sense, in some measure
influenced by the advertising claims of the era, held that
smoking in moderation was not a health hazard
(Burnham 1993).

  In 1938, Raymond Pearl published one of the first
significant epidemiologic studies that indicated smok-
ing to be "statistically associated with an impairment
of life duration" (Pearl 1938, p. 217, quoted in Breslow
1982, p. 134; see also Brandt 1990). But only in the late
1940s and early 1950s did definitive evidence begin to
accumulate from various sources and studies show-
ing the association between cigarette smoking and
overall mortality. First retrospective and then large-
scale prospective studies confirmed that smoking was
associated with higher death rates; excess mortality
was especially pronounced for coronary artery disease
and lung cancer.

  In the late 1940s and early 195Os, research linked
lung cancer to smoking. The initial report by Wynder

and Graham (1950) just preceded an article by Doll
and Hill (1950). Subsequent articles by Doll and Hill
(19521, Levin (19531, and others confirmed the asso-
ciation. Levin's contribution was of particular inter-
est, because he derived the formula for attributable risk
in a footnote to the article-an overt demonstration of
the link between the smoking etiology and the emerg-
ing methodology of epidemiologic analysis.

Public Dissemination

  The findings from these and other studies of the
era were publicized in a 1952 Christian Herald article.
In December 1952, that article was reprinted in the
widely circulated magazine Reader`s Digest as "Can-
cer by the Carton" (Norr 1952). Popular concerns
aroused by this publicity apparently led to an almost
immediate decline in cigarette consumption (Tennant
1971). The decline was temporary but severe enough
to lead the tobacco companies to step up their market
promotion of the relatively new filter-tip cigarette.
Originally intended to attract new smokers by offer-
ing a milder smoking experience, the filtered cigarette
assumed a marketing prominence that was seen as a
tacit acknowledgment that there might be a health risk
in smoking (Fortune 1953). Whether for smoking com-
fort or for supposed health advantage, the market
share of filter brands increased from less than 1 per-
cent in 1952 to 73 percent in 1968 (Tennant 1971).

  The nonprofit consumer advocacy organization
Consumers Union paid attention to smoking through-
out the 1950s. Early mentions in the organization's
monthly magazine Comurner Reports, like so much
commentary elsewhere, warned only against excessive
smoking. In 1953, Consumer Reports found the evidence
connecting smoking to lung cancer "suggestive" and
recommended that until further research results were
available, "those who can" should reduce smoking to
a "moderate" level, which was defined as not more
than one pack a day (p. 74). In the same issue, how-
ever, the magazine reminded readers that smoking had
health benefits; specifically, smoking reduced "the
inner nervous tensions and strains resulting from
man's exposure to the stresses and responsibilities
imposed by society" (p. 74). Smoking, the magazine
further observed, relieved such pressure in a way less
harmful than alcohol or overeating (Consumer Reports
1953).

38 Chapter 2


Reducing Tobacco Use

  In 1954, medical advisers for Consumers Union
spoke more strongly about the research link between
smoking and lung cancer, but the organization
remained vague in its advice to smokers (Consumer
Xeports 1954). In the absence of further scientific sup-
port, this tentativeness was not surprising. It was hard
to imagine that a habit so widespread, so apparently
normal, so integrated into American culture, and so
ennobled by its wartime use could turn out to be fun-
damentally destructive. In 1954, the American Can-
cer Society's (ACS) Tobacco and Cancer Committee
adopted a resolution recognizing an association be-
tween cigarette smoking and lung cancer (Breslow
19821, but the board of directors did not consider the
possibility of a causal association. Efforts of the phy-
sician members of the board were blocked by lay mem-
bers in meetings that were themselves "filled with
smoke" (Breslow 1977, p. 849).

  By 1958, Consumers Union agreed that the medi-
cal research provided nearly definitive evidence on
the risk of lung cancer posed by smoking. The organi-
zation further argued that smokers should not try to
allay their concerns by switching to filter cigarettes, as
no evidence indicated that filters reduced the risk of
cancer. Smokers were thus advised "to cut out or cut
down" on cigarettes (Consunler Reports 1958, p. 636).

Toward a Medical Consensus

  With growing sentiment, in and beyond the
medical community, that there were serious risks to
tobacco use, government agencies became more con-
cerned about tobacco advertising that stated or implied
health benefits to the cigarette. Several times during
the 195Os, the Federal Trade Commission (FTC) issued
orders against cigarette advertising that made health
claims. Congress also took an interest in tobacco
advertising; in 1957, Representative John A. Blatnik
(D-MN) held hearings on deceptive filter-tip cigarette
advertising (Neuberger 1963). The Surgeon General
first brought the Public Health Service into the scene
by establishing a scientific study group in 1956 to ap-
praise the effects of smoking on health. The study
group determined that there was a causal relationship
between excessive smoking of cigarettes and lung
cancer. Surgeon General Leroy E. Burney issued a
statement in 1957 that "the weight of the evidence is
increasingly pointing in one direction: that excessive
smoking is one of the causative factors in lung can-
cer" (Burney 1958, p. 44). In an article he subsequently
published in the Journal of the American Medical Asso-
ciation, Burney reiterated this view and went even

further: "The weight of evidence at present implicates
smoking as the principal etiological factor in the
increased incidence of lung cancer" (Burney 1959,
p. 18351.

  Much of the medical profession, however,
remained ambivalent on the issue. In an editorial sev-
eral weeks after Burney's article, the journal itself ar-
gued against taking the Surgeon General too seriously:
"Neither the proponents nor the opponents of the
smoking theory [that cigarette smoking causes cancer]
have sufficient evidence to warrant the assumption of
an all-or-none authoritative position" (Talbott 1959,
p. 2104).

  In June 1961, the presidents of the ACS, the
American Public Health Association, the American
Heart Association (AHA), and the National Tubercu-
losis Association (later the American Lung Association
[ALA]) urged President John F. Kennedy to establish
a commission to study the health consequences of
smoking (U.S. Department of Health, Education, and
Welfare [USDHEW] 1964). Early in 1962, representa-
tives of these organizations met with Surgeon General
Luther L. Terry, who then proposed establishing an
advisory committee to assess available knowledge and
make recommendations concerning smoking and
health. In April, Terry provided the Secretary of
Health, Education, and Welfare a fuller proposal ask-
ing to reevaluate the Public Health Service's position
on smoking. Among the factors prompting his call for
action, Terry cited new studies on the adverse conse-
quences of smoking, the 1962 Royal College of Physi-
cians report (which had been summarized that year in
Reader's Digest [Miller 1962]), and other evidence of a
shift in medical opinion against smoking as well as
similar views among the national voluntary organiza-
tions. Terry also pointed to efforts to reduce tobacco
use in Britain, Denmark, and Italy; to Senator Maurine
(Brown) Neuberger's (D-OR) proposal that Congress
create a commission on smoking; and to a request from
the FTC for guidance on the labeling and advertising
of tobacco products.

  In the summer, Terry announced the appoint-
ment of a committee to review all of the data on the
medical effects of smoking. The committee was es-
tablished after consultation with representatives of
relevant government agencies, the voluntary health or-
ganizations, the American Medical Association (AMA),
the American College of Chest Physicians, and the
Tobacco Institute. Each organization was empowered
to veto any names proposed for the committee; people
who had taken public positions on the questions at
issue were eliminated from consideration.

Historical Review 39


Surgeon Ger7eral's Report

  While the committee reviewed the data, actions
were being urged or taken in response to the evidence
that had emerged. Leroy Collins, former governor of
Florida and president of the National Association of
Broadcasters, urged broadcasters in 1962 to "make
corrective moves" on their own to limit or regulate
tobacco advertising to which children might be ex-
posed. "We cannot ignore the mounting evidence that
tobacco provides a serious hazard to health," he as-
serted (Nezo York Ti777es 1962, p. 71). Also in 1962-a
busy year for efforts to reduce smoking-Air Force

Surgeon General Major General Oliver K. Niess
ordered an end to the distribution of free cigarettes in
Air Force hospitals and flight lunches (Neuberger
1963). Smoking education was a growing phenom-
enon in public schools, where materials were provided
by the ACS and other voluntary organizations. Church
groups (particularly the Seventh-day Adventists) and
temperance organizations continued their campaign
against smoking. And although the AMA remained
silent on the issue, at least eight state medical societies
had adopted resolutions on smoking and health.

Turning Point: The Surgeon General's Report

  Social movements may be precipitated or
strengthened by events that "dramatize a glaring con-
tradiction between a highly resonant cultural value
[such as health] and conventional social practices [such
as smoking]" (McAdam 1994, p. 40). Rarely in social
history, however, can a single such event be identified
as a key source of social change. The publication of
the 1964 Surgeon General's report on smoking and
health might qualify as such a rarity. The Surgeon
General's report consolidated and legitimized I5 years
of growing evidence of the dangers of smoking to
health (USDHEW 19641. Its publication "marked the
beginning of a revolution in attitudes and behaviors
relating to cigarettes" (Brandt 1990, p. 156). "Begin-
ning" should be stressed, because abandonment of
cigarettes was not precipitous. Smoking prevalence
did begin a persistent but hardly precipitate decline
in 1965 of 0.5 percent per year (USDHHS 1989).
Cigarette sales kept increasing and would not peak
until the late 1970s. Although per capita cigarette con-
sumption reached its highest level in 1963, the year
before the report's publication, it did not begin a steady
year-to-year decline until 1973 (USDHHS 1994).

  Thus, the Surgeon General's report was certainly
a pivotal event, but it did not change smoking pat-
terns overnight. Why this was so-why people did
not, upon learning of the report's findings, immedi-
ately cease either beginning or continuing to smoke-
is a complex phenomenon, even if one disregards the
major role of nicotine addiction. On the one hand,
a change in behavioral norms can be precipitated by
a change in what people generally believe. On the
other hand, people do not always act in their own

best interests, even in response to clearly stated facts
(Schudson 1984; USDHHS 19891. The outcome in a
conflict between cultural mores (in this instance, be-
liefs instilled through the social, behavioral, and physi-
ological habit of smoking; reinforced by marketing)
and scientific fact (as represented in the widely publi-
cized findings of the Surgeon General's report) often
depends on how the -latter is diffused-that is, on
whether new information can become so broadly and
effectively. transmitted and received that it .becomes
accepted knowledge that then supplants habit. As one
sociologist has observed, "The diffusion of new knowl-
edge is a major cause of collective searches for new
norms in the modern world" (Davis 1975, p. 53).

A Stubborn Norm

  In the case represented by the Surgeon General's
report, the diffusion of new knowledge was impeded
by the entrenched norm of smoking, a widespread
practice fueled by the persistent and pervasive mar-
keting of cigarettes (see "Advertising and Promotion"
in Chapter 5). During the decade preceding the
report, many social norms were established or
strengthened through the dominant new. mass
medium, television. Whatever effect television adver-
tising had on cigarette sales, the constant presence of
cigarettes both in advertisements and in the real and
imaginary lives of the medium's "stars" was a strong
force in reinforcing smoking as a norm. Furthermore,
TV-related marketing coincided with, and helped bring
to the public's attention, the availability of the filter-
tipped cigarette-thereby not only reinforcing the

40 Chapter 2


Reducing Tobacco Use

smoking norm but also helping screen the imputed
health hazards of smoking (USDHHS 1994).

  The smoking norm could be found in the most
unlikely settings and thus gave rise to considerable
cognitive dissonance. The first significant government
response to the report was the FTC's 1964 ruling that
warning labels be required on cigarette packs and that
tobacco advertising be strictly regulated (see "Attempts
to Regulate Tobacco Advertising and Packaging" in
Chapter 5). The resulting legislation that was passed,
however (the Federal Cigarette Labeling and Adver-
tising Act of 1965 [Public Law 89-9211, undermined
much of the original proposal's strength by requiring
a more weakly worded warning label than the FTC had
proposed (USDHHS 1994). Furthermore, the act not
only preempted the FTC's ruling but also prohibited
the FTC or any other federal, state, or city authority
from further restricting cigarette advertising until
after the expiration of the law on June 30,1969. In 1969,
former Surgeon General Terry would refer to the 1965
act as a "hoax on the American people" (U.S. House of
Representatives 1969, p. 267, citing Dr. Terry).

  This dissonance between legislative intent and
legislative action was detectable, in more than one
sense, in the smoke-filled congressional hearings at the
time. In 1967, for example, when Dr. Paul Kotin,
director of the Division of Environmental Health Sci-
ences, National Institutes of Health, came to testify
about the health hazards of cigarette smoking, Sena-
tor Norris Cotton (R-NH) asked, "Is it going to preju-
dice anybody if I smoke my pipe?" Dr. Kotin replied,
"I trust it won't prejudice anybody any more than my
smoking my pipe will" (U.S. Senate 1968, p. 14). Dr.
Kotin's smoking was a topic of conversation again in
congressional hearings in 1969. Dr. Kotin along with
Surgeon General William H. Stewart, Dr. Kenneth Milo
Endicott (director of the National Cancer Institute), and
Dr. Daniel Horn (director of the National Clearing-
house on Smoking and Health) came together to tes-
tify in favor of stronger health warnings on cigarette
packages and legislation requiring similar warnings
in all cigarette advertising. At one point, Representa-
tive Dan H. Kuykendall (R-TN) asked Surgeon
General Stewart, "Isn't [Dr. Kotin] one of the most
knowledgeable men in this field?" When the Surgeon
General replied affirmatively, Kuykendall returned,
"Why doesn't he quit smoking?" Kuykendall then
directly asked Kotin whether he was sure that smok-
ing a pipe did not cause lip cancer; Kotin responded,
"A risk I am willing to take, sir" (U.S. House of Repre-
sentatives 1969, p. 167). The next day, Representative
Tim Lee Carter (R-KY) observed that, in fact, all four
of the men in the delegation, including the Surgeon

General, were smokers (U.S. House of Representatives
1969). Actions undermine words, and scenes such as
these were symbolic of a strong wish not to believe in
the health consequences of smoking. Given that the
nation's chief health policymakers did not, or were not
able to, apply to their own behaviors the very evidence
they had gathered, the strength with which the smok-
ing norm persisted among the general population is
more easily comprehended.

Economic and Social Impedance

  General economic conditions also supported the
continuation of smoking. The 1960s and early 1970s
was a time of general prosperity. Real cigarette prices
rose in the 1960s but declined in the 1970s (USDHHS
1994). The affordability of cigarettes increased from
1965 to 1980 and served as an economic counterweight
to the growing awareness of tobacco's ill effects (Lynch
and Bonnie 1994) (see also "Effect of Price on Demand
for Tobacco Products" and "Taxation of Tobacco Prod-
ucts" in Chapter 6).

  Another compelling social condition may have
further limited the initial impact of the Surgeon
General's report. From the early 1960s to 1973, Ameri-
can military personnel were engaged in Vietnam.
During this period, 8.7 million Americans served in
the military, including 2.7 million in Vietnam (Moss
1990). Whether the Vietnam War encouraged smok-
ing has not been a topic of speculation, probably
because of that war's more publicized role in suppos-
edly encouraging the use of marijuana and other drugs
(Klein 1993). But the norm of smoking would only
have been strengthened by the mobilization of a large
military force bringing several million young men and
women into a setting where smoking was tradition-
ally held to offer relief from both stress and boredom,
and where it was part of a lingering cultural image of
the heroic soldier. Moreover, the prevalence of ciga-
rette smoking was and has remained higher in the
military than in the population at large (in 1992,35 vs.
26 percent) (Lynch and Bonnie 1994).

Delayed Effects and Delayed Actions

  A significant biologic explanation for the delayed
effect of the 1964 report can be found in the delayed
progression of smoking-related diseases, which
generally take substantial time to fully manifest
themselves in chronic illness and death. The cigarette's
tremendous growth in popularity during the decades
preceding the Surgeon General's report would thus

Historical Rezlieup 41


Srrrgeo77 Gcrreral's Report

have only begun to show its vast health consequences.
In 1965, an estimated 180,000 persons died from
smoking-related diseases (USDHHS 1989); over the
next two decades, that yearly estimate increased to
337,000, even though smoking prevalence had been
steadily declining since the early 1970s (USDHHS
1989). First-time or long-time smokers in the mid-1960s
to mid-1970s thus had far less opportunity than the
next generation to personally witness the tragic but
convincing demonstration of the health consequences
of smoking. It might be hypothesized that this som-
ber proof of the Surgeon General's report at last evoked
a meaningful response among the surviving relatives
and friends of the deceased.

From Disease Treatment to Risk
Management

  Another possible reason for the delayed response
to the Surgeon General's report was its less-than-
traditional medical perspective. The report's medical
researchers were reporting not the kind of traditional
clinical data that physicians were used to encounter-
ing in their literature but rather data from epidemio-
logic studies that indicated the risks of smoking.
Eventually, such data would be persuasive enough to
mark a perceptual shift to "a new kind of numeracy
among medical researchers and clinicians alike"
(Burnham 1989, p. 19). But in 1964, most physicians
were not prepared to understand-much less be per-
suaded by-the epidemiologic data represented in the
report, nor to incorporate a public health model into
their medical practice.

  Accordingly, the medical profession did not
quickly jump on the smoking reduction bandwagon
that began rolling with the Surgeon General's report.
The American Medical Association Alliance House of
Delegates, in fact, refused to endorse the report when
it appeared in 1964 (Burnham 1989). Medical person-
nel increasingly warned people against smoking, but
this precept did not carry over into practice. In 1964,
smoking remained as acceptable in medical settings
as it was elsewhere. Moreover, although 95 percent of
physicians in that year saw smoking as hazardous, 25
percent continued to smoke (Burnham 1989); even by
the mid-1970s, nearly one in five physicians was a
smoker (Nelson et al. 1994). The AMA was criticized
by other health organizations for not taking a more
aggressive stance to reduce tobacco use. As late as
1982, for example, the association was faulted for help-
ing prepare for Newszueek a 16-page "personal health
care" supplement, in which the only advice provided

on smoking was that a smoker should discuss the risks
with a personal physician and should refrain from
smoking in bed (Iglehart 1984). Soon thereafter, the
AMA had become an active advocate (see "Toward a
National Policy to Reduce Smoking," later in this chap-
ter). By 1990-1991, only 3.3 percent of physicians
smoked, although smoking rates among nurses were
significantly higher (Nelson et al. 1994).
  Some social critics of the time tacitly welcomed
what they saw as a rare reluctance by the establish-
ment to embrace a social movement. Sociologists and
other outside observers of American medicine had
noted a previous tendency of the establishment to
"medicalize" social problems, such as tobacco use and
alcohol abuse. From this perspective, medicine was
viewed askance as an "institution of social control,"
as a "new repository of truth, the place where abso-
lute and often final judgments are made by suppos-
edly morally neutral and objective experts" (Zola 1972,
p. 487). Implicit in this criticism was the fear that the
medical establishment was using its considerable
clout-its professional domination of the world of
facts-to translate all social ills into clinical terms that
could be treated in a clinical setting. One such critic,
medical sociologist Eliot Freidson, wrote that the phy-
sician who calls alcoholism a disease "is as much a
moral entrepreneur as a fundamentalist who claims it
is a sin" (Freidson 1974, p. 253).

  But the medical establishment's initial hesitancy
to join the movement to reduce smoking likely had
little to do with scruples about overstepping its pur-
view. There is no dispute that cancer is a disease and
little dispute that the medical profession is the expert
social authority for defining and treating it. The "moral
entrepreneurship" of the Surgeon General's 1964 re-
port was not to declare cancer a medical problem but
rather to declare smoking a health risk-hence the cen-
tral position of epidemiologic data in the report.

  Thus, while organized medicine followed slowly
and sometimes reluctantly in the wake, and while so-
cial skeptics worried about the Orwellian implications,
a battery of public health officials, politicians, and con-
sumer advocates, armed with the findings of the Sur-
geon General's report, moved against the persisting
social and medical problem of smoking. Ultimately,
the broad cultural current that distrusted medical moral
entrepreneurship embraced these efforts. The "de-
medicalizing" movement, which sought to make health
care both a personal matter and a political matter rather
than one wholly under the guardianship of physicians
(Starr 1982), supported a practice of medicine that took
a preventive stance instead of an exclusively therapeu-
tic one. Preventive action-to prevent smoking, and

42 Chapter 2


thereby to prevent unnecessary illness and death from   called for in the epidemiologically based recommen-
smoking-related illnesses-was precisely the solution   dations of the 1964 Surgeon General's report.

The Diverse Momentum of the Movement to Reduce Smoking

  Another reason for the languid pace of change
in smoking prevalence after 1964 is that it took time to
assemble an active dissemination and lobbying force
around the Surgeon General's report. In the present
period, so many different groups are active in anti-
smoking activity, and so many different strategies are
operating, that sorting them becomes difficult. Since
1964, the campaign to reduce smoking refers to "the
entirety of changes in the social environment spawned
by scientific and social interest in the hazards of smok-
ing" (Warner 1989, p. 144); this movement covers not
only specific activities but also "the changing social
norms that have accompanied them" (p. 144). The span
of activities involves persons, private organizations,
and government agencies, all with different motiva-
tions: those ideologically committed to a movement
to reduce smoking, those who operate profit-making
businesses, those seeking public office, and those in
public office who mandate laws and regulations.
Important actors have included national health orga-
nizations, medical researchers, organized medicine,
government regulatory agencies and health depart-
ments, school officials, voluntary organizations in
health, lobbying groups for reducing smoking, private
firms dealing with the health or insurance needs of
employees, smoking cessation clinics, and individual
medical practitioners.

  The industry-funded Tobacco Institute began
distributing smoking education materials in 1984
KJSDHHS 19941, although with a different agenda. For
example, the institute's "It's the Law" program pur-
ports to discourage minors from purchasing cigarettes
(Tobacco Institute 19901, but the program focuses on
the legal responsibilities of the purchaser rather than
the vendor, characterizes smoking as an "adult behav-
ior" (which may make it more attractive to adoles-
cents), does not address the dangers of smoking, and,
in one assessment, was ineffective in preventing ille-
gal sales (DiFranza et al. 1996).

  The work of the Tobacco Institute highlights what
may be the foremost obstacle to changing the social
norm of smoking: the multifaceted actions of the

industry in preventing prevention. In an analysis of
tobacco industry tactics, the Advocacy Institute (1995)
has defined nine areas of activity: intimidation, alli-
ances, front groups, campaign funding, lobbying,
legislative action, buying expertise, philanthropy, and
advertising and public relations (see the text box). In
its discussion of well over 100 instances in these areas,
documented largely from media reports, the Advocacy
Institute does not accuse the tobacco industry of ille-
gal activity but rather of a far-ranging and systematic
effort to ensure the continued use of tobacco. Taken
together, and backed by the enormous resources of the
industry, these efforts have considerable impact in pro-
moting tobacco use and retarding efforts to reduce or
prevent it. Because of the considerable litigation now
directed at the industry, however (see Chapter 51, the
public is more aware of these efforts and may prove
more resistant than previously to this powerful com-
mercial s:lbterfuge.

Support From Business

  The supportive role of businesses in the move-
ment to reduce smoking probably did not arise from a
spontaneous realization that preventive measures
could improve employee health. Already shoulder-
ing new costs from complying with health-related (but
non-tobacco-related) new federal legislation, such as
the Occupational Safety and Health Act of 1970 (Pub-
lic Law 91-596) and the Toxic Substances Control Act
(1976) (Public Law 94-4691, many companies in the
1970s sought ways to control the rapidly rising costs
of health care (Iglehart 1982). Supporting or enacting
policies to curb a proven health risk (such as smok-
ing) that had expensive consequences simply made
good business sense.

  A special case is insurance. Beginning with State
Mutual Life Assurance Company of America in 1964,
life insurance companies began offering discounted
policies for nonsmokers (Cowell 1985). By 1987,
approximately 80 percent of life insurance companies
offered discounts to nonsmokers (Schauffler 1993).


Framework of Tobacco Industry Tactics

T he Advocacy Institute has developed an overview of tobacco industry strategy, with extensive docu-
mentation taken from current media reporting. The documentation provides examples of each of the

strategies listed below.

I. Intimidation

A. Legal (harassing suits, subpoenas, in-
junctions, outspending plaintiffs)
B. Economic (withdrawal of advertising,
withdrawal of business operations)
C. Political (retribution directed at elected
  and other officials)

D. Personal (harassing researchers, advo-
cates, and reporters)

II. Alliances

A. Strong allies (subsidiaries, trade asso-
ciations, advertising industry, tobacco
  farmers)
B.  Weak allies (labor unions, lawyers' asso-
  ciations, doctors' associations)

III. Front Groups

A. Political groups (Michigan Citizens for
  Fair Taxes, Californians for Statewide
Smoking Restrictions)
B. Scientific groups (Council for Tobacco
Research U.S.A. Inc., Healthy Buildings
  International)
C. Smokers' rights groups (National Smok-
  ers Alliance)

IV. Campaign Funding
A. Candidate funding
  B.  Continued contributions after election
C. Direct funding of interest groups and
      caucuses

D. Political party funding
E.  Funding state ballot initiatives, or fund-
ing opposition to initiatives

V. Lobbying
  A. Support of lobbyists at state and national
    levels

B. Seeking alliances with other lobbying
groups on specific issues
C. Gifts and contributions to specific causes
D. Generating grassroots activity

Source: Advocacy Institute 1995

VI.

Legislative Action
A. Preemption

B. Weakening or diluting legislation, or
making it unenforceable
C. Adding unrelated clauses to, or chang-
ing, the contents of legislative bills
D. Shifting debate (stressing personal free-
dom rather than health; promoting smok-
ers' rights)

VII. Buying Expertise
  A. Enlisting outside experts (economists,
    epidemiologists, medical researchers,
    statisticians, legal counsel)
  B. Creating the Council for Tobacco Re-
     search U.S.A. Inc.

VIII. Philanthropy
   A. Buying innocence by association (finan-
    cial support to wide range of organiza-
     tions)
   B.  Funding (women's groups, racial and eth-
    nic minority groups, homeless shelters,
    acquired immunodeficiency syndrome
    [AIDS] groups, arts groups, educational
    initiatives, community-based nonprofit
    organizations, sporting events)

IX. Advertising and Public Relations
A. Issue framing (choice, civil rights, per-
    sonal freedom)
  B.  Advertising to promote corporate char-
     acter
  C.  Disinformation (health effects, economic
   importance of tobacco)

44 Chapter 2


Health insurance rates, in contrast, have not typically
distinguished between smokers and nonsmokers.
Acceptable actuarial data on additional medical ex-
penses incurred by smokers did not exist until the early
1980s; at present, discounts for nonsmokers or sur-
charges for smokers have not been widely adopted by
health insurance companies (Schauffler 1993). None-
theless, both the health insurance and the life insur-
ance industries have become active in smoking-related
public policy. In 1977, the trade associations of the
two industries formed the Center for Corporate Pub-
lic Involvement to take up public policy issues that
affected them. By 1980, the organization was urging
its members to adopt workplace nonsmoking policies,
and by 1984, it had become an active lobbyist support-
ing legislation to reduce tobacco use (Schauffler 1993).

The Attack on Advertising

  In the 1970s and 198Os, the movement to reduce
smoking was in part the work of grassroots activity, in
part the work of professional consumer advocates, and
in part the work of the public health bureaucracy. In
1966, a complaint filed with the Federal Communica-
tions Commission (FCC) by John F. Banzhaf III called
for the application of the Fairness Doctrine to man-
date repIy time to cigarette advertising on television
and radio broadcasts (see also "Attempts to Regulate
Tobacco Advertising and Packaging" in Chapter 5).
The FCC agreed with Banzhaf's complaint and on June
2,1967, ordered broadcasters to provide "significant"
air time for antismoking messages. Banzhaf, antici-
pating and forestalling an almost certain appeal from
the tobacco industry, appealed his own victory
(Whiteside 1971). Under the guise of seeking equal
rather than significant broadcast time, Banzhaf
succeeded in having his original ruling upheld and
in having its application specified: television and
radio stations were required to run one counter-
advertisement, free of charge, for every three cigarette
commercials. This policy lasted until 1971, when a ban
on cigarette broadcast advertising went into effect.

  The campaign to ban or regulate cigarette adver-
tising has been one of the most visible and emotion-
ally compelling of all the subthemes in the campaign
to reduce smoking. (Highlighted in this section, this
theme is discussed in greater detail in "Attempts to
Regulate Tobacco Advertising and Packaging" in
Chapter 5.) All along, opponents have apparently "re-
sented most of all the ubiquity and presumed power
of cigarette advertising" (Patterson 1987, p. 224). These
critics have argued that advertising is a powerful force
blinding Americans to the health consequences of

smoking, but the tobacco industry has maintained a
vigorous defense of its right to advertise (Patterson
1987).

  In 1969, congressional hearings considered ban-
ning cigarette advertising on television and radio;
strengthening health warnings on packages; extend-
ing the warnings to all cigarette advertising; and
ending the preemptive ban on FTC, state, and local
regulatory activity. This time, the tobacco industry did
not benefit, as they had during hearings in previous
years, from the hesitancy of those conducting the hear-
ings. Since 1964, public concern about the health haz-
.ards of smoking had been growing, and although the
tobacco industry had powerful supporters in the U.S.
House of Representatives, in the Senate, Warren Grant
Magnuson (D-WA) and Frank E. Moss (D-UT) were
canny and committed antagonists. Recognizing it
would have to make some concessions, the industry
agreed to a television and radio advertising ban.

  This concession may not have been unwilling.
There is some indication that since the Fairness Doc-
trine was invoked in 1966, the resulting counter-
advertisements were hurting cigarette sales more than
the cigarette commercials were helping (Hamilton
1972). With the.passage in 1969 of the Public HeaIth
Cigarette Smoking Act (Public Law 91-222), which con-
tained the ban on cigarette advertising on television
and radio, the counteradvertisements vanished.. The
tobacco industry shifted its advertising to print and,
perhaps even more notable, shifted its marketing bud-
get from advertising toward promotion. The latter
move exposed vast audiences to cigarette brands
through techniques such as sponsoring sports events
and, later, merchandising brand-touting items such as
T-shirts and caps. Nonetheless, the elimination of ciga-
rette advertising from the nation's most powerful
medium was at the very least a stunning symbolic
defeat for the tobacco industry. At the same time, the
presence of cigarettes was gradually fading in televi-
sion programming; by 1982, fictional television char-
acters smoked nine times fewer cigarettes than they
had before 1964 (Signorielli 1993).

Toward a National Policy
to Reduce Smoking

  Victories through federal administrative agencies
or through direct assault on Congress were rare. The
first chairman of the new (1973) Consumer Product
Safety Commission claimed authority to set standards
for cigarettes or even to ban them, but Congress in
1976 passed legislation to deny the commission that


authority (Walsh and Gordon 1986). In 1972, the Civil
Aeronautics Board required a nonsmoking section on
commercial air flights, in part because of some volun-
tary action already taken; in 1983, responding to a
Court of Appeals ruling that nonsmokers were inad-
equately protected, the board banned smoking alto-
gether on flight segments up to two hours-but almost
at once Congress passed legislation to reverse this
move (Walsh and Gordon 1986).

  In the executive branch, several voices spoke out
against smoking. During his tenure as Surgeon Gen-
eral and thereafter, Dr. Jesse L. Steinfeld was an active
participant in the national and international movement
to reduce smoking (Steinfeld et al. 1976). Joseph A.
Califano, President Jimmy Carter's Secretary of
Health, Education, and Welfare, declared in 1978 that
smoking was "Public Health Enemy Number One."
When Califano was designated Secretary, he had no
notion that reducing smoking should be a significant
effort of the Secretary's department, but experts he

From Antismoking to Nonsmokers' Rights

consulted invariably urged that his public health efforts
include a major campaign on that topic (Califano 1981).

  Over the years, the main voluntary organizations
increased their aggressive posture against smoking. In
1982, the ACS, the ALA, and the AHA established the
jointly sponsored Coalition on Smoking OR Health as
a Washington-based lobbying organization. The coa-
lition represented some 5 million volunteers across the
country, at least some of whom were physicians and
other civic leaders who could influence particular leg-
islators (Pertschuk 1986). In 1985, the AMA called for
a complete ban on tobacco advertising and promotion
(Troyer 1989). Also that year, a rotating series of four
more specific, more severe, and larger print warning
labels replaced the traditional warning that "The Sur-
geon General has determined that cigarette smoking
is dangerous to your health" (Waxman 1985; see
"Attempts to Regulate Tobacco Advertising and Pack-
aging" in Chapter 5 for discussion of this regulatory
process).

  The rhetoric of the smoking controversy in the
1950s and 1960s focused on the scientific evidence link-
ing smoking and disease. In the wake of the 1964 Sur-
geon General's report and subsequent research and
reports, the battle over the credibility of the scientific
evidence was essentially over. In what has been called
"a remarkable demonstration of creative lobbying"
(Jacobson et al. 1992, p. 391, the tobacco industry
sought to shift the debate from the medical conse-
quences of smoking to the legal implications of
impeding the personal freedom of smokers to smoke
and of tobacco companies to advertise their wares
under the protection of the First Amendment. The
tactic appeared to work. By the late 197Os, the effort
to reduce smoking was foundering "on a traditional
American libertarian ethic: `It's my body and I'll do
with it as I please"' (Brandt 1990, p. 167). Serious dis-
cussion on the ethics of legislation to reduce smoking
emerged (Goodin 1989). To bring a public health per-
spective back into the center of the debate, a
countershift to nonsmokers' rights seemed strategi-
cally sound (Jacobson et al. 1992). During the 198Os,
this strategy acquired a conceptual foundation that
was framed in a persuasive vocabulary when the

terms (and the concerns they aroused) "passive smok-
ing, " "ambient smoke, " "secondhand smoke," and
most commonly, "environmental tobacco smoke"
(ETS) increasingly appeared in research reports and
public debate.

Regulations, Legislation, and Lobbying
for Nonsmokers

  Evidence mounted in the 1970s and 1980s that
smoking was not only an annoyance but also a health
hazard to nonsmokers. The 1972 Surgeon General's
report on smoking and health became the first of the
series to include a review of the effects of ETS. A year
earlier, Surgeon General Steinfeld had called for a na-
tional "Bill of Rights for the Non-Smoker." The call
was answered when the National Interagency Coun-
cil on Smoking and Health developed a Non-Smoker's
Bill of Rights and promoted the nonsmokers' rights
theme among its 34 member agencies (Schmidt 1975).
At the same time, the first successful efforts were
made to segregate smokers and nonsmokers in public
places. In 1971, United Air Lines became the first

46 Chnpfer 2


Redlicing Tobacco Use

major carrier to institute separated "smoking" and
"nonsmoking" sections on its airplanes.

  Analogous to private citizens who were active
in the antismoking movement early on, some private
businesses took the initiative to introduce worksite
regulations for reducing smoking. Typically, the pri-
vate firms would begin with a mild antismoking policy
that was made stricter over time. A life insurance com-
pany in Connecticut, for instance, in 1976 restricted
smoking in parts of the employee cafeteria. In 1983,
smoking was prohibited throughout the cafeteria and
was also banned from all conference rooms. In 1986,
all smoking at the workplace was prohibited except in
designated restrooms and lounges. Moreover, the com-
pany instituted an educational campaign about smok-
ing hazards and provided subsidies for employees who
attended smoking cessation clinics (Petersen et al.
1988). Other firms have also turned to carrots as well
as sticks, paying employees bonuses if they stop smok-
ing for a given length of time (Fielding 1984).

  States began advancing legislation against ET'S
in the early 1970s. In 1973, Arizona passed the first
statewide ban on smoking in public places. This im-
portant step for nonsmokers' rights, which was initi-
ated by a private citizen, Betty Carnes, was defeated
in a vote in 1972 but passed on its second try and a
year later was further strengthened (Schmidt 1975).
Two years later, Minnesota passed the first statewide
act to keep indoor air smoke free; the legislation re-
quired no-smoking areas in all buildings open to the
public unless a posted sign explicitly permitted smok-
ing. By 1975, legislation had passed in 10 states to regu-
late smoking in public places (Schmidt 1975); more
than 30 states and hundreds of local jurisdictions had
done so by 1985 (Koop 1985). By 1990, smoking was
restricted to some extent in public places or worksites
in 44 states, and hundreds of cities and towns had
passed their own, often more rigorous ordinances
(Rigotti and Pashos 1991). In cities with populations
of 25,000 or more, local smoking restrictions reached
more than two-thirds of citizens in various public and
private settings, and one-half of these restrictions could
be judged comprehensive.

  The courts supported these public and private
efforts to protect nonsmokers' rights. In 1976, a Supe-
rior Court of New Jersey ruled that an office worker
with an allergy to tobacco smoke had the right to a
smoke-free office. New Jersey was also the site of a
comprehensive ruling in 1978 that restricted smoking
in restaurants and other public places; this was the first
such regulation to be enacted by administrative rule
(through the State of New Jersey Department of
Health) rather than by new legislation, though the rule

was never actually implemented (Regina Carlson,
memorandum to John Slade, September 30,1996).

  At the federal level, government acted not only
legislatively to regulate public behavior in the states
but also administratively to regulate domains the
government itself directly controlled. For instance, ciga-
rettes were removed from military C rations and K ra-
tions in 1975, and smoking was restricted in all federal
government buildings in 1979. Smoking was banned in
the White House in 1993 (Stephanopoulos 1993).

  Behind many of these reforms in industry and
government were the unified efforts of private citizens.
How these grassroot activists could band together to
form powerful lobbying groups for nonsmokers' rights
was shown in the transformation of a segment of the
Group Against Smokers' Pollution (GASP), Inc., a na-
tional organization founded in 1971. In 1976, local
California chapters of GASP banded together and tried
but failed to effect statewide ordinances to protect
nonsmokers. In 1981, the chapters became Californians
for Nonsmokers' Rights and began focusing on local
legislative activity. Five years later, the group became
a national organization that took its successful local-
level approach to sites throughout the country. By
1986, more than 75 ordinances had been enacted in
California alone; nationwide, more than 400 had been
enacted by 1990 (Samuels and Glantz 1991). In 1985,
Los Angeles banned smoking in most public places
and in businesses employing four or more persons if
nonsmokers requested it (Fritschler 1989). California
has now banned smoking in practically all public
places (Tobacco Education and Research Oversight
Committee 1995).

  By the 198Os, the movement to reduce smoking
proceeded along many avenues and through a wide
set of loosely coordinated organizations. This lack of
systematic action has concerned activists in the move-
ment, who bemoan duplication of effort, lack of com-
munication, organizational rivalries, and the lack of a
federal effort and policy. At the same time, the move-
ment has clearly benefited from its multiple locations;
the movement is represented by active legislative ef-
forts in hundreds of small communities as well as by a
strong presence in Washington, DC, and in state capi-
tals (see also "Direct Advocacy" in Chapter 7 for a dis-
cussion of the influences of these advocacy activities).

ETS: From Annoyance to Carcinogen

  The powerful call for nonsmokers' rights added
considerable momentum to the campaign to reduce
smoking. The Surgeon General's report in 1979


reviewed further research on ETS. Considerable pub-
lic interest was aroused by a Japanese study, published
early in 1981, that found a high incidence of lung can-
cer among nonsmoking women married to smoking
men (Hirayama 1981; Nezc~smerk 1981). While local-
level smoking restrictions began to gather force, often
proving more comprehensive than statewide legisla-
tion, the evidence on passive smoking accumulated.
On releasing his 1982 report on smoking and health,
Surgeon General C. Everett Koop observed that ETS
might be a serious public health problem (Troyer 1989);
two years later, he spoke of solid evidence on this point
(quoted in Molotsky 1984, p. 1).

  The growing urgency of a public health focus
on ETS set the stage for two authoritative messages
that ETS posed a definite danger to all. In 1986, the
National Research Council report Elrvirorzmer7tal To-
bacco Smoke: Menslrrirrg &!~os~~i'es arm' hxessirlg Health
Effects found that ETS exposure increased the risk for
lung cancer by 30 percent in nonsmokers and had del-
eterious effects on the respiratory health of children
(National Research Council 1986). The same year, the
Surgeon General released Tile Health Cor~sequcnces of
Inoo~z~~~fauJ/ Smoki~J~, which concluded that "involun-
tary smoking is a cause of disease, including lung can-
cer, in healthy nonsmokers" (USDHHS 1986, p. 13).
That report also found that children of smoking par-
ents have an increased incidence of respiratory infec-
tions and that separating smokers and nonsmokers

within the same air space "may reduce, but does not
eliminate" exposure of nonsmokers to tobacco smoke
(p. 13).

  Critics charged that the evidence on passive
smoking was weak, but the evidence and the authori-
tative conclusions of the Surgeon General and the
National Academy of Sciences added support for
stronger acts to limit or prohibit smoking indoors. In
1987, Congress banned smoking on domestic air trips
shorter than two hours; in 1990, the ban was effectively
extended to all domestic commercial air travel.

  Two further developments raised public (and
public policy) awareness of ETS to a level that posi-
tioned it in the front ranks of the campaign to reduce
smoking. In 1991, the National Institute for Occupa-
tional Safety and Health, Centers for Disease Control,
issued the report Environmental Tobacco Smoke in the
Workplace, which concluded that ETS can cause lung
cancer and other health problems (National Institute
for Occupational Safety and Health 1991). More
important, in December 1992, the Environmental Pro-
tection Agency (EPA) classified ETS as a "Class A"
carcinogen, the most dangerous class of carcinogens.
The agency's final report, Respirntor!y Health Effects of
hsivc Smoking: LJfJlg Cancer nrld Otkr Disorders, con-
cluded that ETS is a human lung carcinogen respon-
sible for some 3,000 deaths annually from lung cancer
among nonsmokers (EPA 1992).

The Impact of the Movement to Reduce Smoking

  The campaign against tobacco promotion is, in a
sense, a public health hybrid. It is in part a public
health movement, like those oriented to ensure that
food and drugs are pure and that water supplies and
air quality are clean-movements that look to improve
upon the collective provision of healthful environ-
ments. But because the campaign to reduce smoking
necessarily seeks to alter personal behavior, it is per-
ceived or cast by some as a moral reform movement.
"We are in the midst of one of those periodic moments
of repression," writes one observer, "when the culture,
descended from Puritans, imposes its hysterical visions
and enforces its guilty constraints on society, legislat-
ing moral judgments under the guise of public health,
all the while enlarging the power of surveillance and

the reach of censorship to achieve a general restriction
of freedom" (Klein 1993, p. 3). Such critics worry about
possible erosions of civil liberties and express irrita-
tion with the puritanical cast of the movement to re-
duce smoking (Berger 1986; Hitchens 1994; Leonard
1994; Laqueur 1995). One recent historian refers to
health reform movements of this and the past century
as "hygienic ideologies, " because the movements have
sometimes reached levels of "devotion, asceticism, and
zeal" that virtually mark them as "hygienic religion"
(Whorton 1982, p. 4). In sum, the arguments have pit-
ted this moralism against the freedom to choose
(Sullum 1996). In doing so, issues of addiction and
corporate responsibility are sidestepped (Hilts and
Collins 1995).


Reducing Tobacco Use

  It would be hard to deny that moral zealotry has
entered into the contemporary movement to reduce
smoking. But it would be equally hard to argue that
zealotry is the dominant element in the movement.
The contemporary campaign to reduce smoking, like
some elements of the early 20th-century efforts, has
been fueled by medical research and, more recently,
by revelations about the additional but secret medical
research carried on by tobacco companies themselves
on nicotine and other addictive substances (Kluger
1996). But leadership has been both medical and non-
medical and has been oriented to conventional public
policy mechanisms rather than to moral reformation.
Where the broad contemporary health movement has
"an ambivalent orientation toward science and technol-
ogy" and "draws upon Americans' significant and
growing distrust of physicians" (Goldstein 1992, pp.
30-l), the movement to reduce smoking firmly em-
braces establishment medical research. Its sometimes
inventive and ingenious strategies notwithstanding, the
movement has typically avoided ideological ends and
has instead worked toward concrete, public policy ob-
jectives. In this respect, it is self-consciously political,
adopting a style found now in many health movements
(e.g., AIDS, breast cancer, and even advocates of spe-
cific health care reforms).

   Whether or :lc)t the movement to reduce smok-
ing has avoided the finger-pointing associated with
many ideological movements is debatable. On the one
hand, the movement has tended to demonize the to-
bacco companies rather than the smokers who use their
products. This distinction may arise partly because,
some cultural icons aside, smoking has rarely been
perceived as a feature of personal behavior that is cen-
tral to someone's identity. Placing the burden else-
where than on the smoker has been amply reinforced
by the research-steered perceptual transition of smok-
ing as "habit" to smoking as "addiction." As codified
by the 1988 Surgeon General's report (USDHHS 1988)
and reiterated more recently (Lynch and Bonnie 19941,
smoking is now medically viewed as nicotine addic-
tion, and as the title for Chapter 4 states, smoking ces-
sation is now the management of such addiction. This
transition has had considerable impact on overall strat-
egy for reducing smoking, especially in litigation ap-
proaches (see "Litigation Approaches" in Chapter 5).

  On the other hand, as regulations against smok-
ing become more widespread, the tendency to stigma-
tize smokers may increase (Troyer 1989). Moreover,
some critics ha;e complained of an ideology that
smacks of political conservatism, in that the focus for
the problem is turned away from the product source

(the manufacturer) and to the user-victim (the smoker);
this blame-the-victim perspective also characterizes
sociopolitical movements that divert public attention
to personal behaviors and away from larger, corporate
sources of environmental health risks, such as indus-
trial pollution and workplace hazards (Crawford 1979).

   In at least one sense-that of social values-
efforts to reduce smoking have been moralistic. The
contemporary reform movement can fairly be charac-
terized as middle-class-that is, its values are those
connected with traditional values such as deferred
gratification, self-control, and personal responsibility
(Goldstein 1992). Nonsmokers may feel morally su-
perior to smokers, and former smokers may pride
themselves on their personal accomplishment and self-
denial. As one cultural observer has pointed out,
former smokers especially may be "tediously zealous
about the addiction they have left behind" (Styron
1987, p. 284).

  The net result, whatever the role of moral issues,
is the main emphasis the movement places on chang-
ing the social conditions that enable, and the cultural
conditions that legitimatize or romanticize, smoking.
In this sense, the movement to reduce smoking is an
old-fashioned populist movement that seeks to defend
the "public interest" against the moneyed corpora-
tions, the purveyors of death and disease. It is now
less an "anti-smoking" political movement and more
a campaign against tobacco promotion.

  A reflection of this broadly populist attitude has
been the movement's lack of any real links to partisan
politics. Senators Wallace F. Bennett (R-UT) and Rich-
ard L. Neuberger (D-OR) were among the first to seek
curbs on the tobacco industry (Fritschler 1989). In the
early 198Os, Republican Senators Robert W. Packwood
(R-OR) and Orrin G. Hatch (R-UT) introduced legisla-
tion to require more explicit warning labels on ciga-
rette packages (Troyer 1989). House Democrats have
been both key defenders and key critics of the tobacco
industry. In the White House, Democratic President
Lyndon 8. Johnson remained silent on the preemptive
Federal Cigarette Labeling and Advertising Act of
1965, but White House pressure helped support the
Tobacco Institute's efforts to pass the bill (Pertschuk
1986); the President signed the act into law privately
in his office, without guests or comment (Fritschler
1989). Similarly, Democratic President Jimmy Carter
refused to take a position on tobacco (Fritschler 19891,
but he regarded USDHEW Secretary Joseph Califano's
crusade against tobacco as "an enormous political
liability" (Califano 1985, p. 360). The absence of po-
litical affiliation for the antitobacco movement may be


altered, however, by recent changes in the party com-
position of elected officials from tobacco-producing
states.

  The efficacy of efforts to reduce smoking, inde-
pendent of other social changes beginning early in the
20th century, is hard to determine. Students of 19th-
century temperance, for example, have concluded that
although the temperance efforts likely accelerated the
antebellum decline in alcohol consumption, the decline
may have been more deeply tied to independent
changes in styles of liquor consumption (Aaron and
Musto 1981). The antismoking movement of the early
20th century, despite temporary gains, had little long-
term effect on stopping the rapid growth of smoking;
though noteworthy, the emergence of antismoking
legislation in some midwestern and western `states
was brief and showed little convincing evidence of
enforcement.

  But neither the temperance movement of the 19th
century nor the antismoking movement early in the 20th
century commanded the significant allies and the range
of weapons of the contemporary effort to reduce
smoking. The critical factor has been definitive medi-
cal research linking smoking to cancer, heart disease,
chronic obstructive pulmonary disease, and adverse
outcomes of pregnancy (USDHHS 1989). Beginning in
1964, the imprimatur of the Surgeon General of the
United States provided a symbolic centerpiece that has
given inestimable momentum to the campaign. The
all-but-unanimous and compelling character of the
epidemiologic research in that first report and its suc-
cessors is the chief factor that leads to the-conclusion,
"As a target of opportunity for public health action,
smoking stands alone" (Walsh and Gordon 1986, p. 127).
  Measuring the overall impact of the rich and
multifaceted effort to reduce smoking is difficult, in
part because current prevalence should not be judged
against an arbitrary historical benchmark (for instance,
against prevalence at the time of the 1964 Surgeon
General's report) but against an estimate of what
prevalence would have been in the absence of such
efforts. The events of the past decades that coincided
with these efforts are clear: cigarette consumption rose
steadily from the 1930s until 1963, fluctuated, then
fell from 1973 tq the present. But such broad-brush
observations provide little insight into cause and ef-
fect, especially given the multiplier effect of certain
social actions, the differential changes in demographic
and social subgroups, and the influence of forces ex-
traneous to smoking (Warner 1989).

  It is problematic, for example, to try to assess the
relative impact of, on the one hand, government edu-
cational actions and government regulatory actions
and, on the other hand, changing social norms-two
factors that are clearly interrelated. The impact of gov-
ernment curbs on smoking in public places (see "Clean
Indoor Air Regulation" in Chapter 5) may actually be
bound up with "voluntary adjustments to new infor-
mation" (Zimring 1993, p. 97). Similarly, doubts have
been raised as to the influence of curbs on tobacco
advertising (Schudson 1993; see "Advertising and Pro-
motion" in Chapter 51, because such restrictions have
occurred in conjunction with a growing stigmatization
of smoking. Once nonsmoking is established as a
norm, the minority status of smokers makes them
"more vulnerable to negative social evaluations. .
As smokers, the group most interested in defending
the moral position of the cigarette smoker, become both
less numerous and less influential, smoking behavior
and the people who engage in it become more vulner-
able to social reinterpretation" (Zimring 1993, p. 106).
Such a reinforcing chain of events may permit curbs
on advertising, rather than the reverse.
  It is equally difficult to gauge or predict the in-
fluence of government restrictions. On the one hand,
a regulation may be an educative force-for example,
by reminding people to take their Surgeon General
seriously. In some instances (such as indoor prohibi-
tions and access restrictions), government actions in-
terpose a physical barrier. On the other hand, legal or
otherwise formal barriers could have an unintended
effect on individual predisposition, as the abiding aura
of antisocial behavior can be at least as great a stimu-
lus for some as it is a deterrent for others. Finally, the
psychological and social pathways by which economic
actions of government affect smoking are complex.
  Sorting through this complexity is critical to
understanding appropriate policy and action for re-
ducing smoking. The ensuing chapters assess the
available evidence to judge the efficacy of educational
efforts (Chapter 3), the management of nicotine
addiction (Chapter 4), regulatory efforts (Chapter 51,
economic approaches (Chapter 61, and comprehensive
programs (Chapter 7). This brief history of the anti-
smoking movement provides a backdrop to such as-
sessment and may furnish some perspective on future
directions.

50 Clq't'r 2


Reducing Tobacco Use

Conclusions

1.  In the years preceding the development of the    3.  Despite the growing scientific evidence for ad-
  modern cigarette, and for some time thereafter,     verse health effects, smoking norms and habits
  antismoking activity was largely motivated by     have yielded slowly and incompletely. The rea-
  moralistic and hygienic concerns. Health con-     sons are complex but attributable in part to the
  terns played a lesser role.               industry's continuing stimulus to consumption.

2.   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.

Historical Review 51


Surgeon General's Report

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Historical Review 57


Chapter 3
Effective Educational Strategies to
Prevent Tobacco Use Among Young People

Introduction 61

Trends in Tobacco Use Among Young People  61
Reasons Young People Smoke  62
Educational Models for Smoking Prevention  63

Recent Research on Educational Strategies for Smoking Prevention  64
Shorter-Term Follow-Up of School-Based Programs  65
Project Towards No Tobacco Use  65
Know Your Body 65
Project SHOUT 68

Longer-Term Follow-Up of School-Based Programs  69
Life Skills Training Program  69
Minnesota Smoking Prevention Program  70
Waterloo Smoking Projects 70
Project ALERT 71

Summary of Recent School-Based Research Studies  72
Research on Multifaceted Programs  73
Minnesota Heart Health Program: Class of 1989 Study  74
Midwestern Prevention Project 75
University of Vermont School and Mass Media Project  76
Observations on Research on Multifaceted Educational Programs  77

Diffusing Programs to Prevent Tobacco Use  80

National Guidelines 80
School Health Policies and Programs Study  80
A State-Based Assessment 82
Basic Curriculum 82
Supplemental Programs 82
Programs Including Families 83
Community Programs 83
Combined Activities 83
Monitoring Program Objectives 83
Interpreting the Diffusion Process  83

Conclusions 85

References 86


Reducing Tobacco Use

Introduction

Trends in Tobacco Use Among
Young People

  Smoking prevalence among youth underwent a
sustained and substantial decline for about a decade
from the mid-1970s to the mid-1980s. The Monitoring
the Future study, funded by the National Institute on
Drug Abuse, has assessed the substance use behaviors
of large representative samples of high school seniors
annually since 1975 (Giovino et al. 1994; Johnston et al.
1994). The data from this multiyear study have shown
that daily cigarette smoking reached a peak of about 29
percent among high school seniors in 1977. Daily smok-
ing then declined steadily until 1986, falling below 19
percent, but has shown little change since. Detailed
analyses of trends in smoking by adolescents in 1974-
1991, based on Monitoring the Future data and two
other national health behavior survey series, also have
shown consistent evidence that smoking prevalence
among adolescents has generally been stable since about
1985 (Nelson et al. 1995). In 1997, daily cigarette smok-
ing in the month before the survey was reported by 24.6
percent of high school seniors, the highest level since
1979, when 25.4 percent reported daily smoking. Long-
term trends show that daily smoking among seniors
was at a 25-year high of 28.8 percent in 1976 and 1977,
declined to 21.3 percent in 1980, varied in the range of
18-21 percent from 1980 to 1991, and decreased to 17.2
percent in 1992. After that, seniors' daily cigarette use
increased steadily to reach 24.6 percent in 1997, then
decreased to 22.4 percent in 1998 and remained statisti-
cally unchanged at 23.1 percent in 1999 (Johnston et al.
1999). A recent report with more current prevalence
estimates and trend data from 1991 through 1997 shows
that current cigarette use increased overall and for
white, black (the racial/ethnic terms "black" and "Af-
rican American" are both used in this report, according
to the usage in the study cited), and Hispanic high
school students (Centers for Disease Control and Pre-
vention [CDC] 1998). Even so, the prevalence of smok-
ing among African American high school seniors was
lower than that for Asian Americans/Pacific Islanders
and for American Indians/Alaska Natives (US Depart-
ment of Health and Human Services [USDHHSI 1998).

  Although the decade-long decline in smoking
prevalence among young people stalled in the mid-
198Os, it has persisted among all major adult popula-
tion groups in the United States (Giovino et al. 1994).

Changes in prevalence among young people thus do
not seem to be closely linked to changes among adults
(Reid et al. 1992) and may be more heavily influenced
by other social forces. Downward trends in smoking
by adults may, for instance, be partly the result of the
continued accumulation of scientific knowledge about
the long-term health consequences of smoking and
of secondary exposure to cigarette smoke (USDHHS
1989; Environmental Protection Agency 1992). That
no such downward trend was observed among most
groups of adolescents in the past decade may reflect
other factors: prices of tobacco products decreased (see
Chapter 6); during the 198Os, public education efforts
to prevent tobacco use among young people dimin-
ished; and youth-oriented marketing by cigarette
manufacturers intensified (Nelson et al. 1995). More-
over, because of the highly addictive nature of ciga-
rette smoking, the recent increases in prevalence of
smoking among young people could carry over into
their adulthood and eventually arrest or reverse the
long-term declines that have persisted for decades
(CDC 1994a; Giovino et al. 1994).
  In a similar vein, a major portion of tobacco con-
sumption at the beginning of the 20th century was
in the form of spitting tobacco. The emergence of
machine-made cigarettes as the dominant form of to-
bacco use in the 1930s (see Chapter 2) was accompa-
nied by a 38.4-percent decline in total smokeless
tobacco production from 150.2 million to 92.5 million
pounds between 1944 and 1968.

  In the early 197Os, however, the market for
smokeless tobacco reemerged. Between 1970 and 1981,
the production of fine-cut tobacco, used in the manu-
facture of moist snuff, increased threefold from 4.8
million to 15.2 million pounds (USDHHS 1986). Sales
of moist snuff have increased every year since the Fed-
eral Trade Commission (FTC) began monitoring it,
from 36.1 million pounds in 1986 to 55.3 million
pounds in 1997 (FTC 1999). Loose leaf chewing to-
bacco has seen a slight decline in sales over this pe-
riod, from 65.7 million pounds in 1986 to 51.8 million
pounds in 1997.

  The growth in the sales of moist snuff has been
attributed to a smokeless tobacco advertising and
marketing campaign that encourages young non-
users to experiment with low nicotine starter products
with the intent of graduating new users to higher nico-
tine brands as dependence progresses (Connolly 1995).


Surgeon General's Report

The basis and success of this "graduation" strategy is
supported by laboratory and epidemiologic data
as well as tobacco industry documents. Smokeless
tobacco manufacturers appear to be able to manipu-
late the nicotine-dosing characteristics of their prod-
ucts and have developed moist snuff products with a
wide range of bioavailable nicotine (Henningfield
et al. 1995; Djordjevic et al. 1995; Food and Drug
Administration 1996; Tomar and Henningfield 1997).
A national longitudinal study found that young males
were twice as likely to switch from a brand with low
or medium nicotine delivery to a high nicotine deliv-
ery product than to switch in the opposite direction
(Tomar et al. 1995). Advertising and promotional
expenditures have increased for nearly every year
between 1986 and 1997, from $76.7 million to $150.4
million (FTC 1999). In 1997, $103.6 million was spent
for advertising and promotion of moist snuff.
  Smokeless tobacco use is primarily a male behav-
ior. Use of snuff and chewing tobacco by young males
increased sharply through the 1970s and early 1980s.
Data from the National Health Interview Survey indi-
cate that the prevalence of smokeless tobacco use
among males aged 18-24 years increased from 2.2 per-
cent in 1970 to 8.9 percent in 1987 and declined slightly
to 8.4 percent in 1991 (Giovino et al. 19941. Based on
CDC's Youth Risk Behavior Survey, the prevalence of
past-month smokeless tobacco use remained at about
20 percent among high school males during most of
the 1990s (CDC 1992; Kann et al. 1995). Recent data
indicate that smokeless tobacco use may be starting to
decline among high school males (CDC 1998).
  More vigorous steps are clearly required to pre-
vent young people from beginning to use tobacco
products. This chapter considers the effect of educa-
tional programs in such prevention. Throughout the
discussion, the term "education" is used to encompass
the range of activities that impart knowledge, alter per-
ceptions, and modify behavior.

Reasons Young People Smoke

  The public health importance of smoking among
young people has generated a substantial amount of
research on why they take up the habit. The results of
these efforts have provided several consistent insights
that have been reviewed in detail and summarized in
recent reports (Lynch and Bonnie 1994; USDHHS 1994).

  Development of tobacco addiction is a staged
process that requires several years to progress from ini-
tiation to acquisition of an established habit (Leventhal
and Clear-y 1980; McCarthy 1985; see also Flay 1993).

The initial stages are consistently associated with a
well-defined group of risk factors. Early adolescence
(aged 11-15 years, or bth-10th grades) is the period
when people are most likely to try smoking for the
first time. Especially at risk are adolescents whose
parents or guardians smoke or have lower levels of
income and education (USDHHS 1994).

  Young people's perceptions of smoking behav-
iors in proximal and wider social environments are
among the most powerful psychosocial forces influ-
encing whether they begin to smoke (USDHHS 19941.
Cigarette smoking among friends, peers, siblings, and
others from the young person's immediate environ-
ment is consistently associated with smoking initia-
tion. The influence of friends and peers seems to be
especially powerful in the early stages of developing
a smoking habit. Perceptions of the larger social envi-
ronment also seem to have considerable influence on
smoking decisions. Adolescents tend to overestimate
the prevalence of smoking among people their own
age and among adults. Such perceptions-and in gen-
eral, susceptibility to becoming a smoker-are likely
to be strongly influenced by the effects of advertising
(Evans et al. 1995). Young people who perceive high
levels of smoking among their peers and who report
that peers are more likely to approve of cigarette smok-
ing are more likely to become smokers themselves.

  These external influences are likely supported or
opposed by internal, personal factors. The personal
factors most often associated with smoking initiation
include the young person's belief that cigarette smok-
ing is linked with positive functions, such as having
a positive social image and bonding with a peer group.
Among young women, smoking may be viewed as a
means of weight control (French et al. 1994). Adop-
tion of such perceptions may reflect, in part, the influ-
ence of a larger social environment in which smoking
is presented through local and mass media as an
adventurous and glamorous adult behavior. Thus,
smoking provides some young people a perceived tran-
sition from childhood to adulthood (USDHHS 1994).

  These findings, summarized in the 1994 Surgeon
General's report Preventing Tobacco Use Among Young
People, strongly suggest that tobacco use is socially
learned by children and adolescents and that it tends
to have socially relevant meanings for them (USDHHS
1994). Smoking prevention programs should thus
address the most salient psychosocial dimensions
that can influence a young person to not begin smok-
ing. These dimensions include enabling the young to
cope with direct social pressure to smoke from their
friends and peers and correcting or preventing
misperceptions about the social effects and short-term

62 Chapter 3


Reducing Tobacco Use

health consequences of smoking, about peers' and
adults' attitudes toward smoking, and about smoking
prevalence.

Educational Models for
Smoking Prevention

  During the past two decades, several different
theoretical orientations and program objectives have
emerged for educational approaches to smoking pre-
vention. Several changes have influenced these events:
research and evaluation results that highlighted the
ineffectiveness of the models used in earlier programs,
the accumulation of consistent research characterizing
the process of smoking initiation, advances in theo-
ries of human behavior, and promising results obtained
from initial tests of newer educational models.
Another important change is the expansion from
relatively simple strategies and educational techniques
to more complex plans that use multiple educational
channels. Complex sociobehavioral problems are thus
being addressed with more intensive educational
strategies.

  The earliest group (mostly from the 1960s and
1970s) of evaluated programs designed to prevent ado-
lescents from beginning to smoke was based on an
information deficit model (USDHHS 1994). This
approach assumed that adolescents, as rational crea-
tures, would refrain from cigarette smoking if they
were supplied with adequate information demonstrat-
ing that this habit causes serious harm to the body.
The educational techniques associated with these pro-
grams included lectures, demonstrations, films, post-
ers, and books intended to raise levels of awareness
and comprehension of health effects. Many programs
based solely on this objective did increase knowledge
among children and adolescents, as intended, but the
programs were consistently found to be ineffective in
dissuading young people from smoking (Goodstadt
1978; Thompson 1978; Kinder et al. 1980; Schaps et al.
1980,198l). Although this approach alone was clearly
inadequate, information about the health and social
consequences of smoking was retained as an impor-
tant component of later developments in smoking
prevention education.

  The limitations of this approach led to efforts in
the 1970s to identify a more complex set of personal
factors related to cigarette smoking by young people.
Once these factors were identified, educational pro-
grams could be developed to try to modify them. Stud-
ies conducted during these years often observed that
the use of cigarettes was associated with negative or

antisocial patterns of adolescent behavior WSDHHS
1994). Educators interpreted these patterns as reflect-
ing reduced levels of perceived self-worth and poor
attitudes toward family, school, and community;
these factors were hypothesized to be the root causes
of smoking initiation. Various educational strategies
to address these broad educational targets included
programs focused on clarifying values, building self-
esteem, and developing general skills for decision mak-
ing, communication, and assertiveness.

  Such efforts to prevent smoking initiation by
helping young people develop stronger intrapersonal
resources and general social competence have been
collectively referred to as the affective education
model. Evaluations of these programs, however, dem-
onstrated that they were not much more effective in
reducing cigarette smoking among young people than
programs based on the information deficit model
(Schaps et al. 1981; Durell and Bukoski 1984; Hansen
1992). The affective education strategy did mark the
beginning of promising trends in designing education
programs to prevent smoking: many programs began
more directly incorporating results from research
about factors found to influence smoking initiation and
began including more powerful theoretical models of
behavior change.

  By the mid-1970s, results of analytic and theo-
retical research began to highlight a complex set
of psychosocial factors associated with smoking
initiation. Numerous studies had consistently found
that smoking experimentation by the young was as-
sociated with peer smoking, smoking by others in the
immediate social environment, and other social and
psychological factors WSDHHS 1994). Although the
resulting psychosocial intervention programs were
developed through several different conceptual per-
spectives, they tended to share a core set of compo-
nents that compose what is generally called the social
influences model (USDHHS 1991). This model focuses
on the development of social skills to resist social
influences that encourage smoking.

  The initial efforts to design programs based on
these findings used a public health model: the prob-
lem was conceptualized as a social contagion in which
the habit spread through a population by passing from
one person to another. This concept directed program
efforts toward strengthening the resistance of non-
smoking adolescents to the behavior of their smoking
peers. For example, Evans and colleagues (1978) at
the University of Houston used methods derived from
communications and social learning theories to try
"inoculating" young people against peer influences to
smoke cigarettes; the study group of adolescents was

Effa-tiuc Edrrcatior~al Strategies 63


shown videotaped models of credible peers who suc-   formats, used different delivery methods, and been
cessfully resisted such influences (McGuire 1964).     offered to diverse student populations.

  This approach was developed further in small-
scale studies that added other objectives and used
other educational technologies (Botvin et al. 1980;
McAlister et al. 1980; Perry et al. 1980). The appeal of
the overall conceptual approach and the generally
positive results of this initial group of studies stimu-
lated a sustained evolution of the approach through
several stages of development; the result was a gener-
ally recognized social influences model for school-
based programs to prevent smoking (Flay 1985).

  The main goal of this approach was to equip
younger adolescents with specific skills and other
resources that would help them resist direct and indi-
rect social influences to try smoking cigarettes. The
specific objectives usually included having the young
person learn the short-term negative social and health
consequences of smoking and the advantages of re-
maining a nonsmoker; learn that a relatively small
proportion of young people and adults are regular
smokers; recognize the social influences in the imme-
diate environment and from the wider community and
culture that promote smoking; and develop specific
skills for managing direct social pressures from friends
and peers, as well as indirect pressures from adult
modeling, the mass media, and tobacco industry mar-
keting. Although representing a significant departure
from previous approaches, this model retained
the provision of information on the negative short-
term consequences of smoking (from the information
deficit model) and continued to emphasize the devel-
opment of social competencies (from the affective
education model).

  By the mid-1980s, detailed analyses of research
results indicated that social influences programs were
consistently more effective than programs based on
the information deficit or affective education models
in preventing cigarette smoking (Tobler 1986, 1992;
Rundall and Bruvold 1988; Hansen 1992; Bruvold
1993). Some reviewers, however, wondered whether
this evidence was strong enough to justify developing
public policies that would make these school-based
programs a large-scale, key component of policies to
prevent tobacco use (Flay 1985; Cleary et al. 1988;
Kozlowski et al. 1989).

  Social influences strategies have typically been
applied through school-based programs for students
in sixth through eighth grades (primarily during early
adolescence). These programs have taken various

  Concern focused on the quality of the effects
achieved, the quality of the evaluation research that
provided the evidence, and the generalizability of the
programs. The programs' effects reported up to the
mid-1980s were not consistently achieved, were of
short duration, and tended to be small. For example,
Drug Abuse Resistance Education (D.A.R.E.), a drug
resistance program that included but was not pri-
marily focused on tobacco use, has been in wide use
since the mid-1980s. A recent meta-analysis of pub-
lished and unpublished results concluded that the
program's effect on tobacco use was small at best
(Ennett et al. 1994). Limitations in evaluation
methods-such as outcome measurement, attrition ef-
fects, consistency between assignment and analysis
units, and completeness of reported effects on total
populations-precluded drawing clear conclusions
about program effectiveness. These reviewers also
were concerned that the programs might be too com-
plex to be carried out in most schools by most class-
room teachers. Since 1990, many of these questions
have been addressed by research on these educational
strategies (Graham et al. 1991).

Recent Research on Educational Strategies for Smoking Prevention

  Most early research programs on smoking pre-
vention were located exclusively in school settings.
Schools provide direct access to target populations and
have a mission consistent with smoking prevention
education. Schools, however, have some inherent
limitations that reduce their usefulness as exclusive

channels for such education; the obvious one is that
school programs cannot reach individuals who leave
school. This section reviews shorter-term and longer-
term studies of the effects of school-based smoking pre-
vention programs (Table 3.1). The section also reviews
studies of prevention programs that have tried to

64 Chapter 3


Reducing Tobacco Use

enhance such programs by combining them with edu-
cational activities directed toward young people
through parents, community programs, and the mass
media or by combining them with programs that tar-
geted multiple substances.

Shorter-Term Follow-Up of
School-Based Programs

  The group of studies summarized in this subsec-
tion evaluated programs that were based, with few
exceptions, exclusively on educational experiences
provided in school classrooms. These studies gener-
ally have addressed methodological problems com-
monly found in earlier evaluations of smoking
prevention efforts. Improvements include use of bio-
chemical measures to enhance the accuracy of self-
reported smoking behavior, attention to validity issues
related to attrition, and improved consistency between
units of assignment to treatment and units of analysis.
Most of this initial group of studies also improved
on earlier reports by using more diverse study popu-
lations to test these programs and by following
participants into the first year of high school to assess
smoking prevention effects at an intermediate stage
of adolescent development. The studies described
and analyzed in this subsection thus represent the cur-
rent state of the art in the evaluation of school-based
smoking prevention.

Project Towards No Tobacco Use

  Project Towards No Tobacco Use (Project TNT)
was designed to assess the relative effectiveness of three
main components of most smoking prevention pro-
grams based on the social influences model (Sussman
et al. 1993b, 1995). The investigators developed sepa-
rate classroom curricula to address each of these com-
ponents (Sussman 1991; Sussman et al. 1993a). The first
curriculum provided social skills to help students more
easily refuse direct offers of cigarettes from peers; the
second provided methods to counteract the impact of
indirect pressures to smoke cigarettes, such as smoking
(real or perceived) by peers or adults, tobacco industry
advertising, and exaggerated notions of the actual
prevalence of smoking among peers and adults; and
the third improved knowledge of the short-term and
long-term negative effects of smoking. A fourth cur-
riculum addressed all three of these areas and was
similar to the social influences model used with many
other school-based smoking prevention programs.
Each curriculum included 10 lessons designed for

seventh-grade students. The curricula were delivered
on 10 consecutive school days by trained health educa-
tors employed by the project. A control group received
the standard curriculum.

  The study included seventh graders from 48
junior high schools in 27 southern California school
districts. Students from 8 schools were assigned to
receive one each of the four curricula; students from
the remaining 16 schools were assigned to receive the
standard education program provided by their schools.
These populations were relatively diverse: about 40
percent were from minority ethnic groups. Student
reports of smoking behavior were measured immedi-
ately after the curricula were completed in the seventh
grade (n = 6,716) and one year later in the eighth grade
(n = 7,052).

  Analyses of these data indicated that the curricu-
lum that combined all three main objectives drawn
from the social influences model achieved the lowest
increase in weekly smoking prevalence (defined as
smoking one or more cigarettes per week); this increase
was 64 percent lower than the increase in the control
group. The curricula that focused on indirect pressures
to smoke cigarettes and on negative consequences of
smoking also were significantly more effective than the
control condition. The curriculum that focused on
refusal skills did not yield results significantly differ-
ent from the comparison condition. Changes in
psychosocial mediators of program effects were con-
sistent with these results (Sussman et al. 1993a). Simi-
lar effects were obtained for smokeless tobacco use.
A two-year follow-up survey, completed when the
participating students were in ninth grade, showed
that the combined curriculum continued to have a sig-
nificant impact on weekly smoking rates after these
students entered high school (Dent et al. 19951.

Know Your Body

  The Know Your Body (KYB) program, a school-
based effort to reduce risk factors for chronic disease
among young people, addressed cigarette smoking
status, dietary behaviors, and physical fitness through
curricula for fourth- through ninth-grade students
(Walter 1989; Walter and Wynder 1989). Program
components included parent education and periodic
student health examinations. Designed to meet the
rapidly changing educational needs of young people
in this age group, the six-year curriculum progressed
from a focus on knowledge and beliefs to a focus on
decision-making skills (Walter and Wynder 1989). In
the fourth and fifth grades, the curriculum's compo-
nent on smoking prevention concentrated on students'

Effective Educatiorlal Strategies  65


Surgeon General's Report

Table 3.1. School-based and multifaceted educational strategies

Proiect name

Educational methods

School-based educational strategies with shorter-term follow-up

Project TNT (Towards No Tobacco Use)

2 years; 10 class sessions delivered by project staff in grade 7

Know Your Body

6 years; multiple risk factor curriculum delivered weekly by
classroom teachers in grades 4-9, plus parent education

SHOUT (Students Helping Others
Understand Tobacco)

3 years; 18 class sessions in grades 7-8 delivered by project staff,
plus telephone and mail contact in grade 9

School-based educational strategies with longer-term follow-up

Life Skills Training Program       3 years; 30 class sessions delivered by teachers in grades 7-9

Minnesota Smoking Prevention Program

1 year; 5 class sessions in grade 7 delivered by teachers and peers

Waterloo Smoking Projects

3 years; 11 class sessions delivered by project staff in grades 6-8

Project ALERT

2 years; 11 class sessions delivered by teachers and peers in
grades 7-8

Multifaceted educational strategies

Class of 1989 Study (Minnesota Heart
Health Program)

5 years; 17 class sessions delivered by teachers and peers in grades
7-9, plus related school courses and activities and very intensive
community education directed toward adults

Midwestern Prevention
Project

3 years; 15 class sessions delivered by teachers and peers in grades
6-7 or 7-8, plus parent education and participation in school
curriculum, informational media, and community organization

University of Vermont School and
Mass Media Project

4 years; 15 class sessions in grades 5-8 or 6-9 or 7-10 delivered by
teachers, plus 540 television and 350 radio spot broadcasts each year

66 Chapter 3


Reducing Tobacco Use

Comment

5 conditions tested in 48 schools
(n = 6,716)

64% less weekly smoking for full   Very large short-term effect
intervention group by end of     achieved by moderately intensive
grade 8 and 55% by end of grade 9  school program

2 conditions in 15 schools
(n = 911)

73% less smoking by end of
grade 9

2 conditions in 22 schools
(n = 3,655)

33% less monthly smoking by end
of grade 9

3 conditions tested in 56 schools
(n = 5,954)

4 conditions tested in 18 schools
(n = 7,030)

2 conditions tested in 22 schools
(n = 654)

3 conditions tested in 30 schools
(n = 0,527)

18% less weekly smoking
observed at grade 12

Program effects at grades 8
and 9 but not at grade 12

Program effects at grades 8
and 9 but not at grade 12

Program effects less at grades 8
and not at grade 12

2 conditions tested in 13 schools
(n = 2,401)

39% less weekly smoking by end
of grade 12

2 conditions tested in 42 schools
(n = 5,065)

32% less monthly smoking after
1 year; 19% less monthly smoking
by end of grades 9-10

2 conditions tested in 50 schools
(n = 5,458)

40% less weekly smoking by end
of grades 8-10; 31% less weekly
smoking at end of grades lo-12

Very large short-term effect
achieved by very intensive school
program with parent education

Large short-term effect achieved
by intensive school program
supplemented with other contacts

Large sustained effects achieved
by very intensive school program

No long-term effects of
less-intensive school program

No long-term effects of moder-
ately intensive school program

No long-term effects of moder-
ately intensive school program

Large sustained effects achieved
by intensive school programs
supported by intensive commu-
nity programs

Large short-term effects achieved
by intensive school program sup-
ported by parent education, mass
media, and community programs

Large sustained effects achieved
by intensive school program
combined with intensive mass
media intervention

*Results are reported relative to a comparison group.

Effectizfe Edtrcatiollal Strategies  67


Surcpeolr Gtv7cr~l's Report

health beliefs about smoking. Social influences, both
direct and indirect, on decisions about smoking were
addressed in the sixth through eighth grades. Psycho-
logical influences, such as stress and self-image, were
addressed in the ninth grade.

  The classroom program was delivered by the stu-
dents' usual classroom teachers, who had been trained
by project staff. The overall curriculum required about
two hours per week throughout the school year. If the
curriculum gave equal attention to each of the three
targeted behavioral areas, the smoking component
would include about 24 hours of class time per year
over six years. The parent education component
of the program included participation in students'
homework from the curriculum, attendance at school
meetings about the program, receipt of program news-
letters, and self-assessment of risk factors for chronic
disease.

  The program was initially tested with students
attending the fourth grade in 15 elementary schools
from suburban communities near New York City
(Walter et al. 1989). Students in eight schools received
the KYB educational program, and students in the
remaining schools received only measurement acti-
vities from the study. The follow-up survey in the ninth
grade included 593 students (65 percent) from the origi-
nal study cohort.

  Analyses of these data showed that students who
had received the program were significantly less likely
than students not receiving the program to smoke ciga-
rettes (verified through salivary cotinine measures).
Smoking prevalence in the ninth grade was 73 percent
lower among students who had received the program.
This smoking prevention effect was stronger among
boys than among girls. Favorable changes in health
knowledge, dietary behavior, blood cholesterol, and
obesity were also observed (Walter et al. 1988; Walter
and Wynder 1989).

Project SHOUT

  The Students Helping Others Understand
Tobacco (SHOUT) project was designed to assess the
effectiveness of a prevention program delivered to sev-
enth through ninth graders by trained college under-
graduates through classroom activities and telephone
and mail support (Elder et al. 1993b). The program
began with 10 class sessions distributed throughout
the seventh-grade school year. Components focused
on pressures to smoke, refusal skills, negative social
and health consequences of smoking, decision mak-
ing, and commitment to nonsmoking. In the eighth

grade, eight classroom sessions reviewed refusal skills
and engaged students in community action projects,
such as encouraging others to quit, writing letters
about tobacco issues to mass media organizations and
tobacco firms, and debating issues about tobacco
use. Throughout the ninth grade, when students had
transferred into secondary school, the college under-
graduates trained by the program staff made four sup-
portive telephone calls to each participant; 69 percent
of participants were reached at least once (Elder et al.
1994a). Also during the ninth grade, five newsletters
were mailed to students and two to their parents.

  This program was initially tested in 22 southern
California schools. Students from 12 schools received
the SHOUT program, and students from the remain-
ing schools did not. About 45 percent of the students
were from minority ethnic groups. The effectiveness
of the program was assessed through classroom and
mail surveys conducted at the end of each of the three
years. The ninth-grade survey included 2,668 mem-
bers (73 percent) of the original study cohort.

  By the end of the ninth grade, the prevalence of
monthly smoking (defined as smoking one or more
cigarettes per month) was about 33 percent lower
among students who had received the program than
among those who had not. The relative difference in
the two groups' reported smoking increased each year
and was statistically significant at the end of the ninth
grade. The results at the end of the ninth grade were
particularly encouraging, because program contact (via
telephone calls and newsletters) was less costly. It was
not possible to assess whether program effects had
accumulated during the seventh and eighth grades.
Results for ethnic subgroups were consistent with these
overall results but were not always statistically signifi-
cant. Similar effects for ninth graders were obtained
for weekly cigarette smoking and for smokeless to-
bacco use. Assessments of cigarette refusal skills
among students receiving and not receiving the pro-
gram indicated that the program had positive effects
on this mediator of smoking initiation at the end of
the seventh grade but not subsequently (Elder et al.
1993a, 1994b). As was found with Project TNT, the
results of the SHOUT program did not in general sup-
port a strong link between refusal skills and smoking
behavior. In an extension of this program, newslet-
ters and supportive telephone calls were offered again
in 11th grade to a subset of the original intervention
group. Results of an additional follow-up survey
suggested positive effects of providing continued
smoking avoidance support to students throughout the
secondary school years (Eckhardt et al. 1997).

68 Chnpter- 3


Reducing Tobacco Use

Longer-Term Follow-Up of
School-Based Programs

  The preceding group of studies did not address
whether the observed prevention effects were perma-
nent or whether they simply represented delays in
smoking initiation from middle school to later high
school years. Because few people begin smoking
after high school, programs that prevent young people
from smoking throughout the high school years are
likely to prevent young people from ever becoming
regular smokers.

  Several studies of school-based programs to pre-
vent smoking have followed participating students
into the later years of high school to assess the dura-
bility of effects several years after the programs were
implemented.

Life Skills Training Program

  The Life Skills Training (LST) Program \vas
designed to help adolescents develop a wide spectrum
of personal and social skills, including those related
to preventing cigarette smoking and the use of alco-
hol and other drugs (Botvin et al. 1990a). The core
program consists of 12 curriculum units designed to
be taught in 15 class periods to seventh graders. The
problem-specific components of the LST Program are
similar to those included in smoking prevention pro-
grams focused more directly on the social influences
model. These components include offering practice
in assertively resisting peer pressure to smoke and
providing information about the negative short-term
social consequences of cigarette use, the decreasing
social acceptability of use, and the actual prevalence
of use among adolescents and adults. Other program
components address the development of generic per-
sonal and social competencies, such as communica-
tion skills and ways to develop personal relationships.

  One of the notable strengths of this program is
the relatively large number of separate trials reported
by the investigators. The largest trial was conducted
among students attending 56 suburban and rural
schools in three geographic regions of New York
(Botvin et al, 1990a). Students in 34 schools received
the smoking prevention program, and students from
the remaining schools did not. The smoking preven-
tion program included the full IS-session LST Program
in the seventh grade, followed by a lo-session booster
program in the eighth grade and a 5-session booster
ii1 the ninth grade. These programs \vere delivered
by the students' usual classroom teachers, who had
been trained either through group workshops followed

by monitoring, feedback, and reinforcement of imple-
mentation procedures or through use of a training
videotape. This study thus tested whether program
effectiveness could be maintained while using low-cost
methods for disseminating the program to large num-
bers of schools, teachers, and students.
  Analyses of reports from the 4,466 students sur-
veyed at the end of the ninth grade (75 percent of the
original cohort) showed that the prevalence of ciga-
rette smoking was significantly lower among students
who had received the LST Program than among those
who had not. The relative difference in the smoking
scores was about 10 percent. Results were similar for
both teacher training conditions. The analyses indi-
cated that most of the knowledge, attitude, and skill
lrariables that were targeted as mediators of effects
showed significant changes consistent with program
objectives. Program recipients also had significantly
louver levels of marijuana use and alcohol intoxication.
  In a long-term follow-up of the LST Program, data
lvere collected from school, telephone, and mailed
surveys administered six years after the initial 56 pub-
lic schools had been randomized to treatment and
control conditions (Botvin et al. 1995). The 3,597 pre-
dominantly white, 12th-grade students sampled repre-
sented 60.4 percent of the initial 7th-grade sample.
Among all students included in the 12th-grade
follow-up, weekly cigarette smoking was reported by
about 22 percent of those receiving the intervention and
by 27 percent of those in the comparison condition, rep-
resenting an l&percent relative reduction in smoking
prevalence. For the subset of students receiving a rea-
sonably complete version of the program, the relative
reduction in smoking prevalence was 26 percent. The
study is unique in demonstrating effects of a preven-
tion program that lasted through high school. The
generalizability of these results to other populations and
school settings is an important area for exploration.
  Similar support for the effectiveness of the
LST Program has been obtained from shorter-term
studies of variations in implementation procedures
and study populations. These studies have provided
evidence for the effectiveness of booster sessions after
the initial program delivery (Botvin et al. 1983) and
have compared the use of peers and teachers as pro-
gram facilitators (Botvin et al. 1990b). Other studies
have replicated the short-term effectiveness of the pro-
gram with African American and Hispanic adolescents
(Botvin et al. 1989a,b, 1992). Components of the pro-
gram also appear to have had positive effects when
implemented outside the context of a research project
(Bru\-old 1990). These multiple tests of one approach
to school-based smoking prevention provide a


Surgeon Gerzeral's Report

well-rounded picture of the potential effectiveness of
various approaches. The results also demonstrate that
relatively intensive programs that address the core
objectives of the social influences model in the context
of a larger curriculum can reduce smoking prevalence
in diverse target populations and school settings when
the curriculum maintains a reasonable level of integ-
rity to the program design.

Minnesota Smoking Prevention Program

  Two replications of a smoking prevention pro-
gram based on the social influences model were com-
bined into a single study of long-term effects, the
Minnesota Smoking Prevention Program (Arkin et al.
1981; Murray et al. 1984). The core program contained
units that identified social pressures to smoke, offered
practice in skills to resist direct social pressures, pro-
vided information about actual levels of smoking
among peers and adults, and provided information
about the negative short-term social and physiologi-
cal consequences of smoking. These objectives were
addressed in five class periods delivered throughout
the seventh grade; no additional educational compo-
nents were offered in later grades. Both replications
of the program compared the relative effectiveness of
same-age peer leaders and adult leaders.

  The. two studies included 7,030 seventh-grade
students participating in baseline surveys in 18 sub-
urban Minnesota schools. In the first study, students
received a social influences program led by adults
or by peers or received an adult-led program of simi-
lar length on the long-term health consequences of
smoking. In the second study, conducted a year later,
seventh-grade students from the same 18 schools
received the adult-led or peer-led social influences pro-
gram, the adult-led health consequences program, or
no specific smoking prevention program.

  Results from the first study indicated that among
students who were nonsmokers at the start of seventh
grade, those who received the peer-led smoking pre-
vention program were significantly less likely than
those who received the adult-led programs to have
tried smoking by the end of the eighth grade; similar
results were seen for students who at the start had al-
ready tried smoking (Murray et al. 1984). Results from
the second study indicated that at the end of the eighth
grade, students who were initially nonsmokers and
who received any of the test programs were signifi-
cantly less likely than similar students from the schools
receiving no program to have tried smoking (Murray
et al. 1987). In the first study, differences among treat-
ment groups had diminished by the ninth grade and

were not statistically significant. In the second study,
students who had initially tried smoking and who
received the peer-led programs had a significantly
lower smoking prevalence than students receiving the
adult-led health consequences program (Murray et al.
1987). Modest effects of a peer-led program were
detected in an llth-grade follow-up conducted for the
second study (Murray et al. 1988).

  The investigators surveyed members of the origi-
nal study cohorts when the first study participants
were one year beyond high school and the second
study participants were in the 12th grade (Murray et
al. 1989). Those still attending school in their original
districts participated in a classroom survey, and oth-
ers were interviewed by telephone; participation ex-
ceeded 90 percent in both studies. Responses indicated
that the programs had no lasting differential effects
on smoking behavior.

Waterloo Smoking Projects

  The Waterloo Smoking Projects (WSP) in Canada
tested a social influences program designed to follow
students from the sixth through eighth grades. The
program included three main components common
to social influences curricula (Best et al. 1984). The
first component provided information on negative
consequences of smoking, on smoking prevalences in
the general population, and on social influences to
smoke. The second component provided practice in
skills to resist direct social pressures to smoke. The
third component focused on decision making and
public commitment to not smoke. These topics were
delivered in six sessions during the first three months
of the sixth grade. Information about social influences
was reviewed in two booster sessions later in the sixth
grade. Two additional booster sessions in the seventh
grade and one in the eighth grade featured student
presentations and discussions about smoking pres-
sures and decisions. All sessions were presented by
graduate students who were members of the project
staff.

  The evaluation design for this study provided
methodologically stronger evidence for potential
longer-term effects than previous follow-up studies of
school-based programs. The WSP was tested with stu-
dents from 22 schools in two school districts in south-
western Ontario (Flay et al. 1985). Students from half
the schools received the program, and students from
the other half did not. The schools were located in
urban, suburban, and rural areas. The study sample
included 654 students tested at the sixth-grade baseline
classroom survey.

70 Chapter 3


Reduchg Tobacco Use

  At the end of the seventh grade, 18 months after
the baseline survey, results were reported for the 498
students (76 percent) who had been present for all
cross-sectional analyses at each time point. The analy-
ses showed reduced experimentation with smoking
in the entire target population receiving the program
and reduced consumption among students who were
regular smokers before involvement in the program
(Flay et al. 1985). Longitudinal analyses showed
significantly less smoking among program recipients
who had already tried smoking before starting the
program. Psychosocial mediators, such as knowledge
and perceived control, showed changes throughout the
target population that were consistent with program
objectives (Flay et al. 1983).

  Results at the end of the eighth grade were re-
ported for the 439 students (67 percent) who had par-
ticipated in all six school surveys administered through
that time (Best et al. 1984). These analyses indicated
that the program significantly reduced the amount of
experimental smoking among the subgroup that at the
baseline survey had reported never smoking. Effects
that had been detected at the end of the seventh grade
among students with more smoking experience were
still apparent but no longer statistically significant.

  The project surveyed original cohort members at
the 12th grade by classroom survey, mailed question-
naire, and telephone interview. This effort yielded
long-term follow-up data for 560 members (86 percent)
of the original study cohort (Flay et al. 1989). There
were no program effects at the 12th grade for any
smoking level in the overall study sample or for any
subgroups defined by initial level of risk.

Project ALERT

  The Adolescent Learning Experiences in Resis-
tance Training (ALERT) school program was based on
a social influences model that included many features
common to this type of program (Ellickson et al. 1993a).
The overall goal was to provide young people with
the motivation and skills needed to avoid substance
use, including alcohol and marijuana as well as
cigarettes. The motivational component focused on
reducing barriers to resisting social pressures, such as
normative beliefs that most young people and adults
smoke, that this behavior is widely acceptable and
approved, and that smoking has positive physical and
social consequences. The skill component focused on
practicing skills to resist direct social pressures to
smoke. Eight sessions covering these objectives were
delivered one week apart during the seventh grade;

three booster sessions reviewed the main points dur-
ing the eighth grade.

  This program was tested with students from 30
schools in eight school districts located in urban, sub-
urban, and rural communities of California and Oregon
(Ellickson and Bell 1990). In the initial school survey,
about 33 percent of these students were from minority
ethnic groups. Students in 20 schools received the
ALERT curriculum, and students in the other 10 schools
did not. In 10 of the program schools, the curriculum
was delivered by classroom teachers alone; in the other
10 program schools, teachers were assisted by older
peer leaders recruited from nearby high schools.

  The initial assessment of this program was re-
ported for follow-up school surveys completed 15
months after the baseline survey. After substantial
follow-up effort, about 60 percent of the baseline co-
hort of 6,527 students were included in these reports
(Ellickson and Bell 1990). Among students in the treat-
ment group who had experimented with smoking be-
fore the program, smoking was reduced by about 20
percent. Among students who had never smoked,
however, the program did not achieve a statistically
significant reduction. Psychosocial risk factors tar-
geted by the program, including beliefs about the con-
sequences of use and perceived norms for cigarette
smoking, showed changes consistent with program
objectives (Ellickson et al. 1993a). These findings were
generally consistent across school districts in various
geographic regions with differing ethnic and socioeco-
nomic profiles; the results were not affected by whether
an older peer assisted in delivering the program.

  An additional follow-up of these students was
reported at the ninth grade, two years after the baseline
survey (Bell et al. 1993). These analyses included about
75 percent of the baseline sample. Earlier effects on
psychosocial risk factors persisted, but program effects
on cigarette smoking and other substance use behav-
iors had disappeared at this time (one year after the
end of the program).

  A final follow-up survey was completed in the
12th grade, five years after the baseline survey and
four years after completion of the program; 57 percent
of the baseline sample were included in these analy-
ses (Ellickson et al. 199313). By the end of high school,
the program had no detectable effect on cigarette smok-
ing or other substance use behaviors; most program
effects on cognitive risk factors had also disappeared
by this time. Similar to the other longer-term follow-
up studies, these outcomes indicated that program
effects eroded rapidly when the program ended and
that no effects on smoking behavior or related beliefs
were detectable at a later time.

E@fiz'e Educofiorlal Sfrafegies  72


Summary of Recent School-Based
Research Studies
  These reports reflect a high level of consistency
in approaches taken to prevent smoking initiation and
in the results obtained. All studies used some form of
multiple-session school curriculum that was based on
the social influences model and was delivered through
classroom activities beginning in the sixth or seventh
grade; all included a similar set of core curriculum
components; and all reported achieving significant
differences in smoking behaviors for one year or more
after the program was initiated. For most programs,
significant differences were reported through the ninth
grade (the first year of high school and more than two
years after program initiation).

  Some specific features of these results strengthen
the case for the effectiveness of school-based social
influences curricula. The magnitude and scope of the
effects achieved across studies were generally more
impressive than those reported by earlier studies. The
size of the reduction in smoking achieved at the eighth
and ninth grades and the duration of these effects were
larger than those of the short-term follow-up studies.
Most of these studies also reported substantial effects
on theory-based psychosocial mediators of cigarette
smoking that were targeted for change by the pro-
grams, such as relevant knowledge, attitudes, skills,
and perceived norms.  These results thus indicated
important and persistent effects (at least for several
years) across a wide range of outcomes anticipated by
the theoretical approach.  As discussed later in this
section, however, the effects did not persist in the
longer term.

  Programs that were successful in achieving pre-
vention effects through the ninth grade tended to in-
clude a larger number of educational contacts with
students over a longer time period than most earlier
programs. For example, Project ALERT included 11
class sessions over two years; SHOUT included 18 class
sessions, four telephone contacts, and five newsletters
over three years; the LST Program included 30 class
sessions over three grades; and the KYB program in-
cluded an even larger number of class sessions over
six school years. These relatively intensive programs
successfully deterred young people from smoking
cigarettes and using other substances during the peri-
ods that these curricula were provided. Comparable
programs with smaller numbers of contacts over a
more limited time have reported achieving a less sus-
tained effect on smoking initiation (Biglan et al. 1987;
Ary et al. 1990). These observations suggest a dose-
response relationship between how much the students

are exposed to the social influences program and how
effective the program is in preventing students from
smoking. These results suggest that larger numbers
of educational contacts over a longer period of time
may yield larger and more enduring smoking preven-
tion effects. This conclusion is strongly supported by
the long-term reductions in cigarette smoking preva-
lence achieved by the relatively intensive LST Program.
  The results were also obtained within a wide
range of curriculum formats. Some of the recent so-
cial influences programs have tried to reduce the
prevalence of several substance use behaviors often
linked in the behavioral development of young people.
These programs have included efforts within the same
curriculum to prevent the use of smokeless tobacco,
marijuana, and alcohol, as well as cigarettes. Includ-
ing several substances in the program objectives, as
might often be the case in ordinary school programs
to prevent substance abuse, does not appear to have
reduced the potential effectiveness of these programs
in reducing cigarette smoking. In several cases, the
positive effects on smoking behavior were also ob-
served for other substance use behaviors. Similarly,
social influences programs have been successful in
diminishing smoking behavior when they have been
incorporated in a larger health education program that
successfully addressed other health behaviors, such as
diet and physical activity. The success of programs
under this broad diversity of curriculum formats in-
creases confidence in the theoretical relevance and
generalizability of this approach.
   These studies also tested the social influences
model under various implementation conditions.
Successful programs were reported from a diverse
group of geographic areas and with urban, suburban,
and rural populations. A much wider mix of ethnic
student populations has been involved in these than
in earlier studies. Some studies reviewed here have
reported favorable program effects for African Ameri-
can and Hispanic adolescents; similar programs have
demonstrated positive effects for American Indian
adolescents (Schinke et al. 1988, 1994; Moncher and
Schinke 1994). Successful programs also used various
personnel to deliver the programs. These included
programs delivered by students' usual classroom
teachers with or without intensive training, programs
delivered with and without the assistance of peer lead-
ers, programs delivered by college undergraduate or
graduate students, and programs delivered by profes-
sional staff members of the research team. These
diverse characteristics of successful programs further
support the generalizability of the social influences
model.

72 Chapter 3


Reducing Tobacco Use

  The more recent studies can be interpreted with
much greater confidence than was possible with the
pioneering studies reviewed a decade ago because
of improvements in study design, measurement, and
data analysis methods. Internal validity has been im-
ITroved by including larger numbers of schools and
students in study samples to enable investigators to
account for school-level effects on smoking behavior
(Murray and Hannan 1990). This approach also has
improved external validity by providing for tests of
programs with more diverse populations and placing
program activities farther from the direct control of
the chief investigators. In general, these reports have
thus provided stronger demonstrations than were pre-
viously available of the benefits of social influences
programs over other school health education programs
for preventing smoking. The reports also provide
greater assurances that the results obtained could be
achieved in many types of classrooms if this curricu-
lum approach was implemented with a reasonable
level of fidelity.

  The primary limitation of this promising record
of success is its generally short-lived nature. Three of
the studies that followed participants through the 12th
grade consistently found that effects had faded over
the high school years. The fourth, the LST Program,
demonstrated a statistically significant impact through
the 12th grade (Botvin et al. 1995). Thus, although the
majority of programs based on the social influences
model did not permanently protect young people from
pressures or desire to begin smoking, the evidence
shows that all of these programs successfully delayed
this initiation for several years and that the most in-
tensive of these programs reduced smoking prevalence
through the end of high school. These results demon-
strate that larger-scale implementation of intensive in-
terventions based on this model can achieve long-term
reductions in cigarette smoking among young people.

  Further suggestions for overcoming this duration
limitation may be drawn from these recent school-
based studies. The studies provide evidence not only
for the importance of overall program intensity, or the
amount of exposure to the program (discussed earlier),
but also for the effectiveness of programs that target a
relatively broad array of educational modalities for
smoking prevention. The LST Program addresses a
spectrum of developmental concerns in addition to
using a core unit on resistance to social influences that
promote smoking; this curriculum has been shown to
be effective with a wide range of populations. The
KYB program achieved smoking prevention effects
with a curriculum that was embedded in a larger
program to change health behaviors. The SHOUT

program included classroom-based community action
and advocacy components in addition to conventional
units based directly on the social influences model.
Such broader approaches within school settings thus
seem to be effective in addressing the diversity of
smoking prevention needs among adolescents.

  This perspective receives additional support from
a series of studies that have tried to identify more pre-
cisely the strengths of the social influences model by
testing main components separately. The design of
the Project TNT program evaluation provided a direct
comparison between the effects of four curricula
focused on skills training for resisting peer pressures,
on social norms about the prevalence and acceptabil-
ity of smoking, on knowledge of the negative conse-
quences of smoking, or on a combination of the three
elements. Contrary to theory-based expectations, the
social skills curriculum did not perform as well as
the social norms or negative consequences curriculum;
the combined curriculum had the best results (Sussman
et al. 1993b). A similar study found that a curriculum
based on correcting erroneous normative perceptions
was more effective than a curriculum on training in
resistance skills; the results also suggested that a com-
bined curriculum addressing a variety of educational
needs about social influences on smoking was more
effective than curricula focused on individual compo-
nents of the model (Hansen and Graham 1991).

  These studies thus indicate that attempts to
reduce the scope of smoking prevention programs
to skills training alone are likely to be ineffective. Al-
though school programs are well suited to provide
skills training through direct modeling and practice,
as well as to convey knowledge about the conse-
quences of smoking, they may not be as well equipped
to influence young people's perceptions of the preva-
lence and acceptability of cigarette smoking among
their wider peer group and adult society. As is
discussed in the next section, more complex and
intensive programs combining interventions within
and outside of schools may be needed to overcome
the powerful prosmoking cultural images fostered by
the larger social environment.

Research on Multifaceted Programs

  Another group of recent studies has expanded
the traditional school-based scope of educational
methods to prevent smoking. To counteract the
multiple sources of social influences that promote
smoking initiation, these projects enlist the positive
influences of parents, community organizations,

Effectiw Educational Strategies  73


Surgeotz General's Report

and the mass media in addition to offering strong
school programs based on the social influences model.
Relatively few examples of this new direction for
smoking prevention efforts have been reported. Edu-
cational objectives for these programs have generally
been developed directly from programs that have
school-based components only, but specific strategies
reflect various approaches, as might be expected when
new techniques are being developed. Results provide
good evidence that these multifaceted educational
programs can achieve substantial smoking prevention
effects that persist throughout the high school years
more consistently than programs based only in schools.

Minnesota Heart Health Program:
Class of 1989 Study

  The Class of 1989 Study of the Minnesota Heart
Health Program (MHHP) tested the efficacy of a school-
based smoking prevention program conducted in the
context of a wide range of associated school and
community programs designed to improve health
behaviors. These programs focused collectively on the
overall goal of reducing the risk of cardiovascular dis-
ease among the adults of the targeted communities
(Perry et al. 1992).

  Smoking prevention programs were provided in
the seventh through ninth grades. The main compo-
nent of this multifaceted effort was based on the Min-
nesota Smoking Prevention Program (discussed in the
previous section), which was one of the early success-
ful designs for a social influences program (Perry and
Jessor 1985). The Class of 1989 Study used a seven-
session program delivered in weekly sessions during
the seventh grade by peer leaders assisted by teachers
(Perry et al. 1986). This program was followed by a
two-session unit in the eighth grade that addressed
smoking and exercise and by an eight-session unit in
the ninth grade to prevent smoking and drug abuse.
Similar curriculum units on eating and exercise behav-
iors were added to the school curriculum after the
smoking prevention unit in the seventh grade (Perry
et al. 1988).

  These classroom components were supported in
school by the development of health councils through
which students participated in other projects related
to the overall community program theme of cardio-
vascular risk reduction. Altogether, the students in
the Class of 1989 Study participated in five years of
educational programs that were provided through
their schools and were focused on smoking and other
health behaviors.

  The school-based educational components were
complemented and supported over the entire program
period by community education and organization
activities intended to reduce three cardiovascular risk
factors-cigarette smoking, high levels of serum cho-
lesterol, and elevated blood pressure-in adults of the
targeted communities (Mittelmark et al. 1986; Perry et
al. 1992; Luepker et al. 1994). The activities included
individual risk factor screening and education, which
was received by more than 60 percent of all adults;
direct education sessions that were conducted in vari-
ous community settings, which engaged more than 30
percent of all adults; food labeling education in gro-
cery stores and restaurants; intensive mass media edu-
cation; continued education of health professionals;
and community organization to engage citizens, health
professionals, and community leaders in developing
and carrying out annual community education plans.
Although the MHHP did not demonstrate a significant
impact on adults (Luepker et al. 1994), a set curriculum
and face-to-face training were found to increase the
participation of teachers (Perry et al. 1990a).

  The effect of these interventions on the smoking
behavior of the targeted students was assessed through
an evaluation design in which students from one com-
munity received these direct and indirect interventions
and students from a matching community did not
(Perry et al. 1992). At baseline, the target population
consisted of all sixth graders attending the 13 elemen-
tary schools in these two communities. Longitudinal
analyses at each annual follow-up considered students
who had been present since the baseline surveys. The
12th-grade survey included 45 percent of the original
cohort of 2,401 students. Cross-sectional analyses in-
cluded all students participating in each survey.

  Cohort analyses comparing weekly smoking
prevalence and amount of smoking showed that
students in the two communities did not differ sig-
nificantly at the sixth-grade survey, which was admin-
istered before exposure to any substantial amount of
program activities. Significant differences appeared at
the seventh-grade survey, which was administered af-
ter completion of the core components of the smoking
prevention program. Weekly smoking prevalence was
about 40 percent lower in the treatment community co-
hort. Similar effects were found in the cross-sectional
analyses. These significant differences were maintained
through the 12th-grade survey, three years after the
end of direct smoking prevention education and one
year after the end of general community education.

  This study was one of the first demonstrations
in the United States that the effects of educational
programs to prevent smoking could be maintained

74 Chapter 3


Reducing Tobacco Use

through late adolescence-and thus, theoretically,
through life. Longer-term community programs sup-
porting these school-based components appeared to
play a key role in maintaining positive effects.

Midwestern Prevention Project

  The Midwestern Prevention Project (MN'),
a three-year school-based program for preventing
substance use, was supported by several community
interventions explicitly designed for this purpose
(Pentz et al. 1989a). The school program consisted
of 10 classroom sessions in the sixth or seventh grade,
(depending on the year of transition into middle
school) and is the same as that reported by Hansen
and Graham (1991). These sessions emphasized the
negative consequences of cigarette, alcohol, and mari-
juana use; corrected misperceptions on actual levels
of use among peers and adults; discussed direct and
indirect pressures to use substances; practiced skills
to resist pressures for substance use; and obtained
public commitments to avoid substance use. These
activities were presented by classroom teachers with
the assistance of peer leaders. Ten homework sessions
that involved parents' participation accompanied the
school program. These sessions. emphasized clarify-
ing family rules on substance use, practicing tech-
niques for avoiding substance use, and learning ways
to counteract media and community influences to use
substances. The mass media component of this pro-
gram occurred throughout all three years of program
effcrt and was equally available to program and con-
trol group students. Media messages focused on news
coverage of program activities through newspaper
articles, brief television news segments, and radio and
television talk show interviews with project staff.

  During the second year of the program (occur-
ring in either the seventh or the eighth grade) for the
target cohort, a five-session classroom booster program
was combined with homework designed to keep par-
ents actively engaged in prevention efforts (Pentz et
al. 1989b). School administrators, parents, and stu-
dents also planned and presented a parent education
evening featuring communication skills and school
policies on substance use (Rohrbach et al. 1995). Dur-
ing the third year of the program, community leaders
received training in organizing task forces to prevent
substance use. This program component, like the
media component, was equally capable of influencing
students in the program or the control group (Johnson
et al. 1990).

  The overall program was tested in 42 schools
from eight communities in the Kansas City metropoli-
tan area. About 21 percent of the students from these
sixth- and seventh-grade target groups were from mi-
nority ethnic groups. Students from the target grades
in these schools were assigned to the school and par-
ent cotiponents (24 schools) or to a delayed-treatment
control condition (18 schools).. All students and par-
ents were exposed to the mass media components
and were potentially exposed to the effects of the com-
munity organization component beginnirig with the
third program year. Effects were evaluated by using a
one-third sample of the large sixth- and seventh-grade
target group. This study sample was obtained through
baseline surveys of all targeted students in 16 schools
and through a one-fourth sample from the remaining
schools (total n = 5,065).

  Follow-up surveys combined sequential cross-
sectional surveys, including all students present at a
survey point, and longitudinal surveys of a subset of
baseline cohort members. The. one-year follow-up
sample- included 5,008 members of the target popula-
tion, who.were then in the seventh and eighth grades.
Monthly cigarette use was about 32 percent lower
among students who had received the combined
school, parent, and mass media programs than among
students who had received the mass media informa-
tion only. Similar effects were observed among the
subset of students tracked longitudinally (Dwyer et
al. 1989).

  Additional classroom .surveys were completed
with 3,875 students two years after baseline, when the
students were in the eighth and ninth grades (Pentz et
al. 1989b). Significant program effects on monthly and
weekly smoking prevalence were maintained from the
one-year follow-up, although the magnitude of the dif-
ferences between program and control students was
smaller. Similar results were obtained from the panel
of students measured longitudinally (Pentz et al. 1989~).

  The longitudinal panel from the original sample
was followed up into the 9th and 10th grades (Johnson
et al. 1990). The baseline sample included 1,607 sixth-
and seventh-grade students, of whom 1,105 (69 per-
cent) provided complete data at both baseline and the
three-year follow-up. Analyses indicated a significant
treatment effect for monthly cigarette smoking. Stu-
dents receiving the entire program reported about
19 percent less monthly smoking than students who
received only the mass media and community organi-
zation components.

Effcctiue Educational Strategies  75


University of Vermont School and
Mass Media Project

  The University of Vermont School and Mass
Media Project (VSMM) evaluated the effects of supple-
menting a school-based smoking prevention curricu-
lum with intensive mass media campaigns carefully
targeted to the needs of adolescents. Both the school
and the mass media programs shared a set of objec-
tives consistent with the social influences model. These
common objectives stated that adolescents exposed to
the programs would perceive fewer advantages of
smoking, perceive more disadvantages of smoking,
acquire social skills to resist peer pressures to smoke,
and perceive that most people their age do not smoke
(Worden et al. 1988). Other objectives concerned with
smoking cessation and awareness of tobacco industry
marketing to young people were introduced as the tar-
get group matured.

  The school program included grade-specific
lesson plans and teaching materials, and classroom
teachers received annual training. Curriculum con-
tent covered key elements of the social influences
model, such as short-term social and health conse-
quences, awareness of social pressures to smoke, skills
for coping with peer pressures and other social pres-
sures, and decision-making skills related to smoking
behavior (Flynn et al. 1995). The three-grade study
cohort received this program for four years, in either
the 5th-8th grades, 6th-9th grades, or 7th-10th grades.
The program required four class sessions for the units
in the 5th-8th grades and three class sessions for the
units in the 9th and 10th grades.

  The mass media campaigns used the common
objectives and data from high-risk young people in six
predefined age and sex groups. High-risk students
were defined as those who had previous smoking
experience or who knew at least two people in their
immediate social environment who smoked, such as
parents, siblings, or friends. High-risk girls and boys
from three age groups participated in diagnostic re-
search activities on two occasions during the study to
provide information needed to tailor the mass media
campaign to their needs (Worden et al. 1988). These
data were used to develop pilot mass media spots, which
were assessed by small samples of high-risk students.

  Mass media advertisements that clearly ad-
dressed the common educational objectives and were
attractive to their intended target groups were pro-
duced for broadcast as 30- and 60-second television
and radio spots. Spots targeted to the six specific
target groups were broadcast on programs that school
survey data had indicated were popular among these

groups; 36 television and 17 radio spots were pro-
duced. An average of 190 television broadcasts, 350
cable television broadcasts, and 350 radio broadcasts
of these spots was purchased per year for four years
in each target community.

  The evaluation design included four geographi-
cally separate but demographically matched metro-
politan areas from three states (Flynn et al. 1992).
Students in two communities received the mass me-
dia and school programs for four years. Students in
the other two communities received only the school
programs during these four years. The initial cohort
included all students from the fourth through sixth
grades from 50 elementary and middle schools; more
than 99 percent of these students (n = 5,458) partici-
pated in the first school survey. Interventions and
annual follow-up surveys were conducted for the next
four years, beginning at the 5th-7th grades in the 1985-
1986 school year and ending at the Bth-10th grades. A
classroom and telephone follow-up survey attempted
to reach all original cohort members during the IOth-
12th grades.

  Results after four years of the program concen-
trated on the 47 percent of the original cohort who were
fully exposed to the program components (n = 2,540).
These analyses indicated that significant hypothesized
differences in mediators of program effects occurred
in the media-school communities beginning at the end
of the second program year and that the amount and
prevalence of cigarette smoking were significantly
reduced at the beginning of the third program year
(Flynn et al. 1992; Worden et al. 1996). By the end of
the four-year program period, alternative measures of
smoking prevalence and intensity indicated that stu-
dents in the media-school communities reported
34-41 percent less smoking than students in the school-
only communities. Two years later, when the study
cohort was in the IOth-12th grades, differences
between smoking prevalences in the two groups con-
tinued to be statistically significant and of similar mag-
nitude (Flynn et al. 1994). Among students who were
at high risk for smoking in grades 4-6, further analy-
ses showed that these interventions produced signifi-
cant differences in weekly smoking prevalence at
grades lo-12 (Flynn et al. 1997). Cost-effectiveness
analyses indicated that the cost per student smoker
averted as a result of these interventions was about
$754 in 1996 dollars, and the cost per life year gained
was about $696 (Seeker-Walker et al. 1997).

  These findings show that carefully targeted mass
media campaigns can add to school programs a sub-
stantial and enduring effect on smoking prevention
when the program efforts are sufficiently intensive

76 Chapter 3


and the educational objectives for these two channels
are closely coordinated. These interventions did not
include a substantial program component directed to-
ward parents or other adults in the community. The
results provide powerful evidence of the influence of
mass media messages on health behavior decisions
made by young people.

Observations on Research on
Multifaceted Educational Programs

  These studies are notable because they all repre-
sent efforts to extend the impact of school programs
by enlisting the influence, preferably throughout ado-
lescence, of other polrerful forces in the lives of young
people and because their effects more consistently ex-
ceed those achieved by programs in\rolving only the
school (Table 3.1). This notion has added importance
in view of the competition for curricular time ~\.ithin
schools. The studies that M'ere able to follo\v up studv
participants into the later high school years ha\re prd-
vided the best evidence thus far that program effects
can be extended when educational or other prel~en-
tion strategies include multiple components and take
place over longer terms. Because fen- people begin
smoking after high school, these results suggest that
long-term multifaceted programs can prevent signifi-
cant proportions of young people from smoking not
only during their junior and senior high school years
but also for the rest of their lives.

  The interventions used in these three studies
were based on a common core of approaches. The main
shared theme was that a strong school program was
necessary to achieve substantial effects. The school
component of the MHHP included 17 class sessions
explicitly directed toward smoking prevention objec-
tives over three school years; the MPP school program
included 15 class sessions over two school years, as
well as other school-based student activities; and the
VSMM included 14-16 class sessions over four school
years. The intensity of these school programs was simi-
lar to the intensity of successful school-only programs
and approached that recommended by experts (Glynn
1989; CDC 1994b). A related theme was use of the so-
cial influences model in designing programs. The re-
search groups that developed the MHHP and the
MIT included investigators who were key contribu-
tors to the development of this model for school-based
programs. The design of the VSMM program compo-
nents also closely followed this model.

  The third shared theme for these studies was their
focus on entire communities. The MHHP was pro-
vided to, and evaluated in, all schools in a single

moderate-sized community and \vas supported by
communitywide mass media and organizational pro-
grams. Some components of the MPP M'ere provided
to students, parents, and community members in an
entire large metropolitan area. The VSMM was pro-
vided to adolescents in two entire moderate-size
metropolitan areas, and the same large groups were
the focus of targeted media campaigns. The educa-
tional messages of the school-only programs, in con-
trast, generally did not reach beyond the walls of the
selected school. Directing messages to entire commu-
nities of adults and adolescents may have increased
the capacity of multifaceted studies to influence ado-
lescents' normative perceptions of the prevalence and
acceptability of cigarette smoking.
  The importance of the school component was
emphasized by results of a study conducted Lvithin
the context of the Stanford Fi\.e-City Project. This
study shared M'ith the MHHP the goal of reducing car-
diovascular risk factors in entire adult populations and
shared many features of the programs for adults
(Farquhar et al. 1990). The adolescent smoking
feature of this study assessed whether reductions in
cigarette smoking among adults (Fortmann et al. 1993)
M'ere reflected among adolescents. A seven-session
smoking prevention program was provided to ado-
lescents in 7th and 8th grades during the fourth pro-
gram year (Telch et al. 1982; Winkleby et al. 1993), and
a four-session cessation unit was provided to half of
the IOth-grade classes (Killen et al. 1988). The effect of
this combination of programs was assessed through
cross-sectional population surveys conducted over a
lo-year period. No statistically significant differences
in smoking prevalence were detected among partici-
pants aged 12-15,16-19, or 20-24 years.
  The duration of the community programs in the
MHHP was one year less than that of the Stanford study.
The school programs in the MHHP, however, were
much more intensive and of longer duration. Although
differences in evaluation methods preclude direct com-
parisons, results suggested that the MHHP's substan-
tial impact on the smoking behavior of adolescents in
the Class of 1989 Study depended on the presence of a
strong school-based program that was enhanced by the
supportive community environment in which it was
conducted. The Stanford study's lack of effects on ado-
lescents suggested that intensive, communitywide pro-
grams to reduce health risks among adults would not
be sufficient to change adolescent smoking unless these
programs were combined with more intensive school
programs. These contrasting results affirm that a strong
school program is important to the succe~ of educa-
tional strategies for prevention.


  The MHHP community activities were not spe-
cifically designed as smoking prevention programs;
they were directed toward adults and addressed sev-
eral cardiovascular risk factors in addition to smok-
ing These efforts to reduce adolescent smoking may
have resulted because young people were directly
exposed to community program messages and appeals
intended for adults, school programs had heightened
intensity from being conducted in communities
focused on developing healthy behaviors, or parents
stimulated by the community programs gave greater
attention to adolescent health behaviors. The inten-
sity, pervasiveness, and duration of the community
program may also have affected the general norms of
the community on health behavior, which in turn may
have influenced young people to decide against start-
ing to smoke.

  Similar results were obtained by another youth
smoking prevention study conducted in the context
of pervasive community cardiovascular risk reduction
campaigns. The North Karelia Youth Project in Fin-
land included a school program with three sessions in
grade seven, five sessions in grade eight, and two ses-
sions in grade nine (Vartiainen et al. 1998). Intensive
community programs on cardiovascular risk reduction
were conducted for adults, including community
organization and mass communication campaigns for
cigarette smoking cessation, during the years the
school program was delivered. Significant differences
in cigarette smoking prevalence between young
people in the intervention and comparison areas were
found at each follow-up survey through age 21. At
age 28, significant differences in smoking prevalence
were found among those who were nonsmokers at the
baseline survey, in seventh grade. These results pro-
vide strong support for the findings of the MHHP Class
of 1989 Study and emphasize the potential impact on
youth smoking of combining school and community
programs.

  The community component of the MPP was ex-
plicitly designed to complement the school program
to prevent substance use. Program activities that oc-
curred outside the classroom were more focused on
parents' behaviors than is usually found in research
studies on smoking prevention. These activities in-
cluded 10 homework exercises in the first program year
and a wide range of family norm-setting activities;
similar exercises accompanied the second year of the
school curriculum. Parents helped plan and present a
parent education evening in participating schools in
the second year and participated in community orga-
nization activities in the third year.

  The only program components to directly reach
or involve the wider community were the media mes-
sages and community organization activities. The
latter component was not introduced until the third
program year and may not have had much effect on
students' smoking behaviors. Because parents, then,
were the principal focus of educational efforts outside
the classroom, the MPP effects were likely achieved
mainly through strong and consistent parental sup-
port of the objectives of this school-based program.
The media messages may also have influenced ado-
lescents' perceptions of peer, family, and community
smoking norms.

  Results of the MPP, the MHHP, and the North
Karelia Youth Project thus offer the possible common
interpretation that the programs' effects depended on
strong school programs supported by community pro-
grams that may have affected students in two ways:
through substantially increased efforts by parents and
through young people's perceiving that smoking is not
normative. Although parental components similar to
the MPP homework assignments have been included
in some school-only smoking prevention programs, the
full scope of parent-oriented efforts used by the MPP
in support of the school curriculum has not been tested
previously. Further exploration of combined school
and parent programs may be a promising avenue for
future educational research studies. Similarly, these
results highlight the importance of program compo-
nents designed to influence adolescents' normative
perceptions.

   The VSMM shared with the MPP and the MHHP
the general strategy of supplementing a relatively
strong school-based smoking prevention program with
other forms of intervention but differed in several
respects. The combined school and mass media pro-
gram in the VSMM was directed toward the target ado-
lescents, and no adult participation was anticipated
outside of the classroom. The project's resources thus
were applied to influencing adolescents' smoking
behaviors directly through changes in the students'
beliefs, skills, and perceived norms.

  The VSMM also differed in focusing on use of
the mass media as a sole supplement to the school pro-
gram. This design provided a reasonably clear indi-
cation that the magnitude and duration of a relatively
strong school curriculum to prevent smoking could
be significantly increased by a mass media component
that concentrated exclusively on the target audience
of adolescents.

  Three other large-scale tests of mass media ap-
proaches to smoking prevention have been reported.
One study conducted in North Carolina tested three

78 Clmpfrr 3


Reducing Tobacco Use

mass media campaigns that were not combined with
school-based programs (Bauman et al. 1988). The
media campaigns included radio spots on the expected
consequences of smoking, a similar radio campaign
that featured a smoking prevention contest, and the
radio and contest components with television spots
added. The messages were broadcast during three
four-week periods at levels intended to reach 75
percent of the target audience four times during each
period. Each campaign was conducted in two metro-
politan areas; four other communities served as
control areas. Adolescents aged 12-14 years were in-
terviewed through household surveys at baseline
(n =.2,102); 78 percent of them were followed up 11,17
months later. Results indicated that the campaigns had
effects on the recipients' knowledge of the conse-
quences of smoking and other mediators but not on
cigarette smoking behavior (Bauman et al. 1991).

  In the Television, School, and Family Smoking
Prevention and Cessation Project (TVSFP), Flay and
colleagues (1988, 1995) tested a mass media supple-
ment to a school program. The study design was
similar to that used in the MPP. The main study was
conducted in a single metropolitan area. The mass
media component was generally available to members
of the community, and the school program was offered
only to members of the main treatment group. The
main research question thus addressed whether
a school program combined with a mass media cam:
paign had a stronger effect than the mass media
campaign alone. The school curriculum included 10
classroom sessions delivered by trained health educa-
tors during the seventh grade. The media component
included segments that ran for two months in evening
television news shows that were linked to the class-
room sessions. Students in the main intervention con-
ditions were asked to view these segments with their
parents and to complete related homework activities
together. Seventh-grade students from 47 schools par-
ticipated in the study; they were surveyed during the
seventh, eighth, and ninth grades. Program effects
were observed in the follow-up surveys for mediating
variables but not for smoking behavior.

  More promising results have been reported for a
three-year mass media campaign on youth smoking
in Norway (Hafstad et al. 1997). This campaign used
the novel approach of creating messages intended to
stimulate antismoking interactions among young
people through use of provocative messages that pre-
sented starkly negative images of adolescent smokers.
Unlike other mass media approaches, these messages
were presented as movie and newspaper advertise-
ments and posters, as well as through broadcast

media channels. Messages were broadcast or placed
at a relatively high level of intensity over one three-
week period each year for three years. Message themes
were varied each year. The impact of these campaigns
was evaluated over three years by comparing baseline
and follow-up survey results among a cohort of 11,033
young people aged 14 and 15 years for one interven-
tion county and one control county. Results showed
that young people from the intervention county were
less likely to start smoking and more likely to stop
smoking at the follow-up survey. This study demon-
strates the potential impact of relatively intensive,
highly targeted mass media smoking prevention cam-
paigns that are not combined with any other type of
smoking prevention intervention.

  Results of these studies using mass media as a
primary educational strategy suggested that better
outcomes were associated with more intensive, multi-
faceted program efforts on social influences. The
TVSFP intervention included a substantial school
curriculum for the seventh grade but did not include
further sessions in later grades. The mass media
campaign included a maximum of 10 exposures over
a two-month period. The North Carolina study did
not include a direct component for interpersonal edu-
cation; the media component for this study did not
directly address social influences on adolescent smok-
ing and was delivered over a total period of three
months. These program efforts contrast sharply with
the three-year Norwegian media campaign and the 14-
to 16-session school program combined with a mass
media campaign delivered over four years in the
VSMM.

  Because only relatively brief individual messages
about cigarette smoking can be delivered to adoles-
cents through the mass media, it is reasonable to
hypothesize that behavioral effects can be achieved
only when the media spots run frequently and over
many months. Other evidence discussed here indi-
cates that these types of media campaigns are most
likely to be effective when combined with some form
of coordinated interpersonal education, such as school-
based smoking prevention programs. The VSMM
results thus align with those of the MHHP and MPP
in supporting the importance of school programs. The
VSMM also directly targeted normative perceptions
in its school and media components and demonstrated
positive changes in these mediators of adolescents'
smoking behaviors.

  Several guidelines for designing future educa-
tional efforts to prevent smoking can be drawn
from this review of three successful multifaceted
programs. The central role of school programs in

E~fectiw Educatiorzal Strategies  79


smoking pre\.ention education ~`as atfirmed by the
results of all three studies. The MHHI' and the MPP
results both suggested the potter of influencing ado-
lescents' perceptions of cigarette smoking norms
through community programs that enhance the effect
of school programs; the MPP results demonstrated the
effectiveness of parents' participation as a specific strat-
egy for enhancing school prevention programs; and
the VSMM demonstrated that long-term mass media
campaigns targeted to adolescents' beliefs, skills, and

Diffusing Programs to Prevent Tobacco Use

perceived norms could enhance the effect of school
programs.

  On a cautionary note, the theoretical and dem-
onstrated ability of these programs to alter the smok-
ing behavior of young people must be viewed in
the larger context of their practicality. As noted
earlier, the ability to disseminate such programs has
been a matter of active public health engagement. The
following section examines the current status of such
dissemination.

  In the mid-1990s, several surveys were under-
taken to assess the extent to which national guidelines
for tobacco pre\:ention in schools (CDC 1994b) were
being implemented. One of these, the School Health
Policies and Programs Study (SHPPS), queried state
and local education districts directlv about their ad-
herence to guidelines (Collins et al..1995). A second
survey used health department tobacco coordinators
as the primary information source about tobacco pre-
vention programs in schools (J.K. Worden and B.S.
Flynn, Tobacco use pre\.ention education in the United
States, 1994, unpublished data, September 1995).

National Guidelines

  According to the CDC's "Guidelines for School
Health Programs to Prevent Tobacco Use and Addic-
tion" (CDC 1994b), all schools should, for developmen-
tally appropriate ages, provide instruction about the
short-term and long-term negati\,e physiological
and social consequences of tobacco use, about social
influences on tobacco use, about peer norms regard-
ing tobacco use, and about refusal skills. Local school
districts and schools are advised to "re\+ew these con-
cepts in accordance with student needs and educa-
tional policies to determine in which grades students
should receive particular instruction" (CDC 1994b,
p. 9). The guidelines recommend that students in kin-
dergarten through the 12th grade receive curricula for
pre\renting tobacco use. Because tobacco use often
begins in the 6th-8th grades (USDHHS 1994), more
intrnsi\re instructional programs should he provided
in these grades, and students should rtxcei\,e annual
pre\,cntion education thereafter through the 12th

grade. The guidelines also recommend that programs
include support from families, support from commu-
nity organizations, tobacco-related policies, and adver-
tising campaigns for preventing smoking, because
school-based efforts appear to be enhanced by comple-
mentary programs in the community. Finally, an on-
going assessment should monitor whether an adequate
tobacco education program is being maintained.

School Health Policies and Programs Study

  The SHPPS survey, in a follow-up to a similar
sur\`ey conducted by the American School Health As-
sociation in 1989, examined state-, district-, school-, and
classroom-level data (Collins et al. 1995). SHPPS ex-
amined specific instruction provided in six critical ar-
eas: intentional and unintentional injury, alcohol and
other drug use, tobacco use, sexual behaviors, dietary
patterns, and physical activity. The education agencies
in all 50 states and the District of Columbia, a national
sample of 413 school districts, a national sample of
607 middle/junior and senior high schools, and 1,040
randomly selected health education teachers were sur-
veyed. State and district data were collected with self-
administered questionnaires mailed to the person most
knowledgeable about or responsible for each compo-
nent of the school health program. School and class-
room data were collected through on-site personal
interviews with lead health education and classroom
teachers. The multiple levels of data collection were
necessitated by the embedded tradition of local control
in determining educational requirements and content
of instruction. The data from SHPPS are most clearly
assessed bv their relationship to the CDC guidelines.


Reducing Tobacco Use

Guideline: All schools should develop and enforce a school
policy on tobacco use. Policies should prohibit tobacco use
by all students, stnff, and visitors during school-related
activity.

   Almost two-thirds of schools had smoke-free
building policies in place in 1994, though significantly
fewer (37 percent) had prohibited the use of tobacco
products by all persons on school property, in school
vehicles, and at school-sponsored functions away from
the school site. Most schools (83 percent) prohibited
tobacco use by athletes and coaches during school-
sponsored events, and most (89 percent) provided writ-
ten copies of the policy to students, staff, and parents.
Schools were significantly more likely to have used
exclusively punitive consequences (58 percent) in
response to the most recent violation of their school's
tobacco use poiicy than exclusively remedial conse-
quences (2 percent) or a combination of punitive and
remedial consequences (30 percent); few (8 percent)
invoked attendance at a tobacco use prevention pro-
gram as remediation for violations. Only 30 percent
of schools offered tobacco cessation services in or
through the school.

Guideline: All schools should provide tobacco prevention
education in kindergarten through 12th grade. The instruc-
tion should be especially intensive in middle and junior high
school and reinforced i/r high school.

  In 1994, tobacco use prevention education was
required in 37 states (72 percent) and in 83 percent of
school districts. At the school level, 91 percent of
middle/junior high schools and 82 percent of senior
high schools included tobacco use prevention educa-
tion in a required course. However, only 55 percent of
middle/junior high school teachers and 47 percent of
senior high school teachers of health education re-
ported tobacco use prevention as a "major" topic in
their courses. Of the middle/junior and senior high
school teachers who included tobacco use prevention
education as a major topic, only 21 percent spent six
or more class periods on the topic.

Guideline: Schools should provide instruction about the
immediate and long-term consequences of tobacco use, about
social norms regarding tobacco use and the reasons why
adolescents say they smoke, and about social influences that
promote tobacco use. Schools should provide behavioral skills
for resisting social influences that promote tobacco use.

  Of the approximately 50 percent of teachers who
taught tobacco use prevention as a major topic, 74
percent taught both short- and long-term effects of
cigarette smoking. Fewer (61 percent) taught both

short- and long-term effects associated with using
smokeless tobacco. Although 61 percent of teachers
addressed group attitudes (i.e., social norms) about
tobacco use, only 42 percent taught about the actual
amount of smoking and tobacco use among adoles-
cents and adults. Less than half (48 percent) of this
group of teachers provided instruction about "healthy
alternatives" to tobacco use. Sixty-eight percent in-
cluded instruction on social influences. Most teachers
taught behavioral and social skills, though it is unclear
if these skills were taught specifically within the
context of tobacco use prevention education. For ex-
ample, 89 percent of teachers taught decision-making
skills, 87 percent taught skills for resisting social pres-
sures, 81 percent taught communication skills, and 78
percent taught goal-setting skills.

Guideline: lmproue curriculum implementation and
overall program effectiveness.

  In 1994, 82 percent of states had offered in-
service training on teaching tobacco use prevention
during the past two years. However, only 24 percent
of school districts had offered in-service training on
tobacco use prevention. Consequently, it is not sur-
prising that only 9 percent of teachers of health edu-
cation received training on tobacco use prevention
education during the same time period. Although
state-level training is typically designed for district
staff, district-level training is the most common source
of training for teachers. Increased training opportu-
nities for teachers are needed to improve the effective-
ness of tobacco use prevention education.

  The 1994 SHE'S data were analyzed to examine
the extent to which U.S. schools were implementing
the CDC's "Guidelines for School Health Programs to
Prevent Tobacco Use and Addiction" (Crossett et al.
1999). Although data do not exist in SHPPS that spe-
cifically assess adherence to each of the six recom-
mended program areas, three criteria were selected
that reflect a "comprehensive" approach to tobacco use
prevention (Crossett et al. 1999): (1) a tobacco-free
policy consistent with CDC guidelines, (2) at least one
teacher who taught tobacco as a major topic and cov-
ered four essential content areas (short-term health
effects, groups' attitudes toward tobacco, social influ-
ences, and life/refusal skills), and (3) access to tobacco
cessation services for students. Only 4 percent of
middle schools, junior high schools, and high schools
nationwide met all three criteria. Twenty-six percent
met two of the three criteria, and 41 percent met one
of the three. More than one-fourth of schools (29 per-
cent) met none of the three criteria. This analysis is

Effective Educational Sfrategies  81


limited, because not all of the CDC guideline recom-
mendations could be measured directly by SHPPS.
Nevertheless, these findings indicated that very few
schools were fully implementing the CDC recommen-
dations in 1994.

  Schools are faced with many competing demands
for instruction and classroom content. Currently, most
of this nation's schools are providing students with
some basic tobacco use prevention education. How-
ever, the recent increases in tobacco use prevalence
among youth and the overwhelming documentation
of the health consequences of tobacco addiction em-
phasize the need for improvement in what schools are
doing to reduce tobacco use and nicotine addiction
among their students, faculty, and staff.

A State-Based Assessment

  To estimate current program activity in smoking
prevention education across the United States, tobacco
control coordinators in all 50 states and the District of
Columbia were asked to participate in a survey
(Worden and Flynn, unpublished data; unless other-
wise noted, cited data in this section are derived from
this survey). The position of tobacco control coordina-
tor was established to oversee tobacco control and edu-
cation efforts in each state health department, through
either the American Stop Smoking Intervention
Study (ASSIST) program of the National Cancer
Institute (NCI) (Shopland 1993) or the Initiatives to
Mobilize for the Prevention and Control of Tobacco
Use (IMPACT) program of the CDC (USDHHS 1995).
The survey was conducted between December 1994
and March 1995. The tobacco control coordinators
were asked to describe any educational programs to
prevent tobacco use-including school, community,
and mass media activities-that were being imple-
mented in their state during 1994 and to send writ-
ten descriptions or examples of materials used in
these programs. This survey differed from SHPPS in
its primary reliance on health department rather than
education department personnel and in the absence
of a multilevel sampling approach. The state-based
survey, on the other hand, focused more on the types
of materials used.

Basic Curriculum

  The state-based survey determined that school
systems were generally left to create their own tobacco
use prevention programs or to decide which of several
available commercial programs would be imple-
mented. Examples such as Here's Looking At You,

2000 or the LST Program (Bosworth and Sailes 1993;
Glynn 1994) were mentioned by a few of the states. A
number of states had implemented some school-based
educational programs on tobacco use that wer,= supple-
mental to statewide school curricula. Among the
supplementary programs, the most popular was Teens
As Teachers (American Nonsmokers' Rights Founda-
tion 1994). Reported in 10 states, this program trains
older high school youth to discuss with younger
students the physiological and social consequences of
tobacco use. The older youth also may convey the
accurate norm that most young people do not use to-
bacco. Six states reported using the Tar Wars program,
in which medical professionals discuss the conse-
quences of tobacco use with junior high school students
(Tar Wars 1995). Save a Sweet Heart, a program that
emphasizes social influences on tobacco use for junior
high school and high school youth (American Heart
Association 19891, was reported in three states. Spo-
radic use was reported for several other programs, in-
cluding Growing Healthy"; Teenage Health Teaching
Modules, a version of D.A.R.E. that includes tobacco
use prevention; the Minnesota Smoking Prevention
Program; and a curriculum developed at the Univer-
sity of Vermont (Bosworth and Sailes 1993; Gerstain and
Green 1993; Glynn 1994). In several states, either a vol-
untary health agency or a community or school group
originated its own supplement to a school program.

Supplemental Programs

  During 1994, two states-Massachusetts and Cali-
fornia (see Chapter 7)-were particularly active in
developing and implementing supplemental programs
(i.e., in addition to statewide curricula1 using mass
media in smoking prevention. Although smoking
prevention was one of several aims of the generic me-
dia campaigns funded through tobacco tax revenues
in each state, the topic was clearly emphasized in a set
of media spots specifically targeting youth in 1994 in
each state. The Massachusetts campaign was compre-
hensive; seven messages addressed various topics
suggested in the CDC guidelines (Massachusetts De-
partment of Public Health 1994). The 1994 California
campaign used seven television spots and six radio
spots to describe the physiological consequences of
smoking. Using humorous vignettes, the campaign
identified toxic substances in cigarette smoke, such as
arsenic, formaldehyde, ammonia, methane, and
dichlorodiphenyltrichloroethane (DDT).

  On a smaller scale, supplemental efforts with
comprehensive coverage also occurred in West Virginia
and in Denver, Colorado. In West Virginia, through a


Reducing Tobacco Use

contest sponsored by the American Cancer Society,
four winning scripts for radio spots on smokeless to-
bacco use and on environmental tobacco smoke were
selected from more than 300 entries from students in
kindergarten through the 12th grade. The spots were
broadcast on 22 stations and included several topics,
although the only one related to the CDC guidelines
concerned the physiological consequences of tobacco
use. In Denver, a three-month billboard campaign
promoted the theme "Smoking Doesn't Add Up,"
which suggested the financial consequences of tobacco
use (Colorado ASSIST Alliance 1994).

Programs Including Families

  Only two states reported large-scale supplemental
programs that included families: New Jersey in its
community grants programs and Oregon in a program
entitled Parenting for a Positive Future. Three other
states reported using the Unpuffables program, which
requires parents' participation and includes the topics
of social influences and refusal skills (Perry et al.
1990b). It should be noted, however, that this estimate
of parental involvement is likely to be low, since
districts and schools, which vary considerably in the
degree to which they involve parents in school activi-
ties, were not queried directly.

Community Programs

  In general, virtually no states reported community
organization programs dedicated to supplementing
educational programs to prevent tobacco use. Several
programs-including the Kids Against Tobacco program,
which involved 5,000 young people in northwestern
Louisiana-combined tobacco education and advocacy,
but the main emphasis was on inspiring young people
to advocate against tobacco use.

Combined Activities

  At the time of the Worden and Flynn survey, only
Pennsylvania reported combining a mandated school
curriculum with supplemental school, community, and
mass media programs in an educational strategy to
prevent tobacco use. The statewide Youth Against To-
bacco program was sponsored by the state's health and
education departments along with the American Can-
cer Society and the Pennsylvania Medical Society.
These sponsors asked community organizations
throughout the state to participate in the program,
which ran from 1992 through 1995. More than 175,000
young people in 47 counties participated with local

Boy Scouts and Girl Scouts, Boys' &Girls' Clubs, health
organizations, Students Against Driving Drunk,
D.A.R.E., and other groups. Community events in-
cluded the 1994 Farm Show, in which 8,444 young
people pledged not to smoke. The 1994 mass media
program included a rap radio message aired by 223
stations in January and 280 stations in June. Declar-
ing it "not cool" to smoke, the message described the
social consequences of smoking (Pennsylvania Depart-
ment of Health 1992).

Monitoring Program Objectives

  Only Vermont reported having a system in place
to annually assess school program activity. Act 51
stipulates that schools in Vermont annually report the
number of schools implementing a curriculum. In
1994, 219 schools reported using the Here's Looking
At You, 2000 program, 25 used the LST Program, and
19 used other programs (Glynn 1994). Arkansas, In-
diana, Missouri, Pennsylvania, and Rhode Island were
able to report the estimated number of students re-
ceiving specific programs run by voluntary agencies
or local school districts. For example, Indiana reported
that 15 percent of its students received the Growing
Healthy program.

Interpreting the Diffusion Process

  Because of the methodological differences, the
results of SHPPS cannot be compared directly with
those of the state-based survey conducted by Worden
and Flynn. In particular, it is likely that the latter
underestimated the type and amount of tobacco use
prevention activity that may have been occurring on
the local level. The two surveys concurred, however,
in their overall assessment: considerable progress has
been made, but comprehensive school health educa-
tion can be improved in some areas, including tobacco
use prevention. SHPPS, which focused on multiple
activity levels, concluded that few schools met all the
major criteria provided in the CDC guidelines (CDC
1994a; Crossett et al. 19991. As a result of its focus, the
state-based survey concluded that optimal use had not
yet been made of the available research on multichan-
nel methods for maximizing the impact of school
health education programs for tobacco use prevention.

  Thus, the review of reported program activity in
1994 indicated that we are far from attaining an ideal,
national level of educational programs to prevent to-
bacco use. By one set of criteria, only 4 percent of the
middle, junior, and high schools in this nation were

Effective Educatioml Str-ategics  83


meeting three criteria of a comprehensive tobacco use
prevention program in 1994 (Crossett et al. 1999). Sev-
eral reasons have been offered for this shortcoming at
the time. One reason is that the year 1994 fell between
two periods that may have been more active. The first
period was the late 1980s and early 199Os, when the
states of Minnesota and California were implement-
ing large-scale campaigns to reduce tobacco use that
were financed by tax revenues from cigarette sales. For
a brief time, Michigan also developed mass media
spots for preventing smoking among adolescents.
Resources for these efforts apparently shrank (Begay
et al. 19931, and the campaigns faded by 1994. A sec-
ond period, which follows the 1994 activities reported
here, arguably began with the 1994 publication of the
Surgeon General's report Preventing Tobacco Use Among
Young People (USDHHS 1994). That report seems to
have stimulated development of a new set of guide-
lines. In addition, by this time all states had received
support to coordinate their education and policy
efforts to reduce tobacco use. This support came
through the ASSIST program, which began such
activities as early as 1991, and through the IMPACT
program, which supplemented ASSIST coverage.
Therefore, 1994 may represent an interregnum in the
enthusiasm for tobacco prevention education. This
view is supported by the events of the late 1990s. The
major legal and legislative activities (see Chapter 5)
were instrumental in mobilizing several states to
intensify multichannel efforts at tobacco prevention
(described in detail in Chapter 7).

   A second reason is that there has been little
evidence that the community-based approaches to
prevent tobacco use that have been shown to be effec-
tive in controlled research studies have been adapted
effectively to statewide use. Two states, California
and Minnesota, have attempted some evaluation of
community-based programs to prevent smoking on a
statewide scale. In both cases, marketing research tech-
niques similar to those described as diagnostic and
formative research in the VSMM (Worden et al. 1988,
1996) were applied in developing mass media cam-
paigns. Several creative messages for preventing
smoking were developed in each state, but the num-
ber of messages dedicated to young people was
limited; exposure also was limited, because paid ad-
vertising slots were allocated to target groups of adults
as well as youths (Kizer et al. 1990; Minnesota Depart-
ment of Health 1991).

  Although awareness of each of these campaigns
appeared to be high among adolescents, there was no
reduction in smoking behavior (Murray et al. 1994;
Pierce et al. 1994; Popham et al. 1994). Part of the

difficulty may have been the absence of a sufficiently
strong school-based program having similar educa-
tional objectives. It is also possible that, with funds
divided to reach many targeted groups, the media
could not be concentrated sufficiently on smoking pre-
vention among youth to have a measurable effect.

  A third reason is that programs implemented on
a day-by-day basis over the years often lack the essen-
tial ingredients for success that were evident when they
were created and evaluated by researchers. To be ef-
fective, programs should be taught as designed
(Rohrbach et al. 1993). For many curricula, teachers
require training-if not to encourage adoption of the
program, then at least to ensure that the curriculum is
correctly and completely delivered (Perry et al. 1990a;
Smith et al. 1993). Many teachers are resistant to train-
ing (Brink et al. 19911, and teachers who smoke may
be particularly uncomfortable with a curriculum that
discourages smoking. Such resistance may not affect
the quality of a brief, single-pronged program format,
such as the Smoke Free Class of 2000, but may jeopar-
dize the integrity of more long-term and comprehen-
sive curricula. It also has been found that a school
system's decision to use a curriculum is simply not
enough to ensure successful implementation; teach-
ers should be brought in at the earliest stages of adop-
tion (Rohrbach et al. 1993). Teachers and school
administrators with prior experience in tobacco use
prevention education should be involved in orienting
and inspiring other teachers, who will then be more
likely to deliver the curriculum faithfully and effec-
tively (Smith et al. 1993). Successful implementation
also depends on the size of the school organization;
smaller organizations are more likely to adopt new
programs quickly, whereas larger organizations are
more likely to maintain a program once it is adopted
(McCormick et al. 1995).

  A fourth reason is that there appears to be a short-
age of linking agents, who have been found to be
essential for maintaining educational programs to pre-
vent tobacco use (Dijkstra et al. 1993) and have been
recommended in several diffusion studies (Brink et al.
1991; Goodman et al. 1992; Rohrbach et al. 1993). Link-
ing agents are persons or groups that have a strong
incentive for maintaining a program and promoting
its continuation by consistently and faithfully coordi-
nating all of the necessary resources for implementa-
tion. Potential candidates for local linking agents are
school health teachers, principals, volunteers, and
health professionals; each could ensure that school
curricula include a strong component for preventing
tobacco use, much as local voluntary agencies have
supported the Smoke Free Class of 2000 effort (Brink

84 Chapter 3


Reduchg Tobacco Use

et al. 1991). These individuals, working through a
coalition, could also coordinate community program
efforts involving families, community organizations,
and mass media.

  On a state level, the natural linking agents would
be the tobacco control coordinators, who could work
through coalitions or other state agencies to accom-
plish several long-term, comprehensive aims: (1) es-
tablish legislation mandating school-based tobacco use
prevention with guidelines specifying effective cur-
ricula; (2) establish a curriculum training program,
through the state education department, that would
involve school administrators and teachers in the on-
going implementation of school-based curricula to
prevent tobacco use; (3) establish a monitoring and
support system to determine the penetration and qual-
ity of programs throughout the school system and
improve instruction with ongoing teacher training;
(4) work with parents' groups and volunteer organi-
zations to support the school program; and (5) work
Jvith interested citizens to place media messages that
support each of the content areas recommended by the
CDC guidelines.

  On a national level, linking agents could be agen-
cies, such as the NC1 or the CDC, that could support
local and state efforts to reduce tobacco use with
funding and continued coordination, such as by regu-
larly convening state coordinators to share program
ideas. These national linking agents might focus their
diffusion efforts on using the mass media, because
youth in different markets respond equally well to
media-based messages for preventing tobacco use
(Flynn et al. 1992). Considerable opportunity exists

Conclusions

for enhanced diffusion of programs that have demon-
strated effectiveness (Parcel et al. 1989a,b, 1995; O'Hara
et al. 1991; Brink et al. 1995; Parcel 1995; McCormick
and Tompkins 1998; Siegel and Biener 2000). As an
example of such diffusions, the CDC's Division of
Adolescent and School Health initiated the Research
to Classroom project. Through this project, CDC iden-
tified programs with credible evidence of effectiveness
in reducing health risk behaviors among young people.
So far, CDC has identified curricula for sexuality and
tobacco use prevention. The CDC staff review elec-
tronic databases, literature reviews, meta-analyses, and
reports to identify evaluation studies that meet the
criteria for consideration in the Research to Classroom
project. Two external panels, one of evaluation experts
and the other of program experts, review the curricula
and their evaluations. If both panels recommend adop-
tion of the curriculum, based on attainment of identi-
fied criteria, CDC designates the curriculum as a
Program that Works. The Research to Classroom
project identified Project Tozmrds No Tobacco Use and
Lift Skills T~~irii~zg as appropriate tobacco use preven-
tion curricula. Research to Classroom also provides
information and training on these curricula for inter-
ested educators from state and local education
agencies, departments of health, and national nongov-
ernmental organizations. The CDC identifies and
disseminates information on Programs that Work to
help inform local and state choices. The choice to
adopt a curriculum ultimately rests with local deci-
sion makers and must address community standards
and needs.

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.

3.  More consistent implementation of effective
  educational strategies to prevent tobacco use will
  require continuing efforts to build strong,
  multiyear prevention units into school health
  education curricula and expanded efforts to make
  use of the influence of parents, the mass media,
  and other community resources.


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94 Chapter 3


Chapter 4
Management of Nicotine Addiction

Introduction 97

Methods for Managing Nicotine Addiction  100
Self-Help Manuals 100
Efficacy ZOO
Relevant Process Measures 201
Summary 102
Minimal Clinical Interventions 102
Efficacy 204
Relevant Process Measures 105
Summary 105
Intensive Clinical Interventions 105
Problem Solving/Skills Training 106
Rapid Smoking 207
Other Aversive-Smoking Strategies 108
Cue Exposure 108
Nicotine Fading  2 09
Motivational Rewards 110
Social Support  12 0
Weight Control 211
Hypnosis 112
Acupuncture 222
Summary of Intensive Clinical Interventions  122
Pharmacologic Interventions 113
Nicotine Polacrilex 123
Transdermal Nicotine 116
Nicotine Nasal Spray 118
Nicotine Inhaler 220
Bupropion  2 2 1
Clonidine 222
Nortriptylene 223
Other Antidepressants and Anxiolytics  124
Summary of Pharmacologic Interventions  124
Large-Scale Public Health Programs  125
Media-Based Programs 125
Worksite Programs 226
Community Programs 227
Statewide Programs 128
Summary of Large-Scale Public Health Programs  128

Contemporary Issues in Research on Tobacco Addiction  128
Epidemiologic Concerns and Clinical Issues  2 28
Nicotine Dependence 229
Stages of Change 229
Negative Affect 130


Conclusions 1 .i4

References 1.3.7


Reducing Tobacco Use

Introduction

  Preventing tobacco addiction among young
people and promoting abstinence among current
smokers are the final common denominators for pub-
lic health strategies to reduce smoking prevalence. Al-
though prevention efforts are increasingly regarded as
the most promising long-term approach for reducing
tobacco use (Lynch and Bonnie 1994; U.S. Department
of Health and Human Services [USDHHS] 19941, about
1.2 million youths become regular smokers each year
in the United States-adding to the millions of adult
smokers who are candidates for addiction manage-
ment (Leventhal et al. 1991; Centers for Disease Con-
trol and Prevention [CDCI 1998; see "Trends in Tobacco
Use Among Young People" in Chapter 3). Effective
treatments do exist for smoking cessation, and they
are available for both the clinical and the public health
context (Fiore et al. 1996). These treatments compose
an important modality in the effort to eradicate tobacco
use. Many of the adverse health effects of tobacco use
are reversible by cessation WSDHHS 19891-a fact im-
portant to the millions of adults who already smoke,
as well as to the large numbers of young people who
continue to take up smoking.

  Since the 1964 release of the first Surgeon
General's report on the health consequences of smok-
ing, the prevalence of cigarette smoking among adults
in the United States has decreased by 41 percent, fall-
ing from 42.2 percent in 1965 to 24.7 percent in 1997
(Giovino et al. 1994; CDC 1999a). Although these data
represent significant progress in the public health cam-
paign against tobacco use, the steady decline of 0.5
percentage points per year observed from 1965 to 1985
has lessened in recent years. In 1997, approximately
48 million adult Americans smoked; the prevalence
was higher among men (27.6 percent) than among
women (22.1 percent) and among American Indians
and Alaska Natives (34.1 percent) than among blacks
(26.7 percent), whites (25.3 percent), Hispanics (20.4
percent), or Asian Americans and Pacific Islanders (16.9
percent) (Table 4.1). Smoking prevalence was also
lower among college graduates (11.6 percent) than
among high school dropouts (35.4 percent) and higher
among those below the poverty level (33.3 percent)
than above it (24.6 percent) (CDC 1999a). Since smok-
ing prevalence did not decline at a more rapid rate
than that observed in the past few years, the Healthy
People 2000 goal of an adult smoking prevalence of 15
percent or less by the year 2000 (USDHHS 1991) was

not met. Unless smoking prevalence declines at a more
rapid rate than that observed in the past, we will not
achieve the Healthy People 2020 goal of an adult smok-
ing prevalence of 12 percent or less by the year 2010
(USDHHS 2000).

   Considered over the time frame of the last 30
years, however, smoking cessation has increased dra-
matically. Self-reported data from 1997 suggest that
almost 50 percent (44 million) of people who have ever
smoked have successfully quit smoking (Thomas and
Larsen 1993). In 1991, the earliest year for which so-
cioeconomic data are available, the prevalence of
smoking cessation was greater among male, white,
older, more educated, and wealthier persons (Table 4.2)
(Giovino et al. 1994). An encouraging finding from
the 1993 National Health Interview Survey was that
most (70 percent) current adult smokers were inter-
ested in quitting. Such interest was higher among
women, African Americans, and younger persons
(Thomas and Larsen 1993).

  Cessation represents a desired end result to what
is usually a lengthy, demanding, and often frustrating
undertaking. Data on cessation should be interpreted
in light of the fact that for every successful attempt to
quit using tobacco, many more attempts fail. Although
millions of Americans say they want to quit smoking,
studies suggest that only about 6 percent of persons
who try to quit smoking at any given time are suc-
cessful for more than one month (CDC 1993a). Re-
search into tobacco cessation seeks tools that will
translate the desire to quit into prolonged abstinence
from tobacco. Such treatments hold a greater poten-
tial for immediate public health returns than do pre-
vention methods, and cessation treatments may also
be cost-effective (see "Cost-Effectiveness" later in this
chapter).

  In the course of this chapter, the terms "smoking
cessation" and "management of tobacco addiction" are
used interchangeably. Though the former is the more
familiar, the latter better conveys a more rigorous and
systematized approach to a complex addiction behav-
ior. Value judgments on the impact of a particular
modality should be interpreted within a qualitative
system for judging costs and benefits. A small impact
may be viewed favorably if achieved with minimal
intervention. More intense intervention may have a
larger impact, but may not be justified by the resources
it requires.

Malzagemerzt of Nicotirle Addiction  97


Table 4.1. Percentage of adults aged 218 years who were current cigarette smokers,+ by sex, raceiethnicity,

-.    education, age, and poverty status-United States, National Health Interview Survey, 1997

                             Men            Women           Total
                      (n = 15,361)       (n = 20,455)       (n = 35,816)
Characteristic                 % (95% c1+1       % (95% CIl       % (95% CR

Race/EthnicityS
White, non-Hispanic
Black, non-Hispanic
Hispanic
American Indian/Alaska Natives
Asian American/Pacific Islander

27.4  (k 1.0)        23.3  (+ 0.8)       25.3  (+ 0.7)
32.1  (+ 2.4)        22.4  (+ 1.7)        26.7  (k 1.4)
26.2  (k 2.1)        14.3  (k 1.4)        20.4  (+ 1.4)
37.9 (k 13.7)      31.3 (+ 8.8)      34.1 (? 7.7)
21.6 (+ 4.4)       12.4 (k 3.5)      16.9 (k 2.7)

Education (yearslA
18
  9-11
  12
  13-15
216

29.9  (* 3.0)        15.1  (k 2.2)        22.5  (k 1.9)
41.3  (k 3.1)        30.5  (k 2.4)        35.4  (k 2.0)
31.8  (k 1.7)        25.7  (+ 1.3)       28.4  (+ 1.0)
27.4  (+ 1.7)       23.1  (+ 1.4)        25.1  (+ 1.1)
13.0  (+ 1.2)        10.1  (* 1.0)        11.6  (? 0.8)

Age (years)
  18-24
  25-44
  45-64
265

31.7  (k 2.8)        25.7  (+ 2.4)        28.7  (k 1.9)
31.2  (+ 1.3)        26.1  (k 1.1)       28.6  (210.8)
27.6  (k 1.5)        21.5  (k 1.3)        24.4  (k 1.0)
12.8  (i 1.4)        11.5  (k 1.1)        12.0  (& 0.9)

Poverty statusq
At or above
Below
Unknown

27.3 (k 1.0)       21.8 (? 0.8)       24.6 (+ 0.7)
38.7  (k 2.8)        29.8  (+ 1.9)        33.3  (k 1.7)
23.4  (+ 2.0)        18.2  (k 1.5)        20.5  (+ 1.2)

   Total                   27.6 (+ 0.9)       22.1 (k 0.7)      24.7 (+ 0.6)
*Persons who reported having smoked at least 100 cigarettes during their lifetime and who reported currently
smoking every day or some days. Excludes 300 respondents with unknown smoking status.
+95% confidence interval.
SExcludes 74 respondents of unknown, multiple, and other racial/ethnic categories.
SWide variances on estimates reflect the small sample sizes.
*Persons aged 2 25 years. Excludes 305 respondents with unknown years of education.
_I'ublished 1996 poverty thresholds from the Bureau of the Census are used in these calculations.
Source: Centers for Disease Control and Prevention 1999a.

98 Chnpter 4


Reducing Tobacco Use

Table 4.2. Percentage of adults* who abstained from smoking cigarettes in the previous year, by sex,
    race/ethnic@, age, education, and poverty status- United States, National Health Interview
    Survey, 1991+

Characteristic

Sex
Male
Female

RaceiEthnicity
White"
BlackA
Hispanic
American Indian/
Alaska Native
Asian American/
Pacific Islander

Age (years)
18-24
25-44
45-64
265

Education (years)
<12
12
13-15
216

Poverty status**
At or above
Below
Unknown

Total                  42.1   (40.9-43.3)      13.8   (12.5-15.1)      5.7    (5.2-6.3)

Abstinence for        Maintenance
21 day       among abstainers

42.6   (40.8-44.4)      13.8   (12.0-15.6)      5.8    (5.0-6.6)
41.5   (40.0-43.0)      13.7   (12.0-15.4)      5.6    (4.9-6.3)

40.3   (39.0-41.6)
48.7   (45.2-52.2)
52.1    (46.4-57.8)
53.3   (39.7-67.0)

45.0   (33.7-56.3)           NAT             NAY

56.7   (52.9-60.5)      14.0   (9.9-18.1)      7.9    (5.6-10.3)
43.4   (41.8-45.0)      12.7   (11.0-14.4)      5.4    (4.7-6.1)
36.1   (33.9-38.3)      14.1   (11.4-16.8)      5.0    (4.0-6.0)
35.7   (32.2-39.2)      19.4   (14.6-24.2)      6.8    (5.1-8.5)

36.5   (34.1-38.9)      12.9   (10.2-15.6)      4.7    (3.7-5.7)
42.5   (40.8-44.2)      12.8   (10.9-14.7)      5.3    (4.5-6.1)
46.9   (44.2-49.6)      14.3   (11.4-17.2)      6.6    (5.2-8.0)
45.9   (42.5-49.3)      18.8   (14.9-22.7)      8.5    (7.0-10.0)

42.7   (41.4-44.0)      14.8   (13.4-16.3)      6.2    (5.6-6.8)
42.9   (39.5-46.3)       7.5   (4.7-10.3)      3.2    (2.0-4.4)
35.2   (31.2-39.2)      12.6   (8.3-16.9)      4.4    (2.9-6.0)

14.0
7.9
16.3

(12.6-15.4)
(5.1-10.7)
(10.3-22.2)
NA"

Maintenancet among
all persons who
were daily smokers
1 year earlier*

5.6
3.8
8.5

(5.0-6.2)
(2.4-5.2)
(5.2-11.8)
NAY

`Persons aged 218 years who reported having smoked at least 100 cigarettes in their lifetime and smoked
cigarettes daily 1 year earlier and who provided information of their current smoking status.
%ample size = 9,703; race/ethnicity variable excludes 34 respondents of other, unknown, or multiple race;
education variable excludes 24 respondents of unknown education level.
*Abstinence from smoking cigarettes for at least 1 month at the time of the survey. Excludes 92 respondents who
were abstinent from cigarettes for <1 month or for whom duration of abstinence was unknown.
SConfidence interval.
AExcludes persons of Hispanic origin.
%ample sizes too small to derive reliable estimate.
**Poverty statistics are based on definitions developed by the Social Security Administration, which includes a set
of income thresholds that vary by family size and composition.
Source: National Center for Health Statistics, public use data tape, 1991.

Mmnpmerzf of Nicofim Addicfion  99


Surgeon General's Report

Methods for Managing Nicotine Addiction

  Historically, the great majority of smokers (more
than 90 percent) who successfully quit smoking did
so "on their own"-that is, without the assistance of
formal cessation programs (USDHHS 1989; Fiore et al.
1990). With the advent of new treatments, including
pharmaceuticals, more smokers (20 percent) are using
some form of assistance when trying to quit (Zhu et
al. 2000). The success rate among this large group of
unassisted quitters is half that observed for those who
use some form of assistance. Although more than 1
million smokers quit each year, 75-80 percent relapse
within six months (Carmody 1992). Those who quit
may relapse at any time (even after a period of years),
and a substantial portion of quitters go through cycles
of quitting and relapse (Cohen et al. 1989a). Given
this complex context in which the natural history of
smoking occurs (an important leitmotif in the man-
agement of tobacco addiction), it is difficult to assign
a single number to the proportion who quit on their
own. Nonetheless, in the current environment of
declining prevalence, the end result of this cyclic pro-
cess, and of all the interventional efforts brought to
bear on it, is that each year about 3-5 percent of smok-
ers quit for a year, for longer, or for good.

  The success of smoking cessation methods
should be evaluated in terms of both process and out-
come measures. Process measures are designed to as-
sess those variables that are affected by treatments and
that influence outcomes. Ideally, process measures
should target the specific change mechanisms that
treatments are intended to influence. For instance, if a
treatment is intended to provide smokers with coping
skills, process measures might assess a patient's abil-
ity to anticipate and generate appropriate responses
to stresses. If a treatment is intended to promote ces-
sation by reducing withdrawal symptoms, then a with-
drawal symptom scale might be used as a process
measure. Clinically significant outconze measures in-
clude attempts at quitting and abstinence success.
Withdrawal symptom severity and concomitants of
cessation attempts, such as weight gain, may be viewed
as outcomes as well.

Some of the efficacy evaluations reported here
incorporate the results of published meta-analyses.
Meta-analysis is a statistical technique that assesses the
impact of a variable (or, in this context, a treatment)
across a set of related investigations (Dickersin and
Berlin 1992). Meta-analyses may present a more

objective assessment of accumulated research findings
than do traditional narrative reviews (e.g., Cooper and
Rosenthal 1980) and can be useful for identifying study
or treatment characteristics that are associated with
differences in study outcomes (Dickersin and Berlin
1992). Meta-analyses of smoking cessation treatments
have used different techniques for estimating the size
of treatment effects. The precise methods used to cal-
culate and pool these estimates vary (for detailed de-
scriptions, see Fleiss 1981 and Cooper and Hedges
1994). In both meta-analyses and individual studies,
the most frequently encountered measures are the odds
ratio (an estimate of the relative risk for the outcome
in control versus treatment groups) and some form of
effect size (difference in effect between treatment and
control groups).

Self-Help Manuals

  Because of the size of the population who try
quitting on their own, the broad dissemination of ma-
terials that can help them in their efforts-without re-
quiring them to participate in a formal cessation
program-may be a potent strategy at the national
level for decreasing the prevalence of smoking (Glynn
et al. 1990a; Curry 1993). A wide array of self-help
strategies has been developed for smoking cessation
(Curry 1993). This section discusses the efficacy of
written manuals, the most extensively investigated
self-help materials (Curry 1993). The discussion is lim-
ited to studies of such manuals distributed to relatively
small populations of smokers. Self-help materials de-
livered to large populations are discussed later in the
chapter in association with nonprint messages and pro-
grams (self-help or supervised) included in mass me-
dia and community-based efforts.

Efficacy

  In a review of the research literature on self-help
manuals, the median long-term prevalence of cessation
associated with manual-based interventions was about
5 percent (Curry 1993). This proportion is lower than
those of face-to-face cessation programs (Schwartz 1987;
Lichtenstein and Glasgow 1992; Lando 1993). Further-
more, recent evidence suggests that self-help manuals,
when used by themselves, may produce negligible

100 Chnpfer 4


Redllcing Tobacco Use

increases in long-term cessation (Gritz et al. 1992;
Petersen et al. 1992; Gomel et al. 1993; Fiore et al. 2000).

  Because self-help manuals can be distributed, at
low cost, to very large numbers of smokers, even rela-
tively small cessation success could translate into large
numbers of successful quitters. Since 30-40 percent of
smokers each year make a serious effort to quit, self-
help aids could have a vast influence on public health
(Hatziandreu et al. 1990; CDC 1993b, 199913). The avail-
able evidence suggests that self-help manuals work
better for smokers who are less dependent on nico-
tine, more motivated, and more confident of quitting
(Curry 19931, but the relationship between motivation
and success is complex. Less addicted smokers may
be less likely to seek formal treatment (Fiore et al. 1990;
Zhu et al. 2000) and are therefore an apt audience for
self-help manuals. More addicted smokers are more
likely to seek formal self-help programs (Wagner et al.
1990) but may be less successful in quitting (Schoen-
bath et al. 1992). Thus, in view of both their uncertain
effectiveness and their potential to be cost-effective, it
is important to determine whether self-help manuals
have a consistent, albeit small, benefit.

  Although many self-help manuals have been de-
veloped, there is little evidence that they differ in their
effectiveness (Cummings et al. 1988; Glynn et al. 1990a;
Curry 1993). Accordingly, an Expert Advisory Panel
convened by the National Cancer Institute (NCI) has
recommended that public health professionals try to
increase the availability of existing manuals rather than
refine them or develop new ones (Glynn et al. 1990a).
The committee also concluded that if new materials are
deemed necessary, they should, at a minimum, contain
the following components: (1) information about
the social and health effects of smoking; (2) specific
strategies and exercises for quitting; and (3) specific strat-
egies and exercises to avoid relapse and, in the event of
relapse, to try quitting again (Glynn et al. 1990a).

  Manuals tailored to special populations of smok-
ers, such as pregnant women, older adults, African
Americans, and Hispanics, have been developed and
tested (Windsor et al. 1985; Glynn et al. 1990b; Davis
et al. 1992; USDHHS 1998). Although manuals tar-
geted to specific populations have not had consistently
greater success than generic manuals at helping mem-
bers of relevant populations quit (Curry 1993; Rimer
et al. 1994), such manuals have the potential to reach
smokers missed by traditional materials (Curry 1993).

  It appears that combining multiple types of
self-help materials (manuals, videotapes, etc.) does not
improve long-term cessation rates. A meta-analysis of
21 studies using multiple types of self-help without
person-to-person contact found no significant difference

between multiple types of self-help and no self-help at
all (Fiore et al. 2000).

  Reading level has been increasingly recognized
as an important attribute of self-help manuals. Since
the early 197Os, trends in smoking prevalence have
been different for those with differing levels of educa-
tional attainment (Pierce et al. 1989). Smoking preva-
lence has dropped sharply among persons with a
college education (10.1 percentage points between 1974
and 1985) but has declined only marginally among
high school dropouts (2.1 percentage points during the
same period). Concerns about literacy have led to the
recommendation that self-help materials for smoking
cessation be written at no more than a seventh-grade
reading level (Glynn et al. 1990a), although this level
may be too high in some situations.

  Adjuncts to self-help manuals, such as telephone
counseling (Orleans et al. 1991; Curry et al. 1992; Lando
et al. 19921, hot lines (Ossip-Klein et al. 1991), and per-
sonalized feedback (Curry et al. 1991; Prochaska et al.
19931, have also been evaluated. These adjunctive in-
terlrentions have met with varying success (Curry
1993). For example, self-help treatments that include
nicotine gum as well as smoking cessation manuals have
not had greater long-term efficacy than the manuals
alone (Harackiewicz et al. 1988; Killen et al. 1990b).
Computer-generated personalized feedback (Curry et
al. 1991) and telephone outreach, however, have im-
proved cessation success (Orleans et al. 1991; Lando et
al. 1992; Prochaska et al. 1993; Strecher et al. 1994). At
present, research suggests that such adjuvants materi-
ally improve the effectiveness of self-help manuals.

  Adjunctive interventions that require financial
and personnel resources, however, may undercut the
potential population impact of self-help interventions.
The addition of other components to self-help manu-
als may also mark the point at which the self-help
modality merges with more formal assistance, which,
as mentioned earlier, have not appealed to as large a
population of smokers motivated to quit. But at least
one such treatment, proactive telephone counseling (as
opposed to reactive approaches, such as help lines
smokers must call), appears to be effective when used
as an adjuvant (Fisher et al. 1993).

Relevant Process Measures

  Most studies of self-help manuals lack process
measures, and the specific measures used across stud-
ies vary considerably (Curry 1993). Two distinct pro-
cess measures, manual reading and manual use, have
been assessed in some studies of self-help manuals for
smoking cessation. Reading measures simply ask


Swymz Gerzrral'~ Report

smokers whether they read most or all of the manual.
Use measures assess the extent to which smokers
performed the specific exercises recommended in the
manual. In theory, persons who actually read a manual
or practice manual-recommended exercises should be
more successful than those who merely possess a
manual. Curry (1993) concluded that although read-
ing has sometimes been related to program success,
use has been more consistently related to improved
outcomes. Further work is needed to determine with
some certainty whether the information conveyed by
the manuals, rather than nonspecific motivational ef-
fects, is responsible for their efficacy.

Summary

  Although self-help manuals have had only mod-
est and inconsistent success at helping smokers quit,
manuals can be easily distributed to the vast popula-
tion of smokers who try to quit on their own each year.
Adjuvant behavioral interventions, particularly pro-
active telephone counseling, may increase the effect
of self-help materials. Process measures are not rou-
tinely incorporated 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 recommended in the manual are more likely
to quit smoking.

Minimal Clinical Interventions

   Minimal clinical interventions are those that can
be delivered briefly to smokers by health care profes-
sionals during the course of a regular health care en-
counter. These strategies may be as simple as advising
smokers to quit, or they may be as complex as using
computers to tailor the intervention to the individual
smokers. Minimal clinical interventions could have a
great influence at a national level on smoking cessa-
tion, but they have been underused. Findings from a
1985 (Ockene et al. 1987), a 1991 (CDC 1993b), and a
1992 national survey (Tomar et al. 1996) suggest that
nearly 70 percent of American smokers (nearly 36 mil-
lion) make at least one outpatient health care visit each
year; however, only 40-52 percent of the smokers in
the surveys reported that during the preceding year
they had been advised by a health care professional to
quit smoking. In a separate study, 48.8 percent of 2,710
current smokers had been advised by their physician
to stop smoking or to smoke less (Frank et al. 1991).
More than 50 percent of adult smokers in the United
States saw a dentist in 1992, but fewer than 25 percent

of those who saw a dentist in the preceding year re-
ported that the dentist had advised them to quit smok-
ing (Tomar et al. 1996). Among adult users of
smokeless tobacco, 18 percent reported that they had
ever been advised by a dentist and 15 percent had ever
been advised by a physician to quit (Tomar et al. 1996).

  Many clinicians may believe that they are not
equipped to help smokers quit (Wells et al. 1984; Glynn
1988) or that a physician can help a smoker quit
(Ockene et al. 1988a). Training programs for clinicians
have been developed to address this problem (Ockene
et al. 198813; Cummings et al. 1989a,b; Duncan et al.
1991; Manley et al. 1991; Strecher et al. 1991); however,
data suggest that simply training clinicians may not
be effective (Dietrich et al. 1992; Carney et al. 1995;
Klein et al. 1995). However, implementing reminder
systems in the clinic has been shown to triple clinician
intervention with smokers (Fiore et al. 1996, 2000).
Some evidence suggests that the delivery of these mini-
mal clinical interventions is becoming more common
(Gilpin et al. 1992).

  Surveys suggest that smokers who are white, fe-
male, older, better educated, or ill, or who smoke more
cigarettes per day are more likely than others to re-
ceive clinical advice to quit (Ockene et al. 1987; Frank
et al. 1991; Gilpin et al. 1992; CDC 1993b). At present,
clinicians apparently do not ensure that all of their
patients who smoke receive cessation advice and as-
sistance, in part because of structural and policy is-
sues (such as reimbursement) related to medical care
delivery. Nonetheless, such efforts might be more com-
mon if clinicians were trained to view smoking as a
chronic disease, marked by periods of remission and
relapse, rather than as an acute disorder (Fiore and
Baker 1995).

  Researchers have shown that institutional changes
can increase the systematic delivery of minimal clinical
interventions for smoking cessation. For example, brief
physician training, availability of nicotine gum, and
patient chart stickers documenting smoking status can
increase the amount of time physicians spend in cessa-
tion counseling and increase successful cessation by a
factor of 2 to 6 (Cohen et al. 1989b; Ockene et al. 1991).
One proposed change is to expand patient vital signs
to include an assessment of tobacco use (Fiore 1991).
This simple institutional change has been shown to
increase markedly the proportion of patients who re-
port that their health care providers asked and coun-
seled them about smoking cessation (Fiore et al. 1995;
Robinson et al. 1995).

  Finally, institutional changes are critical for
prompting more clinicians to play a role in smoking
cessation. Currently, clinicians are only sporadically

102 Chnyter 4


Reducing Tobacco Use

reimbursed for clinical and pharmacologic treatments
to help patients quit smoking (Group Health Associa-
tion of America, Inc. 1993; Schauffler and Parkinson
1993). Appropriate reimbursement may be essential
to ensuring greater clinical attention to tobacco addic-
tion (Schauffler and Parkinson 1993; Fiore and Baker
1995; Kaplan et al. 1995).

  The Public Health Service-sponsored Clinical
Practice Guideline Trenting Tobncco Use and Dependence
has recommended that health care professionals use
the "five A's" to help their patients quit smoking:
(1) nsk about smoking, (2) ndvise all smokers to quit,
(3) address willingness to make a quit attempt,

(4) assist patients who want to quit, and (5) arrange
follow-up visits (Manley et al. 1991; Glynn and
Manley 1993; Orleans et al. 1993; Houston et al. 1994;
Fiore et al. 2000). These recommendations, based on
a comprehensive review of the empirical literature,
constitute a proscriptive algorithm for clinical inter-
ventions (see the text box).

  Additional follow-up visits, at increasing inter-
vals, with patients who continue not to smoke have
been associated with greater long-term abstinence
(Kottke et al. 1988; Wilson et al. 1988; Orleans et al.
1991). Patients who have relapsed should be helped
to quit again at follow-up visits and subsequent visits.

The Five A's

T o help their patients quit smoking, clinicians can
use the "five As" approach: (1) rusk patients
about smoking, (2) odsjise all smokers to quit, (3) ns-
scss willingness to make a quit attempt, (4) nssist
those who want to quit, and (5) arrnnge follow-up
visits with those trying to quit (Glynn and Manley
1993). These brief clinician interventions, which are
described in this text box, can be completed within
two to three minutes at each visit and have been
associated with a cessation prevalence of 5 percent
(Glynn 1988) to 8 percent (Kottke et al. 1988).

  All patients seen in a primary care setting
should be routinely asked about their smoking sta-
tus. One means of institutionalizing the identifica-
tion of smokers is to expand the vital signs to include
smoking status (Fiore 1991). Another means is to
use stickers or other markers to clearly identify
charts and prompt clinicians to help their patients
who smoke quit (Cohen et al. 1989b; Ockene et al.
1991).

  All patients who smoke should be advised to
quit. This advice should be clearly stated and per-
sonalized. After giving this advice, clinicians should
assess whether smokers desire to quit at the present
time. Clinicians should provide motivational ma-
terials and messages to those not willing to quit.
These patients should be asked about smoking and
advised to quit at all subsequent visits.

  Clinicians should assist patients who want to
quit. The clinician should work together with the
patient to set a date to quit (preferably within two
weeks of the clinic visit) and should provide the

patient with practical advice about how to quit and
self-help materials.

  Clinicians should determine whether the pa-
tient is likely to require adjunctive help and whether
the patient is a candidate for pharmacotherapy.
Pharmacotherapy should be considered for all pa-
tients motivated to make a quit attempt, except in
the presence of specific contraindications (Fiore et
al. 2000). The choice may take into account previ-
ous patient experience, preferences, and other fac-
tors (see "Pharmacologic Interventions," later in this
chapter). Clinicians should also present other treat-
ment options to their patients who want to quit. In
particular, patients should be made aware of com-
munity cessation resources (such as those offered
by the American Cancer Society and the American
Lung Association) and of intensive clinical inter-
ventions (see "Intensive Clinical Interventions,"
later in this chapter) available in the community.
The primary care clinician, however, should con-
tinue to monitor and assist those patients who elect
to undergo intensive treatments.

  Clinicians should arrange for a follow-up visit
to discuss smoking cessation within two weeks of
the chosen date to quit. Researchers have docu-
mented that scheduling follow-up visits or making
follow-up telephone calls improves cessation suc-
cess (Kottke et al. 1988; Wilson et al. 1988; Ockene
et al. 1991, 1992; Orleans et al. 1991). Follow-up
visits should be arranged whether the patient has
been referred to another clinic or treated by the pri-
mary care clinician.

Mamgcnw~~t of Nicotine Addiction   203


Surgeon Gerleral's Rrport

Modifications in treatment, including a discussion of
more intensive efforts, should be considered for relaps-
ing patients at each iteration.

   An area of current active research in minimal in-
terventions is the use of computer-tailored messages
for individual smokers who want to quit. Computer
software that approximates deductive or inductive
human reasoning has been proposed as an efficient and
cost-effective mechanism for this modality (Velicer et
al. 1993). In a large trial of one such system, interac-
tive computer reports plus individualized manuals
produced higher current abstinence (20 percent) and
prolonged abstinence (11 percent) than did standard
manuals, individualized manuals alone, or personal-
ized counselor calls (Prochaska et al. 1993). Similarly,
analyses of two separate controlled trials found that
computer-tailored letters generated significantly
greater cessation proportions in groups receiving them
than in control groups (Strecher et al. 1994). Although
these mechanisms have not been extensively evaluated,
they are a promising avenue for further investigation.

Efficacy

  Kottke and colleagues (1988) performed a meta-
analysis of 39 smoking cessation trials conducted in
medical practice settings. Most of these trials involved
relatively minimal interventions, but some more in-
tensive treatments were included. Participants had a
mean of 4.8 (standard deviation = +4.4) contacts with
these clinic-based programs. The major conclusion of
this analysis was that success increased with the num-
ber of intervention modalities employed, the number
of health care professionals involved in the effort, and
the number of follow-up assessments. Duration of
follow-up (as opposed to number of follow-ups) was
not predictive of success. Using diverse techniques
may be a key characteristic of successful clinic-based
smoking cessation programs (Fiore et al. 2000). A suc-
cessful program might be one in which face-to-face
counseling or advice is given; dates for quitting are
set; pamphlets are distributed; reminders by telephone
are made; smokers are advised and counseled on quit-
ting by physicians, nurses, and other health profes-
sionals; and multiple clinic visits or telephone calls are
made after the smoker's quitting day. In the meta-
analysis by Kottke and colleagues (1988), cessation
assistance delivered by nonphysicians tended to be
slightly more effective than that performed by physi-
cians, but a more recent meta-analysis (Fiore et al. 2000)
found no difference in effectiveness between physi-
cians and nonphysicians. Both individual and group
counseling was effective (Fiore et al. 2000).

  The meta-analysis by Kottke and colleagues (1988)
also suggested, however, that complex interventions are
not necessary for clinic-based success. Compared with
smokers who received no assistance, smokers who
received help consisting of advice only or brief coun-
seling had a 13.1-percentage point increase in cessation
6 months after treatment and a 3.8-percentage point in-
crease after 12 months. Comparable estimates for
smokers whose only treatment was to receive written
self-help materials from health care professionals were
1.6 percent at 6 months and 2.0 percent at 12 months.
The impact of brief intervention is illustrated in one
study by Russell and colleagues (1979), who found that
providing advice in a primary care setting produced
a biochemically confirmed increase in abstinence of
3.3 percentage points; when smokers were told they
would be followed up and when self-help materials
were distributed in conjunction with the advice,
the resulting one-year increase in abstinence was
5.1 percentage points.

  Trials postdating the meta-analysis of Kottke and
colleagues (1988) have also indicated that brief clini-
cal interventions have a small but reliable impact on
smoking cessation success (Cummings et al. 1989a;
Risser and Belcher 1990; Taylor et al. 1990; Ockene et
al. 1991, 1994; Weissfeld and Holloway 1991; Hollis et
al. 1993; Strecher et al. 1994). A meta-analysis of seven
studies found that physician advice to quit increases
cessation by 30 percent (Fiore et al. 2000). The consis-
tency of these findings over a considerable time span
and in multiple settings lends credence to the useful-
ness of minimal interventions.

  Smokeless tobacco use may be particularly ame-
nable to minimal clinical interventions, especially in
dental office settings. Oral lesions caused by smoke-
less tobacco are quite common among users of these
products (Ernster et al. 1990; Tomar et al. 1997) and
provide the opportunity for the dentist to point out
the direct adverse health effects of smokeless tobacco.
Several trials have examined the efficacy of minimal
clinical interventions in smokeless tobacco cessation.

   In a randomized trial conducted in a dental
health maintenance office clinic to test a minimal clini-
cal intervention, Stevens and colleagues (1995) re-
ported significantly higher smokeless tobacco quit
rates in the intervention group than in the usual-care
group at both 3 months (32.2 vs. 21.3 percent) and 12
months (33.5 vs. 24.5 percent). In a randomized clini-
cal trial conducted in private dental offices, Severson
and colleagues (1998) also found that a minimal inter-
vention significantly increased smokeless tobacco quit
rates in the intervention group compared with rates
in the usual-care group at 3 months (17.8 vs. 8.8

IO4 Chapter 4


Reducing Tobacco Use

percent) and 12 months (10.2 vs. 3.3 percent). A mini-
mal intervention trial for smokeless tobacco use among
college athletes, which included dental examinations
to demonstrate oral lesions, 15-20 minutes of counsel-
ing by dental hygienists, and follow-up telephone calls,
found that three-month biochemically assayed quit
rates were 24 percent in the intervention group and 16
percent in the control group (Masouredis et al. 1997).

Relevant Process Measures

  Although minimal clinical interventions provide
smokers with some practical advice about quitting, their
primary purpose is to increase smokers' motivation to
quit. Specific process measures-such as measures of
this motivation-are seldom incorporated into minimal
clinical interventions. The nonspecific measures some
investigators use do not associate clinical success with
changes (such as greater awareness of disease risk or
enhanced belief in one's ability to quit). Nonetheless,
the available evidence suggests that minimal clinical
interventions can enhance smokers' desire and inten-
tion to quit (Russell et al. 1979), decrease the number of
cigarettes smoked per day (Folsom and Grimm 19871,
and increase the number of attempts to quit smoking
(Folsom and Grimm 1987; Cummings et al. 1989b;
Strecher et al. 1991). In addition, patients have reported
that physicians trained to perform more intensive in-
terventions are more helpful than physicians without
such training (Ockene et al. 1991).

Summary

  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 im-
portance of cessation assistance by clinicians, who have
a unique 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," later in this chapter). However, re-
search has not clarified fully the specific elements of
minimal interventions that are most important to clini-
cal success nor the specific types of changes they pro-
duce in smokers that lead to abstinence.

Intensive Clinical Interventions

  Intensive clinical interventions (sometimes called
"formal" or "organized" cessation treatments) are
multisession counseling programs involving extensive
contact between a health care provider and a smoker.
The value of intensive interventions has been ques-
tioned because they are more expensive and reach
fewer smokers than self-help and minimal clinical in-
terventions do (Chapman 1985). However, more in-
tensive interventions continue to attract interest
because they are more successful at helping people quit
smoking (Schwartz 1987). Despite their comparatively
high cost, they are cost-effective (Elixhauser 1990), and
they may be especially well-suited for treating the most
addicted smokers (Lichtenstein and Glasgow 1992;
Orleans 1993).

  Intensive clinical interventions may be charac-
terized by structure and content. Structural variables
include providers' credentials and training; individual,
telephone, or group format; session length; total num-
ber of sessions; and duration of follow-up. Relatively
little research into intensive treatments has been de-
signed to assess the effects of different structural vari-
ables (Lichtenstein and Glasgow 1992). Increased
patient contact results in better outcomes (Land0 1981;
Decker and Evans 1989; Lichtenstein and Glasgow
1992; Fiore et al. 2000). In a meta-analysis of research
on the nicotine patch (Fiore et al. 1994~1, researchers
found that the following counseling features were as-
sociated with significant increases in six-month absti-
nence rates: counseling being a main reason for
clinician-patient contact, at least weekly clinician-
patient meetings during the first 4 weeks of treatment,
and more than six clinician-patient meetings in the first
12 weeks of treatment. A more recent meta-analysis
that was not restricted to nicotine patch studies (Fiore
et al. 2000) found that quitting success increased with
increasing contact time (up to 90 minutes of total con-
tact) and that there was a dose-response relationship
between number of sessions and treatment efficacy
(Fiore et al. 2000). Thirty to 90 minutes of total coun-
seling and four or more sessions were two to three
times more effective in producing long-term smoking
cessation than no contact controls. This research sup-
ports the notion that in general, as the intensity of
clinician-patient counseling increases, so does the long-
term effectiveness of treatment.

   Because so little information is available on
how structural variables affect intensive treatment
outcomes, this section concentrates on a review of con-
tent variables. Content refers to the specific informa-
tion, materials, and techniques to which smokers are

Marlagement of Nicotine Addiction  105


exposed during the course of treatment. The various
contents of intensive smoking cessation interventions
are not easy to evaluate, partly because the method-
ological quality of clinical trials tends to differ across
content areas. For example, trials of relatively unor-
thodox treatments, such as acupuncture and hypnosis,
tend to use shorter follow-up periods than assessments
of efforts involving pharmacologic and behavioral treat-
ments (Schwartz 1987; Ter Riet et al. 1990); inflated effi-
cacy estimates may thus result for unorthodox
treatments. These methodological concerns are handled
here by limiting the review primarily to studies report-
ing outcomes with at least five months of follow-up.

  Another problem in evaluating the content of
intensive interventions is that the evolution of treat-
ments over the past 40 years prevents a cumulative
assessment of specific intensive interventions. More-
over, changing research interests and methodologies
make it difficult to integrate findings from over the
entire period. For instance, pharmacotherapies have
changed greatly during this period and are now in-
corporated routinely into intensive treatments. In ad-
dition, treatment response may be affected by changes
in the nature of the smoking population; for instance,
compared with 40 years ago, a higher proportion of
today's smokers are women. Methodological and sta-
tistical changes have also altered the nature of the stud-
ies themselves: sample sizes are larger to increase
statistical power, and biochemical confirmation of ab-
stinence is now routine, as is the application of the
"intent to treat" principle in analyses. Because of these
refinements, early cessation research is now often ne-
glected, perhaps because it is difficult to integrate with
newer work. On the other hand, some apparently ef-
fective methods, such as rapid smoking, have often
not been evaluated by newer methods. The older lit-
erature on such strategies is included selectively in this
review.

  A related problem, complicating the interpreta-
tion of relatively recent research, arises from what
Lichtenstein and Glasgow (1992) have referred to as a
shift from a "clinical" to a "public health" (p. 518) ori-
entation among smoking cessation researchers. This
shift has resulted in a dearth of theory-driven research
into intensive interventions. In fact, one observer has
suggested that the long-term research trajectory favors
modifying established models over applying innova-
tion in the basic approach to treatment (Shiffman
1993b). Recent emphasis on public health has also
produced a research climate that favors the evaluation
of treatment packages and minimal interventions over
treatment components (Lichtenstein and Glasgow
1992). One reason for this shift is the high cost and

large sample sizes required to evaluate individual com-
ponents. Thus clinical trials rarely allow assessment
of a given treatment's independent contribution.
Smoking cessation trials now tend to combine specific
treatment components into multicomponent interven-
tions. Moreover, within the same study, not only may
groups receive different treatment packages but the
packages may differ in their structural components.

  Finally, the question of selection bias remains a
challenge to interpreting the literature on intensive
interventions. Investigators typically recruit highly
motivated volunteers to serve as subjects, because the
efficacy of intensive interventions can be tested only
if the patients under study actually receive the entire
treatment. Efficacy estimates derived from this atypi-
cal population may not be appropriate for making pre-
dictions about the larger population of smokers. The
principal types of intensive interventions must be
evaluated in the context of these limitations stemming
from the nature of the available evidence.

Problem Solving/Skills Training

  Various strategies try to impart to smokers the
knowledge and skills necessary to cope with cessation-
that is, both to attain and to maintain abstinence when
confronted with withdrawal symptoms or the temp-
tation to smoke (Marlatt and Gordon 1985; Curry and
McBride 1994). This approach (hereafter referred to
as problem solving/skills training) springs from the
observation that most relapse efforts seem to be asso-
ciated with a finite number of factors, such as alcohol
use, negative affect (e.g., depression), and the presence
of others smoking (Shiffman 1982; Baer and Lichten-
stein 1988; Brandon et al. 1990). Problem solving/skills
training tries to help people who have recently quit
smoking anticipate these "high-risk" situations and
learn to cope with them when they arise. Such inter-
ventions also train participants to cope with with-
drawal symptoms, replace positive reinforcements
they had linked to smoking, and meet other challenges
that might be encountered during or after an attempt
to quit smoking.

  General problem solving/skills training targets
challenges that occur early in the quitting process (e.g.,
withdrawal discomfort). Because newly abstinent
smokers often return to regular smoking (Curry and
McBride 1994), one specialized type of intervention
teaches skills to help the former smoker maintain ab-
stinence (Marlatt and Gordon 1985). These interven-
tions also train former smokers to prevent any relapse
from becoming a long-term return to smoking. Former
smokers are encouraged to view relapses as a normal

106 Chapter 4


Reduciq Tobacco USC

part of the quitting process rather than as an indica-
tion of failure (Curry et al. 1988).

  Another type of problem solving/skills training
focuses on coping with the immediate negative affects
of quitting smoking. The growing body of research
on dysphoria (feeling unhappy or unwell) after smok-
ing cessation (Glassman et al. 1988; Covey et al. 1990;
Brandon 1994; Hall et al. 1994) suggests that strategies
that help smokers who have just quit resist negative
moods may be particularly successful (Shiffman
199313). However, a recent meta-analysis (Fiore et al.
2000) did not find that interventions that targeted nega-
tive affect improved cessation rates. These interven-
tions were used with the general population as well
as smokers with a history of depression. It is possible
that the results might be more positive if the studies
were restricted to high-risk populations.

Efficacy

  Because nearly every state-of-the-art smoking
cessation program contains elements of problem solv-
ing/skills training (Curry and McBride 1994), the tech-
nique is difficult to assess as an individual treatment.
Some investigators have failed to uncover evidence that
this technique increases cessation success relative to
comparison groups (Curry et al. 1988; Emmons et al.
1988; Omenn et al. 1988; Minneker-Hiigel et al. 1992;
Zelman et al. 1992). Other studies have found benefi-
cial effects, but these benefits have often been modest
and have come only through protracted treatment (Hall
et al. 1984b; Davis and Glaros 1986; Goldstein et al. 1989;
Stevens and Hollis 1989). Even in studies that report
success in long-term abstinence through skills train-
ing, the overall relapse curves for treatment subjects
have paralleled those for comparison groups (Glasgow
and Lichtenstein 1987; Goldstein et al. 1989; Stevens
and Hollis 1989; Mermelstein et al. 1992; Minneker-
Hiigel et al. 1992; Gruder et al. 1993). A recent meta-
analysis (Fiore et al. 2000) of 104 studies, however,
reported that problem solving/skills training increased
quitting success by 50 percent. Some evidence sug-
gests that problem solving/skills training may be par-
ticularly useful for female smokers (Curry et al. 1988),
those who smoke fewer cigarettes (Hall et al. 1984b),
those who smoke to cope with emotional stress
(O'Connor and Stravynski 1982), and those who are
less prone to negative affect (Zelman et al. 1992).

  Although multicomponent skills-training
programs have sometimes included information about
managing the dysphoria associated with smoking ces-
sation (Tiffany et al. 1986; Kristeller et al. 1993),
relevant behavioral interventions have only recently

begun (Hall et al. 1994). Initial results suggest that
such strategies are promising, but these findings re-
quire replication and extension.

  In sum, the evidence on problem solving/skills
training suggests a beneficial impact (Fiore et al. 2000).
Such training can offer practical strategies about quit-
ting and inculcate desired coping skills.

Releuallt Process Measures

  Skills training rests heavily on two assumptions:
(1) coping skills will help former smokers remain ab-
stinent in the face of temptation, and (2) smokers can
be taught these skills. Some cross-sectional research
(Shiffman 1984) and skills-training intervention trials
(Hall et al. 1984b; Davis and Glaros 1986; Zelman et al.
1992) have suggested that coping strategies help avert
relapse. The available evidence also indicates that
patients given skills training acquire coping skills (Hall
et al. 1984b; Davis and Glaros 1986; Zelman et al. 1992),
and there is evidence that the level of skill acquisition
predicts long-term abstinence (Zelman et al. 1992).
Although the results of one trial suggest that coping
skills are not retained for very long (Davis and Glaros
1986), consistent self-monitoring of smoking during
treatment is associated with longer-term maintenance
(Kamarck and Lichtenstein 1988); this finding suggests
the importance of behavioral characteristics that fos-
ter maintenance.

  One of the goals of skills training is to encourage
relapsed former smokers to renew their efforts to quit
smoking. Curry and colleagues (1988) found evidence
that smokers who had received skills training were
more likely to try quitting again if they relapsed.

Rapid Smoking

  Rapid-smoking strategies typically require that
smokers inhale deeply from a cigarette about every
six seconds until they become nauseated. In theory,
this aversive conditioning transforms the subject's
perception of smoking from a pleasurable activity into
an unpleasant one, thereby making it easier for smok-
ers to give up cigarettes.

  Medical complications produced by rapid smok-
ing can include elevations in heart rate, blood pres-
sure, and carboxyhemoglobin blood levels as well as
electrocardiogram abnormalities (Horan et al. 1977).
Because of these potential problems, candidates for
rapid smoking should be selected carefully
(Lichtenstein and Glasgow 1977). Older persons and
persons with cardiovascular or pulmonary conditions
are generally excluded from rapid-smoking strategies,


Surgeorl Grrwr~l's Report

but some evidence suggests that rapid smoking can
be conducted with these persons if appropriate pre-
cautions are taken (Hall et al. 1984a).

Efficacy

  The 1988 Surgeon General's report on smoking
and health (USDHHS 1988) reviewed the literature on
rapid smoking and reached two conclusions: (1) al-
though its effectiveness is variable when used alone,
rapid smoking yields moderately high long-term ab-
stinence success (40 percent of subjects were abstinent
6-12 months after treatment) when incorporated in
multicomponent behavioral interventions, and (2) aux-
iliary treatment factors, such as patient expectations,
patient-therapist rapport, and admonitions not to
smoke between sessions, can influence how success-
ful rapid-smoking strategies are. Few rapid-smoking
trials have appeared since the 1988 report.

  The mid-1980s advent of pharmacologic treat-
ments for smoking cessation greatly reduced research
interest in rapid smoking. Pharmacologic aids, such as
nicotine gum, appear as efficacious as rapid smoking
(Zelman et al. 1992) and are probably more acceptable
to smokers and program administrators. Nonetheless,
the doubling of long-term success associated with rapid
smoking (Fiore et al. 2000) suggests that it may remain
an option for smokers who are unable to quit through
other methods and for whom such aversive condition-
ing is acceptable.

Relevant Process Measures

  Rapid smoking is intended to produce aversive
conditioned responses to stimuli associated with smok-
ing (USDHHS 1988). The technique reliably produces
tachycardiac responses to cigarettes, and the magnitude
of these responses is directly related to treatment out-
come (Tiffany et al. 1986; Zelman et al. 1992). More eas-
ily observable variables, such as the number of cigarettes
smoked during a rapid-smoking session or the degree
of nausea reported by patients, have not been shown to
be consistently related to outcome (USDHHS 1988).

Other Aversive-Smoking Strategies

  Three other techniques intended to produce aver-
sion to cigarettes have been investigated: satiation
therapy, rapid puffing, and focused smoking. Con-
cern over the safety of rapid smoking (Horan et al.
1977) was partly responsible for investigation of these
alternative aversion techniques. Some evidence sug-
gests that they are less unpleasant and less risky than
rapid smoking (Glasgow et al. 1981; Tiffany et al. 1986).

Satiation therapy requires that patients smoke many
more cigarettes per day than they normally do, usu-
ally about twice as many (Best et al. 1978). Rapid puff-
ing is similar to rapid smoking, but patients are
instructed not to inhale cigarette smoke (Tiffany et al.
1986). Focused smoking requires patients to smoke
for an extended period of time at a normal rate while
concentrating on the negative sensations smoking pro-
duces (Lowe et al. 1980).

Efficacy

  Satiation therapy alone produces relatively little
cessation success (15 percent at one year) (Land0 19821,
but the technique may be more effective when incor-
porated into multicomponent programs (USDHHS
1988). Focused smoking and rapid puffing produce
long-term abstinence rates that are equivalent to, or
slightly lower than, those produced by rapid smoking
(USDHHS 1988; Fi;rp et al. 2000). Because these tech-
niques do not appear to result in significant tachycar-
disc responses (USDHHS 1988), their efficacy is
probably accounted for by mechanisms other than
aversive conditioning.

Cue Exposure

  Cue exposure therapy is based on the premise
that smokers become conditioned to certain cues or
contextual signals correlated with smoking behavior.
When persons who have recently quit smoking are
exposed to these cues, they are motivated to begin
smoking again (Rohsenow et al. 1990-91; Brandon et
al. 1995). In cue exposure therapy, persons trying to
quit smoking are repeatedly exposed to these signals
in a therapeutic context in which smoking is prohib-
ited; the resulting reduced association between smok-
ing and previous cues is hypothesized to reduce some
of the temptation for relapse that former smokers will
face in the natural environment.

  Because cue exposure therapy has produced
promising results with other addictive disorders (Monti
et al. 19931, several researchers have suggested that
such strategies be developed for smoking cessation
(Hodgson 1989; Heather and Bradley 1990). These
strategies may be particularly important for women,
whose responsiveness to nicotine replacement therapy
appears to be less than that of men (Perkins 1996).
Women may be less controlled by nicotine and more
influenced by nonnicotine factors (sensory stimuli, en-
vironmental factors) (Perkins et al. 1999) and may there-
fore respond better than men to behavioral approaches.

108 Chyter 4


Efficacy

   Studies conducted to date that have evaluated
cue exposure have failed to find significant differences
in outcome between cue exposure and comparison
interventions (Lowe et al. 1980; Raw and Russell 1980;
Gtitestam and Melin 1983; Corty and McFall 1984).
However, clinical research on cue exposure for smok-
ing cessation is sparse, and interpretation of most ex-
isting trials is hampered by methodological flaws
(Brandon et al. 1995).

Relevant Process Measures

  Environmental associations with cigarette smok-
ing can be strong enough to provoke the desire to
smoke (Herman 1974; Rickard-Figueroa and Zeichner
1985; Tiffany and Hakenewerth 1991). These provoked
responses may affect treatment outcome (Niaura et al.
1989). However, because cue reactivity has not been
assessed in existing clinical trials of cue exposure
therapy, it is impossible to determine whether such
interventions extinguish motivational responses to
smoking-related cues.

Nicotine Fading

  Nicotine fading is based on the assumption that
withdrawal symptoms will be lessened through a
gradual reduction of nicotine intake (Foxx and Brown
1979; McGovern and Lando 1991). Nicotine fading can
be accomplished either by progressively switching to
brands of cigarettes yielding less nicotine or by using
a series of graduated filters (McGovern and Lando
1991). Once the lowest nicotine level is reached, ces-
sation is attempted. Nicotine fading should be distin-
guished from cigarette fading, in which the number
of cigarettes smoked per day is gradually reduced.
Cigarette fading has generally not been shown to be
an effective smoking cessation technique; participants
generally reach a level beyond which they find it diffi-
cult to reduce cigarette consumption (Land0 1993;
Fiore et al. 2000).

Efficacy

  Foxx and Brown (1979) reported that 4 of 10 sub-
jects who tried nicotine fading had quit smoking at 18
months, but subsequent investigations have found
more modest long-term results (usually around 20
percent) (Beaver et al. 1981; Lando and McGovern 1985;
Burling et al. 1989). Some evidence suggests that nico-
tine fading can increase abstinence success indepen-
dently within a larger smoking cessation program

(Burling et al. 1989). In a community setting where
participants were allowed to select their treatment,
about 25-30 percent of those who chose multicompo-
nent interventions containing nicotine fading achieved
long-term abstinence (Land0 et al. 1990; Lando 1993).
Brand switching and graduated filters have produced
equivalent outcomes (McGovern and Lando 1991).
Cinciripini and colleagues (1995) found that 44 per-
cent of persons using a combined nicotine fading and
skills-training package were abstinent from nicotine
at one year, a proportion significantly higher than that
produced by matched conditions.

Relevant Process Measures

  Nicotine fading is presumed to exert its effects
by gradually weaning smokers from nicotine, thereby
reducing withdra>val symptoms. Reductions in nico-
tine intake and Mithdrawal indexes are thus the pro-
cess measures of primary importance to nicotine
fading. One early study suggests that nicotine fading
reduces the severity of withdrawal symptoms (West
et al. 1984a,b).

  The process measure of reduced nicotine intake
is problematic, because smokers' nicotine consump-
tion seldom matches a given brand's machine-rated
nicotine yields (McMorrow and Foxx 1983). Smokers
are able to compensate for reduced nicotine yield by
adjusting how they smoke-by inhaling more strongly,
holding smoke in longer before exhaling, inhaling
more frequently, or smoking the cigarette closer to its
high-yield butt (Benowitz et al. 1983; Kozlowski et al.
1988). Smokers can also compensate for nicotine fad-
ing by blocking the air inlet holes on the filters that
are used to decrease nicotine intake (McGovern and
Lando 1991). The best available evidence indicates that
although nicotine consumption is indeed reduced by
nicotine fading, the extent of these reductions is smaller
than would be expected (i.e., based on machine rat-
ings); apparently, some compensatory smoking occurs
(Land0 1993). For example, one study (McGovern and
Lando 1991) compared two nicotine fading regimens,
brand switching and graduated filter use, each of
which was designed to reduce nicotine intake by 80
percent by the final stage. Each regimen significantly
reduced nicotine consumption but by far less than 80
percent: brand switching reduced intake by 42.5 per-
cent and graduated filters by 55.2 percent.

  Lando and McGovern (1985) suggested that nico-
tine fading increases smokers' self-efficacy by provid-
ing them with a series of concrete steps that are
mastered before cessation. Self-efficacv does increase
during the fading process (McGo\.ern al;d Lando 1991),


although no more than with comparison treatments
(Burling et al. 1989). Moreover, increased self-efficacy
has not been shown to predict treatment outcome for
nicotine fading (McGovern and Lando 1991).

Motivational Rewards

  Strategies that use motivational rewards are
rooted in operant conditioning theory. These efforts
are designed to provide reasons for remaining absti-
nent to smokers who have just quit-reasons more tan-
gible and immediate than the important but delayed
outcomes that typically motivate cessation attempts
(e.g., improvements in health). In a typical motiva-
tional rewards intervention, the provider collects a
deposit from each participant at the outset of treatment
and refunds a portion of this sum at each follow-up
assessment at which the participant demonstrates ab-
stinence (Paxton 1983). Other variations of this tech-
nique have used nonmonetary rewards (Land0 1982),
punished smokers for every cigarette smoked (Murray
and Hobbs 19811, instructed participants to reward
themselves for abstinence (Tiffany et al. 19861, and
rewarded participants who had reduced their carbon
monoxide levels (Stitzer and Bigelow 1985). Curry and
colleagues (1991) used a theoretical framework that
tested intrinsic motivation (personalized feedback)
against extrinsic motivation (financial incentive). Ab-
stinence at 3 and 12 months was two times higher in
the intrinsically motivated groups.

Efficacy

  When used alone, inotivational rewards foster
relatively high abstinence success in the short term, but
these gains do not appear to be durable (Antonuccio
et al. 1992). Participants often return to smoking after
the term of the contract expires (Paxton 1980,1981). At-
tempts to prolong .abstinence by varying factors such
as duration and frequency of reward have generally
been unsuccessful (Paxton 1981, 1983). Multicompo-.
nent treatments using motivational rewards have some-
times fared better than comparison treatments, but these
comparisons are generally confounded by other factors
(Jason et al. 1990; Lando~et al. 1990) and may lead to
type II errors. A meta-analysis of 62 studies comparing
components of behavioral controls found that motiva-
tional rewards (contingency contracting) did not sig-
nificantly alter long-term cessation rates (Fiore et
al. 2000). In the final results of the Minnesota Heart
Health Program, the failure of community education
methods (which included motivational rewards for
smoking cessation) to produce results that exceeded

secular trends is an important demonstration of the
difficulties in evaluating such modalities (Land0 et al.
1995).

Relevant Process Measures

  The process measures most relevant to this strat-
egy are presumably motivational; making rewards
contingent on abstinence should increase a smoker's
resolution to remain abstinent. However, motivational
measures have been neglected in research on this
intervention. Many programs require participants to
administer their own rewards or punishments. Evalu-
ations of these strategies should routinely assess how
well participants take on this responsibility; to date,
evaluations have not made this assessment.

Social Support

  Social support intervention> try to ease the smok-
.ing cessation process by enlisting the support of sig-
nificant persons in smokers' lives (extratreatment
social support) and by providing support from clini-
cians (intratreatment social support). Both strategies
may range from intense' and pervasive to relatively
minimal and limited. Intensive extratreatment social
support may train participants to elicit aid and sup-
port of family and friends, whereas training clinicians
to communicate caring, concern, and encouragement
increases intratreatment social support. Increasing the
cohesiGeness of smoking cessation groups can enhance
both forms of social support (Hajek et al. 1985; Lando
and McGovern 1991). At the basic level, the simple
use of a group rather than an individual format can be
viewed as a social support intervention.

Efficacy

  Strategies that add social support to fiharmaco-
logic treatment appear to significantly increase long-
term quit rates compared to treatments without social
support, although some intensive interventions have
reported mixed results (Glasgow et al. 1986; McIntyre-
Kingsolver et al. 1986). A recent meta-analysis of 19
studies (Fiore et al. 2000) reported that interventions
to increase social support in the smoker's environment
increase long-term cessation by 50 percent. A meta-
analysis of 50 studies (Fiore et al. 2000) reported that
within-treatment social support increased cessation by
30 percent. -The importance of intratreatment social
support may well be reflected in the finding that indi-
vidual and group counseling are both much more ef-
fective than no contact interventions (Kottke et al. 1988;
Fiore et al. 1996).


Rcducirlg Tobmro Usr

Relevant Process Measures

  Studies of intensive social support interventions
have regularly included measures of smokers' per-
ceived support. These investigations have found that
the amount of support a smoker perceives is directly
related to outcome (Malott et al. 1984; Glasgow et al.
1986; McIntyre-Kingsolver et al. 1986; Gruder et al.
19931, but the trials have typically failed to find evi-
dence that the support itself has increased this per-
ception (Malott et al. 1984; Glasgow et al. 1986). In
one study that found social support intervention to be
effective, the strategy was itself associated with an in-
crease in received support (Gruder et al. 1993). More-
over, this increase in support was statistically related
to the differential outcome. Because support measures
have rarely been incorporated into the evaluation of
group treatments for smoking cessation, little is known
about whether group formats enhance perceived sup-
port and about what influence such support has on
treatment outcome (Hajek et al. 1985).

Weight Control

  Most people who quit smoking gain weight
(Klesges et al. 1989), and this effect may be greater for
women than for men (Williamson et al. 1991; Fant
1996). This effect has been hypothesized to result from
nicotine's ability to modify various mechanisms in the
central nervous system that regulate body weight
(Schwid et al. 1992; Perkins 1993). Apprehension about
weight gain may serve as a barrier to cessation at-
tempts, especially among young women (Gritz et al.
1989). Cessation strategies that address this barrier
have only recently begun to be assessed.

Efficacy

  Two important trials have examined the contri-
bution of a weight control component to a multicom-
ponent smoking cessation program. One study (Hall
et al. 1992) compared a specialized weight control pro-
gram with both a nonspecific weight control program
and a standard program. Patients in the specialized
group learned behavioral self-management, reduced
their caloric intake under the direction of a dietitian,
and received an individualized activity plan from an
exercise counselor. Patients in the nonspecific group
attended several group sessions devoted to discuss-
ing weight-related issues. Results showed that par-
ticipants in both of these weight control programs were
less likely to be abstinent after one year (21 percent
success for both groups combined) than participants
treated with the standard protocol (35 percent success).

  Another study (Pirie et al. 1992) examined the ef-
fects of adding nicotine gum, weight control counsel-
ing, both, or neither to a standardized smoking cessation
program in a sample of women who had indicated that
they were concerned about postcessation weight gain.
After 12 months, the group that added nicotine gum to
the standard program had much greater success (44.4
percent had quit smoking) than the groups that added
weight control counseling to the standard package (27.8
percent success for the group that added weight con-
trol only and 27.6 percent success for the group that
added both weight control and nicotine gum). How-
ever, the standard package alone was the least success-
ful program (19.4 percent had quit smoking) and was
viewed by participants as less appealing than the weight
control component (Pirie et al. 1992).

  A meta-analysis of six studies (Fiore et al. 2000)
that looked at the effect of dieting and physical activ-
ity on smoking cessation did not find that these inter-
ventions increased cessation success. A recent single
study (Marcus et al. 1999) found that vigorous physi-
cal activity increased quit rates.

Relevant Process Measures

  Weight gain has not been a consistent predictor
of smoking relapse (Gritz et al. 1989), and it has pre-
dicted abstinence as well (Hall et al. 1986; Gritz et al.
7989; Hughes et al. 1991b). Nonetheless, actual con-
trol of weight is an important process measure for
weight control interventions-the primary purpose of
which is relapse prevention-because they explicitly
assume that preventing weight gain will boost absti-
nence rates (Hall et al. 1992; Pirie et al. 1992). Neither
published trial of weight control interventions found
differences in weight gain among abstinent subjects
across treatment conditions (Hall et al. 1992; Pirie et
al. 1992). One of the studies (Hall et al. 1992) found
evidence for lower caloric intake in specialized weight
control interventions, especially among women, but
failed to find differences in activity levels across treat-
ment conditions. In sum, despite the intuitive appeal
of weight control interventions to promote smoking
cessation, there is mixed evidence relating such inter-
ventions to cessation success (Fiore et al. 2000). Hall
and colleagues (1992) suggested that such interventions
may interfere with cessation. However, Marcus and
colleagues (1999) found that a vigorous exercise inter-
vention increased quit rates while contributing to weight
management. Pharmacotherapies, including bupropion
sustained release (SR) and nicotine gum, may help to
delay weight gain after cessation (Emont and
Cummings 1987; Doherty et al. 1996; Jorenby et al. 1999).


Hypnosis                       Efficacy

  Some smokers try hypnosis therapy to help them
quit (Schlvartz 1987). Strategies for hypnosis interven-
tions include direct hypnotic suggestions to quit, sug-
gestions intended to produce aversion to smoking, and
training in self-hypnosis to reinforce formal treatment
(Simon and Salzberg 1982).

Efficacy

  The methodological shortcomings of hypnosis
research make it difficult to estimate the value of this
therapy for smoking cessation (Schwartz 1987). Re-
viewers have noted that, in general, hypnosis is not
very effective when used alone, but it may be useful
as part of a multicomponent intervention in which
subjects see a therapist many times (Holroyd 1980;
Schwartz 1987). In methodologically sound studies,
hypnosis often fails to outperform comparison tech-
niques, such as self-help strategies (Rabkin et al. 1984;
Lambe et al. 1986). Hypnosis techniques may work
best for the relatively small proportion of people highly
susceptible to hypnosis (Barabasz et al. 1986; USDHHS
1988). Since the late 198Os, there have been only two
trials of hypnosis in smoking cessation, with incon-
clusi\-e results. Johnson and Karkut (1994) conducted
an uncontrolled clinical trial of hypnosis plus aversion
treatment and reported about 90 percent abstinence at
three months. A similar uncontrolled study of 226
smokers reported a 23-percent abstinence at two years
(Spiegel et al. 1993). A recent review of hypnosis by
the Cochrane group (Abbot et al. 2000) found insuffi-
cient evidence to support hypnosis as a treatment for
smoking cessation.

Releoar; t Process Measures

  Appropriate process measures for studies of
hypnosis are those that assess the various means of hyp-
notic induction and the motivational changes that are
presumed to accrue from them. Because measures have
rarely been collected, little is known about the mecha-
nisms of hypnotic treatments for smoking cessation
(Holroyd 1980; Schwartz 1987; USDHHS 1988).

Acupuncture

  The typical acupuncture treatment for smoking
cessation involves the insertion of needles or staples
into the outer ear, but a number of other techniques
ha1.e been investigated (Schwartz 1988). The most
commonly cited rationale for using acupuncture is that
it relie\,cs the discomfort of nicotine withdrawal.

  The available evidence suggests that acupunc-
ture is no more effective in smoking cessation than
placebo treatments (Schwartz 1987). For example,
Schwartz (1988) reviewed eight studies in which acu-
puncture at a theoretically appropriate site was con-
trasted with acupuncture at a placebo site. Only one
of these studies found greater success among partici-
pants undergoing the procedure with theoretically
appropriate sites (MacHovec and Man 1978). A recent
meta-analysis of five studies (Fiore et al. 2000) found
that acupuncture was no more effective than placebo.

Relevant Process Measures

  Acupuncture is commonly presumed to exert its
effects by easing tobacco withdrawal. At present there
is no evidence that acupuncture is capable of relieving
withdrawal symptoms associated with smoking cessa-
tion (Clavel et al. 1987; Schwartz 1987; USDHHS 1988).

Summary of Intensive Clinical Interventions

  Intensive programs serve an important function
in the nation's efforts to reduce smoking, despite the
resources the programs demand and the relatively
small population of smokers who use them. Such pro-
grams may be particularly useful in treating smokers
who find it most difficult to quit.

  Because intensive smoking cessation programs
differ in structure and content, evaluation is often ham-
pered by variation in methodology and by a lack of
research addressing specific treatment techniques.
Because few studies have chosen to isolate single treat-
ments, assessment of the effectiveness of specific ap-
proaches is difficult. Nonetheless, skills training, rapid
smoking, and both intratreatment and extratreatment
social support have 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 par-
ticular psychological, behavioral, or cognitive mecha-
nisms as the agents of change. The specific impact of
intensive interventions may be masked by the efficacy
of several multicomponent programs, some of which
have achieved cessation proportions of 30-50 percent
(Land0 1993).

  Thus, in their positive effect on smoking cessa-
tion and long-term abstinence rates (Kottke et al. 1988;
Fiore et al. 1994a), intensive interventions seem
little different from other forms of counseling or psy-
chotherapy. With intensive interventions, as with
counseling, it is difficult to attribute the efficacy to


Reducing Tobacco Use

specific characteristics of the interventions or to spe-
cific change mechanisms (Luborsky et al. 1975; Elkin
et al. 1989).

Pharmacologic Interventions

  At first look, nicotine replacement therapy ap-
pears to be the treatment of a disease with its cause.
The rationale, however, is well established. Observa-
tions on the beneficial effects of nicotine replacement
in abstinent smokers were first made in 1967 (Lucchesi
et al. 19671, and the process has its medical precedent
in the use of methadone for opiate dependence. Nico-
tine use, in the form of 10 or more cigarettes a day,
provides continuous neuroexposure (Benowitz 1993).
The resulting tolerance and physical dependence pro-
duce classic withdrawal symptoms (USDHHS 1988).
As Benowitz (1993) has summarized, "Nicotine re-
placement therapy serves primarily to break the daily
addiction cycle by relieving withdrawal symptoms,
thereby facilitating behavioural modification that is
necessary for permanent smoking cessation" (p. 158).
However, as will be discussed later in this chapter, re-
cent data suggest that nicotine replacement may be
effective without behavioral support or counseling. A
number of candidate delivery systems have now been
extensively evaluated with clear and consistent results.
In addition, nonnicotine pharmacotherapies for treat-
ment of tobacco use are now available.

Nicotine Polacrilex

  Nicotine polacrilex (nicotine gum) was approved
by the Food and Drug Administration (FDA) for use
as an aid to smoking cessation in a 2-mg dose in 1984
and in a 4-mg dose in 1994. The nicotine in the gum is
bound to an ion-exchange resin. Chewing the gum
liberates the nicotine, which is absorbed through the
buccal mucosa. Currently, both doses of nicotine
polacrilex are approved for use as over-the-counter
preparations by adults. The package insert instructs
patients to use the gum as needed with the constraint
that they not exceed a daily dose of 20 pieces of 4-mg
gum or 30 pieces of 2-mg gum.

Efiicacy

  With more than 50 studies on its efficacy, nico-
tine gum is the most extensively investigated pharma-
cologic treatment for smoking cessation. This body
of research has been summarized by several major
meta-analyses (Lam et al. 1987; Cepeda-Benito 1993;
Silagy et al. 1994; Tang et al. 1994). The most recent

meta-analysis (Fiore et al. 2000) is summarized in Table
4.3. All meta-analyses found the gum to be effective
in helping smokers quit.

  Lam and colleagues (1987) performed a meta-
analysis of nine randomized, controlled trials of the
2-mg nicotine gum. These authors performed sepa-
rate analyses on the trials conducted in specialized
smoking cessation clinics and on those conducted in
general medical settings. In the specialized clinics, ces-
sation success was greater with nicotine gum than with
placebo gum. In general medical practice settings,
however, nicotine gum was no more successful than
placebo gum; both types of gum were more successful
than usual care. The authors suggested that partici-
pants at the specialized cessation clinics had greater
success because such participants may have been more
motivated to quit and may have received more inten-
sive adjuvant behavioral support than those at the
generalized settings. The authors also speculated that
patients who seek treatment in specialized clinics may
be more physically dependent on nicotine and thus
more likely to benefit from nicotine replacement than
the average patient seen in a general medical clinic.

  Cepeda-Benito (1993) performed a meta-analysis
of 33 trials of the 2-mg gum. As in the review by Lam
and colleagues (19871, the trials were categorized ac-
cording to whether the adjuvant behavioral support
was intensive or brief and according to whether the
control group used placebo gum or no gum. Pooled
estimates of efficacy were derived for short-term (O-8
weeks after treatment) and long-term (12 2 2 months)
outcome measures within each category. Effect sizes
were not systematically related to the type of control
treatment used but were related to the intensity of be-
havioral support provided. When used in intensive
interventions, the gum was associated with greater
abstinence success than the control treatments at both
long-term and short-term follow-up. When used in
brief behavioral interventions, however, the gum out-
performed the control interventions only at short-term
follow-up. The author concluded that nicotine gum is
an effective aid to smoking cessation but questioned
its long-term value in the absence of adjuvant psycho-
social support.

  In the context of a larger review of available nico-
tine replacement therapies, Tang and colleagues
(1994) performed a meta-analysis of 28 randomized,
controlled trials of the 2-mg gum and 6 randomized,
controlled trials of the 4-mg gum. The authors found
that among participants recruited through advertise-
ments to attend specialized cessation clinics, the 2-mg
gum was associated with an ll-percent increase in
success over control treatments. However, among

Mmmger?rtwt of Nicotirw Addiction  2 13


smokers who were directly invited to participate in a
general smoking cessation trial conducted by a non-
specialist physician, the 2-mg gum increased absti-
nence success by only 3 percentage points over control
conditions. Consistent with the analysis by Lam and
colleagues (1987), the authors suggested that these
findings reflect (1) the greater motivation of the smok-
ers who referred themselves (i.e., responded to adver-
tisements instead of being directly invited), (2) the
greater degree of nicotine dependence in the self-
referred group, and (3) the more extensive encourage-
ment and more detailed instructions provided by

therapists in the specialized settings in which the self-
referred smokers were treated.

  Six of the 28 trials of the 2-mg gum (Fagerstrcm
1982,1984; Jarvik and Schneider 1984; Areechon and
Punnotock 1988; Hughes et al. 1989b; Jensen et al.
1990) reported abstinence success as a function of
nicotine dependence as assessed by the Fagerstrijm
Tolerance Questionnaire (described later in this chap-
ter). The authors aggregated these data and found
that the 2-mg gum improved cessation success by
16 percentage points among smokers scoring high
(indicating considerable nicotine dependence) on the

Table 4.3. Meta-analyses of efficacy (estimated odds ratio and abstinence rates) for seven
     pharmacotherapies used in tobacco dependence treatment

Pharmacotherapy

Number of
study groups

Bupropion SR' (n = 2i)
Placebo
Bupropion SR

Nicotine gum, 2 mg (n = 13)
Placebo
Nicotine gum

Nicotine inhaler (n = 4)
Placebo

Nicotine inhaler

Nicotine nasal spray (n = 3)
Placebo
Nicotine spray

Transdermal nicotine
(the nicotine patch) (n = 27)
Placebo
Transdermal nicotine

Clonidine (n = 5)
Placebo
Clonidine

Nortriptyline (n = 2)
Placebo
Nortriptyline

2
4

16
18

4
4

3
3

28
32

6
8

3
3

Estimated          Estimated
odds ratio         abstinence rate
(95% CI')          (95% CI)

1.0
2.1 (1.5, 3.0)

1.0
1.5 (1.3,1.8)

1.0
2.5 (1.7, 3.6)

1.0
2.7 (1.8,4.1)

17.3
30.5 (23.2,37.8)

17.1
23.7 (20.6, 26.7)

10.5
22.8 (16.4,29.2)

13.9
30.5 (21.8,39.2)

1.0
1.9 (1.7,2.2)

1.0
2.1 (1.4, 3.2)

1.0
3.2 (1.8, 5.7)

10.0
17.7 (16.0, 19.5)

13.9
25.6 (17.7,33.6)

11.7
30.1 (18.1,41.6)

*Confidence interval.
`SR = sustained release.
iNumber of studies.
Source: Fiore et al. 2000.

2 24  Chayter 4


ReducilTg Tobacco Use

questionnaire but produced only a 2-percentage point
increase among smokers whose scores indicated low
levels of nicotine dependence.

  When data from the 4-mg gum trials (Puska et
al. 1979; Kornitzer et al. 1987; Tonnesen et al. 1988a,b;
Blondal 1989; Hughes et al. 1990a) were aggregated,
the influence of nicotine dependence paralleled that
seen in trials using the lower dose. Among smokers
highly dependent on nicotine, those who used the
4-mg gum had a 21-percent greater success at cessa-
tion than those using the 2-mg gum. In contrast,
among smokers low in nicotine dependence, those who
used the 4-mg gum had an l&percent lower success
than those using the 2-mg gum. Highly dependent
participants using the 4-mg gum had a 35-percent
greater success than those using the placebo gum, but
this comparative improvement was only 5 percent
greater among less dependent participants.

  Tang and colleagues (19941 concluded that nico-
tine gum is an effective aid to smoking cessation and
suggested that its efficacy is a direct function of the
dependence of the smoker. On the basis of their re-
view of other nicotine replacement therapies (includ-
ing the nicotine patch), the authors concluded that the
4-mg gum is the most effective form of nicotine re-
placement for highly dependent smokers.

  Silagy and colleagues (1994) examined 42 nico-
tine gum trials in their meta-analysis of nicotine re-
placement interventions. To compute effect sizes for
each analysis, the authors combined data from the
longest follow-up assessments (mainly 12 months)
from available trials, regardless of gum dose or type
of control treatment. Across all 42 trials, 42 percent of
participants using nicotine gum quit smoking, whereas
only 18 percent of participants in the control groups,
who used either placebo gum or no gum, succeeded
in quitting. The pooled odds ratio (OR) for the gum-
to-control comparison across all trials was 1.61 (95
percent confidence interval [CI], 1.46-1.78). Differ-
ences between gum and control conditions did not
vary according to the intensity of adjuvant behavioral
support.

  Fiore and colleagues (1990) conducted a meta-
analysis of 13 randomized controlled trials of 2-mg
nicotine gum therapy with at least five months of fol-
low-up (Table 4.3). Nicotine gum treatment was asso-
ciated with a 50-percent increase in quit rates (23.7
percent quit rate vs. 17.1 percent) in the control group.
There were too few studies done in the over-the-
counter setting to allow meta-analysis of the over-the-
counter effect of nicotine gum.

  Taken together, these meta-analyses suggest that
nicotine chewing gum is an effective aid to smoking
cessation. This conclusion continues to be borne out
as evidence continues to accumulate. In an ongoing
project, Silagy and colleagues (1999) have been regu-
larly searching medical databases for new nicotine re-
placement trials, recalculating effect sizes as new data
sources are identified, and frequently publishing the
updated meta-analyses. In the most recent edition of
this meta-analysis, the pooled gum-to-control OR was
estimated at 1.63. That in most settings nicotine-
containing gum is associated with greater cessation
success than placebo gum suggests that the gum's ef-
ficacy is due to its pharmacologic properties. Some
evidence indicates that the efficacy of the 2-mg gum
depends on the presence of intensive adjuvant behav-
ioral support. The meta-analysis by Silagy and col-
leagues (1994) suggests that nicotine gum may be
beneficial even without intensive adjuvant therapy. In
this analysis, however, because 2-mg and 4-mg gum
studies are combined, definitive conclusions about the
efficacy of either dose alone in the absence of behav-
ioral support cannot be drawn. This finding under-
scores the importance of selecting those smokers for
whom nicotine gum is likely to be beneficial. The avail-
able evidence suggests that traditional measures of
nicotine dependence may be a useful basis for select-
ing gum candidates. Both doses of the gum appear to
be of greater value to smokers who are more depen-
dent on nicotine. The 4-mg gum may be particularly
effective for the most dependent smokers.

RelevaA Process Measures

  Nicotine gum is presumed to exert its effects by
replacing a portion of the nicotine that smokers usu-
ally obtain through smoking; in therapy, the gum ame-
liorates aversive tobacco withdrawal (Benowitz 1991;
Hughes 1993). Some evidence suggests that nicotine
gum reliably reduces some withdrawal symptoms.

  Patients receiving the 2-mg nicotine gum have
consistently reported having less total withdrawal dis-
comfort than patients treated with placebo gum (Jarvis
et al. 1982; Hughes et al. 1984,1989a, 1991b; Gross and
Stitzer 1989; Hatsukami et al. 1991). However, studies
have found that withdrawal severity is not consistently
related to smoking relapse (West 1992; Hughes 19931,
and the withdrawal suppression produced by nicotine
gum appears to be somewhat independent of its effi-
cacy. Moreover, the suppression reported seems to
accrue through the lessening of a relatively small sub-
set of withdrawal symptoms (Hughes et al. 1990b). The
2-mg gum consistently alleviates symptoms such as


Sqeo)~ Grtreral's Report

anxiety and irritability but does not appear to reliably
ameliorate craving, hunger, sleep disturbance, or dif-
ficulty concentrating (West et al. 1984a,b; Gross and
Stitzer 1989; Hughes et al. 1989a, 1990a; Hatsukami et
al. 1991). One trial (Hughes et al. 1990a) has found
that the 4-mg gum was no more effective than the
2-mg gum either in suppressing total withdrawal se-
verity or in relieving any of the individual symptoms
of withdrawal. Future research must explore whether
these counterintuitive findings are a result of poor
measurement of withdrawal severity or whether other
mechanisms explain how nicotine gum produces clini-
cal success (Hughes 1993).

Effect on Postcessation Change in Body Weight

  Evidence suggests that the 2-mg gum is capable
of delaying, but not preventing, postcessation weight
gain. Early in the cessation process, smokers given
the 2-mg gum tend to gain less weight than smokers
treated with placebo gum (Gross et al. 1989). During
this period, weight gain among the 2-mg gum users is
inversely related to the amount of gum used (Emont
and Cummings 1987; Fagerstrom 1987; Killen et al.
1990a; Nides et al. 1994). However, differences in
weight gain between smokers using the 2-mg gum,
using placebo gum, and using no gum (Gross et al.
1989; Nides et al. 1994) disappear when follow-up is
conducted after gum therapy has ended.

  Relatively little is known about the weight-
related effects of the 4-mg gum. Early trials did not
show it to diminish weight gain any more than either
the 2-mg gum (Kornitzer et al. 1987; Tonnesen et al.
1988a) or the placebo gum (Puska et al. 1979; Tonnesen
et al. 1988a). These trials, however, tended to use dif-
ferent weight measures and more distal end points
than the typical trial with 2-mg gum, and one trial used
a mixed-dose regimen (Tonnesen et al. 1988a). A more
recent study, however, reported that nicotine gum sup-
pressed weight gain with greater suppression occur-
ring with the 4-mg dose (Doherty et al. 1996). Analysis
of salivary cotinine showed that smokers who replaced
a greater percentage of their baseline cotinine levels
gained less weight.

Side Effects and Likelihood of Inappropriate Use

  Common side effects reported by the 2-mg gum
users include mouth soreness, hiccups, indigestion,
jaw ache, and unpleasant taste (American Medical As-
sociation [AMA] 1993; Tang et al. 1994). Most of these
symptoms are relatively mild and transient, and
many can be resolved by correcting the user`s chew-
ing technique. Symptoms observed less frequently (in

less than 2 percent of patients) include irritability,
lightheadedness, headache, excessive salivation, and
anorexia (AMA 1993). Moreover, absorption of nico-
tine from the gum is highly dependent on the pH of
the mouth (Henningfield et al. 1990). Because nico-
tine is inactivated by an acidic environment, patients
are urged to refrain from eating or drinking anything
but water for 30 minutes before using the gum. Ap-
proximately lo-25 percent of successful abstainers con-
tinue to use the gum for one year or longer (Hajek et
al. 1988; Hughes 1988; Hughes et al. 1991a). Although
discontinuance of use should be encouraged, contin-
ued use confers a substantial reduced health risk com-
pared to a return to smoking. The 4-mg gum appears
to have similar side effects, but it may produce slightly
more dyspepsia and hiccuping than does the 2-mg
gum (Tonnesen et al. 1988a,b).

Transdermal Nicotine

  In 1991, the FDA approved the use of transdermal
nicotine patches as an aid to smoking cessation. Nico-
tine patches contain a reservoir of nicotine that diffuses
through the skin and into the wearer's bloodstream at
a constant rate. Patients are usually instructed to apply
one patch each day. Specific dosing regimen may vary.

  All currently marketed brands are designed to
deliver approximately 0.9 mg per hour of nicotine over
the weaning period.  Most are intended for 24-hour
wear and deliver 21-22 mg of nicotine; one is intended
for waking hours wear (16 hours per day) and deliv-
ers 15 mg of nicotine. Full-strength patches typically
produce serum nicotine levels similar to trough levels
of serum nicotine in moderate to heavy smokers
(Mulligan et al. 19901. On July 3, 1996, the FDA ap-
proved the transdermal nicotine patch for over-the-
counter sales at a dose of 15 mg for use as part of a
comprehensive behavioral program of smoking ces-
sation, although the FDA's proscription does not pro-
vide a clear statement of the constituents of such a
program. Since that time, all varieties of nicotine
patches have become available over the counter, some
as "house brands."

Efficacy

  Several meta-analyses of the efficacy of the nico-
tine patch have been published (PO 1993; Fiore et al.
1994~; Gourlay 1994; Silagy et al. 1994; Tang et al. 1994;
Fiore et al. 2000). Each meta-analysis has concluded
that the patch is an effective aid to smoking cessation.
  PO (1993) combined data from 11 nicotine patch
trials and found that persons using the nicotine patch
had greater cessation success than persons using a

12 6  Chapter 4


Reducing Tobacco Use

placebo patch. This finding held for both short-term
follow-up (3-10 weeks; combined OR = 3.10 J95 per-
cent CI, 2.65-3.621) and long-term follow-up (6-12
months; combined OR = 2.26 [95 percent CI, 1.80-
2.861). Gourlay (19941 pooled the results of six trials
and found that the nicotine patch produced greater
cessation success than a placebo patch at all follow-up
assessments (2-3 months, 6 months, and 12 months;
all pooled ORs were between 2.2 and 2.4 I95 percent
CI, 1.6-3.41). Tang and colleagues (1994) conducted a
meta-analysis of six patch trials. Overall, at long-term
(12-month) follow-up, persons using nicotine patches
had a 9-percent (6-13 percent) greater success at ces-
sation than did persons using placebo patches. Nico-
tine patches were found to be more effectivre among
self-referred subjects than among invited subjects and
slightly more effective among smokers \vho were more
dependent on nicotine. Silagy and colleagues (199-l)
combined data from nine patch trials and found that
at long-term (12-month) follow-up, nicotine patches
were associated with a combined OR of 2.07 (95 per-
cent CI, 1.64-2.62) when compared with control con-
ditions (placebo patches or no patch). Secondary
analyses indicated that the patch's relative efficacy was
not affected by the intensity of adjuvant support. Fiore
and colleagues (1994~) examined 17 nicotine patch tri-
als and found a combined OR of 2.6 (95 percent CI,
2.2-3.0) at the end of the treatment and 3.0 (95 percent
CI, 2.4-3.7) at 72-month follow-up. More intensive ad-
juvant support was found to produce higher absti-
nence rates at six months (26.5 vs. 19.5 percent for
low-intensity interventions) but did not increase the
relative advantage of nicotine patches over placebo
patches. The 16- and 24-hour patches were found to
be equally effective. Neither weaning nor extending
treatment beyond eight weeks was found to improve
outcome. A recent meta-analysis (Fiore et al. 2000) of
27 studies reported that transdermal nicotine increased
long-term cessation by 90 percent (Table 4.3). A meta-
analysis of three studies reported that over-the-counter
nicotine patch use increased successful long-term
cessation by 80 percent (Fiore et al. 2000).

  These meta-analyses strongly indicate that the
nicotine patch is an effective aid to smoking cessation.
This conclusion is buttressed by the findings of a con-
tinuing, regularly updated review of the existing re-
search literature on transdermal nicotine (Silagy et al.
1999). In the most recent release of this evolving meta-
analysis, Silagy and colleagues (1999) found a pooled
patch-to-control OR of 1.84 (95 percent CI, 1.60-2.10).
The data continue to suggest that 16- and 24-hour
patches are equivalent in efficacy, that there is no ad
vantage associated with weaning or tapering of patch

dose, and that the relative efficacy of the patch is fairly
independent of the intensity of adjuvant therapy. Nico-
tine patches have been consistently found to outper-
form placebo patches regardless of dosing regimen and
in a variety of investigational settings. For example, a
study of "real-world" use of the patch-based on a
follow-back of older persons who had filled patch
prescriptions-produced a self-reported cessation pro-
portion of 29 percent at six months (Orleans et al. 1994).
The patch is more effective than placebo treatment
when paired with only brief support, and it is associ-
ated with the higher long-term success when paired
with more intensive counseling or behavioral interven-
tions (Fiore et al. 1994b). Though the nicotine patch
does increase success rates when used with minimal
formal counseling, many nicotine patch clinical trials
invrolve frequent follow-up assessments. Such contacts
might boost success rates obtained with the patch. In
support of this possibility, Jorenby and colleagues
(1995b) found that the combination of nicotine patch
treatment plus frequent assessments produced follow-
up outcomes equivalent to the nicotine patch plus in-
tensive behavioral therapy. Further assessment of this
issue is important, as frequent follow-up contact does
not usually accompany nicotine patch use outside of
clinical trials (Cummings et al. 1994; Swartz et al. 1995).
A meta-analysis of three studies of over-the-counter
nicotine patches, however, indicated that patch therapy
was superior to placebo (Fiore et al. 2000).

Effects on Discomfort of Nicotine Withdrawal

  Some evidence suggests that the nicotine patch
reduces overall measures of nicotine withdrawal dis-
comfort (Daughton et al. 1991; Transdermal Nicotine
Study Group 1991; Jorenby et al. 19961, but this find-
ing has not been consistent (Abelin et al. 1989;
Tannesen et al. 1991; Merz et al. 1993). Use of the nico-
tine patch has been repeatedly found to reduce the
craving for cigarettes (Abelin et al. 1989; Rose et al.
1990; Tonnesen et al. 1991; Transdermal Nicotine Study
Group 1991; Merz et al. 1993; Sachs et al. 1993; Westman
et al. 1993; Fiore et al. 1994b; Levin et al. 1994; Jorenby
et al. 1996), but other symptoms of nicotine withdrawal
are affected less reliably (Palmer et al. 1992). In a study
designed to clarify the impact the patch has on with-
drawal symptoms, the patch reliably reduced craving,
anxiety, and irritability but did not alleviate depressed
mood, restlessness, or sleep disruption (Jorenby et al.
1996). The authors noted that with or without the
patch, most withdrawal symptoms disappeared within
three to four weeks.


Effect on Postcessation Change in Body Weight

  Nicotine patches can attenuate postcessation
weight gain while they are in use (Abelin et al. 1989;
Sachs et al. 1993; Jorenby et al. 1995a; Dale et al. 19981,
but this short-term effect has not always been observed
(Rose et al. 1990; Tonnesen et al. 1991; Transdermal
Nicotine Study Group 1991; Fiore et al. 1994b). More-
over, studies that follow up effects after treatment has
ended have not found that persons who used the nico-
tine patch gained less weight than those who used a
placebo patch (Tonnesen et al. 1991).

Side Effects and Likelihood of Inappropriate Use

  Most side effects of nicotine patch use are rela-
tively mild; less than 5 percent of patients need to dis-
continue patch therapy because of side effects (Hughes
and Glaser 1993). Minor skin irritation at the patch
site is reported by 30-50 percent of patch users and
can be relieved by moving the patch to another site.
Insomnia is reported by l-23 percent of patch users
(AMA 1993). Comparatively rare side effects include
headache, dizziness, fatigue, gastrointestinal distress,
sweating, limb pain, and palpitations (Palmer et al.
1992). Studies have found little evidence that people
will inappropriately use transdermal nicotine systems
(Palmer et al. 1992; Hughes 1993; Jorenby et al. 1995b).

  The risks associated with using the nicotine patch
during pregnancy are largely unknown. Nicotine it-
self poses risks to the fetus, including neurotoxicity
(Slotkin 1998), and pregnant women should first be
encouraged to quit without pharmacotherapy. Because
exposure to nicotine through maternal use of the patch
probably poses less danger to the fetus than does con-
tinued maternal smoking (Hackman et al. 19991, how-
ever, nicotine replacement therapy may be indicated
for pregnant women who are unable to quit smoking
(Benowitz 1991; Lewis and Fiore 1994). However, if a
decision is made to use nicotine replacement therapy
during pregnancy, the physician should consider moni-
toring blood nicotine levels, using doses at the low end
of the effective range, and choosing intermittent de-
livery systems (such as nicotine gum) (Fiore et al. 2000).
The issue is under active investigation.

  Continued smoking while using the patch may
be a significant problem. In an observational study of
self-reported patch use, almost one-half the respon-
dents stated that they smoked while using the patch;
20 percent of the respondents did so every day (Or-
leans et al. 1994). A small number of adverse cardio-
vascular events were reported in patients who
continued to smoke while using the patch. When these
events received much attention from the popular press,

several analyses, including one by an FDA advisory
committee, have documented no association between
nicotine replacement therapy and cardiovascular
events even in patients who continue to smoke inter-
mittently (Working Group for the Study of
Transdermal Nicotine in Patients with Coronary Ar-
tery Disease 1994; Joseph et al. 1996; Benowitz and
Gourlay 1997; Mahmarian et al. 1997). Caution should
be used, however, for patients with acute cardiovas-
cular disease (immediately post-myocardial infarction
or in the presence of serious arrhythmias or serious or
accelerating angina pectoris).

Relevant Process Measures

  Like nicotine gum, the nicotine patch is intended
to reduce tobacco withdrawal symptoms Palmer et
al. 1992; Glover 1993b; Hughes and Glaser 1993). Al-
though the nicotine patch appears to reduce with-
drawal severity, particularly craving for cigarettes,
withdrawal suppression may or may not be respon-
sible for the patch's efficacy (Hughes 1993). For ex-
ample, one trial failed to reveal reliable differences in
withdrawal severity between persons using nicotine
patches and those using placebo patches (Merz et al.
1993); the trial nevertheless found that participants
who used the nicotine patch were nearly twice as likely
to quit smoking. Another trial employing two doses
of transdermal nicotine found that the higher-dose
patch produced significantly greater cessation success
than the lower-dose patch, even though both doses
provided about the same amount of relief from with-
drawal symptoms (Transdermal Nicotine Study Group
1991; Hughes 1993). Clearly, other potential mecha-
nisms of the patch's action, as well as the action of nico-
tine replacement therapy in general, need to be
explored.

Nicotine Nasal Spray

  Nicotine nasal spray was approved for prescrip-
tion use in the United States in March 1996. The spray
consists of a pocket-sized bottle and pump assembly,
which is fitted to a nozzle designed for insertion into
the nose. Each metered spray delivers 0.5 mg of nico-
tine to the nasal mucosa. The recommended dose is 1
mg, or one 0.5-mg spray per nostril, as needed
(Sutherland et al. 1992).

Efficacy

   A number of clinical trials have assessed the effi-
cacy of the nicotine nasal spray as an aid to smoking
cessation. Sutherland and colleagues (1992) found that


Reducing Tobacco Use

26 percent of participants given nicotine nasal spray
were abstinent after one year, compared with only 10
percent of participants given placebo. Hjalmarson and
colleagues (1994) found similar results in a placebo-
controlled trial; at one-year follow-up, abstinence rates
were 27 percent and 15 percent, respectively, for par-
ticipants given active spray or placebo. Schneider and
colleagues (1995) again replicated this effect, finding
continuous abstinence rates of 18 percent and 8 per-
cent among participants given active or placebo spray.
Another study (Blondal et al. 1997) did not find a sig-
nificant difference in abstinence rates between active
spray and placebo groups at one year (25 vs. ;17 per-
cent); active spray was associated with higher absti-
nence rates at six months and earlier in this trial.

  Recently, Blondal and colleagues (1999) provided
all participants in a second trial with active nicotine
patches, then studied the incremental efficacy of add-
ing nasal spray therapy to the patch regimen in a
double-blind, placebo-controlled fashion. Results
showed that participants given the active spray were
more likely to be abstinent -after one year than partici-
pants given placebo (27 vs. 11 percent). Participants
given active spray had a higher rate of abstinence than
participants given placebo a full six years after the start
of treatment 06 vs. 9 percent), but this effect was only
marginally significant. Taken together, the results of
these studies suggest that nicotine nasal spray is an aid
to smoking cessation. A meta-analysis by Silagy and
colleagues (1999) reported a pooled spray-to-control
OR of 2.27, and a recent meta-analysis (Fiore et al. 2000)
reported an OR of 2.7 (30.5 percent long-term abstinence
rate) (Table 4.3).

Effect on Discomfort of Nicotine Withdrawal

  Evidence regarding the nicotine nasal spray's
effects on nicotine withdrawal discomfort is sparse.
The results of two studies suggest that the spray may
be useful for coping with craving, but may not be ef-
fective in alleviating other withdrawal symptoms. One
study (Sutherland et al. 1992) found that, compared
with participants using placebo spray, participants
treated with nicotine spray reported having less total
withdrawal discomfort during the 48 hours immedi-
ately after smoking cessation and reported less crav-
ing for cigarettes during this period. After 48 hours,
however, the two groups reported equivalent levels
of withdrawal discomfort and craving. When craving
did arise, the nicotine spray was consistently rated
more effective than the placebo spray.

  The other study (Hjalmarson et al. 1994) found
that during the first 48 hours of smoking cessation,

users of nicotine spray reported somewhat less severe
withdrawal discomfort than placebo users, but this
effect was not statistically significant. The severity of
craving was found to be similar across both groups,
but the nicotine spray was more helpful in quelling
craving than the placebo spray was. Other clinical tri-
als have not reported comparisons between active and
.placebo spray groups with regard to withdrawal mea-
sures (e.g., Schneider et al. 1995; Blondal et al. 1999).

Effect on Postcessation Change in Body Weight

  The limited evidence available suggests that the
nicotine nasal spray may be capable of delaying, but
not preventing, postcessation weight gain. In one of
the trials (Sutherland et al. 19921, participants were
allowed to use the spray they were assigned for as long
as one year.. Weight effects in that study differed as a
function of duration of spray use: abstinent subjects
who had continued to use the nicotine spray for the
entire year of the study had gained significantly less
weight than subjects still using the placebo spray.
However, change in body weight was equivalent for
abstinent patients who had stopped using either type
of spray during the year.

  Another study (Hjalmarson et al. 1994) failed to
find any statistically significant differences in weight
gain between participants using nicotine spray and
those using placebo spray. The authors observed, how-
ever, that participants still using nicotine spray at the
12-month follow-up tended to gain less weight than
both participants continuing to use a placebo spray
and participants who had stopped using the nicotine
spray before that time.

Side Effects and Likelihood of Inappropriate Use

  Unpleasant side effects are common with the
nasal spray. Between 75 and 100 percent of nasal spray
users reported experiencing irritant effects, such as
runny nose, sneezing, throat irritation, nasal irritation,
watering eyes, and coughing (Sutherland et al. 1992;
Hjalmarson et al. 1994; Schneider et al. 1995). Some
authors have reported that these sensory irritation ef-
fects are actually viewed as desirable by many smok-
ers and have suggested that they may help bridge the
gap between cigarette smoking and nicotine replace-
ment (Glover 1993a; Schneider 1993). Less common
side effects, present in 15-25 percent of users, include
nausea, sweating, headache, dizziness, and cold hands
and feet.

  Because the spray rapidly delivers nicotine to the
user, the potential for inappropriate use (e.g., using
more often or at a higher dose than recommended) is


high. The results of both clinical trials lend some cre-
dence to these speculations. Sutherland and colleagues
(1992) found that 43 percent of abstinent study par-
ticipants who had been given the nicotine spray chose
to continue using it for the entire year of the study;
moreover, mean plasma nicotine concentrations in-
creased over the follow-up period among participants
who continued to use the spray. Participants in the
trial conducted by Hjalmarson and colleagues (1994)
were explicitly encouraged to begin weaning them-
selves from the spray (whether nicotine or placebo)
after three months. Nonetheless, 30 percent of absti-
nent participants who had been given the nicotine
spray continued to use it after one year. Schneider
and colleagues (1995) required that participants in their
trial use the spray daily for six weeks, then allowed
participants to use spray for up to six months
postcessation as needed. Thirty-two percent of par-
ticipants given active spray continued using it daily
for six months, compared with 13 percent of partici-
pants given placebo. The authors also reported that
some continuous abstainers assigned to active spray
reported being concerned that they were dependent
upon the spray at six months postcessation. However,
a substantial proportion of these individuals remained
abstinent many months after drug weaning.

Tonnesen et al. 19931. Each inhaler contains enough
nicotine for approximately 300 puffs. Smokers are in-
strutted to use between 6 and 16 inhalers per day.

Efficacy

  A handful of published trials have examined the
efficacy of the nicotine inhaler as an aid to smoking ces-
sation. Tonnesen and colleagues (1993) found that 17
percent of participants randomized to active inhalers
had quit smoking at six months, compared with 8 per-
cent of participants given placebo. Corresponding rates
at one year were 15 vs. 5 percent. Schneider and col-
leagues (1996) found active-placebo abstinence rates of
17 vs. 9 percent and 13 vs. 8 percent at six months and
one year, respectively. These differences were not sig-
nificant in the Schneider trial, although active inhalers
were superior to placebo at all follow-ups through three
months postcessation. Hjalmarson and colleagues
(1997) found continuous abstinence rates of 35 percent
and 28 percent for active inhaler users at 6 and 12
months, compared with 19 percent and 18 percent,
respectively, among placebo users. Active-placebo
comparisons were statistically significant at all follow-
ups in this trial. The most recent edition of a regularly
updated meta-analysis of nicotine replacement prod-
ucts (Silagy et al. 1999) found an inhaler-to-control
pooled OR of 2.08, and another recent meta-analysis of
four studies (Fiore et al. 2000) reported a pooled OR of
2.5 (Table 4.3).

Relevant Process Measures

  Nicotine nasal spray, like other nicotine replace-
ment products, is intended to aid smoking cessation
by relieving withdrawal symptoms. Although the
spray has been found effective in promoting cessation,
its circumscribed impact on total withdrawal severity
suggests that withdrawal relief is not itself responsible
for the spray's usefulness. The spray's documented
ability to alleviate craving may be what makes it an
effective smoking cessation treatment. More research
is needed to advance definitive conclusions about the

  Taken together, the results suggest that the nico-
tine inhaler is an effective aid to smoking cessation.
However, the findings of Schneider and colleagues
(1996) suggest that the inhaler may be most useful for
producing initial abstinence and that additional inter-
ventions may be needed to prevent relapse among
users of the inhaler.

Effects ou Discomfort of Nicotine Withdrawal

spray's mechanism of action.

Nicotine Inhaler

  Limited information is available regarding the
effects of the nicotine inhaler on nicotine withdrawal
symptoms. Two studies (Schneider et al. 1996;

  In May 1997, the FDA approved the nicotine in-
haler for prescription use. The inhaler consists of a
plastic tube, about the size of a cigarette, that contains
a plug impregnated with nicotine. Menthol is added
to the plug to reduce throat irritation. Smokers are
instructed to puff on the inhaler as they would on a
cigarette. An average puff delivers approximately
13 ,ug of nicotine (about 1/80th the amount of nicotine
contained in an average cigarette puff), which is ab-
sorbed primarily by the buccal route (Glover 1993a;

Hjalmarson et al. 1997) showed that active inhaler use
was associated with decreased craving during the first
several days of the quit attempt but not thereafter.
Hjalmarson and colleagues (1997) assessed a wide ar-
ray of withdrawal symptoms across the cessation at-
tempt, but did not find any effects of active inhalers
on these other than the fleeting effects on craving.
However, this may have been influenced by a floor
effect, as mean withdrawal scores were very low in
both groups across all assessments.

220 Chapter 4


Reducing Tobacco Use

Side Effects and Likelihood of Inappropria te Use

   The most common side effects associated with
inhaler use are throat irritation and coughing. These
are reported by between 20 to 50 percent of active in-
haler users and are less common among placebo
inhaler users (Tonnesen et al. 1993; Schneider et al.
1996; Hjalmarson et al. 1997). Other less common side
effects include nausea, bad taste in the mouth, dizzi-
ness, gastrointestinal disturbances, and oral burning
or smarting. Few (O-9 percent) active inhaler users
have withdrawn from clinical trials or stopped using
the inhaler because of side effects. The potential for
inappropriate use appears to be fairly low, with between
2 to 16 percent of active inhaler users continuing to use
the device at six months postcessation in clinical trials
allowing unrestricted inhaler use (Tonnesen et al. 1993;
Schneider et al. 1996; Hjalmarson et al. 1997).

Effect on Postcessation Change in Body Weight

  Two placebo-controlled inhaler trials have exam-
ined postcessation weight gain (Tonnesen et al. 1993;
Hjalmarson et al. 1997). Neither study found evidence
that active inhaler use prevented or reduced weight
gain among successful quitters.

Relevant Process Measures

  The nicotine inhaler is thought to act by reliev-
ing withdrawal symptoms (Glover 1993a; Leischow
1994), but little published evidence to date supports
this contention. It is often suggested that the inhaler
may be effective because it more closely resembles
smoking than other pharmacotherapies do, replacing
some of the orosensory and behavioral aspects of
smoking (Glover 1993a; Tonnesen et al. 1993; Leischow
1994; Schneider et al. 1996; Hjalmarson et al. 1997).

  Schneider and colleagues (1996) asked partici-
pants to rate their assigned inhalers relative to their
usual brand of cigarettes in terms of sensory effects,
preference, and satisfaction. Results showed that par-
ticipants given the active inhaler rated their devices
more highly than did participants given placebo. How-
ever, the absolute magnitude of the ratings revealed
that the inhalers did not compare very favorably to
cigarettes in either group. The mechanism of action
of the nicotine inhaler would seem to require further
scrutiny.

Bupropion

  Bupropion is an atypical antidepressant that is
believed to work by blocking neurotransmitter
reuptake in noradrenergic and dopaminergic sites in

the central nervous system (Ascher et al. 1995). Anec-
dotal reports of spontaneous smoking cessation in
patients prescribed bupropion for depression, coupled
with a growing appreciation of the importance of nega-
tive affect and clinical depression in smoking mainte-
nance (Hall et al. 1994; Piasecki et al. 1997) have
recently stimulated clinical investigations of a
sustained-release bupropion preparation as an aid to
smoking cessation. These investigations led to the
approval of a smoking cessation indication for
bupropion by the FDA in 1997. The typical dosing regi-
men for smoking cessation consists of 150 mg
sustained-release bupropion per day for three days,
followed by 150 mg twice a day thereafter. Therapy is
initiated one to two weeks before the target quit date
and is generally continued for three months.

  Two large-scale clinical trials of bupropion's ef-
ficacy as a smoking cessation aid have been published
to date. Hurt and colleagues (1997) compared three
doses of bupropion (100 mg, 150 mg, and 300 mg) with
placebo. Abstinence rates in the 150-mg and 300-mg
groups were significantly higher than those of the pla-
cebo group at 12 months. All active treatment groups
were found to have higher abstinence rates than the
placebo group at earlier end points. Jorenby and col-
leagues (1999) studied active and placebo patches and
active and placebo bupropion in a 2 x 2 factorial de-
sign. Abstinence rates after one year showed no dif-
ference between patch-only and placebo groups (16
percent and 15 percent, respectively). Both placebo
and patch treatments were associated with higher ab-
stinence rates when given with bupropion. Thirty
percent of the bupropion-only group (150 mg twice a
day) were abstinent at 12 months, whereas 36 percent
of participants given active patches and bupropion
were counted as abstinent.

  A recent meta-analysis (Fiore et al. 2000) of two
studies reported a pooled OR of 2.1 and an estimated
abstinence rate of 30.5 percent (Table 4.3). Thus, the
available evidence suggests that bupropion is an ef-
fective aid to smoking cessation, and that it may im-
prove quit rates over those observed with conventional
nicotine replacement therapies, although further stud-
ies will be needed to demonstrate such efficacy.

Effect on Discomfort of Nicotine Withdrawal

  The evidence concerning bupropion's ability to
suppress withdrawal symptoms is somewhat mixed.
Hurt and colleagues (1997) found that their groups
using 150 mg and 300 mg reported withdrawal

Mnnngcment of Nicotirrr Addictior~  121


symptoms that were equivalent to those reported by
placebo participants. Individuals assigned to the
IOO-mg group, however, reported withdrawal that was
significantly worse than that among either the placebo
group or the other bupropion groups. The authors sug-
gested that this effect may have arisen because the
lOO-mg dose produced side effects similar to with-
drawal symptoms but was not strong enough to re-
duce true withdrawal symptoms. Jorenby and
colleagues (1999) found that all three groups receiv-
ing active treatments compared with the placebo group
reported reduced withdrawal. The group given both
active patches and active bupropion reported the most
consistent withdrawal relief. Further research is
needed to characterize the reliability and magnitude
of bupropion effects on withdrawal symptoms.

Relevant Process Measures

  Although nicotine replacement therapies are
strongly predicated on the assumption that nicotine
will relieve withdrawal symptoms, withdrawal relief
represents only one of several rationales for using
bupropion as a smoking cessation aid. One hypoth-
esis is that bupropion may selectively reduce depres-
sive symptoms after cessation. However, both trials
mentioned previously excluded individuals with cur-
rent major depression. Both clinical trials (Hurt et al.
1997; Jorenby et al. 1999) also included multiple as-
sessments of postcessation depressive symptomatol-
ogy, and neither found any differences among
treatment groups on these measures. These findings
suggest that bupropion does not work through its an-
tidepressant effects per se in relatively healthy clinical
trial participants.

  Bupropion moderates dopaminergic activity in the
central nervous system, and dopaminergic circuits are
known to play a role in drug reinforcement (Nutt 1997).
This raises the possibility that bupropion may exert its
effects by replacing positive reinforcement associated
with smoking (Hurt et al. 1997). To date, there is no
evidence directly bearing on this hypothesis, and it is
clear that this process is not easily studied in clinical
trials.  Laboratory-based pharmacokinetic and
neuroimaging studies should be performed to explore
this hypothesis.

Effects of Postcessation Change in Body Weight

  Hurt and colleagues (1997) found evidence for a
dose-response effect among continuous abstainers,
suggesting that participants given the highest doses
gained less weight after quitting. Moreover, the dis-
parities between treatment groups in terms of weight

gain increased across time while medication was dis-
pensed. At six-month follow-up, 17 weeks after par-
ticipants went off the assigned medication, no
differences in weight gain were observed. These com-
parisons were limited to a small subsample of continu-
ous abstainers. In the Jorenby and colleagues (1999)
trial, members of all active treatment groups tended
to gain less weight than did placebo participants
over the first seven weeks of cessation. Weight gain
suppression was greatest for the combined patch-
bupropion group. However, none of the groups dif-
fered in weight gain after seven weeks after quitting.
Together, the results of these trials suggest that
bupropion treatment may delay, but not prevent,
postcessation weight gain.

Side Effects

  In both clinical trials, two side effects were re-
ported more commonly among participants given
bupropion than among those given placebo. Dry
mouth was reported by 10 to 15 percent of bupropion
users, and insomnia was reported by about 30 to 40
percent of bupropion users. Bupropion may increase
the risk of seizure and is thus contraindicated for in-
dividuals who are seizure prone, such as individuals
with a history of alcoholism or alcohol abuse, eating
disorder, seizure disorder, or using MAO inhibitors.
No seizures were reported in either clinical trial, but
participants with risk factors for seizure were excluded
from each before enrollment.

Clonidine

  Clonidine is a centrally acting cc,-adrenergic
agonist that dampens sympathetic nervous system
activity. Clonidine is most commonly used in the man-
agement of hypertension; it has not been approved by
the FDA as an aid to smoking cessation. Clonidine is
available for prescription in oral and transdermal
forms; both of these preparations have been investi-
gated in smoking cessation trials. Smokers using
clonidine as an aid to smoking cessation are generally
started on the drug several days before quitting and
are maintained on a fixed daily dose for several weeks.

Efficacy

  Covey and Glassman (1991) conducted a meta-
analysis of nine early trials of clonidine for smoking
cessation. They found that persons given clonidine
were more successful at quitting than those given a pla-
cebo (OR = 2.36). Five of the nine trials assessed out-
come after the therapy was discontinued; only one

122 Chnpter 4


Rrducing Tobacco Use

(Glassman et al. 1988) showed a significant overall ad-
vantage for clonidine. Clonidine trials using adjunc-
tive behavioral therapy were associated with greater
relative success (OR = 4.2) than were trials in which
treatment essentially consisted of dispensing the drug
(OR = 1.7). Trials using transdermal clonidine produced
somewhat greater relative success (OR = 3.2) than did
trials using oral clonidine (OR = 2.2). The two trials
that analyzed efficacy according to sex found clonidine
to be much more effective, relative to placebo, among
women (OR = 11.0) than among men (OR = 0.9). There
is no obvious explanation for this finding.

  Since the Covey and Glassman (1991) meta-
analysis, several large-scale clonidine trials have ap-
peared (Prochazka et al. 1992; Glassman et al. 1993;
Hilleman et al. 1993; Niaura et al. 1996). These studies
indicated a therapeutic effect for clonidine, with some
evidence suggesting that clonidine was more effective
among women (Glassman et al. 1993; Hilleman et al.
1993) and among those most dependent on nicotine
(Glassman et al. 1993).

  A recent meta-analysis (Fiore et al. 2000) of five
clinical trials reported a pooled OR for long-term
effectiveness of 2.1 (25.6 percent abstinence rate)
(Table 4.3). In these studies, the clonidine dose ranged
from 0.1 mg to 0.75 mg per day and was delivered
either orally or transdermally. Because of the side
effects, the lack of a specific dosing regimen, the prob-
lems with abrupt discontinuation of the drug, and
the lack of FDA approval, clonidine has been recom-
mended as a second-line agent for smoking cessation
(Fiore et al. 2000).

Effect on Discomfort of Nicotine Withdrawal

  An early report (Glassman et al. 1984) that
clonidine could reduce tobacco withdrawal symptoms,
especially craving, spurred the initial investigations of
clonidine's usefulness in smoking cessation. Since that
report, evidence for this effect has been mixed.
Clonidine- and placebo-treated patients have had
equivalent levels of withdrawal severity (Wei and Young
1988; Franks et al. 1989; Gourlay et al. 1994). Studies
have fairly consistently found that clonidine diminishes
the specific symptom of craving (Glassman et al. 1984;
Ornish et al. 1988; Prochazka et al. 1992; Gourlay et al.
1994), and some studies have found some effects on
withdrawal symptoms, such as anxiety and irritability
(Ornish et al. 1988; Prochazka et al. 1992).

Side Effects

  Unpleasant side effects are commonly associated
with clonidine use (Gourlay et al. 19941, and as many

as 25 percent of patients may discontinue clonidine
therapy because of them (Covey and Glassman 1991).
The most frequently observed symptoms are dry
mouth, fatigue, and dizziness. Local skin irritation is
common with transdermal clonidine therapy. The in-
cidence of side effects appears to be dose dependent
(Gourlay et al. 1994). Care must also be taken to dis-
continue clonidine gradually to prevent rebound hy-
pertension. No published clinical trials have assessed
the effect of clonidine on postcessation weight gain.

Relevant Process Measures

  Clonidine is presumed to exert its effects by ame-
liorating withdrawal discomfort (Glassman et al. 1984;
Franks et al. 1989). Although a few studies have found
that clonidine reduces withdrawal discomfort, find-
ings from a well-designed, large-scale multicenter trial
(Prochazka et al. 1992) have suggested that this effect
does not necessarily lead to greater abstinence.

Nortriptyline

  Nortriptyline is a tricyclic antidepressant that
blocks reuptake of norepinephrine and serotonin. As
with clonidine, smoking cessation is not an FDA-
approved indication for nortriptyline; its primary
indication is for the treatment of depressive symptoms.
It is a prescription medication and is available in ge-
neric form. In smoking cessation studies conducted
to date, treatment was initiated 2-4 weeks before the
target quit date with gradual titration of dose.

Efficacy

  Two studies have assessed the efficacy of nortrip-
tyline for smoking cessation. Hall and colleagues
(1998) conducted a 2 (nortriptyline vs. placebo) x 2 (his-
tory vs. no history of major depression) x 2 (cognitive
behavioral vs. health education therapy) trial that pro-
duced a 24-percent sustained abstinence rate in nortrip-
tyline users compared with 12 percent in the placebo
group. There was no difference in cessation rates as a
function of previous history of major depression. In a
straight comparison of nortriptyline to placebo,
Prochazka and colleagues (1998) found cessation rates
at six months of 14 percent in participants given
nortriptyline and 3 percent in participants given pla-
cebo. A meta-analysis (Fiore et al. 2000) of these two
studies reported a pooled OR of 3.2 and a 30.1-percent
abstinence rate (Table 4.3). Both studies provide clear
evidence of nortriptyline's therapeutic effect.


Surgeon Gcrzeral's Report

Effect on Discomfort of Nicotine Withdrawal

  The Hall and colleagues (1998) study assessed
both nicotine withdrawal symptoms and negative af-
fect in the first eight days following the target quit date.
There were no significant differences between the drug
therapy groups on nicotine withdrawal severity, sug-
gesting that as with many of the other smoking cessa-
tion pharmacotherapies, withdrawal relief may not be
the primary mechanism of action. The negative affect
measure, however, increased in the first three days in
the placebo group and declined in the nortriptyline
group. This suggests that a negative affect assessment
may be more sensitive to some of nortriptyline's thera-
peutic effects than a conventional nicotine withdrawal
symptom scale.

Side Effects

Tricyclic antidepressants are known to produce
a number of side effects, including sedation and vari-
ous anticholinergic effects. In the smoking cessation
studies, commonly reported side effects included dry
mouth (64-74 percent), lightheadedness (49 percent),
shaky hands (23 percent), and blurry vision (16 per-
cent) (Hall et al. 1998; Prochazka et al. 1998).

Other Antidepressants and Anxiolytics

  Investigators have begun to explore the poten-
tial use of other antidepressants and anxiolytics as
pharmacologic aids to smoking cessation, because
population-based epidemiologic samples have found
that depression and anxiety are associated with ciga-
rette smoking (Breslau et al. 1991; Kendler et al. 1993).
Research has also shown that smokers with a history
of depression are more likely to experience depressive
symptoms (Covey et al. 1990) and to relapse after quit-
ting (Glassman et al. 1988; Anda et al. 1990) than are
smokers without such a history. Some anxiolytics
(Glassman et al. 1984; Hilleman et al. 1992) have been
shownto ameliorate symptoms of tobacco withdrawal,
and preliminary smoking cessation trials using anti-
depressants (Edwards et al. 1989) and anxiolytics
(Hilleman et al. 1994) have yielded encouraging re-
sults. Among the drugs that have been studied or
hypothesized to be useful for smoking cessation are
buspirone hydrochloride, doxepin hydrochloride, and
fluoxetine hydrochloride. Although promising, this
avenue of research is not yet developed enough to
permit the multipart discussion given to other phar-
macologic agents in this chapter.

Summary of Pharmacologic Interventions

   Abundant evidence confirms that both nicotine
gum and the nicotine patch are effective aids to smok-
ing cessation. The efficacy of nicotine gum may de-
pend on the amount of behavioral counseling with
which it is paired. The 4-mg dose may be the better
pharmacologic treatment for heavy smokers or for
those highly dependent on nicotine. The nicotine patch
appears to exert an effect independent of behavioral
support, but absolute abstinence rates increase as more
counseling is added to patch therapy. Nicotine nasal
spray and nicotine inhalers 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 severe enough
that patients must discontinue use. Nicotine nasal
spray appears to have greater potential for inappro-
priate use than other nicotine replacement therapies.
Nicotine replacement therapies, especially the gum
and the patch, have been shown to delay but not pre-
vent weight gain. All nicotine replacement therapies
are thought to work in part by reducing withdrawal
severity. The available evidence suggests that they
do ameliorate some elements of withdrawal, but the
relationship between withdrawal suppression and
clinical outcome is inconsistent.

  Bupropion is the first nonnicotine pharma-
cotherapy for smoking cessation to be studied in large-
scale clinical trials. Results suggest that bupropion is
an effective aid to smoking cessation. In addition,
bupropion has been demonstrated to be safe when
used jointly with nicotine replacement therapy. In the
only direct comparison with a nicotine replacement
product, bupropion achieved quit rates about double
those achieved with the nicotine patch. Bupropion
appears to delay but not prevent postcessation weight
gain. The available literature contains inconsistent
evidence regarding bupropion-mediated withdrawal
relief. Bupropion does not appear to work by reduc-
ing postcessation depressive symptomatology, but its
mechanism of action in smoking cessation remains
unknown. Further research is needed to characterize
bupropion's central nervous system effects, particu-
larly to assess whether the drug partially replaces
smoking-related positive reinforcement.

  Evidence suggested that clonidine is capable of
improving smoking cessation rates. Clonidine is hy-
pothesized to work by alleviating withdrawal symp-
toms. Although clonidine may reduce craving for
cigarettes after cessation, it does not consistently ame-
liorate other withdrawal symptoms, and its effects on
weight gain are unknown. Unpleasant side effects are
common with clonidine use.

124 Chapter 4


  Antidepressants and anxiolytics are potentially
useful agents for smoking cessation. At present, only
nortriptyline appears to have consistent empirical evi-
dence of smoking cessation efficacy. However, tricy-
clic antidepressants produce a number of side effects,
including sedation and various anticholinergic effects.

Large-Scale Public Health Programs

  The shift in recent years from a clinical to a pub-
lic health perspective in smoking cessation research
has led to an increased emphasis on developing and
evaluating cost-effective strategies that can be tvidely
disseminated (Lichtenstein and Glasgow 1992). This
emphasis is reflected in the proliferation of research
on self-help manuals (see "Self-Help Manuals," ear-
lier in this chapter and "Community Programs," later
in this chapter) and on media- and community-based
interventions (Flay 1987; Gruman and Lynn 1993).

  As is true for self-help strategies, media-,
worksite-, and community-based programs have
promise because they can potentially reach many
smokers who may try to quit without formal, face-to-
face assistance (Fiore et al. 1990). Moreover, some evi-
dence suggests that less educated smokers profit from
media campaigns at least as much as more highly edu-
cated smokers do (Macaskill et al. 1992). (Other large-
scale interventions-educational [Chapter 31 and social
[Chapter 7]-are discussed separately.)

  Investigators have evaluated an array of such
programs, but methodological variations across the
individual trials have hampered comparisons among
studies (Flay 1987; Schwartz 1992). Moreover, meth-
odological challenges compromise how research on
these programs may be interpreted. For instance, on-
going coverage of smoking and its health consequences
in the general media may alter the effect of research-
based media information. Similarly, secular trends and
events that could individually affect large populations
of smokers (e.g., the introduction of a new nicotine
replacement product) may alter the impact-and
complicate the assessment-of media campaigns
conducted around the time of such events. Such chal-
lenges may account for the inconsistencies seen in this
area of research.

Media-Based Programs

  Media used to transmit smoking cessation mes-
sages have included television (Brannon et al. 1989;
Korhonen et al. 1992; Mudde and De Vries 1999), ra-
dio (Farquhar et al. 1990; COMMIT Research Group
19911, the telephone (Ossip-Klein et al. 1991; Pierce et

al. 1992), newspapers (Cummings et al. 1987), and the
mail (Gritz et al. 1992; McFall et al. 1993).

  The intensity of media-based programs has var-
ied greatly, and these variations may be related to pro-
gram success. For example, one study (Gritz et al. 1992)
evaluated a minimal mail-based intervention. The in-
vestigators mailed self-help smoking materials to a
sample of nonvolunteer women who smoked and who
belonged to a health maintenance organization. The
intervention had no impact; at no point during the 1%
month follorv-up period were women ivho had re-
ceived the materials more likely to quit smoking or
report changes in their moti\.ation to quit than women
who had not. In contrast, a more intense media cam-
paign evaluated in another study (Orleans et al. 1991)
yielded encouraging findings, albeit among treatment
volunteers. The investigators tested the impact of add-
ing telephone calls from a smoking cessation counse-
lor to an intervention that mailed self-help manuals to
the volunteers. After 16 months, abstinence from
smoking was reported by 23.0 percent of the volun-
teers who had received adjuvant telephone counsel-
ing and by 15.2 percent of those recei\?ng the self-help
materials alone.

  Mass media campaigns of intermediate intensity,
such as televised programs (Flay et al. lY8Y), gener-
ally produce modest increases in abstinence-increases
that fall short of the moderate effect of telephone coun-
seling found among volunteers (Orleans et al. 1991).
The influence of intermediate-intensity interventions
is difficult to determine precisely, because the results
of individual trials may be affected by the peculiari-
ties of the specific communities in which they are tested
and (as previously discussed) by concurrent changes
in secular attitudes toward smoking behavior. These
problems are compounded by the designs of
communitywide and mass media programs frequently
failing to include matched control communities for com-
parison. Although more intensive interventions appear
to increase cessation over time (Flay 1987), the absence
of well-controlled experimental media trials limit any
conclusions about a dose-response relationship for
media-based programs.

  The content of various media-based programs
can be divided into three categories: (1) programs that
present information about the negative health effects
of smoking and exposure to secondhand smoke and
attempt to motivate smokers to quit; (2) programs that
promote the performance of simple cessation-related
activities, such as calling a hot line, requesting self-
help materials, or enrolling in a smoking cessation
contest; and (3) programs that mimic intensive clini-
cal interventions (Flav 1987). In general, informational


or motivational campaigns can be effective in chang-
ing smokers' attitudes, but the effect of such campaigns
on behavior is not clear, in part because of the paucity
of well-controlled trials that yield a consistent pattern
of findings. Research suggests that other types of cam-
paigns have greater potential than informational pro-
grams to influence smoking behavior, especially if the
campaign has multiple components and intense ex-
posure (Flay 1987; CDC 1996,1999b; Pierce et al. 1998).

Worksite Programs

  For many years, advocates for tobacco control
have been enthusiastic about worksite-based programs,
because worksites appear to furnish an ideal setting: a
contained audience, an opportunity for smoker partici-
pation, an environment in which to convey coherent
and consistent messages, and an opportunity to tie in-
dividual smoking cessation to overarching institutional
policy. Much of the early work in this area provided
some justification for the enthusiasm (USDHHS 1986;
Glasgow 1987; Fielding and Piserchia 19891, but more
recent data, described later in this section (Glasgow et
al. 1995; Sorensen et al. 19961, give pause.
  The main components of smoking cessation efforts
in the workplace are nonsmoking policies and specific
assistance for cessation attempts (Gruman and Lynn
1993). The evolution of worksite smoking policies, in-
timately tied to concerns about the health effects of en-
vironmental tobacco smoke (ETS) (Eriksen 1986;
USDHHS 1986), is described in some detail in Chapter
5. Although early assessment suggested that restric-
tive policies had little effect on smoking outside of work
(Glasgow 1987; Rigotti 1989; Tager 1989), most recent
studies have demonstrated either reductions in daily
consumption of cigarettes (Stillman et al. 1990; Borland
et al. 1991; Jeffery et al. 1994) or increases in smoking
cessation (Stave and Jackson 1991; Patten et al. 1995;
Longo et al. 1996). As described in Chapter 5 (see "Clean
Indoor Air Regulation"), there is persistent movement
toward increasing restrictions in public workplaces.
  The strategies for smoking cessation within
workplaces are largely those discussed earlier in this
chapter: self-help, physician's advice, and formal treat-
ment (Gruman and Lynn 1993). As of 1989, about one-
half of worksites that sponsored cessation activities
offered self-help materials (Fielding and Piserchia
1989). Although initial dropout rates were high,
20-26 percent of participants had quit smoking by
6-12 months after the worksite programs had begun
(Orleans and Shipley 1982; Glasgow 1987). Such
proportions compare favorably with those observed
in general populations. Physician's advice to quit

smoking was a component of only about 15 percent of
the company programs, but in a number of studies,
this modality seemed to exert an effect similar to that
observed in general populations: 15-30 percent of par-
ticipants had quit smoking at the one-year follow-up
(Gruman and Lynn 1993). The programs offering for-
mal treatment appeared to produce results at the
worksite that were similar to those found for such pro-
grams outside the workplace.

  A special feature of worksite cessation programs
is the opportunity to provide incentives, such as com-
petitions. Several studies have documented some ef-
ficacy in this approach. For example, in one study, 33
percent of participating workers and 25 percent of all
workers remained abstinent at work (Glasgow 1987).
In a second study, the use of a competition was associ-
ated with significantly greater success at quitting than
was reported for persons not participating in the com-
petition (Klesges et al. 1988). In a review of incentive
programs, from 15 to 60 percent of participants quit
smoking; the average was around 40 percent (Gruman
and Lynn 1993). Some disadvantages of incentives are
that (1) determining the award may be difficult, (2)
employees may falsely claim cessation, and (3) non-
smokers may feel slighted (Fiore et al. 1996). On a
population basis, incentives have not been found to
be effective. In these settings, incentives may be most
attractive to smokers who were going to attempt quit-
ting in any case (Chapman et al. 1993).
  In contrast, a trial of the Take Heart program,
which involved 26 heterogeneous worksites, a low-cost
intervention, random assignment, and use of worker
and management steering committees, failed to pro-
duce short-term improvements in smoking cessation
that exceeded the secular trend (Glasgow et al. 1995).
These results were particularly disheartening in view
of the methodological strengths of the study and the
diversity of the workplace settings. The authors offer
a number of potential reasons for the lack of impact:
the cessation activities may have been inappropriate;
the behaviors may have been more resistant to change
than previously assumed; workers may have had in-
sufficient "ownership" of the project; secular trends
may have been so strong that they canceled out a mod-
est effect; the variability among worksites may have
been too great; and, in general, worksite programs may
not work.

  Similar negative findings were observed by
Sorensen and colleagues (1996) in an even larger trial
of 111 worksites randomized to sites receiving or not
receiving the cessation program. The Working Well
Trial involved more than 28,000 workers in 16 states
and compared seven-day abstinence, six-month


Reclucirlg Tobacco Usr

abstinence, and changes in smoking prevalence for
both types of \%rorksites. Changes occurred in the di-
rection hypothesized, but they were small and non-
significant; for example, the six-month abstinence rate
was only 1.5 percent higher in the program group.
Similarly, the program sites showed a nonsignificant
trend toward greater adoption of smoking bans. The
authors observed that the overall cessation proportions
at both types of sites compared favorably with those
in other worksite programs. The lack of difference may
have resulted from the higher than expected cessation
at control sites, which is a phenomenon reflecting a
general increase in antismoking awareness.

  These studies postdate recent reviews of worksite
cessation efforts. Several early reviews expressed op-
timism about the value of worksite programs but did
not provide a quantitative assessment (Hallett 1986;
Bibeau et al. 1988). In a detailed meta-analysis of 20
worksite programs involving 34 comparisons, Fisher
and colleagues (1990) found that the mean weighted
effect size was significantly positive and that an aver-
age of 13 percent of participants had quit smoking af-
ter treatment. Although modest, these effects provide
some quantitative basis for the enthusiasm for worksite
programs. The addition of the two recent large projects
(Glasgow et al. 1995; Sorensen et al. 1996) may well
alter the meta-analytic balance.

  Although the worksite setting has aforemen-
tioned features favorable to large-scale programs (in-
cluding the importance of adding to a generalized
reduction in exposure to ETS), the strategy cannot be
recommended without qualification. Nonetheless, the
role of such activities, perhaps enlightened by further
targeted research, may be important in multicompo-
nent efforts at smoking cessation.

Community Programs

  Results from a number of long-term trials of
communitywide programs have recently appeared.
(See Chapter 7 for a more detailed discussion of these
projects in the context of approaches used in the 1990s.)
These trials typically incorporate mass media strate-
gies into larger health education programs. Some, such
as the Stanford Five-City Project (Farquhar et al. 1990),
the Minnesota Heart Health Program (Perry et al. 1992;
Luepker et al. 19941, and the Pawtucket Heart Health
Program (Elder et al. 1986; Carleton et al. 19951, have
been aimed at modifying smoking, as well as other
risk factors for cardiovascular disease. Final reports
suggest that these trials have met with little success in
promoting smoking cessation.

  The Stanford Five-City Project (Farquhar et al.
1990; Fortmann et al. 1993) tested an intensive multi-
media approach, including television, radio, newspa-
per, and mass-distributed printed materials. All
materials contained information about modifiable risk
factors for cardiovascular disease. The average resi-
dent of a community receiving the program was ex-
posed to more than 500 educational episodes over the
course of the five-vear program. By the end of this
period, smoking pievalence-the only risk factor on
which an impact could be demonstrated-had declined
13 percent more in the program communities than in
the control ones. The Minnesota Heart Health Program
failed to demonstrate an appreciable impact (Land0 et
al. 1995). The Pawtucket Heart Health Program had
little impact on smoking behavior; its first attempt at a
smoking cessation program prompted only 11 smokers
to quit (Elder et al. 1986, 1987). The final results con-
firmed the lack of impact (Carleton et al. 1995).

  One ambitious community project-COMMIT
(Community Intervention Trial for Smoking
Cessation)-focused on smoking cessation and on
policy strategies to reduce prevalence (COMMIT Re-
search Group 1991; Gruman and Lynn 1993). In 1986,
the NC1 began COMMIT, the largest randomized
smoking intervention trial in the world. The design of
COMMIT included 11 pairs of matched communities-
10 from across the United States and 1 in Canada. One
community from each pair was randomly selected to
be the site in which volunteers and local agencies car-
ried out COMMIT's 58 mandated program activities.
Designed to augment existing community-based efforts
to reduce smoking, these activities occurred between
1988 and 1992.

  The primary end point for COMMIT was smok-
ing cessation among heavy smokers. Main goals in-
cluded increasing the priority of smoking as a public
health issue, increasing the community's ability to in-
fluence smoking behavior, strengthening the
community's existing economic and policy factors
designed to discourage smoking, and fortifying social
norms and values that stressed nonsmoking (Gruman
and Lynn 1993). Main strategies included training
health care providers to routinely assess and manage
nicotine dependence, working with community insti-
tutions and private organizations to create smoke-free
environments, increasing the availability and visibil-
ity of smoking cessation services, and using the mass
media and schools to educate communities about the
dangers of tobacco use.

   Results of COMMIT indicate that even intensive
community-based programs may not have a demon-
strable impact on smoking behavior (COMMIT


Kcwarch Group lWJa,b). Declines in smoking preva-
lence \\.ere no greater in program communities than
in control communities (COMMIT Research Group
1995b). Although the overall populations in the pro-
gram communities became more aware of available
resources for smoking cessation, the prevalence of
smoking cessation among persons who smoked more
than 25 cigarettes per day did not differ between pro-
gram (18.0 percent) and control communities (18.7
percent). Persons who smoked fewer than 25 cigarettes
per day \l.ere significantly more likely to quit in pro-
gram communities than in control communities (30.6
L'S, 27.5 percent), and that result \vas attributable to
success among light smokers with less than a college
education (COMMIT Research Group 1995a).

Statewide Programs

  Recent statewide initiatives have integrated to-
bacco policy and smoking cessation programs. Al-
though Minnesota \vas the first state to implement a
statetride initiati\re to reduce tobacco use, California
has provided what is perhaps the most ambitious ex-
ample. Massachusetts has also conducted a similar
stateivide effort based on a tax increase and incorpo-
rating a mass media campaign, policy initiatives, and
smoking cessation services. These initiatives and oth-
ers are discussed in detail in Chapter 7.

  The state findings are promising. lf this success
is replicated by other states that adopt a dedicated in-
crease in cigarette excise taxes, or that are able to use
resources from settlements tvith the tobacco industry,

statewide and nationwide initiatives may play an
important role in achieving the public health goal of
reducing smoking prevalence among U.S. adults to less
than 12 percent by the year 2010 WSDHHS 2000).

Summary of Large-Scale Public Health Programs

  Community- and media-based programs have
the potential to reach large numbers of smokers who
are reluctant to seek formal treatment. Such programs
could greatly influence smoking prevalence in the
United States. The results from major randomized tri-
als and community-based efforts are thus especially
disappointing. Though these projects have set new
standards for such research and have produced nu-
merous ancillary results of interest, the overall con-
clusions suggest that even large-scale, well-funded
programs may have difficulty promoting changes in
smoking behavior. Similarly, the results to date from
numerous worksite cessation projects suggest either
no impact or a small net effect. On the other hand,
results of the California and Massachusetts initiatives
(see Chapter 7) suggest that tobacco taxes may be an
effective means of funding efforts to reduce tobacco
use. The states that have devoted money obtained
from Medicaid settlements with the tobacco industry
have also had considerable success in implementing a
comprehensive approach (Chapter 7). Their results
suggest that the disappointing outcomes from research
programs may be related to the reach and penetration
of these programs and the isolated context in which
they \vere conducted.

Contemporary Issues in Research on Tobacco Addiction

Epidemiologic Concerns and
Clinical Issues

  Because smoking cessation research has focused
more on improving standard paradigms than on in-
novativ-e approaches (Shiffman 1993b), much of the
current energy is directed to pursuing well-trod paths.
But current directions have an internal logic, because
no new paradigms loom large. Established approaches
are perhaps unfairly criticized for lacking innovation.
As the foregoing discussion demonstratecl, valid meth-
ods for treating nicotine addiction are available, but

they must be better understood and can be improved.
Despite considerable research on smoking cessation
during the past 40 years, the essential elements or com-
bination of elements necessary for successful programs
are difficult to extract. In a number of key areas, how-
ever, careful research can sharpen interpretation of
existing results and provide direction for future inves-
tigation and perhaps even innovation.


Reducing Tobacco Use

Nicotine Dependence

  Dependence, a central construct in research on
drug abuse, has been defined as "self-administration
of a psychoactive drug in a manner that demonstrates
that the drug controls or strongly influences behav-
ior" (USDHHS 1988, p. 248). Evidence strongly sug-
gests that most smokers are dependent on nicotine
(USDHHS 1988). However, most researchers agree that
individual smokers differ in the degree to which they
are dependent (FagerstrGm 1978; McMorrow and Foxx
1983; Pomerleau et al. 1983; Shiffman 1989; Killen et
al. 1992; Niaura et al. 1994). Some occasional smokers
may not meet the criteria for physical dependence
(Shiffman et al. 1991). These differences in degree of
nicotine dependence have important implications for
treatment and research.

  Flaws in the assessment of nicotine dependence
have impeded progress toward understanding its role
in smoking cessation. For example, nicotine depen-
dence consists of both physical and behavioral com-
ponents (USDHHS 1988). However, most smoking
cessation researchers have used the term to refer to
physical dependence exclusively. Although items in
two widely used nicotine-dependence assessment in-
struments (the Fagerstrijm Tolerance Questionnaire
and its successor, the Fagerstr%n Test for Nicotine De-
pendence) assess the extent to which nicotine controls
behavior, the instruments are intended to measure
physical dependence (Fagerstrbm 1983; FagerstrGm
and Schneider 1989; Heatherton et al. 1991). Other in-
vestigators have measured dependence by how much
nicotine smokers typically self-administer (Hurt et al.
1994) or by the severity of withdrawal symptoms
(Brigham et al. 1990-91); these two measures are typi-
cally not highly correlated with each other, and nei-
ther is highly correlated with the Fagerstriim
questionnaires (Kenford et al. 1994). Furthermore, the
scales themselves, especially the Fagerstram Tolerance
Questionnaire, suffer from psychometric limitations
(Lichtenstein and Mermelstein 1986; Pomerleau et al.
1989; Tate and Schmitz 1993). In sum, tobacco research
is hampered by an inadequate conceptualization of
nicotine dependence and an inadequate assessment of
the nicotine dependence construct.

  Because widely used dependence instruments
such as the Fagerstrijm questionnaire are thought to
measure physical dependence, it has been hypothesized
that they can help identify patients who would benefit
from nicotine replacement therapies (Fagerstrgm and
Schneider 1989) or from higher doses of these thera-
pies. The evidence for this assertion is mixed, with
support somewhat more consistent for ths nicotine

gum than for the nicotine patch (Abelin et al. 1989;
Fagerstram and Schneider 1989; Transdermal Nicotine
Study Group 1991; Killen et al. 1992; Kenford et al.
1994; Niaura et al. 1994; Tang et al. 1994). To the ex-
tent that current measures capture variation in depen-
dence, they would be expected to predict outcome in
trials not using nicotine replacement and in groups of
subjects treated with placebo nicotine replacement.
Although this hypothesized correlation between de-
pendence measures and outcome has been found in
several studies (FagerstrGm and Schneider 19891, the
correlations have tended to be weak (Gritz et al. 1991;
Kozlowski et al. 1994) and have usually been signifi-
cant only at relatively short-term follow-up points
(Hall and Killen 1985; Pinto et al. 1987; Gritz et al. 1991;
Norregaard et al. 1993). Specialized assessments of
nicotine dependence are not recommended in current
treatment guidelines, and pharmacotherapy is recom-
mended for all tobacco users interested in quitting. The
one exception is that highly dependent smokers may
derive more benefit from 4-mg (as compared with
2-mg) nicotine gum (Fiore et al. 2000).

  Other measures of nicotine dependence have been
developed, but these have fared no better than the
Fagerstriim questionnaire. For example, the Heaviness
of Smoking Index, a derivative, offers no advantage in
predicting cessation (Kozlowski et al. 1994). Older mea-
sures of smoking motives, such as the Horn-Waingrow
Reasons for Smoking Scale (Horn and Waingrow 1966)
and McKennell's occasion for smoking scales
(McKennell 19701, have good psychometric properties
but questionable construct validity (Shiffman 1993a).

  Continued reconceptualization of nicotine de-
pendence and improved consensus on mechanisms for
measuring it are critical issues for future study. Stron-
ger ties to generic issues of substance abuse-already
begun but not discussed in detail here (see Orleans
and Slade 1993)-can facilitate such research and im-
prove recognition of behavioral mechanisms that are
common to the use of all addictive substances.

Stages of Change

  Smokers differ in their motivation to quit smok-
ing, and these differences are thought to affect treat-
ment prognosis. The transtheoretical model, advanced
by Prochaska and DiClemente (1983), provides a theo-
retical structure for assessing these differences and has
greatly influenced smoking cessation research in re-
cent years. Briefly, the model proposes that smokers
go through a series of stages (not necessarily linearly)
on the way to achieving prolonged abstinence from
smoking: not thinking seriously about quitting in the


next six months, thinking seriously about quitting in
the next six months, planning to quit in the next month,
actually trying to quit, and trying to remain abstinent.
If relapse occurs, smokers return to an earlier stage in
the model. It is hypothesized that smokers in the ini-
tial stages are less ready to quit and thus less likely to
profit from traditional treatments (see Orleans 1993 for
a more detailed discussion).

  Some evidence supports the notion that smok-
ers in earlier stages of change fare worse in smoking
cessation than do smokers in later stages (DiClemente
et al. 1991; Kristeller et al. 1992; Ockene et al. 1992;
Rohren et al. 1994). The finding of interactions between
treatment assignment and stage membership
(Prochaska et al. 1993) has led to the recommendation
that clinical protocols for smoking cessation be based
on stage assessments (Abrams 1993; Orleans 1993;
Velicer et al. 1993; Hughes 1994).

  Evidence is not available, however, that linking
motivational stage to a stage-appropriate strategy
leads to better outcomes than do nontailored interven-
tions of equal intensity (see Prochaska et al. 1993; Fiore
et al. 2000), perhaps because motivation to change is
more a continuum than a set of discrete states
(Lichtenstein et al. 1994). Nonetheless, the stages-of-
change model has considerable theoretical and empiri-
cal appeal as a typology that is easy to use in
day-to-day decision making (Wiggins 1988). Further
refinement and clarification of this model, coupled
with continued assessment of its relationship to smok-
ers' probability of quitting, is a potentially fruitful re-
search area.

Negative Affect

  A negative affective reaction to quitting tobacco
use (Baker et al. 1987; Brandon 1994; Hall et al. 1994)
may be an important predictor of relapse (Shiffman
1982; Brandon et al. 1990; Piasecki et al. 1997). As
mentioned previously, depressed persons are less
likely to quit smoking successfully than persons with-
out a history of depression (Classman et al. 1988; Anda
et al. 1990), and depressed persons suffer an increase
in symptoms after quitting (Covey et al. 1990; Hall et
al. 1991). These related findings have special impor-
tance because the frequency of clinical depression
among smokers may exceed that among nonsmokers
(Frederick et al. 1988; Hall et al. 1991; Brandon 1994).

The role of adverse psychological states-even
mild conditions-in prolonging smoking and imped-
ing cessation is an important avenue for further in-
vestigation. For example, depressed or otherwise
affectively disturbed persons may require special

interventions to succeed in smoking cessation; at least
two studies have identified behavioral treatments that
have boosted success rates among such persons
(Zelman et al. 1992; Hall et al. 1994). As noted, antide-
pressants and anxiolytics have been proposed as smok-
ing cessation aids and are undergoing clinical trials
because of their ability to ameliorate negative affects.

Sex-Specific Differences

  Some studies (Pomerleau et al. 1991; Kenford et
al. 1993; Swan et al. 1993), but not all (Derby et al. 1994;
Whitlock et al. 1997; Gritz et al. 1998), have suggested
that women find it more difficult than men to quit
smoking. The quit ratio (the proportion of persons who
have quit smoking out of those who ever smoked) has
increased at the same rate or at a faster rate among
women than men in recent years (Fiore et al. 1989;
Giovino et al. 1994; Husten et al. 1996). An extensive
review of difference in nicotine effects between men
and women (Perkins et al. 1999) cites complex differ-
ences in psychological and biologic aspects in the main-
tenance of nicotine self-administration. Women may
differ from men in the response to withdrawal, possi-
bly mediated by menstrual cycle phase (Perkins et al.
2000), as well as a variety of nonnicotine effects (Perkins
et al. 1999). For example, although the same treatments
benefit both women and men, some treatments (e.g.,
nicotine replacement therapies) may be less efficacious
in women (Perkins 1996; Wetter et al. 1999; Fiore et al.
2000). Other reviews of this phenomenon (Fant et al.
1996; Christen and Christen 1998) confirm the need
for further exploration of such differences.

   A further difference between men and women
may be related to genetic factors, particularly differ-
ences by sex in the metabolism of nicotine (Messina et
al. 1997; Tyndale et al. 1999). These studies have fo-
cused on differences in the roles of enzymes involved
in the metabolism of nicotine to cotinine (enzymes
CYP2A6 and CYP2D6). The considerable variability
in nicotine metabolism appears to be due to variable
expression of CYP2A6 (Messina et al. 1997) and may
play a role, as yet undefined, in gender response to
therapeutic modalities. Other researchers, using stud-
ies of twins, have postulated that genetic factors may
play a role in predicting which cigarette smokers
progress to long-term addiction, an effect that may be
stronger for men than for women (Heath et al. 1998).

Withdrawal Symptoms

  The vast majority of smokers become physically
dependent on nicotine, and these persons commonly

2 30  Chnpter 4


Reducing Tobacco Use

display several withdrawal symptoms when deprived
of the substance (Shiffman and Jarvik 1976; USDHHS
1988; Hughes et al. 1991b). Conventional wisdom holds
that two persons who have different degrees of nico-
tine dependence will have different degrees of with-
drawal severity when they quit smoking (FagerstrBm
1978; Gritz et al. 1991; Hughes 1993). Withdrawal
symptoms are presumed to give a conflicting (and of-
ten canceling) motivation to people who have other-
wise been motivated to quit (West 1984; Hughes et al.
1991b). The severity of the withdrawal is thus expected
to be a strong predictor of eventual relapse (Gritz et al.
1991; West 1992; Hughes 1993). Some research sug-
gests that the various discomforts of abstinence are
valid indicators of eventual relapse (Baker et al. 1987;
Anda et al. 1990; Hughes 1992; Zelman et al. 1992).
Despite the intuitive appeal of this proposed associa-
tion, other studies have found an inconsistent relation-
ship between withdrawal severity and relapse (Hughes
et al. 1984; Hughes and Hatsukami 1986; Stitzer and
Gross 1988; West et al. 1989; Transdermal Nicotine
Study Group 1991; Prochazka et al. 1992; West 1992;
Hughes 1993). Interpretation of this literature remains
complicated because researchers use different instru-
ments to assess withdrawal, sometimes reporting total
withdrawal discomfort and other times reporting re-
sults on a symptom-by-symptom basis, and because
they assess symptomatology at different time points.
Improved assessment of withdrawal and consensual
definitions, coupled with epidemiologic assessment,
may better clarify the critical connection between the
withdrawal syndrome and the likelihood of relapse.
Recent studies demonstrate that there is considerable
between-subject variability in the time course of smok-
ing withdrawal and suggest that more consistent links
between withdrawal and relapse may be found if this
variability is systematically assessed (Piasecki et al.
1998).

Weight Gain

  As noted earlier in the discussion of specific
modalities, weight gain is a common concomitant of
smoking cessation (Klesges et al. 1989). The average
smoker gains 5-10 pounds after cessation, and a small
percentage of smokers gain more than 25 pounds
(Klesges et al. 1989; Williamson et al. 1991). The con-
cern that smokers express about gaining weight may
be great enough to prevent them from attempting to
quit (Klesges et al. 1988; Gritz et al. 1989; French et al.
1992). Similarly, persons who quit smoking and who
do subsequently gain weight may be more likely to
relapse (Wack and Rodin 1982; Hall et al. 1986). Two

prospective studies, however, found that concern
about weight did not predict cessation success (French
et al. 1995; Jeffery et al. 1997). Innovative strategies
have failed to reduce weight gain or to improve absti-
nence rates among persons concerned about gaining
weight (Hall et al. 1992; Pirie et al. 1992). Because
weight change is a complex metabolic phenomenon
(about which there is a considerable epidemiologic and
biologic literature, not reviewed here) that is subject
to the interplay of behavioral and pharmacologic in-
fluences, further research on the behavior and physi-
ological mechanisms that produce postcessation
weight gain may suggest new strategies for dealing
with this problem and may provide insights into
mechanisms of addiction.

Early Relapse

  Three recent reports from four trials of the nico-
tine patch have found that any smoking during the
first two weeks of using either the nicotine or the pla-
cebo patch is a strong predictor of relapse at long-term
follow-up (Hurt et al. 1994; Kenford et al. 1994;
Stapleton et al. 1995). For example, Kenford and col-
leagues (1994) analyzed data from two patch trials. In
both trials, large proportions (97.1 and 83.3 percent)
of patients treated with the nicotine patch who smoked
during the second week of treatment had relapsed by
the six-month follow-up. Early relapse may predict
longer-term failure-regardless of the cessation strat-
egy, if any-because physiological and behavioral
forces may present their most significant challenges
to smokers during the first two weeks they try to quit.
Strategies that could shepherd smokers through the
first two weeks without a single cigarette might be
expected to improve treatment outcome. According
to another view, most lapses during the first two weeks
of treatment merely identify those smokers who will
find it difficult to quit no matter what the interven-
tion. Even if given adjunctive interventions to help
them pass this two-week period without smoking,
these smokers would be expected to relapse soon af-
ter these adjuncts were withdrawn. Research on treat-
ments for persons who are strongly addicted and likely
to relapse early (should they attempt cessation at all)
is a great challenge for cessation research.

Dose-Response

  More intense interventions yield better outcomes
(Kottke et al. 1988; Lichtenstein and Glasgow 1992;
Fiore et al. 1994c, 2000). Although this general rela-
tionship has not been precisely explained, outcomes

Management of Nicotine Addiction  131


Surgeon Gerzeral's Report

may be influenced by a host of structural factors, in-
cluding session length, session frequency, total num-
ber of sessions, and number and types of treatment
modalities (e.g., telephone contacts and individual vs.
group formats).

  More specific issues must be clarified, such as
determining what level of adjuvant behavioral sup-
port is most cost-effective when used with pharmaco-
therapy. However, a central question surrounding the
use of intensive interventions is whether a greater pro-
portion of smokers can be motivated to enroll in such
treatment. Debate over whether program refinements
can improve outcomes may be moot, from a public
health perspective, if most smokers continue to shy
away from-or cannot afford to spend the time or
money needed for-intensive interventions (Fiore et
al. 1990; Lichtenstein and Hollis 1992). A final area for
dose-response research concerns the optimal dose for
nicotine replacement. Two recent studies (Jorenby et
al. 199513; Hughes et al. 19991 have found that dou-
bling the normal patch dose does not improve cessa-
tion outcomes. There may be some benefit, however,
to combining different smoking cessation pharmaco-
therapies (Blondal et al. 1999; Jorenby et al. 19991, in-
cluding two different nicotine pharmacotherapies
(Fiore et al. 2000).

Treatment Components

  Defining the individual impact of treatment com-
ponents will require controlled trials that systemati-
cally manipulate individual treatment components
against a background of constant treatment intensity.
As Lichtenstein and Glasgow (1992) have noted, smok-
ing cessation researchers have largely abandoned this
line of research because most comparison studies
(though not all; see Stevens and Hollis 1989) failed to
find significant treatment effects. Nonetheless, until
the combined effects of treatment components can be
determined, empirical design of multicomponent treat-
ments will be difficult.

Individualized Treatment

  Investigators have become increasingly inter-
ested in seeking interactions between treatment con-
tent and smokers' characteristics. Identifying such
interactions would allow individual smokers to be
given specific interventions to maximize their chances
of attaining long-term abstinence. Although subject-
by-treatment interactions have been obtained (Zelman

et al. 1992; Niaura et al. 1994), these relationships re-
main too elusive to suggest an overall strategic theory.
Research that incorporates unconfounded compari-
sons of specific ingredients may suggest algorithms
for matching patient and treatment. In view of the
increasing presence of the computer in many people's
lives, computer-assisted tailored treatments warrant
further exploration. Some tailoring and individual-
ization may be appropriate for older smokers whose
other medical problems and pharmacologic treatment
must be given special consideration (Rimer and Or-
leans 1993). Currently, however, there is insufficient
evidence to recommend individually tailored interven-
tions (Fiore et al. 2000).

  An alternative to treatment matching is the strat-
egy of offering smokers increasingly more intensive
treatments as they continue to have trouble quitting
(Abrams 1993; Orleans 19931, despite the risk that this
strategy will reinforce failure. There is insufficient
evidence, however, to recommend such a stepped-care
approach (Fiore et al. 20001. Research must first re-
veal hierarchies of treatment as well as determine when
patients should be given more intensive interventions.

Dissemination and the Role of the Clinician

  Because self-help and minimal clinical interven-
tions are likely to continue to be the preferred method
of cessation for most smokers, innovative strategies
must be developed to improve efficacy and delivery
(Cohen et al. 1989b; Orleans et al. 1991; Fiore et al.
19951. Some of the most effective of the minimal clini-
cal interventions include the institutionalization of
system changes as core components of health care
(Glynn and Manley 1993; Fiore et al. 2000). For ex-
ample, having a screening system in place to identify
smokers triples clinician intervention (Fiore et al. 2000).

  Dissemination is intimately tied to the willing-
ness of clinicians to advise their patients about smok-
ing. An important area for ongoing research is the
investigation of strategies that foster this behavioral
role not only among physicians but also among a broad
range of health care providers, including dentists,
nurses, pharmacists, chiropractors, psychologists, phy-
sician assistants, and pulmonary technicians. But it is
unlikely that behavioral modification for clinicians
would be sufficient to produce the required dissemi-
nation. Reimbursement policies, financial incentives,
and underlying institutional support are all critical for
the effective management of tobacco addiction through
clinical interventions (Kaplan et al. 1995; Rothenberg
et al. 19981.

132 Chapter 4


Reducing Tobacco Use

Cost-Effectiveness

  Ultimately, the test of clinical modalities for treat-
ment of nicotine addiction will be their survival in the
current environment of cost containment and managed
care. Private insurers are unlikely to embrace such treat-
ment unless "they are convinced that there is a market
for such a product and that it is viable financially"
(Schauffler and Parkinson 1993, p. 189). For public in-
surers, demonstration of cost-effectiveness has become
the de facto standard for adoption of new technology
(G. Wilensky, cited in Schauffler and Parkinson 1993,
reference 17), though some may insist on cost-savings,
a strict standard of proof, for preventive practices.

  Smoking cessation has been called the "gold stan-
dard" of cost-effective interventions (Eddy 1992). A
number of studies (and several reviews [Elixhauser
1990; CDC 1992; Tsevat 19921) have addressed issues
of cost-effectiveness in behavioral counseling.
Cummings and colleagues (1989~) calculated that the
cost-effectiveness of brief office counseling during a
routine visit ranges from $705 to $988 per year of life
saved for men and from $1,204 to $2,058 for women.
The use of nicotine gum increases the cost-effectiveness
fourfold. Oster and colleagues (1986) performed a
similar study incorporating nicotine gum with brief
office counseling. The costs per year of life saved
ranged from $4,113 to $6,465 for men and from $6,880
to $9,473 for women. Both studies noted that these costs
compare favorably with those derived for other widely
accepted preventive practices. Altman and colleagues
(1987) found that self-help materials cost $22-144 per
person who quit, a cessation contest costs $129-239, and
a cessation class costs $235-399. In the setting of acute
myocardial infarction, Krumholtz and colleagues
(1993) concluded that a nurse-managed smoking
cessation program after myocardial infarction was
cost-effective, particularly when compared with other
modalities. (These studies are not necessarily reported
in standardized dollarsand are then only roughly com-
parable.)

  An analysis of the cost-effectiveness of imple-
menting the 1996 Agency for Health Care Policy and
Research-sponsored Clinical Practice Guideline Smok-
ing Cessation reported that cost per quality-adjusted-
life-year saved ranged from $1,108 to $4,542. This
compares very favorably with $61,744 for annual mam-
mography for women aged 40-49 years and $23,335
for hypertension screening in 40-year-old men (Crom-
well et al. 1997).

  Because smoking during pregnancy is associated
with lower birth weight, which in turn has been linked
to various adverse outcomes of pregnancy, cessation of

smoking in pregnancy has been the subject of a num-
ber of economic analyses. Several of these have been
performed in a managed care setting. Using patients
in a study performed by the Maxicare Research and
Educational Foundation, Ershoff and colleagues (1990)
weighed the intervention's programmatic costs against
the smoking-related increased costs of medical care in-
curred by mothers who continue smoking and by their
infants. The program consisted of an initial interview,
smoking counseling by a health educator, and a series
of self-help books mailed to participants. The nonsmok-
ing message was reinforced at prenatal care visits. The
investigators concluded that in a health maintenance
organization of 100,000 members, the cost savings from
the cessation program was $13,432, the net benefit was
$9,202, and the benefit-to-cost ratio was 3.17:1.

  Windsor and colleagues (1988) compared three
cessation protocols for women in public health mater-
nity clinics: standard care, standard care combined
with use of a cessation manual developed by the Ameri-
can Lung Association, and standard care combined
with the use of that manual and a pregnancy-specific
manual. At the end of pregnancy, smoking cessation
had been achieved by 2 percent, 6 percent, and 14 per-
cent, respectively, of women in the three groups. The
investigators calculated cost-effectiveness as the cost
per patient divided by the percentage who quit. The
respective values were $104.00, $118.83, and $50.93. In
a second study (Windsor et al. 19931, the treatment
group in a multicomponent intervention involving
counseling and support had a cessation rate of 14.3
percent, and the control group had a rate of 8.5 per-
cent. Under varying assumptions, the economic analy-
sis found that benefit-to-cost ratios ranged from 6.72:1
to 17.18:1 and that estimated savings from statewide
use of the program ranged from $247,296 to $699,240.

  Marks and colleagues (1990) estimated the ben-
efits that would accrue from shifting low-birth-weight
infants into the normal-birth-weight category, from
averting deaths attributable to prematurity, and from
avoiding the long-term costs associated with the care
of premature infants. They concluded that the ratio of
savings to costs would be as high as 6:l. If long-term
costs were omitted, the ratio would still be $3.31 for
each- $1 spent. Finally, in a somewhat different ap-
proach to the problem, Shipp and colleagues (1992)
tried to identify the break-even point for the cost of a
smoking cessation program. Under general circum-
stances, the break-even cost was $32 per pregnant
woman, but this cost varied from $10 to $237, depend-
ing on the probability of adverse outcomes in various
populations.

Management of Nicotine Addiction  133


Surgeon Gerzerd's Report

  As Schauffler and Parkinson (1993) point out,
economic analyses of smoking cessation are often
based on hypothetical populations, start with differ-
ent assumptions about prevalence and intervention
effectiveness, and differ in their estimation of out-
comes. Although initial results are encouraging, con-
siderable work is needed to codify the results and make
them appealing to insurers and employers. In a re-
cent survey, only 8.6 percent of large corporations in
California had even considered using smoking status
in their risk ratings, and only 2.2 percent had imple-
mented such a rating. About 20 percent of companies
offered plans that covered smoking cessation services
(Schauffler and Parkinson 1993). Perhaps observations
comparing long-term hospitalized care of smokers and
nonsmokers will alter this policy. A recent study esti-
mated that helping one smoker to quit reduces antici-
pated medical costs associated with acute myocardial
infarction and stroke by $893 over seven years
(Lightwood and Glantz 1997). Wagner and colleagues
(1995) point out that smokers have consistently

Conclusions

increasing rates of hospitalization over five to six
years of follow-up. In contrast, smokers who quit
have increased hospitalization during the year in
which they quit (probably associated with the medi-
cal reason-e.g., emphysema-for quitting in many
cases); this rate declines thereafter. The authors note
that the cost savings that accrue from reduced utili-
zation would more than pay for effective cessation
interventions within three to four years.

  The alteration of terminology-from "smoking
cessation" to "treatment of nicotine dependence"-
acknowledges the need to make cessation activity con-
sonant both with modern medical practice and with
the current climate for health care delivery. The cur-
rent body of evidence suggests that efficacious and
cost-effective therapeutic modalities are available and
that such consonance can be achieved. Further inves-
tigation not only of theoretical cost-effectiveness but
also of actual use-effectiveness will have considerable
impact on institutionalizing the treatment of nicotine
addiction.

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.

3.

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

4.  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.

5.  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.


Reducing Tobacco Use

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Chapter 5
Regulatory Efforts

Introduction 159

Food and Drug Administration (FDA) Regulations  259
Initial Attempts at Multistate Settlement and Federal Legislation  160
Public and Private Litigation  160

Advertising and Promotion 161

Introduction 161

Attempts to Regulate Tobacco Advertising and Packaging  2 63
Cigarette Warning Labels  2 63
Broadcast Advertising Ban 165
A Midcourse Assessment  166
Smokeless Tobacco Warning Labels  2 67
Regulation of Tobacco Packaging  168
Examples of Product Labeling in Other Countries  2 69
Tobacco Advertising, Commercial Speech, and the First Amendment  2 70
Constitutionality of Regulating Advertising  171
Constitutionality of Regulating Tobacco Advertising  172
A Critical Example: Joe Camel  2 77

Product Regulation 178

Introduction 178

The Constituents of Smoke From Manufactured Cigarettes  179
Regulation by Tar Levels  279
Implications of Nicotine Levels  2 80
Other Constituents in Cigarette Smoke  182
Additives to Tobacco Products  182
Cigarette Additives 182
Smokeless Tobacco Additives 183
The Low-Tar "Alternative" 184
Compensatory Smoking 184
Health Risks From Low-Tar Cigarettes  184
Nicotine Replacement Products 185
Product Regulations for Consumer Education  285
Tobacco Packaging and Informed Choice  286
Tobacco Use and Informed Consent  186
Further Regulatory Steps 287
Judicial Developments and the Status of FDA Regulations  289
The Court of Appeals Ruling on FDA Authority  290
The U.S. Supreme Court Ruling on FDA Authority  191
Legislative Developments 291
Master Settlement Agreement 193

Clean Indoor Air Regulation  193

Introduction 2 93

Health Consequences of Exposure to ETS  195
Other Consequences of ETS  196
Prevalence of Exposure to ETS  196


Legal Foundation for Regulation of Public Smoking  797
Status of Restrictions to Limit Smoking in Public Places  297
Government Restrictions  2 99
Private Sector Restrictions on Smoking in Workplaces  202
Effectiveness of Clean Indoor Air Restrictions  202
Population-Based Studies 202
Effects of Restrictions on Smoking Behavior  203
Case Studies of State and Local Smoking Restrictions  206

Minors' Access to Tobacco  207

Introduction 207

Efforts to Promote Adoption and Enforcement of Minors' Access Laws  209
Restrictions on Distribution of Samples  211
Regulation of Means of Sale  2 2 1
Regulation Directed at the Seller  214
Regulation Directed at the Buyer  216
Enforcement of Laws on Minimum Ages for Tobacco Sales  226
State Settlements 222
Preemption of Local Action by State Policy  223

Litigation Approaches 223

Introduction 223

Private Law as a Means of Risk Control  224
Tort as a Private Law Control  224
U.S. Reliance on Private Law Controls  224
Potential Public Health Benefits of Tobacco Litigation  224
The First Two Waves of Tobacco Litigation  225
The First Wave 225
The Second Wave 226
The Aftermath of the First Two Waves  227
The Third Wave of Tobacco Litigation  229
Common-Law Claims 230
Statutory Claims 231

Individual Third-Wave Cases 235
Aggregation Devices 235
Class Actions 235

Recovery Claims by Third-Party Health Care Payers  238
Small Claims Tribunals to Recover the Cost of Quitting  243
Other Cost Reduction Procedures  243
Claims of Nonsmokers 243
Enhancing Prohibitory Regulation by Private Litigation  250
The International Dimension of Tobacco Litigation  251
Counterthrust: Tobacco Industry Initiation of Litigation and Other Tactics  252
Anticipatory Effects 255
Criminal Proceedings 256

Nature, Extent, and Focus of the Criminal Investigation  257
Key Sources of Evidence  258
Initial Results of the Criminal Investigation  258
Prognosis for Future Actions Through the Criminal Justice Process  259
Comment 259

Conclusions 260

References 262


Reducing Tobacco Use

Introduction

  Efforts to regulate the use of tobacco date back
to its introduction to European colonists of North
America (see Chapter 2). As noted, these early move-
ments to restrict tobacco use were motivated less by
health concerns than by complex political, economic,
and social factors. With the appearance in the 1950s
of substantial scientific evidence on specific health risks
of smoking, and with subsequent dissemination of that
information in the 196Os, general support for a gov-
ernment regulatory response emerged.

  As noted in Chapter 1, such regulatory activities
do not necessarily fit the traditional concept of "inter-
vention," but their effect is to change the way people
use tobacco. Because advertising and promotion are
perhaps the chief social force for continued tobacco
use, their regulation-or the failure to regulate them-
can have substantial effects on smoking prevalence.
The manner in which the product is manufactured,
packaged, and distributed can similarly influence
people's decision to smoke. Regulation of smoking in
public places provides an opportunity to reduce the
quantity of tobacco used, the prevalence of smoking,
and the exposure of nonsmokers to environmental to-
bacco smoke. The regulation of minors' access to ciga-
rettes has considerable potential for postponing or
preventing the uptake of smoking, thereby making a
long-term impact on the smoking epidemic. Finally,
personal litigation and the tort system can influence
the policies and practices of the tobacco industry and
can have an impact on social perceptions of smoking.

  Thus, if a broad definition of intervention can be
entertained, each of these regulatory processes can be
assessed for the nature of its influence on the use of
tobacco. Unlike assessments of more traditional in-
terventions (see Chapters 3 and 41, evaluation of regu-
latory processes must invoke a different set of
measurement tools that are less quantitative but not
necessarily less compelling (see Chapter 1).

  Several key developments in the mid-to-late
1990s have propelled tobacco regulation in new direc-
tions and into new forums. Three key events have
catalyzed these changes. They are discussed briefly
in the next sections and in greater detail later in this
chapter in "Further Regulatory Steps" and "Litigation
Approaches."

Food and Drug Administration (FDA)
Regulations

  First, on August 28, 1996, after receiving public
comment on a proposed rule, the FDA issued final
regulations restricting the sale, distribution, advertis-
ing, and promotion of cigarettes and smokeless tobacco
(Fcrlrral Rcgisfrr 1996). Several tobacco companies, re-
tailers, and advertisers sued the FDA to block the
implementation of the regulations, arguing that the
agency lacked the jurisdiction or authority to regulate
these products and that the proposed advertising re-
strictions violated the First Amendment of the United
States Constitution (Coyly Beahnl, Inc. u. Food and Drug
Adrllirristratiorl, No. 2:95CVOO591 [N.C. Aug. 10, 19951,
rikd irl 10.5 Tobacco Products Litiqatiot~ Reporter [TPLR]
3.379 [1995]).

  On April 25, 1997, the federal district court in
Greensboro, North Carolina, ruled that the FDA had
the authority to regulate cigarettes and smokeless to-
bacco products, as drug delivery devices, under the
Federal Food, Drug, and Cosmetic Act (Coylze Beahm,
Ir~c. il. U.S. Food &T Drug AdnlirJistration, 966 F. Supp.
1374 [M.D.N.C. 19971). The court upheld all of the
FDA's 1996 restrictions involving youth access to to-
bacco products and regulating product labeling. How-
ever, the court "stayed," or temporarily blocked,
implementation of most of these provisions. The only
FDA regulations that escaped this stay were the pro-
hibition on sales of cigarettes and smokeless tobacco
to minors and the requirement that retailers check
photo identification of customers who appear to be
under 27 years of age. These provisions went into ef-
fect on February 28,1997. The age and identification
provisions remained in force until the Supreme Court's
March 21,2000, decision.

  Most notably, the court invalidated the FDA's
restrictions on the advertising and promotion of ciga-
rettes and smokeless tobacco. Both sides in the FDA
case appealed the decision to the Fourth Circuit of the
United States Court of Appeals in Richmond, Virginia.
A three-member panel of the court overturned the
lower court's decision and ruled that the FDA lacked
the authority to regulate tobacco products. The full
Fourth Circuit Court of Appeals declined to review


this reversal. The government petitioned the United
States Supreme Court for review, and the Supreme
Court accepted the case in April 1999. Oral argument
was held December 1999, and the Court, in a 5 to 4
decision, upheld the Fourth Circuit's decision on
March 21,200O. The FDA continued to enforce the age
and photo identification provisions while the case was
appealed to the United States Supreme Court. On
March 21,2000, the Supreme Court ruled that although
premature deaths from tobacco use present "one of the
most troubling health problems facing our nation to-
day" (Food and Drug Administration v. Brown 6
Williamson, 529 U.S. [20001, 120 S. Ct. 1291), the
FDAlacks the authority to issue and enforce its tobacco
regulations.

  These developments, central to most of the regu-
latory efforts covered in this chapter, are discussed in
detail in the major section "Product Regulation," later
in this chapter.

Initial Attempts at Multistate Settlement
and Federal Legislation

  Second, on June 20,1997, a group of 41 state at-
torneys general presented a tobacco settlement pro-
posal to the American public (Tobacco Products Litigation
Reporter 1997a; see "Legislative Developments" and
"Master Settlement Agreement," later in this chapter).
In essence, the proposal was intended to settle all pend-
ing lawsuits against the tobacco industry brought by
states and other governmental entities as well as all
pending class action lawsuits. Although the settlement
did not include 9 of the 50 states, its scope was inher-
ently national: to enact its stipulated regulations of
the tobacco industry, the settlement presumed the pas-
sage of congressional legislation that would necessar-
ily affect the legal rights of all Americans. The
settlement included provisions for IDAauthority, new
warning labels, advertising restrictions, youth access
prohibitions, rules to reduce public exposure to envi-
ronmental tobacco smoke, and a provision designed
to provide financial incentives for tobacco manufac-
turers to reduce sales to underaged consumers.

  Despite its intuitive appeal-that the slow, and
largely unsuccessful, course of change possible
through individual lawsuits would be retired for a
sweeping, national, unified policy that dealt with the
tobacco problem-the settlement raised concerns from
the start. Public health advocates recognized that given
the settlement's national scope, it was taking on the
role of being the chief public health policy tool for
reducing tobacco use.  These critics feared that the

settlement (and moreover the legislation it presumed)
would fail in this role. In particular, by limiting future
lawsuits against the tobacco industry, the settlement
might in the end benefit the industry more than the
public.

  A number of bills filed in Congress in 1997 and
1998 intended to codify the terms of the proposed na-
tional settlement. One of the bills, S. 1415 (National
Tobacco Policy and Youth Smoking Reduction Act,
105th Cong., 2nd Sess., S. 1415, Congressional Record,
144:S5034-S5084), which ultimately departed from the
settlement proposal in a number of areas, was debated
on the Senate floor for several weeks. It was vehe-
mently opposed by the tobacco industry and rejected
by the Senate almost one year to the day after the at-
torneys general announced the proposed national
settlement. The regulatory implications of the national
settlement proposal are discussed together with the
FDA rules, primarily in the "Product Regulation" sec-
tion of this chapter.

  Ultimately, this activity served as prologue to a
Master Settlement Agreement that was negotiated in
November 1998. On November 23, 1998, the agree-
ment was reached between state attorneys general and
major U.S. tobacco companies to settle pending and
prospective lawsuits by states to recover Medicaid
expenditures incurred as a result of tobacco use. Forty-
six states signed the agreement, pending the required
ratification in state courts (four states settled separate,
individual lawsuits with the industry). The agreement
requires tobacco companies to pay $246 billion to states
over 25 years and to adhere to specified restrictions
on tobacco advertising and promotion. Some provi-
sions are also made for improved disclosure of tobacco
industry documents released in litigation. A separate,
parallel agreement with the United States Tobacco Com-
pany was negotiated for smokeless tobacco products.

Public and Private Litigation

  Third, throughout 1997 and 1998, while federal
legislation was being filed and debated, the states of
Mississippi, Florida, Texas, and Minnesota settled their
lawsuits against the tobacco industry. Besides produc-
ing sizable settlement funds for the individual states,
these settlements (in all but Mississippi) feature provi-
sions akin to public health regulations. For example,
the Florida settlement (Florida u. American Tobacco Co.,
Civil Action No. 95-1466 AH, sets. II.A.l and II.A.2
[Fla., Palm Beach Cty. Aug. 25, 19971) was the first to
incorporate a ban on outdoor advertising and to call
for statewide restrictions on vending machines. The

160 Chapter 5


Reducing Tobacco Use

Minnesota settlement (Minnesota u. Philip Morris Inc.,
No. Cl-94-8565 [Minn., Ramsey Cty. May 8,19981, cited
in 13.2 TPLR 3.39 [19981), which followed a trial and
the release of thousands of incriminating internal docu-
ments from the tobacco industry, contains an even
wider array of public health restrictions, including a ban
on promotional items and a national prohibition on com-
mercial placement of tobacco products in movies.

  Settlements of other private suits against the in-
dustry in the late 1990s have also resulted in impor-
tant regulatory measures. For example, in a class action
lawsuit alleging that flight attendants were injured by
exposure to environmental tobacco smoke (Brain 2'.
PhilipMorris Inc., No. 91-49738 CA [221 [Fla., Dade Cty.
Oct. 9, 19971, cited in 12.6 TPLR 3.397 [1997]), the to-
bacco industry agreed to support legislation banning
smoking on all airlines departing from or landing in
the United States. In a California case, R.J. Reynolds

Advertising and Promotion

Tobacco Company agreed to accept advertising restric-
tions and to fund counteradvertising programs for
teens. The latter provision was based on a claim that
the company was violating the California consumer
protection law by using their Joe Camel advertising
campaign to target minors (Mangini u. R.J. Reynolds
Tobacco Co., No. 939359 [Calif. Sept. 8, 19971, cited in
12.5 TPLR 3.349 [1997]).

  As of September 1998, these nonnational litiga-
tions against the tobacco industry had had a greater
and more immediate impact on tobacco regulation
than the delayed FDA rules, proposed national settle-
ment, and defeated federal legislation. Regulation
through litigation is a new tool for reducing tobacco
use. Specific regulatory measures contained in these
smaller-scope settlements are discussed in relevant
sections of this chapter,

Introduction

  Industries use various marketing tools and strat-
egies to influence consumer preference, thereby in-
creasing market share and attracting new consumers.
The tobacco industry is among the most intense in its
efforts; among U.S. manufacturers, only the automo-
bile industry markets its products more heavily (Cen-
ters for Disease Control [CDC] 1990a). It may be
assumed that cigarette manufacturers, like other in-
dustrial entities, direct their money and marketing ef-
forts in ways that will reach consumers they believe
are most likely to purchase their products. The ensu-
ing discussion focuses on direct product marketing and
excludes other promotional and public relations efforts
that are not product specific.

  The potential influence of cigarette advertising
and promotion on smoking prevalence has been a sub-
ject of concern and debate for many years (U.S. De-
partment of Health and Human Services [USDHHSI
1994).' Much of the concern has focused on whether
consumers know about the adverse health effects of
smoking and can make informed choices; whether
children and adolescents are exposed to and are af-
fected by tobacco advertising and promotion; and
whether tobacco companies inappropriately target

advertising and promotion to specific consumer
groups. A contentious debate has persisted about
whether marketing induces demand and what the
appropriate role of government is in protecting the
consumer. Although some of these issues are not fully
settled, they provide the background for considering
the reduction of smoking through regulating cigarette
advertising, promotion, product availability, and prod-
uct presentation.

  In May 1981, a Federal Trade Commission (FTC)
staff report (see "A Midcourse Assessment," later in
this chapter) concluded that consumer knowledge
about the health effects of cigarette smoking was gen-
erally inadequate (Myers et al. 1981). Since then, adult
smoking prevalence has declined substantially (from
33.5 percent in 1980 [Giovino et al. 19941 to 24.7 per-
cent in 1995 [CDC 1997a]), and the general population's
knowledge about the adverse health effects of tobacco
use has improved (in recent years, 80-90 percent of

' In the following discussion, advertising refers to company-
funded advertisements that appear in paid media (e.g., broad-
casts, magazines, newspapers, outdoor advertising, and transit
advertising), whereas promotion includes all company-sponsored
nonmedia activity (e.g., direct-mail promotion, allowances,
coupons, premiums, point-of-purchase displays, and entertain-
ment sponsorships).

Regulatory Efforts 162


Surgeon Gerwd's Rrporf

the general population has known that smoking is a
health hazard [USDHHS 1989, 1998131). During the
same period, revenue devoted to advertising and pro-
motion by the tobacco companies has increased from
$1.24 billion in 1980 to a high of $6.03 billion in 1993
(FTC 1999) and $5.10 billion in 1996 (FTC 1999). To-
bacco companies spent $5.66 billion on advertising and
promotion in 1997 (FTC 1999). The relationship among
these three events is not straightforward, and consid-
erable ancillary information is needed for proper in-
terpretation. In particular, the effects that both
knowledge and advertising and promotion have on
smoking prevalence are complex. For example, the
increase in smoking uptake among women beginning
in 1967 was associated with the marketing of specific
cigarette brands for women (Pierce et al. 1994a). Simi-
larly, an increase in smoking initiation among adoles-
cents during 1985-1989 has been ecologically
associated with considerable increases in promotion
expenditures, as exemplified by the Joe Camel cam-
paign (see "A Critical Example: Joe Camel," later in
this chapter) (CDC 199513). Regardless of how these
associations are interpreted, the actions of the tobacco
industry bespeak the industry's belief in corporate
benefit from a major investment in advertising and
promotion-an investment that may be interpreted as
even exceeding an economically optimal level (see
Chapter 6).

  The tobacco industry has argued that its main
purpose in advertising is to maintain brand loyalty and
to capture a greater market share of current smokers
(USDHHS 1994). Intensive review of the available
data, however, suggests a positive correlation between
level of advertising and overall tobacco consumption-
that is, as advertising funds increase, the amount of
tobacco products purchased by consumers also in-
creases (USDHHS 1989, 1994; Smee 1992; Pierce and
Gilpin 1995; also see Chapter 6). Furthermore, several
judicial opinions (reviewed in "Constitutionality of
Regulating Tobacco Advertising," later in this chap-
ter) have questioned whether the enormous invest-
ment in advertising serves only brand loyalty It has
also been argued that a significant part of the expand-
ing budget for tobacco marketing is for promotion to
specific market segments (Hollie 1985). Other observ-
ers have suggested that marketing campaigns heavily
target cultural and ethnic minorities through product
development, packaging, pricing, and brand promo-
tion (Warner et al. 1986; Ernster 1993).

  Underlying these observations is awareness of
a basic commercial principle: to continue to be SUC-
cessful, a product must not only retain consumers but
also, over time, gain new consumers. Gaining new

consumers is necessarily of particular concern to the
tobacco industry. Advocates for reducing tobacco use
have pointed out that if the tobacco industry is to main-
tain current consumption or even slow the ongoing
decline in smoking, the industry must aggressively
seek replacement smokers for the estimated 3,500
Americans who quit smoking each day and for the
additional 1,200 tobacco customers and former cus-
tomers who die each day of smoking-related illnesses
(CDC 1993b, 199713).

  The facts about uptake of tobacco use strongly
suggest where the industry's replacement smokers will
come from. Epidemiologic studies show that nearly
all first use of tobacco occurs before high school gradu-
ation (USDHHS 1994). Whether tobacco companies
deliberately market their products to preadults is dif-
ficult to ascertain. Nonetheless, indirect evidence of
the importance of advertising and promotion to the
tobacco industry is provided by surveys that suggest
that most adolescents can recall certain tobacco adver-
tisements, logos, or brand insignia; these surveys cor-
relate such recall with smoking intent, initiation, or
level of consumption (Alexander et al. 1983; Goldstein
et al. 1987; Pierce et al. 1991; Evans et al. 1995).

  The American Medical Association (Utah Delega-
tion 19891, together with a broad range of public health
organizations, has called for stricter regulation of ciga-
rette advertisements and even for a complete ban-
resolutions that were reiterated in 1995 (American
Medical Association House of Delegates 1995). Many
public health and smoking prevention groups specifi-
cally seek government regulation to address what they
consider discriminatory practices of tobacco manufac-
turers in targeting members of minority groups
(Warner et al. 1986). These groups claim that adver-
tisements overwhelm smoking prevention messages
and increase the number of people who smoke each
year beyond the number that would smoke if adver-
tising and promotion affected only market share. In-
dustry officials deny targeting and argue that because
most of the population is now aware of the risks asso-
ciated with tobacco products, citizens can make in-
formed decisions for themselves. More important, the
tobacco industry claims its First Amendment consti-
tutional right to promote its products (Cotton 1990;
Tollison and Wagner 1992; see the discussion in "Con-
stitutionality of Regulating Tobacco Advertising," later
in this chapter).

  Such arguments and counterarguments have
been at the heart of a 30-year endeavor to regulate
advertising and promotion in the tobacco industry. A
review of this effort, with some specific examples from
the United States and other countries, provides insight

262 Chapter 5


Reduhg Tobacco Use

into the strengths and weaknesses of both sides of
the argument and suggests several areas for policy
development.

Attempts to Regulate Tobacco Advertising
and Packaging

  Regulatory efforts to restrict the advertising and
promotion of cigarettes were among the earliest re-
sponses to the 1964 landmark report of the Surgeon
General's Advisory Committee, which set forth over-
whelming scientific evidence on the health hazards of
cigarette smoking. A week after the January 11,1964,
release of the report, the FTC filed a Notice of Rule-
Making Proceeding (January 17, 1964) that appeared
in the January 22,1964, Federal Register. The notice set
forth the agency`s tentative views of how the require-
ments of the Federal Trade Commission Act (Public
Law 96-252) would apply to the advertising and la-
beling of cigarettes in light of the Advisory
Committee's report (Federal Register 1964). In a perti-
nent part, section 5 of the Federal Trade Commission
Act states that "unfair or deceptive acts or practices
[are] declared unlawful" and that the commission has
the power to proceed against them as an administra-
tive agency.

  In its notice of rulemaking, the FTC stated its
concern with "two ways in which cigarette advertis-
ing may be unlawfully misrepresenting or concealing
the health hazards of smoking. First, the Commission
has reason to believe that many current advertisements
falsely state, or give the false impression, that ciga-
rette smoking promotes health or physical well-being
or is not a health hazard, or that smoking the adver-
tised brand is less of a health hazard than smoking
other brands of cigarettes" (Federal Register 1964,
p. 530). The FTC also stated that much cigarette ad-
vertising then current portrayed cigarette smoking as
pleasurable, desirable, compatible with physical fit-
ness, or indispensable to full personal development
and social success-all without informing the con-
sumer of the health hazards of cigarette smoking.

  The FTC posited that the dangers to health from
cigarette smoking are so serious that knowledge and
appreciation of them would be a material factor in in-
fluencing a person's decision to smoke cigarettes or to
smoke a particular brand. (This point is considered in
detail in "Tobacco Packaging and Informed Choice,"
later in this chapter.) Affirmative disclosures of these
health hazards might thus be necessary in cigarette
advertising that could cloud or obscure public con-
sciousness of these health hazards. After receiving

written comments and materials from interested
parties and after conducting hearings in March 1964
on the proposed rule (see the text box "Response From
the Tobacco Industry-1964"), the FTC issued on June
22,1964, the "Statement of Basis and Purpose" regard-
ing its proposed Trade Regulation Rule. (A Trade
Regulation Rule is, in effect, an administrative statute
with the force of law.) In this document, the commis-
sion announced that it would require warnings on ciga-
rette packages and in advertisements for cigarettes that
cigarette smoking is dangerous to human health.

Cigarette Warning Labels

  After participating in hearings before the U.S.
House of Representatives Committee on Interstate and
Foreign Commerce on cigarette labeling and FK rules,
the commission postponed until 1965 the implemen-
tation of any Trade Regulation Rule. In that year, the
Federal Cigarette Labeling and Advertising Act of 1965
(Public Law 89-92) required that the warning "Cau-
tion: Cigarette Smoking May Be Hazardous to Your
Health" (Federal Cigarette Labeling and Advertising
Act, sec. 4) be placed in small print on one of the side
panels of each cigarette package. The act permitted
no additional labeling requirement under any federal,
state, or local law, thus effectively preempting any
other health messages on cigarette packages. The act
also suspended for three years the FTC's authority to
require health warnings on cigarette advertising.

  This preemption was strongly opposed in the
minority view of Representative John E. Moss (D-CA),
who presented the argument as follows:

I most strongly object to sections 6 and 7 of this
bill. Section 6 would prevent the Federal Trade
Commission, the Food and Drug Administration,
and the U.S. Public Health Service in administer-
ing their respective laws from imposing any addi-
tional requirement with regard to the labeling of
cigarettes involving a health warning. The bill
would also preclude State and local health authori-
ties from imposing such requirements.

Section 7, the preemption provision of the bill,
provides that no cautionary statement with respect
to smoking and health other than specified in this
legislation shall be required on any package; and
that no such statement with respect to smoking
and health shall be required in advertising for ciga-
rettes packaged in conformity with the labeling
provisions of this legislation.

Rep/a tory Efforts   2 63


Surgeon Gellend's Report

The Secretary of Health, Education, and Welfare
has said that preventing any regulatory agency
from imposing a label warning requirement other
than that prescribed in the bill is "a position which
we consider too inflexible."

The National Interagency Council on Smoking and
Health submitted a petition to the committee ask-
ing us "not to approve any legislation which will
prevent the Federal Trade Commission from car-
rying out its reaffirmed intention of requiring
health warnings in cigarette advertising" (Moss
1965, pp. 2365-6).

Representative Moss concluded his minority report
with a strong condemnation:

In summary I am strongly opposed to those fea-
tures of this legislation which would preclude the
imposition of more stringent labeling requirements
or the imposition of health warnings in advertise-
ments which Federal, State, or local health authori-
ties may deem necessary in the future in the proper
exercise of their respective powers. We must face
the facts as presented to us by the Surgeon Gen-
eral, American Cancer Society, American Medical
Association, American Heart Association, and the

National Tuberculosis Association. We must first
concern ourselves with public health and welfare,
not legislate to the whims of a special interest
(Moss 1965, p. 2367).

  In commenting on the 1965 labeling law, the Sec-
retary of the Department of Health, Education, and
Welfare outlined an alternative view of effective health
warnings on cigarette packages (Celebrezze 1965).
Secretary Anthony J. Celebrezze recommended that the
warning appear in large type on the main faces of the
package. He commented:

The statute should require the warning to be
prominent and conspicuous but should leave the
precise location and size of the warning on the la-
bel, and related matters, to regulation in the light
of the expertise and experience of the regulatory
agency. . . . [Ten]-point type, which is 2 points
smaller than the type size used in typing this let-
ter, is hardly calculated to invite the consumer's
attention. . . .

If the required warning is in effect negated or dis-
claimed on the label or in accompanying literature
by words, statements, designs, or other graphic
material, the warning requirement shall be deemed

I          Response From the Tobacco Industry-1964

I n April 1964, in rapid response to the Surgeon
General's report, the tobacco industry published
a voluntary code for advertising and marketing prac-
tices (Gray 1964). The stated purpose of the code
was "to establish uniform standards for cigarette
advertising and to provide means whereby compli-
ance with this code can be ascertained promptly and
fairly and on a consistent basis" (p. 141). The code
was designed to restrict cigarette advertisements
aimed at young people, to limit implied or direct
health claims to those that could be medically and
scientifically proved, and to curb the so-called viril-
ity theme in cigarette advertisements. The code spe-
cifically prohibited advertising that suggested that
cigarette smoking was essential to "sexual attrac-
tion," "success," sophistication, athletic abilities,
physical stamina, and "social prominence" (p. 143)-
images that the industry recognized as influencing
smoking by young people.

  At hearings before the House Interstate and
Foreign Commerce Committee on June 25, 1964,
Bowman Gray, Chairman of the Board of R.J.
Reynolds Tobacco Company, speaking on behalf of
the industry, told Congress, "This advertising code
represents a sincere effort by the industry to respond
to criticism of the industry's advertising which has
been voiced in some quarters. It is an earnest effort
at industry self-regulation. I hope the industry will
be given reasonable opportunity to implement this
code" (Gray 1964, p. 141).

  The code was to be enforced by an indepen-
dent administrator. All advertisements were to be
precleared, and violations of the code were subject
to a fine of $100,000. Enforcement provisions of the
code were dropped shortly after passage of the Fed-
eral Cigarette Labeling and Advertising Act in 1965.

i

164  Chapter 5


Reducing Tobacco Use

not to have been met. . . [Congress should con-
sider giving the department] specific authority to
prohibit or regulate the use of statements that
while not clearly negating the warning and while
literally true or at least not demonstrably false,
may give the consumer the misleading impression
that a given cigarette is safer than others
(Celebrezze 1965, p. 2359).

These recommendations predate by three decades simi-
lar implementation of warnings in other countries (de-
scribed in "Examples of Product Labeling in Other
Countries," later in this chapter); such an approach,
however, has not been taken in this country.

  The 1965 law also required that the FTC annu-
ally transmit to Congress a report on the effectiveness
of cigarette labeling, on current cigarette advertising
and promotion practices, and on recommendations for
legislation. In June 1967, in its first report to Congress,
the FTC recommended that the package label be
changed to "Warning: Cigarette Smoking Is Danger-
ous to Health and May Cause Death from Cancer and
Other Diseases" (FTC 1967, p. 30).

Broadcast Advertising Ban

  In 1969 Congress passed the Public Health Ciga-
rette Smoking Act (Public Law 91-2221, which prohib-
ited cigarette advertising on all media subject to
Federal Communications Commission (FCC) regula-
tion, especially radio and television broadcasting, and
required that each cigarette package contain the label
"Warning: The Surgeon General Has Determined That
Cigarette Smoking Is Dangerous to Your Health" (Pub-
lic Health Cigarette Smoking Act, sec. 4). This new
law also preempted any other health warning require-
ments for cigarette packages. The prohibition on
broadcast media advertising became effective on Janu-
ary 2, 1971. The FTC issued complaints against the
cigarette companies that eventually led to a consent
decree requiring the companies to add the statutory
label warning to their advertising in magazines, news-
papers, and outdoor displays (Trade Regulation Reporter
1973).

  The prohibition on television and radio advertis-
ing was challenged-not by the cigarette companies,
but by a group of broadcasters-in Capital Broadcasting
Co. u. Mitchell (333 E Supp. 582 [D.D.C. 19711). That
case upheld the constitutionality of the congressional
prohibition by a 2 to 1 vote. Despite this victory, a so-
bering note was struck in the dissenting opinion of
Judge J. Skelly Wright. Far from casting his vote against
smoking prevention, Judge Wright was concerned that

upholding the act, and thus upholding the prohibition
on broadcast advertising, would actually aid the tobacco
industry. His reasoning-which proved correct-was
that the ban would put an end not only to tobacco ad-
vertising but also to the cost-free counteradvertising that
had been running in the electronic media since 1969,
when the FCC's Fairness Doctrine was first held appli-
cable to cigarette advertising.

  The Fairness Doctrine, which was put forth in
1949 (and ceased applying to tobacco in 1971 after ciga-
rette advertising on radio and television ended), re-
quired that whenever material covering "`a
controversial issue of public importance' " (Banzhaf II.
FCC, 405 E2d 1082, 1086 [D.C. Cir. 19681, cert. denied,
396 U.S. 842,90 S. Ct. 50 [19691) was aired, the broad-
caster had an obligation to present, to some degree,
both sides of the issue. Although the Fairness Doc-
trine had not previously been interpreted to apply to
advertising, in Banzhaf the Federal Circuit Court of
Appeals ruled that the FCC had the authority, through
the Fairness Doctrine, to require that radio and televi-
sion stations carrying cigarette advertising devote (i.e.,
without charging advertising fees) a significant
amount of broadcast time to presenting the case against
smoking. (For more on the plaintiff, John F. Banzhaf,
see "The Attack on Advertising" in Chapter 2.) In the
court's ruling, Chief Judge David Bazelon observed
that "if we are to adopt [the tobacco industry's] analy-
sis [of Congress' intention in enacting the Federal Ciga-
rette Labeling and Advertising Act], we must conclude
that Congress legislated to curtail the potential flow
of information lest the public learn too much about
the hazards of smoking for the good of the tobacco
industry and the economy. We are loathe to impute
such a purpose to Congress absent a clear expression"
(Bamhaf, p. 1089).

  However, three years later, in Capital Broadcasf-
ing Co. ZI. Acting Afforney General (405 U.S. 1000 [1972],
aff'd sub nom. Capital Broadcasting Co. u. Mitchell, 333 F.
Supp. 582 [D.D.C. 197111, it was Judge Wright's view
that the television and radio counteradvertising that
had arisen from the Fairness Doctrine was so effective
that the tobacco companies actually favored the chal-
lenged ban. There is some support for this view. Per
capita cigarette consumption in the United States,
which had declined (with some fluctuation) generally
since the 1964 report to the Surgeon General on the
health effects of smoking, had leveled off and then in-
creased after cigarette advertising was removed in 1971
from radio and television. Some analysts have asserted
that these changes indicate that the cost-free
counteradvertisements opposing cigarette use, which
along with the commercials promoting cigarettes,

Rcglilafory Efforts 265


Surgeof' Gerwal's Rrporf

largely disappeared from the airwaves except for a
relatively few public service announcements, were
more effective in discouraging consumption than ciga-
rette commercials were in encouraging consumption
(Warner 1979). Moreover, the prohibition of cigarette
advertising on broadcast stations has allowed the to-
bacco companies to avoid the significant expense of
advertising on national television and to devote their
promotional dollars to other media.

A Midcourse Assessment

  A decade after the broadcast ban, the FTC issued
a staff report in May 1981 on cigarette advertising
(Myers et al. 1981). This report asserted that "the domi-
nant themes of cigarette advertising are that smoking
is associated with youthful vigor, good health, good
looks and personal, social and professional acceptance
and success, and that it is compatible with a wide range
of athletic and healthful activities" (p. 2-13). Although
such advertising included the required general warn-
ing about the health hazards of cigarette smoking and
listed the cigarette's tar and nicotine contents (as de-
termined by FTC testing methods), the advertisements
otherwise made no mention of the adverse health con-
sequences of smoking cigarettes. The overriding mes-
sage of cigarette advertising was thus that smoking is
a positive, desirable experience.

  Details from a nonpublic version of the FTC re-
port revealed, for example, that a primary theme for
the marketing of Salem cigarettes was the association
of the cigarette with the lifestyle of young adult males
who were (in the words of the company's campaign
notes) "masculine, contemporary, confident, self-
assured, daring/adventurous, mature" (Banzhaf 1982,
p. 260). The report quoted from a Dora1 cigarette cam-
paign that sought to project the image of "an indepen-
dent, self-reliant, self-confident, take-charge kind of
person" (p, 260) and a campaign that depicted a "Win-
ston man" as "a man's man who is strong, vigorous,
confident, experienced, mature" (p. 260). Taking an-
other tack, the Eve cigarette campaign sought to por-
tray the smoker as a "sophisticated, up-to-date,
youthful and active woman who seems to have dis-
tinct ideas about what she wants" (p. 261). The cam-
paign for the Lark brand was designed to position it
as a "youthful, contemporary brand that satisfies the
lifestyles of the modern smoking public" (p. 260) and
emphasizes "moments of post-tension and relaxation"
(pp. 260-l ).

  The nonpublic version of the FTC report also
detailed and quoted from the conclusion of a market-
ing and research firm that had conducted focus group

interviews to help Ted Bates and Company, Inc., de-
velop a marketable image for Viceroy cigarettes. The
report, summarizing the results of the research, as-
serted that many smokers perceived the smoking habit
as a dirty and dangerous one engaged in only by "very
stupid people" (Banzhaf 1982, p. 262). The report con-
cluded: "Thus, the smokers have to face the fact that
they are illogical, irrational and stupid. People find it
hard to go throughout life with such negative presen-
tation and evaluation of self. The saviors are the ra-
tionalization and repression that end up and result in
a defense mechanism that, as many of the defense
mechanisms we use, has its own logic, its own ratio-
nale" (p. 262).

  This marketing analysis went on to state that
because there "are not any real, absolute, positive quali-
ties or attributes in a cigarette" (Banzhaf 1982, p. 262),
the most effective advertising is designed to "reduce
objections" (p. 262) to the product by presenting a pic-
ture or situation ambiguous enough to provide smok-
ers with a rationale for their behavior and a means of
repressing their health concerns about smoking. The
advertisement must thus project the image that ciga-
rettes have clearly beneficial functions, such as improv-
ing the smoker's self-image and self-acceptance or
serving as a stimulant or tranquilizer that offers an ac-
ceptable means of self-reward. Accordingly, the analy-
sis recommended that advertisers should start from "the
basic assumption that cigarette smoking is dangerous
to your health" (p. 263) and then try to circumvent the
problem rather than fight what would be a losing battle.
  A particularly notable element of the report was
how to persuade young people to smoke:

For the young smoker, the cigarette is not yet an
integral part of life, of day-to-day life, in spite of
the fact that [young smokers] try to project the
image of a regular, run-of-the-mill smoker. For
them, a cigarette, and the whole smoking process,
is part of the illicit pleasure category. _ . In the
young smoker's mind a cigarette falls into the
same category with wine, beer, shaving, wearing
a bra (or purposely not wearing one), declaration
of independence and striving for self-identity. For
the young starter, a cigarette is associated with in-
troduction to sex life, with courtship, with smok-
ing "pot" and keeping late studying hours
(Banzhaf 1982, p. 263).

The survey then recommended a strategy for attract-
ing young people to start cigarette smoking: present
the cigarette as one of a few initiations into the adult
world and show the cigarette as part of the illicit
pleasure category of products and activities. To the

166 Chapter 5


Reducing Tobacco Use

degree possible under legal constraints, the strategy
advised relating the pleasure of smoking cigarettes to
the pleasures of adult or illicit activities, such as drink-
ing alcohol, smoking marijuana, or having sex (Myers
et al. 1981). Brown & Williamson Tobacco Corpora-
tion stated that these proposals were never imple-
mented and did not represent their policy.

  In sum, the marketing and research firm recom-
mended that successful cigarette advertising must ei-
ther consciously or unconsciously deal with smoking
and health issues by repressing the health concerns of
the consumers of the product and providing a ratio-
nalization for consumption. The 1981 FTC report also
concluded that the federally mandated health warn-
ing had little impact on the public's level of knowl-
edge and attitudes about smoking. The report further
observed that the warning was outworn, abstract, dif-
ficult to remember, and not perceived as personally
relevant (Myers et al. 1981). These concerns contrib-
uted to Congress' enactment of the Comprehensive
Smoking Education Act of 1984 (Public Law 98-4741,
which required four specific, rotating health warnings
on all cigarette packages and advertisements (Com-
prehensive Smoking Education Act, sec. 4):

SURGEON GENERALS WARNING: Smoking
Causes Lung Cancer, Heart Disease, Emphysema,
and May Complicate Pregnancy.

SURGEON GENERAL'S WARNING: Quitting
Smoking Now Greatly Reduces Serious Risks to
Your Health.

SURGEON GENERALS WARNING: Smoking by
Pregnant Women May Result in Fetal Injury, Pre-
mature Birth, and Low Birth Weight.

SURGEON GENERAL'S WARNING: Cigarette
Smoke Contains Carbon Monoxide.

  The Comprehensive Smoking Education Act of
1984 thus amended the Federal Cigarette Labeling and
Advertising Act and required warnings to be placed
on advertisements as well as on cigarette packages.
The act preempts state and federal attempts to place
additional warnings on packages, but it preempts only
state action with regard to advertising. The FTC re-
tains such jurisdiction under section 5.

  From the first, the exact appearance of warning
labels (wording, layout, and positioning on packages
and advertisements) has represented compromises
between the recommendations of the FTC and smok-
ing prevention advocates and those of the tobacco

industry. In 1969, for example, the FTC recommended
a warning on cigarette packages that specifically men-
tioned death, cancer, heart disease, chronic bronchitis,
and emphysema. The resulting legislation required
the legend to provide the general warning only that
smoking is "dangerous" to one's health (Public Health
Cigarette Smoking Act of 1969, sec. 4). Similarly, in its
1981 report on cigarette advertising, the FTC recom-
mended that new warning labels use a "circle-and-
arrow" format that would be more effective than the
traditional rectangular format, but Congress did not
take this approach in the Comprehensive Smoking
Education Act of 1984. Also, the new labels did not
incorporate the FTC's recommendations to contain
specific references to addiction, miscarriage, and death
and to disclose the brand's yields of tar, nicotine, and
carbon monoxide.

Smokeless Tobacco Warning Labels

  Requirements for warning labels on smokeless
tobacco products lagged behind those on cigarettes by
more than 20 years. By the mid-1980s, the strong evi-
dence that smokeless tobacco causes oral cancer, nico-
tine addiction, and other health problems and that its
use was increasing among boys led Massachusetts to
adopt legislation requiring warning labels on packages
of snuff and caused 25 other states to consider similar
legislation (USDHHS 1989).

  The Massachusetts law was preempted, before it
could take effect, by the federal Comprehensive
Smokeless Tobacco Health Education Act of 1986 (Pub-
lic Law 99-252). This law not only required three ro-
tating warning labels on smokeless tobacco packaging
and in all advertising (except billboards) but also stipu-
lated that the labels have the circle-and-arrow format
that the FTC had recommended earlier for cigarette
warnings. The three rotating labels read as follows
(Comprehensive Smokeless Tobacco Health Education
Act of 1986, sec. 3):

WARNING: This product may cause mouth
cancer.

WARNING: This product may cause gum disease
and tooth loss.

WARNING: This product is not a safe alternative
to cigarettes.

Initially, the FTC excluded utilitarian items-such as
hats, T-shirts, lighters, and jackets-bearing the name
or logo of smokeless tobacco products. A consortium

Regulatory Efforts 167


Surgeon General's Report

of Public Citizen and several prominent health orga-
nizations sued the FTC, arguing that this exclusion was
contrary to the provisions of the act, which sought a
comprehensive rather than a narrow use of health
warnings (Public Citizen v. Federal Trade Commission, 869
E2d 1541 [D.C. Cir. 19891). The Court of Appeals for
the District of Columbia ruled for the plaintiff, stating
that the act was intended to cover utilitarian items,
since those were among the smokeless tobacco
industry's most effective means of promoting its prod-
ucts to adolescents. The court elaborated its point,
saying that adolescents were less likely than adults to
read magazines and newspapers and thereby less
likely to encounter the mandated warnings there.
Adolescents were also likely to have passed the criti-
cal moment of decision by the time they obtained the
product itself and encountered its warning label.  Ac-
cordingly, in 1991, the FTC issued a final rule requir-
ing health warnings to be displayed on utilitarian items
and providing for the manner in which the warnings
were displayed.

  All advertising of smokeless tobacco products is
also banned on any medium of electronic communi-
cation subject to the jurisdiction of the FTC. Under
this act, federal agencies and state and local govern-
ments are preempted from imposing additional health
warnings on smokeless tobacco products and adver-
tisements (except for billboards, which were excluded
from this act). Furthermore, instead of stipulating
where the labels must be positioned, the act required
only "conspicuous and prominent" placement (Com-
prehensive Smokeless Tobacco Health Education Act
of 1986, sec. 3). Implementation was left to the FTC,
which enacted enabling regulations on November 4,
1994.

Regulation of Tobacco Packaging

  Package size of tobacco products has been an-
other area of public health concern and action. Evi-
dence that levels of tobacco consumption reflect the
affordability of tobacco products (see Chapter 6) has
raised concern about selling cigarettes in packs con-
taining fewer than the usual 20 cigarettes. In many
countries, cigarettes are sold in packages of 15,10, or 5
cigarettes. These smaller package formats have been
dubbed "kiddie" packs in Canada by smoking preven-
tion activists (Chretien 1994). Research has shown that
young people account for many sales of smaller ciga-
rette packages (Wilson et al. 1987; Nova Scotia Coun-
cil on Smoking and Health 1991; IMPACT Research
1993), probably because of their low price and ease of
concealment.

  These findings have led some jurisdictions to
prohibit the marketing of packages containing fewer
than 20 cigarettes. An Australian state legislature has
also passed such a ban (the Western Australia Tobacco
Control Act of 1990). In Canada, several provinces
have banned small package sizes, and the revised fed-
eral Tobacco Sales to Young Persons Act of 1993 na-
tionally banned packages of fewer than 20 cigarettes.

  Another issue of concern regarding tobacco pack-
aging is the use of potentially misleading descriptive
words in the labeling of some tobacco products (Davis
et al. 1990). A recent Gallup poll found that words
such as "slim," " low tar," and "light" conveyed mes-
sages viewed as healthful (Gallup Organization, Inc.
1993, pp. 23,251. Cohen (1992) reported that tobacco
companies have long known that their customers
equate the marketing term "low tar" (p. 85) with health
benefits. Chapman and colleagues (1986) reported that
smokers tend to systematically underestimate the ac-
tual tar deliveries of their particular brands, and Gori
(1990) found that one-half of smokers interviewed in
the United States and Europe assume that the lower
the tar rating, the lower the brand's propensity to cause
disease. The Coalition on Smoking OR Health (1988)
has further analyzed how promoting cigarette brands
as having low tar and low nicotine content communi-
cates a message to consumers that these brands have
health benefits.

  The use of such descriptive words in cigarette
brand names has been called into question because
variations in the way cigarettes are actually smoked
may mean that the actual yield of toxic constituents
from cigarettes differs from the levels determined by
currently accepted testing procedures (Henningfield
et al. 1994; see "Compensatory Smoking," later in this
chapter). For example, smokers of reduced-tar
cigarettes may (deliberately or not) inhale harder to
draw more smoke through the denser filter and deep
into the lungs and may smoke the cigarette down
closer to the filter, thereby inhaling greater concentra-
tions of toxins. This concern led to the appointment
of an ad hoc committee of the President's Cancer Panel
of the National Cancer Institute (NC11 to evaluate the
current FTC protocol for testing tar, nicotine, and car-
bon monoxide. One of the conclusions of this panel
was that "brand names and brand classifications such
as `light' and `ultra light' represent health claims and
should be regulated and accompanied, in fair balance,
with an appropriate disclaimer" (NC1 1996, p. vii). This
recommendation has not yet been carried out.

  A further aspect of tobacco packaging that is cur-
rently receiving significant attention, although prima-
rily outside the United States, is the possibility of

168 Chapter 5


Reducing Tobacco Use

legislated plain (or "generic") packaging for tobacco
products. This initiative is partly motivated by the
belief that removing much of the brand image of to-
bacco products would not only make the product less
attractive but also weaken the connection with-and
thus lessen the effect of-visual and verbal image-
linked efforts to promote particular brands (Mahood
1995). There is evidence that young people find plain
packaging less attractive (Beede and Lawson 1992;
Centre for Health Promotion 1993) and that plain pack-
aging makes health messages more noticeable (Centre
for Behavioural Research in Cancer 1992). In Canada,
the federal government has considered using plain
packaging for tobacco products (Standing Committee
on Health 1994; Health Canada 1995131, and the prov-
ince of Ontario, in enacting the Tobacco Products
Control Act in 1994, authorized the requirement for
plain packaging on all cigarettes sold in Ontario. Such
packaging reforms have not yet been enacted in any
jurisdiction.

Examples of Product Labeling in Other Countries

  In recent years, many countries have taken sig-
nificant action on specifying packaging and warning
labels for tobacco products. All countries of the Euro-
pean Union must comply with a May 15,1992, direc-
tive (Council Directive 92/41/EEC 1992 O.J. [L 1581)
that requires stipulated health warnings on each of the
main package panels. In Thailand, pursuant to its To-
bacco Products Control Act, which was based on prin-
ciples developed in Canadian regulations (discussed
later in this section), prominent black-and-white health
messages are required on the front of the package.
South Africa and New Zealand require detailed health
messages on the main package panels; the messages
are based largely on Australian packaging.

  The messages appearing on Australian cigarette
packages are based on the work of the Centre for
Behavioural Research in Cancer (1992). These mes-
sages were required as of January 1, 1995, and were
incorporated into a broad effort "to inform smokers of
the long-term health effects of tobacco use" (Lawrence
1994, p. 1). The Australian system uses six rotating
messages covering 25 percent of the front of the ciga-
rette packets. One side of the packet is entirely given
to the labeling of dangerous constituents, and all
the labels must be in black and white. Thirty-three
percent of the rear main packet panel must be covered
by the same health message given on the front of the
pack and followed by an elaboration of that message
(Chapman 1995).

  Of special interest are the package regulations
currently in place in Canada. The Canadian health
messages were established by regulatory power
granted under the 1988 federal Tobacco Products Con-
trol Act, which came into effect on January 1,1989. This
legislation gives broad regulatory powers over tobacco
product packaging. It also gives regulatory authority
to require package inserts, although this power has not
yet been acted on. By eventually delegating formula-
tion of the precise warnings to administrative regula-
tion, this legislation took the approach that had been
recommended 25 years earlier by the U.S. Department
of Health, Education, and Welfare (Celebrezze 1965; see
also "Cigarette Warning Labels," earlier in this chap-
ter). This law also makes clear that the various prov-
inces of Canada can require additional messages and
that the provision of federal messages does not pre-
empt other messages. The first set of regulations fol-
lowing this law required that four specific rotating
health messages be placed on the two main panels of
cigarette packages and be printed in a large typeface;
this set of regulations stipulated that the messages must
be "prominently displayed in contrasting colours" (De-
partment of National Health and Welfare 1989, p. 64)
and cover at least 20 percent of the panel face.

  When the mandated Canadian health messages
started appearing on tobacco products in 1989, it was
clear to many public health workers that the language
of the regulations had left the tobacco companies too
much room for interpretation and had resulted in less
prominence and contrast than the regulations had in-
tended. Minister of National Health and Welfare
Henry Perrin Beatty commented, "It's very clear that,
when you look at [the health warning on cigarette
packs], it's not designed to stand out. If our experts
[at the Department of National Defencel knew as much
about camouflage as the tobacco company did,
nobody'd ever find our fellows" (Spectator 1989). This
situation gained more attention when it was revealed
that a prominent tobacco lobbyist had apparently in-
fluenced development of the regulations (Fraser 1989).
Health advocates subsequently campaigned to attain
more prominent messages through revising the regu-
lations (Mahood 1995).

  New legislation was enacted on August 11, 1993
(Department of National Health and Welfare 19931, and
all packaging for tobacco products destined for sale in
Canada had to comply by September 11,1994. Among
these precedent-setting regulations (Mahood 1995)
were the following requirements:

o  The message must cover at least 25 percent of the
top of each main panel.

Regulafory Efforts 169


SurgeoH Gc~leral's Report

The message must be framed by a stipulated bor-
der (on many packs, this border yields a total mes-
sage area that uses over 40 percent of the surface).
Each of eight rotating messages must be presented
one-half of the time in black on a white background
with a black border. The other one-half of the time,
the messages must be white on a black background
surrounded by a white border.

One entire side panel must be used to present in-
formation on the toxic constituents.

Every side panel of tobacco cartons must display a
black-on-white message covering 25 percent of the
panel area and stating "Cigarettes are addictive and
cause lung cancer, emphysema, and heart disease"
(Department of National Health and Welfare 1993,
p. 3278).

The message must bear no attributions.

  One ironic result of these requirements was that
cigarettes manufactured in the United States for the
Canadian market were produced, albeit only for ex-
port, with health messages that conform with the rec-
ommendations provided in 1965 by the U.S.
Department of Health, Education, and Welfare.

  The Canadian regulations were reversed in 1995,
when the Supreme Court of Canada held that the
country's complete ban on overt tobacco advertise-
ments (another key component of the 1993 regulations)
and its requirement of unattributed health warnings
on packages were in violation of the tobacco industry's
freedom of expression and the Canadian Charter of
Rights and Freedoms (RJR-MacDonald Inc. v. Attorney
General of Canada, File Nos. 23460, 23490 [Can. Nov.
29-30, 1994, Sept. 21, 19951, cited in 10.6 TPLR 2.167
[1995]). These central elements of Canada's Tobacco
Products Control Act fell because the Canadian gov-
ernment did not meet its constitutional obligation of
proving that the approach taken was the least drastic
means of achieving a public health objective. These
narrow evidentiary grounds on which the decision was
made left room for the Canadian government to
counter. The government offered a new proposal,
called Tobacco Control: A Blueprint to Protect the Health
of Canadians, that reinstated the advertising ban, im-
posed restrictions on brand-name promotion and
sponsorship, instituted controls over packaging and
labeling, and increased product regulation and report-
ing requirements.

  In creating a new legal framework, the Canadian
government would make tobacco a de facto illegal
product whose sale could be permitted but would be

subject to specific conditions. This reversal of the
burden of proof gives constitutional allowance to the
advertising restrictions in Canada. Following the un-
veiling of the Blueprint, the tobacco industry brought
forward a voluntary proposal to restrict advertising.
Subsequent resumption of advertising has been con-
troversial, and the industry has been accused of breach-
ing its own code (LeGresley 1996).

Tobacco Advertising, Commercial Speech,
and the First Amendment

  Regulation of tobacco advertising in the United
States is legally problematic. Although protections
afforded by the First Amendment to the U.S. Consti-
tution may be modified for commercial speech, includ-
ing advertising, such modification is an area of
intensive legal debate. The two decades of lawsuits
described in this section make it clear that a concerted
and persistent government interest is essential if such
restriction of free speech is to be upheld in courts. To
satisfy legal scrutiny, the government's efforts must
clearly show that any restrictions directly and materi-
ally advance its asserted interest-protecting the health
of the American people.

  The United States Supreme Court has defined
commercial speech as "expression related solely to the
economic interests of the speaker and its audience"
(Cerrtral Hudson Gas 6 Electric v. Public Service Commis-
siolz of New York, 447 U.S. 557 [19801). Commercial
speech thus includes advertisements by cigarette
manufacturers that invite consumers to buy their prod-
uct. As the Supreme Court has observed, "For most of
this Nation's history, purely commercial advertising
was not considered to implicate the constitutional pro-
tection of the First Amendment" (United States v. Edge
Broadcasting Co., 113 S. Ct. 2696,2703 119931). Restric-
tions on commercial speech were viewed as being simi-
lar to economic regulation and were routinely upheld.
A midcentury example key to later efforts to restrict
tobacco advertising occurred when the Supreme Court,
in Vulentine v. Ckrestensen (316 U.S. 52 [2d Cir. 19421,
rev'd), held that the state could prohibit the street dis-
tribution of handbills containing commercial adver-
tising matter (see also Village of Sckaumburg v. Citizens
for a Better Environment, 444 U.S. 620 [19801). Such pre-
cedents enabled the courts to uphold the 1972 congres-
sional ban on tobacco advertising on radio and
television (Capital Brondcasting Co., 405 U.S. 1000).
Subsequent legal scrutiny, however, has acted to re-
verse this trend.

2 70  Chapter 5


Reducilzg Tobacco Use

Constitutionality of Regulating Advertising

  In 1975, the United States Supreme Court held
for the first time that commercial advertising in gen-
eral was entitled to protection under the First Amend-
ment. In Bigelozo v. Virginia (421 U.S. 809 [19751), the
Court struck down a state statute banning commer-
cial advertisements for abortion referral services. The
Court found that "the relationship of speech to the
marketplace of products or services does not make
Icommercial advertising] valueless in the marketplace
of ideas" (p. 826). However, the Court emphasized
that it was defending not merely commercial speech,
but speech that contained "material of clear `public
interest' " (p. 822).

  The Court also defended commercial speech in a
case involving advertising of the price of pharmaceu-
ticals. In Virginia Stnte Board of Pharmcy ZJ. Virgilzia
Citizens Consumer Council, Ix. (425 U.S. 748 1197611,
the Court found that the constitutional protection af-
forded to advertisements of the price of pharmaceuti-
cals was shared by advertisers and recipients of the
information. The Court noted the importance of in-
formation to consumers: `As to the particular
consumer's interest in the free flow of commercial in-
formation, that interest may be as keen, if not keener
by far, than his interest in the day's most urgent politi-
cal debate" (p. 763). The Court pointed out that ad-
vertising is disseminating information to the consumer
about who is producing the product, for what reason,
and at what price, even if it does not "editorialize on
any subject, cultural, philosophical, or political"
(p. 761).

  In that same ruling, however, the Supreme Court
emphasized that commercial speech would not be af-
forded the same level of protection as other forms of
speech and therefore that the state can regulate adver-
tising if such regulation is in conformity to a valid
public interest. These interests include avoiding de-
ceptive and misleading claims; preventing unlawful
activities, such as the sale of alcoholic beverages to
minors; and protecting public health. "The First
Amendment . . . does not prohibit the State from in-
suring that the stream of commercial information flow
cleanly as well as freely" (Virginia State Board of Phar-
macy, pp. 771-2).

  Most cases involving regulated advertising are
assessed through a four-pronged test to determine
whether the regulations violate the First Amendment.
This test was set forth in Central Hudson (447 U.S. 557).
First, the speech being suppressed must have forfeited
its First Amendment protection by being unlawful
or deceptive or fraudulent: "The First Amendment's

concern for commercial speech is based on the infor-
mational function of advertising. . . . Consequently,
there can be no constitutional objection to the suppres-
sion of commercial messages that do not accurately
inform the public about lawful activity. The govern-
ment may ban forms of communication more likely to
deceive the public than to inform it" (p. 563). Second,
the government must assert a substantial interest in
regulating the speech. Third, regulating commercial
speech must directly and materially benefit this gov-
ernment interest. Fourth, the government must show
that the means chosen to benefit its interest are no more
extensive than necessary. (This four-pronged test is
discussed more fully in "Constitutionality of Regulat-
ing Tobacco Advertising," later in this chapter.)
  The level of deference the Supreme Court gives
to legislatures in meeting these four requirements
seems to vary. In some cases, the Court defers to the
legislative judgment that the speech restriction will be
effective (Posadas de Puerto Rico Associates u. Tourism
Co777par7y of Puerto Rico, 478 US. 328 119861; Edge Broud-
casting), while in other cases the Court demands more
empirical support for the legislature's assumptions and
conclusions (Rubirl zl. Coors Brewing Co., 514 U.S. 476,
115 S. Ct. 1585 [1995]; 44 Liquormart, Inc. ~7. Rhode ls-
/and, 517 U.S. 484, 116 S. Ct. 1495 119961).
  In Poslzdas de Puerto Rico, the Supreme Court up-
held a statute that prohibited advertising legal gam-
bling casinos to residents. The Court found that even
though nonfraudulent advertising that concerned a
legal activity deserved First Amendment protection,
the commonwealth's legislature could take steps to
regulate it. The government has a substantial interest
in protecting the health, safety, and welfare of its citi-
zens, and this interest includes reducing the demand
for gambling among residents through the regulation
of advertising. The Court accepted the argument by
the commonwealth that resident gambling would dis-
rupt moral and cultural patterns, cause an increase in
crime, foster prostitution, and develop corruption. In
Board of Trustees of the State University of New York u.
Fox (492 U.S. 469 [1989]) (also known as Fox III), the
Court deferred to the legislature and refused to set
aside a State University of New York statute that pro-
hibited private commercial enterprises from operat-
ing on campus. In Edge Broadcasting (113 S. Ct. 26961,
the Court upheld a federal statute that prohibited the
broadcast of lottery advertisements generally but per-
mitted advertisements of state-run lotteries on stations
licensed to a state that conducts lotteries. The Court
held that "the State [has] `a strong interest in adopting
and enforcing rules of conduct designed to protect the
public' " (p. 2706). Citing Fox III with approval, the

Regulfltory Efforts 171


Court said, "Within the bounds of the general protec-
tion provided by the Constitution to commercial
speech, we allow room for legislative judgments"
(p. 2707).

  In contrast, in 44 Liquovnzavt, the Supreme Court
looked closely at the logic of the Rhode Island gov-
ernment in the ban it imposed on liquor price adver-
tising. The Court considered that the Rhode Island
restriction was a total prohibition and that there was
too weak a connection between banning speech regard-
ing prices and the state's assertion that this restriction
would reduce liquor consumption. Furthermore, the
Court was aware of the concern that the legislature
had been captured by one group of economic competi-
tors (small liquor stores that could not otherwise com-
pete in price wars) and that the law was then drafted
at the expense of the disfavored economic competitor
(larger liquor chains). In the 44 Liquwnzart decision
citing the dissent in Rhode Island Liquor Stores Associa-
tion u. Evening Call Pub. Co. (497 A.2d 331 [R.I. 19851),
it was "suggested that the advertising ban was moti-
vated, at least in part, by an interest in protecting small
retailers from price competition" (p. 491, FN4).
  In Coors Brezuitlg Co., the Supreme Court struck
down a regulation restricting the printing of alcohol
strength on beer labels. The Court found that the re-
striction did little to advance the government interest
in preventing "strength wars" between competing beer
manufacturers, particularly when other types of alco-
hol were required to list the alcohol potency on their
labels. Finding that the speech restriction lacked a logi-
cal foundation, the Court viewed the regulation
skeptically.

  The pattern that emerges from these legal judg-
ments is that where a law restricting commercial speech
has a solid grounding in logic and empirical data, the
Court will uphold it. If the regulatory system has a
faulty connection between its goal and its method, the
law will fail the third prong of the Central Hudsorr test
and be struck down. In 44 Liquormart, Justice John Paul
Stevens' plurality opinion required that the social
science evidence supporting the legislative rationale di-
rectly and materially tie the government's goal (reduc-
ing liquor consumption) to its methodology (restricting
liquor price advertising); the government failed to meet
this legal requirement. Furthermore, the Court views
harshly laws that impose a total ban on speech and thus
paternalistically deprive consumers of information be-
cause the government perceives that the ban is "for their
own good."

Constitutionality of Regulating Tobacco Advertising

  Government regulations of tobacco product ad-
vertising can withstand legal scrutiny if they are care-
fully crafted and are not overbroad (Edge Broadcasting,
p. 2705 [citing Fox III, p. 4801). Courts have found state
and local regulations of tobacco advertising to be pre-
empted by the Federal Cigarette Labeling and Adver-
tising Act when they conclude that the regulation is
based on "smoking and health." If the regulation is
not preempted, then it must pass the four-pronged test
advanced in Central Hudson. Reasonable regulations
on tobacco advertising are likely to be upheld.

Preemption and the Federal Cigarette Labeling and
Advertising Act

  The Federal Cigarette Labeling and Advertising
Act preempts a "requirement or prohibition based on
smoking and health . . . imposed under State law with
respect to the advertising or promotion of any ciga-
rettes the packages of which are labeled in conformity
with the provisions of this chapter" (15 U.S.C. [United
States Code] 1334[bJ). In Cipo[[one u. Liggeff Group Inc.
(505 U.S. 504,112 S. Ct. 2608 [1992]), the Supreme Court
interpreted that language narrowly, allowing
Cipollone to sue the tobacco industry if the claim were
not based on a failure to warn about smoking and
health issues in product advertising or promotion. The
claim would not be preempted if it were based on more
generalized state interests, such as preventing inten-
tional fraud or enforcing manufacturer warranties. In
Marzgirzi ~1. R.]. Reynolds Tobecco Co. (22 Cal. App. 4th
628 [19931), the California Court of Appeals restated
the Cipo/lorle holding by declaring that regulations are
preempted only if they demand a "requirement or pro-
hibition based on smoking and health. . . imposed
under State law with respect to.. . advertising or pro-
motion." If one of these elements is missing, the state
law is not preempted.

  State and local governments can still regulate to-
bacco advertising if they justify the law with a valid
rationale not related to health. For example, Baltimore
asserted that its ordinance restricting tobacco adver-
tising on billboards was a reasonable and necessary
measure for reducing illegal consumption of cigarettes
by minors (Perm Advertising of Baltimore, Inc. z?. Mayor
arrd Cify Council of Baltimore, 862 E Supp. 1402 [Md.
19941). The city claimed that the focus of the ordinance
was not on protecting the health of young people; the
language of the ordinance was instead exclusively re-
lated to preventing youth from engaging in illegal
transactions. (This assertion was made even though
Baltimore does not criminalize youth purchase or

2 72  Chapter 5


Reducing Tobacco Use

possession of tobacco products; Baltimore criminalizes
the sale of tobacco to minors.) The district court ac-
cepted this stated intent of the ordinance. Even when
legislators who supported the ordinance made certain
health-related comments, the court discounted these
as not necessarily being representative of the motives
of the city council as a whole.

  On appeal by the advertising company that was
the plaintiff in the case, the Fourth Circuit Court of
Appeals further held that the Baltimore ordinance was
not preempted by the Federal Cigarette Labeling and
Advertising Act because it did not relate to the con-
tent of advertising, but rather to billboard location
(Penn Advertising of Baltimore, Inc. u. Mayor artd City
Council of Baltimore, 63 E3d 1318 ]4th Cir. 19951). The
court interpreted the ordinance as a limited physical
restriction in a limited media, for Baltimore allows such
billboards in parts of the city zoned for commercial
and industrial use. The court also observed that the
Baltimore ordinance did not restrict tobacco industry
advertising in other media, such as newspapers and
magazines. State or local governments that cannot
separate such ordinances from health-related issues,
however, will have difficulty passing the preemption
test. In Minnesota, for example, the court struck down
a municipal statute that restricted tobacco advertising
explicitly to protect health (Chiglo u. Cify of Prestott, 909
F. Supp. 675 [D. Minn. 19951).

The Four-Pronged Test

Is the Advertising Unlawful or Misleading?

  A central justification for affording constitutional
protection to advertising is the consumer's interest in
the free flow of information (Central Hudson). Public
health and smoking prevention groups often question
whether attractive images that portray smoking as a
socially acceptable, sexual, and athletic activity have
any informational use to the consumer (Lowenstein
1988). Despite the emotive, noninformative character
of cigarette advertising, the tobacco industry might
argue that restricting such advertising should fail the
first prong of the Central Hudson test because the prod-
uct being advertised is lawful for adults and its pro-
motion is not directly deceptive or fraudulent.

  Certainly, advertisements that use images to con-
nect health, vitality, and the good life with cigarette
smoking distort the truth (Law 1992). Yet the United
States Supreme Court's definition of "inherently mis-
leading" refers to advertisements that promote fraud,
represent overreaching, or create consumer confusion
(Ohralik ZI. Ohio State Bar Assn., 436 U.S. 447,462 [19781).
Proscriptions against misleading advertising have not

traditionally extended to "puffery" or imagery alone
(Zauderer u. Office of Disciplinary Counsel of the Supreme
Court of Ohio, 471 U.S. 626 [1985]). For example, courts
have held that advertisements for alcoholic beverages
that project images of drinkers as successful and fun-
loving and do not warn of the dangers of alcohol abuse
are not legally "misleading" (Oklahoma Telecasters As-
sociation u. Crisp, 699 E2d 490,500 [lOth Cir. 19831, reu'd
OII other gromds sub nom; Capital Cities Cable, Inc. u.
Crisp, 467 U.S. 691 [1984]1. By analogy, courts may not
find that promotions are directly misleading simply
because they project images of smokers as glamorous
people and do not mention the associated dangers of
smoking.

  A cigarette advertisement would be found to be
misleading, however, if it included unsubstantiated
health claims. Advertisements could not assert that
cigarette smoking poses little or no risk to health or
does not affect breathing. For example, the FTC chal-
lenged as false and misleading a newspaper advertise-
ment (or advertorial), paid for by R.J. Reynolds Tobacco
Company, that claimed smoking is not as hazardous
to health as the public has been led to believe. Al-
though the tobacco company initially stated that the
statement was not commercial speech because it did
not invite the public to purchase a particular product,
the parties entered into a consent decree under which
R.J. Reynolds agreed to stop the advertisement and to
avoid future misrepresentation of scientific studies
(Bureau of National Affairs, Inc. 1990).

  Some proponents of restricting tobacco advertis-
ing argue that courts in the future could find the vi-
sual images projected in cigarette advertisements to
be inherently deceptive or misleading. A legal opin-
ion for the American Medical Association concluded,
"Given what the cigarette advertising does portray,
what it fails to say, and the vast public ignorance of
the dangers and addictive quality of smoking, particu-
larly among young persons, it is plain to us that this
kind of advertising can be proscribed as deceptive or
misleading" (Blasi and Monaghan 1986, p. 506). Analo-
gously, the Supreme Court has construed the preemp-
tive provisions of the cigarette labeling act to permit
tort actions against cigarette manufacturers in the in-
stance of fraudulent misrepresentation or conspiracy
to misrepresent or conceal material facts (Cipollone).

  Furthermore, to the extent that recent documents
from the tobacco industry show that the industry pur-
posefully marketed to minors, the courts may find this
to be a deceptive advertising practice that leads to an
illegal act. There is no constitutional speech protec-
tion for proposing illegal transactions, such as sales of
cigarettes to minors. The tobacco company Liggett


Group Inc. has admitted that the entire tobacco indus-
try conspired to market cigarettes to children (.Settl~-
m~zt Agreement Between Settling States a!ld Brooke Group
LTD, Liggett 0 Myers, 1~. nnd Liggett Group, Inc., cited
in 13.1 TPLR 3.11 [1998]), and documents obtained in
litigation from the other tobacco companies and re-
cently made Public confirm that tobacco companies
have purposefully marketed to children as young as
14 years old (Coughlin et al. 1999). Regulation of some
tobacco advertising may thus pass the first prong of
the Central Hudson test (see the discussion of the
Mangini case in "A Critical Example: Joe Camel," later
in this chapter).

Is the Government's Interest Substantial?

  Appellate courts have consistently found that
states have a substantial interest in limiting tobacco
advertisements (see, for example, Penn Advertising;
Oklahoma Telecasters; and Dunagirz z,. City of Oxford, 718
E2d 738 [5th Cir. 19831, cert. denied, 467 U.S. 1259
[1984]). Because of the strong epidemiologic evidence
associating smoking with lung cancer, heart disease,
and other causes of morbidity and mortality (USDHHS
1989), no court would deny that the federal govern-
ment has a compelling interest in reducing smoking.
As evidence mounts concerning the health hazards of
environmental exposure to cigarette smoke (Environ-
mental Protection Agency [EPA] 1992; Leary 1993;
Reynolds 1993; Bero et al. 1994; California EPA 19971,
the federal government may also exercise its police
powers to protect nonsmokers.

  The Federal Cigarette Labeling and Advertising
Act preempts state and local governments from regu-
lating cigarette advertising based on "smoking and
health." Instead, as noted, many governments (such
as those of Baltimore and New York City) are assert-
ing an interest in preventing minors from being in-
volved in illegal transactions. Additional nonhealth
rationales include avoiding deceptive advertising and
providing economic (as opposed to health-based) con-
sumer protection.

Does the Regulation Directly Benefit t/w Public Irrtercst?
  The third prong of the C~ntunl Hudson test requires
that governmental regulation of commercial speech
must advance the government interest. The Supreme
Court has not yet given clear direction as to what level
of evidence is required to show that such regulation
directly advances the government interest, but the Court
is beginning to demand some scientific or statistical
evidence of efficacy. In Florida Bur v. Weizt For If, Inc.
(515 U.S. 618,632 [1995]), the Court was satisfied with a
general assertion by the state that common sense

dictated that restricting attorneys from advertising by
direct mail would reduce ethical violations by attorneys
and have a positive effect on the public's opinion of at-
torneys. Limited social science evidence was presented,
yet the restriction was upheld. On the other hand, in
44 Liquormart, Justice Stevens' plurality opinion stated
that one reason the Rhode Island statute was struck
down was that the state had not produced evidence
that its speech restriction would directly and materi-
ally produce the results desired to advance the gov-
ernment interest.

  Even if the courts require empirical support of
efficacy, tobacco advertising restrictions can still sat-
isfy the third prong of the Central Hudson test. There
is extensive social science research regarding the ef-
fect of tobacco advertising on the purchasing habits of
teen smokers and on the positive imagery with which
children regard and recognize tobacco advertising
images. After R.J. Reynolds Tobacco Company intro-
duced the Joe Camel advertising campaign in the late
198Os, the market share of Camel cigarettes among
teenagers increased at least 20-fold; from the same
point in time, the previous decline in overall teenage
smoking prevalence was reversed (CDC 1994b). An
association between a rise in young girls' smoking
habits and the tobacco industry's decision to target
marketing to adolescent girls has also been docu-
mented (Pierce et al. 1994a).

  Some relevant legal judgments suggest that al-
though the courts tend to require more than a
commonsense assertion of the government's interest
in restricting commercial speech, something less than
empirical evidence may suffice. For example, although
Justice Stevens in 44 Liqnormflrt demanded empirical
evidence, he also recognized there is "some room for
the exercise of legislative judgment" (p. 508). The Su-
preme Court in Edenfield v. Forze (113 S. Ct. 1792 [1993])
suggested the need for a scientific validation of a con-
nection between regulation and the achievement of a
substantial state interest: the Court stated that the
government "must demonstrate that the harms it re-
cites are real and that its restriction will in fact allevi-
ate them to a material degree" (p. 1800).

  In cases involving advertising restrictions for al-
coholic beverages, the courts have consistently
accepted-even in the absence of objective scientific
studies-the reasonable legislative belief that such re-
strictions would lower consumption. The Tenth Cir-
cuit Court of Appeals found it not "constitutionally
unreasonable for the State of Oklahoma to believe that
advertising will not only increase sales of particular
brands of alcoholic beverages but also of alcoholic
beverages generally" (Oklalzonra Telecasters, p, 501).

2 74  Chapter 5


Reducipzg Tobacco Use

Similarly, the Ohio Supreme Court found that the ad-
vertising of drink prices would encourage and stimu-
late consumption of alcoholic beverages (Qrieensgate
lrwestment Co. v. Liquor Corrtrol Commission, 433 N.E.Zd
138,142,69Ohio St: 2d 361 [Ohio 19821). The adver-
tising prohibition was thought to be closely connected
to the state's interest in preventing consumption.

  Courts have found a direct relationship between
advertising and consumption or abuse in other dan-
gerous products and activities (see, for example, Will-
innrs U. Spencer, 622 E2d 1200 (4th Cir. 19801; Capitnl
Broadcasting). In Central Hudson, the Supreme Court
found an immediate connection between advertising
and the demand for electricity. The Court in Mkromedk,
Inc. u. City of SRU Diego (453 U.S. 490 [1981]) similarly
found a link between billboard advertisements and traf-
fic safety. The Court stated that this link is established
by the "accumulated, common-sense judgments of
local lawmakers" (p. 509).

   Claims made on behalf of the tobacco and ad-
vertising industries that tobacco advertising is de-
signed not to increase consumption but only to develop
brand loyalty and gain an increased market share
(Boddewyn 1989) may be unpersuasive to the courts
(Chetwynd et al. 1989; Joossens 7989). Although some
of the studies showing that advertising increases to-
bacco consumption have methodologies that are
controversial-such as econometric (Lewit et al. 1981;
Schneider et al. 1981; Seldon and Doroodian 19891,
cross-cultural (Hamilton 1976; Reuijl19821, and adver-
tising recognition (Goldstein et al. 1987; DiFranza et
al. 1991; Fischer et al. 1991a)-the courts would likely
accept the legislature's reasonable belief that what the
studies show is true. For example, the Ninth Circuit,
in a 1997 opinion after 44 Liquormart, maintained that
"common sense suggests that advertising increases
participation" (Valley Broadcasting Co. v. United Stntes,
107 E3d 1328, 1344 [9th Cir. 19971). This portion of
Posadas de Puerto Rico has survived 44 Liquormnrf.

  In an analogous situation, alcohol industry argu-
ments against the relationship between advertising and
consumption were rejected by the Fifth Circuit Court
of Appeals, which held that Mississippi's ban on intra-
state liquor advertising directly promoted the state's
interests in the health and safety of its citizens. The
court said that it did not `I. . . believe that the liquor in-
dustry spends a billion dollars a year on advertising
solely to acquire an added market share at the expense
of competitors. . . . we hold that sufficient reason exists
to believe that advertising and consumption are linked
to justify the ban, whether or not `concrete scientific evi-
dence' exists to that effect" (Dunagin, p. 750). Because
the tobacco industry spends six times as much as the

liquor industry on advertising and promotion (FTC
19951, because smoking remains the leading cause of
avoidable death in America (McGinnis and Foege 19931,
and because about 50 million Americans still smoke,
even small reductions in smoking behavior-whether
consumption or uptake-resulting from reduced adver-
tising could achieve significant health benefits.

  Cases trying to restrict alcohol advertising have
also, however, set precedents that may. stand in the
way of comparable cases involving tobacco advertis-
ing. Most notably, in 44 Liquormnrt, Inc. zl. Rticine (829
F. Supp. 543 [R.I. 1993]), the Rhode Island District Court
judge found that the state's specific statute banning
liquor price advertising had had "no significant im-
pact on levels of alcohol consumption" (p. 549). Jus-
tice Stevens, in his plurality opinion, found that the
statute could not survive without social science evi-
dence because "speculation certainly does not suffice
when the State takes aim at accurate commercial in-
formation for paternalistic ends" (44 Liquormart, Inc.
i'. Rhde lshzd, p. 5071.

  Yet the Fourth Circuit Court of Appeals, the high-
est court to rule on tobacco advertising restrictions,
has twice upheld Baltimore's limitation on tobacco
advertising. The Fourth Circuit noted several differ-
ences between the liquor price advertising prohibition
in 44 Lir]uorninrt, Inc. U. Rhode Island and the limited re-
strictions in the Baltimore ordinance. 44 Liquormart dealt
with a total ban on speech directed to adults, whereas
the Baltimore ordinance was a partial restriction of
speech that targeted children as consumers of an adult
product. The Fourth Circuit Court also held there was
a close connection between the government's goal of
preventing teen participation in illegal transactions and
the limited speech restriction intended to support that
goal (Penn Advertising, 63 E3d 1318; Penn Advertising of
Baltimore, Inc. v. Mayor and City Council of Baltimore, 101
E3d 332 [4th Cir. 199611. By contrast, a notable reason
for the Supreme Court's rejection of advertising restric-
tions in 44 Liquormart was that the government had
not proved a clear tie between its interest and the re-
strictions supposedly supporting that interest.

   The Fourth Circuit reaffirmed its decision in Penn
Advertisitzg after the Supreme Court had asked it to
review the decision in light of 44 Liquormart. The
Fourth Circuit specifically stated, "We have read the
opinion in 44 Liquormart and have considered its im-
pact on the judgment in this case. . . we conclude that
44 Liquormnrt does not require us to change our deci-
sion" in this case (Penn Advertising of Baltimore, Inc. u.
Mnyor aild City Co1411cil of Baltimore, 101 E3d 332 [4th
Cir. 19961, cert. denied, 117 S. Ct. 1569 [1997]).


  Because a restriction like that upheld in Penn
Advertising cannot constitutionally be a complete ban
on all advertising of the product, some minors will
be exposed to some level of adult tobacco advertising.
This limit in scope does not constitute serious grounds
for an appeal. A recent decision involving liquor
regulation notes that the "Supreme Court has made it
clear in the commercial speech context that
underinclusiveness of regulation will not necessarily
defeat a claim that a state interest has been materially
advanced" (Bad Frog Brewery, Inc. v. New York State Li-
quor Authority, 134 E3d 87, 99 [2d Cir. 199811. In sum,
the regulation need not cure all ills but it does need to
advance the state interest in a demonstrably significant,
rather than a small or otherwise circumstantial, way.

Is the Regulation of Advertising a Reasonable Fit?
  The Supreme Court has made it clear that this
standard is not to be confused with the "least restric-
tive means" test. In Edge Broadcastirzg (p. 27051, the
Court said that the "requirement of narrow tailoring
was met if `the . . regulation promotes a substantial
government interest that would be achieved less ef-
fectively absent the regulation,' provided that it did
not burden substantially more speech than necessary
to further the government's legitimate interests." The
existence of less restrictive methods of achieving the
government's goals does not automatically defeat the
legislation as it would in political speech cases. In-
stead the Court looks to see if the restriction does not
sweep more broadly than necessary. In Florida Bar
the Court stated,

In Fox, we made clear that the "least restrictive
means" test has no role in the commercial speech
context. . "What our decisions require," instead,
"is a `fit' between the legislature's ends and the
means chosen to accomplish those ends, a fit that
is not necessarily perfect, but reasonable; that rep-
resents not necessarily the single best disposition
but one whose scope is `in proportion to the inter-
est served,' that employs not necessarily the least
restrictive means but . . , a means narrowly tai-
lored to achieve the desired objective" (citations
omitted) (p. 632).

  In practical terms, the decision implies that re-
strictions on tobacco advertising that target areas
where children gather, such as schools and play-
grounds, do not create a total ban, because the tobacco
industry will still have many alternative channels to
communicate with its adult customers. Adults can still
receive information on price, quality, comparative
product features, and any other information to help

them make an informed decision on tobacco products.
Even if the tobacco industry were limited to commu-
nicating in tombstone format (black letters on a white
background), the government would not have prohib-
ited the flow of information.

  For a similar reason, 44 Liquormart, Inc. v. Rhode
Island does not change this analysis. The rationale the
Supreme Court used there in overturning Rhode
Island's alcohol advertising restriction-that the
statute was a paternalistic ban on the free flow of truth-
ful information-does not apply in tobacco advertis-
ing regulations like those upheld in Penn Advertising,
because the tobacco industry would still have many
avenues of communication open to it and could com-
municate all aspects of information.

  Justice Stevens in 44 Liquormart also generally
rejected a vice exception to commercial speech restric-
tions. In Posadas de Puerto Rico, the Court was willing
to allow the legislature broad deference to curb speech
that promoted "vice" activities such as gambling. Jus-
tice Stevens rejected this approach that allowed legis-
latures to ban speech rather than the vice itself. He
stated, however, that "a `vice' label that is unaccom-
panied by a corresponding prohibition against the
commercial behavior at issue fails to provide a prin-
cipled justification for the regulation of commercial
speech about that activity" (44 Liquormart, Inc. u. Rhode
Island, p. 514). In the case of restricting tobacco adver-
tising aimed at children, the restriction matches the
prohibition. It is illegal to sell tobacco products to
minors, and therefore the legislature has a principled
reason to prevent commercial speech in the limited
area where it has already prohibited the commercial
activity. This is in accord with Justice Clarence
Thomas' view that a jurisdiction "may not restrict ad-
vertising regarding commercial transactions except to
the extent that it outlaws or otherwise directly restricts
the same transactions within its own borders" (p. 525).

  In 44 Liquormart, Justice Sandra Day O'Connor's
concurrence set out the guideposts she would use to
judge commercial speech restrictions. "The availabil-
ity of less burdensome alternatives to reach the stated
goal signals that the fit between the legislature's ends
and the means chosen to accomplish those ends may
be too imprecise to withstand First Amendment scru-
tiny. If alternative channels permit communication of
the restricted speech, the regulation is more likely to
be considered reasonable" (44 Liquormart, Inc. u. Rhode
Island, pp. 529-30 [internal citations omitted]). The
ruling presupposes that other less restrictive alterna-
tives, such as price increases and access restrictions,
have been tried (if enacted) and have not completely
solved the problem. It is reasonable for a legislature

176 Chapter 5


Rcduciug Tobacco Use

to conclude that limited restrictions on commercial
speech aimed at youth must be a component of an
overall plan to limit youth involvement with tobacco
products. At the same time, the tobacco industry will
have alternative channels to communicate to adults
all the information in which adults are interested, in-
cluding price, tar and nicotine levels, and taste. In the
context of alcohol advertisements, courts have asserted
that "the state's concern is not that the public is un-
aware of the dangers of alcohol. . . . The concern in-
stead is that advertising will unduly promote alcohol
consumption despite known dangers" (Drlnngirr, cert.
denied, 467 U.S. 1259).

  The preceding review of relevant cases suggests
that carefully designed, reasonable government restric-
tion of cigarette advertising would likely meet
the Supreme Court's four criteria for restricting
commercial speech and would therefore be found
constitutional.

A Critical Example: Joe Camel

  Perhaps the most discussed tobacco promotion
of the 1990s-and one that brings together many of
the issues discussed in the preceding section-is the
advertising campaign for Camel cigarettes that features
a cartoon camel character called Old Joe (often referred
to as Joe Camel). Assertions have been made that this
campaign improperly targeted minors, seeking to at-
tract them to cigarette smoking. These concerns were
heightened in the wake of the 1994 Surgeon General's
report on smoking and health, which focused on ado-
lescents (USDHHS 1994). That report's major conclu-
sions included the following: those who smoke usually
begin by age 18; most adolescent smokers become ad-
dicted to nicotine; tobacco addiction is associated with
the later development of other drug addiction; tobacco
use is related to psychosocial risk factors; and some
cigarette advertising appears to be particularly effec-
tive on adolescents.

  Critics argue that the cartoon character of Joe
Camel, which has been used by R.J. Reynolds Tobacco
Company in its advertising campaign for Camel ciga-
rettes since 1988, has had substantial impact on smok-
ing among underaged youth (DiFranza et al. 1991;
Fischer et al. 1991a; Breo 1993; CDC 1994b). The char-
acter appears in print advertising and on promotional
products disseminated by the company, such as mugs,
matchbooks, store exit signs, and soft drink can hold-
ers. After a staff investigation, in 1994 the FTC de-
clined, by a 3 to 2 vote, to issue a complaint charging
that advertising using the Joe Camel character violated

section 5 of the Federal Trade Commission Act by in-
ducing minors to smoke. Subsequently, the FTC did
bring a complaint against R.J. Reynolds on May 28,
1997, alleging that "the purpose of the Joe Camel cam-
paign was to reposition the Camel brand to make it
attractive to younger smokers. . . . The Joe Camel cam-
paign induced many of these children and adolescents
under the age of 18 to smoke Camel cigarettes or in-
creased the risk that they would do so. . . . R.J.
Reynolds' actions . . have caused or were likely to
cause substantial and ongoing injury to the health and
safety of children and adolescents under the age of 18
that is not offset by any countervailing benefits and is
not reasonably avoidable by these consumers" (In re
R.]. Rcyr7olds Tobacco Co., Docket No. 9285 [FTC, May
28, 19971, ritcd ill 12.3 TPLR 8.1, 8.2 [1997]). As late as
the spring of 1998, Joe Camel memorabilia were still
being offered for sale in R.J. Reynolds catalogs. The
FTC ultimately dismissed its complaint as no longer
necessary after the November 23, 1998, Master Settle-
ment Agreement banned the use of all cartoon charac-
ters, including Joe Camel, in the advertising, promotion,
packaging, and labeling of any tobacco product.

  The Federal Trade Commission Act grants no
private right of enforcement (Holloway u. Bristol-Myers
COY~J., 485 E2d 986 [D.C. Cir. 19731). However, the
California Unfair Competition Law authorizes actions
for injunctive relief (a measure sought to prevent a
given course of action) not only by specified state and
local officers but also by persons acting for the inter-
est of themselves or the general public. A private ac-
tion was brought in California state court by Janet
Mangini, who asserted that R.J. Reynolds' advertising
practices in the Joe Camel campaign violated the Fed-
eral Trade Commission Act and the California statu-
tory law of unfair competition (Mangini u. R.]. Reynolds
Tobacco Co., 7 Cal. 4th 1057,875 P.2d 73 [Cal. 19941, cert.
denied, 1994 U.S. LEXIS 8361 [Nov. 28, 19941). Unfair
competition is defined to include "any unlawful, un-
fair or fraudulent business act or practice and unfair,
deceptive, untrue or misleading advertising" (Califor-
nia Business & Professions Code, sec. 17200). R.J.
Reynolds, in contesting Mangini's action, asserted that
federal law preempted any action in the state courts.
The Federal Cigarette Labeling and Advertising Act, as
amended by the Public Health Cigarette Smoking Act
of 1969, provides that "no requirement or prohibition
based on smoking and health shall be imposed under
State law with respect to the advertising or promotion
of any cigarettes the packages of which are labeled in
conformity with the provision of this Act" (Public Health
Cigarette Smoking Act of 1969, sec. 5[b]).


  The Sup-cvne C`L)LII.~ of C`alit~~rnia rejected the
preemption argument and held that the cause of dc-
tion against the nd\.ertisin~-that it improperI\
targeted minors--\vould stand. According to the tour;,
the ad\,ertising had apparently been effecti1.e in tar-
geting adolescents: Camel cl+
                 `t~3rettes rt'ere chosen b\
an estimated 0.5 percent of teenage smokers in lY&
(the last full year of sales before the Joe Camel cam-
paign) and by an estimated 25-33 percent in 1992 (as
quoted in the decision; other sources cite a substan-
tial, although smaller, increase (CDC 1991b]). In 1992,
teenage smokers accounted for about $176 million of
Camel sales, a vastly greater amount than the $6 mil-
lion in sales for 1988 (Mi711,yyi11i, p. 1060). The portion
of the MITJI@II~ lalvsuit regarding the Joe Camel ad\Ter-
tising campaign \vas settled September 8, lYY7, tvhen
R.J. Reynolds agreed to cease placing Joe Camel on
California billboards, placing Joe Camel materials in
magazines and ne\vspapers, and distributing proniu-
tional materials through retail mechanisms (M1711::i/li
il. R.]. Rel/rzo/& T&?ri-c~ Co., iitvil if? 12.5 TPLR 3.319
[1997]). it also agreed to pay the cities and counties
that had joined the action as co-plaintiffs SY million
for a counteradvertising campaign, presumable to dis-
pel the lingering effects of the Joe Camel marketing.

  In another state, Washington, a pri\,ate action
using that state's la\v failed to prohibit adiwtising
using Joe Camel (Sfmrii.; ~1. X.1. Rct//mlds 72wc-~-o Ccl., Ko.
CY4783C [W.D. Wa. Dec. 9, 194-I], citvll irk Y.6 TI'LR
2.171 [19Y3]). Nonetheless, the decision of the Supreme
Court of California indicates that at least in some in-
stances in some jurisdictions, private parties acting as
representatilres of the general public can bring an

Product Regulation

action normally brought only under specific federal
or state la\v against cigarette advertising.

  Thus, as tvith a number of other legal issues (see
"Litigation Approaches," later in this chapter), the
judicial response to aggressive pursuit of legal policy
options is still unfolding. Although the process of le-
galls regulating tobacco advertising and promotion
has-been under \vay for decades, the extent of such
regulation and its ultimate limits are not yet known.

  The most significant developments in this area
revol\:ed around the release of-and subsequent
reaction to-the FDA'sAugust 10,1995, preliminaryde-
termination. The determination accompanied a pro-
posed rule that sought to restrict the availability and
marketing of tobacco products to children and adoles-
cents. The FDA's final determination that it had au-
thoritv to regulate cigarettes and smokeless tobacco
products (released on August 28,1996) is discussed later
in this chapter, where the analysis of product regula-
tion focuses on "Further Regulatory Steps."

  Arguably the second most important develop-
ment in this area was the June 20,1997, proposed agree-
ment that \vould have settled lawsuits between 41 state
attorneF.5 general and the tobacco industrv. Because
the ad\wtising and promotion provisions of that agree-
ment directlv presupposed legislation that would have
upheld the FDA'S asserted jurisdiction to regulate to-
bacco products, this key multistate agreement is, like
the FDA announcemelit, discussed later in this chap-
ter, \vhcre the analysis of product regu!ation focuses
on "Legislati1.e De\.elopments" and "Master Settle-
ment I\greenient."

Introduction

  Cigarette smoke contains approximately 1,000
chemicals, including a number of carcinogens and other
toxic chemicals, such as hydrogen cyanide and oxides
of nitrogen (USDHHS 1989). Regulating tobacco prod-
ucts requires appropriate assessment of these primary
and secondary products of combustion and other sub-
stances that mav be inhaled. Current tobacco product
regulation requires that cigarette advertising disclose
levels of "tar" (an all-purpose term for particulate-
phase constituents of tobacco smoke, man\; of w,hich

are carcinogenic or otherwise toxic) and nicotine (the
psychoactiv-e drug in tobacco products that causes ac-
diction [USDHHS 19881) in the smoke of manufactured
cigarettes and that warning labels appear on packages
and on some (but not all) advertising for manufactured
cigarettes and smokeless tobacco;' the current federal


la\vs preempt, in part, states and localities from impos-
ing other labeling regulations on cigarettes and smoke-
less tobacco (see the pre\.ious major section,
"Ad\.ertising and Promotion").

  Since the mid-198Os, federal la\\- has required
makers of manufactured cigarettes and of smokeless
tobacco products to submit lists of additi\,es to the
tobaccos (but not to filters or papers) in their products
to the Secretarv of Health and Human Services (Com-
prehensive Smbking Education Act, Public Lalj. 98-371,
sec. 5; Comprehensive Smokeless Tobacco Health Edu-
cation Act of 1986, Public Laiv 99-252, sec. 4). Infor-
mation about the quantitv ofadditi\.es used ancl their
placement in specific brands is not required, and the
Secretary is bound by lalz to safeguard the lists from
public disclosure. In 1991, attornevs for six manufac-
turers released to the public the.list of ingredients
added to tobacco in 1993.

  Tobacco products are explicitly protected from
regulation in \.arious federal consumer safetv 1`~~~s
(L'SDHHS 198Y). Although regulation requirtis pub
lit reporting of some constituents in cigarette smoke,
cigarette manufacturers are not required to report to a
go\-ernmental body (or to include on product labels
for consumers) brand-specific information about the
nicotine content or anv other propertv (e.g., nitro-
samine le\.els, ammonia le\,el, pesticide resiclues,
heavy metals [lead, cadmium, mercury, or chromium],
pH, or sugar content) of the material that forms the
tobacco rod of their products. At the \`erv least, know,l-
edge of the upper bound of nicotine in the tobacco rod
of cigarettes is important because actual smoking ma\;
produce constituent levels that \.arv considerably from
that in smoke deliverv yields reported to the FTC
(USDHHS 1988; see also "Compensatory Smoking,"
later in this chapter). Those measurements were con-
ducted by the Tobacco Institute Testing Laboratory.

  The Comprehensive Smokeless Tobacco Health
Education Act of 1986 requires smokeless tobacco
manufacturers to report the total nicotine content of
their products to the Secretarv of Health and Human
Services (Public Law 99-252, sec. 4), but the Secretary
may not release the data to the public. A uniform pro-
tocol implementing this provision M'as published in
the March 23, 1999, Fedcrnl R~@~trr. No federal public
health laws or regulations apply to cigars, pipe tobac-
COS, or fine-cut cigarette tobaccos (for "roll-your-o\vn"
cigarettes) in anv manner other than prohibiting the
advertising of small cigars through electronic media
(USDHHS 1989).

The Constituents of Smoke From
Manufactured Cigarettes

  Since 1967, the FTC has regularly published
tables of tar and nicotine delivery of smoke from manu-
factured cigarettes. Since 1980, the tables have also
included a measurement for carbon monoxide
deliverv. The data are based on results of a standard-
ifed, machine-dri\ren test procedure (Pillsbury et al.
1969) that provides a basis of comparison among vari-
ous brands of cigarettes. Manufacturers are not re-
quired to print these values on the product package,
but "ultra Io~v" cigarette brands often include tar and
nicotine deliveries on the package, presumably to dif-
ferentiate these brands (Davis et al. 1990). No brand
ha\ing a tar yield above 11 mg prints this information
on the package. Carbon monoxide deliveries are not
listed either on packages or in advertising (USDHHS
1989).

Regulation by Tar Levels

  The FTC's tables of tar le\,els have provided some
jurisdictions \vith criteria for regulating tar content by
le\,ying taxes on higher-tar cigarettes or, in the case of
countries in the European Union, by altogether ban-
ning high-tar cigarettes. The apparent assumption be-
hind such action-that discouraging or banning
consumption of higher-tar cigarettes will result in
reduced morbidity and mortality from smoking-
related diseases-has been questioned, as is discussed
in the section "Compensatory Smoking," later in this
chapter.

   Tar content has in several instances served as the
basis for cigarette taxation, on the presumption that
the taxing structure would provide a competitive ad-
l'antage to low-tar brands-an advantage of interest,
for supposed public health reasons, to the jurisdiction
levying the tax. For several years beginning in 1971,
New York City taxed cigarettes that had either tar
yields over 17 rng or nicotine yields over 1.1 mg an
additional 3 cents per pack and cigarettes that exceeded
both thresholds, 4 cents (Lc~rrg Islnr~il K~bncco C~J., fr~c. ~1.
Limfqt/, 74 Misc. 2d 445,343 N.Y.S.2d 759 [N.Y. 19731).
Although the levy was upheld by the courts, the law
seems to have been repealed because of allegations that
unequal taxation across political boundaries was fos-
tering smuggling (Ranzal 1973). There are no reports
on the effects this tax may have had on consumption
patterns.

  In 1978, the British government imposed a
supplementary tax on cigarettes having a measured
tar yield greater than 20 mg (Gray and Daube 1980


Figure 5.1. Sales-weighted nicotine and tar levels in smoke as percentage of 1982 levels

1  Average of all brands*

YO(   1   ,   ,   ,   ,   (   (   ,   ,   ,   ,   ,   ,   ,   ,  901
1982  1983  1986  lY88  19YO  1992  1991  1996        1982 1984 1986 1988 1990 1992 1994 1996

                 Year                                      Year

1  Low-tar category (6-15 mg tar)*

90
1982  1981  1486  1988  1YYO  199' 19'34  1YYh

                \I'mr

                                -  Nicotine

*By Federal Trade Commission method.

1  High-tar category (>I5 mg tar)*

1  Ultra-low-tar category (~6 mg tar)#

YU/   ,   I   ,   ,   1   ,   ,   ,   ,   ,   ,   ,   ,   ,   ,
1982  1984  19%  1988  1990  1992  1994  1996

                Year

- Tar

Source: Kessler 1994b; Federal Trade Commission, unpublished data, 1998.

[note misprint in this publication: on page 93, line 3,
"more" should ha\,e been "less"; correction furnished
by Michael Daube, Februarv 13, 19961). Within three
months of the imposition of the tax, the market share
of such brands fell from 15 to 3 percent (Michael M.
Daube, letter to John Siade, February 24,1995). Asirni-
lar tax was used in Sweden, but it IVas repealed to
achieve uniformity Lvith tax policies of the European
Union (Paul Nordgren, letter to Da\,id T. Sweanor,
December 23,1994).

  Among countries in the European Union, a
fixed ceiling on tar content has been used as a regu-
latory method. The European Union has imposed a

graduated decline in the upper limit of tar deliveries
permitted for cigarettes sold in member countries. Be-
ginning January 1, 1993, the ceiling was 15 mg tar
delivery per cigarette; after December 31, 1997, the
ceiling \vas 12 mg (Council Directive 90/239/EEC
1990 O.J. [L 1371).

Implications of Nicotine Levels

   The FTC's tables on nicotine levels have revealed
a recent change in the ratio of tar to nicotine in ciga-
rettes. Kessler (1994b) has reported that for 1982-1991,
the ratio of average sales-weighted nicotine yield to


tar yield' in cigarette smoke has risen steadily for each
of three major tar-yield categories and for the overall
market (Figure 5.1). Gi\,en the addictive properties of
nicotine and its contribution to cardio\,ascular disease
(USDHHS lY88), this change may have important pub-
lic health implications. Moreo\-er, "lots-yield" and
"ultra lolz--yield" cigarettes in the same period had
higher nicotine yield to tar ratios than did brands in
the high tar-!lield categories. Consumers Ivho pay
more heed to the "numbers" for tar le\rels than to the
much smaller (but no less important) numbers for
nicotine levels may be under the illusion that the): are
reducing their health risks and increasing their
chances of quitting by smoking "lo\\`-tar" cigarettes.
(This illusion is further discussed in "The Lo\\.-Tar
`AlternatixTe,' " later in this chapter.)
  A manufactured cigarette generally contains

ii-10 mg of nicotine (USDHHS 19881, regardless of the
machine-measured nicotine deli\,erv in the smoke. L`n-
der usual smoking conditions, consumers absorb about
lo-30 percent of the nicotine contained in the tobacco
rod of the cigarette (USDHHS 1988; Beno'rvitz and
Henningfield 1994). Some thought has recently been
given to systematically lo\vering the nicotine content
of tobacco products to le\rels that \vould not pose a
threat of addiction (Benowitz and Henningfield 19%;
Douglas 1994). Benowitz and Henningfield (199-l) ha1.e
suggested that addiction is unlikely to be sustained
below a nicotine dose of about 5 mg ier day. This dose
is about one-fourth the dailv dose commonly ingested
by tobacco users. To achie\e such a ceiling for ciga-
rettes, the nicotine content of the tobacco rod Lvould
have to be 0.5 mg or less, assuming that the smoker
consumes about 30 cigarettes per day and receives 30
percent of the nicotine available. Ho\ve\,er, cigarettes
with such low levels of nicotine may not be popular
(Campbell 1994). The experience of Philip Morris
Companies Inc. in trying to sell a low-nicotine-content
cigarette, "Next," illustrates this point; the company
judged the test-marketing of this cigarette a failure.
Such failure provides indirect support for the impor-
tance of nicotine addiction to the tobacco industrv.

Mandating the reduction of nicotine for the
purpose of weaning smokers from tobacco products
\\-as contemplated as a strategy available to the FDA
in legislation proposed to enable the multistate settle-
ment agreement with the tobacco companies (see

"Legislative De\,elopments" and "Master Settlement
Agreement," later in this chapter). A similar strategy
is used in some voluntary stop-smoking programs (e.g.,
Gahagan 1987). But this strategy cannot work unless
accurate measures are available of the actual nicotine
uptake that smokers and other tobacco users receive.

  In 1994, the NC1 convened an ad hoc expert com-
mittee to determine the adequacy of the standard,
smoking-machine-based, FTC protocol for determin-
ing the tar and nicotine content of cigarettes. The com-
mittee concluded that "the FTC test protocol was based
on cursory observations of human smoking behavior.
Actual human smoking behavior is characterized by
\vide variations in smoking patterns, which result in
[Tide \.ariations in tar and nicotine exposure. Smok-
ers i\,ho slvitch to lolzer tar and nicotine cigarettes fre-
quently change their smoking behavior, which may
negate potential health benefits" (NC1 1996, p. vi).

  III 1496, Massachusetts enacted a law designed
to obtain reports of brand-specific nicotine levels that
more closelv approximate the uptake by actual smok-
ers of the& brands. The statute instructs the state
Department of Public Health to establish standards for
nicotine yield ratings that "accurately predict nicotine
intake for a\.erage consumers" (Mass. Gen. Laws ch.
93, sec. 3078). Each cigarette and smokeless tobacco
manufacturer must then report, in a manner consis-
tent \z,ith these standards, the nicotine yield rating of
each brand of tobacco products it produces. These
reports become public records.

Other Constituents in Cigarette Smoke

   Tar and nicotine measurements have tradition-
ally been used as surrogate measures for other toxic
constituents in cigarette smoke, because changes in tar
and nicotine levels presumably are predictive of
changes in the levels of most other particulates. Stud-
ies suggest otherwise. For example, tar level as mea-
sured by smoking machines is not a good predictor of
benzo[a]pyrene level (Kaiserman and Rickert 1992). In
general, declared tar values are not predictive of
tobacco-specific nitrosamine levels (Fischer et al. 1990,
1991b). Similarly, tar delivery is a poor predictor of
the delivery of gas-phase constituents, such as carbon
monoxide, hydrogen cyanide, and acrolein (Young et
al. 1981).

  In Canada, the Department of National Health and
Welfare (Health Canada) has undertaken a program to
develop methods for collecting and analyzing toxic
constituents, other than tar, nicotine, and carbon mon-
oxide, in tobacco smoke. Methods have been devel-
oped to measure the levels of benzo[a]pyrene, the


tobacco-specific nitrosamines, h!-drogen cyanide, ben-
zene, formaldeh\,de, I-amino-biphen~l, and hea\.v
metals such as lectcl and cadmium (Health Canada
lYY5a). The Department of National Health and Wel-
fare intends to require manufacturers to use these test
methods to provide quantita ti\,e reports on these chemi-
cals in tobacco smoke or, in the case of heavv metals, in
the tobacco itself (Health Canada lYY5a).

  Rickert (I 994) has described the presence of the
potent bladder carcinogen I-amino-biphenvl in the
sidestream smoke from all 10 brands of cigarettes
tested in a study for Health Canada. Under occupa-
tional safety regulations, the permissible level of ex-
posure to 4-amino-biphenyl is zero. Applying these
standards to cigarette smoke rvould require either that
this material be absent from cigarette smoke entirely
or that cigarette smoke not be permitted in spaces sub-
ject to regulation.

  An important de\.elopment indicating a possible
design flare in the manufacture of cigarettes has been
the report that cellulose acetate fibers are shed from ciga-
rette filters. Such fibers, coated ivith tar, have been ob-
served in the lungs of smokers; this obscr\.ation suggests
that these fibers may be long-li\.ed in human tissue and
may be associated with disease (I'aulv et al. lYY5).

Additives to Tobacco Products

  Hundreds of ingredients besides tobacco are used
in the manufacture of tobacco products. Additives
make cigarettes more acceptable to the COIISU~~~; thcv
can make smoke seem milder (and easier to inhalei,
prolong shelf life, prolong burning, and impro\.e taste.
These additives may be a single chemical used as a
humectant or a complex mix of chemicals used as a
flavorant.

Cigarette Additives

  The six major cigarette manufacturers reported
a pooled list of 599 ingredients that \vere added to the
tobacco of manufactured cigarettes as of 1991 (R.J.
Reynolds Tobacco Company 19%). The list is anno-
tated lvith references to Ivhich materials are approved
for use as food additives by the FDA (under the cat-
egor) "Generally Recognized as Safe") and are thought
to be safe by the Fla\,or and Extract Manufacturers
Association of the United States. HoFvever, that a
material is regarded as safe \vhtn ingested in foods
provides no assurance of its safety in a tobacco prod-
uct, Mrhere it \viIl be combined bzith other substances,
heated to high temperatures, and may be inhaled into
the lungs.

  The American Health Foundation (1990) has
pointed out the toxic potential of numerous cigarette
tobacco additives under expected conditions of use.
Heating and burning may lead to the formation of car-
cinogens from some of the additives used. For in-
stance, amino acids used as additives are known to
form compounds of various elements, including
genotoxic agents (known to damage DNA) and experi-
mental carcinogens, during heating. Licorice root ex-
tract contains glycyrrhizin, and both are used as
additives in cigarettes; glycyrrhizin produces carcino-
genic by-products when burned. The leukemia-
producing agent benzene is a component of cigarette
smoke that may be formed from the combustion of
many cigarette additives. Because the Federal Food,
Drug, and Cosmetic Act requires that a food additive
"be safe under the conditions of its intended use" (sec.
321), tobacco additives in manufactured cigarettes may
not fulfill the specifications of the law were the law
applied to tobacco.

  The use of additives may reinforce cigarette
smoking by strengthening the addictive effects of nico-
tine. At least one major domestic cigarette maker uses
some additives to boost the absorption of nicotine in
cigarette smoke (Kessler 1994~). Ammonia compounds
alter the pH of nicotine in tobacco, converting it from
the protonated, bound form (various nicotine salts) to
the unprotonated, freebase form. Freebase nicotine
more readily enters the smoke stream and has been
predicted to cross lung and oral cavity membranes
more quickly than nicotine salts do (Henningfield et
al. lYY5). The broader issue of enhancing the delivery
of nicotine is discussed in the introductory section of
"Further Regulatory Steps," later in this chapter.

  Sel,eral European countries regulate cigarette ad-
diti\,es, but onlv to a modest extent. In France, the to-
tal percentage df the cigarette that consists of additives
is listed on the side of the package. Among representa-
ti\re brands manufactured in the United States but sold
in France (e.g., Camel, Kent, Marlboro, and Winston),
the cigarette labels indicate that between 6.2 and 10.0
percent of each cigarette is composed of additives. The
British government maintains a list of "permitted" or
"nppro\red" additi\,es for smoking tobacco and ciga-
rette paper (Le\vis and Davis 1994, p. 206). The list,
ivhich had 474 ingredients in 1988, specifies the maxi-
mum le\,el permitted for each specific additive (Lewis
and Davis 19Y4). In Canada, the Tobacco Products Con-
trol Act (sec. 10; Department of National Health and
Welfare lY8Y) requires manufacturers to report a quar-
terly list of ingredients used in their products. Cana-
dian producers use far fewer additives-about 50 in
all-than do American manufacturers.


  Massachusetts, Minnesota, and Texas ha\,e en-
acted laws to require the disclosure of nontobacco in-
t?redients in tobacco products (Mass. Gen. Lalvs ch.
$4, sec. 307B; Minn. Larys ch. 227 [ 1997); Vernon's Texas
Statutes and Codes Annotated ch. 161, sec. 161.252
[199i]). Health officials in the Canadian province of
British Columbia ha\,e announced their intention of
taking similar steps there.

  The Massachusetts la\v, applicable to cigarettes
and smokeless tobacco, requires the manufacturer to
report, in descending order bv 12-eight, measure, or nu-
merical count, the identitv of each brand's added con-
stituents other than tobacco, reconstituted tobacco
sheet, or bvater. Ingredients that are recognized as safe
\\Then burned and inhaled are exempted. The Depart-
ment of Public Health is then instructed to disclose the
reported information to the public to the extent that
"there is a reasonable scientific basis for concluding that
the availabilitv of such information could reduce risks
to public health" (Mass. Gen. La\vs ch. Y-I, sec. 3078).

  The tobacco industry challenged the statute in
court on both preemption and trade secret grounds.
The Federal District Court ruled that nothing in fecl-
era1 la\v preempted Massachusetts from taking this
action, and the court of appeals affirmed (P/~i/i/l !l/lrll--
rig LITC. P. Hr7~s/~h7l;sy~~, 122 E3d 58 [lst Cir. 19971). Horn-
ever, the same Federal District Court thereafter issued
a preliminarv injunction that pre\.ented the state from
enforcing th'e ingredient disclosure provision of the
statute; the court ruled that doing so \vould expose
the trade secrets of the manufacturers (Pl~i/i/~ Morris
Irlc. :I. Hnrshha,~~~, Civil Action No. 96-113YY-GAO,
Civil Action No. Yh-11619-GAO, 1997 U.S. Dist. LEXIS
21012 [D. Mass. Dec. 10, 1997]). That ruling is cur-
rently under appeal. Texas has adopted a similar stat-
ute requiring the tobacco industry to submit a list of
ingredients and nicotine vield ratings to the Texas
Department of Health by -December 199X (Vernon's
Texas Statutes and Codes Annotated ch. 161, sets.
161.252, 161.254, 161.255).

  The Minnesota statute requires manufacturers of
tobacco products to publiclv disclose, for each brand,
ivhether the product contains detectable levels-in
either its unburned or its burned states-of ammonia
or ammonia compounds, arsenic, cadmium, formal-
dehyde, or lead. The industrv filed suit in Federal Djs-
tric;Court to enjoin the enfoicement of the statute but
agreed to drop the suit as part of its Mav 1998 settle-
ment of the state's Medicaid reimbursement la\vsuit
(discussed in "Recoverv Claims by Third-Party Health
Care Payers," later in this chapter) (Mirrrwsot~7 7'. Philip
Morris Iuc., citcll ill 13.2 TPLR 3.3Y, 3.45 [1998]).

  Most recently, British Columbia health officials
announced plans to require cigarette manufacturers
to disclose to the government all ingredients, includ-
ing additives used to treat the papers and filters.
Manufacturers ~~rould also have to test and report on
44 poisons that the health officials claim are contained
in cigarette smoke (Reuters 1998).

Smokeless Tobacco Additives

   In 199-f, ten manufacturers of smokeless tobacco
products released a list of additives used in their prod-
ucts (Patton, Boggs & Blot2 1994). As with the addi-
ti1.e list for cigarette tobacco, the smokeless tobacco
list notes ~~hich of the 562 materials listed have been
appro\.ed for use in foods by- the FDA and also notes
ivhich arc regarded as safe bv the Federal Emergency
Management Agency. As \vith cigarette tobacco, ap-
plying these safety standards to nonfood substances
is problematic; holz.ever, smokeless tobacco used in an
unaltered (unburned) state lessens some of the con-
cern o\`er the possible hazards of aclditives.

   The list of ndditit~es to smokeless tobacco in-
cludes sodium carbonate and ammonium carbonate,
\vhich are alkalinizing agents that increase the level
of "free" (chemically uncombined) nicotine in moist
snuff bv raising the pH le\rel (Slade 1995). A division
of the S\yedish Tobacco Company has stated that so-
dium carbonate is added to its moist snuff brands to
alkalinize the tobacco and thus enhance nicotine
absorption (Kronquist 1994). The pH of moist snuff
products-lvhich is not reported to consumers-
\-arks from acidic to alkaline, providing a wide range
of free-nicotine levels in various products (Djordjevic
et al. 1995; Henningfield et al. 1995). Products for per-
sons entering the market (such as those that have easy-
to-use unit dosages) are acidic (thus reducing
absorption) and have \`ery low levels of free nicotine,
Lvhercas products for more experienced users (such
as the Copenhagen brand) are alkaline and have high
levels of free nicotine. The epidemiology of moist snuff
use among teenagers and young adults indicates that
most no\Jices start with brands having low levels of
free nicotine and then graduate to brands with higher
levels (Tomar and Henningfield 1992; Tomar et al.
1995). These patterns are consistent with the industry's
marketing strategies as reflected in their advertising
and marketing activities and their internal documents
(Connolly 1993).

  Sweeteners and flavorings, such as cherry juice
concentrate, apple juice, chocolate liqueur, and honey,
are used in various smokeless tobacco products, and
dominant fla\,ors are often mentioned in the product


name (e.g., the Skoal Cherry, Long Cut brand). As with
manufactured cigarettes, these additivrcs increase pal-
atabilitv and may intensifv use of smokeless tobacco,
at least-among novices (Freedman 1994).

The Low-Tar "Alternative"

  As the health hazards of smoking have been in-
creasingly documented, the production of lower-tar
cigarettes has increased. The FTC's tables on avrerage
sales-weighted tar levels for cigarettes on the U.S.
market from 1968 through 1987 reflect this shift toward
lower-tar cigarette brands (USDHHS 1981,1989).' The
public health implications of this shift merit closer
inspection.

Compensatory Smoking

Considerations of product regulation must take
into account the variability in toxic exposure attribut-
able to specific smoking practices. The overall evi-
dence suggests that many smokers compensate when
smoking low-deliverv cigarettes by inhaling more tar
and nicotine than are measured by smoking machines
under standard conditions. Any potential health ben-
efit implied by machine measurements of loller tar and
nicotine yields may thus be mitigated bv such com-
pensatory smoking.

  Studies have shovzn that as consumers sl\-itched
to lower-yield cigarettes in Great Britain, they tended
to smoke more cigarettes each day (Ferris 198-l), al-`-
parently to compensate for the lovz,er nicotine yield
per cigarette. Similar compensatory measures may
have occurred in the United States. For example, smok-
ers in Cancer Prevention Study I, conducted during
the 1960s \zhen loM-er-yield brands were rare, smoked
fewer cigarettes per day than smokers in Cancer I+-
vention Studv II, which was conducted during the
198Os, by which time most smokers used louver-yield
brands (Thun et al. 1997). Strong evidence suggests
that smokers increase the number of cigarettes con
sumed as nicotine availabilitv is reduced, and vice
versa (USDHHS 1988; Kaufman et al. 1989; Palmer
et al. 1989; Stellman and Garfinkel 1989; I%egri et al.
1993; Thun et al. 1997). In addition, loller nicotine
delivery in the FTC test is associated Ivith smoking a
greater number of cigarettes (USDHHS 1988). This

compensatory effect has been confirmed in other stud-
ies (Benowitz et al. 1983; Bridges et al. 1990; Hofer et
al. 1991; Wood ward and Tunstall-Pedoe 1992; Coultas
et al. 1993); only one published study found no such
effect (Rosa et al. 1992). In an abstract, Byrd and col-
leagues (1994) reported no compensatory effect, but
their small study population may not have been rep-
resentative of all smokers; for instance, the nicotine
intake seen among the group that smoked the ultra
lo\\,-delivery cigarettes was smaller than that observed
bv others.

Health Risks From Low-Tar Cigarettes

Even when compensatory smoking is not ac-
counted for and calculations are derived from
machine-rated tar levels, the risk of lung cancer is only
slightly lower from using low-tar cigarettes than from
using high-tar cigarettes, and reduced tar level has little
if any impact on the occurrence of other cigarette-
caused lung disease or of heart disease (USDHHS 1981,
1989; Parish et al. 1995; Wannamethee et al. 1995).

  Giovino and colleagues (1996) have examined
results from several national surveys of tobacco use
for attitudes and behaviors related to the use of IoM,-
tar cigarettes. In these surveys, current smokers of low-
tar brands vvert found to be more likely than smokers
of high-tar brands to acknowledge the health risks of
smoking, to express concerns about these risks, to re-
port that they had been advised by a physician to stop,
and to report that they had experienced negative health
consequences from smoking. These smokers were also
more likely, hovvevrer, to believe that smoking a low-
tar brand reduced those risks. For example, in the 1987
National Health Interview Survey, 44 percent of smok-
ers reported that thev had switched to a low-tar
cigarette to reduce their health risk, and 48 percent of
lo\\,-tar brand users thought their brand was less haz-
ardous than most other brands (Giovino et al. 1996).
These attitudes were confirmed by a 1993 Gallup poll
in lvhich 49 percent of respondents stated that they
believed that the advertising message in terms such
`1S "low tar, " "101~ nicotine," or "lower yield" was that
the "brand [was] safer"; only 4 percent believed that
the advertisements were "false/misleading" (Gallup
Organization, Inc. 1993, p. 23).

The analysis by Giovino and colleagues (1996)
also suggested that many smokers of low-tar cigarettes
may have used these brands instead of quitting. Low-
tar &ers were more likely than high-tar users to have
tried unsuccessfully to stop smoking. Similarly, a
greater proportion of people who had successfully quit
smoking had been high-tar cigarette users. This latter


obser\ration has been confirmed in another survey:
those M.ho had stopped smoking tended to have been
higher-tar cigarette smokers (Cohen 1996). As was
previously suggested (Kessler 1994b), the higher ra-
tios of nicotine yield to tar yield in lower-tar cigarettes
than in higher-tar cigarettes could impede efforts to
quit among persons \vho smoke loiver-tar cigarettes.

  Assessment of consumer attitudes, as well as
epidemiologic consideration of health risks from
loafer-yield cigarettes, has raised concerns about the
reporting of FTC test results (Henningfield et al. 1994).
An ad hoc committee of the President's Cancer Panel,
convened in December 1994 (Jenks 1995), concluded
that consumers misunderstand the FTC test results and
should be given a range of values for smoke deliver-
ies (reflecting the M'av cigarettes are actuallv smoked)
and that these \ralues;hould be included on iach pack-
age and in all advertisements (NC1 19%). The com-
mittee also concluded that terms such as "light" and
"ultra light" are in fact health claims that mislead
consumers.

Nicotine Replacement Products

  The "safe cigarette," long sought, has not been
found (Gori and Bock 1980; USDHHS 1981,1989; Slade
1989,1993), and the axiom that no tobacco product is
safe wrhen used as intended remains true (USDHHS
1989). As long as tobacco products are sold, some
people \vill be unable to stop using nicotine (Kozlowski
1987). ILove nicotine deli\-ery devices have been tried
in test markets (R.J. Reynolds Tobacco Company 1988;
Slade 1993; Hilts 1994), and several tobacco compa-
nies have patents for various designs (David A. Kessler,
letter to Scott D. Ballin, February 25, 1994; Slade 1994;
Htvang 1995b). All designs share the ability to deliver
nicotine for inhalation with a minimum of, or no, tar-
thereby avoiding the smoking-associated increased
risk of cancer (although not the nicotine-associated
increased risk of cardiovascular disease) (USDHHS
1988).

  Nicotine replacement products have been devel-
oped and marketed by pharmaceutical companies as
adjuncts to help people stop smoking (Jarvik and
Henningfield 1993). As was discussed in Chapter 4
(see "Pharmacologic Interventions"), concerns over
possible intentional or unintentional misuse of these
products have been weighed against the health ben-
efits resulting from their effectiveness as a cessation
aid. Nicotine gum and nicotine patches, previously
approved by the FDA as prescription drugs for brief
use (months), \vere approved in 1996 for over-the-
counter use, concluding an intense examination of the

issues of nicotine availability. Both a nicotine nasal
spray and a nicotine inhaler were approved for pre-
scription use. The Drug Abuse Advisory Committee
(1994) of the FDA has expressed concern about the
potential abuse liability of the spray and the inhaler,
because the pharmacokinetics of their delivered dose
of nicotine comes closer than the gum or patch to what
occurs through using tobacco products. Benowitz and
Pinney (1998) concluded that the benefits from over-
the-counter availability of the gum and patch would
outlzeigh the risks. In December 1996, the FDA's Drug
Abuse Advisory Committee recommended approval
of the nicotine inhaler for prescription use (FDA Drug
Abuse Advisory Committee, draft minutes of Decem-
ber 13, 1996, meeting).

  Nicotine maintenance is not an approved thera-
peutic approach, but some observers have called for a
coordinated clinical and public health program to ex-
plore this option (Slade et al. 1992). A useful program
not only must substantially reduce health risks and
satisfy addicted individuals who cannot otherwise stop
using tobacco products but also must include realistic
safeguards to prevent the neM' onset of nicotine de-
pendence among the young, to prevent relapse among
those who have already stopped, and to further re-
duce overall smoking prevalence.

  The elements of such a program would include
research to (1) fully characterize the population that
lvould benefit from nicotine maintgnance, (2) identify
potential delivery devices for nicotine or an appropri-
ate analogue, (3) explore fully the safety of these de-
\rices as Mel1 as the safety of nicotine or the chosen
analogue (including assessments of potential cardio-
vascular, fetal, cognitive, and performance problems
consequent to use of the drug, as well as other poten-
tial health effects), and (4) design a drug distribution
svstem that would be acceptable to intended users but
&at would substantially limit access by novices to to-
bacco use and by those who have already been suc-
cessful at achieving abstinence from nicotine (Slade et
al. 1992).

Product Regulations for Consumer
Education

  The previous discussion of product regulation
centered on the contents of the tobacco product itself.
Another critical focus for product regulation is pack-
aging, a promising field for public information and
education on smoking and health. Government ac-
tions in this area have included product packaging to
convey health messages (see "Attempts to Regulate


Tobacco Ad\.ertising and Packaging," earlier in this
chapter). The goal of this packaging strategy, as dis-
cussed in the follo\ving section, is to help ensure that
the purchase of tobacco products occurs only as a trans-
action invol\?ng informed consumer choice. Also dis-
cussed is a related, more complex goal for this strategy:
to help ensure a situation of informed consumer con-
sent rather than simply choice.

Tobacco Packaging and Informed Choice

  The current required warning labels on U.S. to-
bacco packages are but a single, narrow means by
which package-based messages can promote informed
choice among consumers. The vast amount of infor-
mation available on the adverse health effects of to-
bacco use constitutes a \vide range of messages that
can be presented this way (USDHHS 1989). This in-
formation can appear on packages in many ways,
given the numerous variables such as size, wording,
placement, colors, graphics, typefaces, and package
inserts.

  The potential public education value of package-
based health messages is inherent in their exception-
ally large rate of exposure to consumer vierz. In the
United States, about 478 billion cigarettes \vere con-
sumed in 1997 (Tobacco Institute 1998). Each of these
cigarettes will be removed from a package that could
be vielved bv many cigarette users at exactly the time
they are preparing to engage in the activity such mes-
sages are intended to prevent. These messages can be
seen not onlv immediatelv before use but also at the
point of sale or at any time the package is in the pos-
session of the user. The messages do not have to be
directed only at tobacco users; any exposed package
can be vielved by, and can provide information equally
germane to, users and nonusers alike.

  An example of the potential inherent in package
messages is provided from Canada. In legislation
supplementing the Tobacco Products Control Act (sec.
9), the federal go\`ernment of Canada not only increased
the number of rotating messages from four to eight but
also made neiv stipulations regarding the messages'
size, location, and color (Department of National
Health and Welfare 1993; for details on these changes,
see "Examples of Product Labeling in Other Countries,"
earlier in this chapter). These changes follo\ved stud-
ies undertaken to determine the existing messages' leg-
ibility, readability, believability, and ease of
understanding. These studies had indicated that health
M-arnings were read about 1 .-I times per daV (t\romen,
1.8 times; men, 1.2 times) and that cigarette packs ivere
a primary source of tobacco-related health information

for 55 percent of smokers, second only to television (59
percent) and well ahead of newspapers (17 percent)
(Tandemar Research Inc. 1992; Kaiserman 1993).

Tobacco Use and Informed Consent

  Although many discussions of tobacco use in-
voke "free choice," the more rigorous legal concept is
"informed consent." As applied to tobacco use, in-
formed consent would obtain only when potential
purchasers of tobacco products could make fully in-
formed purchase decisions after carefully weighing the
health risks of using those products. Thus, like pa-
tients considering whether to undergo potentially
harmful medical procedures, consumers considering
whether to use tobacco would have to know which
health problems are caused by the product's use, what
increases in personal risk of these various problems
occur through this use, what the prognosis is should
any of these problems arise, and what effect ending or
adjusting the use could have on these problems.
Courts of law in this country and elsewhere have ar-
ticulated the duty of product manufacturers to warn
consumers about product hazards. A particularly clear
statement of the principles involved in informed con-
sent is found in an Ontario Court of Appeal decision
concerning oral contraceptives:

Once a duty to warn is recognized, it is manifest
that the warning must be adequate. It should be
communicated clearly and understandably in a
manner calculated to inform the user of the na-
ture of the risk and the extent of the danger; it
should be in terms commensurate with the grav-
itv of the potential hazard, and it should not be
neutralized or negated by collateral efforts on the
part of the manufacturer. The nature and extent
of any given warning will depend on what is rea-
sonable having regard to all the facts and circum-
stances relevant to the product in question (Bucl~r
i'. Orfho Plznrnlncclitical [Crrrzndnl Ltd., [ 19861 54
O.R.2d 101 [Ct. App.] [Can.]).

Similarly, a U.S. court has described an adequate prod-
uct Iyarning in the following way:

In order for a warning to be adequate, it must pro-
vide "a complete disclosure of the existence and
extent of the risk involved" (!&~/i&s ~1. GaliTejto/l
Ynchf B~sill, Itzc., 727 E2d 330 [5th Cir. 19841) citing
Almrr Brofhcrs Fnrrm ~5 Feed Mill, 117~. v. Diamomi
Laborntorics, 11x., 437 E2d 1295, p. 1303 [5th Cir.
19711). A warning must (1) be designed so it


can reasonably be expected to catch the attention
of the consumer; (2) be comprehensible and gi\re
a fair indication of the specific risks in\.ol\,ed lvith
the product; and (3) be of an intensity justified by
the magnitude of the risk (I'o:~/iil~~, p. 338).

  At issue, then, is IVhether consumers ha1.e re-
ceived adequate ivarning for informed consent to ap-
ply to tobacco use. Although public kno\\,lcdge about
the health effects of tobacco use has inipro~~ed o\-ei
the past 15 vears (FTC 1983; L:SDHHS lL)XY), widence
persists of iaps in understanding. An American Can-
cer Society (ACS) study sholred respondents a list of
selected causes of death and asked Ivhich \j.as respon-
sible for the greatest number of deaths (Marttila &
Kiley, Inc. 1993). The stud\, found that onlv one in fi1.e
Americans could corrtctl\' identif\, cigar&c smoking
as the listed cause associated \jith the most deaths. Sim-
lar studies in other countries (Hill and Gray,, I%-!; Gallup
Canada, Inc. 19%; En\-ironic5 Research Group Limited
lY91; Health and Welfare Canada lW1 [unpublished
data]) ha\-e found a similar lath of kno\~~lt~dgc.

  These studies indicate that the public continues
to underestimate the magnitude of the risks arising
from tobacco use. The resulting inabilitl, of consum-
ers to make fullv informed decisions about tobacco use
could be interpreted as a failure on the part of the
manufacturer to achie\.e informed consent from users
of the product. To date, this issue has not been legall!,
adclressed, and the pre\-iouslv discussed notion of in-
formed choice, lvhich carries clearer legal implications,
is generallv in\,oked.

Further Regulatory Steps

  Although some of the aforementioned product
regulations address the chemical constituents of to-
bacco use, none directly broaches the issue of whether
tobacco, as a nicotine deliverv svstem, should be sub-
ject to federal regulation as an addictive product. In
March 1994, the Coalition on Smoking OR Health
([CSH] composed of the American Heart Association,
the American Lung Association, and the American
Cancer Society) filed a petition with the FDA to de-
clare all cigarette products to be drugs under section
201 of the Federal Food, Drug, and Cosmetic Act (CSH
1994a). This petition follo\ved an earlier one bv the
same coalition requesting the classification of lov,-tar
and low-nicotine cigarettes as drugs and similarlv clas-
sifying the proposed nelv I~.]. Revnolds Tobacco Com-
pany "smokeless cigarette" as adrug (CSH 1WX).

  A felt- [2-eeks earlier, the FDA had made public
that it w.as in\.cstigating lvhether it might assert juris-
diction ol'er tobacco products (Kessler 1994a). The
legal basis for such a mo\`e requires demonstrating that
the manufacturers of tobacco products intend to af-
fect the structure or function of their customers bod-
ies (21 U.S.C. section 321 [g] [l]). The Commissioner
of the Food and Drug Administration, David A.
Kessler, M.D., had indicated in testimony before Con-
oress that there \vas evidence that pointed to this con-
Flusion (Kessler lYYJb,c).

  The FDA has concluded that w,ords used by to-
bacco companies to describe some effects of smoking
(e.g., "satisfaction," "strength," and "impact") are eu-
phemisms that actually describe pharmacologic effects
of nicotine (Kessler 1993b, p. 150). Dr. Kessler has
noted that cigarettes are sophisticated, carefully de-
signed de\.ices. Industry patents disclose a detailed
kno\vledgc of nicotine pharmacology and describe as
desirable those product refinements that increase the
efficiencv of nicotine deli\,erv. One company has pat-
ented a series of nicotine analogues having desired
pharmacologic effects, much as a conventional phar-
maceuCical company might develop a new drug that
produces effects similar to those of an existing drug.

  The FDA has disclosed several specific examples
of product manipulation to adjust the delivered dose
of nicotine in cigarettes (Kessler 1994~). The Brown &
Williamson Tobacco Corporation has used in cigarettes
sold in the United States a strain of tobacco (Y-l) that
had been geneticallv engineered to have a high nico-
tine content. According to a major American tobacco
company's handbook on leaf blending and product
de\,elopment, ammonia compounds can be used as
additives to boost the delivery of nicotine in smoke to
enhance the "impact" and "satisfaction" from smoke
(Kessler 1994c, p. 365). In an official prosecution
memorandum to the U.S. Attorney General, Represen-
tative Martin T. Meehan (D-MA) has asserted that
product manipulation of Eclipse brand cigarettes
has taken place. Meehan cites the addition of
high-nicotine-content tobacco near the filter and the
addition of potassium carbonate to change the pH of
the tobacco (or to enhance absorption through the mu-
cous membranes) (Meehan 1994; see "Criminal Pro-
ceedings," later in this chapter). Moreover, information
obtained from internal industry documents suggests
that at least some tobacco companies have long had
an accurate and detailed knoivledge of nicotine phar-
macology. Dr. Kessler told Congress that "such re-
search \~ould be of interest to the industry only if the
industrv \verc concerned with the physiological and
pharmacological effects of nicotine. Certainly, this is


not consistent It-it11 the inc~u5tr\.`5 wprcsentation that
nicotine is of interest to it onI\. hecause of flaI.0ur and
taste" (Kessler lYYlc, p. 36%

  Follolz,ing his testimony before Congress, in a
speech at Columbia University School of La\l-, Dr.
Kessler emphasized the importance of preventing nico-
tine dependence among children and teenagers. Call-
ing it "a pediatric disease" (David A. Kessler. Remarks.
Presented at the Samuel Rubin Program, Columbia
University School of Lalz, iXe\v L'ork Cit!; March 8,
1995, unpublished), he outlined a number of specific
priorities for public health action:

A comprehensi\-e and meaningful approach to
preventing future generations of young people
from becoming addicted to nicotine in tobacco is
needed. Any such approach should: First, reduce
the manv a\-enues of easy access to tobacco prod-
ucts available to children and teenagers; second,
get the message to our \;oung people that nicotine
is dddicti\,e, and that tobacco products pose seri-
ous health hazards--and not just for someone else;
and third, reduce the po'\verful imager\, in tobacco
ad\.ertising and promotion that encourages young
people to begin using tobacco products (p. 19).

   On August 10, 1995, the FDA announced the
result of its investigation. The agencv stated that e\,i-
dence appears to indicate that "nicotine in cigarettes
and smokeless tobacco products is a drug and [that]
these products are nicotine deli\-cr\- de\?ccs under the
Federal Food, Drug, and Cosmetic-Act" (Fc[f~~r~7/ R~;;is~
tcr 1YYJa). In August 1 YYS, the FDA issued in the F&
L'r17/ R~`;{isfc,r (1 1 a proposed rule of regulations
restricting the sale and distribution of cigarettes and
smokeless tobacco products to protect children and
adolescents and (2) an analysis of the FDA's jurisclic-
tion o\.er cigarettes and smokeless tobacco. The FDA
requested comments on its proposed regylations and
annlvsis of its jurisiiction, and indicated that it \\-ould
give-serious consideration to comments filed \Vith the
agencv concerning the evidence amassed during its
investigation. The Clinton administration also sug-
gested that Congress could eliminate the need for this
rulemaking bv passing Ned. legislation to affirm the
FDA's authority over tobacco products and address
the issue of tobacco use among minors.

  In its legal analvsis of its proposed jurisdiction
over tobacco products, the FDA argued that cigarettes
and tobacco products "affect the structure or anv func-
tion of the bode" (key language for ini,okihg the
agencv's authorizing legislation) and that it is the in-
tent oi tobacco manufacturers that their products have

addictive effects (Fed~al Rc~yisf~~r 1995a). The argument
XZ'~S presented as a logical chain of inference: the ad-
dictive properties of tobacco are "widely known and
foreseeable" by tobacco manufacturers; consumers use
the product to satisfy their addiction; and tobacco
manufacturers know of the addiction, know of con-
sumers use, and have facilitated that use (Fc~drral Rq-
ister lY95a). An extensive analysis, including internal
documents from tobacco companies, was used to elu-
cidate these assertions (Federal Register 1995a). The
FDA presented a further legal discussion of whether
the cigarette is a device and postulates that the ciga-
rette is "a consciously engineered instrument to
effectuate the delivery of a carefully controlled amount
of the nicotine to a site in the human body where it
can be absorbed" (Federrrl Rqister 1995a).

  The proposed regulations centered on restricting
the availability and appeal of tobacco products to chil-
dren and adolescents and consisted of the following
provisions:

The tobacco industry would be required to spend
at least $150 million per year to support smoking
pre\,ention education for children.

Tobacco sales would be prohibited to those under
18 years of age, and vendors would be required to
see photo identification as proof of age.

Vending machines, self-service displays, and mail-
order sales \vould be prohibited, as would the sale
of incli\.idual cigarettes or packs of fewer than 20
cigarettes.

The sale or gift of promotional items bearing brand
names, logos, or other brand identity bvould be
prohibited.

Free samples \~ould be banned.

Only black-and-Mhite text advertising for cigarette
products ivould be permitted in publications for
I\-hich more than 15 percent of the readership is
under age 18 and in publications with more than 2
million voung readers.

Outdoor tobacco advertising kvould be prohibited
\\.ithin 1,000 feet of schools and playgrounds. All
other outdoor tobacco advertising would have to
be in black-and-Mhite text.

Sponsorship of sporting or entertainment events
using specific brand names or product identifica-
tion would be prohibited, although the use of com-
pany names would not.


  The proposed regulations stirred immediate
action from the tobacco industrv. Four lan.suits
were filed immediatelv after the F~Jcvi7/ Rr,~isf~,~
announcement. A larvsu;t filed bv tobacco companies
in federal court in Greensboro, North Carolina, as-
serted that the FDA had no jurisdiction o\.er cigarettes.
The plaintiffs l\.ere Bro\vn & Williamson Tobacco Cor-
poration, Liggett Group Inc., Lorillard Tobacco Con-
pan);, Philip Morris, and R.J. Re\,nolds Tobacco
Company (Czir7ll Sfrwt /~lfivllrll lYY5).~ Parts of the ad-
\ ertising industr!: Ivhich has a large stake in the out-
come of the proposed regulations, also filed suit on
the grounds of infringement of First Amendment rights
(,-lffwrimf7 24di7~~rtisirig Fdt~ri7tioi2 i'. K~5slf~r. Civil Action
No. 2:95CVOO593 [M.D.N.C. Aug. 10,1995], cited i/7 10.5
PPLR 3.401 [lY95]). In addition, a smokeless tobacco
companv (UII;~& Stiltf5 Tr~lwcio CP 7'. Fwif iril[f Drfiq
.-\dllrillj~fl.l7fj~l,l, Ci\.il Action ho. h:Y5CV0066f
[M.D.N.C. Sept. 19, 19931) and a trade group repre-
senting con\.cnience stores (N~rtior7i7/ A5.5ch-ii7ti~~i1 (If Ctlff-
ili~llitvfc~~ S/r)fw il. k'twlflr, Ci\.il Action No. ?!:YSCVOO70h
[M.D.N.C. Oct. 1, 19951) filed suit.

  By the January 2, 1996, close of the public con-
ment period on the proposed rules, the FDA had re-
cei\-ed more than 95,000 indix-idual comments, the
largest outpouring of public response in the agency's
history. From March 18 to April 19, lYY6, the FDA re-
opened the comment period for the limited purpose
of seeking comments on the statements of three former
Philip Morris employees about that company's alleged
manipulation of nicotine in the design and production
of cigarettes and to seek comments on further expla-
nations of certain provisions in the proposed rule.

  The re\ie\v process culminated in a Rose Gar-
den ceremony at the White House on August 23,1996,
in ivhich President Clinton announced the publication
of the final FDA rules. To emphasize that the FDA's
central intent was to reduce tobacco use among young
people, these final rules essentially regrouped the regu-
lations from the original announcement into t\vo cat-
egories: reducing minors' access lo tobacco products
and reducing the appeal of tobacco products to m-
nors. The only notable changes to the former rules
\vere that the ban on mail-order sales \\ras eliminated
and the ban on vending machines and self-ser\+ce
displays was relaxed to allow exceptions for certain
nightclub and other "adults-onlv" facilities totallv in-
accessible to persons under the-age of 18. Similarly,
the limitation to black-and-white text for in-store
advertising excepted adults-onlv facilities if the adlw-
tising was not visible from the butside.

  In place of its original regulation requiring the
tobacco industry to spend at least 5130 million each

year to support tobacco prevention education for chil-
dren, the final rules lvere less explicit. The FDA pro-
posed to require the six tobacco companies with a
significant share of sales to minors to educate that
population about the health risks of using tobacco
products. This action \\fould be pursued under pro-
cesses dictntecl by section 518(a) of the Federal Food,
Drug, and Cosmetic Act (FDCA). Cnder the act, the
FDA may require manufacturers to inform the
consumer about unreasonable health risks of their
products.

  The various provisions were to be phased in be-
hveen six months and t\vo years from August 28,1996,
the date of publication in the Fcdcr-nl R~yisfcv. Two prin-
cipal hurdles to quick and full implementation of the
FDA regulations soon emerged. First, as noted above,
sel.eral tobacco companies, retailers, and advertisers
had sued the FDA to block implementation of the regu-
lations. Second, \.arious legislative proposals, which
began circulating in Congress both before and after
publication of the FDA's final rule, threatened to alter
or bar the FDA's regulation of tobacco products.

Judicial Developments and the Status of FDA
Regulations

  Three briefs filed on October 15, 1996, on behalf
of the plaintiffs in these suits moved for summary judg-
ment, arguing that the proposed regulations exceed
the agency's jurisdiction and are contrary to congres-
sional intent, that tobacco products are not "drugs" or
"de\.ices" ivithin the agency's statutory grant of au-
thority, and that the advert&g restrictions are a vio-
lation of the First Amendment (M~wlcy's Lifipfior~
R~~pol.t~: Toh7cic~ 1996b).

  On April 25, 1997, the federal district court in
Greensboro, North Carolina, ruled that the FDA pos-
sessed the authority to regulate cigarettes and smoke-
less tobacco products as drug delivery devices under
the FDCA (Coyrw Rcnlw, Ii~c. il. U.S. Ford C Dq Ad-
~r~irfistmtirv~, 966 F. Supp. 1374 [M.D.N.C. 19971). The
ruling, how-e\w, marked a considerably qualified vic-
tory for the FDA. Although the court upheld all of the
agency's restrictions involving youth access and label-
ing, the court temporarily blocked implementation of
most of these pro\,isions. Only the FDA's prohibition
on sales of cigarettes and smokeless tobacco to minors
and the requirement that retailers check photo identifi-
cation of customers who are under 27 years of age es-
caped the court's stay. These provisions went into effect
on Februarv 28, 1997; and remained in force until March
21, 2000, tl;e date of the Supreme Court decision.


  Notably, the court in\-alidated the FDA's restric-
tions on advertising and promotion ot cigarettes and
smokeless tobacco on the basis that thev exceeded the
agencv's statutorv jurisdiction. The pertinent federal
statut;, 21 G.S.C. section 360j(e), provides, in part, that
the government may "require that A de\.ice be re-
stricted to sale, distribution or use. upon such other
conditions as the Secretarv nmv prescribe." The FDA
had argued that it \vas au;hori/ed to restrict the "sale,
distribution or use" of tobacco products pursuant to
section 360j(e) and that its advertising nncl promotion
restrictions lvere valid becd~lse advertisitlg and pro-
motion constitutes an "offer of sale" (Cwrlc' R~w/fIf!,
p. 13%). Judge William L. Osteen Sr. disagreed. The
court reasoned that the \\.ord "sale" as emploved in
the statute did not encompass the advertising or pro-
motion of a product. The court also ruled that the
"section's grant of authoritv to FDA to impose `other
conditions' on the sale, distribution, or use of restricted
devices [does] not authorize FDA to restrict advertis-
ing and promotion" (p. 1398). Furthermore, because
the court ruled that the FDA \\`as not authorized to
restrict advertising and promotion, the court did not
reach or discuss arguments that these prol~isions
\.iolated the First Amendment to the United States
Constitution.

Most important, holzcver, Judge Ostetn agreed
lvith the FDA's contention that tobacco products fall
x1-ithin the "drug" and "dc\,ice " definitions of the
FDCA. To position its authority ivithin these defini-
tions, the FDA had to 1iai.e demonstrated that tobacco
products are "intended to affect the structure or an\'
function of the body" (21 U.S.C. section 331 Is111 Ilclj.
Judge Osteen ruled that the effects of tobacco prod-
ucts are "intended" I\-ithin the meaning of the FDCA
and that tobacco products affect the structure or funs-
tion of the body \\-ithin the meaning of that act. Thy
court also ruled that pursuant to its "de\.ice authori-
ties," the FDA could regulate tobacco products as
medical devices.

Both sides in the case appealed the decision
to the Fourth Circuit of the United States Court of
Appeals in Richmond, Virginia. The go\,ernInent
and the tobacco companies presented oral arguments
to a three-member panel of this court on August 11,
1997. The case became inacti\ e follmz-ing the death of
one of the panel judges on Februarlr 22, 19%. A neI\
judge ivas appointed, and on June?, 1998, the three-
member panel conducted a second hearing on the
appeal.

The Court of Appeals Ruling on FDA Authority

  On August 11, 1998, the Fourth Circuit Court of
Appeals overturned the lower court decision and ruled
in a 2 to 1 decision that the FDA lacks the authority to
regulate tobacco products (B~OXIII G Willin TO~CCO
COI./L ~1. Food & Drq Adnlirli~f,,atiorz, No. 97-1604 [4th
Cir. lY%]). The majority opinion (Judge H. Emory
Widener Jr.) found that the FDA had based its deter-
mination of authority solely on literal interpretations
of "drug" and "device" in the FDCA but did not con-
sider statutorv language as a whole, the legislative his-
tory, and thee history of evolving congressional
regulation in the area, including consideration of other
relevant statutes. Judge Widener held that there is an
internal inconsistency in the FDA's claim of authority
to regulate tobacco under the FDCA, since a declara-
tion that cigarettes are unsafe (the basis of the FDA's
claim) necessitates a ban on cigarette sales-an action
that lsould be opposed by polverful economic and
political forces. Widener reasoned that although the
FDA M-ould ha\,e the authority to grant exemptions to
the ban because potential public health benefits might
out\veigh harms, such exemptions M-ould undermine
the agency's essential vie\\, that cigarettes are unsafe.
The only exemption open to the FDA would thus be
based on social and economic rather than health-
related considerations. A rvell-known catch \~ould
then corme into play: social and economic consider-
ations are within the pur\.icc\~ of Congress, not the
FDA. Judge Widener pointed out that Congress had
been a\vare for decades that the FDA lacked the au-
thority to regulate tobacco on social and economic
grounds, had rejected attempts to gi1.e the FDA such
authority, and had enacted numerous pieces of legis-
lation that did not grant such authority.
  The dissenting opinion (Judge Kenneth K. Hall)
took the position that the intrinsic contradiction in the
FDA's authority under the FDCA is irrelel,ant: ".
ivhether the regulations contravene the statute is a
question ~,holl>, apart from IVhtther any regulations
could be issued. It is no argument to say that the
FDA can do nothing because it could have done more"
(BIVZ'II & W~//~~~~~~S`CIII, p. 48). The opinion proposed
that the FDA's current position is a response to "the
increasing level of knoll.-ledge about the addicti1.e
nature of nicotine and the manufacturer's deliberate
design to enhance and sustain the addictive effect of
tobacco products" (p. JO). Judge Hall stated that prec-
edents in administrative la\v clearly indicate latitude
for an agency to change its approach in the light of
ne\v information. He further asserted that earlier toll-
qessional action clid not ha\.e the benefit of the lel,el
h


of elidense gathered LX. the FDA in forming its cur-
rent position. Finall\,, iie pointed out that the term
"sale, distribution and LIW" (p. 58) is not full\. defined
in the FDCA and is therefore subject to agencl' inter-
pretation. This term "can reasnnabl!~ be construed to
include all aspects ot a product's journev from the fac-
tow to the store and to the home" (p. 5X). Thus, the
judge reasoned, the authorit!, to regulate tobacco pro-
motion should be upheld. The full Fourth Circuit
Court of Appeals declined to rc\-ie\\- this rc\.ersal. The
i?o\.ernment petitioned the United States Supreme
?ourt for re\-ielv, and the United States Supreme Court
accepted the case in April 1999. Oral ar:;unient l\.ds
held December 19YY, and the Court, in a 5 to 1 deci-
sion, upheld the Fourth Circuit's decision on hlnrch
2 1 , 2000.

The U.S. Supreme Court Ruling on FDA Authority

  On March 21, 2000, b\, a 5 to 1 \ ate, the United
States Supreme Court affi&ned the Fourth Circuit dc>-
c&ion and o\.erturncd the FDA's asserticon of jurisdic-
tion o\-er cigarettes and smokeless tobacco products
(F~J0tf 1717rf nIX&' .,~il~lli,li~tr'iltic,r, ;`. RULi'Ii & 1t'i//i,7,775clIl
Td'ilii0 Corp., 53Y U.S. [20001, 120 s. c-t. I31 1.
,J.s a result, the FDA no longer has regulator\. author-
itv to enforce the final rule it issued in 1 YYh.
  Justice Sandra Da\' O'C onnor \\.rotc the majorit\.
opinion for the Court. In ruling h
                  acrainst the FDA, she
noted that "The agencv has ampI\, demonstrated that
tobacco use, particularl\, among childi-en and adoles-
cents, poses perhaps thi single most significant threat
to public health in the United States" (p. 1315). Ne\ -
ertheless, the majoritv ruled that Congress had pre-
cluded the FDA from asserting jurisdiction o\.er
tobacco products as customarilv marketed because
"5uch authoritv is inconsistent \vi;h the intent that Con-
gress has expressed" (p. 1297) in the Federal Food, Dmg,
and Cosmetic Act and other tobacco-specific statutes.
  Justice O'Connor noted the unusual nature of
both the case the Court \j.as deciding and the role of
tobacco in the United States. She tvrote:

Otving to its unique place in American historv and
society, tobacco has its o\vn unique political historv.
Congress, for better or for \vorse, has created a dik-
tinct regulatorv scheme for tobacco products,
squarelv rejected proposals to gi\pe the FDA juris-
diction o\-er tobacco, and repeatedly acted to pre-
clude anv agencv from exercising significant
policymaking autllorit!. in the area (p. 1315).

  Justice Stephen Breyer wrote the dissenting opin-
ion. He disagreed lvith the majority view that Con-
gress never intended the FDA to have the authority to
assert jurisdiction over tobacco products. In summa-
rizing \vhy the four justices in the dissent believed the
FDA had acted la\vfully, Justice Breyer tvrote:

The upshot is that the Court today holds that a regu-
latory statute aimed at unsafe drugs and devices
does not authorize regulation of a drug (nicotine)
and a de\.ice (a cigarette) that the Court itself finds
unsafe. Far more than most, this particular drug
and de\,ice risks the life-threatening harms that
administrati\,e regulation seeks to rectify (p. 1331).

Legislative Developments

In an effort to claiify the public health perspec-
ti\.e on potential legislation, on September 17, 1997,
President Clinton outlined the principles he believed
must be at the heart of any national tobacco legisla-
tion (1 lohler lYY7):

.A comprehensi\.e plan to reduce youth smoking,
includin;: tough penalties if targets are not met.
Full authority for the FDA to regulate tobacco
products.

An end to the tobacco industrv's practice of
marketing and promoting tobacco-to children.
Broad document disclosure (especially of those
documents relating to marketing tobacco to
children).

Progress to\zard other public health goals, such as
reducing environmental tobacco smoke (ETS), ex-
panding smoking cessation programs, strengthen-
ing international efforts to control tobacco, and
pro\,iding funds for health research.

Protection for tobacco farmers and their communities.

   A number of bills intended to enable the enact-
ment of the June 20,1997, multistate settlement agree-
ment Tvere introduced into the U.S. Senate in late 1997
and earlv 1998. In March 1998, the Senate Commerce
Cornmit;ee bill introduced bv Senator John McCain
(R-AZ) became the focus oi all settlement-related
legis1atiL.e activity in the Senate. The Commerce
Committee endorsed a preliminary version of a sub-
stitute bill, S. 1415, on March 30, 1998, bv a wrote of 19
to 1. On Ma\ 1, 1998, the Commerce Committee's \`el--
sion of the bill-S. 1115.IiS (the "McCain Committee


Bill")--Mas reported by Senator McCain to the full
Senate. Among other things, the McCain Committee
Bill would have done the follo\ving:

o Required the tobacco industry to pay $516 billion
($147.5 billion more than was specified in the June
20th multistate settlement agreement) over 25 years
to help states and the federal government bear the
medical costs of smoking-related illness.

o Raised cigarette taxes by $1.10 per pack over five
years.

. Preserved the FDA's ability to regulate the
tobacco industry in ways that the June 20th agree-
ment did not.

o Drastically reduced cigarette marketing, advertis-
ing, and promotion (Kelder 199X).

  In addition, the Floor Manager's Amendment to
the bill would have established a detailed regulatory
scheme to be administered by the FDA (S. 1415.RS
[Floor Manager's Amendment of May 18, 1998, 105th
Cong., 2nd Sess.]). First, the FDA could designate de-
monstrablv safer products as "reduced risk tobacco
products"<sec. 913[a][2][A]). Second, the FDA would
have the authority to promulgate performance stan-
dards, including "the reduction or elimination of nico-
tine yields" (sec. 907[a1(2][Al[l]) and "the reduction
or elimination of other constituents or harmful com-
ponents of the product " (sec. 907[a][2][A][ii]). The
agency \vould follo\~ normal administrati\se proce-
dures, unless it sought to eliminate "all cigarettes, all
smokeless tobacco products, or anv similar class of
tobacco products" (sec. 907[b][3][A]j or to require "the
reduction of nicotine yields of a tobacco product to
zero" (sec. 907[b][3][8]). In that tl'ent, the amendment
stipulated, "the standard may not take effect before a
date that is 2 vears after the President notifies the Con-
gress that a iinal regulation imposing the restriction
has been issued" (sec. 907[b][3][B]). Third, the Floor
Manager's Amendment \1rould ha\re required that the
FDA be given the additive information specified in the
settlement agreement Mithin six months of enactment
(sec. 904[a1[31).

The amendment would also ha\:e required that
manufacturers share \yith the FDA "all documents.
relating to research activities, and research findings,
conducted, supported, or possessed by the manufac-
turer (or agents thereof) to the health, behavioral,
or phvsiologic effects of tobacco products, their con-
stituents, ingredients, and components, and tobacco
additives" (sec. 904(a][l]) or "to marketing research

involving the use of tobacco products" (sec. 904Ia1[51).
Tobacco product advertising would be required to in-
clude a "brief statement of the uses of the tobacco prod-
uct and relevant warnings, precautions, side effects,
and contraindications" (sec. 903[a1[81[Bl[i]). Further-
more, the FDA would be given explicit power to im-
pose "restrictions on the access to, and the advertising
and promotion of, the tobacco product" (sec. 906[d][ll).

  Senate bill 1415 was vehemently opposed by the
tobacco industry. On April 8, 1998-nine days after
the Commerce Committee endorsed the preliminary
version of the McCain Committee Bill-Steven F. Gold-
stone, RJR Nabisco's chief executive officer, announced
that his company was pulling out of the congressional
process for developing comprehensive tobacco legis-
lation. Blaming Congress for failing to stick to the
terms of the June 20th agreement, Mr. Goldstone,
speaking to the National Press Club in Washington,
DC, declared his company's intention not to sign the
consent decrees to voluntarily limit advertising that
were part of the McCain Committee Bill. Philip Mor-
ris, Brown & Williamson, United States Tobacco, and
Lorillard made similar announcements shortly after
Mr. Goldstone's speech.

In retrospect, one can conclude that this tobacco
company brinkmanship-when paired with a widely
disseminated, industry-sponsored advertising cam-
paign that portrayed the McCain Committee Bill as a
vast "tax-and-spend" proposal-was a major force in
scuttling the proposed legislation. Emboldened by the
effect that the industry-sponsored advertising campaign
had on public opinion, the tobacco industry's Senate
allies greatly altered the McCain Committee Bill, cul-
minating in the Floor Manager's Amendment on May
18, 1998. Some of these amendments would have in-
creased the bill's potential harmful impact on public
health. For example, in this final form, the bill had been
shorn of almost all of its funds for initiatives to fund
tobacco use redtiction, and the tobacco industry had
been given a potential means of immunity in the form
of caps on plaintiffs' attorneys' fees (Kelder 1998).

  On June 17,1998, the McCain Committee Bill died
after four weeks of intense debate and political ma-
neuvering. In the absence of congressional action to
enact the proposed settlement, individual state law-
suits proceeded. Four states-Mississippi, Florida,
Texas, and Minnesota-have settled their suits with
the tobacco industry. Because these settlements in-
volve the recovery of Medicaid payments made by the
states, they are discussed with other such litigation
approaches, later in this chapter (see "Recovery Claims
bv Third-Party Health Care Payers").


Master Settlement Agreement

  On November 23, 1998, 11 tobacco companies
executed a legal settlement \\ith 16 states, the District
of Columbia, and fi1.e cnnimonrvealths and territories.
The plaintiffs had sued the tobacco industrv to recoup
I\edicaid costs for the care of persons injured b\,
tobacco use. The suit alleged that the companies had
\?olated antitrust and consumer protection la\vs, had
conspired to lvithhold information about acl\-erse
health effects of tobacco, had manipulated nicotine It\.-
els to maintain smoking addiction, and had conspired
to \vithhold lolver-risk products tram the market.

  In the settlement, the companies agreed to pa!.
states 5216 billion o\.er 25 vears. But in addition, the
settlement agreement contained a number of impor-
tant public health pro\-isions (see the test box). The
agreement placed significant marketin, 0 restrictions on
the industry bv prohibiting direct ad\.ertising and pro-
motion aimed at \roung people, LX. limiting brand nanit`
sponsorship at &.ents that might be frequenttyl LX
vouth, bv requiring the renio\.al of street ad\-c,rtisin;:
lvithout restrictions on cnunterdcl\.ei-tisin~, L~J. plaiins
substantial restrictions on lobbvin;: and on the suppres-
sion of research findings, and bir requiring major coon-
tributions from the industrv to cessation and pre\.twtion

Clean Indoor Air Regulation

activities (Wilson 1YYY). In addition, the agreement dealt
I\-ith such issues as legal fees, court supervision, civil
liabilities restrictions, and public disclosure. Unlike the
1997 settlement, the 1998 settlement contained no pro-
visions regarding FDA authority.

  The agreement raised a number of issues for
states, but foremost among these has been the compe-
tition bettreen tobacco control efforts and other state
spending priorities. The National Governors Associa-
tion issued a policv statement that reaffirmed states'
entitlement and asserted that the federal go\rernment
had no legitimate claim to settlement funds. The asso-
ciation committed to spending "a significant portion of
the settlement funds on smoking cessation programs,
health care, education, and programs benefitting chil-
dren" but reser\.ed the right to make funding decisions
tailored to states' indi\?dual needs (National Governors
Asvwiation IYYY). Bv micl-lC)Y9, 37 states had allocated
their first and second settlement payments. Of these,
2.3 had specified some portion of the monev for public
health activities, and 16 had specifically -designated
sptwding for tobacco control and prevention efforts.
Specific issues related to the allocation of Master Settle-
ment Agreement funds to tobacco control efforts in
states are discussed in Chapter 7.

Introduction

  If the regulation of tobacco products themsel\.es
has been characterized bv ~10~. and incremental ad-
vances, the regulation of where and ho\v tobacco prod-
ucts are used-that is, the regulation of exposure,
particularly of nonsmokers, to ETS-has encountered
comparatively little resistance. Public and private
steps to regulate ETS have become both more com-
mon and more restrictive o\ser the past se\.eral decades.

  There arc various reasons for this broad and rapid
implementation. One reason is that the public health
necessity of regulating ETS exposure is manifest: ETS
is known to cause acute and chronic diseases in non-
smokers (National Academv of Sciences 1986;
USDHHS 1986; National Institute for Occupational
Safety and Health 1991; EPA 1992; California EPA
lQY7): Moreover, this demonstrated health threat is
unentangled with legal or ethical issues ot "informccl

choice" or "informed consent" (see "Product Regula-
tion," earlier in this chapter)-hence a popular name
for this exposure, fwssiw smoking. Regulating ETS
exposure also has important implications for reduc-
in;: smoking: studies have shown that restricting
smoking in public settings increases the likelihood that
smokers in these settings smoke fewer cigarettes or
quit smoking entirely (Petersen et al. 1988; Borland et
al. 1990a; Stillman et al. 1990; Sorensen et al. 1991a;
Woodruff et al. 1993). It has been estimated that the
combined effect of general smoking cessation and
smoking reduction in public settings could decrease
total cigarette consumption by as much as 40 percent
(Woodruff et al. 19931, although this conclusion may
be questioned based on assessment of worksite inter-
ventions (see "Worksite Programs" in Chapter 4). A
second reason for the expansion of ETS regulations is
that their public support, a kev marker for successful


Major Provisions of the Master Settlement Agreement

I n addition to the monetar\, pavments from the
                       _ .
tobacco industry to states, the settlement pro-
vided for other requirements and restrictions:

Youth Access

No free samples except in an enclosed area
where operator ensures that no underage
persons are present.

No gifts to youth in exchange for buying tobacco
products.

No gifts through the mail without proof of age.
Prohibits sale, manufacture, or distribution of
cigarettes in packages of felver than 20 until
December 31, 3001.

Marketing

o  No brand name sponsorship of concerts, team
sporting el.ents, or e\.ents l\.ith a .significant
irouth audience.

o  No sponsorship of e\ ents in \vhich paid partici-
pants are underage.

o Bans use of tobacco brand names in stadiums
  and arenas.

.  Bans use of cartoon characters in tobacco ad\-t,r-
tising, packaging, and promotions.

o  Bans payments to promote tobacco products in
entertainment settings, such as mo\ies.

o  Bans distribution and sale of merchandise \\ith
brand name tobacco logos.

Lobbying

o  Prohibits industr!, from supporting di\wsion of
settlement funds to nonhealth LISTS.

o  Restricts industr!- from lobbying against restric-
tions of advertising on or in school grounds.

o  Prohibits ne\z challenges by the industry to state
and local tobacco control 1arl.s enacted before
June 1, 19%.

Outdoor Advertising

o  Bans transit and outdoor advertising, including
billboards.

o Tobacco billboards and transit ads to be
removed.

o At industry expense, states could substitute
advertising discouraging youth smoking.

Cessation and Prevention

o  The tobacco industry will contribute $25 million
annually for 10 years to support a charitable
foundation established by the National Associa-
tion of Attorneys General to study programs to
reduce teen smoking and to prevent diseases
associated lvith tobacco use. The foundation,
since named the American Legacy Foundation,
is governed by a board and will carry out a sus-
tained national advertising and education pro-
gram to counter tobacco use by young people
and educate consumers about the health hazards
of tobacco use. It w?ll also evaluate the effec-
ti\,eness of counteradvertising campaigns,
model classroom educational programs, and ces-
sation programs and Lvill disseminate the results.
Other actit?ties include commissioning and
funding studies on the factors that influence
vouth smoking, developing training programs
ior parents, and monitoring youth smoking to
determine the reasons for increases or failures
to decrease tobacco use rates.

o  The industry Mill contribute $1.15 billion over
five years to support the National Public Edu-
cation Fund, which will carry out a national sus-
tained advertising and education program to
counter youth tobacco use and to educate con-
sumers about tobacco-related diseases. The to-
bacco industry will continue to contribute $300
million annually to the fund as long as the par-
ticipating tobacco companies hold 99.05 percent
of the market.


implementation, is implicit: national studies suggest
that most of the U.S. public experiences discomfort and
annoyance from ETS exposure (CDC 1988,1992b), and
smaller-scale surveys have found that the great ma-
jority of both nonsmokers and smokers favors smok-
ing restrictions in various public locations, including
the workplace, restaurants, and bars (CDC 1991). A
third reason is that employers might be expected to
support ETS regulations, because prohibiting smok-
ing in the workplace can help employers realize lower
maintenance and repair costs of buildings and prop-
erty, lower insurance costs, and higher productivitv
among nonsmokers (Mudarri 1994). Employer sup-
port, however, may be influenced by other factors (see
"Effectiveness of Clean Indoor Air Restrictions," later
in this chapter).

  Not surprisingly, during the 1980s the tobacco
industry identified ETS regulation as the single most
important issue confronting the industrv's economic
future (Chapman et al. 19901. The industry is con-
cerned that the increasing focus on ETS mav cause the
public and policymakers to view smoking as an envi-
ronmental issue rz-ith broad social consequences in-
stead of as a personal beha\+or in\,olving indi\-idual
choice. The tobacco industrv is also concerned about
legal backlash from possib-le ETS-related litigation
against employers and about revenue losses from pos-
sible decreased cigarette consumption due to smok-
ing restrictions (Chapman et al. 1990). An example of
the latter concern may be found in California, M-here
Tvorkplace restrictions extant in 1990 have reduced
consumption by an estimated 148 million packs per
year, at a value of 5203 million in pretax sales (Wood-
ruff et al. 1993).

Health Consequences of Exposure to ETS

  The detrimental health effects of exposure to ETS
are well established (National Research Council 1986;
USDHHS 1986,200Ob; EPA 1992; California EPA 1997).
The most comprehensive revierv of the respiratory ef-
fects of ETS to date is the 1992 report of the EPA, which
states that ETS is a human lung carcinogen that annu-
ally accounts for approximately 3,000 lung cancer
deaths among adult nonsmokers in the United States.
Autopsy reviews (Trichopoulos et al. 1992) and stud-
ies of ETS metabolites in body fluids (Hecht et al. 1993)
provide biologic support for epidemiologic studies
linking ETS and lung cancer. ETS also has subtle but
significant effects on the respiratory health (including
cough, phlegm production, and reduced lung function)
of adult nonsmokers.

  Among children, ETS has far-reaching health ef-
fects. ETS causes bronchitis and pneumonia, account-
ing for an estimated 150,000-300,000 annual cases in
infants and young children, and causes middle ear
diseases (infections and effusions). ETS causes addi-
tional episodes of asthma and increases its severity,
worsening an estimated 400,000-l,OOO,OOO cases
annually. As a risk factor for new cases of asthma,
ETS may account for 8,000-26,000 annual cases (EPA
1992; California EPA 1997).

  In an important ruling, Judge Osteen of the U.S.
District Court annulled Chapters l-6 and the Appen-
dices to the EPA's 1992 report (EPA 1992; F~~IL'-CUY~~
TO~WCCCI COO/JL'~l7tii'l' Sf~bili;~ti~t? CO~,LJ. iI. United SfflfPs
El7i~irorlr77r7ltnl Protccfion A~E~IcJ/, 4 F. S~pp. 2d 435
[M.D.N.C. 19981). The decision was a mix of proce-
dural and scientific concerns. Judge Osteen found that
the EPA had not complied with the procedural require-
ments of the Radon Gas and Indoor Air Quality Re-
search Act of 1986, had acted bevond congressional
intent, and had violated administrative law procedure
by dra\ving conclusions about ETS prior to conclud-
ing a scientifically sound risk-assessment study. The
judge \vas also concerned with the amount of evidence
in the record supporting EPA's final basis for its plau-
sibility hypothesis, \vith some of the animal labora-
tory tests that he felt were inconclusive but were cited
as compelling evidence of the dangers of ETS, and with
the EPA's choice of epidemiologic studies to support
its findings.

  Considerable information appeared after the
EPA's 1992 report that supported its general conclu-
sions (Brownson et al. 1992a; Stockwell et al. 1992;
Fontham et al. 1994; Cardenas et al. 1997). A recent
meta-analysis of workplace ETS exposure and increased
risk of lung cancer also provided needed epidemiologic
support (Wells 1998). The ninth EPA report on carcino-
gens was released in the year 2000 and lists ETS as a
known carcinogen for the first time (USDHHS 2000).

  Since the 1992 EPA report, further evidence link-
ing ETS and heart disease has been assembled as well.
(Glantz and Parmley 1995; Steenland et al. 1996; Cali-
fornia EPA 1997; Kawachi et al. 1997; Law et al. 1997;
Howard et al. 1998; Valkonen and Kuusi 1998; Wells
1998). If ETS is a causal risk factor for coronary heart
disease, it likely accounts for many more deaths from
heart disease than from lung cancer (EPA 1992; Wells
1994). A review of 12 epidemiologic studies has esti-
mated that ETS accounts for as many as 62,000 annual
deaths from coronary heart disease in the United States
(Wells 1994). However, because smoking is but one of
the manv risk factors in the etiology of heart disease,


quantifving the precise relationship betlz-een ETS and
this diskase is difficult.

  Strong evidence is also accumulating that ETS is a
risk factor for sudden infant death syndrome (Jinot and
Bayard 19%; DiFranza and Lew lYY5; Klonoff-Cohen
et al. 1995; Anderson and Cook 1997; California EPA
1997; Alm et al. 1998; Dybing and Sanner 1999). In a
large U.S. study, maternal exposure during pregnancy
and postnatal exposure of the netvborn to ETS increased
the risk of this syndrome (Schoendorf and Kiely 1992).

Other Consequences of ETS

  Separate from their concerns about direct health
effects, most nonsmokers are annoyed by ETS expo-
sure (CDC 1988; Bro\vnson et al. 1992b). U.S. survey
data have suggested that 71 percent of all respondents,
including 43 percent of current smokers, are annoyed
by ETS (CDC 1988). Similarly, data from urban St.
Louis and Kansas City, Missouri, have sholvn that 66
percent of all respondents and nearly 40 percent of
current smokers lvere annoyed bv ETS exposure
(Brownson et al. 1992b). The term "annoyance," a
seemingly minor attribute, has some nontrivial rami-
fications. Public attitudes tolrard smoking, an amal-
gam of concerns about health and social interactions,
have changed in the past decade, as is discussed in
greater detail in the section "Effectiveness of Clean
Indoor Air Restrictions," later in this chapter. The find-
ings from one survev suggested that the proportion of
Americans ~.ho fa\,&ed a total ban on smoking in res-
taurants and Lvorkplaces increased from less than one-
fifth in 1983 to almost one-third in 1992 (Gallup
Organization, Inc. 1992). The proportion fa\.oring no
restrictions fell from as high as 13 percent in 1983 to 5
percent in 1992. Similarly, by 1992, more than 90 per-
cent of respondents favored restrictions or a total ban
on smoking in trains and buses as rvell as in hotels
and motels. More than 90 percent "agreed" or
"strongly agreed" that ETS is injurious to children,
pregnant \\-omen, and older adults. Thus, an impor-
tant consequence of information on ET'S has been a
changing social norm regarding smoking and an evol\--
ing foundation for clean indoor air regulations.

  Because of the consequences of ETS, employers
are likely to save costs by implementing policies for
smoke-free \vorkplaces. Savings include those associ-
ated with fire risk, damage to property and furnish-
ings, cleaning costs, workers compensation, disability,
retirement, injuries, life insurance, absenteeism, pro-
ducti\ritv losses, and svnergistic occupational risks
such as asbestos exposure (Kristein 1989). Such costs
\vere estimated at 51,000 per smoking employee in 1488

clollars. In a recent report on the savings associated
with a nationwide, comprehensive policy on clean in-
door air, the EPA estimated that such a law would save
$4 billion to $8 billion per year in operational and
maintenance costs of buildings (Mudarri 1994).

Prevalence of Exposure to ETS

  Exposure to ambient tobacco smoke is wide-
spread. The 1988 National Health Interview Survey
reported that an estimated 37 percent of the 79.2 mil-
lion U.S. nonsmoking workers worked in places that
permitted smoking in designated and other areas and
that 59 percent of these experienced moderate or great
discomfort from ETS exposure in the workplace
(National Center for Health Statistics 1989). Since the
advent of urinary cotinine screening, firmer documen-
tation of ETS has become available. In a study of 663
nonsmokers attending a cancer screening, Cummings
and colleagues (1990) found that 76 percent of partici-
pants were exposed to ETS in the four days preceding
the interview. The authors concluded that the work-
place and the home \vere the primary sources of ETS
exposure among these nonsmokers. The best single
predictor of urinary cotinine was the number of smok-
ers among friends and family members seen regularl)
by the study participant. In a study of 881 nonsmok-
ing \,olunteers, Marcus and colleagues (1992) found
that employees in workplaces that were "least restric-
tive" (i.e., allo\,ved smoking in numerous locations)
\vere more than four times more likely to have detect-
able salilra cotinine concentrations than employees
from smoke-free workplaces were (p. 45).

  The largest study of population exposure to ETS
!1-ith biochemical markers is the CDC's Third National
Health and Nutrition Examination Survey, conducted
from 1988 to 1991 on a nationally representative sample
of 16,818 persons aged 2 months and older (Pirkle
lYY6). Serum cotinine was measured in 10,642 partici-
pants aged 4 years and older. The data indicate high
concordance between reported ETS exposure and se-
rum cotinine le\,el. Among nontobacco users, 87.9
percent had detectable levels of serum cotinine, and
the le\,el M'as significantly and independently associ-
ated \vith both the number of smokers in the house-
hold and the number of hours of work exposure. The
authors concluded that both the work and the house-
hold environments make important contributions to
the lvidespread exposure to ETS experienced by chil-
dren and adults.

  Some improvement in ETS exposure has been
noted. A shady from California found that nonsmokers'
self-reported exposure to ETS at work declined from


2Y percent in 1990 to 22 percent in lYY3 (Patten et al.
lYY?b). This decline w-as not as pronounced, holz,e\-er,
among some sociodemographic subgroups, such as
Xfrican Americans, Asian Americans, and persons
\vith less than a high school education. During the
same period, the percentage of employees reporting
that they I\-orked in smoke-free \vorkplaces greatl\
increased (from 35 to 65 percent). Sur\-ev data from
Missouri in 1993 indicated that 11 percent of the poppy-
lation lvere exposed to ETS in the \\.orkplace and 1X
percent in the home en\.ironnient (Bro\\.nson et al.
lYY5a). Among subgroups, \-oungcr persons, men,
Hispanics, and persons \\,ith -less than a high school
education had more 1%.orkplace exposure to ETS. Simi-
larly, data from rural Missouri sho\vcd higher pre\a-
Icnce of kvorkplace ETS exposure among 1 ounger
persons, men, African Americans, and persons l\.ith
less than a high school education (Bro\z.nson et al.
IYY5a). Emmons and colleagues (lYY2) analvzed en-
tries in diaries recording ETS esposure among 186
persons \vho rvere former smokers or had ne\ el
smoked. Approximatelv 50 percent of the dail\, ETS
exposure \\.as attributed to the \vorkplacc, and 10 per-
cent I\.as attributed to the home en\?ronment. Ho\?.-
c\-er, for persons \vho lived \vith a smoker, more
exposure occurred in the home than in the \vorkplace.

  Relatilrely felt population-based data that spe-
cificallv examine the levels of ETS exposure in the
rcorkplace have been collected. Such data ma\' be
important, because exposure levels likely \.ary griatl\
b\r Lvorkplace, and recent studies ha1.e indicated that
higher levels of ETS (measured by intensity or dura-
tion of ETS exposure) increase the risk of lung cancer
in nonsmokers (Brownson et al. 1992~1; Stocklvell et al.
lY92; Fontham et al. 199-l). In a re\,ie\v of existing stud-
ies, Siegel (1993) found that ETS concentrations var-
ied widely b\r location; mean le\rels of nicotine
measured in the ambient air lvere 4.1 ,ug/m' for of-
fices overall, 4.3 pg/m' for residences tvith at least one
smoker, 6.5 ,ug/m' for restaurants, and 19.7 p'g/m' for
bars. In a sur\rey of 25 Massachusetts bvorksites,
Hammond and colleagues (1995) found that the type
of lvorksite smoking policy had a great effect on nico-
tine concentrations. Levels of nicotine ranged from
8.6 pg/m' in open offices that allolved smoking to 0.3
Jig/m' in worksites that banned smoking.

Legal Foundation for Regulation
of Public Smoking

  The legal foundation for regulating public
smoking is based on case la\v pertaining mainlv to the

protection of the health of workers. Under common
la\2- (the body of law based on court decisions rather
than jio\,ernment laws or regulations), employers must
pro\-ide a lvork environment that is reasonably free of
recognized hazards. Courts have ruled that common-
lax\, duty requires employers to provide nonsmoking
emplovees protection from the proven health hazards
of ETS.exposure (Skveda 1994).

  Three pioneering cases have demonstrated the
basis for this protection. In Shimp 7'. Ntw ]evsq Bell
Ttd~~~~l~orr~~ Co. (368 A.2d 408, 115 N.J. Super. 516 [19761),
a secretay, \vho \vas allergic to cigarette smoke sought
an injunction requiring a smoking ban. The court or-
dered the emplover to provide a safe Lvorking envi-
ronment bv restricting smoking to a nonwork area.
Similarly, in the case of S\llil/l 7'. Wcstcrr~ Elccfric Co.
(613 S.\Y.2d 10 [Mo. App. 198231, the Missouri Court
of Appeals o\-erturned a lolver court and forced the
emplo\,er to "assume its responsibility to eliminate the
hazarc~ous conditions caused by tobacco smoke" (p.
13). Finall!; in L~,cI 7'. Dqwrf?!w~!~ of Pfltl/ic \Vc/,fflrc (No.
15385 [Mass. Mar. 31, 191131, c'ifcd irl 1.2 TPLR 2.82
[19X6]), a social xvorker sued her employer, seeking
relief from ETS exposure at tvork. The Massachusetts
Superior Court ruled in favor of the plaintiff and re-
quired a smoke-free workplace. Additional protections
to employees are extended bv federal statute, such as
the Americans lvith Disabilities Act of 1990 (ADA)
(Public Larz. 101-336), and by rulings in workers com-
pensation claims.

Status of Restrictions to Limit Smoking in
Public Places

  Although the health risks of ETS exposure be-
gan to be publicized in the early 1970s (NC1 1991),
momentum to regulate public smoking increased only
in 1986, M-hen reports by the Surgeon General
(USDHHS 1986) and the National Academy of Sciences
(1986) concluded that ETS is a cause of lung cancer in
nonsmokers. Since then, government and private busi-
ness policies that limit smoking in public places have
become increasingly common and restrictive (Rigotti
and Pashos 1991). The designation of ETS as a class A
(kno$t.n human) carcinogen by the EPA (1992) stimu-
lated further restrictions on smoking in public places
(Brownson et al. 1995a), but a recent court ruling set
aside that report (see "Health Consequences of Expo-
sure to ETS," earlier in the chapter),

  Although many of the regulatory efforts discussed
herein focus on go\,ernment's passage of a law or an
ordinance, other regulations can be implemented by


Table 5.1. Summary of landmark events in the development of U.S. policies for clean indoor air

Year                                   Event

1971

1972

The Surgeon General proposes a federal smoking ban in public places.
The first report of the Surgeon General to identify environmental tobacco smoke (ETS) as a health risk
is released.

1973

Arizona becomes the first state to restrict smoking in several public places and to reduce ETS exposure
because it is a health risk.

The Civil Aeronautics Board requires no-smoking sections on all commercial airline flights.

1974

1975

1977

Connecticut passes the first state law to apply smoking restrictions to restaurants.

Minnesota passes a comprehensive statewide law for clean indoor air.
Berkeley, California, becomes the first community to limit smoking in restaurants and other public
places.

1983

1986

San Francisco passes a law to place pri\,ate workplaces under smoking restrictions.

A report of the Surgeon General focuses entirely on the health consequences of involuntary smoking;
ETS is proclaimed a cause of lung cancer in healthy nonsmokers.
The National Academy of Sciences issues a report on the health consequences of involuntary smoking.

Americans for Nonsmokers Rights becomes a national group; it had originally formed as California
GASP (Group to Alleviate Smoking Pollution).

1987

The U.S. Department of Health and Human Services establishes a smoke-free environment in all of its
buildings, affecting 120,000 employees nationvvide.

Minnesota passes a law requiring all hospitals in the state to ban smoking by 1990.
A Gallup poll finds, for the first time, that a majority (55 percent) of all U.S. adults favor a complete
ban on smoking in all public places.

1988   A congressionally mandated smoking ban takes effect on all domestic airline flights of two hours or less.

New York City's ordinance for clean indoor air takes effect, banning or severely limiting smoking in
various public places and affecting 7 million people.

California implements a statewide ban on smoking aboard all intrastate airplane, train, and bus trips.

1990

A congressionally mandated smoking ban takes effect on all domestic airline flights of six hours or
less.

The U.S. Environmental Protection Agency (EPA) issues a draft risk-assessment on ETS.

1991

CDC's National Institute for Occupational Safety and Health issues a bulletin recommending that
secondhand smoke be reduced to the lowest feasible concentration in the workplace.

1992

Hospitals applying for accreditation by the Joint Commission on the Accreditation of Healthcare
Organizations are required to develop a policy to prohibit smoking by patients, visitors, employees,
volunteers, and medical staff.

The EPA releases its report classifying ETS as a group A (known human) carcinogen, placing ETS in the
same category as asbestos, benzene, and radon.


Table 5.1. Continued

Year                                   Event

1993

1994

1995

1996

1997

1998

Los Angeles passes a ban on smoking in all restaurants.

The U.S. Postal Ser\.ice eliminates smoking in all facilities.

Congress enacts a smoke-free policy for WIC (Special Supplemental Food Program for Women,
Infants, and Children) clinics.

A w-orking group of 16 state attorneys general releases recommendations for establishing smoke-free
policies in fast-food restaurants.

Vermont bans smoking in all public buildings and many pri\,ate buildings open to the public.

The U.S. Department of Defense prohibits smoking in all indoor military facilities.

The Occupational Safety and Health Administration proposes a rule that would ban smoking in most
U.S. \vorkplaces.

San Francisco passes a ban on smoking in all restaurants and \1-orkplaces.

The Pro-Children's Act requires persons proI,iding iederallv funded children's services to prohibit
smoking in those facilities.

Next York City passes a comprehensi\-e ordinance eifecti~~rly banning smoking in most workplaces.

Maryland enacts a smoke-free policy for all lvorkplaces except hotels, bars, restaurants, and private
clubs.

California passes comprehensive legislation that prohibits smoking in most enclosed workplaces.

Vermont's smoking ban is extended to include restaurants, bars, hotels, and motels, except those
holding a cabaret license.

The C.S. Department of Transportation reports that about 80 percent of nonstop scheduled U.S. airline
flights between the United States and foreign points will be smoke free by June 1, 1996.

President Clinton signs an executive order establishing a smoke-free environment for federal
employees and all members of the public visiting federally owned facilities.

The California EPA issues a report determining that ETS is a toxic air contaminant.

Settlement is reached in the class action lawsuit brought by flight attendants exposed to ETS.

The U.S. Senate bans smoking in the Senate's public spaces.
California law takes effect banning smoking in bars unless a bar has a separately ventilated smoking
area.

agencies with special authoritv. An example of a non-
government regulatory; action'is the recent adoption of
an accrediting standard that prohibits smoking in hos-
pita1 buildings (Joint Commission on Accreditation of
Healthcare Organizations 1992; Longo et al. 1995).

Government Restrictions

  Selreral of the noteworthy events in clean indoor
air regulation are shown in Table 5.1. These events
include federal, state, and local activities.


Federal Laws artd Regulatiom

  The most notable federal regulation of ETS is the
requirement that domestic airline flights be smoke free.
The regulation ~`as first enacted in 1988 for domestic
flights lasting two hours or less and M'as renewed in
1989 for domestic flights lasting six hours or less (Table
5.1). Since the earlv 197Os, the Interstate Commerce
Commission (ICCj has required that smoking on
interstate buses be confined to the rear of the bus
and that smoking sections constitute no more than 10
percent of total seating capacity. Similar ICC regula-
tion for trains was repealed in 1979. In 1987, congres-
sional legislation that threatened to withhold federal
funds influenced the State of Nelv York's Metropoli-
tan Transportation Authority to ban smoking on
the MTA Long Island Rail Road (USDHHS 1989).
Currently, the Occupational Safety and Health Admin-
istration is considering regulations that should either
prohibit smoking in all workplaces or limit it to sepa-
rately ventilated areas (Fc[lr~l~l Rqistcr 1994). Further-
more, the federal gol.ernment has instituted
increasinglv stringent regulations on smoking in its
oM'n facilities, and the Pro-Children's Act of 1994 (Pub-
lic Law 103-227, sets. 1041-1041) prohibits smoking in
facilities in which federally funded children's services
are provided on a regular or routine basis.

State Lazes ad Regulatiom

  As of December 31,1999, smoke-free indoor air
to some degree or in some public places was required
by 45 states and the District of Columbia. These re-
strictions vary widely, from limited restrictions on
public transportation to comprehensive restrictions in
worksites and public places (CDC, Office on Smoking
and Health, State Tobacco Activities Tracking and
Evaluation System, unpublished data). In 1973, Ari-
zona became the first state in which public smoking
was regulated in recognition of ETS as a public health
hazard (Table 5.1). Five states (Alabama, Kentucky,
New Mexico, North Carolina, and Wyoming) have ei-
ther no legislation or legislation that preempts locali-
ties from enacting any law to restrict smoking in public
places (see also Figure 5.2).

  As of December 31, 1999, laws restricting smok-
ing in government worksites were present in 43 states
and the District of Columbia: 29 limit smoking to des-
ignated areas, 2 require either no smoking or desig-
nated smoking areas with separate ventilation, and 11
prohibit smoking entirely. Twenty-one states have
1aLys restricting smoking in private worksites: 20 limit
smoking to designated areas, and 1 (California) re-
quires either no smoking or separate ventilation for
smoking areas.  Thirty-one states have laws that

Figure 5.2. Cumulative number of state laws and amendments enacted for clean indoor air, 1963-1998

1963  1965  1Y67  1969  lY71  1973  1975  lY77  lY7Y  1981  lYX3  lY85  1987  1YHY  1991  1993  1995  1997

                                  Year

IV&>: The category "state" includes the District of Columbia.
Source: National Cancer Institute, State Cancer Legislative Database, unpublished data, August 31, 1998.


regulate smoking in restaurants; ot these, onlv Utah
and Vermont completely prohibit smoking in restau-
rants, and California requires either no smoking or
separate \.entiIation for smoking areas (CDC, Office
on Smoking and Health, State Tobacco Acti\,ities
EL-aluation System, unpublished data).

  In 1991, Maryland proposed a regulation that
lvould prohibit smoking in most \vorkpIaces in the state,
including restaurants and bars (M~7ryl17111l Rqi~fcr 1991).
Despite strong support among both nonsmohers and
smokers for restrictions on public smoking in the state
(Shopland et al. lYY5), this proposal bias aggressi\.ely
challenged bv the tobacco industrv (Spavd lY94), \vhich
questioned the state's legal authoi-it! to.regulate smok-
ing through administrati\.e rule rather than la!\. [n earl\,
1995, the original regulation It-as modified by Iegisld-
tive action to permit some esceptions for the hospital-
itv industry, and the rules ivent into effect. In October
1491, the state of Washington also enacted an ektensi\.c
indoor Ivorkplace ban. In this instance, a temporar>,
injunction \vas dismissed b\, the state court, and the ban
event into effect \vithout litigation (CSH lYY4b).

  In North Carolina, legislation Ivas enacted on Jul\
15, lYY3 (HB 9571, that required that smoking be per-
mitted in at least 20 percent of space in state-controlled
buildings but also formally required nonsmoking
areas. An important preemption clause prohibited
local regulatory boards from enacting more restrictive
regulations for public or pri\,ate buildings after Octo-
ber 15,1993. During that three-month "ivindn\v of op-
portunity," 89 local agencies passed nei2' measures
providing some increased protection from ETS. De-
spite the rush to ne\v restrictions, researchers estimated
that bv the year 2000, the preemption \~ould prevent
39 percent of priorate emplovees in North Carolina from
being protected from ETS iConlisk et al. 1995).

Local Ordillaiices

  The modern era of local ordinances for clean in-
door air began in the early 1970s (Pertschuk 1993). In
1977, Berkeley, California, became the first community
to limit smoking in restaurants and other public places
(Table 5.1). After the release of the 1986 Surgeon
General's report on the health consequences of ETS, the
rate of passage of local ordinances accelerated (Figure
3.3). Bv 1988, nearlv 400 local ordinances to restrict
smokini had been enacted throughout the United States
(Pertschuk and Shopland 1989). The trend toward
smoke-free local ordinances has accelerated since 1989
(Rigotti and Pashos 1991; Pertschuk 1993). As of June
30, 1998, public smoking \vas restricted or banned in
820 local ordinances. Of those that specified \vhich

agency was responsible for enforcement, 44 percent cited
health departments or boards of health, 19 percent
named city managers, 3 percent said police departments,
and 6 percent identified other agencies (Americans for
Nonsmokers' Rights, unpublished data, June 30, 1998).
The effectiveness of various enforcement mechanisms
and the Ie\rel of compliance achieved are not known.
Data from Wisconsin suggest that implementation may
be just as important as legislation in achieving policy
goals (Nordstrom and DeStefano 1995).

  One study examined the impact a local ordinance
had on restaurant receipts (CDC 1995a). Contrary to
some prior claims, an analysis of restaurant sales after
a ban on smoking in this community (a small suburb
of Austin, Texas) showed no ad\,erse economic effect.
In a series of ecologic analyses, Glantz and Smith (1994,
1997) analyzed the effect of smoke-free restaurant and
bar ordinances on sales tax receipts. Over time, such
ordinances had no effect on the fraction of total retail
sales that [Vent to eatin g and drinking places. The
authors asserted that claims of economic hardship for
restaurants and bars that establish smoke-free policies
ha\.e not been substantiated.

Private Sector Restrictions on Smoking
in Workplaces

  T\VO national data sets are available to ascertain
the level of workplace smoking restrictions among pri-
vate firms in the United States. A survey conducted
by the Bureau of National Affairs, Inc. (19911, estimated
that 85 percent of large workplaces had policies
restricting smoking. The percentage of smoke-free
\vorkplaces has increased dramatically, from 2 percent
in 1986 to 7 percent in 1987 and to 34 percent in 1991.
Similarly, data from the 1992 National Survey of
Worksite Health Promotion Activities indicated that 87
percent of workplaces with 50 or more employees regu-
lated smoking in some manner and that 34 percent were
smoke free (USDHHS 1993). The 1995 Update of the
Business Responds to AIDS Benchmark Survey con-
ducted by CDC also found that 87 percent of worksites
with 50 or more employees had a smoking policy of
some kind (National Center for Health Statistics 1997).

  The prevalence of smoking policies in small
\vorkplaces, tvhere the majority of Americans work,
is less \velI studied. A comprehensive examination
of workplace smoking policies from the NCI's tobacco
use supplement to the Current Population Survey
(n = 100,561) indicated that most indoor workers sur-
vexed (81.6 percent) reported that an official policy
go;,erned smoking at their \vorkplaces, and nearly
half reported that the policy could be classified as


"smoke-free"-that is, that smoking XVL?S not permit-
ted either in ivorkplace areas or in common public-
use areas (Gerlach 1997). This proportion \.aried by
sex, age, ethnicity, and occupation: blue-collar and
service occupations had significantly less access to
smoke-free environments. Though data Ivere not spe-
cifically reported by wrorkplace size, the range of occu-
pations suggests that the survey included a substantial
proportion of persons who M'ork in smaller workplace
environments. But for all workplace sizes, the data
suggest that access to smoke-free environments could
be substantially improved.

Effectiveness of Clean Indoor
Air Restrictions

  Although it is generally accepted that regulatory
changes influence nonsmokers' exposure to ETS and
smokers' behavior, relativelv felt eifaluation studies
quantify these effects o\,er- time. Evaluating such
changes is hampered bv the complex interaction of
social forces that shape behavior, bv the decline in

smoking and smoke exposure in the overall popula-
tion, and by the overlapping effects of concomitant
regulatorv policies (e.g., a new law for clean indoor
air passed at or around the time of an increase in the
cigarette excise tax). Controlling for such potential
confounding factors in studies is difficult.

Population-Based Studies

Efiects 011 Nonsmokers' Exposure to ETS

  Despite the widespread implementation of re-
strictions against public smoking, few population-
based studies have examined whether these
restrictions have reduced nonsmokers' exposure to
ETS. One such study from California used data col-
lected in 1YYO and 1991 to examine the association be-
tween the strength of local ordinances for clean indoor
air and cross-sectional data on nonsmokers' exposure
to ETS in the workplace (Pierce et al. lY94b). Expo-
sure to ETS in the workplace ranged from 25 percent
of workplaces in areas with a strong local ordinance
to 35 percent in areas with no local ordinance.

Figure 5.3. Cumulative number of local laws and amendments enacted for clean indoor air, 1979-1998

1487      1989      19Yl      lY93      1995     1997

     Year

IV&c: Ordinances must specifically mention these locations to be counted. Therefore, other ordinances may cover
these areas without being included in these figures.
*Before 1983, there were four lvorkplace ordinances: one passed in 1975, one in 1979, and two in 1980. These are
not included in this chart, because data for consecutive years only became available beginning in 1983 for
workplaces.
Source: American Nonsmokers' Rights Foundation, unpublished data, June 30, 1998.


  In measuring the impact of a state\\ide law for
clean indoor air, researchers in Missouri examined self-
reported data on EPS exposure from 1 YYO through 1993
(Brownson et al. 199%). Nonsmokers' exposure to ETS
in the workplace declined slightly the vear the la\~ \~as
passed and substantiallv more after the la\2 [vent into
effect. Exposure to ETS in the home remained con-
stant o\.er the stud\, period; this finding suggests that
the declining ivorkplace exposure \vas more likelv
linked to the smoking regulations than to the nl.erajl
declining smoking pre\.alence obser\-ed during the
study period. Despite improvements o\~er time, ETS
exposure in the ivorkplace remained at 35 percent in
the final vear of the stud\, (1993). Other data from
California indicate that nonsmokers employed in
w,orkplaces \lith no policy or a polic!, not co\.ering
their part of the \i-orkplace \vere eight times more likel)
to be exposed to ETS (at \2-ark) than those employed
in smoke-free tvorkplaces (Borland et al. 1992).

Attitudes Toward Restrictions and Bnrzs

   Studies ofalrareness and attitudes toivard Ivork-
place smoking restrictions and bans hat-e been cow
ducted in cross-sectional samples of the general
population and among employees affected b!; bans.
In a 1989 survey of 10 U.S. communities, most respon-
dents favored smoking restrictions or smoke-free
environments in all locations, including rzorkplaces,
government buildings, restaurants, hospitals, and bars
(CDC 1991). Although support for smoking restric-
tions was higher among nonsmokers, across the 10
communities, 82-100 percent of smokers fairored re-
strictions on smoking in public places. Support \vas
highest for smoking bans in indoor sports arenas, hos-
pitals, and doctors' offices. A 1993 survey from eight
states showed greater support for ending smoking in
fast-food restaurants and at indoor sporting e\-ents
than in traditional restaurants and indoor shopping
malls (CDC 1994a).

  Support for proposed changes may differ from
support for actual, implemented changes. yet in stud-
ies of smoke-free hospitals, patients, emplovees, and
physicians have overwhelminglv supported ihe policv
(Rigotti et al. 1986; Becker et al: 1989; Hudzinski ana
Frohlich 1990; Baile et al. 1991; Offord et al. 1992). In
some instances, a majority of smokers support a
smoke-free hospital (Becker et al. 1989). Studies of
smoking restrictions and bans in other industries
also have found that nonsmokers overwhelmingly
favor smoke-free workplaces (Petersen et al. 1988;
Borland et al. 1990b; Gottlieb et al. 1990; Sorensen et
al. 1991b). Time-and consequent habituation-can

make changes more acceptable. In a prospective study
of a smoking ban in a large workplace, Borland and
colleagues (1990b) found that attitudes of both non-
smokers and smokers toward the smoke-free work-
place rzere more favorable six months after such a
policy ivas implemented. Although most smokers re-
ported being inconvenienced, they also reported that
they recognized the overall benefits of the policy. Two
studies from Massachusetts found that one and two
vears after t\vo local 1aM.s for clean indoor air were
enacted, 65 percent of the businesses surveyed favored
the la\y (Rigotti et al. 1992, 1994). The authors con-
cluded that a self-enforcement approach achieved high
le\,els of abvareness (about 75 percent) and intermedi-
ate levels of compliance (about 50 percent) (Rigotti et
al. 199-l).

Effects of Restrictiorls ad Bans OH Nousmokers'
Exposure to ET5

  As has been found in population-based research,
studies conducted in individual workplaces have
found that smoke-free lvorkplaces have been effective
in reducing nonsmokers' exposure to ETS. Effective-
ness has been measured bv the perceived change in
air quality in the workplace after a smoke-free policy
\vas instituted (Biener et al. 1989; Gottlieb et al. 1990)
and hy measurement of nicotine vapor before and af-
ter such a policy (Stillman et al. 1990). Conversely,
Ivorkplace policies that allow smoking in designated
areas without separate ventilation result in substan-
tial exposure to ETS for nonsmokers (Repace 1994).

  An analysis of the effects of a smoke-free
ivorkplace in The Johns Hopkins Medical Institutions
found that concentrations of nicotine vapor had de-
clined in all areas except restrooms at one to eight
months after the ban (Stillman et al. 1990). In most
areas, nicotine concentrations after the ban were be-
loll- the detectable level of 0.24 pg/m'.

Effects of Restrictions on Smoking Behavior

  An additional benefit from regulations for clean
indoor air may be a reduction in smoking prevalence
among workers and the general public. For example,
in a multivariate analysis, moderate or extensive laws
for clean indoor air were associated with a lower smok-
ing prevalence and a higher proportion of quitters
(Emont et al. 1993). Another study also found an as-
sociation between local smoking restrictions and smok-
ing preiralence (Rigotti and Pashos 1991).


SUP~YUI G~ik~hii'. /L~jkvr
  .Y

Table 5.2. Summary of studies on the effects of a smoke-free workplace on smoking behavior

Authors/year                 Location

AndreIvs 1983           Boston, Massachusetts

Rigotti et al. 1986          Boston, Massachusetts

  Industry

Hospital

Hospital pediatric unit

Sample size

   965

   93

Rosenstock et al. 1986

Puget Sound. Washington

Petersen et al. 1988

Becker et al. 1989

Biener et al. 1989

Scott and Gerberich 1989

Borland et al. 199Ob

Connecticut

Baltimore, Maryland

I'ro\.idencc, Rhode Island

Midlvestern United States

Australia

Health maintenance
organization

Insurance company

Children's hospital

Hospital

Insurance company

Public service

Centers for Disease
Control 1YYOc

Gottlieb et al. lY90

Pueblo, Colorado         Psychiatric hospital      1,032

Government agency

Hudzinski and Frohlich 19`~O

Stillman et al. 1990

Baile et al. 1941

Borland et al. 1991

Ne\v Orleans, Louisiana

Baltimore, .Llar~~land

Tampa, Florida

,Austrnlia

Sorensen et al. 1YYla

Hospital

Hospital

Hospital

Telecommunicatiolis
companv

Telephone company

Brenner and lLIielck 1992

Goldstein et al. 1992

Augusta, Georgia

National random
sample

Hospital

Offord et al. lYY2

Wakefield et al. 1992b

Rochester, Minnesota

Hospital

Australia

Representative
sample

Jefferv et al. 1994        Minneapolis-St. Paul, Minnesota   Diverse Lvorksites

447

1,210

704

535

452

2,113

1,158

1,946

2,877

349

620

1,120

439

1,997

10,579

1,929

32 worksites;
total number
of individuals
not reported


  Change in individual or overall smokers' consumption        Change in prevalence

Not reported                           -8.5% at 20 months follow-up

-2.3 cigarettes per shift (I' < 0.01) at 12 months folloiv-up; no change in   No significant change
o\rerall consumption

-2.0 cigarettes per day (I' < 0.003) at 4 months follow-up         No significant change

-5.6 cigarettes per day at 12 months follo~v-up

No change at 6 months follow-up

1.6'; at 13 months follokv-up

-1.2'yr at 6 months follow-up

-3.9 cigarettes per day at lvork at 12 months follo~r-up

22.5';; of smokers decreased consumption at 7 months follo\v-up

No significant change

-5.1 ?ir at 7 months follow-up

-7.9 cigarettes per day in smokers ot 25 or more cigarettes per da\.
at 6 months follow-up

-1 .O'Z at 6 months follow-up

-3.5 cigarettes per day at lvork at 13 months folio\\--up; -1.8 cigarettes
per day over 24 hours

-4.0% at 13 months follow-up

12.0% reduction in consumption of 15 or more cigarettes per day at
lvork at 6 months follolv-up (I' < 0.001)

-3.4% at 6 months follow-up

25% of smokers no longer smoked at work at 12 months follo\v-up

-3.3 cigarettes per day at 6 months follorv-up (I' = 0.0001)

Not reported

-5.5'; at 6 months follow-up

407 of smokers decreased consumption at 4 months follow-up

-3.5 cigarettes per day at 18 months follow-up (I' < 0.05)

-1.5% at 4 months follow-up

-3.1% at 18 months follow-up

Not reported

21% of smokers quit at 20 months
follow-up

-1.8 cigarettes per day in men, -1.4 cigarettes per day in women

Cessation proportion of 30%

57% of smokers reported they had cut down on number of cigarettes
smoked

Not reported

9% of smokers stated they had quit
because of the ban

-2.9% at 30 months follow-up

-5 cigarettes per day on workdays vs. leisure days

Not reported

-1.2 cigarettes per day

-20 at 24 months follow-up


  In recent !.cars, researchers ha1.e increasingly
recognized the role of the enr-ironment' in influencing
indi\-idual smoking behavior through perceived cues
(NC1 1991; McKinlay 1993; Brownson et al. 1995b), many
of xvhich ha1.e their origins in generally held rules about
acceptable beha\,iors (i.e., social norms) (Robertson
1977). Smokers frequently respond to environmental
cues when deciding kvhether to smoke at a given time
(NC1 1991). For example, a smoker may recei\,e a per-
sonal, habit-deri\.ed cue to smoke after a meal or on a
Iyork break, but this cue may be \2-eakened (and even-
tually even canceled) by a social, policy-derived cue not
to smoke if the person is in a smoke-tree restaurant or
worksite (Brownson et al. lY95b).
  Numerous studies have assessed the potential
effects of workplace smoking bans on employee
smoking behavior (Table 5.2). These studies have been
conducted in health care settings (Andrekvs 1983;
Rigotti et al. 1986; Rosenstock et al. 1986; Becker et al.
1989; Biener et al. 1989; CDC 1990~; Hudzinski and
Frohlich 1990; Stillman et al. 1990; Baile et al. 1991;
Goldstein et al. 1992; Offord et al. lY92), government
agencies (Gottlieb et al. 19YO), insurance companies
(Petersen et al. 1988; Scott and Gerberich lY8Y), and
telecommunications companies (Borland et al. 1991;
Sorensen et al. 1991a) and among random samples of
the working population (Brenner and Mielck 1992;
Wakefield et al. 1992b). Most of the studies based in
hospitals or health maintenance organizations that
banned smoking found a decrease in the average num-
ber of cigarettes smoked per day. Se\.eral of the has-
pita1 studies found significant declines in the overall
prevalence of smoking among employees at 6-20
months follow-up (Andrelvs 1983; Stillman et al. 1990).
Studies of smoking behavior in other industries ha\,c
found similar results; in most settings, daily consump-
tion, overall smoking pre\,alence, or both had de-
creased at 6-20 months after \vorkplaces were made
smoke free.

In a population-based study of California resi-
dents, the prevalence of smoking \vas 14 percent in
smoke-free \vorkplaces and 21 percent in rzrorkplaces
with no smoking restrictions (Woodruff et al. 1993).
Consumption among continuing smokers eras also
lower in smoke-free bvorkplaces, and the percentage
of smokers contemplating quitting was higher. In 1992,
Patten and colleagues (1995,) follo\ved up a large
sample of persons (first inter\,ie\ved in 1990) to deter-
mine the influences a change in lvorksite setting might
have had on smoking. These researchers observed
a statistically nonsignificant increase in smoking
`The term "en\.ironment" is detincd Ivoaill!- to Include the Itpi,
wcidl, tvmnorllii, dn~l ph\3ical en\ ircwmtwt (Clleadk et dl. 1 W.2).

prevalence among the group that changed from a
smoke-free fvorkplace to one at which smoking was
permitted. The prevalence of smoking among other
groups was unchanged or had declined. Although
these results are tentative, particularly in view of sam-
pling difficulties during the follow-up interview, they
signal the potential impact workplace policies can have
on smoking behavior.

Case Studies of State and Local Smoking
Restrictions

Recent reviews have presented case studies on
the passage of state and local laws for clean indoor air
(Samuels and Glantz 1991; Fourkas 1992; Jacobson et
al. 1992; Traynor et al. 1993). These studies describe
the issues that states and local communities dealt with
in enacting smoking restrictions in public places.

In a case study of six states, the ability of key leg-
islators to support legislation and the existence of an
organized smoking prevention coalition were key de-
terminants of lz.hether statewide legislation was en-
acted for clean indoor air (Jacobson et al. 1992).
Although the enactment of such legislation was not
waranteed when these factors were favorable, enact-
0
ment \vas unlikely when they were unfavorable. Two
other factors \vere cited as key in enacting legislation
in the six states studied: an active executive branch
that pressured the legislature to act, especially by mak-
ing such legislation an executive policy priority, and
existing local ordinances that created a policy environ-
ment favorable to the enactment of statewide smok-
ing restrictions.

The study found that coalitions that succeeded
in enacting legislation to restrict smoking in public
places featured organized commitment, including both
a full-time staff and a professional lobbyist. Success-
ful coalitions also had established close working rela-
tionships M.ith key legislative sponsors to develop
appropriate policy alternatives and to coordinate leg-
islative strategy. Finally, effective coalitions used me-
dia and grassroots campaigns to mobilize public
sr~pport for smoking restrictions.

  Another important component in the legislativ-e
debate was how the issue of smoking restrictions was
framed. In all six states reviewed, the tobacco industry
tried to shift the focus from the credibility of the scien-
tific evidence on the health hazards of ETS to the con-
troversial social issue of personal freedom; specifically,
the industry lobbied extensively for including nondis-
crimination clauses in legislation to restrict smoking
(Malouff et al. 1993). Another common strategy that


the tobacco industry has used is to support the pas-
sage oi state la\ys that preempt more stringent local
ordinances (Brolvnson et al. 1993b).

  Because of the possible countereffect of preemp-
tive legislation and because of the difficulty in enact-
ing statelyide legislation, public health ad\rocates have
suggested that advocates for reducing tobacco
use should devote more resources to enacting local
ordinances (Samuels and Glantz 1991; Fourkas 1992;

Minors' Access to Tobacco

Jacobson et al. 1992). A local strategy can usually im-
pose more stringent smoking restrictions than state-
M,ide legislation does. Like the study of Jacobson and
colleagues (1992) on statewide initiatives, a study of
local initiati\res found that two key ingredients for
success ivere the presence of a strong smoking pre-
\,ention coalition and sympathetic political leadership
Ii-ithin the elected body (Samuels and Glantz 1991).

Introduction

  Minors' access to tobacco products is an area of
regulation relativelv free from the social and legal de-
bate that often arises from other regulatory efforts.
E\.en the staunchest opponents of reducing tobacco use
concede that tobacco use should be limited to adults
and that retailers should not sell tobacco products to
children and adolescents. \r'et as \vas discussed in de-
tail in the Surgeon General's report on smoking among
young people, a significant number of minors use to-
bacco, and a significant number of them obtain their
tobacco through retail and promotional transactions,
just as adults do (USDHHS 199-l; CDC 1996a,b; Kann
et al. 1998). Whether intended exclusi\,elv for adults
or not, these commercial transactions are supported
bv vast resources. The multibillion-dollar tobacco in-
d&try spends a large proportion of its marketing dol-
lars to support a vast network of wholesale and retail
activity. In 1997, cigarette makers spent $2.44 billion
on promotional allo\vances to the wholesale and re-
tail trade and an additional $1.52 billion on coupons
and retail value-added promotions (FTC 1999). These
figures were 42 percent and 26 percent, respectively,
of the entire $5.1 billion spent on advertising and pro-
moting cigarettes in the United States that year.

  In general, the availability of cigarettes to the
adult population has not been a regulatory issue since
the first quarter of the 20th century (see Chapter 21,
although recent FDA statements about nicotine levels
in cigarettes have raised the possibility of some regu-
lation of adult use (see "Further Regulatory Steps,"
earlier in this chapter). The primarv regulatorv focus
for cigarette access has been on reducing the'sale of
tobacco products to minors (Forster et al. 1989;

Hoppock and Houston 1990; Thomson and Toffler
1900; Altman et al. 1992; CDC 1992a; Cummings et al.
1 c)92; F~~fcrn/ RL's~s~P~ 1993, 1996). Broad-based public
support for limiting minors' access to tobacco has de-
\,eloped in the relatively brief time (since the mid-
1980s) that this issue has been in the public eye
(DiFranza et al. 1987, 1996; CDC 1990a,b,c, 1993a,
lYY-la, 1996a,d; Jason et al. 1991; Hinds 1992; Keay et
al. 1993; Landrine et al. 1994, 1996; USDHHS 1994).

  Reducing the commercial availability of tobacco
to minors is a potential avenue for reducing adoles-
cent use. Groiying evidence suggests that tobacco
products are widely available to minors. Uniformly,
surveys find that teenagers believe they can easily
obtain cigarettes (see, for example, Forster et al. 1989;
Johnston et al. 1992; CDC 1996a; Cummings et al. 1998;
University of Michigan 1999). As noted, this access is
by no means confined to borrowing cigarettes from
peers or adults or stealing them at home or from stores;
purchase from commercial outlets is an important
source for minors who use tobacco. An estimated 255
million packs of cigarettes were illegally sold to mi-
nors in 1991 (Cummings et al. 1994), and daily smok-
ers aged 12-17 vears smoked an estimated 924 million
packs of cigarettes in 1997 (DiFranza and Librett 1999).
Be&Teen 20 and 70 percent of teenagers who smoke
report purchasing their own tobacco; the proportion
\,aries by age, social class, amount smoked, and fac-
tors related to availability (Forster et al. 1989; Response
Research, Incorporated 1989; CDC 1992a, 1996a,d;
Cummings et al. 1992, 1998; Cummings and Coogan
1992-93; Mark Wolfson, Ami J. Claxton, David M.
Murray, and Jean L. Forster, Socioeconomic status and
adolescent tobacco use: the role of differential avail-
ability, unpuL7lished data). In a re\,iew of 13 local


o\er-the-counter access studies published betivern
1987 and 1993, illegal sales to minors ranged from 32
to 87 percent Gtli dn approximate r\.eiglited-a\.erage
of 67 percent. Several local studies published in 1996
and 1997 found somewhat lolver over-the-counter
sales rates to minors: 22 percent (Klonoff et al. 1997)
and 2Y percent (CDC 1996) in twro separate studies in
California and 33 percent in Massachusetts (DiFranza
et al. 1996). Nine studies of vending machine sales to
minors published between 1989 and 1992 found ille-
gal \.ending machine sales ranging from 82 to 100 per-
cent Lvith an approximate ueighted-average of 88
percent (USDHHS 1994). Comparison of the results of
these research studies lyith the results of later statewide
Synar surveys (see below) is problematic for four
reasons: (1) the research studies M'ere generally local
surveys of a to\vn, city, or county, lvhereas the Synar
surveys are based on statewide samples; (2) the sam-
pling methods vary across the research studies; (3) store
inspection methodologies \.arv; and (4) some of the
research studies contain results of se\.eral surveys,
often pre- and post-intervention (CSDHHS 1998a).

  Several factors suggest that rvidespread reduc-
tion in commercial a\-ailability may result in reduced
prevalence or delayed onset of tobacco use by young
people: the reported importance of commercial
sources to minors, the easv commercial availabilitv
that has been demonstrat&, and the reductions in
commercial a\,ailability demonstrated \vhen legal re-
strictions have been tightened, as outlined belo\y (Ja-
son et al. 1991; DiFranza etal. 1992; Hinds 1992; Forster
et al. 1998). One psychological study supports the po-
tential impact of limiting minors' access to cigarettes
(Robinson et al. 1997). In this investigation of 6,967
seventh graders of mixed ethnicit, the best predictor
of experimentation lvith cigarettes \j'as the perception
of easv availability. Regular smoking \vas hea\.ilv in-
fluenced by cost (see Chapter 6).

   Direct studies of factors that influencs minors'
access bar-e produced mixed results, ho\l.e\rer. Set.-
era1 investigators found that state lairs on minimum
age for purchasing tobacco products did not bv them-
selves ha1.e a significant effect on cigarette smoking
among youth (Wasserman et al. 1991; Chaloupka and
Grossman 1996). Other studies ha\,e pro\.ided el.i-
dfnce in single communities (~~ithout comparison
groups) that compliance lvith youth access regulations
does lead to reductions in regular smoking by adoles-
cents (Jason et al. 1491; DiFranza et al. 1992). In a
nonrandoniired, controlled community trial (three
intervention and three control communities), Rigotti
and colleagues (lY97) found that although illegal sales
rates to minors decreased significantlv more in the

control communities than in the intervention commu-
nities, there was no difference between control and
intervention communities in either self-reported
access to tobacco from commercial sources or in smok-
ing behavior among youth. The authors suggest that
illegal sales rates were not reduced sufficiently in the
intervention communities to cause a decrease in com-
mercial access that was substantial enough to impact
youth smoking. Noting that these studies were lim-
ited by their scope or sample size, Chaloupka and
Facula (1998) analyzed data from the 1994 Monitor-
ing the Future surveys on 37,217 youths. Using per-
sonal and ecologic variables in a two-part multivariate
model to estimate cigarette demand by youth and av-
erage daily cigarette consumption, the investigators
found thatadolescents are less likely to smoke and that
those who smoke consume fewer cigarettes in the fol-
lowing settings: where prices are higher, in states that
use cigarette excise tax revenues for tobacco control
activities, where there are stronger restrictions on
smoking in public places, and in states that have
adopted comprehensive approaches to measuring re-
tailer compliance \vith youth access laws. The authors
concluded that comprehensive approaches, including
enforcement of minors' access laws, will lead to a re-
duction in youth smoking. A large, community-based
clinical trial-seven intervention and seven control
communities-also found an intervention effect
(Forster et al. 1998). In this study, communities that
developed ne\v ordinances, changes in merchant poli-
cies and practices, and changes in enforcement prac-
tices experienced a significantly smaller increase in
adolescent smoking than did the control communities.
Further exploration of this issue may be required to
substantiate the impact of the enforcement of minors'
access 1acz.s.

   As commercial sales to minors are decreased,
there is e\.idence that minors may shift their attempts
to obtain cigarettes to "social" sources, e.g., other ado-
lescents, parents, or older friends (Hinds 1992; Forster
et al. 1998). One study found that adult smokers aged
18 and 19 years were the most likely group of adults
to be asked by a minor for cigarettes (Ribisl1999). This
study did not assess how frequently minors asked
other minors for tobacco. There is also evidence, how-
ever, that minors who provide tobacco to other minors
are more likelv to purchase tobacco than other minors
w,ho smoke (Wolfson 19971, and in any event, some of
the cigarettes provided by minors to other minors were
initiallv purchased from commercial sources (Forster
et al. 1997). Whether the source is social or commer-
cial, it is clear that a comprehensive approach to re-
ducing minors' access is needed; smokers of all ages


in addition to tobacco retailers must a\.oid pro\isio:l
of tobacco to minors.

Efforts to Promote Adoption and
Enforcement of Minors' Access Laws

  Public organizations at the federal, state, and lo-
cal levels ha1.e become acti1.e in encouragin;: state and
local jurisdictions to adopt and enforce minors' access
la\vs. The NCI-ACS collaboration knnlvn as ASSIST
(American Stop Smoking Inter\.ention Stud)-) has iden-
tified reducing minors' access to tobacco products ai
one of its goals for its 17 demonstration states;. The
Robert Wood Johnson Foundation's SmokeLess States
program also encourages funded states to address
minors' access. The USDHHS has ividel\- distributed
a model state la\v as a result of an in\.estijiation b\, the
Office of Inspector General (OIG) reporting little Or nc)
cnforcenient of state lalvs on minimum ages for tw
bacco sales (OlG 1990; USDHHS IYYO). C;,vi~~iii~~ C//J
~TOhiiO Flw: fIl'i'i'llt;il~~ h'iiclfi,lc' ~4tftfiitrc~ri iri C/lilifJl~~l
,711~j \i)llf/2, a report from the Institute ot Mcdicint~
(IOM), includes an estensil e study of minors' access
and a series of recommendations about state and local
lalvs in this area (Lynch and Bonnie 1991). A group of
75 state attorneys ieneral formed a Ivorking group on
the issue and released a set of recommendations re-
garding retail sales practices and legislation aimed at
reducing tobacco sales to minors (Working Group of
State Attorneys General 1991).

  Efforts to curb illegal sales to minors ha1.e also
occurred at the federal level. The former FDA pro-
gram (see description in Chapter 7) Leas a major effort
for several years. Probably the most sustained and
tvidespread attention to the issue of minors' access
lairs and their enforcement \vas precipitated by the
C.S. Congress, lvhich in 1992 adopted the Sonar
Amendment as part of the Alcohol, Drug Abust; and
h;lental Health Administration Reorganization Act
(Public La\v 102-321, sec. 1926), lvhich amended the
public Health Service Act. This provision requires
states (at the risk of forfeiting federal block grant funds
for substance abuse pre\w~tion and treatment) to adopt
laws establishing minimum ages for tobacco sales, to
enforce the law, and to sholv progressi1.e reductions
in the retail availabilitv of tobacco products to minors.
The implementation df the Synar Amendment, l,vhich
initiallv was to go into effect during fiscal year 1991,
leas delayed because regulations about how states
Lvere to i&plement the statute had not yet been final-
ized. During the considerable lag betw.een passage of
the amendment and the issuance of final regulations,

advocates for Synar-like restriction of youth smoking
and those opposed to the Synar approach used the
draft regulations to encourage states to adopt laws that
in these parties' differing viekvs M'ere the minimum
necessar\ for states to comply tvith the Synar Amend-
ment (P:l~~fw~/ Rqi.<tu 1993; DiFranza 1994~; DiFranza
and Godshall 1YY-t). These anticipatory responses, to-
gether \\.ith the opinions and concerns they elicited,
l\`ere analyzed in a study conducted in 1995 by
Do\vne~~ a~;d Gardiner (1996). An interim report from
the Olc in lYY5 indicated that states lvere finding the
iniplement`ltit,n process difficult. Although 85 percent
of states performed some inspections, the majority did
not use a rigorous sampling scheme. Fifty-six percent
I-cported no state\\ide enforcement activity (OIG 1995).

  The draft regulations w.ere finalized in early 1996
attt>r a re\ie\v of comments from the health commu-
nit\,, state agencies, and the tobacco industry. Respon-
sibilit,, for im~~lement~~tion was placed with the
Substance Abuse and Mental Health Services Admin-
istration (SXMHSA), ivhich in the course of 1996 con-
ducted t\z.o technical assistance meetings with states
and issut>d three separate guidance documents. Un-
der these regulations, the Synar Amendment requires
the 50 states, the District of Columbia, and U.S. juris-
dictions to do the follo\ving:

Ha1.r in effect a lalz prohibiting any manufacturer,
retailer, or distributor of tobacco products from sell-
ing or distributing such products to any person
under the age of 18.

Enforce such Iaivs in a manner that can be reason-
able expected to reduce the extent to which tobacco
pr&ucts are available to persons under the age
of 18.

Conduct annual random, unannounced inspections
to ensure compliance with the law; inspections are
to be conducted to pro\ride a valid sampling of out-
lets accessible to underaged youth.

De\-elop a strategy and time frame for achieving
an inspection failure rate of less than 20 percent
among outlets accessible to underaged youth.
Submit an annual report detailing the state's ac-
ti\,ities in enforcing the late, the success achieved,
methods used, and plans for future enforcement.

  III the event ot noncompliance with these regu-
lations, the Secretary of Health and Human Services
is directed bv statute (42 U.S.C. section 300X-26[c]) to
mal\c reducvti~,ns of from 10 percent (for the first
applicable fiscal year) to 40 percent (for the fourth


applicable fiscal \,ear) in the noncompliant state's fed-
eral block grant for substance dhse programs. Al-
though no additional monies ha\,e been appropriated
to offset the costs of complying \\,ith these regulations,
states mav use block grant funds for certain Synar-
related administrative activities, such as developing
and maintaining a list of retail outlets, designing the
sampling methodology, conducting Synar survev in-
                                       .
spections, and analyzing the sur\`ey results.

  In the several years following the issuance of the
final Synar regulation, some significant advances have
been made in enforcement of youth access laws. All
states have laws prohibiting sale or distribution and
they are enforcing those laws (USDHHS 1998a). Fur-
ther, the median rate at which retailers failed to com-
ply with laws prohibiting tobacco sales to minors in
1998 was 24.4 percent compared Ivith the median
rate of 40 percent in 1997 and pre-1997 studies that
found violation rates ranging from 60 to 90 percent
(LSDHHS, in press). In the course of implementing
Synar, every state has been required to establish a sam-
pling methodology that measures the statewide retailer
\,iolation rate lvithin a known confidence inter\.al and
to establish inspection protocols for conducting the
statelride sur\rey of tobacco retailers. These protocols
include restrictions on the ages of minor inspectors and
to establish procedures for recruiting and training of
both minor inspectors and adult escorts. Addition-
ally, the random, unannounced inspections conducted
by the states in compliance M'ith the Synar regulation
provide the largest body of stateivide data available
on the level of retailer noncompliance.

  Tlventy-tw.0 states and tLt-0 U.S. jurisdictions
modified their vouth access lairs iz.ithin a vear of
implementing Synar inspections. These changes im-
proved the states' ability to enforce the 1~71~ by clarify-
ing responsibilitv for enforcement, defining violations,
clarifying penalties, restricting vending machine sales,
and establishing a list of tobacco vendors through re-
tail licensure or vendor registration (USDHHS, in
press).

  In spite of these acl\.ances in enforcement of
youth access larvs, states also encountered difficulties
while attempting to comply bsith the Svnar mandate.
The Synar regulation does not allow fo; the allocation
of federal dollars (e.g., the Substance Abuse Preven-
tion and Treatment Block Grant) to be used for enforce-
ment. For many states, this proved to be a significant
problem, because enforcement of youth access laws
had not been previouslv vielved as a priority, and states
M'ere unwilling to redjrect already limited funds for
prevention and treatment services to IaM enforcement.
Some states addressed the problem by earmarking

re\.enue derived from fines, fees, or taxes. Other states
implemented collaborative enforcement efforts among
several agencies so that the financial burden would be
shared. And still other states relied heavily on the use
of volunteer youth inspectors and adult escorts
(USDHHS lYY8a). As the FDA became active in the
youth access issue, a few states were able to use FDA
funding for enforcement to cover some of the cost of
Synar inspections in 1998.

   Another obstacle to enforcement involved devel-
oping a valid random sample of tobacco outlets in the
state when there was no accurate or current list of ven-
dors available. Although a few states addressed this
problem by working to pass retailer licensing laws at
the state level, states initially had to build lists by rely-
ing on information from wholesale tobacco distribu-
tors and vending machine distributors and by
searching existing lists that inadvertently identify to-
bacco vendors (e.g., convenience store association
membership lists) (USDHHS 1999).

  Other less frequently cited obstacles to enforcc-
ment included fear of lawsuits from cited vendors,
concerns \2-ith the liability issues associated with work-
ing nith vouth, and opposition to conductingenforce-
ment from state and local officials, law enforcement,
and the general public in regions of the country where
the economy is tied to the production of tobacco
(USDHHS 1999).

  In addition to federal and state efforts targeting
illegal tobacco sales to minors, a great amount of local
activity has occurred. Many local ordinances have re-
sulted from the lvork of various groups, particularly
in California, Massachusetts, and Minnesota (DiFranza
1994a,b; Kropp 1995; Forster et al. 1996, 1998). These
ordinances-which may, for example, prohibit vend-
ing machine sales or all self-service sales of tobacco,
require the tobacco sellers to be aged 18 years or older,
require checking identification before sale, specify civil
penalties for violators of the minimum-age law, require
posting that law at the point of purchase, and require
compliance checks with a specified timetable-permit
creatilre responses at the local level to the minors' ac-
cess problem. Compared with state officials, local of-
ficials deal with fewer retailers and a more limited set
of constraints and are freer to tailor their policy to lo-
cal conditions. Tobacco interests are less influential at
the local level, because industry representatives are
more likely to be perceived as outsiders, and their cam-
paign contributions are less likely to be important to
local officials; moreover, community members and
local advocacy groups are often more effective against
tobacco interests at this level than they are in statewide
policy arenas (Sylvester 1989). Policy implementation


is also likely to be more consistent at the local le\rel, be-
cause local advocates can monitor the process and be-
cause enforcement officials are more likely to 1~ax.e been
a part of the policy's adoption. Ho\ve\.er, many of the
policies at the federal, state, and local le\rels are inter-
related: the federal Synar Amendment is implemented
through state lalvs and has led to enforcement at the
state and local level (USDHHS 1998a). The former FDA
enforcement program operated through contracts \vith
state agencies or organizations to conduct compliance
checks in communities across the states. State agen-
cies often fund local coalitions and projects, and local
efforts influence and support efforts at the state le\.el.
For example, much of the local activity in California
and Massachusetts ~\rould not 1~aL.e been possible
\\-ithout actions implemented at the state level, spe-
cifically designated funding.

  LaM-s enacted bv states pertaining to minors ac-
cess to tobacco as oi December 31, 1999, ha\ e been
compiled bv the CDC (CDC, Office on Smoking and
f-Iealth, Sta;e Tobacco Activities Tracking and El-alua-
tion System, unpublished data)(Table 5.3). Dates of
enactment or amendment indicate that some legisla-
ti\Te change occurred in all but one state from Januar\
1990 to December 1997 (National Cancer Institute, Stati
Cancer Legislative Database, unpublished data, Octo-
ber 6, 1998).

Restrictions on Distribution of Samples

  Tobacco product samples pro\.ide a lolv-cost or
nn-cost initiation to their use and thus encourage ex-
perimentation at early ages. Many states or other ju-
risdictions have laws that prohibit not onlv sales but
also any samples distribution of tobacco to minors,
lvhereas some laws specify exceptions permitting par-
ents or guardians to provide tobacco to their children.
All states have a specific restriction on the distribu-
tion of free samples to minors, and a fe\v states or lo-
cal jurisdictions prohibit free distribution altogether
because of the difficulty of controlling who receives
these samples. A ban on product sample distribution
can extend to coupons for free tobacco products. In
Minnesota, the attorney general levied a $95,000 civil
penalty against the Brown & Williamson Tobacco Cor-
poration for allowing such coupons to be redeemed in
the state (Minnesota Attorney General 1994). The re-
ports from both the IOM (Lynch and Bonnie 1994) and
the Working Group of State Attorneys General (1994)
recommended a ban on the distribution of free tobacco
products. The final FDA rules issued in August 1996
Tvould have prohibited the distribution of free samples
(see "Further Regulatorv Steps," earlier in this

chapter). The proposed multistate settlement pre-
sumed congressional legislation that would uphold
those rules (see "Legislative Developments" and "Mas-
ter Settlement Agreement," earlier in this chapter).

Regulation of Means of Sale

  Hobv tobacco can be sold may also be regulated
to make it more difficult for minors to purchase it. His-
toricallv, the first such restrictions adopted have been
regulations of cigarette vending machines, which are
an important source of cigarettes for younger smok-
ers (Response Research, Incorporated 1989; Cummings
et al. 1992, 1998; CDC 1996d). These regulations have
taken the form of total bans, restrictions on placement
(e.g., being \\sithin \,ielv of an employee instead of in
coatrooms or entrances, or not being near candy or
soda machines), restrictions on the types of businesses
I\.here \-ending machines may be located (e.g., limited
to liquor-licensed businesses, private businesses, or
businesses lvhere minors are not permitted), and re-
strictions on characteristics of the machines themselves
(e.g., requiring electronic locking devices or coin slugs
purchased over a sales counter) (Forster et al. 1992a;
DiFranla et al. 1996). The final FDA rules would have
prohibited vending machines except in certain night-
clubs and other adults-only facilities totally inaccessible
to persons under age 18. The proposed multistate settle-
ment anticipated legislation supporting this prohibition.

  Forty-one states and the District of Columbia
ha\.e lalvs that restrict minors' access to vending ma-
chines, including two states, Idaho and Vermont, that
ha\,e enacted legislation totally banning vending ma-
chines. However, many of the state vending machine
1aMs are weak. For example, 21 states and the District
of Columbia do not restrict placement if the machine
is supervised, and Ne\v Jersey bans vending machines
in schools only (CDC, Office-on Smoking and Health,
unpublished data, 2000). However, more than 290 lo-
cal jurisdictions, including New York City, have been
able to adopt and enforce outright bans on cigarette
vending machines or to severely restrict them to loca-
tions, such as taverns, where minors are often excluded
(American Nonsmokers' Rights Foundation, unpub-
lished data, 2000).

  Representatives of tobacco manufacturers and
retailers have strongly opposed bans on cigarette vend-
ing machines and have argued instead for weaker re-
strictions, if any, especially for what they term "adult"
locations (Minnesota Automatic Merchandising
Council 1987; Adkins 1989; Parsons 1989; Grow 1990;
Moylan 1990; Pace 1990; Gitlin 1991). Many of these
locations, including bars and other liquor-licensed


Table 5.3. Provisions of state laws relating to minors' access to tobacco as of December 31,1999

Minimum age
for tobacco

State

sales

Tobacco   Vending
license    machine
required   restrictions

Alabama
Alaska
Arizona
Arkansas
California'

19
1Y
18
18
18

yes
yes+
110
yes
110

Colorado
Connecticut'
Delaware?
District of Columbia
Florida'

18
18
18
18
18

no
yes+
yes
yes+
ves

Georgia
Hawaii
Idaho
Illinois'
Indiana'

18
18
18
18
18

yes
110

no

no

110

Iowa'             18        Vt'S+
Kansas            18         vest
Kentucky'          18       yes+
Louisiana'         18         yes
Maine            lti            ves

Maryland
Massachusetts'
Michigan'
Minnesota
Mississippi'

18
18
18
18
18

vest

ves
yes
ves
yes

no

yes
yes
yes
yes

ves

Yes
yes
yes
yes

yes
yes
yes'
yes
yes

ves '

yes
yes
yes
ves

no

no

VES

ves
yes

Enforcement  Sign-posting
authority   requirements*

yes
no

no
Yes
no

no
Yes
no
Yes
Yes

Yes
Yes
Yes
yes
Yes

yes
yes
no
no'l'
yes

110
Yes
yes
yes
yes

no
yes
yes
110
yes

Yes
yes
yes
no
Yes

yes
no
yes
yes
yes

yes
no
yes
yes
ves

no

no

no
yes
yes

Prohibits
purchase,
possession,
and/or use
by minors

Yes
ye9
yes
yes
yes

yes
yes
Yes
no
Yes

yes
yes
yes
yes
yes

yes
yes
yes
yes**
yes

yes
no
yes--
yes
yes""

*Refers to the requirement to post the minimum age for purchase of tobacco products.
-Excludes chewing tobacco or snuff.
TExcept minors at adult correctional facilities.
`Some or all tobacco control legislation includes preemption.
`Requires businesses that ha\-e vending machines to ensure that minors do not have access to the machines;
however, the lall- does not specify the type of restriction, such as limited placement, locking device, or
supervision.
"Signage required for sale of tobacco accessories, but not for tobacco.
**Except persons rvho are accompanied by a parent, spouse, or legal guardian 21 years of age or older or in a

private residence.

++A pupil may not possess tobacco on school property.
Source: Centers for Disease Control and Pre\.ention, Office on Smoking and Health, State Tobacco Activities
Tracking and Elraluation System, unpublished data.


Table 5.3. Continued

State

Missouri
Montana'
Nebraska
Nevada'
Ne\v Hampshire

Ne\v Jersey'
Ne\v Mexico'
New, York'
North Carolina'
North Dakota

Ohio
Oklahoma'
Oregon'
Pennsyl\.ania'
Rhode Island

South Carolina'
South Dakota'
Tennesseei
Texas
Utah'

Vermont
Virginia'
Washington'
West Virginia'
Wisconsin'
Wvoming'

Total

Minimum age   Tobacco   Vending
for tobacco    license    machine
  sales    required   restrictions

1X
18
IS
18
18

110

ves

18
18
18
18
18

vet;

ves

ves

ves

ves

18
18
18
18
1X

no

ves
yes"
ves 4i

VeS

WS'

no

ves
*lO?C* i :
\,t`S`"

Vt?S'
WS

no
Vt?S-
yes-

ves

no

no

ves
yes

ves

no
vesT

no

ves

no

35

ves

\'es

vcs

ves

VeS

18
18
18
18
18

18
18
18
18
18
18

ves

ves

\'t?S

ves

VCS

31

yes
no

yes
yes

14

Enforcement
authority

no

yes
I10

VPS

\'fS

yes
VtTS

ves

110

no

no

ves

Vt`S

no

ves

no

yes
ves

ves

ves

ves

ves

ves

ves

110

no

33

Sign-posting

requirements

yes
yes
no

no

ves

ves

ves

ves
yes
no

yes
yes
yes
no

yes

no

no
yes
ves

no

yes
yes
yes
no
yes
yes

36

Prohibits
purchase,
possession,
and/or use
by minors

no
ye@
yes
no
yes

no
yes
no
yes
yes

no
yes
yes
no#
yesqT

no

yes
Yes
yes
yes

yes
yes
yes
yes
yes
yes

42

**A pupil mav not possess or use tobacco on school property
"Except ven&ng machines.
"A retail license exists for those retailers 12-ho manufacture their o\vn tobacco products or deal in nonpaid
tobacco products.

" On any public street, place, or resort.


businesses, do not prohibit minors entry and ha1.e
been shorz-n to be readily accessible to underaged buy-
ers (Forster et al. 1992b; Wakefield et al. lYY2a;
Cismoski and Sheridan 1993). Because less-restrictive
measures must be consistently implemented to be ef-
fective, and because such implementation is difficult,
the USDHHS (1994) and the IOM (Lynch and Bonnie
1994) recommend a total ban on cigarette vending
machines. The 1996 FDA rules Lvould have excluded
locations that are inaccessible to minors, but the
multistate settlement proposed a total ban.

  Restrictions on vending machines are a category
of regulation of self-service cigarette sales. A general
ban on self-service would require that tobacco be
physically obtained from a salesperson and be stored
so that products are not directly accessible to custom-
ers. In one study of 4X9 over-the-counter purchase
attempts, minors \vere successful at purchasing in 33
percent of locations where cigarettes ivere behind the
counter and 15 percent of locations bzhere cigarettes
were openly available (Forster et al. 19%). In another
study, stores that did not give customers access to to-
bacco products were less likelv to sell to minors (12.8
percent) than stores that permitted direct contact lvith
tobacco products (30.6 percent)(Wildev et al. lYY5a).
Finally, data suggest that shoplifting is an important
commercial source of tobacco to underaged vouth
(Cummings et al. 1992, 1995; Cismoski and Sheridan
1994; Lynch and Bonnie 1994; Forster et al. lYY5; Wilde!
et al. 1995b; CDC lYY6d; Rosl\,ell Park Cancer Insti-
tute 1997). Shoplifting mav be deterred bv regulations
that specify that until the moment of purchase, single
packs, any amount less than a carton, or all tobacco
products must be physically handled by an emplo\,ee
onlv (Cismoski 1991; Wildev et al. 1YYSa; Cald\veil et
al. iY96).

   Several states have addressed the issue of self-
service sales of tobacco products. For example, Idaho
and Minnesota restrict self-service sales to onlv those
stores that do not allo\v minors to enter and that ob-
tain most of their sales from tobacco. Texas prohibits
self-service sales in any location accessible to minors.
Three hundred and ten localities have chosen to re-
strict tobacco sales by prohibiting self-service displays
(American Nonsmokers' Rights Foundation, unpub-
lished data, 2000). Opposition to this measure is
generally organized by tobacco distributors and
retailers, who fear the loss of slotting fees-payments
(often substantial) to retailers for ad\,antageous
placement of tobacco products and for point-of-
purchase advertising in their business (Gersten 1994;
Thomas A. Briant, letter to Litchfield Tobacco Retail-
ers, February 16, 1993; Cald\vell et al. lYY6). The 10M

recommends a ban on self-service displays (Lynch and
Bonnie 19941, and the Working Group of State Attor-
nevs General (1994) recommends to tobacco retailers
that they eliminate such displays. That this recom-
mendation is not unreasonably burdensome has been
demonstrated by one study in which 28 percent of re-
tailers in 14 communities complied voluntarily (Forster
et al. 1995) and by another study involving 15 cities in
northern California (Kropp 1995). The 1996 FDArules
would also have prohibited self-service displays
except in certain adults-only facilities; thq proposed
national settlement further stipulated that in
non-adults-only facilities, tobacco products must be
out of reach or otherwise inaccessible or invisible to

consumers.

  Anecdotal reports have suggested that single or
loose cigarettes are sold in some locations. Such sales
are often prohibited by state or local law, at least im-
plicitly because single cigarettes do not display the
required state tax stamp or federal warning. Fre-
quently, single cigarettes are kept out of sight and are
available onlv by request. Researchers in California
found that e\;en after a state law explicitly banned the
sale of single cigarettes, almost one-half of tobacco re-
tailers sold them to their customers (Klonoff et al. 1994).
The study found that the stores that made loose ciga-
rettes available sold them to almost twice as many
minors as the); did to adults. That finding lends sup-
port to the argument that single cigarette sales are an
important avenue to addiction for some youth. A re-
cent studv in Central Harlem has produced similar
results: 7il percent of the licensed outlets sold single
cigarettes to minors (Gemson et al. 1998). The IOM,
the 1996 FDA rules, and the proposed multistate settle-
ment ha\,e all recommended that the sale of loose or
single cigarettes be explicitly prohibited (Lynch and
Bonnie 1YYq).

Regulation Directed at the Seller

  All states now have a law specifying the mini-
mum purchaser's age for legal sale of tobacco prod-
ucts. For all but two states, that age is 18; Alabama
and Alaska specify age 19. Almost two-thirds of the
states and many local jurisdictions require tobacco
retailers to display signs that state the minimum age
for sale. Some regulations specify the size, wording,
and location of these signs. Other regulations specif!,
the minimum age for salespersons; these regulations
recognize the difficulty young sellers may experience
in refusing to sell cigarettes to their peers.

   Most of these laws define violation either as
a criminal offense (e.g., misdemeanor or gross


misdemeanor), \2-ith accompanving penalties, or as a
civil offense, \Vith specified ci\-il penalties (e.g., fines
and license suspension). Ci\-il offense 1alt.s are thought
to make enforcement easier and are therefore more
likely to be carried out, since they do not generall)
require court appearances. Many state or local lalvs
specify penalties onlv against the salesperson. Apply-
ing penalties to business oIl,ners, \j.ho generalI\. set
hiring, training, super\?sing, and selling policiis, Is
considered essential to pre\.enting the sale of tobacco
to minors, although tobacco retailers ha1.e \,igorousl\
opposed these measures (Skretnv et al. 1990; FeighcrL
                          -
et al. 1991; McGrath 199Ja,b).

   More than one-half of the states and some local
jurisdictions require that tobacco retailers obtain li-
censes for over-the-counter sales, but smokeless to-
bacco is exempted by 13 of these states (CDC, Office
on Smoking and Health, unpublished data). Licen-
sure sometimes is simpl!. a mechanism tor collecting
taxes or generating re\.enue; in other states and cities,
conditions are attached that relate to minors' access.
In addition to civil penalties, retail licensure for tobacco
represents another approach ior facilitating \,outh ac-
cess la\v enforcement efforts and strengthen.ing sanc-
tions for \.iolators of the la\\.. Retail liccnsure can
facilitate the identification of retailers. The lack of a
current and accurate list of tobacco \-endors has been
cited by manv states involved in Svnar enforcement
as d serious `impediment to efficient enforcement
(USDHHS 1999). Retail licensure can also create an
incentive for retail compliance. License suspensions
or revocations could be imposed as penalties for via-
lation of youth access lakes, resulting in revenue loss
for retailers. Licensure \~ould also provide a source
of funds to pav for enforcement and retailer educa-
tion when licensing fees or fines for violations are ear-
marked for such education purposes. Finally, retail
licensure provides a mechanism for administrative
adjudication of vouth access law violations. License
holders byho fail-to comply M.ith the law could be held
accountable before the licensing authoritv.

No published empirical research examines the
effects of tobacco retail licensure on either enforcement
efforts or retail compliance. Studies on policies tar-
geted to increase retail compliance, however, suggest
several specific elements of licensure policies that
should be present in order to increase the likelihood
of positive effects. The points below outline the wavs
in xvhich licensure policies could be used to enhance
retail compliance efforts.

Licensure la!vs must explicitly link the privilege of
selling tobacco products to retail compliance with
youth access laws (Levinson 1999).

Licensure should cover both retail stores and vend-
ing machines (Levinson 1999).
License holders should be required to renew their
license annually (LeLinson 1999; USDHHS 1999).

License holders should be fined for violation of
I\;outh access laws (Levinson 1999).
Fines should be high enough to encourage vendors
to comply with youth access laws but not so high
as to risk loss of community or judicial support for
the imposition of penalties (Lynch and Bonnie
1 YY1).

Fines should be graduated so that greater conse-
quences are associated \vith increased number of
\ iolations. Repeated violations should lead to li-
cense suspension or re\,ocation (CDC 1995a; NC1
1l.d.).

License fees should be sufficient to cover the aver-
age cost of compliance checks (CDC 1995a).

The re\`enue from fines should subsidize the costs
of enforcement (Working Group of State Attorneys
General 1994).

  In addition to these items, several other policy
elements have been suggested for incorporation into
licensure la\vs. These licensure policy components
should communicate clear and consistent messages
about the illegality of tobacco sales to minors and
should promote societal norms intolerant of youth ac-
cess la\v violations (Kropp 1996). These elements in-
clude mandatory posting of warning signs within clear
sight of consumers, mandatory checking of age iden-
tification, state provision of merchant and clerk edu-
cation about vouth access law requirements (i.e.,
consequences for violations and techniques for im-
proving merchants' and clerks' skills at detecting un-
derage youth and refusing sales), restrictions or bans
on self-service displays, and ensuring that clerks are
at or above the legal purchase age.

  Without enforcement provisions, however, li-
censing laws are not effective measures to restrict mi-
nors' access. Before 1996, only 16 states with licensing
laws specified the agency with enforcement responsi-
bility, despite recommendations (USDHHS 1990;
Lynch and Bonnie 1993; Working Group of State At-
torneys General 1994) that states adopt a licensing re-
quirement that has civil penalties and a designated


enforcement agent. In its 1998 report, SAMHSA indi-
cates that all but one state requiring licenses have a
designated enforcement agency (USDHHS IYY8a; see
"Enforcement of Laws on Minimum Ages for Tobacco
Sales," later in this chapter).

   State laws and local ordinances can be a mecha-
nism for increasing retailer awareness of youth access
laws and retailer ability to comply with the law. Of-
ten referred to as responsible vendor laws, this type of
legislation can require retailer education and training
as a condition of retail tobacco licensure or simply re-
quire education and training for all tobacco vendors.
Numerous studies have shown the potential benefit
of comprehensive merchant education and training
programs in helping to reduce illegal sales to minors
(Altman et al. 1989, 1991, 1999; Feighery 1991; Keay
1993; Cummings et al. 1998). In many instances, rep-
resentatives of tobacco retailers have supported the
passage of responsible vendor laws (McGrath 1995a,b;
Thomas A. Briant, Letter to Lit&field Tobacco Retail-
ers, February 16, 1995) when these laws also exempt
business owners from penalties or specify lower pen-
alties for tobacco sales to minors if owners ha\,e trained
their employees. Under such conditions, employee
training would relieve retailers of responsibility for on-
going supervision and monitoring of employee behav-
ior and likely result in decreasing the impact of youth
access laws. It should be noted, however, that as a
result of both Synar and FDA attention to the problem
of youth access to tobacco, several states have Lvorked
to ensure the modification of youth access and/or re-
tail licensure la\ys to mandate vendor education and
training without the incorporation of clauses reliev-
ing retailer responsibility (USDHHS 1998a). These ef-
forts recognize that responsible vendor lags ha\,e the
potential to be an effective rva); to increase the ability
of retailers and clerks to comply with the larv bv accu-
rately detecting underage purchases and confidently
and safely refusing sales.

  The general availability of tobacco products in
retail outlets that have pharmacies has led to some
concerns. In the United States, stores that have phar-
macies usually sell tobacco products, contrary to a 1971
policy recommendation of the American Pharmaceu-
tical Association (1971) that cited the inconsistency of
selling cigarettes with their function as health institu-
tions. A few small chains and a growing number of
independent stores with pharmacies are tobacco free,
but all large chains and most independent stores sell
tobacco products. Pharmacies (and stores that have
pharmacies) that sell tobacco products are as likely as
other outlets to sell to minors (Brown and DiFranza
1992). On the other hand, a study has shown that

pharmacists who work in stores that do not sell to-
bacco have a better understanding of the dangers of
tobacco than do pharmacists who work in stores that
sell tobacco, and they also feel more confident that they
can help customers who use tobacco stop (Davidson
et al. 1988). Two-thirds of pharmacists surveyed in
Minnesota believed that members of the profession
should not work in stores that sell tobacco products
(Martinez et al. 19931, and many felt that the contigu-
ity of tobacco products and pharmaceuticals produces
professional dissonance (Taylor 1992; Kamin 1994).
Both the Canadian Medical Association and the Ameri-
can Medical Association are opposed to tobacco sales
in pharmacies and in stores that have pharmacies
(Staver 1987; Sullivan 1989). The Canadian provincial
government of Ontario banned such sales in 1994 (An
Act to Prevent the Provision of Tobacco to Young Per-
sons and to Regulate its Sale and Use by Others, Stat-
utes of Orleans, ch. 10, sec. 3[61 [1994] [Can.]).

Regulation Directed at the Buyer

  State and local jurisdictions are increasingly im-
posing sanctions against minors who purchase, at-
tempt to purchase, or possess tobacco products (CDC
1996~; Forster et al. 1996). These laws are favored by
some law enforcement officials and tobacco retailers
because of the potential deterrent value (Parsons 1989;
Talbot 1992). Some advocates for reducing tobacco use
argue, however, that such laws are part of an effort to
deflect responsibility for illegal tobacco sales from re-
tailers to underaged youth; that these laws are not an
efficient substitute for laws regulating merchants, be-
cause so many more minors than retailers are involved;
and that sanctions against minors are more difficult to
enforce than those against retailers (Carol 1992;
Cismoski 1994; Lynch and Bonnie 1994; Mosher 1995;
Wolfson and Hourigan 1997). Other advocates have
insisted that some of the responsibility must devolve
on the purchaser and that laws prohibiting possession
should be vigorously enforced (Talbot 1992). Although
not taking a stand on the advisability of purchase and
possession laws, the Working Group of State Attor-
neys General (1994) recommended that such laws
should be considered only after effective retail regula-
tions are already in place.

Enforcement of Laws on Minimum Ages
for Tobacco Sales

  Although laws on the minimum age for tobacco
sales have been part of many state statutes for decades,
only in the past few years has attention been focused


on enforcing these laws by federal, state, or local agen-
cies (Lynch and Bonnie 1994; Fc,tf~rnI Rc:gi5fer 1996;
LSDHHS, in press). As more information has become
a\-ailable about the implementation and effects of v-ari-
ous minors' access lalvs, it is becoming clear that orga-
nized enforcement efforts are essential to realizing the
potential of these Ialvs. Enforcement of minimum-age
la\vs is more likely to occur Ivhen enforcement is self-
supporting through license fees and revenues from pen-
alties and tvhen the penaltv schedule includes civ,il
penalties that are large enough to be tffectiv-e but are
seen as reasonable and simple to administer (Working
Group of State Attorneys General 199-l). La\v enforce-
ment officials have sometimes balked at applving crim-
nal penalties against clerks and retailers for selling
tobacco to minors. Enforcement ma\' be more effecti\.e
if sanctions can be imposed on managers or business
owners rather than, or in addition to, salespersons
(Working Group of State Attorncvs General IYYJ).

  Moreov,er, the lY92 enactment of the Svna~
Amendment (Public La\v 102-321, sec. 1926, discussed
in the introduction to this section) has forciblvr Lxo~~gl~t
this issue to the fore, because the amendmei~t requires
states to enact and enforce legislation restricting the
sale and distribution of tobacco products to minors.
As a result, all states have law-s prohibiting the sale
and distribution of tobacco to minors and all states
enforce these law through a statewide coordinated
program. Additionally, all states have no\z designated
a lead agencv and all but one ha\-e an agency respon-
sible for enforcing their minimum-age laiv (Table 5.4)
(USDHHS, in press). In addition to federal and state
enforcement efforts, a number of local jurisdictions
around the countrv have begun activ,ely enforcing the
law against tobacco sales to minors, and local ordi-
nances can include a schedule of required compliance
checks (Lynch and Bonnie 1994; Working Group of
State Attorneys General 1994; Forster et al. 1996;
DiFranza et al. 1998).

  Compliance checks are most often carried out by
having an underaged buyer, under the supervision of
a law enforcement officer, licensing official, or some
other designated adult, attempt to purchase tobacco.
In jurisdictions where the minor is held legally at fault
if a purchase is made (and where no exceptions are
made for compliance checks), minors participating in
compliance checks are sometimes instructed not to
complete the purchase even if the salesperson is will-
ing; in these cases, the retailer is considered to be in
noncompliance with the youth access law if the pur-
chase is entered into the cash register (Hoppock and
Houston 1990; Cummings et al. 1996).

  Selreral innolrative civil enforcement approaches
have been attempted in California. The district attor-
neys in Sonoma and Napa Counties have used the Cali-
fornia Business and Professions Code section 17200 to
file civ,il lawsuits against store owners whose outlets
repeatedlv sold tobacco to minors. Civil enforcement
has prol.ed to be more efficient than criminal citations
and has resulted in fines and penalties as well as reduc-
tions in tobacco sales to minors (Kropp and Kuh 1994).

  Increased emphasis on enforcement, coupled
w,ith passage of laivs against possession of tobacco by
minors, may result in enforcement resources being
selectively funneled to apprehending underaged
smokers rather than penalizing the merchants who sell
tobacco to these minors. A survey of 222 police chiefs
in Minnesota rev,ealed that although more than 90 per-
cent \vere enforcing the law against minors' posses-
sion, 10 percent reported applying penalties to minors,
and onlv 6 percent reported any enforcement against
merchants (Forster et al. 1996).

  A vigorous and multidimensional campaign has
been mounted by the tobacco industry and its allies to
prevent or undermine effective enforcement of minors'
access laws and to resist the proposal that retailers be
held accountable for their stores' compliance. Since
1992, laws sponsored by the tobacco industry but os-
tensiblv intended to bring states into compliance with
requirements of the Svnar Amendment have been
passed in Georgia, Idaho, Kentucky, Louisiana, Mary-
land, Mississippi, North Carolina, Oklahoma, South
Dakota, and Tennessee (DiFranza 1994~; DiFranza and
Godshall 1993). Tobacco industry representatives and
their allies have lobbied successfully for the inclusion
of language such as "knowingly" or "intentionally"
in the lavv prohibiting sale of tobacco to minors; the
impact of such language may be to render the law
unenforceable. Industry interests have sought to in-
clude various restrictions on how, how often, and by
whom enforcement or compliance testing can be con-
ducted. Examples of these restrictions include oppos-
ing employing teens in compliance testing or requiring
that only very young teens can function as buyers, in-
sisting that enforcement be done only by the alcohol
control authority or some other state agency, oppos-
ing compliance checks carried out by advocacy groups
or for public health research, and opposing require-
ments that compliance checks occur on a specified
schedule. The industry has further proposed imme-
diate reentry and confrontation after an illicit sale-a
procedure that could compromise collecting evidence.
Industry representatives have also consistently main-
tained that merchants ought not to be responsible for
the costs incurred in complying with minimum-age


Table 5.4. Agencies responsible for enforcing state laws on minimum age for tobacco sales as of fiscal
     year 1998

State/Territorv

Lead agency

Alabama

Alaska

Arizona

Alcoholic Beverage Control Board
Department of Health and Social Services,
Division of Alcoholism and Drug Abuse
Department of Health Services, Office of
Substance Abuse and General Mental Health

Arkansas

California

Colorado

Connecticut

Department of Health, Bureau of Alcohol
and Drug Abuse Prevention
Department of Health Services
Department of Human Services, Alcohol
and Drug Abuse Division
Department of Mental Health and Social
Serlrices, Office of Addiction Services

Delalvare

District of
Columbia

Department of Public Safet\j, Alcoholic
Beverage Control Commission
Department of Human Ser\~ices, Addiction
Prevention and Recovery Administration

Florida

Department of Business and Professional
Regulation, Division of Alcoholic Be\,erages
and Tobacco

Georgia

Halvaii

Department of Public Safety
Department of Health, Alcohol and Drug
Abuse Division

Idaho

Department of Health and Welfare, FACS
Di\zision, Bureau of Mental Health and
Substance Services

Illinois

Liquor Control Commission

Indiana

Family and Social Ser\,ices Administration,
Di\.ision of Mental Health

Iowa

Department of Public Health, Di\,ision of
Substance Abuse and Health Promotion

Kansas

Department of Social and Rehabilitation
Seri-ices, Alcohol and Drug Abuse Services

Kentucky     Department of Alcoholic Beverage Control

Enforcement agency

Alcoholic Beverage Control Board
Attorney General's Office

Department of Health Services, Office
of Substance Abuse and General Mental
Health

Tobacco Control Board

Department of Health Services

State and local law enforcement

Department of Revenue Services

Department of Public Safety, Alcoholic
Beverage Control Commi&ion

Department of Consumer and Regulatory
Affairs and the Metropolitan Police
Department

Department of Business and Professional
Regulation, Division of Alcoholic
Beverages and Tobacco

Department of Public Safety

Department of Health with Department
of the Attorney General

Department of Health and Welfare, FACS
Division, Bureau of Mental Health and
Substance Services

No one agency responsible for
enforcement

Indiana Alcoholic Beverage Commission
Excise Police

Department of Public Health, Division of
Substance Abuse and Health Promotion

Department of Revenue, Alcoholic
Beverage Control Board

Department of Agriculture (specified
state law) with the Department of
Alcoholic Beverage Control (appointed)

Source: C.S. Department of Health and Human Services, in press


Table 5.4. Continued

State/Territory

Louisiana

h4aine

\laryland

h4assachusetts

Michigan

Minnesota

Mississippi

Missouri

Montana

Nebraska

Nevada

Nel\- Hampshire

New Jersey

New Mexico

New York

North Carolina

Korth Dakota

Lead agency

Department of Rei-enue and Taxation,
Office of Alcoholic Beverage and Tobacco
Control

Department of Mental Health and Mental
Retardation, Office of Substance Abuse
Department of Health and Mental Hygiene,
Alcohol and Drug Abuse Administration
Department of Public Health, Bureau of
Substance Abuse Serl-ices

Department of Communit\~ Health, Bureau
of Substance Abuse Serl.ices
Department of Human Services, Chemical
Dependency Program Di\.ision
Department of Mental Health, Di\-ision of
Alcohol and Drug Abuse
Department of Mental Health, Di\?sion of
Alcohol and Drug Abuse
Department of Public Health and Human
Ser\-ices, Di\.ision of Addicti\.e and Mental
Disorders

Department of Health and Human Services
Attorney General of the State of Ne\,ada
Department of Health and Human Services,
Bureau of Substance Abuse Services

Department of Health and Senior Services

Department of Regulation and Licensing,
Alcohol and Gaming Division

Department of Health, Office of Alcoholism
and Substance Abuse Services

Department of Human Resources, Division
of Mental Health, Developmental Disabilities
and Substance Abuse Services

Department of Human Services, Division of
Mental Health and Substance Abuse Services

Enforcement agency

Department of Revenue and Taxation,
Office of Alcoholic Beverage and Tobacco
Control

Department of Mental Health and Mental
Retardation, Office of Substance Abuse
State Comptroller's Office

Department of Public Health, Tobacco
Control Program with the Attorney
General's Office

Department of Community Health, Bureau
of Substance Abuse Ser\,ices

Department of Human Services, Chemical
Dependency Program Di\,ision
Office of Attorney General

Department of Mental Health, Division of
Alcohol and Drug Abuse
Department of Public Health and Human
Services, Division of Addictive and
Mental Disorders

Nebraska State Patrol

State Attorney General
Department of Health and Human
Services, Bureau of Substance Abuse
Services

Department of Health and Senior Services
with local health agencies
Department of Regulation and Licensing,
Alcohol and Gaming Division (statutory),
Department of Health and Department of
Public Safety (by executive order)
37 local county health units and 10 district
offices of the state's Department of Health
Local police and sheriff's departments

State and local law enforcement agencies
are responsible for enforcing state and
local laws prohibiting tobacco sales to
minors. The Department of Human
Services, Division of Mental Health and
Substance Abuse Services, is responsible
for conducting compliance surveys.


State/Territory

Ohio

Oklahoma

Oregon

Pennsyl\,ania

Rhode Island

South Carolina

South Dakota

Tennessee

Texas

Ltah

Vermont

Virginia

-

\Vashington

West Virginia

Wisconsin

Wyoming

American Samoa

Guam

Marshall Islands

Lead agency

Department of Alcohol and Drug Addiction
Services

Alcoholic Beverage Laxv Enforcement
Commission

Department of Human Resources, Office of
Alcohol and Drug Abuse Programs
Department of Health, Office of Alcohol
and Drug Abuse Programs
Department of Health, Di\-ision of Substance
Abuse

Department of Alcohol and Other Drug
Abuse Serlrices

Department of Human Str\-ices, Division of
Alcohol and Drug Abuse

Department ot Agriculture
Commission on Alcohol and Drug Abuse
and Department of Health
Department of Hum,ln Ser\.ices, Di\,ision of
Substance Abuse

Department of Liquor Control

Department of Agriculturt~ and Consumer
Serl-ices

Department of Social and Health Ser\,ices,
Dii-ision of .~lcohol and Substance Abuse

Department of Health and Human Resources,
Di\-ision of Alcoholism and Drug Abuse
Department of Health and Family Serl?ces,
Bureau of Substance Abuse Services

Department of Health, Di\,ision of BehaL-ioral
Health and Substance Abuse Program

Department of Humm and Social Serv-ices,
Social Services Di\,ision

Department of Mental Health and Substance
Abuse

Office of the Attornev General

-

Enforcement agency

Department of Alcohol and Drug
Addiction Services
Alcoholic Beverage Law Enforcement
Commission

Oregon State Police

Department of Health, Office of Alcohol
and Drug Abuse Programs
Department of Health, Division of
Substance Abuse (The Division of
Substance Abuse transferred from the
Rhode Island Department of Health to the
Department of Mental Health, Retardation,
and Hospitals on September 1,1998.)
Department of Revenue and Taxation

Di\,ision of Alcohol and Drug Abuse
coordinates enforcement with the Attorney
General's Office and 66 county state's
attornevs

Department of Agriculture
State Comptroller

Department of Human Services, Division
of Substance Abuse
Enforcement and Licensing Division of the
Department of Liquor Control
Alcohol Be\.erage Control Board

Liquor Control Board

Alcohol Be\,erage Administration

Department of Health and Family Services,
Bureau of Substance Abuse Serlrices

Local law enforcement agencies

Department of Public Health

Department of Mental Health and
Substance Abuse

Chief Prosecutor of the Office of the Police
Comntissioner


Table 5.4. Continued

State/Territory         Lead agency

Micronesia     Department of Health

Northern Marianas  Department of Public Health

Palau        Ministrv of Justice, Bureau of Public Safet!
         M.ith Ministrv of Commerce and Trade
       (responsible ior licensing)

Puerto Rico

Department of Health, Mental Health and
Anti-Addiction Ser\+ces Administration

Virgin Islands

Department of Health, Di\-ision of Mental
Health, Alcoholism and Drug Dependent\

Ialvs, such as the costs of making tobacco inaccessible
to minors or of ha\ing merchants monitor their ON'II
staff (DiFranza 1991~; DiFranza and Godshall 1YY-L).
Despite, or in some cases in response to, these indus-
trv efforts, many states ha1.e successfully strengthened
their youth access laws and/or removed industry-
inspired loopholes and provisions for affirniati1.e de-
fense. Six states amended state lal\- to permit minors
to participate in compliance checks conducted for en-
forcement purposes. Tlventy-three states IIOIV ha1.e
this provision in their minors' access la\v. T\VO states
passed legislation that will provide a more accurate list
of tobacco retailers for compliance checks and three
states added provisions that address funding for en-
forcement and education programs (USDHHS, in press).

  The reports from both the 10M (Lynch and
Bonnie 1994) and the Working Group of State Attor-
new General (1994) include strong recommendations
that active enforcement of minors' access la\vs be
implemented, that merchants be held responsible for
sales in their stores, and that access la\vs supported
by the tobacco industry be rejected.

  Using another type of enforcement, some pri\.ate
groups and states have conducted lawsuits against
commercial outlets that violate minors' access laws.
`4 selection of these cases, one of which also named a
tobacco company as a codefendant, is discussed in
"Enhancing Prohibitory Regulation by Private Litiga-
tion," later in this chapter.

  Traditional law enforcement agencies often re-
sist conducting tobacco enforcement for a number of
reasons. Thev believe that tobacco enforcement diverts
limited resoirces from other more pressing crime and

Enforcement agency

No single agency; enforcement by local
police and health departments
Department of Public Health
Bureau of Public Safety

Department of Treasury

Department of Licensing and Consumer
Affairs

that the public does not support the use of officers for
such enforcement. They have also argued that the ill-
feeling of members of the business community gener-
ated by the issuance of citations negatively affects other
enforcement efforts. Finally, the officers themselves
frequently resist because they do not want to facilitate
potential job loss for a clerk for \vhat they perceive to
be a "minor" infraction or because they believe that
prosecutors and judges lvill be reluctant to penalize
(USDHHS 1999).

  Other agencies can be a suitable alternative for
the conduct of enforcement. Chief among them are
public health departments, tzrhich recognize the im-
portance of conducting enforcement, and alcohol bev-
erage control agencies (ABCs), which are highly
experienced in conducting undercover compliance
checks. ABCs retain a staff of inspectors that are fa-
miliar tvith the protocols that may be employed dur-
ing retail inspections (i.e., consummated and
unconsummated buys). ABCs also tend to recognize
a connection betbveen alcohol and tobacco enforcement
and accept the importance of conducting tobacco in-
spection for practical reasons if not for health reasons.
This, in turn, results in less of a philosophical resis-
tance to actually issuing citations for violations. Fi-
nally, because ABC authorities regularly engage in
enforcement directed at retailers, tobacco enforcement
conducted by this agency will not likely generate
as negatixre a backlash from retailers and the general
public as enforcement conducted bv traditional law
enforcement (USDHHS 1999).


State Settlements

  All four states that settled their la\vsuits against
the tobacco industry in 1997-1998 tvon youth access re-
strictions in their settlement agreements. (The e\,ents
leading up to these four settlements, along with their
implications as a litigational tool for reducing tobacco
use nationw,ide, are discussed in "Recovery Claims by
Third-Party Health Care Payers," later in this chapter.)
For example, the tobacco industry defendants in the state
of Florida case agreed to support IWLV state la\vs or regu-
lations to prohibit the sale of cigarettes in vending
machines, except in adult-onlv locations or facilities
(Floriiin ~1. AIIIUI'CITII fi~Iwcco Co., cii.il Action No. 95-1166
AH, sec. II.A.2 [Fla., Palm Beach Cty. Aug. 35, 19973).
The industry also agreed to support new state laws in
Florida to increase civil penalties for sales of tobacco
products to minors (including retail license suspension
or revocation) and to strengthen civil penalties for the
possession of tobacco by minors. The Florida settlement
(sec. lI.B) further requires the tobacco industry to pay
5200 million for a two-vear pilot program to reduce to-
bacco use by minors, -including enforcement, media,
educational, and other vouth-directed programs. L'outh
access provisions of the Texas settlement that pertain to
nelv state laM-s mirror the terms of the Florida agree-
ment (fil.~~?s il. A11wriii7~7 fi~clborio CO., No. 5YhCV-9 1 (E.D.
Tex. Jan. 16, 19981, sets. 7[a-cl).

  The state of Minnesota LVOII the most compre-
hensive array of public health and youth access restric-
tions to date IThen it settled its case after a highly
publicized trial in 1998 (h/li~~rwwf~? ~1. Plri/ifT h-lw~i~ I/K.,
iit& irk 13.2 TPLR 3.39). One provision of the Minne-
sota settlement forbids tobacco manufacturers from di-
rectlv or indirectly opposing state statutes or
regulations intended to reduce tobacco use bv minors.
A list of 1egislatil.e proposals col.ered b!' the prohibi-
tion is attached to the settlement agreement (Schedule
B) and includes the folIoEying measures:

Expansion of self-service restrictions and remo\,al
of the current exception for cigars.
Amendment of the current law, for restricting youth
access to vending machines to clarify that machines
w?th automatic locks and machines that use tokens
are covered.

"Enhanced or coordinated funding" for enforce-
ment efforts under sales-to-minors provisions of the
criminal code or the statute and ordinances invol\,-
ing youth access.

La~vs to "encourage or support the use of technol-
ogy to increase the effectiveness of age-of-purchase
laws" (e.g., programmable scanners or scanners to
read drivers' licenses).

Restrictions on wearing, carrying, or displaying to-
bacco indicia in school-related settings.
Establishment or enhancement of nonmonetary in-
centi\:es for youth not to smoke (e.g., expand com-
munity services programs for youth).

  Moreover, prohibiting tobacco companies from
challenging the enforceability or constitutionality of
current Minnesota laws encompasses some key youth I
access statutes, such as those pertaining to the sale of
tobacco to minors (Minnesota Statutes sec. 609.685) and
the distribution of samples (Minnesota Statutes sec.
325.77) (Mirzrrcsotn ~1. Pl~ilip Movris Iuc., cited ill 13.2 TPLR
3.39, sec. IV.A.2). Another injunctive provision, forbid-
ding the tobacco industry from targeting children
through advertising, promotion, or marketing, also
prohibits the industry from "taking any action the pri-
mary purpose of which is to initiate, maintain or in-
crease the incidence of underage smoking in
Minnesota" (Miri!~~sc~fn ~1. Philip Morris ~IIC., No. Cl-94
8363 [Minn., Ramse]l: Cty. May 8, 19981, cifclf ir? 13.2
TPLR 2.112, 2.113 [1998]).

  The Minnesota settlement also includes a large
industry-funded program to reduce teen smoking. The
program includes counteradvertising, classroom edu-
cation, community partnerships, research, advocacy,
and prevention components (Milztwofn ~7. Philip Mor-
ris Ir~c., cjf~`~1 irz 13.2 TPLR 3.39, sec. VIII.A.2).

  Although Mississippi (the first state to settle) did
not initially secure public health restrictions, it later
imported some of those contained in the sweeping-
Minnesota settlement by exercising the "most favored
nation" clause (discussed in "Recovery Claims by
Third-Party Health Care Payers," later in this chapter)
in its original settlement agreement (I'R Newswire
1998a). Intended to ensure that Mississippi would re-
cei1.e the benefits any later similar settlement might
receive, the most favored nation clause also enabled
the state to substantially increase the dollar amount of-
its settlement with the industry. Furthermore, although
the revised agreement prohibits Mississippi from gain-
ing any additional monetary benefit based on future
state settlements, it does not limit the incorporation of
additional public health provisions or financial adjust-
ments in the event that Congress adopts national to-
bacco legislation.


Preemption of Local Action by State Policy

  As noted earlier in this section (see "Efforts to
promote Adoption and Enforcement of Minors' Access
La~vs"), the initiati1.e to address minors' access, as 1vell
as many creati1.e solutions, has come from the local
Ic\.el. In state legislatures, the balance of po\\`er be-
t\j-een forces for and against reducing tobacco use is
most often tipped in favor of tobacco USC. The re\.erse
is often true at the local le\-el, \Vhere jurisdictions 1ial.e
enacted inno\.ative approaches that l1aL.e been c\-alu-
ated by researchers. At the state level, ho\ve\-er, to-
Lmxo industry representati\.es ha\ e sought to preclude
legislative or enforcement authority at the local lel,el
b!r including preemption language, usualI!. attached
to rveak statelvide restrictions.

  As of 1998, 30 states had preempti\ e tobacco COP
trol larvs, although they \.ar\' \videl\. in the kind of re-
<trictions thev preempt (CDC 1999). No preempti\~c
tobacco contrbl lairs haw been enacted since Julv lW%
The tobacco industry has adopt4 preemptidn as a
main strategy to undermine, o\`crturn, and prohibit
future efforts to adopt local policies to reduce tobacco
use (Siegel et al. 1997; Goro\.itr et al. lY9X). For in-
stance, in 1991 and 1992, the tobacco industr\, spent
illore than S2 million to lobbv for the repeal &f local
clean indoor air ordinances (`Travnor et al. lYY3). In
California in one vear alone, theindustrk. spent 518.9
million on an initiative to repeal all local ordinances
for reducing tobacco use and to eliminate local author-
ity to enact nets ordinances (Siegel et al. 1997).

  A memorandum of the 1991 Smokeless Tobacco
Council described a strategy to oppose local ordinances

Litigation Approaches

and ad\,ance statewide antitobacco bills containing
preemption clauses (Siegel et al. 1997). In addition,
the Tobacco Institute stated that a priority for 1993 was
to "encourage and support statewide legislation pre-
empting local laws, including smoking, advertising,
sales, and \-ending restrictions" (Tobacco Institute
19Y2). This strategy would work against the passage
of strong tobacco control laws at the local level and
xvould relieve logistical difficulties of the tobacco in-
dustry in devoting resources toward multiple local
jurisdictions (Siegel et al. 1997; Gorovitz et al. 1998).

  E\,en tchen a preemption clause is not specifi-
callv included, tobacco industry representatives have
argued that state lalvs that address minors' access are
intended to preempt local action, and that argument
has been used bv at least one court to invalidate more
restricti\.e local ordinances (DiFranza 1993). Both the
IOM (Lunch and Bonnie 1994) and the Working Group
of State.Attorneys General (1994) recommend that state
Ia\vs include language specifically stating that they are
not meant to preempt stronger local ordinances.

  One of the U.S. health objectives for 2000 was to
reduce to zero the number of states \vith preemptive
smohe-free indoor air laws (Objective 3.25) (National
Center for Health Statistics 1997); an objective proposed
for 2010 is to reduce the number of states w?th any pre-
empti1.e tobacco control laws to zero (USDHHS 2000a).
Most states have preemptive tobacco control laws, and
1 Y ha\.e preemptive pro\risions for minors' access laws.
Thus, achie\rement of the 2000 objective is unlikely (CDC
1999).

Introduction

  Society deploys various regulatory controls to
confront risks arising from dangerous products or
practices. As has been discussed in previous sections
in this chapter, these controls include those intrinsic
to the practice itself, such as preventive design and
safety procedures built into a product or into the tech-
llology of its use, as well as external regulation by go\`-
ernment agencies and private parties, such as property
owners, employers, or insurers. Certain institutions
also absorb and spread losses when a practice does

result in injuries, such as relief institutions that assist
victims and social and private insurance that compen-
sates the injured. Another regulatory control, intro-
duced here, is private law (referred to generally in this
section as litigation and held distinct from the more
sweeping legislative scope of public law). In the course
of vindicating the claims of injured persons, private
law generates, broadcasts, and reinforces safety
standards. The various controls are not independent
but interact in complex ways. For example, preven-
tive design may stem from the imposition or anticipa-
tion either of government regulation or of liability


Private Law as a Means of Risk Control

  Private la\~ remedies combine existing public
standards 1x7ith a public institution-the courts-that
is passi\.e in accepting these standards but is also, ac-
cordingly, reactive ~vhen the standards change. In pri-
vate laIv, the initiati1.e to enforce a change or decision
is shifted a\Vav from an enterprise or a government to
pril,ate actors-tvpically, trictirns or their surrogates.
This diffusion of&e enforcement initiatilre is matched
by the decentralized pronouncement of liability stan-
dards, M.hich are less often established at a given mo-
ment than thev are formulated o\`er time, largely by
courts respondin, 0 increnientallv to specific cases
brought before them. Private ia\< standards are con-
text sensitive, incorporating changing popular values
and understandings. In the United States, this incor-
poration of popular \Yeics is accelerated by the use of
ci\.il juries.

Tort as a Private Law Control

  In the tort system, lvhich applies to actionable
\2-rongful acts other than breach of contract (tort is a
Middle English Ivord meaning "injury"), information
about instances in \vhich injurers (and their insurers)
are forced to compensate \+ctims coalesces slo\t,l\. into
a bodv of kno\~,ledge that, ,ickno\\-Iedged b\~ other
poten&l injurers , generates \.arious pre\ enti1.r effects
(Calabresi 1970). Ho\ze\.er, because each instance of
remedv iii\.ol\,es indi\.iduali/ed determination of li-
abilitv and damages, the production of these prewn-
ti\.e eifects by the tort system is highlv inefficient. The
process is also \.er\' ehpensi\.e, because a large portion
of the money that the tort system extracts from injur-
ers is cons&ied by the tort i,rocess itself (Kakalik and
Pace 19%). Nonetheless, although relati\,elv inefficient
for compensating specific classes of injuries, the tort
system effecti\.ely generates o\.crall prel.enti1.e effects
and is flexible and adapti\,e (American Lalv Institute
1991; Galanter 19%).

U.S. Reliance on Private Law Controls

  Societies differ in the ~\`a)' they deploy this alter-
native set of controls. The Cnited States has tended to
rel\! more heal.ilv on pi+\-ate ld\~ controls than do other
industrialized countries (Kagan 19Ql; Galanter 1994).

The expansilre U.S. system of private remedy is con-
joined \\Tith a lesser emphasis on administrative controls
and social insurance (Pfennigstorf and Gifford 1991).
  Where excessive risks are associated with a prod-
uct or practice, the U.S. tort system typically acts tc,
shift part of the cost of these risks back to the produc-
ers and users. Such litigation campaigns follow a fa-
miliar course toward preventing particular risks: after
a period of innovation and experimentation, a fcbz
successful lawsuits provide a model and incentive for
other lawyers and plaintiffs; the threat of a mounting
tide of litigation (and occasionally an actual tide) leads
to a flow of compensation, modifications in the use or
design of the product, and occasionally bankruptcy of
the defendant; and eventually the litigation abates as
product modifications break the link to risk (McGovern
1986; Galanter 1990; Sanders 1992; Hensler and
Peterson 1993; Durkin and Felstiner 1994; Schmit 1994).

Potential Public Health Benefits of Tobacco
Litigation

  As applied to lawsuits against the tobacco indus-
try, private litigation has the potential to do the
following:

o  Enlist a new' cadre of skilled, resourceful, and re-
lentless advocates on the side of reducing tobacco
use-the incentive being the contingency fees
plaintiffs' attorneys ivould receive if they won or
settled cases against the industrv.

.

Force the industry to raise prices dramatically to
co\.er their actual or anticipated liabilities. Studies
suggest that such higher costs \~ould lower tobacco
consumption-especially among children and
teenagers, \~ho are more price-sensitive than adults
(Daynard 1988; Hanson and Logue 1998). For ex-
ample, after Philip Morris raised its wholesale ciga-
rette prices by 10 percent in one year to cover legal
settlements it,ith four states, a Wall Street stock ana-
lyst estimated that these increases reduced o\,erall
consumption of [Philip Morris] cigarettes by nearly
3 percent (H\vang 1998).

o Encourage the manufacture of safer (to the
extent possible) products, which have lower liabil-
it\; risks. For instance, a noncarcinogenic nicotine
dflivery device, though retaining the health risks
of nicotine, could create less liability both to imli-
vidual users and to third-party health care payers.

o Discontinue dishonest practices that increase the
risk of liability, especially for punitive damages.


Deterring such "intentional torts" is a main goal of
the civil justice system.

Delegitimize the industry politically by exposing
patterns of unsavory practices. For example, man!;
politicians discontinued taking tobacco cornpan!
contributions in the late 19905, largelv because the
discoverv process in pending la\i.suits rei,ealed in-
dustry misconduct (Abramson 1998). Loss of po-
litical esteem or loyalty ~.ould ease the \vay for
effecti\,e tobacco control legislation.

Educate the public about the risks of tobacco USC,
since laiz-suits attract extensi\,e, free media coverage.

Compensate injured parties, including smokers,
afflicted nonsmokers, their families, and the health
care compensation svstem (Davnard 1988).

The First Two Waves of Tobacco Litigation

  Starting in the 195Os, injured smohers tried to use
the emergence of product liabilitv to secure remedies
from the tobacco companies. &ring the first tI1.o
l\`aves of tobacco litigation, hundreds of la\vsuits \vcre
tiled against U.S. tobacco companies b\z indi\.iduals
claiming tobacco-related injuries to health. (B\r ant'
count, 808 cases \\`erc filed betiveen 195-I and- I%%
[Bernstein Research lY%].) Not one of the claims re-
sulted in anv plaintiff, or plaintiff's attornev, recei\.-
ing anv financial compensation.

The First Wave

  The first \jrave of tobacco litigation \vas launched
in 1954, inspired bv the appearance in the early 1950s
of scientific reportsand popular magazine articles that
indicated that smoking caused lung cancer. Although
convinced that this new information \vould lveigh in
as evidence of culpability, the plaintiffs' attorneys Ivere
o\,ermatched. The tobacco companies presented a COP
certed defense in everv claim, no matter 110~. small
the damages sought, and through all stages of litiga-
tion. From the earliest cases, the tobacco companies
retained lawvers from the countrv's most prestigious
law firms and directed them to spare no expense in
exhausting their ad\,ersaries' resources before trial
(Rabin 1993). Plaintiffs' attorneys, typically operating
from small practices under a contingent fee arrange-
ment rvith clients \vho could not afford protracted liti-
gation, found themselves both outnumbered and
outspent on all fronts.

  Only a handful of the first-\\ra\.e tobacco cases
ever came to trial. Those that did found the courts

un~\~illing to impose strict liabilitv on the tobacco in-
dustry. Plaintiffs typically brought suit against tobacco
companies under one or both of two theories: negli-
gence and implied lvarranty. Under a theory of negli-
gence, plaintiffs tried to show that the tobacco
companies knelt enough about the potential harm of
tobacco products to induce them to "engage in [fur-
ther] research adopt Lvarnings, or, at a minimum,
refrain from ad\.ertising that suggested the absence of
an\' health concerns" (Rabin 1993, p. 114). However,
because plaintiffs' attorneys could offer no evidence
at that time that the tobacco industry was aware of the
potential harm of their products, this negligence theory
met \2.ith failure.

  Most plaintiffs' cases relied on the theory of im-
plied \j'arrant): \\.hich imputes strict liability even in
the absence ot negligence. The mere marketing of a
product that \vas not of merchantable quality or rea-
sonabl\ fit for use n~ould thus support legal recovery
of da&ages (Rabin 1993). The plaintiff's ability to rely
on negligence or implied or express warranty was
greatlv constrained bv t\vo circumstances: since 1965,
health I\-arnings had been mandated on tobacco prod-
ucts and on some ad\.ertising (see "Cigarette Warning
Labels," earlier in this chapter), and the tobacco in-
dustr\r had a\.oided making direct claims that their
prc'ducts had positi1.e health effects. Since early 1966,
then, smokers could no longer argue (or at least not
easily) that the tobacco companies had not warned
them of the hazards posed in using their products
(Schlvartz 1993). The doctrine of implied warranty, in
particular, thus seemed invalid to plaintiffs who were
seeking damages from the tobacco industry.

  In general, the courts of that time were unrecep-
ti1.e to strict liability arguments. The courts regarded
the manufacturer as "an insurer against foreseeable
risks-but not against unknowable risks" (Lrrrtilpue ZI.
R./. Rqrwlds ~~clhnrcc~ Co., 317 E2d 19, 37 [5th Cir. 19631,
cert. [JL'llil'il, 375 U.S. 865 [lY63]) or against "the harm-
ful effects of which no developed human skill or fore-
sight can afford" (p. 23). The American Law Institute,
a prestigious and influential association of lawyers,
judges, and academics, adopted this outlook in its 1973
commentarv on section 402A of the Restatement (Sec-
ond) of To&, rvhich deals with strict liability for de-
fectil-e products. The nonbinding yet authoritative
influence of the restatement sounded "the death knell
for the first \vave of tobacco litigation" (Rabin 1993, p.
117; Ci\,elber 19%).


The Second Wave

  A second \va\`e of tobacco litigation began in
1983, inspired by the success that lawyers had recently
achieved in suing asbestos companies: they had not
only recovered substantial verdicts (and fees) but also
effectivelv ended the production and use of asbestos
in the United States.

  As \vas the case with the first wa\re of tobacco
litigation, in the second wave the "lawyers' litigation
strategies rather than their legal arguments.. consti-
tuted the first line of defense" (Rabin 1993, p. 121). The
tobacco industry continued to successfully pursue the
strategy it had developed during the first wave, tak-
ing countless depositions and filing and arguing ev-
erv motion it could, thus threatening to inflict heavy
f&ancial losses on any plaintiff's attorney (Daynard
1994a,b). This strategy was summarized by J. Michael
Jordan, an attorney \vho successfully defended R.J.
Reynolds Tobacco Company in the 198Os, in an inter-
nal memo to his colleagues: "[Tlhe aggressive pos-
ture we have taken regarding depositions and
discovery in general continues to make these cases ex-
tremely burdensome and expensi\-e for plaintiffs' law,-
yers. To paraphrase General Patton, the \vay lye
\von these cases Mras not by spending all of [RJRJ's
money, but by making that other son of a bitch spend
all of his" (Hlrir~ P. Lig~etf GwI//~. Irli., 81-l F. Supp.
414, 421 [D.N.J. 19931).

  To trV to overcome the disparitv of legal resources
that had o~~erwhelmed the first-1vai.e cases, plaintiffs'
attorneys sometimes pooled resources on a case-bv-
case basis. The Tobacco Products Liabilit!, Project, a
nonprofit advocacy group established at Northeastern
University in 1984 to encourage la\vsuits against the
tobacco industry as a public health strategy, ser\red as
a clearinghouse of relevant information for attornevs,
potential plaintiffs, medical experts, and the media. It
began holding annual conferences in 1985, at i\-hich
participants share information about ne\z' legal tactics,
as well as solIre problems about emerging difficulties.
  Besides pooling resources and sharing strategies,
plaintiffs' attorneys needed to find an effective legal
strategy. To find a new theory, plaintiffs' counsel
shifted their focus from implied or express lvarranty
to strict liability, which became a more attractive strat-
egy as courts applied strict liability and comparative
fa&t principles to defective product cases concerning
many other products (Edell 1987; Rabin 1993). Smok-
ers' awareness of risks and, accordingly, their
"freedom of choice" (Rabin 1993, p. 122) became the
linchpins of the tobacco industry's defense against
these liability tactics. Though consistently denying the

reality of the risks, the tobacco industry paradoxically
argued (with great success) that smokers had freely cho-
sen to smoke and had thereby assumed what risks there
might be of smoking and had negligently contributed
to their own harm. To prove the plaintiff's assumption
of risk, counsel for the tobacco industry generally
needed to show that the injured smoker, knowing the
dangers and risks involved in smoking, chose to smoke
anyway. To prove contributory negligence, the tobacco
defense typically showed that, by smoking, the injured
smoker breached a personal duty to protect himself or
herself from injury and thereby contributed to the harm
suffered (Kelder and Daynard 1997).
  Just as it had aided the tobacco industry in ne-
gating charges of negligence and warranty during the
first wave of tobacco litigation, the Federal Cigarette
Labeling and Advertising Act`s imposition of a warn-
ing label on cigarette packaging and advertising
greatly strengthened the industry's countercharge that
plaintiffs had legally assumed their own health risk
and were guilty of contributory negligence. As a re-
sult, jurors were responsive to the industry's defense.
In essence, jurors tended to blame plaintiffs for their
disease instead of identifying the tobacco industry as
the makers of the product that caused the disease
(Davnard 1994a,b). When counsel for plaintiffs pointed
to the addictive nature of tobacco, which arguably lim-
ited the smoker's ability to make a free choice, defense
counsel rebutted by pointing to the large number of
former smokers who successfully quit (Rabin 1993).
  Taking the freedom-of-choice defense one step
further, defense counsel typically drew on, and pre-
sented to the jury, information demonstrating that the
claimant's lifestyle was overly risky by choice or was
e\`en in some way immoral. By presenting this some-
lvhat extraneous material obtained through aggressive
pretrial discovery, the defense "appear[ed] to have had
considerable success in trying not just the plaintiff's
decision to smoke but his or her character more gen-
erally" (Rabin 1993, p. 124). The resulting "full-dress
morality play" seemed to have effectively negated any
jury sympathy for the plaintiff's plight (p. 124).
  The case that culminated and best symbolized the
uphill battle of second-wave plaintiffs was filed by Rose
Cipollone, a dying smoker, in 1983. The case reached
the jury in 1988, four years after her death, and the jury
awarded the plaintiffs $400,000. But this verdict,
subsequently overturned on appeal, was only one
moment in a protracted legal battle. As one analyst
describes, in Ci~7dorze D. Ligyett Group Inc., ". . . over
100 motions were filed, and most of the motions were
argued. There were also four interlocutory applications,
one resulting in the grant of an appeal and the Third


Circuit's initial decision on preemption, an appeal
from the final judgment to the Court of Appeals fol-
lowing a trial of about four months, and tM'o peti-
tions for ii'l'fi01.17I.i to the Supreme Court of the United
States, one of Mrhich leas granted resulting in the his-
toric argument before that Court" (Kelder 1994, p. 4).

  After nearly a decade, Cipc~llo~c, the quintessen-
tial second-\vave case, rzas sent back to the trial court
by the United States Supreme Court. The Court ruled
that although the Federal Cigarette Labeling and Ad-
\,ertising Act of 1965 did not in\.alidate any claims in
private litigation, its successor, the Public Hkalth Ciga-
rette Smoking Act of 1969, preempted anl. claims based
on the manufacturers' failure to lvarn aiter 1969 in its
ad\,ertising and promotions (Ci/~llo~l~ ~1. Ligytf Gro~/p
I~rc., 505 U.S. 504, II2 S. Ct. 2608 [IYY21). Howe\.er, the
Court left open to the plaintiff the option of proceed-
ing under a Mide range of legal theories, including
theories of breach of express Marrant?, defecti\-e de-
sign, fraudulent misrepresentation, and conspiracv to
defraud. But the difficulties of mustering a sufficient
showing that such \?olations bv the defendants 1%.ere
the proximate cause of Mrs. Cipollone's injuries (as
it-e11 as the cause of her death in 198-l) persuaded the
plaintiff's counsel that there \vas little likelihood of a
significant recoverv (Lo\~ellIY92). In 1992, fi\,e months
after the Supreme Court ruling, the h;e\v Jersey fed-
eral district court approved the request of the Cipollone
estate's lawyer to \vithdralv from the case.

It had'been a lengthy, expensive effort for the
plaintiff's counsel: 5500,000 in out-of-pocket expenses
and approximately $2 million in attornev and para-
legal time (Kelder iY9-l). Posttrial proceedings cost an
additional $150,000 in out-of-pocket expenses and
5900,000 in attorney and paralegal time. Tit/~ maga-
zine estimated that the cigarette industry spent at
least $75 million defending the Cipollmw case (Koepp
IY88). Michael Pertschuk, co-director of the Advocacy
Institute, a public interest group dedicated to reduc-
ing tobacco use, has estimated that altogether tobacco
companies were spending approximately $600 million
per year defending the 50 or so cases pending against
them (Stone 1994). Tobacco defendants' reputation for
relentless legal battle dissuaded many lawyers from
entering the frav. Even formidable litigants such as
the asbestos prdducers refrained from trving to ern
broil the tobacco manufacturers as being jointly respon-
sible for asbestos injuries (Rabin 1993).

The Aftermath of the First Two Waves

  The collapse of the Ci/~ollorlr~ case \vas lvidely
\,iewed as signaling the end of the second Leave of

tobacco litigation. Commentators advanced various
explanations for the failure of tobacco litigation, in-
cluding superior lawyering resources, coordination,
and tactics (Rabin 19931, as well as popular resistance
in the form of jury reluctance to alvard damages to
smokers (Schwartz 1993). Many observers concluded
that product liability litigation had a limited role to
play in the regulation of tobacco. Rabin (1993) found
that tobacco presents an instance of "the effective lim-
its of tort laL2;" because "tort laM- and tort process seem
to conspire against any effective role for the tobacco
litigant" (p. 127). Sch\vartz (1993) concurred "that tort
lar\. does not have a major role to play in the develop-
ment of public policy for smoking in the 1990s" (p. 132).

  At that juncture, tobacco litigation seemed to il-
lustrate that the incidence and outcome of litigation
are influenced by the identity, resources, and status of
the parties and by the incentives and strategies of their
la\z,\;ers. Striking differences ha1.e been noted between
the large organization M.ith a continuing interest in an
area of legal contro\,ersy and the individual litigant
\~ho t!rpicallv seeks a remedy only once (Galanter
lY73). One-time litigants tend to be represented by
lalzyers ~~210 practice in smaller units that have less
capacity for coordination and less capacity to invest
strategically in litigation. The monetary stakes-and
thus the incenti\,es-are also lowrer for these smaller
litigants than for their corporate opponents, who can
extract full benefit from the information and experi-
ence generated by litigation expenditures (Galanter
IY71; S&M-artz 1993).

   Nonetheless, at the end of the second wave of to-
bacco litigation, it M'as argued that the tobacco indus-
try was not untouchable and that its proud record of
nearer, at that point, having paid a penny to its victims
masked a high vulnerability to litigation (Daynard 1988,
1993a,b, 1994a,b; Daynard and Morin 1988). The
industry's "scorched earth" litigation tactics (Daynard
IY94a) had indeed made suing tobacco companies pro-
hibitively expensive for most plaintiffs and their attor-
neys. Also, the industry's firm and widely publicized
policy of never settling cases further discouraged liti-
gation, because plaintiffs' attorneys, working on con-
tingency fees, realized that they could not expect to be
paid unless and until they had succeeded at trial and
on subsequent appeals. Furthermore, the low volume
of cases in the first and second waves allowed the in-
dustry to concentrate its legal resources against the few
plaintiffs' attorneys who ventured forth against it.

  But a very different scenario was also possible.
Although the low-volume litigation environment of
the first and second waves favored the defendants, a
high-volume environment might favor plaintiffs. As


happened lvith asbestos litigation, courts facing the
problem of clearing large numbers of tobacco cases off
their dockets \~ould need to find \va\`s to expedite
them. Firm trial deadlines, case consolidations, and
class actions would likely be favored; scorched earth
defense tactics would no longer be permitted. Defei~-
dants -rvould no longer be able to focus all their atten-
tion and legal resources on defeating a febv plaintiffs.
Some cases thus might break through the industry's
defenses, and these victories lvould provide both prac-
tical examples and moral support for plaintiffs' attor-
neys. At some point, the defendants might realize that
their nonsettlement policy had ceased to discourage
plaintiffs and should begin settling. At that point, the
third M'ave of tobacco litigation-virtually a tidal
Mave-\vould have begun (Davnard 1994a).

Given a pre-1994 legal en\,ironment characterized
by a low volume of tobacco litigation, felt lawyers
could afford to ignore the highly unfavorable cost/
benefit ratio that i~ould likely meet any effort to bring
a lawsuit against the tobacco industry. No single law-
ver, howe\,er motivated, could hope to change this situ-
ation through his or her OM'II efforts. The transition
from the low-\.olume to the high-\.olurne scenario
l~ould require public events that signaled clearlv to
lawyers that the en\-ironment \vas changing (Daynard
1994a).

  Paradoxically, although the Cifwllr~rlc~ case lvas
Midely vie\yed as emblematic of I\-hv plaintiffs' attor-
neys \vere M'ell advised to avoid tobacco litigation, it
was also a crucial forerunner for the e\,ents that \t-ould
soon change the litigation en\?ronment. Specifically,
the Supreme Court's 1992 decision in the cnse-
though of no a\-ail to the resource-depleted plaintiffs'
attornevs-presented other plaintiffs' attorneys tvith
a range-of potentially de\.astating legal theories. The
trial itself had provided documentary elpidence-
lvhich, as it turned out, represented the tip of the
iceberg-that could be used to help establish the ele-
ments of a plaintiff's claims against the cigarette manu-
facturers (Daynard and Morin 1988; Daynard 1993a,b).

  Among the legal theories ad\.anced in the first
twro \vaves that remained viable after Ci/~~~//r~rl~ lvere
(1) a theory that cigarettes Ip-ere defectif,e and unnec-
essarily dangerous, because evidence disco\,ered b!
plaintiffs' attorneys and antismoking activists strongly
suggested that the tobacco industrv had kno\vn for
manv vears hoM. to make cigarettes &at nere less likely
to cause cancer; (2) a theory that cigarettes \yere
defecti\,e, because the\, contained tobacco adulterated
\yith many nontobacco carcinogenic substances; (3) a
theory that cigarettes \1-ere defective, because of the
dangers inherent to tobacco; (4) a theory of ci\?l con-

spiracv based on evidence that cigarette manufactur-
ers had joined together beginning in the 1950s to plan
and carry out a strategy for marketing cigarettes while
concealing the harmful and addictive nature of this
product in the face of the developing scientific evidence
of their dangers; and (5) a "Good Samaritan" theory,
I\rhereby plaintiffs could argue that the tobacco com-
panies, having pledged in 1954 to objectively investi-
gate the possible dangers of smoking, were obliged to
carry out their promise and take reasonable action on
what they found (Daynard 1988).

  Potential support for some or all of these ap-
proaches had surfaced during the tortuous process of
the Ci@lorw case. Documents uncovered in the case
prol,ided evidence that the tobacco industry had
fraudulently misrepresented the safety of their prod-
uct and deliberately concealed knowledge about the
harmful and addictive nature of cigarettes. The ev-
dence suggested that the tobacco industry had con-
spired to defraud the American public by pretending
that it l,vas conducting good-faith efforts to uncover
the links between smoking and health and by falsely
assuring the public that the results were negative or
inconclusi\re (Davnard and Morin 1988). Some ana-
lysts predicted that future fraud and conspiracy claims
\2-ould be strengthened when the court documents
from Nrrirl~s \vere released to plaintiffs' attorneys or
\vhen other documentary evidence of tobacco indus-
try misdeeds was uncovered (Daynard 1993a,b). In
the additional trove of documents reviewed by Judge
H. Lee Sarokin in Hr7irlc,s--many of them relating to
the Council for Tobacco Research's "special projects"
di\?sion-i,vas information that might support a find-
ing that "the industry research which might indict
smoking as a cause of illness was diverted to secret
research projects and that the publicized efforts were
primarily directed at finding causes other than smok-
ing for the illnesses being attributed to it" (Hnirlus ~7.
L;<ygt?t Gro~/j. frlc., Civil No. 84-678 [HLS] [D.N.J. 19921,
c-if(w i/l 7.1 TPLR 2.1 [1992]). Calling the tobacco in-
dustrv "the king of concealment and disinformation"
(Hoill& ~1. Lig;cft Group I/K., 975 E2d 81, 88 [3d Cir.
19921)--a remark that led an appellate court to dis-
qualifv Judge Sarokin from further consideration of
the case on the grounds that he failed to appear im-
partial (p. 98&Judge Sarokin concluded that the docu-
ments he had reviewed were not protected by
the attorney-client privilege, as the industry had
claimed, because the industry's attorneys had been
participating in an ongoing fraud, and the documents
were therefore discoverable under the well-recognized
crime/fraud exception (Hairws, cited irk 7.1 TPLR 2.1).
The same court that disqualified Judge Sarokin from


further consideration of the case also agreed that the
evidence cited bv him ~vould support his conclusion
that the crime/fraud exception \vould apply (Hnir7cs,
975 E2d 81).

The Third Wave of Tobacco Litigation

  The third 1val.e of tobacco litigation \vas sparked
b!r tw-o key events. On February 25, 1994, FDA Con-
missioner Da\?d Kessler, relying primarilv on a docu-
ment discovered in the Ci;xdlo77c case, sent a letter to
the CSH reporting that the FDA had rtcei\.ed "mount-
ing e\-idence" that "the nicotine ingredient in cigarettes
is a po\zerfully addicti\-e agent" and that "cigarette
vendors control the lel-els of nicotine that satisf\. this
addiction" (Kessler lY%a). The letter made front-page
nebvs. The second e\,ent occurred three da\,s later,
jvhen an ABC tele\,ision D,~I/ 077~ report alle&i that
tobacco companies manipulated the nicotine lel,els in
cigarettes (Davnard 1991b).

o Documents obtained from Brown & Williamson
and its parent, British-American Tobacco Company,
lvere analyzed (Hanauer et al. 1995).

o  In\~estigati\re journalists obtained documents from
R.J. Reynolds Tobacco Company (Levy 1995).

o  In November 1995, Dr. Jeffrey Wigand, Brown &
Williamson's former vice president for research, tes-
tified under deposition (7'&acco Pmducfs Lifigatiofr
RqJrlrffv~ 1995c).

A series of journalistic and congressional in\.es;-
tigations ensued in the spring of lY%, and internal
Brown & Williamson Tobacco Corporation documents
Ivere leaked to the press. These documents indicated
that the company had studied nicotine for vears, that
its internal stance on se\,eral issues related to smoking
and health differed from rvhat it ivas telling the
public, that it possessed findings regarding the
addictiveness of nicotine and the health dangers of
smoking and ETS that had been il+thheld, and that
Bro\vn & Williamson attornevs w'ere in\,ol\.ed in the
management of the research -projects (Hanauer et al.
1995). When on April 14, 1994, the chief executive
officers of the seven leading U.S. tobacco comp-
anies testified under oath before a congressional
subcommittee-and a large television ne\vs audience-
that thev did not believe that nicotine w'as addictive,
the indu-stry's public credibility plummeted. Suddenly
the industry appeared to millions of people, includ-
ing plaintiffs' attorneys, as dishonest, disreputable, and
legally vulnerable (Daynard 1994a; Srntflc Post-
I~7tdli&7cu 1994; see "Nature, Extent, and Focus of the
Criminal Investigation," later in this chapter).
  Further revelations about the tobacco industry's
knowledge of the harmfulness of smoking and the
addictiveness of nicotine, as well as about the
industry's misbehavior, subsequentlv surfaced in sev-
era1 forms:

.

.

.

Slvorn statements \vere given to the FDA (first
made public on March 18, 1996) in lvhich three
former Philip Morris employees (Ian L. Uydess,
Ph.D., a former associate senior scientist; Jerome
Ri\,ers, a shift manager at a cigarette manufactur-
ing plant in Richmond, Virginia; and William A.
Farone, Ph.D., the director of applied research at
Philip Morris' tobacco unit) stated that Philip Mor-
ris not only belie\.es it is in the nicotine delivery
business but also controls nicotine levels in its
brands (~~1!~~7icc~ P!.r)d!ic-fs Lifi~~fltioll RC[JU7'fC7
1 Y%a,b,c).

The FDA analyzed both the public evidence and
the additional evidence that its investigators gath-
ered about the tobacco industry's past and present
know.ledge of, and behavior toward, the addictive
quality of the nicotine in its products (Fcdtml REP
isfiv. lYY5b3.

On March 20, 1997, Liggett Group Inc., the smallest
domestic cigarette manufacturer, admitted that nico-
tine was addicti\Te and that the industry had tar-
geted minors. Liggett turned over incriminating
industry documents to the attorneys general and
class action attorneys whose cases the company had
agreed to settle (Attor~zr!/s Gwer-nl Scfflenwnf Agrer-
777c~77f, iita-l ir7 12.1 TPLR 3.1 [1997]).

o  Beginning in 1997, first hundreds, then thousands,
and finally millions of industry documents began to
surface after being uncovered through the discovery
process in litigation by the Minnesota attorney gen-
era1 and Blue Cross and Blue Shield. These docu-
ments began appearing on Internet Web sites of the
Commerce Committee of the U.S. House of Repre-
sentatives (http:// . ~~~~~w.house.gov/commerce),
Minnesota Blue Cross and Blue Shield (http://
\vw~.mnbluecrosstobacco.com), and the Minnesota
District Court (http:// . M ww.courts.state.mn.us/

o Philip Morris documents indicated that the
company's researchers studied and wrote about the
pharmacologic effects of nicotine on smokers (Hilts
and Collins 1995).

district). The analysis of these documents has only
begun, but they appear to support a wide range of
legal claims against the industry.


  This third wa\re of tobacco litigation is more di-
verse than its predecessors, in part because of the new
Lvealth of factual information available to plaintiffs'
attorneys. The series of revelations described above
has generated a new set of allegations. For example,
the industry has consistently claimed that nicotine is
not pharmacologically active, that it is not addictive,
and that anvone who smokes makes a free choice to
do so. But ai was made clear by the FDA's 1995 State-
ment of Jurisdiction over cigarettes as drug-delivery
devices; the documents of Philip Morris Companies
Inc., Brown & Williamson-British-American Tobacco
Company, and R.J. Reynolds Tobacco Company relat-
ing to nicotine; and the information being provided
by whistle-blowers such as Jeffrey Wigand and Ian
Uydess, the industry was well aware of the pharma-
cologically active, addictive, and harmful nature of its
products and was not forthright with its customers,
the public, and public authorities about these facts.
There is also evidence that the industry understood
its consumers' need for adequate nicotine to sustain
their addictions and that the industry designed its
products accordingly.

   The tobacco industrv also has claimed that
there is no definitive proof-that smoking causes dis-
eases such as cancer and heart disease. Yet the discov-
ered company documents sho\v that by the 1460s
various tobacco companies had proved in their OM'~
laboratories that cigarette tar causes cancer in labora-
tory animals (Davnard and Morin 1988; Hanauer et
al. 1995). Finally, the industry has claimed that it is
committed to determining the scientific truth about the
health effects of tobacco by conducting internal inves-
tigations and by funding external research. However,
the Brown & Williamson-British-American Tobacco
Company documents indicate that rather than con-
ducting objective scientific research, Brown &
Williamson attorneys have been involved in selecting
and disseminating information from internal as well
as external scientific projects for decades. An example
of the latter is the industry's misrepresenting the work
of the Council for Tobacco Research as objective scien-
tific research on smoking and health. AI1 research find-
ings from this council are sent through the industry's
attorneys, thereby gaining the protection of attorney-
client privilege and potentially enabling the industry
to choose which findings it will release and how it will
present those findings to the public. The potential for
this practice was suggested when certain Brown &
Williamson-British-American Tobacco Company
documents were found to include directions for dis-
posing of damaging documents held by the company's
research department (Hanauer et al. 3995). This

conduct by the industry arguably misled the public
and caused them to buy tobacco products; it also de-
flates the free choice argument the tobacco industry
has used to deter further government regulation of its
products and to defend itself in products liability law-
suits (Hanauer et al. 1995).

  The information outlined above has generated a
host of claims put forward by plaintiffs in the third wave
of tobacco litigation. Some of these are similar to claims
raised in the first two waves but have a much fuller
factual support. These common-law (judge-created)
legal theories include fraud, fraudulent concealment,
and negligent misrepresentation; negligence; negligent
performance of a voluntary undertaking; breach of
express and implied warranties; strict liability; and
conspiracy. Other, statutory (statute-created) claims
new to tobacco litigation include violation of consumer
protection statutes, antitrust claims, unjust enrichment/
indemnity, and civil violations that invoke prosecu-
tion under the federal Racketeer Influenced and Cor-
rupt Organizations Act (Kelder and Daynard 1997).

Common-Law Claims

  An illustrative use of currently available evidence
to support a common-law legal theory of fraudulent
misrepresentation is Count Five of the complaint filed
in April 1998 by 21 Blue Cross and Blue Shield plans
against the tobacco industry (Blue Cross a& Blue Shield
of NL.ZU Icrscy ~1. Plzilip Morris 1E.D.N.Y. Apr. 29, 19981,
cI'f~`d ;)I 13.2 TPLR 3.51 [19981). Among the allegations
listed in Count Five are the following (Blue Crks nr~d
Blue Shitdd, p. 3.95):

301. Defendants represented and promised to
those who advance and protect the public health
and provide or pay for health care and health care
services that they Mrould discover and disclose all
material facts about the effects of cigarette smok-
ing and other tobacco product use on human
health, including addiction.

302. Defendants have made and continue to make
representations, statements and promises about
the safety of cigarettes, other tobacco products and
nicotine in general and their effect on human
health and addiction. Such representations, state-
ments and promises were and remain materially
false, incomplete and fraudulent at the time
Defendants made them, and Defendants knew or
had and continue to have reason to know of their
falsity. Only Defendant Liggett has recently con-
ceded that the nicotine in cigarettes is addictive;


Liggett made this admission for the first time only
in March 1997.

303. In testimony before Congress in January 1998,
executives of other Tobacco Companies tried to
have it both ways concerning the question of ad-
diction. They stated that they personally did not
think nicotine was addictive, but conceded that
under some definitions, it wfould be considered
addictive.

303. In \?ew of the documentary record establish-
ing that the Tobacco Companies ha\-e knolvn for
years M.ith certainty that nicotine is addicti\-e, such
testimony is dishonest and part of an on-going
attempt to disseminate false and misleading
information.

305. At all relevant times Defendants intention-
ally, willfullv or recklesslv misrepresented mate-
rial facts about the human health hazards of
tobacco use, including addiction, and the associa-
tion of cigarette smoking and other tobacco prod-
uct use with various diseases of the heart, lung
and other vital organs.

306. Because of Defendants' secret internal re-
search, Defendants' knov,rledge of the material
facts about tobacco use, health and addiction \vas
and is superior to the kno\vledge of the YCIBS
[Blue Cross and Blue Shield] Plans' members ~.ho
purchased, used and consumed the Tobacco Com-
panies' cigarettes and other nicotine tobacco prod-
ucts. Defendants' knowledge of the material facts
about tobacco use, health and addiction M'as and
is also superior to that of the BC/BS Plans, which
undertook to provide health care financing for
their members. Public access to these facts is
limited because such facts are exclusively within
Defendants' control.

313. The BC/BS Plans reasonably and justifiably
relied on Defendants' materially false, incomplete
and misleading representations about tobacco use,
health and addiction. As a result of such reliance,
the BC/BS Plans did not take, or would have taken
sooner, actions to minimize the losses resulting
from tobacco-related injuries and diseases and to
discourage and reduce cigarette and other nicotine
product use and the costs associated therewith by
the BC/BS Plans' members.

314. As a direct, foreseeable and proximate result
of the foregoing conduct of Defendants, the BC/
BS Plans ha\,e suffered damages through payments
for the costs of medical care due to smoking.

315. As direct and proximate result of Defendants'
fraudulent misrepresentations and nondisclosures,
the BC/BS Plans have suffered and will continue
to suffer substantial injuries and damages for
\vhich the BC/BS Plans are entitled to recovery,
and for lvhich Defendants are jointly and sever-
ally liable.

Statutory Claims

  The nelver claims include a variety of theories
based on federal and state statutes. As with the
common-la\v claims, these statute-based actions are
illustrated in the April 1998 complaint that 21 Blue
Cross and Blue Shield plans filed against the tobacco
industrv.

Cowstrmrr Protection

  Consumer protection claims are based on state
statutes, tvhich vary somewhat from state to state but
generallv forbid unfair methods of competition and
unfair 0; deceptive acts or practices in commerce. A
typical set of consumer protection allegations is that
of Blue Cross and Blue Shield of Florida (B/UP Cross
rjrlil R/W Sllirlil, p. 3.102). It makes the following
allegations:

378. In the conduct of trade or commerce, De-
fendants have engaged and do engage in unfair
methods of competition, unconscionable acts or
practices and unfair or deceptive acts or practices
including but not limited to the following:

a.  Intentionally, willfully and knowingly seeking
to addict persons, including BC/BS Florida
  members and their children, to the use of haz-
ardous cigarettes and other nicotine tobacco
products, knowing that such addiction physi-
cally changes and damages smokers' brain
  structures and creates and constitutes a sub-
stantial unfair impediment or interference in
the smokers' ability to choose whether to con-
tinue smoking, making the transaction no
longer an arm's length one between an equally
Lvilling buyer and seller, which is similar to
many other deceptive and/or unfair devices


and practices that affect bargaining po\Ver or
relative information;

b. Targeting people \vith decepti1.e advertising
by misrepresenting the characteristics, ingre-
dients, uses or benefits of Defendants' tobacco
products; and

c. Engaging for decades in a \vide variety of mis-
representations and fraudulent concealment of
material facts, directlv or by implication, in-
cluding but not limited to: (1) misrepresenta-
  tions and fraudulent concealment of the
  addictive nature of nicotine and of the adverse
health consequences of nicotine tobacco prod-
ucts; (2) misrepresentations and fraudulent
  concealment about Defendants' ability to ma-
nipulate and their practice of manipulating
nicotine levels and the addictive qualities of
nicotine tobacco products; (3) misrepresenta-
tions that the Defendants would provide the
public and governmental authorities with ob-
jective, scientific information regarding ciga-
rettes and other tobacco products; (4)
fraudulent concealment of certain aspects of
cigarettes and other tobacco products, includ-
ing the a\,ailability of safer, less-addictive
products as a substitute to cigarettes and other
tobacco products; (5) causing a likelihood of
confusion about the source, sponsorship, ap-
proval or certification of cigarettes ancl othei
tobacco products; (6) misrepresenting that
nicotine tobacco products ha1.e sponsorship,
appro\.al, characteristics, ingredients or bcn-
  efits that thev do not 1laL.e and that Defendants
kne\v that they did not have; (7) misrepresent-
ing that cigarettes and other tobacco products
were of a particular qualitv or grade, \\,lien
Defendants knelt that the!: \\.cre not; (8) en-
gaging in unconscionable trade practices;
(9) fraudulently promoting filter and lo\\.-tar
cigarettes as safer; (10) fraudulentlv nianipW
lating scientific research into the liealth haz-
ards of smoking; and (11) fraudulently creating
  their "research councils" and using them to
spread false information about their products
and to promote false information that ciga-
rettes or other tobacco products \vere safe
  or that adverse health effects had not been
  established.

379. The conduct described abo\ie and through-
out this Complaint constitutes deceptive and

unfair methods of competition, unconscionable
acts or practices and unfair or deceptive acts or
practices all impacting the public interest, in vio-
lation of Fla. Stat. 5 [section] 501.204.

380. As a direct and proximate result of such
wrongful activity, BC/BS Florida has suffered
losses and will continue to suffer substantial losses
and injuries to its business or property, including
but not limited to its being required to pay and
paying the costs of medical care for disease, ill-
ness, addiction and adverse health consequences
caused by cigarettes and other tobacco products.

Autitrllst

The federal government and most states have
antitrust laws. These are designed to prevent busi-
nesses in the same industry from cooperating in ways
that deprive consumers or other entities of benefits
they would otherwise receive from a competitive
marketplace.

Count Three of the complaint by the 21 Blue Cross
and Blue Shield plans explains how antitrust theory
applies in a tobacco case (B/UP Cross ard B/UP Shield,
p. 3.93):

281. Since the early 195Os, and continuing until
the present date, the Defendant Tobacco Compa-
nies, aided and abetted by the other Defendants
herein, ha\,e \,iolated Section 1 of the Sherman Act,
15 U.S.C. 5 1, bv entering into, adhering to and
continuing to observe the terms of a combination
or conspiracy in unreasonable restraint of trade
and commerce in the market for cigarettes in the
United States. Such illegal concerted action has
eliminated commercial competition that would
ha\,e existed but for the conspiracy. Specifically,
Defendants ha\,e conspired: (1) to suppress inno-
vation and competition in product quality
by agreeing not to engage in research, develop-
ment, manufacture and marketing of less harmful
cigarettes and other nicotine products; (2) to sup-
press output in a market, and to engage in con-
certed refusal to deal, by agreeing to keep at zero
the output of less harmful cigarettes and other
nicotine products; and (3) to suppress competition
in marketing by agreeing not to take business from
one another by making claims as to the relative
safetv of particular brands, whether or not such
clainis lvould have been truthful. But for the
conspiracy, competition in the market for cigarettes
in the United States would have been far more


vigorous, and consumers and others l~ould ha\-e
reaped enormous benefits.

282. But for the conspiracy, one or more of the
Tobacco Companies would ha1.e de\,eloped a com-
mercially successful, less harmful cigarette; such
a cigarette would ha\re garnered a substantial share
of the cigarette market; and those \vho used that
product rather than conventional cigarettes ~vouid
have had significantly feller health problems. As
a consequence of the abo\~e, the BC/BS Plans
rvould ha\,e incurred substantially louver costs.

283. A relevant market in Ivhich Defendants' \.io-
lations occurred is the manufacture and sale of
cigarettes and other nicotine products in the
United States. Because, inter alia, such products
are phvsically addictive, the); are not reasonabl\.
interchangeable \vith other consumer products,
nor are they characterized by cross-elasticitv of
price lvith other consumer products. Within ~this
broad relelrant market there Lvould have existed,
but for Defendants' conspiracy, a rele\.ant
submarket for the manufacture and sale in the
United States of less harmful cigarettes and other
nicotine products which \vould still ha1.e deli\-ered
nicotine but which would have had materiallv less
deleterious health effects than the productsactu-
ally manufactured and sold by Defendants. Such
products kvould ha\,e proven attracti\-e to man:'
smokers, rzho ~vould have chosen to buy them of
they had been available.

284. Because Defendants have conspired to sup-
press output of less harmful cigarettes and other
nicotine products, and to refuse to deal in such
products, their conduct is unreasonable per se
under the Section 1 of the Sherman Act. There is,
moreover, no colorable justification for the con-
certed action alleged herein, which is unrelated to
any lawful business transaction, does not promote
efficiency, does not advance the interests of con-
sumers and does not promote interbrand or
intrabrand competition.

285. Antitrust law protects competition over in-
novation and product quality just as it protects
price competition. Defendants willfully violated
antitrust law by agreeing to suppress competition
related to the safety of their products. It was clearly
foreseeable that this antitrust violation lvould
injure smokers' health, and it leas just as foresee-
able that the violation Mould, at the same time,

cause those financially responsible for smokers'
health care to suffer an injury in their business or
property, by paying increased costs and expenses
for health care services and products. These two
kinds of injury are inextricably intertwined. Each
flo\zs directly from the anticompetitive effects of
the illegal conduct. The harm suffered by the BC/
BS Plans is the precise type of harm that a con-
spiracv to suppress competition related to prod-
uct safety \vould be likely to cause. Accordingly,
this harm reflects the anticompetitive effects of the
\.iolation.

Antitrust violations permit the injured party to receive
treble damages as \vell as attorneys' fees.

Federal Racketeer lflflllellcen Ned Corrupi
Orgmixtiom (RICO) Act

  The federal go\,ernment and some states have
statutes designed to control or eradicate "racketeer
influenced and corrupt organizations." "Racketeer-
ing" is defined as a pattern of \riolations of specified
criminal statutes ("predicate acts") (18 U.S.C. section
1961[ 1 I). Among these statutes are those criminalizing
mail and lvire fraud (18 U.S.C. sections 1341, 1343).
The evidence put forth that the industry committed
these predicate acts is similar to the evidence that it
committed common-law fraud (BIIIL' Cross nrzd Blare
Sllirlr-i, p. 3.88, para. 260[al):

The Defendants engaged in schemes to defraud
members of the public, including the BC/BS Plans
and their members, regarding the health conse-
quences associated with using nicotine tobacco
products. Those schemes have involved suppres-
sion of information regarding the health conse-
quences associated with smoking, as well as
fraudulent misrepresentations and omissions rea-
sonably calculated to deceive persons of ordinary
prudence and comprehension. Defendants' mis-
representations and fraudulent concealment of
material facts, directly or by implication, include
but are not limited to the following: misrepresen-
tations and fraudulent concealment of the addic-
tive nature of nicotine and the adverse health
consequences of tobacco products; misrepresen-
tations that such health effects of addictiveness
\vere unknown or unproven; misrepresentations
about Defendants' ability to manipulate and about
the manipulation of nicotine levels and the addic-
ti1.c qualities of cigarettes; misrepresentations that


the); ~vould pro\-ide the public and go\w-nmental
authorities lcith objecti\,e, scientific information
regarding all phases of smoking and health; and
fraudulent concealment of certain aspects of smok-
ing and health, including the availability of safer
cigarettes and less addictive cigarettes. Defendants
executed or attempted to execute such schemes
through the use of the United States mails and
through transmissions bv wire, radio and televi-
sion communications in interstate commerce.

The federal RICO Act makes it unlawful to receive in-
come derived, directly or indirectly, from a pattern of
racketeering activity or to participate, directly or indi-
rectly, in the conduct of an enterprise's affairs through
a pattern of racketeering activity. The relevance of the
RICO Act to tobacco litigation M'as also delineated in
the Blue Cross and Blue Shield plans' complaint (RIL~P
Cross nmf B/w Shit~ld, p. 3.92):

271. At all relevant times, the Tobacco Institute,
CTR (formerly TIRC) and STRC I the Smokeless To-
bacco Research Council] have constituted an en-
terprise within the meaning of 18 U.S.C. s 1961(4)
or, in the alternative, each Defendant has consti-
tuted an enterprise within the meaning of 18 L.S.C.
5 1961(4). Each enterprise is an ongoing organiza-
tion. Each enterprise and its activities affect inter-
state commerce in that the enterprise is engaged
in the business of maximizing the sales of ciga-
rettes and other nicotine products.

272. As alleged above, Defendants ha1.e engaged
in a pattern of racketeering activity that dates from
1953 through the present and threatens to continue
into the future. These racketeering acts generated
income for Defendants because thev contributed
to: the suppression and concealment of scientific
and medical information regarding the health ef-
fects of nicotine products; the suppression of a
market for alternative safer or less addicti1.e to-
bacco products; the manipulation of nicotine to
create and sustain addiction to Defendants' prod-
ucts; the targeting of teenagers and children and
minorities M'ith marketing and advertising
designed to addict them, all to protect and ensure
continued sales of Defendants' unsafe and addic-
tive tobacco products; and the a\Toidance and shift-
ing of smoking related health care costs to others
including the BC/BS Plans by the methods stated
above, including illicit litigation tactics such as
unfounded claims of attorney-client privilege and
other means.

273. Defendants have used or invested their illicit
proceeds, generated through the pattern of rack-
eteering activity, directly or indirectly in the ac-
quisition of an interest in, or in the establishment
or operation of each enterprise, in violation of 18
U.S.C. 5 1962(a). Defendants' use and investment
of these illicit proceeds in each enterprise is for
the specific purpose and has the effect of control-
ling the material information distributed to the
public concerning the health effects of smoking;
suppressing and concealing scientific and medi-
cal information regarding the adverse health ef-
fects of smoking and the alternatives of safer or
less-addictive cigarettes; devising means for ma-
nipulating nicotine to create and sustain addiction
to Defendants' products; directing marketing and
advertising toward minorities, teenagers and chil-
dren to addict them; and enticing more individu-
als to smoke or to use Defendants' unsafe nicotine
tobacco products.

274. Each Defendant also conspired to violate 18
U.S.C. $1962(a), in violation of 18 U.S.C. 5 1962(d).
As detailed above, the conspiracy began in 1953,
continues to the present and threatens to continue
into the future. The object of the conspiracy was
and is to protect the Tobacco Companies' business
operations by investing their illicit proceeds, gen-
erated through a pattern of racketeering activity,
in each enterprise. Each Defendant agreed to join
the conspiracy, agreed to invest racketeering-
generated proceeds in each enterprise in order to
continue enterprise operations and agreed to the
commission of and knowingly participated in at
least two predicate acts within ten years of each
other. Each Defendant knew that those predicate
acts were part of racketeering activity that would
further the conspiracy.

273. Defendants' violations of 18 L.S.C. 3s 1962 (a)
and (d) have proximately caused direct injury to
the business and property of the BC/BS Plans
because the BC/BS Plans have been required to
incur significant, concrete financial costs and ex-
penses attributable to tobacco-related diseases; have
been unable to participate in a market for alterna-
tive less harmful or less addictive nicotine prod-
ucts, or to advise, suggest, promote, subsidize or
require their members to use alternative products
such as safer or less addictive tobacco products or
other nicotine delivery devices; and have not been
as effective as they would otherwise have been in
helping their members not to use hazardous tobacco

234  ChjJtt'l 3


Rcdnciug Tobacco Use

products. In absence of the Defendants' violation
of 18 USC. ss 1962 (a) and cd), these costs and ex-
penses lvould have been substantially reduced.

Finally, the RICO Act provides a civil remedy for enti-
ties that have been financially injured as a result of
RICO violations (1X U.S.C. section 19641~1). As \vith
the antitrust laws, the remedy includes treble damages
and the recolrerv of attornevs' fees.

Taken together, the allegations in the case brought
by the 21 Blue Cross and Blue Shield plans provide an
important summarv of the legal approaches that are
no\v available to plaintiffs but \vere not available to
earlier third-wrave cases.

Individual Third-Wave Cases

   Some third-wa\.e cases in\-o1L.e onlv minor modi-
fications of standard second-\vave product liabilit),
claims by individual smokers against cigarette mak-
ers. In September 1995, one such case achie\.ed the
distinction of being the first clear plaintiff's \,ictor\,
after Cipollor~c. A state court jurv alvarded $2 million,
including $700,000 in punitive damages, to a smoker
\~ho had developed mesothelioma (a cancer associated
ii-ith asbestos exposure) after smoking asbestos-filtered
Kent cigarettes in the 1950s. The defendant had \~on
four of these filter cases since 1991. While alvaiting
appeals, observers speculated Mhether the result sig-
nified a change in public perceptions (Hwang 1995a;
2'lacLachlan 199%). Ultimately, the jury's alyards of
both compensatory and punitive damages lvere up-
held on appeal (Horowitz il. Lorillurd Tohcco Co., No.
965-245 [Super. Ct. San Francisco Cty. 19951, cwt. iic-
r~ied, 118 S. Ct. 1797 [1998]).

  In what is perhaps the most important damage
recoverv case to date (TXxmo PI.O~IIC~S Litiptiou Rc-
/wtw 1496d), on August 9,1996, a jury in Jacksonville,
Florida, awarded $750,000 to Grady Carter, a former
air traffic controller who smoked from age 17 in 1947
until cancer was diagnosed in 1991. Grady and his
\vife, Mildred, sued Brown & Williamson Tobacco
Corporation on the grounds of negligence and strict
liability. The jury found that the Lucky Strike ciga-
rettes that were manufactured by the defendant were
"unreasonably dangerous and defective" (7bhocco
P~@~wts Litiggntiorz Reporter 1996d, p. 1.114). Of special
significance was that the plaintiff's attorney did not
have to undergo the burdensome discovery process
that industry attorneys had used successfully in the
past. The means of avoiding this process was a spe-
cial court order issued to ease the management of the
large number of tobacco liabilitv cases filed in that

jurisdiction (111 w Cjgnwtfe Cosrs [Fla., Duval Cty. Jan.
23, 19961, cited irl 11.1 TPLR 2.3 [1996]; Ward 1996).
Doubt was cast on the impact of the case, however,
lvhen a Florida appellate court overturned the jury's
findings on the basis that the plaintiff had failed to file
his claim lvithin Florida's four-year statute of limita-
tions (Bro:clrl 6 Williamorl Corp. u. Crrrter, No. 96-4831,
1998 Fla. App. LEXIS 7477 [Fla. Dist. Ct. App. June 22,
19981).

  In an individual damage recovery action similar
to Cnrtcr and brought by Norwood Wilner (the same
plaintiff attorney who had successfully argued the
Cortrr. case), a jury found Brown & Williamson Tobacco
Corporation liable for the wrongful death of smoker
Roland Maddox and awarded his family just over $1
million in compensatory and punitive damages
( Wiif[lii-klM~lflfos ~1. Brozcv~ G- Williamsot Tobacco Corp.,
No. 97-03522-CA, Div. CV-H [Fla. 4th Cir. Jacksonville
19981). Attorney Wilner has taken two other tobacco
cases to trial that have resulted in jury verdicts for the
defense, and it is estimated that he had 150 additional
cases pending as of July 1998 (Corzrzov 51. X.1. Reynolds
Tolwc-c-0 Co., No. 95-01820-CA, Div. CV-H [Fla. Cir.
Du\,al Cty. May 5, 19971; Krrrbizyk P. X.1. Reynolds To-
bncro Co., No. 9504697-CA, Div. CV-H [Fla. Cir. Duval
Ct):. Oct. 31, 19971; Ecorzowisf 1998).

  The growth of individual tobacco litigation dur-
ing the third wave has been exponential. For example,
R.J. Reynolds Tobacco Company reported in July 1995
that 68 cases of all sorts were pending against it; the
number had risen to 203 cases in July 1996 and to 448
cases as of August 7,1997 (Daynard 1997).

Aggregation Devices

  The third \vave got much of its impetus from the
use of procedural devices and legal theories that ag-
gregated claims. Aggregation raised the potential
value of each case for plaintiffs' attorneys, increasing
their willingness to invest large amounts of money and
time in pursuing them. This process denied the in-
dustrl: the ability to discourage such cases by escalat-
ing liiigation costs, a strategy that had served it well
during the previous two waves of tobacco litigation
(see "The Aftermath of the First Two Waves," earlier
in this chapter). The most important of these aggrega-
tion devices have been class actions and third-party
payer reimbursement actions.

Class Actions

  The class action device figures prominently in the
third \vave of tobacco litigation. This set of procedures


enables d group of persons suffering from a ion~inw
injury to bring a suit to secure a definiti\,e judicial rem-
edv for that injurv on behalf of all members of the
group. Class actibn procedures ha\,e tivo principal
forms-one for cases that seek a single remedy for the
common benefit of a category of plaintiffs (Federal
Rules of Civil Procedure, Rule 23[b][l]), and a some-
l\rhat more complicated one knolrn as (Rule 23[b][3]
procedures) for cases that seek the resolution of a large
number of indixridual claims that share COIII~IOII fac-
tual or legal issues (Federal Rules of Civil Procedure,
Rule 23[b1[31).

   Tobacco class actions have, in the main, raised
two types of issues. One type, exemplified by the
claims in the Crrsfarro case (Ci7sff7im if. Aukv~icf77I 7&7mJ
Co., No. 94-1044 [E.D. La. Feb. 17, 19951, iit~il irr 10.1
TPLR 2.1 [lY93], I.c~v'~I 84 F.3d 73-1 [5th Cir. 19961) and
its progeny, seeks recovery for the cost of treating ad-
dicted smokers for their addictions and for monitor-
ing their medical condition for signs of impending
disease. It does not, hcn\~e\~er, seek reco\`ery for the
cost of treating tobacco-caused diseases, nor for the
other costs (tangible or intangible) to smokers and their
families that flop- from tobacco-caused disease. The
other type of issue, exemplified by the claims in the
Erzg/c case (E/~~~lc il. R.1. Rc>!/r~olds fi&ncco CP., No. 94-
08273 CA [XI] (Fla., Dade Cty. Oct. 31, lYY4], cifd i\z
9.5 TPLR 2.147 [1994], (7ff'ij 672 So. 3d 39 [lY%]), seeks
damages for the full range of costs that flo~v from
tobacco-caused diseases. The C~75tt7r10 case in\,olws a
much larger number of plaintiffs than E~r~q/c~, but each
plaintiff seeks a much smaller recol-cry

  To date, both Ca.ita/w and E/~Slc~-t~pe claims ha1.e
been brought under the more complex Rule 23(b)(3)
class action procedures designed for the resolution of
indi\?dual claims that share common legal or factual
issues. Courts have generallv been reluctant to allow
these procedures for Gsff7rlo-type claims, \zith the
courts particularly concerned about the individualized
proceedings on behalf of millions of addicted smok-
ers, each making relatively small claims, that \vould
follow from a favorable resolution of the common is-
sues (Cnst~~rzo 7'. Ar~wic-nrz Toh7c~o Co., 85 F.3d 734 [5th
Cir. 19961; Srr~ll ~1. Loriflnni 72~twcca Co., 1998 WL 398176
[N.Y.A.D. 1 Dept. July 16, 19981; Rilrr~ljs 71. A,rlcricnr~
T'd~acco Co., No. (X-5903 [E.D. Pa. Aug. 22, 19973, \`a-
cated 176 F.R.D. 479 [1997], iitcll ii1 12.4 TPLR 2.227
(19971). The possibility oi using the simpler class ac-
tion procedure for Cas~~~w-type claims, lvhich Mould
seek a single judicial order setting up an insurance-
tvpe fund that claimants could draw on as they used
addiction-related medical or pharmaceutical ser\?ces,
has not been fully explored. By contrast, courts have

been more lvilling to permit Rule 23(b)(3)-type proce-
dures for Ellgle-type claims, where class action proce-
dures promise to simplify the trials of a smaller (but
still very large) number of serious individual claims
E/qle, 672 So. 2d 39; Bur,ir~ u. Philip Morris Cos., No. 92-
1405 [Fla., Dade Cty. Mar. 15, 19941, cited irr 9.1 TPLR
2.1 119941; Richnvdsoll ZJ. Philip Morris, luc., No.
9614505O/CE212596 [Md. Cir. Ct. Baltimore City Jan.
28, 19981).

  For a class action of either type to be certified,
iour technical requirements must be met. First, the
members of the proposed plaintiff class must be so
numerous that joining each plaintiff to the suit would
be impractical. Second, the claims of each member of
the class must turn on some questions of law or fact
that are common to all the members of the class. Third,
claims of the class representatives must not be antago-
nistic to those of the other members of the class.
Fourth, the representative plaintiffs and their attorneys
must be able to fairly and adequately represent the
interests of the entire class (Federal Rules of Civil Pro-
cedure, Rule 23[a]). Where members of the class have
conflicting interests, the class may be divided into sub-
classes represented by different attorneys (Federal
Rules of Civil Procedure, Rule 23[c][4][A]).

  Besides meeting these four requirements, a Rule
23(b)(3) class action needs to surmount two other sig-
nificant hurdles. First, the court must determine that
the action is "manageable," meaning that a reasonable
plan for trying the entire case, including the individual
claims, can be devised. Second, the common issues
must "predominate" ol'er the individual issues, leav-
ing the court to make the judgment whether the hen=
efits likely to be obtained from trying the case as a class
action outweigh the difficulties likely to be encoun-
tered in doing so (Federal Rules of Civil Procedures,
Rule 23[b][3]).

  Once a Rule 23(b)(3) class is certified, the class
representatives must undertake the onerous and ex-
pensii,e process of notifying each member of the class.
This is necessary because Rule 23(b)(3) class members
have the significant right to opt out of the class and
pursue their claims individually.

  The class action device soives the problem 01
aggregation, reduces the imbalance of resources often
found between the parties, achieves economies of scale
and avoids duplicative litigation. The great advan-
tage of the class actions being pursued in the third
M'ave of tobacco litigation is that resources arc
expended on behalf of thousands or millions oi clasr
members rather than on behalf of a single individua
(Kelder and Daynard 1997). This advantage provide!
more of a level playing field and means that thf


tobacco companies b4ll not be able to successfull~~ pur-
sue their usual first- and second-LVal-e strategy of forc-
ing opponents to spend exorbitant suins of nione\
until, nearlv bankrupted, the\ are forced to I\-ithdral\
(Kelder anA Daynard 19971.. In its unanimous deci-
sion, the appellate court in Bwir~, after considering and
rejecting defense objections to the plaintiffs' request
for class certification, alluded to the great promise that
the class action strategy holds for plaintiffs challeng-
ing the tobacco industr\r: ". if \ve \vere to construt'
the rule to require each person to file a separattl la\\,-
suit, the result 1Vould be o\~er\~helinin;: and financiall\,
prohibiti\,e. Although defendants ~vould not lath tlli>
financial resources to defend each separate la\\-suit, the
t.ast major-itv of class niemberh, in less ad\.dnta~cwus
financial positions, ~voulcl he depri~~t~d of 4 rcwied\.
We decline to promote such a result" ([ivcjiri, ~-rf(`il ii7
9.1 TPLR 2.4).

  But \zith these benefits come ne\\. problems.
Only coninion issues can be dealt \I-ith in d class pr<1-
reeding, thus leal.ing incli\.iduali/ed features to Lw
dealt \Vith in separate trials. As noted, some or indn\
potential class members may choose to opt out of thi>
class to pursue indi\~idual cases, thcrebv reducin;: the
ad\.antage of eliminating duplicatix e litigation. If
wine class members are more se\.erel\, injured than
others, intractable conflict niav arise ol.er distributing
the proceeds (Coffee 1986, 1987). If the injur\, is con-
tinuing outside the class, as it is in the case of tobacco
use, there is the problem of providing for future plain-
tiffs (Hensler and Peterson lYY3). These problems are
o\.erlaid and compounded bv issues in\.ol\,ing the le-
gal agents representing the plaintiffs. Class actions
are organized and managed bv entrepreneurial la\v-
vers, and their interests and those of the client class
mav diverge (Coffee 1986). Finally, there is the dan-
ger-that the class action de\?ce ele\,ates the stakes so
high that defendants and plaintiffs settle \vithout reso-
lution of other (nonmonetarv) merits of the claim. Just
t\.hich of these problems aresufficiently salient to dis-
courage use of the class action device in the several
1 arieties of tobacco cases is still an issue.

  C~starzo ~1. A~wicnrl Tobm-c-o Co., filed March 2Y,
1993, in federal court in New, Orleans (MacLachlan
IYY4-951, was an unparalleled attempt by a coalition
of traditional plaintiffs' Ialvyers, mass disaster lalvvers,
and class action specialists from around the country to
diminish the organizational advantages enjoved by the
tobacco industrv during the first two waves bf tobacco
litigation. Each'of a coalition of 62 law firms pledged
s100,OOO annuallv to fund a massive class action suit,
~`11 behalf of millions of nicotine-dependent smokers,
charging the tobacco industr\, tvith promoting

addiction and thus disabling smokers from quitting
(Janofsky lYY-la; Shapiro lY91a; Curriden 1995). The
plaintiffs requested damages for economic losses and
emotional distress, as \2-ell as medical monitoring and
injuncti\-e relief. In Februarv 1995, the district court
granted the plaintiffs' request for class certification
conditionall\~ and in part (Ci7rt~7r70, citc>il ij~ 10.1 TPLR
2.1). Judge Okla Jones II granted certification for is-
sues of fraud, breach of warrantv (express or implied),
intentional tort, negligence, stiict liability, and con-
sumer protection issues. Certification was denied for
other issues, including the questions of causation, in-
jury,., and defenses regarding the claims of each smoker.

  Normally, a trial judge's decision to certify a class
is not subject to re\.ie\\, bv a higher court until the trial
court has reached a final disposition of the Ivhole case,
\\.hich max. be vears later. But Judge Jones in Cat;tnfm
granted sieciai permission to allo\~ the defendants to
appeal his class certification decision to the United
States Court of Appeals for the Fifth Circuit (Collins
19Y)sc). On May 23, 1996, a three-judge panel of the
appellate court \.acated Judge Jones' decision and re-
manded the case back to the district court M'ith instruc-
tions to dismiss the class action. The court of appeals
reasoned that the variations in the state laws of the SO
states in \vhich the injuries occurred classwide, com-
bined Lvith trial management problems not addressed
by the district court, justified decertification of the
nationrvide class (Cnsfarw, X4 F.3d 734).

  The coalition of labvyers that forlned around
C~7stor7o opted to pursue another approach and began
to file stateM-ide class actions shortly after the decerti-
fication bv the court of appeals. Bv mid-1998, the coa-
lition hack filed 26 such cases (To&y 1998).

  Another class action, Errg/c P. R.1. Rcyr&ds ~)hncco
Co., No. 9408273 CA (20) (Fla., Dade Cty.), cited ill 9.3
TPLR 3.293 (1994), filed in a Florida state court May 5,
1993, on behalf of smokers suffering from "diseases
like lung cancer and emphysema," sought billions of
dollars in damages from the seven leading tobacco
companies, the Council for Tobacco Research U.S.A.
Inc., and the Tobacco Institute, a tobacco-financed
public relations association (Janofsky lYY4a, p. 11). The
suit alleged that by denying that smoking is addictive
and by suppressing research on the hazards of smok-
ing, the tobacco industry has deceived the public about
the dangers of using tobacco products (Janofsky 1994~).
On October 31, 1993, E,Is/P, filed by a personal injury
la\vver ~`110 chose to remain apart from the Crr.stnw
coalition, had the distinction of becoming the first
tobacco-related class action laxvsuit to be granted class
certification (EIIS/U P. R.]. RI'L/IIO/I~S 7?h~-c-c~ Co., No. Y4-
(IX273 CA [XI [Fla.. Dade Ctv. Oct. 31, IY`H], iif~il ir7


Y.5 TPLR 2.117 [199-l]). When the defendants sought
to oirerturn the class certification, the Florida Supreme
Court upheld it, pairing the \vay for the case to go to
trial (R.1. Rr~/rzolds Co. ~7. Elr~lc, 672 So. 2d 39 [Fla. Ct.
App. 19961). A jury selection for the trial began on
July 6, 1998 (Eior~or~ist 1998).

Recovery Claims by Third-Party Health
Care Payers

  In the late 197Os, a number of scholars and advo-
cates began urging legal theories and statutory reforms
that would permit third-party health care payers to col-
lect the expenses of caring for tobacco-caused disease
from the manufacturers themselves (Garner 1977;
Daynard 1993a,b, 1994a; Gangarosa et al. 1994). Such
claims involve complex questions about ascertaining the
amount of tobacco-caused injury and the apportionment
of damages attributable to each defendant. The stakes
in these potential cases are undoubtedly large: one
study estimates that 7.1 percent of total medical care
expenditures in the CTnited States is attributable to
smoking-related illnesses (CDC 1994~). Another study
estimates that tobacco use is responsible for about 18
percent of all Medicaid expenses (Clymer 1994). How-
ever, calculation of such effects invites the counter-
argument (albeit amoral) that tobacco's costs to the state
are offset in part by the savings afforded bv the prema-
                                 -
ture deaths of smokers (Geyelin 1995).

  Beginning in 1994, the go\rernments of three
states-Minnesota, Mississippi, and West Virginia-
as well as Blue Cross and Blue Shield of Minnesota,
filed lawsuits to secure reimbursement from the
tobacco industry for health care expenditures for ail-
ments arising from tobacco use. Three years later, 11
states had filed such legal actions. Since this settle-
ment has not vet been embodied in the congressional
legislation necessary to give it the force of lalv (see
"Legislative Developments" and "Master Settlement
Agreement," earlier in this chapter), four states-
Florida, Minnesota, MississipQi, and Texas-have
settled their claims with the tobacco industrv. Addi-
tional third-party payers-such as labor union pen-
sion funds and Blue Cross and Blue Shield plans
(whose joint case is described in detail in "Common-
Law Claims," earlier in this chapter) in states other
than Minnesota-also began to file suit against the
industry in 1997 and 1998.

Medicaid Reimbursement Cases

  Mississippi filed suit on May 23, 1994, against
tobacco manufacturers, wholesalers, and trade groups

on the basis of common-law theories of restitution,
unjust enrichment, and nuisance to recover the state's
outlays for treating the tobacco-related illnesses of
welfare recipients (Janofsky 1994a; Woo 1994~; Moore
~1. Anwicnrz Tobacco Co., Cause No. 94:1429 [Miss., Jack-
son Cty. Feb. 21, 19951, riterl ~JI 10.1 TPLR 2.13 [1995]).
The first state to do so, Mississippi, embraced a strat-
egy that merited the attention of other third-party
claimants. Rather than proceeding in a trial court on a
theory of subrogation (whereby the state would have
acted in the place of injured smokers to recover claims
the state had paid to those smokers), Moore chose to
proceed in equity (i.e., before a single judge in a
nonjury proceeding) on theories of unjust enrichment
and restitution (Kelder and Daynard 1997). Moour's
equity claims were grounded in the notion developed
in the literature that the State of Mississippi had been
injured directly by the behavior of the tobacco industry
because Mississippi`s taxpayers had been forced to pay
the state's Medicaid costs due to tobacco-related
illnesses.

  The state planned to use statistical analysis to il-
lustrate the percentage of Medicaid costs that can be
attributed to tobacco use. If the lawsuit succeeded,
the defendants would pay for Medicaid costs under a
formula that calculates liability according to market
share (Lew 1994). The lawsuit sought tens of millions
of dollars in damages, including punitive damages as
~vell as recoverv for future tobacco-related expendi-
tures (Woo 1994~). Lawyers from 11 private plaintiffs'
la\\, firms participated in the suit. Instead of Qromis-
ing the private lawyers a percentage of the potential
damages, the state sought to compel the tobacco com-
Qanies to Qav the lalvvers' fees (Woo 1994~).

SuQerficially, th;s state case (and that of other
states) resembled subrogation claims, in which a party
11-110 Qays a claim (tvyically an insurer) may pursue
that claim, acting in ;he place of the original claimant
and subject to the defenses that might be raised against
him or her. But the Mississippi complaint avoided
asserting the claims of the health care recipients; in-
stead, it asserted the proprietary claims of the state as
a health care funder (distinct from any claims of those
tvhose health was injured by tobacco).

  This proprietary stance is significant because, as
detailed earlier in this section, the tobacco companies
M'on many of the first- and second-wave cases by as-
serting the defenses of assumption of risk and con-
tributory negligence or by asserting that the smoker's
w+llfulness, not the industry's misbehavior, was the
proximate cause of the smoker's smoking and conse-
quent illness. These defenses should not be available
to the tobacco industry in medical cost reimbursement


wits because these suits are not brought on behalf of
injured smokers. They are brought, instead, on behalf
of the states themselves to recol'er the medical costs
they have been forced to pay to care for indigent smok-
ers. The tobacco industry cannot plausibly argue that
the states chose to smoke or that they contributed to
the financial harm caused to them (Daynard 1994b;
Kelder and Davnard 1997).

The decision in the Mississippi medical cost re-
imbursement suit demonstrates that this commonsense
argument can prevail, even in states that lack sQecia1
legislation that creates an independent cause of action
for the state. The tobacco industrv defendants in Mtu)rt'
;I. .-ln~c~.icnrf E~Iwrco Co. filed a m&ion for judgment on
the pleadings on October 11, 1993. The defendants
argued that, under MississipQi lalv, assignment/sub-
rogation \vas the state's exclusi\,e remedy for Qursw
ing the recoverv of medical benefits from potentialI>-
liable third parties. Further, the defendants argued that
because Mississippi's counts for restitution, indemnit!;
and nuisance in the complaint did not assert a subro-
<Tation claim, thev had to be dismissed. Alternati\.ely,
0
the defendants argued that the case should be trans-
ferred to a Mississippi circuit court, \\.here thousands
of jury trials should have to be conducted (Kelder and
Daynard 1997).

  In response, MississiQpi Attorney General Mike
h'foore pointed out that "this `remedy,' as the industrv
knolzs, would be cost pr0hibitiL.e and exhausti\,e of
our State's limited judicial resources" (Mrww ~7. ;Irlwri-
~;TII 7c)bncco Co., No. 94:1429 [Miss., Jackson Ctv. Oct.
11, 19941, cited irk 9.5 TPLR 3.597, 3.598 [199-l]). He ar-
wed that "although the Medicaid Laiv did further
:,
codifv the State's right to be subrogated, this right is
in lzdditiolz to, and not in derogation of, the State's statu-
tory and common law remedies. There is no language
in the Medicaid Laxv that implies an exclusive rem-
edy, and well-settled rules of statutorv interpretation
require a construction that the Medicaih Law clrfJnjzrlcii,
not contracted, the State's remedies [emphasis in origi-
IJal]" (Q. 3.598).

  On February 21, 1995, Chancellor William H.
bfyers, presiding over the Chancery Court of Jackson
County, denied the tobacco industry defendants' mo-
tions to obtain a judgment on the pleadings and to re-
lnove the claim from the chancery court to a
kfississippi circuit court. The court simultaneously
granted the state's motion to strike the affirmative
defenses of the defendants; the tobacco industry thus
could not rely on the defenses of assumption of risk
~lnd contribdtorv negligence, !2-hich have Proved a
nlainstav in earlier battles-and which might have
      i

been allo~ved had the state proceeded on a theory of
subrogation (irobnci-a Z+od~ct.s Lifipfim Reporter 1995a).

  On July 2, 1997, Mississippi settled its claims so
that it \vould receive at least $3.3 billion over 25 years,
with annual payments of at least $135 million continu-
ing in perpetuity. A provision of the settlement agree-
ment guaranteeing Mississippi most favored nation
(MFN) treatment, w,hich meant that Mississippi would
get the benefit of any better agreement that another
state might achie\.e, was little noticed at the time but
has since proved immensely important; additional
settlement terms from later industry arrangements
I\-ith the other three states have been granted to
MississiQQi.

  The second state to bring suit against the tobacco
industry Ivas Minnesota (Mi~znesoto v. Philip Morris I77c.,
No. Cl&-P565 [Minn., Ramsey Cty. Nov. 29, 19941,
c-itcp,l ijr 9.3 TPLR 3.273 [1994]). Minnesota's suit al-
leged an antitrust conspiracv and an elaborate course
of traudulent behavior on the part of the defendants.
Specifically, the tobacco companies were alleged to
ha\-e violated the state's laws against consumer fraud,
unla~~ful trade practices, deceptive trade Qractices, and
false advertising, as well as violated the duty they vol-
untarily undertook to take responsibility for the
Qublic's health, to cooperate closely with public health
officials, and to conduct independent research and dis-
close to the public objective information about smok-
ing and health. The suit sought various damages,
including restitution, forfeiture of tobacco profits, at-
torneys' fees, and treble damages for several statutory
violations. Blue Cross and Blue Shield of Minnesota,
the state's largest private medical insurer, joined as a
co-plaintiff with the state (Woo 1994b). Like most other
states that brought Medicaid reimbursement cases,
Minnesota and the insurer retained private counsel to
provide representation under a contingency fee
arrangement.

  Following a three-month trial and in the midst
of closing arguments, Minnesota settled its case-the
last of the four states to do so-on May 8, 1998. The
industrv agreed to pay about $6.1 billion to Minne-
sota anh $469 million to Blue Cross and Blue Shield of
Minnesota (which was also a plaintiff) over 25 years,
an amount substantially larger proportionately than
the three earlier state settlements, resulting in substan-
tial increases in their settlement packages under the
MFN clauses. The industry also agreed to the follow-
ing public health concessions (Minursota P. Philip
Mwris It7i., citt>il i/z 13.2 TPLR 2.112):

o  Disband the Council for Tobacco Research.


.

.

.

.

.

.

.

.

.

.

.

.

Not pay for tobacco placement for mo\ies (a pro-
vision that inherently extends hevond Minnesota's
borders).

Stop offering or selling in .Minnesota nontobacco
merchandise, such as jackets, caps, and T-shirts,
bearing the name or logo of tobacco brands.
Remove all tobacco billboards in Mimiesota within
six months and eliminate such ads on buses, taxis,
and bus shelters.

Refrain from targeting minors in future advertis-
ing and promotions.

Refrain from misrepresenting the evidence on
smoking and health.

Refrain from opposing in Minnesota certain new
la\vs designed to reduce youth tobacco use, as well
as clean indoor air laws that could adversely affect
the industry.

Institute new lobbying disclosure rules for
Minnesota.

Release internal indexes to millions of previously
secret industry documents, thereby providing a
means for attorneys and researchers to find relevant
information more easilv.

Maintain at industry expense for 10 years a deposi-
tory of millions of tobacco documents in Minne-
apolis and another such depositor\, in Great Britain.
Instruct retailers in Minnesota to move cigarettes
behind the counter to restrict minors' access to
those cigarettes.

Pay out SllO million in fees to the pri\.ate attor-
neys \~ho represented the plaintiffs.
Gi1.e Minnesota its Olin MFN clause, limited to
improi.ed public health pro\-isions in future state
settlements.

Through the MFN process, many of the public
health concessions that Minnesota obtained from the
industry are also being incorporated in the prior state
agreem;nts (Branson 1998).

  The Florida case (f lori[fl? 7'. ,;2/11~`rjt~/r Tr&~~cct~ Crl.,
No, 95-1166AO [Fla., Palm Beach Cty. Feb. 21, 19951,
c-if~~j i/l 10.1 TPLR 3.1 119951 [Complaint]; Geyelin 1995)
was the first conforming \vith a statute tailored for the
purpose of establishin, 0 such a claim. In Mav 1994,
Florida amended this little-used statute, \vhi& pro-
\-ided for recoverv bv the state from third parties
responsible for Medicaid costs, to permit the state to

sue on behalf of the entire class of smokers on Medic-
aid, tc, dse statistical proof of causation, to bar assump-
tion of risk as a defense, and to permit recovery
according to the defendants' share of the cigarette mar-
ket (Rohter 1994; Woo 1994a). Apparently having sec-
ond thoughts about the statute (which had passed by
a wide margin), the state legislature considered repeal-
ing it, eliciting a vow from Florida's Governor Lawton
Chiles to veto a repeal (Hwang 1995a). After an un-
successful last-minute attempt by the tobacco compa-
nies to have the Florida Supreme Court bar state-
agencies from initiating a lawsuit under the statute,-
Florida filed its medical cost reimbursement suit on
February 21,1995, seeking $4.4 billion (Florida, citcn ill
10.1 TPLR 3.1; Geyelin 1995).

  The complaint in the Florida lawsuit contains
extended factual allegations regarding the defendants'
knowledge (or lack of knowledge) about the harmful--
ness of tobacco. Raising the familiar causes of action,
the complaint also emphasizes the tobacco industry's
alleged violations of consumer protection laws. Spe-
cifically, it criticizes the industry's use of advertising
to target minors.

  The Florida Supreme Court narrowly upheld the
liability law, on which the state's case is based, in a 3
to 3 ruling that produced equivocal results for both
sides. The court agreed with the defendants that the
state could only use the law to recover damages in-
curred since July 1, 1994, and that the names of indi-
vidual Medicaid recipients would have to be supplied-
so that the tobacco companies could challenge their-
claims (il~c~,lr!/ fin Hmltl7 Cnw Arin~i~7isfmfltior7 ZJ. Asod-
~ltcll I~~tllr~fr~ic~ of Flrjrilla, 678 So. 2d 1239 [Fla. 19963).
But the majority decision left most of the law's key
provisions intact. The presiding state circuit court
judge, Harold J. Cohen, next ordered both parties to
try to resol\,e the dispute by engaging in mediation,
ivhich broke off after four days and produced no re-
sults (Kennedy 1996). Judge Cohen then dismissed 15
counts of the state's 1%count claim against the tobacco
industry in a ruling issued September 1996 (Floriiln P.
AIIIPV~~~/I Ebnc-co CU., No. CL 95-1466 AH [Fla., Palm
Beach Cty. Sept. 16,1996]). The following month, ho\v;
ef'er, he rejected the defendants' request to depose the
hundreds of thousands of Medicaid recipients
supplied to the court by the state in compliance with
the supreme court decision. The judge held that the
hundreds of thousands of recipients need only be iden-
tified by case number, not by name (Florirln ~1. A~wi-
~1711 7i,b[7i-cc~ Co., No. CL 95-1466 AH [Fla., Palm Beach
Cty Oct. 18, 39963, citcrl i/l 11.7 TPLR 2.236 [1996]). 11~
yet another setback for the defendants, Judge Cohen


permitted the state to add a count of racketeering to
its claim (MacLachlan 1996-1997).

  Florida settled its case on August 25,1997, for at
least $11 billion o\-er 25 years, \vith annual payments
of at least $340 million continuing thereafter. It ob-
tained its own MFN clause, as \vell as an additional
5200 million for a tlvo-year initiative to reduce youth
smoking, an agreement to ban cigarette billboards and
transit advertisements, and an agreement by the in-
dustr!, to lobby for a ban on cigarette \.ending ma-
chines. As a consequence of Mississippi's MFN clause,
Florida received similar benefits.

   The Texas suit \vas inno\.atil.e in that it was
brought in federal rather than state court. The case
12-as also the first to include claims under the federal
RICOAct. On Januarv 16,1998, Texas settled its claims
for at least $14.5 billion o\-er 25 vears. \j,ith annual
payments of at least 5580 million continuing thereaf-
ter, as xvell as public health provisions similar to those
negotiated bv Florida and its o\j.n MFN clause.

Although West Virginia \\.as one of the first three
states to file a suit against the tobacco companies, its
case did not fare as neatlv as those of Mississippi, Clin-
nesota, and the later-arri\.ed Florida and Texas. Filed
on September 20, 1994 (McGnm~ ~1. A~~wim~~ Tohcc-o Co.,
No. 94-1707 [W.Va. Cir. Ct. Kanal\ha Cty. Sept. 20,
19941, citc~d i,l 9.4 TPLR 3.516 [1994]), West Virginia's
suit named 23 defendants, including Kimberlv-Clark
Corporation, de\,eloper of a process once ised in
Europe-but never, according to a company spokes-
person, in the United States-to control nicotine lev-
els in tobacco products (Hrvang and Ono 19951, and
United States Tobacco Company, the largest manufac-
turer of chewing tobacco and snuff. The West Virginia
action "asks the Court for damages to cover \vhat West
Virginia has paid providing medical care to people af-
flicted M.ith tobacco-related illness, and what the state
will pav in the future for tobacco victims. The lalvsuit
     i
also seeks punitive damages to prevent a repetition of
such conduct in the future" (West Virginia Attorney
General 1994, p. 2). Citing an "intentional and LIIICOII-
scionable campaign to promote the distribution and
sale of cigarettes to children," the complaint also re-
quires that the defendants be enjoined from "aiding,
abetting or encouraging the sale of cigarettes to
minors" (p. 4) and be fined $10,000 for each violation
of the injunction. West Virginia's complaint is signed
hv lawyers from five private firms, including a promi-
nent asbestos litigation firm that is also involved in
the Mississippi case.

  Unlike the Mississippi and Minnesota claims,
the West Virginia case met M'itli early difficulties. On
kqa!: 3, 1995, Kanawha Countv Circuit Court Judge

Irene C. Berger dismissed 8 of the suit's 10 counts,
including fraud, misrepresentation, and conspiracy, as
being outside of the state attorney general's powers.
Ironically, Berger's decision is based in part on a
decision that Attorney General Darrell V. McGraw Jr.
himself, the named plaintiff in the suit, authored when
he srr\,ed on West Virginia's Supreme Court, holding
that the state attorney general lacked common-law
authority (i.e., he could bring only statutory claims).
The t\vo remaining counts of the West Virginia action
dealt lvith consumer and antitrust charges (Mac-
Lachlan 1995a).

  On May 13, 1996, Judge Berger permitted the
West Virginia Public Employees Insurance Agency Fi-
nance Board to join as co-plaintiffs. This ruling "es-
sentiallv re\-i\-ed" (Meol~y'.~ Litipfiorr Rrprfs: Thcco
1996`~) the case by pro\.id;ng the state with a means of
hiring legal counsel after the tobacco companies won
an October 1995 order barring the attorney general
from retaining priorate law firms on a contingency fee
basis (MacLachlan 1995a,b,c).

  Among the numerous other states currently try-
ing to recoup Medicare expenditures, Oklahoma
stands out for an innovation in its suit. The Oklahoma
suit names, among other defendants, three industry
lalv firms: Shook, Hardy and Bacon of Kansas City,
Missouri; Jacob, Medinger and Finnegan of New York;
and Chadbourne and Parke of New York. Shook,
Hardy and Bacon has represented tobacco companies
since 1953 (Kelder and Daynard 1997). The suit ac-
cuses the la\v firms of helping the tobacco companies
conceal the health risks of smoking and alleges they
kept documents confidential by falsely claiming they
lverc protected by attorney-client privilege (Oklnhon7n
iI. R.]. Rc!/rlol[l~ Tobncccl CO., NO. CJ961499L [Okla.,
Cle\.eland Cty. ALIT. 22, 19961, citeii in 11.7 TPLR 3.901
[19961).

   Other notable settlements mentioned earlier in
this chapter include the Liggett Group Inc.`s 1997
settlement with most of the states, in return for a frac-
tion of future profits, public admissions of the dan-
gers and addictiveness of nicotine and the past
misbehairior of the industry, and disclosure of secret
industrv documents (Tohocco Products Lifipfiorr Re-
,t~ortcr 1497a). The same year brought in another key
settlement-that of R.J. Reynolds Tobacco Company
and a dozen California cities and counties, which had
alleged that R.J. Reynolds' Joe Camel campaign was
aimed at minors (see "A Critical Example: Joe Camel,"
earlier in this chapter). R.J. Reynolds agreed to dis-
continue the campaign in California and to give the
plaintiffs 19 million for a counteradvertising campaign
(M~~i~~j/lj, citc,d irr 12.5 TPLR 3.349). In October 1997,


the industry settled the first phase of a class action
brought on behalf of nonsmoking flight attendants for
substantial money and other concessions (Broi,~, iit&
ill 12.6 TPLR 3.397). This case is discussed in detail in
"Claims of Nonsmokers," later in this chapter.

Finally, at the time of lyriting, a group of state
attorneys \vere holding discussions about settling some
or all of the remaining state cases. According to pub-
lished reports, as a starting point "the states have de-
cided to use the [public health] concessions gained by
Minnesota as part of its $6.5 billion settlement" (Meier
1998a).

Other Third-Party Reimhrrsemelrt Cases
Although the parties seeking recovery in Medic-
aid reimbursement cases are public officials, the cases
are based on private law theories of recovery-that is,
the officials proceed not as auth0ritatiL.e public regu-
lators but as holders of rights conferred by the general
la%v. Such use of private la\v reco\`ery as an instru-
ment of state policy suggests further possibilities of
analogous suits bv private funders of health care and
mav provide incentives for attorneys to organize such
suits. Health insurers, rvidely seen as reluctant to en-
force their rights to recoup from third parties, may be
mindful of such opportunities in an increasingly com-
petitive health care setting.

  Indeed, Blue Cross and Blue Shield of Minnesota
was a co-plaintiff lvith the State of Minnesota in its
action against the tobacco industrv. In 1996, the Mill-
nesota Supreme Court unanimouslv rejected an indus-
trv challenge that co-plaintiff I31ue Cross and Blue
S&eld could not remain in the cast`. This ruling per-
mitted the insurance company and the state to pursue
their claims directlv against the defendants, rather than
on behalf of individual smokers (Mi/lrlc~lfrr il. f%ili/~
Morris Irlc., 551 N.W.2d 490 [Minn. 19961). When the
industrv settled \vith the State of Minnesota in May
1998, it also settled M.ith Blue Cross and Blue Shield ot
Minnesota-for 5469 million to be paid over a five-
year period Weinstein 1998a).

  In March 1998, two Minnesota health mainte-
nance organizations filed a separate suit against the
industry, Mith claims paralleling those in the Minne-
sota case that was still in trial (Howatt 1998). The fol-
lowing month, Blue Cross and/or Blue Shield Plans
in 37 states combined in three legal actions to sue the
major tobacco companies and their public relations
firms to recover damages allegedly caused by a con-
spiracy to addict their insurance plan members to ciga-
rettes (e.g., Blzrr CKW nr7ii B/z~r Shield, cited irk 13.2 TPLR
3.51; Nl7fiorral Law ]olm7/ 1998).

  These plans are alleging that tobacco companies
conducted an "ongoing conspiracy and deceptive, il-
legal and tortious acts " that have resulted in the plain-
tiffs suffering "extraordinary injury in their business
and property," having been required to expend many
millions of dollars on costs attributable to tobacco-
related diseases caused by defendants who "know-
ingly embarked on a scheme to addict millions of
people, including members of the [Blue Cross and Blue
Shield] Plans, to smoking cigarettes and other tobacco
products-all with the intent of increasing their an-
nual profits. . [and forcing] others to bear the cost of
the diseases and deaths caused by the conspiracy"
(Blrre Cross ad Hue Shield, p. 3.32).
  The plans allege a conspiracy to hide the health
effects of tobacco products, violations of federal rack-
eteering laws and of antitrust laws, and unjust enrich-
ment, among other theories (Tohncco Pron~cts Lif@tioll
Rqmrter 1998). They request damages in the forms of
payments for treatments of tobacco-related diseases,
court orders to require corrections of unlawful behav-
ior, damages in excess of $1 billion for past and future
harm, and other forms of relief.

Bankruptcy trusts representing the interests of
injured plaintiffs who have made claims against the
asbestos industry filed suit against the tobacco indus-
try in late 1997 (Bourque 1997). The trusts allege that
they paid claims to victims of asbestos exposure whose
injuries were substantially caused by either active or
passi\.e exposure to cigarette smoke. Alleging the
unjust enrichment of the tobacco companies at the ex-
pense of the trusts, the latter seek to recover expendi-
tures and payments made to the asbestos settlement
class and seek punitive damages against the defen-
dants (T~J~ICCO Products Lifipfioll Reporter 1997b).

The trusts allege that among persons exposed to
asbestos, direct or indirect exposure to tobacco smoke
is a substantial contributing factor in both the devel-
opment of cancer and the frequency and severity of
symptoms of asbestosis, a disease from which many
asbestos Lvorkers suffer. The trusts also allege that to-
bacco companies knew or should have known that
their products would cause these injuries (Fnlise ~1.
Auuicnrl Tobacco Co., No. 97-0-7640 [E.D.N.Y. Dec.
31, 19971, c-ifcd ill 12.8 TPLR 3.504 [1997]).

  The asbestos trusts accuse the tobacco companies
of suppressing the truth concerning the nature of their
products and their carcinogenic effects. They allege
that tobacco industry products were at least partly re-
sponsible for the illnesses suffered by asbestos plain--
tiffs. The trusts thus want the tobacco companies to
pay a share of the billions of dollars in damages-
awarded to those plaintiffs (Bourque 1997).


Small Claims Tribunals to Recover the Cost of
Quitting

  Related to these expansil-e addiction suits are a
series of more limited claims based on the addicti1.e
properties of cigarettes. As \Vith large suits, small
claims for the recol-er>- of costs related to quitting to-
bacco use depend on lvhether judges and juries ac-
cept the addiction argument that underlies the product
liability portion of the third Ii-a\-e of tobacco litigation.
In this scaled-dorm \.ersion, claims for modest
amounts might be brought in small claims courts, ob-
iiating some of the litigation ad\.antages enjo\ ed b\
the manufacturers. In one case, an individual smoke1
sutxl Philip Morris Companies Inc. for 51,154 in a
\Vasliington State small claims court to reco\.er the
costs of consulting a doctor, buvin g nicntine patches,
and joining a health club-all acti\-ities undertaken to
help the plaintiff quit smokin, ~7 cigarettes (Haves 1993;
Janofskv 1993). Because the court rejected the suit on
the pi-eiiminarv ground that the statute of limitations
had expired, tl;e suhstanti1.e merits of the claim l\.c`rt'
nnt considered (Montgomerv 1993).

In July 1998, an AusGalian appellate court al-
!oIved a formerlv addicted smoker to proceed before
the Nelz South Wales consumer claims tribunal \\`ith
a S1,OOO claim for the cost of a stop-smoking proq-am,
as \vell as for mental suffering caused b\, the addic-
tion and the effort to quit (Australian Nei1.s Netivork
19%). Were a timely small claims case to succeed, the
recoverv b~ould be small. Incentives for lalvvers to
bupplv and plaintiffs to consume the legal ser\,ices
needed to pursue such a claim might be provided IX,
statutorv provision allow%ig ivinning plaintiffs to re-
cover atiorneys fees. Or if such claims could be suffi-
ciently standardized and simplified, they might
proceed without lawyers (e.g., by preparing "kits" to
enable plaintiffs to represent themselves).

Other Cost Reduction Procedures

  Several other procedures have been used or may
he a\:ailable to reduce the costs-for plaintiffs, their
attorneys, and the courts-of resolving individual
claims. -One such procedure is to combine pretrial and
)>erhaps trial proceedings for se\,eral, or e\`en many,
cases. In July 1998, a California court ordered that
proceedings in a varietv of actions pending in \.arious
California courts be colnbined (Associated Press 1998).
Earlier, a Tennessee court ordered several pending in-
~1 ividual cases to be combined for trial (Mn.v Grt Liti-
~`~lfjoll Rryort~ 1998). Asbestos trials have occasionally
,\
combined hundreds and e\ en thousands of indi\ idual

claims (Ac~/l[l~, frlc. P. .Gztc, 710 A.2d 944 [Md. Ct. Spec.
App, 1998]). These procedures permit courts to achieve
substantial efficiencies M'ith the formalities of class
action certification. Efficiencies can also be obtained
bv case management orders that set firm schedules for
tr-ials and pretrial proceedings (111 IY Ci~czr-cftr Cr?ses,
iitc,li if? 11 .I TPLR 2.3).

  Another procedure available in some jurisdic-
tions is "offensive collateral estoppel," lvhich exempts
future plaintiffs from retrying issues on which specific
defendants 1ial.e lost in prior trials (Blorlilrl.-TorzXue
Ll?lJclr~lrt,~r-ic's i'. Ulrii'rrY+l/ oj /lli/7OiS FolfJ?L~nfiorl, 402 U.S.
313,91 S. Ct. 113-l [1971]). This device has not yet been
used in tobacco litigation.

Claims of Nonsmokers

  .~lthou~h most litigation in\lol\-ing adverse
health effects from exposure to ETS has not directly
in\.ol\.ed tobaccn companies, a line of cases has devel-
nped during the 1990s naming tobacco companies as
detcndants and targeting the companies' beha\,ior in
attempting to, as a British-American Tobacco Company
Ltd. document from 1988 put it, "keep the controversy
aIi1.e"-referring to the industry's common strategy
of shifting the focus from persona1 health to personal
freedom (Boy 1988; Chapman lY97).

  Claims of nonsmokers asserting damages from
ETS ha\,e been filed on behalf of both indi\,idual and
class plaintiffs. As nonsmokers, alleged victims of ETS
are not \-ulnerable to the defense that they knowingly
subjected themselves to the dangers of tobacco use.
Hllt/~xr ~7. Anrcricnt~ Tot~nrrc~ Co. ([Miss., Jones Cty. May
12, 19931, c-ifctl irf 9.3 TPLR 3.335 [19941 [Amended
Complaint]), filed May 13, 1993, seeks damages from
six tobacco companies and others for the lung cancer
death of Burl Butler, a nonsmoker and "paragon of
clean li\ing" (Greising and Zinn 1993, p. 331, who al-
legedly contracted the disease after inhaling custom-
ers' tobacco smoke for 35 years while working at his
barber shop (Kraft 1994). Butler became the first case
in which documents allegedly stolen from Brown &
Williamson Tobacco Corporation by one of its former
employees were admitted into evidence, despite
objections by the defendants that attorney-client
privilege prohibited disclosure. Lawyers for Butter's
estate contend that "the documents v,:ill show, among
other things, that tobacco companies manipulated and
suppressed scientific research for years to mislead their
customers about smoking's dangers" (Ward 19%).
State Circuit Court Judge Billy Joe Landrum postponed


commencement of the trial 1.111 motion bv the plaintiffs
to allolv ne\v defendants to be added to Gie action. The
amended complaint now contends that manufactur-
ers of talcum polvder used by Butler in his barber shop
"knelr or should have knolvn that En\.ironmental To-
bacco Smoke can act synergistically ryith Talc, to
cause respiratorv diseases, including lung cancer, and
other health problems" (Rrltl[xr. il. Philip M0l.G [i7c`., Civil
Action No.:945-53 [Miss., Jones Cty. Mar. 3,1996], cited
ir7 11.3 TPLR 3.307, 3.315 [lYy6] [Second Amended
Complaint and Request for Trial by Jury]). A new trial
date has not vet been set.

  Another case involved a Ivoman who had never
smoked but Lvho \vas subjected to prolonged and re-
peated exposure to ETS since childhood and died of
lung cancer in 1996 at the age of 4-l (BIlckir7@flrii il. R.].
Rqt,rdd~ Thcr~~ Co., 713 A.2d 381 [N.H. lY%]). Two
years before her death, Roxanne Ramsey-Buckingham
sued the major tobacco companies and a local store in
strict liabilitv and under Restatement (Second) of Torts,
section 389. She alleged "that the defendants kne\v or
should ha1.e knon-n that it \vas unlikelv that their prod-
ucts tvould be made rtasonablv safe prior to their cus-
tomarv and intended LISA, an`? that it \vas foreseeable
that i&. Ramse);-Buckir~Rham ~vould be endangered
by ETS from the defendants' cigarettes" (1-7. 383). A
superior court judge dismissed her larvsuit in 1995 on
the basis that New Hampshire does not recognize a
strict liabilitv cause of action under section 384.
Holvever, the- Nelv Hampshire Supreme Court reili-
stated the lar\.suit in Ma!. 1998, ruling that "section
389 is not a form of strict liability because it requires
the defendant's kno\vledge of the product's danger-
ous condition and does not require that the product
be defecti1.e. The comments to section 3X9 make it
clear that a bystander, assuming he is \vithin the
scope of foresceabilitv of risk, is o\veci a dutv under
larz. and ma!' rec0l.e; on a sholj,ing of breacii, dam
age, and causation" (p. 38.5). The case ~vas sent back
to the trial court for further proceedings.

  One case that Ivas triecl before a jury in March
1998 resulted in a I-erdict for the defendants. In that
case, R]R Nol~i~o Holtlir7;;s, Corps. ~1. Dlirrj1 (657 N.E.Zd
1220 [Ind. 19951) a nonsmoking nurse \vho I\-orked for
17 years at a Veterans Administration Hospital died of
lung cancer at the age of 56. Her IvidoIver sued a group
of tobacco companies, claiming that her exposure to
ETS from her patients at the hospital had killed her. A
six-person jury returned a L'erdict for the defendants.
Intervielved after the trial, some of the jurors explained
that thev had had doubts as to ivhether the cancer that
killed Xlrs. Wiley had originated in the lungs or, as

the tobacco companies' lawyers had argued, in the
pancreas and had then spread to the lungs (Dieter 19~8).

  The most prominent ETS case with tobacco corn-
pany defendants has been Broiu u. Philip Morris &IS.,
which was brought against the six major cigarette
manufacturers in 1991. Seven current and former non-
smoking flight attendants, who contracted lung can:
cer or other ailments and who face an increased risk of
disease as a result of exposure to ETS on airplanes, filed
a class action suit on behalf of thousands of flight at-
tendants harmed by exposure to ETS on flights that
predated the federal ban on smoking on domestic air-
line flights. In 1992, a Dade County circuit judge dis:
missed the class action aspect of the complaint, but t\vc
years later, a three-judge panel of the District Court 01
Appeal of Florida, Third District, unanimously reversed
the order of dismissal and ordered that the class action
allegations be reinstated (Broifl, rited iir 9.1 TPLR 2.1).

   In late December 1996, the Circuit Court for Dade
County authorized the mass notification of some
150,000 to 200,000 flight attendants so they could ei.
ther sign up as plaintiffs or exclude themselves fron
the case to pursue their own suits if they wished. Ir
June 1997, jury selection in the trial began. More thar
three months later, midway through the companies
presentation of their defense, the parties announced 2
proposed settlement whereby the defendants woulc
pay $300 million to establish the Broin Research Foum
dation. The settlement would permit flight attendanti
harmed by ETS exposure aboard airlines to sue tht
tobacco companies, regardless of statute of limitation<
issues. In the event of such individual actions, the de
fendants \zould assume the burden of proof on the is
sue of Lzrhether ETS exposure is capable of causing
disease in nonsmokers. Dade County Circuit Judg
Robert I'. Kave appro\,ed the proposed settlement or
February 3, iYy8, calling it "fair, reasonable, adequate
and in the best interests of the class," but challenger
to the settlement have appealed (Broil? P. Phi/i/l Morri
Ccls., No. 9 l-49738 CA (221 [Fla., Dade Cty. Feb. 3,1y981
iitc,ll ;,I 13.1 TPLR 2.79 119981). As of August 1998, thl
appeal ivas pending.

  One Jvorkplace setting that has generated sub
stantial exposure to ETS has been casinos. In 1997
nine casino dealers filed a class action lawsuit again5
17 tobacco companies and organizations. The lawsui
seeks tens of millions of dollars in damages and clas
certification of up to 45,000 casino dealers working il
Nevada, along with their estates and family member:
The plaintiffs in this case, B~~ilill~l 1'. Au7u~m77 Toh-c
Co. (No. CV-N-97-0057%DWH [D. Net. 1997]), are also
seeking to get medical monitoring for the dealers \vhl
ha\-e had years of exposure to ETS on the job. In Apri


IWS, a federal judge denied all of the motions to
dismiss b!~ the defendants, except for The American
Tobacco Company, Lvhich has merged \Vith Brolvii Cy:
\Villiamson Tobacco Corporation.

  In April lYY8, a group of nonsmoking casino
\j.orkers filed a lalz-suit in Nell ]erse\r Superior Court
against several tobacco companies and the industrv's
trade association, the Tobacco Institute, because ;he
r\-orkers lvere being made sick bv their exposure to
                           -
ETS at \\rork (Smothers 1998).

  In a unique case from California, the Cit!, Attor-
nev of Los Angeles filed suit in Jul\, lYY8, against I6
tobacco companies (those that sell cigarettes, iisars,
or pipe tobacco) and 15 retailers on the grounds that
the\. are \.iolating Proposition 65, an initiati\.e statute
pas-sed bv the \,oters of California in lYS6. That la\\.,
l\nolvn as the Safe Drinking Water and Toxic Enforce-
ment Act of lY86 and contained in California Health
~~iid Safetl. Code section 252-lY.6, pro\-ides that "no
pc'rxon in the course of doin ;q business shall Aiic>~\ingl!
and intentionallv expose anv indi\-idual to a chemical
hnolvn to the sta;e to cause cancer or reproducti\,e tox-
lcit\, \vithout first gi\,ins clear and reasonable lj~arn-
ins to such indi\idudl."

  The laljwlit specificall>, lists 46 chemicals referred
to as carcinogenic constituents of tobacco smoke and 8
(arsenic, cadmium, carbon disulfide, carbon monoxide,
lead, nicotine, toluene, and urethane) as reproducti\.c
toricants. The tit\, attornev's complaint cite< a nuinbei
of prominent government studies: 7`/1~, HPO/~~I CO,IW
~jiic'lws ofIw~~lii~ltnr,t/ SljwkirlS, the lY86 report of the U.S.
Surgeon General on smoking and health; Elli'/r.rlil,r2c',it111
fiJh7cco S~~mx-~~: Mens~rri,~~ E.r/~cw~irc~; 171111 Aw~~ir~<~ H~wltl~
Eif~cts, published in 1986 bv the National Research
Council; X~~s/ljintorq H~nltl~ Efik-t~ IJ~ I'~75.~i;v SJrrcJkiJ~;;:
LlirlS Cflrlccl- izliif Otiw Diwr-df,r;, a report issued bv the
C.S. Environmental Protection Agwcv in Januarv iYY3;
c111d H~~7ltl1 Ef(trfs of ES~TCIS~LTL to E,lill,.orllllr'rlt~7/ Toht~~~(~
         _.
~~~wX-~~, published bv the California En\ironmcntaI Pro-
tection Agency in September lYY7. The complaint al-
leges that "N&withstanding this ovemhelming boci~
of governmental information, and notlvithstanding their
W\I~ kno\vledge of these facts since at least lY81, the
T~~ICCO Defendants ha1.e each know?ngly and intention-
~11I\, concealed from, and thercbv decei\~cd, e\-cry non-
imoking individual exposed to en\ironmentaI tobacco
illloke bv the sale and use of tobacco products in Cali-
fornia. Bv these acts of kno\vin g and intentional con-
cealment and deception, the Tobacco Defendants, `IIlL

their agents, the Retailer Defendants, have each
incli\~iduall!~ \.ioIated Proposition 65" (Cdiforl7in iI. Phili{J
M0/.ri4 Ir7i., No. BC 194217 [Calif., Los Angeles Cty. July
11, 19981, cifcd ii/ 13.4 TPLR 3.195 [lYYX]).

  The City of Los Angeles' la\vsuit will likely ben-
efit from a court decision rendered in 1997 in a federal
court located some 3,000 miles a\vav. A nonsmoker in
Florida filed a la\vsuit against \,arious tobacco com-
panies, alleging that she suffers from severe emphy-
sema and an arra\- of other injuries as a result of
prolonged exposure to ETS from the normal and fore-
seeable use of the companies' products. The compa-
nies filed a motion to dismiss her case, contending that
the Federal Cigarette Labeling and Advertising Act
preempts claims based on state IaM- duties to dissemi-
nate information relating to smoking and health. A
judge in the L'.S. District Court for the Southern Dis-
trict of Florida denied the motion to dismiss, conclud-
in;: that the ff~t`rdl act's preemption of state
regulations "L>aseJ on smoking and health" does not
prt~t~mpt regulations in\.ol\ing ETS. "The Court finds
it unlikel\~ that C`ongress intended the word `smok-
ing' tc> mi'atl inhalin;: second-hand smoke," since the
"Congressional reports make clear the purpose of the
[ tedernl act] is not to inform non-smokers of the haz-
ards of breathing second-hand smoke but rather to
inform smokers and potential smokers of the dangers
of acti\,eI\. smoking" ( l&ol/~ir~ i'. P/~ili/~ Morris, Iuc., No.
Y6-l/81-GIL'-KI,XG, 1997 WL 535218 [S.D. Fla. Aug.
IX, IYY7]). The court also ruled that the federal act did
not LX, implication preempt a claim based on harm
from ETS (SITeda 199X).

ETS Crises Ayniust h'orltobncco Parties

  Injunctive relief from ETS. In 1976, Donna
Shimp (see "Legal Foundation for Regulation of Pub-
lic Smoking," earlier in this chapter), an office worker
in Ne\\, Jersey, sought inter\rention from the courts to
pro\?dc her relief from exposure to ETS at her worksite
(Slrijlr/l, 368 A.2d 408). The court ruled that the evi-
dence \~as "clear and o\wM-helming. Cigarette smoke
contaminates and pollutes the air, creating a health
hazard not merelv to the smoker but to all those around
her rz,ho must re@ upon the same air supply. The right
of an indi\+dual to risk his or her own health does not
include the right to jeopardize the health of those who
must remain around him or her in order to properly
perform the cluties of their jobs" (p. 415). In granting
an injunction to ensure that Shimp be provided a
smoke-free \\.orkpIace, the Ne\v Jersey Superior Court
provided a clear example of taking seriously the health
concerns of nonsmokers \vho are forced to breathe ETS.


The Sl7itrr/~ decision preceded most ot the medical stud-
ies that have demonstrated the ad\.vrse health effects
of ETS. In the 22 vears since Q~\JI/J, Ia~vsuits designed
to protect nonsmdkers from the health hazards caused
by involuntary exposure to ETS ha\-e escalated.

  A 1982 decision from the Missouri Court of Ap-
peals gave additional momentum to nonsmoking
Lvorkers seeking legal relief from on-the-job exposure
to ETS. In S~llit/l (643 S.W.Zd 101, the Missouri Court
of Appeals reversed a trial court's dismissal of a laiv-
suit brought bv a nonsmoking ivorker lvho \z.as seek-
ing an injunction--a form of direct interlwltion by a
court-to pre\.ent his emplover from exposing him to
tobacco smoke in the lvorkpiace. The court of appeals
ruled that if Paul Smith lvere to pro1.e his allegations
at trial, then "by failing to exercise its control and as-
sume its responsibilitv to eliminate the hazardous con-
dition caused b>r tobacco smoke, defendant [Western
Electric Co.] has breached and is breaching its duty to
provide a reasonably safe \vorkplace" (p. 13). A-
though the nonsmoking lvorker e\.entuaIlv lost his case
after it ivas sent back to the trial court, the court of
appeals decision remains as a precedent that t\.ill help
similar cases survi\,e motions to dismiss (S\\&a 199X).

  The follo\zGig !`ear, a nonsmoking social \\,orker
in Attleboro, Massachusetts, \j'as granted a teniporar\
restraining order (w,hich bv la\v could last no more
than 10 days) against smoking in the open office area
lvhere she lrorkecl ivith about 3Y c[o\vorkers. 13 of
\vhom smoked. In LcXv (ciftvl i/r 1 .2 TPLli 7.82), a sup-
rior court judge denied a motion bv the emplover to
dismiss the case, ruling that "an emplover has no dut\
to make the it-ork place safe if, and oniv if, the risks at
issue are inherent in the \\.orh to be done. Otlierl\,ise,
the employer is required to `take steps to pre\.ent in-
jury that are reasonable and appropriate under the cir-
cumstances'. AccordingI!; this court cannot sav that
plaintiff's claim fails to make out a legally cognizable
basis for relief" (p. 2.83). The case lads settled in Janu-
arv 19% \vhen the emplover, the Con~mon~~ealth of
Massachusetts, agreed to bro\.ide the plaintiff, Marie
Lee, and the other nonsmoking \\,orkers there, \t-ith a
separate nonsmoking area \\,ith \-entilation separate
from the \-entilation in the smoking area. As it turned
out, only 4 of the office's f0 lsorkers chose to \\.nrk in
the smoking area (Siveda 1998).

Hnirdicay DiscrizzzirzntiozzlAzzzf~ric~zzs
With Disabilities Act

  A new' theor!, for ensuring ETS protection for
nonsmokers in\-ol\,ed using the ADA. As the ratio-
nale for applving the ADA to the r\rorkplace, parmet

and colleagues (1996) explained: "The ADA was en-
acted in 1990 to provide a `clear and comprehensive
national mandate for the elimination of discrimination
against individuals with disabilities' [42 U.S.C. section
12101(b)(l)]. The act prohibits discrimination against
individuals bvith disabilities on the job [42 U.S.C. sec-
tion 12112(a)] and in places of `public accommodation'
142 U.S.C. section 12182(a)], as well as by state and lo-
cal governments [42 U.S.C. section 121321" (p. 909).

  Initially, some plaintiffs did not succeed in ac-1
quiring relief from ETS under the ADA. For example,
in Hnrtuc~r C. Virgi/zio Electric mil Powr Co. (831 F. Supp.
1300 [E.D. Va. 1993]), an employee suffering from bron-
chial asthma sued his employer, contending that in
failing to ban smoking at the workplace, the companq
had violated the ADA by discriminating against him
because of his disability. Harmer contended that after-
he requested a smoke-free work environment, the com-
pany retaliated against him by reducing his job au--
thoritv and failing to promote him.  Though
recogn&g Harmer's disability, the district court dis-
missed the claim, saying that he "still must show that
he is entitled to a complete smoking ban as a reason=
able accommodation to his disability, and he is unable
to do so" (p. 1306). This \vas so "because the manv
smoking limitations that the employer had put in plac;,
coupled \vith improvements such as the installation
of air filtration devices, were sufficient to enable the
plaintiff to Lvork. Of course, a patient more severeI\.
disabled might have required further accommoda-
tions" (Parmet et al. 1996, p. 912).

  In hm'y i'. Cnrni~rr of Dr~`nlil.s, f/lc. (8'79 E SUFJT
610 [N.D. Tex. 1995]), two women hypersensitive to
ETS filed suit under the ADA, contending that the>-
lvere effecti\,elv precluded from attending musical
performances a; the defendant's establishment because
smoking \x.as permitted there. After a one-day, jurv-
\vai\,ed trial, a federal judge ruled against the plain-
tiffs, but noted that they should have brought theil
claim under the ADA's reasonable accommodation
provision, instead of the section of the act that bar:
the establishment of rules that "screen out" disabled
people (p. 643).

   A different result had occurred in a case from Con
necticut. In Stnrrv~ P. McLhjzn/d'.i COY/J. (51 E3d 353 136
Cir. 199533, plaintiffs brought an action under the ADA
42 U.S.C. section 12101, saying that the presence of to-
bacco smoke in the defendants' restaurants was prevent
ing the plaintiffs from having the opportunity to benefi
from the defendants' goods and services. The plain-
tiffs, all of ivhom have adverse reactions to ETS, alsc
alleged that the defendants' restaurants are places o-
public accommodation under 42 USC. section 12181-


\ttcr a district judge granted the, deienclants motion to
Jismiss the case, the United States Court of Appeals for
tilt' Second Circuit rc\-ersed, ruling that "1x-e find that
t~l,lintiffs' complaints do on their face state a cogni7ablr
ilainl against the defendants under the Americans l\.ith
l>i~,lbilities Act" (p. 3.551. The court noted that "the de-
ti~miiiiation of \\.liether a particular modification is `rea-
5c)nable' in\ ol\.es a fact-specific, case-I~\.-case inquir\.
tllat considers, among other factors, the cffecti\.eness of
the modification in light of the nature of the disabiliti.
111 question and the cost to the organization that \IDLII~I
Implement it [p. 3561. We see no reason It-h\., undei
tile appropriate circumstances, a ban on smokil;:_ could
ni)t be a reasonable n~odification" (p. 337).

  An Illinois \voman suffering from chronic se\ ere
allergic rhinitis and sinusitis sought a smoke-free I\-ark
ivi1-ironnient and sued her former eniplo\-er after it
"repeatedI\, refused to provide" the plaintiff \\.ith a
I-c,lsonable~acconi~io~lation to her disabilit\.. Afttxr til-
ill:; an ADA claim lvith the Equal Emplv\~mtwt Op
p~lrtuiiity Commission anJ a I\-orker'h conipensatic~n
claim, she fvas terminated. A federal judge in H~~~If~vc~r.
:` ~/iii:lcw rlllillirl .-hJiir7tl3~. l/Ii (No. 95 c -Llw, 1995
\\ L (383613 [N.D. III. No\.. 17, 19951) granted the dt,-
ttwdants' motion to dismiss, sa\.in;: that the plaintiff
"Jot5 not, and cannot, allege that hw sensiti\ iti. to
IETS] substantialI>- limits her abilit!, to find empjo>.-
mcnt as a typist generallv. Thus, Hornever is not a
qualified indil-idual ivith a disability, and, accordingI!;
1\ not entitled to the protection of the ADA" (p. 3).

Ho\ve\ er, the Cnited States Circuit Court of Ap-
ptsals for the Se\.enth Circuit unanimousI\, re\,ersed
the district court's rolling and sent the case back fol
trial. Noting that the district court had ignored
Hornever's claini that she \vas disabled in that hcl
hwath&g, an essential life activity, ij.as affected bv ETS,
the court of appeals ruled that "II.~ cannot sa\- it this
\tase that it \vould be impossible for her to sl;ol\- that
~c'I. chronic se\rere allergic rhinitis and sinusitis either
alone or in combination M.ith ETS substantiallv limits
llclr abilitv to breathe" (Horllcy/o. 71. St~7111~1/ Tult'hirr il.+
Y'( ;llfc's, l;~c., 97 E3d 959, 962 iith Cir. 19&l).

  In October lYY7, a Ne\\. York jurv alvarded
`~~(),300 to an asthmatic prison guard, Keith Muller
( \1dicr il. Cnsfcllo, No. `M-CV-832 (FJS) CCJD,, 1996 WL
I'llclii [N.D.N.Y. May 20, 1996]), w.110 had been fired
after he had made numerous complaints about the ef-
tc'ct of ETS exposure on his health. While ser\,ing as a
`ilrrectional officer, Muller had become seriously ill-
l~~cluding numerous occasions ivhen he had to be taken
t ! 1 `1 hospital directlv front the prison xvhere he
`\orked-after being &posed to ETS. After Muller's
tl.c'ating phvsician hacl recommended that he lvork in

a smoke-free en\.ironment, the Nets York State Depart-
ment of Correctional Services instead provided him
lz.ith a mask that, according to Muller, made him even
niore ill. Furthermore, Ivearing the mask had subjected
Muller to lvidespread ridicule, putting him in even
greater personal danger from the breakdown in the
respect that the inmates had for him. Whereas a judge
in 19% had barred the plaintiff's negligence and civil
rights claims in Mlrllw ~1. CosfcTllo, the court allo\ved
Muller's ADA claim to proceed.

  Ruling on posttrial motions, the judge reduced
the a\vard to 5300,000 because of the cap on compen-
satory damages contained in 32 U.S.C. section
lWlaib)(3). The court also rejected the defendant's
motion to \,acate or reduce the verdict as excessive,
ruling that the "plaintiff submitted evidence of dis-
crimination that had taken place o\`er a period of Vears
during \\.hich time he \vas forced to endure mental
  
suttering, embarrassment, econoniic hardship, actual
termination and physical injure. In view of this evi-
dciice, the Court finds that the jury alvard of $300,000
is not c\cessi\,e and does not shock the conscience as a
matter of la\\." (,l/l~/ll~ ~1. Cwfc,llr), 997 F. SLIDE. 299, 303
IN.D.N.1'. 19981).

  In a more recent case, three asthmatic women
SLI~C~ ReJ Lobster and Rubv Tuesdav restaurants un-
der the ADA. The plaintiffs in Etlwnrils 7'. GMRI, Illi.
(No. 116693 [Md., Montgoniery Cty. Nov. 26, 19971,
c-/tvA irk 13.1 TPLR 3.1 [199X]) said that they attempted
to patronize the defendants' restaurants but were
forced to 1eaL.e because of the ETS there. In their com-
plaint, the plaintiffs stated that the defendants' "fail-
ure to establish a police prohibiting smoking in their
restaurants throughou;the state discriminates against
the Plaintiffs on the basis of their disability in their
use and enjoyment of" the restaurants (p. 3.3).

  The 1990s have seen the development of cases in
1%.hich a nonsmoker li\ing in an apartment or condo-
minium unit is being adverselv affected by smoke en-
tering his or her d\velling sp&c from elsewhere. In
June 1998, a Boston Housing Court judge ruled in fa-
\.or of nonsmoking tenants ~.ho bvere being e\-icted
for nonpavnient of rent W-58 Gi7ir15I~~ro1iglr Strwt Rc-
irlf1/ Trrl5f tl. Rtue il/ltf Krisfv Hnik, No. 9842279, Bos-
toll Housing Court [1998lj. After pleading with the
landlord for sweral months to do something about
the problem of smoke from a first-floor nightclub
constantlv entering their second-floor apartment
and disrupting their ability to use and enjov their


apartment, the tenants got no relief. Attrr the\, \vith-
held their monthly rent pa!,mcnts of S1,150, tll-e land-
lord brought an action in housing court seeking their
eviction. The court ruled that "the e\.idence does dem-
onstrate to the Court that the tenants' right to quiet
enjoyment [of their apartment] \vas interfered lvith be-
cause of the second hand smoke that \~as emanating
from the nightclub belor%r" (p. 34). The court ruled
that "as the tenants describe the second hand smoke
Lvithin their apartment at nighttime, the apartment
would be unfit for smokers ancl non-smokers alike"
(p, 7). That interference M.ith the quiet enjoyment of
the tenants' apartment was a defense to the effort to
evict them, Also, the court found for the tenants in
the amount of $3,350-the same amount that the ten-
ants had withheld over the course of three months.

  In Lk~orki~7 7'. Paley (Y3 Ohio App. 33 383, 638
N.E.2d 636 [Ohio Ct. App. 199311, D\vorkin, a non-
smoker, entered into a one-year lease lvith Paley to
reside in a two-familv d\velling; the lease leas later
renewed for an additional one-vear term. During the
second year, Paley, a smoker, mo\.ed into the d\velling
unit below Dlvorkin's. T\VO Lveeks later, Dlvorkin
lvrote to I'alev to tell her that her smoking \vas annov-
ing him and causing him phvsical discomfort, noting
that the smoke came through-the common heating and
cooling systems shared by the t\vo units. Within a
month, Dlvorkin vacated the premises. Eight months
later, he brought a legal action to terminate the lease
and recover his securitv deposit from Palev. The larv-
suit, rvhich alleged that I'alev had breached the co\`-
enant of quiet enjovmcnt and statutory duties imposed
on landlords (including doing "\\.liate\,er is reasonabl\r
necessarv to put and keep the premises in a fit and
habitable condition," p. 387) \~a5 dismissed on a mo-
tion for summar> judgment. I-lol\.e\,er, the Cuyahoga
County Court of Appeals re\,ersed the dismissal,
concluding that a re\ielv of the affidavits in the case
"reveals the existence of general issues of material fact
concerning the amount of smoke or noxious odors
being transmitted into appellant's rental unit" (p. 387).
The case leas thus sent back to the trial court.

  In June 1998, a prominent Ne\v York law firm,
Weil, Gotshal & Manges LLI', sued the o\vner and land
lord of the office building lvhere it is located, as \j,ell
as the tenant located one floor below, because of ETS
seepage into its office space. The firm alleges in its
lawsuit, that as a result of the smoke infiltrating into
its 29th floor offices, "some of WG&M's partners, as-
sociates and employees have suffered illness, discom-
fort, irritation and endangerment to their health and
safety, and/or 1laL.e been unable to use or occupv their
offices or lvorkstations on the WG&M 29th Floor

  Man\: landlords are not waiting to be sued. The
Building &vners and Managers Association Interna-
tional, a trade association for 16,000 office landlords
and owners, has been advising its members to lessen
their risk of ETS liability by banning smoking when-
ever possible. During the past two years, the propor-
tion of member office buildings that banned smoking
increased from 68 to SO percent (White 1998).

United States Supreme Court Ruling on ETS in
Pvisorls -Eighth Amendment Issues
  Perhaps the most frequent area of litigation in-

\.ol\,ing exposure to ETS has come in a setting where
the exposure is both involuntary and inescapable-
prisons. A landmark case that eventually reached the
United States Supreme Court started in Nevada when
a nonsmoking prisoner was housed in the same cell as
a hea1.y smoker (McKiulwy 51. A~zdcusorz, 924 E2d 1500
[9th Cir. 19911). The nonsmoker brought a civil rights
lawsuit against the prison officials, claiming that his
Eighth Amendment right to be protected from cruel
and unusual punishment was being violated due to
his constant exposure to ETS. Although his case was
thro\vn out initially by a district court in Nevada, the
lawsuit \vas reinstated bv the United States Court oi
Appeals for the Ninth Circuit. The court ruled that
e\-en if the inmate could not show that he suffered from
serious, immediate medical symptoms caused by ex-
posure to ETS, compelled exposure to that smoke is
nonetheless cruel and unusual punishment if at such
le\-els and in sucli circumstances as to pose an unrea-
sonable risk of harm to the inmate's health.

  On June 18,1993, the Supreme Court ruled in a 7
to 2 decision that McKinney's case could go forward.
The Court affirmed "the holding of the Court of Ap-
peals that McKinney states a cause of action under the
Eighth Amendment by alleging that petitioners [the
prison officials] have, w.ith deliberate indifference, ex-m
posed him to levels of ETS that pose an unreasonable
risk of serious damage to his future health" (Hc//i~l~ P.
AkKi/7rwy, 113 S. Ct. 2175 [1993]).

ETS aud Child Csstod!y Cases

  Disagreements between parents who are divorc-
ing can, of course, cover a wide variety of subjects.
One of the issues that has increasingly become a sig-
nificant subject of disputes that have ended up before-
a judge in probate court has been the exposure to ETS
on the part of a child or children caught up in a


custody battle. O\,er the past 11 years, there have been
recorded cases in at least 20 states (Siveda 1998). One
of the earliest \~as Wilk il. WI'IX- (If{ w Wili iI. Wilk, 7X1
S.W.Zd 217 [MO. App. 19891). The trial court in this
case granted primary custody of the children to the
mother, who had been advised by a doctor that the
children, one of tvhom leas asthmatic, should not
be taken to the father's home because he smoked. The
fvlissouri Court of Appeals ruled that the trial court
did not err in a\varding custodv of the minor children
to the mother.

  In a case from Kansas, an ex-isif-e \\.ith custnd\~
sought permission to 1iioL.e ii.ith her children to aii-
other state; the ex-husband responded \yith a motion
to obtain custodv. The district court did make the
change bv al\-arding custodv to the es-husband after
finding &at the ex-Irife's s&oking had harmed the
children. The es-\\.ife appealed, arguing that thwe had
been no evidence to pro\e that her smoking had cc~used
her children's health problems. The court of appeal%
affirmed the district court's change of custody, notins
that there Ivas e\ridence that her smoking had harmed
the children: "That finding is supported b\, the testi-
IIIOII~~ of three doctors that s~con&l~and smoke aggra-
\.atei the children's health problems and placed them
at risk for further health problems" (/\I VI' .~I~/I~~(./I[J~~,
913 P.2d 221 [Kan. Ct. App. Mar. 22, 19961).

  In some cases, the smoking issue is not sufficient
to produce a change of custodv. For example, in H~~/uI
i'. HCIIII (Ol-A-Ol-9209-CHO0363, lYY3 WL21983 [Term.
Apt). Feb. 3, 1993]), the trial court a\varded custodv of
~3 five-vear-old child to the father. The mother appealed
the divorce decree, arguing before the Court of Ap-
peals of Tennessee that the father smoked around the
child. The court said that "Other than exposure to vio-
lent movies and cigarette smoke, no e\ridence is cited
that the father has neglected or mistreated the child"
(17. 2). The trial court's judgment \vas affirmed, with
the mother being accorded visitation rights. In Bngqcff
;`. Snthcr-lnlrd (No. CA 88-224,1989 WL 5399 [Ark. App.
Ian. 25, 1989]), a nonsmoking father attempted to ob-
tain a change in custody on the basis of, among other
things, the fact that the mother smoked in the pres-
ence of children who were allergic to smoke. Although
the lower court had found that circumstances were not
5~) changed as to warrant a change in custody, it did
acknowledge that smoking was detrimental to the chil-
dren. The mother was forbidden to smoke in the home
or allow anyone else to smoke in the home; the judge
"made it clear that he would exercise continuing ju-
risdiction over the parties to insure compliance with
that order" (p. 3).

  Rulings in other cases ha\re been the product
of compromise. In !Vor?llclitt il. Ri'orfllcrltt, a 1997 case,
a nonsmoking father objected to ETS around his
2-vear-old son, \~ho has asthma and has had repeated
res 3iratorv infections, bronchitis, allergies, and ear-
-k
aches (Slveda 1998). As part of a joint custody agree-
ment, a Warren County, Tennessee, judge ordered the
mother to keep her son array from ETS. Each parent
was to ha\.e custodv for six months per year.

Victims of Smoking-Related Fires

  Smoking is the leading cause of deaths and inju-
ries by residential fire. According to the Building and
Fire Research Laboratory of the National Institute of
Standards and Technology, cigarettes start more fatal
fires than anv other ignition source, causing about 30
percent of ali fire deaths in this country. For example,
in IYSY, 11,000 cigarette-ignited fires caused 1,220
deaths, 3,358 injuries, and $481 million in property
damage (Karter lYY3).

  In lc)84, Congress passed the Cigarette Safety Act
(Public La\%. Y&567), creating a Technical Study Group
to assess the feasibilitv of dewloping a less incendi-
ar\' cigarette. The g&p concluded that changing a
standard cigarette's diameter, paper porosity, and to-
bacco density \vould produce a cigarette that would
not transfer enough heat to cause a fire when dropped
on most upholster\; (Technical Study Group on Ciga-
rette and Little Cigar Fire Safety 1987). The tobacco
industr>z maintains that e\`en if such cigarettes could
be manufactured, \,\rhen smoked they would not burn
as thoroughly as current brands, meaning that fire-safe
cigarettes \~ould deliver more tar, nicotine, and car-
bon monoxide to the smoker (Levin 1987).

  The prospect of technologies for making less in-
cendiary cigarettes raises the question of whether the
manufacturers might be held liable for failure to in-
corporate such a feature. Until now, product liability
litigation for fires caused by cigarettes has met with
no more success than smokers' claims for injuries to
health. The first such case to produce a judicial deci-
sion, Lnrllke ~1. Fufo~inr~ Coy. (709 P2d 684 [Okla. 1985]),
involved a fire started when a cigarette ignited a sofa,
resulting in severe burns to much of the plaintiff's
body. The Oklahoma Supreme Court applied the so-
called consumer expectation test to find that the ciga-
rettes in question were not dangerous to an extent
beyond what ivould be expected by the ordinary con-
sumer. The consumer expectation test, which evolved
from comments to section 402A of the Restatement
(Second) of Torts, today sur\ri\res as the law in a mi-
nority of jurisdictions (American Law Institute 1995).


The prevailing \ie\v, endorsed bv the current draft of
the Restatement (Third) of Torts; would determine li-
abilitv for defective product design bv a risk-benefit
standard that evaluates the qualitv oi the manufac-
turer's design decision by revie!iing whether the
manufacturer properlv \veighed the comparative costs,
safety, and mechanical feasibility of one or more alter-
native designs (Green 1995). In La~lke, the court found
that evidence regarding the feasibility of manufactur-
ing a less incendiary cigarette was irrelevant to con-
siderations of consumer expectation, but such e\,idence
might be found persuasive in a jurisdiction following
a risk-benefit standard for determining design defects.
Whether the tobacco companies suppressed research
and product de\,elopment regarding fire-safe cigarettes
is under investigation bv the antitrust division of the
U.S. Department of Justice (Shapiro 1994~).

  Fire claims by smokers \~ould face many of the
familiar obstacles to recovery but, as two pending
claims illustrate, many of the potential plaintiffs in fire
litigation are not smokers but third parties untainted
by the decision to smoke. In K~~rrrc~! il. Philips Morris
Cns. ([D. Mass. May 11, 19921, cilcil 111 7.2 TPLR 3.65
[1992]), suit \vas brought on behalf of a kvoman M.ho
died in a fire started by her husband's cigarette. The
plaintiff's attorneys focused "on the issue of additives
and other manufacturing techniques that cigarette
makers use to ensure that cigarettes kvill stay lit even
if they aren't being smoked" (Wilke and Lambert 1992).
On February 16,1996, Judge Robert E. Keeton granted
summary judgment" in favor of Philip Morris, hold-
ing that even under the more forgi\.ing standard of
liability for design defect, "fatal gaps" existed in ev-
dence submitted by the plaintiff in supporting her
claim that adoption of an alternative design by the
company would ha1.e prevented the fire started by Mr.
Kearney's cigarette (&YZY,IC!/ ~7. P/li/i;j Mm-l-is Irlc., 916 F.
Supp. 61,66 [D. Mass. 19961).

  Another cigarette-caused fire claim seeks recov-
ery based on the fire-related injuries recei\fed bv a
21-month-old infant trapped in her child car &at
(Ski~~uu~r~ ~1. Phi/i/~ Morris Cm., Cause No. 26291 [Tex.,
Johnson Cty. Oct. 7, 19941, iif& ill 10.1 TI'LR 3.91
[19951).

Enhancing Prohibitory Regulation by Private
Litigation

En,forciug Minors' Access Lazus

Enforcing these widespread and important statutes is
typicallv left to government officials who have com-
peting commitments and limited sanctioning powers.
A pioneering suit, brought by tobacco activists against
a Massachusetts convenience store chain, sought to
supplement this ineffectual arrangement by private
enforcement. The initiative first took the form of a test:
case, sponsored by the Tobacco Products Liability
Project, charging that Philip Morris was engaged in a
"civil conspiracy" with the convenience store chain to
sell cigarettes to minors.  A divided Massachusetts-
Supreme Court found the conspiracy unproven (Kyte
71. Philip Morris lw., 408 Mass. 162, 556 N.E.Zd 1025
[Mass. 19901). The plaintiffs then refocused the suit-
directly against the convenience store chain, alleging-
that it had violated the Massachusetts Consumer Pro-
tection Act, which allows consumers to bring civil suits-
directly against vendors for money damages and in-
junctions. The suit terminated in a settlement in which
the chain agreed to demand proof of age from would-m
be cigarette purchasers.  In 1992, the Tobacco Prod-
ucts Liability Project launched a project to research the
legal basis for such suits in all 50 states and to provide
informational and strategic support for such litigation
(LeMr 1992).

  After the settlement in K$c, the attorney general
in Massachusetts, acting under the state's consumer
protection laws (Mass. Ann. Laws ch. 93a, sec. 1) bee
gan to conduct tests using minors posing as custom-
ers to gauge retailer compliance with state bans on-
tobacco sales to persons under 18 years of age (Mass.-
Ann. Laws ch. 270, sec. 6). Settlements were reached
\2-ith several supermarket chains in 1994 for monetary
damages as well as implementation of measures de-
signed to reduce the risk of further illegal tobacco sales
to minors (Tobacco Products Liability Project 1996). By
1998, state attorneys general offices in 26 states began
working M.ith the National Association of Attornevs
General and the Tobacco Control Resource Ceniel
(1998) to develop approaches to prevent illegal tobacco
sales to minors.

  K,I& presents an instance of a lawyer functioning
as a private attorney general to secure the enforcement
of underenforced public standards. This case suggests-
that restrictions on sales to minors might be enforced
more effectively by establishing informational net--
works and incentives (such as the recovery of attor-
neys' fees) to facilitate widespread and routine

  Although selling cigarettes to minors is prohib-
ited in all states and the District of Columbia, retail
store employees frequently ignore the law (Le\v 1992).

A summary judgment is a judgment granted kvithout a formal
trial \vhen it appears to the court that there is no genuine issue of
fact and that the moving party is entitled to judgment as a matter
crt ld\\.


exertions by la\v!.ei-s. Such pri\.ate enforcement is a
\j.ell-established feature of a number of regulatorv re-
(rimes, including consumer credit regulations, securi-
0            I
ties la\\Ts go\,erning insider trading, and bounties paid
ior apprehending persons ivlio defraud the goi.eni-
ment. In de\-ising such strategies, the risks of underuse,
o\.eruse, and abuse must be identified to frame a
scheme of incenti\,es that vields optimum results.

One state's highest court has upheld the legal
\.aliditv of using the civil provisions of consumer pro-
tection statutes to enforce penal lal1.s prohibiting tn-
bacco sales to minors. The California Supreme Court
held that a pri\-ate and for-profit enterprise had stand-
ing under that state's consumer protection lal\,s to
maintain a pi-i\-ate action in the public interest, e\`en
though the underl\?ng penal statute contained no pro-
\%ions for a private right of action (Stcll~ >i)lctlr ,-ldrlic--
tio17, lric-. il. Lffch Sfow. /r7i., 17 Cal. 4th 553, 557, 71
Cal. Rptr. 2d 73i [19YH]).

  State and local lalvs restricting the ad\w-tising
and promotion of tobacco products (see "Ad\.ertising
and Promotion," earlier in this chapter) provide an-
other occasion for pri\,ate initiati\.es. The California
Supreme Court held that federal preemption did not
extend to bar a suit claiming that the "Joe Camel" ad-
\.ertising campaign targeted minors and thus violated
California's ban on unfair business practices (see "A
Critical Example: Joe Camel," earlier in this chapter)
i.t2~777gir1i, 875 I?2d 75). This suit, like Kl/tc~, in\-ites con-
sideration of the benefits and costs of the pri\.ate at-
torney general device. Such an evaluation must
compare the performance of pri\-ate efforts \\.ith ac-
tual rather than idealized go\.ernmental regulatory ac-
tixity. For example, the FTC did secure a consent
decree against the Pinkerton Tobacco Company ([/I rt'
Pirkertm 70hncc0 Co., 115 F.T.C. 60, 1992 F.T.C. LEXIS
35 [Jan. 9, 19921) to cease promotion of its smokeless
products at a televised tractor pull. On the other hand,
after FTC staff lawvers recommended in 1993 that the
FTC charge R.J. Re$nolds Tobacco Company v,`ith LIS-
ing the Joe Camel campaign to promote cigarettes to
children, the commissioners \.oted 3 to 2 to take no
action (fTC:lV~tclr lY91).

  The presence of pri\,ate attornew general may
add to the limited resources of public ;egulators. The
U.S. Department of Justice recently settled a Iat\-suit
against Madison Square Garden for circumventing the
1971 federal ban on broadcast advertising of cigarettes
bv placing cigarette advertising \\rhere it u,ould be dis-
piayed in television broadcasts. The case ended lj.ith

a consent decree in \vhich the arena admitted no
rvrongdoing but agreed to remove cigarette advertis-
ing from sites IThere it \~ould be seen on television
(Thomas and Sch\i-artz 1995). The government's en-
forcement capacity in this area could be amplified if
there \vere sufficient incentives for private litigants.

The International Dimension of Tobacco Litigation

Tobacco Litigation Abroad

  The first ancl second Lva\res of tobacco litigation
\vert` uniquelv L:.S. phenomena, but the third wave
has an international dimension that its predecessors
lacked. Only a fe\z. years after a 1990 survey reported
that "there has been no history of tobacco litigation in
the [European Community]" (Cooper 7 990, p. 291),
counterparts of many of the third-M-ave litigation ini-
tiati\.es ha\,e appeared in other countries. In Austra-
lia, emplo!,ees injured by ETS have recovered
substantial damages from their employers (Daynard
lYY4a). A public interest group, the Consumer's Fed-
eration of Australia, secured a judicial declaration that
the Tobacco Institute of Australia Ltd. had falsely
claim4 that "there is little evidence and nothing which
pro\.es scientifically that cigarette smoke causes dis-
ease in non-smokers" (Davnard 1994a, p. 60). A French
public interest group, acting as private attorneys gen-
eral, successfully enforced bans against tobacco adver-
tisements on radio and teleirision (Gol/ulni~z P. Societc
Natior7i7lf~ D'Erploi~i7tin77 It7d77strirllc de Tahncs et
All771r7c~ftc~ [SE/T,-11 [Tribunal de Grande Instance de
blontargis Dec. 19, 19961, cifctl irl 11.8 TPLR 3.1073
[ 1YYhj). In Canada, a class action suit based on addic-
tion \%`as filed against Canada's three largest tobacco
manufacturers. To sholv that the tobacco companies
knr\v of nicotine's addictiveness, the suit relied on
documents unco\rered in the United States Wan Rijn
lYY5). In England, the Legal Aid Board granted cer-
tificates of eligibility for legal aid to fund 200 cases
brought bv smokers alleging that tobacco manufactur-
ers had failed to meet their legal duty to minimize the
risks of smoking (PR Newskvire 1995). Legal Aid`s
\i,illingness to finance the litigation comes after a three-
year battle for funding, led by the British group Ac-
tion on Smoking and Health (Milbank 1995).

Foreign Plaintiffs ilz the American Courts

  Overseas sales are an increasingly important sec-
tor of the American tobacco industry: exports grew
from 8 percent of total production in 1984 to 35 per-
cent in 7YYh (MacKenzie et al. 1991; U.S. Department
of Ag-iculture lY%). The absence of lvarnings on the


packaging of exports and the aggressi\ e promotional
acti\-it? might help foreign plaintiffs \I-ho brought
claims in U.S. courts ol'erconic some of the barriers
that ha1.e protected tobacco companies from domestic
plaintiffs. Holyever, such litigation r~ould face other
formidable obstacles, including the problem of estab-
lishing a substanti\rt right to reco\`er according to for-
eign law and an expanded notion of the responsibilities
of multinational corporations for merchandise sold
o\`erseas. Such an expansion seems unlikely in the
light of the reluctance of U.S. courts to provide a fo-
rum for foreign victims of corporate misconduct. This
reluctance was dramatized in the litigation arising
from the 1984 chemical plant explosion in Bhopal, 1~
dia (Jasanoff 1985; Cassels lYY3; Calanter 1994). Al-
though the U.S. courts decided that the case should be
tried in India rather than in the United States ([II IP'
Ll/ricl/f cd~idc~ c~J!`/l. G175 I-1 /f7/lt Di!i.i75tH 17t ~hOj"71, I,l,fii7
irl Deimlw~, 19&i, 634 F. Supp. 8-12 [S.D.N.\i 1%6], izff'cl
it! prt 809 E2d 1 Y5 [2d Cir. 19871, c-c~`t. ~l~/~ic~l, G-X C .S.
871, 10X S. Ct. 199 [lYX7]), the L'.S. parent cornpan!
ITas required, as a condition of moving the case to
India, to submit to the jurisdiction of the Indian courts.
A number of rulings in the Bhopal litigation also cre-
ated the basis for enhanced liability of U.S. multina-
tional corporations for their over&s operations. In a
later proceeding, a U.S. court ackno\zledged that a for-
eign government might establish itself as the esclu-
si\-e representative of \.ictinis of a mass tort (R~?rlo Ri ;I.
LIt~ioi~ Cilrl~l'tft~ CIWII~. LT Ol~istiis Co., 984 F.23 582 (3d
Cir. 19931). If any of the current third-It-al-e claims
flourish, foreign claims lvill likelv be presented to U.S.
lalvyers and filed in U.S. courts..

  On Mav 12, 19Y8, the Republic of Guatemala be-
came the first nation to file a Iall-suit against the U.S.
tobacco industry for the recovery of public health care
expenses (Davis 1998) (Gi~~tcr~~~~ln ~1. Ti)l~ic.cj l~l,fitl~tc,
[D.C. May 12. 19981, zitcd i/j 13.3 TPLR 3.121 [lY%]).

Counterthrust: Tobacco Industry Initiation of
Litigation and Other Tactics

   In its 1993 la\t.suit filed in U.S. District Court in
Greensboro, North Carolina, the tobacco industry
accused the EPA of using improper procedures, inclu&
ing statistical manipulation, to arri1.e at a predeter-
mined conclusion and sought "a declaration that EPA's
classification of ETS as a Group A [kno\vn human1
carcinogen and the underlving risk assessment are
arbitrary, capricious, vio1atiL.e of the procedures re-
quired bv laiv, and unconstitutional" (FIIIPCIIWII K~Pnxr~

CtwjJt'ri7fii'L' Sfabili~nfio~l Corp. i'. UJlifrLf sti7tes. Etwirnfl-
\rrr,rtnl PnJtrv-tiorr AScrrcy [M.D.N.C. June 22, 19931, cited
i/l 8.2 TPLR 3.97 [1993]). As discussed earlier in this
chapter (see "Health Consequences of Exposure to
ETS"), on July 17, 1998, U.S. District Judge William L.
Osteen Sr. issued a ruling whereby the court annulled
Chapters l-6 and the Appendices to EPA's Rrspir~tory
Htvlth Effects of Pmsiuc Snmkir~g: LUJI~ Cn~mr nrzd 0th~
Disodcrs (EPA 1992; Meier 1998b). The judge reached
his conclusion only after having denied the EPA's mo-
tion to dismiss the case even though the EPA had never
taken, and indeed had no authority to take, final agency
action (e.g., the adoption of a regulation restricting
smoking) based on its report (F/wCurd Tobacco Coop-
c~r'~7fiw Sffltli/iznfiorl Corp. P. Clrlifd Sfates E~wirafzrw/zfn[
Prc~ft~ctior~ AXLVC!/, 857 E Supp. 1137 [M.D.N.C. 19941).

  This lawsuit, filed in 1993, was not the first in-
stance of the tobacco industry attacking scientists and
their rzrork on ETS. Internal industry memos were cited
in an article in April 19% in the !&/l .%wf ]OUYH~/:
"Determined to keep reports about second-hand
smoke from mushrooming, the tobacco industry mo-
bilized a counter attack in the mid-1980s to systemati-
callv discredit anv researcher claiming perils from
passi1.e smoke" (Twang 1998). In a February 25,1985,
letter, Anthony Colucci, who was a top scientist at R.].
Revnolds Tobacco Company, wrote to H.E. Osmon, a
dir&tor of public affairs at R.J. Reynolds: `I. we an-
ticipate that if [then-EPA scientist James] Repace runs
true to form there \viIl be a good deal of media copy
\z,ritten about their [Repace's and naval researcher
Alfred LoMyrey's] analyses and thus wc should begin
eroding confidence in this w,ork as soon as possible"
(H\z.ang 1998).

  A British-American Tobacco Company memo
from lY88 details a meeting at which Philip Morris
unveiled its plans to organize the "selection, in all pos-
sible countries, of a group of scientists either to criti-
cally re\,ie\v the scientific literature on ETS to maintain
controversv, or to carry out research on ETS. In each
countrv a group of scientists lvould be carefully se-
lectecl,-and organized by a national coordinating sci-
entist" (Boyse 1988, p. 2). The Philip Morris plan begins
by draining up a list of "European scientists wrho have
had no previous association with tobacco companies"
(p. 2). The scientists are then contacted and

asked if they are interested in problems of Indoor
Air Quality: tobacco is not mentioned at this stage.
CVs are obtained and obvious "anti-smokers" 01
those M.ith "unsuitable backgrounds" are filtered
out. The remaining scientists are sent a literature
pack containing approximately 10 hours of


reading matter, including "anti-ETS" articles. The\
are asked for a genuine opinion as independent
consultants, and if thev indicate an interest in pro-
ceeding further a Philip Morris scientist makes
contact. Philip Morris then expects the group of
scientists to operate ivithin the confines of dcci-
sions taken by PM scientists to determine the gen-
eral direction of research, r\,hich apparentI\. \I-ould
then be "filtered" L7y la\vyers to eliminate areas of
sensitivity (p. 3).

   As this obserlw notes. "Although the industr\. is
in great need of concerted effort and action in the, <TS
area, the detailed strategv of Philip Clorris lca\ es smm-
thing to be desired. The escessi\.e iii\-ol\~emcnt of cx-
tvrnal law,vers at this \-er\' basic scientific Iv\.el i>
questionable" (Boyse lYW,`p. 27-l. Chapman (IWT)
has described this 198X memo as one that "pr~~mi5e.s to
blo\v apart the facade that the tobacco industr\ carries
out neutral research into passi1.e sniokins" (p. I S6Y).

  A study published in Ma\- IYYK in tht> /~~1/~.~~111 cli
t//c ArrwriiIT,! -Mdiid .-\~sclillllj~ll,-(Bdl.nt"; and Bern 1 `NX)
concluded that of the 31 percent (3`) out of 106j oi ar-
ticles re\.ie\ved that concluded that ETS is not harmful
tn health, 7-l percent (2Y out of 39) of these \\ere \\.ritten
by authors ivith tobacco industrv affiliations. In this
surve!; the authors included articles \vhose stated or
implied purpose \zas to re\-ie\\- the scientific cx.idencc
that ET5 is associated mith one or more health outcomes.
rirticles were excluded if thev did not focus specificnll!~
on the health effects of ETS or if thev \sere not \vritten
in English. The authors noted, "In Inultiple logistic rc-
gression analvses controlling for article qualit!; ptw
revierv status,-article topic, and year of publication, the
0nlv factor associated ivith concluding that paisi1.c
smoking is not harmful leas Lvhether an author \j'as
affiliated \vith the tobacco industrv" (p. 1566). The au-
thors also found that the "conclusi& of re\.ie\v articles
are stronglv associated with the affiliations of their ELI-
thors. Authors of re\ie\v articles should disclose pu-
tcntial financial conflicts of interest, and readers should
consider authors' affiliations i\,hen deciding ho\z. to
iudge an article's conclusions" (p. 1366).

Other Idusty-Syorrsored Oyyositiolr to Stntc
Tobacco Control lllitiativrs lzmi Advocates

  Tobacco interests have used the courts
proactively against other measures to prel'ent smok-
iilg. The proliferation of third-rvnve litigation against
the tobacco industry has been matched by a more ag-
:$essive use of litigation bv tobacco interests. For VY-
alnjple, the industry and iis allies filed a prccmpti\-t`
~lldllenge, on state constitutional gro~~iids, 10 the

  Arguably,, the most s\veeping litigation measure
taken by, the tobacco industry ~vas initiated on August
IO, lYY?, \vhen Philip Morris and others filed suit to
block the FDA from regulating the sale, promotion, and
distribution of cigarettes to minors. Discussed earlier
in this chapter (see "Further Regulatory Steps"), the
suit challenged the agenc\r's authorit\ to regulate ciga-
rettes under the Federal Food, Drug, and Cosmetic Act.
The la\rsuit further charged that the proposed regula-
tions \vould violate the tobacco companies' freedom
of speech and xvould impair their ability to compete
(Collins lYY5b).

  Tobacco companies ha\,e also used litigation tac-
ticdllv to iimpede the flon- of darnaging information.
Bro\v~n & Willianxon Tobacco Corporation brought suit
against a paralegal aide accused of stealing confiden-
tial and potcntiall~~ incriminating documents ilVj/flft,
Torrilrlf & COIII~S 7'. h'ilh7777s, 8Y2S.W.2d 5X4 [Kv. lY%]).
The documents, scxme of xhich w'ere ultimately ob-
taintvl Lx. members of Congress, ha\ t` sho1z.n that the
tob,\ic~~-m,,nui,lc~tu~-t'r~ not c~nlv knc\v of both the
addiiti\,tx and the ial-cino;gtwic prc~yerties i>f t<jbacco


use but also concealecl the e\-idencc for decades
(Shapiro lYY1b). R.J. Reynolds brought suit (R.1.
Rqrwld~ Tr)lwrrc~ Ccl. il. /O/J~T DOPS, Y5-CVS-5867 [N.C.,
Forsyth Cty. 19941, iitc~rl ill 9.4 TPLR 2.95 [lYY4]) to stop
the solicitation of damaging information from tobacco
insiders (Nntior~nl Ll7w IOUUI~T! 1991). In March 1994,
Philip Morris filed a $10 billion libel suit in Virginia
circuit court against the American Broadcasting Com-
pany (ABC) tele\,ision net\\-ork, a reporter, and a pro-
ducer of the network's magazine program 017,p OIIC,.
The suit concerned a broadcast segment that focused
on Philip Morris' chief competitor, R.J. Reynolds To-
bacco Company, and that accused R.J. Reynolds (and,
in effect, the entire tobacco industry) of increasing the
levels of nicotine in cigarettes to cause addiction among
smokers (Chamberlain 1994; Janofsky lY94b). R.J.
Reynolds subsequently filed a similar suit. In August
1995, after a siege of unusually aggressi\,e disco\,ery
(Frankel lY95), ABC agreed to apologize for its "mis-
take" in accusing the manufacturers of "spiking" nico-
tine and to pay for Philip Morris' legal expenses,
reportedlv some $15 million (Freedman et al. lYY5).
ABC preferred to avoid the rigors of further litigation
e\`en though "the nettvork's onn la\\-yers felt they had
a 65 percent chance of lvinning the case" (Landler
1995). Philip Morris subsequently took out full-page
advertisements in the New firrk i'?rrft?, Wl75/JiJJ$tOJJ fosf,
Wr?I/ St,cct /wr.,wl, and other nelvspapers, proclain-
ing ABC's capitulation. That Philip Morris chose to
respond to the nelzs report rvith legal action, rather
than mounting an aggressi\,e ad\w-tising campaign as
it has done in the past, is seen as reflecting the
company's decision to turn o\.er responsibilitv for
public relations to its la\v);ers (Landler 14%).

  Tobacco companies ha1.e hea\,ily funded organi-
zations that oppose smoke-free 1aIvs and policies. The
National Smokers Alliance (NSA), for example, pur-
ports to be a membership organization on behalf of
smokers. When NSA's Senior Vice President Car\
Auxier ~vas asked M.hy his organization, rvhich boasts
that it is "a nonprofit, grass-roots membership organi-
zation ivith more than 3 million members," in fiscal
vea;- 1996 collected only $71,000 from dues (enough
ior 7,100 members) \j,hile its total receipts lvere more
than $9 million, Auxier chose not to ans!ver (Leek
1998). The NSA has vigorously attacked the smoke-
free bar la\v in California, including publicizing bar
ow'ners lvho ha\.e engaged in ci\-il disobedience (PR
Ne\cs\vire 1998b). Regarding this and other media-
attracting actions, Morain (1998) points out, "Assist-
ing that group is one of the world's largest public
relations firms, Burson-Marsteller. The company has
a long-standing account writ11 the tobacco industrv and

is renoivned for its ability to generate news coverage.
As the organizers tell it, they're merely tapping the
grass roots of the body politic, giving a voice to every-
day people. Opponents deride the [supposed grass-
roots] campaign as `Astroturf' " (p. A23).

  In opposing a lawsuit based on harm from ETS,
Philip Morris tried to subpoena scientific researchers'
raw data that support epidemiologic research on the
link bettveen ETS and lung cancer. A state judge re-
jected the company's attempt to get the raw data, citing
a 1990 Louisiana privacy law. The court found that "en-
forcement of the subpoenas would leave the research-
ers with the knowledge throughout continuation of their
studies [that] the fruits of their labors had been appro-
priated by and were being scrutinized by a not unbi-
ased third party whose interests were arguably
antithetical to theirs" (Iu w Pl~ilip Morris I)Jc., 706 So. 2d
665, 1998 La. App. LEXIS 138 14th Cir. Jan. 28, 19981).

  One important industry tactic is to attack the in-
tegritv of leading tobacco control researchers and ad-
vocat& (Sweda and Daynard 1996). For example, a
group called Californians for Scientific Integrity (CSI)
sued the University of California in 1997, in part, over
Dr. Stanton Glantr's 1994 study on the economic im-
pact of smoke-free restaurant laws. Public officials
around the country have used that study to support
passage of clean indoor air laws in their cities and
tol+w. Funded by the NSA (Sullivan 19971, the CSI
lawsuit alleged that public funds were used improp-
erlv in supporting the study. Earlier in 1997, the NSA
had paid SlO,OOO to Michael Evans, clinical professor
of managerial economics at the J.L. Kellogg Graduate
School of Management at Northwestern University, to
kvrite a report that attacked the Glantz study on smoke-
free restaurants (Price lYY7). In November lY97, Sac-
ramento Countv Superior Court Judge Joe S. Gra)
dismissed the CSI la\vsuit, saying that "there M'ere no
grounds for the case " (Weinstein 1997%). A lawyer for
the university \\-rote in a brief that led to the dismissal
that the "true agenda of this action was patentlxr
ob\,ious-to muzzle scientists lvhose research publi-
cations and speech on subjects relating to tobacco, to-
bacco control and the politics of tobacco have been a
thorn in the side of the tobacco industry for decades"
(Weinstein lYY7b).

lrlrlzrstr?/-Spolrsor~~ Litigation Agnirrst Local
Tohcco Control Efforts

  The tobacco industry has used litigation, as ~vei
as the threat of litigation, to try to thwart local mea
sures to reduce tobacco use. Forexample, R.J. Reynold
Tobacco Company financed a 1991 larzrsuit filed by Ic
cdl restaurant wvners in Puyallup, Washington (Suttt


Anticipatory Effects
  La\\. \\-orks not only by coercilre imposition but
also bv signals about authoritati\,e (and potentially
ch~~ngeable) norms and about the potential disposition
of legal coercion. Litigation may have an effect not
onl\. cw those \vho are parties to it but also on other
p&ntial legal actors (plaintiffs, defendants, and at-
tome! s \\.ho learn about the litigation) (Galanter 1983).
Dt>ptmding on the outcome of a litigation, similarly
situ~ilted injurd parties, for example, may abandon or
mcdih-or con\-ersely, inay decide to continue-their
ri5h-cl'edting beha\.ior or may be either encouraged to
make ~~ Iq+il claim or discouraged from claiming. Law-
I crs ma\ be encouraged to mount or discouraged from
&ountii;;: claims or defenses. Unin\,olved actors (such
ds pi>tcn&l business partners) 1~1~0 anticipate dealing
11 ith parties or potential parties may respond to liti-
CT ition signals b\, mdif\ing (or e\`en terminating) their
h`
dc,ilin;ls \\.ith those parties. Such signals may be de-
r-i\ cd not onI\- from ,iuthoritati\.c decisions but also
frc>m the pro&s of the litigation itself, Lvhich may ex-
hibit ad\.antages to be gained or costs to be a\,oided.
For example, iie\\`s organizations \.ielving the fierce
and e\pcvisi\.e industr\f response to critical depiction
ni;1\. hesitate to yortrav industrv practices negatively
(Fr&dtmnn and Ste\.e& 1995). .
  Xlore often, third-,,,d,.e tobacco litigation pro-
\-ides dramatic e\.idence of the indirect, dnticipatory
effects of litigation on reducing tobacco use. In early
1995, three pron-tinent manufacturers recoiled from
business dealings \vith cigarette makers to avoid the
rish of getting embroiled in liability litigation. The
.M~in\~illc Corporation sued R.J. R&nolds Tobacco
Company for a declaratory judgment that the corpo-
ration does not have a contract to supply fiberglass
for cigarette filters (Appleson 1995). A fexv days later,
Harlev-Davidson, Inc., responding to a 1993 suit by
the Lorillard Tobacco Company to enforce an agree-
ment licensing the rnoforcyclc maker's name for a
brand of cigarettes, countersued, alleging that tobacco
liability risks reduced Lorillard's ability to fulfill
its contract (Rose and Hlvang 1995). Papermaker
Kimberly-Clark Corporation (which had been named
a dct'endant in the West Virginia health care provider
suit), the x4,orld leader in tobacco papers, decided to
sell its cigarette paper business. The company denied
that liability fears or shareholder acti\%m played any
part in its decision, but anal>`sts said that such con-
cerns tvere dominant factors (Collins 199_?a). Other
companies, such ds Pfizer, ha\,e dopted policies "pro-
hibiting units from doing business tlrith Big Tobacco
dnd its suppliws" (Mallory lc)93, p. 39).


  .~llL3tllty set ot ,liti~rs rt5ponsi\ c` to 5ignal5 about
liability arc in3urer5. I'rt5ulllabl~~, \ irtuall!, ,111 of the
suppliers and professionals \\-hco ser\`e cigarette mak-
Cl-S Ccll-n` liaI?ilit!* insurance. Pht? tOhCC0 lll~1lllfZlCtLl~-
crs themsel\.es ha\-e been insured for at least some
liability risle, altllougll the iilllOullt 0t' insurance co\`-
erase of the tobacco companies is unkno\z.n (Reidv and
Carter lYY5). lf an!; of these insured parties are found
liable for promoting or sellin, 0 tobacco products, the
il7t;Llrers ccjil be e\pt~cted to contest Cot erase, using aS
defensty against liability to the insured llldllv of the
same arguments that plaintiffs use to establish the li-
ability of the insured. If, tor example, liability involves
attribution to the industry (It I\llLliVldgc Of a CZlLlSill
link to disease or concealment of that information, then
to defeat col'erage, the insurer ma\' likelvise claim that
the insured had \\~ron#ullj~ and kilo\\-insly obtained
co\-el-agf fL)r J business practice lvhose dangers xvere
concealed from the insurer. "In effect," note tivo ana-
Ivsts, "the insurance industrv L\.ill ha1.e to pro1.e the
\`erv thing the polic\.holder -is trying to deny in tile
tobacco-related suits" (Reid,, andCarter 1995, p. S38).
Thus a "breakthrough" bv tobacco plaintiffs may lead
to a "second front" of liability battles bet\Veen tobaCC0
defendants and their insurers.

  Indeed, in lC)Yh. Imperial Tobacco Limited (No.
j00-05-01~08~-Yh~ [Canada S. Ct., Pro\. of Quebec,
Dist. of Montreal Jan. 12, IYYhl, c-lfc'ti irk 11. 1 Tl'Lli 3.3`1
[ IYY~]) filed suit in the Superior Court of Queb~i
a g a i ii s t  t iv 0 To r 0 ii t 0 - I2 a 5 e d I i d b i 1 i t \' i n 5 u r rl n 5 t'
comy~l~~ies-A~~~erii;ln Home Insuranic Cr)mpan\,
and Commercial Union Assurance Cornpan\, of
Cai7ada-demandi~~~ that the!. pa>' legal CO~tS~dllcI
any damages arisin;; from a clays action suit filed
against Imperial in Ontario b\. \,tr. Da\-id CapLIt<) and
three other persons in IYYj. The Canadian class I1c-
tion suit, \\,hich has not Fct beell resol\-ed, See!+ ~ldlll-
ages on behalf of nicotine-acidicted persons \t.hr-, ll~l\Y
suffered because of their addiction to nicotine. lrnpe-
ria[ claims to ha\.e hacl policies issued b\, the insurers
obligating them to reimburse Imperial for ICgdl i,)StS
incurred in the class action and to pa\' dll\' turther cost4
thev may incur in this matter. The tobacco compan!.
is, in essence, asking the Superior CoLlrt of QLIebec ford
declaration that the ti\-o named insurance companies
must pav all of Imperial's It,`
              )`711 ices and all SLlI-llS
a,-ardeJ b\i an e\.entual finding of liability b\, the
Olltario co& c fih~ccc~ f'r~~f~rcf~ Lifr;<crficl\r &`/JL~!?c'/~ 11)%b).
  Finally, the investment communit!, is greatly in-
terested in the potential effects of legal liabilit>, 011 the
jLttLil-e profitability and sol\,enc\. of the tobacco COIlI-
patlies. T&~,lcco cases are close]\, tracked bi, ini.est-
ment an,il\,sts, and "t'\.en intcrinl-e\.rnt5 in pi`ripheral

cases can propel share prices in one direction or an-
other" (Orcv 1495, p. 7'0). The overhang of potenti,il
liability cas;s a shadow on tobacco stocks. Opinions
differ about just hovv much these stocks are discountecl
for liability, but there is general agreement that the re-
mo\.al of the liability shadow would be worth man\!
billions in increased stock value. This volatile corubj-
nation of possible liability and latent value means that
any breach in the previously impregnable liability,
ramparts ~~oulcl inaugurate a period of pronounccci
instability among tobacco investors. Some analysts
imagine a zone of agreement that would locate a com-
prehensive settlement, which would in turn unlocl\
the unrealized value of tobacco stocks while provid-
ing generously for the victims of tobacco. Howetrer,
because present litigants cannot preclude future
plaintiffs, it remains unclear whether litigation can
provide the finality and closure that a comprehen-
sive settlement would require. Litigation can set off
ramifying effects and in general advance a formerlk
sluggish or obstructed state of affairs, but it is not
clear whether it can contain these effects or design
an all-encompassing resolution or policy.

Criminal Proceedings

  Another arena in which attention is being given
to the acti\,ities of the tobacco industry is the criminal
justice system. Since lYY5, the C.S. Department of Jus-
tice has conducted an ongoing investigation of the al-
lt>ged \.ioIation of federal criminal laws by tobacco
companies, tobacco company executives, tobacco
inclListr~-sLlppclrted trade and scientific associations,
and other entities that have conducted business M'ith
the tobacco industry.

The Justice Department initiated a formal in\,es-
tigation of the tobacco industry in response to the fil-
ing in 1YY-l of a comprehensil~e legal analysis, referred
to as a prosecution memorandum, by Representative
Martin T. Meehnn (D-MA) kvith the U.S. Attorney Gen-
eral (t-lohler 1YY-I; Mallory 1991, 1993; Meehan lY91;
Schlvartz 1c)Y-l; Miga 1995; Reuters 1996; Rodriguez
and Taylor lYY8). The prosecution memorandum pe-
tition& the Justice Department to consider allegations
that tobacco companies, tobacco company executi\.es,
and others had \.iolated multiple criminal la\vs by pro-
\-iding false information to the FDA and the U.S. Sur-
geon General (18 U.S.C. section I001 ), committing
perjury- in testimony before Congress (18 U.S.C. sec-
tion IQ1 ), perpetrating mail and \Vire fraud (18 ti.S.C.
sections 1341 and 1313, respectix.ely), engaging in de-
cepti1.e ad\.ertising practices (15 ti.S.C. section 52), and


\.iolating federal conspiracy and racketeering law,s (18
L .S.C. sections 371 and 1962, respecti\.ely) (Meehan
1994; Shane 1997; Cor/70r0f[~ Crirlti, Rf~prff~r 1998;
Clifford E. Douglas. The criminal in\,estigation of the
tobacco industry. Speech to the 13th Annual Confer-
ence of the Tobacco Products Liabilitv Project; Mav 31,
                             -
1998; Boston; unpublished data).

Nature, Extent, and Focus of the Criminal
Investigation

  The Justice Departmtnt'q in\.estigation began `as
a preliminar~~ inquire focused on nlleg?d perjur\. ari>-
ing out of testimonv deli\ wed under o;lth b\, Se\.t'tl
:obacco comp nv execu tiws l\,ho stated before a con-
gressional subc&mittee on April 14, 1994, that the\,
did not believe that nicotine is addicti1.e. The initi;ll
inquirv was later expanded to a formal grand jurv in-
\.estigation to address broader allegations that tobacco,
companies had, among other things, \iolatcd 1 S L .L;.C.
section 1001.

  Section 1001 prohibits the making ot f,3lsc stc3tc-
men& to agencies and officials of the federal go\.erii-
ment (Hilts 1995; Novak and Freedman 19Y5; Appleson
1996; Blum 1996; Freedman 1996; Thomas and
Sch\vartz 1996; Stohr 1 YY7). In contrast to the le\,cl of
proof required for a she\\-ing of perjur); section 101) 1
does not require a sho\2%ig that a person ktio\vingl\r
lied under oath. It alsoallo\vs prosecution for the witI;-
holding of information. Besides addressing potential
section 1001 \riolations, the in\,estigation continues to
focus on other allegations of criminal conduct, includ-
ing fraud, conspiracv, and racketeering (Cole and Tay-
Ior 19%; Car-pwatr Ct'irw Rcprfcr 1998; Da\,is and Duff!
1998; Douglas, unpublished data; Duffy and Taylor
1998; Meier 1998~).

  As of mid-1998, txvo federal grand juries \vere con-
sidering evidence of alleged tobacco industry \vrong-
doing. One grand jury was assigned to hear evidence
presented by prosecut& from the Fraud Section of the
Justice Department's Criminal Division regarding the
broad allegations of criminal misconduct described
abo\,e. The second grand jurv \\`as assigned to review
information presented bv the b.5 attornev for the East-
ern District of Ne\v York: The \vork of thesecond grand
jury concerned a related criminal in\Testigation Lvhose
focus is an alleged conspiracy by major tobacco manu-
facturing companies to suppiess legitimate medical re-
search and promole biased research through the
itldustrv-sponsored Council for Tobacco Research. The
Justice department coordinated these complementar);
investigations (Cohen and Gevelin 1996; Thomas and
Schrzartz 1997; Da\,is and Duf;v 19%).

  A third criminal investigation was begun in 1995
to determine \vhether a major cigarette manufacfur-
ing company may have committed securities fraud by
failing to disclose all it knew about nicotine. Under
securities lal\-s, companies are required to disclose sig-
nificant information that may affect their stock price.
The third in\.estigation was initiated by the U.S. attor-
ney for the Southern District of New York, following
the publication of an investigative news article that
reported that, based on a revie\\r of 2,000 pages of pre-
\-iwtsl\, undisclosed documents, Philip Morris Com-
panic; Inc. had conducted many years of secret
rescarih into the pharmacologic effects of nicotine on
the hut31~3n brain and central nervous system (Freed-
man and Lambet-t 1995; Hilts and Collins 1995). The
securities frc3~td in\.estigation subsequently was con-
\olidated \\.ith the main Justice Department investi-
gation (Philip Morris Companies Inc. 1998).

  Federal prosecutors have interviewed witnesses,
compiled comprehensi\-e company dossiers, and is-
suej subpoenas, all under the supervision of the U.S.
.Attorne\. General. Selw-al of the major cigarette manu-
tdituriiig iomptiies, such as R.J. Revnolds Tobacco
Cornpan!. and Philip Morris Companies Inc., as well
as others, confirmed publicly that they are the subject
of Wet-al criminal investigations relating to the mat-
ters described abo1.e and that employees of the com-
panies ha\,e recei\.ed requests for information,
including orders to produce internal documents and
subpoenas to testify before the grand juries (Goshko
1995; Hilts 1995; Miga 1995; Associated Press 1996a,b;
Bloomberg Business Nexus 1996a,b; Federal Filings-
Do\\ Jones Nc\z,s lW6; Johnston 1996; Jones 1996;
Reuters 1996: Thomas and Schwartz 1996; Tribune
Ke1z.s Ser\,ices 1996; Weiser and Schwartz 1996; Shaffer
1997; Philip Morris Companies Inc. 1998).

  In an April 1998 announcement that it had
reached a cooperation agreement with a cigarette
manufacturing company in support of the criminal
in\,estigation, the Justice Department identified five
main subject matter areas on which it was focused (U.S.
Department of Justice 19%). These were industry
kno~~ledge of the health consequences of smoking
cigarettes and the addictive nature of nicotine; the tar-
geting of children and adolescents by the industry; the
manipulation of nicotine by the industry; control of
research by the Council for Tobacco Research, includ-
ing special projects conducted under the auspices of
the council; and la\v);er involvement in directing re-
search or crafting false or misleading statements by
any of the tobacco ckmpanies to the Congress, the FDA,
and the American consumers concerning the above.


  The announcement ot the cooperation agreement
leas interpreted by legal experts as a sign that the crimi-
nal inr,estigation \vas accelerating and the Justice De-
partment \vas likely lo file broad conspiracy charges
against major cigarette companies in the future (Cole
and Taylor 19%; Cor/wrufv Crir~rc Rqwrfcv, IYY8; Dou-
glas, unpublished; Duffc and Tavlor IYYK; Keil 1YY8;
Lwin and Ostrotz. 1998;~Sch~vart; 1998a).

Key Sources of Evidence

  The gathering of evidence by the Justice Depart-
ment was advanced by the increased availability of an
array of outside resources. These included the results
of the exttnsi\re in\,estigation of the tobacco industrv
conducted by the FDA from 1991 to 19%. The FDA's
administrative record and investigative files lyei-e
made al.ailable to the Justice Department, pro\.iding
prosecutors and in\.estigators w.ith a significant hod!
of information concerning tobacco manufacturers'
knowledge of the addicti1.e nature of nicotine and of
the manipulation and control of Ihe substance (Fc~l~~r-~rl
RC~ijff'f 1995b, lYY6).
I
  Another important source of information for JUS-

tice Department officials \vas the \.oluminous hearing
record procluced o\.er a l&month period in IYYJ bv
the Subcommittee on Health and the En\~ironment &f
the Committee on Energy and Commerce in the U.S.
House of Representati\.es (19Y5a,b,c,d). The subcom-
mittee, chaired bv U.S. Representati\,e t-lenr!, A.
Waxman (D-CA), yield numerous hearings in \\.hich
testimony \vas obtained from a \-arietv of ~vitnesscs,
including the commissioner of the FDA, other federal
government health officials, experts in nicotine addic-
tion, tobacco company representati\ es, and former
tobacco company scientists, among many othc23. In
addition, Representative lVaxman made available bun-
dreds of prer-iously secret nicotine research docume:i ts
from the largest cigarette manufacturer by reading
them into the public record on the floor of the House
of Representatives in Julv 1995 (Associated Press 1995;
C~~)~gw.ssio,lr~/ RrTiclr[l lYY%a,b; Schlz-artr lY)c)5).

  A third significant source of e\,idence in suppwt
of the Justice Department's criminal inx~esfigation
lvas the emergence of internal tobacco companvhx-
ments and testimonv obtained in pri\,ate lal\.suits
brought against tobacco industry defendants. Start-
ing in 1994, these civil cases xvere initiated by state at-
torneys general, private classes of allegedly addicted
and injured smokers, and individual plaintiffs, as de-
scribed earlier in this chapter (see "The Third Wa1.e of
Tobacco Litigation"). The simultaneous litigation of
numerous civil suits and the Justice Department's

pursuit of its criminal investigation have produced a
notable synergy. Millions of pre\riously undisclosed
tobacco industry documents that were obtained
through the discovery process in civil lawsuits became,
in many instances, readily accessible to federal pros-
ecutors (Curriden and Rodrigue 1997; Geyelin 1998;
Meier 1998~; Rodriguez and Taylor 1998; Scherer and
Ryba k 1998; Schwartz 19%~).

Initial Results of the Criminal Investigation

  The Justice Department's ongoing investigation
resulted in a first conviction in 1998. Under the terms
of an agreement with the government, a biotechnol-
ogv company, DNA Plant Technology Corporation,
pliaded guilty to a misdemeanor charge of conspir-
ing to break a law that had made it illegal to export
tobacco seeds. The company was found to have cl>-
gaged in such unlawful conduct in cooperation with a
leading cigarette manufacturing company, identified
as an unindicted coconspirator, with whom it had
contracted to patent and develop a genetically altered
tobacco code-named k-l, M-hich contained appioxi-
mately twice the nicotine of ordinary tobacco. Accord-
ing to the Justice Department, the prosecution
memorandum submitted by Representative Meehan,
and the FDA, one of the goals of the cigarette con-
pany in conspiring with the biotechnology company
~\`as to de\,elop a reliable source of supply of high-
nicotine tobaccos that could then be used to control
and manipulate the nicotine levels in several popular
cigarette brands (Meehan 1991; Failers/ Rqi.sfcr 1995b,
1996; Meier 1998d; Neergaard 1998; Schwartz 199Pb;
Schn'artz and Connolly 1998; Taylor 1998; Taylor and
Rodriguez 19%; Weinstein 1998b).

  Beginning in 1997, the threat of criminal liability
led certain individuals associated lvith the tobacco in-
dusty, such as Thomas S. Osdene, Ph.D., former Di-
rector of Research for Philip Morris Companies Inc.,
and Roger R. Black, current Director of Leaf Blending
for Bran-n & Williamson Tobacco Corporation, to
decline to anslver questions under oath, choosing
instead to invoke the Fifth Amendment right against
self-incrimination (Gevelin 1997; Meier 1997; Weinstein
1997a; Anderson 1998). Some officials sought immu-
nity from prosecution in exchange for their coopera--
tion. Such offers \vere met with mixed responses from
the Justice Department. Typically they were rejected,
but in one publicized instance a request for immunity
\vas granted (Geyelin 1997; Stohr 1997; Weinstein
1997a). The Justice Department granted immunity to
Janis A. Brax.0, a scientist formerly with DNA Plant-
Technology Corporation and coholder of the patent for


a high-nicotine tobacco plant called Y-l, del,eloped for
Bro~-n & Williamson Tobacco Corporation.

prognosis for Future Actions Through the Criminal
Justice Process

  Federal prosecutors possess considerable discre-
tion both in terms of bringing charges against alleged
r2-rongdoers and, in the t\rent a strong case is dew-
aped, in seeking concessions from criminal targets in
the plea-bargaining process. In light of these options,
the Justice Department may seek to require tobacco
manufacturing companies to modify their ad\,ertising
ancl marketing practices so as to render them unap-
pealing to young people, stop manipulating nicotine
or using nicotine-enhancing chemicals, pay the fed-
eral government significant monetary penalties, and
submit to regulation by the FDA (C~/X~JX~~~ C~irlw RI,-
IwrYtlr 1998; Douglas, unpublished data ).

  Gi\ren the breadth and complesity of the crim-
nal investigation of the tobacco industry, as \vell as the
substantial burdens of proof that prosecutors must
satisfv pursuant to the federal criminal statutes noted
abov;, it is not possible to predict the outcome of the
current criminal investigatik.e process. From its incep-
tion, the investigation \vas anticipated to be a lengthy,
complicated operation, in part because of the
government's responsibilitv to process and re\.itw
millions of pages of documents obtained from the to-
bacco industry and other sources (Thomas and
Schwartz 1996).

  With the Justice Department's accumulation of
a growing bodv of evidence, including company
documents and-grand jury testimony, as well as the
cooperation of the Liggett Group Inc. in support of
the government's investigation, some legal experts
have described the investigation as likely to result in
further action (Cole and Taylor 1998; Cor/~or,atc CrirlltT
Reporfr~ 1998; Douglas, unpublished data; Duffy and
Tavlor 1998; Keil 1998; Levin and Ostrow 1998;
Schwartz 1998a). One recent indicator that the issu-
ance of indictments might be near was the delivery
by Justice Department officials of letters to Brown &
Williamson Tobacco Corporation and its officials, for-
mally notifying them that they are the targets of a
criminal investigation and that they face possible
prosecution (Davis and Duffv 1998; Meier 1998~; Milrll
                       '
Stwrf ~ollrr?n/ 1998).

  Further criminal action against the tobacco in-
dustry also raises the likelihood of diluting the influ-
ence of the industry's political lobby, thereby
strengthening the abilitv of public health proponents
to advocate for more `stringent regulation of the

manufacture, sale, distribution, advertising, and pro-
motion of tobacco products (Douglas 1998).

Comment

  After 40 years in lvhich two waves of product
liability litigation proved unavailing, there has been a
recent upsurge of in\,estment and innovation in to-
bacco litigation. This third \vave of litigation departs
from its predecessors in various wavs:

. It mo\`es away from exclusi\,e reliance on smokers
as plaintiffs, because so many cases have been de-
cided against them as the victims of their own, in-
formed behavior choices. Plaintiffs now include
states, cities, pension funds, priaiate health care pro-
\,iders, and persons exposed to ETS, none of whom
can be blamed for smoking in the face of warnings.

o It multiplies the range of legal issues. Instead of
focusing exclusively on common-law tort doctrine,
third-\va\~e litigation also invokes various statutory
claims under consumer, antitrust, and other pro-
tecti1.e legislation.

o It expands from the classic private lawsuit by a dis-
crete plaintiff to the class action device.

o It expands from solely seeking monetary damages
to including claims for injunctive relief, medical
monitoring, and the recovery of attorneys' fees.

o It shifts from a pure model of private law to mixed
strategies in lvhich private law is used to effectu-
ate public policy by defending public fiscal inter-
ests and by enhancing the performance of statutory
and regulatory controls of tobacco.

.

It enlarges the roster of claimants' lawyers from
those M'ho specialize in representing individual
plaintiffs in personal injury cases to include mass
tort specialists and entrepreneurial securities class
action 1aMyers. These attorneys, who typically
practice in larger firms than individual plaintiff at-
torneys and have greater financial resources, are
joined in more complex coalitions, including alli-
ances M'ith government lawyers.

  Considerable uncertainty surrounds each of the
several third-wave litigation initiatix-es and their
potential contribution to reducing tobacco use. The
prospect of using private law in these ways has cap-
tured attention only recently. In a wide-ranging 1993
revie\\, of tobacco policy (Rabin and Sugarman 1993),
virtuallv all of the attention to private law was devoted


to smokers' product liability litigation. The ne\ver le-
gal theories that are no~v a\.ailable to plaintiffs have
considerable potential. Just ho\~ these initiatives will
fare depends both on developments within the legal
system and on forces outside it.

  Normally, la\z incorporates and reflects public
opinion. In a setting Mhere smoking declines and be-
comes disreputable, particularly among the educated
and influential (Zimring lYY3), where smokers are in-
creasingly \,iewed either as victims of coercion and
addiction or as a minority group becoming more dis-
tanced from others (Gusfield lYY3), and where evi-
dence accumulates that the tobacco companies
aggressively recruit new smokers and suppress knowl-
edge of harmful effects of smoking, the law can be ex-
pected to respond to pressures to extend accountability
and to provide remedies, if not to smokers then to those
who are otherwise adversely affected by smoking.

  However, other forces are working against an
enlarged role for the civil justice system in the effort to
reduce tobacco use. Important groups, displeased with
the expansion of legal accountability, hai.e mounted a
protracted and influential campaign to curtail the civil
justice system and \\Teaken the position of claimants
within it (Galanter 1993, 1994). Apart from these ex-
ternal constraints, the \Tery magnitude of tobacco
injurv-the vast number of potential claimants
involved-raises apprehension about the courts' in-
stitutional capacities to respond. Driven by the desire
to conserve their scarce resources, courts \vill find \vavs
to ration the judicial attention bestolled on any &
able set of related cases (Sanders 1992). As the size of
the potential victim class increases, the chances tor
individualized judicial resolution clecrease. It has been
argued that the litigation about Agent Orange, the

Conclusions

Bhopal disaster, and asbestos-related injury should be
viewed as instances in which the sheer number of
claims "simply overwhelm[edl the capacity of legal
institutions to meet victim compensation needs" and
led to improvisation of formulaic administrative solu-
tions (Durkin and Felstiner 1994, p. 159; cf. Henderson
and Twerski 1991, on judicial aversion to such mas-
sive projects).

  A balanced assessment of the possible contribu-
tion of private law initiatives to the effort to reduce
tobacco use must consider not only the costs and ben-
efits of the various initiatives but also the likelihood
of accomplishing similar results by other institutional
means (Komesar 1994). Typically, private law involves
high transaction costs (Galanter 1994). Private law is
by definition the creature of independent actors whose
operations are not centrally managed and are at most
partially and intermittently coordinated; each actor is
trying to maximize its own gains as it defines them.
No single initiative or the sum of such efforts will nec-
essarily produce an optimal policy to reduce tobacco
use. Yet private law may be a valuable component in
reducing tobacco use precisely because it is an arena
in Mhich multiple courses of action are advanced bv
energetic champions who are open to new ideas ani
~.ho, independent of government, can undertake in-
novative and even risky initiatives without securing
official approval or competing for priority with other
political commitments. Such initiatives may thus be
able to stimulate and shape policy solutions. Other
than as an agent or catalyst, however, it seems unlikely
that the judicial forum, in a setting involving politi-
calls powerful actors and an unpredictable number of
inclioate future claimants, will itself provide the ulti-
mate policy resolution.

Aduertisiug and Promatiou

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

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

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


Product Regdrztiorr

Minors'Access to Tobacco

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

7
-.  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.

3.  Because cigarettes \vith 10~. tar and nicotine con-
  tents are not substantiallv less hazardous than
higher-vield brands, co&umers may be misled
by the implied promise of reduced toxicity un-
  derlying the marketing of such brands.

4.  Additives to tobacco products are of uncertain
  safety Cohen used in tobacco. Kno\vledge about
  the impact of additi\,es is negligible and lvill
  remain so as long as brand-specific information
  on the identitv and quantitv of additives is
  unavailable. .

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

Clear1 indoor Air Regulation

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

? -.   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.

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.

I.   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
  \2Then revocation of the license is a provision of
   the 1aM.

3 -.  The effect of reducing minors' access to tobacco
  products on smoking prevalence requires further
   e\,aluation.

Litigation Apyronches

1.  Tlz-o historic \vaves of tobacco litigation were ini-
  tiated by private citizens, were based largely on
  theories of negligence and implied warranty, and
   17ere unsuccessful.

7 A.  A third \va\`e 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 un-
   resolved.

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.


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Janofsky M. Mississippi seeks damages from tobacco
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Kann L, Kin&en SA, Williams BI, Ross JG, Lowry R,
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Levin M. Smoker group's thick lvallet raises questions;
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Lo\\,ell AM. Cipollone 1.. Liggett Group, Inc.: the ef-
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MacLachlan C. Cigarette makers claim gain in court.
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MacLachlan C. Help wanted for Mass. tobacco suit.
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MacLachlan C. Questions abound for tobacco jury.
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Mon@ni P. X.1. Rty7ol~s Tohncco Co., 7 Cal. 4th 1057,
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Mnryla~zil Rqister. Title 09. Department of Licensing
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Mns Tort Lifipticul Re/~orte~ Tennessee court consoli-
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Meehan M. Letter and prosecution memo from Con-
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Meier B. Tobacco company subject of investigation
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Mcfrormfi~, hc. ~1. City c!f.Sm Diego,453 U.S. 490 (1981)

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Wynder EL, Hecht S, editors. Lzlrr~ Cnrrcer. UICC Tech
nical Report Series. Vol. 25. Workshops on the Biolog
of Human Cancer Report No. 3. Geneva: Internation:
Union Against Cancer, 1976.

Young JC, Robinson JC, Rickert WS. How good are th
numbers for cigarette tar at predicting deliveries c
carbon monoxide, hydrogen cyanide, and acrolein
]ourtud of Tmirology md EtnGmwttwfal Henlfh 1981;7(5
801-8.

Zimring FE. Comparing cigarette policy and illicit dru
and alcohol control. In: Rabin RL, Sugarman SD, ed
tors. Srllokitzg Policy: Low, Politics, rrr~d Culture. NeJ
f'ork: Oxford University Press, 1993:95-109.

Wolyit? ~1. Philip Morris, Inc., No. 96-1781-CIV-KING,
1997 WL 535218 (SD. Fla. Aug. 18, 1997).


Chapter 6
Economic Approaches

Introduction 295

Supply of Tobacco and Tobacco Products  295

Tobacco Price Supports 298
Minimum Prices, Nonrecourse Loans, and Quotas  .iOO
Effects of Price Supports on Market Prices  300
Assessments to Offset Federal Costs of Price Supports  307
Discussion 302

Evolution of the U.S. Cigarette Industry  3Oi7
Economic Implications of Concentrated Tobacco Production  308
High Tobacco Concentration and the Impact of Pre\.ention Policies  308
Discussion  3 7 7
Trade Policy, Tobacco, and Tobacco Products  .i 77
Past Tobacco-Related Trade Polic\z  ,372
Section 301 of the Trade Act of 19>4  3 17
Multinational Trade Agreements ,370
Discussion and Recent De\.elopments 378
Economic Impact of the L.S. Tobacco Industrv  ,320

Effect of Price on Demand for Tobacco Products  322

Studies Using Aggregate Data  32.3
Studies Using Indi\.idual-Level Data 327
Behavioral Economics Studies of Cigarette Demand  3.15
Studies of Smokeless Tobacco Use and Price  33.5
Cigarette Prices and Other Substance Use  336
Discussion 331

Taxation of Tobacco Products  337

Rationales for Tobacco Taxation  338
Historical or Comparative Standard  338
Cigarette Taxes and Cigarette Prices  347
International Tobacco Taxes 345
Discussion 350

Fairness Standard and Optimal Cigarette Taxes  350
Equity, Incidence, and Distribution of the Tobacco Tax Burden  350
Estimates of the Costs of Smoking  352
Theoretically Optimal Cigarette Taxes  353
Cigarette Taxes and Health  355
Tobacco Taxation and Revenues 33;

Conclusions 359

References 360


Introduction

  This chapter revielvs recent research on economic
,ispects of tobacco production and the use of tobacco
products in the United States. Much of the chapter
tocuses on the impact of \.arious go\.ernmentaI
policies related to tobacco. As z\-as the case lvith the
regulatorv effects examined in Chapter 5, the "inter\,en-
iions" recounted here require a broader detinition and
2 different set of measurement tools (see Chapter 1).

Supply of Tobacco and Tobacco Products

  The chapter first considers the suppI\' of tobacco
;1nd tobacco products. The histor\, of tobacco ancl the
wolution of the cigarette industrv in the United States
.ire brieflv discussed. More comprehensi\.c summa-
ries can be found in the 1992 Surgeon General's report
Srlwliirlg (7/1(1 H~ltll i/l flw .+~l~`rii~~; (U.S. Department of
/Health and Human Services [LSDHHS] lYc)2) and in
w-era1 sources cited herein. Tobacco-related suppI\.-
5ide policies are revic\ved in mow detail. In particular,
the tobacco support program is cIowl\- examined, and
rt5 economic implications are discussed. That section
i\ follolved bv a discussion ot the impact of tobacco
taxes and other prevention policies on prices in the
highly concentrated U.S. cigarette markets. U.S. trade
policy relating to tobacco and tobacco products is re-
\ie\Yed, followed by a discussion of the domestic and
international impact of these policies. Finally, the

economic impact of tobacco on the U.S. economy and
its implications for policy are described.

  In the second part of the chapter, economic stud-
ies of the denland for tobacco are reviewed. Although
se\ era1 factors affect the demand for tobacco products,
this section focuses on the effects of tobacco prices (par-
ticularI\~ as they are raised by increasing tobacco taxes)
on demand. Recent econometric and other informa-
tiw studies of the demand for tobacco products are
described. (A more detailed re\.iewr of early studies is
contained in the 19x9 Surgeon General's report RLK'IIC-
iq file, Hb?lf/f c0l75c'ij111'1121'5 of .smbkiry: 25 Yt?nrs of
1'wgw+ [USDHHS lYHY].)

  The third part of the chapter focuses on the most
important economic policv in the campaign to reduce
tobacco use-higher cigarette excise taxes. This sec-
tion re\,ielVs the aIternati\.e rationales for imposing
cigarette and other tobacco taxes, including a histori-
cal or comparati\.e approach, one based on the eco-
nomic costs of cigarette smoking, one focused on the
health benefits of higher taxes, and one based on the
re\.enue potential of the taxes. Discussion of the ap-
propriate Ie\,el of the taxes suggested by each approach
folio\\-s its re\ier\-.

  Tobacco is a truly American plant. The first
kno\ln elridence of tobacco use is depicted in car\.ings
on a Mayan temple in Chiapas, Mexico, that date from
4.~2. 600-900 (Wagner 1971). Europeans \vere first in-
troduced to tobacco in 1492 \z,hen American Indians
presented gifts of the substance to Christopher Colum-
bus. On Columbus' return home, tobacco \\`as intro-
duced to Spain and throughout Europe. Tobacco \%`as
widelv grown bv earlv English settlers in America and
    i
was exported from the colonies to England, Inhere it
\vas reexported to manv other destinations. Colonial
tobacco exports to England grew from 100,000 pounds
in 1620 to 100 million pounds just before the Re\-nlu-
tionary War, making tobacco the single most important

commodity exported from the colonies to England
(Johnson 1984). Indeed, tobacco \vas so important in
some colonies that it M'as sometimes used as the unit
of account (Johnson 1984).

  The high tariffs imposed by England on tobacco
and other imports from the colonies contributed to the
start of the Revolutionary War. In the newly formed
Cnitcd States, tobacco soon became the leading agri-
cultural export commodity. The tobacco industry
play4 a significant part in the U.S. economy of the
19th and earlv 20th centuries. Although tobacco con-
sumption has declined in recent years, it is still eco-
nomicallv important in major tobacco-producing states.


  In many kvays, tobacco is an ideal crop to gro".
It gro\Vs under a \,ariety of soil and climatic condi-
tions and thrives under specific but fairly co~~~n~o~~ cir-
cumstances. The tobacco plant has prodigious leaf
growth yet takes up relatively little field space, and
the financial return for tobacco is both absolutely and
relatively high compared with other agricultural com-
modities (Goodman 1993). For example, in 1993, the
per acre value of tobacco in the United States, 53,780,
was well above the values for other crops (Grise 1995).
Because of these factors, tobacco is grown in more than
120 countries and thus is the most widely grown non-
food crop in the world (cotton acreage substantially
exceeds that of tobacco, but tobacco is grown in about
twice as many countries as cotton is). In the United
States, tobacco is a highly profitable crop for other rea-
sons, including agricultural price supports that guar-
antee relativelv high prices; the availabilitv of loans
from government, or tobacco companies, o; both; the
provision of seed, fertilizer, and other agricultural in-
put from external sources; and export subsidies (Food
and Agriculture Organization of the United Nations
1990). Counter to these proii table arrangements, to-
bacco grooving is relatively labor-intensive, demands
heavy use of fertilizers and pesticides, and often re-
quires the use of fuel for tobacco curing.

  Tobacco is a storable product, and its quality ini-
tially improves with age. After being harvested, tobacco
goes through several steps in a processing course, in-
cluding sorting and grading (according to tvpc and
quality) and curing and drying by \-arious techniques
(including flue, fire, sun, and air curing). Most of this
processing is done on the tobacco farm before the prod-
uct is sold to the producers of cigarettes and other to-
bacco products.

  Several types of tobacco are gr0lt.n in the United
States and throughout the world. Burlev and flue-
cured tobacco, the primarv ingredients in cigarettes,
are the most important of the domestically grolvn types
of tobacco; they account for about 93 percent of total
production (Tables 6.1 and 6.2). Most burle!, tobacco
is grolvn in Kentucky and flue-cured tobacco is gro\zn
primarily in North Carolina. These tlvo states account
for about two-thirds of domestically grolvn tobacco.

  Although several other types of tobacco are
grown in 14 other states, about one-quarter of the to-
tal domestic production is concentrated in Georgia,
South Carolina, Tennessee, and Virginia. Other im-
portant types of domestically gro\yn tobacco include
Maryland tobacco, an important component of ciga-
rettes because it burns slol~ly; fire-cured tobacco,
which is used in snuff; dark air-cured and sun-cured
tobaccos, which are used in chewing tobacco and small

dark cigars; and other types used for cigar leaf (Johnson
1984).

  In 1992, the United States had about 124,000
farms producing tobacco, down sharply from 330,00()1
in 1964 (U.S. Department of Agriculture [USDA]-
1998a). Tobacco was grown on an estimated 644,000
acres in 1999, down sharply from its recent peak of
836,000 acres in 1997. In 1998, tobacco farms produced-
almost 1.5 billion pounds of tobacco at a total value of
approximately $2.7 billion. After inflation is accounted
for, however, the value of domestically grown tobacco
has fallen since 1980. More than 1.4 billion pounds of-
domestically grown tobacco were used in 1998, with
less than two-thirds of this used domestically, while
the remainder was exported (Table 6.3).

  Domestic consumption of domestically grown,
unmanufactured tobacco fell steadily from the 1950s
through the early 199Os, from a peak of almost 1.6 bil-
lion pounds in 1952 to about 900 million pounds in
1993 (Table 6.3). After rising for a few years, domestic
consumption of domestically grown tobacco fell to just
o\`er 900 million pounds in 1998. Declining prevalence
of tobacco use is not the only-or even the main-
factor behind the long-term decrease; domestically pro-
duced cigarettes contain about 35 percent less tobacco
than they did 40 years ago (Womach 1994b). Further-
more, the use of imported tobacco in domestically pro-
duced cigarettes has greatly increased in recent years.
III 1950, the imported tobacco content of domes&call?
produced cigarettes was approximately 6 percent. By
1993, this proportion had risen to about 40 percent.
The increased use of foreign tobacco is partly due
to impro\,ements in the quality of this tobacco, its rela-
tively low price, reduced barriers to trade in tobacco,
and the increased market penetration of lower-quality
generic cigarettes, which include a higher share of im-
ported tobacco.

  The decline in the domestic use of tobacco grown
in the United States has been offset somewhat by in-
creased exports of domestically grown tobacco. HoM':
ever, unmanufactured exports peaked at 765 millioli
pounds in 1978 and have fallen fairly steadily since; in
1998, total exports were 539 million pounds (Table 6.3),
The largest export markets for U.S.-grown tobacco in
recent years have been Japan, Germany, the Nether-
lands, and Turkey (USDA 1998a).

  The combination of declining U.S. tobacco ex-
ports and increased tobacco production in foreign
countries (particularly Argentina, Brazil, Malawi, and
Zimbabwe) has reduced the U.S. share in world to-
bacco exports. In 1960, the United States' share of world
tobacco exports was 27 percent. By 1997, this share had
fallen to 11 percent. Moreover, in 1993, the United State:


Table 6.1. Burlev tobacco woduction and value, 1975-1998

Crop year

1973

1976

1977

1978

1979

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998'

Production
(million lbs.)

   640

   664

   613

   614

   472

   558

   726

   777

   327

   673

   542

   420

   428

   468

   498

   592

   637

   700

   627

   568

   480

   516

   629

   590

Average price    Real price
to farmers      to farmers*
(cents/lb.)      (cents/lb.)

  105.5           196.1

  114.2           200.7

  120.0           198.0

  131.2           201.2

  133.2           200.0

  165.9          201.3

  180.7           198.8

  181.0           187.6

  177.3           178.0

  187.6           180.6

  159.7          148.4

  156.5           142.8

  156.3           137.6

  161.0          136.1

  167.2           134.8

  175.3           134.1

  178.X           131.3

  181.5           129.4

  181.6           125.7

  184.1           124.2

  185.5           121.7

  192.2           122.5

  188.5           117.4

  190.3           116.7

Farm value
(million $)

  675.1

  758.3

  735.6

  805.8

  685.6

  925.7

1,311.9

1,406.4

  934.4

1,264.4

  865.6

  657.3

  669.0

  753.5

  832.7

1,037.g

1,174.7

1,270.5
1,138.6
1,045.7

  890.4

  991.8

1,185.7
1,123.3

Real farm
value*
(million $1

1,254,s
1,332.7

1,213.9

1,235.8

  944.4

1,123.4

1,443.2

1`457.4

  938.1

1,217.0

  804.4

  599.7

  588.9

  636.9

  671.5

  794.0

  862.5

  905.6

  788.0

  705.6

  584.3

  632.1

  738.7

  688.9

*Real price to farmers and real farm value are obtained by dividing the nominal average price and farm value
by the national Consumer Price Index; the average of 1982-1984 is the benchmark.
`Subject to revision.
Sources: U.S. Department of Agriculture 1996,1999a; U.S. Department of Labor 1999.

lost to Brazil its historically dominant position as the
leading exporter of tobacco (Womach 1994b).

  These trends for domestically grown, unmanufac-
tured tobacco have not been observed for domestic pro-
duction of the chief manufactured tobacco product--the
cigarette (Table 6.3). Although total annual domestic
consumption fell fairly steadily from a 1982 peak of 634
billion cigarettes to an estimated 435 billion in 1999, total

domestic cigarette consumption peaked in 1996. The
difference is the result of large increases in the export
of domestically produced cigarettes. In 1985, the
United States exported 58.9 billion cigarettes. Exports
peaked in 1996 at more than 240 billion cigarettes, al-
most one-third of total domestic production in that
year. Since 1996, however, cigarette exports have
fallen, to an estimated 150 billion by 1999.


Table 6.2. Flue-cured tobacco production and value, 1975-1998

Crop year

1975

lYi6

1977

lY78

1979

1980

1981

1982

1983

lYX4

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

199#

Production
(million lbs.)

Average price    Real price
to farmers      to farmers*
(cents/lb.)      (cents/lb.)

1,415

1,316

1,124

1,206

Y74

1,086

1,141

994

855

850

789

667

683

796

838

920

882

901

892

X07

854

897

1,014

815

99.8           185.5

110.1          194.0

117.6           194.1

135.0           207.1

140.0           192.8

144.5           175.4

1

66.3

78.5

T-
i / Y

81.1

71.9

52.7

58.7

61.3

67.4

67.3

72.3

72.h

f-8.1

83.1

85.0

78.6

73.3

59.8

39.3

39.7

36.3

35.0

128.0

126.5

123.0

116.3

111.6

117.7

116.9

107.2

107.7

Farm value
(million $)

Real farm
value+
(million $)

1,412.2       2,624.Y
1,452.Y      2J53.4
1,321.8       2,181.2

1,628.l       2,497.l

1,363.3       1,877.5

1,569.3       1 ,YO4.5
1,903.6       2JIY4.2
1,774.3       1,838.6

1,521.0       1,527.2

1,539.4       1,481.6

1,356.3       1,260.5

1,018.5         929.3

1,083.`)         954.2

1,283.9       1,085.3

1,402.g       1,131.3

1,539.2       1,177.6

1,519.7       1,115.8

1,555.l       1,108.4

1,499.5       lJ37.7

1,370.3         924.6

1,532.l       1,005.3

1,645.l       1,048.5

1,744.l       1,086.7
1,430.o         877.3

"Real price to farmers and real farm \.alue are obtained by dividing the nominal average price and farm value
by the national Consumer Price Index; the a\w-age of 1982-1984 is the benchmark.
+Subject to revision.
Sources: U.S. Department of Agriculture 1996, 1999a; U.S. Department of Labor 1999.

Tobacco Price Supports
  Despite being such a profitable crop, tobacco, like
other C.S. crops, has benefited from agricultural price
supports that have been in place for much of the 20th
centurv. In the lY2Os, before these supports ivere in
place, iobacco cooperatives had formed in various re-

and consequently raise tobacco prices and the inconw
of tobacco farmers. These and other agricultural coop-
eratives were largely responding to the steep reduc-
tions in the prices of tobacco and other agricultur~~L
products during the recession of 1921. The cooper<?-
tives had little success and were eventually disbandcci.

gions in an attempt to control the supple of tobacco


Table 6.3. Selected production and trade statistics for U.S.-grown, unmanufactured tobacco and for

U.S.-produced cigarettes, 1975-1999

Pounds of tobacco* (millions)          Number of cigarettes' (billions)

Actual use

Year

1975

1476

1977

1978

1979

lY8O

lY81

1 YX2

19x3

1984

lY85

I%6

1987

1988

198Y

1990

1991

1992

1993

1 Y94

1993

1996

1997

1998
1999"

*Marketing war, beginning July 1 for flue-cured and cigar lvrappw and October 1 for all other types.
`Calendar ykar. May contain imported tobacco.
hallows for estimated inventory change.
"Preliminary estimate.
`Not available.
Sources: U.S. Department of Agriculture 1997c, 1998a, 199Ya.

  Total
production

2,182

2,136

1,913

2,053

1,527

1,786

2,064

1,994

1,429

1,738

1,511

1,163

1,191

1,370

1,367

1,625

1,664

1,722

1,614

1,583

1,268

1,503

1,714

1,489

1,267

Total

Domestic

  use

1,941

1,907

1,895

1,955

1,869

1,759

1,762

1,663

1,532

1,621

1,620

1,572

1,688

1,565

1,677

1,791

1,616

1,590

1,436

1,604

1,491

1,698

1,494

1,440

.J

1,286

1,229

1,202

1,190

1,175

1,104

1,065

1,034

9.36

Sjj

1,000

981

1,115

1 ,010

1,096

1,163

976

960

898

1,080

958

1,068

962

901

1

Exports

633

hi8

b93

7h5

h9-l

b-l9

h97

628

5%

hh6

620

591

573

---
332

.i82

h31

640

630

538

523

533

630

532

539

  1

Total
production

651.2

693.4

665.9

695.9

704.4

x-l.1

736.5

b94.2

667.0

668.8

665.3

638.0

689.4

694.5

677.2

709.7

694.5

71X.5

661.0

725.5

746.5

754.5

719.6

679.7

635.0

Domestic
consumptio4

  607.2

  613.5

  617.0

  616.0

  621.5

  631.5

  640.0

  634.0

  600.0

  600.4

  594.0

  583.8

  575.0

  562.5

  540.0

  525.0

  510.0

  500.0

  485.0

  486.0

  487.0

  487.0

  480.0

  485.0

  435.0

Exports

50.2

61.4

66.8

74.4

79.7

82.0

82.6

73.6

60.7

56.5

58.9

63.9

100.2

118.5

141.8

164.3

179.2

205.6

195.5

220.2

231.1

243.9

217.0

201.3

150.0


  The price bupport s!,stem came into existence a
decade later. In response to the impact that the 1930s'
Great Depression had on farmers, Congress passed the
Agricultural Adjustment Act of 1933 (Public Lalv 73-
10) to control the supply of tobacco and other agricu-
tural products Lvhose prices had fallen sharplv. The
intent of this and subsequent agricultural price support
programs \vas to support the income of farmers and
stabilize the qunntitv and prices of agricultural com-
modities. These ;>rograms also ga1.e tobacco farmers
some ability to counteract the economic powrer of the
highly concentrated cigarette producers (Warner 1988).

Minimum Prices, Nonrecourse Loans, and Quotas

  The federal program for tobacco price supports
involves specific economic inter\-entions and assis-
tance. To stabilize the price and quantity of tobacco
produced, the program guarantee5 minimum market
prices and establishes marketing quotas. Minimum
(or support) prices are essentially determined by past
tobacco prices adjusted for changes in cost indexes.
When unable to find a pri\.ate buver at a price at or
above the support level, a tobacco farmer is eligible
for a nonrecourse government loan from a local price
stabilization cooperati\.e. This t\.pc of loan a1low.s fol
a commodity, in this case tobacco, to be used as collat-
eral for the loan at the support price. Cnder annual
contracts lvith the cooperati\.es, USDA's Commoditv
Credit Corporation loans funds it has borro\ved from
the U.S. Treasury (in the past, at less than market rates
of interest [Johnson l%-!]). Each cooperati1.c` processes
and stores the tobacco it has recei\,cd as the farmer's
collateral, and the Commoditv Credit Corporation
collects interest on the loan. The cooperati1.e then at-
tempts to sell the tobacco. If the cooperatil-e can re-
cei\ve a price above the support price, the proceeds arc
used to repay the loan, and anv excess receipts go to
the tobacco tanner. This pro&s has created the ap-
pearance that tobacco farmers are not bein;; dircctl\'
subsidized (Johnson 1984).

  Marketing quotas, determined b!r the C.S. Secre-
tarv of Agriculture, are intended to be sufficient to meet
th; domestic and foreign demand for U.S. tobacco at a
price abolre the go\,ernment support price. Originally,
tobacco could be grolvn only on land that had been
assigned a quota, tvhich \vas based on that farm's pro-
portion of tobacco produced lvhen the program IVES
initiated (with a limited amount of new production
allowed each vear). Consequently, almost the onlv rvay
to begin growing tobacco \vas to buv or rent a farm
that had been granted the right to gro\\' tobacco. In
1961, farmers m-ho grerv flue-cured tobacco approved

intracounty lease and transfers of allotments; burley
tobacco farmers followed suit in 1971. For the first
several decades, these quotas were implemented
through national acreage allotment systems. The acre-
age allotments were replaced by poundage quotas in
1965 for flue-cured tobacco and in 1971 for burley to-
bacco. The switch to poundage quotas increased flex-
ibility for tobacco growers. In any given year, tobacco
farmers could sell up to 10 percent more than their
quota if yields exceeded expectations (because of fa-
vorable weather conditions, for example). In the fol-
lowing year, however, farmers would have to sell
proportionately less than that quota. The opposite
would apply when yields fell short of expectations. If
yields fell short for several years, tobacco farmers could
accumulate excess quotas up to an amount equal to
their normal quota. This arrangement resulted in a
more stable supply of flue-cured and burley tobacco
(Johnson 1984).

  Every three years, tobacco farmers vote on whether
to continue the price support program and whether to
approve any substantive changes in the system. If the
referendum is approved by a two-thirds majority,
tobacco farmers are subject to marketing quotas.

Effects of Price Supports on Market Prices

  Despite the numerous factors that affect the sup-
ply and demand for tobacco, the quota and price
support svstem keeps market prices at or above the
support le\.el. This effect has been evident-and its
correction attempted-almost from the outset. As a
result of the Agricultural Adjustment Act of 1933, to-
bacco prices increased almost immediately. These in-
creases resulted from limits on output achieved by
\.oluntarv agreement. In 1934, Congress passed the
Tobacco Control Act (Public Law 73-483) to deter non-m
cooperatilse tobacco farmers from overproducing and
taking ad\.antage of the relativelv high prices result-
ing from the reduced supplies of participating farm-
ers. This act led to sharp reductions in tobacco
production and consequently to a steep rise in tobacco
prices. In early 1936, however, the United States Su-
preme Court found sections of the Agricultural Ad-
justment Act unconstitutional, which led Congress to
repeal the Tobacco Control Act as well.

  In 1935, Congress enacted the Tobacco lnspec-
tion Act (Public LaM 74-314), which required the USDA
to provide tobacco grading (or quality evaluation) ser-
\?ces at no cost to tobacco growers. In 1936, the Soil
Conserl,ation and Domestic Allotment Act (Public Laib
74-461) was passed. This act covered tobacco, as we1
as most other agricultural products covered by the


Agricultural Adjustment Act of 1933, and rewarded
farmers for diverting production from soil-depleting
crops (including tobacco) to soil-conserving crops. The
limited success of the Soil Conser\ration and Domes-
tic Allotment Act led to the passage in 1938 of the sec-
ond Agricultural Adjustment Act (Public La\z 75-430).
The neIv act included quotas for tobacco and other
agricultural products and imposed penalties on farn-
ers \vho violated their quotas. Even ivith subsequent
amendments, the tobacco price support program es-
tablished by the Agricultural Adjustment Act of 1938
is essentially the same today.

  The Agricultural Adjustment Act of 1938 set the
support price at 75 percent of parity (ivherc paritv re-
flects a\rerage tobacco prices from 1919 through 1429).
At the beginning of World War II and later through
the Agricultural Act of 1949 (Public Law 81-4391, this
proportion ivas raised to YO percent of paritv, I\ hich
was based on average prices for the preceding 10 vt'ars.
In 1960, fo slow the rate of gro\\.th in tobacco irices,
Congress set nell- support le\-cls based on the 1YSY le\,el
and a three-vear moving al~erage of prices paid b\
farmers. Sinqilarlv, in 1980, the support prices for tlih
eight loliest qualitv grades of tobacco l\.ere louvered
directlv.

Assessments to Offset Federal Costs
of Price Supports

  Until new legislation \~as passed in the IYXOs,
the costs to the federal government from operating the
tobacco support program were substantial. In 1981
alone, the total administrative cost of the program was
$13.1 million. Moreover, the federal government,
through the Commodity Credit Corporation, bore all
costs if the local cooperatives were unable to sell the
tobacco they received as collateral for the nonrecourse
loans. By April 1982, losses from unpaid loan princi-
pal totaled $57 million, and interest losses amounted
to $591 million by the end of 1981 (General Account-
ing Office [GAO] 1982). These losses spurred opposi-
tion to the tobacco support program, which Izras being
threatened with dissolution. To reduce some of the
costs of operating the program, in 1981 Congress
amended the Tobacco Inspection Act, imposing fees
on tobacco growers sufficient to cover the cost of the
grading services provided by the USDA.

  Far more significant changes to the tobacco sup-
port program were introduced by the No Net Cost
Tobacco Program Act of 1982 (Public Law 97-218),
which was mandated bv the Agriculture and Food Act
of 1981 (Public Law 97-98). The act M'as intended to
reduce the losses of the tobacco support program bv

imposing an assessment on every pound of tobacco
brought to market under the loan program. The as-
sessments \vere supposed to generate revenues suffi-
cient to offset all future losses from these loans. Thus,
aside from the administrative costs, the tobacco sup-
port program leas supposed to operate at no net cost
to taxpayers. Other changes were introduced through
the act. Rather than distributing excess receipts from
the sale of loan tobacco to farmers, these profits were
retained bv the Commodity Credit Corpora6on. Farm-
ers of flue-cured tobacco could sell their right to grow
tobacco In other active tobacco grokvers in the same
county; moreover, institutional owners of these rights
ivere required to sell them by December 1984. Finally,
the U.S. Secretary of Agriculture 12ras given the author-
it\, to sloiv the grolvth in the support price by allow-
ing the price to increase by as little as 65 percent of the
increase implied by the parity formula. These changes
led four relatively small associations of tobacco groby-
ers (grolt-ers of cigar tobacco in three areas) to stop
participating in the support program (Miller 1994).

  Initially, assessments were expected to be rela-
ti\el\f lo\\, because of the size of past losses. However,
as a iesult of the tobacco support program, U.S. sup-
port prices w'ere well above tobacco prices in world
markets, lvhich led producers of cigarettes and other
tobacco products to increase their use of imported to-
bacco. At the same time, reductions in quotas were
limited bv statute. Consequently, the quantity of to-
bacco prdduced exceeded the quantity demanded at
the support price, and the surplus was used as collat-
eral for nonrecourse loans (Miller 1994). By 1985, with
a growing stock of U.S.-grown tobacco under loan, the
no-net-cost assessment on flue-cured tobacco was high:
25 cents per pound (Miller 1994). (The assessment on
burley tobacco would have been 30 cents per pound
but was limited to 4 cents by legislation.)

  The high assessments, the growing importance
of imported tobacco in the production of cigarettes and
other tobacco products, the increasing stocks of tobacco
under loan, and the falling quotas of the early to mid-
1980s created a crisis for tobacco farmers and the to-
bacco support program (Northup 1993). Congress
responded by making several changes to the support
program (Tobacco Program Improvements) contained
in the Consolidated Omnibus Budget Reconciliation
Act of 1985 (Public Law 99-272). The 1985 act lowered
the tobacco support price by 26 cents per pound for
both flue-cured and burley tobacco. In adciition, both
buyers and sellers of surplus tobacco were required to
bear part of the burden of running the program (grow-
ers of other types of tobacco continued to be respon-
sible for the'full assessment). These changes were


meant to encourage the use of domesticall\ gro\Vn to-
bacco ol'er imported tobacco in the manuiacturing of
cigarettes and other tobacco products (Miller IYY1).

  Also as a result of this legislation, the amount of
flue-cured and burley tobacco that could be sold ivith-
out penaltv leas reduced from 110 percent of quota to
103 percelit. The formulas used to determine the sup-
port prices ior flue-cured and burley tobacco \z.ere also
changed. These prices bvere nolv based on their levels
in the preceding vear, and adjustments 12-ere to be made
from a fi\.e-year iloving average 0i prices and changes
in the cost of production. Past prices ~,ould be given
two-thirds weight, and the remainder n~oul~l be based
on production costs (tvhich included general \,arinble
expenditures but excluded costs of land, overhead,
assessments, and other expenses not directlv related
to tobacco growing). The legislation also brdught the
major cigarette manufacturers into the quota-setting
process, because they t~ould be annually providing
the U.S. Secretarv of Agriculture M.ith their intended
purchases of tob&co. These manufacturers would be
penalized if they did not purchase at least YO percent
of this intended amount.

  When these changes took place, U.S. cigarette com-
panies agreed to buy all future surplus stocks Of tobacco
(for the next eight years for flue-cured tobacco and the
next five vears for burlev tobacco). Some of the exist-
ing stocks under loan \vere sold at sharp discounts; the
federal go\`ernment absorbed the losses. These changes
Lvere somervhat successful in reducing surplus tobacco
stocks as \vell as the amount of tobacco brought under
loan in any gi\.en year. O\w the nwt ii\.e years, stocks
of tobacco declined bv nearlv 10 percent, and total loan
outlavs fell bv nearlv 90 percent.

-To fund deficit reduction of the federal budget,
the Omnibus Budget Reconciliation Act of 1YYCl (Pub-
lic La\v 101-508) added further marketing assessments
on all commociity price support programs betiveen
1991 and lYY5; the marketing assessments Ivere sub-
sequently extended through 1998 (USDA 1997~). To-
bacco grot\.ers and buyers each paid an additional
assessment equal to 0.5 percent of the support price
level. These additional assessments generated esti-
mated relrenues Of more than $28 million in iiscal vear
1997 (Womach 1999).

  To further curb the use of imported tobacco, the
Omnibus Budget Reconciliation Act of 1993 (Public
Larz 103-66) included the requirement that, beginning
in 1993, domestically produced cigarettes include a
minimum of 75 percent domestically grolvn tobacco.
If this lals leas violated, the cigarette manufacturer was
assessed on the amount of foreign-grown tobacco used
in excess of the 25-percent limit. The assessment rate

\~as determined by the difference betw,een a\rcrage
prices of imported and domestic tobacco. Those pro-
ducers M,ho used `III excess of imported tobacco were
iurther required to make up the shortfall by purchas-
ing tobacco stocks under loan. The act also subjected
imported tobacco to the no-net-cost assessments be-
ginning in lYY4. Effective September 13, 1995, ho\%.-
e\rer, the domestic content requirement was dropped
as part of a presidential tariff-rate quota proclamation
because of its inconsistency with the General Agree-
ment on Tariffs and Trade (GATT).

  In general, the tobacco quotas have fallen in re-
cent years, while support prices, after adjustment fol
inilation, have fallen sharplv (Tables 6.4 and 6.5). A>
of March 31, 1995, the principal and interest value 01
tobacco loan inventory was $1.6 billion (Robert H
Miller, Tobacco loan status report, unpublished data)
Mhich was down significantly from the $2.75 billior
held as of June 30,1986 (Warner 1988).

  The no-net-cost assessment for the 2000 crop o
flue-cured tobacco is 2.5 cents per pound for the pro
ducer and 2.5 cents per pound for the purchaser. Simi
larly, the no-net-cost assessment for the 2000 crop o
burley tobacco is 3 cents per pound for both the groove
and the buyer.

  In fiscal year 2000, the federal government bud
geted approximately $14 million for administering th
tobacco support program (Womach 1999). In total, tk
directlv tobacco-related activities of the USDA gener
ated an estimated $174 million in net revenues in fi+
cal venr lYY9. The positi1.e net revenues are the rcsu!
of re\.enues generated by the loan program and var'
ous assessments that more than offset the expenditure
on the tobacco program and other tobacco-relate
activities (including subsidized tobacco crop insurance
tobacco inspection and grading, tobacco research, dat
collection and analysis, and other activities) (Womac
14Y9).

Discussion

  Selreral conclusions emerge from analyses 0i t!-
tobacco support program. The program's success i
stabilizing tobacco prices is particularly e\%lent ~,.hc
they are compared with the prices of other agricultur
commodities (including those covered by their 01%
support programs). One result of the price stability
that output has also been relatively stable. As Johns?
(1984) notes, "growing tobacco has been as close to
sure thing as one can find in U.S. agriculture" (p. 5:

  The quantity of tobacco grown domestical-
is artiiicially 10~. as a result 0i the supply restriction
created by the tobacco support program. Consequent'


Table 6.4. Characteristics of the tobacco support program: flue-cured tobacco, 1975-2000

Year

197j

I Y76

  -...
lY//

  ->
I')/b

1 Y79

1 W)

1981

192

1983

1 w4

I')85

1986

1987

I 'MS

IWY

1 Y90

1991

1992

1993

1994

1995

1996

1997

1998

1 YY9

2000

National
marketing
quota
(million lbs.)

National      Real average
average        support
support price      price*
(cents/lb.)        (cents/lb.)

No-net-cost assessment+
    (cents/lb.)

Producers    Buyers

1,4Y I
1,26S

1,116

1,117

1,095

1,094

1,013

I ,o 13

y 10

804

775

7,Y

707

754

891

S/S

878

892

PI2

803

93s

xi4

974

813

666

533

93.2

106.0

113.8

I21 .o

139.3

141.5

158.7

169.9

I hY.Y

I W.C)

1hY.Y

143.8

143.5

144.2

14h.S

I4X.S

152.8

133.0

157.7

138.3

139.7

160.1

163.1

162.8

163.2

164.0

173.2

186.3

lS7.8

185.6

178.1

171.7

174.6

176.1

170.6

lh3.5
137.Y$

131.2

126.3

121.Y

118.4

113.8

112.3

111.2

109.1

106.8

104.8

102.0

101.0

99.9

98.0

95.6"

3.0

7.0

7.0

2.50

2.50

2.00

1.13

1.12

1 .oo

1 .oo

I .oo

1.00

3.00

0.80

1 .oo

1 .oo

1 .oo

1 .oo

2.50

1.50

2.00

1.13

1.12

I .oo

I .oo

1.00

3.00

5.00

I .80

1.80

1 .oo

1 .oo

1.00

2.50

*Real a\`erage support price is obtained by di\Gding the nominal support price by the national Consumer
Price Index; the average of 1982-1984 is the benchmark.
`No-net-cost assessment includes marketing budget deficit assessments from 1991 through 1998.
IThe effective support price in 1985 Leas 165.0 cents/lb. by reduction of certain grades.
`I'reliminarv estimate.
Sources: Us. Department of Agriculture 1997b, IY99a,b.


Table 6.5. Characteristics of the tobacco support program: burley tobacco, 1975-2000

1975

1976

977

978

979

1 980

981

982

1 983

983

985

986

987

1 988

989

Year

1990

1991

19Y2

1993

1994

1993

1996

1997

1998

1999

2000

National          National      Real average
marketing          average        support
quota       support price*      price+
(million lbs.)        (cents/lb.)        (cents/lb.)

670             96.1           178.6

635             109.3            192.1

636             117.3            193.6

614             124.7            191.3

614             133.3            183.6

614             145.9            177.1

660             163.6            180.0

680             175.1            181.5

647             175.1            175.8

582             175.1           168.5

524             148.8            138.3

493             14X.8            133.x

464             148.8            131.0

473             150.0            126.8

5x7             153.2            123.5

601             155.8            IIY.2

724             158.4            116.3

668             164.Y            II 7.5

602             168.3            116.5

536             171.4            115.7

546             1/2..i            113.2

631             173.7            110.7

704             17h.0            109.7

635             177.8            1OY.l

4.51             178.9            7 07.3

247              180.5           105.2"

No-net-cost assessment7
    (cents/lb.)

Producers    Buyers

1.0

3.0

9.0

4.0

2.75

2.00

0.80

1.00

1.00

I .oo

I .oo

I .oo

4.50

1 .oo

1 .oo

1 .oo

3.00

3.00

3.00

1.25

2.00

0.80

1.00

1 .oo

I .oo

I .oo

3.50

3.60

I .oo

1 .oo

1 .oo

3.00

3.00

3.00

*The support price \vas reduced from 178.8 cents/lb. and the no-net-cost assessment was reduced from
30 cents/lb. bv Public La\v F-157, sec. 6 (IYH5).
+Real average support price is obtained by dividing the nominal support price by the national Consumer
Price Index; the a\.erage of IYP2-1984 is the benchmark.
iNo-net-cost assessment includes nlarketin;: budget deficit assessments from 1991 through 1998.
Vi-eliminary estimate.
Sources: U.S. Department of Agriculture lYY7a; 1998a,b; 1999a. 2000.


prices for domesticall\, grow\-ii tobacco are artificiallv
high. Some estimates of the distortions resulting from
the support program \1-cre pro\.ided by Sumner and
Alston (1985) in their analysis of the economic conse-
quences of renio\-ing the tobacco price support svstem.
Their estimates 12.ere based on a detailed simultaneous
equations model of the supplv and demand for tobacco
and tobacco products (cigarettes) that allows for sub-
stitution bet\\-een domestic and foreign tobacco in ciga-
rette production. The authors estimated that domestic
tobacco output K-ould rise by 5&100 percent or more
if supplv restrictions \vere eliminated. This large in-
crease in the quantitv of tobacco supplied should lead to
sharp reductions iii- tobacco prices. As a result of the
increase in output, tobacco prices I\Y~LI~CI fall b\. 3-30
percent, and the \-ariabilitv of tobacco prices ~vnulcl in-
crease. Ho\\.el.er, o\.erall rel'enues from tobacco grow\--
ing ~vould rise bv 15-60 percent or more.

Moreo\.er,this analysis predicted that the sharp
drop in domestic tobacco prices that \\~oulcl follo\\~ the
removal of supplv restrictions ~~0~11d lead domestic
producers of cigaiettes and other tobacco products to
use less foreign-gro\\,n tobacco.  These estimates as-
sumed the elimination of the program in 1983 and thus
do not take into account the more recent changes in its
operation. More recent estimates from Zhang and co-
leagues (2000) suggest that the conclusions of Suninel
and Alston (1985) still applv. For example, thev esti-
mated that the price support program raised tobacco
leaf prices by 36 cents a pound in 199-l. This price is
about 21 percent above the estimated price in the ab-
sence of the support program.

  The removal of the support program should also
make domestic tobacco growers more competiti\.e in
world markets. In the 198Os, U.S. tobacco prices ex-
ceeded world market prices by JO-60 cents per pound
(Warner 1988). Although part of the differential can
be explained by the higher quality of U.S. tobacco, a
significant factor is the U.S. tobacco support program.
Sumner and Alston (1985) predicted that U.S. tobacco
exports would have grown bv about 100 percent if the
tobacco support program hai been eliminated in 1983.
This change would have had an ad\rcrse impact on
foreign tobacco growers, as producers of foreign ciga-
rettes and other tobacco products increased their use
of tobacco grown in the United States.

  Although the artificially high prices resulting
from the support program tend to increase the income
of small tobacco farmers, thev likely recei\re relativelv
less benefit from the program than the tobacco quota
owners. Because most small tobacco farmers rent some
or all of their allotments from the quota o\vners at a
significant cost (Watkins 1990), these farmers pav rents

equix-alent to the excess value created by the support
program. In the absence of the program, reduced in-
come for these farmers lvould likely be offset by the
resulting reduced rent they paid. Quota owners, on
the other hand, have been estimated to lose about $800
million annually M'ere the support program eliminated
(Sumner and Alston 1985).

  Despite the differing likely effects on quota own-
ers and small tobacco growers, eliminating the tobacco
support program \~ould probably not alter existing
trends in the concentration of tobacco production into
larger farms (Sumner and Alston 19%). Rucker and
colleagues (1995) ha1.e estimated that eliminating the
program's intercounty restrictions on the transfer of
tobacco quotas I\-ould ha\ e little o\serall impact beyond
redistributing lvealth from some tobacco growers and
quota 011 ners to others. (Consequently, these research-
ers suggest that the restrictions have remained in ef-
fect not because the gains associated with them are
large but because the political costs of removing them
are.)  Moreo\.er, remo\%~g supports would cause a
mo\.ement a\vav from regions \vhere the costs of grow-
in;; tobacco ari relativelv high torz-ard those where
costs arc relati\.el>. Io~v. -The loss of income to quota
o\\`ners \zo~ild lead to reductions in personal income
of up to 2-3 percent for counties that are highly de-
pendent on tobacco; larger losses would occur in the
relati\.elv high-cost counties. However, total incomes
would rise in areas that experienced a great expan-
sion ~JI tobacco growing. In comparison, the effect of
altering another government program would be con-
siderable. Increases in cigarette excise taxes are also
likely to bring significant losses to quota owners.
Sumner and Wohlgenant (1985) estimated that dou-
bling the federal cigarette excise tax in 1983 would
louver quota oM.ners' lease income by an average of 13
percent, or about $44 million.

  As a result of the sharp drop in the price of to-
bacco, cigarette prices could fall. Tobacco costs, how-
ever, are a relatively small component of cigarette
prices. Grise (1995) estimates that the 40- to 50-cent
per pound drop in tobacco prices resulting from the
elimination of the support program r~ould reduce ciga-
rette prices by only l-2 percent. Zhang and colleagues
(2000) estimaie an even smaller impact, concluding that
cigarette prices are 0.52 percent higher than they would
be in the absence of the support program. As noted
by Sumner and Alston (19851, a reduction in cigarette
prices would lead to a rise in U.S. cigarette exports.
Moreo\.er, estimates of the price responsiveness of ciga-
rette demand (described in "Effect of Price on Demand
for Tobacco Products," later in this chapter) suggest
that the reduction would lead to an increase of no more


than 1 percent in cigarette smoking. At least part of
the increase \voulcl come from increased smoking
among young people.

  Opponents of the tobacco support program sug-
gest that it can be removed w+th little impact on the
farmers it is intended to benefit. For example, the less
than 2-percent reductions in cigarette price that would
result from eliminating the support program could be
more than offset by an increased excise tax on ciga-
rettes. A portion of the revenues generated from the
tax hike could be used to help tobacco farmers diver-
sify into other crops (through low-interest loans,
grants, or other programs) or to purchase the farmer's
tobacco base to retire it from tobacco growing (Northup
1993). Similarly, some of the funds could be used to
develop nonfarm businesses, train farmers for other
occupations, provide income support, and offer other
economic support for local economies in transition
(Womach 1994a).

  Critics also point out that the support program
creates indirect political consequences: the depen-
dence created by the support program results in a
strong political constituency, composed of tobacco
farmers and holders of tobacco allotments, that can
impede legislation to reduce tobacco use (Taylor 1984;
Warner 1988; Zhang and Husten 1998). In the absence
of the support program, tobacco growing \vould likely
become much more concentrated (Sumner and Alston
1985). Warner (1988) has observed that the reduction
in numbers would lead to reduced political influence.
Moreover, he describes the apparent inconsistency
present when one arm of the federal government seem-
ingly endorses tobacco production by continuing an
economic support program even as another engages in
numerous activities to reduce tobacco use (Warner 1988).

Evolution of the U.S. Cigarette Industry

  Through much of the 19th century, most of the
demand for tobacco products centered on smokeless
tobacco and cigars (see Chapter 2). Cigarettes were
relatively less popular, although the demand for them
increased gradually during the middle of the century
(USDHHS 1992). The watershed year for the cigarette,
however, was 1881, when James Albert Bonsack an-
nounced his de\,elopment of a machine that replaced
hand-rolling as the primarir means of making ciga-
rettes. The mechanization df production significantly
reduced the costs of manufacturing cigarettes and,
consequently, reduced cigarette prices. The steep de-
clines in cigarette prices relati1.e to the prices of other
tobacco products, due largely to Eonsack's cigarette

machine, contributed significantly to the rapid rise in
the popularity of cigarettes during the late 19th and
early 20th centuries (Wagner 1971).

  James Buchanan Duke was the first cigarette pro-
ducer to acquire rights to the new machines, which he-
installed in 1884. Duke entered into long-term con-
tracts with Bonsack to use the machines at a cost lower
than Bonsack would make them available to other
producers. Because of the resulting substantial cost
advantage in production for his company, Duke
successfully waged price wars with other producers
while still earning relatively high profits. Over the next
decade, the Duke family formed a holding company,
which was composed of their firm and several corn--
petitors they had acquired. By 1889, as a result of its
aggressive pricing and marketing strategies, the hold-
ing company effectively monopolized U.S. cigarette
markets (controlling more than 90 percent of the mar-
ket), as well as portions of the markets for other to-
bacco products. Eventually, in an attempt to avoid
antitrust prosecution under the Sherman Act, the
Dukes converted the holding company into The Ameri-
can Tobacco Company. By 1901, The American Tobacco
Company dominated all of the U.S. tobacco market<
except cigars. The company was also a considerable
presence in cigarette markets around the world.

  In response to allegations that The American To-
bacco Company was abusing its market position, the
U.S. Department of Justice charged the firm with vio-
lating the Sherman Act. In 1911, the Supreme Court
dissolved the company, thereby creating several new
firms from the conglomerate, including a new Ameri-
can Tobacco Company (which later became American
Brands, Inc.), Liggett & Myers Tobacco Company, R.J.
Reynolds Tobacco Company, and Lorillard Tobacco
Company. The American Tobacco Company was also
divested of its foreign holdings (Imperial Tobacco Ltd.
and British-American Tobacco Company Ltd. [B.A.T.
Company]). Imperial Tobacco Ltd. eventually rno;
nopolized cigarette manufacturing in Great Britain,
and B.A.T. Company concentrated on manufacturing
in British colonies and elsewhere. Both companies
ultimately resumed some operations in the United
States (Johnson 1984). Although Imperial Tobacco Ltd.
eventually dropped out of U.S. markets, B.A.T. Indus-
tries PLC, the parent company of B.A.T. Company,
owns Brown & Williamson Tobacco Corporation, a
large U.S. cigarette manufacturer.

  R.J. Reynolds Tobacco Company (which had nc
cigarette production after the breakup) soon devel-
oped a new type of cigarette by using burley tobacco,
which was quickly copied by the other producers. By
the lY2Os, the cigarette producers were competing


`tsgressi\.elv in promoting their main brand-for ex-
ample, R.J. Revnolds Tobacco Companv's Camel, The
.\merican Tobacco Compan>"s Lucky Strike, and
Liggett Cy: Myers Tobacco Company's Chesterfield. In
addition, firms on the competiti\,e tringe attempted to
compete through price \vith their so-called IO-cent
brands (Robert 1967). (For a more detailed discussion
L,f the domestic operations of U.S. cigarette firms be-
fore World War II, see the Surgeon General's report
$iwX-i/7,y (712~1 H~wltl~ ir7 t/7(, A~7c~riin5 [USDHHS 19921).

  The U.S. Department of Justice e\,entually chal-
lenged the four producers' coordinated \vholesale and
retail pricing practices.  In IY-ll, on the basis of con-
juct starting as earl\ as 1933, these producers xvere
I:harged \vith \,iolatin g the Sherman Act bv conspir-
ing to restrain trade in an attempt to monopolize the
Industry Their \vholesale tobacco-yurchasitig prac-
tices Ivere deemed to be monopsonistic-that is, char-
-1cteristic of a market situation tvhere one buver exerts
.I disproportionate influence-and their retail pricing
\\-a~ thought to reflect collusi\.e beha\,ior. In 1916, bas-
~ng its decision on the no\,el legal concept of "conscious
parallelism," the Supreme Court upheld a jury deci-
,ion that found the firms guiltv. The uniformit\~ of
;>rices at both the \vholesale and ;he retail le\,el (a result
that could occur in anv highly competiti\.e market),
the near-SVnchronoLis increases in prices, and the rais-
ing of 12-holesale prices \vheii labor costs irei-e falling
.vere vieived bv the court as evidence of tacit collusion.

As a result, the firms xvere fined up to $250,000 each, a
relati\.elv minor penaltv compared \zith their profits.

Jol;nson (lY83) and others have noted that the
Court's decision \vas not supported by purely eco-
nomic reasoning. There rvas little if any evidence that
cigarette firms \vere jointly restricting output to raise
cigarette prices and, consequently, profitability. Simi-
larly, there \vas no evidence that the firms limited
their \\rholesale purchases of tobacco to depress to-
bacco prices and production costs and, consequently,
to increase profits.

  The Court's decision had little impact on the sub-
sequent structure of the U.S. cigarette industrv. The
practical result has been that, from 1916 until today,
the combined market shares of the six major firms (five
after the merger of Bro\vn & Williamson and Ameri-
can Brands, Inc.) has exceeded YY percent, although
indi\,idual market shares ha\.e changed significantly
(Table 6.6).

  More important in changing relati1.e market
shares ivas the release of information during the 1950s
and 1960s on the health consequences of cigarette
smoking. In the lYX)s, Philip Morris Companies Inc.,
1i.J. Re~~nolds Tobacco Company, and Lorillard Tobacco
Companv aggressi\,elv marketed filtered cigarettes
(Marlboro, Winston, a'nd Kent, respectii,ely), xvhich
lvere percei\,ed as less dangerous than standard
unfiltered cigarettes; The American Tobacco Companv
and Liggett & Mi,ers Tobacco Company \vere not as

rable 6.6. Domestic market shares of U.S. cigarette firms, selected years

      R.J.     Philip      Brown &     American
Year   Reynolds    Morris     Williamson     Brands     Lorillard

1913       0.2       NA*         NA         35.3        77 1
                                                              &k.

1925      31.6        0.5         NA         31.3         1.9

i 9-10      21.7        9.6          7.8         29.5         5.4

1955      23.8        8.5         10.5         32.9         6.1

1970      31.8       16.8         16.9         19.3        8.7

1975      32.5       23.8          17.0         14.2         7.9

IY80      32.8       30.8         13.7         10.7         9.8

1985      31.:       35.8         11.X         7.4        8.2

1991      27.8       43.4         11.1         7.0        7.3

1996      24.6       47.8         17.2         NA         x.-l

Liggett &
Myers

  34.1

26.6

20.6

  15.6

  6.5

  4.4

  2.2

  5.0

  3.4

  1.9

Total

91.7

91.8

94.6

99.4

100.0

99.8

100.0

99.9

100.0

99.9

-X.4 = Not available.
%xwces: Tennant 1950; O\wton 1981; Clarifeld lY83; Standard & I'oc)r's lYXc), 1993; Federal Trade
.`Ornmission 1997.


s~~cc~ssful in marketing their competing brands
(Johnson 1981). Similarly, after the 1964 release of the
U.S. Surgeon General's first report on the health conse-
quences of cigarette smoking, and after the Federal
Trade Commission's (FTC) publishing of tar and nico-
tine content in the late 1 Y6Os, Philip Morris Companies
Inc. and R.J. Reynolds Tobacco Company introduced
and aggressively marketed lo\v-tar and lobv-nicotine
cigarettes (again, products percei\,ed as healthier than
existing cigarettes), whereas the other companies \vere
less successful. As a result of the brand loyalty these
two firms Lt'ere able to establish at this time, they came
to dominate cigarette markets; in 1996, the two firms
had a combined market share of 73.3 percent.

  Another notable change in the tobacco industry,
beginning in the lY6Os, was the di\.ersification of the
cigarette-manufacturing companies. Perhaps in part to
offset the impact that the campaign to reduce tobacco
use had on the industrv's profitability, the six major
domestic cigarette producers acquired or merged !2-ith
U.S. firms in a \,ariety of nontobacco markets, includ-
ing food, alcoholic beverages, and transportation. Both
U.S. and international cigarette producers significantly
expanded their international acti\-ities. Di\.crsification
was relativelv easv because of the high profitabilitv from
          _ -
cigarettes and the lo~v long-term debt of these firms
(Overton 1981). By 1972, no major domestic cigarette
companv ivas completelv dependent on tobacco for its
revenue (Johnson lY84). Durin, 0 the l%Os, diversifica-
tion strategies and successes among the six firms var-
ied markedly; some firms returned to a focus 011
cigarettes and other tobacco products, \\.hereas others
di\.ersified further. B\, the late l%Os, a three-tiered
classification of \Vorld cigarette producers, based on
their international activities, had emerged: those in-
volved in most global tobacco markets (Philip Morris
Companies Inc., B.A.T. Industries PLC, 1i.J. Reynolds
Tobacco Company, and Rothmans International Tobacco
Ltd.); those \\ith some international, but not global,
activities (including American Brands, Inc.); and smaller
firms concentrating primaril!, on their domestic mar-
kets (including Liggett & Myers Tobacco Company and
Lorillard Tobacco Company) (L'SDHHS lYY2).

Economic Implications of Concentrated Tobacco
Production

  The concentration of production among relati\d)
few firms in the cigarette industry has implications for
cigarette pricin,, ~7 marketing, product de\.elopment, and
other activities. Clearly, the cigarette industrl, is an
oligopoly; no more than six firms ha1.e controlled vir-
tually all cigarette output in the United States for the

past 80 vears (Table 6.6). Economic theory suggests
that fir& in oligopolistic industries have substantiat
market pobver in that their production decisions wilt
have a significant impact on price. Moreover, these
firms recognize their interdependence. That is, each
firm recognizes that its pricing and marketing strate-
gies have a significant impact on the sales and profit-
ability of its competitors, as well as on its own sales
and profitability. Consequently, each firm understands
that its competitors are likely to respond to any changes
in its own pricing, marketing, or other strategies.

  Economic theory provides several possibilities
regarding the conduct and performance of firms in an
oligopolistic industry. At one extreme, if entry is easy
and if sunk (nonrecoverable) costs are low, firms in an
oligopolistic industry will behave competitively. That
is, firms will have little market power (their output
decisions will have little impact on market prices),
prices will reflect the costs of production, and firms
will not earn excessive profits. At the other extreme,
firms could behave collusively, jointly restricting out-
put, raising prices well above costs, and earning very
high profits. Most theoretical models of oligopolistic
industries suggest behavior between the two extremes:
prices and profitability will be above and output will
be below Ivhat would result from highly competitive
behavior, and output will be higher and prices and prof-
itability will be lolver than their levels in a monopo-
lized or highly collusive industry.

  Casual empiricism suggests that cigarette prices
ha1.e historically been bye11 above costs, thereby allow-
ing cigarette producers to achieve a rate of return ~-41
above that earned in most other industries. Even after
the health consequences of cigarette smoking became
apparent, the U.S. tobacco industry led all U.S. indus-
tries in profitability (Miles 1982). Moreover, in the t\vc
major antitrust cases brought against the cigarette in-
dustry in the 20th century, firms were found guilty ir
1911 of monopolization and in 1946 of a conspiracy tc
restrain trade (collusion). Most industry analysts sug-
gest that the primary source of market power in the
cigarette industry is the entry barriers resulting fron?
marketing efforts, tvhich create significant brand loy-
alties that are nearly impossible for a nets producer tc
overcome.

High Tobacco Concentration and the Impact of
Prevention Policies

  The high concentration of the cigarette industrk
and the apparent market polver this concentratior
engenders have implications for the effects of changes
in cigarette taxes and other prevention policies on the


pricing, marketing, and other strategies of cigarette
firms. For example, the historically high profitabilitv
of existing cigarette producers pro\.ides them Lvith thk
resources needed to s~~ccessf~~llv de\-elop and market
new' products, as leas seen in ;he de\.clopment and
introduction of filtered cigarettes in the lY5Os and lots-
tar and lolv-nicotine cigarettes in the 1YhOs in response
to the initial reports linking cigarette smoking to lung
cancer. More recently, in response to the increased
alrareness of the harmful effects of en\-ironmental to-
bacco smoke (ETS) on nonsmokers and the ~~idesprcad
restrictions on smoking that ha\-e been designed to
protect nonsmokers, R.J. Re\,nolds Tobacco Cornpan\,
introduced its Eclipse brand in se\ era1 test markets
beginning in mid-lYY6, and Philip Morris Companies
Inc. is currentI>, testing its Accord brand in the Lnitccl
States and Japan. Both are ostensibl\, "smokt~lt~ss" cig,3-
ret&s, primarilv heating rather than burning tobacco;
consequently, both generate less secondhancl smoke
than con\.entional cigarettes.

  Economic theor\, can predict sonic effect\ of in-
creases in excise tax&on price, output, and profitabil-
itv. At one extreme, tax increases in a perfectl\
competiti\.e market \vith constant costs of production
should result in price increases of the same magnitude
rzith no impact on long-run profitabilitv. Reductions
in output \\.ould depend on the effect that price has
on demand. At another extreme, standard models for
a monopolized market suggest that producers; and
consumers \ynuld share the burden of the tax increase
but consumers \vould pav a greater share of the tax,
because demand is less s&iti\-e than production to
price. Output and profitabilit!, t~ould fall, Ivith smallet
reductions in both-again because demand is less sen-
sitive to price. Recent advances in the theoretical and
empirical study both of oligopolistic behavior and of
the supplv of addictii.e goods haire vielded se\,eral
interesting predictions. Perhaps most interesting is the
possibility that prices ITi increase by more than the
amount of the tax increase i~hen excise taxes are raisecl.

  Several early studies of these relationships pro-
duced generally inconsistent conclusions concerning
hoM' much cigarette prices rzould increase after an in-
crease in cigarette taxes (Barzel 1976; Johnson 1978;
Sumner 1981; Sumner and Ward 1981; Bulo\~ and
Pfleiderer 1983; Bishop and \Ibo 1985; Sulli\,an lY85;
Sumner and Wohlgenant 1983; Ashenfelter and
Sullivan 1987). One general Meakness of these stud-
ies w'as their failure to account for the dynamic inter-
action of firms in an oligopolistic industrv. Instead,
the studies generally assumed that rules fo; the firms'
behavior \vere established, and then, \vith obselved
prices and taxes, the studies lvorked back\\-ard to

determine the degree of competition within the indus-
trv (Harris 1987).

   More recent studies have addressed these weak-
nesses. Harris (1987) used the estimates obtained from
se\,eral studies of cigarette demand and supply to
e\raluate the impact of doubling the federal cigarette
excise tax in 1983; moreover, Harris' framework al-
lo\ved the change in the tax to affect the interaction of
firms in the industrv. Using data on wholesale and
retail cigarette prices as well as the costs of produc-
tion, Harris concluded that the ii-cent increase in the
tax 14 to a 17-cent increase in the retail price of ciga-
rettes. He further argued that the price increase above
the tax hike could not be accounted for by increases in
production costs. Instead, this increase was attributed
to the recognized interdependence of cigarette firms
in an oligopolistic industry; that is, the firms recog-
nize that their profitability \vould rise if all could suc-
cessiull~ restrict output and raise prices. However,
because foi-ma1 agreements on output and prices are
illegal, the firms are alert to other bases on which they
can coordinate their behavior. Harris suggested that
such a base \\`as the announced increase in the federal
ta\, scheduled for January 1, 1983, lvhich served as a
ioordinnting mechanism for a joint oligopolistic price
increase. As Bnrnett and colleagues (1995) note, Har-
ris' analvsis fails to account for existing trends in ciga-
rette prices. Barnett and colleagues argue that Harris
attributed too much of the coordinated rise in price to
the increase in the federal tax, because the upward
trend in prices predates the consideration of the tax
hike. The authors suggest that producers used the in-
troduction of discount cigarettes in 1981 to coordinate
the earlier price hikes for premium brands, because
the lolver-priced "generic brands" would keep more
price-sensitil-e smokers in the market. The spirit of
this argument is the same as Harris', because both sug-
gested that certain e\,ents served as focal points allow-
ing firms to engage in more collusive behavior without
appearing to establish a formal agreement.

  Keeler and colleagues (Sung et al. 1994; Barnett
et al. 19%; Keeler et al. 1996) used national- and state-
lc\.el data to estimate the effects of cigarette tax in-
creases on price. Their empirical models have been
used to examine the interaction of cigarette supply and
demand in determining cigarette prices. By using
alternative assumptions about firm behavior, these
studies formally account for the oligopolistic aspects
of the cigarette industry in their empirical models of
cigarette supplv. At least some of these models also
account for the+addictive nature of cigarette demand.

  In a study using data on all U.S. states from 1960
through 1990, Keeler and colleagues (1996) conclude


c~\\~la~~i thti li\.pnthL5i\ a5 follo~\3: iigdrette firms Lvit1-t
nl,lrht't ~cJ\\ t't- ma\. s;ft relati\ el\, low prices to "hook"
i~~ti5uiilt~r5 on thtsir ddciiiti\-e product, thus raising the
tature ciemdnc-l for their (-igdt-ettes; policies (including
tCl\ incrc~,tssrsJ that reduce future smoking also reduce
the tit-tns' prufitabilitv of maintaining lo\v prices. Nev-
tWhele+s, the relativelv lo\v prices of these for~vard-
looking firms (comp,~;ed \vith those of more myopic
firms) I\-ill still c~ceecl the marginal and average costs
of pr~dustion and distribution. A similar hypothesis
lids been ~tscci to explain studies that found Ihat ciga-
rette producers appear to ad\,ertise beyond the profit-
tn~~simi~ing le~,el (Sholtxlter 1991). These firms rnal
be engC~ging in excessive ad\.crtising (i.e., more than
can be recouped through brand switching among cur-
rent smokers) to attract new consumers and hoping to
I,itcr bcnetit from a hi,gher demand for cigarettes as `i-
result of these tie\vlv addicted consumers.
The rapid incr&ses in cigarette prices since the
e,irl\ I %X)5, I\.liich are only pnrtlv explained bv incrcdst~s
in taxes and costs, thus reflect I-7rofit-maximizing
beha\-ior b>f ;i highly concttitr~~tcd cigarette industr\~
that anticipate5 dtueas.ed future ~lemand as xiditiotiC~l
c'iforts to rcduw tobaccn ust' are implemented (Kecket
c't ,il. 1-W). ;Itl empiric-al dppliiation of this model tc
tlic <uppI\ anti demand for cigarettes (Sho\vnlter IWl)
sLippc)rb tlicwl li\~pothews concerning the belialjor of
tirni5 \\ itli nidrket po\x.t~r that dre selling an addicb\ t`
pt~c~LiLlit.
  ;I 5ci~uicl gtxtup of empirical studies has foc~ised
011 tlic tx~l,itic>ti5liips bc`t\x.twi industrv concentratioti~
tri5tt-iiti~~n5 c>ii iigdrctte ad\~ertising, cigarette pricr~.
,Incl mdrket po\\.er. One such analysis supports the
ion\ twticIndl \\,isdoni that advertising is an important
ic)tiipt`titi\ e strategy in de\~elopin, u and m;lintainin$
br,incl io\~dIt~~ for firms in the cigarette indt.tstr\
~N~u\~~ii ~IW?). Another analvsis, using nn empiricA
niodt>l that ;Illo\\5 firms in an oligopolistic indurtrv tc
h;l\ t` some cicyt-et> of market polver, conclucies ;lial
dd\.cdi5iti~q raist5 market po\vet- and, consequetitl~-
pr~~tit,lbilit\ in the cigarcttt> industrv (TremblCtv anti
Tretnbl,~\~ iW3). A likelv eupl,wati& of this ef&ct i>
that b\, tostcritig lov;llt\T to existing brdncls, cigdrettt
ad\ vr;isiii:g raises LGrri&s to other brand5 that try tc
tlntct- the market and shCue in the profits.
  Se\-et-al studies (Porter 19X6; Mitchell ant?
~~lulherin lc)Sti; Eckard Ic)c)l) ha\,e ~oncl~~deci that bnn-
niti;; ii ~arrtte acl\~crtising from television and radii
    h
mdclv the industr\- c`\ cn less conipetiti\x!, thercbv fur
tlitlr raising pt-nfit~iL%lit\,. One such stud\, atfribufeti
the incrtuses in cigitdte prices after thedadL.ertisitis
bdn to the rcduiecl cotnpt~tition taultin~ front the L7d1-
(Porter I%%). This cotiilu5ion ~vas supported, tc) wnic


Discussion


effecti\-ely in foreign markets (this t),pe of association
is exempt from antitrust lal~ under the Webb-Pomertne
.4ct).

   As Grise (1990) notes, trade in tobacco and tobacco
products would be even higher if not for general trade
policies and, in particular, widespread agricultural and
industrial policies that protect domestic tobacco grow-
ers and producers of tobacco products. Numerous
countries have policies that support domestic tobacco
growing; in the United States, examples are the tobacco
support program and the short-lived mandatory mini-
mum content of domestic tobacco in domestic ciga-
rettes. Likewise, both tariff and nontariff barriers to
trade in tobacco and tobacco products ha\re been
erected around the \vorld. These barriers include quo-
tas, restricted product lists, exchange controls, prior
deposits, mixing regulations, licensing requirements,
and limits on advertising and other promotional ac-
tivities (Grise 1990). Moreover, in se\,eral countries (in-
cluding Japan, South Korea, and Thailand), various
aspects of the manufacture and distribution of cigarettes
have long been controlled by go\rernment monopolies
that have largely prevented the import of foreign ciga-
rettes (GAO 1992).

   When tariff and nontariff barriers to trade are used
to protect domestic tobacco and tobacco products, to-
tal supply of these products is usuallv louver than it
would be others-ise, lvhereas domestic supplv is higher.
In the case of tobacco products, this arrang&ent has
public health benefits resulting from the generally
higher prices and reduced consumption of the pro-
tected products. Domestic suppliers benefit b!r sup
piying more at higher prices. Foreign suppliers,
howei'er, are likely to lose in this arrangement, because
their access to these markets is limited and costs of sup-
plying the markets are higher. In addition, restrictions
on advertising and promotion in gi\ren countries are
likely to make it difficult for nelz firms to successfully
enter newlv opened markets lvhere existing brands are
firmly entrenched (Chaloupka and Corbett 1998).

Past Tobacco-Related Trade Policy

  In general, tobacco products exported from the
United States are specifically exempted from federal
laws and regulations concerning the export of poten-
tially harmful products, including the Federal Hazard-
ous Substances Act (Public La\v 86-613), the Toxic
Substances Control Act (Public Law 94-469), and the
Controlled Substances Act (Public La\v 91-513) (GAO
1992). Similarly, although federal regulations (1) re-
quire that all cigarette packaging and advertising in
the United States contain health rtarning labels and

(2) prohibit television and radio cigarette advertising,
there are no federal regulations or laws concerning the
packaging or advertising of domestically produced
cigarettes that will be exported (GAO 1992).

  Various U.S. policies and programs have been
used to help domestic tobacco growers and cigarette
companies expand into foreign markets (Connolly and
Chen 1993). These policies include the USDA's Food
for Peace Program, which sent more than $1 billion in
domestically produced tobacco to developing countries
in the 1970s and early 198Os, and the 1984 Export Credit
Guarantee Program, which exported domestically
grown tobacco and helped U.S. cigarette producers
enter Mideast markets (including AIgeria, Egypt, Iraq,
and Turkey) (Taylor 1984). Perhaps the most impor-
tant, however, is Section 301 of the Trade Act of 1974
(Public Law 93-618) and its subsequent amendments.

Section 301 of the Trade Act of 1974

  The Trade Act of 1974 was initiated by the Nixon
administration when it sought permission to begin the
Tokyo Round of GATT. GATT, an international trade
agreement honored by nearly 120 countries, governs
various aspects of international trade. (GATT is dis-
cussed in greater detail in "Multinational Trade Agree-
ments," later in this chapter.) The first of these
agreements was reached among 23 nations shortly af-
ter the conclusion of World War II. Since then, seven
rounds have occurred, including the Uruguay Round,
which concluded in April 1994 after more than seven
years of negotiations.

  The Trade Act of 1974 included in its final legis-
lation various measures with the stated purpose of-
promoting free trade. One of these measures was Sec-
tion 301, \vhich gave the President the authority to in-
vestigate cases where trade and other practices of
foreign countries were considered unjustifiable, unrea-
sonable, or discriminatory in that they limited the abil-
ity of U.S. firms to sell their goods and services in
foreign markets.

  Section 301 expanded the authority given to the
President by the Trade Expansion Act of 1962 (Public
La\v X7-794). That earlier legislation allowed for inves-
tigations of unjustifiable trade sanctions (those that di-
rectly violated GATT). Consequently, the act applied
only to goods covered by GATT (which at the time ex-
cluded agricultural products, including tobacco). Set-m
tion 301 expanded presidential authority to include
trade in all C.S. goods and services and allowed the in-
vestigation of practices that were unreasonable but did
not necessarily violate GATT. If negotiations were not-
successful in ieducing or eliminating the unjustifiable


or unreasonable limits on trade, Section 301 authorized
the President to impose retaliatory trade sanctions. Ini-
tially, Section 301 recei\,ed little attention, although it
rz-ould later become a rvidely used tool of U.S. trade
policy (Nivola 1993).

  Section 301 of the Trade Act of lY73 \vas strength-
ened by the Trade and Tariff Act of 1984 (Public Lab\
98-573) and the Omnibus Trade and Competiti\.eness
Act of 1988 (Public La\1 100418). NOM. known as "Su-
per 301," the section required the U.S. Trade Repre-
sentati\,e to annually identify countries and their
practices that consistently limited market access to ti.S.
firms. More important, if negotiations failed to elimi-
nate the unfair trading practices of these countries,
mandatory retaliatory measures \vere to be imposed
unless the President deemed these measures harmful
to U.S. economic interests.

   Four Section 301 cases in the late 1980s dealt \j.ith
cigarettes: cases against Japan in 1985 and Taiil-an in
1986 were initiated by the U.S. Trade Reprtsentati\,t
at the President's request, and cases against South
Korea in 1988 and Thailand in 1989 ivere the result of
the U.S. Cigarette Export Association's petitioning of
the U.S. Trade Representati\,e. Threats of retaliatorv
sanctions under Section 301 led to agreements tvith
each country; as a result, U.S. cigarette firms \vere per-
mitted access to those markets. The opening of the
markets resulted in aggressive tobacco ad\,ertising by
U.S. firms (Roemer 1993). Each of the four newly
"opened" countries has la\vs, regulations, and ordi-
nances concerning cigarette advertising and promo-
tion. The go\,ernments of some of the countries ha\,e
alleged that U.S. cigarette companies have violated
restrictions on advertising and promotion.

   A brief review of the four Section 301 cases fol-
lows; more details are contained in reports from the
GAO (1990, 1992), and an empirical analysis of their
impact on cigarette smoking is contained in Chaloupka
and Laixuthai (1996).

Jayall

  The tobacco industry in Japan is largely monopo-
lized by the company Japan Tobacco Inc. In 1979, Ja-
pan was the subject of two Section 301 cases, one
involving cigars, which was prompted by the Cigar
Association of America, and a second related to pipe
tobacco, which was initiated at the request of the As-
sociated Tobacco Manufacturers. The two cases were
resolved in an agreement with Japan, which reduced
market restrictions and lowered import duties (GAO
1990).

  Before 1986, the domestic cigarette monopoly
Leas protected from foreign competition through tar-
iffs of 28 percent on all imported cigarettes and through
Japanese distribution practices, which discriminated
against imported cigarettes. The threat of Section 301
sanctions led to an October 1986 agreement that elimi-
nated Japanese cigarette tariffs and changed excise tax
payment procedures and other distribution practices
that adversely affected imports of U.S. cigarettes. Ex-
isting Japanese policies related to cigarette advertis-
ing and other promotional practices were not affected
by the agreement.

  The agreement resulted in a significant expan-
sion of U.S. cigarette firms in Japan. Japanese imports
of U.S. cigarettes more than tripled in 1987 alone and
Fontinued to rise in 1988 and 1989, by which time the
market share of U.S. firms leas more than 15 percent
(Grise 1990). This growth appeared to have slowed or
stopped in the early 1990s. Total U.S. cigarette exports
to Japan ranged from 54.0 billion to 57.7 billion annu-
alla during 1991-1993.

  A dotvn\vard trend during the 1970s and 1980s in
per capita cigarette consumption in Japan appears to
have re\,ersed itself after theJapanese cigarette markets
\verc opened to U.S. firms. Overall per capita consump-
tion appears to have remained steady or increased
slightly in recent years. However, among Japanese
\lomen, smoking prevalence rose from 8.6 percent in
1986 (before the agreement) to 18.2 percent by 1991. The
1991 rates \vere even higher among young adult women
(27 percent) (Connolly and Chen 1993).

  Part of this increase may be the result of adver-
tising and promotional activities by U.S. cigarette firms
in Japan. Between 1987 and 1990, total expenditures
on cigarette advertising and promotion by U.S. ciga-
rette companies in Japan nearly doubled. Most of these
expenditures tvere on television advertising, which is
allowed in Japan (but subject to some restrictions).
Before the agreement, the domestic monopoly did not
engage in extensive advertising. Afterward, it signifi-
cantly expanded its advertising and promotional ef-
forts. As a result, cigarette advertising moved from
40th to 2nd place in total television advertising in Ja-
pan (Sesser 1993).

Tnizvafr

  Virtually all aspects of the tobacco industry in Tai-
wan are controlled by a state-run monopoly. In 1986,
the U.S. Trade Representative threatened Taiwan with
retaliatory trade sanctions over several governmental
policies that limited the market access of U.S. cigarette
companies. These policies included quotas and tariffs


011 im}wlkd 'is< IrcttLls, `1 twii 011 the rt?ail salt ot ini-
pc~rted cigarettes, and a ban on print ad\-t\rtisin;: of
imported cigarettes. An agreement \\`a~ reached in De-
cember 1986 that reduced tariffs and eliminated other
barriers, thcreb!. allort+ng C.S. cigarette companies
greater access to the TaiIvanese cigarette market. The
agreement also contained se\-era1 restrictions relating
to cigarette packaging (rzhich \vas required to haIre a
specified health \f,ai-ning label) as ~~ell as ad\,ertising
and promotional acti\-ities (e.g., the distribution of free
samples IVES limited and poiiit-of-t7urchase promo-
tions \vere restricted to licensed establishments).

  The agreement greatlv increased C.S. cigarette
companies' access to the Tai\\anese cigarette market.
In 1987 alone, total L'S, cigarette shipments to Taitvan
increased 3+fold, and the market share of U.S. ciga-
rette companies rose from 2 to 17 percent (Grist 1 YYO);
by lYY7, the mark& share of imported cigarettes had
risen to 30 percent (Hsieh ancl \r'in lYY8). Moreover,
TaiLvan's imports of relati\.elv higher-quality U.S. to-
bacco rose, as the portion of U.S. tobacco in Tairvanese
cigarettes increased from 35 to 55 percent to better com-
pete \z,ith imported cigarettes (Grise 1YYOi. Ho\:,ever,
per capita consumption of cigarettes, after increasing
somet\-hat during the 19705 and earlv IYHOs, tell from
1957 through 1996, due to public and $1 ate antismok-
ing policies (Hsieh and \I'in 1998). Smoking pre\-alence
among Tailvancse \~omen significantI\, increased in the
late lY8Os and has remained stables throughout the
1990s (Hsieh and l'in lc)Y8).

  Adwrtising and promotion of U.S. cigarettes af-
ter the agreement are likelv to ha\-<, contributed to the
large rise in the market share of U.S. cisarctte compa-
nies in T<ii\\,an. Before the agreement, the onI\, ad\,er-
tising and promotion permitted b!, the Tai\\.nn-Tobacco
dr Wine Monopol~~ Bureau \t.erc ne\\. product announce-
ments and the use of billboards in tlic Lmrf;lu's brdiirli
offices and distribution centers (GAO lYY2). In 1987,
spending on ad,.ertisiii $ and promotional acti\.ities b\.
U.S. cigarette firms in Tail\-an rose sharpI>, but fcil
somel\.hat in the next three \`ears. Ne\-ertheless, total
spending rose b)' -l3.8 per&t from 1 Y87 to IYYO (GAO
1 YY2). Gi\,eii preagreement restrictions on ad\.ertis-
iii:< and promotion. almost all of these r\peiiditurc>s
rzould have been for poj,it-of-I-7Lirchase and magazine
ad\.ertising. Xd\.ertising by the Tailvanese cigarette
moiiapolv. ho\j.e\.er. ~vds limited elen further after the
ageement.

  Authorities in TaiI\,an ha\-e alleged that point-of-
purchase promotional acti\.ities bv L'S. cigarette com-
panies ha1.e violated the terms of the lYX6 agreement
(GAO 1992). The agreement limits these activities to li-
iensed \~.holesale, distribution, and retail establishments,

Lvhich the Taiivan Tobacco & Wine Monopoly Bureau
defines as those with a permit registering them as
profit-seeking enterprises. Taiwanese authorities con-
tend that U.S. cigarette firms have distorted this defi-
nition to include unlicensed retailers selling cigarettes,
resulting in Midespread advertising and unauthorized
sales of U.S. cigarettes (GAO 1992).

  After 1987, the government of Taiwan enacted
several strong tobacco control policies, largely in re-
sponse to the liberalization of cigarette trade resulting
from the Section 301 agreement (Hsieh and Yin 1998).
Many of these policies were initially rejected by the
U.S. Trade Representative as unfair or discriminatory
toward the tobacco industry and in violation of the
1986 agreement. One contentious issue pertained to
the health warning labels proposed for cigarette ad-
iwtising and packaging. The Taiwanese government
initially proposed a set of strong, rotating health warn-
ing labels that would appear on the front of cigarette
packaging and on all advertising. In response to the
U.S. Trade Representative's opposition, the content of
the label M'as changed to "excessive smoking is dan-
gerous to health," and the label was placed on the side
of packaging (Hsieh and Yin 1998). Eventually, in 1992,
the labels were changed to include six rotating warn-
ings communicating more specific information about
Ihe hazards of smoking.

  The dispute over the Smoking-Hazards Pre\:en-
tion Act, introduced in 1991 \z.ith the stated aim of pro-
tecting the public health by pre\,enting and controlling
damage from tobacco products, \vas even more COP
tcntious (GAO lYY2). The aim of the act \yould be ac-
complished by prohibiting smoking bv those under
IS vears of age, banning \w~ding machine sales of to-
bacco products, limiting the tar and nicotine content
of all cigarettes, rquiring that the packaging of all to-
bacco products include not only health warning labels-
but also tar and nicotine content in Chinese, and ban-
ning all tobacco aj\.ertising and certain other promo-
tional activities. The act \vas immediately challenged-
by the U.S. Trade Representative as a unilateral \,iola-
tion of the 1986 agreement that allowed U.S. cigarette
companies to ad\,ertise in Taiwan (GAO 1992). Sesser
(lY93) reports that a confidential position paper drafted
by the U.S. Trade Representative in January 1992 stated
that the proposal was an attempt to protect the Tai-
ilanese cigarette monopolv from foreign competition
and that the various measures proposed would have
little impact on smoking. In July 1993, the Clinton
administration's US. Trade Representative, Michael
Kantor, stated that his office would not challenge the
act if it was enacted (Sesser 1993). Six years after its
introduction, the Smoking-Hazards Preirention Act l\.as


finall\- enacted j\,ith compromise clauses that permit
cigar&e ad\,ertising in magazines (Hsieh and l'in 19YS).

South Karen

  South Korea's Tobacco & Ginseng Corporation
controls all aspects of that countr\,`s tobacco grn\\-ing
and production, l\.hich hacl traditionall\, been prw
tected bv high tariffs imposed on foreign cigarettes.
In lY82,-South Korea enacted and aggressi\.elv en-
forced legislation making it a criminal offense t(, sell,
bu),, or possess foreign cigarettes (Edd!, and Walden
lYY3). Beginning in 1987 , almost all cigarette ad\.er-
tising and other promotional activities \j.ere banned
b!. the Tobacco Monopol?. Act. After petitioning b!z
the U.S. Cigarette Export Association in Januarl. 1988,
the U.S. Trade Representati\.c in\.estigatcd these prac-
tices. In response to the threat of retaliator\, sanctions
on South Korean textile eNports to the United States, a
Record of Understanding \~as signed hi. the t1x.o coun
tries in May lY88. This agreement opened South Ko-
rt'an cigarette markets to C.S. firms b\. eliminating the
ban on the sale of foreign cigarettes, I-educing tlic tar-
iff on imported cigarettes, alIn\\-in g tht> distribution of
free samples, and allolviii s some print acl\-ertising of
cigarettes and the sponsorship of sporting e\wits. The
agreement also prohibited ad\-ertising that targeted
\vomen and voung people (smoking is prohibited in
South Korea-for persons under 30 wars of age). Fi-
nall\J, all cigarette packagin g and niagazine ad\.ertis-
ins i\.ere required to include a health \\.arning label.
  Although cigarette smoking had been increasing
steaclilv in South Korea during the 19X&, the rate of
oroiztl; in smoking more than tripled ~vhen cigarette
h
markets M'ere opened to foreign competition (Roemer
1993). Much of the increase appeared to have been the
result of dramatic increases in smoking pre\.alence
among voung people. From 1988 to 1989 alone, smok-
ing pre\,alence among male teenagers rose frotll I8 to
30 percent, and smoking pre\.alence among female teen-
agers increased from 2 to 9 percent (Sesser 1993). hluch
of the increase in consumption \~as accounted for bv
the increased use of imported cigarettes. Import share
in the market rose from 0.06 percent before the agree-
ment to nearlv 8.5 percent in 1993 and continued to in-
crease steadilv (U.S. Department of Commerce, Tobacco
Export Task Force Analvsis, unpublished data, No\.em-
ber 13,1995). Part of th; increase mavbe attributable to
an increase in adjrertising bv U.S. cigarette companies
in South Korea after the liberalization of cigarette trade.
In late 1988, South Korea passed the Tobacco Business
Act (effective January 1, 19891, xl-hich limited ad\,er-
tising and promotional efforts to p"int-of-yurchasc

ad\-crtising, magazine adlrertising, and sponsorship of
public e\.ents (GAO 1992). In 1991, the Korea Tobacco
Association (comprising the U.S. Cigarette Export As-
sociation firms and the Korean tobacco monopoly) out-
lined a self-regulating voluntary marketing agreement
to comply \vith the Record of Understanding and the
Tobacco Business Act.

  Ne\,erthelcss, the South Korean government in-
dicates that some promotional activities of U.S. ciga-
rette companies \,iolate the spirit of the Tobacco
Business Act. These allegations concern distribution
of free cigarettes, advertising placement for televised
c\.t`nts sponsored bv U.S. tobacco firms, the distribu-
tion of nontobacco. "gifts" bearing company trade-
marks, r7nd the targeting of youth. Although no formal
actions related to these I,iolations were initiated, the
Koreans did begin renegotiating the Record of Under-
standing i\,ith the United States in 1995. In August
lYY'i, the UniteJ States government agreed to modify
the market access agreement \\rith the Koreans to al-
ln\v them greater flexibilitv to impose nondiscrimina-
tnr!, health-based measures that restrict the use of
tobacco products, including limitations on tobacco
product ad~.ertising.

  Perhaps the most publicized and contentious
Section 301 dispute Ilas initiated by the U.S. Trade
Representati\-e in response to petitioning by the U.S.
Cigarette Export Association in April 1989 over
Thailand's \,irtual ban on the import of cigarettes and
complete ban on cigarette ad\,ertising and other pro-
motional activities in that country. The complaint cited
\-arious restrictions on the importation and sale of ciga-
rettes and referred to discriminatory duties and taxes
on cigarette imports (GAO 1992). `All aspects of the
domestic tobacco markets in Thailand are controlled
by a go\.ernment-run monopoly, which stopped its
0w.n cigarette advertising and promotion in April 1988.
Ho\j.ever, foreign companies continued their activities,
\vhich prompted a total government ban on cigarette
ad\,ertising in Thailand in February 1989. The formal
investigation began in May. After no agreement could
be reached, the U.S. Trade Representative consented
to submit the complaint to the GATT dispute resolu-
tion process.

  The panel created by GATT investigated the U.S.
complaint that the import barriers and advertising
restrictions lvere a \riolation of the international
agreement's principles.  In October 1990, the GATT
Council sustained the panel's recommendations and
ruled that the ban on imports \\.as a \.iolation of the


GATT treaty. However, the council upheld the high
Thai cigarette excise taxes (applied to both domestic
and foreign cigarettes) and the right of the government
to restrict the overall supply of cigarettes. Regarding
the Thai advertising ban, the council noted that GATT
allows member nations to use lrarious policies to pro-
tect public health if the policies are applied to both
domestic and foreign products. A cigarette advertis-
ing ban that made it difficult for new foreign firms to
compete with existing domestic firms was ruled justi-
fiable under the treaty, because alloying advertising
could stimulate the demand for cigarettes, particularly
among youth (Contracting Parties to the General
Agreement on Tariffs and Trade 1991; Roemer 1993).
This decision teas based on Article XX of GATT, which
states that:

Subject to the requirement that such measures are
not applied in a manner which p1-ould constitute a
means of arbitrary or unjustifiable discrimination
between countries where the same conditions pre-
vail, or a disguised restriction on international
trade, nothing in this Agreement shall be construed
to prevent the adoption or enforcement by any
contracting parties of measures necessary to
protect human health [or] necessary to secure
compliance with 1aM.s or regulations which are not
inconsistent with the provisions of this Agreement.

  The GATT ruling led to an agreement in No\,en-
ber 1990 betlveen the Cnited States and Thailand that
allowed the importation of U.S. cigarettes into Thai-
land. Imported cigarettes were then subject to the same
laM-s and regulations as those marketed by the Thai
Tobacco Monopoly (GAO 1992). Thus, U.S. cigarettes
would be taxed the same and subjected to the same
supply restrictions, and the adlpertising and promo-
tion of these cigarettes (including the use of cigarette
company logos, trademarks, and other symbols on
nontobacco products) \vould be prohibited. The Thai
government, however, has indicated that U.S. cigarette
companies have tried to circumvent the ban on pro-
motional activities bv tactics such as sponsoring sport-
ing events and placing cigarette logos or symbols in
televised programming. No formal complaints ha\,e
been filed.

  After its SLICC~SS in upholding the ban on adver-
tising and promotion, the Thai government in 1992
enacted two la\vs restricting smoking: the Non Srnok-
ers Health Protection Act and the Tobacco Products
Control Act. The first act restricted smoking in desig-
nated public places. The second \vas a comprehen-
sive act that required that all tobacco products disclose

their ingredients, allowed the Ministry of Public Health
to determine all aspects of labeling, including health
warnings, and banned the following: smoking by
those under 18 years of age (imposing fines on viola-
tors); vending machine sales; distributing free samples,
exchanges, and gifts of cigarettes; tobacco advertising
(including, under the Thai definition of advertising,
the use of cigarette logos and other symbols on
nontobacco products) except in international maga-
zines and live telecasts originating outside Thailand;
advertising products with the same name as tobacco
products; producing, importing, advertising, and sell-
ing products imitating tobacco products; and selling
cigarettes not complying with th? labeling provisions
(Roemer 1993).

  The cigarette trade agreement that opened the-
Thai cigarette market to US. firms has led to a rise in
imports from less than 1 percent of the market before-
the agreement to about 4 percent in 1993. Because of-
current trends, this change is likely to increase sub-
stantially in the future (e.g., U.S. cigarette exports to
Thailand rose by more than 56 percent from 1992 to
1993). Part of the increase may be the result of in-
creased smoking prevalence among women and young
people in Thailand (USDA 1994a).

Multinational Trade Agreements

The North American Free Trade Agreement

  In 1993, the United States approved the North
American Free Trade Agreement (NAFTA), a compre-
hensive agreement that eliminated most of the barri-
ers to trade between the United States, Canada, and
Mexico; implementation began January 1, 1994. This
agreement further reduced already low trade barrier:
betrveen the United States and Canada resulting fron
an earlier free trade agreement. More important, the
nect agreement substantially reduced existing trade
barriers between the United States and Mexico b)
eliminating all nontariff barriers to trade and by phas-
ing out most tariffs. Mexican tariffs on U.S. tobaccc
and tobacco products were initially set at 50 percent
the 1998 rate was 25 percent. Supporters of the agree
ment argued that it would lower prices, lead to a ne
increase in jobs (particularly in export industries), ant
spur economic growth in all three countries. Oppo
nents countered that U.S. firms would have an incen
tive to shift production to Mexico to reduce labor ant
other operating costs, thereby leading to a net reduc
                       -
tion in C.S. employment.


  Before the agreement, some trends in tobacco
production in the United States, Canada, and Mexico
\vere similar. Total tobacco production and acreage
de\.oted to tobacco grooving in 1990 lrere rvell belo\\
their 1981 levels in all three countries, but doIvnlvard
trends in the United States had reversed b\r 1987. Sim-
larl"; in recent years, tobacco production in Mexico has
been expanding (USDA 1997cl). During the 1980s and
earlv 199Os, cigarette consumption fell sharplv in both
the United States and Canada but rose in Mixico. At
least part of the increase in the Mexican demand fnt
cigarettes resulted from increases in income, \vhich
contributed to a shift to the consumption of higher-
quality cigarettes among Mexican smokers (USDA
1992). Since 1991, ho\Vel.er, cijiarettc imports into
Mexico have fallen as consumer purcliasins po\\.t't
declined; no imports \vere expected in 19% (USDA
1997d).

  Trade in tobacco among the three countries \vas
relati\,elv limited before the agreement. Mesican e\-
ports of iobacco to the United States I\-ere about 3 per-
cent of total esports, or less than 2 percent of total U.S.
tobacco imports. Similarly, less than 1 percent of L.S.
tobacco imports came from Canada, and about 7 per-
cent of U.S. tobacco exports event to Canada. Finally,
almost no tobacco \vas exported from the Cnited States
to Mexico (USDA 1992).

  Trade in tobacco products (mainly cigarettes) \j.as
even more limited before the agreement. In 1990, just
over 0.1 percent of total U.S. cigarette exports \Vetit to
blexico, and only 0.07 percent \2-ent to Canada. Simi-
larly, there \vas no trade in cigarettes betlveen Canada
and Mexico. The only exception \vas for exports of
cigarettes from Canada to the United States, ~~hich
\vere almost 64 percent of total Canadian cigarette ex-
ports and almost 20 percent of total Canadian produc-
tion (USDA 1992). However, as is discussed later in
this chapter (see "International Tobacco Taxes"), most
of these cigarettes M'ere reintroduced into a Canadian
black market to evade the significantly higher Cana-
dian cigarette taxes (Sweanor and Martial 1994).

  Because of the earlier free trade agreement be-
tween the United States and Canada, NAFTA does not
appear to have had a significant impact on trade in
tobacco and tobacco products between the tw.0 coun-
tries. If anything, the reduction in Canadian cigarette
taxes in 1994 has led to a substantial reduction in Ca-
nadian cigarette exports to the United States, as the
smaller differential in cigarette prices reduced the in-
centive to export cigarettes to the United States for
bootlegging back into Canada.

  The agreement's elimination of Mexican import li-
censes on tobacco and cigarettes, and gradual reduction

in Mexican tariffs on tobacco and tobacco products,
holyever, \vere expected to increase Mexican imports
of both flue-cured and burley tobacco as well as ciga-
rettes from the United States (USDA 1992). The elimi-
nation of U.S. tariffs on Mexican tobacco and the
impro\.ed quality of this tobacco wrere also expected
to result in increased Mexican tobacco exports to the
United States. I'ri\,atization of the unmanufactured
tobacco industry in Mexico, however, has changed the
nature of the industry and has led to an improvement
in the quality of Mexican leaf tobacco (USDA 1997d).
The slog\- elimination of tariffs and the improved qual-
ity of domestically grobvn tobacco, coupled with the
decline in the \-alue of the peso, appear to have lim-
ited the impact of NAFTAon trade between the United
States and Mexico in tobacco and tobacco products.
This ma\ change, ho\\-e\-er, as tariffs are further re-
duced and, el,entually, eliminated and if the peso con-
tinues its recent strengthening against the dollar.

  This latest GATT agreement, which concluded in
April 1991, in\rol\,ed 117 countries, and many other
nonmembers have agreed to abide by its provisions.
Formal appro\.al of the agreement by the U.S. Con-
gress came at the end of 1994.

  Se\,eral basic principles are outlined in GATT: a
commitment to achieving free trade by limiting and
eventually eliminating tariff and nontariff barriers to
trade, the notidiscriniinator); application of any restric-
tions on trade to all member countries, the compensa-
tion of trading partners for any damages resulting from
changes in trade barriers, and the negotiated settle-
ment of any trade disputes through an orderly pro-
cess rather than through retaliation. However, GATT
has had no enforcement power.

  Since the conclusion of its first round in 1947,
GATT has led to sharp reductions in tariffs and other
impediments to trade in manufactured goods. Before
the most recent round, GATT had not been applied to
trade in agricultural commodities or services. The 1994
Uruguay Round, however, significantly expanded
GATT's coverage to include trade in agricultural prod-
ucts, ser\,ices, and more. Moreover, the new agree-
ment created the World Trade Organization, a
permanent forum for GATT members to address trade-
related issues among member countries. This forum
strengthened GATT's ability to resolve trade disputes.

  Supporters of the GATT treaty have argued that it
Lvill lead to a substantial increase in world trade to the
economic benefit of all countries inv-olved. For example,
President Bill Clinton stated in the introduction to the


L~LI~LI~!. Round .~gret~niciits .,\ct that the treat), ~\.htw
fullv implemented, ~~.ou]d add 5100-X1(1 billion to the
L.Sl econoni\. annuall\, and \j,ould create hundreds of
thousands of ne\v jobs.  He \\-ent 011 to note tll`lt be-
cause the United States is the \rorld's largest trading
nation, it \VOLII~ be the biggest bencficiari~ of the treat\
CC .S. Congress 1 YYl).

  The Urugua!, Round of GATT \j'as expected to
benefit the U.S. tobacco industry by reducing the his-
torically high tariffs on tobacco and tobacco products
imposed in numerous countries and bv reducing other
lvidelv used nontariff barriers to trad-e. For example,
the European Communitv \\uLII~ reduce tariffs on ci-
gars by 50 percent, tariffs & cigarettes and other manu-
factured tobacco products bv 36 percent, and tariffs
on unmanufactured tobacco bv 20 percent, and the
Philippines \\.auld reduce tariffs on leaf tobacco, ci-
gars, and cigarettes bv 10 percent (USDA 1YWb). Sim-
larlv, foreign access to U.S. markets \\.ould rise, as U.S.
tariifs on cigar lvrappers lvould be eliminated. At the
same time, U.S. tariffs on cigar filler and binder to-
bacco, cigars, and most cl+
              `crirettes 1~0uld be reduced
by JS percent; tobacco stems and refuse LX, 20 percent;
and other unm~~nuiacture~l toL?acco and smoking to-
bacco bv 15 percent (USDA 39Y4b).

More important, Section 472 of the Lrugua!,
Routid Agreements Act allon.ed the President of the
United States to \\.ai\.e Section I lOri(a) c)f the Omnibus
Budget Reconciliation Act of lYY3 if he determined that
this action \vas necessarv or appropriate to conipl\~
\t.ith international trade aqeements that include thi>
United States. As noted pre\.iousl>., the IYY3 lcgisla-
tion recluiring that cigarettes manufactured in the
United States include a minimum of Z percent dc)-
niesticall\, gro\\`n tobacco or face penalties \\.a.5 \\.ai,.ed
b>, President Clinton's tariff rate-quota proclamation
in September 199-I.

   The redactions in t~~bacco-rcl`ite~l trade barriers
achie\.ed in the Uruguay Round appear to ha\.e had a
dramatic impact on global trade in tobacco and tobacco
products (Chaloupka and Corbctt IYY8). From IYW to
1997, for example, there \~as a 12.5percent increase in
unmanufacturecl tobacco exports globall\~, follows ing a
decade of almost no grol\.th; similarli; global cigarette
exports rose bv 12 percent from 199.3 to I YYh, l\Iiile glo-
bal cigarette c&sumption rose by, 5 percent (Chaloupka
and Corbett 1998). As discussed pre\~iousl~~, ho\Ve\,er,
the GATT Council's resolution of the tobacco-related
dispute bet\\-een Thailand and the Cnited States clearl\*
indicates that the adoption and implementation of
strong tobacco control policies aimed at improving
public health is consistent L\.ith the liberalization of
trade.

Discussion and Recent Developments

  The threat of retaliatory trade sanctions undel
Section 301 of the Trade Act of 1974 has successfu]]\-
opened some foreign markets to U.C cigarette manL]-
facturers, thereby significantly expanding trade in to.
bacco products between the United States and these
countries. Chaloupka and Laixuthai (1996), in their
empirical examination of these agreements, concluded
that the market share of L.S. cigarette companies in
the affected countries 1~2s 600 percent higher, on a\.-
erage, in 1991 than it should have been in the absence
of these agreements. More important, they concluded
that o\.erall cigarette smoking rose as a result of the
Section 301 agreements. Chaloupka and Laixuthai
(I 9%) estimated that per capita cigarette consumption
in 19Yl \vas 10 percent higher, on al'erage, in the four
countries than it should ha\,e been had the markets
remained closed to U.S. cigarettes. They attributed the
increase in smoking to gwater competition in the cig-
rette markets, resulting in 1oIrer cigarette prices and
increased cigarette ad\,ertising. In addition, they pre-
dieted that similar actions in other historically clowd
countries ~~-0uld lead to similar increases in cigarettt
smoking:.

  SimilarI>., the imylemcnt~itioli of multinationa
algrwnients liberalizing trade, including trade in tr>
bacco and tobacco products, is likely to further increase
L`.S. clports of tobacco and tobacco products to COLIU
tries around the \\wrld. A probable consequctic~~ 0
this incrt>ase is that the prices of cigarettes and othe
tc>bacco products \\.ill fall as trade barriers are reduce-c
or eliminated and competition is enhanced. As is di\
cusst~l in dt,tail later in this chapter (see "Effect of Prim4
on Demand for Tobacco Products"), reductions in prier
\\.ill stimulate the uw of cigarettes, particulnrl\r ~llll~i~l~
`lclolt+xcYlts `17ld \ oun g adult5 Bcc~lLlse ot the sLlL~~t<lll
tial health cons~equences associated \\,ith cigirctts
smoking, one likelv result of the increased liberalija
tion (IF trade in tobacco and tobacco products, then, i
;1 global increase in rnorbiditv and mortnlitv related Ii
cigarette smoking and other tobacco use. Recent ehtj
mate5 confirm the relationship betn-een trade liberal
i/ation and tobacco ~1st'. Tavlor and colleagues (i
press) conclude that reductions in trade barriers SIC-
balls ha\.e led to increased tobacco use, kvith tht, lars
est impact in lore- and middle-income countries.

  The apparent conflict bct\\feen some L'.S. politic
that promote free trade and help U.S. firms enter f01
eign tobacco markets and other U.S. policies that bnt
discouI-alge smoking; domesticallv and support intern;
tional efforts to reduce tobacco ~7se has been descriLw
in tl\-o GAO reports. The reports \\`ere completed `


.  Rather than ha\-ing one polic!. dominate, Congress
could require that health matters be included in
the tr;tcle police process through the participation
  of the LSDHHS so that these issues could be con-
  sidered case b\, case.

  Se\,rral factors indicate that the apparent cli-
~hotomy bct\veen trade and health policy is changing
in fa\.or ot' the third approach suggested bv the GAO.
For example, in 1989 d bill \\.dci introducecl 111 Congress
to (I) require U.S. cigarette firms in foreign markets to
operate under the same ' :guidelincs as the\. do in do-
mestic markets, (2) mandate health learning labels on
all exported tobacco products, and (3) sti-oiigl>~ discour-
dge the esecuti\.c branch from assisting U.S. tobacco
conipan\i efforts to open forei,
                   `~711 tobacco mdrket5
t Knenier~ lYY3J. Later that \sear. as ;I result of the U.S.
Trade Reprewnt,lti\ c'\ in\ cstigdtion ot Thdil~iiid'~
trdde practices, `3 public hedrin, l' 011 the i`l5C' L\ `15 IlCld

Sumerous congressmen, public health officials, and
others (including former L;.S. Surgeon General C.
E\,erett Koop) testified against tobacco-related U.S.
trade policies (Eddy and Walden 1993). Although nei-
ther effort Leas successful (the bill did not pass, and
the hearing produced ii0 change in trade policy), both
linhcd the issue vf the health consequences of tobacco
LIW to U.S. trade polis\,. The 1990 GAO report, for ex-
Ll~npl~, \\.as the direct ;csult of the failed 1989 bill.

  More rcientlv, interagencv discussions betlveen
the cjtfic`e of the U.S. Trade Ripresentative and offi-
ci,jls from the USDHHS ha\,e pursued the harmoniza-
tion of trade and health policv Lvhile representatives
tram the LSDHHS ha\ e participated in recent nego-
tiations \\.ith T;lii\-an, South Korea, and others concern-
in;: cigart>ttc trade issues (Holzman 1997). Moreover,
the U.S. Trade Reprtsentati\~c has shown greater sen-
siti\ it\, to public health concerns and has not opposed
nr,nililcrimin~t~~r~, tobacco control legislation in other
c~~untrics (Bloom .I YYX; National Cancer Policy Board
IYYS). This position has been formalized as pait of the
Doggt'tt Amendment to the Department of Commerce
and Relattd Aseiicies Appropriations Act, 1998, that
allo\\,s for the uw of Section 301 ill \`ery limited cir-
cumst,inces. Specifically, the Doggett Amendment,
spconsored b\, Lloyd Doggett (D-TX), states that:

None of the funds pro\icled bv this Act shall be
a\.ailable to promote the sale or export of tobacco
or tobacco products, or to seek the reduction or
remo\-al by anv foreign country of restrictions on
the marketing of tobacco or tobacco products, ex-
ccpt for restrictions \1.hich are not applied equally
to all tobacco or tobacco products of the same type
(Public Lar\~ 105119, Section 61X).

Similar glidelines rz.ere Distributed by the Clinton
administration to all diplomatic posts in February 1998.
These guidelines state that:

In light of the serious health consequences of to-
bacco use, the U.S. Government \vill not promote
the sale or export of tobacco or tobacco products
or seek the reduction or removal by any foreign
country of iiondisci~iiiiiiiator~ restrictions on
the marketing of tobacco or tobacco products. At
the same time, the U.S. Government will continue
to seek elimination of discriminators trade prac-
tices and lvill stri1.e to ensure that U.S. firms are
accorded the same trcatnient in fowign countries
~5 that countrv's o\vn firms and firms from other
countries (The National Economic Council and
The N~ltion,ll Styurit\. Council of the White House,


Final Guiclelincs on IHealth, Trade, and Commer-
cial Issues, facsimile transmission to all diplomatic
and consular posts, February 16, 1998).

Moreo\,er, as part of the guidelines, U.S. diplomatic
"posts are encouraged to assist and promote tobacco-
control efforts in host countries."

  Several important issues remain unresolved.
Perhaps most important is the opening of Chinese ciga-
rette markets to U.S. and other multinational tobacco
companies as part of China's World Trade Organiza-
tion accession. With more than 300 million cigarette
smokers (67 percent of men but only 7 percent of
lvomen), China is a particularly attractive market for
international cigarette producers. In recent years, U.S.
and other multinational tobacco companies have en-
tered the Chinese tobacco markets through joint ven-
tures with the Chinese government's tobacco
monopoly, the China National Tobacco Corporation
(Holzman 1997).

Economic Impact of the U.S. Tobacco
Industry

  Tobacco grooving played a key role in the devel-
opment and groll-th of the U.S. economv. Throughout
much of the 20th century, holve\,er, the-importance of
tobacco to the overall economy has diminished sig-
nificantly, although its regional and local importance
in some areas remains high.  Several recent studies
provide more detailed c\.idence concerning the eco-
nomic importance of tobacco to the U.S. economv.

A recent study by American Economics Cr&p,
Inc. ([AEG] 19%), lrhich i1.a~ funded bv the tobacco
industry, provides some information concerning the
impact of tobacco on the U.S. economy in 1994. The
report updates similar pre\,ious reports by other firms,
including that by Price Waterhouse (lYY2). AEG di-
vided the macroeconomic effects of tobacco into those
affecting the core sector, \\,hich includes tobacco pro-
duction and distribution, and those affecting the sup-
plier sector, ivhich consists of industries producing and
distributing intermediate goods for the core sector (in-
cluding the goods and services used in cigarette prc>-
duction). The analysis also separately considered
expenditure-induced impacts, Lvhich depend on the
multiplier effects associated with spending by those
in the core and supplier sectors, and tobacco-related
tax revenues, including those raised by tobacco taxes,
general sales taxes on tobacco products, and income
and other taxes on tobacco industrv emplovees and
firms. The studv estimated that in 1494, mori than I .8

million persons were employed, earning $54.3 billio
in wages and benefits, as a result of the tobacco busj
ness in the United States. Total estimated tax revenue
from tobacco were almost $36 billion in 1994. The rt
port concluded that tobacco made a significant contr
bution in every state and the District of Columbia.

  Several recent studies, however, have indicate,
that these estimates significantly overstated the ccc
nomic impact of tobacco on the U.S. economy. At th
request of the Coalition on Smoking OR Health (CSH
Arthur Andersen Economic Consulting (1993) rc
viewed the Price Waterhouse estimates for 1990. The
concluded that, as a result of several methodologic:
flaws, the Price Waterhouse "employment and job lo:
figures are grossly inflated" (p. 1). For example, of th
681,351 jobs Price Waterhouse attributed to tobacco i
its core and supplier sectors, only 259,616 were direct1
related to tobacco growing, manufacturing, warehou:
ing, and wholesaling. Of the difference, 166,791 wer
retail jobs and 254,944 were supplier jobs, most of whit
Lvere not devoted full-time to tobacco. Thus, statin
that these jobs depended on tobacco was inaccurate.

  Other studies questioned the Price Waterhous
assumption that every one job that is dependent o
tobacco creates, through the multiplier effect, an add
tiona12.35 jobs throughout the economy. This assume
effect would result because those who purchase tobacc
products would generate income for those who produc
and those who distribute tobacco, who in turn woul
spend this income on other goods and services-thereb
generating income for others, as this effect spread eve
further. Warner (1994) and Arthur Andersen Econom
Consulting (1993) noted that this multiplier effect
likely to significantly overstate the impact of tobaccf
because it implicitly makes the incorrect assumptio
that money spent on tobacco would not be spent else
Lvhere in the absence of tobacco. Instead, those func
not spent on tobacco would be spent on other gooc
and services, creating jobs and generating income th;
~rould also be spent.

   Warner and Fulton (1994) addressed these issue
by using a macroeconomic model to consider the nl
impact of tobacco on the economy of one state, Mich
gan. The Price Waterhouse study had estimated thi
direct tobacco-related employment in Michigan w:
7,721 in 1YYO and that all tobacco-related employmel
in Michigan totaled 69,575. Warner and Fulton (198
estimated that in 1992 in Michigan, 7,843 jobs direct1
depended on tobacco but that only an additional 11,28
jobs lvere either indirectly related to tobacco or induce
by spending from those whose jobs were dependeI
on tobacco. (This estimate for indirect tobacco-relate
jobs did not consider [as the Price Waterhouse estimai


did] the impact of income deri\,ed from tobacco pro-
duction and distribution in the rest of the nation and
spent on products produced in Michigan.) These re-
searchers further estimated that, in the absence of to-
bacco, total employment in Michigan should ha\.e risen
b!, about 5,600 because of a redistribution of spending
aLcay from tobacco products to other goods and ser-
I-ices, including those more integral to the Michigan
economv. As a result of the changes in employment,
total incbmes in Michigan ~\fould have been $226 mil-
lion higher in 1992 in the absence of tobacco. This
amount resulted not only from incomes associated
xvith nelv jobs but also from higher incomes for those
\lith existing jobs (in part because of a change in job
mix from lolver-income to higher-income jobs in the
absence of tobacco).

  Warner and colleagues (1996) extended this
analysis to examine the impact of tobacco on the re-
gional economies of the United States. The research-
ers examined the effects of reducing or eliminating
domestic expenditures on tobacco on nine regional
economies (the eight regions defined bv the L'.S. Dc-
partment of Commerce, Bureau of Economic Anal\,-
sis, subdi\.iding the Southeast into tit-o parts based on
tobacco grooving and producing). The\, estimated that
the elimination of spending on tobacco products in
1993 IVould ha\,e led to 303,000 fexver jobs in the South-
east tobacco region, 12-bile increasing jobs in all othci
regions bv about the same amount. B\, the \`ear 2000,
they estimated that, under this scenario, the ioss in jobs
in the tobacco region ~~ould fall to about 222,000 as
the regional economy adjusts, \Vhile the net impact
nationally \vould be an increase in jobs of 133,000. A
more realistic scenario-one that doubles the recent
rate of decline in tobacco use-is estimated to ha1.e
smaller effects on employment. Warner and colleagues
(1996) estimated a loss of 36,600 jobs in the tobacccl
region by the year 2000, an amount equal to 0.2 per-
cent of total regional emplovment. They concluded that
the industry's claims concerning job losses resulting
from reduced tobacco use are significantly overstated
and that the impact of tobacco on employment should
not be a primary concern, given the magnitude of the
toll it takes on health.

  The AEG and Price Waterhouse reports \vere lim-
ited also because thev presented static estimates of the
economic impact of tobacco (Arthur Andersen Economic
Consulting 1993). That is, the reports ignored underly-
ing trends in the domestic demand for cigarettes, trends
in the import and export of tobacco and tobacco prod-
ucts, and changes in agricultural and manufacturing
technologies that themselves are reducing employment
in tobacco grooving and manufacturing. Warner and

Fulton (199-I) considered these factors by predicting the
net impact that eliminating tobacco-related revenues
t~,ould have on the Michigan economy if existing down-
\\,ard trends in tobacco sales continued: by 2005, the
loss of re\`enue from tobacco in Michigan would yield
a net gain of 1,500 jobs in the state.

   A similar issue was considered in two recent re-
ports of the USDA (1993, 1997~). The reports noted
that the large declines in tobacco production through-
out the 1980s had a relatively minor impact on the
macroeconomics of major tobacco-growing regions.
Indeed, total personal income, adjusted for inflation,
gre\l- bv 13-57 percent from 1979 through 1989 in the
nine major regions analyzed; the average growth in
all U.S. tobacco-grooving counties was 28 percent
(USDA 1993). This phenomenon M'as attributed to the
relatil-elv small share of tobacco in these diverse re-
gional economies (on average, less than 1 percent of
total income ivas accounted for by tobacco in tobacco-
cTro\\.ing counties). E\,en though acreage devoted to
b
tobacco grooving has declined over time, rising prices
ha\,e helped to keep gross income from tobacco grow:-
in;: relati\.clv stable, lvhile clearlv reducing the share
of tobacco iti local economies (USDA 1997~).

  Critics of higher cigarette excise taxes and other
policies to reduce tobacco USE have argued that the
ni~lcroeconomic consequences of these policies would
be significant, particularly for some state and local
economies. For example, economist Dwight R. Lee
predicted that the 75-cent increase in the federal ciga-
rette excise tax included in the proposed 1993 Health
Securitv Act should lead to a loss of about 82,000 jobs
and 51 .G billion in incomes in the tobacco sector, which
\j-ould cause an additional loss of 192,000 jobs and an
attendant loss of income throughout the economy (U.S.
House of Representatives 1994). He further noted that
southern states lvould be particularly hard hit by this
tax increase.

  Similar arguments, based on the AEG and Price
Waterhouse analvses, were made in the recent debate
over proposed national tobacco legislation. For rea-
sons noted pre\Tiously, predictions based on these es-
timates are almost certain to substantially overstate the
effects of higher tobacco taxes and stronger preven-
tion policies on the U.S. macroeconomy. As discussed
previously, Warner and colleagues' (1996) regional
analysis of the economic role of tobacco concluded that
tobacco has a negative net economic impact in all
but the most tobacco-dependent region. Thus, it ap-
pears inappropriate to raise concerns about adverse
economic impact in opposing policy measures that
~~~ould cliscourage tobacco use.


  Moreo\w, nidn\. supporters ot legislation calling
for increases in the ciiarettc excise ta\ ha\ e urged that
measures be included to mitigate the p<wiible ad\.erse
economic impact of the higher taxes for tobacco-
producing regions. For example, Richard J. Durbin
(D-IL) suggested that part of the re\`enues from higher
cigarette excise taxes could be earmarked for efforts
to help tobacco farmers srz,itch to other crops, thereby
easing the transition for tobacco-producing regions.
Likewise, the CSH (1993) recommended that a portion
of new tobacco tax revenues be earmarked for buying
out tobacco allotments, constructing infrastructure and
modernizing equipment for agricultural di\rersifica-
tion, and stimulating economic de\.elopment in areas
relative117 dependent on tobacco. Similarly, President
Clinton ialled for assistance for tobacco farmers and
their communities to be included in any tobacco legis-
lation sent to him (USDA 1998a).

  A final objection to the AEG and Price Water-
house estimates is that thev failed to consider the health
and other consequences of cigarette smoking (Arthur
Andersen Economic Consulting 1993). In one sense,
they underestimated the economic contribution of
cigarette smoking. As Schelling (I%%) and Warner
(1994) note with some irony, the emplo\:ment figures
in these and other industrv-ful-tded studies do not

include the income that tobacco generates for health
care personnel, undertakers, and a variety of other per-
sons \t,hose jobs are related to the negative health con-
sequences of tobacco use; nor do these industr\;-
estimates include the considerable income derivei
from specifically smoking-related services, such as air
filtration systems. The total amount spent in the
United States to treat smoking-related illnesses has
been estimated to exceed the total amount spent on
tobacco products (Centers for Disease Control and-
Prevention [CDC] 1994; Warner 1994). Similarly, as
described in greater detail later in this chapter (ill-
"Estimates of the Costs of Smoking"), the Price-
Waterhouse study did not include other economic costs
associated kzith cigarette smoking, such as lost pro-
ductivity due to smoking-related morbidity and mor-
talitv. Finally, as Northup (1993) states, the Price
Wat&house estimates of employment dependent on
tobacco invite a disturbing comparison, for they im-
ply that "one person must die each year to sustain t\vo
jobs. Put another Ivay, at least twenty-two people must
die to support the forty-four year career of a [tobacco
industrv] employee. Surely, no one would argue that-
this is an acceptable trade-off. It is absurd for the to-
bacco industrv to use lost jobs as a rationale for not
sa\-ing li\.es" ip. X6).

Effect of Price on Demand for Tobacco Products

   One of the fundamental lades of economics is that
of the do\vnl\,ard-sloping demand cur\.c: as the price
of a product rises, the quantit): demanded of that prod-
uct falls. In the terminologv ot econonii5ts, this in\-erse
relationship arises from the process knoit-n as the
consumer's constrained utilitv maximization. That is,
r\.hen facing a gi\wi set of prices, consumerci 1%.ill trv to
maximize the benefits or satisfaction the\. recei\,e from
consuming, but these efforts are constrained L7\. the cow
sumers' available resources, including income and time.

  The demand for tobacco products is different
from the demands for most other consumer goods
because of the addictive drug (nicotine) found in these
products. The key implication that addiction has for
demand is that past consumption decisions \vill be
an important determinant of current choices.  For
example, to an addicted smoker, one of the benefits of
continued cigarette smokin g is a\.oiding nicotine

\\ithdrawal. In the past, many researchers vielbred ad-
dicti1.e consumption as an irrational behavior not cow
duci\.e to standard economic analysis (e.g., Elster 1979;
Winston 1980; Schelling 1984). This vierv implied that
the demand for addictive products, including tobacco,
did not tollol~ the basic la\~s of economics, including
that of the do\\.n\2,ard-sloping demand function that
ordinarily applies lvhen constraints (such as cost) are
raised against use. HovveL~er, as rvill be described late?
in this section, numerous studies of cigarette smoking
and other tobacco use, including several recent stud:
ies that explicitly account for tobacco's addictive na-
ture, find a strong inverse relationship betlveen price
and consumption.

  To economists, price includes not only the monc\r
price of purchasing a product but also the time and
other costs associated \vith buying and using that prod-
uct. Measures that limit minors' access to tobacco, for


example, may discourage underaged smoking by rais-
ing the time and potential legal costs associated bvith
obtaining these products. Similarly, sufficientlv strin-
gent restrictions on smoking in public places \~ill raise
the costs of smoking, M-hether by forcing people out-
doors if they want to smoke (thereby increasing time
and perhaps comfort costs) or by imposing fines for
smoking in restricted areas (thereby increasing money
costs).

  The health consequences associated M.ith ciga-
rette smoking are another important component of the
price of cigarettes. As consumers percei\.e greater
health risks from cigarette smoking, their demand for
cigarettes tends to fall. This effect is clearly seen in
the reductions in smoking prevalence and average
rigarette consumption that occurred soon after the re-
lease of the 1964 Surgeon General's report on smok-
ing and health, lvhich for the first time dre\\
r\-idespread public attention to the health problems
caused by cigarette smoking (U.S. Department of
Health, Education, and Welfare 1964). Thus, \vhen
economists and others studv the demand for tobacco
products, efforts are made to include not only mane!'
prices but also measures that reflect the other costs of
consuming these products.

  In addition to price, several other factors affect
the demand for any product. Disposable income,
for example, is an important determinant of demand.
In general, as income rises, so does consumption of
most goods. Economists define these goods as nor-
mal goods. Inferior goods, on the other hand, are those
for which demand falls as income rises. An indi\,i-
dual's tastes or preferences tvill also affect demand.
Because these tastes are difficult to observe and mea-
sure, certain sociodemographic characteristics are LISU-
ally included as proxies in studies of the demand for
tobacco. These characteristics include sex, ethnicity,
education, religious beliefs, marital status, and employ-
ment status.

  Finally, because the addictive nature of tobacco
use has been clearly documented, many recent stud-
ies of demand have tried to account for the effects of
past consumption on current consumption. Many of
these studies were based on a model that applies the
standard rational, utility-maximizing paradigm of eco-
nomics to the consumption of addictive substances
(Becker and Murphy 1988). This model explicitly rec-
ognizes the intertemporal links in consumption by
making current consumption decisions dependent on
past choices. The model thus incorporates the elements
of tolerance, reinforcement, and withdrawal, which
distinguish the consumption of addicti\,e from non-
addictive substances (LSDHHS 1988).

  Although many of the factors described in this
introduction have an important impact on demand,
the studies subsequently reviewed in this section em-
phasize the effects of money prices on cigarette smok-
ing and other tobacco use. In reviewing empirical
studies of the demand for cigarettes and other tobacco
products, this section focuses primarily on estimates
of the price elasticity of demand, which is defined as
the percentage change in consumption that results
from a l-percent increase in price. (An overall reduc-
tion in cigarette consumption comprises both a reduc-
tion in the number of cigarettes consumed by current,
persisting smok ers and a reduction in the prevalence
of smoking itself-which itself comprises both an in-
crease in smoking cessation and a decrease in smok-
ing initiation.)

  Numerous studies have estimated the price elas-
ticitv of demand for cigarettes. These studies used di-
\wse econometric and other statistical methods on
different types of data from many countries. Relatively
fe\\. studies ha\-e examined the demand for other to-
bacco products, and none have examined the effects
on brand choice of the price differentials between pre-
mium brands and the lower-price discount and generic
cigarettes.

Studies Using Aggregate Data

  Se\,eral studies of the demand for cigarettes in
the United States have used aggregate data (Table 6.7).
Some of these M'ere time series studies for the nation
as a tvhole or for geographic units (notably Califor-
nia). Others employed pooled cross-sectional time se-
ries data consisting of annual observations for some or
a11 states over time. Price elasticity (the percentage
change in the quantity demanded resulting from a
l-percent increase in price) estimates obtained from
recent studies using aggregate data fall in the overall
wide range of -0.14 to -1.12, but most of these estimates
are betr-2-een -0.3 and -0.5. Differences in the estimates
resulted from differences in theoretical and empirical
modeling, in the data employed, and in the economet-
ric and statistical methods used to analyze these data.

  All but two of these studies were econometric
studies that tried to control for other factors that could
affect the demand for cigarettes, including income,
socioeconomic and demographic factors, and exist-
ing policies for reducing tobacco use. The other two
studies (Baltagi and Goel 1987; Peterson et al. 1992)
used alternative quasi-experimental methods that
compared changes in cigarette consumption in states
with tax increases \vith those in states with no tax in-
creases; both studies obtained estimates of the price


Table 6.7. Recent estimates of the price elasticity of cigarette demand from aggregate data

Study

Advisory Commission
on Intergovernmental
Relations 1985

Estimated price
elasticity

   -0.45

Bishop and Yoo
1985

-0.45

Baltagi and Levin
1986

-0.14

Porter 1986

-0.27

Baltagi and Goel
1987

Seldon and Doroodian
1989

-0.56 (1956-1964)
-0.17 (1972-1983)

   -0.40

Seldon and Boyd
1991

Showalter 1991

-0.22 (short run)
-0.37 (long run)

-0.56 to -0.71

Simonich 1991

-0.37

Tegene 1991

-0.66 (1956)     Time series for United States, 1956-1985; Kalman
-0.15 (1985)     filter methods; allows change in elasticity over time.

Chaloupka and Saffer
1992

-0.28

Time series of state cross-sections, 1975-1985; two-step
endogenous law model; detailed modeling of short-
and long-distance smuggling.

Flewelling et al.
1992

-0.25 to -0.35

Peterson et al. 1992

-0.49

Comments

Time series of state cross-sections, 1981-1983;
ordinary least squares methods; detailed effort to
account for short-distance smuggling of cigarettes.

Time series for United States, 1954-1980; three-stage
least squares methods; simultaneous model of supply
and demand.

Time series of 46 state cross-sections, 1963-1980;
instrumental variables methods; partial adjustment
model used to account for habitual consumption.

Time series for United States, 1947-1982; two-stage
least squares methods; simultaneous model of supply
and demand.

Time series of state cross-sections, 1956-1983;
quasi-experimental methods.

Time series for United States, 1952-1984; three-stage
least squares methods; simultaneous model of demand
and advertising.

Times series for United States, 1953-1984; varying
parameter methods.

Time series of annual state cross-sections, 1956-1988;
simultaneous modeling of supply and demand with
addiction; detailed modeling of short- and long-
distance smuggling.

Quarterly time series for United States, 1960-1983;
two-stage least squares methods.

Quarterly time series for California, 1980-1990;
ordinary least squares and ridge regression methods.

Time series of state cross-sections, 1955-1988;
epidemiologic approach.


Table 6.7. Continued

Study

Keeler et al. 1993

Becker et al. 1994

Harris 1994

Hu et al. 1994

Sung et al. 1994

Barnett et al. 1995

Goel and Morey 1995

Hu et al. 1995b

Moore 1995

Tremblay and
Tremblay 1995

Yurekli and Zhang 2000

Estimated price
elasticity

-0.3 to -0.5
(short run)
-0.5 to -0.6
(long run)

-0.36 to -0.44
(short run)
-0.73 to -0.79
(long run)

-0.47 (1493)

-0.39 (long run)

-0.40 (short run)
-0.18 (long run)

-0.76 to -1.12

-0.28 to -0.37

-0.30 (state tax
elasticity)

Not applicable

-0.41

-0.48 to -0.62

Comments

Monthly time series for California, January 1980-
December 1990; detailed modeling of addiction; full
information maximum likelihood with instrumental
variables and correction for autocorrelation.

Time series of annual state cross-sections, 1956-1985;
instrumental lpariables methods; detailed modeling of
short- and long-distance smuggling and addiction.

Annual time series for United States, 1964-1993;
separate modeling of smoking participation and
average consumption; controls for changes in average
nicotine deliverv per cigarette.

Monthly time series for California, January 1984-
December 1991; intervention analysis.

Time series of annual state cross-sections for 11
ivestern states, 1967-1990; recursive model of supply
and demand M.ith addiction; generalized least squares
methods correcting for heteroscedasticity and
autocorrelation.

Annual time series for United States, 1955-1989;
simultaneous modeling of supply and demand.

Time series of annual state cross-sections, 1959-1982;
joint demands for cigarettes and alcohol; accounts for
addiction.

Quarterly time series for California, 1980-1992;
autoregressive moving-average time-series methods.

Time series of annual state cross-sections, 1954-1988;
reduced form estimates of impact of cigarette taxes on
various smoking-related mortality rates.

Annual time series for United States, 1955-1990;
simultaneous modeling of supply and demand.

Time series of annual state cross-sections, 1970-1995;
detailed modeling of smuggling and clean indoor
air laws.


elasticitv of demand comparable to those obtained in
the econometric studies.

   Several difficulties can be encountered \vhen ana-
lysts use time series data to estimate the demand for
cigarettes. In a time series model, estimated price and
income elasticities of demand are sensitive to the in-
clusion of variables controlling for the effects of other
determinants of smoking, including advertising,
changes in existing policies for reducing tobacco use,
and increased awareness of the health consequences
of smoking. A serious problem can also result from the
high correlations that are likely to exist among many of
the variables reflecting key determinants of smoking.
These correlations can lead to unstable estimates for the
parameters of interest. However, excluding potentially
important but highly correlated determinants of de-
mand could produce biased estimates of the impact of
the included \,ariables on demand. Time series esti-
mates are also more likely to estimate the short-run
responses of demand to changes in independent vari-
ables rather than the long-run responses that are of
greater interest to policymakers. HoLyever, recent
studies using state-of-the-art econometric methods
for time series data have appropriately addressed
many of these difficulties (Seldon and Boyd 1991;
Simonich 1991; Fle\velling et al. 1992; Barnett et al. 1995;
Hu et al. 1995b; Meier and Licari 1997). Almost all of
the estimates obtained from time series methods based
on alternative economic theories and applied to vari-
ous data produced estimates of the price elasticitv of
demand in a relativelv narrolv range, Lvhich ivas cen-
tered on -0.4.

   The use of state cross-sectional data over time
can also create various estimation problems. In gen-
eral, such studies considered in this section employed
data on state taxes paid for cigarette sales; these data
may not accurately reflect average cigarette smoking
within the states, because cigarettes may ha1.e been
smuggled from lolz.-tas states into high-tax states.
(This problem is discussed in detail in "Theoretically
Optimal Cigarette Taxes," later in this chapter.) In
particular, these sales data are likely to overstate COP
sumption in low-tax states and understate consump-
tion in high-tax states. If this smuggling is not
controlled for, estimates of the price elasticity of de-
mand from these data are likelv to overstate the im-
pact of price on cigarette smoki& However, many of
the most recent studies of cigarette demand that em-
ployed pooled time series cross-sectional data for states
made careful efforts to control for both casual and
organized smuggling of cigarettes (Advisory Commis-
sion on Intergovernmental Relations [ACIR] 1985;
Baltagi and Levin 1986; Showalter 1991; Chaloupka

and Saffer 1992; Becker et al. 1994; Yurekli and Zhang
2000). Although imperfect, these efforts should have
significantly reduced the biases associated with the use
of the pooled state data. When analyses controlled-
for the possible smuggling of cigarettes from low-tax
to high-tax states, estimated price elasticities of de--
mand that were based on state tax-paid sales data were
generally in the range of -0.3 to -0.5.

  A further problem in the analysis of aggregate
data arises because cigarette prices are determined by
the interaction of supply and demand. Failing to ac-
count for simultaneity would lead to biased estimates
of the price elasticity of demand. Several recent stud-
ies that employed both pure time series data and
pooled state-level data have theoretically and empiri-
cally modeled the supply and demand for cigarettes
(Bishop and Yoo 1985; Porter 1986; Showalter 1991;
Sung et al. 1994; Barnett et al. 1995; Tremblay and
Tremblay 1995). Most studies that controlled for the
potential simultaneity biases in their aggregate data
produced estimates of the price elasticity of demand
that were in the narrow range found in other studies
An alternative approach to the simultaneity problerr
is to use natural experiments, such as the large increase
in the California cigarette excise tax, to look at the im-
pact of price on demand. Several recent studies have
used this approach (Sung et al. 1994; Hu et al. 1995b)
Estimates of the price elasticities of demand based or
this natural experiment are consistent with those ir
other studies.

  Many of the most recent studies of cigarette de
mand that used aggregate data empirically modelee
the addicti\.e aspects of cigarette consumption in thi
context of Becker and Murphy's (1988) economil
model of addictive behavior (Showalter 1991; Becke
et al. 1994; Sung et al. 1994). One of the most interest
ing implications of the economic models of demant
for addictive goods, including cigarettes, concern
short-run versus long-run effects. Economists gener
ally define the short run as a period during which a
least some factors have not fully responded to th
change being examined. In contrast, the long run i
when all changes have occurred; the Congressionz
Research Service (CRS) defined the long run for ciga
rette demand as 69 years, a time period that would
allow the current 12- to 80-year-old population (whit
includes almost all smokers) to adjust to a change i
cigarette taxes (GravelIe and Zimmerman 1994). Fc
addictive goods, the long-run impact of price o
demand will exceed the short-run impaci because th
latter largely entails current consumption, which reF
resents an established addiction that tends to be s101
to decrease even in the face of a price increase. In th


studies that used such a model, the estimated long-
run impact of price elasticities of demand indeed
exceeded-by up to tlvice as much-the estimates for
the short-run impact, presumably because the long-
run impact reflected would-be newly addicted con-
sumers M'ho Ivere put off bv price increases. (These
short- and long-run effects are further discussed in "To-
bacco Taxation and RelTenues," later in this chapter.)

  Finally, studies employing aggregate data are
generally limited because they estimate the effects of
prices and other factors on aggregate or per capita es-
timates of cigarette consumption. Such studies thus
cannot provide information on the effects of prices and
other policies on smoking prelralence, initiation, ces-
sation, or quantity and tvpe of cigarette smoked. Simi-
larly, these studies can&t explore differences that sex,
age, and socioeconomic status may ha1.e on respow
si\.eness to price and other policies. Furthermore, ag-
gregate studies are of onlv limited use in considering
the health effects of changes in existing policies for
reducing tobacco use. A fe\~ recent studies ha\,e ad-
dressed some of these limitations. Harris (199-f) used
annual time series data on both smoking pre\.alence
and average cigarette consumption among smokers
during 1964-1993. The study estimated that the price
elasticitv of smoking prevalence in 1993 leas -0.738
and that the elasticity for average consumption among
smokers was comparable; the 1993 total price elastic-
itv of demand of -0.47 was comparable to that obtained
in other studies. Towrnsend and colleagues (1991) used
aggregate data on smoking prevalence and average
consumption constructed from the biennial data gath-
ered in the British General Household Surlreys from
1972 through 1990. The study found that men and
women in lower socioeconomic groups \Vere most re-
sponsive to changes in cigarette prices, that women
kvere more responsii,e to price than men, and that
smokers in the youngest age groups (16-19 years and
20-24 years) w&e least affected by price. In another
study, Moore (1995) used state data from 1954 through
1988 to analyze the effects of cigarette taxes on
smoking-related death rates. The study estimated that
a lo-percent increase in cigarette taxes would prevent
an estimated 5,200 smoking-related deaths each vear.

Studies Using Individual-Level Data

  Relatively few studies of cigarette demand have
been based on individual-level data. Table 6.8 sum-
marizes the findings of these studies for samples of
adults, and Table 6.9 presents the results of studies
focusing on adolescents and young adults.

  In general, the estimated price elasticities of de-
mand obtained from these studies were comparable
to those found in the aggregate studies. By using self-
reported measures of smoking prevalence and aver-
age cigarette consumption, these studies avoided some
of the problems associated with aggregate data on state
taxes paid for cigarette sales. Each of these studies
also carefully considered the effect that casual smug-
gling could have on their estimates of the price elas-
ticity of demand. Moreover, because an individual
smoker's purchase decisions are too small to affect the
market price of cigarettes, the use of individual-level
data in these studies a\Toided the potential simultane-
ity biases inherent in the use of aggregate data. How-
e\`er, the use of individual-level data may be subject
to a substantial ecological bias, to the extent that omit-
ted \.nriables affecting tobacco use may be correlated
\vith the included determinants of demand. Exclud-
ing these \.ariables \vill, consequently, produce biased
estimates for the included variables (see the later dis-
cussion of Wasserman et al. 1991). Furthermore, the
use of indi\~idual-lel-el data is subject to potential re-
porting biases. Studies using individual-level data
ha\-e implicitly assumed that underreporting is pro-
portional to true consumption (i.e., heavy, moderate,
and light smokers underreport by the same propor-
tion). With this assumption, elasticity estimates will
not be systematically biased.

   The use of individual-level data allows research-
ers to explore issues difficult to address adequately
lvith aggregate data. In particular, researchers can use
a tw-o-part method to distinguish between the effects
of cigarette price on two decisions: whether to smoke
(smoking prevalence) and how many cigarettes to
smoke (cigarette consumption). Likewise, the effects
of cigarette prices on smoking cessation can be inves-
tigated. Individual-level data also allow researchers
to explore the differential responses of various socio-
economic and demographic groups to changes in ciga-
rette prices and existing prevention policies. However,
the potential underreporting of cigarette consumption
can be problematic in interpreting these data (Warner
1978).

  Lewit and colleagues (Lewit et al. 1981; Lewit and
Coate 1982; Grossman et al. 1983) were the first to use
individual-level data to examine the effects of prices
and smoking prevention policies. Lewit and Coate
(1982) used data on 19,288 persons aged 20-74 years
\yho had participated in the 1976 National Health In-
terlriew Survey. The investigators first estimated the
effects of cigarette price on smoking prevalence and
then looked at the effects of price on cigarette consump-
tion. These equations \vere estimated not only for


Table 6.8. Estimates of the price elasticity of cigarette demand fpr adu!.@ from indjvjduzd-1-ye!d?Aa

Study

Estimated price
elasticities

   -0.42

Comments

Lewit and Coate
1982

Mullahy 1985

-0.47

Chaloupka 1990

   -0.60 (men)
not statistically different
from zero (women)

Chaloupka
1991 and 1992

-0.27 to -0.48

Wasserman et al.
1991

0.069 (1970)
-0.23 (1988)

Hu et al. 1995a          -0.46

Ohsfeldt et al. 1997

-0.03 (tax
elasticity, males)

Centers for Disease  -0.25 (full samplei
Control and       -0.11 (Ivhites)
Prevention 1998     -0.32 (blacks)
              -1.89 (Hispanics)
             -0.29 (at or beloit,
                 median income)
              -0.17 (above median
                  income)
              -0.26 (men)
              -0.19 (Momen)

Evans and
Ringe11999

-0.25 lo -0.56

Ohsfeldt et al. 1999

  -0.15 (tax
elasticity, males)

1976 National Health Interview Survey; ordinary least
squares methods; elasticities by age and sex.

1979 National Health Interview Survey; instrumental
variables and probit methods; detailed modeling of
addiction; elasticities by sex.

Second National Health and Nutrition Examination
Survey, 1976-1980; instrumental variables methods;
detailed modeling of addiction; elasticities by sex.

Second National Health and Nutrition Examination Survey,
1976-1980; instrumental variables methods; detailed
modeling of addiction; elasticities by age and educational
attainment.

1970,1974,1976,1979,1980,1983, and 1985 National
Health Interview Surveys; generalized least squares and
two-part methods; allow changes in elasticity over time.

California Behavioural Risk Factor Surveys, 1985-1991;
tlvo-part methods; controls for interdependence of other
behavioral risk factors and smoking.

1985 Current Population Survey, males aged 16 years and
older; treats taxes and control policies as endogenous;
elasticity estimates for prevalence only.

1976-1980, 1982, 1985, 1987-1992 National Health
Intervie Surveys; tlvo-part methods.

Natality Detail data, 1989-1992, pregnant women;
two-part models.

1992/93 Current Population Survey, males aged 16 years
and older; treats taxes and control policies as endogenous;
elasticity estimates for prevalence only.


the full sample but also for subsamples based on age
(20-25 years, 26-35 years, and 36-71 years) and sex.
Price had a greater impact on Jvhether a respondent
smoked at all than on boll- many cigarettes a respon-
dent smoked. The estimated elasticitv of demand for
smoking prevalence was -0.26 for the full sample, and
the total price elasticity of demand \vas -0.42. The ef-
fects of price were larger for younger persons: the to-
tal estimated price elasticity for persons 20-25 years
old \vas approximately double that for persons 26-74
years old. The studv also found that men, particu-
larly those aged 20-35 vears, were quite responsive to
changes in cigarette prices, lvhereas \vomen \vere al-
most unaffected by price.

  These findings regarding age are substantiated
as well by Lewit and colleagues (1981), ~~110 used data
from Cycle III of the Health Examination Sur\.ev (1966
1970) to examine the impact that prices and the anti-
smoking advertisements broadcast under the Fairness
Doctrine had on cigarette smoking among 6,768 ado-
lescents (12-17 years old). Using the same basic meth-
ods emploved in the study by Le\vit and Coate (1982),
this analysis estimated that the impact of price on ado-
lescent smoking (measured at a total price elasticitv of
-1.44) was about three times that for adult smoking
(Lewit and Coate 1982). The study by Lewit and col-
leagues (1981) also confirmed that price had a greater
impact on the decision to smoke (elasticitv of
-1.20) than on the average quantity of cigarettes eon-
sumed by smokers (elasticitv of -0.25). These findings
lvere generally supported by another analysis of data
from the 1974, 1976, 1977, and 1979 National House-
hold Surveys on Drug Abuse (Grossman et al. 1983).

  Mullahy (1985) was the first to estimate cigarette
demand on the basis of a theoretical and empirical
model treating cigarette smoking as an addictive be-
havior. This model implied that a person's smoking
decisions at any point in time are dependent on that
person's smoking history. However, unlike most of the
more recent econometric applications of addictive be-
havior, this analysis assumed that individuals behave
myopically-that is, they ignore the future conse-
quences of their cigarette addiction when making cur-
rent smoking decisions. Using data on 13,794 persons
who participated in the 1979 National Health Interview
Survey, Mullahy (1985) estimated smoking prevalence
and average cigarette consumption separately for men
and women (aged 17 years and older). In finding that a
person's past cigarette smoking had a significant
impact on current smoking decisions, the analysis
supports the hypothesis that cigarette smoking is an ad-
dictive behavior. The study also found that both smok-
ing prevalence and average cigarette consumption

w-ere in\:erselv related to cigarette prices. Finally,
Mullahy estimated that men were somewhat more re-
sponsive to price than women (total price elasticities
of demand were -0.56 and -0.39, respectively).

  Wasserman and colleagues (1991) used data from
several of the National Health Interview Surveys from
the 1970s and 1980s to consider how the price sensi-
tivity of cigarette demand changed over time. Using
a generalized linear model, the investigators concluded
that cigarette demand has become more responsive to
price over time. In the earlier years of their sample,
they found that increased cigarette prices did not re-
duce cigarette smoking. However, they estimated that,
beginning in 1985, when the overall price elasticity of
cigarette demand was -0.23, increases in cigarette
prices Lvould reduce smoking. As part of the same
study, these investigators used data on 1,891 youth
aged 12-17 years who had participated in the Second
National Health and Nutrition Examination Survey
(1976-1980). Unlike Lewit and colleagues (1981),
Wasserman and colleagues (1991) found that the esti-
mated price elasticity for youth was not statistically
different from that for adults. Indeed, the estimated
effects of price on youth smoking were not statistically
different from zero in any of the models. The investi-
gators attributed their relatively low estimates of the
price elasticity of demand to their including in their
demand equations an index that controlled for smok-
ing restrictions. This index, which was highly corre-
lated with price, had a negative significant effect on
smoking (particularly on young people's decision to
smoke). Wasserman and colleagues argued that be-
cause of the high correlation between the index and
cigarette prices, excluding this index would lead to
biased estimates of the effect of prices on demand.
Indeed, when they excluded the index from their esti-
mated equations, their estimated price elasticities were
comparable to those from other studies.

  Chaloupka (1990,1991,1992) used data from the
Second National Health and Nutrition Examination
Survey (1976-1980) in applying the Becker and
Murphy (1988) model of rational addiction to cigarette
smoking. The assumption of rational (or nonmyopic)
addictive behavior implies that individuals consider,
to some degree, the future consequences of their cur-
rent smoking decisions (which depend on past
choices). Chaloupka's estimates supported the hy-
potheses that smoking is an addictive behavior and
that the future consequences of this addiction are an
important determinant of current cigarette smoking.
Moreover, the estimated long-run price elasticity of
demand (in the range of -0.27 to -0.48) was well above
that obtained when the addictive aspects of cigarette


Table 6.9. Estimates of the price elasticity of cigarette demand for youth and young adults from
      individual-level data

Study

Lewit et al.
1981

Lewit and Coate
1982

Grossman et al.
1983

Chaloupka
1991

Wasserman et al
1991

  Not statistically different
from adults (generalized linear
modeling); not statistically different
from zero (two-part model)

Douglas and     No significant effect of prices on
Hariharan 1994     smoking initiation decisions

Chaloupka and
Grossman 1996

-0.675     -0.638    -1.313

Chaloupka and
Wechsler 1997

-0.53     -0.38     -1.11

Chaloupka et al.
1997

-0.43     -0.16     -0.59

   Estimated price elasticities

Prevalence  Quantity   Total

-1.20     -0.25     -1.44

-0.74     -0.20     -0.89

0.88     -1.55     -0.67
-0.62      0.11     -0.51
-0.93      0.91     -0.02
-0.89      0.73     -0.16

Not statistically different
     from zero

Comments

Health Examination Survey, Cycle
III, 1966-1970; ordinary least squares
methods for consumption and
smoking participation; aged 12-l 7
years.

1976 National Health Interview
Survey; ordinary least squares
methods; elasticities by age and
sex; aged 20-25 years.

(1974)
(1976)
(1977)
(1979)

National Household Surveys on Drug
Abuse, 1974,1976,1977, and 1979;
least squares methods; aged 12-17
years.

Second National Health and Nutrition
Examination Survey, 1976-1980;
instrumental variables methods;
detailed modeling of addiction;
aged 17-24 years.

Second National Health and Nutrition
Examination Survey, 1976-1980;
generalized (iterative weighted) least
squares and two-part methods; aged
12-l 7 years.

1988 and 1989 National Health
Interview Surveys; hazard models
of smoking initiation; detailed
modeling of addiction.

1992,1993, and 1994 Monitoring the
Future surveys of Bth, IOth, and 12th
graders; two-part methods; mostly
aged 12-18 years.

1993 Harvard College Alcohol Study;
two-part methods; college students
mostly aged 18-22 years.

1992,1993, and 1994 Monitoring the
Future surveys of Sth, lOth, and 12th
graders; smokeless tobacco use by
young males; two-part methods;
mostly aged 12-18 years.


Table 6.9. Continued

Estimated price elasticities

Study

Prevalence  Quantity Total

Lewit et al. 1997      -0.87 (prevalence)
               -0.95 (intentions)

Centers for Disease    -0.37      -0.21     -0.58

Control and
Prevention 1998

Douglas 1998

DeCicca et al.,
unpublished data,
April 1998

DeCicca et al.,
unpublished data,
August 1998

Dee and Evans,
unpublished data,
1998

Evans and Huang,
unpublished data,
1998

Chaloupka and
Pacula 1999

No significant effects of prices on         1987 National Health Interview
smoking initiation decisions; elasticity      Survey; hazard models of smoking
of approximately -1 .O for duration        initiation and cessation; detailed
      of smoking            modeling of addiction.

-1.32 (8th grade)
-0.95 (10th grade)
-0.71 (12th grade)
-0.03 (smoking onset, 8th to 12th grade)

1988 National Education Longitudinal
Survey; treats each wave indepen-
dently for prevalence; longitudinal
data used to estimate effect of price
on smoking onset.

-1.994 to -0.746 (8th grade)
-1.230 to -0.660 (10th grade)
-0.982 to -0.274 (12th grade)
-0.505 to -0.025 (smoking onset,

8th to 12th grade)

-2.19 to -2.Ol(Sth grade)
-1.15 to -0.94(12th grade)
-0.79 to -0.63 (smoking onset,
      8th to 12th grade)

-0.20 (1977-1992)
-0.50 (1985-l 992)

-0.928 (men)
-0.595 (women)
-0.639 (whites)
-1.108 (African Americans)

Comments

1990 and 1992 data from COMMIT*
sites; 9th graders.

1976-1980, 1982,1985,1987-1992
National Health Interview Surveys;
two-part methods; aged 18-24 years.

1998 National Education Longitudinal
Survey; treats each wave indepen-
dently for prevalence; longitudinal
data used to estimate effect of price
on smoking onset.

Re-analysis of DeCicca et al. April 1998
data with same methods; differences
in sample construction and variable
definitions.

1977-1992 Monitoring the Future
surveys; high school seniors; state-
aggregated prevalence rates; allow for
state effects and state-specific time
trends.

1992,1993, and 1994 Monitoring the
Future surveys of Sth, lOth, and 12th
graders; prevalence only; mostly aged
12-18 years.

*COMMIT = Community Intervention Trial for Smoking Cessation.


Table 6.9. Continued

Estimated price elasticities

Study           Prevalence  Quantity   Total

Harris and
Chan 1999

-0.831     -0.165    -0.996
   (aged 15-l 7 years)
-0.524     -0.255    -0.779
   (aged 18-20 years)
-0.370     -0.274    -0.644
   (aged 21-23 years)
-0.202     -0.455    -0.657
   (aged 24-26 years)
-0.095     -0.234    -0.329
   (aged 27-29 years)

Tauras 1999

Tauras and
Chaloupka
1999b

Gruber 2000

0.269 to 0.466 price elasticity of cessation

-0.121     -0.67     -0.791

-0.666     -0.059 (older teens,
  Monitoring the Future surveys)
-0.210     -0.003 (younger teens,
  Monitoring the Future sur\,eys)
-0.311     -0.029 (all teens,
  Monitoring the Future surveys)
-1.534     -1.576 (older teens,
  Youth Risk Behavior Sur\,eyJ
0.419     -0.227 (younger teens,
  Youth Risk Behavior Survey)
-0.126     -0.526 (all teens,
  Youth Risk Behavior Survey)
-0.376     -0.145 (older teens,
  Natality Detail files)
-0.240     -0.058 (younger teens,
  Natality Detail files)
-0.353     -0.124 (all teens,
  Natality Detail files)

Comments

1992-1993 Current Population Survey;
two-part methods; also considered
differential effects of premium and
discount brand prices.

Monitoring the Future survey
longitudinal data; young adults;
multiple failure duration analysis;
parametric and semi-parametric
models.

Monitoring the Future longitudinal
data formed from high school senior
surveys for 1976-1993; mostly aged
18-32 years.

1991-l 997 Monitoring the Future
surveys of 8th, IOth, and 12th graders;
1991,1993,1995, and 1997 Youth Risk
Behavior Surveys; 1991-l 997 Vital
Statistics Natality Detail files for teens
giving birth before age 19; two-part
models; state and year fixed effects.


smoking rvere ignored. Furthermore, these estimates
of the price responsiveness of demand rvere not sensi-
tive to the inclusion of variables reflecting smoking
restrictions. Chaloupka (1990, 1991, 1992) found that
young adults \vere not resp0nsiL.e to changes in ciga-
rette prices (in contrast to the findings of Lei\-it and
Coate [19X2]) and that men and less-educated persons
[Vere much more responsive to changes in cigarette
prices than \vere \\romen and more-educated persons.

  Douglas and Hariharan (1994) applied ideas from
Becker and Murphy's (1988) economic model of ad-
diction to look at smoking initiation decisions. Using
data from the 1978 and 1979 smoking supplements to
the National Health Inter\%\\- Surly, Dou,qlas and
Hariharan estimated a parametric duration model that
accounted for obserl-ed patterns of smoking initiation:
the "hazard" of smoking initiation rises sharpI>, from
ages 12 through 20 and then declines dramatically, \vith
initiation being unlikely after age 25. On the basis ot
this model, the analysis found that increases in ciga-
rctte prices had no impact on teenagers' decision5 tcl
begin smoking. Douglas (1998) extended this I\-ark
by estimating a model of the hazards of smoking in-
tiation and cessation using data from the cancer risk
factor supplement to the lY87 National Health Inter-
\rie\v Sur\:ey. Douglas also finds little empirical c`\ i-
dence that higher cigarette prices ~~~ould reduce
smoking initiation. Ho\ve\rer, the ini.estigators noted
that their estimated price effects \\ere likelv to be bi-
ased do\vn\vard because of problems tvith the mea-
surement of the price variables thev emploved.
Douglas did find, ho\ve\.er, that increas& in cigarette
prices significantly in&ease the likelihood of smoking
cessation, concluding that a lo-percent increase in price
lvould reduce the duration of smoking by approxi-
mately 10 percent.

  More recent work by Tauras confirms the findings
that higher cigarette prices induce smoking cessation
(Tauras 1999; Tauras and Chaloupka 1999a). Using the
longitudinal data on young adults from the Monitor-
ing the Future project, Tauras (1999) estimated paramet-
ric and semi-parametric duration models that allow for
multiple cessation attempts bv voung adult smokers.
His estimates indicate that thi likelihood of an initial
cessation attempt and the probabilities of subsequent
attempts rise as cigarette prices rise, \vith an average
price elasticity of cessation of 0.333. In a somewhat less
sophisticated analvsis using the same data that exam-
ined the potential-for gender differences in the effects
of price on cessation, Tauras and Chaloupka (IYYYb)
concluded that the likelihood of smoking cessation
among both voung adult men and young adult women
rises significantlv as cigarette prices rise.

  Hu and colleagues (1995a) used data from the
19851991 California Behavior Risk Factor Surveys to
estimate smoking prevalence and average cigarette
consumption through equations that accounted for the
interdependence of smoking and other behavioral risk
factors. Using txvo-part methods, Hu and colleagues
found that their estimates of the price elasticity of
smoking prevalence were significantly lower when
allowing for the interdependence of smoking and other
behavioral risk factors (such as drinking and obesity),
rzrhereas their estimates of the effect of price on aver-
age cigarette consumption bv smokers were unaf-
fected. The analysis estimated-that the price elasticity
of demand \tras -0.46 overall, -0.21 for smoking preva-
lence, and -0.22 for cigarette consumption.

  More recently, data from the 1976-1980, 1983,
1985, and 1987-1992 National Health Interview Sur-
\`evs have been used to study the effects of prices on
snioking among adults (CDC 199X). Researchers found
that both the probability of smoking and the a\`erage
cigarette consumption among smokers M'ere inversely
related to cigarette prices, \\,ith an overall estimated
price rlasticitv of demand of -0.25. In addition, they
found significant differences in price responsiveness
for \.arious subpopulations, including those defined
by ract/ethnicity, age, family income, and gender.
They found that blacks are ttl-ice as responsive as
ivhites to changes in cigarette prices and that Hispan-
ics are e\`en more price sensitive. Similarly, the re-
searchers' estimated price elasticity of -0.58 for young
adults (aged 18-24 years) is lvell above that estimated
for the full sample, lvhereas individuals with family
incomes at or belolv the sample median \vere about 70
percent more responsive to price than those with
higher family incomes. Finally, they found that men
are much more price responsive than \vomen.

  To determine Irhether smokers engage in any
form of compensating behavior in response to higher
cigarette taxes, E\rans and Farreliy (1998) focused on
the data from the 1979 Smoking and 1987 Cancer Con-
trol Supplements to the National Health Interview
Sur\,ey. These supplements \l-ere unique in that they
collected information on the brand of cigarettes smoked.
This information was converted into detailed data on
tar and nicotine content, length of cigarette, and type of
filter. The investigators found that continuing smok-
ers engage in compensating beha\?or in response to
higher cigarette taxes. That is, they found that smok-
ers in high-tax states were more likelv than smokers in
lo\\.-tax states to smoke higher-tar alid higher-nicotine
cigarettes as \vell as longer cigarettes. This compensat-
ing beha\,ior bv continuing smokers left their average
dailv tar and nicotine intake unchanged. Moreover,


younger smokers \2-ere much more likely to engage in
this compensating behavior, so much so that the higher
taxes led to an increase in average daily tar and nico-
tine intake among continuing young adult smokers.

  Recent research by Chaloupka and colleagues fo-
cused on the price responsiveness of cigarette smoking
among adolescents and young adults. Chaloupka and
Wechsler (1997) used 1993 data from 16,277 students in
140 U.S. colleges and universities to estimate the price
elasticity of cigarette smoking among young adults.
Using two-part methods, the investigators separately
estimated the effects of prices on smoking prevalence
and on average consumption among smokers after con-
trolling for restrictions on cigarette smoking and limits
on youth access to tobacco. College students, who were
mostly aged 18-22 vears, were very responsive to
changes in cigarette pi-ices. The estimated price elastic-
ity of smoking prevalence in this population was -0.53,
and the elasticity for average cigarette consumption was
-0.58, for an overall price elasticity of demand of -1.11.

  Chaloupka and Grossman (1996) employed simi-
lar methods to examine cigarette smoking among more
than 110,000 voung people participating in the 1992,
1993, and 199i Monitoring the Future surveys of 8th-,
IOth-, and 12th-grade students. Like several other re-
searchers, Chaloupka and Grossman found that smok-
ing bv vounger persons is vcrv responsive to changes
in cigaiette prices. Their estimated elasticitv of smok-
ing prevalence for this sample of mostlv 12- through
18-year-olds \~as-0.675, rvith an overall e&mated price
elasticity of demand centered on -1.313. Chaloupka and
Pacula (1999) used these data to look at the differential
response by gender and race, concluding that Young
men and young African Americans are more respon-
sive to price than young \vomen and voung iyhites.

Most recently, Tauras and Chaioupka (John A.
Tauras and Frank J. Chaloupka. Price, clean indoor air
laws, and cigarette smoking: evidence from longitudi-
nal data for young adults, unpublished data, July 1,
1998) used data from the longitudinal component of
the Monitoring the Future sur\.eys to estimate the ef-
fects of price on young adult smoking. Using 35 pan-
els formed from the 1976 through 1993 high school
senior surveys, they estimated models controlling for
unobserved state and individual factors affecting ciga-
rette demand. For their sample ofvoung adults, mostly
aged 18-32, Tauras and Chaloupka estimated an over-
all price elasticity of demand centered on -0.79. Taken
together, these estimates imply that increases in ciga-
rette prices Mould lead to relatively large reductions
in smoking among adolescents and young adults.

  This conclusion is supported by recent studies
by Lewit and colleagues (1997) and Evans and Huang
(William N. Evans and Lynn X. Huang, Cigarette taxes
and teen smoking: new evidence from panels of rc.
peated cross-sections, unpublished data, April 15,1998;
Harris and Chan 1999; Gruber 2000). Lewit and co]-
leagues used data for ninth-grade students in 1990 and
1992 collected in the 22 North American communities
from the Community Intervention Trial for Smoking
Cessation (COMMIT). They found that both youth
smoking prevalence and youth intentions to smoke are
inversely related to cigarette prices, with estimated
price elasticities of -0.87 and -0.95, respectively. Evans
and Huang estimated a somewhat smaller effect of
-0.20 for high school seniors by using annual, state-
level measures of smoking prevalence aggregated from
the 1977 through 1992 Monitoring the Future surveys,
However, they concluded that this had increased over-
time, estimating an elasticity of -0.50 for the period
from 1985 through 1992. Harris and Chan (1999), LIS-
ing data from the 1992-1993 Tobacco Use Supplement
to the Current Population Survey, provide consistent-
evidence that price responsiveness falls with age. Their
estimated elasticities range from -0.996 for 15- to 17-
vear-olds to -0.329 for 27- to 29-year-olds. Gruber (2000)
reaches a somewhat different conclusion using data
from the 1991 through 1997 Monitoring the Future
survevs, the 1991,1993,1995, and 1997Youth Risk Be,
ha\,io; Surveys, and the 1991 through 1997 Vital Sta-
tistics Natality Detail files for teens giving birth before
their 19th birthday. His estimates indicate that older
teens are relatively more responsive to price than
younger teens (approximately 17 to 18 years of age
compared M.ith approximately 13 to 16 years of age)
His estimated price elasticity of smoking prevalence
for older teens centers on -0.67, ivhile he finds thal
younger teens, on average, are not sensitive to price
In addition, he concludes that price sensitivity among
older teens is greatest for more socioeconomically dis
advantaged groups, such as voung blacks or those witk
less educated parents.

  In contrast, DeCicca and colleagues (Phili
DeCicca, Donald Kenkel, and Alan Mathios, Puttiq
out the fires: \vill higher taxes reduce youth smoking?
unpublished data, April 1998) concluded that highe
cigarette taxes have a verv small impact on smokin:
initiation among youth. -Using data from the 1988
1990, and 1992 waves of the National Education Longi
tudinal Study (NELS) of 1988, and treating each wav
separately, the investigators estimated price elasticitie
for youth smoking prevalence comparable to those di:
cussed abo\,e. Horvever, when they used the 1ongitL
dinal data to examine the onset of daily smokin


Reducirl,o Tobacco U_se

betlveen 8th and 12th grade among youth not smok-
ing in 8th grade, DeCicca and colleagues found little
effect of price. In a separate analvsis of the same data,
Dee and E\.ans (Thomas S. Dee and William N. E\rans,
A comment on DeCicca, Kenkel, and Mathios, unpb-
lished data, May 10, 1998) come to the opposite con-
clusion. Dee and El-ans made t\l-o adjustments to the
construction of the sample used bv DeCicca and
colleagues-including respondents \vith missing data
on some co\Tariates (about 20 percent of the sample)
and redefining several variables based on the categori-
cal data. After making these changes, Dee and E\,ans
estimated a price elasticity for the onset of smoking of
-0.63, consistent M'ith several of the other recent stud-
ies of vouth smoking based on cross-sectional data.
  in response to Dee and E\.ans, DeCicca and co-
leagues (Philip DeCicca, Donald Kenkel, and Alan
Mathios, Putting out the fires: \\ill higher taxes reduce
vouth smoking?, unpublished data, August 1998) COP
ducted a reanalysis of NELS data b!, using an aItern,i-
tive approach to dealing Lvith the problem of missing
data. Their reanalysis produced some\vhat more sig-
nificant estimates for the effect of cigarette taxes on
the onset of daily smoking betlveen 8th and 12th grade;
the implied price elasticities from alternati\.e specifi-
cations ranged from -0.023 to -0.X5. Ho\\-e\.er,
smaller, less significant effects are found for models
that employ cigarette prices. After obtaining separate
estimates based on race and ethnicity, DeCicca and col-
leagues concluded that higher cigarette taxes ha\,e little
impact on smoking onset bv black and \2-hite vouth
but significantly reduce on.& among Hispanic $outh
and youth of other races. The use of longitudinal data
to research the impact of cigarette tax and price changes
on smoking initiation is clearly an important and ap-
propriate step. The differing conclusions from earlier
studies of the same data suggest, hobyever, that these
discordant results should be Meighed cautiously
against the prevailing findings of recent studies.
  Finally, two recent studies by Ohsfeldt and col-
leagues (1997, 1999) examined the impact of cigarette
and other tobacco taxes on the probabilities of ciga-
rette and smokeless tobacco use by males 16 vears of
age and older using data from the 1985 and 1942/1993
Current Population Surveys. To account for the po-
tential reverse causality between demand and tobacco
control policies (including taxes), the researchers esti-
mate a simultaneous equations model. They find con-
sistent evidence that higher cigarette taxes reduce the
probability of smoking.

Behavioral Economics Studies of Cigarette
Demand

  Behavioral economics is the relatively new ap-
plication of the principles of consumer demand theory
to experimental psychology (Hursh and Bauman 1987).
In a laboratory setting, behavioral economists study-
ing addictio~i-related behaviors focus on the impact
of unit price on drug dependence, including nicotine
dependence. Price, in this literature, is defined as the
response required to receive one dose of the drug
(Bickel et al. 1993; Bickel and Madden 1999). As in
standard economic theory, a key prediction of this
branch of behavioral economics is that drug consump-
tion is in\.ersely related to price. One advantage of
this experimental approach in the analysis of cigarette
demand is that it allows researchers to study the ef-
fects of differences in cigarette prices that are many
times larger than the price differences observed in
cross-sectional data, time series data, or both. One limi-
tation, hoive\,er, is that these methods are generally
applicable onlv to dependent individuals. Thus, for
temple, their do not pertain to initiation.

In a seiies of papers, Bickel, DeGrandpre, and
their colleagues reported the results of research on ciga-
rette smoking in their behavioral economics labora-
tar!' (Bickel et al. 1991, 1992; DeGrandpre et al. 1992,
1991; Bickel and DeGrandpre 1996). In the experi-
ments, nicotine-dependent smokers were rewarded
\vith two puffs on a cigarette after the completion of a
specified number of responses. The total number of
puffs received is the measure of consumption, and the
number of responses required is the measure of price.
The number of responses required to receive two puffs
varied from 100 to 3,200, thereby allowing the research-
ers to study the impact of price on demand over a large
range of prices. As in the econometric and other stud-
ies described previously, this experimental approach
found an inverse relationship between cigarette smok-
ing and price. More interesting, however, is the nature
of the relationship between price and consumption. The
investigators found that the price elasticity of demand
rose as price rose. That is, the percentage reduction in
consumption for a given percentage rise in price was
larger at higher prices.

Studies of Smokeless Tobacco Use
and Price

  Although numerous studies have examined the
impact of cigarette prices and smoking prevention
policies on cigarette smoking, relatively few studies


ha\,e examined the corresponding issues for smoke-
less tobacco use, and \.irtually none consider such use
in di\Terse culture groups. Similarly, few analyses have
examined the possible substitution of smokeless to-
bacco products or cigarettes in response to changes in
their relative prices.

  Ohsfeldt and colleagues begin to address these
gaps in the literature in two studies of smokeless to-
bacco use (Ohsfeldt and Boyle 1994; Ohsfeldt et al.
1997, 1999). Using state-level data for males aged 16
years and older who had participated in the Septem-
ber 1985 Current Population Survey, Ohsfeldt and
Boyle examined the impact of various tobacco taxes
on the prevalence of smokeless tobacco use. Their
analysis, which controlled for other determinants of
demand, found that higher taxes on smokeless tobacco
were associated with lower use of smokeless tobacco.
The prevalence of smokeless tobacco use, however, was
positively related to cigarette excise taxes. The inves-
tigators suggested that these findings might partly
explain the growth in smokeless tobacco use among
young males during the 1980s. During this period,
when cigarette excise taxes ivere rising more rapidly
than smokeless tobacco taxes, comparatively larger
increases occurred in cigarette prices. As the research
previously described indicates, increases in cigarette
prices significantly reduce cigarette smoking. Ohsfeldt
and Boyle's analysis, howe\rer, suggested that tobacco
use overall might not be significantly reduced, because
some smokers might turn to using the comparatively
less expensive smokeless tobacco products. These find-
ings were generallv confirmed by the analysis by
Ohsfeldt and colleagues (1997) of the individual-level
data from the September 1985 Current Population Sur-
vey and their subsequent analvsis of data from the
September 1992, January 1993, dnd May 1993 surveys
(Ohsfeldt et al. 1999). The authors concluded that
higher smokeless tobacco taxes reduce the probability
of smokeless tobacco use but that higher cigarette taxes,
while reducing the probability of smoking, increase
the likelihood of smokeless tobacco use.

  Similarly, using data on young males from the
1992, 1993, and 1994 Monitoring the Future suri'eys of
8th-, lOth-, and 12th~grade students, Chaloupka and
colleagues (1997) concluded that both the pre\.alence
and the frequencv of smokeless tobacco use are in-
xrersely related toits price. Thev estimated an overall
price elasticity of smokeless tobacco demand by young
males of -0.39, with more than two-thirds of the effect
on the prevalence of smokeless tobacco use.

Cigarette Prices and Other Substance Use

  Little is known about the relationships between
cigarette prices and other substance use, whereas much
is known about the impact of cigarette price on smok-m
ing. Economists define two goods as complements if
an increase in the price of one good reduces the con-
sumption of not only that good but also the consump--
tion of the other. Conversely, substitutes are goods
for which an increase in the price of one results in an
increase in the consumption of the other. A few very-
recent econometric studies have examined the relation-
ship between cigarette prices and other substance use
(Pacula 1998a,b; Chaloupka et al. 1999; Farrelly et al.
1999; Pacula et al. 2000).

  Research on patterns of substance use among
youth generally concludes that youth begin with to-
bacco, or alcohol, or both and that some youth progress
to marijuana and other illicit drug use (Kandel 1975;
Kandel and Yamaguchi 1993; USDHHS 1994). Other
research concludes that cigarette smoking is a signifi-
cant predictor of both the probability and the frequency
of other drug use (USDHHS 1988; Henningfield et al.
1990). This research suggests that cigarettes and other
substances are complements for one another and that
higher cigarette prices, by discouraging smoking
among youth, could significantly reduce youth and
adult drinking and illicit drug use.

  Pacula (1998a), in the first econometric examinaj
tion of this "gateway hypothesis," used data from the
National Longitudinal Survey of Youth to examine tht
impact of cigarette prices in earlier years on curreni
marijuana use by young adults. Her estimates are con-
sistent with the gateway hypothesis; that is, higher pas
cigarette prices (which are expected to reduce past ciga,
rette smoking) reduce the likelihood that a young aduf
currently uses marijuana. However, she finds no rela
tionship between contemporaneous cigarette price!
and marijuana use (Pacula 1998b). Chaloupka ant
colleagues (1999) used data from the 1992 through 199~
Monitoring the Future surveys of Bth-, IOth-, and 12th
grade students to examine the relationship betweel
current cigarette prices and current cigarette smokin;
and marijuana use. They found that higher cigarettl
prices, in addition to reducing current cigarette smok
ing, also reduce current marijuana use. Farrelly an4
colleagues (1999) found similar evidence for adult
using several of the recent National Household Sur
\`eys on Drug Abuse. In addition, they found tha
higher cigarette prices reduced alcohol use. More rE
cently, using a longer time series of data from the Monk
toring the Future surveys of 12th-grade student!
Pacula and colleagues (2000) found little impact c


Reducing Tobacco Usr

cigarette taxes on youth marijuana use. The growing
evidence suggests that cigarettes and marijuana are not
substitutes for one another, implying that higher ciga-
rette prices Mill not lead to increased marijuana use,
with several studies implying the opposite-that
higher cigarette prices will reduce both cigarette and
marijuana smoking. Much more research is needed,
however, to firmly establish these relationships.

Discussion

  A few general conclusions can be dra1z.n from
these studies of the effects of cigarette prices on smok-
ing. First, increases in cigarette prices lead to signifi-
cant reductions in cigarette smoking; most studies, using
a wide variety of data and methods \1-ith \,arious
strengths and weaknesses, predict that a IO-percent
increase in price \2-ill reduce o\,erall cigarette consump
tion bv 3-3 percent. Second, the effects of increases in

Taxation of Tobacco Products

cigarette prices are not limited to reductions in average
cigarette consumption among smokers but include sig-
nificant reductions in smoking prevalence. These ef-
fects on smoking prevalence constitute both an increase
in smoking cessation among smokers and a reduction
in smoking initiation among potential young smokers.
Third, although evidence concerning the effects of
prices on adolescent smoking is mixed, the majority
of the e\,idence from recent studies indicates that ado-
lescents and young adults are significantly more re-
sponsive than adults to changes in cigarette prices.
Most recent studies found that adolescents and young
adults \vere tivo to three times more sensitive than
adults to price. Ongoing research, particularly that
based on longitudinal data, will help clarify this issue.
Finally, the limited number of studies of smokeless
tobacco use suggest that increases in smokeless tobacco
prices lvould reduce the prevalence of smokeless to-
bacco use.

  As the preceding section indicates, numerous
studies of the demand for cigarettes confirm a funda-
mental principle of economics: increased tobacco
prices will reduce tobacco use. In general, several fac-
tors will determine the retail prices of cigarettes and
other tobacco products. For example, factors that re-
duce the supply of tobacco will raise the prices of to-
bacco products. As described previously, these factors
include tobacco price support programs, market po\l-er
and collusive behavior among firms in the markets for
tobacco products, and restrictions on trade in tobacco
and tobacco products. The most important policv-
related determinants of prices, however, are taxes on
tobacco products.

  In the United States, tobacco is taxed in various
ivays by the federal, state, and local governments. The
most important of these are the excise, or per unit, taxes
imposed on cigarettes and the general sales tax (an ad
valorem tax) applied to cigarettes and other tobacco
products in most states. Ad valorem taxes are a fixed
percentage of the price and thereby increase or de-
crease as price changes. Excise taxes, on the other
hand, do not change over time ri,ith prices.

  Tobacco taxes have relatively low administrative
costs and can generate substantial revenues. In recent
years, increased taxation of tobacco products has been
used as a strategy to reduce tobacco consumption and
thereby to improve public health. For example, the
health benefits of tax-induced reductions in smoking
were often cited by supporters of the federal cigarette
excise tax proposed as part of the Clinton admini-
stration's proposed Health Security Act of 1993, which
included an increase of 75 cents per pack. (The act did
not pass.) Similarly, anticipated large reductions in
youth smoking were, in part, the rationale for tax in-
creases of up to $2.00 per pack proposed as part of
most proposals for national tobacco legislation and the
average 52.00 state and federal tax set as a goal for
2010 by the Healthy People 2010 initiative. The health
benefits of higher taxes were also the focus of the large
voter-initiated tax increases in Arizona, California,
Massachusetts, Michigan, and Oregon, as well as the
large legislated tax increases in Alaska, Maine, and
elselvhere.


Rationales for Tobacco Taxation

  Alternative approaches have been used to deter-
mine the appropriate level of cigarette and other to-
bacco taxes. One such approach is the historical or
comparative standard, which looks at the relative value
of these taxes over time or cross-sectionally. A second
approach is to use an efficiency standard based on the
external costs of smoking; this approach implies that
tobacco taxes can be thought of as "user fees" suffi-
cient to cover the external costs of tobacco use. This
approach, however, raises questions concerning the
fairness of such taxes. A further argument has been
made for substantial increases in tobacco taxes, because
these tax hikes Mould lead to substantial reductions
in the morbidity and mortality associated with ciga-
rette smoking. Finally, because taxes on cigarettes and
other tobacco products are a relatively simple way to
generate revenues, it has been suggested that these
taxes can be set at levels that maximize their returns.
Each of these alternatives will be discussed.

Historical or Comparative Standard

Federal Tobacco Taxes

  Tobacco has been taxed in North America since
the British government first imposed taxes during co-
lonial times. Beginning in 1794, the U.S. government
imposed tobacco taxes that periodically rose \vith rev-
enue needs and subsequentlv fell because of consumer
opposition. Since 1864, \vhen cigarette and other to-
bacco taxes were included in a package to finance the
Civil War, taxes on tobacco in one form or another have
remained a part of the federal tax system. Taxes con-
tinued to rise and fall over the next 87 years, generally
increasing with revenue needs during the Spanish-
American War, World Wars I and II, and the Korean
War (Table 6.10). The final Lear-related increase in the
federal excise tax per pack of cigarettes w'as from 7.0
cents to 8.0 cents per pack on November 1,1951, lvhere
it remained for the next three decades.
  The most recent federal tax increases were moti-
vated by a need to raise revenues for a different
purpose-to reduce the increasing federal budget defi-
cit. The first of these hikes in the federal cigarette ex-
cise tax came as part of the Tax Equity and Fiscal
Responsibility Act of 1982 (Public Lalz- Y7-248), xvhich
temporarily doubled the per pack tax to 16.0 cents,
effective January 1, 1983. The tax was to revert to 8
cents on October 1, 1985, but after several extensions,
the 16-cent tax was made permanent in 1986. As the
result of two I-cent increases included in the Omni-
bus Budget Reconciliation Act of 1990, the tax per pack

was increased to 20.0 cents on January 1, 1991, and-
then to 24.0 cents on January 1, 1993. Finally, as a re-
sult of the 1998 budget agreement, federal cigarette
excise taxes are scheduled to rise by 10 cents per pack
in 2000 and by an additional 5 cents per pack in 2002.-

  Also as part of the Consolidated Omnibus Bud-
get Reconciliation Act of 1985, taxes of 8.0, 24.0, and-
45.0 cents per pound were imposed on chewing to-
bmacco, snuff, and pipe tobacco, respectively. These
were the first new federal taxes on chewing tobacco
and snuff since 1965, when the taxation was set at 10
cents per pound. These taxes are currently 12.0,36.0;
and 67.5 cents per pound (Table 6.11). This assessment
amounts to approximately 2.7 cents per 1.2-ounce can
of snuff, 2.3 cents per 3-ounce pouch of chewing to-
bacco, and 6.3 cents per 1.5-ounce pouch of pipe to-
bacco. Tobacco for roll-your-own cigarettes is not taxed
at the federal level.

State aud Local Tobacco Taxes

  All 50 states and the District of Columbia cur-
rently impose excise taxes on cigarettes. The first of
these was a tax levied by Iowa in 1921. It was fo!-
lowed in 1923 by taxes in Georgia, South Carolin%
South Dakota, and Utah. On October 1, 1969, NortE
Carolina became the last state to impose a tax on ciga-
rettes. As of May 1, 2000, these taxes ranged from 2.E
cents per pack in Virginia to S1.ll per pack in New
York (Table 6.12). Forty-four states currently imposs
taxes on tobacco products other than cigarettes (Tabh
6.13); only 17 states imposed such taxes in 1964. Ir
general, these other taxes are ad valorem taxes. The
general sales tax in most states applies to cigarette:
and other tobacco products, with the tax base in mos
states including the excise tax. As of November 1,199s
these sales taxes added 8-25 cents per pack to the pricl
of cigarettes (Table 6.12). In eight states, 450 cities ant
counties impose additional taxes on the sale of ciga
rettes, and 85 of these also tax other tobacco product:
The largest of the local cigarette taxes are those im
posed in Chicago (combined county and city taxes c
34 cents per pack) and New York City (8 cents pe
pack).

  At least until the 195Os, state taxes on cigarette
were enacted and raised to generate revenues rathe
than to discourage consumption. The average ye;
such taxes were initiated in the six major tobaccc
producing states (1939) slightly predates the averag
year for the other states (1940) (Warner 1981). Befor
the widespread publicity on the health consequence
of smoking, the average tax rate in the six tobacco stat6
was only slightly lower than that in the other statt


(2.5 vs. 2.9 cents per pack). Since the release in the
mid-1950s of the first reports describing the adverse
health effects of cigarette smoking, and even more so
since the 1964 release of the initial Surgeon General's
report on smoking and health, state governments have
actively used cigarette taxes as a principal tool in their

Table 6.10. Federal cigarette excise taxes, selected
      dates, 1864-2002

Effective date

June 30, 1864*
Aoril 1, 1865+

1
August 1,1866t
March 2,1867
July 20, 1868
March 3,1875
March 3,1883
August 15,1897
June 14,1898
Julv 1, 1901"
Julv 1, 1910
October 4, 1917
February 25,1919
July 1, 1940
November 1,1942
November 1,195l
January 1,1983
January 1,199l
January 1,1993

Tax per pack of 20 cigarettes (cents)

       4.0, 8.0, x.0+20';

             10.0

             3.0
         0.8, 2.-I

             3.5

              1 .o
          2.4,1.0

              2.0

             3.0

        1.08,2.16

             2.5

              1.1

             6.0

              6.5

             7.0

             8.0

             16.0

             20.0

            24.0

campaigns to reduce tobacco use. For example, the

grew substantially over this period. By May 1, 2000,
number of tax increases has risen from an average of

the simple average of cigarette taxes in the six largest
less than three per year in the early 1950s to an aver-
age of more than eight per year in the late 195Os, and a

tobacco-growing states was 7.1 cents compared with
record 22 states increased their cigarette taxes in 1965
(Table 6.14). Similar activity occurred during 1967-

46.5 cents in the remaining states and the District of
1970, tlhen antismoking ads were broadcast under the

Columbia.
Fairness Doctrine and after cigarette advertising on
television and radio was banned in 1971. The once-
negligible difference in cigarette excise tax rates be-
tM-een the tobacco-producing states and other states

January I,2000                34.0
January 1,2002'                39.0

  The use of increased cigarette and other tobacco
taxes to discourage all tobacco use was even more ob-
v,ious in the late 1980s and earlv 1990s. In November
1988, California v,oters approved the Tobacco Tax and
Health Protection Act (Proposition 99), the then-
largest single increase (25 cents per pack) in any state
excise tax on cigarettes. New taxes were also imposed
on other forms of tobacco. The novel feature of this
tax hike M'as that 20 percent of the new revenues gen-
erated by the tax increase was earmarked for tobacco-
related education activities and 5 percent was allocated
to tobacco-related research.

  The success of Proposition 99 in California led to
a similar voter-approved measure in Massachusetts.
In November 1992, voters passed Question 1, which
raised the state cigarette tax from 26 cents to 51 cents
per pack and increased the state tax on chewing

Table 6.11. Federal excise tax rates (cents/pound)
     on chewing tobacco, snuff, and pipe
     tobacco, selected years, 1986-2002

Year

Chewing
tobacco

Snuff

Pipe
tobacco

*Lower rate applied to cigarettes valued at $6 or less     1986         8.0       24.0       45.0

per 100 packs of 25 each.
`Lower rate applied to cigarettes valued at $5 or less
per 100 packs of 25 each.
$Lower rate applied to cigarettes valued at $8 or less
per 1,000. Higher rate applied to cigarettes valued at
more than $12 per 1,000.
"Lower rate applied to cigarettes valued at $2 or less
per 1,000.
`Scheduled.
Source: Orzechowski and Walker 2000.

1991        10.0       30.0       56.25

1993        12.0       36.0       67.5

2000        17.0       51.0       95.67

2002*        19.5       58.5      109.69

*Scheduled.
Sources: Advisory Commission on Intergovernmen-
tal Relations 1991; Bureau of Alcohol, Tobacco and
Firearms 2000.


Table 6.12. State cigarette excise taxes and sales taxes (cents/pack) aDplied to cigarettes

State

Alabama

Alaska

Arizona

Arkansas

California

Colorado

Connecticut

Delaware

District of Columbia

Florida
Georgia

Hawaii

Idaho

Illinois

Indiana

IoM-a

Kansas
Kentucky

Louisiana

Maine
Maryland
Massachusetts
Michigan

Minnesota
Mississippi
Missouri

Excise tax rate

May 1,
2000

16.5

100.0

58.0

31.5*

87.0

20.0

50.0

24.0

65.0

33.9

12.0

100.0

28.0

58.0

15.5

36.0

24.0

3.0

20.0

74.0

66.0

76.0

75.0

18.0

18.0

17.0

-

Sales tax
November 1,
  1999

  11.0

   0

  16.0

  13.0

  25.0

   0

  19.0

   0

  19.0

  17.0

   8.0

  15.0

  11.0

  20.0

  13.0

  11.0

  13.0

  15.0

  11.0

  18.0

  16.0

  18.0

  20.0

  19.0

  19.0

  11.0

L

State

Excise tax rate    Sales tax
May 1,    November 1,
   2000         1999

Montana

Nebraska

Nevada
New Hampshire
New Jersey
New Mexico

New York

North Carolina

North Dakota

Ohio

Oklahoma
Oregon
Pennsylvania
Rhode Island

South Carolina

South Dakota

Tennessee

Texas

Utah

Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming

18.0

34.0

35.0

52.0

80.0

21.0

111.0

5.0

44.0

24.0

23.0

68.0

31.0

71 .o

7.0

33.0

13.0

41.0

51.5

44.0

75
-.

82.5

17.0

59.0

12.0

0

13.0

20.0

0

17.0

14.0

13.0

10.0

18.0

13.0

12.0

0

17.0

23.0

13.0

11.0

21.0

18.0

15.0

15.0

11.0

23.0

15.0

16.0

11.0

*Arkansas tax can rise to 33 cents if the state does not appropriate adequate funds for breast cancer
research and control.
Sources: Orzechowski and Walker 2000; Centers for Disease Control and Prevention, Office on Smoking and
Health, State Tobacco Activities Tracking and Evaluation System, unpublished data.

tobacco by 25 percent. Although Massachusetts law   recommended that at least part of the funds be all
prevents funds raised by the tax from being earmarked   cated to activities related to reducing tobacco use.
for tobacco-related education and prevention efforts,     More recently, Michigan voters in 1994 enactc
the funds are placed into a Health Protection Fund,   Proposal A, which changed the financing for MicI
and the wording of the approved measure strongly   gan public schools. Part of this plan included raisir


the general state sales tax (Ivhich is applied to ciga-
rettes and other tobacco products) from 4 to 6 percent
and tripling the state excise tas on cigarettes to 73 cents
per pack, representin g the largest single increase in
cigarette taxes ever implemented in the United States.
NeM taxes kvere also imposed on \.arious other tobacco
products. Six percent of the ne\v revenues \vere ear-
marked for health impro\,ement actilrities, including
tobacco-related education and pre\.ention efforts.

  III November 1994, Arizona \.otcrs appro\.ed the
Tobacco Tax and Health Care Act, \\-hich included <3
40-cent increase in the state cigarette tax \vith enrmark-
ing provisions similar to those in California, Massa-
chusetts, and Michigan. At the same time, ho\ve\,er,
\-oters in Colorado rejectecl a tax hike of JO cents pei-
pack \\ith similar features. In No\,ember 1996, Oregon
voters approved Measure 41, \1-hich increased cigarette
taxes bv 30 cents per pack, raised the tax on other to-
bacco products from 35 to 65 percent of i\.holesale
price, and dedicated a portion of the increased re\`-
enue to tobacco use pre\,ention and education. Sim-
lar large cigarette-tax increases, including some that
dedicate significant funds to tobacco control acti\.ities,
haire been recently legislated in a number of states,
including Alaska, Maine, Nelv Jersey, and I'Ke\\, York.
In addition, in 1998, \.oters in California appro\.ed an
additional 50-cent per pack increase in the state ciga-
rette tax.

  The relative ease \\ith \2-hich cigarettes and other
tobacco products can be transported and the potential
profits from illegal acti\,itv of this kind have limited
state and local governments' abititv to further raise
tobacco taxes. The large disparities-in price resulting
from differences in tobacco taxation create incenti\.es
to (1) smuggle on a casual level (invol\ring small quan-
tities for personal use) or on an organized le\,el (in-
\,olving large quantities, generally for resale); (2)
purchase cigarettes through tax-free outlets, including
military stores and American Indian reservations; and
(3) illegally divert cigarettes within the usual distri-
bution system by forging tax stamps, \vhich results in
underreporting. Altogether, this "butt legging" (ACIR
1977) can result in a net loss of revenues \vhen tobacco
taxes are increased.

  Although casual smuggling has always been a
problem, states reported that organized smuggling
activities rose significantly after the cigarette tax hikes
of the late 1960s. In response to state pressure, the
Trafficking in Contraband Cigarettes Act of 1978 (Pub-
lic Law 95-575) was enacted. This act, w-hich dealt onlv
with the organized smuggling of cigarettes, prohib-
ited the single-transaction transport, receipt, shipment,
possession, distribution, or purchase of more than

60,000 cigarettes not bearing the tax indicia of the state
in lvhich the cigarettes \vere initially sold. The ACIR
(1985) suggests that the law was even more effective
than its proponents predicted. Casual smuggling,
ho\\-e\,er, may become a more significant problem as
the differences betlveen cigarette taxes in neighboring
states increase as the result of some of the recent large
tax hikes in some states.

  Se\.eral econometric analyses of cigarette demand
ha\.e carefullv considered the effects of price differen-
tials on organized and casual cigarette smuggling on
state cigarette sales (Baltagi and Levin 1986, 1992;
Chaloupka and Saffer 1992; Becker et al. 1994; Saba et
al. 1995; Jackson and Saba 1997; Yurekli and Zhang
X00). In general, these studies concluded that smug-
gling has a significant, but small, impact on cigarette
demand, implving that a state cigarette tax increase
\\ill lead to s&me smuggling. Yurekli and Zhang
(3000). for example, estimate that, on average, 6 per-
cent of state cigarette tax revenues were lost due to
smu~gting activities in 1995. However, given the mag-
nitude of these estimates, Merriman (1994) and Baltagi
and Le\ in (1992) estimated that state cigarette taxes
AI-C belo\\. their rel,enue-maxin~izing levels. Thus,
states can raise cigarette taxes and generate increased
re\.enues, even as cigarette sales decline and interstate
smuggling increases.

Cigarette Taxes and Cigarette Prices

  Increases in cigarette and other tobacco taxes re-
sult in higher prices for these products. Most ciga-
rette taxes, howe\-er, are excise taxes; unless they are
increased regularlv o\`er time, the value of the tax will
fall in real terms (ifter analysis accounts for the effects
that inflation, as measured by the Consumer Price In-
dex, has on the tax). Because taxes are an important
component of price, one of the consequences of an ex-
cise tax system w.ith relati\rely infrequent increases is
that, at least during the period between excise tax in-
creases, the real price of cigarettes will fall over time
as the prices of other goods and services increase more
rapidly.

  When trends are examined in real cigarette prices
o\`er the past four decades, three clear periods are ob-
served (Table 6.15). The first is 1955-1971, when states
lvere increasing taxes not only to raise revenues but
also to discourage smoking. The real value of state
taxes during this period approximately doubled from
13.1 cents (1982-1984 dollars) to 26.4 cents per pack.
This increase was more than sufficient to offset the re-
ductions in the real federal tax (from 29.9 cents to 19.8


Table 6.13. State tax rates on tobacco products other than cigarettes as of January 1,200O

State                 Taxes on other tobacco products

Alabama

Cigars retailing for:
   a) ~3.5 cents each or less, 5150 per thousand;
   b) >3.5 and 55 cents each, $3.00 per thousand;
   c) >5 and 28 cents each, $4.50 per thousand;
   d) >8 and 110 cents each, $7.50 per thousand;
   e) >10 and 520 cents each, $15 per thousand;
   f) >20 cents each, $20.25 per thousand.
Little cigars: 2 cents for each 10 or fraction thereof.
Smoking tobacco:
   a) 11.125 ounces, 2 cents;

b) >0.125 ounces and <2 ounces, 5 cents;
c) >2 ounces and <3 ounces, 8 cents;
d) >3 ounces and 14 ounces, 11 cents;
e) 3 cents additional tax for each ounce or fraction part thereof over
-l ounces.

Chelving tobacco: 0.75 cents of each ounce or fraction thereof.
Snuff:
   a) ~0.625 ounces, 0.5 cents;

b) >0.625 ounces, and 11.625 ounces, 1 cent;
c) >1.625 ounces and 12.5 ounces, 2 cents;
d) >2.5 ounces and 53 ounces, 2.5 cents;
e) >3 ounces and 15 ounces (cans, packages, gullets), 3 cents;
f) >3 ounces and 15 ounces (glasses, tumblers, bottles), 3.5 cents;
g) >5 ounces and 56 ounces, 4 cents;
h) 1 cent additional tax for each ounce or fraction thereof over 6 ounces

Alaska

Arizona

73? of \\-holesale price.
Cigars retailing for:
   a) 15 cents, 6.1 cents for each 3 cigars;
   b) >3 cents, 6.1 cents each.

Little cigars: 12.9 cents for each 20 or fraction thereof.
Smoking and che\ving tobacco and snuff: 6.5 cents per ounce or
   major fraction thereof.

Arkansas

California*

Colorado

Connecticut*

Delaware
District of Columbia

Plug tobacco: 1.6 cents per ounce or fraction thereof.
23% of manufacturers' invoice price.
61.56? of \vholesale price.*
20') of manufacturers' price.
20") of manufacturers' price.
15'; of \Vliolesale price.
None.

*Little cigars taxed at the same rate as cigarettes.
`California rate reset at beginning of each fiscal year; Ne\v Hampshire rate reset semiannually.
TMaryland tax becomes effective July 1, 2000.
Sources: Orzechowski and Walker 2000; Centers for Disease Control and Prevention, Office on Smoking and
Health, State Tobacco Activities Tracking and E\raluation System, unpublished data.


Table 6.13. Continued

State

Florida
Georgia

Taxes on other tobacco products

Smoking tobacco, chelving tobacco, and snuff: 25% of wholesale price.
Little cigars: 1%.eighing 53 pounds per 1,000, 2 mills each.
All other cigars: 13'5 of wholesale price.
40'7 of lvholesale price.
405 of wholesale sales price.
18"; of M-holesale price.
15'; of \vholesale price.

22'; oi ivholesale price.

10"; of original invoice price from the manufacturer to the wholesaler.
hone.
Cigars:

a) a list price of $120 per thousand or less, tax is 8% of net invoice price;
b) a list price of o\.er S120 per thousand, tax is 20% of net invoice price.

Smoking tobacco: 33 T of net invoice price.
Cheitring tobacco and snuff: 62' ; of Mholesale sales price.
Cigars and smoking tobacco:  16 (; of Lvholesalc sales price.
All other products 15'; of ivholesale price.
75(; of lvholesale price for smokeless tobacco products. 15% of wholesale price
for cigars and pipe tobacco.
16? of Mholesale price.
35'; of lzholesale price.
157 of manufacturers' list price.
IO? of manufacturers' price.
12.5% of bvholesale price.
15? of wholesale price.
302 of M-holesale price.
Chewing tobacco and snuff: 17.9? of wholesale price invoiced to retailer.
482 of wholesale price.
25% of product value.

20% of wholesale price.
2% of wholesale price.
28% of wholesale price.
17% of \2-holesale price.
Cigars, cheroots, stogies, etc., weighing >3 pounds per thousand retailing for:
   a) 14 cents each, $10 per thousand;
   b) >-1 cents each, $30 per thousand.
Little cigars: 9 mills each.
Smoking tobacco: 403 of factory list price.
Chewing tobacco and snuff: 307 oi factory list price.

Hawaii

Idaho

Illinois

Indiana

10M'il*

Kansas
Kentucky
Louisiana

hlaine*

Maryland'
Massachusetts

Michigan
Minnesota
Mississippi
Missouri

Montana

Nebraska

Nevada
New Hampshire+
New Jersey
New Mexico

New York

North Carolina
North Dakota
Ohio
Oklahoma


Table 6.13. Continued

State

Taxes on other tobacco products

Oregon*
Pennsylvania
Rhode Island
South Carolina

South Dakota

Tennessee*

Texas

65':; of ivholesale sales price.
None.
20c; oi w,holesale price.
Cigars, cheroots, stogies, etc., retailing for:
  a) 15 cents each, $11 per thousand;
   b) >5 cents each, S20 per thousand.
Little cigars: 2 cents ior each 8 or fraction thereof.
Smoking tobacco: 36'4 of manufacturers' price.
Chewing tobacco and snuff: 5% of manufacturers' price.
10% of wholesale price.
6% of wholesale price.
Cigars: Tax on cigars and tobacco is based on weight per 1,000 and retail selling
price.

a) 23 pounds per 1,000, 1 cent for each 10 cigars;
b) >3 pounds per 1,000 and retailing for 13.3 cents each, $7.50
per 1,000;

c) >3 pounds per 1,000, retailing for >3.3 cents each and
containing a substantial amount of nontobacco ingredients,
$11 per thousand;

d) >3 pounds per 1,000, retailing for >3.3 cents each and
containing a substantial amount of nontobacco ingredients,
$15 per thousand;

Utah

Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming

  e) Chelving, pipe, or smoking tobacco, and snuff: 35.213% of the
   manufacturers' list price exclusi\:e of anv trade discount, special discount,
     or deal.
35'; of manufacturers' selling price delilwed into state.
41c; of distributors' price.
None.
74.9'; of Ivholesale price.
None.
2OY of u\-holesale price.
All other products 2O'r of rvholesale price.

cents per pack); as a result, cigarette taxes continued
to account for about 50 percent of cigarette prices.

  During the 197Os, howe\rer, the real price of ciga-
rettes dropped significantly because of the stability of
cigarette excise taxes and the relati\,ely rapid increases
in the prices of other goods and serv-ices. During this
period, the real value of the federal cigarette tax (which
was unchanged in nominal terms) fell bv more than
50 percent, and the real value of state taies dropped
by nearly as much. The net result \vas a decline of
38.5 percent in the real price of cigarettes. Moreo\,er,

during this period, taxes as a share of cigarette prices-
fell from 46.8 to 33.1 percent, because the nontax com-
ponent of real price was relatively stable.

  Since 1981, however, the real price of cigarettes
has increased sharply, from 69.3 cents to 127.1 cents-
per pack in November 1992, and further in early 1993.
Important factors behind this increase were the fed-
eral tax increases in 1983,1991, and 1993, which tripled-
the nominal value of the cigarette excise tax. Also
important M'as the steady rise in the real value of av-
erage state excise taxes on cigarettes, from a low of


Table 6.14.  Number of increases and decreases in
     state excise taxes on cigarettes,
     July 1,1950-May 1,200O

1950

1951

1952

1953

1954

1955

956

1 957

958

959

960

961

962

963

964

965

966

967

Year

1968

1969

1970

1971

1972

1973

1974

1975

Increases
(Decreases)

Year

2

7 (1)

0

2

3

11

5 (1)

8

4

15

3 (2)

17 (1)

2

13

5

22

4 (1)

12

8

20

7

16

5

2

2

5

1976        1

1977        4

1978      1 (1)

1979        3

1980        2

1981      6 (1)

1982        10

1983        13

1984        1

1985        11

1 Y86         6

1987       13

1988        3

1989      14 (1)

1990        8

1991      13 (1)

1992        7

1993      15 (2)

1994        8

1995        5

1996        2

1997        9

1998        2

1999        3

2000        1

Increases
(Decreases)

Sources: Orzechowski and Walker 2000; Centers for
Disease Control and Prevention, Office on Smoking
and Health, State Tobacco Activities Tracking and
Evaluation System, unpublished data.

14.0 cents per pack in 1982 to 19.4 cents per pack in
1993. However, even with the increases in the real
values of the federal and state taxes on cigarettes, taxes
as a share of price fell substantially from 1981 to 1993

Reducing Tobncco Use

(from 33.1 to 24.9 percent). The most important factor
behind the rise in real cigarette prices, then, was the
sharp rise in nontax (i.e., manufacturer-added) price
components. In 1981, the real value of the nontax por-
tion of average cigarette prices was 46 cents. By 1993,
this amount was 79.5 cents, which is an increase of
more than 70 percent. As described earlier in this chap-
ter, in "High Tobacco Concentration and the Impact of
Prevention Policies," much of this increase was attrib-
utable to the less than perfectly competitive supply
side of the cigarette market. The result of the increases
in both the tax and the nontax components of ciga-
rette prices was an increase of almost 85 percent in the
real price of cigarettes from 1981 to 1993.

  Real cigarette prices declined sharply as a result
of "Marlboro Friday" in April 1993, when wholesale
cigarette prices, first ior Marlboro then soon after for
other premium brands, were cut by 25 percent. More
recently, however, real cigarette prices have risen sig-
nificantly. These increases are partly the result of in-
creases in state and federal cigarette excise taxes over
the past few years. More important, however, are the
significant increases in wholesale cigarette prices be-
ginning in 1997. These prices increased by more than
12 percent between March 1997 and April 1998, return-
ing to their 1992 nominal level (USDA 1998a1, in part
the result of increased costs associated with tobacco
industry settlements with Mississippi, Florida, Texas,
and Minnesota. Wholesale prices increased an addi-
tional 45 cents per pack in November 1998, on the day
the Master Settlement Agreement was announced.
This increase, the largest in history, was followed nine
months later by an additional 1 g-cent per pack increase
(USDA 2000).

International Tobacco Taxes

  Among industrialized countries around the world,
the United States has one of the lowest average prices
and taxes on cigarettes (Table 6.16). As of December
31, 1996, the average tax in the United States was 66.0
cents per pack, well below the taxes imposed in almost
every other industrialized country. At that time, taxes
in various other countries, in U.S. dollars, ranged from
$5.23 per pack in Norway to 47 cents per pack in
South Africa. Most developed countries have at least
double the average tax in the United States. Some in-
teresting features of these taxes include earmarking
for tobacco-related education and other health-related
activities (in Denmark, Finland, Iceland, Peru, and else-
where), the creation of state-based Health Promotion
Foundations in Australia and the Health Sponsorship
Council in Ne\v Zealand to fund sporting and artistic


Table 6.15. Cigarette taxes and cigarette prices, 1955-2000 (cents/pack)

Taxes as a
percentage of
average
prices

Real
average
federal
tax+'

                                                                 Real
    Weighted   Average    Average                 Real             average
      average     federal    cigarette               average         cigarette
Year   state tax*+    taxt     price*            state tax+"        price'

1955       3.5       8.0        22.7                  13.1                84.7

1956       3.8        8.0         23.2                  14.0               85.3

1957       3.9        8.0         23.8                   13.9                84.7

1958       4.0        8.0         25.0                  13.8               86.5

1959       4.2        8.0         25.6                   14.4                88.0

1960       4.7        8.0         26.1                  15.9               88.2

1961       4.7        8.0        26.1                  15.7               87.3

1962       5.1        8.0         26.9                  16.9                89.1

1963       5.2        8.0         26.8                  17.0               87.6

1964       5.6        8.0         27.9                  18.1               90.0

1965       5.9        8.0         28.2                  18.7               89.5

1966       6.9        8.0         30.0                  21.3                92.6

1967       7.1        8.0         30.5                  21.3               91.3

1968       8.4        8.0         32.3                  24.1               92.8

1969       9.1        8.0         32.8                  24.8                89.4

1970      10.2        8.0         37.1                   26.3               95.6

1971      10.7        8.0         38.9                  26.4               96.0

1972       11.6        X.0         30.0                  27.8               95.7

1973      12.1        8.0         10.3                 27.3              90.8

1974      12.1        8.0         41.8                  24.5               84.8
               -
*State taxes are an average of taxes in all taxing states (42 in 1955; 50 in 1970 and thereafter) and the District of
Columbia, weighted by tax-paid cigarette sales in those states.
`Nominal and real average state and federal tax data are for the fiscal year ending June 30.
%ice reflects the median retail price for cigarettes (including generic brands) in all taxing states, generally as
of November 1 of the state fiscal year.
%`ercentages cannot be calculated directly from the tax and price information, because taxes are weighted
average taxes for the entire fiscal year, whereas prices and percentages are generally as of November 1.
`Real cigarette taxes and prices are obtained by dividing the nominal taxes and prices by the national
Consumer Price Index; the average of 1982-1984 is the benchmark.
7Preliminary estimate.
Source: Orzechowski and Walker 2000.

48.7

47.4

48.8

48.0

46.6

48.9

48.6

48.3

49.4

49.3

49.8

51.4

50.8

49.2

48.9

47.7

16.8

47.7

18.4

47.6

29.9

29.4

28.5

27.7

27.5

27.0

26.8

26.5

26.1

25.8

25.4

24.7

24.0

23.0

21.8

20.6

19.8

19.1

18.0

16.2

events previously backed by the tobacco industry, and
the differential taxes on cigarettes w+th high-tar and
high-nicotine content used in previous years in the
United Kingdom (Roemer 1993).

  One consequence of the differences in cigarette
taxes and prices across countries is the potential for
casual and organized cigarette smuggling and other
forms of tax evasion. The cigarette industry, for ex-
ample, frequently argues that cigarette tax increases


Table 6.15. Continued

Year

Weighted
average
state tax*+

Average
federal
tax+

Average
cigarette
price$

Taxes as a
percentage of
average
price5

Real
average
state tax+'

Real
average
federal
taxtA

Real

average
cigarette
price'

1975      12.2        8.0         44.5         44.5       22.7        14.9     82.7

1976      12.4        8.0         47.9          41.4       21.8        14.1      84.2

1977      12.5        8.0         49.2         40.5       20.6        13.2      81.2

1978      12.9        8.0         54.3         37.1        19.8        12.3     83.3

1979      12.9        8.0         56.8         35.5        17.8        11.0      78.2

1980      13.1        8.0         60.0         34.3        15.9         9.7      72.8

1981      13.2        8.0         63.0         33.1        14.5         8.8      69.3

1982      13.5        8.0         69.7         29.9        14.0         8.3      72.2

1983      14.7       12.0         81.9         26.8        11.8        12.0      82.2

1984      15.3       16.0         93.7         33.2        14.7        15.4     91.1

1983      15.9       16.0         97.8         32.3        14.8        14.9     90.9

1986      16.2       16.0        104.5         30.8        14.8        14.6     95.3

1987      16.9       16.0        110.0         29.9        14.9        14.1     96.8

1988      18.2       16.0        122.2         28.1        15.4        13.5     103.3

1989      21.8       16.0        127.5         26.5        17.6        12.9     102.8

1990      24.7       16.0        131.1         26.4        18.9        12.2'    110.3

1991      25.9       16.0        153.3         25.6        19.0        11.7     112.6

1992      26.5       20.0        173.5         25.6        18.9        14.3     123.7

1993      28.0       22.0        183.7         23.9        19.4        15.2     127.1

1994      31.5       24.0        169.3         31.4       21.3        16.2     114.2

1995      31.2       24.0        175.8         31 .o       20.5        15.7     115.4

1996      31.7       24.0        179.6         31.6       20.2        15.3     114.5

1997      31.8       24.0        185.4         30.5        19.8        15.0     115.5

1998      34.1       24.0        195.0         31.5       20.9        14.7     119.6

1999      36.4       24.0        217.5         28.2       21.8        14.4     130.6

2000     39.891     29.Oq        292.6          22.1      23.241      16.9_   170.58

will actually lead to reductions in tax revenues due to   nonexistent or relatively weak policies concerning
smuggling and other tax evasion (British-American   cigarette smuggling and their lack of enforcement
Tobacco Company Limited 1994). The smuggling   (ACIR 1977,1985; Joossens and Raw 1995; Joossens et
problem is exacerbated by the relative ease with which   al., in press). Joossens and Raw (1995, 1998) argued
tobacco products can be transported, the potential prof-   that many of these other factors can be as important
its from this illegal activity, the presence of corruption   as price differences in spawning cigarette smuggling.
and organized crime, the widespread street selling, the   For example, they noted that there is little evidence of
availabilitv of tax-free and duty-free cigarettes, and the   smuggling in some of the highest priced European


Table 6.16. Average retail cigarette price and total taxes per pack (U.S. dollars/pack), selected countries,
      December 31,1996

Country

Norlvay
United Kingdom
Ireland

Denmark

Finland

Australia

Sweden

Ne\v Zealand
Canada (highest provincial taxes)
Singapore
Hong Kong

France
Belgium
Germany
Canada (average provincial taxes)

Austria

Netherlands
United States (highest state taxes)
Italy
Canada (lowest provincial taxes)
United States (average state taxes)

Greece
Portugal
United States (low-est state taxes)

Thailand

Tailvan

Brazil
Spain
South Africa

Average
retail price

  7.05

  3.27

  3.94

  1.75

  4.54

  4.50

  4.47

  4.17

  4.09

  3.72

  3.62

  3.47

  3.23

  3.18

  3.00

  2.8-l

  2.66

  2.65

  2.17

  2.02

  I .90

  1.82

  1.77

  1.60

  1.58

  1.45

  1.43

  1.08

  1.04

Total taxes

  5.23

  4.30

  4.16

  4.02

  3.48

  2.92

  3.13

  2.79

  2.97

  1.87

  1.76

  2.61

  2.39

  2.28

  1.97

  2.11

  1.94

  1.24

  1.59

  1.12

  0.66

1.33

  1.43

0.34

0.89

  0.62

  1.06

0.81

0.47

Tax as a percentage
of retail price*

     74

     82

     84

     85

     77

     65

     70

     66

     73

     50

     49

     75

     74

     72

     66

     74

     73

     47

     73

     55

     35

     73

     81

     21

     56

     43

     74

     75

     45

Notes: (al Figures given are for a package of 20 of the most popular price category; (b) exchange rates are
from the Bank of Canada Official Exchange Rates as of December 31, 1996.
*The tax as a percentage of retail price refers to the portion of the average retail selling price that composes all
applicable taxes and other fees imposed on the product.
Source: Smoking and Health Action Foundation (Canada), unpublished data, April 30, 1997.


countries, including France, Nor\\-a\; Sl\.eden, and the
United Kingdom, ivhereas there is &tensi\.e et-idence
of smuggling in countries \vith relati\.ely lo\r prices,
such as Spain and Ital\,. Merriman and colleagues (in
press) pro\-ide empiri&l evidence that the perceil-ed
le\.el of corruption explains more of the 1 ariance in
experts estimates of the magnitude of cigarette smug-
gling than do cigarette prices. Moreo\w, Joossens and
colleagues (Joossens and Rain 1498; Joossens et al., in
press) concluded that much of the smuggling that does
occur in Europe and elselihere is encouraged by mul-
tinational tobacco companies. Thursb\ and Thursb\T
(1994) prrn.ided empirical support for this argument,
based on their analysis of data from the United States
from tvhich thev concluded that increases in federal
cigarette excise taxes lead to increased comnicrcial
cigarette smuggling.

  Perhaps the most interestin, 0 international con-
parison is betlvcen cigarette tax polic\ in the United
States and Canada. In 1970, a\-w-age taxes (includin;:
sales taxes) on cigarettes \\.rre 30 cents per pack in
Canada and 30 cents per pack in the United States. BL-
1980, the al'erage Canadian tax, 46 cents per pack. ~va7;
double the U.S. tax. Real prices in both countries had
fallen sharplv throughout the lY7Os, but after lY80, the
gap bet\\Teen' the tivo countries \\.idened rapidI\,. One
main reason for this change w.as the adoption oi an ad
valorem tax bv the federal and pro\,incial jio\wnments
in Canada. As a result, cigarette taxes in Canada
doubled bet\veen 1980 and 1981, leading to a 25
percent increase in real cigarette prices. In response
to pressure from the cigarette industry, hoi\-e\,er, the
ad \,alorem tax structure j\.as replaced \vith an excise
tax system in 1984.

`The growth in Canadian taxes slolved o\w the
next fe\v vears. Most taxing took place at the pro\in-
cial rather than the federal level. In 1988, ho\ve\w,
the Canadian federal government committed to an
aggressive campaign to reduce tobacco use; highlight-
ing the campaign \vas a ban enacted that vear on to-
bacco advertising. In 1989, the federal tax;vas raised
b>, 2 cents per cigarette, and another hike of 3 cents
per cigarette occurred in 1991. At the same time, pro-
vincial taxes \yere increasing rapidlv. By early 1991,
the average tax per pack of cigareties lx-as $2.96 (in
U.S. dollars), lvhich is more than five times the a\er-
age U.S. tax.

  The large disparities in Canadian and U.S. ciga-
rette prices led to substantial smuggling, which \vas
enabled by the long stretches of unmonitored border
between Canada and the United States, the relativeI\
wak border controls, and the high concentration of
the Canadian population near U.S. borders (S\vcanol

and Martial 1943). Much of the black market trade
that resulted 12-as in Canadian-produced cigarettes that
had been exported to the Cnited States (exports were
not subject to the Canadian taxes) and then smuggled
back into Canada. Relatively little black market trade
in\-ol\-ed cigarettes produced in the United States; U.S.
cigarettes use a blend of tobacco different from Cana-
dian cigarettes and are less desired by Canadian smok-
ers (Siveanor and Martial 1993). In a short-lived effort
to reduce the smuggling problem, a tax of 80 cents per
pack \vas applied to Canadian cigarette exports in mid-
February 1992. This tax \vas repealed six weeks later,
although preliminary evidence indicated that it had
btwl successful in reducing smuggling (Sweanor and
Martial iYY4). After the repeal of the export tax, Ca-
nadian cigarette exports to the United States rose dra-
maticall\: and smuggling increased again.

  In response to an aggressive industry-sponsored
campaign, the federal tax on cigarettes in Canada was
reduced bv SJ.00 per carton on Februarv 9, 1993. More-
o\-er, the federal go\.ernment agreed to match provin-
cial reductions in taxes up to an additional $10.00 per
carton. Quebec immediatelv louvered its provincial tax
b! Sl 1 .OO per carton for a &tat tax cut of $26.00 per
carton, leading to a 50-percent drop in price. By Au-
gust 1991, four other provinces had reduced cigarette
taxes substantially. These cuts reduced the average
Canadian tax per pack from $2.96 before the federal
tax cut to 91.97 as of December 31, 1996 (in U.S. dol-
lars), lvhich \vas an amount still well above the aver-
age U.S. cigarette tax of 66 cents per pack at that time.

  The Canadian experience \vas cited by the tobacco
industrv during the recent debates over the proposed
national tobacco settlement as evidence that a black
market in cigarettes would develop in the United States
in response to large cigarette tax increases. However,
there is little evidence to support this contention. Given
that Canadian cigarette taxes xvere reduced because of
smuggling from the United States, it is likely that these
taxes lvould be increased if the United States were to
adopt large tax increases, making it unlikely that wide-
spread smuggling of cigarettes from Canada into the
United States ~vould occur. Cigarette prices in Mexico,
hot\-e\.er, are rvell below. those in the United States, and
large increases in U.S. prices could make smuggling
cigarettes from Mexico a highlv profitable lrenture. TO
date, ho\zre\-er, no empirical evidence supports the con-
tention of significant smuggling of cigarettes from
Mexico into the United States. Furthermore, unlike the
U.S.-Canadian border, the border between the United
States ancl Mexico is relativ-elv short and heavily
guarded, making it much more- difficult to smuggle
large quantities of a bulk\, product like cigarettes.


  Finally, se\-era1 relati\.ely eas\. options exist for
limiting cigarette smuggling (Joossens and \ran der
MerIve 1997; Joossens et al., in press). These include
prominent tax-paid markings on all tobacco products
and sizable increases in the penalties for cigarette
smuggling. The ACIR (19851, for example, concluded
that the Trafficking in Contraband Cigarettes Act (Pub-
lic Law 95-575), which prohibited the transportation,
receipt, shipment, possession, distribution, or purchase
of large quantities of cigarettes that did not bear the
tax indicia of the state in which the cigarettes are found,
led to a significant reduction in interstate cigarette
smuggling resulting from interstate price differentials.

Discussion

  If one applies Cook and Moore's (1993) discus-
sion of alcohol taxes to cigarette taxes, a provocati\,e
question arises when one compares previous cigarette
excise taxes \\ith current ones: whv is the current tax
rate deemed appropriate ivhen it ii just over one-half
the level that \\`as deemed appropriate in lY51? Un-
less it is in the public interest to tax cigarettes at a much
lower rate norv than then (an odd notion, given that in
1951 much less evidence ~vas available on the health
hazards of smoking), a case can be made for restoring
taxes to their earlier levels. Similar arguments can be
made at the state level, particularlv in those states
Lvhere taxes have not changed or ha;e been increased
modestlv and infrequentlv over time.

Other, comparative- standards for appropriate
taxes could be used. For example, as sl1oiz.n in Table
6.12, state excise taxes on cigarettes differ substantially;
these differences reflect several factors, including the
importance of tobacco for the local economv. At an-
other level of comparison, large differences betiveen
cigarette taxes in Canada and the United States ga\-e
rise to a significant black market trade, \\,hich in turn
resulted in reductions in Canadian taxes. At the glo-
bal level, cigarette and other tobacco taxes in the United
States are among the lokyest in industrialized coun-
tries around the lvorld. Such comparisons suggest that
relativelv high taxes mav be appropriate in some ar-
eas and lorz- taxes appropriate in others. On the other
hand, one could argue that the taxes on all tobacco
products should be equivalent. This last issue is dis-
cussed in greater detail in the next section, "Fairness
Standard and Optimal Cigarette Taxes."

  Taxes on smokeless tobacco products are much
lower than taxes on cigarettes, particularly at the fed-
eral level. The limited research suggests that increases
in cigarette excise taxes mav have reduced cigarette
smoking but also may have contributed to an increased

use of smokeless tobacco products (Ohsfeldt and Boyle
1994; Ohsfeldt et al. 1997, 1999). Some public health
advocates and others have therefore called for the
equalization of taxes on tobacco (CSH 1994; U.S. House
of Representatives 1994).

Fairness Standard and Optimal
Cigarette Taxes

  Fair tax policy is an issue that is often debated-
but difficult to apply when "optimal" taxes of poten-
tially hazardous substances are discussed (Cook and
Moore 1993). For taxes on cigarettes and other tobacco
products, part of the debate revolves around the per-
ceived health benefits and reductions in social costs
associated with higher taxes.

  In their analysis of economic interventions to re-
duce alcohol abuse, Cook and Moore (1993) noted that
several criteria can be included to judge fairness by
those on both sides of the debate. These criteria in-
clude a horizontal equity criterion, which suggests that
equals should be treated equally; a vertical equity cri-
terion, lvhich suggests that those with the greatest abil-
itv to pav should be taxed more heavily; and a benefit
ciiterion-, which suggests that those who receive the
greatest benefit from government activities should be
tased more heavily. If the basic notion is accepted thai
people Mrho are otherwise similar should be taxed dif-
ferently because one uses more tobacco products thar
the other (a notion that \,iolates the horizontal equit)
criterion), then other questions about fairness nrisc
These include questions concerning the allegec
regressility of the taxes and the external costs of smok
ing and other tobacco use (Cook and Moore 1993).

Equity, Incidence, and Distribution of the Tobacco
Tax Burden

  As has been discussed previously, increases il
cigarette excise taxes are passed on to consumer
through higher cigarette prices. Primarily because c
the less than perfectly competitive nature of the ciga
rette industry, prices have increased by more than rc
cent increases in cigarette taxes. Because consumers wi
pay at least the full amount of a tax increase in highs
cigarette prices, some questions of fairness revolv
around the distributional effects of the tax hike. To ur
derstand these effects, it is useful to look at the relatior
ship betIveen tobacco use and income (or expenditures
(As Cook and Moore 119931 note, income or expend
tures are not the only scale on which fairness can L-
judged, but they are the most commonly used.)


  A 1990 report by the Congressional Budget
Office (CBO), lvhich used data from the 1985-1985
Consumer Expenditure Surve); made se\,eral obser-
vations. For example, expenditures on tobacco prod-
ucts increased Ivith income except for people in the
highest income quintile. As a percentage of posttax
income, however, spending on tobacco rras highest in
the lowest income quintile (4.0 percent of posttax in-
come) and fell almost proportionatelv 11-ith increased
income. Also, if expenditures on tobacco are consid-
ered as a percentage of expenditures on all goods and
services, ho\ve\.er, the share of tobacco expenditures
fell graduallv over the first four income quintiles (from
1.6 to 1.1 p&cent) and dropped sharplv onlv in the
                                1 -
top quintile (to 0.7 percent). Thus, the CBO notes, if
annual familv expenditures are more reflecti1.e of life-
time income than annual familv income, then expen-
ditures on tobacco are onlv sljghtlv regressi\.e 0l.t'~
income classes. Finally, the CBO noted that vounger
tamilies spent a higher percentage of income on to-
bacco products and that their share of spending on
tobacco products as a percentage of total expenditures
\vas higher as ivell.

  To examine the distributional impact of cigarette
excise tax increases on consumers, the CBO simulated
iThat the effects on expenditures w,ould be lvere the
1990 federal excise tax on cigarettes ( 16 cents per pack)
doubled. At first glance, the simulated increase ap-
peared to fall most hea\,ily on the lo\\-est income cate-
gories, thereby implying that cigarette taxes are
regressive. However, irhen income tax brackets and
transfer payments (discussed in the next section, "Es-
timates of the Costs of Smoking") Lvere indexed to ac-
count for the price increases associated M.ith excise tax
hikes, lolvering individual income taxes and raising
transfer payments, the apparent regressilrity of the tax
\vas reduced. When looking at the tax increase rela-
tive to expenditures rather than income, the CBO coil-
eluded that cigarette taxes \vere approximatel\
proportional rather than regressive. Finally, the CBO
noted that the largest share of the simulated tax increase
was paid for by families in the third and fourth income
quintiles and that the smallest share was paid by fam-
lies in the lowest income (first and second) quintiles.

   All of the CBO estimates lvere based on measures
of current income. Lyon and Schwab (1995) used an
alternative approach that used measures of permanent
or lifetime income to examine the distributional effects
of cigarette and other "sin" taxes. This approach could
account for the intertemporal nature of cigarette con-
sumption decisions. The investigators concluded that
cigarette excise taxes are as regressi\.e as \vas implied
by studies based on current income.

  Although cigarette taxes fall most heavily on
louver income groups, two recent studies suggest that
increases in cigarette taxes may reduce the perceived
regressivity of these taxes. A study using data from
the British General Household Survey concluded that
people in the lowest income groups were the most re-
sponsive to price increases (Townsend et al. 1994). Simi-
lar findings have been obtained in the United States
using data from 13 of the National Health Interview
Surl,eys conducted from 1976 through 1993 (CDC 1998).
The price elasticitv of cigarette demand by those at or
belol~ the median;ncome M'as estimated to be approxi-
matelv 70 percent higher than that for persons above
the m;dian. Another study found that less educated
persons \1-ere more responsive than more educated
persons to cigarette price changes (Chaloupka 1991).
Gi\.en the high correlation between income and edu-
cation, the three studies implied that increased ciga-
rette taxes l\,ould reduce observed differences in
smoking among socioeconomic groups (i.e., that smok-
ing pre\,alence is higher in the lower socioeconomic
groups) and wrould thereby counter the perception that
cigarette taxes are regressi\re. Recent research from
de\.eloping countries supports the hypothesis that
lolzper income populations are relatively more sensi-
tive to price (Jha and Chaloupka 1999; see Chaloupka
et al., in press, for a thorough review). Indeed, while
cisnrette taxes mav fall more heavily on lower income
groups, an increase in the cigarette tax, because of the
greater price sensitivity of louver income smokers, may
actually be progressive. Moreover, given the estimates
from these studies, the health benefits resulting from
reductions in smoking stimulated by increased ciga-
rette taxes Lvould be disproportionate117 larger in the
lowest income populations.

  Finally, as the CBO report pointed out, although
the potential regressivity of cigarette taxes is of some
concern, the U.S. tax system is a mix of many different
taxes. increased progr&sivity of other taxes and trans-
fer programs could be used to compensate low income
families for the tax increase. The CBO considered three
alternative changes-a 5-percent increase in food
stamp payments, a lo-percent increase in the earned
income tax credit, and a combination of the two-to
offset the potential regressivity of an increase in the
cigarette excise tax. In each case, the CBO concluded
that these changes would spend about 15 percent of
the net revenues resulting from the tax increase. A simi-
lar idea \vas implicit in the proposed Health Security
Act of 1993, which proposed a federal tax increase of
75 cents per pack to partiallv finance the provision
of health insurance and the expansion of benefits
to the uninsured and underinsured, most of whom are


in lo\\ er sniioeic~tiotiiii grc'ups. Like\\ ista, se\.eral rf-
cent proposals for national tobacco legislation contain
pro\~isions that r~ould offset the potential regressi\Tity
of large increases in cigarette taxes.

Estimates of the Costs of Smoking

  An alternati1.e approach to the question of fair-
ness deals \vith the notion that smokers and other to-
bacco users impose costs on nonusers. One of these
costs is the health consequences for nonsmokers of
exposure to ETS. A second is the financial external
effect caused by collectively financed programs (e.g.,
Medicaid and Medicare) Mhere payments in and out
are not tied to changes in costs and life expectance
caused bv smoking. Thus it can be argued that it ~vould
be fair fir smokers and other tobacco users to pay for
the consequences of their use. Cigarette and other to-
bacco taxes are one relatively efficient approach for
attaining this result. Ho\ve\,er, to set taxes at a level
sufficient to co\.er fhe costs of cigarette smoking and
other tobacco ~1st~ requires an estimaCe of these costs.

   All studies of the economic costs of tobacco LISA'
have focused on Ihe costs of cigarette smoking. The
Office of Technology Assessment (U.S. House of Rep-
resentati\.es 1YY-l) has noted that although measuring
these costs is an inexact science, three general compo-
nents are included:

.  The direct costs of pro\idin, 0 health care ser\-ices
to those persons L\.ith smokin, ~r-reldW diseases.
Such costs include expenditures for pre\.enting,
detecting, diagnosing, and treating smoking-
  related diseases and medical conditions.

o  The indirect morbidit\; costs associated \vith lost
earnings from \\,ork because of smoking;-related
  illness.

o  The indirect mortality costs related to the loss of
future earnings from premature death from
smoking-related causes.

   Researchers ha1.e tried to estimate the economic
costs of cigarette smoking bv using data from the United
States (Rice et al. 1986; %anning et al. 1989, lY91;
Hodgson 1992; CDC 1991; U.S. House of Representa-
tives 1991; Miller et al. 1998, 1999) and elservhere (see
Lightlvood et al., in press, for a comprehensi\,e retie\<.).
In addition, as part of the research resulting from Propo-
sition 99, se\.eral recent studies ha\.e estimated these
costs for California (California Department of Health
Ser\-ices 1 YY3; Rice and Max lW2; %lav and Rice 1 YY5).

  Most of the estimates of the economic costs of
smoking have been prevalence based. That is, the,]
are based on the estimated prevalence of smoking-
related illnesses in a given year and on the costs asso.
ciated with those illnesses. Because of the long lags
between smoking initiation and the onset of mo\t
smoking-related illnesses, these estimates reflect his.
torical trends in smoking and thus cannot be used to
predict the impact of changes in smoking prevention
policies except over long periods. However, this ap-
preach has been widely used because of its relative]\
simple methodology and the availability of reliab(c
data (Rice et al. 1986).

  Several of the recent estimates of the costs of
smoking have been incidence based (Oster et al. 1984;
Manning et al. 1989, 1991; Hay 1991; Hodgson 19Y2).
That is, these studies attempt to estimate the average
additional costs of smoking over the smoker's lifetime.
Cost estimates would differ by the person's age, sex,
and level of smoking (i.e., a heavy smoker would ha\.e
higher lifetime cosfs than a relatively light smoker with
the same characteristics). These estimates of the costs
of smoking can be useful for policymakers, who can
estimate the change in the costs of smoking associated
with a change in smoking behavior resulting from a
change in policies to reduce smoking. However, these
estimates are sensitive to assumptions about future
costs and about issues suc11 as technological change
and its diffusion (Hodgson 1988).

  Many of the studies of the economic costs oi
smoking ha\,e included notablv different direct costs
in their computations. For example, most include the
costs of hospital and nursing home care, physicians'
fees, and medications used to treat smoking-related
illnesses. One such study estimated that these costs in
1993 \vere $50 billion and that 13.3 percent of them
\z'ere paid through public sources (CDC 1994). Ho\\.-
e\`er, some studies of direct costs have been limited to
the costs associated \vith lung cancer only, Lvhereas 0th
ers examined a more comprehensive list of smoking-
related illnesses, including cardiovascular disease and
chronic obstructi1.e pulmonary disease.

  Other more recent studies have sought a broader
measure of the direct costs of smoking by comparing
the differences betlveen total health care spending b>
smokers and nonsmokers. The most sophisticated of
these recent studies control for other risk factors like]\
to be correlated \vith smoking in an effort to isolate
the impact of smoking on medical expenditures (Miller
et al. 1998, 1999). These recent studies estimateci-
smoking-attributable medical care costs of between $53
billion and S73 billion for 1993, or between 6.5 percent
and 11.8 percent of all U.S. health care expenditure5.


RedlrcirlLq Thmo USC

  It is likely, however, that these studies have un-
derestimated the direct costs of smoking for a variety
of reasons (Warner et al. 1999). For example, they
ignore other significant economic costs, including the
costs of transportation associated with obtaining
medical care and the costs of nonmedical care associ-
ated with accommodating a person ivith a smoking-
related chronic illness. These estimates also generally
fail to account for other medical care costs related to
cigarette smoking, such as burn care from injuries in
smoking-related fires and perinatal care for low-birth-
weight infants of mothers \vho smoke. Few studies
have attempted to include the direct costs for non-
smokers of diseases related to exposure to ETS, and
none of these studies has tried to estimate the intan-
gible costs of smoking-related illnesses (i.e., the pain
and suffering associated \vith the illness and the grief
experienced by family and friends).

  A human capital approach is generally used to
estimate the indirect morbiditv and mortalitv costs
associated with cigarette smoking. This apbroach
views an individual as producing a stream of output
or earnings computed at market value or as the im-
puted value of housekeeping services. Thus, the value
of a person is reflected by his or her earnings, and the
lifetime value for that person is equal to the discounted
stream of future earnings (Max and Rice 1995). This
approach places a relatively high value on morbidity
and mortality among young adults, men, and the more
educated because of the relatively higher earnings that
would be lost by these smokers (Markandya and
Pearce 1989); moreover, lost earnings may not be an
accurate reflection of the value people place on their
health or on their lives. Furthermore, the human capi-
tal approach is in contrast to the "willingness-to-pay"
approach, which tries to estimate the value a person
assigns to reducing his or her risk of premature death.

  A more controversial component in the compu-
tation of the lifetime costs of smoking concerns the
treatment of transfer payments. These transfer pay-
ments include the reduction in income taxes and in-
surance premiums paid by smokers because of reduced
earnings associated with smoking-related illnesses, the
value of Social Security and private pensions foregone
because of smoking-related premature deaths, higher
health care costs associated with smoking-related
illnesses and paid bv public and private insurance
plans, and increased Asick pay and disability benefits
paid during smoking-related illnesses. Particularly ob-
jectionable to many people is the idea that foregone
Social Security and private pension benefits from smok-
(frs who die piematurely from smoking-related illnesses
should be considered "benefits" to nonsmokers. As

Harris (U.S. House of Representatives 1994) and oth-
ers have noted, premature deaths are not considered a
benefit when policymakers determine what levels of
funded research are appropriate for reducing prema-
ture deaths from other risk exposures (CSH 1994;
Warner et al. 1995, 1999). Nevertheless, several recent
estimates of the costs of smoking have considered these
foregone benefits in their computations of the economic
costs of cigarette smoking (Manning et al. 1989, 1991;
Shoven et al. 1989). These studies aim to provide a
complete accounting of the costs of smoking to answer
the question of whether payments by those who have
ever smoked into collectively financed systems such
as Medicare and Social Security equal receipts by those
\\,ho have ever smoked.

Theoretically Optimal Cigarette Taxes

  As \vas just discussed, several estimates of the
optimal or fair tax on cigarettes are based on the vari-
ous studies of the costs of smoking. In the context of
the preceding discussion, an optimal tax is one that
equates the total revenues from these taxes to the net
external costs of cigarette smoking. These estimates
have ranged from those implying that current taxes
more than cover the external costs of smoking (Man-
ning et al. 1989) to those that have suggested that cur-
rent taxes are far too low. For example, one such study
that included the costs of the long-term intellectual and
physical consequences resulting from smoking-related
low birth weight among infants born to mothers who
smoke indicated that $4.80 was an appropriate tax on
a pack of cigarettes (Hay 1991).

  Another study (Pigou 1962) advanced a similar
notion in providing a theoretical justification for taxes
on goods with market prices not fully reflecting the
social costs associated with their production and con-
sumption. From that perspective, these taxes could
be viewed as improving economic efficiency by rais-
ing a smoker's marginal cost of smoking to a level
nearer the social marginal cost. For some goods, taxes
could generate revenues that exceed total external costs
because the taxes would be based on marginal rather
than average external costs (Cook and Moore 1993).

  Estimates of optimal taxes on cigarettes imply that
smokers are fully informed about the risks associated
with cigarette smoking (Cordes et al. 1990). If smokers
underestimate these risks, then even higher taxes could
be appropriate to discourage people from smoking.
This issue may be particularly relevant for an addic-
tive product such as cigarettes if, when people take up
smoking, they do not fully understand the addictive
properties oi consumption and the implications of


addiction for future choices. Gruber and Koszegi
(2000), for example, concluded that if these "internali-
ties" are taken into account, they suggest sizable addi-
tional taxes of one dollar or more per pack of cigarettes.
  Among the most widely cited recent estimates
of the optimal tax are the studies of the economic costs
of cigarette smoking by Manning and colleagues (1989,
1991). These incidence-based estimates used data from
the RAND Corporation's Health Insurance Experiment
and the 1983 National Health Interview Survey. To
calculate the optimal tax on cigarettes, the analyses
estimated both the lifetime external costs associated
with cigarette smoking and the perceived "savings"
that result from smokers' dying earlier and not realiz-
ing their pension and Social Security benefits.
  Using their midrange estimates, Manning and col-
leagues (1989, 1991) concluded that for a new smoker,
the total external cost of smoking was 43 cents per pack
of cigarettes in 1986. This estimate comprised 1 cent in
extra costs for sick leave, 2 cents in costs for smoking-
related fires, 5 cents in added costs for group life insur-
ance, 9 cents in lost tax revenues (to finance retirement
and health benefits), and 26 cents in spending on addi-
tional medical care. These costs would be offset, how-
ever, by an estimated 27 cents per pack in external
savings resulting from smoking-related premature
deaths. Converting these figures to 1995 dollars (based
on the medical service price index and the gross national
product deflator), the CRS estimated a net external cost
of 33 cents per pack for cigarettes, which is approxi-
mately two-thirds of the average federal, state, and lo-
cal taxes on cigarettes of 30 cents per pack in late 1993
(Gravelle and Zimmerman 1994). The CRS thus con-
cluded that smokers were more than paying their wav.
  Critics of the studies of Manning and colleagues
(1989, 1991) contend that many of the assumptions
made in obtaining the estimates are inappropriate. If
the analyses had not included the effects of unrealized
pension and Social Security benefits of smokers who
die prematurely, the resulting external costs of smok-
ing would have amounted to approximately 89 cents
per pack in 1995 dollars.

  Moreover, the studies of Manning and colleagues
(1989,1991) made a debatable distinction between in-
ternal costs (those borne by the smoker) and external
costs (those that smokers impose on nonsmokers). For
example, the lost productivity costs described in those
analyses were treated as internal costs, whereas only
the higher, collectively financed, group premiums for
health, life, and otherinsurance that nonsmokers paid
to cover smoking-related costs not reflected in the pre-
miums paid by smokers were considered external costs.

  More controversial, however, was these analy-
ses' assumption that the cost of ETS was an internal
cost. This assumption was based on the argument that
the family is the economic unit involved in making
smoking and other decisions and that the health con-
sequences of ETS are largely confined to the nonsmok-
ing spouses of smokers. As Manning and colleagues
(1991) note, when this assumption is modified to treat
the consequences of passive smoking as external costs,
the estimated external costs of smoking rise signifi-
cantly. For example, under the assumptions of
Gravelle and Zimmerman (1994) concerning prices, the
estimates of Manning and colleagues (1991) imply that
including the relatively conservative estimate of 2,400
lung cancer deaths from ETS would add approximately
31 cents per pack (in 1995 dollars) to the external costs
of smoking. Similarly, updating the researchers' esti-
mates of the costs of neonatal care for smoking-related
low birth weight would add more than 4 cents per pack.
Doing the same for deaths from smoking-related fires
would add 20 cents per pack and for smoking-related
fetal deaths would add 31 cents per pack.

  These estimates probably understate the true
costs of ETS. After reviewing the literature on the links
between ETS and heart disease, Glantz and Parmley
(1995) concluded that 30,000-60,000 persons die pre-
maturely from heart disease related to ETS. Including
these numbers in estimates by using the same assump-
tions used in the CRS report would add at least an-
other 70 cents to the estimate of the optimal tax.
Moreover, the CRS report ignored the 150,000-300,000
cases of ETS-linked lower respiratory tract infections
in children up to 18 months old and the ETS-linked
worsening of asthma in 200,000 to 1 million children
(Environmental Protection Agency [EPA] 1992). ln-
eluding these costs \vould lead to an even larger opti-
mal tax. Finally, the estimates excluded the long-term
developmental consequences suffered by infants with
smoking-related low birth weight (Hay 19911; were
these costs included, the optimal cigarette tax would
be nearlv SS per pack.

Using the human capital approach, Manning
and colleagues (1989,199I) estimated that the life of a
nonsmoker who died prematurely from ETS exposure
was worth $1.66 million. In a recent cost-benefit
evaluation of the proposed Smoke-Free Environment
Act of 1993 (introduced in the 103rd Congress but not
passed), the EPA (Mudarri 1994) used the willingness-
to-pay approach and obtained a $4.8 million baseline
estimate of the value of a life. The EPA also used this
approach to include the effects of ETS on heart dis-
ease and children's health when calculating the value
of benefits from reduced ETS exposure.


  By using the willingness-to-pay approach and
making some relatively conservative assumptions, the
EPA estimated that the total benefits from the reduced
ETS exposure that Lvould result from a ban on smok-
ing in all worksites ITas $39-71 billion per year. This
estimate assumed that the ban would reduce the num-
ber of current smokers by 3-6 percent, the number of
future smokers by 5-10 percent, and consumption
among continuing smokers by lo-15 percent; the re-
sulting total long-run reduction in consumption would
be la-22 percent. The combined effect of these reduc-
tions in smoking and of the creation of designated
smoking areas was predicted to reduce out-of-home
exposures to ETS by 90 percent and in-home exposures
by a midrange estimate of 6 percent. Estimates from
the 1992 EPA report on ETS and lung cancer suggested
that 73 percent of exposures to ETS occur outside the
home and that 27 percent occur in the home. The total
reduction in ETS exposure rvas thus predicted to be 66
percent; if it were applied to estimated total ETS costs
of $58.7-106.9 billion, this reduction ~rould vield the
EPA's estimated cost benefits of $39-71 billion. Gi\,en
current cigarette sales of about 24 billion packs per year,
this estimate implied that the per pack external costs
of ETS lvere between $2.33 and $4.45. This estimate is
likely to be lo\y, because the short-term and long-term
costs of fetal and perinatal exposure to ETS lvere not
included in the EPA's computations.

  Viscusi (1995), hoM-ever, reached a much different
conclusion in analyzing the social costs of smoking. This
investigator updated much of the analysis by Manning
and colleagues (1989, lYYl), used a willingness-to-pav
approach, and included the same ETS risks used in the
EPA's analysis (Mudarri 1994). Viscusi, however, ar-
gued that the EPA approach overestimated the risks of
ETS by failing to account for the change in the tar con-
tent of cigarettes and the changes in cigarette consump-
tion per smoker. Noting that the average tar content of
cigarettes declined from 46.1 mg per cigarette in 1944
to 12 mg per cigarette in 1994, Viscusi asserted that the
health risks associated with cigarette smoking, as well
as the risks from exposure to ETS, are linearly related to
the tar content of cigarettes. Although presenting no
evidence for either assertion, he contended that esti-
mates of the health risks based on consumption of
higher-tar cigarettes and exposure to ETS from higher-
tar cigarettes need to be adjusted to reflect the decline
in tar content. When not adjusting for tar, Viscusi ob-
tained an estimate for the per pack external costs of ciga-
rette smoking well above the average tax on a pack of
cigarettes; when adjusting for tar, he concluded that
current cigarette taxes exceed the external costs of
smoking.

  A clear consensus is lacking regarding the opti-
mal tax on cigarettes. Optimal tax calculations from
prevalence-based estimates that include the direct and
indirect costs of smoking-related morbidity and mor-
tality are likely to be inappropriate, because the calcu-
lations include lost productivity and other costs that
should arguably be considered internal costs. Similarly,
optimal tax calculations from the recent incidence-
based estimates probably underestimate the optimal
tax, because these calculations exclude many of the
external costs of smoking. Nevertheless, because of
the grooving evidence of the substantial health conse-
quences of exposure to ETS (including fetal and peri-
natal exposure), a tax that would generate sufficient
revenues to cover all external costs from smoking is
likely well abo1.e the current average of federal, state,
and local taxes on cigarettes.

Cigarette Taxes and Health

  As the review of studies on cigarette demand
demonstrated, increases in cigarette prices lead to sub-
stantial reductions in cigarette smoking by deterring
smoking initiation among youth, prompting smoking
cessation among adults, and reducing the average ciga-
rette consumption among continuing smokers. Be-
cause of the substantial health consequences of
cigarette smoking and the health benefits of smoking
cessation, these reductions in cigarette smoking would
lead to significant improvements in health by reduc-
ing smoking-related morbidity and mortality. Thus,
increases in cigarette excise taxes, which would result
in increases in cigarette prices, would be an effective
policy tool in improving health.

  Several recent studies have provided some esti-
mates of the health benefits resulting from cigarette
tax increases. For example, Warner (1986) used pub-
lished estimates of price elasticity (Lewit et al. 1981;
Lewit and Coate 1982) to estimate the impact of higher
cigarette excise taxes on smoking and health. The
study predicted that a sustained, real 15 percent tax-
induced increase in cigarette prices in 1984 (which
would have been equivalent to restoring the federal
tax to its real value in 1951-a nominal tax of 32 cents
per pack) would deter 800,000 young people from
smoking and encourage about 2.7 million adults to
quit. Using the conservative assumption that one of
every four lifelong smokers dies prematurely of a
smoi<ing-related illness, the researchers estimated that
this tax increase would reduce premature deaths
among persons 12 years and older by 860,000.

  The GAO (1989) used the same estimates of price
elasticitv to predict the health benefits from a sustained,


real tax increase of 21 cents per pack in 1989 (lvhich
they estimated m~ould raise the price by 15 percent).
Using the one-in-iour assumptions made by Warner
(1986), the analysis estimated that this tax increase
would reduce the number of youth who smoke by
500,000 and would subsequently reduce premature
deaths from cigarette smoking among youth by
125,000.

  Harris (1987) used various estimates of the price
elasticity of demand in an analysis of the health impli-
cations of the 1983 tax hike and corresponding price
increase. The analysis concluded that this tax increase
deterred 600,000 young people from smoking. After
reviewing the epidemiologic literature, Harris esti-
mated that an additional 54,000 young people and a
total of 100,000 people would survive to at least 65
years of age as a result of the tax increase.
  Two recent studies directly examined the health
benefits of increases in cigarette excise taxes (Moore
1995; Evans and Ringell999). Using annual state-level
death rates from smoking-related diseases (including
heart disease, lung cancer, cardiovascular disease,
mouth and throat cancer, and asthma), the study di-
rectly estimated, through appropriate econometric
methods, the impact of higher taxes on health. The
resulting estimates implied that a lo-percent increase
in cigarette excise taxes would save approximately
5,200 lives annually. Similarly, Evans and Ringel
(1999), using data from the 1989-1992 Natality Detail
files, concluded that higher cigarette taxes \yould sig-
nificantly improve birth outcomes.
  The CSH (1994) analyzed the health benefits of
higher cigarette excise taxes by using relatively con-
servative estimates of the price elasticity of demand
and of deaths related to cigarette smoking. The studv
estimated that, based on 1992 taxes and cigarette smok-
ing data, an increase of 75 cents per pack in the federal
cigarette excise would reduce premature deaths by
900,000. The study further estimated that a $2.00
increase would save an additional 1 million lives.
  Similarly, Chaloupka (1998) provided estimates
of the effects of alternative cigarette tax and price in-
creases contained in various national tobacco settle-
ment proposals based on Chaloupka and Grossman's
(1996) econometric analysis of youth smoking. For
example, he estimated that a $1.50 increase in cigarette
taxes and prices, phased in over a relatively short pe-
riod of time and then adjusted for inflation, would re-
duce overall cigarette consumption by approximately
30 percent, while cutting the prevalence of youth smok-
ing nearly in half. Given the CDC's recent estimate
that l&620,878 youth in the 1995 cohort of O- through
17-year-olds would eventually become smokers and

that 32 percent of regular smokers eventually die from
a smoking-related disease, Chaloupka (1998) estimated
that this tax would prevent approximately 2.5 million
premature deaths in this cohort.
  The substantial econometric literature clearly in.
dicates that increases in cigarette prices will reduce
both smoking prevalence and average cigarette con-
sumption. Because of the well-documented health
consequences of smoking, tax-induced increases in
cigarette prices would generate substantial improve-
ments in health. Thus, higher taxes on cigarettes and
other tobacco products appear appropriate from a pub-
lic health perspective.  In addition, at a gathering
convened by the CDC to evaluate the criteria for de-
fining an optimal cigarette tax, economists raised two
further reasons for higher cigarette taxes (Warner et
al. 1995). First, to the extent that adolescents and young
adults do not fully understand the addictive nature of
cigarette smoking, the argument could be made that
higher cigarette taxes can reduce smoking by youth
before it is too late for them to quit easily. Second, to
the extent that youth behave more myopically than
adults (in particular, more than the adults that they
will later be), young people are more likely to take on
a habit with l&g-term health consequences. Thus, by
discouraging smoking, the higher tax can help correct
youth's myopic behavior.

  Although higher cigarette taxes are likely to pro-
duce substantial improvements in health, several fac-
tors could mitigate the impact of these taxes. First, as
the limited research on the demand for smokeless to-
bacco products suggests (Ohsfeldt and Boyle 1994;
Ohsieldt et al. 1997, 1999), increases in cigarette taxes
not matched bv similar increases in smokeless tobacco
taxes may induce people to substitute other tobacco
products with similar health consequences. For es-
ample, the large increases in Canada's cigarette excise
taxes and the consequent increases in the differential
between cigarette taxes and taxes on roll-your-own
tobacco led to a sharp rise in the use of the latter (De-
partment of Finance, Canada 1993). This substitution
could easily be avoided by increasing all tobacco taxes
simultaneously. Canada's experience also raises the
issue of equalized taxes between nations, because
relatively large tobacco tax hikes resulted in a border-
crossing black market in cigarettes and other tobacco
products as well as in other efforts to avoid taxes. Al-
ternatiirely, as Evans and Farrelly (1998) found, the
higher taxes may lead smokers to change the kinds of
cigarettes they smoke (i.e., they may switch to higher-
tar and higher-nicotine cigarettes), thereby reducing
the health benefits of higher cigarette taxes. The re-
sults of the study by Evans and Farrelly suggest that

3% Chl7pt" 6


taxes based on the tar, nicotine, and carbon monoxide
content of cigarettes (first suggested by Harris 1980)
may be the most appropriate means to address the
public health consequences of smoking.

  Of course, cigarettes and other tobacco products
are not the only goods that can be taxed on the basis of
these arguments. Heavy consumption of alcoholic
beverages, for example, also leads to health problems,
unintentional injuries, property damage, and other
consequences. Cook and Moore (1993) provide a de-
tailed discussion of the rationale for higher alcoholic
beverage excise taxes. A number of studies of the "op-
timal" tax on alcoholic beverages ha\Tc concluded that
current taxes are well beloiv the le\.el that \~ould cover
the social costs of alcohol abuse (Manning et al. 1989,
1991; Saffer and Chaloupka 1994).

Tobacco Taxation and Revenues

   An alternative rationale for tobacco taxes is that
they are a relatively simple \\`ay to generate revenues.
Even some prominent proponents of the free market
philosophy have supported tobacco taxes to generate
revenues. "Sugar, rum, and tobacco," Lvrote Adam
Smith in his 1776 economic treatise, Arl IIII~"~II/ Irrto 1/1('
~NfitllTCfil~ij C1711.sf>s oftIll> ~V~~~7lfl~ ofNiltio,14,"are comrnodi-
ties which are no where necessaries of life, \vhich are
become objects of almost universal consumption, and
which are therefore extremely proper subjects of taxa-
tion" (1976, Book V, p. 474).

  As described earlier in this chapter (in "Ration-
ales for Tobacco Taxation"), various lti\,els of go\rern-
rnent have long used cigarette and other tobacco taxes
to raise revenues. Such policy is supported by eco-
nomic theory. An economically efficient way to raise
revenues while minimizing the M.elfare losses associ-
ated with the price distortions resulting from taxes is
to impose relatively higher taxes on goods with more
inelastic demand (one for which the percentage reduc-
tion in demand is smaller than the percentage increase
in price) (Ramsey 1927). As described earlier in this
chapter (in "Effect of Price on Demand for Tobacco
Products"), the numerous studies of cigarette demand
and the limited studies of the demand for other to-
bacco products have implied that overall demand, at
least in the short run, is inelastic. Thus, large increases
in tobacco taxes can generate substantial increases in
revenues, particularly in the short run.

  Since 1960, the dollar amount of federal revenues
generated by tobacco taxes has increased significantly,
from $1.9 billion to nearly $5.9 billion in 1997. Over
this same period, state revenues from tobacco ha1.e also
increased significantly in nominal terms, from slightly

less than $1 billion to more than $7.5 billion. As new
sources of tax revenues have been identified, however,
tobacco revenues ha\,e constituted a smaller propor-
tion of total revenues. Tobacco taxes accounted for
3.36 percent of all federal revenues in 1950, but they
rvere only 0.44 percent of revenues in 1989 (CBO 1990).
Similarly, total federal tobacco tax revenues as a share
of the gross national product fell from 0.55 percent in
1950 to 0.08 percent in 1989.

  Merriman (1994) considered whether cigarette
excise taxes are set to maximize the revenues from
these taxes. More specifically, Merriman tested the idea
that elected officials, in an effort to maximize their own
utility, mav increase taxes on some goods to the point
lyhere re\:enues from these taxes begin to decline
(Buchanan and Lee 1982). Using published estimates
of cigarette demand (Becker et al. 19941, the study
found that cigarette excise taxes in every state were
Mel1 below, the revenue-maximizing level of these
taxes, at least as of 1985. Furthermore, these estimates
of the marginal revenue effects of higher taxes were
loljrer-bound estimates, because they held constant
other states' taxes (a consideration that allowed for
increases in the casual and organized smuggling of
cigarettes in response to a tax hike in a given state).
Coordinated state tax increases, as a result, would gen-
erate even higher re\`enues.

  Grossman (1993) considered this issue of maxi-
mizing the federal excise tax on cigarettes. Using pub-
lished estimates of cigarette demand (Chaloupka 1991;
Becker et al. 19941, Grossman predicted that in the long
run, a real federal tax rate of $1.26 would maximize
federal tax revenues at S16 billion and would gener-
ate even larger immediate increases in revenues. Like-
xvise, Becker and Grossman (1994) suggested that the
long-run revenue-maximizing value of the federal ciga-
rette excise tax is 95 cents per pack in 1994 dollars.
This tax would generate approximately $12 billion in
total revenues and would raise considerably more than
in the short run. These estimates were consistent with
the prediction that a sustained real increase of 75 cents
in the federal tax on cigarettes would in the long run
lead to a net increase in cigarette tax revenues of just
over $16 billion (Gravelle and Zimmerman 1994).

  Other studies, however, have predicted that
higher federal taxes would generate much greater rev-
enues (Harris 1994; Womach 1994a). For example,
Harris has predicted that raising the federal tax to $2.00
per pack would have generated nearly $20 billion in
additional revenues annually, on average, from 1995
through 1999, xvhereas Chaloupka (1998) estimates that
a $1.50 increase lvould, in the short run, raise $22.5
billion annuallv.


  The differences among the predicted revenue ef-
fects of higher cigarette taxes mav be attributed to dif-
ferent assumptions used to obtain these estimates as
well as to differences in the period for which the pre-
dictions are made. For example, two studies (Gross-
man 1993; Becker and Grossman 1994) have assumed
a linear demand function for cigarettes. One of the
implications of this function is that the price elasticity
of demand rises as price rises. Thus, when the effects
of a large increase in the cigarette excise tax are pre-
dicted, cigarette demand is assumed to become more
responsive to price. This assumption implies that there
is an inverted U-shaped relationship between cigarette
taxes and revenues: increasing cigarette taxes from
relatively low levels will initially lead to increased rev-
enues; beyond some point, further increases in taxes
will lead to even larger reductions in demand, thereby
causing revenues to fall. The same basic argument is
implicit in the well-known Laffer curve, Lvhich relates
income tax rates to income tax revenues.
  The assumption of a linear demand function for
cigarettes is in contrast to the assumption made by
some other analysts that the price elasticity of demand
is constant over the range of prices under consider-
ation. Because almost all of the studies described in
this section found that the demand for cigarettes is
inelastic, the assumption of a constant elasticity im-
plies that even very large increases in taxes \~111 al-
ways generate large increases in revenues.
  The differences in revenues predicted by these
two assumptions, although only minor \vhen analv-
ses predict the impact of relati\,ely small cigarette tax
increases, grow with the size of the tax increase. Be-
cause either assumption could be questioned, the rev-
enue effects of a tax increase will likelv fall some\yhere
between the predictions obtained from the t\vo
(Grossman et al. 1993). The limited evidence from the
behavioral economics literature suggests, hoL1-ev-er,
that the effects of large increases in cigarette prices \vill
lead to larger reductions in cigarette demand than pre-
dicted by the assumption of a linear demand function
(Bickel et al. 1991).

  A second key factor leading to the differences
discussed here is the distinction between the short-run
and long-run effects of the tax hikes. Economic theory
implies that the demand for most consumer goods will
be more responsive to price in the long run than in the
short run. For cigarettes and other tobacco products,
additional factors increase the likelihood that the long-
run effects of an increase in price on cigarette demand
will exceed the short-run effects-that is, price elastic-
ity will increase in a manner similar to the increase for
other, nonaddictive goods and services. Increased

cigarette taxes will thus lead to smaller increases in
revenues in the long run than in the short run.
  That adolescents and young adults are more re-
sponsive to prices than older adults are and the fact
that cigarette smoking is an addictive behavior are of
particular importance when predicting the short-run
and long-run revenue effects of higher cigarette taxes,
Age difference in price elasticity implies that sustained
real tax increases will lead to greater reductions in
smoking prevalence and consumption as the number
of adolescents and young adults who have not yet
decided to smoke replaces the number of older adults
who already smoke. The assumption of addiction
implies that price has a cumulative effect on consump-
tion: the price increase immediately reduces current
consumption by discouraging young people from ex-
perimenting or-continuing to experiment with smok-
ing, as well as by encouraging current smokers to
smoke less; futureconsumption is then reduced by the
continuously fewer current smokers who also continue
to smoke less in the face of a sustained real increase in
price. The cumulative effect of price on consumption
thus exceeds the immediate effect. This sequence ulti-
matelv leads to reduced revenues.
in summary, federal and most state excise taxes
on cigarettes are undoubtedly well below their revenue-
maximizing levels. Thus, relatively large increases in
these taxes would lead to substantial gains in revenues,
particularlv in the short run. Moreover, because of the
relatively inelastic demand for cigarettes, increases in
cigarette taxes are an economically efficient means of
generating substantial revenues while imposing rela-
tively small lvelfare losses. But if there is little argu-
ment that large increases in cigarette taxes would
generate substantial increases in tax revenues in the
short run, there are some questions on the revenue-
maximizing values of these taxes and the long-run
stability of revenues generated by large increases in
cigarette taxes.

  Part of the difficulty in estimating the effects of
large taxes on cigarettes is that there is little experience
in the United States with relatively large increases. Sim-
larly, it is unlikely that the long-run effects of the more
recent large tax increases have been fully played out.
The short-term experience in Canada is of limited use
in addressing these issues. Cigarette taxes in Canada
increased more than 500 percent between 1982 and 1992,
Mhich increased real cigarette prices by 170 percent, and
total smoking fell by 38 percent (Sweanor and Martial
1994). Because of the effects of other, contemporane-
ous activities to reduce tobacco use, the impact of the
large price increases on smoking were consistent with
the estimates from the studies of U.S. cigarette demand


described in this chapter. Moreover, total federal and
provincial revenues generated by Canadian cigarette
taxes \vere 240 percent higher in 19Y2 than in 1981 e\ren
M.ith the concomitant considerable black market in

cigarettes. This experience suggests that large increases
in cigarette taxes in the United States would generate
sizable tax revenues for manv vears.
                       . I

Conclusions

1.  The price of tobacco has an important influence    3.  Policies that influence the supply of tobacco, par-
  on the demand for tobacco products, particularlv     titularly those that regulate international com-
  among young people.                merce, can have important effects on tobacco use.

3 i.  Substantial increases in the excise taxes on ciga-    1.  Although employment in the tobacco sector is
  rettes would have a considerable impact on the     substantial, the importance of tobacco to the U.S.
  prevalence of smoking and, in the long term, re-     economy has been overstated. Judicious policies
  duce the adverse health effects caused by tobacco.     can be joined to higher tobacco taxes and stron-
                          ger prevention policies to ease economic diver-
                            sification in tobacco-producing areas.


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Chapter 7
Comprehensive Programs

Introduction 373

Conceptual Frameworks 373

Description of Comprehensive Programs 374
Program Goals for Reducing Tobacco Use Statewide  374
Program Components for Reducing Tobacco Use Statewide  375

Community Intervention Trials 376

Statewide Interventions 387

Community Mobilization 382
National Programs 383
ASSIST 383
IMPACT 384

SmokeLess States Program 384
National Programs to Reduce Youth Access to Tobacco  381
States Currently Funded in the Nationwide Program to Reduce Tobacco Use  385
Examples of Major State Programs  385
Minnesota 386
California 387
Massachusetts 389
Arizona 391
Oregon 392
Maine 393

Programs Funded by State Settlements With the Tobacco Industry  391
Mississippi 391
Florida 395
Texas 397

Minnesota Settlement Program 397
Programs Meeting the Needs of Special Populations  398
Programs for the African American Community  398
Programs for Women 400
Federal and State Programs  401
Religious Organizations 401
Special Efforts to Reduce Chewing Tobacco Use  402

Components of Community Programs  403
Community Advocacy and Mobilization  403
Electronic Networking 403
Direct Advocacy 405
Media Advocacy 407
Countermarketing 309


Summary 47 6

Conclusions 11 T

References 318


Introduction

  A comprehensive approach to reducing tobacco
use recognizes that individual behavioral choices
occur in a larger, complex context: a social setting of
family, community, and culture; a complex economic
and physical environment; formal and informal gov-
ernment policy; and the prevailing legal atmosphere
(Green and Richard 1993). The specific programs re-
vie\\Ted in prior chapters can be better understood as
part of a general framework for health promotion
(World Health Organization [WI-IO] 1986; Ht~lfll
Pmnofiolr Illferrlntiorznl 1997). Using such a frame-
work, this chapter will review- community-based
intervention studies and the current models for con-
prehensive tobacco prevention and control that are
funded by specific excise taxes or by settlements with
the tobacco industrv.

The evaluation of multicomponent interwntions
and socioecological models of health promotion poses
a special problem (Green and Kreuter 1991; Sanson-
Fisher et al. 1996; Nutbeam 1998). The most effective
models of health promotion are social movements that
evolve (Kickbusch 1989; Allison and Rootman 1996;
Downie et al. 1996; Nutbeam 1998). Thus, the nature
and complexity of health promotion interventions do
not fit the tightly defined, controlled, and presumably
reproducible research model that is more suitable for
epidemiologic testing (Elder et al. 1993; Mittelmark et
al. 1993; Baum 1995; Allison and Rootman 1996;

Conceptual Frameworks

Macdonald et al. 1996; Nutbeam 1996, 1998). None-
theless, surveillance data, periodic surveys, and other
administrative data from multiple sites permit these
interventions, as well as "natural experiments," to be
studied. Traditionally, per capita consumption data,
adult prevalence surveys, and surveys of tobacco-
related behaviors among young people have been the
core of this surveillance approach. Recently, a broader
arrav of legislative, economic, media, and program
data-has emerged to enhance sur\,eillance of the social
environments that influence the use of tobacco prod-
ucts. For example, the WHO's Glliilrlirzes ,fw Co~ztrol-
/i/r;; 1711d MoJrifoiir7~~ thr TohnCro E@?JJ7iC (WHO 1998)
provides detailed recommendations on the types of
data that should be monitored for both planning and
e\,aluating tobacco control efforts. For the United
States, the Centers for Disease Control and Prevention
(CDC) has published background information on
sources of national surveillance data (Giovino et
al. lYY4). The Federal Trade Commission provides
annual estimates of trends in the tobacco industry's
advertising and promotion expenditures. Surveillance
data on protobacco influences are not well monitored,
however, particularly at the state level. Finally,
Wakefield and Chaloupka (1999) have provided a con-
ceptual framework for the monitoring of comprehen-
sive tobacco control programs, particularly those that
focus on preventing teenage smoking.

  From its formation in the mid-1970s, health pro-
motion has emerged as an approach that offers greater
potential for change in the health-related behavior
of populations than does health education (Green
and Richard 1993; Downie et al. 1996; Hcnltlz Pronto-
fioil IJ7termfional 1997). Health promotion emphasizes
social, economic, and other environmental influences
as the primary determinants of health behavior change
(WHO 1986; Downie et al. 1996; Hmltl7 PmJ~~ofioJl
/i~f~~rr~~tiom/ 1997). Though such health promotion
strategies have been characterized as a ne\v approach

to public health, ecological and policy-oriented
approaches are similar to the public health methods
of the latter part of the 19th century and the early de-
cades of the 20th century (Kickbusch 1989; Green and
Richard 1993; Mullan 2000). As the role of individual
risk behaviors, such as tobacco use, was increasingly
understood in the middle of the 20th century, individu-
ally focused educational strategies gained primacy
(Green and Richard 1993). These strategies produced
some important changes in health behaviors, but their
limits \2-ere realized in the cardiovascular disease


prevention programs that took place in the United
States during the 1970s and lY8Os (see "Community
Intervention Trials," later in this chapter) (Green and
Richard 1993; Luepker 1994; Winklebv 1994; Fisher
1995; Schmid et al. 1995; Susser 1995). -

  The shift from a health education approach that
targets the individual to a health promotion approach
that uses social, policy, and environmental strategies
has several advantages. First, by recognizing that
many environmental determinants of health behavior

Description of Comprehensive Programs

are not under the direct control of the individual, the
ecological focus avoids blaming persons who fail to
modifv their behavior. Second, many educational
strateiies are more effective with better-educated,
wealthier persons and may thereby increase the dis-
parities in health between population groups and fail
to reach those in greatest need. Third, regulatory and
policy interventions can be more cost-effective than
multiple efforts to modify individual behavior.

  The importance of comprehensive economic,
policy, and regulatory interventions to reduce tobacco
use has long been recognized by international experts
(WHO 1979). For example, the evolving WHO guide-
lines for such interventions have increasingly empha-
sized policy and legislative measures, stressing that
these types of health promotion and health protection
strategies are essential elements of any national effort
to reduce tobacco use (WHO 1998). In an extension
of the WHO's efforts, the National Cancer institute
(NCI) released a blueprint for related public health ac-
tion in the United States (NC1 1991). This monograph
stressed that the application of social environmental
approaches should not compete \vith individual ap-
proaches but should be combined synergistically with
them. Similarly, the Center for Substance Abuse Pre-
vention (CSAP) of the Substance Abuse and Mental
Health Services Administration (SAMHSA) published
guidelines that provide the concept, structure, and
operations of a community-based approach to reduce
tobacco use among youth (SAMHSA 1998a,b). To fur-
ther help states overcome common obstacles to
enforcing youth access laws, CSAI' also has prol,ided
a document that provides strategies to address prob-
lems such as interagency and intraagency issues, in-
sufficient or uncoordinated resources, or lack of data
sources (U.S. Department of Health and Human Ser-
vices [USDHHS] 1999). More recently, the CDC (1999a)
has synthesized a comprehensive framework for state-
wide programs to reduce tobacco use. This framework
integrates four program goals with four program com-
ponents; optimally, each of the goals lvould be fully
addressed in the implementation of each of the com-
ponents. The framervork, described in the next sec-
tion of this chapter, recognizes that comprehensive pro-
grams will continue to evolve, in response both to new

information and to new circumstances. In addition,
the framework represents a distillation of evidence and
judgment that have been discussed in detail in the ear-
lier chapters of this report and that have been tested
in the community-based trials and the comprehensive
programs discussed later in this chapter.

Program Goals for Reducing Tobacco
Use Statewide

1.  Preuerrt ilritiatiorr amorlg yomg people. The
hallmarks of this goal are

o Decreasing young people's access to tobacco
products.

o Increasing prohealth messages.
o Reducing protobacco messages.
o Increasing the price of tobacco products.

Some of the mechanisms for decreasing
young people's susceptibility to tobacco use are
promoting vouth empowerment activities,
providing school health education, offering
positive alternatives, deglamorizing tobacco use,
and in\,olving parents and families.

2.  Promotr quitting among adults and yo1411g
people. An environment that supports efforts to
quit using tobacco can be fostered by

o Increasing access to culturally appropriate,
effective cessation services (e.g., by expanding
insurance coverage).
9 Increasing the price of tobacco products.
o Increasing restrictions on environmental
tobacco smoke (ETS).


o Increasing prohealth messages.
o Decreasing protobacco messages.

3. Eiimiuate exposure to ETS. The continued ex-
pansion of policies to eliminate exposure to ETS
can be achieved by

o Developing support for implementation.
o Enforcing voluntarv private policies.
o Enforcing public pilicv and public regulation.
o Expanding coverage o? public areas.

1. Iderztify and eliminate disparities nmoq popla-
tim groups. Intrinsicallv linked to achieving the
first three goals, elimina;ing disparities entails

Increasing the price of tobacco products
through culturally acceptable programs.
Decreasing exposure to ETS.
Increasing prohealth messages.
Decreasing protobacco messages, particularly
those aimed at population subgroups.
Increasing the availabilitv of culturally
acceptable cessation services.
increasing protective factors among young
people.
Decreasing young people's access to tobacco
products.

Development, funding, and implementation
the major elements-some of which appear in
several of these goals-are critically linked to com-
munity involvement and, as noted, to a culturallv
appropriate approach.

Program Components for Reducing
Tobacco Use Statewide

Community interventions. Working through
social organizations, systems, and networks
promotes an environment that facilitates indi-
vidual health choices and establishes freedom
from tobacco use as the norm. The term "commu-
nity" encompasses a diverse set of entities, includ-
ing medical societies; schools; school districts;
departments of education; voluntary health agen-
cies; civic, social, and recreational organizations;
businesses and business associations; city and
county governments; public health organizations;
labor groups; managed care systems; faith com-
munities; and organizations for racial and ethnic
minority groups.

Community-based activities can include sup-
porting legislated removal or restriction of stimuli
to use tobacco (such as advertising and promotion,

easy access to tobacco products via self-service
display and vending machines, and ongoing ex-
posure to ETS) as well as providing positive alter-
natives (such as promoting cessation, encouraging
prevention advocacy, developing role modeling
through parents and adults, and fostering youth
empowerment). By changing the community set-
ting and institutions with which adults and young
people interact, community-based activities work
to denormalize, deglamorize, and discourage to-
bacco use and to provide access to resources that
increase users' abilitv to control their addiction and
use of tobacco. This approach has the potential to
effect substantial, sustained, populationwide
change in tobacco use behavior.

Collrlterlnnrketing. Changing a social environ-
ment that fosters a norm of tobacco use is an
essential element of national, state, and local pro-
grams. This change requires strategies to counter
the billions of dollars spent in advertising and pro-
motion that reach young people and adults with
misleading images about tobacco. Countermarket-
ing efforts can include using media advocacy, paid
media, and counteradvertising; increasing
prohealth promotions and sponsorships; and pro-
viding information on the tobacco industry's mar-
keting and promotional tactics. These public
health messages should use a strategy that targets
all age groups and populations. In a comprehen-
sive strategy, education messages will be mutu-
ally reinforcing: clean indoor air messages will
provide added motivation for adults to quit smok-
ing; cessation messages for adults will discourage
tobacco use among young people and accentuate
the problem of addiction; and youth prevention
messages will increase the salience of the tobacco
issue among parents and community leaders.

Program policy ad regulatiou. Areas in which
policy and regulation to reduce tobacco use have
been applied include minors' access, tobacco pric-
ing, advertising and promotion, clean indoor air,
product regulation, product labeling, ingredient
disclosure, and policies on insurance coverage
for cessation services. Policies and regulations can
be established at the federal, state, and local lev-
els (see Chapter 5). Ideally, policies and regula-
tions need to be implemented at both the
community level and statewide. Educating the
public about policies and regulation is crucial
to acceptance, but such education must be sup-
ported by adequate enforcement.


4. Surveillarlce aud evaluatiorz. Surveillance and
evaluation efforts are necessary to make the
ongoing refinements that lead to more effective pre-
vention strategies. In addition to traditional
surveillance methods, nontraditional approaches-
such as monitoring the promotional activity of the
tobacco industry at the state and local levels, moni-
toring the economic impact of smoking laws and
other ETS policies, and performing periodic surveys
of public opinion on program interventions-are
critical for reducing tobacco use.

  The conceptual framework for comprehensive
efforts to reduce tobacco use has been used to
develop the current generation of statewide programs.
However, even the most comprehensive programs

Community Intervention Trials

currently in place have not been able to fully imple-
ment all recommended components. Policy and regu-
lation components are especially hampered, since
many state and local actions are limited by federal
mandates and preemptions (see "Preemption of Local
Action by State Policy" in Chapter 5). Moreover, only
two states, California and Massachusetts, have imple-
mented comprehensive programs for a sufficient time
to provide evaluation data on the overall efficacy of
the emerging comprehensive model.

  The following sections summarize the history
and development of community-based, statewide, and
other large-scale efforts to reduce tobacco use and con-
clude with a review of existing data on the efficacy of
the comprehensive model.

  Large-scale trials to prevent cardiovascular
disease have been a major source of data on population-
based approaches to reducing tobacco use. An empha-
sis on the importance of addressing social and cultural
determinants of smoking behavior grew directly out
of early work on cardiovascular disease epidemiology.
The Seven Countries Study, which was started in the
mid-1950s by Keys and colleagues (Aravanis et al. 1970;
Blackburn et al. 1970; Buzina et al. 1970; Fidanza et al.
1970; Kimura and Keys 1970; Taylor et al. 1970a,b),
examined risk factors for cardiovascular disease in
populations around the world and documented that
disease rates and risk factors differed markedly across
cultural and social environments (WHO 1982). In that
study, more than 12,500 men aged 40-59 years from
Finland, Greece, Italy, Japan, the Netherlands, the
United States, and Yugoslavia were recruited for a pro-
spective study of the relationship between personal
behaviors (e.g., diet, physical activity, smoking) and
risk of cardiovascular disease (Aravanis et al. 1970;
Blackburn et al. 1970; Buzina et al. 1970; Fidanza et al.
1970; Kimura and Keys 1970; Taylor et al. 1970a,b). Al-
though the most striking differences in lifestyle across
cultures were in the composition of the men's diet,
smoking was found to be a significant risk factor. This
study, and many other early studies of cardiovascular
disease epidemiology, encouraged researchers to start
community trials to modify the identified risk factors
in whole population groups (WHO 1982).

  Two landmark community trials that began
in 1972 grew directly out of the work of the Seven Coun-
tries Study investigators: the Stanford Three-Commu-
nity Study (Farquhar et al. 1977) and the Finnish North
Karelia Study (Puska et al. 1985). A third, less directly
tied to this early work, was the Israeli Community Syn-
drome of Hypertension, Atherosclerosis and Diabetes
(CHAD) program (Gofin et al. 1986) begun in 1971. In
addition, two worksite trials focusing on population-
level changes in cardiovascular disease risk factors
developed out of the Seven Countries Study and from
related early work on cardiovascular disease epidemi-
ology: the Belgian Heart Disease Prevention Project
(Kornitzer et al. 1980) and the United Kingdom Heart
Disease Prevention Project (Rose et al. 1980). Though
investigators in these initial studies recognized the im-
portance of the social and cultural environment in
modifying risk factors for cardiovascular disease, in-
cluding smoking (Farquhar 1978; WHO 1979; Farquhar
et al. 1981,1985; Rose 1981; McAlister et al. 1982; Puska
et al. 1985), the smoking cessation techniques of the
time were primarily individually oriented (McAlister
et al. 1976; Meyer et al. 1980).

   The Stanford and North Karelia studies shared
some community organizing and conceptual perspec-
tives in their planning (WHO 1982). Logistical and
cultural differences between the United States and Fin-
land dictated significantly different implementation,
however. In the Stanford study, an intervention that


Rducirlg Tobacco Use

primarily used mass media was compared with the
same mass media intervention plus intensive face-to-
face counseling for high-risk individuals and was also
compared with a control community that received no
intervention. In the initial results, the community
cohort receiving both the mass media and the face-to-
face counseling for high-risk smokers had a signifi-
cantly greater decrease than the control community in
the prevalence of smoking (-50 vs. -14.9 percent) and
in the number of cigarettes smoked (percentage reduc-
tion of 51.6 vs. 21 .O percent) (Farquhar et al. 1977,1985;
Maccoby et al. 1977; Meyer et al. 1980).

  In the Finnish study, the people of North Karelia
province requested the intervention because of concerns
raised by the results of the Seven Countries Study, in
which residents of their province had participated
(Puska et al. 1985,1995). The intervention had a strong
focus on community organizing and environmental
modification, together with multiple educational com-
ponents using mass media and other strategies
(McAlister et al. 1982; Puska et al. 1985). Although the
intervention's early efforts had a greater emphasis on
increasing direct cessation services than on prevent-
ing smoking, the importance of nonsmoking environ-
ments and other environmental changes \yas clearly
recognized and emphasized (Koskela 1981). The five-
year follow-up results of the studv found no signifi-
cant difference in smoking prevalence between the
North Karelia province and Kuopio, a comparison
province with similar baseline smoking rates (Puska
et al. 1979). Ten years on, a significantly greater re-
duction in smoking prevalence was observed among
men in North Karelia than in Kuopio (Salonen et al.
1981; Puska et al. 1983a,b; Vartiainen et al. 1986). The
intervention trial has been continued, and new pre-
vention and population-based cessation strategies
have been added (Vartiainen et al. 1986; Korhonen et
al. 1992,1993). Analyses of 20-year trends (from 1972
to 1992) in smoking in the two provinces found a sig-
nificantly greater decline in smoking prevalence for
adult men in North Karelia (from 52 to 32 percent) than
in Kuopio (50 to 37 percent) and in southwestern Fin-
land. Smoking prevalence for adult women increased
at similar rates in both provinces (increasing from 10
to 17 percent in North Karelia and from 11 to 19 per-
cent in Kuopio) (Vartiainen et al. 1998). The 20-year
difference in trends in men between the two provinces
appeared to be primarily related to cessation during
the first 10 years and to prevention during the last 10
years.

  The CHAD program had a somewhat more indi-
vidually focused intervention model directed at reduc-
ing the risk factors for cardiovascular disease among

residents in Israeli housing projects (Abramson et al.
1981). The health care providers serving the interven-
tion communities provided risk factor screening and
counseling for families, couples, and individuals liv-
ing in the four adjacent housing projects. The resi-
dents of comparison housing areas received usual care
from their providers. In the intervention communi-
ties, group discussions were held to provide social
support and increase group influences on individual
lifestyle changes. Comparisons between community
health surveys conducted at baseline (1969-1971) and
after five years (1975-1976) showed a significantly
greater decline in smoking prevalence among men but
not among women in the intervention communities
than in control communities (Gofin et al. 1986). At the
lo-year follow-up (1981), the prevalence of smoking
had declined significantly between 1976 and 1981
among both men and women in the CHAD follow-up
cohort, whereas no change or a slight increase in smok-
ing had occurred among adults in Israel overall (Gofin
et al. 1986).

  The Belgian Heart Disease Prevention Project was
a controlled, multifactorial trial involving men aged
40-59 years at baseline at Belgian worksites (Kornitzer
et al. 1980). Thirty pairs of factories were studied, with
one site from each pair randomly assigned to the in-
tervention group and one site to the control group. At
baseline screenings for risk factors for cardiovascular
disease, individuals in the upper two deciles of risk
were identified and received semiannual individual
counseling from the medical staff. Medical advice to
quit smoking w'as reinforced in the factories by anti-
smoking posters, written messages, and health educa-
tion conferences encouraging workers to quit smoking
and to encourage the same to their friends who smoked.
Changes in smoking prevalence at the intervention and
control worksites were monitored among both the
high-risk individuals and in random samples of the
total worksite populations. After two years of inter-
vention, a significantly greater percentage of the high-
risk smokers quit in the intervention group than in the
control group (18.7 vs. 12.2 percent), but no difference
was observed in the random samples.

  The United Kingdom Heart Disease Prevention
Project was started in 1971 with 24 pairs of English
and Welsh factories. Each member of the pair was ran-
domly assigned to intervention or control status (Rose
et al. 1980; Bauer et al. 1985). At baseline and in 1977-
1978, risk factor screening for cardiovascular disease
was conducted among men aged 40-59 years in the
intervention sites and in a lo-percent random sample
of similarly aged men at the control sites. Over a five-
to six-year period, all men in the intervention sites


received healthy lifestyle ad\.ice by mail and bi
worksite posters. Men in the inter\,ention sites found
at baseline to be at high risk for cardiovascular dis-
ease \vere provided medical counseling on risk factor
change, including smoking cessation. At the end of
the intervention in 1977-1978, a small but significant
reduction in smoking prevalence had occurred among
the high-risk smokers in the intervention site (Rose et
al. 1980). Five intervention and five control worksites
were resurveyed in 1983, approximately 12 years after
the baseline screening and at least 5 years afier the end
of the intervention program (Bauer et al. 1985). There
was no significant difference in the prevalence of smok-
ing between intervention and control factories, but the
smokers at the intervention sites reported smoking sig-
nificantly fewer cigarettes per day.
  The initial design and implementation of the
North Karelia and Stanford Three-Community trials led
to the design of several other cardiovascular disease
prevention trials around the world. These included
the Swiss National Research Program from 1977 to 1980
(Gutzwiller et al. 1985), the South African Coronary
Risk Factor Study from 1979 to 1984 (Steenkamp et al.
1991), and the Australian North Coast Healthy Lifestyle
Programme from 1978 to 1980 (Egger et al. 1983). The
early trials also influenced the development of two
communitywide mass media-based smoking cessation
trials implemented in Australia in the 198Os, in Sydney
from 1983 to 1986 and in Melbourne from 1983 to 1986
(Pierce et al. 1986, 1990; Macaskill et al. 1992).
   In the Swiss trial, two towns in the French-
speaking and two towns in the German-speaking
regions of the country were assigned to either interven-
tion or reference status (Gutzwiller et al. 1985). Baseline
surveys of risk factors for cardiovascular disease were
conducted among random samples of residents aged
16 to 69 years in all four towns in 1977-1978 and
repeated at the final assessments in 1980-1981. In the
interval, communitywide health education and health
promotion interventions were conducted in the two
intervention towns, including media campaigns,
counseling of high-risk individuals, and community
organization efforts to encourage environmental and
social changes. The prevalence of smoking in the con-
munities declined from 32.8 to 27.4 percent in the
intervention towns and from 37.1 to 35.3 percent in the
reference towns, a significant net effect of 3.6 percent
decline.

  In the South African Coronary Risk Factor Study,
three rural communities, matched in size, socioeco-
nomic status, and cultural factors, were assigned to
low-intensity prevention, high-intensity prevention,
and control status (Steenkamp et al. 1991). Both

the low- and the high-intensity sites received a mass
media educational campaign using so-called small
media, such as posters, billboards, mailings, and
coverage in local newspapers. In the high-intensitv
community, high-risk individuals, including smokers,
received personal interventions from health care pro-
viders. Risk factors for cardiovascular disease were
measured in a cohort of residents aged 15 to 64 years
from each community in 1979 and in 1983. The baseline
prevalence of smoking was higher among men (49.2
vs. 44.4 percent) and women (17.0 vs. 14.5 percent) in
the high-intensity intervention community than in
the control community, but the difference was not sta-
tistically significant. After the four-year intervention,
the net change in smoking prevalence in the high-
intensity community, relative to the control commu-
nity, was not significant for men but was significant
for women. Women in both the low- and the high-
intensity intervention communities had significantly
higher rates of quitting than women in the control com-
munity, but no differences were observed for men.

  The Australian North Coast Healthy Lifestyle
Programme replicated the design of the Stanford
Three-Community Study (Egger et al. 1983). In 1978,
three communities in northern New South Wales, Aus-
tralia, were assigned to a media intervention, media
intervention plus community program, or control sta-
tus. A two-year study for preventing cardiovascular
disease was conducted, including a smoking cessation
component called "Quit for Life." The media inter-
ventions used professional commercial media and
advertising techniques and a social marketing and
health promotion framework involving print, posters,
radio, television, and other advertising techniques.
The community programs for smoking cessation in-
cluded promotions of smoking cessation organizations,
kits handed out by doctors, distribution of self-help
materials, and telephone help lines. The smoking ces-
sation campaigns also incorporated other community
activities-such as organized runs, stress management
training, and computerized health testing-that con-
veved the overall program's broader theme of healthy
lifestyles. Risk factors for cardiovascular disease, in-
cluding smoking, were measured in random samples
of residents aged 18 years and older in each commu-
nitv in 1978 (baseline), 1980, and 1981. In the multiple
log&tic regression analysis model, which controlled for
baseline differences among the three communities in
age and sex distributions, there was a statistically
greater decline in smoking in the two intervention com-
munities than in the comparison community, with the
largest differences among young smokers. Declines
in the prevalence of smoking in the area assigned to


media inter\-ention plus communitv program ranged
from 15.7 percent among men aged- 1 H-25 irears to 6.1
percent among women aged 65 Jrears and older.

  In the 1980s. a community~~ide mass media-
based smoking cessation campaign i1.a~ conducted in
Sydney and Melbourne, Australia (D\z.ver et al. 1986;
Pierce et al. 1986). The Sydney campai@ began in mid-
1983, and the Melbourne campaign began one yeal
later (during the preceding year, Melbourne \vas used
as a control citv for the Svdnel, campaign). The "Quit
for Life" campaigns in\.ol\.ed inno\.ati\,e and pro\`oca-
tive smoking cessation messages deli\ cred through
paid spots on the radio, on tele\.ision, and in net\-spa-
pers. These messages \~ere supported bv a telephone
"Quit Line," self-help "Quit Kits," and a Iiospital-based
"Quit Centre," all of \j.hicti \\`ere promoted at the end
of the paid ad\~ertiscmcnts used in the campaigns. The
campaigns ivei-e c\,aluated through monthlv random
telephone sur\.evs in the tit.0 iommuniticsl In addi-
tion, a cohort of-rcsijents was inter\ it>r\.cd in April-
June 1983 and again in Ma\ IYXI. In the c.ohort, 23
percent of smokers in S\,dne\- and Y percent in
Melbourne quit during the initial (control) ve`ar before
the campaign \Vas begun in Melbourne (Pierce et al.
1986). The monthI\' pre\,alence estimates demonstrated
an approximatelv l-percent decline in Svdnev in com-
parison with the rest of Australia CD\\ v& et-al. 1986).
The media campaigns Lvere continued through 1986,
along rvith additional programs in conjunction with
physician-, school-, and communitv-based activities.
Long-term evaluation of trends in smoking in the t\vo
cities from 1981 to 1987 suggests that the sustained
campaigns mav have contributed to a decline in smok-
ing prevalenceof about 1.5 percentage points per year
in both communities among men but had little impact
on women (Pierce et al. 1990). An analysis of the
campaign's potential differential impact across educa-
tional levels suggested that the Australian mass media
and community campaigns did not contribute to an
increase in the gap in smoking pre\,alence bet\veen
educational groups (Pierce 1989; Macaskill et al. lYY2).

  The lack of a consistently positive effect from these
initial community trials was attributed more to an
incomplete understanding of comprehensive interlren-
tions and to the relatively ITeak, quasi-experimental
designs of the studies than to concern about the effi-
cacy of the overall approach (Farquhar 1978). The con-
tinuing enthusiasm for the potential efficacy of the
communitywide approach was reflected in both na-
tional and international reviews and guidelines
(Blackburn 1983; WHO 1982; USDHHS 1983; National
Cholesterol Education Program Expert Panel 1988;
Shea and Basch 19YOa,b). Similarly, the positii e results

from the Australian communitywide antismoking
media campaigns and smoking cessation data from
the North Karelia trial encouraged the planning of
smoking-specific community efforts in the United
States in the late 1980s.

  Three major community-based trials for prevent-
ing cardiovascular disease were funded by the Na-
tional Heart, Lung, and Blood Institute (NHLBI) in the
early 1980s: the Stanford Five-Citv Project, the Min-
nesota Heart Health Program, and the Pawtucket
Heart Health Program. Each had comparison and in-
ter\-ention communities and stronger designs and
e\.aluation methodologies than the studies initiated in
the 1970s. Each study \vas developed by an indepen-
dent team of investigators, and the NHLBl maintained
a collaborati\.e research relationship among the stud-
ies (Winklebv et al. lYY7). All three shared common
inter\rention approaches that lasted five to eight years
and focused on the major risk factors for cardiovascu-
lar disease (hypertension, cigarette smoking, high di-
ctarv fat, obesity, and sedentarv lifestyle). Each project
used mass media, community mobilization, and mul-
tiple educational channels, such as health care provid-
ers, schools, lvorksites, and \-oluntarv agencies. The
programs integrated individual and social change ap-
proaches, cmploving some combination of social learn-
ing theory, social neti,vork diffusion theory, and social
marketing to guide the planning and implementation
of the interventions (Bandura 1977; McGuire 1973;
Rothman lY7Y; Rogers 1983). The three projects dif-
fered initially in their relative emphasis on specific
modalities (Stanford emphasized media; Minnesota,
population screening; and I'aivtucket, community or-
ganizations) (Shea and Basch 1990a1, but frequent col-
laborations among projects decreased these differences
over time. Manv innovative strategies were devel-
oped, and the piocess evaluations on specific smok-
ing prevention and cessation interventions were posi-
tive (Glasgow et al. 1985; Sallis et al. 1985; Altman et
al. lY87; Elder et al. 1987,19Y3; King et al. 1987; Lando
et al. lYYO,1991; Perry et al. 1992; Pechacek et al. 1994).
n`onetheless, the overall impact of the three interven-
tions on smoking prevalence \vas modest.

  The Stanford Five-City Project began \1-ith baseline
survevs in 1979. Five cities in Northern California were
selected on the basis of location, size, and media mar-
kets (Farquhar et al. 1985). Monterey and Salinas shared
a media market and \vere assigned to the intervention
group. The three control cities (Modesto, San Luis
Obispo, and Santa Maria) Mere isolated from the me-
dia market of the intervention communities. The
communitvlvide educational campaigns began in
1980 in collaboration 12.ith existing communitv


organizations. The two treatment cities recei\,ed con-
tinual exposure for five years; each vear, four to five
separate risk factor education campaigns took place,
one of which focused on smoking. Evaluations in-
cluded independent, cross-sectional population
samples aged 25 to 74 years surveved at baseline and
at 25, 51, and 73 months, as well as a cohort formed
from the baseline survey that M'as resurveyed at 17,
39, and 60 months. Initially, the cohort samples in the
intervention con;munities experienced a significantly
greater decline in smoking prevalence than those in
the control communities (-7.66 \`s. -3.76 percent)
(Farquhar et al. 1YYO; Fortmann et al. 1993). Bv the
end of the intervention in 1986, the cross-sectional
surveys showed no such difference in declining
prevalence. At the final folloiv-up in 1989-1990, a more
rapid though nonsignificant decline was detected in
the control communities than in the intervention com-
munities (Winkleby et al. 1996).

  In the Minnesota Heart Health Project, three pairs
of communities were selected, with one of each pair
assigned to educational intervention and the other to
comparison status (Jacobs et al. 1986; Murray et al.
1994). The communities Lvere matched on size, com-
munity type, and distance from the Minneapolis-
St. Paul metropolitan area. After a lh-month baseline
assessment period, a 5- to 6-year intervention program
was started in November 1981 in the first education
site, Mankato, Minnesota (Luepker et al. 1994). The
second and third education sites, Fargo-Moot-head on
the North Dakota-Minnesota border and Bloomington,
Minnesota, were started 22 and 28 months later in 1983.
The staggered entry alloLved for a gradual develop-
ment of the intervention program and a stronger e\.alu-
ation design (Luepker et al. 1994). Starting in 1980,
annual cross-sectional survevs among residents aged
25 to 74 years were conducted in all six sites. A ran-
dom sample of residents surveyed before the start of
the education program \vas resurveyed. For long-term
smoking cessation, the cross-sectional survey data
provided evidence of an intervention effect for M'omen
but not for men; no such effect was obserlred for ei-
ther sex in the cohort sample (Luepker et al. 1994;
Lando et al. 1995). Unexpectedly, large declines in
smoking prevalence, especiall\; among men, \vere ob-
served in comparison communities.

  In the Pawtucket Heart Health Program, the
impact of a communitywide program for reducing
risks for cardiovascular disease in Pawtucket, Rhode
Island, was compared with trends in a nearby matched
community in southern Massachusetts (name Ivithheld
to honor a confidentiality agreement with the city gov-
ernment) (Carleton et al. 1995). Pawtucket was selected

as the intervention site from among a pool of nincX
potential northeastern New England cities; thcl
comparison site had similar sociodemographic char-
acteristics. Surveys of risk factors for cardiovascula,
disease were conducted with random samples ot
residents aged 18 to 64 years in the two communitieh
at two-year intervals, beginning in 1981 and continL1.
ing until 1993. Communitywide educational strategies
emphasized public awareness campaigns, behavior
change through existing community resources and
volunteers, and community activation to promote in-
volvement and environmental changes (Elder et al.
1987, 1993; Lefebvre et al. 1987). During the seven-
year intervention program from 1984 to 1991, more
than 500 community organizations were involved,
including schools, religious and social organizations,
larger worksites, and city government departments.
Overall projected risk for cardiovascular disease
declined significantly in Pawtucket during the educa-
tional program, but the prevalence of cigarette
smoking declined only slightly and did so more !n the
comparison than in the intervention communitv
(Carleton et al. 1995).

  Concurrent \vith the community-based
cardiovascular disease prevention trials in the United
States, an antitobacco community education program
ivas initiated in India (Anantha et al. 1995). The trial
ivas conducted between 1986 and 1992 in the
Karnataka State. One intervention area (117 villages)
and tLt.0 control areas (136 and 120 villages) were se-
lected \\?thin the Kolar District. A baseline survey was
conducted in 1986, and follow-up surveys were con-
ducted t\vo and fi1.e years later. Villages \yere ran-
domly sampled in each of the three areas, and the to-
bacco use habits of all residents of each household were
assessed. A subsample of the villages selected at
baseline \,vas resur\,eyed t\1-o and five years later to
provide cohort follow--up. After the baseline survey, a
three-year educational campaign used health worker
staff from Primary Health Centres to visit each village
at least once a lveek and deliver health education mes-
sages about the risks of cigarette smoking and other
forms of tobacco use, particularly chewing. Handbills,
photographs, posters, and films m multiple languages
rvere used to reinforce health education counseling de-
livered to individuals and small discussion groups.
Among tobacco users in the intervention area, preva-
lence declined 26.3 percent for men and 36.7 percent
for \vomen. The proportional reduction in the preva-
lence of any tobacco use was significantly greater in
both men and \vomen in the intervention area than in
the t\1-o control areas (10.2 vs. 2.1 and 0.5 percent for
men and 16.3 vs. 2.9 and 0.6 percent for M-omen).


  The Federal Republic of Germany began the Ger-
man Cardiovascular Prevention (GCP) Studs in the
mid-1980s (GCP Studv Group 1988). The se\ren-year
prevention campaign in the GCP Studv targeted more
than 1 million people in six intervention regions lvhose
demographic and socioeconomic structure reflected
that of the West German population. The reference
population was sampled from the total West German
population. The goal of the campaign was to reduce
four risk factors for cardiovascular disease (hyperten-
sion, hypercholesterolemia, smoking, and obesitv) bv
using a multifaceted prevention program. Public health
services, voluntary welfare federations, institutions for
adult education, sports and consumer associations, and
other existing communitv resources and facilities \vere
used extensively. The campaigns sought the in\.ol\re-
ment of health care providers and emphasized consunl-
ers' access to them. Special emphasis M'as placed on
improving community knorzrledge and awareness of
healthy nutrition, the benefits of physical activity, and
the importance of quitting smoking. To identify per-
sons at high risk for hypertension and hvpercholester-
olemia, screenings were conducted at social t\,ents,
in factories, and at other communitv settings in close
cooperation with physicians, pharniacists, and health
insurance companies. To discourage smoking, non-
smoking restrictions were extended in public places,
and educational campaigns M'ere conducted in the
media and in community settings to promote smoking
cessation and to help smokers quit. For the e\.nluntion
of risk factor trends, representative samples of residents
aged 25-69 years from the intervention regions and of
the national population of West Germany were sur-
veyed before the intervention (May 1984 to March lY86),
at midstudy (February 1988 to April 1989), and at the
end of the intervention (April 1991 to April 1992)
(Hoffmeister et al. 1996). In the national reference
sample, the prevalence of smoking declined from 34.0
percent at baseline to 33.5 percent at the end of the study.
In the intervention region, the prevalence of smoking
declined from 35.4 percent at baseline to 32.5 percent
at the end of the study, for a net change of -6.7 percent
(P < 0.001). The decline occurred exclusively among
men (net change of -7.9 percent, I' < 0.001). Among
women, the prevalence of smoking increased in both
the intervention regions and nationwide, and no inter-
vention impact was noted (net change of -1 .X percent).

  Using a somewhat different design, the Com-
munity Intervention Trial for Smoking Cessation
(COMMIT) was started in the late 1980s (COMMIT Re-
search Group 1991). COMMIT focused solely on smok-
ing cessation and built on the initial experience in the

ongoing trials to prevent cardiovascular disease. COM-
MIT M'as planned as a randomized community trial with
11 pairs of communities and had adequate statistical
popver to detect relatively small intervention effects (Gail
et al. 1992). One community of each pair was randomly
allocated to the intervention program, and the other
was monitored as a control. The 11 interirention com-
munities received a four-year educational program
that focused on adult cessation, with special empha-
sis on "hea\,):" cigarette smokers (those who smoked
23 or more cigarettes per day). The intervention
philosophy of the trial assumed that a comprehensive
communitw~ide strategy would make it difficult for
residents in the 11 targeted sites to avoid exposure to
messages about the importance of nonsmoking and
w,ould alert smokers to the many opportunities for
cessation. Interventions focused on four primarv edu-
cational channels: media-based and communitywide
e\~ents, health care providers (e.g., physicians and den-
tists), \x,orksites and other organizations, and cessa-
tion resources. Within these channels, the centrally
de\.eloped protocol specified 58 mandated activities,
designed to be carried out largely by community vol-
unteers and local staff or agencies with limited external
wsources (Lichtenstein et al. 1990-1991). Intervention
acti\.ities started after the baseline survev and random-
ization, beginning M.ith community mobilization in
Januarv 1989 and continuing lvith protocol-defined
inter\wtion through December 1992. A telephone sur-
vey \\-a~ conducted in each of the 22 sites to estimate
baseline prevalence and identify cohorts of heavy
and light-to-moderate smokers. Cohort members were
contacted annually bv telephone, with a final assess-
ment in early 1993. A final prevalence survey was
conducted in all 22 communities from August 1993 to
January 1994.

  There was a high degree of community owner-
ship rvithin the 11 intervention sites (Bracht et al. 1994;
Lichtenstein et al. 1996), and program staff and com-
munity organizations diligently delivered the 58 man-
dated activities. Hence, the modest effects observed
in this trial were sobering for the public health com-
munity (Fisher 1995; Susser 1995). No cessation effect
was observed for the "heavy" smokers for whom the
trial was specifically designed (COMMIT Research
Group 1995a). Among the evaluation cohort of light-
to-moderate smokers, a significantly greater propor-
tion quit in the intervention than in the control
communities (30.6 vs. 27.5 percent) over the four-year
intervention period, and the effect w'as strongest
among the less educated residents of the communi-
ties, O\,erall the prevalence of smoking declined


slightly (but nonsignificantlv) more in the intervcn-
tion cdmmunities (3.5 percentage points) than in the
comparison communities (3.2 percentage points)
(COMMIT Research Group lYY5b). The quality and
statistical power of the overall trial design (Gail et al.
1992) make it unlikely that any true intervention
effects were missed. The COMMIT intervention pro-
tocol sought to apply the most effective smoking ces-
sation strategies as defined bv the published literature
(Lichtenstein et al. 1990-1991; COMMIT Research
Group 1991). The investigators were limited, however,
in their ability to be involved in many of the recom-
mended ecological and policy-oriented health promo-
tion strategies (WHO 1979; Green and Richard 1993)
because of restrictions imposed by federal funding of
the study (Fisher 1995; Susser 1995). In addition,
process data showed that implemented protocol did
not have a significant impact on many important in-
termediate variables (e.g., physician and dentist coun-
seling rates, worksite smoking bans, public attitudes
toward smoking) (Glasgow et al. 1997; Ockene et al.

Statewide Interventions

1997; Taylor et al. 1998). Therefore, the failure of the
COMMIT interventions to use certain strategies or to
change intermediate social and policy variables suggests
that the study was not an adequate test of the efficac-,
of the social-environmental approach to reducing to-
bacco use.

Several reviewers have provided some perspec-
tives on the modest smoking cessation effects observe(j
in these community trials (Green and Richard 1YY3;
Luepker 1994; Winkleby 1994; Fisher 1995; Susse,
1995). Common themes are (1) the difficulty in oh-
serving intervention effects because of the largtx
secular declines in risk factors for cardiovascular dis-
ease, including smoking, that occurred during tllc,
period when the trials were implemented and (2) tllc
need for a more comprehensive health promotion a~>-
preach. A more complete understanding is needed ot
why such modest and mixed smoking cessation effects
have been observed in numerous well-designed and
well-implemented communitywide trials.

  Concurrent with the implementation of the corn-
munity intervention trials, a broader national move-
ment to reduce tobacco use began to emerge in the
1980s. Unlike the communitv intervention trials, this
movement, and the large-scale inter\.cntions that
developed from it, was not structured around research
hypotheses and preplanned evaluation designs.
Rather, the movement was characttri7ed by commu-
nity mobilization at the national, state, and local
levels and encompassed the principles of health pro-
motion as a social movement that evolves (Kickbusch
1989; Allison and Rootman 1996; Dolvnie et al. 1996;
Nutbeam 1998). Funding for these efforts came from
both federal and private sources; hoLyever, an impor-
tant manifestation of this national mo\.ement \vas the
establishment of statewide interventions funded by
increases in cigarette excise taxes or settlements \Vith
the tobacco industry. Such increases Lvere the result
of voter initiatives, beginning M'ith those in California
in 1990 and Massachusetts in 1993. The next section
of this chapter reviews the main elements of the na-
tional movement.

Community Mobilization

  A significant step in organizing the movement to
reduce tobacco use w'as the founding in 1981 of the Co<l-
lition on Smoking OR Health, which consisted of repn.~-
sentatilpes from three major \.olunteer health agen&,\:
the American Cancer Societv (ACS), the American
Heart Association, and the Am&ican Lung Association.
The formation of a national coalition prompted stattcs-
and local-le\,el leaders of these organizations to form
similar triagencv coalitions. Some of these state and lo-
cal coalitions expanded to include representatives from
other groups, such as medical societies, other voluntc~~~l
health organizations, and state health department\.
These coalitions bvere among the first efforts to mobi-
lize communities at the state and local levels.

   The consensus of the 1985 International SumtniI
of Smoking Control Leaders in Washington, DC, 11 11'
that only unified, broadly based, strategically cohtBr-
ent, and flexible national movements for reducltls
smoking were destined to be successful. To help b~iilci
such movements, the summit participants rccon-
mended producing a handbook on coalition buildin::


The resulting ACS publication, S!l&c~ Fi~/?firf$: .4 Srl~lX--
i~i,q COII~YOI M~~IWII~II~ Ririliiir~z G~ridi, (Pertschuk and
Erickson 1987), examined the strengths and weak-
nesses of net\%-orks and coalitions and gave sugges-
tions for building and strengthening these forums.
This guide was one of the earliest produced on com-
munitv organizing to reduce tobacco use.

A survey conducted bv the Association of State
and Territorial Health Officials determined that as of
December 31,1989, coalitions for reducing tobacco use
had been formed in 46 states and the District of
Columbia (CDC 1990). Only Hawaii, Kentucky, Mis-
sissippi, and South Carolina did not have state-level
coalitions at that time. Of the 47 coalitions, 34 concen-
trated on reducing tobacco use; the remaining 3 ad-
dressed tobacco use, as lye11 as other chronic disease
risk factors. Although Colorado established the first
tobacco-related coalition in 1963, coalitions in 38 states
lucre not established until after 1981. Coalition acti\%
ties included lobbying, prot'iding public education,
educating health care professionals, conducting re-
search and evaluation, and developing and implement-
ing a state plan for reducing tobacco use (I'ertschuk and
Erickson 1987).

  Until recently, the United States remained with-
out a national program for tobacco-related risk reduc-
tion analogous to those established for hvpertension
,~nd hypercholesterolemia. During the IWOs, three
nationally funded programs-t\co by the federal go\`-
ernment and one bv a private foundation-anal one
federally funded re&arch project have helped states
and localities mobilize for reducing tobacco use. As
noted, several states provided funds for state and
local community organizing.

National Programs

ASSIST

  The American Stop Smoking Intervention Study
(ASSIST) for Cancer Prevention is a partnership be-
tween the NC1 and the ACS to establish coalitions that
focus on using public policy change to reduce tobacco
use (see also "Community Programs" in Chapter 4).
The ASSIST project was developed after many NC1
consultants had recommended that communitv-based
coalitions for reducing tobacco use be established
in entire states or in large metropolitan areas. The
ASSIST guidelines provided both the rationale for the
coalition model and the flavor of the overall project:

Smoking is a public health problem that affects ev-
eryone in a community, not only smokers. The
solution to the smoking problem requires the ac-
tive involvement of a broad range of groups and
indi\riduals.

Significant and enduring changes in smoking be-
havior require a change in social norms, that is,
that smoke-free environments and lifestyles are
preferred and encouraged among all social groups.
Changes in social norms occur over time with the
involvement and support of a broad representa-
tion of interest groups.

Tremendous resources are invested each minute of
e\-ery day to encourage young people to begin
smoking as a normal and acceptable behavior. The
resources required to counter this effort and to ef-
fect a significant change in smoking behavior far
exceed the funds ai,ailable through this [ASSIST]
project. A large contribution of direct and in-kind
support in the form of time, energy, volunteers, and
other resources \vill be required. Only through the
commitment of a variety of groups and organiza-
tions can adequate resources be made available.

The intent of ASSIST is not to create a new insti-
tution de\.oted to smoking control but rather to
increase the capacity for existing groups and or-
ganizations to sustain and enhance their role as
smoking control agents beyond the life of ASSIST.
Activities by different groups will be coordinated
and efforts thereby magnified, and strategies and
training will be disseminated and institutional-
ized in each coalition member group (NC1 1991,
pp. l-2).

  ASSIST included an initial planning phase (1991-
1993) and a subsequent implementation phase (1993-
1998) for the 17 states chosen for participation. The
implementation phase was then extended to Septem-
ber 1999. During the planning phase, the coalitions
performed comprehensive site analysis and developed
a plan for reducing tobacco use. For planning, each
state received approximately $400,000 per year to de-
velop its own comprehensive, five-year plan (Manley
et al. 1997a). During the implementation phase, states
have been receiving an average of approximately $1.2
million per year to carry out the action steps in accor-
dance with NC1 guidelines and ASSIST program ob-
jectives. Intensive training of state health department
and voluntary agencv personnel in the ASSIST states
was a primary activity during the planning phase and


early years of the implementation. This training fo-
cused on the program objectives, including policv
changes, media advocacv, and communitv mobiliza-
tion. An interim evaluaiion of impact (Manley et al.
1997b) found that per capita cigaretteconsumption and
inflation-adjusted cigarette prices were nearly identi-
cal in the 17 ASSIST states and the remaining non-
ASSIST states (excluding California) before 1993, when
full funding for the ASSIST intervention began. By
1996, per capita consumption in the ASSIST states M'as
about 7 percent less than in the non-ASSIST states. This
decrease occurred in the face of a general decline in
cigarette prices during the period of evaluation. These
interim results suggest that the ASSIST program has
been associated M.ith a significant decrease in cigarette
consumption and that increased price from taxation
mav not be the only program influence.

IMPACT

   In its Initiatives to Mobilize for the I're\,ention
and Control of Tobacco Use (IMPACT) program, the
CDC has funded the District of Columbia and 32 states
that do not recei\-e funding from the ASSIST project.
The exception is California, which is not funded bv
ASSIST or by the CDC but since 1989 has had a to-
bacco control program funded by the state excise tax
on cigarettes. (The California program is described
later in this chapter.) A portion of IMPACT funds sup-
ports community mobilization at the state and local
levels, Mith particular focus on racial and ethnic mi-
noritv groups and \vomen. The IMPACT program also
provides extensive training to representatix-es of state
coalitions in subjects such as media adxwacy, policy
advocacy, and coalition building.

  Recently, the IMPACT program has been ex-
panded to include key national organizations to help
them mobilize their constituencies in efforts to reduce
tobacco use. Funds have been especially directed to
organizations that ser\.e populations targeted by the
tobacco industry's marketing plans and that are his-
torically underrepresented in the movement to reduce
tobacco use (Farquhar et al. 1985; USDHHS 1998).

SmokeLess States Program

  In 1994, the Robert Wood Johnson Fmndation
initiated the SmokeLess States program to provide
additional funds to state coalitions. In the initial round
of funding, the program alyarded more than $13 mil-
lion in either four-year implementation grants or two-
war capacitv-building grants to 1Y state coalitions and
also funded a youth-specific project in Tucson, Arizona

(Robert Wood Johnson Foundation 1994). Two years
later, funding for the SmokeLess States program was
expanded to $20 million. In this second round of fund-
ing, awards Lrere made to 13 new states; in addition,
implementation grants were made to some of the states
that had previously received capacity-building grants.
In lc)98, SmokeLess States funded another $6 million
in grants to eight states that had been funded for four
vears each. Currently, the SmokeLess States program
iunds 28 states and 2 cities at a total of $39 million per
year. The SmokeLess States program focuses on help-
ing state coalitions develop policy options, including
prevention progratns similar to those in place in Cali-
fornia and Massachusetts (as discussed later in this
chapter) and other efforts aimed at reducing tobacco
consumption, especially among young people. Ad-
ministered bv the American Medical Association
(1998), this giant program differs from ASSIST and
IMPACT in that it does not have strict requirements
concerning the makeup of the coalition, although com-
munitv mobilization is a required program activitv.

National Programs to Reduce Youth
Access to Tobacco

  In 1996, SAMHSA issued regulations to imple-
ment the Svnar Legislation. These regulations and the
provisions of the Synar Amendment to the 1992
ADAMHA (Alcohol, Drug Abuse, and Mental Health
Administration) Reorganization Act established a na-
tionwide effort to reduce youth access to tobacco by
requiring states to have and enforce laws prohibiting
the sale of tobacco products to anyone under age 18.
Failure to meet the requirements of the Synar legisla-
tion could result in penalties against a state's Substance
Abuse Prevention and Treatment Block Grant. The full
discussion of the state efforts to meet these require-
ments is provided in Chapter 5. By establishing a
coordinated program in all 50 states and the District
of Columbia to address this problem, SAMHSA has
prolidtd a core resource to the tobacco control effort
across this country.

  In 1996, the Food and Drug Administration
(FDA) issued a rule mandating that tobacco retailers
not sell tobacco to anyone under age 18 and that they
require a picture identification card from anyone u11-
                                    i
der the age of 27 who attempts to purchase tobacco
(Fcdtwl Rfxistcr lYY6). In support of this rule, the FDA
entered into contracts with state agencies to institute
compliance checks of retailers and has implemented
mass media and direct education campaigns to inform
retailers of this rule. However, the March 21, 2000.
ruling of the United States Supreme Court held th<lt


average alyard for states and the District of Columbia
is $1.13 million. The average aw:ard for territories is
$140,000. The total includes supplemental awards of
$499,400 for asthma and ETS, funded in conjunction
with the Environmental Protection Agency, and
$244,000 for Smoke-Free Kids and Soccer. The state
awards almost close the funding gap between the
former NCI-funded states (ASSIST) and the other
states. States with excise tax or settlement-funded pro-
grams are required to match federal funds 4 to 1. For
all others, the match is 1 to 10.

the FDA lacks jurisdiction to regulate tobacco prod-
ucts as customarilv marketed. Follo\\,ing this decision,
the FDA immedi6tely began the process of terminat-
ing the contracts jvith state agencies and shutting down
its enforcement program. The full discussion of this
program is provided in Chapter 3.

States Currently Funded in the Nationwide
Program to Reduce Tobacco Use

  In 1998,49 state health departments and the Dis-
trict of Columbia received fund.ing from the LSDHHS
for activities to reduce tobacco use. The NCI's ASSIST
project provided 17 states with approximatelv $27.5
million, and the CDC's IMPACT program funded 32
states and the District of Columbia with approximatelv
512 million. In Februarv 1998, the CDC and the NCI
It'ere given joint rcsponsibilitv to assist states and na-
tional organizations in amalgamating the findings of
comprehensive research projects, the CDC and NC1
programs, and the state and local programs funded
by tax initiatives and legal settlements b\-ith the tobacco
industry. This process will continue the evaluation of
a national program that includes all states, the District
of Columbia, territories, and tribes and aims to bring
svnchrony and coherence to the efforts of all groups
working to reduce tobacco LISC.

  In May 1999, the CDC launched the National
Tobacco Control Program (NTCP) transitioning fund-
ing through various federal initiatives into one national
program. The purpose of the NTCP is to build and
maintain a coordinated national effort to reduce the
health and economic burden of tobacco use. Federal
funding is intended to support core public health to-
bacco control functions or to enhance existing tobacco
control programs within state and territorial health
departments. The program framework is based on the
comprehensive tobacco control framework outlined
earlier in the chapter (see "Description of Comprehen-
sive Programs"). The NTCP funds tobacco control
programs in all states, the District of Columbia, and
seven U.S. territories. The NTCP also includes initia-
tives to fund American Indian tribal organizations to
develop or improve tobacco-related regional resource
networks and outreach to tribes. In 2000, the NTCP
launched a new initiative to aid in the elimination of
disparities in health status and outcomes among popu-
lations as it relates to tobacco use. In fiscal year 1999,
the NTCP awarded $50 million to 50 states, the District
of Columbia, and seven territories for a five-year
cooperative agreement starting June 1,1999, to May 30,
2004. In fiscal year 2000, funding to the states, theDis-
trict of Columbia, and territories totaled $59 million. The

Examples of Major State Programs

  State coalitions have encouraged both legislation
and voters' initiatives to raise state excise tax levels on
tobacco products and earmark some portion of the new
rt\.enue for tobacco prevention and control programs
(Shultz et al. 1986; Nicholl 1998). In 1985, the Minne-
sota Coalition for a Smoke-Free Society 2000 led a
legislati\,e effort that ~vt';ls the first to pass tobacco use
pre\,ention legislation that centered on an increase in
the state cigarette excise tax. Since 1985, more than 40
other states haIre increased their excise tax on ciga-
rettes; as part of the appropriations process, some of
these states have also funded selected tobacco control
acti\,ities \\.ith this revenue increase. One such state-
Maine-in May 1997 legislated an excise tax increase
that earmarked funds for a more comprehensive to-
bacco control program.

  In some states, voters' initiative process, rather
than the legislative process, has been the primary
mechanism by which new revenue from an excise tax
increase of tobacco products has been earmarked for
tobacco prevention. Voters in 24 states and the Dis-
trict of Columbia are permitted to sign petitions that
place a proposed law on the state ballot for referen-
dum (Nicholl 1996). Since 1988, in eight such states,
coalitions have tried to use the voters' initiative pro-
cess to fund statewide tobacco control programs. State
coalitions were successful in winning voter approval
in four of these states: California in 1988, Massachu-
setts in 1992, Arizona in 1994, and Oregon in 1996.
Initiatives were unsuccessful in Montana (19901,
Nebraska (19921, Arkansas (19921, and Colorado (1994)
(Moon et al. 1993; Ross 1996; Nicholl 1998).

The four state programs funded by successful
voters' initiatives are described in the next sections of
this chapter. They follow discussions of the two state
programs (in Minnesota and Maine) that were estab-
lished by iegislatecl appropriations for a comprehen-
sive tobacco control plan.


Minnesota

  In 1975, Minnesota ~z'as one of the first states that
passed statewide comprehensive legislation for clean
indoor air. In 1983, the Commissioner of Health
formed the Center for Nonsmoking and Health, Ivhich
oversaw the development of T/w Mirl~wsotn PI1711 fill
Nor~smokillS t71111 H~nltl~ (Minnesota Department of
Health 1984) by a muitidisciplinary technical advisory
committee in 1984. In that same year, nearly 30 public
and private organizations within the state formed the
Minnesota Coalition for a Smoke-Free Society 2000.
  By drawing increased attention to the hazards of
smoking and of ETS exposure, the Minnesota Depart-
ment of Health, together with civic and community
leaders, stimulated legislation to implement the rec-
ommendations of T/w Mir~rtcwfn P/O/I fbr h~or~wwkir~g
nrzrl Hrrrlflr. The legislative history and debate sur-
rounding the passage of the resulting 1985 compre-
hensive legislation for preventing tobacco use have
been summarized by Shultz and colleagues (lY86). The
legislation provided for an increase in the state ciga-
rette excise tax from $0.18 to $0.23, ivith one cent of
the revenue increase earmarked for a public health
fund, approximately one-half of \Vhich L>.as to be set
aside for preventing tobacco use. Further, this legisla-
tion authorized the Commissioner of Health to launch
a major state\Vide initiative-the Minnesota Tobacco-
Use Prevention Initiative-to promote nonsmoking
and established state aid for school-based programs
to prevent tobacco use.

  The legislation allocated funding to support the
school-based programs at the rate of SO.52 per student
during the 1985-1986 school year and SO.54 per student
during future years. School districts \vere authorized
to use these nets funds for staff in-service training, cur-
ricula and materials, community and parent alvareness
programs, and e\,aluation.

  Three principles guided the state's tobacco con-
trol programs. First, a broad base of public support
was developed by the collaboration of the Minnesota
Coalition for a Smoke-Free Society 2000, the Associa-
tion for Nonsmokers-Minnesota, \wluntary health
agencies, health professionals, and insurers. Second,
the program maintained a positive approach that
stressed the consequences of tobacco use rather than
attacked the tobacco industry or blamed smokers.
Third, the program focused on preventing tobacco use
among adolescents and young \vomen ~t.ho had not
yet become addicted to cigarettes or smokeless
tobacco.

  The mass media campaigns were the most vis-
ible component. The campaigns included paid televi-
sion, radio, and outdoor/transit advertising directed
at two target populations: 12- to 13-year-old boys and
girls and 18- to 24year-old women. The goal of the
media campaign was to change a social climate that
encouraged the use of tobacco. Advertisements fo-
cused on increasing the awareness of the negative as-
pects of tobacco use that are most important to young
people-unpleasant social and personal consequences,
such as bad breath, smelly clothes, and addiction.
  To foster community tobacco control programs,
T/w Mirlrwsofo PIorr for Nor7srrmkirzg nrzd Hcalfh recom-
mended that schools, health services, and other
community organizations be involved in providing
prevention and education programs about tobacco use.
A granting program was established in 1986 to fund
21 proposals from local organizations that could dem-
onstrate a coordinated approach for involving multiple
local organizations in the prevention effort. A second
cycle of local projects was funded in 1988.
  Schools throughout the state were involved in an
intensive effort to plan, implement, and evaluate effec-
tive programs for students from kindergarten (K) to
grade 12 and in technical institutes. Since the start of
these programs in the 1986-1987 school year, the per-
centage of school districts addressing smoking in grades
K-4 steadily increased but remained fairly constant in
grades 5-10. The number of school districts in the state
rz.ith a tobacco-free policy, howelrer, steadilv increased.
Each of the main program elements- funded by
the Minnesota Tobacco-Use Prevention Initiative has
been e\.aluated (Minnesota Department of Health 1989,
1991). L'outh and adults targeted by the program were
a\\`are of the media campaign, and the evaluation data
suggested that the campaign improved young people's
attitudes tolvard tobacco use (Minnesota Department
of Health 1991). There \vas a steady increase in the
number of school districts wfhose curricula included
components for pre\,enting tobacco use (Minnesota
Department of Health 1991). Nonetheless, a prospec-
tive study indicated that schools using the prevention
curricula pvere not more effective in reducing adoles-
cent tobacco use than bvere a randomized control group
of schools (Murray et al. 1992). In that study, a com-
parison of trends in adolescent tobacco use in Minne-
sota and Wisconsin betbveen 1986 and 1990 found a
slightly larger (but nonsignificant) net decline in Min-
nesota: The investigators suggested that greater reach
and penetration of preventive efforts may be required
to produce statelride reductions in adolescent tobacco
use (Murray et al. 1992).


California

  In November 1988, the Tobacco Tax and Health
Promotion Act (Proposition 99) \vas passed by Cali-
fornia voters, thus mandating the start of California's
Tobacco Control Program. The program is the largest
and most comprehensive undertaken in the United
States to reduce tobacco use. Initially, the program
defined three long-term objectives: (1) to reduce the
initiation of cigarette smoking by children and youth
under age 19 from the 1987 rate of 26.4 percent to no
more than 6.5 percent bv 1999, (2) to reduce cigarette
smoking among adults aged 20 years and older from
the 1987 rate of 26.0 percent to 6.5 percent by 1999,
and (3) to reduce smokeless tobacco use among males
aged 12-21 years from the 1987 rate of 8.9 percent to
no more than 2.2 percent by 1999 (Tobacco Eclucation
Oi,ersight Committee 1991). The excise tax rate on
cigarettes in California rose from $0.10 to $0.35 on Janu-
ary 1, 1989, Lvhen Proposition 99 \\`as implemented.
On Januarv 1, 1993, the tax increased to $0.37, \vhere it
remained in 1999. Funding for tobacco control efforts
began during fiscal year lY8Y (July 1989-June 1990).
The fiscal year 1999 budget in California was $126.8
million ($3.90 per capita) for tobacco control activities
funded bv the Department of Health Services and the
Departn&t of Education.

  The NCI's planning frame\vork (NC1 1991) was
used to establish the program's target groups, in-
tervention channels, and interventions to reach them
(Bal et al. 1990). Community mobilization is a key part
of California's extensiire program for reducing tobacco
use. Community-based programs are the responsibil-
itv of the California Department of Health Services and
6i local health departments (58 county and 3 city).
These local agencies, advised by local coalitions, es-
tablished multiple subcontracts with community-
based organizations to conduct events, programs, and
presentations for diverse racial and ethnic groups (To-
bacco Education Oversight Committee 1991). Local
lead agencies have been a cornerstone of the program
by mobilizing communities to eliminate exposure to
ETS, by closing channels for minors' access to tobacco,
and by advising local policymakers. The local lead
agencies receive approximately 20 percent of funds
allocated for education programs to achieve these ends.

  The statewide media campaign, which receives
about 12 percent of funds, has been the program's most
visible element. Launched in 1990, the media cam-
paign has focused primarily on changing public opin-
ion to denormalize tobacco use. In particular, it has
sought to raise public awareness of the tobacco
industry's manipulative and deceptive marketing

tactics and of the dangers of ETS. Although young
people are a direct target audience for some campaign
messages, the campaign has focused more on chang-
ing social norms and reducing adult tobacco use to
influence youth, many of whom begin using tobacco
to be more adultlike. Funding for the statewide me-
dia campaign was about 924 million ($0.75 per capita)
in 1998 but has varied considerably over the years, as
is discussed later in this section.

  About 16 percent of education funds are spent on
competitive grants to community-based organizations.
More than tlvo-thirds of these grants have targeted
racial and ethnic minoritv communities. The competi-
tive grants program has-had multiple funding cycles,
and 46 separate projects were funded in 1993. In ad-
dition, the competitive grants program funds several
state\vide projects, such as the Tobacco Education
Clearinghouse of California, which distributes library
and video materials, and the California Tobacco Con-
trol Resource Partnership, Lvhich provides technical
assistance and training to local lead agencies. The com-
petitive grants program has also been used to estab-
lish regional linkages among local governments and
local nongovernmental organizations. Twenty-four
percent of the education funds go to school-based
programs to prevent tobacco use and are distributed
through the California Department of Education. The
project estimated that it would reach approximately
350,000 students through programs implemented be-
tkveen 1993 and 1996.

  The single largest share, by far, of the education
funds-59 percent through 1996-goes to the medical
care programs. This percentage is notably higher than
the 35 percent specified by the legislation (Novotny
and Siegel 1996). As a result of this redistribution, the
portions of the program that deal with reducing to-
bacco use-designated for 20 percent of the fund-
have never been fully financed. In the first year, 16.5
percent of funds were allocated for such program
efforts; in the second cycle, 12 percent were allocated;
in the third, 10 percent. This diversion of funds was
the result of executive decisions and was strongly sup-
ported by the tobacco industry and the California
Medical Association. After the third diversion, civil
action was initiated by Americans for Nonsmokers'
Rights, supported by the American Lung Association
and the ACS, to prevent the reallocation. The Sacra-
mento Superior Court found in favor of the plaintiffs
in early 1995. The state appealed, and the judgment
for the plaintiffs \vas upheld in December 1996 (A~~rcri-
cfl115 for Norrsmoke~s' Ri~llfS i'. stfite of Cdifmifl).

The complicated course of these events, as de-
tailed by Novotny and Siegel (1996), has highlighted


the role of the tobacco industry in countering efforts
to reduce the use of its products and the opposing strat-
egy of health advocates. Begay and colleagues (1993)
have pointed out that since Proposition 99 passed, the
tobacco industry's political expenditures in California
have risen tenfold, from $790,050 in the 1985-l 986 elec-
tion to S7,615,091 in the 1991-1992 election, during
which the tobacco industry contributed more heavily
to candidates for the California legislature than to can-
didates for the U.S. Congress. In a further analysis,
this same research group (Traynor et al. 1993) detailed
the specific industry strategies to prevent local con-
trol of tobacco use. Using case studies, they docu-
mented the industry's use of front groups to conceal
its involvement, its organization of local referenda to
defeat or suspend local ordinances, and its financing
of local election campaigns to repeal ordinances by
popular vote. Glantz and Begay (1994) have also
analyzed the relationship between campaign contri-
butions and votes on individual tobacco-related bills
in the California legislature. Using a "tobacco policy
score" (p. 1178) that ranked legislators according to
their stance for or against reducing tobacco use, they
found a significant relationship between the amount
of money received from tobacco sources and a
protobacco position. This ongoing documentation of
tobacco industry influence, though not a formal part
of the California Tobacco Control Program, has been
one of its notable features, and it provides a model of
health advocacy for other states and localities.

  The program, xvhich has e\,olved considerably
since 1989, remains a multifocal, multichannel ap-
proach to the broad range of issues that confront large-
scale efforts to reduce tobacco use (Tobacco Education
and Research Oversight Committee 1995; Pierce
et al. 1998a). In 1993, the California Tobacco Control
Program was revised, and program priorities ivere
refocused (Pierce et al. 1998a). Four broad priority
areas, or policy themes, Ivere established for use in the
program planning and funding decisions:

.  Protecting people from exposure to ETS.

.  Revealing and countering tobacco industry
influence.

o  Reducing young people's access to tobacco
products.

o Providing cessation services.

  The California Tobacco Control Program contin-
ues to place its primary emphasis on a broad statewide
infrastructure that reaches into communities across the
state. The program's basic structure is composed of a

state-level office and several statewide and regional
programs that foster a collaborative grassroots approach
to serve a decentralized structure of community pro-
grams across the state (Pierce et al. 1998a).

  Surveillance and evaluation activities to assess
program performance and impact were established
as part of the initial program structure (Bal et al. 1990;
Tobacco Education Oversight Committee 1991). The
evaluation is composed of large triennial surveys
(Pierce et al. 1994, 1998a) and smaller ongoing sir-
veys (Pierce et al. 1998b), a more targeted evaluation
of program components (Independent Evaluation
Consortium 19981, and a wide array of local program
evaluation efforts. Evaluation is complicated, how-
ever, by the multiplicity of prevalence surveys avail-
able and by potential error from using data from
surveys with differing methods (Novotny and Siegel
1996; Siegel et al. 2000). Establishing specific rela-
tionships between large-scale social interventions and
a change in tobacco use is difficult, but the temporal
relationship between the decline in California's to-
bacco consumption and the efforts generated by
Proposition 99 can be clearly observed.

Per Capita Cigarette Consurnptiolt

  Before the implementation of the program in
1989, the rate of decline in monthly per capita ciga-
rette consumption was 0.42 packs, which was signifi-
cantlv greater than the rate of 0.36 in the rest of the
couniry (Pierce et al. 1998a,b). From Januarv 1989
through December 1993, the decline in California in-
creased significantly, to 0.65 packs, while the decline
in the rest of the United States increased nonsignifi-
cantly, to 0.45 packs. Until early 1992, the media pro-
gram M'as the only part of the tobacco control program
that M'as fully implemented. An econometric analysis
(Hu et al. 1995) has estimated that of the 1,051-million
pack decrease in sales between 1990 and 1992, approxi-
matelv 232 million (22 percent) \vere attributed to the
media campaign and the remaining 819 million (78
percent) to the excise tax increase. Between 1993 and
1996, the rate of decline in per capita consumption in
California slokved significantly, to 0.17, but virtually
halted altogether in the rest of the country (at 0.04
packs) (Pierce et al. 1998b3). Consumption decreased
more rapidly in California than in the rest of the coun-
try, even though the California cigarette excise tax
changed only slightly during this period (from $0.35
in 1993 to $0.37 in 1994). Between 1993 and 1996, how-
ever, expenditures for tobacco control were reduced
by more than 50 percent from their initial funding lev-
els in fiscal year 1990 and 1991. During 1989-1993,
spending for advertising and promotions by the


tobacco industry exceeded tobacco control expendi-
tures in California by a ratio of about 5 to 1; from 1993
to 1996, that ratio increased to nearly 10 to 1 (Pierce et
al. 1998b).

Adult Smoking Prevalence

  Data on adult patterns of smoking pre\,alence are
not as consistent or as easy to evaluate as consump-
tion trends (Novotny and Siegel 1996). Nevertheless,
the trends in these data are consistent with the pat-
terns noted in the per capita consumption analyses.
From 1989 to 1993, smoking prevalence declined in
California almost twice as rapidly as in the rest of the
country (Pierce et al. 1998b). However, from 1993 to
1997, the rate of decline in California appeared to ~10~`.
Overall, smoking prevalence has declined from 26.7
percent in 1988 to 16.7 percent in 1995 in California
and from 30.2 percent in 1988 to 24.7 percent in 1995
in the rest of the country (CDC 1996; Pierce et al. 1998b).
A recent analysis of trends in adult prevalence of smok-
ing in California compared with the rest of the United
States observed a significant decline in smoking preva-
lence in California from 1985 to 1990 and a slower but
still significant decline from 1990 to 1994, a period in
which there was no significant decline in the remain-
der of the nation (Siegel et al. 2000).

Youth Tobacco Use Prevaleuce

  The lack of consistent youth smoking surveil-
lance data between California and other states has
impeded the evaluation of program impact on tobacco
use among young people in California. Holz-ever, one
multivariate analysis of data from the school-based
Monitoring the Future survey of Sth-, 1 Oth-, and 12th-
grade students showed that irom 1992 to 1994, the in-
crease in youth smoking rates that was experienced
nationwide was slowed significantly in California
(I' < 0.001, controlling for price, smoking policies, and
other nonprogram effects) as a result of the combined
effect of the tax increase in 1994 and the implementa-
tion of the state's tobacco control programs (Chaloupka
and Grossman 1996). Pierce and colleagues (1994) have
concluded that the media campaign was successful
in stopping the rise in teen smoking that had been oc-
curring in California before the campaign launch.

  Results from other analyses of youth tobacco use
data are consistent with the result found by Chaloupka
and Grossman (1996). In data reported by the Califor-
nia Independent Evaluation Consortium, between 1991
and 1996, rates of smoking during the past 30 days
among California youth in the 8th and 10th grades in
the Monitoring the Future survey increased, but the

increase in California was less pronounced than in
other states (Independent Evaluation Consortium
1998). Among Sth-grade youth, since 1993 the preva-
lence of smoking during the past month has varied
from 12 to 14 percent in California while steadily in-
creasing from 17 to 22 percent in the rest of the coun-
try. Similarly, among IOth-grade youth, past-month
smoking prevalence in California has been about 18
to 19 percent since 1992 while increasing from 22 to 32
percent in the rest of the country. Data from the
telephone-based California Youth Tobacco Survey in-
dicate that the prevalence of smoking during the past
30 days among 12- to 17-year-olds increased from ap-
proximately 9 percent in the early 1990s to 11.9 per-
cent in 1995. Prevalence declined gradually after 1995,
to 10.9 percent in 1997, while increasing in the rest of
the country (Pierce et al. 1998a).

Other Fidiugs

  Since the start of the program in 1990, numerous
changes in intermediate outcomes have been noted
related to changes in social norms; clean indoor air
policies in public places, worksites, and bars; and vol-
untary policies to ban smoking in homes.

Massachusetts

  In November 1992, Massachusetts voters ap-
proved an initiati\,e petition known as Question 1,
establishing the Health Protection Fund with revenue
generated from a 25-cent increase in the state's ciga-
rette excise tax and a 25-cent increase in the wholesale
price of smokeless tobacco products. Revenues have
been used to fund the Massachusetts Tobacco Control
Program, a comprehensive set of activities and services
that emphasize prevention programs at the local level
and that focus on young people. The Massachusetts
program was modeled, in part, on California's pro-
gram. The overall goal of the program was to reduce
tobacco use in Massachusetts by 50 percent by the end
of 1999 (Abt Associates Inc. 1995). With the passage
of Question 1, the excise tax on cigarettes in Massa-
chusetts rose from $0.26 to $0.51 on January 1, 1993.
This tax was fully absorbed by the industry through
wholesale price reductions (CDC 1996). However, in
October 1996 the cigarette tax increased to $0.76 per
pack (with comparable increases on smokeless tobacco
products), where it currently remains.

  Funding for tobacco control efforts began with a
large media campaign in October 1993. In late 1993
and early 1994, funding for local agencies was begun,
and several statewide initiatives were undertaken to
provide direct services, as well as technical assistance,


training, and materials for localities. Starting in late
1994, with the first year of complete implementation,
the program received $43.1 million (33.7 percent) of
the $127.8 million placed in the Health Promotion Fund
created by the revenues from the excise tax increase.
Other key programs receiving appropriations from the
Health Promotion Fund were those for comprehensive
school health education ($28.8 million, or 22.5 percent
of the Health Promotion Fund in fiscal year 1995), drug
education ($5.0 million, or 3.9 percent), and other
health-related programs ($50.7 million, or 39.7 percent)
(Abt Associates Inc. 1995). After the first funding year,
the program's budget declined to $41.8 million in 1995-
1996 and to $36.8 million in 1996-1997. Funding was
increased for other programs receiving appropriations
from the Health Promotion Fund (Abt Associates Inc.
1997).

  Community-based education activities and pre-
vention activities are two main elements of the Mas-
sachusetts program. The state's 10 regionally based,
primary care Prevention Centers have added a com-
ponent for reducing tobacco use and provide ongoing
technical assistance and training to local community
programs. Local community initiatives have included
programs to increase community awareness about
the hazards of tobacco use, to promote tobacco-free
workplaces and public facilities, and to enforce local
regulations and ordinances for reducing tobacco use;
needs assessments in the community; mobilization of
youth service agencies to prevent and reduce tobacco
use among children and adolescents; funding of
community-based agencies to Lvork Lvith at-risk adult
populatiot&, including cultural and linguistic minority
groups, women of childbearing age, and blue-collar
workers; and funding of school-based health centers
(Abt Associates Inc. 1995).

Per Capita Cigarette Corrszmption

  As in California, Massachusetts has experienced
a persistent pattern of I c ecline in per capita cigarette
consumption. Before the 1993 implementation of these
tobacco control programs, per capita cigarette con-
sumption was declining in Massachusetts at a rate
approximately equivalent to that of the rest of the coun-
try (6.4 percent in Massachusetts and 5.8 percent in
the states other than California [CDC 19961). Between
1992 and 1997, per capita consumption in Massachu-
setts declined by 31 percent (from 117 to 81 packs per
adult), while the decline in the remaining 48 states was
only 8 percent (Abt Associates Inc. 1997). Between 1993
and 1996, the decline in per capita consumption has been
more consistent in Massachusetts than in California
(CDC 1996). Although program funding declined about

15 percent in Massachusetts from 1995-1996 to 1996-
1997 (Abt Associates Inc. 1997), it declined less than in
California.

Adult Smoking Prevalence

  Adult smoking prevalence has been monitored
in Massachusetts both by the annual survey conducted
through the Behavioral Risk Factor Surveillance Sys-
tem (BRFSS) and by special Massachusetts Adult To-
bacco Surveys conducted in 1993,1996, and 1997. Data
from the BRFSS indicate that adult smoking prevalence
in Massachusetts declined from an average of 23.5
percent for 1990-1992 to 20.6 percent in 1997. In the
rest of the country (excluding California), prevalence
declined from 24.1 percent in 1990-1992 to 23.4 per-
cent in 1993-1995 (CDC 1996; Abt Associates Inc. 1997).
The Massachusetts survey produced different preva-
lence estimates but corroborated a similar decline in
the prevalence of smoking among adults in Massachu-
setts (from 22.6 percent in 1993 to 21.1 percent in 1996
and 20.6 percent in 1997) (Abt Associates Inc. 1997).

Youth Tobacco Use Prevalence

  As in California, the observed nationwide in-
crease in the prevalence of smoking among young
people from 1992 to 1994 was significantly less ev-
dent in Massachusetts (Chaloupka and Grossman
1996). Follow-up data from the Youth Risk Behavior
Survey (YRBS) indicated that the prevalence of cur-
rent smoking among Massachusetts high school stu-
dents (grades 9 to 12) declined from 35.7 percent in
1995 to 34.4 percent in 1997 while increasing from 34.4
to 36.1 percent nationwide (CDC 1996, 1998). Data
from the YRBS and other survey sources suggest a dif-
ferential pattern by age: the prevalence of current
smoking increased in Massachusetts among older stu-
dents in a manner similar to that of the rest of the coun-
try but declined among younger students. Between
1993 and 1996, the prevalence of smoking during the
past 30 days among 8th-grade students in Massachu-
setts declined from 26.5 to 26.0 percent but increased
from 16.7 to 21.0 percent nationwide (Briton et al. 1997).
For Massachusetts, the prevalence of current smoke-
less tobacco use among 9th-12th graders decreased
from 8.4 percent in 1995 to 6.0 percent in 1997; for
males, the decline was from 15.1 to 10.3 percent (Kann
et al. 1998). In the nation as a lvhole between 1993 and
1996, lifetime use of smokeless tobacco among 9th-
12th graders decreased from 25 to 20 percent, and cur-
rent use decreased from 9 to 6 percent (Briton et al.
1997). The most recent data from the 1999 YRBS in
Massachusetts indicated a continuing decline in the


prevalence of current smoking, down to 30.3 percent
among 9th-12th graders (GoodenoLv 2000); however,
national comparison data for 1999 are not yet available.

A 1996 survey of 12- to 14-year-olds in Massachu-
setts and a national comparison sample (Houston
Herstek Fa\,at, Youth exploratory 1996, Massachusetts
Department of Public Health, presentation of findings,
unpublished data) found that Massachusetts youth had
significantly higher le\Tels of agreement \vith issues
addressed in the state media campaign. For example,
59 percent of Massachusetts youth but only 35 percent
of youth in the national sample agreed M'ith the state-
ment, "Smoking cigarettes decreases vour stamina and
smokers have a hard time keeping up in sports." Re-
sults from a longitudinal survey of Massachusetts
youth provided additional support for the efficacv of
the Massachusetts antismoking media campa-ign
(Siegel and Biener 2000). In a four-year follow,-up of
youth aged 12 to 15 vears in 1993, this studv found that
among the younger-adolescents (aged 12 tb 13 years at
baseline), those exposed to antismoking advertisements
were significantly less likely to progress to established
smoking. However, among older adolescents (aged 14
to 15 years at baseline), exposure did not prevent pro-
gression to established smoking.

Other Findings

  There have been multiple changes in intermedi-
ate measures of program impacts related to youth
access, protection of nonsmokers from ETS, and avail-
ability of cessation services (Abt Associates Inc. 1999).
For example, by 1999, nearly two-thirds of Massachu-
setts residents lived in cities and towns with some kind
of smoking restriction in restaurants, and 26 percent
were protected bv complete bans. Prior to the start of
the program, less than 1 percent of Massachusetts resi-
dents lived in towns with complete bans. Additionally,
the local restaurant smoking restrictions were found to
be more restrictive in communities receiving funding
from the Massachusetts Tobacco Control Program.

Arizona

  In November 1994, Arizona voters passed Propo-
sition 200, which increased the state cigarette excise
tax from $0.18 to $0.58. Revenues from the tax increase
were earmarked for the state's Medicaid program (70
percent of revenues), for programs for preventing and
reducing tobacco use (23 percent), for research on pre-
vention and treatment of tobacco-related disease and
addiction (5 percent), and for an "adjustment account"
(Arizona Tobacco Tax and Health Care Act 1994, sec.
2C4) to offset lost revenue to other state programs

currently funded by revenue from the existing $0.18
excise tax (2 percent). The petition drive to place the
initiative on the November 1994 state ballot and the
campaign to win voter approval was led by the Ari-
zona for a Healthy Future coalition. Although public
support for the initiative was strong when it was first
proposed in 1993 (71 percent in favor, with 56 percent
indicating strong support), the initiative was vigor-
ously opposed in a well-funded advertising effort on
television, in posters, and by direct mail. Proposition
200 was narrowly approved, garnering approximately
51 percent of the vote (Nicholl 1998).

  With the passage of Proposition 200, analysts
estimated that the revenues earmarked for tobacco
prevention and education programs would be ap-
proximately $25 million per year (Meister 1998).
However, measures passed during the 1995 session
gave the legislature control over the funds and lim-
ited expenditures to $10 million per year (Madonna
1998). Additionally, multiple restrictions were placed
on hots the funds could be used, and an advisory com-
mittee was appointed that included legislative and
business representatives hostile to the program
(Meister 1998). Although the Coalition for Tobacco-
Free Arizona led an effort to keep the goals of the newly
created Arizona Tobacco Education and Prevention
Program (AzTEPP) "comprehensive," the program
efforts were narrowed to a focus on youth prevention;
adult cessation activities were restricted to pregnant
women and their partners. Not until the fiscal year
that began on July 1, 1997, with a new governor and
health department director, were the programmatic
restrictions lifted from the health department and the
program allowed to proceed with the implementation
of the "draft" comprehensive tobacco control plan
originally proposed by the Coalition for Tobacco-Free
Arizona.

  The expenditures of AzTEPP reflect the political
history of the program: $9.7 million in fiscal year 1996,
$18.2 million in 1997, and $28.2 million in 1998. Al-
though the countermarketing campaign has expanded
(with spending increasing from $7.4 million in 1996 to
$13.2 million in 1998) (Riester and Linton 1988), the
greatest expansion in the program has been in the
scope and focus of the local programs (Meister 1998)
(with funding increasing from $1.7 million in 1996
to $9.4 million in 1998). Recent program efforts have
focused on all of the elements in the coalition's draft
comprehensive tobacco control plan (Meister 19981,
thereby expanding its adult cessation activities
(discussed at the fourth annual AzTEPP meeting in
February 19991, but one of the factors that had been
minimized in earlv health department efforts was


evaluation. Only recently have baseline data coilec-
tion surveys been initiated (Meister 1998); as a result,
no outcome data have been reported on the program,
and subsequent evaluation efforts will be compro-
mised by the lack of baseline data collected before the
start of the multiple large-scale program efforts.

  Respondents to an initial statewide telephone
survey conducted in 1998 (Arizona Cancer Center
1998); about two and a half years after the media
campaign's launch, reported that the advertising cam-
paign, which stressed how damaging tobacco use is
and how unappealing it is to the user, to peers, and to
the opposite sex, had influenced their attitudes in the
intended direction. For example, HO percent of young
people reported that the advertisements made them
think about the negative aspects of tobacco use, and
58 percent of pregnant or postpartum women said the
advertisements made them uncomfortable around
smokers. Young people who had been exposed to the
television advertisements in the previous 30 days were
less likely to be susceptible to using tobacco than were
youth who had not seen the advertisements. The
campaign's impact on reported behaviors is less clear,
especially among young people. Among respondents
who were using tobacco at the start of the campaign,
23 percent of adults, 37 percent of pregnant or post-
partum women, and 27 percent of young people said
the advertising campaign had convinced them to try
quitting. However, 23 percent of young people also
reported that the campaign had convinced them to
irzcwnsc their tobacco use. Cummings and Clarke
(1998) noted that such an unintended effect, if it is real,
might represent young smokers' negative reaction to
a narrowlv focused youth campaign with no messages
directed at changing broader social norms.

  In response to a request from the Arizona Joint
Legislative Audit Committee, the State Auditor Gen-
eral conducted a performance audit of the AzTEPP
(State of Arizona, Office of the Auditor General 1YYY).
This audit noted that evaluations of the state and local
levels of programs have not yet produced an adequate
assessment of the program's tobacco control efforts.
Thus, the audit recommended that the program
needed to improve its evaluations to measure its ef-
fectiveness in preventing youth from starting to use
tobacco, encouraging and assisting tobacco users to
quit, and reducing exposure to secondhand smoke.
Specifically, the audit found that the program had been
unable to establish a baseline on tobacco use among
youth and had only preliminary assessments in place
to assess cessation services. The program has estab-
lished adequate methodologies to measure the preva-
lence of adult smoking; however, follow-up results are

not yet available. Thus, the audit concluded that "The
program's evaluation approach to date leaves it far short
of knowing whether its programs are working" (p-ii).

  In response to this audit, the Arizona Department
of Health Services (AzDOHS) has implemented
changes in its surveillance and evaluation systems.
Expanded surveillance systems for youth have been
planned and will be implemented in 2000; however,
no baseline data are available on youth smoking rates,
For adults, a baseline survey of adults was conducted
in 1996 and repeated in 1999. Using methodology simi-
lar to that used by the state BRFSS, the 1996 and 199~
Arizona Adult Tobacco Surveys were conducted by
telephone interviews on representative samples of
more than 4,500 adults in Arizona aged 18 years and
older. Results from these surveys indicate that the
prevalence of smoking among adults declined from
23.8 percent to 18.8 percent overall (AzDOHS 2000).
Among adults aged 18 to 24 years, a significant de-
cline was observed also, from 27.5 percent in 1996 to
21 .O percent in 19YY. Both of these rates compare very
favorably to national trends, where rates overall among
adults have not declined in recent years and rates
among younger adults have been increasing. Finally,
smoking rates among Hispanics declined from 23.5
percent to 13.6 percent, which was the largest decline
seen in any race/ethnic group in the state. Multiple
other indicator variables suggest that these changes
may be related to increases in smoke-free policies, ad-
\?ce from doctors and dentists, and exposure to tele-
\,ision antismoking information. Finally, these declines
in smoking prevalence are consistent with declines in
per capita sales (Orzechowski and Walker 2000) that
indicate that declines in Arizona since 1996 are larger
than those observed in the rest of the country.

Oregon

  On November 5, 1996, Oregon voters approved
Measure 44, raising the state cigarette excise tax from
SO.38 to $0.68 (with a proportional increase in the tax
rate on other tobacco products) and designating
90 percent of the increased revenue for the Oregon
Health Plan (to expand insurance for medically
underserved state residents) and the remaining
10 percent for a statewide tobacco prevention and edu-
cation program managed by the Oregon Health Divi-
sion. Survey data indicated that support for the
initiative was increased by having the new revenue
earmarked in this way (CDC 1997; Nicholl1998). The
Oregon campaign to place the initiative on the Novem-
ber 1996 ballot was initially led by the Committee to
Support the Oregon Health Plan, tvhich represented


primarily the private health care sector. Nonprofit and
public health organizations added their support and
worked in a loosely organized network led by the ACS.
Later in the campaign, both groups combined efforts
and resources. The measure had strong support from
state media (receiving endorsements from all major
newspapers and a majority of the smaller ones), from
leading business groups, and from the governor, who
conducted a three-day supportive media tour before
the election.

  The Oregon Health Division used its existing
Oregon Tobacco Control Plan as the model for the new
statewide program. Revenue from Measure 44 dur-
ing the 1997-1999 biennium was projected to be $170
million; of this, 10 percent (approximately $17 million)
per biennium was appropriated to fund the Tobacco
Use Reduction Account administered by the Oregon
Health Division. The resulting Oregon Tobacco Pre-
vention and Education Program has eight elements:
(1) local community-based coalitions, (2) comprehen-
sive school-based programs, (3) statewide public
awareness and education campaigns, (4) a cessation
help line, (5) tribal tobacco prevention programs,
(6) multicultural outreach and education, (7) demon-
stration and innovation projects, and (8) statewide
leadership, coordination, and evaluation.

  The 1997-1999 biennium budget for these eight
elements is combined into five categories: (1) local
coalitions-$6.5 million (38 percent), (2) public aware-
ness and education-$4.6 million (27 percent), (3) state-
wide and regional projects-$2.75 million (16 percent),
(4) schools-$2 million (12 percent), and (5) statewide
coordination and evaluation-$1.2 million (7 percent).

  Evaluation data from Oregon indicate that the
program has successfully implemented each of the
program elements and is achieving its performance
objectives (Oregon Health Division 1999). Local
community-based coalitions were created in all 36
Oregon counties. Twenty-four school projects were
funded, reaching 58 of the 198 (30 percent) school dis-
tricts in the state. Surveys indicated that approxi-
mately 75 percent of adults and 84 percent of the young
people recalled seeing the state's public awareness
campaign. In January 1999, more than 1,500 Orego-
nians called the cessation help line. All nine federally
recognized Indian tribes in Oregon are now receiving
funding to implement prevention and education pro-
grams to reduce tobacco use. Multicultural outreach
and education programs have been established for
Hispanic, Asian/Pacific Islander, and African Ameri-
can populations in Oregon. Five demonstration
projects have been funded focusing on pregnant
women, health care delivery systems, and creative

ways to reach youth audiences. The program has also
established a comprehensive and multifaceted surveil-
lance and evaluation system and has strengthened
program management.

  Trends in per capita consumption in Oregon were
compared with the remainder of the country (exclud-
ing California, Massachusetts, and Arizona) for the
period before program implementation (1993-1996)
and after (1997-1998). From 1993 to 1996, consump-
tion increased 2.2 percent in Oregon and decreased
0.6 percent in the rest of the country (CDC 1999b). In
1997 and 1998, per capita consumption declined 11.3
percent in Oregon (from 92 to 82 packs per adult). Be-
tween 1996 and 1997, per capita consumption in the
rest of the country declined only 1 .O percent (from 93
packs per adult to 92 packs per adult).

  Smoking prevalence among adults in Oregon has
been consistent with the observed declines in per capita
consumption. Data from the BRFSS indicate that the
prevalence of smoking among adults aged 18 years and
older in Oregon declined from 23.4 percent in 1996 to
21.9 percent in 1998 (Oregon Tobacco Prevention and
Education Program 1999). The proportion of women
who smoked during pregnancy, as reported on state
birth certificates, dropped from 17.7 percent in 1996 to
15.2 percent in 1998. Data suggest that smoking rates
among young people are continuing to increase as in
the rest of the country.

Maine

  In June 1997, the Maine legislature approved HP.
1357, An Act to Discourage Smoking, Provide Tax Re-
lief and Improve the Health of Maine Citizens, which
increased the state cigarette excise tax from $0.37 to
$0.74 and earmarked the increased revenue for the
Tobacco Tax Relief Fund. The act established the To-
bacco Prevention and Control Program within the
Maine Bureau of Health and provided $3.5 million in
funding for fiscal years 1998 and 1999. The legislative
effort to gain passage of the act was a combined effort
of the state public health community, legislative lead-
ership, and executive branch support.

  The Bureau of Health has developed the Maine
Tobacco Prevention and Control Program to expand
the existing ASSIST program structure and to meet the
legislative requirement of the 1997 state statute. The
legislation specified that the program include an on-
going, major media campaign; grants for funding
community-based programs; program surveillance
and evaluation; and law enforcement efforts regard-
ing transportation, distribution, and sale of tobacco
products. The program's initial $4.35 million annual


budget included $1.6 million for a multimedia cam-
paign, $1.25 million for community and school grants,
$625,000 for statewide cross-cutting activities, $400,000
for state staffing, $400,000 for evaluation, and S75,OOO
for enforcing youth access provisions.

  In April 2000, legislation was passed in Maine
that appropriated additional funds to expand the
Maine Tobacco Prevention and Control Program; a
total of $18.3 million from the settlement is going to
tobacco control. Of this total amount, $8.35 million
will be used for community and school-based grants,
funding communities and schools to achieve the goal
of reducing tobacco addiction and use and resulting
disease, with a focus on those at highest risk such as
youth and disadvantaged populations. About $6.75
million will be used for cessation and statewide mul-
timedia campaigns; 51.2 million is for evaluation for
independent program evaluation, research, and out-
comes monitoring; $200,000 funds five positions in the
Bureau of Health for administering the programs; and
$1.8 million for improved prevention and treatment
of tobacco-related diseases for those with Medicaid
Insurance.

Programs Funded by State Settlements
With the Tobacco Industry

  As was discussed earlier in this report (see
"Legislative Developments" and "Master Settlement
Agreement" in Chapter 51, all 50 states, the District of
Columbia, and five commonwealths and territories
have settled lawsuits with the tobacco industry to rc-
claim statewide costs spent treating Medicaid patients
for diseases related to tobacco use. Four of those states
settled their individual lawsuits vzith the industry-
Mississippi in July 1997, Florida in September 1997,
Texas in January 1998, and Minnesota in Mav IYYH-
and the remaining parties jointlv settled in November
1998 in the multistate Master Settlement Agreement.

  Because of a "most favored nation" clause (ex-
plained in "Recovery Claims by Third-Party Health
Care Payers" in Chapter 5), the four separate settle-
ments have been closely linked, particularly in 110~
the terms of their awards affect the kind of compre-
hensive programs discussed in this chapter. Most
notably, when the State of Florida received in its
settlement $200 million that was earmarked for a
two-year pilot program to reduce tobacco use among
young people, the State of Mississippi, though it had
settled its lawsuit earlier, received $62 million for the
same type of pilot program specified in its lawsuit.
Texas and Minnesota received no such additional

aw.ard, because their lawsuits did not specifically set
aside funds for a parallel pilot program, although Min-
nesota received funds earmarked for smoking cessa-
tion and tobacco-related research. Language in the
Texas and Minnesota settlements, however, released
Florida and Mississippi from existing requirements to
use their pilot program funding within two years and
to direct their programs exclusively to young people.

  Because program planning in Florida and Mis-
sissippi was already in place when the youth-onlv
restriction was removed, an emphasis on preventing
tobacco use among young people has been evident in
their pilot programs' first years of activities. These
activities are described in the next two sections of this
chapter. Brief descriptions of settlement-funded plans
in Texas and Minnesota follow. This report does not
attempt to describe the various plans and legislative
proposals that are developing (at the time of this writ-
ing) in the 46 states, the District of Columbia, and the
five commonv~ealths and territories included in the
joint settlement of January 1998.

Mississippi

  The Partnership for a Healthy Mississippi, a
nonprofit corporation representing a broad range of
public and private interests, plans and manages the
state's pilot program. The program's mission is to cre-
ate a youth-centered, statewide collaboration dedicated
to fostering a healthier Mississippi and eliminating to-
bacco use among Mississippi youth. The partnership
ivill award grants in five designated areas: (1) commu-
nitv/school/youth activities and partnerships, (2) law
enforcement, (3) public awareness, (4) health care ser-
vices and research, and (5) evaluation.

  In the first year, with a budget of $23.7 million,
approximately 25 community and youth partnership
coalitions were funded, and more are planned for the
second vear. Local coalitions-one-quarter of whose
membership must be young people-are among
the stateM-ide and regional organizations supported
by community assistance statevvide partner grants to
provide training, tobacco prevention activities for ra-
cial and ethnic minority groups, and other technical as-
sistance. Specific programs that have been funded by
the partnership are 4-H Youth Programs, Frontline
(an advrocacy organization for 14- to 18-year-olds), com-
prehensive school health programs, and a comprehen-
sive school health nurses pilot project. In the first two
years, $4 million has been allocated to these activities.

  The law enforcement program has awarded
grants to municipalities to enforce the Mississippi
Juvenile Tobacco Access Prevention Act of 1997. These


awards lvill range (accordin g to population size) from
a minimum of 55,000 per municipality to a maximum
of $250,000. A total of 512.65 million has been bud-
geted over the first trz,o years of the program for these
aM-ards. The grants \\-ill require municipalities to con-
duct periodic enforcement checks on the illegal sale
of tobacco to minors, provide retailer education pro-
grams, provide education programs in schools, orga-
nize vouth partnerships, and 1% ork \vith communit\
coalitions on enforcement issues. Other enforcement
activities are being performed statetridc bv the Mis-
sissippi Attorney General's Office.

  The partnership has budgeted $12.3 million fol
a countermarketing media campaign and other pub-
lic aw-areness acti\,ities to be conducted during the first
t\vo years. The health care ser\.ices and research con-
ponent focuses on nicotine addiction and cessation
among young people. An expenditure of 55 million is
anticipated for the first and second years for training
health providers in cessation counseling, for research-
ing childhood and adolescent tobacco abuse, and for
coordinating cessation services in the state, including
a telephone help line. The Mississippi State Depart-
ment of Health will manage the e\~aluation of the pi-
lot program and \Vill focus on program effecti\-eness
in preventing initial tobacco use among young people,
helping young people quit smoking, and reducing
young people's exposure to ETS. An expenditure of
S2 million is anticipated for the first and second years'
evaluation activities.

  Since 1998, the Partnership for a Healthy Missis-
sippi has managed the pilot program to reduce youth
tobacco use through a seven-member Board of Direc-
tors (www.healthy-miss.org) (McMillen et al. 1999).
The major youth programs that have been implemented
have included (1) the Reject All Tobacco (RAT) pro-
gram among students in grades K-3, (2) the Students
Working Against Tobacco (SWAT) Program for students
in grades 4-7, and (3) the Frontline youth advocacy
movement. Community programs have involved 26
community/youth partnership grants, targeted pro-
grams in collaboration with statewide organizations,
and the school nurse program in 52 Mississippi school
districts. Grants have funded 245 municipalities and
74 counties to empower the local law enforcement agen-
cies to reduce sales to minors. Cessation services have
included the Adolescent and Child Tobacco Treatment
Center and a Mississippi Tobacco Quitline. Finally, a
"Question It" public awareness campaign has focused
on the 12- to 17.year-old audience.

  The Mississippi State Department of Health has
established a consortium of evaluation contracts in-
volving multiple state universities to implement

program evaluation efforts. The o\rerall coordination
is being managed by the Social Science Research Cen-
ter at Mississippi State University, with the evaluation
of the media component conducted by the University
of Mississippi, community programs conducted by
Jackson State Universitv, law enforcement component
by Mississippi State University, and the school nurses
component by Mississippi State University (McMillen
et al. 199Y). A baseline Social Climate Survey of To-
bacco Control and Tobacco Use was conducted in 1999
among 3,040 adults aged 18 years and older that
provided benchmark data on several social norm
intermediate indicator variables (McMillen et al. 1999).
Sur\.eillance of youth tobacco use patterns is being con-
ducted by the Mississippi State Department of Health.
The Youth Risk Behavior Survey was conducted among
students in grades 9 to 12 in 1993,1995, 1997, and 1999
and among students in grades 6 to 8 and 9 to 12 in 1998
and 1999. Results indicate that in Mississippi, smok-
ing rates among students in grades 9 to 12 had been
increasing, as in the rest of country, between 1993 and
1997 (Mississippi State Department of Health 2000).
Betlveen 1997 and 1999, smoking rates among students
in grades 9 to 12 appear to have stopped increasing
and leveled off. Among students in grades 6 to 8,
smoking rates did not decline betlveen 1998 and 1999.

Florida

  Program planning and implementation initially
were managed by the Governor's Office, with direct
leadership provided by Governor Lawton Chiles, who
12-as a partv to the state's lawsuit and a member of the
small tean; who negotiated the settlement agreement.
The Florida Tobacco Pilot Program is now managed by
the Office of Tobacco Control within the Florida De-
partment of Health. The program has sought the input
of Florida youth in planning the program focus and
materials and in working toward the main goals of
changing voung people's attitudes about tobacco use,
increasing youth empowerment through community
involvement, reducing young people's access to tobacco
products, and reducing youth exposure to ETS. These
four goals will be addressed through program compo-
nents similar to those of the Mississippi program:

.  Marketing and communications initiatives are
planned to directly counter the tobacco industry's
marketing efforts. A commercial advertising firm,
working closely \vith teen advisors, has developed
the "Truth" campaign, a direct attack on the image
of smoking as cool and rebellious. The campaign's
multichannel approach-based on techniques used


by the tobacco industrv-incluhcs tcle\,isinn, print,
and billboard acl\.ertising, as ~fell as consumer
items, such as "Truth'`-imprinted T-shirts and
stickers.

Youth programming and community partnership
activities recruited young people to a Teen Tobacco
Summit in early 1998 to ad\rise on the overall de-
velopment of the program. Chapters of Students
Working Against Tobacco are currently active in
all 67 counties.

Education and training programs focus on school-
aged children. Conducted in partnership with
communities, schools, voluntary agencies, profes-
sional organizations, and universities, these pro-
grams ensure that effective tobacco prevention
curricula are presented in middle and high schools
across the state and that tobacco prevention strat-
egies are being implemented in grades K-12 in
conjunction with the Sunshine State Standards.

Enforcement initiatives are aimed at improving
Florida's efforts to reduce the accessibility of to-
bacco products to minors. The Florida Department
of Business and Professional Regulation, Division
of Alcoholic Beverages and Tobacco, provides en-
forcement, educational, and marketing initiatives
to ensure compliance \vith all tobacco laws.

The evaluation and research component monitors
the performance of each of the program initiati\,es
and the progress of the overall program in meeting
goals and objectives. Under the leadership of the
Florida Department of Health, and \vith the con-
sultation of the Unilrersitv of Miami, baseline data
were collected by Florida universities in all major
areas before the pilot program began in earlv 1998.

  In the first full year of operation, the program
budget was approximately 570 million, \\ith program
component allocations of approximately $26 million for
marketing and communications, SlO million for youth
programming and community partnerships, S13 mil-
lion for education and training, S8.5 million for enforce-
ment, and $4 million for evaluation and research. An
additional $5 million was budgeted for programs tar-
geting minority populations and 53.5 million for ad-
ministration and management. In the second year,
approximately $45 million more r\.as appropriated for
program operations; however, there were significant
unexpended funds from the first year of operations that
enabled major program components, such as the mar-
keting and communications activities, to continue a
level of expenditure similar to the first year.

Youth Tobacco Use Preualerlce

  Between 1998 and 1999, the prevalence of i.,I'.
rent cigarette use among middle school student\
(grade? 6 to 8) declined from 18.5 to 15.0 percent (CD(
1999~). Among high school students (grades Y to I?),
current cigarette use declined from 27.4 to 25.2 pL,1`-
cent. However, these declines were significant on],
for non-Hispanic white students; the change in cLIr-
rent smoking among non-Hispanic black and Hispanic
middle and high school students was small and llcjll-
significant. Current cigar use declined significantl\
only for middle school students (from 14.1 to 11.9 per-
cent), and this decline was almost entirely among
males. Similarly, current smokeless tobacco use C~C-
clined only among middle school students (from 6.q
to 4.9 percent) and remained unchanged among high
school students.

  In early 2000, additional declines in youth to-
bacco use were observed (Florida Department of
Health 2000). Current cigarette use among middle
school students declined to 8.6 percent, or an overall
54-percent decline since the 1998 baseline. Among high
school students, current cigarette use declined to 20.9
percent, or an overall 24-percent decline since the 1998
baseline. Although declines between 1998 and 1999
\vere significant only for non-Hispanic white students,
the declines observed in 2000 were significant among
all racial/ethnic groups, except among the non-
Hispanic black and "other" categories of high school
students. Declines in current tobacco use, which in-
clude the use of cigars and smokeless tobacco, also
l\.ere significant. Since the 1998 baseline survey, cur-
rent cigar use declined by 46 percent among middle
school students and 21 percent among high school stu-
dents. Smokeless tobacco use declined by 54 percent
among middle school students and by 19 percent
among high school students. Declines in current to-
bacco use w'ere consistent across grade, gender, and
ethnicity as \vell.

  Using additional data collected as part of the
overall program evaluation, the Florida Tobacco Con-
trol Program has connected the declines in youth
smoking prevalence with program activities (Univer-
sitv of Miami 1999). Results suggest that students who
reported recei\?ng elements of a comprehensive to-
bacco use prevention education in school had greater
declines in smoking between 1998 and 1999 than those
students who reported not receiving such education
in school. Similarly, the Community Partnerships in
the 67 Florida counties were classified as "excellent,"
"a\rerage," or "needing improvement" based upon
program record data, and these ratings were linked
to data from the Florida Youth Tobacco Survey fur


I YY8 and lYY9 in those counties. Declines in smoking
prevalence lvere related to the classification, lvith the
greatest declines among middle and high school stu-
dents in counties rated as "alwage" or "excellent."
Similar ratings of counties on the level of local enforce-
ment of youth access laws ivere related to vouth smok-
ing prei.alence, Lvith the highest le\,els of enforcement
in counties with the lotz.est prevalence. Finally, data
from the Florida Anti-Tobacco Media E\.aluation
(FAME) have indicated that the "Truth" campaign is
producing impressi\~e alvareness among vouth and
changes in attitudes and knwzledge consistent lvith
the campaign themes. BetIveen lYY8 and lYYY, the
prevalence of Florida youth aged 16 years and uncle1
1%.ith antitobacco attitudes increased from 59 to 64 per-
cent but decreased slightlv nationlvide.

National data against trhich to compare the
Florida data from 1998 and 19YY are not yet a\.ailnble,
but some data suggest that the prevalence of tobacco
use among young people mav ha\,e peaked nation-
lvide and could be starting to decline (Universitv of
Michigan 1998). III addition, the impact of state exiise
tax increases that have occurred since the 1 YYX baseline
data collection might be assessed.

Adult Smoki?lg Preualerzce

  In 1998, the Florida Behavioral Risk Factor
Surveillance System (BRFSS) expanded its assessment
of tobacco issues. The tobacco module will enable
changes to be assessed in tobacco use prevalence,
cessation behalriors, family rules about tobacco use,
environmental tobacco smoke exposure at home, and
workplace policies regarding smoking.

Texas

  The legislative plan developed by the Texas
Interagency Tobacco Task Force (1998) incorporated the
CDC recommendations for community and school-
based programs to reduce tobacco use. The plan in-
cludes a public awareness campaign, cessation and
nicotine addiction treatment, programs for diverse or
special populations, enforcement of laws to reduce
minors' access, surveillance and evaluation, and state-
wide program administration. The plan requests
$20.75 million for fiscal year 2000 and $61.25 million
for fiscal year 2001 to implement, evaluate, and ad-
minister the programs proposed.

  In the fall of 1999, the Texas legislature created
an endowment fund of $200 million and requested the
Texas Department of Health to conduct a pilot study
based upon recommended interventions included in
the 1998 tobacco task force plan. This pilot would be

funded by int-estment revenue from the endowment
fund, approximately S9 million per year. In response
to this requirement, the Texas Department of Health
has begun an Intervention Effectiveness Pilot Study
in conjunction \\ith uni\,ersities in the state.

  To assess the impact of tobacco use prevention
activities in the state, the Texas Department of Health
has conducted the Texas Youth Tobacco Survey in 1998
and 1999 among middle and high school students from
a sample of students statewide and in eight regions of
the state. Results from the 1998 survey indicated 31
percent of middle school students and 43 percent of
high school students \yere currently using some form
of tobacco products (Texas Department of Health). For
cigarettes alone, 21 percent of middle school students
and 33 percent of high school students were current
smokers.

Minnesota Settlement Program

  In Minnesota, the Minnesota Partnership for Ac-
tion Against Tobacco, the Tobacco Work Group of the
Minnesota Health Improvement Partnership, and the
Minnesota Blue Cross and Blue Shield (which received
a separate S469-million settlement award [see "Recov-
ery Claims by Third-Party Health Care Payers" in Chap-
ter 51) all have developed plans for the statewide effort
to reduce tobacco use. In the 1999 Omnibus Health
and Human Services appropriation bill, the Minnesota
legislature set aside $968 million from the state's
tobacco settlement to establish two health-related
endowments: one for preventing tobacco use and
supporting local public health efforts (S590 million)
and the other for tobacco-related medical education
and research ($378 million). The interest earned from
these endowments will support long-term programs.

  The 1999 Minnesota Omnibus Health and
Human Services bill established an ambitious goal to
reduce tobacco use among young people by 30 per-
cent bv the vear 2005. In response to this, the Minne-
sota Department of Health developed the Mirz~~esotn
y~ifll Tol~rrccc, Pww~~ti(~l Illifintiw: Strrrtl;tric Plnrr (Min-
nesota Department of Health 1999). This plan defined
major activities that will be funded from January 1,
2000, through June 30,2001, in four component areas:
Statewide Public Information and Education Cam-
paign, Statewide Programs, Community-Based
Pre\,ention Programs, and Youth Leadership Projects.
The strategic plan established "initial indicators of suc-
cess" for each program component to enable program
performance to be assessed.

   The Statelvide Public Information and Educa-
tion Campaign Ivill have a proposed budget of $7.5


million for the l&month period. The campaign will
include both a media component and grassroots
organizing efforts focused on the target audience of
12- to 1 T-year-old youth. The Statewide Programs will
be budgeted at $3.55 million for the initial l&month
period. Evaluation activities, training, and technical
assistance services will be funded along with statewide
organizations to support the community-based efforts.
The Community-Based Prevention Programs will be
budgeted at S4.4 million for the initial 1%month
period. Community-based prevention efforts will
include tobacco-use prevention activities at the local
level and projects that focus on populations at risk.
Finally, the Youth Leadership Projects will be budgeted
at $1 million for the initial 18-month period and will
work in conjunction with the community-based
prevention efforts. These activities will seek to em-
power Minnesota's youth to take leadership in the
planning and implementation of tobacco prevention
and control programs at the local level. The Minne-
sota Department of Health has established an evalua-
tion plan to track progress of the initiative, with the
first comprehensive report on program effectiveness
to be delivered to the legislature in January 2003.

Programs Meeting the Needs of Special
Populations

  The recent Surgeon General's report K~l~~rn) USC?
Anzor1g U.S. Rarinl/Efl~lic Mirlorit!/ Gvo~r;j$ provided a
summary of the various approaches that have been used
to prevent and control tobacco use among racial/eth-
nic minority groups in the United States (USDHHS
1998). This report highlighted the need for more re-
search on the effect of culturally appropriate programs
to address this problem. Few new findings ha\,e
emerged since the publication of that report; hence, the
elimination of disparities in health among population
groups remains hampered by the lack of culturally ap-
propriate programs of proven efficacy. Belolv are some
examples of community-based interventions that have
proven to be effective and that may serve as examples
for the development of future program initiatives.

  Uniting and mobilizing the movement to reduce
tobacco use among racial/ethnic groups have not been
easy. Tension frequently occurs between various orga-
nizations within the community regarding appropriate
strategies to achieve particular goals, "turf" disagree-
ments, competition for fund-raising dollars, and other
issues. Many of these problems were identified during
the 1989-1992 COMMIT trial. Though COMMIT
researchers did not attribute to internal dissension the

program's inability to reach its goals (Thompson et al,
1993), internecine rivalry can splinter community mo-
bilization efforts and greatly impair the effectiveness of
any program trying to reduce tobacco use.

  Diverse views and dissent are an expected part
of organizing activity. A more serious issue for com-
munity mobilization has been a lag in engendering
support from all segments of society. Historically, the
movement to reduce tobacco use has been dominated
by organizations composed of middle- and upper-class
white Americans and often led by white males (see
Chapter 2). For many years, participation in the move-
ment was further limited to organizations concerned
with health and medical issues and nonsmokers' rights.

  In the early 198Os, increasing dissatisfaction was
voiced by women and underrepresented communities
who felt that their issues and contributions were not
adequately integrated into mainstream efforts to reduce
tobacco use (Jacobson 1983). In recent years, a number
of persons and organizations representing more diverse
perspectives have assumed a greater role (see the text
boxes "Uptown, " "X," and "Dakota"). Particularly in
view of the tobacco industry's targeted marketing to
women, African Americans, Hispanics, and young
people (USDHHS 1994,1998), such heightened activity
is of critical importance to ensure a nonsmoking norm
Mithin diverse communities. In some instances-
exemplified by the low and declining smoking preva-
lence among African American youth (USDHHS
lY91)-such a norm may have already taken hold.

Programs for the African American
Community

  Several leadership groups, such as the National
Black Leadership Initiative on Cancer, which is funded
by the NCI, and the National Association of African
Americans for Positive Imagery, funded in part by the
CDC, have begun to have a voice in activities to re-
duce tobacco use in the African American community.
For example, in 1989, a strong coalition guided com-
munity mobilization efforts to mount a successful cam-
paign against the test-marketing of Uptown, a neM
brand of cigarettes targeting African Americans (see
the text box "Uptown"). A similar community-
organized campaign in 1995 resulted in the withdrawal
of X, another new brand seemingly intended for the
African American community (see the text box "X").

  In lYY2 and 1993, the ACS provided funds for
community demonstration projects to use Patlrwm~s to
FI.CC~OV~: Wi~lj~ill:; tile fi,$t Apimt Tobncco, a self-help
guide for African American smokers (Robinson et al.


Uptown

I n mid-December 1989, R.J. Reynolds Tobacco
Company announced that on February 5,1990, it
would begin test-marketing a new cigarette in Phila-
delphia, Pennsylvania. The cigarette, to be named
Uptown, was the first to be marketed directly to
African American smokers. Within 10 days of this
announcement, the Coalition Against Uptown Ciga-
rettes (CAUC) was formed. Using existing church
and community organizations and word of mouth,
the coalition gre\v to include 26 diverse organiza-
tions representing health, religious, and community
groups. The group's leaders bvere African Ameri-
cans w.ith long-standing ties to the Philadelphia
African American community. The Philadelphia
chapter of the National Black Leadership 1nitiatiL.e
on Cancer, an organization funded in part LX the
National Cancer Institute and dedicated to r&luc-
ing cancer in the African American community, and
the Committee to Prevent Cancer Among Blacks
facilitated the coalition's formation. Also acti\.e in
the CAUC were se\,eral other organizations that
addressed local issues on cancer control. These
groups included chapters of the American Cancer
Society and the American Lung Association, as \\.ell
as the Fox Chase Cancer Center.
  The CAUC decided that its initial goal \~ould
be to limit R.J. Reynolds' ability to use Philadelphia
as a test market by convincing African American
smokers to boycott the ne\,v cigarette. The coalition
mobilized both smokers and nonsmckers in support
of this goal by focusing on R.J. Revnolds' strategv to
promote tobacco use among Africin Americans. %he
coalition initially used local media to reinforce the
messages being sent through grassroots channels and
did not seek out national coverage, which the coali-
tion members believed would hinder their goal of

1992). Awardees used Pnthnys to Frccdoril to bring
tobacco control efforts to the African American com-
munity. Through these demonstration projects, many
ACS divisions began or enhanced their work in the
African American community.

  A recent study in three predominately low-
income, African American neighborhoods has demon-
strated that culturally appropriate interventions can
produce significant declines in smoking behaviors
(Fisher et al. 1998). The Neighbors for a Smoke Free

building a local, grassroots constituency. On behalf
of the CAUC campaign, Dr. Louis Sullivan, then
Secretary of Health and Human Services, addressed
the Cniversity of Pennsylvania School of Medicine
on January 18, 1990. In his remarks, Secretary
Sullivan said that "at a time when [African Ameri-
cans] desperately need the message of health pro-
motion, Uptown's message is more disease, more
suffering and more death for a group of people al-
ready bearing more than its share of smoking-
related illness and mortality" (quoted in Heller
lYY0, pp. 32-3).

  The national media embraced the story. Sec-
retary Sulli\,an's remarks were prominently fea-
tured in the evening news and were front-page
headlines across the country. R.J. Reynolds initially
responded by defending their targeted marketing
strategy, but the companv later claimed that Up-
to\vn \vas not aimed specifically at African Ameri-
cans. On January 19, lYY0, R.J. Reynolds canceled
the Philadelphia test-marketing of Cptolvn. On
Januarv 31, 1990, the company canceled production
of the cigarette.

  The course of events suggests that the Uptown
coalition played a decisive role in altering R.J.
Reynolds' targeting strategy. A united response from
Philadelphia's African American community, an or-
ganized local grassroots effort, the strategic alliance
\vith a national figure, and media management were
associated M.ith product cancellation less than two
months after introduction. The episode highlights
the importance of timing in measures to reduce to-
bacco use. In this instance, a marketing campaign
appears to have been derailed in its beginning stages
by short-term, high-intensity media advocacy (see
"Media Advocacy," later in this chapter).

North Side organized residents in wellness councils
to encourage nonsmoking in their areas. A citywide
advisory council, composed mostly of African Ameri-
cans, carried out central planning for the program and
provided linkages to community resources and tech-
nical assistance to neighborhood councils. The pro-
gram implemented a wide range of activities over a
24month period, including smoking cessation classes,
billboard public education campaigns, door-to-door
campaigns, and a "gospelfest." A quasi-experimental


X

I n early 1945, the memory of the grassroots vic-
torv against Uptown cigarettes (see the previous

text box, "UptoMn") served as a rallying cry in the
African American community in Boston against the
potential threat of a new brand-X cigarettes. As
with Uptown in Philadelphia, the first information
about this cigarette brand came in local media-
in X's case, in articles in the Bo.sto/~ C/oh and the
Bostorr Htwld.

  This distinctive menthol cigarette brand was
packaged in the Afrocentric colors red, black, and
green and featured a prominent "X," a symbol fre-
quently associated with the well-knoMn, deceased
African American leader Malcolm X. Community
leaders in Boston and throughout the United States
thought that the product had the potential to attract
young African Americans-a group whose smok-
ing rates had dropped dramatically in recent years.
The use of "X" on a cigarette brand also \vas seen as
a defamation of Malcolm X, a noted nonsmoker. Al-
though manufactured and distributed by two com-
panies tvithout large marketing budgets, there M'as
a fear that even a small success with X cigarettes
would stimulate the creation of similar products by
the major tobacco companies, which would have
significant resources for advertising and promotion
in African American communities.

   The National Association of African Americans
for Positive Imagery (NAAAPI) and the Boston-
based organization Churches Organized to Stop
Tobacco took the lead in opposing X cigarettes. T\VO
NAAAPI leaders, Reverend Jesse W. Bro\vn, Jr., and

design l\.as used to evaluate the impact of this pro-
gram. The three intervention neighborhoods in St.
Louis were matched by ethnicity, income, and educa-
tion with three comparison zip code areas in Kansas
City, Missouri. Baseline and follow-up random-digit
dialing telephone surveys were conducted among
adults (aged 18 years or older) in the three interven-
tion and three comparison areas in 1990 and in 1992.
Smoking pre\.alence declined significantly in the
St. Louis neighborhoods, from 34 to 27 percent, but
declined only slightly in the Kansas City comparison
areas, from 34 to 33 percent. Thus, the results of this
trial suggest that a culturally appropriate community-
organizing approach to smoking cessation that

Chary:-b D. Sutton, both of whom had been involved
in the Coalition Against Uptown Cigarettes, spoke
in Boston in February 1995 about the need for com-
munities to mobilize against tobacco marketing,
Their visits were covered extensively by print and
broadcast media. As a result of NAAAPI's orga-
nizing efforts, the manufacturer and distributor of
X cigarettes received calls from around the coun-
try, most notably from the organizations involved
in the African American Tobacco Education Net-
work of California.

  Because the brand's marketing seemed to be
confined to the Boston area, NAAAPI decided to
demand in writing that X cigarettes be withdrawn
immediately to prevent any wider distribution. The
manufacturer (Star Tobacco Corporation, Petersburg,
Virginia) and distributor (Stowecroft Brook Distribu-
tors, Charlestown, Massachusetts) both responded
within 10 days to that request, although they contin-
ued to insist that the cigarette brand had not been
specifically targeted to the African American com-
munitv. On March 16,1995, news conferences were
held in Boston and Los Angeles by tobacco advo-
cates to announce the withdrawal of X cigarettes
from the market.

  The course of events suggests that the actions
of activist groups had direct influence on the out-
come. As Leas the case writh the Uptown protest,
the X experience suggests the critical role of a rapid
but organized community response in efforts to
pre\,ent the targeted marketing of tobacco products
to racial and ethnic minority groups.

emphasizes local authority and involvement in pro-
gram planning can have a significant impact on the
smoking behavior among residents of low-income,
African American neighborhoods.

Programs for Women

  The Women vs. Smoking Network, a project of the
Advocacy Institute, was the first national network of
lvomen's organizations and women's leaders to
focus on reducing tobacco use among rvomen. With
financial support from the NCl, the network provided
technical assistance and information to `Lz'omen's orga-
nizations in an effort to interest them in the movement


to reduce tobacco use. The network also focused on
obtaining media coverage for issues concerning
rvomen and smoking. The netxvork's most notable ef-
fort was the release of a plan by R.J. Reynolds to mar-
ket cigarettes to young, uneducated women (see the
text box "Dakota"). Subsequent media attention made
this one of the most widely covered tobacco stories of
1990 (Pertschuk 1992). The netwwk XV~S short-lived
(1989-19911, however, because of lack of funding. The
International Nettvork of Women Against Tobacco
(INWAT) \vas established in 1990 as an international
organization to counter the marketing and promotion
of tobacco products to \vomen and to foster the dc\.el-
opment of programs for the pre\rention and cessation
of tobacco use among \vomen. Through support from
the American Public Health Association, INWAT has
11-orked to dralv attention to issues concerning rz~~men
and tobacco and has sought to unite and inform
Ivomen's advocates around the \vorld. As a record of
its Herstories project, INWAT assisted in preparing an
issue of L%r,lll SuwX-itl;< :711d Htv7ltil (INWAT 1994) that
\~as a collection of brief essavs about the role of to-
bacco in \vomen's li\res in \`arious countries. INWAT
has also published and distributed an international
directorv that lists tvomen \~ho are advocates for
reducing tobacco use and includes their areas of spe-
cialization (American Public Health Association 1991).
The National Coalition for Women Against Tobacco,
lvhose sponsoring organization is the American Medi-
cal Women's Association, provides educational mate-
rials and advocacy messages to counteract tobacco
industry marketing and combat tobacco use among
Lvomen and girls (http:// M~w.womeliagainst.org).

Federal and State Programs

  At the federal level, the CDC's IMPACT program
awarded three-year cooperative agreements in 1994
to selected national organizations to enhance their
work in reducing tobacco use at the national, state, and
local levels. Organizations were chosen on the basis
of their ability to provide services and outreach to
young people, women, blue-collar and agricultural
workers, African Americans, Hispanics, Asian Ameri-
cans and Pacific Islanders, and American Indians.

  Among the states, California has made a concerted
effort to involve racial and ethnic minority groups and
\vomen in its efforts funded-by Proposition 99-to
reduce tobacco use (see the section on California, ear-
lier in this chapter). In 1990, four organizations were
funded to form networks among Hispanics, African
Americans, Asian Americans and Pacific Islanders, and
American Indians. Members of the networks convene

meetings, share experiences, participate in the devel-
opment of culturally appropriate materials, and help
community organizations reach their respective com-
munities. These net\\Torks currently conduct programs
and campaigns to build a strong statewide coalition
among their respective populations (Tobacco Educa-
tion Oversight Committee 2000). California also has
funded a statelvide organization, Women and Girls
Against Tobacco, to focus on tobacco product market-
ing that targets females. Created in 1992, the organi-
zation focuses on empowpering women's and girls'
organizations to divest themselves of tobacco indus-
tr). sponsorship and funding and on eliminating
tobacco ad\-crtising in leading magazines with read-
ership among voung ivomen (Women and Girls
Against Tobacco-, n.d.).

Religious Organizations

  Although not specifically representative of
minority or underserved groups, some religious orga-
nizations that have an important impact in minority
communities have had long-standing invoivement in
issues related to reducing tobacco use. The Interfaith
Center on Corporate Responsibility, a coalition of 250
Roman Catholic and Protestant institutional investors,
pioneered the corporate responsibility movement in
the early 1970s. The value of their combined portfo-
lios is estimated at $40 billion. In 1981, the Province of
St. Joseph of the Capuchin Order was the first mem-
ber of the coalition to file a shareholder resolution with
a tobacco company on the issue of smoking and health.
Since then, the coalition has filed numerous share-
holder resolutions with the major tobacco companies.
These resolutions are a unique opportunity to engage
in a public dialogue with executives of major tobacco
companies; the shareholder meetings frequently re-
cei\-e media attention.

  A more recent effort to involve religious organiza-
tions and thereby diversify efforts to reduce tobacco use
is the formation of the lnterreligious Coalition on
Smoking OR Health. The stated purpose of the group is

to mobilize the faith communities in the United
States to improve the effectiveness of public
policy concerning tobacco. The Coalition is con-
cerned with policies affecting United States cor-
porations in\,olved in the manufacture and sale
of tobacco products. The primary focus of the
Coalition is educating policy makers within both
the legislative and executive branches of the
United States fecleral government (Interreligious
Coalition on Smoking OR Health 1993, p. 1).


Dakota

T he Women vs. Smoking Network, under the
aegis of the Advocacy Institute, ~`as a project
aimed at informing and uniting women's organ-
zations to oppose the tobacco industrv's efforts to
market its products specifically to women. In No-
vember 1989, the network sent a letter to the editor
of more than 100 newspapers nationwide. Several
newspapers printed the letter, which responded to
a Philip Morris advertisement that had previously
run in these newspapers as a mock apology to
women for alleged "shortages" of their new ciga-
rette, Virginia Slims Super. As a result, several ma-
jor national papers and ABC Nc~rjs subsequently ran
stories on tobacco ad\rertising that targeted lvomen.
Soon thereafter, the controversy and media cover-
age surrounding the planned test-marketing of
Uptown cigarettes to African Americans began (see
the text box "Uptown"). In response, many jour-
nalists wrote stories on the related issue of targeted
marketing to women. These stories prepared the
public for the events that followed.

  In February 1990, an anonymous source sent
the Women vs. Smoking NetLvork copies of confi-
dential marketing documents for a new cigarette
brand, Dakota. The cigarette, produced by R.J.
Reynolds Tobacco Company, was scheduled for test-
marketing in April 1990. The marketing documents,
entitled "Dakota Field Marketing Concepts," con-
sisted of more than 200 pages of test-marketing pro-
posals from t\yo different ad\,ertising firms. The
marketing documents described Dakota, Mhich \vas

  The coalition was formed in cooperation Lvitli
leading organizations within the mainstream tobacco
control community. As of Januarv 1991, the coalition
had enlisted 16 main religious orianizations, includ-
ing Catholic, Muslim, and Protestant denominations,
in the effort to support a large increase in the federal
excise tax on a pack of cigarettes (Interreligious Coali-
tion on Smoking OR Health 1994).

Special Efforts to Reduce
Chewing Tobacco Use
  In 1995, Oral Health America established the
National Spit Tobacco Education Program (NSTEP),

code-named Project Virile Female, as a cigarette ex-
plicitly for young women (18-20 years old). The
demographic and psychological profile prepared by
Trone Advertising Inc. of the typical Dakota smoker
described her as a "Caucasian female, 18-20 years
old, with no education beyond high school, work-
ing at whatever job she can get" (Butler 1990, p. I,
citing Trone Advertising Inc.). She aspired to have
an ongoing relationship with a man and "to get
married in her early twenties and have a family."
She spent her free time "with her boyfriend doing
\1-hate\,er he is doing." The marketing documents
also included specific promotional strategies to
attract young women to the new cigarette.

  Recognizing the value of the documents, staff
of the Advocacy Institute negotiated with the Wnsll-
ir2$orr Post for front-page coverage of the story in
exchange for initial exclusive release of what the
institute staff called "Dakota Papers." The Wad-
irlglo,~ Posf ran the story on Saturday, February 17,
1990, tvith the headlin;, "Marketers Target `Virile
Female': R.J. Reynolds Plans to Introduce Ciga-
rette" (Specter 1990). The Advocacy Institute held
back further details on the documents until Tues-
day, February 20, so that the director of the Women
1's. Smoking Net\vork could appear on CBS T1lis
Morriill:; M'ith Dr. Louis Sullivan, then Secretary of
Health and Human Services, to "release" the story
of the documents. Secretary Sullivan strongly con-
demned R.J. Reynolds' plans to target women in its
marketing strategies.

fan effort aimed at reducing the use of smokeless to-
bacco among youth in sports. Oral Health America
teamed up former major league baseball players, such
as Joe Garagiola, Hank Aaron, and Bill Tuttle, to help
get the message out that smokeless tobacco products
arc not a safe alternativ-e to smoking. The components
of NSTEP include in-stadium events, public service
announcements that have been televised during ma-
jor league baseball games, printed materials, and edu-
cational videos. An external evaluation of NSTEP is
being developed to address all levels of the program
and its public health impact.

  Significant successes of the program include the
inclusion of spit tobacco on the national tobacco policy
agenda, M'ith specific credit to NSTEP and national


  Within the next fe\v bceeks, representatilres of
the Women vs. Smoking Network appeared on NRC
Nic~17fl!/ NLTIT, CBS 771is Mov/I~u~, CBS Ew~I~II;; N<~i~~~,
the Ml~cNril-Lchwr Ncw~Horl~, Ni~l7tmfcl7, and
Nightli77e. Representatives Lvere also interviewed by
major national newspapers, including L/S,4
Todny; by numerous local papers; by CBS Radio
Network, the Black Radio Network, and National
Public Radio; and by local talk S~OM'S. Last, repre-
sentatives were asked to testify on the topic at con-
gressional hearings. The network follolved up on
the publicity bv spotlighting several different
projects, including a petition to the tobacco compa-
nies to adhere to their o\\`n \roluntarv code of cor-
porate ethics.

  Even the cigarette's proposed name dre\V criti-
cism. Groups in North Dakota and South Dakota
objected to the name, as did Sioux tribal organiza-
tions, because "Dakota" means "friend" or "allv"
in the Sioux language. These groups formed a coa-
lition of more than 4U organizations and collected
25,000 signatures on a petition objecting to the USC
of the word and demanding that R.J. Revnolds cease

chairman Joe Garagiola by lawmakers and Secretary
of Health and Human Services Donna Shalala. >lore
than S70 million in electronic media coverage has been
generated directly from NSTEP efforts. In addition,
NSTEP activities appear to have substantially in-
creased the coverage of smokeless tobacco issues in
the print media. Before NSTEP there were approxi-
mately 500 print articles annually devoted to smoke-
less tobacco; since NSTEP that number has climbed to

Components of Community Programs

Community Advocacy and Mobilization
Electronic Networking

  Interactive communication technologies, such as
computer networks, have been used extensively by
advocacy groups for reducing tobacco use. For ex-
ample, daily communications played an important

selling the cigarette, rvhich had been test-marketed,
as planned, beginning in April 1YYO. The Women
VS. Smoking Nettvork provided strategic counsel-
ing and technical support to the grassroots coali-
tion and \vas instrumental in helping arrange a press
conference in Washington, DC, in June 1990, which
featured then Surgeon General Antonia Novello,
Senator Larry Pressler (R-SD), and others objecting
to the marketing plan.

  Although advocacy groups \vere able to gen-
crate considerable community and media mobili-
zation, R.J. Reynolds continued test-marketing.
Advocates felt they had raised national concern
about the targeting of cigarette advertising, al-
though this impression was not directly verified
through survey research. Dakota cigarettes were
\vithdra\vn trvo years later, however, because the
brand did not sell as well as officials had hoped
04~77c~icn77 Mcrlit-111 iV~w 1992). In this instance, al-
though ad\,ocates might attribute the end result to
the effective use of the media to promote the agenda
for reducing tobacco use, the demise of the Dakota
brand \vas probably more attributable to market
forces.

more than 5,000. One article alone appeared in more
than 800 netzspapers on a given Meekend, and NSTEP
estimated the value of this media coverage at $15 mil-
lion. A recent survey of major league baseball players
and coaches found that more than 44 percent of smoke-
less tobacco users want to quit in the next six months,
perhaps attributable to NSTEP's active participation
in educating ballplayers during spring training.

part in the response to Philip Morris' Bill of Rights Tour
(see the text box later in this chapter). Many active,
functioning networks now provide communication
services to assist in efforts to reduce tobacco use.

  The Institute for Global Communications, based
in San Francisco, \vas an early provider of issue-
specific networks to the general public. PeaceNet and


EcoNet, which were dev~eloped in 1 YH6, are among the
most widelv used and well known of the institute's
networks. As of October 1994, the institute reported a
combined membership of 12,000 people from 130 coun-
tries (Moore 1994). Within these networks, and others
like them, are smaller groups focused on a specific as-
pect of an issue or a particular policy. For instance,
among HandsNet's 2,500 member organizations,
which span the nonprofit sector, is a forum linking 200
community coalitions on substance abuse. This forum,
managed by the Boston-based group Join Together and
supported by the Robert Wood Johnson Foundation,
provides on-line technical assistance to these coalitions.
The forum also provides news summaries and infor-
mation available on funding opportunities and
proposed legislation.

  Several networks link people who work in health-
related areas. In 1993, the Public Health Network pro-
vided forums, e-mail service, and databases for
its membership, which was composed of nearly 600
users from state and local health agencies and of
program directors who were members of the CDC's
Public Health Leadership Institute. In 1998, this
network was replaced by the Information Network for
Public Health Officials. Established by the CDC's Pub-
lic Health Practice Program Office, the network links
the public health community to the Internet and pro-
vides access to on-line information. Planned l'arent-
hood Federation of America hosts PI'XNet, a network
for its affiliates in regional and national offices, pri-
marily for communication within the organization
itself. During the lYYOs, the CDC offered the electronic
resource WONDER to public health officials, acade-
micians, and others so that thev were able to commu-
nicate via e-mail with and ha;,e access to the CDC's
databases of health data.  The advent of the Internet,
including Web-based e-mail and list serv technology,
has facilitated the exchange of public health informa-
tion for health professionals and the public. CDC now
offers its health data, materials, databases, electronic
journals, and other resources on its Web site at
www.cdc.gov.

  In 1990, the Advocacy Institute founded
SCARCNet, a multiuser interactive bulletin board that
served the tobacco control community. (The history
of the bulletin board's sponsoring organization-the
resource center known by the acronym SCARC-is
discussed in "Impact of Direct Ad\;ocacy," later in this
chapter.) When SCARCNet ceased in January 2000, it
had more than 1,000 subscribers and was circulated to
thousands of readers throughout the wrorld on vari-
ous networks. SCARCNet's most popular feature \~as
the "Daily Bulletin," which each day summarized

major newspaper and journal stories on reducing to-
bacco use (Advocacy Institute 1994). The "Daily Bul-
letin" was accompanied by a "Morning Briefing,"
which put these news stories in perspective for the
tobacco control community. The contents of the "Dailv
Bulletin" stories were retained and stored in a data-
base that is currently available for searching at
\vww.tobacco.org.  Another notable feature of
SCARCNet was the publication of "Action Alerts."
These two-page summaries of current issues requir-
ing immediate action included objectives for action,
suggested actions, media bites, quotes, and talking
points and were sent to SCARCNet as needed (on av-
erage, twice per month). The conferencing section on
SCARCNet, called the "Strategy Exchanges," provided
a forum for planning, counseling, and experience
sharing. The technology allowed for concurrent but
separate discussions on discrete issues, such as clean
indoor air, tobacco advertising and promotion, tobacco
pricing policies, and minors' access to tobacco prod-
ucts. Since its inception in 1990 to its final edition on
January 31, 2000, SCARCNet, along with its global
counterpart GLOBALink, became an important re-
source for the tobacco control community. In Febru-
ary 2000, the American Legacy Foundation began its
support of a newly designed and enhanced news ser-
vice system that harnesses advances in Web technol-
ogy to build on SCARCNet's valued features. This
system provides users with the leading national news
stories and also includes a news service that allows
users to receive a customized selection of other stories
based on their geographic location and specialty
areas of greatest personal interest (e.g., advertising, en-
forcement, etc.).

  SCARCNet has served as a model for other pub-
lic health advocacy networks. Examples include Safety
Net (an advocacy network for violence prevention) and
the Marin Institute's ALCNet (a network for alcohol
control advocates), which is modeled closely after
SCARCNet. ALCNct has been used for media advo-
cacy as Lvell, particularly to facilitate strategy devel-
opment to counteract certain alcohol products and
promotions.

  As with other modalities used for social change,
the precise role of on-line networks-one element in a
multifaceted approach-is difficult to define. Al-
though process measures are available (e.g., frequency
of interactions and message traffic), they do not assess
the basic value of computer links in furthering the
agenda for reducing tobacco use, nor is it likely (as is
noted at the beginning of this chapter for social inter-
ventions overall) that their efficacy can be precisely
estimated. Current enthusiasm for the mechanism,


however, rvill probably ensure its continuation, and
accrued anecdotal experience-to date, quite positive-
\vill provide the ultimate judgment.

Direct Advocacy

History md Actizlitirs

  National-level activities, including the lz'ork of
the Coalition on Smoking OR Health (see "Further
Regulatory Steps" in Chapter 5; see also "Communitv
Mobilization," earlier in this chapter) and others (see
Chapter 2 and USDHHS lYHYb), have played a promi-
nent role in the evolving policy changes concerning
the reduction of tobacco use. Of equal interest, from
the point of vie\v of the potential impact of ad\.ocacy,
are decentralized grassroots organizations.

  The nonsmokers' rights movement originated in
the early 1970s (see "From Antismoking to Nonsmok-
ers' Rights" in Chapter 2). It consisted of individuals
acting on their own and of small grassroots organiza-
tions of people irritated bv ETS or con\,inced that theil
health suffered from it. &ring this period, the docu-
mented adverse health effects of ETS were first being
brought to the public's attention (Steinfeld 1972; U.S.
Department of Health, Education, and Welfare 1972).
As research documenting these health hazards accu-
mulated, nonsmokers' rights organizations gre\v in
number and strength.

  Many of the early grassroots organizations used
the acronym GASP to represent similar titles, includ-
ing the Group Against Smokers' Pollution, the Group
Against Smoking Pollution, the Group to Alleviate
Smoking in Public Places, and Georgians Against
Smoking Pollution. Other acronyms w-ere also used,
including FANS (Fresh Air for Nonsmokers), TAPS
(Texans Against Public Smoking), and ANSR-
pronounced "answer"- (Association for Nonsmokers
Rights). Organizations were small, poorly funded, and
often run from home by volunteers.

  Initially, many nonsmokers' rights organizations
simply provided a forum for nonsmokers to express
their concerns about smoking and ETS. These groups
helped legitimize their members' complaints and em-
power them to take protective actions. Such actions
required courage, assertiveness, and no small measure
of tact, since smoking in public areas was normative
at the time. Group members might thus learn how to
politely ask people to refrain from smoking; or to ob-
viate direct confrontation with smokers, groups might
provide members with signs, cards, or buttons asking
people not to smoke in their presence.

  Early in the movement, nonsmokers' rights
associations adopted public policy change as an

important goal. Groups began to work for passage of
measures to restrict public smoking. Such regulations
are often referred to as clean indoor air laws (see "Clean
Indoor Air Regulation" in Chapter 5). To encourage
these measures, an early GASP organization produced
a "Bill of Rights" that stated, in part, that

Non-Smokers have the right to breathe clean air,
free from harmful and irritating tobacco smoke.
This right supersedes the right to smoke when the
tlvo conflict. Non-Smokers have the right to
express-firmly but politely-their discomfort
and adverse reactions to tobacco smoke. . Non-
Smokers have the right to take action through
legislativ-e channels, social pressures or any other
legitimate means-as individuals or in groups-
to pre\:ent or discourage smokers from polluting
the atmosphere and to seek the restriction of
smoking in public places (Group Against Smokers'
Pollution, n.d.1.

  O\rer time, manv organizations moved to encom-
pass broade r policy goals for reducing tobacco use-
in particular, thev sought M-ays to decrease tobacco use
by minors. Lariely as a consequence of those efforts,
direct advocacy and public policy change became im-
portant parts of these organizational strategies.

  In some communities, nonsmokers' rights orga-
nizations Marked in isolation. In others, they formed
associations lvith medical societies, voluntary health
associations, and other organizations; the result was a
more intense effort to ensure passage of desired legis-
lation. Despite initial obstacles, in many communities
nonsmokers' rights associations were a driving force
in moving their allies toward a legislative approach to
reducing tobacco use. For example, one of the earliest
and most influential nonsmokers' rights organizations
was California GASP, founded in 1976, which eventu-
ally became Americans for Nonsmokers' Rights
(ANR). ANR is now the principal national-level
tobacco control group devoted primarily to promot-
ing legislation for clean indoor air. In California, ANR
helped support the passage of such ordinances in many
localities. Partly as a result of ANR's work, California
has more local ordinances for clean indoor air than any
other state. ANR has served as a national consultant
to other groups pursuing such legislation.

Impact of Direct Adz~ocncy

  In retrospect, the grassroots organirations can bc>
seen as ha\.ing -\lorked to diminish the Iegitimacv of
tobacco use in the txye3 of the public anJ the crt~dibil-
it\, of the tobacco indu~tr\. Tht> passage ofordinanct~s


c3gainst public smoking (see "Clean Indoor Air Regu-
lation" in Chapter 5) occurred over se\~eral years, dur-
ing cvhich a shift in public opinion about smoking
became evident. During the 1960s and 197Os, the right
to smoke was largely unquestioned. In more recent
vears, declining smoking prevalence and public opin-
ion polls have indicated an increasing intolerance for
public smoking (USDHHS lY8Yb). The work of non-
smokers' rights organizations is coeval with these
legal, epidemiologic, and social changes. Sorting out
cause and effect is difficult, but the nonsmokers' rights
movement seems to have contributed to the changing
social norm (Glantz 1987).

  There were, however, some important exceptions
to the emerging nonsmoking norms. By the mid-lY80s,
it was apparent that both the traditional educational
efforts and the passage of ordinances to protect non-
smokers from ETS had a limited effect on young
people's smoking-related attitudes and behaviors
(USDHHS 1994). Efforts to reduce smoking appeared
unable to reduce the prevalence of smoking among
teenagers (Lynch and Bonnie 1994), and smoking
prevalence among white females began increasing
sharply during the 197Os, as did the prevalence of
smokeless tobacco use among males.
  The failure to decrease smoking among young
people is as difficult to assess as is the success observed
among adults (particularly among adult men). Ana-
lyzing the effect of prevention activities on young
people must include weighing the hampering effects
of advertising and promotional efforts backed bv the
tobacco industry's enormous marketing budget (see
"Advertising and Promotion " in Chapter 5; DiFranza
et al. 1991; Pierce et al. 1991; Lynch and Bonnie 199-I;
USDHHS 1994). Whate\.er the interplay of the forces
involxred, the result is that protobacco actixitv directed
at those entering the market has been generaIl\, suc-
cessful. An exception is the continued decline in pre\`a-
lence among young African Americans, particularly
among young women (USDHHS lY98).
  Perhaps some of the shortfall in grassroots efforts
to reduce tobacco use is associated Lvith the earlv iso-
lation of these groups from the established naiional
advocacy organization. Anecdotally, there is evidence
of a culture clash. When the nonsmokers' rights move-
ment emerged in the 197Os, many medical and volun-
tary health organizations decried \vhat they perceived
as the unprofessional, indecorous, confrontational ap-
proach that these activists took to an issue that had
previously fallen in the domain of the traditional pub-
lic health structure. Some traditional organizations in
the public health arena may also have felt that

grassroots organizations were infringing on their
"turf" and their fund-raising base.
  For their part, nonsmokers' rights associations
objected to lvhat they saw as the overly cautious, mea-
sured approach of researchers, medical associations,
and volunteer health associations, whose efforts
seemed to have done little to solve the problems ot
day-to-day exposure to ETS. The grassroots organi-
zations urged voluntary health organizations to exam-
ine their mission statements and dedicate appropriate
resources to cost-effective solutions to reducing to-
bacco use.

  In time, both approaches acknowledged that the
lack of coordination and cohesion was a significant
barrier to their efforts. The groups noted that, in con-
trast, the tobacco industry operated as a monolith
through the coordinated efforts of the Tobacco Insti-
tute, a lobbying and public relations organization
representing the industry. This insight led to the emer-
gence of several groups-somewhat disparate in their
approaches-that attempted to bridge some of the dis-
tance between the grassroots and national approaches
to reducing tobacco use.

  Among the oldest of these groups is DOC (Doc-
tors Ought to Care), which was founded in 1977 as a
national coalition of health professionals, students, and
concerned individuals. DOC groups take an activist
approach to public health problems and sponsor com-
munity projects and events on reducing tobacco use
and other issues. From the outset, members chose COP
trontational programs, such as counteradvertising and
picketing industry-sponsored sports events, to
delegitimize the tobacco industry and focus attention
on its acti\-ities bv involving both physicians and
voung people in advocacy activities. DOC groups use
&tire, ridicule, and parody in their work to appeal to
children and teenagers (Blum 1982); for example, they
have sponsored "Emphysema Slims" tennis matches
featuring appearances by "Martina Nosmokanova."
DOC also maintains a large archive of activities related
to the tobacco industry, including past advertising
campaigns and marketing strategies (Mintz 1995). The
acti\+ties of DOC are similar in style, if not content, to
those of the Australian organization Billboard Utilising
Graffitists Against Unhealthy Promotions (BUGA-UP),
which was founded in 1979. BUGA-UP members,
some of whom are physicians, have used unconven-
tional tactics, such as spray-painting billboards that
advertise tobacco products (Jacobson 1983).

  Another group is Stop Teenage Addiction to To-
bacco (STAT), which \vas founded in 1985 with the aim
of reducing tobacco use among minors. From its
inception, STAT aimed to unite the medical and


scientific arm and the grassroots arm of the movement
to reduce tobacco use. Although STAT frequently ap-
proaches tobacco issues from the activist perspective,
the organization has long included key members
of the medical and public health establishment in
its leadership. DOC, STAT, and other groups have
attempted to make the activist, confrontational ap-
proach to reducing tobacco use acceptable to the more
conservative medical and voluntary health organiza-
tions. Partly because of these efforts, an activist
approach is now an important component of the move-
ment (see the text box "Bill of Rights Tour").

  Another impetus for a more unified movement
\vas the establishment of the Smoking Control Adlro-
cacy Resource Center (SCARC) at the Advocacy Insti-
tute in 1987. The Adlrocacy Institute's mission-to
study, analvze, and teach public interest advocacy-
included a'focus on smoking reduction as a model
public interest movement. The institute received fund-
ing from the Henry J. Kaiser Family Foundation to
establish SCARC. Rather than be a frontline organ-
Tation, SCARC proposed to help build the mo\,ement's
infrastructure. As such, SCARC \vould be v-ielved as
a neutral player and \t,ould not vie I\Tith the
movement's other organizations in seeking media,
voluntary, or funding sources. Since its formation,
SCARC has served three important roles as convener,
tobacco industry monitor, and center for strategic
development, training, and counseling (Butler 1990).

Media Advocacy

  Media advocacy for reducing tobacco use was
developed during the lY8Os by a small number of ac-
tivists working primarily in the United States, Canada,
Australia, and the United Kingdom. The attendees at
the September 1985 International Summit of Smoking
Control Leaders resolved to produce a handbook that
would provide guidance on using the media to sup-
port tobacco control. The resulting document, Smoke
Si~rlals: T/V .S~~lr~kirl;~ Corlfvol Mcdin Hnr2itEook Pertschuk
19871, describes many of the important themes and
skills needed for using what would later be dubbed
"media advocacy." In January 1988, the Advocacy In-
stitute convened a t\vo-day consensus workshop,
sponsored bv the NCI, that produced a second hand-
book on media advocacy, M&i17 SfrntL><yies ,f<~ .S~&ill~q
Co77frol: Glrirlrlirzc~.~ (USDHHS 198Ya), which formally
recognized the importance of media advocacy in re-
ducing tobacco use (and in which the term "media
advocacy" was first employed).

  Media advocacv has been defined as the strate-
gic use of mass media to advance a social or public

policy initiative (NC1 1YYl). In contrast to the goal of
traditional health communications efforts, the goal of
media advocacy is to change public policy and thereby
generate a broader impact on tobacco use by creating
an environment in which smoking is not normative.
S777ok Si~~~~~ls articulates six critical tasks the media
must perform to help accomplish this goal: (1) edu-
cate the public about the severity of the risks of smok-
ing, the susceptibility of every smoker, and the health
benefits of quitting; (2) educate the public about the
health risks of ETS; (3) alert citizens and policymakers
to injurious public policies that promote smoking, in-
cluding insufficiently regulated advertising and pro-
motion of cigarettes, as well as unrestricted smoking
in public areas and the workplace; (4) respond to and
counteract the propaganda and disinformation cam-
paigns of the tobacco industry; (5) counter the eco-
nomic and political influence of the tobacco industry,
\vhich th\z,arts the adoption of remedial policies; and
(6) reinforce e\.olving social nonsmoking norms
(I'ertschuk 1987).

  Media ad\,ocacy campaigns have been likened
to political campaigns "in lvhich competing forces con-
tinuouslv react to unexpected events, breaking news,
and opportunities" (Pertschuk et al. 1991, p. 3). Such
campaigns require both presenting the public health
side of an issue and negating the opposing side. Like
political campaigns, media advocacy campaigns re-
quire quick reactions that contrast with the carefully
planned, fixed agendas of traditional media programs.

  Media advocacy recognizes the pokential of the
press to place on the public agenda issues concerning
the reduction of tobacco use and to either advance or
retard progress toward policy goals. Successful me-
dia influence requires gaining access to the news and
framing or shaping coverage of the resulting story.
These strategies are interrelated, since the framing of
a story helps determine whether a journalist will agree
to cover it.

  The use of media advocacy has two daunting limi-
tations: it is a new technique that requires complex
skills and an understanding of the news media, and it
demands a large investment in time (Wallack 1990). But
another apparent barrier-the reliance on an outside
party (the media) to achieve program goals-is also a
source of considerable strength: media advocacy is a
means by which public health practitioners can indi-
rectly confront and compete with forces that are tradi-
tionally beyond their policy and financial reach. These
forces represent powerful vested interests-the tobacco
industry, advertising industry, retail establishments that
sell tobacco, and others. The financial and political
influence of these entities can limit the ability of public


I n fall 1989, Philip Morris, the largest U.S. manu-
facturer of cigarettes, contracted with the U.S.
National Archives and Records Administration to
sponsor a commemoration of the 200th anniversary
of the Bill of Rights. The commemoration involved
a national advertising campaign, including com-
mercials on prime-time television and full-page
advertisements in major newspapers, asking Ameri-
cans to "Join Philip Morris and the National Archives
in celebrating the 200th anniversary of the Bill of
Rights" (cited in Advocacy Institute 1989, p. 1). Philip
Morris soon announced plans to transport Virginia's
copy of the Bill of Rights to all 50 states in coopera-
tion with the Virginia State Library and Archives.
  Advocates for reducing tobacco use inter-
preted Philip Morris' effort as an attempt to link
smoking with the national freedoms guaranteed by
the Bill of Rights. These groups believed that Philip
Morris would use its association with the Bill of
Rights Tour, which highlighted themes of liberty
and freedom of expression, to gain public support
for the company's claim of a First Amendment right
to advertise. Philip Morris' project \tTi.ith the National
Archives raised concern in the C.S. House of Rep-
resentatives, which held hearings on the issue but
did not intervene. Advocates for reducing tobacco
use began using the l&month tour schedule to
coordinate local efforts to counter what they con-
sidered to be a tobacco-marketing plan.
  The Washington state chapter of Doctors
Ought to Care (DOC) built a countersymbol, the
"Statue of Nicotina," to travel with the tour. At a
press conference, comments from the president of
the chapter, Dr. Robert Jaffe, captured the flavor of
the symbol's proposed use:

Nicotina is modeled [on] the Statue of Liberty.
She's holding a cigarette in her upheld hand,
instead of a torch, and her eyes are closed, the
symbol of shame that she's been made a
symbol of tobacco. The chains from her ciga-
rettes in the pack help to illustrate to all of the
children who are going to see the Bill of Rights
Tour that this is a dangerous, addictive drug.
At her feet are the words, "Give me your poor,
your tired, your women, your children yearn-
ing to breathe free .I' (quoted in Wallack et al.
1993, p. 185).

  The Advocacy Institute published an advance
schedule of the national tour, including dates and
specific locations for each of the tour's stops. The
institute also tracked activities in various states and
disseminated strategic information through Action
Alcrfs posted on SCARCNet, the institute's com-
puter network dedicated to sharing information on
reducing tobacco use. SCARCNet (see "Electronic
Networking," earlier in this chapter) was a key
mechanism for advocates to share information and
develop strategies. In addition, the American Lung
Association and the American Medical Association
provided materials and strategic support to its in-
terested affiliates.

  Initially, Philip Morris responded to protests
at tour sites by establishing a "speaker's corner"
that restricted protesters to a site away from the
exhibit hall. At first, this strategy successfully
muted attacks and deflected positive attention from
protesters. Indeed, by appearing to encourage
protesters, Philip Morris was portrayed by some me-
dia reports as being faithful to the spirit of the Bill
of Rights. As the tour continued, however, groups
opposed to the sponsorship learned from experience
in other states. The groups refined their message,
learned 110~. best to respond to Philip Morris'
spokespersons, discussed public reaction to their
protests, and modified their tactics appropriately.
They developed a simple slogan, "Bill of Rights Yes/
Philip Morris No" (cited in Wallack et al. 1993, p.
1861, to clarify the theme of their protests.
  With the changed approach, advocates re-
ported improved media coverage of the protests.
At almost everv tour stop, advocates staged press
conferences beiore the opening of the exhibit and
displayed the Statue of Nicotina, which was trans-
ported from state to state. By February 1991, five
months into the tour, Philip Morris scaled down
the number of scheduled stops. The tour, accom-
panied by advocates for reducing tobacco use,
continued through its conclusion in Richmond,
Virginia, in December 1991.

  The ultimate effectiveness of this advocacy
effort is difficult to judge, but the effort played an
obvious role in muting the public relations benefits
to the tobacco industry. At the very least, the re-
sources invested by the industry did not appear to
bring the expected return.


Ralucirlg Tohcco Use

(as well as private) agencies to use confrontational tac-
tics. In addition, many communities prefer consensus
building to confrontation with powerful opposition
parties. However, because the visible products of me-
dia advocacy-the media reports themselves-emerge
from a disinterested party (the media) rather than from
parties for or against reducing tobacco use, this new-
est form of social intervention can be successful in pre-
viously problematic areas.

  As with other social interventions, the precise
contribution of media advocacy to the effort to reduce
tobacco use is difficult to judge. Events like those sur-
rounding the marketing of the cigarette brands Up-
town, X, and Dakota and the Philip Morris-sponsored
Bill of Rights Tour demonstrate the role that media
advocacy can plav in the overall effort.

Countermarketing

Mass Media in ToOacco Corrtrol

  In contemporary society, the mass media are the
most important means of educating and informing the
public and, through public response to media, policy-
makers. By design or not, the media plays an enor-
mous role in influencing the smoking behavior of
individuals and the actions of policymakers in both the
public and the private sector (Pertschuk 1987). Public
health programs have used various health communi-
cation programs to inform and influence the behavior
of the general public. Traditionally, communication
programs intended to reduce tobacco use have tried
to influence the behavior of individuals. Most such
media campaigns have focused on influencing the
behavior of adult smokers-and hence have focused
more on smoking cessation than on prevention. Flay
(1987) describes three prominent types of mass media
programs and campaigns designed to influence
smoking-related knowledge, attitudes, and behavior:
(1) those that inform the public of the negative health
consequences of cigarette smoking and try to motivate
smokers to quit, (2) those that promote specific smok-
ing cessation actions to those smokers motivated to
quit (e.g., smokers are encouraged to call a help line
or to request specific materials, such as a tip sheet or a
self-help manual), and (3) those that promote smok-
ing cessation self-help clinics for those smokers who
desire to quit. A smaller number of campaigns have
focused on youth, either encouraging young people
to avoid using tobacco products or convincing young
people who smoke to try to quit (USDHHS 1994).

  A factor that has limited the success of traditional
mass media campaigns is the small size of the cam-
paign budgets compared with the advertising and

marketing budgets of the tobacco industry (Flay 1987;
USDHHS 1994). In addition, these campaigns to re-
duce tobacco use have experienced drawbacks because
of their traditional reliance on public service announce-
ments (PSAs). Although PSAs have been an integral
part of such efforts for many years, the number of PSAs
on any subject provided to broadcasters has increased,
whereas the amount of donated air time available for
PSAs has decreased. Also, the advent of cable tech-
nology, which has increased the number of channels
through lvhich people can be reached and therefore
has diffused the audience, has further hampered
efforts to reach targeted groups efficiently. By the mid-
198Os, it had become apparent that the role of the
media in the effort to reduce tobacco use required re-
evaluation. In the following sections, the uses of mass
media approaches for tobacco control are summarized.

Effects of Protobacco Advertising amI Promotion

  The effect of tobacco advertising and promotion
activities on both adult consumption and youth ini-
tiation has been the subject of considerable research
over the past decade (see "Advertising and Promo-
tion" in Chapter 5). While noting that existing evi-
dence suggests that tobacco marketing increases the
level of tobacco consumption, the 1989 Surgeon
General's report Rcducillg the Health Co~~sequcnces
of Sl?lokirl~: 25 Ytvrs of Progress concluded that the
issue is so complex that a sufficiently rigorous study
capable of providing definitive scientific evidence is
not available and that "none is likely to be forthcom-
ing in the foreseeable future" (USDHHS 1989b, pp.
516-7). The 1994 Surgeon General's report Prezw~ti~zg
Tr&ncco Use Amor~g Youug Peo,& similarly noted the
absence of a definitive longitudinal study of the direct
relationship of tobacco advertising to adolescent smok-
ing. However, acknowledging the value of recent
nonlongitudinal studies focused on young people, the
report offered this major conclusion: "Cigarette
advertising appears to increase young people's risk of
smoking by affecting their perceptions of the perva-
siveness, image, and function of smoking" (USDHHS
1994, p. 6). Also in 1994, the Institute of Medicine con-
cluded that the preponderance of evidence suggests
that tobacco marketing encourages young people to
smoke (Lynch and Bonnie 1994).

  In its rule to restrict the access and appeal of to-
bacco products to young people, the Food and Drug
Administration (FDA) reviewed the quantitative and
qualitative evidence and concluded that cigarette ad-
vertising is causally related to the prevalence of smok-
ing among voung people (Fcdcrnl Register 1996). The


agency also cited statements from internal documents
of the tobacco industry to sho\~ the importance of the
vouth market segment to the industry's continued
success. More recently, a 1998 Report to the United
Kingdom's Chief Medical Officer by the Scientific
Committee on Tobacco and Health concluded unani-
mously that tobacco advertising and promotion influ-
ence young people to begin smoking (Scientific
Committee on Tobacco and Health 1998).

   Survey data sho\v that among children who
smoke, most use the most heavily advertised brands
of cigarettes, whereas many adult smokers buy generic
or value category brands, which have little or no im-
age advertising (CDC 1994). A major econometric
marketing study found that young people are three
times more affected by advertising than are adults
(Pollay et al. 1996). Research has also pointed to the
impact of other tobacco promotional activities, such
as sponsorship of public entertainment events and dis-
tribution of specialty or premium items. These activi-
ties constitute the largest (and an increasing) share of
tobacco marketing expenditures. The CDC has esti-
mated that today's U.S. teens already have been ex-
posed to more than 520 billion in imagery advertising
and promotions since age 6, creating a "friendly fa-
miliarity" for tobacco products and an environment
in which smoking is seen as glamorous, social, and
normal (Eriksen 1997). Although the effect of this ex-
posure is difficult to quantify, especially nation\\.ide,
one study has estimated that 3-l percent of all youth
experimentation with smoking in California betIvecn
1993 and 1996 can be attributed to tobacco promotional
activities (Pierce et al. 1998). A recent study found that
teenagers who can readily name a cigarette brand and
who own a tobacco-company-sponsored promotional
item are more than tlvice as likely to become estab-
lished smokers than adolescents ~`110 do neither
(Biener and Siegel 2000).

Effects of Tobacco Couzzterwzarketizzg

  In light of ubiquitous and sustained protobacco
messages, countermarketing efforts of comparable in-
tensity and duration are needed to alter the social and
environmental context of tobacco use. Evidence of
effectiveness comes from three main sources: (1) the
natural experiment of the counteradvertising cam-
paign that occurred during the late 1960s as the result
of a Fairness Doctrine ruling (also discussed in "Broad-
cast Advertising Ban" in Chapter 5), (2) school and
community intervention studies incorporating mass
media approaches (see "Supplemental Programs" in
Chapter 3), and (3) recent experience with large paid

media campaigns in several U.S. states and with a na-
tionwide campaign funded by the FDA. Because of
the special sensitivity of young people to tobacco mar-
keting and the high rates of tobacco use among teen-
agers, the subsequent review in this chapter will focus
on countermarketing media campaigns that include
prominent youth-targeted components. The literature
provides strong evidence of the value of mass media
campaigns to inform the public at large-including
young people-about the hazards of smoking, to pro-
mote specific cessation actions and services (such as
telephone help lines), and to provide cessation clinics
to adult smokers (Flay 1987; Pierce 1995).
  The Fairness Doctrine campaign. In 1967, the
Federal Communications Commission (FCC) applied
the Fairness Doctrine (discussed in "Broadcast Adver-
tising Ban" in Chapter 5) to cigarette advertising and
required broadcasters to provide a significant amount
of airtime to antismoking messages-a requirement
interpreted by the FCC at that time to be about one
antismoking message per three tobacco advertising
messages). This requirement resulted in the onlv sus-
tained nationwide tobacco control media campaign
to date. From mid-1967 through 1970, roughly $200
million in commercial airtime (in 1970 dollars) or $75
million per year w'as donated for antismoking mes-
sages on television and radio (Warner 1986; USDHHS
1989b).

  The campaign produced significant reductions
in both adult and youth smoking behaviors (Hamilton
IY72). For the first time in the 20th century, adult per
capita cigarette consumption fell for more than three
consecutive vears. Teenage smoking prevalence was
3 percentage- points smaller during the Fairness Doc-
trine period than it was in the 16 months before the
campaign, and the campaign was associated overall
\vith a 3.4-percentage point reduction in teen smoking
prevalence. Perhaps the ultimate indicator of the
campaign's impact was a change that followed the
campaign's end: with the 1971 enactment of congres-
sional legislation banning tobacco commercials from
television-and with them, the Fairness Doctrine-
mandated counteradvertisements-per capita
cigarette consumption immediately resumed its
upbvard trend (see "Broadcast Advertising Ban" in
Chapter 5).

  Hamilton (1972) suggested that during the Fair-
ness Doctrine period, the antismoking campaign mes-
sages had an effect that was nearly six times that of
cigarette advertisements. Warner (1979) noted that the
government's broadcast ban-and the consequent end
of the countermarketing campaign-was especially
detrimental to the ongoing effort to pre\rent young


people from smoking. Cigarette promotion remained
highly visible in the print media and in tobacco com-
panies' sponsorship of sporting events at the same time
the broadcast ban "virtually eliminated mass promo-
tion of the antismoking cause" (p. 445).

  Community intervention studies. As described
in "Research on Multifaceted Programs" in Chapter 3,
multicomponent youth-directed programs that include
a prominent mass media component have shown long-
term success in postponing or preventing smoking
onset in adolescents. In the University of Vermont
School and Mass Media Project, the study featuring
the most intensive paid counteradvertising campaign,
the preventive effect actually increased during the two-
vear intervention period among the adolescents at
iligher risk for smoking (Flynn et al. 1997)-a rare
outcome for most campaigns trying to change health
behaviors. The authors noted that counteradvertising
can effectively reach higher-risk youth because of their
greater exposure to the mass media, particularly ra-
dio and television. It is also likely that higher-risk
youth make their decisions about tobacco use earlier
in life than lower-risk vouth; mass media influences
can be especially powerful in shaping attitudes and
normative perceptions at early ages.

  State-based media campaigns. Mass media cam-
paigns are standard components of the well-funded,
ongoing tobacco control programs in California, Mas-
sachusetts, Arizona, Florida, and other states recei\,-
ing money for counteradvertising programs from state
excise tax increases or tobacco settlement allotments
(as was discussed in "Example of Major State Pro-
grams," earlier in this chapter). Although it is diffi-
cult to sort out the effectiveness of media campaigns
from other program components, evaluations of these
statewide public education programs, particularly in
California and Massachusetts (see "Supplemental Pro-
grams" in Chapter 3), have shown their success in re-
ducing tobacco use among adults, slowing the uptake
of tobacco among youth, and protecting children from
exposure to ETS (CDC 1996). A recent study of the
Massachusetts media campaign in 1993 and 1997 found
that among younger adolescents (those aged 12-13
years in 1993), those who had been exposed to the
counteradvertising campaign on television were about
half as likely to have become smokers as those who had
not been able to recall campaign advertisements (Siegel
and Biener 2000).

  Food and Drug Administration campaign. In
1998, the FDA launched a national advertising
campaign to help retailers comply with the age and
photo identification provisions of the FDA's rules to
prevent tobacco sales to children and adolescents. The

campaign began with a test in Arkansas and by year's
end was active in 42 states. Funded annually at about
$9 million, the campaign featured radio spots, bill-
boards, newspaper advertisements, posters, and store
signage. The overall approach was to use humor to
relieve the discomfort clerks may feel when checking
young people's identification/proof-of-age cards and
to increase awareness of the rule provisions among re-
tailers, underage youth, and the general population.
One counter card, for example, reads, "Our cashier
really stinks at guessing ages. So if you want ciga-
rettes, can we see some I.D.?"

  A campaign tracking survey (Market Facts 1998)
in nine states with test and control sites found that
during the first year of the campaign, knowledge of
age 27 as the cutoff age for checking identification
increased from 34 to 54 percent in test sites and from
31 to 40 percent in control sites. Most important was a
small but significant decline in the average number of
times minors tried to buy tobacco. According to re-
tailer self-reports, this number declined from 3.4 times
each day before the campaign to 2.8 times daily after
the media effort. In control sites, the frequency of un-
derage purchase attempts did not decrease from be-
fore (2.4 times daily) to after (2.7 times daily) the time
of the campaign. For customers from whom identifi-
cation was requested in the test sites, retailers reported
that the proportion of those who were "often" or "al-
ways" irritated declined from 34 percent to 28 percent.

  Counteradvertising and entertainment media.
The increase in movie depictions of tobacco use is a
powerful media influence promoting use among teens
(Stockwell and Glantz 1997). In focus groups, young
people are not able to recall antismoking messages on
television or in the movies, but they recall specific
movies that portray smoking and can identify actors
and actresses who smoke in their entertainment roles
(Crawford et al. 1998). Counteradvertising holds
promise for helping denormalize and deglamorize
these portrayals in the entertainment media. In an
experimental study, Pechmann and Shih (1999) found
that placement of a 30-second California Department
of Health Services tobacco counteradvertisement
before the popular movie Rmlify Bites served to inocu-
late teenagers against the movie's pervasive
prosmoking cues without detracting from their enjoy-
ment of the film. Because paid advertising in movie
theaters is a highly efficient method of reaching
adolescents, the authors recommend this tactic as a
nationwide cost-effective prevention strategy.

  Research on best practices. Although produc-
ers of counterad\.ertising campal, `011s use formative re-
search techniques to de\,elop products, inconsistent


testing methods hinder comparison of the eftecti\,e-
IWSS of different messages. This situation has helped
create the impression that there is little agreement
over "what works" in tobacco counteradvertising, as
typified by this Wd7i77,@r7 Pnrt headline: "The Anti-
Smoking Campaign's a Many Splendored Thing, and
That's the Problem" (Teinowitz 1998).
  Goldman and Glantz (1998), using available fo-
cus group data and research reports obtained from a
number of states, concluded that t\vo message strate-
gies, industry manipulation and the hazards of ETS,
are the most effective for denormalizing smoking
among young people and reducing consumption
among adults. The researchers reported that addic-
tion and cessation messages can also be effective, but
that four strategies are not effective: youth access,
short-term health effects, long-term health effects, and
romantic rejection.  They also characterized
California's counteradvertising campaign as more
"confrontational with the industry" (p. 772) than Mas-
sachusetts' "more youth-oriented approach" (p. 772),
citing this difference as a major reason for their find-
ing that the California media campaign was relativelv
more cost-effective. This paper elicited some strong
responses. The University of Vermont School and Mass
Media Project investigators (Worden et al. 1998) em-
phasized the limitations of focus group results and the
importance of audience age in reactions to messages.
They argued that for young people aged 10 to 12 years
(the age group in which they recommended starting
prevention efforts), presenting messages that foster
positive social influence and social norms have proved
most effective in reducing tobacco use among youth.
Balch and Rudman (1998) responded that young
people participating in 110 focus groups in five differ-
ent states considered numerous concepts and judged
five to be more credible, relevant, and persuasive:
addiction, short-term health effects, athletic perfor-
mance, role model for vounger siblings, and effects on
family. From Massachusetts, Connolly and Harris
(1998) noted that industry manipulation and ETS
themes constituted 32 percent of all youth-targeted
messages and 37 percent of all messages in the Massa-
chusetts tobacco control media campaign and that on
a per capita basis, the state actually outspent Califor-
nia on these messages. Moreover, the researchers re-
ported that Massachusetts experienced a larger decline
in per capita cigarette consumption than did Califor-
nia for the period 1990-1996.

  To obtain data in a more quantitative way,
Pechmann and Shih (1999) created a typology based
on 196 youth-oriented antismoking television adver-
tisements. They identified three main types-fear

appeals, peer norms, and tobacco marketing-and
further subdivided these into seven main messages:
(1) smokers may face serious health problems, (2) to-
bacco company deception results in disease and death,
(3) smokers endanger their family members, (4) smok-
ing is unattractive, (5) smokers are perceived by peers
as misguided, (6) most young people choose not to
smoke, and (7) advertisement shows how tobacco corn-
panies market their products. The investigators tested
a sample of 56 of their advertisements in a group of
ethnically diverse 7th, 9th, and 10th graders. After
viewing a selection of test and placebo advertisements,
study participants completed an evaluation survey to
assess the effect of each category on their intent to
smoke and on other pertinent measures, such as atti-
tudes toward smoking and knowledge of tobacco
marketing tactics. Results showed that only three of
the seven messages were highly effective in reducing
teenagers' intent to smoke: those that conveyed that
smokers endanger their family members, that smok-
ers are perceived by peers as misguided, and that most
young people choose not to smoke.
  In the Massachusetts campaign study (Siegel and
Biener 2000), the authors tested eight smoking-related
knowledge and attitude variables corresponding to
campaign themes. Only one variable, perceived youth
smoking prevalence, changed significantly with expo-
sure to the media campaign at baseline and was asso-
ciated with the reported reduction in tobacco uptake.
Exposed youths were more than twice as likely than
their unexposed peers to have an accurate perception
at folloll--up that fewer than half of the students at their
high school were smokers. Variables that did not
change were kno\vledge and attitudes related to low-
tar cigarettes, environmental tobacco smoke, chem-
cals, rvrinkles, tobacco company tactics, dating, and
sports. This finding points to the power of the mass
media, especially television, to set social norms and
supports the effectiveness of counteradvertising mes-
sages that denormalize tobacco use.
  As part of a three-year study exploring racial/
ethnic and gender differences in teen tobacco use, a
group of 11 CDC-funded university-based Prevention
Research Centers conducted a series of focus groups
during 1996-1997 to explore potentially effective
counteradvertising strategies and messages. Six of the
11 centers used television spots from CDC's Media
Campaign Resource Center for Tobacco Control to elicit
reactions and stimulate discussion. For the most part,
different centers used different advertisements, and
they did not attempt to "test" the advertisements in
any standardized way to determine relative effective-
ness. Nevertheless, the conclusions that emerged from


Teen Focus Group Response to Counteradvertising Messages
      (Findings from 11 Prevention Research Centers)

o  Without an overall context provided by ongo-
ing advertising and other program elements, the
message that tobacco companies are manipu-
lating young people to smoke ("they're lying
to you") has relatively low interest and salience
among teens and may be miscomprehended.

.  Attempts to explain the concept of nicotine ad-
diction and make it personally relevant for
young nonsmokers is difficult because most
have not experienced the physical cra\,ings of
addiction and tend to take messages literally.

o  The television spot shorvn to the most iocus
groups (about physical performance and fea-
turing the U.S. Women's National Soccer Team)
was easily understood, attention getting, and
credible and may be generalizable (with some
  effort) to nonathletic endeavors.

.  Young people did not like advertisements that
  feature text.

o  Young people, particularly whites, were sharply
critical of any advertisement they perceived as
  corny, "cute," staged, or unhip.

this research (Tobacco Network, unpublished data) give
some indication of the complexity of people's response
and the considerable challenges to crafting effective
messages (see the text box "Teen Focus Group Response
to Counteradvertising Messages").

  Audience targeting. The use of counteradver-
tising aimed only at young people rather than the use
of a general marketing approach has been controver-
sial. Glantz (1996) criticized the public health
community's "preoccupation with youth" (p. 157),
particularly youth access campaigns, as an ineffective
strategy and one that diverts energy from reducing
adult smoking and creating a smoke-free society.
Cummings and Clarke (1998) warned that campaigns
focused exclusively on young people may be counter-
productive if the messages make smoking more ap-
pealing to youth by promoting it as somethi?; that is

As advertising professionals have reported in
the research literature, humor was found to be
a double-edged sword: it can be very effec-
tive, but if used inappropriately can be seen
as tri\.ializing the issue. In some focus groups,
humorous advertisements obtained both the
highest and the IoM-est scores.

Young people reacted emotionally and favor-
ably to true, nonpreachy stories about the im-
pact of smoking on a person's or family
member's life (such as a television spot from
California featuring a man whose wife had
died from exposure to his smoking).

Cartoons tend to have low "stopping power"
because teens have seen so many, whereas the
use of surprising characters like animals (such
as the "Animals" and "Butts" spots from Min-
nesota) can rivet attention. These attention-
getting spots do not necessarily communicate
an effective countermessage, however.

Messages that portray the negative social effects
of tobacco use perform well among teens; mes-
sages that focus on health effects can be effec-
ti\,e if they are presented dramatically but
realistically (such as a California spot featuring
a laryngectomy patient smoking a cigarette).

not for them. Indeed, a chief criticism of the tobacco
industry-funded booklet Tohcco: Hclyir~~ Youth Say No
was that it portrayed tobacco use as a forbidden fruit
and a badge of maturity, thereby increasing its attrac-
tion to youth (DiFranza and McAfee 1992). The Insti-
tute of Medicine noted that "as adolescents venture
more and more into the community, their perceptions
that certain norms seem to apply only to them and
not to adults may promote health-compromising
behaviors" (Lynch and Bonnie 1994, p. 87). Young
people participating in focus groups conducted dur-
ing the third year (1997-1998) of the CDC-funded
Tobacco Network project reported that they respect
and regard policies targeted to the public at large, such
as clean indoor air laws, but resent policies specific to
them, such as youth access restrictions. They also
resented the inconsistent enforcement of general


Tips for Success in Health Promotion Campaigns

.  Target yourlgpeople in grades six ard rlilre (ages
22 a~ln 15). These years define critical periods
in most children's social development, times
when many young people change schools and
  peer groups.

.  Target adults with comylementary, uorrcontra-
dictoq messages. In a comprehensive strategy,
media messages that inevitably spill over from
one audience to another can be mutually rein-
forcing and synergistic. Clean indoor air mes-
sages can provide added motivation for adults
to quit smoking. Cessation messages for adults
can affect young people's perception of norms
and highlight the problem of addiction. Pre-
vention messages for young people can increase
the salience of the tobacco issue among parents
and community leaders.

.  Highlight rlonsmoking as the majority behavior.
Most young people overestimate the number
of their peers who use tobacco. Campaigns
should not seek to correct this misperception
nrrti highlight an increasing "problem" of kids
  who smoke.

.  Present realistic tobacco-free lifestyles as prac-
ticed bv diverse, appealing, and interesting per-
sons. \iouth behaviors are driven bv how, young
people perceive the behaviors oi people like
them. Having a repertoire of social choices is a
fundamental need for teens, \~ho are going
through a period of profound social and envi-
  ronmental transition.

policies, such as allowing teachers but not students to
smoke on school property.

  Worden (in Cummings and Clarke 1998), referring
to the research literature on multifaceted education cam-
paigns, noted that reducing the demand for tobacco
among young people requires a combination of direct
(to youth) and indirect (to adults) messages and careful
attention to audience segmentation. He stressed that
young people and adults need separate media cam-
paigns that do not contradict each other. For example,
a youth-directed television spot that communicates the

.  Provide constructive alternatives to tobacco
use and discourage destructive alternatives.
Sports and other youth-oriented activities as-
sociated with the tobacco-free lifestyle can pro-
vide some of that positive social repertoire.

o  Commw~icate the relevant dangers of tobacco.
Certain dangers of tobacco, if explained in a
creative and memorable manner, resonate with
young people-for example, addiction por-
trayed as a loss of control, the carcinogenicity
of environmental tobacco smoke, the toxic
chemicals in tobacco products and smoke, and
the tangible suffering and visible disfigurement
  from tobacco-related diseases. Communicate
health messages through personal testimonies
(tell a story) and creative executions that break
through young people's sense of immortality
  and their (and adults') resistance to traditional
health messages.

.  Encourage youth empowerment ad control.
  Teens need to be offered information and anec-
dotal experience from lvhich they can begin to
understand the world and take control of their
  o~`ii lives.

o  Abaiidori the serzrch for the "magic-bullet"
message. There is no single best motivator for
pre\renting or reducing tobacco use. Campaign
messages for both voung people and adults
should feature a \.ariety of themes, appeals (fear,
humor, satire, testimonials, etc.), and execu-
tional styles. Maximize the number, variety,
and novelty of messages rather than communi-
cating a fe\V messages repeatedly.

message "most kids don't smoke" can be neutralized
by an adult-aimed but youth-vielved spot that says
"more and more kids are smoking e\rery day."

Chflrflcteristics of Successful Campaigns

  Though debate continues over the relative effec-
tiveness of strategies employing specific messages, the
experience rel-ieived in preceding sections suggests
ca~stns~s that counteradvertising campaigns must
have sufficient reach, frequency, and duration to be


.

.

Use multiple noq)reachy voices. Not only do
different teens require different appeals and
creati\re executions, but diversitv of messages
is itself a sophisticated message. Teens
strongly reject attempts by anyone to domi-
nate or direct them. Messages about indus-
try manipulation, if they are to be relevant and
acceptable to youth, should be delivered by
nonauthoritarian sources (such as Florida's
"Truth" campaign teenagers), not \vith melo-
dramatic appeals. A\-oid highlighting a single
theme, tagline, identifier, or sponsor.

Use a completneiftar~y, reirlforciilg inis of tele-
zGsiorf, radio, print, arid outdoor adzlertising.
The campaign should also csplore the \-al-i-
0~1s alternnti\,e media options a\.ailable (e.g.,
mo\ie trailers, the Internet, other computer
resources, \,ideo games, materials for schools
and community groups). The media mix is
especially important in \,ie\l- of todav't; pro-
liferating fragmented media market.-

Iffuoluepareifts andfamilics in acti\.itics that
\vill reduce risk factors and promote protec-
tive factors for voung people at risk for to-
bacco use. Parents and other family members
ha\Te substantial influence on the perceptions
and behaviors of young people.

successful. The 1967-1970 media campaign, enabled
by the Fairness Doctrine, achieved high frequency (one
antismoking advertisement per three cigarette adver-
tisements), extended reach (virtually complete audi-
ence penetration through three [pre-cable television]
national networks), and long duration (three and a half
years). The youth-aimed media campaign of the Uni-
versity of Vermont School and Mass Media Project
exposed 50 percent of the target population to each
television and radio spot about 6 times each year over
a four-year period (about the midpoint in the recom-
mended exposure range of 3 to 10 times per year). This
level of exposure is possible only through paid media
placement.

  Another lesson from health promotion campaigns
is the need for research at every phase of campaign
planning and implementation. Campaigns should be
grounded in the extensive literature on psychosocial
risk factors for initiating, continuing, and stopping
tobacco ust and should be guided by expertise in

o  Maximize use of existing high-quality media
materials produced bv the government, volun-
tary agencies, and a n&nber of individual states.
(A new, high-quality television spot commonly
costs more than SlOO,OOO to produce.) A large
collection of advertisements is currently avail-
able through the CDC's Media Campaign Re-
  source Center for Tobacco Control. The cost of
placing an advertisement will vary significantly
by state and media market.

.  Include grassroots promotions, local media ad-
z~ocacy, evertt spomorshiys, and other com-
mauit?y tie-ins to support and reinforce the
counterad\rertising campaign (see "Media Ad-
\.ocacy," earlier in this chapter). Work in con-
cert 14th other interventions to promote policies
that aim to change social norms regarding to-
bacco. A local "look" for local media messages
(e.g., featuring people of ethnic or geographic
representation similar to the viewing audience)
appears to be more important for adults than
for youth, because young people tend to share
and be shaped by a more universal, multiethnic
  vouth "media Ivorld."

communications theory and practice. Media materials
should undergo rigorous audience pretesting to ensure
they achieve predetermined communication objectives
with their target audiences. Ongoing measurement of
the communications' impact is needed to evaluate the
effectiveness of the campaign and to guide midcourse
corrections.

  Through the Columbia University Preventior
Research Center in New York City, the CDC convened
a panel of youth marketing and research experts in 1996
to advise the agency on effective countermarketing
approaches to prevent tobacco use among young
people. Over two years, the expert panel reviewed the
literature, interviewed experts in tobacco control and
health promotion, and drew on their private-sector
experience and resources to develop a set of strategic
guidelines for such a campaign (McKenna et al. 2000).
This work, supplemented by other reviews of
counterad\)ertising campaigns (USDHHS 1994;
I'echmann I 997; Siegel 1998; Teenage Research


Unlimited 1909; I'echmann and Reibling 20001,
yielded recommenddti~)lis for cftecti\,e media can-
paigns to prevent tobacco use (see the text box "Tips
for Success in Health Promotion Campaigns").

  These recommendations serve as general guidance
for tobacco counteradvertising efforts, but further
research is needed to refine our understanding of the
role and effects of mass media. Relevant areas for fur-
ther investigation include determining the impact of

Summary

counterad\,ertising on tobacco use behaviors, on readi-
ness to quit, on attitudes toward tobacco advertising
and tobacco use, and on other predictors of initiation
and cessation; identifying the most effective themes,
techniques, and messages; tailoring messages to high-
risk groups; exploring the role of new communication
tools, such as the Internet; attributing impact; and ex-
amining the interaction of media campaigns with pri-
vate and public tobacco control policies.

  The conceptual framework described at the start
of this chapter defines the basic components of the health
promotion intervention model. The statewide tobacco
control programs being funded either bv increases in
cigarette excise taxes or settlements lvith the tobacco in-
dustry are creating a ne\v laboratory to test many of these
conceptual models for comprehensive tobacco control.
Recently, both the Institute of Medicine (IOM) and re-
searchers have released reviews of the emerging data
from these statewide tobacco control efforts. In their
report, the IOM (2000) noted that it is difficult to at-
tribute a reduction in tobacco use to any single factor;
nevertheless, they conclude that "multifaceted state
tobacco control programs are effective in reducing to-
bacco use"(p. 1). In a review focusing more specificall!,
on the effectiveness of these ne\v statewide tobacco con-
trol programs on teenage smoking, Wakefield and
Chaloupka (1999) conclude that "There is consistent
evidence the programs are associated \vith a decline in
adult smoking prevalence"(p. 6), but they are some\\,hat
more cautious about the impact of these programs on
vouth smoking. Nevertheless, thev do conclude that
%otwithstanding these cautions; \ve find that the
weight of evidence falls in fa\,or of comprehensi\~e
tobacco control programs being able to reduce teenage
tobacco use" (p. 6).

  In the consideration of the emerging data from
these statewide tobacco control programs, it is impor-
tant to note that many programmatic elements of the
comprehensive tobacco control program frame\vork
are still being refined and evaluated. Thus, no current
statewide program serves an ideal or model program.
Wakefield and Chaloupka (1999) conducted a careful
re\rie\v of the \rarious elements of the statelvide

programs in Arizona, California, Florida, Massachu-
setts, and Oregon. They placed special attention on
the strengths of the "inputs'`-"namely, what was
nct~lnl/!/ i~~plwwltrd as part of the programs." Addi-
tionally, they assessed how "actual implementation of
program strategies may differ substantially from in-
tended implementation" and noted that "the extent of
disparity may vary over time and between programs."
Much more evaluation research is needed in order to
sort out the efficacy of individual components of these
evolving comprehensive programs and to refine the
comprehensi\re program structure.

  Finally, although the data from these statewide
tobacco control programs are encouraging, these results
need to be considered in the perspective of the less fa-
\,orable results from the community trials. The concep-
tual frame\vork for the comprehensive tobacco control
programs shares many elements with the theoretical
models used to de\,elop the community trial interven-
tions. Hoivever, as Wakefield and Chaloupka (1999)
noted, the programs actually implemented may differ
substantiallv from the intended implementation. There
has been sbme effort to analyze how the program
components Lvithin the emer& statewide tobacco
control programs may differ from interventions tested
\\,ithin the community trials (Green and Richard 1993;
Schmid et al. 1995), but much more M.ork is needed in
this area. As the IOM (2000) and Wakefield and
Chaloupka (1999) concluded, the results from the state-
\vide tobacco control programs are favorable. However,
both revielvs emphasize the importance of continued
sur\,eillance and evaluation efforts to monitor program
performance, to provide accountability for the use of
public funds, and to improve program efforts.


Conclusions

The large-scale interventions conducted in com-
munitv trials have not demonstrated a conclusi\.e
impact on preventing and reducing tobacco use.

Statewide programs ha\re emerged as the new
laboratory for de\vAoping and evaluating comprc-
hensive plans to reduce tobacco use.

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

1.  Results of statelvide tobacco control programs sug-
gest that vouth behaviors regarding tobacco use are
more difkcult to change than adult ones, but initial
results of these programs are generally favorable.

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

Introduction 435

Continuing to Build the Scientific Base  433

The Changing Tobacco Industry  434

The Need for a Comprehensive Approach  435

Identifying and Eliminating Disparities  436

Improving the Dissemination of State-of-the-Art Interventions  436

Tobacco Use in Developing Nations  437

Tobacco Control in the New Millennium  438

References 439


Introduction

  Tobacco use, particularly cigarette smoking, re-
mains the leading cause of preventable illness and death
in the United States (McGinnis and Foege 1993). A ma-
jor challenge to our nation's public health leaders in
the new millennium is to make this disturbing obser-
vation a thing of the past. Such a goal is no millennial
dream. This Surgeon General's report provides evi-
dence that tobacco use in this nation can be reduced
through existing modalities of interventions.

  The substantial body of literature reviewed in this
report indicates that each of the modalities-educational,
clinical, regulatory, economic, and social-provides
evidence of effectiveness. The six major conclusions of
this report provide the framework for the development
of a coherent, long-term tobacco policy for this nation.
Thus, although our knowledge about tobacco control re-
mains imperfect, we know more than enough to act now.
Widespread dissemination of the approaches and meth-
ods shown to be effective in each modality and especially
in combination would substantiallv

o  Reduce the number of young people who will
  become addicted to tobacco.

.  Increase the success rate of young people and
adults trying to quit using tobacco.

o  Decrease the level of exposure of nonsmokers to
  environmental tobacco smoke (ETS).

Continuing to Build the Scientific Base

o  Reduce the disparities related to tobacco use and
its health effects among different population
  groups.

o  Decrease the future health burden of tobacco-
related disease and death in this country.

  These achievable improvements parallel the
health objectives set forth in Healthy People 2010, the
national action plan for improving the health of all
people living in the United States for the first decade
of the 21st century (U.S. Department of Health and
Human Services [USDHHS] 2000). Twenty-one specific
national health objectives related to tobacco use are
listed in Healthy PEOFJ~P 2010, including reducing the
rates among young people and adults to less than
half of the current rate of use. Attaining all of these
tobacco-related objectives will almost certainly
require significant national commitment to the vari-
ous successful approaches described in this report.

  The report's major conclusions are not formal
policy recommendations. Rather, they offer a sum-
mary of the scientific literature about what works. In
short, this report is intended to offer policymakers,
public health professionals, professional and advocacy
organizations, researchers, and, most important, the
American people guidance on how to ensure that ef-
forts to prevent and control tobacco use are commen-
surate with the harm it causes.

  Beginning with the 1964 Surgeon General's re-
port, Snlokirzg a/zd Health (U.S. Department of Health,
Education, and Welfare 19641, tobacco control policy
in this nation has been built on a foundation of scien-
tific knowledge. Each of the subsequent 24 reports of
the Surgeon General on tobacco use has documented
a vast and growing body of scientific literature. The
substantial research reviewed in this report focuses on
a key segment of the literature-what has been tried
in the decades-old effort to reduce tobacco use. In turn,
this focus clarifies which efforts work best. Certainly
more research is needed so that these efforts can be

more efficient and effective; the key conclusion from
this report, however, is that we know more than
enough to take actions now to decrease the future
health burden of tobacco-related disease and death in
this country.

  In the process of applying our current state of
knowledge about preventing and controlling tobacco
use, accountability and evaluation of the public health
effort will be critical. However, because of the wide
array of educational, clinical, regulatory, economic, and
social influences that have been and will need to be
brought to bear on the tobacco use problem, the direct


impact of a specific maneuver on a specific outcome
becomes less meaningful as the combined effects be-
come more substantial. Investigators tend to work on
small, manageable aspects of the tobacco use problem,
but the synergistic influence of multiple factors over
time will likely extend far beyond the outcomes pre-
dicted from these smaller research undertakings. For
example, as this report demonstrates, the most effica-
cious educational programs are those that take place
in a larger community context, one that engenders and
supports an environment of nonsmoking. Similarly,
although clinical interventions to manage tobacco ad-
diction clearly have some specific power to help smok-
ers quit, primarily through pharmacological means, the
social environment remains a major determinant of
whether these new former smokers maintain their ab-
stinence from nicotine addiction. Regulatory efforts,
on the other hand, raise a host of social and economic
issues and can produce broad societal changes-issues
and changes, however, that are difficult to isolate, docu-
ment, and evaluate. Economic strategies also have a
great potential, but being fundamentally political in

The Changing Tobacco Industry

nature, they require public consensus and changes in
social norms before they can be attempted. Finally, the
public health advocacy involved in social program
modalities is virtually impossible to assess in a pro-
spective or controlled research design.

  The research and evaluation tools of public health
must expand to meet these complex issues. Compre-
hensive, multifactorial approaches to tobacco control
appear to offer the most promise. However, the pen-
alty for comprehensive approaches is a loss of statisti-
cal power to attribute outcomes to specific activities.
Within each of the modalities, appropriate evaluation
methodologies are being used (see Table 1 .I). However,
many of these methodologies involve retrospective
case study, time trend, econometric, and surveillance ap-
proaches to evaluate the "natural experiment" as it
evolves in the changing social environment. Thus, the
traditional biomedical and epidemiologic research
methods that have worked so well in defining the health
consequences of tobacco use are not well suited to evalu-
ating the potentially most efficacious methods to reduce
tobacco use.

  This report documents that this country's efforts
to prevent the onset or continuance of tobacco use
have faced the pervasive, countervailing influences
of tobacco promotion by the tobacco industry. De-
spite the overwhelming and continually growing body
of evidence of adverse health consequences of tobacco
use, the norm of social acceptance of tobacco use in this
nation has receded more slowly than might be ex-
pected, in part because of such continued promotion.

  Litigation and legal settlements have produced
notable changes in the tobacco industry's public posi-
tions on health risks, nicotine addiction, and advertis-
ing and promotion limits. Additionally, individual
manufacturing companies have become more directly
involved in efforts to limit the access of underage per-
sons to tobacco products and to prevent young people
from initiating tobacco use. In this rapidly changing
social and legal environment, it is difficult to project the
nature and scope of future changes by the industry or
their impact on the national effort to reduce tobacco use.
Nevertheless, any analysis of changes in patterns of

tobacco use must consider the influence of these indus-
try changes.

  One of the major arenas of potential change will
be in the tobacco product itself. The manufactured
cigarette that is widely marketed in the developed
world was noted to be changing dramatically when
this issue was first considered by the Surgeon General
in 1981, in Tlrr Clzm@rr~ Cigarelk (USDHHS 1981).
Recent public statements by the tobacco industry sug-
gest that the pace of changes in the manufactured ciga-
rette could be accelerating in the future. The public
health implications of changes in manufactured ciga-
rettes and other tobacco-containing products will re-
quire careful and significant attention from both public
health researchers and policymakers.

  The litigation environment has demonstrated
the importance of tobacco industry documents in
analyzing the industry's influence. Legal and public
health analyses are just beginning to sift through the
millions of pages of documents made public as part
of the various legal actions undertaken over the last


decade. As this process continues, public health   contributed to the character, pace, or direction of
researchers mav develop better methods to define and   changes in tobacco use patterns in this country or
evaluate the industry's past activities that may have    around the world.

The Need for a Comprehensive Approach

   The evidence of effectiveness summarized in this
report emphasizes that public health success in reduc-
ing tobacco use requires activity using multiple mo-
dalities.  A comprehensive approach-one that
optimizes synergy from applying a mix of educational,
clinical, regulatory, economic, and social strategies-
has emerged as the guiding principle for future efforts
to reduce tobacco use. The public health goals of such
comprehensive programs are to reduce disease, dis-
ability, and death related to tobacco use through pre-
vention and cessation, as well as through protection
of the nonsmoker from ETS.

  The emerging body of data on statewide tobacco
control efforts is coming from programs broadly fo-
cused on prevention, cessation, and protection of the
nonsmoker from ETS (Chapter 7). Preventing initia-
tion among young people is a primary goal of any to-
bacco control effort. However, young people will
perceive contradictory or inconsistent messages in our
prevention efforts if programs do not also address the
smoking behavior of millions of parents and other
adult role models and the public health risks of ETS.

   The Centers for Disease Control and Prevention
(CDC) recently released Best Pvnctices for Compr-
cIIc~~jIz]c Tdmcco Cu17f1.01 PI.O~~MRS (CDC 1999), which
recommends that states establish tobacco control
programs that are comprehensive, sustainable, and
accountable. This document draws upon "best prac-
tices" determined by evidence-based conclusions from
research and evaluation of such comprehensive pro-
grams at the state level. In the review of evidence from
these states, it was evident that reducing the broad
cultural acceptability of tobacco use necessitates
changing many facets of the social environment. Nine

specific elements of a comprehensive program are de-
fined in the guidance document. Although the im-
portance of each of the elements is highlighted, the
document stresses that these individual components
must work together to produce the synergistic effects
of a comprehensive program.

  A medical analogy might be helpful to under-
stand the practical implications of the current state of
knowledge about these best practices of tobacco con-
trol. If we found a combination of nine therapy ele-
ments that effectively treated an almost incurable
disease (e.g., advanced lung cancer), we would study
the combined therapy in many ways to learn more
about how it worked and which aspects of this combi-
nation therapy were most effective. However, while
we were doing this research, we would give every
patient with the disease the full combination of the
nine therapy elements.

  In the same way, with the nine components of
Best PJXC~~CCS, we need to continue evaluating ongo-
ing comprehensive programs to gain more knowledge
about how the components work individually and in
combination. But while this research continues, states
should be applying all nine components.

  Best Practices thus provides effective guidance for
state-level efforts; a comprehensive national tobacco
control effort, however, requires strategies that go be-
yond this guidance to states. As documented in ear-
lier chapters of this report, a comprehensive national
effort should involve the application of a mix of edu-
cational, clinical, regulatory, economic, and social strat-
egies. In each of these modalities, some of the program
and policy changes that are needed can be addressed
most effectively at the national level.


Identifying and Eliminating Disparities

  The elimination of health disparities related to
tobacco use poses a great national challenge. Although
this issue was not a main aspect of the current report,
two other recent USDHHS publications have taken
this focus. The 1998 Surgeon General's report Tobacco
Use Anloug U.S. Racial/Ethnic Minority Groups was the
first to address the diverse tobacco control needs of
the four major U.S. racial/ethnic minority groups-
African Americans, American Indians and Alaska
Natives, Asian Americans and Pacific Islanders, and
Hispanics (USDHHS 1998). Similarly, Healthy People
2010, released in January 2000, has two overarching
goals: increase quality and years of healthy life and
eliminate health disparities among different segments
of the U.S. population (USDHHS 2000). Both publica-
tions not only highlight the significant disparities in
health that exist in the United States but also stress the
critical need for a greater focus on this issue, both in
research and in public health action.

  Cultural, ethnic, religious, and social differences
are clearly important in understanding patterns of to-
bacco use, but little research has been completed on the
relative effectiveness of interventions for prevention and
treatment in some of the population groups or com-
munities. Reaching the national goal of eliminating
health disparities related to tobacco use will necessi-
tate improved collection and use of standardized data
to correctly identify disparities in both health outcomes
and efficacy of prevention programs among various
population groups. Broader historical, societal, and
community characteristics can have a significant in-
fluence on the manner in which prevention and con-
trol strategies that work overall for the population as
a whole may impact diverse groups. Many of these
broader variables do not lend themselves to traditional
measurement methods, nor are they easily assessed at
the individual level through the use of traditional epi-
demiologic methods.

Improving the Dissemination of State-of-the-Art Interventions

  One of the greatest challenges in tobacco control
and public health in general continues to be overcom-
ing the difficulty in getting advances in prevention and
treatment strategies effectively disseminated, adopted,
and implemented in their appropriate delivery systems.
Simply stated, our recent lack of progress in tobacco
control is attributable more to the failure to implement
proven strategies than it is to a lack of knowledge about
what to do. The result is that each year in this nation,
more than 1 million young people continue to smoke,
and more than 400,000 adults continue to die prema-
turely from tobacco-related diseases.

   Within each of the modalities reviewed in this
report, some specific research advances in tobacco pre-
vention and control strategies have not been fully
implemented. Studies are urgently needed to identify
the social, institutional, and political barriers to the
more rapid dissemination of these research advances.
Understanding these barriers and determining how
they could be overcome would benefit not only tobacco
control but also public health efforts more broadly.


Rrducirlg Tobncco Use

Tobacco Use in Developing Nations

  Analyses by the World Health Organization
(WHO) have concluded that by 2030, current smok-
ing patterns will produce about 500 million premature
deaths from tobacco-related disease among people
alive today (World Health Organization 1999). WHO
further estimates that by 2030, tobacco is expected to
be the single greatest cause of death worldwide, ac-
counting for an estimated 10 million deaths per year.
Although the impact of tobacco-related disease and
death has been until recently a problem primarily for
the delreloped countries of this lvorld, WHO no\v es-
timates that by 2020, 7 of e\`erv 10 tobacco-related
deaths will be in the developing'world.

  This report addresses research on strategies to re-
duce tobacco use within our nation's social, legal, and
cultural environment. Nev-ertheless, findings from
this report may have broad utility in the planning of
tobacco control efforts around the world. As Chapter 2
documents, the public health response in this country
to the scientific findings about the health consequences
of tobacco products has taken more than four decades
to emerge. In many parts of the developing rvorld,
the problems of tobacco use are similar to those in this
country in the 1950s and 1960s. Hence, a key public
health question for this millennium may be the fol-
lowing: can the time interval be significantly short-
ened between when the health risks of tobacco for a
developing country are recognized and when a com-
prehensive national response is begun?

  WHO, the World Bank, and the United Nations
Foundation, with technical assistance from the CDC,
have undertaken major new initiatives to address this
problem. The WHO Tobacco Free Initiative is develop-
ing an international tobacco control infrastructure,
which includes a global tobacco surveillance system,
intervention tool kits, and regional technical assistance
workshops. The World Bank has published C~rrbill~~
the Epidemic: Gozw~zm~~fs ~2nd the Ecommirs of tobacco
Control (Jha and Chaloupka 1999). This document
provides an economic analysis that supports a
multipronged approach to tobacco control, involving
raising excise taxes, promoting policy changes related
to the sales and promotion of tobacco products as well
as to restrictions on smoking in public places, and M.id-
ening access to smoking cessation therapies. The sci-
entific findings in this report are consistent with the
programmatic recommendations of both the \YHO
Tobacco Free Initiative and the World Bank document.

  A momentous undertaking of WHO and mem-
ber states, including the United States, is the develop-
ment and negotiation of the Framework Convention
on Tobacco Control. If brought to its intended ratifi-
cation in the next few years, this agreement would
provide a framework within which countries could
develop more specific bilateral and multilateral pro-
tocols for cooperation on containing the spread of the
tobacco epidemic. The framework would enable coun-
tries to start from a common understanding of the is-
sues, priorities, and strategies necessary to harmonize
tobacco control efforts between themselves so that
some countries do not benefit at the expense of others.
This is the spirit of the other activities of U.S. govern-
mental and nongovernmental agencies in their effort
to collaborate with WHO and with other countries in
their development of surveillance, cessation, preven-
tion, mass media, regulatory, economic, and social
approaches to global tobacco control.

  In the near future, emphasis must be placed on
the de\relopment of surveillance systems so that coun-
tries can know the extent, distribution, and trends of
the tobacco consumption problems in their popula-
tions. These systems will also track-for international
comparison and monitoring of progress-the emer-
gence of new forms of tobacco promotion, as well as
new legislation, regulations, and programs for coun-
tering tobacco use. In the longer term, the gaps must
be filled in each country's defenses against the incur-
sions of tobacco use on their young people and other
vulnerable populations. In particular, there will be a
continuing need to ensure that the rapidly expanding
knowledge about the efficacy of various tobacco con-
trol modalities be made available to the developing
world.

  The challenge to the world is to prevent tobacco
use, particularly smoking, from ever becoming the lead-
ing cause of preventable illness and death in the world.
Dr. Gro Harlem Brundtland, the current director-
general of WHO, clearly defined this challenge when
she stated, "If we do not act decisively, a hundred years
from no\v our grandchildren and their children will
look back and seriously question how people claim-
ing to be committed to public health and social justice
allowed the tobacco epidemic to unfold unchecked"
(Asma et al., in press).


Tobacco Control in the New Millennium

  Tobacco use will remain the leading cause of
preventable illness and death in this nation and a grow-
ing number of other countries until tobacco preven-
tion and control efforts are commensurate with the
harm caused by tobacco use. This report provides the
composite review of the major methods-educational,

clinical, regulatory, economic, and social-that can
guide the development of this expanded national ef-
fort. This report is, therefore, a prologue to the devel-
opment of a coherent, long-term tobacco policy for this
nation.


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Abbreviations

ABC

ACIR

ACS

ADA

ADAMHA

AEG

AHA

AHRQ

AIDS

ALA

ALERT

AMA

ANR

ASSIST

AzTEPP

BRFSS

BUGA-UP

CAUC

CBO

CDC

CHAD

COMMIT

CRS

CSAP

CSH

D.A.R.E.

DOC

EPA

ETS

FCC

FDA

FDCA

FTC

GAO

American Broadcasting Company
Advisory Commission on Intergovernmental
Relations

American Cancer Society
Americans lvith Disabilities Act
Alcohol, Drug Abuse, and Mental Health
Administration

American Economic Group, Inc.
American Heart Association
Agency for Healthcare Research and Quality
acquired immunodeficiency syndrome
American Lung Association
Adolescent Learning Experiences in
Resistance Training
American Medical Association
Americans for Nonsmokers' Rights
American Stop Smoking Intervention Study
Arizona Tobacco Education and Prevention
Program

Behavioral Risk Factor Surveillance System
Billboard Utilising Graffitists Against
Unhealthy Promotions
Coalition Against Uptozwn Cigarettes
Congressional Budget Office
Centers for Disease Control and Prevention
Community Syndrome of Hypertension,
Atherosclerosis and Diabetes
Community Intervention Trial for Smoking
Cessation
Congressional Research Service
Center for Substance Abuse and Prevention
Coalition on Smoking OR Health
Drug Abuse Resistance Education
Doctors Ought to Care
Environmental Protection Agency
environmental tobacco smoke

Federal Communications Commission
Food and Drug Administration
Food, Drug, and Cosmetic Act
Federal Trade Commission
General Accounting Office

GASP

GATT

GCP

ICC

IMPACT

INWAT

IOM

IRS

KYB

LST

MFN

MHHP

MPP

NAAAPI

NAFTA

NC1

NELS

NHLBI

NSA

NSTEP

NTCP

OIG

OR

PSA

RICO

SAMHSA

SCARC

SHOUT

SHPPS

STAT

TNT

TPLR

Reducirzg Tobacco Use

Group Against Smokers' Pollution, Inc.,
Group Against Smoking Pollution, Group to
Alleviate Smoking in Public Places,
Georgians Against Smokers' Pollution
General Agreement on Tariffs and Trade
German Cardiovascular Prevention Study
Interstate Commerce Commission
Initiatives to Mobilize for the Prevention and
Control of Tobacco Use
International Network of Women Against
Tobacco

Institute of Medicine

Internal Revenue Service
Know Your Body

Life Skills Training
most favored nation
Minnesota Heart Health Program
Midwestern Prevention Project
National Association of African Americans
for Positive Imagery
North American Free Trade Agreement
National Cancer Institute
National Education Longitudinal Study
National Heart, Lung, and Blood Institute
National Smokers Alliance
National Spit Tobacco Education Program
National Tobacco Control Program
Office of Inspector Genera1
odds ratio

public service announcement
Racketeer Influenced and Corrupt
Organizations Act

Substance Abuse and Mental Health Services
Administration

Smoking Control Advocacy Resource Center
Students Helping Others Understand
Tobacco
School Health Policies and Programs Study
Stop Teenage Addiction to Tobacco
Towards No Tobacco Use
7-obncco Products Litigntior~ Reporter


TVSFP   Television, School, and Farnil!, Smoking
     Pre\xvition and Cessation Project

U.S.C.     United States Code

USDA   U.S. Department of Agriculture

USDHEW  U.S. Department of Health, Education, and
        Welfare

USDHHS  U.S. Department of Health and Human
        Services

VSMM

WCTU

WHO

WSP

YRBS

University of Vermont School and Mass
Media Project
National Woman's Christian Temperance
Union
World Health Organization
Waterloo Smoking Projects
Youth Risk Behavior Survey


Reducirlg Tobacco Use

List of Tables and Figures

Chapter 1

Issues in Reducing Tobacco Use, Summary,
and Conclusions

Table 1.1.   Characteristics of interventions 9

Table 1.2.  Examples of a qualitative assessment of
     intervention impact 77

Figure 1 .l.  Influences on the decision to use tobacco  7

Figure 1.2.  Overvietv of relationships among
        interventions 8

Chapter 2

A Historical Review of Efforts to Reduce Smoking
in the United States

Figure 2.1.  Adult per capita cigarette consumption and
     major smoking and health e\-ents, United
      States, 1900-1999 3.3

Chapter 3
Effective Educational Strategies to Prevent Tobacco
Use Among Young People

Table 3.1.   School-based and multifaceted educational
      strategies 66

Chapter 4
Management of Nicotine Addiction

Table 4.1.

Table 4.2.

Table 4.3

Percentage of adults aged 218 years who
were current cigarette smokers, by sex, race/
ethnicity, education, age, and poverty
status-United States, National Health
Interview Survey, 1997 98

Percentage of adults who abstained from
smoking cigarettes in the previous year, by
sex, race/ethnicity, age, education, and
poverty status--United States, National
Health Interview Survey, 1991  99

Meta-analyses of efficacy (estimated odds
ratio and abstinence rates) for seven
pharmacotherapies used in tobacco
dependence treatment 71-2

Chapter 5
Regulatory Efforts

Table 5.1.

Table 5.2.

Table 5.3.

Table 5.3.

Figure 5.1.

Figure 5.2.

Figure 5.3.

Summary of landmark events in the
development of U.S. policies for clean
indoor air  2 9s

Summary of studies on the effects of a smoke-
free workplace on smoking behavior  20-1

Provisions of state laws relating to
minors' access to tobacco as of
December 31, 1999   212

Agencies responsible for enforcing state laws
on minimum age for tobacco sales as of
fiscal year 1998 218

Sales-weighted nicotine and tar levels in
smoke as percentage of 1982 levels  280

Cumulative number of state laws and
amendments enacted for clean indoor air,
1963-1998 200

Cumulative number of local laws and
amendments enacted for clean indoor air,
1979-1998 202

Chapter 6
Economic Approaches

Table 6.1.

Table 6.2.

Table 6.3.

Table 6.4.

Table 6.5.

Table 6.6.

Table 6.7.

Burley tobacco production and value,
1975-1998 297

Flue-cured tobacco production and value,
1975-1998 298

Selected production and trade statistics for
U.S.-grown, unmanufactured tobacco and
for U.S.-produced cigarettes, 1975-1999 299

Characteristics of the tobacco support
program: flue-cured tobacco,
1975-2000   303

Characteristics of the tobacco support
program: burley tobacco, 1975-2000 304

Domestic market shares of U.S. cigarette
firms, selected years 307

Recent estimates of the price elasticity of
cigarette demand from aggregate data  324

133


Table 6.8.

Table 6.9.

Table 6.10.

Table 6.11.

Table 6.12.

Table 6.13.

Table 6.14.

Estimates of the price elasticity of cigarette
demand for adults from individual-level
data 328

Estimates of the price elasticity of cigarette
demand for youth and young adults from
individual-level data 330

Federal cigarette excise taxes, selected dates,
1864-2002 339

Feder,rl excise tax rates (cents/pound) on
chewing tobacco, snuff, and pipe tobacco,
selected years, 1986-2002 339

State cigarette excise taxes and sales taxes
(cents/pack) applied to cigarettes 310

State tax rates on tobacco products other
than cigarettes as of January 1, 2000  342

Number of increases and decreases in state
excise taxes on cigarettes, July 1, 1950-
May 1,200O 335

Table 6.15.  Cigarette taxes and cigarette prices,
     1955-2000 (cents/pack) 346

Table 6.16.  Average retail cigarette price and total taxes
     per pack (U.S. dollars/pack), selected
       countries, December 31,1996 348

Chapter 7
Comprehensive Programs

No tables or figures.

Chapter 8

A Vision for the Future-Reducing Tobacco Use in
the New Millennium

No tables or figures.


  prevention and education programs  ?iiiWO~l
  smoking pre\.alence  .$I 7-9s
,`1<~cw~/ fiw Hcwltii C,iw rlif,llir?i~~~ii~icrrl iv. ilw~iinfcif
/,lii>h~k~5 ai Floridi?  741, 253
Agcnc!~ for Health Care Policy and Research  13.3
Agcncv for Healthcare Research and Quality  71
Aggregation dc\ices 23.5
Agricultural Act of 1949 XI1
Agricultural Adjustment Act of 1933  300
Agricultural Adjustment Act of 1938  307
AHA. SW American Heart Association
AHRQ. SW Agencv for Hcalthcare Research and Qualit!
Airline flights

  en\-ironmental tobacco smoke regulation  200
ALA. Scc~ American Lung Association
Alaska Natives. S~ZL' American Indians and Alaska Natives
ALCNet 1011
Alcohol

  impact of cigarette prices on use  .X%-33;
Alcohol, Drug Abuse, and Mental Health Administration
Reorganiration Act 209, ,383
Xlcc~h~ol be\.erage control agencies
   enforcement of sales to minors laws  U-37?
                                    ---
:\liohol List'

l-l7ilclr.iitc)r.il'~, //IL-   1st;
i\MA. SW American Medical Association
Ambient smoke -fin

,-lrlrcriinil Aiii'c'l~ti5i~l~~ Fc?fc7/27ti0/l T' K~~55l~~~~ IS9
American Anti-Tobacco Societv 37
American Broadcasting Cornpan\*  2i-l
American Cancer Society  39, 7s;. .?8.3
American Economics Group, Inc. 320-372
American Health and Temperance Association  37
American Health Foundation 782
American Heart .r\ssociation  39, -ib
American Indians and Alaska Nati\.es

  smoking prevalence 97-98
American Lung Association Ii.3
American Medical Association 12
American School Health Association  80
American Stop Smoking Inter~xzntion Studv  82, S-i, 209,
383-384, 385
American Tobacco Company. SW ~7lsc Court cases
  formation ot 30, 306-
  Plug War 32
Americans for Nonsmokers' Rights JO.5
Americans with Disabilities Act  73:, 216-221;
I-amino-biphenyl 782
Ammonia con~pounds 782
Ammonium carbonate 183
ANR. SW Americans for Nonsmokers' Rights
Anti-Cigarette League ot America  32
,~lllfi~fi+~7i.io ]014f-,11i/ 31
Antideprc+sants

Index

A

ABC. Sc,c, American Broadcasting C-ompan\,
ABCs. SW Alcohol be\,crage control agtvcies
/iCf/ilidS, /,I(- i' ,4hfe  243
Accord brand 309

ACS. SW American Cancer Societ\,
Acupuncture therapy 112
Ad valorem taxes 337
ADA. SW Americans with Disabilities Act
.4DAMHA. SW Alcohol, Drug Abuse, and Mental health
Administration Reorganiration Act
Addiction. Scc~ Management of nicotine addiction;
  Nicotine addiction
Additives

  to cigarettes 783-783
  regulations concerning  773
   to smokeless tobacco 7h'i%l#
Adolescent Learning Experiences in Resistance
Training 77
Adolescents. SW Youth
Ad\.ertising. SW O/G Federal Cigarette Labeling ,IIKI
Advertising Act; Packaging
  attempts to regulate  7 6.3-l 70
  brand loyalty and 702
  broadcast ad\,ertising ban 705-706
  commercial speech and  7 ;0-1;_7
  constitutionality of regulation  7;7-7;;
  FCC antismoking broadcast requirement 45
  four-pronged test 7 ;.3-[;;
  FTC staff report concerning  266-767
   health claims 39
  "Joe Camel" ad campaign  7.5. 7 ;;-1;8
  overview of regulatory efforts  74-1.5
  potential influence on smoking
    prevalence 767-702
  proposed FTC regulation of 1964  17
  public interest benefit from regulation  7 71-l 16
  radio and television advertising ban
  reasonable fit of regulation 7;6-1;; 45
    restrictions on  23
  smokeless tobacco campaign 67-62
  spending by tobacco companies  161
  substantial government interest 77-i
  targeted to women 37
  unlawful or misleading  7 7.3-7 74
  voluntary code published by the tobacco
   industry 164
Advocacy campaigns
  direct advocacy 4(1.&W
   media ad\.ocacv iOiG109
Advocacy Institute 2%-1-I. 102, 401
AEG. S& American Economics Group, Inc.
Affxtive education models 6.3
African Americans


  cttecti\ ent'ss in sniohlng cei~ation  14.
     IL-124
Antitobaccoism

  earlv campaign against cigarettes  3044
Antitrust iacvs 3-233
Anxiety

  treatment during smoking cessation  I24
Anxiolvtics

  effectiveness in smoking cessation  74,724
Ari7ona

Proposition 200, 397

  statewide ban on smoking in public places  47
Arizona Tobacco Education and Prevention Program
392-392

Asian Americans and Pacific Islanders
  smoking prevalence  97-98
ASSIST. Sw American Stop Smoking Intervention Study
Australia

   Consumer's Federation of Australia  277
  North Coast Healthy Lifestyle Programme  37%379
  warning label requirements  709
   Western Australia Tobacco Control Act of 1990  768
Aversive-smoking strategies 707-108
A7TEPP. Sw Arizona Tobacco Education and
Prevention Program

B

Bons,lck, ldmtxs Albert
  cigarette rolling machine patent  30, 306
Brand loyaltv
  advertising and  7 62
Brand slvitching 709-770
Brandt, Allan b'i. 34
Broadcast xl\ ertising ban  76.7-766
Broils ~1. Phil/p Morris Cm.  767, 236. 237, 244
Bro\vn & Williamson-British-American Tobacco
Company 223

H7fil7nf7 i'. C~rflfo P/fi7ruu7ccfrtim/ /Cormdo/ Ltlf.  786
RIK~;~&~I il. R.]. Rqrmlds Tobnrco Cu.  243
BUGA-UP. Sn, Billboard Utilising Graffitists Against
Unhealthy Promotions
Bupropion

   effect on discomfort of nicotine
     Lvithdrawal 727-722
  effects of postcessation change in body weight  722
  efficacy for smoking cessation  74.721
  relevant process measures  722
   side effects 122
Burlev tobacco

  domestic consumption  296-297
  support program 302, 303
Burney, Dr. Leroy E. 39
Buspirone hydrochloride
  smoking cessation treatment  714
lii/t/~~r i'. :\rirtYiil7ir Th7c-c-c~ co.  24%`4`4

C

Califano, Joseph A. 46
Cdlifornid
  dult smoking pre\,alence  359
  per capita cigarette consumption .38S-389
  pre\,cwtion and control programs  x;-389
  Proposition 65 14.5
  Proposition YY 3.39, .?a;-388
  !wuth tobacco use prevalence  389
California Tobacco Control Program 358
California L'nfair Competition Law  7;;
Cl7/ifOl./l/~7 i' P/ii/i/l Mol'ri5 ltli   745
Californians tar honsmokers' Rights 4,
Californians tor Scientific Integrity  2.54
Camel cigarettes
  "Joe Camel" ad campaign  7.3, 7/Y-778
Canada
  health messages on cigarette packages  786
   Tobacco Products Control Act  769, 770, 782
  tvarning label requirements   169-770
C~711[7dil711 Clmrt~~r of Rigi7t.i 1717d Fwcdo~~rs  7 70
Cancer. Sw Lung cancer
Cancer Pre\,ention Studies 784


  Pawtucket Heart Health Program  727, .3;9-.3RO
  Stanford Five-City Project  7;. 72;. 3;9%380
Carnes Bettv
C3rter `G&v ?,
            7'-
`
Carter: Jimm~v 49
Cnstnr70 i'. h;~ii7ri 7ih?i1-0 CO.  236, 2.3;
CAUC. Sw Coalition Against Uptol1.n Cigarettes
CBO. SW Congressional Budget Office
CDC. Scp~* Centers for Disease Control and Pi-e\-ention
Celebrw.ze, Anthony J. 76&7i+d
Cellulose acetate fibers  7 52
Center for Corporate Public In\ ol\,ement  47
Center for Substance Abuse and Prwention  ,374
Centers for Disease Control and Prevention
   tr7i~iroJrrrff~/ltl7l Toh7rilJ SWOkf Ill t/i?
    workplnr~~ 48

Gliillr~/ifw.i for Si/?d H~~iiltl? /'rl',(v'7H?' ii, I'fw~~trt
TdJi7~C~~ LIW ililil Adi~ic-tic~Jl  77. 80-82
Initiatives to Mobilize for the Pre\.ention and
Control of Tobacco Use program  82
National Tobacco Control Program 385
report development 5
Research to Classroom project  8.5
Third National Health and Nutrition Examination
Survey 7 96

CCllff'i?/ HlidSOfl Gl75 C; Elt'Ctrif i'. Pfil!lic- _SL'Fi,ic-c' CLlli7~lli55iOil
of New York  7 70
Crr7trnl H1idsoi7 test  7 i_`, 7;.?-7;;
Centre for Behavioural Research in Cancer   769
Cessation of smoking. SW also Management of nicotine
addiction

   incidence of 97,99
CHAD. SW Community Syndrome of Hypertension,
Atherosclerosis and Diabetes program
717~ Ci7nr7g117~ Ci;wrcttc 434
Chewing gum, nicotine 773-776
Chewing tobacco. SW Smokeless tobacco
Chicago Anti-Cigarette League 32
C/7i<~/O D. Lx/ (If Prc5tcu7  7 7.3
Child custody cases
  ETS rulings 248-249
Children. SW Youth
Cl7r7stinr7 fftwld 38
Cigarette advertising. SW Ad\sertising
Cigarette brands
   Accord 309
  Chesterfield ad campaigns 37
   Dakota 102-40.3
  Eclipse 309
  "Joe Camel" ad campaign  7 5. 7;;Pl;Y

Lucky Strike ad campaigns 3;
Next 787

slvitching brands for nicotine fading  709-770
L!ptown 399
x 400

Cigarette fading 709
Cigarette Safety Act 749
Cigarettes. SCCT also Tax issues; Tobacco; Tobacco use
   additi\,es 782-783
  adult per capita consumption linked to major
    smoking and health events in the U.S.  33
   antitobaccoists' \,iews  30-3 7
  appeal to women 36-3;
   attraction of 3-1-36
   constituents of smoke  1 i9-782
  del,elopment of filter-tip cigarettes 38
   distincti\.e features of 35-36
  domestic consumption  297,299
  domestic market shares of companies  3Oi
  early medical studies 38
  effect of price increases  19
  effect of price on demand  .322-335
   e\ olution of the industrv  m-377
  tactors involved in incrfased consumption  37
   introduction of 30
  lolv-price stores 377
  pre\,alence of use 97-98
  prohibition mo\~ement 32
   reduced-tar cigarettes  768
  rolling machine in\-ention  30
  sales of single cigarettes  274
  samples distribution to minors  217
   smokeless 309

  smuggling acti\-ities  347
  use among youth  67-67, 97-98
Cigars

  appeal of cigarettes over cigars  35-36
Cipollone, Rose  2 7, 226
c;/Jd/~W i'. L;gzCc'tt &Jli/J, Illi.  3-1, 7 72, 7 73, 226-228
Civil Aeronautics Board 46
Class actions 236-738
Class of 1989 Study  76-i.5, 78
   Clean indoor air. SW n/so Env-ironmental tobacco
     smoke

attitudes toward restriction, and bans  203
case studies of state and local smoking
restrictions 206-20;
consequences of exposure to ETS  793, 7 95-7 96
effectiveness of restrictions  202-206
legal foundation for regulation of public
smoking 7 9;

nonsmokers' exposure to ETS 202-203
overview of regulation  16
prevalence of exposure to ETS  796-79;
status of restrictions to limit smoking in public
places 7 9/-X-7

Clinical inter\.entions
   intcnsi\e 7 3. iO.i-17.5
   Illillilll`~l I ;. /0_7-1f)T

44;


    o\,er\.ie\\ ot  I?
Cliniidl Practice Guidt~line If)?, I.33
Clunidine
   etfect on discomfort of nicotine \vithdra\\-al    123
  efficacv fot- xnoking cessation  74, 7x-773
  relevant process niedsures  IZ.3
   side effcck 77.3
Coalition Against Uptown Cigarettes  399
Coalition for a Smoke-Free Socictv 2000  385-386
Coalition for Tobacco-Free Ari7o1;a  ,397
Coalition on Smoking OR Health  2 T, 46, 78;. 401-402
College graduates
  smoking prevalence 97-95
Collins, Lerov 40
Commercial programs
  educational programs  82, 8.3
Commercial speech
  constitutionalitv of regulation  777-17.2
  definecl 770
  vice evcepfion  7 76
COMMIT. SW Community Intervention Trial for Smoking
Cessation
Committee of Fifty to Study the Tobacco
  Problem 3 7
Commodity Credit Corporation .GI)-.?UZ
Common-law claims 2.X-737
Community-based inter\.entions
  overGie\y of 20
Community Intervention Trial for Smoking Cessation  20,
  12;-1-7s,.w-.i82
Community programs
  countermarketing 409-476
  direct advocacy 405-40;
  electronic netkvorking 403%40.i
   inter\-ention trials 37638.2
  for management of nicotine addiction
      72;-7z
   media advocacv  40;-4ol-?
  multifaceted educational programs  7.3%so
Community Syndrome of Hvpcrtensinn, Alher-osclerosis
and Diabetes program  3;6-377
Compensatory smoking
   low-tar cigarettes anil 784
Comprehensive programs
   communitv interl.entioii trials .i,-b-.~S_7
   communitv program components  403-4 IO
  description .3;4-.iYi,
    overvielv of  3-27
    statetvide interventions  .H-40.3
Comprehensive Smokeless Tobacco Hedth Education Act
of 1986 75, ro:, 7/5
Comprehensive Smoking Education Act of 198-l  7.5, 76;
Computer-generated personalized feedback
  efficacy in management of nicotine addiction 101,
     704, 7 3.2
Congressional BuLlget Office  ii I
Coirtk~tii~lt 7 Philip Mcvri~ /iii. 13.3
CPJIJIO~ ;I. li./. R~~i/i~~d,l> `Tohiiic~ Cc,.  Ii.;
Consolidated Anti-Cigarette League ii


Cnpitnl Broadcmti77g Co. v. Mitd7ell  165
Capifal Cities Cab/r, Ir7r. il. Crisp  173
Cnstnr7o v. A777ericn77 Tobacco Co.  236, 237
Cer7tml H17dsor7 Gns 6 Electric v. Public Sewice

i'. Ul7itd Stntrs Elli~irtrrlrllc,rltrrl Profrrfior7
Aget7cy 195, 252

Tohrro Corp. 197

Food ar7d Drug Ad777inistrnfim7 ~1. Brow77 0

44 Liquorn7nrf 172, l/d. 77.5
44 Liqmwarf, 117~. il. Rncir7e  175
44 Liquor777art, 117~. il. Rl7odc Ish77d  176
Gainsborough Street Rmlty Trust ~1. Reece nr7d Kristy

Hailc 247-248

drs Trbacs et All7lr7zettes  252
Guatcvrala ~1. Tobacco Institute 252
Hnir7cs ~7. Liggett Group, I77r.  226, 228-229
Hnrn7er 7'. Virginia Electric nrzd Power Co.  246
He/w7 i'. Hrl7n 249

Hollouny ~1. Brisk&Myers Corp. 177
Ho777eyer v. Sfm7lcy Tulchi77 Associates, Inr.  237
Horowitz v. Lorillard Tobacco Co.  235
1t7 re A7~bzrcl7on 249
117 re Ciprcttr Cases  235, 243
117 rt' Cm-Willim7s Tobacco Co.  253
177 re Kirk Fordicc 05 Goverr7or of Mississippi  253
In re Pl7ilip Morris lr7c.  254
It7 rc Pirdwrtotz Tobmx Co.  251
ln re R.]. Reymlds Tbbarco Co.  I77
117 re U17ior7 Carbide Corp. Gas Plat7t Disaster. at Bhopl,

lr7dia it7 Dercr77hcr, 7983 252
In re W/k 71. Wilk 249
Knrbizcl77yk ~1. R.]. Reyr7olds Tobncro Co.  23.5

Kenr77ey 7'. Pl7ilip Morris Cm.  250
Kyfe ~1. Pl7ilip Morris Cos.  250
LRfI7kP il. Fufnriilr7 C(JK/J. 249-250
Lnrtiquc 7'. X.1. Rcy77olds Toborro Co.  22.5
Lee il. Deprtri7er7t of Public- Wdfnw  2 97
Lnr7<y Islal7d Tobncco Co., II~c., 7'. Lindsny  l/9
Lo7risim7n ~1. Atfrerica77 Tobncco Co.  253
Mnr7gir7i P. X.1. Rryr7old~ Tobacco Co.  161, 7 72,
177-l ia, 241

Mnrylar7d 1'. Pl7ilip Morris Ir7c.  253
Mnssachusett~ ~1. Pl7ilip Morris Ir7c.  253
McGrw 17. Au7ericarr Tobarco Co.  247
MrKir7r7cy v. Andersor7 268
Meltro777tdiil l77r. 71. City of 5777 Diegu  275
Mir777rwtn ~7. Philip Morris Iur.  161, 183, 222,
23s240,242

Monrc ~1. A777cricn77 Tobm-co Co.  238-239
M77IIer ~1. Costello 247
Nafinr7al Aswriiltior7 of Co77iw7iel7re Stores

Cou~7riI of Baltimore  172-l 73,175-1?6
Philip Morrk [!7r. v. Bl77777ct7tl7nl  253
P17ilip Morris 17~. ~7. Grnl7m7  253
Pl7ilip Morris I77r. ~1. Harhbnrger  183, 253
Po.517h5 dc Pucrtc~ Rico Associates ~1. Towisrr7 Company

of Puerto Rim  171, 175, 176
Public Citim7 ~1. Fcdernl Trade Cor77777issior7  168
Qwo7sg7tr Ir7wstr77rvrt Co. ~1. Liquor Co77troI

Rl7odc Island Liq7mr Stores Associnfior7 v. Ever7iq Call

P7rb. Co. 172

Rirl7nrrlor7 ~1. Pl7ilip Morris, It7c.  236
R.]. Reyj7olds Tobncco Co. z'. E~glc  238
R.]. Reynolds Tobnrro Co. ~1. \olrr7 Does  254
RJRmM~cDo)7nld fr7r. 71. ilttort7ey Gemwl o,f

Cn17nda 170

R/R Nnbisco Holdi77gs, Corps. 1'. D111717  24-2
Rubin 71. Coors Brewir7g Co.  2 71
Shimp x NPZO jersey Bell Telepl~om~ Co. 197,

245-246

Slripr77nr7 ~1. Pl7ilip Morris Cm.  250
%rn/l v. Lorillnrrl Tobacco Co.  236
Sn7itl7 1'. W&err7 Ekrtric Co.  19i
Sparks u. R.]. Rcyr7olds Tobnrco Co.  7 78
S tnrru7 P. McDormld `s Corp.  246
Stnte ~1. Goodricl7 35

Stop Youtl7 Addirtion, Im. ~1. Lurky Stores, Inc.  252
Take Fiw Ver7di77g, Ltd, ~1. Tow77 of Prozlit7crtour7  255
Terns ~1. Auwrim77 Tubnrro Co.  222
llr7itcd Stntcs Tobncco Co. v. Food nr7d Dr7rg


D

Dakota brand 402103
D.A.R.E. Sre Drug Abuse Resistance Education
Day, James Roscoe 32
Day 01rr 2%
Dental examinations
   as intervention for smokeless tobacco
     cessation  7 03-7 05
Department for Overthrow of Tobacco Habit  37
Department of Commerce and Related Agencies
Appropriations Act  37 9
Department of Narcotics
  campaign against tobacco 33
   formation of 37
Dependence
   defined 7 29
   measurement of 729
Depression
  and negative affective reaction to smoking
     cessation 2 30
  treatment during smoking cessation  724
Developing nations
   tobacco use in 437
Direct advocacy
   effectiveness of 20
  history of 105
  impact of 405~4Oi
DNA Plant Technology Corporation  258
DOC. Srr Doctors Ought to Care
Doctors Ought to Care  306,408
Doggett Amendment 379
Doxepin hydrochloride
  smoking cessation treatment 721
Drug Abuse Advisory Committee  2 85
Drug Abuse Resistance Education  64, 82
Drugs. See Substance use

Duke, James Buchanan
  mechanization of cigarette manufacture  30. 306
Dllrlngirf il. Cify of o.Yforll  771, 7 75
Diivrkir? i'. Pf/ky 2`48
Dysphoria 707

E

Eclipse brand 309
EcoNet 401
Economic issues

behavioral economics studies of cigarette
demand 335-336
cigarette prices and other substance use
336-337

economic influences on smoking  41
economic model of addictive behavior  370
effect of price on demand for tobacco
products 322-337
evolution of the U.S. cigarette industry
306-377

  impact of prevention policies  308-377
  impact of the U.S. tobacco industry  320-322
  implications of concentrated tobacco
    production 308
  policy over\,iew 78-20
  supply of tobacco and tobacco products
     29.5-298
  taxation of tobacco products 337-359
  tobacco price supports 298-306
  trade policv 377-320
Etftvrfirld i'. Fr?rw 7 i4
E~fxt, H~onh7.iti77~  7 T-7, 7 i2. 7 76
Edison, Thomas  32
Education
  reading level as attribute of self-help manuals  707
Educational programs
   affective education model 63
   basic curriculum 82
   combined activities 83
  commercial programs  82
  communitv programs 83
  diffusing programs 80-85
  Drug Abuse Resistance Education  64
   information deficit model 63
  longer-term follow-up of school-based
     programs  69-73
  models for smoking prel-ention programs  63-61
  monitoring program objecti\,es  83
  multifaceted programs ;.?I-80
  national guidelines for 80
   overview of 72
  programs including families 83
  research on effectiveness of programs  64-80
  School Health Policies and Programs Study  SO-82
  shorter-term follow-up of school-based
    programs 65-68


RedlrcinR Tbhncco USC

   social influences model 63-G-l
   state-based assessment 82-83
  supplemental programs 82-83
  Tobacco Institute programs 43
Edic~ards il. GMRI. im. 247
Eighth Amendment issues
  U.S. Supreme Court ruling on ETS in prisons  248
Electronic networking 403-105
Euw!/ i'. Cnrilz~?i of Drcnrw, Illi.  246
Endicott, Dr. Kenneth Mile 47
England

  Legal Aid Board 251
Et+ il. R 1. Rr~yrdfs ToPncco CO.  236, Z37-238
En,ironmental Protection Agency
   classification of ETS I8
Environmental tobacco smoke. SLY II/W Clean indoor air
   attitudes toward restrictions and bans  202-20.3
  cases against nontobacco parties  245246
   and child custody cases 218-249
  consequences of exposure  791-7 96
  effects of restrictions on smoking behavior  203-706
  failure to disclose harm from ETS suits against
    tobacco companies 245
  legislation against lb, 17
  nonsmoker claims against
     manufacturers 243-245
  nonsmokers' exposure to 202-203
  nonsmokers' rights organizations  405-107
  prevalence of exposure 296-197
  research concerning J/-i8
  ruling on ETS in prisons  248
  tobacco industry response X2-253
Et1z~irorzt72ct2ta/ Tobacco Smoke: Mcaswirzg
EXPOSES md Asscssiug Health Effc&  48
Emiromwtztal Tobacco Smoke iri t/w Workplncc  38
EPA. See Environmental Protection Agency
ETS. See Environmental tobacco smoke
European Union

  banning of high-tar cigarettes  2 79
  ceiling on tar content of cigarettes  180
  warning label requirements 769
Excise taxes 337,338
Export Credit Guarantee Program  312
Extratreatment social support 110-112

F

Fagerstrijm questionnaires 229
Fairness Doctrine  l&15,45, 165, JZO-$12
Falisr ZJ. Amricav Tobacco Co.  242
FAME. SW Florida Anti-Tobacco Media Evaluation
Families

  education programs that include 83
FCC. SW Federal Communications Commission
FDA. See Food and Drug Administration
FDCA. See Federal Food, Drug, and Cosmetic Act
Federal Cigarette Labeling and Advertising Act  II, 49.
l63-165,164,167,172-1/-1,777,226-22;

Federal Communications Commission
  broadcast advertising ban  45, 165-l 66
   Fairness Doctrine l&15,45, 165
Federal Emergency Management Agency  183
Federal excise tax 338
Federal Food, Drug, and Cosmetic Act  182,189
Federal Hazardous Substances Act  312
Federal Republic of Germany
  prevention program 382
Federal Trade Commission
  complaint against R.J. Reynolds Tobacco
    Company 7 77

orders against health claims in cigarette
advertising 39

  required M-arning labels on cigarette packs  41
  staff report on cigarette advertising  166-767
  tobacco advertising regulation 25,41
  Trade Regulation Rule 163
Federal Trade Commission Act  15, 763, 177
Finland

  North Karelia Study  78,3;6-378
First Amendment

advertising restrictions and  159, 170-l 71
tobacco companies' lawsuit against FDA
189-l 90

"Five A's" approach 103
Fla\,or and Extrdct Manufacturers Association of the
United States 7 82

Flavorings 183-781
Floor Manager's Amendment 192
Florida

  programs funded by settlements with the tobacco
    industry  395-396
Florida Anti-Tobacco Media Evaluation 397
F/oridn 8~71. i'. hk'rlt Fat' It, If7C.  174
Florida Tobacco Pilot Program 395-396
F/oridn zl. ilmrricarz T~hcco Co.  160, 222, 230
Flue-cured tobacco

  domestic consumption 296,298
  support program 302-303
FIl~Knred Tobncco Cooperafizw Stahilizafior~ Corp. u. United
Shfes Emiro~~rmwtal Protectim Ageq  2 95, 252
Fluoxetine hydrochloride
  smoking cessation treatment  124
Focused smoking 108
Food 6 Drug Adn~ir~isfrhv~ u. Brozcw & Willinmsor~ Tobacco
Corp. 2 91
Food additives 182

Food and Drug Administration
  Drug Abuse Advisory Committee  185
  proposed regulation of tobacco as an addictive
   product 187-l 92

proposed regulation restricting tobacco use by
youth 188

  rulings on authority of  190-l 92
  sales to minors regulation  381
  tobacco product regulation  15-l 6,159-l 60
Food o,~d DrliS Adruirlisfmtiot~ zl. Brow 0 Willinmor?  160
Food for Peace Program 372

351


Ford, Henry

  campaign against tobacco  .i7
Formal cessation treatments 706
44 Liqrmm7f?  7 72, 7 74, 7 7.i
44 Liqzmwn7~t, 11~. i'. Rncirw  77.5
34 Liquom77t, [Ifc. 7'. Rhode lslo/frl  176
F0.x 111 771-7i2
Freedom-of-choice defense 7 7
FTC. SW Federal Trade Commission

G

Haile 247-248

GASP. SW Group Against Smokers' Pollution, Inc.
Gaston, Lucy Page

  campaign against tobacco 32
GATT. SW General Agreement on Tariffs and Trade
GCP Study. SW German Cardiovascular Prevention Study
General Agreement on Tariffs and Trade  302,372,
375326,377-318

Generally Recognized as Safe additives  182
Genotoxic agents 282
German Cardiovascular Prevention Study 387
GLOBALink 404
Glycyrrhizin 2 82
Goldston, Steven F.  7 92
Go7rrlnir7 7'. Socictc' N~7tior7iilc D'Erplniti7tim7 /~7~frist~i~~l/~~ de

nmi' Addictiar7 72, SO-82
Gum, nicotine  173-7 7 6

H

Hnirrcs ~7. Liggrtt Group, I7rc.  226, 228-229
Handicap discrimination 246-247
HandsNet 404
Hamer ia. Vir$r?in E/cctrir- nr7d I)oiwl. co  ?Jb
Hatch, Orrin G. 49
7-/7r Hcnlth CO/?WI~"""`C" of ~idIir7tn~!/ 5t77CJki/i;;  48
Health insurance. SW Insurance companies
Health movement
   antitobaccoism views 37
Health promotion
  characteristics of successful campaigns  414-416
  community intervention trial5 376-382
  community program components  403-47 6
  comprehensive program description  374-376
  efforts by religious organizations  401-402
  federal programs 407

  national programs 383-385
  programs for special populations  398
  programs for the African American
    community 398-400
  programs for women 400-402
  reducing use of chewing tobacco  402&403
   statewide interventions 382-403
  strategies  373-374
Health Protection Fund 389-390
Health Security Act 337
Hralthy Pcoplt~ 2000: Nntiorml Hen/t/l Prornotio~z nrzd Disense
PKwv7tiaf7 OlJjccfirv5 5, 97, 433
Htdtiy Pco/dc 2070  5, 77, 13, 97, 436
Heart disease. SW Cardiovascular disease
Heart Disease Prevention Project 3/6,377,377-378
Heaviness of Smoking Index  729
Helm i'. Hdm 249

Here's Looking At You, 2000 program  82,83
High school dropouts
  smoking prevalence 97-98
Hispanics

  efficacy in management of nicotine addiction  101
Hvpnosis therapv  772

I

ICC. 5~~~ Interstate Commerce Commission
IMI'ACT. 5~~3 Initiatives to Mobilize for the Pre\,ention
and Control of Tobacco Use
Imperial Tobacco Ltd. 306
Implied l\,drranty claims 1;
1 n d i a

antitobacco community education
program 380

   chemical plant explosion 252
Indoor air. 51~~ Clean indoor air; Environmental tobacco

smoke

Information deficit models 63
Informed consent 786-787
Inhaler, nicotine 7X-727
Initiatives to Mobilize for the Prevention and Control of


Rerhci17~~ Khx-co Use

Institute for Global Communications 103
Insurance companies
  cost-effectiveness of management of nicotine
     addiction 733-734
   nonsmoker discounts 13
Intensive clinical interventions
  acupuncture 272
  aversi\,e-smoking strategies  7u7-70s
   content variables 2 0.5-706
  counseling effectiveness  105
  cue exposure 7 08-709
  description 7 05
  dose-response outcomes 737-7.32
  focused smoking 7 08
  hypnosis 172
   motivational relrards 770
  nicotine fading 709-770
   overx4ew of 73
  problem-solving training 706-70;
  rapid puffing 108
  rapid-smoking strategies  711;-7oh'
  satiation therapy 708
   selection bias 706
  shift from clinical to public health
     orientation 106
  skills training  7 06-7 0;
  social support 770-777
   structural \,ariables 70.5
  iveight control  7 7 7
Interfaith Center on Corporate Responsibility  -707
International issues
  foreign plaintiffs in U.S. courts  2.5-2.52
  increase in foreign tobacco use  296-79;
  tobacco litigation abroad 257
   tobacco taxes 345-350
  tobacco use in developing nations  13;
  trade policy 377-320
International Network of Women Against Tobacco  407
International Red Cross 32
International Summit of Smoking Control Leaders  382
Internet sites X73-40.5
Interstate Commerce Commission 200
Interventions. Scr nlsc~ Clinical interventions
   characteristics of 9
   classification of 7-8
  community-based 20
  community trials 376-382
   dissemination of 436
  evaluating outcomes 8, 70
  qualitative assessment of 70-77
Intratreatment social support 770-777
INWAT. Set International Network of Women Against
Tobacco
Israel
  Community Syndrome of Hypertension,
    Atherosclerosis and Diabetes 376-3;;
"It's the Law" program 1.3

1

Japan
  trade policy 373
Jefferson, Thomas 30
"Joe Camel" ad campaign  75, 7 77-l 78
Johnson, Lvndon B. 19
Join Together  404
Jordan, David Starr 32
Juvenile Work 37

K

h'hiiiw/k z'. x.1. kh/f?(J!il5 Tthmt~ Co.  2%
Kmrr~cy lv. Philfp Mt&ris Cm.  250
Kellogg, Dr. John Harvey 37
Kessler, David A. ZS;-768,229
"Kiddie" packs 768
Kids Against Tobacco program  83
King James I

  antismoking campaign  29
King Tobacco Diplomacy 311
Knolz Your Body program  65, 68, 72, 73
Koop, Dr. C. Everett 48
Kotin, Dr. Paul 47
Kuykcndall, Dan H. 41
KYB. Sw Know Your Body program
Kufc 7'. Philip Mtwk Cm.  250

L

Labeling. Sw Packaging; Warning labels
LI1111kt i'. Fflfvrin/l corj7. 219-250
hfiqw il. R./. Rrymlds Tthmt~ Co.  225
Latter-day Saints

  campaign against tobacco 33
Lawsuits. See Court cases
LL'L' i'. Dt~jmrtll7rflf of Plll~lit- Wtdfffw  19;
Legal Aid Board 257
Legal issues. Sw Court cases
Licensure policies 27.5
Licorice root  7 82
Life insurance companies
   nonsmoker discounts  13
Life Skills Training Program  69-70, i2, 73,85
Liggett & Myers Tobacco Company  306-307
Liggett Group, Inc.  774,789
  See o/so Cipllorw il. Ligpff Gmp, Iur.
Litigation. Sw irlw Court cases
   aftermath of the first two waves of tobacco
   litigation 227-229
  aggregation devices  235
  anticipatory effects 255-256
   antitrust laws 232-233
  approaches  22.3-260
   claims of nonsmokers  213-250


class actions 236-238
common-law claims 230-237
consumer protection claims  Y-232
cost reduction procedures  213
criminal proceedings 2.56-259
enforcing minors' access laws  250-251
enhancing prohibitory regulation by private
litigation 250-257

ETS and child custody cases  248-239
ETS cases against nontobacco parties  245-246
ETS claims against manufacturers  243-245
failure to disclose harm from ETS suits against
tobacco companies 245
first wave of tobacco litigation  225-226
foreign plaintiffs in U.S. courts  252-252
handicap discrimination/Americans with
Disabilities Act 246-247
industry-sponsored opposition to state and local
control efforts 253-2.55
Medicaid reimbursement cases 238-242
overview of  2 7-18
potential public health benefits of tobacco
litigation 221-225

private law as means of risk control  224-225
Racketeer Influenced and Corrupt Organizations
Act 233-235

restrictions on advertising  2.51
ruling on ETS in prisons  248
second wave of tobacco litigation  226-227
seepage of smoke from one dwelling unit to
another 217-248

small claims tribunals to recover the cost of
quitting 243
statutory claims  231-23s
third-party reimbursement cases 238-2d2
third wave of tobacco litigation  229-256
tobacco industry response to the science of
ET'S 252-253

  tobacco litigation abroad 2.51
  tort as a private law control  22-i
  U.S. reliance on private larz- controls  221
  victims of smoking-related fires  219-250
Loans
   nonrecourse 300
Local ordinances

  industry-sponsored opposition to  254-255
  restricting environmental tobacco smoke 20l-2G
Local taxes 338-341

Long Islamf Tobncco Co., lw., i'. Lindsq  179
Lorillard Tobacco Company 289,306-30;
Loz~isiann 1'. Atnericnv Tohm-CJ Ccl.  253
Low-tar cigarettes 168, 284-785
Loyal Temperance Legion
  campaign against tobacco 33
LST Program. See Life Skills Training Program
Lung cancer

earlv research relating smoking and  38-39
environmental tobacco smoke and  295
low-tar cigarettes and 184

M

Maddox, Roland 235
Madison Square Garden 257
Magnuson, Warren Grant 45
Mail-based programs
  for management of nicotine addiction  125-226
Maine Tobacco Prevention and Control Program  393
Males
  management of nicotine addiction  130
  prevalence of smokeless tobacco use  62-62
  smoking prevalence 9i-98
Management of nicotine addiction
   clinical issues 228-232
  community programs 127-128
   cost-effectiveness 133-133
  dose-response  7 31-l 32
  early relapse 731
  epidemiologic concerns 128-232
  the "five A's" approach  103
   hot lines 101
  incidence of smoking cessation  97,99
   individualized treatment  132
   intensiv-e clinical interventions  705-113
  large-scale public health programs  225-728
  media-based programs 225-126
  meta-analysis of 100
   methods for 700-728
   minimal clinical interventions  102-105
  negative affective reaction  130
  nicotine dependence 729
   odds ratios 100
    outcome measures  1uu
   o\.erview ot 13-74
  personalized feedback 101
  pharmacologic interventions 113-725
   process measures  100,701-702
   research issues 726-132
   role of the clinician  132
  self-help manuals 1011-702
  sex-specific differences  130
  stages of change  129-130
  statetvide programs 728
  telephone counseling 107
  treatment components 132
  weight gain 131
  \vithdra\val symptoms  130-237
  vvorksite programs  126-12;
Mangini, Janet 1;;
Mn,l,yirri ~7. R.1. Rryrolds Tol~ncc-0 Co.  767, 1 ii!. 7 77-7 78,
Manuals, self-help 100-102
.Marijuana use
  impact of cigarette prices on  336-337
  impact of school-based prevention programs  7
Marketing quotas 300
"Marlboro Friday" 335
Maryland tobacco 296
Mnrylar7d ~1. Philip .Morri5 IM.  2.53

-394

211

2, is


Mass media campaigns. 5,~ Media-based programs
Massachusetts
  adult smoking prevalence 390
   Health Protection Fund 389-390
  per capita cigarette consumption  .39U
  Tobacco Control Program 389
  youth tobacco use pre\,alence  390-397
~Massi~/~~is~~tf. il. Pldij~ Morris Ir7i.  -753
Master Settlement Agreement  5. 77, 7bO. 777. 293-794
Maxicare Research and Educational
Foundation 733
McCain Committee Bill   192
McGrw i'. Awcricnri fiJbilii0 Cc,.   247
McKi17r7e1/ il. A77ifrmrr  248
Measure'14 392
Media
  ad\socacy for reducing tobacco USC  40;-409
  broadcast advertising ban 76.5-766
  community advocacy programs  17;
  effectiveness of ad\.ocacy programs  70
Media-based programs
  for management of nicotine addiction 725-17(>

prevention campaigns  -- -- -_I
               / 6-, , , /h-T9

MLYlk Sfrl?tf'~iPY for Srlrc,h-iiy Co~ltrrll~ Gl/iilc/irri?
Medicaid reimbursement cases 1.?8-247
Meehan, Martin T. 2s;
Meta-analyses 700
M&w?mfin 1,7c. i'. citu of 5717 Dif::`O  7 7.7
MFN. Set Most favoied nation treatment
MHHP. Set, Minnesota Heart Health Program
Michigan Anti-Cigarette Society  37
Midwestern Prevention Project 7.5, 78
Miller, William 30
Millerites 30

Minimal clinical interventions
  efficacy  7 04-7 05
  the "five A's" approach  703
   overview of 73

40;

  recommended institutional changes  702-103
  relevant process measures   705
   role of the clinician  132
   underuse of  7 02
Minimum prices 300
Minnesota

Coalition for a Smoke-Free Society 2000  38.5-386
legislation regulating smoking in public places  47
programs funded by settlements with the tobacco
industry 397-398

Minnesota Blue Cross and Blue Shield
   Web site 229
Minnesota District Court
   Web site 229

Minnesota Heart Health Program  i&75, 7i-i8, 770. 72/,
379-380

712~' M~I~HPSO~~I Ph for h'01751m1ki~7~ m7d Hcnltl7  386
Minnesota Smoking Prevention Program  70, SL
Mii7i7csota il. Philip M71rris Ir7s.  167. 783, 27-7. ?39-24U, 242
Minorities

smoking prevalence 97-98

  targeted by tobacco advertising 762
Minors. 5,~~ Sales to minors
Mississippi

  programs funded by settlements with the tobacco
     industrv  394-395
Mississippi Julr&ile Tobacco Access Prevention Act

394-39.5

Monitoring the Future Study  67
MOllr-c i'. Al77iTicnl7 mm-co co.  X8-239
Mormons

  campaign against tobacco 33
Moss, Frank E. 4.5
Moss, John E. 163-764
Most favored nation treatment 239-247
Motivational rwvards intervention 720
MPP. Sw MidLvestcrn Prevention Project
Mlillf~i- C'. Costd/o  247
Multifaceted education programs ;.3-SO
Multinational trade agreements 376-375
Multistate settlements 760

N

NAFTA. 5'~' North American Free Trade Agreement
Nasal spra!`, nicotine 778-720
National Anti-Cigarette League 32
Notiorml A5w~-rnt7orr of Corrwrricvm~ Stows P. Kcskr  189
National Cancer Institute 82. 768, 787,374
National Center for Chronic Disease Prevention and

Health Promotion 5
National Health Interview Survey  97-99. 784
National Heart, Lung, and Blood Institute  .?;9
National Institute for Occupational Safety and Health  48
National Institute on Drug Abuse  61
National Interagency Council on Smoking anal Health  46
National Research Council 48
National Smokers Alliance 254
National Spit Tobacco Education Program  402-403
National Tobacco Control Program 385
National Tobacco Policy and Youth Smoking Reduction
Act 760

National Woman's Christian Temperance Union
  campaign against tobacco 37-34
NCI. Sw National Cancer Institute
Negative affecti\,e reaction  701, 230
Kegligence claims 17
Neighbors for a Smoke Free North Side  399
Neuberger, Richard L. 39
New Jersey

  legislation regulating smoking in public places  47
Newspapers. Sw Media-based programs
"Next" brand 787

XHLBI. Sw National Heart, Lung, and Blood Institute
Nicotine

addiction level 787
change in ratio of tar to nicotine  780-7s7
classification as a drug  78/-/8`s
content in cigarettes  751


dependence 729

disclosure requirement  75
FagerstrGm questionnaires 1-79
gum  21.3-726
increasing levels of "free" nicotine  782,783
inhaler 710-727

  maintenance programs  7 s.5
  nasal spray 778-720
  reduced-nicotine cigarettes 2 68
  replacement products 785
  requirements for disclosure of le\.els  7/s
  smokeless tobacco as delivery system  67-62
   transdermal 726-778
Nicotine addiction. SW illso Management of nicotine
addiction
  stages of process
Nicotine fading 7 09-77 i'
Nicotine polacrilex  773-276
Nicotine replacement therapies
   overview of 7 3-74
Niess, Major General Oliver K.  10
No Net Cost Tobacco Program Act  307
Non-Smoker's Bill of Rights  46
Non Smokers Health Protection Act  376
Non-Smokers' Protective League of America  32
Nonrecourse loans 300
Nonsmokers' rights
  ETS and child custody cases  248-219
  ETS cases against nontobacco parties  245-246
  ETS claims against manufacturers  -743-215
  failure to disclose harm from ETS suits against
    tobacco companies 215
  grassroots organizations 105
  handicap discrimination/Americans with
     Disabilities Act -746-24;
  institution of nonsmoking areas in public
    places 46-1;

legislation against ETS i/
Non-Smoker's Bill of Rights  46
research on ETS 4/-18
ruling on ETS in prisons  248
seepage of smoke from one dlvelling unit to
another 2-17-248

  victims of smoking-related fires  249-7.76
North American Free Trade Agreement  376-37;
North Carolina

mass media campaign on smoking pre\ ention
i&/9

North Coast Healthy Lifestyle Programme  378~379
North Karelia Study 72?,3,`6-3i8
Nortllcrltt i'. Nortlmtt 249
Nortriptyline

   effect on discomfort of nicotine
     withdrawal 7 24
  efficacy for smoking cessation  71, 723
   side effects 721
Norway

  mass media campaign on youth smoking  79
NSA. SW National Smokers Alliance

NSTEP. SW National Spit Tobacco Education Program
NTCI'. SW National Tobacco Control Program

0

Ochsner, Alton 38
Odds ratios 700

Office of Health Promotion and Disease

Prevention 5

Office on Smoking and Health  5
Ohrnlik 5'. Ohio Stntr Bnr Assrr.  7 73
Ok1d70~~217 Tdccaskrs A.ssociiltiorz 7'. Crisp  7 73, 7 74, 7 75
Ok/dm~~ il. R./. Rcyr7olds Toohnrco Co.  217
Old Joe. Srr "Joe Camel" ad campaign
Omnibus Trade and Competitiveness Act  373
Operant conditioning theory 770
Oral Health America 402
Oral lesions

   smokeless tobacco and 704
Oregon
   Measure 44 392

Oregon Health Plan 392-393
Oregon Tobacco Pre\,ention and Education Program  393
Organized cessation treatments 70.5
Osteen, Judge William L., Sr.  790

P

Pacific Islanders. &Y' Asian Americans and Pacific
Islanders

Packaging. SW ~7ls~ Ad\.ertising; Warning labels
   for consumer education 7Si-78;
   and informed choice  781,
  "kiddie" packs [OS
  plain packaging recomn-\enclations  769
  rtagulation ot  1 b8-7 ;(I
   used in other countries  7(;!%7;0
I'ack\vood, Robert W. 19
Parenting for a Positive Future  83
Pat-tnwhip for a Healthy Mississippi  .?91-393
Passi\-e smoking 40
/',7t/lii'i77/> tcr ~rc~Ld~~rr; CV//fJfi/f'q f/k' F/`qirt /Iprir75f
  fid~,7iiO 19R-399

fi7i'/iifc'i i' ~c7/i2c'51clf7 >>li/it R17>;77. /17i-.  186-7s;
Pa\vtucket f~jeart Health Program  72;. 379~.%W
PeaceNet 403~4-l
Pearl, Rnvmond 38
Pease, D1'. Charles G. 37
Peer-led pre\,ention programs 70
Peer smoking

  impact on tobacco use by youth  67, 63-6-I
P1v177 Ad~c~rtisi/r;; of Bnlti,rwL~, I~Ic. F. Mayor or7d City Ct11[17ci/
of Ralti,lJclrl~  7 72-7 ;?. 7 74, 7 ;.i-7 76
Pershing, General John Joseph  37
Personalized feedback
  efficacy in management of nicotine addiction  701,
     704, 7.32


Pharmacies
   tobacco sales and  27 6
Pharmacologic interventions
  antidepressants 723-724
  anxiolytics 723-72-7
  bupropion 7 21-122
   clonidine 122-723
  efficacy 77-I
  nicotine gum 77.?%776
   nicotine inhaler 720-727
  nicotine nasal spray 778-720
  nicotine polacrilex 773-776
  nortriptyline 723-223
   o\wview of  7 3-7 4
  summary of 724-72.5
   transdermal nicotine 776-778
Philip Morris Companies Inc.  306-308, 108
  First Amendment rights lai\suit  789
  investigation of research  25i
   "Next" brand 787
Pi~ilip M~v/s //ii. i'. Bl~rrrwlflrnl  253
Plli/i/~ Morris Irrc-. 1'. Grnimr~~  -7.53
I'ililip Momis /II~. 7'. H171.5/1/~71;:`~~1~  7 8.3, 2.53
Physical dependence 729
Pinkerton Tobacco Company 2.52
Pipe smoking
  appeal of cigarettes oI,er pipes  35-36
Plug War 32
I'o~i7da~ de PuiJrfo Rim Asoiiofc~~ i'. Toririsrt~ Corqu7,y of
Pwrfcl Rico  777, 77.5, 7 /6
Poverty status
  smoking prevalence and 97-98
PPXNet 40-I
Pregnancy
  cost-effectiveness of smoking cessation  133
  environmental tobacco smoke dangers  196
  use of transdermal patch during  778
President's Cancer Panel  768, 785
Prwmfit~<~ To2mcc~1 U~c Amoq Yourlj~ Peopk  62, 83
Prevention programs
  business support 43,15
   school-based 65-80
  Tobacco Institute smoking education materials  4
Price supports 298-306
Price Waterhouse 320-322
Prisons
  ruling on ETS 248
[`rivate law
  potential public health benefits of tobacco
   litigation 221-225
  tort as a private law control  224
  U.S. reliance on private law controls  224
T'roblem solving/skills training
  for smoking cessation 706-707
I'roduct regulation
   overview of 75-16
t'rograms that Work 85
Project ALERT 71, 72
Project SHOUT 65, 72, i.3

Project TNT. Sw Project `Towards No Tobacco Use
Project Tolvards No Tobacco Use  65, 73, 85
Promotion of tobacco products. Sw n/so Advertising
  spending by tobacco companies  767
Proposition 65 215
Proposition 99 339,38;-388
Proposition 200 397
PllPliC Cifkffl i'. Fedfrill Tldc CUll?lfliSSiUf7  7 68
Public Health Cigarette Smoking Act  45. 165, 767, 7 77,
22;

Public health programs
  for management of nicotine addiction  725-728
Public Health Service
   Clinical Practice Guideline 703
  early study on health effects of smoking  39
Public smoking. Set Clean indoor air;
En\ ironmental tobacco smoke

Q

  Co~ffrfli55ic~l? 7 7.5
"Quit Centre" 3i9
"Quit for Life" campaign 3i8-379
Quotas 300

R

Racketeer Influenced and Corrupt Organizations
Act 233-235
Radio. SLY, ~/se Media-based programs
  cigarette advertising ban  165-766
Radon Gas and Indoor Air Quality Research Act of
1986 195
Rapid puffing   708
Rapid-smoking strategies 7CG208
Rmfer's Dipf 38, 39
Reduced-tar cigarettes 768, 281-785
Regulatory efforts. See o/so Court cases
  for advertising and promotion  267-278
  clean indoor air regulation  79J-2Oi
  on FDA authority  7 90-7 92
  federal legislation  7 60
  Food and Drug Administration
    regulations 759-l 60
  litigation approaches 223-260
   minors' access to tobacco  207-223
   multistate settlement 760
   overview of  7 1-7 8
  product regulation  7 78-7 9g
  public and private litigation  760-167
  response from the tobacco industry  101
Relapses
  early relapse 737
  minimal clinical interventions  7 03-l 04
  negative affective reaction and  730
  problem sol\,ing/skills training Z&Y-7Oi


S

Safe Drinking Water and Toxic Enforcement Act of
lY86 235
Sales taxes 33;
Sales to minors
  agencies responsible for enforcement of state
     lalvs 218-221
  buyer-directed regulation 276
  early prohibition legislation  3 7
   enforcement of laws  27 Y-222
  enforcing la~.s  2X-251
   incidence of 20;-208
  influencing factors  X8
  means of sale regulation  217-274
  o\,er\.ier\, of regulation  lb-77
  preemption of local action by state policy  223
  regulation of  209-23
  restrictions on distribution of samples  277
  seller-directed regulation  774-776
  state laws relating to  272-27.3
   state settlements 222-223
  vending machine sales 208
SAMHSA. SW Substance Abuse and Mental Health
  Ser\,ices Administration
Samples distribution 277
Sarokin, Judge H. Lee 278-229
Satiation therapy 708
Save a Sweet Heart program  82
SCARC. SW Smoking Control Ad\.ocacy Resource Center
SCARCNet 404.408
School-based prevention programs
  longer-term follow-up 69-73
  multifaceted programs  ;3-so
  shorter-term follo~v-up 6.3%68

  summary of research studies  72-73
School Health Policies and Programs Study  SO-82
Secondhand smoke 46
Self-help manuals

as adjunctive interventions  101
effectiveness of mail-based intervention  125
efficacy  2 00-7 07
o\,erview of 73

  relevant process measures 707-702
Self-service displays 274
Senate Commerce Committee bill  791
Seven Countries Study 376-377
Seventh-day Adventists
   antitobaccoism views 30-37
Sherman Act 306-307
Siiirn/l i'. New /evscy Bell TelephJHe co.  19i,245-246
S/li~J17f171? i'. P/dip Morris cos.  250
Shoplifting
  deterring  274
SHPPS. SW School Health Policies and Programs Study
Skills training

  for smoking cessation 706-207
S~mll il. Lorillanl Toh~cco Co.  236
Sfllif/l i'. Cvc5tcrx Ekfric co. 797
Smoke

Smoke Free Class of 2000  84
Smke sip7ls: TllL~ S,rrrkiry Corrfd Mrdiii Hnr1dhJk  a;
Smokeless cigarettes 309
SmokeLess States program 209.383
Smokeless tobacco
   additi\res 783-784

  effect of price increases  7 9
  effect of price on demand  335-336
   efforts to reduce use of  402-403
   federal excise taxes ,339
   minimal clinical inter\-entions  703-705
   oral lesions and 704
  prevalence of use 07-62
  requirement for disclosure of nicotine content  179
  tvarning label requirements  767-768
Smokeless Tobacco Council 223
Smoking. SW Cigarettes; Tobacco use
Smoking behavior

   effects of restrictions 203-206
Smoking Cessation 733
Smoking cessation. SW o/sio Management of nicotine
addiction incidence of  97,99
Smoking Control Advocacv Resource Center  40;
Smoking-Hazards Prevention Act 324-375
Smoking reduction. SW also Health promotion
  hygiene movement 30-37
  impact of movement 48-50
   moral issues -IF--I9
Smuggling activities 347
Snuff. SW n/w Smokeless tobacco
   increased use of  67 -62



Third-party reimbursement cases 2.3$P?42
Three-Corn~~i~~~~it~ Study .3;6--37,s
Tobacco. Sao 17150 Cigarettes; Promotion of tobacco
products
  domestic consumption  296,299
  economic implications of concentrated
    production 308
  genetic engineering of  787,258
  increase in foreign tobacco use  296-297
  minimum prices 300
   nonrecourse loans 300
  price supports 298-306
  prohibition movement 32
   quotas 300
  samples distribution to minors  217
  supply of 295-298
   taxation of 337-359
  types of 296
TO~IZCC(J: Htdpiri,y l'o~~llz Soy h'c,  473
Tobacco addiction
  stages of process  62
Tobacco and Cancer Committee  39
Tobacco Business Act 315
Tobaccc~ Corltrol: A BIuppritIt to Pmfect t/w Htwlfl~ of
Carmdiar~s 7 i0
Tobacco Control Act 300
Tobacco control coordinators 82
Tobacco industry
  changes in 434-435
   domestic market shares 307
  economic impact of 320-322
  economic importance of  7 9
   evolution of 306-327
  response to the science of ETS  252-253
  tactics to promote tobacco use  43-44
  voluntary code for advertising and marketing
    practices 264
Tobacco Inspection Act .?OO-307
Tobacco Institute 223
  "It's the Law" program 43
  smoking education materials  43
Tobacco Monopoly Act 375
Tobacco products
  effect of price on demand  322-337
Tobacco Products Control Act  769, 770, 782,376
Tobacco Products Liability Project  226, 250
Tobacco Program Improvements 307
Tobacco Sales to Young Persons Act of 1993  168
Tobacco support program
   overview of 7 9
Tobacco Tax and Health Care Act  341
Tobacco Tax and Health Promotion Act  339,38/-388
Tobacco use. SW n/so Health promotion; Sales to minors
   in the American colonies 29
   bv American soldiers 32-33,47
  &minalization of 29
  delayed progression of related diseases and  47-42
  early history of 29-30,295
   early medical studies  38-39

   econL>niic influences 47
  effect of price increases  79
   efforts for control in the future  27, 438
  historical aspects 72
   influences on 7
   and informed consent 186-787
   issues in reduction of   6-11
  by minorities 97-98
  wrerview of historical aspects  72
  prevalence of 6, 97-98
  reasons for use among youth  62-63
   social influences 47
  tobacco industry promotion tactics 4314
  trends among )iouth 67-62
  by youth 97-98
Tobncco USC Anmrg U.S. Rncin//Ethr7ic Mirmify Grotrps
  398
Tort
  as a private law control  224
Toxic Substances Control Act  312
Trade Act of 1974  372-37 3
Trade and Tariff Act  373
Trade Expansion Act 372
Trade policy
  global production 377
  with Japan 373
  multinational trade agreements  326-318
  past policy 372
  recent developments 378-320
   Section 301 of the Trade Act of 1975  372-373
   lvith South Korea  375
   Ivith Tairvan 37.3-37.5
   lvith Thailand 375-376
Trade Regulation Rule 763
Trafficking in Contraband Cigarettes Act  347, 3.50
Transdermal nicotine 776-778
Transthcoretical model 729-730
Trask, George
   dntitob,iccoism \,ic\vs 37
`rwl7~ir7<~ Tohiii-0 Il.i,~ ,?rllf Dt~/`""fcwic~  703
TVSFP. SLY* Tele\,ision, School, and Family Smoking
Pre\ ention and Cessation Project

U

2,

Underaged smokers. SPL, Salvs to minors
Unfair competition
   defined 7 77
L'nited Air Lines

  institution of nonsmoking sections  46-J;
Cnited Kingdom Heart Disease Prevention Project  376,
  3;;-3;8

University ot Vermont School program  K-7


Lnpuffables program 83
Upton71 brand 399
Uruguay Round Agreements Act 328
Uruguay Round ot GATT 377-378
U.S. Ci&rette Export Association  372-372
U.S. Department of Health and Human Ser\?ces  .i
U.S. House of Representatives

Web site 229

U.S. National Archives and Records Administration  408
U.S. Supreme Court
  ruling on ETS in prisons  24s
USDHHS. %P U.S. Department of Health and Human
Services
Uydess, Jan 230

V

w

Walsh, Dr. James 1.  38
Warning labels. SLOP nl.so Packaging
   circle-and-arrow format 76;
   FTC recommendations 767
  FTC requirement 47
  regulatory requirements 763-765, 767
  smokeless tobacco requirements  167-168
   used in other countries  769-l 70
Waterloo Smoking Projects 10-X
Waxman, Henry A. 2.58
WCTU. See Woman's Christian Temperance Union
Webb-Pomerene Act 372
Weight control programs 271
Weight gain
  bupropion effecti\,eness  7 22
  nicotine gum effectiveness 276
   nicotine inhaler effectiveness  121
  nicotine nasal spray effectiveness  119
  relapse and 737 '
  transdermal patch effectiveness 778
Wil, Gots/lrll 85 MI?/f~~L'S LLP 71. Lorl<gst,yy+ Ass(tria&s,
  /-.P. 248
LVcstcrn Australia Tobacco Control Act of IYYO  768
Whltt~, Ellt~n Gould tlarmon
   anti tob,lii~~i\nl t ic>\\.5  i&ii

Whites

  smoking prevalence 97-98
WHO. Sw World Health Organization
WHO Tobacco Free Initiative  637
Wiiiilicii:Mi7ildr,s il. Browri & Will~nttrsorr Tnbaccc~ Cnr;~  23.5
Widener, Judge H. Emory, Jr.  290
Wigand, Jeffrey 230
Wiley, Harvey W. 32
Willard, Frances

  campaign against tobacco 37
lJVi//iillflS i' spt'tf"`~ 7 7s
Wilner, Nor\\-ood 2.35
Withdra\val symptoms
  bupropion effecti\,eness 727-122
   clonidine effectiveness  723
  nicotine gum rftectiveness  775776
   nicotine inhaler effectiveness  720
  nicotine nasal spray effectiveness  219
  nortriptvline effectiveness  724
  relapse and 730-1.37
  transdermal patch effectiveness  77 7
LVb/fJitl i'. P/ii/i/l MOrYii lilC.  245
Woman's Christian Temperance Union
  campaign against tobacco 37-34
Women. SW n/so Pregnancy
  appeal of cigarettes 36-37
  management of nicotine addiction  130
  prevention and education programs 4OO-407
  responsiveness to cue exposure therapy  108
  smoking pre\,alence  97-98
  lveight control programs following smoking
     cessation  7 7 7
lkrf7crl i'S. SlllOkilf<~ Nr~ticYlrk  400, 402403
WONDER 404
Working Well Trial 226-727
Workplaces
  environmental tobacco smoke exposure  196-797
  environmental tobacco smoke litigation 245-246
  private sector restrictions on environmental tobacco
     smoke 202
   state restrictions on environmental tobacco
     smoke 207
  worksite programs for management of nicotine
     addiction 726-22;
World Bank 437
World Health Organization 374,437
World Trade Organization 32;
Wright, Judge J. Skelly  7 65
WSP. Sw Waterloo Smoking Projects
I/t!yf?tt, Tnfwr7f 0 Collrbs i'. Willinrm  2.53

X

"X" brand 400


Y

Z