Executive Summary 1

Reducing Tobacco Use

Executive Summary

to tobacco, increase the success rate of young people

and adults trying to quit using tobacco, decrease the

level of exposure of nonsmokers to environmental tobacco smoke, reduce the disparities related to tobacco

use and its health effects among different population

groups, and 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] 2000a). Twenty-one specific

national health objectives related to tobacco use are

listed in Healthy People 2010, including reducing the rates

among young people and adults to less than half of the

current rate of use. Attaining all of these tobaccorelated objectives will almost certainly require significant national commitment to the various successful

approaches described in this report.

The major conclusions of this report are not formal policy recommendations. Rather, they offer a summary 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 importantly, the

American people guidance on how to ensure that efforts to prevent and control tobacco use are commensurate with the harm it causes.

This report of the Surgeon General on smoking

and health, Reducing Tobacco Use, appears at a time of

considerable upheaval in the arena of tobacco use control and prevention. Legal and legislative efforts to

protect children from tobacco initiation and to diminish the prevalence of smoking among adults are in a

state of flux, with some important gains and some sobering setbacks. Major changes in the public stance of

the tobacco industry have evoked a reevaluation of

strategies for controlling and preventing tobacco uptake. Enormous monetary settlements have provided

the resources to fuel major new comprehensive antitobacco efforts, but the ultimate cost and benefit of these

resources are still to be determined. Into this changing

landscape, the report introduces an assessment of

information about the value and efficacy of the major

approaches that have been used—educational, clinical,

regulatory, economic, and comprehensive—to reduce

tobacco use. The report evaluates the scientific evidence for each approach, attempts to place the approaches in the larger context of tobacco control, and

provides a vision of the trajectory for tobacco use prevention and control based on these available tools.

Thus, although our knowledge about tobacco control remains imperfect, we know more than enough to act now.

Widespread dissemination of the approaches and

methods shown to be effective in each modality and

especially in combination would substantially reduce

the number of young people who will become addicted

Major Conclusions

1. Efforts to prevent the onset or continuance of tobacco use face the pervasive, countervailing influence 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 (economic, regulatory, and comprehensive) are likely

to have the greatest long-term population impact.

Those with a smaller span of impact (educational

and clinical) are of greater importance in helping individuals resist or abandon the use of

tobacco.
2 Executive Summary

Surgeon General's Report

4. Each of the modalities reviewed provides evidence of effectiveness:

• Educational strategies, conducted in conjunction with community- and media-based

activities, can postpone or prevent smoking

onset in 20 to 40 percent of adolescents.

• Pharmacologic treatment of nicotine addiction, combined with behavioral support, will

enable 20 to 25 percent of users to remain abstinent 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.

• Regulation of advertising and promotion, particularly that directed at young people, is very

likely to reduce both prevalence and uptake

of smoking.

• 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.

• An optimal level of excise taxation on tobacco

products will reduce the prevalence of smoking, the consumption of tobacco, and the longterm health consequences of tobacco use.

5. The impact of these various efforts, as measured

with a variety of techniques, is likely to be underestimated because of the synergistic effect of

these modalities. The potential for combined

effects underscores the need for comprehensive

approaches.

6. State tobacco control programs, funded by excise

taxes on tobacco products and settlements with

the tobacco industry, have produced early, encouraging evidence of the efficacy of the comprehensive approach to reducing tobacco use.

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. 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 concerns played a lesser role.

2. In contrast, in the second half of the 20th century, the impetus for reducing tobacco use was

largely medical and social. The resulting platform has been a more secure one for efforts to

reduce smoking.

3. Despite the growing scientific evidence for

adverse health effects, smoking norms and habits

have yielded slowly and incompletely. The reasons are complex but attributable in part to the

industry’s continuing stimulus to consumption.

Chapter 3. Educational Strategies

1. Educational strategies, conducted in conjunction

with community- and media-based activities, can

postpone or prevent smoking onset in 20 to 40

percent of adolescents.

2. Although most U.S. schools have tobacco use prevention 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.
Executive Summary 3

Reducing Tobacco Use

Chapter 4. Management of Nicotine

Addiction

1. Tobacco dependence is best viewed as a chronic

disease with remission and relapse. Even though

both minimal and intensive interventions increase smoking cessation, most people who quit

smoking with the aid of such interventions will

eventually relapse and may require repeated attempts before achieving long-term abstinence.

Moreover, there is little understanding of how

such treatments produce their therapeutic effects.

2. There is mixed evidence that self-help manuals

are an efficacious aid to smoking cessation. Because 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

substantial proportion of people quit smoking.

4. The success of counseling and advice increases

with the intensity of the program and may be improved by increasing the frequency and duration

of contact.

5. The evidence is strong and consistent that pharmacologic treatments for smoking cessation

(nicotine replacement therapies and bupropion,

in particular) can help people quit smoking.

Clonidine and nortriptylene may have some utility as second-line treatments for smoking cessation, although they have not been approved by

the Food and Drug Administration (FDA) for this

indication.

Chapter 5. Regulatory Efforts

Advertising and Promotion

1. Since 1964, numerous attempts to regulate advertising and promotion of tobacco products

have had only modest success in restricting such

activity.

2. Current regulation in the United States is considerably less restrictive than that in several other

countries, notably Canada and New Zealand.

3. Current case law supports the contention that advertising does not receive the protections of free

speech under the First Amendment to the Constitution that noncommercial speech does.

Product Regulation

1. Warning labels on cigarette packages in the

United States are weaker and less conspicuous

than those of other countries.

2. Smokers receive very little information regarding 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 packaging and

in advertising may be misleading to smokers.

3. Because cigarettes with low tar and nicotine contents are not substantially less hazardous than

higher-yield brands, consumers may be misled

by the implied promise of reduced toxicity underlying the marketing of such brands.

4. 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.

5. Regulation of tobacco product sale and promotion is required to protect young people from

influences to take up smoking.

Clean Indoor Air Regulation

1. Although population-based data show declining

environmental tobacco smoke (ETS) exposure in

the workplace over time, ETS exposure remains

a common public health hazard that is entirely

preventable.

2. Most state and local laws for clean indoor air reduce 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 nonsmokers, smoking bans have additional benefits,

including reduced smoking intensity and potential cost savings to employers. Optimal protection of nonsmokers and smokers requires a

smoke-free environment.
4 Executive Summary

Surgeon General's Report

Minors’ Access to Tobacco

1. Measures that have had some success in reducing

minors’ access include restricting distribution,

regulating the mechanisms of sale, enforcing minimum age laws, and providing merchant education and training. Requiring licensure of tobacco

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.

2. 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 initiated 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 claimants, making statutory as well as common-law

claims and using more efficient judicial procedures. 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 actions of individuals are likely to be a valuable

component in some larger context of strategies

to make tobacco use less prevalent.

Chapter 6. Economic Approaches

1. The price of tobacco has an important influence

on the demand for tobacco products, particularly

among young people.

2. Substantial increases in the excise taxes on cigarettes would have considerable impact on the

prevalence of smoking and, in the long-term,

reduce the adverse health effects caused by

tobacco.

3. Policies that influence the supply of tobacco, particularly those that regulate international commerce, can have important effects on tobacco use.

4. 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 stronger prevention policies to ease economic diversification in tobacco-producing areas.

Chapter 7. Comprehensive Programs

1. The large-scale interventions conducted in community trials have not demonstrated a conclusive

impact on preventing and reducing tobacco use.

2. Statewide programs have emerged as the new

laboratory for developing and evaluating comprehensive 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.

4. 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 generally

favorable.
Executive Summary 5

Reducing Tobacco Use

Background

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 influences 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 attempts, where possible, to differentiate their techniques

and outcomes. The report also attempts a more difficult 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.

This report of the Surgeon General was prepared

by the Office on Smoking and Health, National Center

for Chronic Disease Prevention and Health Promotion,

Centers for Disease Control and Prevention (CDC), U.S.

Department of Health and Human Services, to report

current information on the health effects 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 two prior monographs: Growing Up Tobacco Free, a report of the Institute of Medicine (Lynch

and Bonnie 1994), and Healthy People 2000: National Health

Promotion and Disease Prevention Objectives, an ongoing

work of the Office of Health Promotion and Disease

Prevention (USDHHS 1991).

Several concerns guided preparation of the report. 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 difficulties 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 attempted 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 interaction of interventive efforts is noted several places in

the report (see, for example, the discussion of the interaction of school education with community-based

programs in Chapter 3), such demonstration of synergy 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 tobacco 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 coming

years.
6 Executive Summary

Surgeon General's Report

Issues in Reducing Tobacco Use

Two themes have permeated the history of tobacco use in the United States. First, and most obviously, tobacco is an extraordinary economic fuel, and

its powerful economic impact comes into direct conflict with its vast social costs. Second, antitobacco activity 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 processes as the leading causes of death during the 20th

century (Rothenberg and Koplan 1990). But this replacement has occurred during a period of remarkable 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 the decline 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 collectively as “interventions,” although the term,

in a more narrow sense, is often reserved for circumscribed, planned, and measurable activities. Many of

the maneuvers described in this report do not meet

the narrower definition, but all share the common

characteristic of being directed toward a reduction in

tobacco use.

The result is a considerable challenge for evaluation. In an environment in which multiple interventions are in play, the ability to attribute an individual

positive outcome (e.g., smoking cessation, prevention

of smoking uptake) to one of them is virtually impossible. Although the epidemiologic methods exist to

evaluate attribution in the aggregate, data are rarely

available to make such judgments. The challenge of

evaluating these separate efforts and strategies results

from their disparate nature and the type of metric that

may be appropriate to their evaluation.

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 relative 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 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 econometric information—that

is, on administrative data sets and survey results that

are subjected to correlation and trend analysis. Finally,

comprehensive program strategies are often evaluated

using surveillance data systems, trend analyses, and

case studies.

In each instance, some form of evaluation is possible, 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 presumed

number of persons who start smoking or some number who quit, but to do so would usually require numerous assertions and assumptions. Without a

common metric, the various types of efforts to reduce

tobacco use are difficult to compare quantitatively, and

perhaps a more qualitative approach should be used.

One approach 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 estimate of its potential

impact. For example, clinical methods to manage nicotine addiction may now be thought to have relatively

high impact, but a relative small span. Economic measures can be judged to have both high impact and large

span. Each of the interventions has its appropriate

place and context: they 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, a reasonable case can be made that

the large-scale strategies (economic and regulatory)

have the greatest direct impact on that barrier. But the
Executive Summary 7

Reducing Tobacco Use

Findings

Each of the approaches described in this report

shows evidence of effectiveness. In some instances,

the synergism that might be expected through interaction among these various efforts has been documented, and the implications for future tobacco control

and prevention activities are noted.

Historical Review (Chapter 2)

The forces that have shaped the movement to

reduce tobacco use over the past 100 years are complex 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 (U.S. Department of Health, Education, and Welfare 1964), the

movement to reduce tobacco use was fueled by knowledge of the health risks that tobacco use poses and by

reaction against the continued promotion of tobacco

in the face of such known risks. Despite overwhelming evidence of adverse health consequences of smoking, the stubborn norm of smoking in the United States

has receded slowly, in part because of such continued

promotion that works synergistically with tobacco

addiction. Although strategies 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 persons 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 modality

and to ignore the larger context in which prevention

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 1990s, 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 comprehensive approach presupposes an interdependence

of the available strategies. A coordinated, cohesive

infrastructure 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 program elements is difficult, and there is no experimental 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.

Finally, a separate theme—not a major focus of

the current report because two other recent, important

publications have emphasized this issue—is the

elimination of health disparities related to tobacco use,

which poses a great challenge to this nation. The 1998

Surgeon General’s report, Tobacco Use Among U.S.

Racial/Ethnic Minority Groups (USDHHS 1998), 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. Healthy People 2010 has two overarching

goals: increase quality and years of healthy life and

eliminate health disparities among different segments

of the U.S. population. Evidence reviewed in these

two publications highlights the significant disparities

in health that exist in the United States. These publications also highlight the critical need for a greater

focus on this issue, both in research and in public health

action.
8 Executive Summary

Surgeon General's Report

takes place. The reported size, scope, and duration of

program effects have become larger in recent reports.

In particular, several large programs have attempted

a multifaceted approach that incorporates 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 assurance that these

effects can be achieved in a variety of circumstances

when programs include the critical multiple elements

that have been defined by this research literature.

To summarize the major findings, school-based

social influences programs have significant and substantial short-term impacts on smoking behavior.

Those programs with more frequent educational contacts 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 implementation models and student populations. The smoking prevention effects of strong school programs can

be extended through the end of high school or longer

when combined with relatively intensive efforts directed through other powerful channels, such as strategies 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 recommendations 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 implementing the major components of CDC’s Guidelines for

School Health Programs to Prevent Tobacco Use and Addiction (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 policies that included the entire school environment.

Schools, however, should not bear the sole responsibility for implementing educational strategies to

prevent tobacco use. Research findings, as noted, indicate 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

guidelines and numerous Healthy People 2010 objectives

recognize the critical role of implementing tobacco-free

policies involving faculty, staff, and students and relating to all school facilities, property, vehicles, and events.

Although significant progress is still required, the current 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 complex field that continues to broaden its understanding

of the determinants of smoking cessation. Current literature 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 eventually able to do so. The available approaches to management 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 behavioral interventions, particularly proactive

telephone counseling, may significantly increase the effect of self-help materials. Process measures are not routinely 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 than are persons who try to quit smoking without them.

Substantial evidence suggests that minimal clinical 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 importance 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 or the specific changes

they produce in smokers that lead to abstinence.
Executive Summary 9

Reducing Tobacco Use

Intensive Clinical Interventions

Intensive programs—more formally, systematic

services to help people quit smoking—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 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 specific treatment techniques.

Because few studies have chosen to isolate single treatments, assessment of the effectiveness of specific approaches is difficult. Nonetheless, skills training, rapid

smoking, and both intratreatment and extratreatment

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 psychological, behavioral, or cognitive

mechanisms 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 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 psychotherapy. With intensive interventions, as with counseling, it is difficult to attribute the

efficacy to specific characteristics of the interventions

or to specific change mechanisms.

Pharmacologic Interventions

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 behavioral counseling with which it is

paired. The 4-mg dose (rather than the 2-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 inhalers and nicotine nasal spray are effective

aids for smoking 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 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 pharmacotherapy for smoking cessation to be studied in largescale 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 reducing postcessation symptoms of depression, but its

mechanism of action in smoking cessation remains

unknown.

Evidence has suggested that clonidine is capable

of improving smoking cessation rates. Clonidine is

hypothesized to work by alleviating withdrawal symptoms. Although clonidine may reduce craving for cigarettes after cessation, it does not consistently ameliorate

other withdrawal symptoms, and its effects with

weight gain are 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, tricyclic antidepressants produce a number of side effects, including sedation and various anticholinergic

effects, such as dry mouth.

In summary, research on methods to treat nicotine 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 component of a comprehensive tobacco control effort. It

has been estimated that smoking cessation is more costeffective than other commonly provided clinical preventive services, including Pap tests, mammography,

colon cancer screening, treatment of mild to moderate

hypertension, and treatment of high levels of serum

cholesterol.
10 Executive Summary

Surgeon General's Report

Contemporaneously with the appearance of this

report, research advances in managing nicotine addiction have been summarized in evidence-based clinical

practice guidelines by the Centers for Disease Control

and Prevention (CDC). That document confirms that

less intensive interventions, such as brief physician advice to quit smoking, could produce cessation 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 interventions 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 disseminating 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 payers. Similarly, CDC’s Best Practices for Comprehensive

Tobacco Control Programs advises states that tobaccouse treatment initiatives should include

• Establishing population-based counseling and

treatment programs, such as cessation help lines.

• Making the system changes recommended by the

CDC-sponsored cessation guidelines.

• Covering treatment for tobacco use under both

public and private insurance.

• Eliminating cost barriers to treatment for underserved 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 consequences of smoking (USDHEW 1964). Underlying

these attempts is the hypothesis that advertising and

promotion recruit new smokers and retain current

ones, thereby perpetuating 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 tobacco 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 packages but effectively preempted any further federal, state,

or local requirements for health messages. In 1969, a

successful court action invoked the Fairness Doctrine

(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 tobacco products on broadcast media, because such legislation also removed the no-cost broadcasting of

antitobacco advertising. A decade later, a Federal Trade

Commission (FTC) staff report asserted that the dominant themes of remaining (nonbroadcast) cigarette

advertising associated smoking with “youthful vigor,

good health, good looks and personal, social and professional 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 industry policy. Nonetheless, some of these concerns led to

the enactment of the Comprehensive Smoking Education 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 recommendations that product packages should bear information about associated risks of addiction and

miscarriage, as well as information on toxic components 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 character “Joe Camel.” Considerable research has demonstrated 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 Federal 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
Executive Summary 11

Reducing Tobacco Use

lawsuit in California resulted in a settlement whereby

the tobacco company agreed to cease its Joe Camel

campaign; notably, the Supreme Court of California

rejected 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 allpurpose term for particulate-phase constituents of tobacco 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) advertising for manufactured cigarettes and smokeless tobacco. 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 Education Act of 1984) requires cigarette and smokeless tobacco product manufacturers to submit a list of

additives to the Secretary of Health and Human Services; 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 explicitly

protected from regulation in various federal consumer

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 considering the need for regulating nicotine delivery, tar

content, and the use of additives, until recently no regulation had directly broached the issue of whether tobacco should be subject to federal regulation as an

addictive product. Responding in part to several petitions 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 levels, and by the concept that smoking is a pediatric disease 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 protect

children and adolescents and (2) an analysis of the FDA’s

jurisdiction over cigarettes and smokeless tobacco. The

final regulations published by the FDA on August 28,

1996, differed only slightly from the proposed regulation. The announcement prompted immediate legal

action on the part of the tobacco industry, advertising

interests, and the convenience store industry, which

challenged the FDA’s jurisdiction over 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 tobacco 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 congressional legislation that would uphold the FDA’s asserted 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 FDA

lacked jurisdiction to regulate tobacco products. In

November 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

Federal 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

jurisdiction over cigarettes and smokeless tobacco and

regulations restricting the sale and distribution of cigarettes and smokeless tobacco to protect children and

adolescents (principally codified at 21 Code of Federal 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

tobacco smoke and (2) consistent epidemiologic evidence of adverse health effects of ETS. Since 1971, a

series of rules, regulations, and laws have created

smoke-free environments in an increasing number

of settings: government offices, public places, eating

establishments, worksites, military establishments,

and domestic airline flights. As of December 31, 1999,

smoking was restricted in public places in 45 states

and the District of Columbia. Currently, some 820 local
12 Executive Summary

Surgeon General's Report

ordinances, 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 restrictions and smoke-free environments is high. Research

has also verified that the institution of smoke-free

workplaces effectively reduces nonsmokers’ exposure

to ETS. Although smoke-free environments have not

reduced smoking prevalence in most studies, such

environments have been shown to decrease daily tobacco consumption among smokers and to increase

smoking cessation.

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 proportion 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 regulation of self-service cigarette sales; in general, such

regulation requires that cigarettes be obtained from a

salesperson and not be directly accessible to customers. 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 training is an important component of comprehensive minors’ access programs. Penalties for sales to minors

vary considerably; in general, civil penalties have been

found to be more effective than criminal ones. Requiring 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 revocation 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 number of states and local jurisdictions are imposing sanctions against minors who purchase, possess, or use

tobacco products. Sanctions against both buyers and

sellers are enforced by a variety of agencies and mechanisms. Because regulations in general may be more

effective if generated and enforced at the local level,

considerable energy is devoted to the issue of opposing or repealing preemption of local authority by states.

Public health analyses have resulted in strong recommendations 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 instances in which injurers are forced to compensate the

injured can create a force that generates preventive

effects. Though relatively inefficient as a system for

compensating specific classes of injuries, the tort system 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 institutionalizing 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

relying 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 exhaustion 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 pointing to the large number of former smokers who successfully quit. Taking freedom-of-choice defense even
Executive Summary 13

Reducing Tobacco Use

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 United

States Supreme Court left open several other approaches, 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 differs 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 disclose, 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 presenting 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 expenditures for treating tobacco-related illnesses. In the

absence of congressional legislation needed to give that

settlement the force of law, four states made independent 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 industry. Subsequently, a multistate Master Settlement

Agreement was negotiated in November 1998 covering 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 litigation initiated by the tobacco industry itself has increased 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 pursuit of its interests on a number of fronts, litigation

against the industry has had undoubted impact on

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 manufactured tobacco product; to the advertising, promotion, 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 consumer 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 products need to be sufficiently regulated to protect underage youth from influences to take up smoking.

Finally, involuntary exposure to ETS remains a common 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 consumers 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 conclude 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 consumers 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 promotion of tobacco products in this country is considerably less restrictive than in several other countries,

notably Canada and New Zealand. The review of current case law in this report supports the contention

that greater restrictions of tobacco product advertising 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.
14 Executive Summary

Surgeon General's Report

ETS contains more than 4,000 chemicals; of these,

at least 43 are known carcinogens (Environmental 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 serum cotinine, a

marker for exposure to ETS (Pirkle et al. 1996). The

research reviewed in this report indicates that smoking bans are the most effective method for reducing

ETS exposure. Four Healthy People 2010 objectives address this issue and seek optimal protection of nonsmokers through policies, regulations, and laws

requiring smoke-free environments in all schools,

worksites, and public places.

Despite the widespread support among the general 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 minors. 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 reducing 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, judgment and forecasting depend on the results of complex analysis of administrative and survey data. Such

analyses have led to a number of conclusions regarding 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 tobacco, and use different forms of taxation as a possible mechanism for reducing tobacco use.

Supply

The tobacco support program has successfully

limited the supply of tobacco and raised the price

of tobacco and tobacco products. However, the principal beneficiaries of this program are not only the

farmers whose income is supported but also the owners of the tobacco allotments. If policies were initiated

to ameliorate some short-run effects, the tobacco support program could be removed without imposing

substantial losses for many tobacco farmers. Eliminating 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 constituency that has successfully impeded stronger legislation

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 resulting small reductions in price would have on demand.

Throughout the 1980s and 1990s, competition

within the tobacco industry appeared to have decreased

as a result of the favorable deregulatory business climate and an apparent increase in collusive behavior.

This reduction in competition, coupled with the addictive nature of cigarette smoking, has magnified 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 sanctions 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 comparable 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
Executive Summary 15

Reducing Tobacco Use

redistribution of spending and changes in types of

job—from the elimination of revenues derived from

tobacco products. Moreover, as the economies of

tobacco-growing regions have become 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 cigarette

consumption among smokers; relatively large reductions 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 potential substitution among cigarettes and other tobacco

products as their relative prices change.

Taxation

After the effects of inflation are accounted 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 estimates 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. Nevertheless,

current federal and most state tobacco taxes are well

below their long-run revenue-maximizing levels.

In short, the research reviewed in this report supports 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

tobacco prevention and control strategies. Research

indicates that increasing the price of tobacco products

would decrease the prevalence of tobacco use, particularly among minors and young adults. As noted, however, 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 industrialized countries and that the taxes on smokeless tobacco

products are well below those on cigarettes. Making

optimal use of economic strategies in a comprehensive program poses special problems because of the

complexity of government and private controls over

tobacco economics and the need for a concerted, multilevel, 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 control

cardiovascular disease (in the United States, notably 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 Intervention

Trial (COMMIT) for Smoking Cessation, also failed to

meet their primary goals for smoking reduction and

cessation. Similarly, the results to date from numerous

worksite-based cessation projects suggest either no impact or a small net effect (summarized in Chapter 4).

As these studies were under way in the 1970s

and 1980s, health promotion—an organized approach

to changing social, economic, and regulatory

environments—emerged as a more effective mechanism for population behavior change than traditional

health education. Although the aforementioned
16 Executive Summary

Surgeon General's Report

community-based research projects used a health promotion perspective, 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 comprehensive multimes-sage, multichannel approach that used some or all of the modalities described

in Chapters 3 through 6.

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 behavior. 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 advocacy. An interesting observation that supports the logic

behind comprehensive programs is that initial shortcomings 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 mediating by the Advocacy Institute, a more unified approach to reducing tobacco use has been achieved

among the participating organizations.

Media advocacy—the use of mass media to advance public policy initiatives—has also been effective

in placing smoking issues in the public eye and maintaining a continued impetus for reducing tobacco use.

Case analysis of 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 smoking cessation and decrease the likelihood of initiation.

Countermarketing campaigns also can have a powerful influence on public support for tobacco control activities 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 14-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

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.

Perhaps the most important aspect of comprehensive programs has been the emergence of statewide tobacco control efforts as a laboratory for their development

and evaluation. The number of states with such programs 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 programs on per capita consumption, adult prevalence,

and youth prevalence are generally favorable, the uniform data systems needed to conduct more controlled

evaluations of these efforts are still emerging. Nevertheless, the Institute of Medicine (2000) has concluded

that these “multifaceted state tobacco control programs

are effective in reducing tobacco use” (p. 4). The challenge for the new millennium will be to ensure that these

ever-increasing comprehensive statewide tobacco control 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 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 programs, each of these various modalities discussed in

this report is represented with varying degrees of intensity. As noted above, some of the recommendations

for actions within these modalities could most effectively 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, economic, and social approaches indicates the importance

of their sustained and long-term implementation. Program evaluation and research efforts are needed to

improve our understanding of how these various elements 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
Executive Summary 17

Reducing Tobacco Use

diversity of statewide tobacco control programs, critical 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)

In its assessment of the trajectory of tobacco control activities in the coming years, the report focuses

on six future challenges: the scientific base, the changing tobacco industry, the need for comprehensive approaches, identifying and eliminating disparities,

improving dissemination of interventions, and influencing tobacco use in developing nations.

Continuing to Build the Scientific Base

Beginning with the 1964 Surgeon General’s

report, Smoking and Health, tobacco control policy

in this nation has been built on a foundation of scientific 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 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 become 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 predicted from

these smaller research undertakings. For example, as

this report demonstrates, the most efficacious 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 addiction

clearly have some specific power to help smokers quit,

primarily through pharmacologic means, the social environment remains a major determinant of whether

these new former smokers maintain their abstinence

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, document, and evaluate. Economic strategies also have a

great potential, but being fundamentally political in

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 prospective or controlled research design.

The research and evaluation tools of public health

must expand to meet these complex issues. Comprehensive, multifactorial approaches to tobacco control

appear to offer the most promise. However, the penalty for comprehensive approaches is a loss of statistical power to attribute outcomes to specific activities.

Within each of the modalities, appropriate evaluation

methodologies are being used. However, many of

these methodologies involve retrospective case study,

time trend, econometric, and surveillance approaches

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 evaluate

the potentially most efficacious methods to reduce tobacco use.

The Changing Tobacco Industry

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. Despite 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 expected, in part because of such continued promotion.

Litigation and legal settlements have produced

notable changes in the tobacco industry’s public positions on health risks, nicotine addiction, and advertising and promotion limits. Additionally, individual

manufacturing companies have become more directly

involved in efforts to limit the access of underage persons 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
18 Executive Summary

Surgeon General's Report

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 industry 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,

The Changing Cigarette (USDHHS 1981). Recent public

statements by the tobacco industry suggest that the

pace of changes in the manufactured cigarette could

be accelerating in the future. The public health implications of changes in manufactured cigarettes and

other tobacco-containing products will require 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 researchers may

develop better methods to define and evaluate the

industry’s past activities that may have contributed to

the character, pace, or direction of changes in tobacco

use patterns in this country or around the world.

The Need for Comprehensive Approaches

The evidence of effectiveness summarized in this

report emphasizes that public health success in reducing tobacco use requires activity using multiple

modalities. 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, disability, and death related to tobacco use through prevention 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 focused on prevention, cessation, and protection of the

nonsmoker from ETS (Chapter 7). Preventing initiation among young people is a primary goal of any tobacco 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.

CDC recently released Best Practices for Comprehensive Tobacco Control Programs (CDC 1999), which

recommends that states establish tobacco control

programs that are comprehensive, sustainable, and

accountable. This document draws on “best practices”

determined by evidence-based conclusions from research and evaluation of such comprehensive programs 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 defined

in the guidance document. Although, the importance

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.

Best Practices thus provides effective guidance for

state-level efforts; a comprehensive national tobacco

control effort, however, requires strategies that go beyond this guidance to states. Moreover, a comprehensive national effort should involve the application of a

mix of educational, clinical, regulatory, economic, and

social strategies. 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 major aspect of the current report,

two other recent USDHHS publications have taken this

focus. The 1998 Surgeon General’s report Tobacco Use

Among 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 2000a). Both publications

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

tobacco use, but little research has been completed
Executive Summary 19

Reducing Tobacco Use

on the relative effectiveness of interventions for

prevention and treatment in some of the population

groups or communities. Reaching the national goal of

eliminating health disparities related to tobacco use

will necessitate 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 influence on the manner in which prevention and control 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

using traditional epidemiologic 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 overcoming 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 become

regular smokers, and more than 400,000 adults continue to die prematurely from tobacco-related diseases.

Within each of the modalities reviewed in this

report, some specific research advances in tobacco prevention 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 public health efforts more broadly.

Tobacco Use in Developing Nations

Analyses by the World Health Organization

(WHO) have concluded that by 2030, current smoking patterns will produce about 500 million premature deaths from tobacco-related disease among

people alive today (WHO 1999). WHO further estimates that by 2030, tobacco is expected to be the single

greatest cause of death worldwide, accounting 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 developed

countries of this world, WHO now estimates that by

2020, 7 of every 10 tobacco-related deaths will be in

the developing world.

This report addresses research on strategies to

reduce tobacco use within our nation’s social, legal,

and cultural environments. Nevertheless, 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 world, 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 following: can the time interval be significantly

shortened between when the health risks of tobacco

for a developing country are recognized and when a

comprehensive 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 developing 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 Curbing

the Epidemic: Governments and the Economics 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

widening access to smoking cessation therapies. The

scientific findings in this report are consistent with the

programmatic recommendations of both the WHO

Tobacco Free Initiative and the World Bank document.

A momentous undertaking of WHO and member states, including the United States, is the development and negotiation of the Framework Convention

on Tobacco Control. If brought to its intended ratification in the next few years, this agreement would

provide a framework within which countries could

develop more specific bilateral and multilateral protocols for cooperation on containing the spread of the

tobacco epidemic. The framework would enable countries to start from a common understanding of the issues, priorities, and strategies necessary to harmonize

tobacco control efforts among themselves so that some

countries do not benefit at the expense of others. This

is the spirit of the other activities of U.S. governmental
20 Executive Summary

Surgeon General's Report

and nongovernmental agencies in their effort to collaborate with WHO and with other countries in their

development of surveillance, cessation, prevention,

mass media, regulatory, economic, and social approaches to global tobacco control.

In the near future, emphasis must be placed on

the development of surveillance systems so that countries can know the extent, distribution, and trends of

the tobacco consumption problems in their populations. These systems will also track—for international

comparison and monitoring of progress—the emergence of new forms of tobacco promotion, as well as

new legislation, regulations, and programs for countering tobacco use. In the longer term, the gaps must

be filled in each country’s defenses against the incursions 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 control modalities be made available to the developing

world.

The challenge to the world is to prevent tobacco

use, particularly smoking, from ever becoming the leading cause of preventable illness and death in the world.

Dr. Gro Harlem Brundtland, the current directorgeneral of WHO, clearly defined this challenge when

she stated, “If we do not act decisively, a hundred years

from now our grandchildren and their children will

look back and seriously question how people claiming 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 growing number of other countries until tobacco prevention 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 effort. This report is, therefore, a prologue to the development of a coherent, long-term tobacco policy for this

nation.
Executive Summary 21

Reducing Tobacco Use

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