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Ending the Tobacco Problem: A Blueprint for the Nation PART I BACKGROUND
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Ending the Tobacco Problem: A Blueprint for the Nation 1 Epidemiology of Tobacco Use: History and Current Trends Since at least the colonial era, tobacco has been a popular commodity in the United States, with tobacco use increasing almost exponentially from the 1800s to the mid-1960s (DHHS 2000a). The invention of the cigarette fueled this dramatic rise in tobacco consumption, and cigarette smoking quickly outpaced the use of any other form of tobacco product (Brandt 2007). When tobacco use peaked in the mid-1960s, more than 40 percent of the U.S. adult population smoked cigarettes (National Center for Health Statistics 2005). This chapter reviews the growth of tobacco use over the 20th century, and the dramatic reversal of that trend beginning in 1965. The chapter examines recent trends in the epidemiology of smoking over the past four decades, takes a close look at the characteristics of smokers and those who have quit smoking, and discusses variations in the prevalence rate of smoking by sociodemographic characteristics and state of residence. Finally, the chapter highlights some possible threats to continued progress in reducing smoking in the United States. GROWTH OF THE TOBACCO PROBLEM In the late 19th and early 20th centuries, Americans consumed tobacco primarily in the form of chewing tobacco and cigars. According to Giovino, the per-capita consumption of tobacco products in the early 1880s was approximately 6 pounds of tobacco per person aged 18 and older; 56 percent of that tobacco was in the form of chewing tobacco, whereas only 1 percent took the form of manufactured cigarettes (Giovino 2002). For several reasons, cigarettes became the preferred tobacco product of Americans over
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Ending the Tobacco Problem: A Blueprint for the Nation the 20th century; in particular, cigarettes served as a more efficient vehicle for the absorption of nicotine and a less expensive form of tobacco. Also, by the 1880s, cigarette production had been mechanized with the advent of the Bonsack machine, which made it possible to produce additional units for little or no additional cost, and the prices of cigarettes were cut in half (Chaloupka et al. 2002; Giovino 2002). The lower price made cigarettes more accessible to a wider clientele (DHHS 2000b). By the 1950s, manufactured cigarettes represented 80 percent of per-person tobacco consumption (Giovino 2002). In 1900, on a per-capita basis, American adults smoked approximately 54 cigarettes per year. That number increased almost exponentially until its peak in 1963, when an estimated 4,345 cigarettes were consumed per adult in that year alone, as shown in Figure 1-1 (ALA 2006). This growth in consumption occurred for many reasons, but was driven largely by the mass production of cigarettes; the mildness, packaging, addictiveness, and convenience of the product; glamorization of smoking in movies and on television; and persuasive advertising campaigns (Chaloupka et al. 2002; DHHS 2000a; Giovino 2002). The milder flavor of the Turkish and domestic blended tobacco products also increased the appeal of cigarettes to a wider clientele. In the early twentieth century, cigarette manufacturers developed new blends using American-grown tobacco, such as sugared burley tobaccos (Giovino 2002). Manufacturers also used new methods of curing the tobacco, including flue FIGURE 1-1 Per capita consumption of cigarettes among adults ages 18 years and older from 1900 to 2004. SOURCES: (ALA 2004, 2006; Capehart 2004).
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Ending the Tobacco Problem: A Blueprint for the Nation curing. This process results in a product called “bright tobacco,” which has a high sugar content and a medium nicotine content (IOM 2001). These production changes created cigarettes that were milder and less alkaline than other forms of tobacco. The more acidic nature of these cigarettes allowed the nicotine in their smoke to be efficiently absorbed by the lungs. This feature provided cigarettes an advantage over cigars, as cigar smoke is absorbed in the mouth rather than in the lungs. More nicotine is absorbed with cigarettes compared to cigars due to the much larger surface area of the lung compared to the mouth. In addition, nicotine more quickly gets into the brain via the carotid artery following pulmonary absorption compared to buccal absorption, in which it travels through the liver before getting to the brain. Furthermore, as cigarettes are inhalable, they require less skill to use than cigars (DHHS 2000b; Giovino 2002). Thus people who may have abstained from smoking because they were intimidated by the cigar were drawn to the ease of smoking a cigarette (DHHS 2000b). The efficient absorption of nicotine has the added effect of making cigarettes more addictive than other forms of tobacco (Giovino 2002). These two features combined in order to drive high addiction rates among soldiers in World War I, to whom cigarettes were distributed without charge (Burns et al. 1997; DHHS 2000a; Schoenberg 1933). Intensity and innovation in advertising have been hallmark features of the cigarette industry throughout its history. In 1913, Camel became the first cigarette brand to gain nationwide popularity, following a mass marketing campaign by the R. J. Reynolds Company that introduced this “American blend” cigarette to the American public through a teaser advertisement (R.J. Reynolds 2006). Other companies followed suit, especially after World War I, as heavy advertising propelled the demand for cigarettes on a national scale (Schoenberg 1933). Ernster reported that Lucky Strike drew women’s attention with the diet slogan “Reach for a Lucky Instead of a Sweet” (Ernster 1985). Throughout the 1930s and 1940s, meanwhile, the Brown and Williamson Company included health claims in its ads for Kool, the first menthol cigarette distributed nationwide, claiming that smoking menthol cigarettes could protect against colds and soothe the throat (IOM 2001; R.J. Reynolds 2006). The boom period of tobacco consumption occurred between the 1920s and the mid-1960s (DHHS 2000b). During this period, tobacco users shifted from the traditional practices of using chewing tobacco, inhaling snuff, and smoking cigars and pipes, to smoking cigarettes, and the number of tobacco users increased as the rising number of initiates, including many women, became cigarette smokers (DHHS 2000b; Giovino 2002). The manufactured cigarette was convenient because it was already rolled and, along with the safety match, it provided an easy, portable, and disposable indulgence (DHHS 2000b).
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Ending the Tobacco Problem: A Blueprint for the Nation Over the 20th century, cigarette consumption fell only a few times before 1965: during the Great Depression, at the end World War II, and in 1953 and 1954 (Giovino 2002). The drop in consumption during the Great Depression was directly related to the decline in real disposable income,1 whereas the declines in the early 1950s followed the first real claims of tobacco’s harmful effects on health, which linked smoking to the development of cancer (Giovino 2002; Hamilton 1972; Havrilesky and Barth 1969). Hamilton (1972) showed that the reduction in consumption in the mid-1950s was attributable to the health scare associated with the use of tobacco products and that the effect of this public concern negated any market boost that might have come from advertising. Other studies suggest that the positive health claims in cigarette advertising made during this period might have had an indirect negative effect on tobacco consumption by giving the impression that protection was needed, thereby reinforcing the health scare (IOM 2001). To mollify the public’s growing concern about the health effects of smoking, tobacco companies introduced filtered cigarettes in the 1950s and the so-called low-tar cigarettes in the 1960s. Filters reduce tar and nicotine yields on government test machines. The market share of filtered cigarettes jumped from less than 5 percent in 1953 to almost 20 percent 2 years later. By 1960, more than half of all cigarettes consumed had filters (Giovino 2002). In 2004 and 2005, 99 percent of cigarettes on the market had filters (FTC 2007). The market share of low-tar cigarettes, those purportedly yielding less than or equal to 15 milligrams of tar, increased from 2 percent to more than 55 percent in the 20 years between 1967 and 1987. By 2003, almost 85 percent of cigarettes distributed within the United States were low-tar products (FTC 2005; Giovino 2002). Some manufacturers added chemicals to cigarettes to improve their flavor and aroma. One such chemical was menthol, an additive with an anesthetizing effect that was claimed to sooth the throat (Gardiner 2004; IOM 2001). Because menthol did indeed make the passage of tobacco smoke into the throat a smoother experience, consumers inhaled more deeply. In 1963, 16 percent of cigarettes sold in the United States contained menthol. The market share of menthol cigarettes peaked at slightly under 30 percent in the 1980s (FTC 2005; Giovino 2002; Giovino et al. 2004). 1 Historical records show that per capita cigarette consumption rises and falls in tandem with changes in price and in real incomes (DHHS 2000b). Although demand for cigarettes is what economists call “relatively inelastic” because of their addictiveness, that just means that consumption responds less than proportionally to changes in price, not that consumption is unresponsive to price. Several studies have estimated the price elasticity of the demand of cigarettes at approximately −0.40, which implies that a 10 percent increase in the price would result in a 4 percent decrease in consumption (Chaloupka et al. 2002; Hamilton 1972).
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Ending the Tobacco Problem: A Blueprint for the Nation DECLINE IN TOBACCO USE: 1965–20052 Despite the development of new products purportedly reducing smokers’ exposure to tobacco toxins, Americans have greatly reduced their tobacco consumption since the publication of the first Surgeon General’s report on the harmful effects of cigarette smoking in 1964. In fact, cigarette consumption has declined substantially since the mid-1960s (see Figure 1-1 for annual trends). By 1983, the annual per-capita consumption of cigarettes had declined approximately 20 percent from the 1963 level to 3,494 cigarettes per adult; by 2004, it had declined an additional 49 percent to 1,791 cigarettes, its lowest level in 67 years (ALA 2006; Capehart 2005). The halving of per-capita consumption of cigarettes over the last 20 years stems from a decline in smoking prevalence coupled with a decline in the number of cigarettes smoked per day among those who smoke.3 The percentage of adults who currently smoke (see Box 1-2 for a definition of this and other terms) has also declined in the past 40 years, as indicated in Figure 1-2. In 1965, 41.9 percent of Americans ages 18 years and over, or approximately 52.2 million adults, smoked either every day or on some days (National Center for Health Statistics 2005). The percentage of adults who are current smokers declined steeply between 1965 and 1991, with an estimated 39 percent drop in the prevalence of cigarette smoking. By 2005, the prevalence of adult cigarette smoking had declined to half the 1965 rate. An estimated 20.9 percent of American adults, or 45.1 million people, were current smokers in 2005 (CDC 2006b). The reduction in the prevalence of current smokers was driven by an increase in the rate of smoking cessation as well as a decrease in the rate of smoking initiation. Between 1965 and 2005, the percentage of adults who once smoked and who had quit more than doubled from 24.3 to 50.8 percent, as shown in Figure 1-3 (CDC 2006b; TIPS 2005a). Furthermore, the percentage of adults who have never smoked more than 100 lifetime cigarettes increased by approximately 23 percent from 1965 (44 percent) to 2005 (54 percent) (CDC 2005c; TIPS 2005b). Smoking initiation among adolescents and young adults has also declined since the mid-1960s, as estimated by the National Survey on Drug Use and Health (NSDUH) (SAMHSA 2005). In 1965, among adolescents aged 12 to 17 years, 125.5 of every 1,000 smoked a cigarette for the first time. In 2003, 102.1 per 1,000 youths in the same age range had smoked a cigarette for the first time (Figure 1-4). The reduction in smoking initiation saved more than half a million adolescents from having a first cigarette between 1965 and 2004. Young adults (individuals ages 18 to 25 years) have 2 See Box 1-1 for a list of commonly used data sets regarding tobacco use. 3 As discussed in a subsequent section, mean number of cigarettes per day consumed by current smokers rose steadily until 1979, when the trend reversed.
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Ending the Tobacco Problem: A Blueprint for the Nation BOX 1-1 Commonly Used Data Sets BRFSS Behavior Risk Factor Surveillance Survey. State-level prevalence of current tobacco use and cessation among adults (ages 18 years and older). All 50 states have participated since 1996. CPS Current Population Survey Tobacco Use Supplement. National- and state-level prevalence of tobacco use and cessation behavior among individuals ages 15 years and older. MTF Monitoring the Future. National-level prevalence of cigarette use, age at initiation, and cessation behavior among students in the 8th, 10th, and 12th grades, as well as young adults. NHIS National Health Interview Survey. National-level prevalence of tobacco use and cessation behavior among adults. Surveillance data have been collected since 1965, with changes in the definitions of current and former smoker made in 1991. NSDUH National Survey on Drug Use and Health. Formerly the National Household Survey on Drug Abuse. National-level prevalence of tobacco use by specific form, including bedes and kreteks among individuals ages 12 years and older. Surveillance since 2002. YBRSS Youth Behavior Risk Surveillance System. traditionally been less likely to initiate smoking behavior than adolescents, but their initiation rates also declined, from an annual level of 89.4 first-time smokers per 1,000 people in 1965 to one of 67.5 per 1,000 in 2003 (SAMHSA 2005). It should be noted, however, that despite this overall decline in initiation since 1965, trends over the past twenty years are not entirely encouraging. Developments in youth and young adult initiation over the past two decades are discussed in further detail later in the chapter when the committee more closely reviews recent developments. Industry Response These reductions in smoking over the past half century represent hard-won successes for tobacco control programs, because efforts to reduce tobacco consumption have frequently been countered by the tobacco industry in ways designed to maintain its customer base. Just as it did in the early part of the 20th century, the tobacco industry has recently attempted to use pricing, new product development, and advertising to counteract health-driven declines in tobacco consumption (Chaloupka et al. 2002).
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Ending the Tobacco Problem: A Blueprint for the Nation BOX 1-2 Definition of Terms Smoker Adult:a person aged 18 years or over who has smoked at least 100 cigarettes in his or her lifetime. Adolescent: (a) a person between the ages of 12 and 17 years who has smoked even once or twice,b (b) a person between the ages of 12 and 17 years who has ever smoked, even one or two puffs.c Current Smoker Adult (1965 to 1991): a person who was ever a smoker who reported smoking now. Adult: (1992 to present): a person who was ever a smoker who reported that he or she currently smokes either every day or on some days. Adolescent: a person between the ages of 12 and 17 who smokes on one or more days in the past 30 days. Former Smoker Adult (1965 to 1991): a person who was ever a smoker who no longer smokes. Adult (1991 to present): a person who was ever a smoker who no longer smokes every day or on some days. Heavy Smoker Adult: a current smoker who smokes at least 25 cigarettes in one day. Adolescent: a high school senior who smoked in the past 30 days and smoked at least one-half pack of cigarettes per day.d aDefinitions for adults come from the National Health Interview Survey. bMonitoring the Future. cYouth Behavior Risk Surveillance System and Youth Tobacco Survey. dMonitoring the Future. SOURCE: Adapted from text in Giovino (2002). The tobacco industry has dramatically increased its investment in advertising and promotional expenditures since the 1960s. From 1963 to 2003, total advertising and promotional expenditures by the five largest tobacco manufacturers increased from $1.5 billion (indexed for inflation) to $15.15 billion, the largest amount ever reported to the Federal Trade Commission (FTC 2005). Expenditures have risen particularly dramatically in recent years; the $15.15 billion spent in 2003 represents a 48 percent increase over the $10.25 billion spent in 2000, and an increase of 170 percent over the $5.62 billion spent in 1990 (FTC 2005). It should be noted, however, that the allocation of these advertising and promotional expenditures has changed substantially in recent years. As
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Ending the Tobacco Problem: A Blueprint for the Nation FIGURE 1-2 Current smoking prevalence among adults, selected years from 1965 to 2005 (all years for which NHIS data on annual smoking prevalence are available are included). Solid lines represent changes in smoking prevalence between consecutive years. Dotted lines represent approximate changes in smoking prevalence between nonconsecutive years. For years 1965 to 2004, age-adjusted data are provided. For 2005, crude data are provided. SOURCES: (CDC 2006b; National Center for Health Statistics 2006). the industry’s advertising opportunities have become increasingly limited, tobacco companies have dedicated significant portions of their marketing budgets to price discounts and other promotions at the retail level (Chaloupka et al. 2002; White et al. 2006). As discussed further below, the main target of these price-oriented promotions is current smokers. Manufacturers have also developed new products with the hopes of countering prevalent health concerns. Marketing campaigns have promoted purportedly low-tar, low-nicotine, and low-yield products, catering to perceptions that such cigarettes are safer or less harmful than the alternatives (Giovino et al. 1996). Taking advantage of the increasing popularity of these purportedly low-yield products, the R.J. Reynolds Company repositioned the Winston brand in 1997, claiming that its product was made with “100 percent tobacco” and “no additives” (Arnett 1999). Manufacturers have also promoted menthol-containing products, in response to consumer perceptions that such cigarettes were less harmful than nonmenthol brands (Gardiner 2004; IOM 2001; Pollay and Dewhirst 2002).
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Ending the Tobacco Problem: A Blueprint for the Nation FIGURE 1-3 Cessation rate among adult EVER smokers selected years from 1965 to 2005 (all years for which NHIS data on annual cessation prevalence are available are included). Solid lines represent changes in cessation prevalence between consecutive years. Dotted lines represent approximate changes in cessation prevalence between nonconsecutive years. SOURCES: (TIPS 2005a; CDC 2003, 2004b, 2005a,b, 2006b). FIGURE 1-4 Smoking initiation rates among adolescents and young adults, 1965 to 2003. SOURCE: (SAMHSA 2005).
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Ending the Tobacco Problem: A Blueprint for the Nation FIGURE 1-14 Smoking prevalence among adults by state or territory, 2005. SOURCE: (Kaiser Family Foundation 2006). Located at: http://www.statehealthfacts.org/cgi-bin/healthfacts.cgi?previewid=292&action=compare&category=Health+Status&subcategory=Smoking&topic=Adult+Smoking+Rate. percent), Oklahoma (26.1 percent), Tennessee (26.1 percent), Ohio (25.9 percent), and Arkansas (25.7 percent). The states that ranked the lowest in current smoking had prevalence rates of less than 15 percent. Only two of the contiguous 48 states met this criterion: California with 14.9 percent and Utah with 10.5 percent. Puerto Rico and the Virgin Islands also had very low current smoking prevalence rates: 12.7 and 9.5 percent, respectively. State-level cessation rates ranged from 42.5 percent in Kentucky to 62.5 percent in Connecticut. Kentucky, the state with the highest smoking prevalence rate, also had the lowest quit rate (CDC 2005c). Of the six states with the lowest quit rates, three (Tennessee with 45.9 percent, Ohio with 49.0 percent, and Kentucky with 46.1 percent) also ranked in the top six in smoking prevalence. All six of the states ranking the highest among current
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Ending the Tobacco Problem: A Blueprint for the Nation FIGURE 1-15 Smoking cessation prevalence among adults by state or territory, 2004. SOURCE: (Kaiser Family Foundation 2006). Located at: http://www.statehealthfacts.org/cgi-bin/healthfacts.cgi?previewid=3&action=compare&category=Health+Status&subcategory=Smoking&topic=Attempts+to+Quit+Smoking. smokers had quit rates of less than 50 percent. In the states with the highest quit rates, 60 percent or more of individuals who had ever smoked had quit. These included Utah (60.1 percent), Vermont (60.5 percent), California (62.0 percent), and Connecticut (62.5 percent). All four of these states had smoking prevalence rates at or below 20.0 percent. Many factors contribute to the differences in the smoking cessation prevalence and smoking cessation rates among states, including the demographic and social characteristics of the state populations. The communities with large percentages of poor populations and populations with low levels of education tend to have the highest prevalence of smoking (Dell et al.
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Ending the Tobacco Problem: A Blueprint for the Nation 2005). As discussed in Chapter 5, it is likely that variations in the levels of tobacco control activities among the states also account for some of these variations in smoking prevalence. It is widely accepted that California’s lower prevalence is attributable at least in part to the intensity of tobacco control efforts in that state (CDC 1996). Kuiper and colleagues (2005) present evidence that comprehensive state programs reduce the prevalence of smoking among adults and adolescents at the state and national levels. Jemal and colleagues (2003) examined comprehensive smoking cessation programs among 33 states and found that the intensity of the program had a very large negative correlation with the prevalence of current smoking (r = −0.81, p < 0.0001) and a large positive correlation with the quit rate (r = 0.82, p < 0.0001) among adults ages 30 to 39 years. The impact of comprehensive state tobacco control programs is discussed in more detail in Chapter 5 of this report. States with a high prevalence of smoking among adults also have high rates of smokers who made no attempt to change their behavior in the last year (Burns and Warner 2003), suggesting that environment plays a role in sustaining smoking behavior or promoting cessation efforts. Comorbidity Several recent studies have documented a relationship between mental illness and smoking among adults and adolescents (Black et al. 1999; Lasser et al. 2000; Upadhyaya et al. 2002). As used by Lasser and colleagues (2000), the term “mental illness” in this context is defined very broadly to include major depression, bipolar disorder, dysthymia, panic disorder, agoraphobia, social phobia, simple phobia, generalized anxiety disorder, alcohol abuse, alcohol dependence, drug abuse, drug dependence, antisocial personality, conduct disorder, or nonaffective psychosis (Lasser et al. 2000). Adults who currently experience symptoms of these disorders smoke more than 44 percent of the cigarettes consumed in the United States (Lasser et al. 2000). Lasser and colleagues also found that adults with a lifetime history of mental illness (broadly defined as above) were more likely to be current smokers than adults with no history of mental illness. Adults with mental illnesses manifesting within the past month were the most likely to smoke and the least likely to quit. Figure 1-16 compares the smoking prevalence and cessation rates by mental illness status. The study also revealed that those with a larger number of mental illness comorbidities have a greater likelihood of smoking and a greater tendency to smoke heavily. EMERGING CHALLENGES Although the prevalence of smoking among adults continues a 40-year decline, some recent trends suggestive of a flattening in rates of adult smok-
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Ending the Tobacco Problem: A Blueprint for the Nation FIGURE 1-16 Current smoking prevalence and quit rates among individuals ages 15 to 54 years by mental illness status. SOURCE: (Lasser et al. 2000). ing and cessation raise an important question: Are tobacco control programs confronting a hardening target? The term “hardening” is used in this context to refer to the residual smokers who either resist cessation efforts or who have more difficulty quitting than former smokers (Burns and Warner 2003). For the purposes of this report, the key question is the one posed by a recent National Cancer Institute monograph: Is achieving abstinence harder, and do changes to interventions need to be made? This chapter has identified several subpopulations that appear to pose an elevated risk of lifelong smoking. Because these groups are more likely to continue to smoke despite cessation efforts, it seems likely that more aggressive efforts may be needed to reach them and to change their behavior. Another potentially worrisome trend is the increase in initiation by young adults (18–24) and a possible increase in occasional smoking that may be associated with it. Such an increase was shown in one national survey (CDC 2005b), but not in another, (see Figure 1-9). Occasional smokers differ from heavier or hard-core smokers in many ways: occasional smokers are more highly educated whereas hard-core smokers have lower levels of education; occasional smokers are more likely to be racial and ethnic minorities whereas hard-core smokers are more likely to be white; and hard-core smokers tend to begin smoking at an earlier age (Augustson and Marcus 2004). Whether an increase in occasional smoking, if it is occurring, signals a more difficult challenge for tobacco control is not altogether clear. Percentage
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Ending the Tobacco Problem: A Blueprint for the Nation SUMMARY The phenomenal increase in tobacco use over the course of the 20th century was finally reversed in the wake of the publication of the Surgeon General’s important report in 1964. The data reviewed in this chapter suggest that the gradual decline in tobacco use since 1965 can be divided into two phases, the first running from 1965 to about 1980 and the second running from 1980 to the present. During the initial period, there was a sharp decline in smoking prevalence, accompanied by a modest increase in the average number of cigarettes smoked per day by smokers. Since then, however, the continued decline in smoking prevalence has been accompanied by a substantial decline in cigarettes smoked per day among those who smoke. As will be explained in Chapters 3 and 5, the committee believes that a substantial portion of the declines in smoking prevalence and smoking intensity over the past 25 years is attributable to tobacco control interventions, especially price increases and the emergence of a strong antismoking social norm. In the committee’s opinion, the data suggest that the Surgeon General’s 1964 report and the dissemination of information on the adverse health effects of smoking had a strong impact on smoking prevalence. However, industry efforts to respond to the health threat of smoking by promoting filtered and so-called “light” cigarettes tended to counteract the effects of antismoking messages and to sustain smoking by those who smoked the most heavily. This interpretation would explain the increase in smoking intensity during this initial phase of tobacco control activity. During the second phase of tobacco control efforts, however, the tobacco industry’s dominance of the playing field was finally challenged by strong advocacy at the local and state levels and by significant increases in price. These efforts not only sustained the downward trend in prevalence but also helped to cut down on the intensity of smoking among a significant portion of smokers. If this overall interpretation is correct, it suggests that continued implementation of strong tobacco control interventions will be needed to sustain progress. However, it also tends to highlight some important warning signs. First, tobacco control efforts will need to address the needs of a residual population of smokers who are particularly difficult to influence (e.g., smokers with mental illness). Second, a disturbing increase in later-onset, less frequent smoking by 18- to 25-year-olds could portend a growing cohort of new smokers who may be overlooked by traditional prevention programs for teens and by traditional cessation programs developed for older smokers. Finally, the volatile and frequently high rate of initiation of smoking among teens poses a continuing obstacle to society’s long-term goal of reducing the public health burden of tobacco use.
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Ending the Tobacco Problem: A Blueprint for the Nation REFERENCES ALA (American Lung Association). 2004. Trends in Tobacco Use. New York: American Lung Association. ALA. 2006. Trends in Tobacco Use. New York: American Lung Association. Arnett JJ. 1999. Winston’s “No Additives” campaign: “straight up”? “No bull”? Public Health Reports 114(6):522-527. Augustson E, Marcus S. 2004. Use of the current population survey to characterize subpopulations of continued smokers: a national perspective on the “hardcore” smoker phenomenon. Nicotine and Tobacco Research 6(4):621-629. Bachman JG, O’Malley PM, Johnston LD, Schulenberg JE, Ludden AB, Merline AC. 2001. The Decline of Substance Use in Young Adulthood: Changes in Social Activities, Roles, and Beliefs. Research Monographs in Adolescence. Mahwah, NJ: Lawrence Erlbaum Associates, Inc. Barbeau EM, Krieger N, Soobader MJ. 2004. Working class matters: socioeconomic disadvantage, race/ethnicity, gender, and smoking in NHIS 2000. American Journal of Public Health 94(2):269-278. Black DW, Zimmerman M, Coryell WH. 1999. Cigarette smoking and psychiatric disorder in a community sample. Annals of Clinical Psychiatry 11(3):129-136. Brandt AM. 2007. The Cigarette Century: The Rise, Fall, and Deadly Persistence of the Product That Defined America. New York: Basic Books. Breslau N, Johnson EO, Hiripi E, Kessler R. 2001. Nicotine dependence in the United States: prevalence, trends, and smoking persistence. Archives of General Psychiatry 58(9):810-816. Bulow J, Klemperer P. 1998. The tobacco deal. Brookings Papers on Economic Activity. Microeconomics 1998:323-394. Burns DM, Lee L, Shen LZ, Gilpin E, Tolley HD, Vaughn J, Shanks TG. 1997. Cigarette smoking behavior in the United States. Changes in Cigarette Related Disease Risks and Their Implication for Prevention and Control. Smoking and Tobacco Control Monograph No. 8. Bethesda, MD: DHHS, National Institutes of Health, National Cancer Institute. Pp. 13-112. Burns DM, Major JM, Shanks TG. 2003. Changes in Number of Cigarettes Smoked per Day: Cross-Sectional and Birth Cohort Analyses Using NHIS. Those Who Continue to Smoke: Is Achieving Abstinence Harder and Do We Need to Change Our Approach? Smoking and Tobacco Control Monograph 15. Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health, National Cancer Institute. Pp. 83-99. Burns DM, Warner KE. 2003. Smokers who have not quit: is cessation more difficult and should we change our strategies? Those Who Continue to Smoke: Is Achieving Abstinence Harder and Do We Need to Change Our Approach? Smoking and Tobacco Control Monograph 15. Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health, National Cancer Institute. Pp. 11–32. Capehart T. 2004. The Changing Tobacco User’s Dollar. Washington, DC: Economic Research Service, U.S. Department of Agriculture. Capehart T. 2005. Tobacco Outlook: Tobacco Acreage Plunges for 2005 Crop Year. Washington, DC: Economic Research Service, U.S. Department of Agriculture. CDC (Centers for Disease Control and Prevention). 1994. Changes in the cigarette brand preferences of adolescent smokers—United States, 1989–1993. MMWR (Morbidity and Mortality Weekly Report) 43(32):577-581. CDC. 1996. Cigarette smoking before and after an excise tax increase and an antismoking campaign—Massachusetts, 1990–1996. MMWR (Morbidity and Mortality Weekly Report) 45(44):966-970.
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