PERSPECTIVES How Far We Have Come in the Last 50 Years in Smoking Attitudes and Actions David Burns University of California, San Diego School of Medicine, Del Mar, California
Abstract Dramatic changes in smoking behavior and attitudes about smoking have occurred over the 50-year interval since the release of the 1964 smoking and health report to the Surgeon General. Between 1965 and 2011, adult prevalence of cigarette smoking fell from 51.9 to 21.6% among men and from 33.9 to 16.5% among women, with an increasing fraction of smokers who do not smoke every day. Federal taxes have increased from $0.08 in 1965 to $1.01, with even larger increases in many state taxes. Workplace restrictions on smoking
have increased from only 3% of workers protected by workplace smoking bans in 1986 (e.g., those working in fireworks factories) to more than 70% of workers being protected in 1999. Equally dramatic changes have occurred in restrictions on smoking in the home. The evaporation of the remaining societal support for smoking may be an important part of the “end game” for cigarette smoking in the United States. Keywords: tobacco; Surgeon General; public policy; norm changes
(Received in original form August 8, 2013; accepted in final form September 24, 2013 ) Correspondence and requests for reprints should be addressed to David Burns, M.D., Professor Emeritus, UCSD School of Medicine, 1120 Solana Drive, Del Mar, CA 92014. E-mail [email protected] Ann Am Thorac Soc Vol 11, No 2, pp 224–226, Feb 2014 Copyright © 2014 by the American Thoracic Society DOI: 10.1513/AnnalsATS.201308-258PS Internet address: www.atsjournals.org
Dramatic changes in smoking behavior and attitudes about smoking have occurred over the 50-year interval since the release of the 1964 smoking and health report (1) of an advisory committee to Surgeon General Luther Terry. More than half of those who are currently ever smokers have quit (2), taxes on cigarettes have increased (3), locations where smoking is allowed have been greatly restricted (4), and cigarette smoking has been denormalized among both adolescents and adults as the result of tobacco-control efforts (5). These changes are legitimately characterized as one of the great public health achievements of the last half century. The unfortunate corollary of that accomplishment, however, is that with all of the evidence that has been amassed, all of the tools that have been developed, and all of the effort that has been expended, nearly half of those ever smokers are still smoking. This glass slightly more than half full provides an opportunity to reflect on the changes over the past 50 years to 224
understand how they came about and how we might accelerate change going forward. In 1965, the prevalence of cigarette smoking for those over age 18 years was 51.9% among men and 33.9% among women (6). By 2011, prevalence had fallen to 21.6% among men and 16.5% among women (7). One additional important trend in smoking prevalence is the increasing fraction of smokers who do not smoke every day. In 2011, that percentage was 22.2% nationally (7), with more than onethird of all smokers being nondaily smokers in some states with very low smoking prevalence, such as California. This trend has been accompanied by a dramatic fall in the percentage of all smokers who smoke more than one pack per day and a fall in the average number of cigarettes smoked per day even among daily smokers (7). Some of this shift may be explained by the increasing fraction of all smokers under age 30 years among whom occasional smoking, as a stage of smoking initiation, is more
common, but it also appears that the fraction of occasional smokers is increasing even among smokers at ages when initiation is rare. Effects of cost, restrictions on where smoking is allowed, and increasing cessation activity are additional potential explanations for this trend, and one hoped-for outcome would be a reduction in the intensity of nicotine addiction that may accompany the reduced frequency of smoking, particularly the trend toward nondaily smoking. Federal taxes have increased from $0.08 in 1965 to $1.01, with even larger increases in many state taxes (3). Workplace restrictions on smoking have increased from only 3% of workers protected by workplace smoking bans in 1986 (e.g., those working in fireworks factories) to more than 70% of workers being protected in 1999 (8), and only 22.9% of workers report exposure to other smokers’ tobacco smoke during the past 7 days (9) in 2010. Equally dramatic changes have occurred in
AnnalsATS Volume 11 Number 2 | February 2014
PERSPECTIVES restrictions on smoking in the home (9), even in the homes of current smokers. The environment surrounding the smoker has become increasingly restrictive, and their behavior has become increasingly denormalized. Restrictions are commonly proposed for multifamily housing, and the entire campuses of many universities and workplaces are now smoke-free, with no designated smoking area. The changes in smoking behavior and changes in attitudes and norms about smoking are not uniformly distributed across populations of smokers. Race, ethnicity, income, sex, education, occupation, and other individual characteristics lead to different life experiences with smoking and different resultant smoking behaviors, attitudes, and norms. These differences are a substantial contributing factor to the differences in observed disease outcomes by socioeconomic status. One difference that has become increasingly disparate over time is the effect of the state in which one lives. The smoking prevalence for the heaviest smoking state (Kentucky) is more than twice the prevalence of the lowest prevalence state (California), even when Utah, with its large nonsmoking Mormon population, is excluded (9). Marked disparities also exist across states in tax rates on tobacco products and restrictions on where smoking is allowed by regulation as well as by environmental norms. The state-specific disparities in smoking prevalence appear to be selfreinforcing based on a series of synergies that influence smoking behavior. Logic dictates that states that have had the greatest success in achieving smoking cessation should have a remaining population of smokers with greater difficulty quitting. Those who have already quit must, almost by definition, have an easier time obtaining abstinence than those who have not yet quit, and one might expect that those states that have the largest fraction of ever smokers who have successfully quit would begin to see lower rates of cessation among those “hardened” smokers who remain. However, the opposite trend emerges when cessation attempts and success are examined (10). States with lower current prevalence, and higher fractions of ever smokers who have quit, continue to have higher rather than lower rates of cessation and cessation success. One explanation that has been offered for this observation (11) is that, Perspectives
even as the remaining population of smokers is composed of those who have more personal barriers to cessation, the environment surrounding those smokers has dramatically enhanced forces driving and supporting cessation. In that battle of opposing forces, the rate of change in the environment has outpaced the “hardening” of the residual smoking population. This social dynamic is self-reinforcing. For example, as the prevalence of smoking falls, it may be easier to pass tax increases, which in turn drive the prevalence down further. When there are fewer smokers, it is easier to pass restrictions on where smoking is allowed, and those restrictions then spread to the home environment, with the effect of these combined restrictions being a reduction of both smoking prevalence and number of cigarettes smoked per day. It is generally accepted that both the changes in the environment and the tobacco-control efforts that generate them have direct independent effects in reducing smoking prevalence. They also interact as described above. It is easier to raise taxes and restrict smoking when the prevalence of smoking is low. Thus, the reality underlying these parallel tobacco-control trends is not passive; it is actively synergistic. Changes in workplace rules about smoking are more effective in promoting cessation if there is support for cessation from tobacco-control programs. Implementation of these workplace rules precipitates restrictions on smoking in the home and changes the norms about the acceptability of smoking in the general environment. Denormalization of tobacco use reduces initiation and promotes cessation as well as providing political support for increases in taxation. Thus, each individual change not only alters smoking behavior directly but also facilitates a cascade of other environmental changes, which spiral back to reinforce support for, and the effectiveness of, the original intervention. Reinforcement across tobaccocontrol modalities is likely to be even greater when very powerful policy changes, such as increases in cigarette taxes, are implemented. Nevertheless, the strength of the wide array of tobacco-control strategies as they interact with one another, even without the effect of increases in taxation, is demonstrated by the success of California in lowering smoking prevalence even in the face of the modest contribution of its rank of 33rd in cigarette tax rates among the states (CDC 2103). This synergy offers the hope
that future declines in cigarette smoking may accelerate as the social approval that allowed smoking to flourish is replaced by restrictions, barriers, and social disapproval, encouraging and supporting even hardened smokers in their efforts to successfully quit. The result may be an acceleration of the decline in smoking prevalence, as some critical level of smoking prevalence needed to provide social support for smoking is crossed. This increase in cessation activity has been observed among those aged 18 to 64 in recent data from the National Health Interview Survey (2). The progressively enlarging disparities across groups and geographic locations result in a diminished value for national estimates of phenomena associated with smoking and a rising value of data from groups defined by geography or individual characteristics. Examination of the disparities of tobacco-control forces and resulting effects on smoking behaviors across states provides an understanding of what is effective. A similar examination of the group-specific environmental forces surrounding populations of smokers defined by their individual characteristics, and study of the network of interactions those smokers experience, is currently the goal of many tobacco-control research efforts. A shift from national population data to data on norms, perceptions, and behaviors denominated by these subgroups of the population is needed for the data to be relevant for future tobacco-control efforts. Even state-specific data may have less relevance when considering strategies to reach smokers as the residual smoking population moves to clusters defined by a multitude of individual factors such as education, urban/rural residence, or characteristics such as the presence of mental illness. As we move to consideration of the unique or distinct environmental features surrounding these residual clusters of smokers in the population, we gain better insight into the challenges of reaching these smokers and the difficulties in changing the norms and pressures that impact them as a subpopulation distinct from the general environment. Rightly or wrongly, these groups are often considered hard to reach and “hardened” to the conventional approaches to tobacco control and population-based cessation. New programmatic efforts are developed that use data derived from each specific group to customize distinct cessation approaches for 225
PERSPECTIVES that unique group, with a perceived need for group-specific messaging and original program elements crafted based on the differences in that group’s microenvironment. This crafting is critical for evolution of tobacco-control programs to match the shifting smoking population; however, crafting programs based solely on the differences may create a blind spot to the reality that the same forces that influence the general population are also likely to have an effect on the new subgroups as well. It is important not to lose the potential synergies of these population-wide effects as we focus on the residual subpopulations of smokers. For example, the substantial and potentially growing fraction of current smokers with mental health issues (12) suggests that provision of cessation services as an element of treatment programs should be encouraged, and few would dispute that approach as a reasonable treatment synergy. However, limiting the locations in which tobacco products are sold, a program traditionally associated
with adolescent prevention efforts, and efforts to raise other barriers to purchase (e.g., cost) may have a powerful effect on the most severely mentally ill population, who can have more limited personal and financial resources to overcome these barriers. In our narrowed focus on the specifics of the residual smoking population, the reality that these populations have been slower to respond to global tobacco-control influences should not be taken as a demonstration that these global strategies have no effect and can be abandoned. Tobacco control has been a remarkably successful public health effort, but nicotine addiction retains a powerful hold on a large segment of the U.S. population. Our past success should not blind us to the need to change our approaches as the characteristics of the smoking problem change. Our past success is also no guarantee of continued future declines. We can draw on what we learn from differences across states in the effectiveness of tobacco-control efforts, and from national data defining specific populations, as we
References 1 U.S. Department of Health, Education, and Welfare. Smoking and health: report of the Advisory Committee to the Surgeon General of the Public Health Service. Washington: U.S. Department of Health, Education, and Welfare, Public Health Service, Center for Disease Control; 1964. PHS Publication No. 1103 [accessed 6 July 2013]. Available from: http://profiles.nlm.nih.gov/NN/B/C/X/B/ 2 Centers for Disease Control and Prevention. Quitting smoking among adults—United States, 2001-2010. MMWR Morb Mortal Wkly Rep 2011;60:1513–1519. 3 Orzechowski and Walker. The tax burden on tobacco – 2011 [accessed 6 July 2013]. Available from: http://www.taxadmin.org/ fta/tobacco/papers/Tax_Burden_2011.pdf 4 U.S. Department of Health and Human Services. The Health consequences of involuntary exposure to tobacco smoke: a report of the surgeon general. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2006 [accessed 6 July 2013]. Available from: http://www.surgeongeneral.gov/library/reports/secondhandsmoke/ report-index.html 5 U.S. Department of Health and Human Services. Preventing tobacco use among youth and young adults: a report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2012 [accessed 6 July 2013]. Available from: http://www.surgeongeneral.gov/library/reports/preventingyouth-tobacco-use/full-report.pdf 6 U.S. Department of Health and Human Services. Women and smoking. A report of the surgeon general. Rockville, MD: U.S. Department of
226
7
8
9
10
11
12
shift our focus to the residual, and likely tougher, subgroups of the population who remain heavily addicted. Examining the environmental realities of these subgroups to help design and evolve tobacco-control efforts as we move forward must play an increasing role and absorb greater resources if we are to be successful. As we move forward, the lessons of the past tell us that cigarette smoking is an addiction, and, as is true for all addictions, a tolerant cultural context is essential for its continued existence. It is changes in that cultural context that deserve the bulk of the credit for the decline in smoking prevalence that has occurred over the past 50 years, rather than changes in our successful treatment of addiction as a brain disease. Equally arguable and equally hopeful, it may be the evaporation of the remaining societal support for smoking as prevalence drops below a critical threshold that ultimately produces the “end game” for cigarette smoking in the United States. n Author disclosures are available with the text of this article at www.atsjournals.org.
Health and Human Services, Public Health Service, Office of the Surgeon General; 2001. p. 36 [accessed 6 July 2013]. Available from: http://www.cdc.gov/tobacco/data_statistics/sgr/2001/ complete_report/index.htm Centers for Disease Control and Prevention. Current cigarette smoking among adults - United States, 2011. MMWR Morb Mortal Wkly Rep 2012; 61:889–894. Shopland DR, Anderson CM, Burns DM, Gerlach KK. Disparities in smoke-free workplace policies among food service workers. J Occup Environ Med 2004;46:347–356. Centers for Disease Control and Prevention. Tobacco control state highlights 2012. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2013 [accessed 6 July 2013]. Available from: http://www.cdc.gov/tobacco/data_statistics/state_data/ state_highlights/2012/sections/index.htm Burns D, Warner KE. Smokers who have not quit: is cessation more difficult and should we change our strategies? Burns D, editor. In: Those who continue to smoke: is achieving abstinence harder and do we need to change our interventions? Smoking and Tobacco Control Monograph No. 15, USDHHS, NIH, NCI, NIH Pub. No. 03–5370, pp. 11–31, 2003 [accessed 6 July 2013]. Available from: http://cancercontrol.cancer.gov/brp/tcrb/monographs/15/ monograph15-chapter1.pdf Warner KE, Burns DM. Hardening and the hard-core smoker: concepts, evidence, and implications. Nicotine Tob Res 2003;5: 37–48. Centers for Disease Control and Prevention. Vital signs: current cigarette smoking among adults aged >18 years with mental illness - United States, 2009-2011. MMWR Morb Mortal Wkly Rep 2013;62:81–87.
AnnalsATS Volume 11 Number 2 | February 2014
Abstract Dramatic changes in smoking behavior and attitudes about smoking have occurred over the 50-year interval since the release of the 1964 smoking and health report to the Surgeon General. Between 1965 and 2011, adult prevalence of cigarette smoking fell from 51.9 to 21.6% among men and from 33.9 to 16.5% among women, with an increasing fraction of smokers who do not smoke every day. Federal taxes have increased from $0.08 in 1965 to $1.01, with even larger increases in many state taxes. Workplace restrictions on smoking
have increased from only 3% of workers protected by workplace smoking bans in 1986 (e.g., those working in fireworks factories) to more than 70% of workers being protected in 1999. Equally dramatic changes have occurred in restrictions on smoking in the home. The evaporation of the remaining societal support for smoking may be an important part of the “end game” for cigarette smoking in the United States. Keywords: tobacco; Surgeon General; public policy; norm changes
(Received in original form August 8, 2013; accepted in final form September 24, 2013 ) Correspondence and requests for reprints should be addressed to David Burns, M.D., Professor Emeritus, UCSD School of Medicine, 1120 Solana Drive, Del Mar, CA 92014. E-mail [email protected] Ann Am Thorac Soc Vol 11, No 2, pp 224–226, Feb 2014 Copyright © 2014 by the American Thoracic Society DOI: 10.1513/AnnalsATS.201308-258PS Internet address: www.atsjournals.org
Dramatic changes in smoking behavior and attitudes about smoking have occurred over the 50-year interval since the release of the 1964 smoking and health report (1) of an advisory committee to Surgeon General Luther Terry. More than half of those who are currently ever smokers have quit (2), taxes on cigarettes have increased (3), locations where smoking is allowed have been greatly restricted (4), and cigarette smoking has been denormalized among both adolescents and adults as the result of tobacco-control efforts (5). These changes are legitimately characterized as one of the great public health achievements of the last half century. The unfortunate corollary of that accomplishment, however, is that with all of the evidence that has been amassed, all of the tools that have been developed, and all of the effort that has been expended, nearly half of those ever smokers are still smoking. This glass slightly more than half full provides an opportunity to reflect on the changes over the past 50 years to 224
understand how they came about and how we might accelerate change going forward. In 1965, the prevalence of cigarette smoking for those over age 18 years was 51.9% among men and 33.9% among women (6). By 2011, prevalence had fallen to 21.6% among men and 16.5% among women (7). One additional important trend in smoking prevalence is the increasing fraction of smokers who do not smoke every day. In 2011, that percentage was 22.2% nationally (7), with more than onethird of all smokers being nondaily smokers in some states with very low smoking prevalence, such as California. This trend has been accompanied by a dramatic fall in the percentage of all smokers who smoke more than one pack per day and a fall in the average number of cigarettes smoked per day even among daily smokers (7). Some of this shift may be explained by the increasing fraction of all smokers under age 30 years among whom occasional smoking, as a stage of smoking initiation, is more
common, but it also appears that the fraction of occasional smokers is increasing even among smokers at ages when initiation is rare. Effects of cost, restrictions on where smoking is allowed, and increasing cessation activity are additional potential explanations for this trend, and one hoped-for outcome would be a reduction in the intensity of nicotine addiction that may accompany the reduced frequency of smoking, particularly the trend toward nondaily smoking. Federal taxes have increased from $0.08 in 1965 to $1.01, with even larger increases in many state taxes (3). Workplace restrictions on smoking have increased from only 3% of workers protected by workplace smoking bans in 1986 (e.g., those working in fireworks factories) to more than 70% of workers being protected in 1999 (8), and only 22.9% of workers report exposure to other smokers’ tobacco smoke during the past 7 days (9) in 2010. Equally dramatic changes have occurred in
AnnalsATS Volume 11 Number 2 | February 2014
PERSPECTIVES restrictions on smoking in the home (9), even in the homes of current smokers. The environment surrounding the smoker has become increasingly restrictive, and their behavior has become increasingly denormalized. Restrictions are commonly proposed for multifamily housing, and the entire campuses of many universities and workplaces are now smoke-free, with no designated smoking area. The changes in smoking behavior and changes in attitudes and norms about smoking are not uniformly distributed across populations of smokers. Race, ethnicity, income, sex, education, occupation, and other individual characteristics lead to different life experiences with smoking and different resultant smoking behaviors, attitudes, and norms. These differences are a substantial contributing factor to the differences in observed disease outcomes by socioeconomic status. One difference that has become increasingly disparate over time is the effect of the state in which one lives. The smoking prevalence for the heaviest smoking state (Kentucky) is more than twice the prevalence of the lowest prevalence state (California), even when Utah, with its large nonsmoking Mormon population, is excluded (9). Marked disparities also exist across states in tax rates on tobacco products and restrictions on where smoking is allowed by regulation as well as by environmental norms. The state-specific disparities in smoking prevalence appear to be selfreinforcing based on a series of synergies that influence smoking behavior. Logic dictates that states that have had the greatest success in achieving smoking cessation should have a remaining population of smokers with greater difficulty quitting. Those who have already quit must, almost by definition, have an easier time obtaining abstinence than those who have not yet quit, and one might expect that those states that have the largest fraction of ever smokers who have successfully quit would begin to see lower rates of cessation among those “hardened” smokers who remain. However, the opposite trend emerges when cessation attempts and success are examined (10). States with lower current prevalence, and higher fractions of ever smokers who have quit, continue to have higher rather than lower rates of cessation and cessation success. One explanation that has been offered for this observation (11) is that, Perspectives
even as the remaining population of smokers is composed of those who have more personal barriers to cessation, the environment surrounding those smokers has dramatically enhanced forces driving and supporting cessation. In that battle of opposing forces, the rate of change in the environment has outpaced the “hardening” of the residual smoking population. This social dynamic is self-reinforcing. For example, as the prevalence of smoking falls, it may be easier to pass tax increases, which in turn drive the prevalence down further. When there are fewer smokers, it is easier to pass restrictions on where smoking is allowed, and those restrictions then spread to the home environment, with the effect of these combined restrictions being a reduction of both smoking prevalence and number of cigarettes smoked per day. It is generally accepted that both the changes in the environment and the tobacco-control efforts that generate them have direct independent effects in reducing smoking prevalence. They also interact as described above. It is easier to raise taxes and restrict smoking when the prevalence of smoking is low. Thus, the reality underlying these parallel tobacco-control trends is not passive; it is actively synergistic. Changes in workplace rules about smoking are more effective in promoting cessation if there is support for cessation from tobacco-control programs. Implementation of these workplace rules precipitates restrictions on smoking in the home and changes the norms about the acceptability of smoking in the general environment. Denormalization of tobacco use reduces initiation and promotes cessation as well as providing political support for increases in taxation. Thus, each individual change not only alters smoking behavior directly but also facilitates a cascade of other environmental changes, which spiral back to reinforce support for, and the effectiveness of, the original intervention. Reinforcement across tobaccocontrol modalities is likely to be even greater when very powerful policy changes, such as increases in cigarette taxes, are implemented. Nevertheless, the strength of the wide array of tobacco-control strategies as they interact with one another, even without the effect of increases in taxation, is demonstrated by the success of California in lowering smoking prevalence even in the face of the modest contribution of its rank of 33rd in cigarette tax rates among the states (CDC 2103). This synergy offers the hope
that future declines in cigarette smoking may accelerate as the social approval that allowed smoking to flourish is replaced by restrictions, barriers, and social disapproval, encouraging and supporting even hardened smokers in their efforts to successfully quit. The result may be an acceleration of the decline in smoking prevalence, as some critical level of smoking prevalence needed to provide social support for smoking is crossed. This increase in cessation activity has been observed among those aged 18 to 64 in recent data from the National Health Interview Survey (2). The progressively enlarging disparities across groups and geographic locations result in a diminished value for national estimates of phenomena associated with smoking and a rising value of data from groups defined by geography or individual characteristics. Examination of the disparities of tobacco-control forces and resulting effects on smoking behaviors across states provides an understanding of what is effective. A similar examination of the group-specific environmental forces surrounding populations of smokers defined by their individual characteristics, and study of the network of interactions those smokers experience, is currently the goal of many tobacco-control research efforts. A shift from national population data to data on norms, perceptions, and behaviors denominated by these subgroups of the population is needed for the data to be relevant for future tobacco-control efforts. Even state-specific data may have less relevance when considering strategies to reach smokers as the residual smoking population moves to clusters defined by a multitude of individual factors such as education, urban/rural residence, or characteristics such as the presence of mental illness. As we move to consideration of the unique or distinct environmental features surrounding these residual clusters of smokers in the population, we gain better insight into the challenges of reaching these smokers and the difficulties in changing the norms and pressures that impact them as a subpopulation distinct from the general environment. Rightly or wrongly, these groups are often considered hard to reach and “hardened” to the conventional approaches to tobacco control and population-based cessation. New programmatic efforts are developed that use data derived from each specific group to customize distinct cessation approaches for 225
PERSPECTIVES that unique group, with a perceived need for group-specific messaging and original program elements crafted based on the differences in that group’s microenvironment. This crafting is critical for evolution of tobacco-control programs to match the shifting smoking population; however, crafting programs based solely on the differences may create a blind spot to the reality that the same forces that influence the general population are also likely to have an effect on the new subgroups as well. It is important not to lose the potential synergies of these population-wide effects as we focus on the residual subpopulations of smokers. For example, the substantial and potentially growing fraction of current smokers with mental health issues (12) suggests that provision of cessation services as an element of treatment programs should be encouraged, and few would dispute that approach as a reasonable treatment synergy. However, limiting the locations in which tobacco products are sold, a program traditionally associated
with adolescent prevention efforts, and efforts to raise other barriers to purchase (e.g., cost) may have a powerful effect on the most severely mentally ill population, who can have more limited personal and financial resources to overcome these barriers. In our narrowed focus on the specifics of the residual smoking population, the reality that these populations have been slower to respond to global tobacco-control influences should not be taken as a demonstration that these global strategies have no effect and can be abandoned. Tobacco control has been a remarkably successful public health effort, but nicotine addiction retains a powerful hold on a large segment of the U.S. population. Our past success should not blind us to the need to change our approaches as the characteristics of the smoking problem change. Our past success is also no guarantee of continued future declines. We can draw on what we learn from differences across states in the effectiveness of tobacco-control efforts, and from national data defining specific populations, as we
References 1 U.S. Department of Health, Education, and Welfare. Smoking and health: report of the Advisory Committee to the Surgeon General of the Public Health Service. Washington: U.S. Department of Health, Education, and Welfare, Public Health Service, Center for Disease Control; 1964. PHS Publication No. 1103 [accessed 6 July 2013]. Available from: http://profiles.nlm.nih.gov/NN/B/C/X/B/ 2 Centers for Disease Control and Prevention. Quitting smoking among adults—United States, 2001-2010. MMWR Morb Mortal Wkly Rep 2011;60:1513–1519. 3 Orzechowski and Walker. The tax burden on tobacco – 2011 [accessed 6 July 2013]. Available from: http://www.taxadmin.org/ fta/tobacco/papers/Tax_Burden_2011.pdf 4 U.S. Department of Health and Human Services. The Health consequences of involuntary exposure to tobacco smoke: a report of the surgeon general. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2006 [accessed 6 July 2013]. Available from: http://www.surgeongeneral.gov/library/reports/secondhandsmoke/ report-index.html 5 U.S. Department of Health and Human Services. Preventing tobacco use among youth and young adults: a report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2012 [accessed 6 July 2013]. Available from: http://www.surgeongeneral.gov/library/reports/preventingyouth-tobacco-use/full-report.pdf 6 U.S. Department of Health and Human Services. Women and smoking. A report of the surgeon general. Rockville, MD: U.S. Department of
226
7
8
9
10
11
12
shift our focus to the residual, and likely tougher, subgroups of the population who remain heavily addicted. Examining the environmental realities of these subgroups to help design and evolve tobacco-control efforts as we move forward must play an increasing role and absorb greater resources if we are to be successful. As we move forward, the lessons of the past tell us that cigarette smoking is an addiction, and, as is true for all addictions, a tolerant cultural context is essential for its continued existence. It is changes in that cultural context that deserve the bulk of the credit for the decline in smoking prevalence that has occurred over the past 50 years, rather than changes in our successful treatment of addiction as a brain disease. Equally arguable and equally hopeful, it may be the evaporation of the remaining societal support for smoking as prevalence drops below a critical threshold that ultimately produces the “end game” for cigarette smoking in the United States. n Author disclosures are available with the text of this article at www.atsjournals.org.
Health and Human Services, Public Health Service, Office of the Surgeon General; 2001. p. 36 [accessed 6 July 2013]. Available from: http://www.cdc.gov/tobacco/data_statistics/sgr/2001/ complete_report/index.htm Centers for Disease Control and Prevention. Current cigarette smoking among adults - United States, 2011. MMWR Morb Mortal Wkly Rep 2012; 61:889–894. Shopland DR, Anderson CM, Burns DM, Gerlach KK. Disparities in smoke-free workplace policies among food service workers. J Occup Environ Med 2004;46:347–356. Centers for Disease Control and Prevention. Tobacco control state highlights 2012. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2013 [accessed 6 July 2013]. Available from: http://www.cdc.gov/tobacco/data_statistics/state_data/ state_highlights/2012/sections/index.htm Burns D, Warner KE. Smokers who have not quit: is cessation more difficult and should we change our strategies? Burns D, editor. In: Those who continue to smoke: is achieving abstinence harder and do we need to change our interventions? Smoking and Tobacco Control Monograph No. 15, USDHHS, NIH, NCI, NIH Pub. No. 03–5370, pp. 11–31, 2003 [accessed 6 July 2013]. Available from: http://cancercontrol.cancer.gov/brp/tcrb/monographs/15/ monograph15-chapter1.pdf Warner KE, Burns DM. Hardening and the hard-core smoker: concepts, evidence, and implications. Nicotine Tob Res 2003;5: 37–48. Centers for Disease Control and Prevention. Vital signs: current cigarette smoking among adults aged >18 years with mental illness - United States, 2009-2011. MMWR Morb Mortal Wkly Rep 2013;62:81–87.
AnnalsATS Volume 11 Number 2 | February 2014
