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PUBLIC POLICY FOR THE CONTROL OF TOBACCORELATED DISEASE Michael F. Bierer, MD, MPH, and Nancy A. Rigotti, MD
Although tobacco use in North America predated the arrival of Columbus and tobacco was a major crop of the Colonies, cigarette smoking is primarily a phenomenon of the twentieth century. Adult per capita cigarette consumption was extremely low in 1900 but rose steadily throughout the first half of the century (Fig. 1), peaking in 1963 at a rate of 4345 cigarettes per year for each adult. Scientific studies first cited cigarette smoking as a health concern in the 1930s, and strong epidemiologic links between smoking and lung cancer appeared in the 1950s. However, for tobacco control in the United States, the watershed year was 1964, when the first Surgeon General's Report on Smoking and Health was released. 53 This landmark document, a carefully peerreviewed consensus of medical knowledge at the time, concluded that cigarette smoking "is causally related" to lung cancer and laryngeal cancer in men, causes chronic bronchitis, and is associated with an increased risk of a variety of other illnesses, including coronary artery disease. Based on this evidence, the advisory committee that produced the report concluded that "Cigarette smoking is a health hazard of sufficient importance in the United States to warrant appropriate remedial action."53 That report-controversial in its day but now well-acceptedlaunched what has since been called "the anti-smoking campaign," consisting of a "wide variety of private and public sector activities intended to reduce the disease burden of tobacco use." S1 Although some tobacco control efforts had begun earlier, sustained public health From the General Internal Medicine Unit, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts MEDICAL CLINICS OF NORTH AMERICA VOLUME 76· NUMBER 2 • MARCH 1992
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and policy efforts to reduce these hazards largely began in 1964 and have expanded over the ensuing years. Early efforts were directed at educating smokers about the health hazards of cigarettes and expanding scientific knowledge of the health consequences of smoking. This was followed by efforts to restrict cigarette advertising and then the development of the nonsmokers' rights movement, the latter fueled by changing public attitudes about the acceptability of smoking and growing epidemiologic evidence about health risks of involuntary smoking. More recently, efforts to restrict children's access to tobacco products, to hold cigarette manufacturers legally responsible for the dangers of their products, and to increase the excise tax on cigarettes have gained more attention. Government actions aimed at reducing the health consequences of smoking have occurred at all levels-city, state, and federal-and have been supported by a wide spectrum of groups promoting the development of tobacco control policies. Currently, these range from local grass-roots advocacy groups focusing on a particular cause such as nonsmokers' rights, to the Coalition of Smoking OR Health, formed in 1982 to coordinate public policy activities for the American Cancer Society, American Lung Assocation, and American Heart Association. Opposing these groups is the well-funded tobacco lobby, a collection of interest groups whose goal is to protect the economic and political interests of tobacco manufacturers and growers. Current public policy on tobacco is a product of a quarter century of struggle between these opposing forces. Although stronger policies are needed, the antismoking campaign, in aggregate, has clearly influenced smoking behavior.59 Adult per capita cigarette consumption has fallen 3% to 8% in years of major antismoking events, such as the release of the 1964 Surgeon General's Report on Smoking (Fig. 1).51 Warner has estimated that both per capita cigarette consumption and smoking prevalence would be far greater today in the absence of the antismoking campaign since 1964. He estimates that approximately 789,000 premature deaths were averted between 1964 and 1985 as a result of this campaign. 59 Nonetheless, tobacco smoking remains the major preventable cause of death in the United States, responsible for an estimated 434,000 deaths in 1988. 15 Stronger public policies and private sector initiatives are clearly needed to control the epidemic of tobacco-related disease. This review focuses on public policies whose goal is to reduce tobacco use. We summarize present and proposed policies, addressing their rationale, current status, and the evidence for their effectiveness in reducing tobacco smoking. Although it is clear that tobacco control policies, taken together, have affected smoking behavior, it has been more difficult to identify the independent effect of individual policies because different actions overlap in time, and the opportunities for controlled experiments are few. Nonetheless, we review what is known about each policy's effectiveness. We conclude by addressing how a physician can influence the environment through shaping policy. For this review, the term policy encompasses rules or laws that shape the environment with the aim of affecting smoking behavior.
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lit Surgeon General's R.port
ADULT PER CAPITA CONSUMPTION 4500 4000
F.lrnell Doctrine
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Mtlllgeson
TV .nd IIIdlo
lit
SmokingC.ncer Concern
3000
Nonsmokm Rights Movement
Begins
2500 2000
Fed,r.t Ciger,1Ie Tu Doubles
1500
1000 500
1900
1920
1940
YEAR
1960
1980
Figure 1. Adult per capita cigarette consumption related to major smoking policy events in the United States. (From US Department of Health and Human Services, Public Health Services, Centers for Disease Control: Smoking Control Policies. In Reducing the Health Consequences of Smoking: 25 Years of Progress. A Report of the Surgeon General. Rockville, MD, DHHS Publication No (COG) 87-8411, 1989.)
TOBACCO CONTROL POLICIES: AN OVERVIEW
The range of current and proposed tobacco control policies is broad. To organize them, we have adopted a taxonomy of policy types originally proposed by Walsh and Gordon 55 ; (1) efforts to inform or persuade; (2) economic incentives to discourage tobacco use; and (3) direct restraints on tobacco use (Table 1). Policies in the first category aim to educate the public about the health risks of cigarette smoking and to persuade individuals to stop or not to start smoking. The category also includes policies that attempt to restrict the persuasive, prosmoking messages of tobacco advertising. Policies in the second category increase the cost of smoking to the smoker by increasing the price of cigarettes or the cost of insurance premiums. Recent efforts to establish the legal liability of tobacco manufacturers for the hazards of their product-so-called tobacco product liability suits-are included in this category because proponents have argued that the lawsuits, if successful, will affect cigarette use via economic means. For tobacco
C.Il
I-'
00
Table 1. TAXONOMY OF TOBACCO CONTROL POLICIES: ACTUAL AND PROPOSED Information and Education
1. Require health warnings on packages or advertisements 2. Mandate education programs A. Schools B. Mass media (counter·advertising) 3. Restrict or ban advertising and promotion 4. Issue government reports (e.g., Surgeon General's Reports) 5. Require disclosure of constituents of tobacco products or smoke*
Economic Incentives
1. Increase tobacco taxation (e.g., excise tax) 2. Mandate insurance incentives A. Premium price differentials (smokernonsmoker) B. Cover smoking cessation treatment costs 3. Change tobacco crop price support system 4. Establish legal liability A. Of purveyors/manufacturers B. Of employers for environmental tobacco smoke exposure
Direct Restraints on Tobacco Use
1. Restrict smoking in certain places (e.g., public places, workplaces, schools, hospitals) 2. Restrict distribution or sales A. By age (minors) B. Via certain outlets (e.g., vending machines) 3. Regulate production composition* 4. Ban manufacture, sale, or use
*Not discussed in this report. Modified from US Department of Health and Human Services, Public Health Service, Centers for Disease Control: Smoking control policies. In Reducing the Health Consequences of Smoking: 25 Years of Progress. A Report of the Surgeon General. DHHS Publication No (CDC) 87'8411, 1989.
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manufacturers, the cost of defending these suits will require increases in the price of cigarettes which will reduce tobacco consumption. Tobacco farm policy is also included in this category and is discussed briefly. The final category of policies includes diverse actions that reduce the opportunity to smoke by restricting who may smoke (e.g., adults only) or where smokers may light up (e.g., not in public places or at work). This category also includes the strongest potential policya total ban on tobacco sales and use-and the review discusses why such a ban is not likely to be adopted. Information and Education
Congress' first action in the wake of the 1964 Surgeon General's Report was to attempt to inform the public about the hazards of tobacco use by requiring cigarette packages to carry health warning labels. Since then, the message about the hazards of tobacco use has broadened considerably and now includes the health effects of involuntary tobacco smoke exposure, the addictive nature of tobacco smoking, the health effects of other tobacco products, and methods of quitting smoking. Mandated efforts to educate the public have remained the mainstays of government action on tobacco for the past quarter century. Congress has required a growing array of warning labels on tobacco products and advertisements, mandated the production of a yearly Surgeon General's Report summarizing new scientific knowledge about the health risks of tobacco, and restricted some forms of tobacco advertising. Individual states have required that schools teach curricula on tobacco and health. Warning Labels on Tobacco Products. Eleven days after the Surgeon General released the 1964 Report of the Advisory Committee on Smoking and Health linking tobacco smoking to lung cancer, the Federal Trade Commission (FTC) released recommendations that strongly worded warning messages be required on tobacco products and advertisements. 51 Before it took effect, the FTC rule was pre-empted by Congressional action mandating a less definitive message. On January I, 1966, the words "Caution: Cigarette Smoking May Be Hazardous to Your Health" began to appear on cigarette packages, but not on advertisements. Over the ensuing two decades, a similar series of dramatic struggles occurred, with the FTC generally taking a strong pro active stance on the requirement to warn the public and Congress acting to vitiate FTC recommendations. The result was an evolving series of warning labels on packages and advertisements. In 1970, the original label was replaced with a stronger message, "WARNING: The Surgeon General Has Determined That Cigarette Smoking Is Dangerous to Your Health," which remained for 15 years. Congress acted again in 1984, prodded by an FTC report that the existing label was inadequate because it did not name the specific risks of smoking and because it had lost effectiveness after 15 years of exposure. Since 1985, a rotating
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set of four new "Surgeon General' s Warnings" has been required on all cigarette packages and advertisements in the United States: "Smoking Causes Lung Cancer, Heart Disease, Emphysema, and May Complicate Pregnancy." "Smoking by Pregnant Women May Result in Fetal Injury, Premature Birth, and Low Birth Weight." "Quitting Smoking Now Greatly Reduces Serious Risks to Your Health." "Cigarette Smoke Contains Carbon Monoxide." In 1986, a similar rotating warning-label system was mandated for smokeless tobacco packages and advertisements. 7 Existing warning labels in the United States are tame by the standards of some other countries. For example, they stand in stark contrast to prominent new messages slated to appear on tobacco products sold in Great Britain as of 1991. These messages (e.g., "Smoking Kills," "Smoking Causes Cancer," and "Protect Children: Don't Make Them Breathe Your Smoke") will be enhanced by greater size on the package. 7 US warning labels have been criticized for being too wordy, using technical terms that may be misunderstood, stating facts rather than delivering clear warnings, lacking visual imagery that might enhance the message (especially when appearing in tobacco advertisements), and being difficult to see, especially in advertisements and on billboards, where studies have found that they are not noticed, or at least not remembered. 21 , 25 Current legislation does not provide mechanisms for updating the contents of messages to reflect new knowledge or to prevent overexposure, Finally, current warnings do not cover one of the least known but most important facts about smoking behavior-its addictive nature, There has been little study of the effectiveness of warning labels in altering smoking behavior. Although not provable, it is likely that warning labels attracted considerable attention when they first appeared on cigarette packages in 1966 and may have contributed to the decline in tobacco use that occurred shortly after the original Surgeon General's Report. It is less clear that warning messages continue to discourage cigarette use. School Curricula About Tobacco and Health. Efforts to prevent the initiation of smoking are a cornerstone of any effort to reduce the health consequence of tobacco use. Because nearly all cigarette smokers start to smoke in childhood or adolescence, young people must be informed about the hazards of tobacco use-not only its health consequences, but also its addictiveness. Government could play a role in this process by ensuring that such initiatives are universal and meet certain standards, but the Federal Government has taken no action on this subject, Many states, however, have taken a lead by requiring education about tobacco as part of general health or drug-abuse prevention curricula. A few states require proficiency in knowledge of nicotine and tobacco effects as part of teacher certification. The level of
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compliance with these state laws and the effects of such teaching on the initiation of smoking are not known. 51 Tobacco Advertising and Promotion. Cigarettes are one of the most heavily advertised consumer products in the United States. Cigarette manufacturers spent $2.4 billion promoting their products in 1986 and $3.3 billion by 1988. 14• 60 In 1985, cigarettes were the most heavily advertised product category on billboards, second in magazines, and third in newspapers. 19 In addition, tobacco manufacturers promote cigarettes in ways other than traditional print advertising. These include the distribution of free tobacco products and the sponsorship of sporting events, concerts, and other events like the 1990-1991 tour of the National Bill of Rights, underwritten by Phillip Morris. Expenditures on these promotional activities have risen at least 25-fold over the past 20 years and now total $1.5 billion per year. 14 Tobacco manufacturers have spent a growing proportion of their marketing budgets on promotional activities rather than traditional advertising. Promotional activities accounted for only 13% of the budget in 1970, whereas by 1988 they made up 61 %.14. 60 Broadcast of sponsored sporting events, such as the Marlboro Grand Prix (an automobile race), affords dissemination of cigarette brand-name and logo in association with thrilling athletic achievement without the appearance of any product warnings. 9 Public health interest in tobacco advertising and promotion derives from concerns that advertising encourages individuals to start smoking, stimulates cigarette consumption among the smokers, and impedes their efforts to quit. Supporting this is the common observation that tobacco advertising associates smoking with culturally desirable qualities such as sexual attractiveness, good health, vigorous outdoor activities, and material and social success. 51 Tobacco manufacturers counter that they do not intend to advertise to children and that their advertisements do not increase demand; rather, advertisements only lead established smokers to switch brands. They assert that they are merely advertising a legal product. Empirical evidence about the effects of tobacco advertising has been methodologically difficult to assemble, and the effects of tobacco promotion have not been studied. Currently available evidence is diverse in methods and conclusions. The best studies examine the relationship between cigarette advertising expenditures and cigarette consumption, using techniques of regression analysis. The results are conflicting, but some have found small relationships between advertising expenditures and cigarette sales. The 1989 Surgeon General's Report reviewed these data in detail and concluded: "There is no scientifically rigorous study available to the public that provides a definitive answer to the basic question of whether advertising and promotion increase the level of tobacco consumption." However, it also noted that review of all available types of evidence strongly suggests that advertising and promotional activities do stimulate cigarette consumption. 51 Other public health concerns about tobacco advertising have been raised. It has been suggested that the promotion of low-tar, lownicotine cigarettes serves to falsely reassure smokers that these are safer
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cigarettes and that they present an alternative to stopping smoking. 19 Another concern about tobacco advertising is that it interferes with efforts to inform the public about the health hazards of tobacco smoking because media that accept tobacco advertising provide less coverage about the harm of tobacco use. There is substantial evidence documenting an inverse relationship between magazines' tobacco advertising budgets and the extent of their coverage of tobacco and health issues. 56 A final, broader concern is that the presence of tobacco advertisements in the environment reduces public perceptions that smoking is objectionable or dangerous. Although this is hard to prove, 44% of Britons in a 1986 survey, for example, believed that if cigarette smoking was seriously hazardous, then the government would have forbidden advertising. 14 Concern about the prosmoking effects of tobacco advertising has led to numerous proposals to limit tobacco advertising and promotion. To date, the strongest federal actions taken have been to prohibit cigarette advertising on broadcast media (e.g., radio and television) in 1971 and to extend that ban to cover smokeless tobacco products in 1986. 51 State and local governmental initiatives have been limited because the federal law banning broadcast advertising also pre-empted states from regulating tobacco advertising for health-related reasons. However, states and localities have some leeway to regulate local advertising media; for example, tobacco advertising is banned on many municipal transit systems. Proposals that would further limit tobacco advertising and promotion are widely discussed in the public health community. A bill containing the strongest proposal-a total ban on all tobacco advertising and promotion-has been introduced (but not passed) in previous Congressional sessions, and the proposal has been widely supported by medical and public health organizations. 51 Its success has been limited in part by controversy over whether commercial speech (e.g., advertising) should have the same Bill of Rights protection as noncommercial speech. Less comprehensive proposals include those that would impose stronger limits on the permissible imagery of advertisements, limit some elements of tobacco promotion such as free distribution of cigarette samples, and remove the tax deductibility of tobacco advertising, thereby effectively increasing the cost of advertising. 51 An alternate proposal would attempt to counter the effect of tobacco advertising by requiring the media to publish or broadcast antismoking messages-so-called counter-advertising. There is some evidence that this approach can be effective. In 1967, when radio and television tobacco advertisements were still permitted, the Federal Communications Commission ruled that broadcasters had to allot time to Public Service Announcements that counterbalanced the message of tobacco advertising. During the 3 years when these were broadcast (1968 to 1970), per capita cigarette sales fell by 6.9% and smoking by adolescents declined by 3% (Fig. 1).51 Although counter-advertising proposals are appealing, identifying the source of funds to support them has been more difficult.
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Economic Incentives
Economic forces can discourage tobacco use by increasing the costs of manufacturing, selling, or consuming tobacco products. Governments can influence the price of tobacco products by taxing them, thereby directly affecting consumers. Insurers' policies can provide more indirect economic incentives; by making the smokers' premiums more expensive, insurers can effectively increase the cost of being a smoker. Tobacco crop price supports exert economic incentives on the producer and, indirectly, on the consumer of tobacco. Finally, tobacco product liability suits, if successful, may serve to increase tobacco manufacturers' costs of doing business. Tobacco Excise Taxes. Excise taxes-sales taxes on a specific product-have been levied on tobacco products since colonial times. Currently, the Federal Government, all states, and nearly 400 cities and counties impose an excise tax on cigarettes. In 1989, excise taxes added an average of 38 cents to the price of a pack of cigarettes: The federal tax was 16 cents, and the average state tax was 22 cents. 49 The federal tax was increased to 20 cents on January 1, 1991, and will increase to 24 cents in 1993. State taxes vary widely from 2 cents in North Carolina to 40 cents in Connecticut. Generally, they are lower in tobacco-growing states. 49 Cigarette excise tax rates, in constant dollar terms, have fallen since 1964, because the periodic increases in cigarette taxes have not kept pace with inflation. Furthermore, the tax rate as a percentage of retail price has declined, indicating that manufacturers have increased cigarette prices at a faster rate than the tax increases mandated by government. 51 The effect of excise taxes on tobacco consumption has been carefully studied by economists, who have calculated the price elasticity of demand for cigarettes-an estimate of how much the quantity purchased decreases with a given rise in price. Contrary to expectation about a highly addictive substance, there exists significant price elasticity of demand for tobacco products. Younger age groups are particularly sensitive to increases in price, which appear to decrease not only cigarette consumption but the rate of initiation of smoking by adolescents. 37, 38, 51 This has important implications: Because most smokers develop dependency before age 20, excise taxes have their greatest impact on this vulnerable group and may be useful tools for preventing the initiation of smoking. Empirical studies have demonstrated that excise tax increases do reduce smoking. Following the doubling of the federal excise tax on cigarettes in 1983, the quantity of cigarettes purchased decreased by 12%.51 The benefit of a tax increase, in terms of morbidity and mortality, is seen many decades after the increase, as the cohort with a lower prevalence of smoking comes of age. It has been projected that the 1983 increase in federal excise tax will ultimately avert 860,000 premature smoking-induced deaths among AmericansY Further evidence derives from comparing the United States with Canada, where tobacco
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taxes are far higher. In Canada, taxes account for fully two thirds of the price of cigarettes and add the equivalent of US $2.25 to the cost of a pack of 20 cigarettes, whereas in the United States taxes add only $0.38. As would be expected, the slope of the decline in per capita tobacco consumption in Canada is significantly steeper than in the United States. 33 Thus, cigarette excise taxes are a public policy tool whose potential to reduce tobacco use-and especially prevent the initiation of smoking-is particularly well documented. There is wide support in the public health and medical communities for increasing tobacco excise taxes, adjusting their method of calculation so that their real value is not eroded by inflation, and channeling (or "earmarking") the revenues generated from tobacco taxes to fund other anti tobacco and prohealth activities. 51 Tobacco excise taxes are also politically attractive because they generate revenue. Opponents of cigarette excise-tax increases criticize them for being regressive. They argue that these taxes widen disparities in income rather than equalize them, because the tax burden attributable to tobacco is proportionately greater for the poor than it is for the wealthy. Proponents of excise taxes counter that tobacco is not a necessary commodity and that it may be desirable to provide an economic disincentive for poorer individuals to purchase this product. The California Experience. The State of California recently increased its tobacco excise tax dramatically, providing the nation with a natural experiment for observing the effects of increasing taxation and earmarking resulting revenue to fund antitobacco activities. Proposition 99, the Tobacco Tax and Health Promotion Act, was passed by citizen referendum in California in 1988. The law raised the state excise tax on cigarettes by an additional 25 cents per pack. Revenues raised by the tax, estimated at nearly $600 million per year, go into a Tobacco Product Surtax Fund. The Surtax Fund supports many dimensions of health improvement in the state, much of it tobacco-related: education of children to prevent smoking; training of health care providers in techniques to help smokers quit; research on tobacco-related disease; and a large and impressive state wide media campaign designed to counter the false images created by tobacco advertising. The media campaign, totalling more than $28.6 million, is the largest media effort sponsored by any government unit in the United States. 3 The goal of the law was to create a multipronged approach to smoking cessation and prevention and thereby reduce tobacco use. California's initiatives permit evaluation of the combined effects of counter-advertising and increased cigarette prices on tobacco use. At the time of its passage, 25% of Californians smoked, and the burden of smoking-related costs in the state was estimated to be $7.1 billion annually. Despite some tobacco industry counterattacks on the California Tobacco Tax Initiative, the law is having significant impact. The prevalence of smoking among Californians older than age 20 in 1990, the year following the tax increase and new educational program, was projected to be 24.6%. The observed rate was 21.4%, a statistically
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significant reduction of 13% compared with the expected rate. 40 Tobacco consumption also fell faster than projected after the law, giving additional support to the conclusion that the California experiment is reducing smoking in that state. 40 The multiplicity of the programs in California, however, makes it difficult to isolate the independent effects of the increased cost of tobacco and the counter-advertising campaign. Insurance Premium Differentials. Insurance companies in most states are legally entitled to consider smoking status in determining the price of policies. Soon after the release of the 1964 Surgeon General's report on smoking, the first life insurance policy with discounted rates for nonsmokers was offered. Over the next decade, 30 more companies followed suit. In 1979, the first actuarial analysis of mortality differences revealed a 100% to 125% mortality excess for smokers. 51 As of 1986, most of the largest companies offered premium differentials, and discounts for nonsmokers (or surcharges for smokers) were as great as 40%. The maximum dollar savings for not smoking was approximately $300 per year on a $150,000 policy; the minimum was $10 on a $25,000 policy. 51 The health insurance market differs from that of life insurance. Most private health insurance is sold to groups, not individuals, which makes it logistically difficult to offer different rates based on individual behavior. Health maintenance organizations must set rates based on community experience and must petition the Federal Government to use smoking as a criterion for modification of rates. Only about 15% of health insurers selling individual policies offer discounts to nonsmokers, and the average discount is about 10%.51 Some property and auto insurance premiums are also cheaper for nonsmokers, because nonsmokers have a lower rate of claims on both types of policies. The effects on smoking of rate differentials for insurance policies are unknown but could work by several means. 51 The increased cost of being a smoker, although not present at every pack-purchasing decision, probably confers some inducement not to smoke. There may also be a social message about the undesirability of smoking conveyed by the increased premium. These effects are mitigated by the relative infrequency of policy purchasing (i.e., usually only once per policy covering many years), the paucity of reminders about smoking from the insurance company after the purchase is made, and the usual practice of sharing the cost of a policy with employers. Reimbursement for Smoking Cessation Programs. Just as the cost of smoking influences its frequency and prevalence, so too may the economic cost of quitting influence the likelihood that a smoker will give up the habit. It has been suggested that the cost of a cessation program may serve as a barrier to quitting and that if cessation programs were covered by a third party, more smokers would use them. 51 Health insurers have largely taken the position that they need data showing that the treated former smoker is cheaper, in aggregate, than the nontreated smoking policyholder before they will cover the cost of cessation programs and treatment in their packages of services. No good data to this effect currently exist. Only 11 % of health insurers surveyed in 1985 covered the cost of cessation programs for policy hold-
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ers with diagnoses secondary to tobacco abuse, and none did for policyholders without a smoking-related diagnosis, unless such coverage was purchased as part of a special package. 51 Tobacco Crop Price Support Programs. The "tobacco subsidy" arrangement, whereby the US Government assures US farmers the receipt of set prices for tobacco crops, does not directly affect smoking behavior but may have indirect effects. Most important, as Warner has written, it "looms large as a symbol" of at least partial government support of the tobacco industry.s8 In recent years, tobacco manufacturers have imported more tobacco and decreased their demand for domestic leaf, thereby decreasing the market price of tobacco. As a result, maintaining the price of tobacco costs ever more; by the mid1980s, the cost exceeded $1 billion. Furthermore, by shielding farmers from the effects of decreased domestic demand on tobacco prices, the subsidy discourages exits from the market and the planting of alternative crops. It thus helps to maintain the economic and political strength of the tobacco lobby. Direct Restrictions on Smoking
A third category of public policy acts directly to reduce tobacco by limiting an individual's access to tobacco products or the opportunity to use them. The strongest policy of this type would be a total ban on the sale, possession, or use of tobacco products, analogous to laws regarding other addictive substances such as heroin or cocaine. Such a policy is unlikely to be adopted for several reasons. First, tobacco was widely used and socially accepted long before its health hazards and addictive potential were fully appreciated. Second, sales of tobacco products are supported by strong economic and political interests. Third, the failure of alcohol prohibition suggests that a ban on tobacco sales would be similarly difficult to enforce. Short of a total ban on sales are policies restricting where smoking may occur and who may buy cigarettes; those are covered in this section. State and local governments, rather than the Federal Government, have taken the lead in this tobacco control issue. Smoking Restrictions in Public Places and Workplaces. Over the past two decades, a wave of social actions restricting or banning smoking in public places and workplaces has developed. This is the result of mounting scientific evidence about the health risks of involuntary tobacco smoke exposure and growing public anti smoking sentiment. 42 ,SO Actions have occurred in both the public and private sectors, ranging from federal, state, and local legislation mandating smoking restrictions, to limits adopted voluntarily by private businesses, hospitals, hotels, and schools. The result is a patchwork of smoking restrictions that affect the daily lives of a growing number of Americans. Although the Federal Government has taken some action-most prominently, the legislation banning smoking on virtually all domestic airline
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flights as of 1989-the majority of public sector actions have occurred at the state and local levels,17 where a growing number of states and communities have enacted laws restricting smoking in public places and workplaces. Less often, state and local governments have used their administrative powers to limit smoking, such as issuing executive orders banning smoking in government buildings or health department regulations requiring restaurant no-smoking sections. The intent of these laws, regulations, and policies is to reduce individuals' exposure to passive smoke, but their impact may be broader. They have the potential for far-reaching effects on the acceptability of cigarette smoking and on smoking behavior. They may, by limiting the times and places where smoking is permitted, reduce the prevalence of smoking by encouraging current smokers to quit and discouraging young people from adopting the habit. The laws are most likely to have these effects if they are comprehensive in coverage. Because adults spend more time at work than in any other single place outside the home, it is likely that laws limiting smoking in all worksites will have the greatest effect on smoking behavior and attitudes. They will also offer the greatest protection from passive smoking exposure. 42,50 Smoking has been addressed by state laws for a century. Early laws limited smoking in selected areas such as stables to prevent fires or explosions. These differ from the current round of laws, which were first enacted at the state level after 1970 and at the local level around 1980 and which were often initiated by grassroots nonsmokers' rights groups, voluntary health organizations, or public health officials. These newer laws covered a wide variety of places and were specifically designed to protect nonsmokers from the annoyance and health effects of exposure to tobacco smoke. Even so, the laws vary in content, ranging from the weakest, which restrict smoking in government buildings or a handful of public places, to more comprehensive legislation, often termed clean indoor air acts, that restrict smoking in all enclosed public places, in restaurants, and in both public and private sector worksites (Fig. 2).51 As of 1988, 42 states and the District of Columbia had adopted a restriction on smoking in at least one public workplace, and a dozen states had adopted comprehensive clean indoor air acts. Southern states and major tobacco-producing states have relatively fewer laws. As of January, 1988, over 82% of Americans lived in states with some state law restricting smoking, compared with only 8% in 1971. 51 A more recent analysis of city no-smoking ordinances documented that the number of laws increased 10-fold between 1980 and 1989. By mid-1989, 51 % of US cities with a population greater than 25,000 had adopted some smoking restriction, and 17% had adopted comprehensive laws. 44 City laws are more common in larger cities and Western cities; they are less common in tobacco-producing states. If current trends continue, smoking restrictions in public places and workplaces can be expected to be the norm by the end of the century. Although these no-smoking laws are becoming widespread, there
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Number of SIlII" wtth laws in eneet
45
45 _
40
Extensive
40
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PUBLIC POLICY FOR THE CONTROL OF TOBACCORELATED DISEASE Michael F. Bierer, MD, MPH, and Nancy A. Rigotti, MD
Although tobacco use in North America predated the arrival of Columbus and tobacco was a major crop of the Colonies, cigarette smoking is primarily a phenomenon of the twentieth century. Adult per capita cigarette consumption was extremely low in 1900 but rose steadily throughout the first half of the century (Fig. 1), peaking in 1963 at a rate of 4345 cigarettes per year for each adult. Scientific studies first cited cigarette smoking as a health concern in the 1930s, and strong epidemiologic links between smoking and lung cancer appeared in the 1950s. However, for tobacco control in the United States, the watershed year was 1964, when the first Surgeon General's Report on Smoking and Health was released. 53 This landmark document, a carefully peerreviewed consensus of medical knowledge at the time, concluded that cigarette smoking "is causally related" to lung cancer and laryngeal cancer in men, causes chronic bronchitis, and is associated with an increased risk of a variety of other illnesses, including coronary artery disease. Based on this evidence, the advisory committee that produced the report concluded that "Cigarette smoking is a health hazard of sufficient importance in the United States to warrant appropriate remedial action."53 That report-controversial in its day but now well-acceptedlaunched what has since been called "the anti-smoking campaign," consisting of a "wide variety of private and public sector activities intended to reduce the disease burden of tobacco use." S1 Although some tobacco control efforts had begun earlier, sustained public health From the General Internal Medicine Unit, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts MEDICAL CLINICS OF NORTH AMERICA VOLUME 76· NUMBER 2 • MARCH 1992
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and policy efforts to reduce these hazards largely began in 1964 and have expanded over the ensuing years. Early efforts were directed at educating smokers about the health hazards of cigarettes and expanding scientific knowledge of the health consequences of smoking. This was followed by efforts to restrict cigarette advertising and then the development of the nonsmokers' rights movement, the latter fueled by changing public attitudes about the acceptability of smoking and growing epidemiologic evidence about health risks of involuntary smoking. More recently, efforts to restrict children's access to tobacco products, to hold cigarette manufacturers legally responsible for the dangers of their products, and to increase the excise tax on cigarettes have gained more attention. Government actions aimed at reducing the health consequences of smoking have occurred at all levels-city, state, and federal-and have been supported by a wide spectrum of groups promoting the development of tobacco control policies. Currently, these range from local grass-roots advocacy groups focusing on a particular cause such as nonsmokers' rights, to the Coalition of Smoking OR Health, formed in 1982 to coordinate public policy activities for the American Cancer Society, American Lung Assocation, and American Heart Association. Opposing these groups is the well-funded tobacco lobby, a collection of interest groups whose goal is to protect the economic and political interests of tobacco manufacturers and growers. Current public policy on tobacco is a product of a quarter century of struggle between these opposing forces. Although stronger policies are needed, the antismoking campaign, in aggregate, has clearly influenced smoking behavior.59 Adult per capita cigarette consumption has fallen 3% to 8% in years of major antismoking events, such as the release of the 1964 Surgeon General's Report on Smoking (Fig. 1).51 Warner has estimated that both per capita cigarette consumption and smoking prevalence would be far greater today in the absence of the antismoking campaign since 1964. He estimates that approximately 789,000 premature deaths were averted between 1964 and 1985 as a result of this campaign. 59 Nonetheless, tobacco smoking remains the major preventable cause of death in the United States, responsible for an estimated 434,000 deaths in 1988. 15 Stronger public policies and private sector initiatives are clearly needed to control the epidemic of tobacco-related disease. This review focuses on public policies whose goal is to reduce tobacco use. We summarize present and proposed policies, addressing their rationale, current status, and the evidence for their effectiveness in reducing tobacco smoking. Although it is clear that tobacco control policies, taken together, have affected smoking behavior, it has been more difficult to identify the independent effect of individual policies because different actions overlap in time, and the opportunities for controlled experiments are few. Nonetheless, we review what is known about each policy's effectiveness. We conclude by addressing how a physician can influence the environment through shaping policy. For this review, the term policy encompasses rules or laws that shape the environment with the aim of affecting smoking behavior.
517
PUBLIC POLICY FOR THE CONTROL OF TOBACCO-RELATED DISEASE
,
lit Surgeon General's R.port
ADULT PER CAPITA CONSUMPTION 4500 4000
F.lrnell Doctrine
3500
Mtlllgeson
TV .nd IIIdlo
lit
SmokingC.ncer Concern
3000
Nonsmokm Rights Movement
Begins
2500 2000
Fed,r.t Ciger,1Ie Tu Doubles
1500
1000 500
1900
1920
1940
YEAR
1960
1980
Figure 1. Adult per capita cigarette consumption related to major smoking policy events in the United States. (From US Department of Health and Human Services, Public Health Services, Centers for Disease Control: Smoking Control Policies. In Reducing the Health Consequences of Smoking: 25 Years of Progress. A Report of the Surgeon General. Rockville, MD, DHHS Publication No (COG) 87-8411, 1989.)
TOBACCO CONTROL POLICIES: AN OVERVIEW
The range of current and proposed tobacco control policies is broad. To organize them, we have adopted a taxonomy of policy types originally proposed by Walsh and Gordon 55 ; (1) efforts to inform or persuade; (2) economic incentives to discourage tobacco use; and (3) direct restraints on tobacco use (Table 1). Policies in the first category aim to educate the public about the health risks of cigarette smoking and to persuade individuals to stop or not to start smoking. The category also includes policies that attempt to restrict the persuasive, prosmoking messages of tobacco advertising. Policies in the second category increase the cost of smoking to the smoker by increasing the price of cigarettes or the cost of insurance premiums. Recent efforts to establish the legal liability of tobacco manufacturers for the hazards of their product-so-called tobacco product liability suits-are included in this category because proponents have argued that the lawsuits, if successful, will affect cigarette use via economic means. For tobacco
C.Il
I-'
00
Table 1. TAXONOMY OF TOBACCO CONTROL POLICIES: ACTUAL AND PROPOSED Information and Education
1. Require health warnings on packages or advertisements 2. Mandate education programs A. Schools B. Mass media (counter·advertising) 3. Restrict or ban advertising and promotion 4. Issue government reports (e.g., Surgeon General's Reports) 5. Require disclosure of constituents of tobacco products or smoke*
Economic Incentives
1. Increase tobacco taxation (e.g., excise tax) 2. Mandate insurance incentives A. Premium price differentials (smokernonsmoker) B. Cover smoking cessation treatment costs 3. Change tobacco crop price support system 4. Establish legal liability A. Of purveyors/manufacturers B. Of employers for environmental tobacco smoke exposure
Direct Restraints on Tobacco Use
1. Restrict smoking in certain places (e.g., public places, workplaces, schools, hospitals) 2. Restrict distribution or sales A. By age (minors) B. Via certain outlets (e.g., vending machines) 3. Regulate production composition* 4. Ban manufacture, sale, or use
*Not discussed in this report. Modified from US Department of Health and Human Services, Public Health Service, Centers for Disease Control: Smoking control policies. In Reducing the Health Consequences of Smoking: 25 Years of Progress. A Report of the Surgeon General. DHHS Publication No (CDC) 87'8411, 1989.
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manufacturers, the cost of defending these suits will require increases in the price of cigarettes which will reduce tobacco consumption. Tobacco farm policy is also included in this category and is discussed briefly. The final category of policies includes diverse actions that reduce the opportunity to smoke by restricting who may smoke (e.g., adults only) or where smokers may light up (e.g., not in public places or at work). This category also includes the strongest potential policya total ban on tobacco sales and use-and the review discusses why such a ban is not likely to be adopted. Information and Education
Congress' first action in the wake of the 1964 Surgeon General's Report was to attempt to inform the public about the hazards of tobacco use by requiring cigarette packages to carry health warning labels. Since then, the message about the hazards of tobacco use has broadened considerably and now includes the health effects of involuntary tobacco smoke exposure, the addictive nature of tobacco smoking, the health effects of other tobacco products, and methods of quitting smoking. Mandated efforts to educate the public have remained the mainstays of government action on tobacco for the past quarter century. Congress has required a growing array of warning labels on tobacco products and advertisements, mandated the production of a yearly Surgeon General's Report summarizing new scientific knowledge about the health risks of tobacco, and restricted some forms of tobacco advertising. Individual states have required that schools teach curricula on tobacco and health. Warning Labels on Tobacco Products. Eleven days after the Surgeon General released the 1964 Report of the Advisory Committee on Smoking and Health linking tobacco smoking to lung cancer, the Federal Trade Commission (FTC) released recommendations that strongly worded warning messages be required on tobacco products and advertisements. 51 Before it took effect, the FTC rule was pre-empted by Congressional action mandating a less definitive message. On January I, 1966, the words "Caution: Cigarette Smoking May Be Hazardous to Your Health" began to appear on cigarette packages, but not on advertisements. Over the ensuing two decades, a similar series of dramatic struggles occurred, with the FTC generally taking a strong pro active stance on the requirement to warn the public and Congress acting to vitiate FTC recommendations. The result was an evolving series of warning labels on packages and advertisements. In 1970, the original label was replaced with a stronger message, "WARNING: The Surgeon General Has Determined That Cigarette Smoking Is Dangerous to Your Health," which remained for 15 years. Congress acted again in 1984, prodded by an FTC report that the existing label was inadequate because it did not name the specific risks of smoking and because it had lost effectiveness after 15 years of exposure. Since 1985, a rotating
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set of four new "Surgeon General' s Warnings" has been required on all cigarette packages and advertisements in the United States: "Smoking Causes Lung Cancer, Heart Disease, Emphysema, and May Complicate Pregnancy." "Smoking by Pregnant Women May Result in Fetal Injury, Premature Birth, and Low Birth Weight." "Quitting Smoking Now Greatly Reduces Serious Risks to Your Health." "Cigarette Smoke Contains Carbon Monoxide." In 1986, a similar rotating warning-label system was mandated for smokeless tobacco packages and advertisements. 7 Existing warning labels in the United States are tame by the standards of some other countries. For example, they stand in stark contrast to prominent new messages slated to appear on tobacco products sold in Great Britain as of 1991. These messages (e.g., "Smoking Kills," "Smoking Causes Cancer," and "Protect Children: Don't Make Them Breathe Your Smoke") will be enhanced by greater size on the package. 7 US warning labels have been criticized for being too wordy, using technical terms that may be misunderstood, stating facts rather than delivering clear warnings, lacking visual imagery that might enhance the message (especially when appearing in tobacco advertisements), and being difficult to see, especially in advertisements and on billboards, where studies have found that they are not noticed, or at least not remembered. 21 , 25 Current legislation does not provide mechanisms for updating the contents of messages to reflect new knowledge or to prevent overexposure, Finally, current warnings do not cover one of the least known but most important facts about smoking behavior-its addictive nature, There has been little study of the effectiveness of warning labels in altering smoking behavior. Although not provable, it is likely that warning labels attracted considerable attention when they first appeared on cigarette packages in 1966 and may have contributed to the decline in tobacco use that occurred shortly after the original Surgeon General's Report. It is less clear that warning messages continue to discourage cigarette use. School Curricula About Tobacco and Health. Efforts to prevent the initiation of smoking are a cornerstone of any effort to reduce the health consequence of tobacco use. Because nearly all cigarette smokers start to smoke in childhood or adolescence, young people must be informed about the hazards of tobacco use-not only its health consequences, but also its addictiveness. Government could play a role in this process by ensuring that such initiatives are universal and meet certain standards, but the Federal Government has taken no action on this subject, Many states, however, have taken a lead by requiring education about tobacco as part of general health or drug-abuse prevention curricula. A few states require proficiency in knowledge of nicotine and tobacco effects as part of teacher certification. The level of
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521
compliance with these state laws and the effects of such teaching on the initiation of smoking are not known. 51 Tobacco Advertising and Promotion. Cigarettes are one of the most heavily advertised consumer products in the United States. Cigarette manufacturers spent $2.4 billion promoting their products in 1986 and $3.3 billion by 1988. 14• 60 In 1985, cigarettes were the most heavily advertised product category on billboards, second in magazines, and third in newspapers. 19 In addition, tobacco manufacturers promote cigarettes in ways other than traditional print advertising. These include the distribution of free tobacco products and the sponsorship of sporting events, concerts, and other events like the 1990-1991 tour of the National Bill of Rights, underwritten by Phillip Morris. Expenditures on these promotional activities have risen at least 25-fold over the past 20 years and now total $1.5 billion per year. 14 Tobacco manufacturers have spent a growing proportion of their marketing budgets on promotional activities rather than traditional advertising. Promotional activities accounted for only 13% of the budget in 1970, whereas by 1988 they made up 61 %.14. 60 Broadcast of sponsored sporting events, such as the Marlboro Grand Prix (an automobile race), affords dissemination of cigarette brand-name and logo in association with thrilling athletic achievement without the appearance of any product warnings. 9 Public health interest in tobacco advertising and promotion derives from concerns that advertising encourages individuals to start smoking, stimulates cigarette consumption among the smokers, and impedes their efforts to quit. Supporting this is the common observation that tobacco advertising associates smoking with culturally desirable qualities such as sexual attractiveness, good health, vigorous outdoor activities, and material and social success. 51 Tobacco manufacturers counter that they do not intend to advertise to children and that their advertisements do not increase demand; rather, advertisements only lead established smokers to switch brands. They assert that they are merely advertising a legal product. Empirical evidence about the effects of tobacco advertising has been methodologically difficult to assemble, and the effects of tobacco promotion have not been studied. Currently available evidence is diverse in methods and conclusions. The best studies examine the relationship between cigarette advertising expenditures and cigarette consumption, using techniques of regression analysis. The results are conflicting, but some have found small relationships between advertising expenditures and cigarette sales. The 1989 Surgeon General's Report reviewed these data in detail and concluded: "There is no scientifically rigorous study available to the public that provides a definitive answer to the basic question of whether advertising and promotion increase the level of tobacco consumption." However, it also noted that review of all available types of evidence strongly suggests that advertising and promotional activities do stimulate cigarette consumption. 51 Other public health concerns about tobacco advertising have been raised. It has been suggested that the promotion of low-tar, lownicotine cigarettes serves to falsely reassure smokers that these are safer
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cigarettes and that they present an alternative to stopping smoking. 19 Another concern about tobacco advertising is that it interferes with efforts to inform the public about the health hazards of tobacco smoking because media that accept tobacco advertising provide less coverage about the harm of tobacco use. There is substantial evidence documenting an inverse relationship between magazines' tobacco advertising budgets and the extent of their coverage of tobacco and health issues. 56 A final, broader concern is that the presence of tobacco advertisements in the environment reduces public perceptions that smoking is objectionable or dangerous. Although this is hard to prove, 44% of Britons in a 1986 survey, for example, believed that if cigarette smoking was seriously hazardous, then the government would have forbidden advertising. 14 Concern about the prosmoking effects of tobacco advertising has led to numerous proposals to limit tobacco advertising and promotion. To date, the strongest federal actions taken have been to prohibit cigarette advertising on broadcast media (e.g., radio and television) in 1971 and to extend that ban to cover smokeless tobacco products in 1986. 51 State and local governmental initiatives have been limited because the federal law banning broadcast advertising also pre-empted states from regulating tobacco advertising for health-related reasons. However, states and localities have some leeway to regulate local advertising media; for example, tobacco advertising is banned on many municipal transit systems. Proposals that would further limit tobacco advertising and promotion are widely discussed in the public health community. A bill containing the strongest proposal-a total ban on all tobacco advertising and promotion-has been introduced (but not passed) in previous Congressional sessions, and the proposal has been widely supported by medical and public health organizations. 51 Its success has been limited in part by controversy over whether commercial speech (e.g., advertising) should have the same Bill of Rights protection as noncommercial speech. Less comprehensive proposals include those that would impose stronger limits on the permissible imagery of advertisements, limit some elements of tobacco promotion such as free distribution of cigarette samples, and remove the tax deductibility of tobacco advertising, thereby effectively increasing the cost of advertising. 51 An alternate proposal would attempt to counter the effect of tobacco advertising by requiring the media to publish or broadcast antismoking messages-so-called counter-advertising. There is some evidence that this approach can be effective. In 1967, when radio and television tobacco advertisements were still permitted, the Federal Communications Commission ruled that broadcasters had to allot time to Public Service Announcements that counterbalanced the message of tobacco advertising. During the 3 years when these were broadcast (1968 to 1970), per capita cigarette sales fell by 6.9% and smoking by adolescents declined by 3% (Fig. 1).51 Although counter-advertising proposals are appealing, identifying the source of funds to support them has been more difficult.
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Economic Incentives
Economic forces can discourage tobacco use by increasing the costs of manufacturing, selling, or consuming tobacco products. Governments can influence the price of tobacco products by taxing them, thereby directly affecting consumers. Insurers' policies can provide more indirect economic incentives; by making the smokers' premiums more expensive, insurers can effectively increase the cost of being a smoker. Tobacco crop price supports exert economic incentives on the producer and, indirectly, on the consumer of tobacco. Finally, tobacco product liability suits, if successful, may serve to increase tobacco manufacturers' costs of doing business. Tobacco Excise Taxes. Excise taxes-sales taxes on a specific product-have been levied on tobacco products since colonial times. Currently, the Federal Government, all states, and nearly 400 cities and counties impose an excise tax on cigarettes. In 1989, excise taxes added an average of 38 cents to the price of a pack of cigarettes: The federal tax was 16 cents, and the average state tax was 22 cents. 49 The federal tax was increased to 20 cents on January 1, 1991, and will increase to 24 cents in 1993. State taxes vary widely from 2 cents in North Carolina to 40 cents in Connecticut. Generally, they are lower in tobacco-growing states. 49 Cigarette excise tax rates, in constant dollar terms, have fallen since 1964, because the periodic increases in cigarette taxes have not kept pace with inflation. Furthermore, the tax rate as a percentage of retail price has declined, indicating that manufacturers have increased cigarette prices at a faster rate than the tax increases mandated by government. 51 The effect of excise taxes on tobacco consumption has been carefully studied by economists, who have calculated the price elasticity of demand for cigarettes-an estimate of how much the quantity purchased decreases with a given rise in price. Contrary to expectation about a highly addictive substance, there exists significant price elasticity of demand for tobacco products. Younger age groups are particularly sensitive to increases in price, which appear to decrease not only cigarette consumption but the rate of initiation of smoking by adolescents. 37, 38, 51 This has important implications: Because most smokers develop dependency before age 20, excise taxes have their greatest impact on this vulnerable group and may be useful tools for preventing the initiation of smoking. Empirical studies have demonstrated that excise tax increases do reduce smoking. Following the doubling of the federal excise tax on cigarettes in 1983, the quantity of cigarettes purchased decreased by 12%.51 The benefit of a tax increase, in terms of morbidity and mortality, is seen many decades after the increase, as the cohort with a lower prevalence of smoking comes of age. It has been projected that the 1983 increase in federal excise tax will ultimately avert 860,000 premature smoking-induced deaths among AmericansY Further evidence derives from comparing the United States with Canada, where tobacco
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taxes are far higher. In Canada, taxes account for fully two thirds of the price of cigarettes and add the equivalent of US $2.25 to the cost of a pack of 20 cigarettes, whereas in the United States taxes add only $0.38. As would be expected, the slope of the decline in per capita tobacco consumption in Canada is significantly steeper than in the United States. 33 Thus, cigarette excise taxes are a public policy tool whose potential to reduce tobacco use-and especially prevent the initiation of smoking-is particularly well documented. There is wide support in the public health and medical communities for increasing tobacco excise taxes, adjusting their method of calculation so that their real value is not eroded by inflation, and channeling (or "earmarking") the revenues generated from tobacco taxes to fund other anti tobacco and prohealth activities. 51 Tobacco excise taxes are also politically attractive because they generate revenue. Opponents of cigarette excise-tax increases criticize them for being regressive. They argue that these taxes widen disparities in income rather than equalize them, because the tax burden attributable to tobacco is proportionately greater for the poor than it is for the wealthy. Proponents of excise taxes counter that tobacco is not a necessary commodity and that it may be desirable to provide an economic disincentive for poorer individuals to purchase this product. The California Experience. The State of California recently increased its tobacco excise tax dramatically, providing the nation with a natural experiment for observing the effects of increasing taxation and earmarking resulting revenue to fund antitobacco activities. Proposition 99, the Tobacco Tax and Health Promotion Act, was passed by citizen referendum in California in 1988. The law raised the state excise tax on cigarettes by an additional 25 cents per pack. Revenues raised by the tax, estimated at nearly $600 million per year, go into a Tobacco Product Surtax Fund. The Surtax Fund supports many dimensions of health improvement in the state, much of it tobacco-related: education of children to prevent smoking; training of health care providers in techniques to help smokers quit; research on tobacco-related disease; and a large and impressive state wide media campaign designed to counter the false images created by tobacco advertising. The media campaign, totalling more than $28.6 million, is the largest media effort sponsored by any government unit in the United States. 3 The goal of the law was to create a multipronged approach to smoking cessation and prevention and thereby reduce tobacco use. California's initiatives permit evaluation of the combined effects of counter-advertising and increased cigarette prices on tobacco use. At the time of its passage, 25% of Californians smoked, and the burden of smoking-related costs in the state was estimated to be $7.1 billion annually. Despite some tobacco industry counterattacks on the California Tobacco Tax Initiative, the law is having significant impact. The prevalence of smoking among Californians older than age 20 in 1990, the year following the tax increase and new educational program, was projected to be 24.6%. The observed rate was 21.4%, a statistically
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significant reduction of 13% compared with the expected rate. 40 Tobacco consumption also fell faster than projected after the law, giving additional support to the conclusion that the California experiment is reducing smoking in that state. 40 The multiplicity of the programs in California, however, makes it difficult to isolate the independent effects of the increased cost of tobacco and the counter-advertising campaign. Insurance Premium Differentials. Insurance companies in most states are legally entitled to consider smoking status in determining the price of policies. Soon after the release of the 1964 Surgeon General's report on smoking, the first life insurance policy with discounted rates for nonsmokers was offered. Over the next decade, 30 more companies followed suit. In 1979, the first actuarial analysis of mortality differences revealed a 100% to 125% mortality excess for smokers. 51 As of 1986, most of the largest companies offered premium differentials, and discounts for nonsmokers (or surcharges for smokers) were as great as 40%. The maximum dollar savings for not smoking was approximately $300 per year on a $150,000 policy; the minimum was $10 on a $25,000 policy. 51 The health insurance market differs from that of life insurance. Most private health insurance is sold to groups, not individuals, which makes it logistically difficult to offer different rates based on individual behavior. Health maintenance organizations must set rates based on community experience and must petition the Federal Government to use smoking as a criterion for modification of rates. Only about 15% of health insurers selling individual policies offer discounts to nonsmokers, and the average discount is about 10%.51 Some property and auto insurance premiums are also cheaper for nonsmokers, because nonsmokers have a lower rate of claims on both types of policies. The effects on smoking of rate differentials for insurance policies are unknown but could work by several means. 51 The increased cost of being a smoker, although not present at every pack-purchasing decision, probably confers some inducement not to smoke. There may also be a social message about the undesirability of smoking conveyed by the increased premium. These effects are mitigated by the relative infrequency of policy purchasing (i.e., usually only once per policy covering many years), the paucity of reminders about smoking from the insurance company after the purchase is made, and the usual practice of sharing the cost of a policy with employers. Reimbursement for Smoking Cessation Programs. Just as the cost of smoking influences its frequency and prevalence, so too may the economic cost of quitting influence the likelihood that a smoker will give up the habit. It has been suggested that the cost of a cessation program may serve as a barrier to quitting and that if cessation programs were covered by a third party, more smokers would use them. 51 Health insurers have largely taken the position that they need data showing that the treated former smoker is cheaper, in aggregate, than the nontreated smoking policyholder before they will cover the cost of cessation programs and treatment in their packages of services. No good data to this effect currently exist. Only 11 % of health insurers surveyed in 1985 covered the cost of cessation programs for policy hold-
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ers with diagnoses secondary to tobacco abuse, and none did for policyholders without a smoking-related diagnosis, unless such coverage was purchased as part of a special package. 51 Tobacco Crop Price Support Programs. The "tobacco subsidy" arrangement, whereby the US Government assures US farmers the receipt of set prices for tobacco crops, does not directly affect smoking behavior but may have indirect effects. Most important, as Warner has written, it "looms large as a symbol" of at least partial government support of the tobacco industry.s8 In recent years, tobacco manufacturers have imported more tobacco and decreased their demand for domestic leaf, thereby decreasing the market price of tobacco. As a result, maintaining the price of tobacco costs ever more; by the mid1980s, the cost exceeded $1 billion. Furthermore, by shielding farmers from the effects of decreased domestic demand on tobacco prices, the subsidy discourages exits from the market and the planting of alternative crops. It thus helps to maintain the economic and political strength of the tobacco lobby. Direct Restrictions on Smoking
A third category of public policy acts directly to reduce tobacco by limiting an individual's access to tobacco products or the opportunity to use them. The strongest policy of this type would be a total ban on the sale, possession, or use of tobacco products, analogous to laws regarding other addictive substances such as heroin or cocaine. Such a policy is unlikely to be adopted for several reasons. First, tobacco was widely used and socially accepted long before its health hazards and addictive potential were fully appreciated. Second, sales of tobacco products are supported by strong economic and political interests. Third, the failure of alcohol prohibition suggests that a ban on tobacco sales would be similarly difficult to enforce. Short of a total ban on sales are policies restricting where smoking may occur and who may buy cigarettes; those are covered in this section. State and local governments, rather than the Federal Government, have taken the lead in this tobacco control issue. Smoking Restrictions in Public Places and Workplaces. Over the past two decades, a wave of social actions restricting or banning smoking in public places and workplaces has developed. This is the result of mounting scientific evidence about the health risks of involuntary tobacco smoke exposure and growing public anti smoking sentiment. 42 ,SO Actions have occurred in both the public and private sectors, ranging from federal, state, and local legislation mandating smoking restrictions, to limits adopted voluntarily by private businesses, hospitals, hotels, and schools. The result is a patchwork of smoking restrictions that affect the daily lives of a growing number of Americans. Although the Federal Government has taken some action-most prominently, the legislation banning smoking on virtually all domestic airline
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flights as of 1989-the majority of public sector actions have occurred at the state and local levels,17 where a growing number of states and communities have enacted laws restricting smoking in public places and workplaces. Less often, state and local governments have used their administrative powers to limit smoking, such as issuing executive orders banning smoking in government buildings or health department regulations requiring restaurant no-smoking sections. The intent of these laws, regulations, and policies is to reduce individuals' exposure to passive smoke, but their impact may be broader. They have the potential for far-reaching effects on the acceptability of cigarette smoking and on smoking behavior. They may, by limiting the times and places where smoking is permitted, reduce the prevalence of smoking by encouraging current smokers to quit and discouraging young people from adopting the habit. The laws are most likely to have these effects if they are comprehensive in coverage. Because adults spend more time at work than in any other single place outside the home, it is likely that laws limiting smoking in all worksites will have the greatest effect on smoking behavior and attitudes. They will also offer the greatest protection from passive smoking exposure. 42,50 Smoking has been addressed by state laws for a century. Early laws limited smoking in selected areas such as stables to prevent fires or explosions. These differ from the current round of laws, which were first enacted at the state level after 1970 and at the local level around 1980 and which were often initiated by grassroots nonsmokers' rights groups, voluntary health organizations, or public health officials. These newer laws covered a wide variety of places and were specifically designed to protect nonsmokers from the annoyance and health effects of exposure to tobacco smoke. Even so, the laws vary in content, ranging from the weakest, which restrict smoking in government buildings or a handful of public places, to more comprehensive legislation, often termed clean indoor air acts, that restrict smoking in all enclosed public places, in restaurants, and in both public and private sector worksites (Fig. 2).51 As of 1988, 42 states and the District of Columbia had adopted a restriction on smoking in at least one public workplace, and a dozen states had adopted comprehensive clean indoor air acts. Southern states and major tobacco-producing states have relatively fewer laws. As of January, 1988, over 82% of Americans lived in states with some state law restricting smoking, compared with only 8% in 1971. 51 A more recent analysis of city no-smoking ordinances documented that the number of laws increased 10-fold between 1980 and 1989. By mid-1989, 51 % of US cities with a population greater than 25,000 had adopted some smoking restriction, and 17% had adopted comprehensive laws. 44 City laws are more common in larger cities and Western cities; they are less common in tobacco-producing states. If current trends continue, smoking restrictions in public places and workplaces can be expected to be the norm by the end of the century. Although these no-smoking laws are becoming widespread, there
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Number of SIlII" wtth laws in eneet
45
45 _
40
Extensive
40
1::'':"::,
