Introduction

The overall purpose of this chapter is to identify the tobacco control measures that have worked up to now as the basis for subsequent considerations in Chapters 15 and 16 (“The Changing Landscape of Tobacco Control: Current Status and Future Directions” and A Vision for Ending the Tobacco Epidemic: A Society Free of Tobacco-Related Death and Disease,” respectively), which look forward to how to reduce and even end the tobacco epidemic. Previous Surgeon General's reports on smoking and health have articulated a vision for ending the tobacco epidemic through a variety of methods, including sustained use of successful interventions, a comprehensive approach, and continued support to build the scientific foundation for action (U.S. Department of Health and Human Services [USDHHS] 2000, 2004, 2006, 2010, 2012). Recent recommendations made by expert groups also emphasize comprehensive coordinated approaches to reducing tobacco use and its harms (Bonnie et al. 2007; USDHHS 2010; World Health Organization [WHO] 2008b). The potentially relevant literature is vast and, consequently, coverage in this chapter is analytic and synthetic without providing an exhaustive review of all relevant evidence (supporting reviews are provided online at www.surgeongeneral.gov in Appendices 14.1–14.5).

This chapter first considers the shifting public image of tobacco use during the past 50 years, which has been critical to driving the decline of tobacco smoking (see Chapter 2, “Fifty Years of Change 1964–2014”). Tobacco use has serious economic and social implications for the population, and is intimately tied to collective images and attitudes that can positively or negatively impact use. As scientific knowledge about the disease effects of smoking has advanced, and as research on tobacco industry documents and litigation have uncovered the deceptive and covert activities of tobacco companies, attitudes toward tobacco use and smoking in public places have changed from accepting to increasingly unfavorable.

In the second part of this chapter, the changing nature of tobacco products is reviewed and a brief overview is provided of current efforts to regulate tobacco manufacturing, marketing, and use. Tobacco and other commercial tobacco products that contain nicotine cover a wide range, including not only conventional cigarettes, cigars, and smokeless tobacco but dissolvable tobacco products (DTPs), electronic delivery systems, low nitrosamine smokeless tobacco, and water pipes. The emergence of such new products has become increasingly germane to the formulation of tobacco control policies.

The third section covers two key tobacco control measures—tobacco taxes and clean indoor air laws, which both have a large span and size of population impact (USDHHS 2000). Other legal strategies, including restrictions on advertising and access to tobacco by minors, are also briefly reviewed. It concludes with a brief review of litigation as a tobacco control strategy.

The fourth section in this chapter focuses on clinical, educational and community-wide strategies and approaches for tobacco cessation. It reviews the evidence that tobacco use is a chronic condition of addiction with remission and relapse, requiring repeated interventions and, often, multiple attempts to quit successfully for the long-term. A series of interventions and treatments are briefly reviewed, including counseling, quitlines, and medications. Approaches for tobacco dependence treatment through the health care delivery system are also reviewed (e.g., a national network of quitlines, supporting the “5A's model”).

The comprehensive educational and community-wide strategies acknowledge that individual behavioral choices occur in a larger, complex context: a social setting of family, schools, community, and culture; a complex economic and physical environment; formal and informal government policies; and the prevailing legal atmosphere. The review covers a mix of programs developed as large-scale research and demonstration studies (e.g., the National Cancer Institute's [NCI's] American Stop Smoking Intervention Study [ASSIST], the Community Intervention Trial for Smoking Cessation [COMMIT]), and comprehensive state programs often carried out by state and local public health agencies.

The final section of this chapter briefly reviews international tobacco control activities and related issues, including trade policies.

The Changing Public Image of Tobacco

The level of social acceptability of smoking was a major contributing factor in the rising prevalence of smoking up to the middle of the twentieth century, and then to the declining prevalence of smoking during the past 50 years (Cummings 2009). The importance of the changing public image of tobacco is discussed in greater detail in Chapter 2, as well as in previous Surgeon General's reports (U.S. Department of Health, Education, and Welfare [USDHEW] 1979; USDHHS 2000, 2006, 2012), and in several histories of tobacco control (Kluger 1996; Brandt 2007; Proctor 2011).

When the first Surgeon General's report was issued in 1964, up to 60–70% of young and middle-aged men were current smokers, and almost 50% of young women were smokers as well (see Chapter 13, “Patterns of Tobacco Use Among U.S. Youth, Young Adults, and Adults,” Figure 13.9A and 13.9B). In the 1960s and even into the 1970s and 1980s, smoking was permitted nearly everywhere—smokers could light up at work; in hospitals, school buildings, bars, and restaurants; and on buses, trains, and airplanes. In the mid-1960s, the culture of smoking was so accepted that even the Surgeon General's Advisory Committee had ashtrays on the table, when they met to discuss the evidence that would eventually conclude that cigarette smoking is a cause of cancer and other life-threatening diseases (Figure 14.1).

Figure 14.1

Meeting of the 1964 Surgeon General's Advisory Committee. Source: © Fred Ward-1964-www.AwardAgency.com

For anyone growing up in the 1950s and 1960s, it was common to see doctors; athletes; radio, movie, and television celebrities; and popular cartoon characters advertising various cigarette brands (Figure 14.2). In fact, the marketing of cigarettes was so commonplace that the 1967 Federal Trade Commission (FTC) report commented “…that it is virtually impossible for Americans of almost any age to avoid cigarette advertising” (FTC 1967). In 1964, tobacco companies were major sponsors of popular television shows on all three television networks (Pollay 1994). These companies also arranged for product placements in movies, and other entertainment media, to increase the social image of smoking as popular, sophisticated, and classy (Mekemson and Glantz 2002; USDHHS 2012). As reviewed in previous reports, the tobacco companies have viewed the movie industry as an opportunity for advertising as far back as the Nickelodeon era when movies were silent, cost only a nickel, and ad slides played between reels (USDHHS 2012).

Figure 14.2

Cigarette advertisements. Source: Richard Pollay Tobacco Advertising Collection at Roswell Park Cancer Institute, Buffalo, NY.

Although comprehensive historical tracking of portrayals of tobacco use in U.S. films is only available since 2002, a study of a random sample of major movies released between 1950–2002 found that smoking incidents declined from 10.7 incidents per hour in 1950 to a minimum of 4.9 in 1980–1982 but increased to 10.9 in 2002 (see USDHHS 2012, Figure 5.11). Despite declining tobacco use and increasing public understanding of the dangers of smoking in the real world, by 2002 smoking in movies had returned to levels observed in 1950, when smoking was nearly twice as prevalent in reality as it was in 2002 (Glantz et al. 2004). Beginning in 2002, Thumbs Up Thumbs Down!, a project of Breathe California of Sacramento-Emigrant Trails, has collected data on every film that was in the Top 10 theatrical box office for at least 1 week (which includes 83% of all films released in the United States and 96% of tickets sold) (Centers for Disease Control and Prevention [CDC] 2011c; Polansky et al. 2012). These data show that the number of tobacco incidents increased between 2002–2005, then declined from 2005–2010 and rebounded in 2011 and 2012 (Figure 14.3A).

Figure 14.3A

Total tobacco incidents in top-grossing U.S. movies, by Motion Picture Association of America rating. Source: Polansky et al. 2012.

Based on these data on tobacco incidents, population exposure to smoking incidents in movies can be estimated from box office attendance data (one impression equals one tobacco incident on screen viewed by one audience member one time) (CDC 2011c; Polansky et al. 2012). Theatrical impressions substantially underestimate total exposure because they include only in-theater exposure, not viewing on home media: broadcast, cable, satellite, and on-demand; on DVD and Blu-ray and on streaming media. Youth-rated movies delivered 20.4 billion impressions to domestic theatrical audiences in 2005 (Figure 14.3B). This exposure dropped by 73%, to 5.5 billion in 2010, then rebounded to 14.9 billion impressions in 2012. Of the youth-rated impressions that year, 99% (14.8 billion/14.9 billion) were delivered by PG-13 movies. While R-rated films on average include more smoking than PG-13 films, youth are much less likely to view R-rated films than PG-13 films; as a result, youth receive about three times the absolute exposure to smoking images from PG-13 films than R-rated films (Sargent et al. 2012). In 2012, impressions delivered by youth-rated movies comprised 56% (14.9 billion/26.5 billion) of all in-theater tobacco impressions (Polansky et al. 2012).

Figure 14.3B

Tobacco impressionsa delivered by top-grossing U.S. movies, by Motion Picture Association of America rating. ^a One impression equals one tobacco use incident on screen viewed by one audience member. Source: Polansky et al. 2012.

The 2012 Surgeon General's report concluded that there is a causal relationship between depictions of smoking in movies and initiation of smoking among young people (USDHHS 2012). The report based this conclusion on a large body of epidemiologic, behavioral, and experimental data. Subsequently, additional evidence shows a dose-response relationship between frequency of exposure to onscreen smoking images in movies and increased risk of smoking initiation (Dal Sin et al. 2011; Hanewinkel et al. 2012; Sargent et al. 2012; Morgenstern et al. 2011, 2013a, b). Additionally, based on the actual mix of films that adolescents viewed, it has been estimated that reducing in-theater exposures from a current median of about 275 annual exposures per adolescent from PG-13 movies down to approximately 10 or less would reduce the prevalence of adolescent smoking by 18% (95% CI, 14–21%) (Sargent et al. 2012).

Reports on the health risks of cigarette smoking were published with increasing frequency from the 1920s, but it was not until the 1950s and 1960s that medical research on smoking and cancer began to receive widespread media attention and the public began to recognize the adverse consequences (see Chapter 2) (Brandt 2007). In a 1966 Harris poll, only 40% recognized smoking as a major cause of lung cancer, 27% considered it a minor cause, and one-third were uncertain, saying that “science has not yet determined the relation between smoking and lung cancer” (Saad 2002). One explanation for people not believing that smoking was a health risk is the aggressive actions of the tobacco industry in suggesting scientific uncertainty and controversy about the findings (e.g., the “Frank Statement” on smoking issued in 1954 [Pollay Advertising Collection, n.d.]) (Brandt 2007). Over time, the public's perception of smoking gradually shifted from viewing smoking as a minor health concern to increasing acceptance that there are serious health risks associated with smoking. Smoking became increasingly less acceptable as a social practice (Sadd 1998). In 2001, Gallup asked this question again and found that 71% of Americans identified smoking as a major cause of cancer, 11% said it was a minor cause, and 16% were unsure (Sadd 2002).

The first large-scale national counter-advertising campaign to educate the public about the health risks of tobacco use was launched in 1967, under the Fairness Doctrine, which required broadcasters to provide free media time for antismoking public service announcements in response to cigarette commercials (Cummings 2002). Several studies have concluded that the antismoking messages mandated by the Fairness Doctrine resulted in a sharp reduction in smoking, which rebounded after the antismoking ads went off the air in 1971, as a result of the broadcast advertising ban (O'Keefe 1971; Warner 1989; Simonich 1991). Beginning in 2000, the American Legacy Foundation launched the truth® campaign, a broadcast counter-advertising campaign which primarily targeted teens and young adults (Healton 2001). This extensively evaluated campaign was found to have been successful in creating a high level of awareness of its messages among the intended target audience, and to have been effective in discouraging youth from smoking (Farrelly 2002; Richardson et al. 2010). Additional evidence in support of the effectiveness of paid counter-advertising campaigns comes from the sharp declines in cigarette consumption observed in localities that have invested heavily in mass media campaigns (Farrelly et al. 2008; NCI 2008).

Changes in the Tobacco Industry, Products, and Product Regulations

In 1964, the evidence on tobacco and health focused on cigarettes since most tobacco users in the United States were cigarette smokers, and most tobacco consumption per person was in the form of cigarettes (USDHEW 1964). Subsequent reports of the Surgeon General were mandated by the U.S. Congress to address the health consequences of cigarettes. The rise of smokeless tobacco use in the 1970s and 1980s led Surgeon General C. Everett Koop to request a report on these products by the National Institutes of Health (NIH) (USDHHS 1986). The 2010 Surgeon General report provided some discussion of the changing tobacco industry and products (USDHHS 2010), but other than that report, most Surgeon General's reports on the health consequences of smoking have provided little discussion of the health effects of tobacco products other than cigarettes. The current report includes information on tobacco products other than cigarettes, because of the rapidly changing nature of tobacco products, trends in new product use, and the tobacco industry itself, since the turn of the twenty-first century. Such information is becoming increasingly relevant to future tobacco control approaches, as the array of products is becoming increasingly diverse.

The tobacco industry's strategies have evolved, and are continuing to evolve, in ways that will influence attitudes towards it and the use of tobacco products. Over the past two decades, there have been several mergers and acquisitions of tobacco-related businesses in what may be a response to the new international regulations on tobacco products, a declining domestic cigarette market, and a growing international tobacco business. In 1994, the American Tobacco Company exited the tobacco business by selling off its cigarette brands to British American Tobacco (BAT). Starting in 1994, popular American brands such as Lucky Strike, Pall Mall, Carlton, and Misty were marketed in the United States by the BAT subsidiary, Brown & Williamson, which in 2004 was acquired by R.J. Reynolds (RJR) forming a new publicly-traded holding company called Reynolds American, Inc. (RAI). In 2008, RAI acquired Conwood Smokeless Tobacco Company and changed the name of the company to American Snuff Company. In 2009, RAI launched Camel Snus and, the following year, RJR introduced Camel DTPs. RAI also acquired the rights to market ZONNIC nicotine replacement products and purchased Niconovum AB, a Swedish company making oral nicotine replacement products. In 2003, Philip Morris changed its name to Altria and, in 2009, acquired U.S. Smokeless Tobacco Company. Shortly after, Altria began to market Marlboro Snus along with other smokeless tobacco products, such as Skoal and Copenhagen, in the United States. The international cigarette business continued through a new entity, Philip Morris International. In 2012, Lorillard acquired Blu Electronic Cigarettes, the manufacturer of Blu electronic cigarettes. In 2013, RJR announced that it will introduce VUSE electronic cigarettes and Altria announced that it will introduce MarkTen electronic cigarettes, thus, all three major cigarette manufacturers plan to have electronic cigarettes on the market (Sizemore 2013).

Some of the new products, such as electronic nicotine delivery systems (ENDS), marketed as “electronic cigarettes,” were developed and/or are marketed by companies that had little or no experience in developing and marketing traditional tobacco products (WHO 2009c; Henningfield and Zaatari 2010; Cobb and Abrams 2011). Additionally, other tobacco products, such as bidis and waterpipes, have long histories of extensive use in other countries, but have been more recently marketed and adopted in the United States (WHO 2006; CDC 2012c). Given the level of evidence linking tobacco product use to ill health, all products containing tobacco and nicotine should be assumed to be both harmful and addictive, although the risk from the use of tobacco products depends not only on the type of product but also on how they are used (i.e., the actual doses of toxins that are taken in, and whether the product is used in addition to other products, promotes initiation of tobacco use, or delays smoking cessation) (WHO 2006, 2007). Thus, establishing a meaningful rank order of actual risk per product is not possible (Gray and Henningfield 2006; WHO 2006, 2008a).

Table 14.1 provides a summary of these products. It is meant to be illustrative, rather than comprehensive, because the nature of the products and their marketing is changing rapidly and an expanding array of products and manufacturers are being discussed in the trade literature. The products are categorized by their general form and mode of use, and not necessarily with reference to their definition by the U.S. Food and Drug Administration (FDA), or WHO, or statutory definitions by the U.S. Congress, FTC, or the Bureau of Alcohol, Tobacco, Firearms and Explosives. Together, the modified novel products, summarized in Table 14.1, pose challenges to research, surveillance, health policy, and regulation because they vary so widely in form, mode of use, apparent contents, designs and emissions, and potential health effects, including addictiveness, and marketing claims, implicit and explicit. Moreover, following introduction into the market, many products have been rapidly modified, perhaps in response to consumer feedback and market testing. For example, ENDS have grown from a category of novelty products in 2005 to an extensively marketed and increasingly accessible category, with awareness of ENDS doubling from 16.4% in 2009 to 32.2% in 2010 and ever use of ENDS more than quadrupling from 2009 (0.6%) to 2010 (2.7%) (American Legacy Foundation 2012; Regan et al. 2013). Studies and assessments by FDA and independent scientists have demonstrated enormous variability in design, operation, and contents and emissions of carcinogens, other toxicants, and nicotine from ENDS (Westenberger 2009; WHO 2009c; Henningfield and Zaatari 2010; Cobb and Abrams 2011; American Legacy Foundation 2012). The marketing claims for ENDS also vary widely and have included claims of safety, use for smoking cessation, and statements that they are exempt from clean air policies that restrict smoking (WHO 2009c; Cobb et al. 2010; Henningfield and Zaatari 2010; American Legacy Foundation 2012; Cheah et al. 2012).

Table 14.1

Modified traditional tobacco products and novel tobacco products.

Another less prevalent, but expanding and diversifying group of products is categorized by FDA as DTPs, which were evaluated by FDA's Tobacco Products Scientific Advisory Committee (TPSAC) in 2012 (TPSAC 2012). Extensive TPSAC deliberation and public comments, including from public health organizations and the tobacco industry, led to conclusions that reveal great uncertainty as to whether these products are likely to contribute positively or negatively to public health (TPSAC 2012). The products were generally found to be lower in toxicants than traditional tobacco products, and lower in their likelihood of delivering comparable levels of disease-causing toxins as traditional tobacco products. TPSAC found that such products could confer potential health benefits at the individual and population levels if they were adopted as total substitutes for cigarettes by cigarette smokers who would not have otherwise quit. On the other hand, many of the products have apparently been developed and marketed to undermine smoking cessation efforts, by enabling cigarette smokers to manage restrictions on smoking by using them “for when you can't smoke” (TPSAC 2012). Another concern was the possibility that these products would emerge as initiation products and, thus, lead to initiation in persons who would not have otherwise done so. People who initiate nicotine exposure with DTPs might also be at risk for subsequent use of more toxic products, including cigarettes. Consequently, TPSAC concluded that the health risks of this category of products will be strongly determined by how they are marketed and how they are actually used (TPSAC 2012).

As discussed by WHO, tobacco products vary widely in form, content, and emissions, but virtually all types are primarily represented by products that are designed and manufactured to be addictive (WHO 2006). Earlier reports of the Surgeon General have described the addictive properties of tobacco products and the role of nicotine (e.g., USDHHS 1986, 1988, 1989, 2010), as have other authoritative agencies (Royal College of Physicians [RCP] of London 2000; National Institute of Drug Abuse [NIDA] 2012; WHO 2006, 2007, 2012b). This report does not review this foundational evidence, but does address some factors contributing to product addictiveness that are relevant to consideration of these emerging products for nicotine delivery. As discussed in the 2010 Surgeon General report, the ongoing research is contributing to further improvements in the understanding of the neurobiology and role of tobacco product design factors in tobacco addiction, as well as advances in the diagnosis and treatment of addiction and withdrawal as described in the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual (American Psychiatric Association 2013). In addressing the public health consequences of these products, consideration needs to be given to ingredients and design features that can contribute to product addictiveness, and marketing approaches that can contribute to use patterns leading to addiction (WHO 2006; NCI 2008; USDHHS 2010, 2012).

Cigarettes carry the highest risk of addiction following initiation, due to cigarette designs that facilitate efficient and tolerable inhalation of nicotine-laden toxic smoke deep into the lung (RCP 2000; WHO 2001; USDHHS 2010). Although focused largely on cigarettes and conventional smokeless tobacco products, NCI Monographs 13 and 19 (NCI 2001, 2008) and an IOM report (Stratton et al. 2001) describe how product characteristics may be reflected in marketing, in order to stimulate initiation and foster continued use that leads to the development and maintenance of addiction. For example, cigarettes were designed to make smoke more easily inhalable and to provide low-tar and nicotine yields in smoking machine tests (NCI 2001). Smokeless tobacco products were designed with nicotine delivery and flavor characteristics targeted to certain populations, such as low-dose nicotine delivery fruit-flavored products for initiation by youth and higher dosage products targeted to tolerant longer term users (USDHHS 1994; Federal Register 1995, 1996). Similarly, FDA's TPSAC found that menthol in cigarettes was a design feature that produced physiological effects, including sensory effects contributing to tobacco use; and marketing and product branding of menthol and its effects also contributed to initiation and persistence of cigarette smoking (TPSAC 2011).

Tobacco Control Policies

Public health efforts to control tobacco use have been bolstered by policies at the national, state, and local levels. This section briefly examines the effectiveness of selected regulatory approaches (e.g., taxes and smokefree indoor air policies) to prevent tobacco use, encourage cessation, and reduce exposure to secondhand smoke among nonsmokers. This section also includes a brief discussion of advertising and restricted access for minors. Several of these policies are among the most effective tobacco control strategies of the past 50 years (e.g., taxation and smokefree indoor air policies) and are the cornerstone of state and local tobacco control efforts covered in a later section in this chapter. These strategies are reviewed here, however, since over the history of tobacco control, they have commonly been applied individually.

Taxes

In the United States, the federal government, all 50 states, the District of Columbia, and many local governments tax tobacco products. Although many factors affect the final price of cigarettes and other tobacco products, the most important policy-related determinant of tobacco prices is excise taxes on tobacco products. Taxes on tobacco provide revenue to governments at a relatively low administrative cost, making these taxes especially appealing. Moreover, higher taxes have decreased consumption of tobacco products, especially cigarettes, and thereby improved public health (USDHHS 2012). This combination of increasing revenues and improving public health has made tobacco taxation a valuable and effective policy lever in recent decades. In 2012, the federal tax rate was $1.01 per pack (Orzechowski and Walker 2012) and the mean state tax rate was $1.53 per pack (Campaign for Tobacco-Free Kids 2013). The average price, nationally, for a pack of cigarettes in 2012 was $6.00 (Campaign for Tobacco-Free Kids 2012b).

Figure 14.4 shows that the inflation-adjusted retail price of cigarettes in the United States had remained relatively low for much of the twentieth century, and then increased by over 70% from 1997–2002. This large increase was partly the result of two federal tax increases (from $0.24 to $0.34 in 2000 and from $0.34 to $0.39 per pack in 2002) and the numerous increases in state excise taxes; it also reflected the significant increases in the wholesale price of cigarettes. In fact, between 1998–2003, wholesale prices for cigarettes increased 122% (Capehart 2004), largely as a result of the increased costs associated with expenses for individual state tobacco settlements and expenses related to the Master Settlement Agreement (MSA). The more recent sharp increases in the inflation-adjusted retail price of cigarettes are due to another federal tax increase (from $0.39 to $1.01 in 2009) and numerous increases in state and local taxes. Since January 1, 2002, 47 states, the District of Columbia, and several U.S. territories have increased their cigarette excise taxes a total of 105 times. Even Kentucky, North Carolina, and Tennessee—tobacco-producing states that have long resisted raising tobacco taxes—have increased tax rates on cigarettes. As of March 31, 2013, the rates ranged from $0.17 per pack in Missouri to $4.35 per pack in New York (Table 14.2).

Figure 14.4

Annual retail tobacco price index and per capita (18+) cigarette consumption—United States 1900–2012. Source: Orzechowski and Walker 2013; U.S. Bureau of Labor Statistics (BLS) 2013; U.S. Department of Agriculture 2013; U.S. Department (more...)

Table 14.2

State cigarette excise taxes (dollars per pack) and sales tax rate applied to cigarettes.

Moreover, hundreds of municipalities impose taxes on cigarettes, but the rates are generally relatively small when compared with state taxes. However, in recent years, several cities and counties have implemented large increases. For example, in 2002, New York City increased its tax on cigarettes from $0.08 per pack to $1.50 per pack. Similarly, both the city of Chicago and Cook County, Illinois (Cook County includes Chicago as well as many other jurisdictions), raised taxes on cigarettes. Combining federal, state, and local taxes, individuals purchasing cigarettes in New York City and Chicago, Illinois, paid the highest cigarette excise taxes in the country at $5.85 and $5.66 per pack, respectively, as of December 12, 2012 (Campaign for Tobacco-Free Kids 2013).

Another kind of tax, the general sales tax, is also quite common. In 2013, 45 states and the District of Columbia imposed general sales taxes on cigarettes; as of November 1, 2012, these taxes added between $0.14 and $0.43 to the price of a pack of cigarettes (Table 14.2). In addition, 9 states currently apply excise taxes on tobacco products other than cigarettes; these taxes are predominantly ad valorem. Finally, in most states the general sales tax is applied to other tobacco products as well as to cigarettes.

Previous Surgeon General's reports (USDHHS 2000, 2012) have concluded that increases in cigarette prices, including those that result from increases in excise taxes, reduce the initiation, prevalence, and intensity of smoking among youth and adults. Additionally, two comprehensive reviews of the literature summarize the evidence on the impact of price on tobacco consumption; one is included in the International Agency for Research on Cancer (IARC) Handbooks of Cancer Prevention in Tobacco Control (IARC 2011), and the second a summary of key findings by Chaloupka and colleagues (2011). Five general conclusions can be drawn from these reviews (Chaloupka 2011; IARC 2011). First, increases in cigarette prices can lead to substantial reductions in cigarette smoking. The consensus estimate from the two reviews is that a 10% increase in cigarette price will result in a 3–5% reduction in overall cigarettes consumed. Second, increases in cigarette prices will decrease not only the prevalence of smoking but also the average number of cigarettes smoked by smokers. Third, much previous research on cigarette consumption among youth suggests that both youth and young adults are more responsive than adults to changes in cigarette prices, with several studies finding youth and young adults to be two to three times as responsive to changes in price as adults (see USDHHS 2012 for a complete review). Fourth, there is greater price responsiveness among lower income populations (IARC 2011). Finally, state excise tax increases create revenues for states.

In 2009, the Children's Health Insurance Program Reauthorization Act increased the federal tax rate on cigarettes from 39 cents per pack to 100.66 cents per pack. For the first time, it also applied the same tax rate to cigarette-like small cigars (from 3.7 cents per pack to 100.66 cents per pack) and roll-your-own tobacco (from 4.5 cents per pack to 100.66 cents per pack) (Campaign for Tobacco-Free Kids 2009). However, there remain substantial differences in the federal taxes on these products (cigarettes, small cigars, and roll-your-own tobacco) and other tobacco products, including regular cigars, pipe tobacco, and smokeless tobacco, which are taxed at much lower rates. In addition, the industry manipulated the weight of some small cigars by adding a few grams of filler to make them qualify as large cigars, thus avoiding the tax increase (CDC 2012a). This change in classification resulted in a dramatic, immediate increase in large cigar use over a 2-month period. The industry also began repackaging and marketing pipe tobacco to be used for roll-your-own cigarette production. Evidence indicates that despite continued decreases in cigarette consumption in the United States, consumption of re-engineered pipe tobacco and large cigars has increased substantially since the federal tobacco excise tax was increased in 2009 (CDC 2012a).

As discussed in previous Surgeon General's reports, several significant challenges have impeded the effectiveness of excise tax increases. As the differential levels of taxation have widened between states, tax avoidance and evasion practices have increased. Tax avoidance and evasion, also known as illicit trade, occurs along a continuum of individual and group behaviors. Tax avoiders at both the individual and group levels pay some local, state, and federal taxes, whereas tax evaders do not. Tax avoidance activities include individual cross-border, Internet, and untaxed purchases on tribal lands, as well as consumer behaviors such as product switching, carton purchases, and using cheaper outlets. Individuals and small-scale organizations also bootleg cigarettes in low tax jurisdictions for resale in high tax jurisdictions. Tax evasion includes illegal activities often conducted by large-scale organizations, such as organized smuggling, counterfeiting, and illegal manufacturing. In states and municipalities with the highest taxes, such as New York and Chicago, as many as 40% of cigarettes consumed were purchased in a lower-tax jurisdiction (Merriman 2010; Virginia State Crime Commission 2013). More than one-half (55.4%) of smokers report using at least one price-minimization strategy when purchasing cigarettes—including carton purchasing, Indian reservation purchase, generic brands, coupon use, and Internet purchase—with an average reduction of $1.27 per pack (22%) (Xu et al. 2013). In addition, the tobacco industry has developed extremely sophisticated mechanisms to blunt and mitigate the effects of price increases. These include Web-based, mail-order, brand repositioning, and store-based discounting that is timed to scheduled price increases.

Tax avoidance and evasion undermine the efficacy of high prices in reducing consumption and initiation, especially among price-sensitive groups (IARC 2011). However, IARC concluded that there is sufficient evidence that tax avoidance and evasion reduce, but do not eliminate, the public health and revenue impact of tobacco tax increases (IARC 2011).

Selected state experience suggests that all levels of government can enhance revenue collection and minimize tax avoidance and evasion through several promising policy approaches. For instance, California and Massachusetts have both implemented a high-tech cigarette tax stamp, which includes encrypted information on payments that is reported electronically to the state's revenue collection entity. Electronic data collection and reporting allows for more consistent monitoring of tax and MSA payments, improves tobacco licensure management, and makes the stamps harder to counterfeit. California has found that this tax stamp, combined with enhanced tobacco tax payment enforcement, has helped reduce state tax evasion by 37% since its implementation in 2005 (McIntosh 2007). The state estimates that an additional 101 million packs per year are sold through legal retail distribution channels instead of illegally, valued at $87.7 million per year (Bartolo and Kimsey 2013). Improved tax stamping technology appears to be a promising state tobacco control practice.

It has been suggested that this promising state practice could also be expanded to the national level with a national track and trace system. A track and trace system, in the tobacco control context, is a system that can track goods from manufacture to distribution to sale, identifying points in the supply chain where taxes should be paid and confirm payment. WHO's FCTC includes establishing a national track and trace system and recommends that system include, at a minimum: nonpredictable serialization of all tobacco products to the level of the smallest saleable unit, with each unique code linked to a secure database of information on that product; common numbering standards for serialization, which should include information about the manufacturer, date of manufacture, and brand; human-readable printing/labeling of serialization of numbers on all traded units; establishment of parent-child relationships between different packaging units so individual cartons and cases can be separated from master cases during shipping; recordkeeping along the supply chain; maintenance of relevant data by supply-chain partners; query interfaces between the databases of supply-chain partners and enforcement authorities; and a standard protocol for transferring queries and data (WHO 2010).

The Tobacco Control Act authorizes the FDA to implement a national track and trace system (15 U.S.C. §920(b)(3)). The Department of the Treasury's Alcohol Tobacco Tax and Trade Bureau, which is responsible for collecting federal tobacco excise taxes, while not authorized to implement a national track and trace system, has authority over product markings (e.g., tax stamps) to facilitate this tax collection (26 U.S.C. §5723(b)). These two agencies would benefit from working together to develop a track and trace system that could meet their two complementary goals: to collect federal tobacco excise taxes and to control tobacco product regulations (Department of the Treasury 2010).

Data from France indicate that price increases can be a win-win scenario for tobacco control and the government. From 1990–2005, cigarette prices tripled, consumption was cut in half, and government revenue from tobacco doubled, adjusted for inflation (Peto 2013; Jha and Peto, in press). The 2009 U.S. federal tax increase on cigarettes and subsequent tax increases at the state and local levels represent recent successes in tobacco control. However, a substantial range persists in the levels of cigarette excise taxes across states, and cigarettes and noncigarette tobacco products are not similarly taxed. Another issue is that current tax levels are static and do not account for inflation. Increasing the federal tax for noncigarette products, implementing systems to control for tax avoidance and evasion (e.g., high-tech tax stamps and track and trace systems), shrinking the tax disparity between states and localities, and establishing a taxation system that accounts for inflation, would likely improve the impact of taxes on the prevalence of tobacco use, especially among young smokers most sensitive to price. Closing the gap in these federal tax rates would further reduce tobacco use and increase tobacco revenues at the federal level.

Finally, there is concern that the dramatic drop in funding for tobacco control programs, which has occurred concurrently with a dramatic increase in tax-related revenue to states, may not be entirely coincidental. Although increases in price from excise taxes still make money for a state despite decreased consumption, fiscal agencies in states may not perceive the same relationship between increased funding for effective tobacco control programs and state revenues. Although long-term reductions in smoking may lower state expenditures for health care, this is a much less tangible effect than the immediate loss of tax and MSA revenue from a significant decline in cigarette consumption due to a tobacco control program effect. For example, some state governors raised concerns about the 2009 federal tax increase because they thought the resulting consumption drop would lower their tax and MSA revenues.

Smokefree and Tobacco-Free Legislation

As discussed later in this chapter, smokefree legislation at the state and local levels is a key component of a comprehensive tobacco control strategy (Task Force on Community Preventive Services 2005; CDC 2007; USDHHS 2012). Although progress has been made to increase the protection of nonsmokers in the United States from exposure to secondhand smoke since the release of the 1986 Surgeon General's report on the health consequences of involuntary exposure to tobacco smoke (USDHHS 1986a), biomonitoring of exposure indicates that about 40% of nonsmokers, and about one-half of young children 3–11 years of age, continue to be exposed (CDC 2010). Wide geographic, occupational, and demographic disparities remain (CDC 2008b,c, 2010). In 2008, it was estimated that only about one in three residents of the United States live under state or local laws that make worksites, restaurants, and bars completely smokefree (CDC 2008b, 2010).

As described in Chapters 6–10 and previous reports, exposure to secondhand smoke has been linked to a wide variety of adverse health effects affecting the fetus, infants and children, and adults (USDHHS 2006, 2010). The primary purpose of laws and policies on secondhand smoke is to protect nonsmokers from exposure to secondhand smoke. However, a growing body of evidence suggests that these policies have the additional benefit of lowering smoking rates among youth and young adults. There are several pathways for this effect including lower visibility of role models who smoke, fewer opportunities to smoke alone or with others, and diminished social acceptability and social advantage for smoking (Alesci et al. 2003; Eisenberg and Forster 2003; Wakefield and Forster 2005). One study, Dinno and Glantz (2009), indicated that although the prevalence of smoking and cigarette consumption was higher in people with low education and income (using the 2002 Tobacco Use Supplement to the Current Population Survey), a cross-sectional analysis found that this group exhibited the same reductions in smoking associated with the presence of clean indoor air laws and tax increases on tobacco products as did people in higher education and income groups.

Policies on clean indoor air take the form of legislation and/or regulations at the federal, state, local, and institutional levels that prohibit smoking in specified locations, such as workplaces, public places, restaurants, bars and casinos, schools, day care centers, and health care facilities (USDHHS 1989, 2000). Although there have been laws on clean indoor air for 40 years, their coverage has expanded dramatically in recent years (Hyland et al. 2012). As of May 31, 2013, 24 states, the District of Columbia, Puerto Rico, and the U.S. Virgin Islands have laws that prohibit smoking in all workplaces, including bars and restaurants (American Nonsmokers' Rights Foundation [ANRF] 2013a). As noted earlier in this chapter, the movement for laws on clean indoor air largely began at the local level, and many states without comprehensive laws have cities or counties with such laws. The spread of these local laws is shown in Figure 14.5. The ANRF (2013a) estimated that as of May 31, 2013, comprehensive local and/or state laws on clean indoor air covered 49% of the U.S. population. Figure 14.6 provides a map of the implementation of these laws (ANRF 2013b).

Figure 14.5

Number of municipalities and local laws covering smoking in workplaces, restaurants, and enclosed public places, generally, 1978–2013. Source: American Nonsmokers' Rights Foundation 2013a.

Figure 14.6

Map of 100% smokefree laws, United States, May 31, 2013.

Many locations are smokefree because they are environments oriented towards youth. According to the CDC School Health Policies and Programs Study for 2006, in that year 70% of states and 95% of school districts, included in a nationally representative sample, prohibited smoking by students in school buildings, grounds, vehicles, and off-campus school-sponsored events (Jones et al. 2007). However, only 47% of the states, but 78% of the school districts, had smokefree schools in which the same restrictions applied to staff (Jones et al. 2007). At least 1,178 U.S. colleges and universities were completely smokefree as of July 8, 2013, which includes having 100% smokefree residential housing policies (ANRF 2012d). On the basis of data from the Tobacco Use Supplement of the Current Population Survey, CDC reported that in 2009 the median proportion (by state) of households with smokefree policies for everyone living in or entering the home was 81% (King et al. 2013). Finally, smoking has been prohibited in vehicles, when children younger than certain ages are present, in nine U.S. cities or counties, six states, Puerto Rico, nine Canadian provinces/territories, and six Australian states (Global Advisors Smokefree Policy 201).

Relatively little evidence is available about sociodemographic disparities in the coverage of smokefree policies in public and private locations. In one study, Skeer and coworkers (2004) examined differences in community characteristics in relation to the strength of their local policies on clean indoor air in public places; they found that towns with higher education levels and greater per capita income were more likely to have the most restrictive policies. Gonzalez and colleagues (2013) found that Hispanics and Asians have benefited more from the rapid spread of clean indoor air laws and non-Hispanic Blacks have benefited less. A CDC report, using 1999–2004 National Health and Nutrition Examination Survey data, found that youth were three to four times as likely as adults to be exposed to secondhand smoke in the home (CDC 2008a). In this study, non-Hispanic Blacks were the most likely and Mexican Americans the least likely to be exposed to secondhand smoke at home (17.9%; 95% CI, 15.2–21.0), and members of low-income families were three times as likely to be exposed, as their counterparts in the highest income group (5.9%; 95% CI, 5.1–7.0). Poverty income ratio was defined as the ratio of family income to the U.S. Census Bureau poverty threshold

In addition to reducing exposure to secondhand smoke, smokefree policies and laws have also been found to reduce active smoking. The 2006 Surgeon General's report concluded that workplace smoking restrictions lead to less smoking. The 2012 Community Guide's conclusion on the effects of smokefree policies found that these policies reduce the prevalence of tobacco use, increase the number of tobacco users who quit, and reduce tobacco use initiation among young people (Community Preventive Services Task Force 2012). IARC (2009) concluded that there is strong evidence that smokefree workplaces lead to increased successful cessation among smokers and that smokefree policies reduce tobacco use among youth. A 2010 systematic review by the Community Preventive Services Task Force found that smokefree policies were associated with a median 3.4% reduction in tobacco use prevalence and a median 6.4% increase in tobacco use cessation (Hopkins et al. 2010; Task Force on Community Preventive Services 2010). The 2010 Cochrane review found that there is limited evidence about the impact of smokefree laws on active smoking, but that the trend is downward (Callinan et al. 2010).

As of 2013, a summary of progress in implementing smokefree policies includes:

• Smokefree legislation had been adopted by 36 states and over 3,500 municipalities (ANRF 2013b).
• 2,311 states, commonwealths, territories, cities, and counties had a law that restricted smoking in one or more outdoor areas (Americans for Nonsmokers' Rights [ANR] 2012b).
• 4 states prohibit smoking in privately owned vehicles when a child is present (ANR 2012a; CDC 2012d).
• The state of Maine and the city of Boston, Massachusetts, enacted smoking bans in public housing beginning in 2012.
• As of March 31, 2013, there were a total of 19 states with smokefree policies on public school campuses (K–12) (CDC STATE System, unpublished data). Seven of the 19 states also had smokefree policies on private school campuses (K–12). Three states (Arkansas, Iowa, and Oklahoma) banned smoking on public college campuses; and Iowa also had a smokefree policy for private college campuses. Iowa was the only state with smokefree policies for all four types of campuses: private and public schools (K–12) and colleges.
• In 2008, 45% of U.S. hospitals had a smokefree campus policy, with an additional 15% of hospitals pursuing smokefree policies (Williams et al. 2009). As of 2012, 4 national hospitals, clinics, insurers, and health service companies had adopted smokefree policies nationwide that extend to all sites; 3,419 local and/or state hospitals, health care systems, or clinics had adopted smokefree campus grounds; and 105 psychiatric hospitals had adopted smokefree indoor air policies (ANRF 2013f). A total of 34 states banned smoking in hospitals (CDC 2012d). Of these, three states (Arkansas, Illinois, and North Dakota) have designated smoking areas on hospital campuses. Eight states or territories and 154 municipalities have enacted smokefree indoor air laws in nursing homes, in addition to 64 individual nursing homes across the country (ANRF 2013e).
• In 2004, the Federal Bureau of Prisons made all federal facilities 100% smokefree, restricting smoking by correctional facility inmates, employees, and visitors. Nearly all states have adopted smokefree and/or tobacco-free policies in correctional facilities also. Correctional facilities in 19 states are smokefree and tobacco-free indoors and outdoors, 15 states are smokefree and tobacco-free indoors, 1 state and 1 territory are smokefree indoors and outdoors, and 12 states are smokefree indoors only (ANRF 2013c).
• DoD and all of the armed forces except the Coast Guard have set goals to increase tobacco-free areas, but have yet to achieve them despite promoting tobacco-free lifestyles through public education campaigns, commander training, the banning of all tobacco use during basic training, and the prohibition of tobacco use by instructors in the presence of students. A report by IOM, Combating Tobacco in Military and Veteran Populations (IOM 2009), provides an update on these efforts to promote tobacco-free environments in the military.
• Reviews by CDC (2010) have shown where the greatest levels of disparity in exposure to secondhand smoke remain. These areas of disparity include many states without comprehensive smokefree legislation, and among lower socioeconomic status populations, and service and hospitality workers.

Tobacco Product Litigation

When the nation's first Surgeon General's report on smoking and health was released in 1964, litigation against cigarette manufacturers concerning the health effects of their products had been ongoing for 10 years. It would take an additional 30 years until tobacco litigation began to have a deep impact on the landscape of tobacco control. This history of tobacco product litigation is described in more detail online at www.surgeongeneral.gov in Appendix 14.2. Additionally, a summary of major tobacco litigation cases is also provided online in Appendix 14.3.

Litigation against tobacco companies has proven to be a tool for advancing the fundamental public health goal of tobacco control—reducing the morbidity and mortality caused by tobacco products. It can contribute to tobacco control in several ways:

• Tobacco litigation has offered an opportunity to shed light on the practices of tobacco manufacturers by exposing once-secret internal documents and giving a voice to former industry insiders (Bero 2003).
• The media coverage of tobacco litigation serves to educate and reinforce messaging about the health risks associated with the use of tobacco products (Dunlop and Warner 2010).
• Litigation, when successful, can lead to increases in price due to the high cost of verdicts or settlements to manufacturers, which results in reduced consumption of tobacco products, particularly among youth (Chaloupka and Pacula 2001).
• Very large punitive damages have the potential to encourage manufacturers to examine their practices and change behaviors that could trigger such monetary sanctions (Table 14.3) (Guardino and Daynard 2005).
• Settlements may include provisions that restrict marketing practices that might be difficult to achieve through legislation (Jacobson and Warner 1999).
• Litigation complements other tobacco control efforts and can serve as a public reminder of the need for state and federal policy interventions (Vernick et al. 2007).
• By focusing on the conduct of the manufacturers and their role in the injuries at issue, tobacco litigation plays an important role in denormalizing the industry and its practices that contribute to the toll of tobacco use on public health (Vernick et al. 2007).

Table 14.3

Punitive damages in tobacco litigation.

State Attorney General Cases

The 2000 Surgeon General's report and Appendix 14.2 (found online at www.surgeongeneral.gov) provide a summary of several of the most influential cases, including the State Attorney General cases, which started in 1994. The first four of these lawsuits against the tobacco industry to recover health care expenditures for treating tobacco-related ailments of Medicaid recipients were brought by Mississippi, Minnesota, Florida, and Texas. In each of these first four cases, the tobacco industry settled separately with the state. All together, the four settlements resulted in the tobacco industry agreeing to pay a total of $35.3 billion over a 25-year period (Miura et al. 2006).

Shortly after settling separately with Mississippi, Minnesota, Florida, and Texas, the tobacco industry sought to resolve the outstanding state-brought Medicaid reimbursement lawsuits by entering into a comprehensive settlement agreement. On November 23, 1998, the four largest tobacco companies (Brown & Williamson, Lorillard, Philip Morris, and R.J. Reynolds) entered into the MSA with the remaining 46 states and five territories. They entered into this agreement after failing to reach a congressionally brokered global settlement, which would have given the tobacco industry certain immunities from liability going forward (Givel and Glantz 2004).

Under the MSA, the tobacco industry agreed to make annual payments to the states for a 25-year period in return for each state abandoning its Medicaid reimbursement claim. By 2012, the participating tobacco companies had paid the states approximately $87 billion in MSA payments, not including payments to the four states that settled separately (National Association of Attorneys General 2012). On average, the tobacco industry pays each participating state and territory about $120 million in MSA payments annually. After the initial 25-year period elapses, the tobacco industry will continue to make annual payments to the states based on domestic cigarette sales.

The MSA, however, did not require states to earmark the tobacco industry's payments for tobacco control programs; the attorneys general who negotiated the settlement did not have the power to do so. As a result, most states use their MSA payments for general purposes, unrelated to public health. In 1999, CDC published guidelines recommending the amount states should spend on tobacco cessation and prevention efforts (CDC 1999, 2012e). Only a few states spend the CDC's recommended amount on tobacco control (CDC 2007a; American Lung Association 2012). The MSA also specifies that at least $1.65 billion of the states' recovery would be directed to create an independent public health foundation to conduct programs to reduce youth tobacco use. This foundation, which became the American Legacy Foundation (Legacy), was established in 1999. Starting in 2000, Legacy implemented the national truth® campaign—a mass media counter-marketing effort focused on preventing youth smoking. Legacy also provided over $120 million in grant funding to support state and local tobacco control efforts.

In addition to the monetary payments, the MSA included provisions directly benefiting the public health, such as prohibitions or restrictions on: outdoor advertising, distribution of promotional merchandise, sponsorship of public events, targeting underage smoking, and political lobbying. The MSA also improved access to the tobacco industry's documents by requiring the companies to fund, and update for 10 years, a searchable Web site containing millions of documents produced in litigation; however, in practice, the availability of the documents was only practical when Legacy established the Legacy Tobacco Documents Library at the University of California at San Francisco.

It has been suggested that one of the greatest public health consequences of the MSA was the tobacco industry's decision to increase cigarette prices after execution of the MSA (Cutler et al. 2002). To cover the initial payments to the states and payments for the tobacco control programs under the MSA, the tobacco industry had to increase the price of cigarettes. The increase in cigarette retail prices created a decline in cigarette sales of about 10% over the next couple of years, with the most significant decrease in consumption by younger adults (Daynard et al. 2001; Sloan and Trogdon 2004). Although the MSA was not able to earmark payments to states for tobacco control programs, it appears to have had a large overall impact on tobacco control and public health through payments to states, restrictions on marketing methods, and substantial funding of tobacco control and public health programs. More specifically, the landmark settlement also included the establishment of a national public health education foundation with resources dedicated exclusively to reducing the tobacco epidemic, and thus, is widely recognized as one of MSA's lasting legacies. That entity—the American Legacy Foundation—has been a leader in using national mass media to help increase antitobacco-related knowledge, attitudes, beliefs, and behaviors among youth and adults. In its first 2 years alone (2000–2002), 22% of the overall decline in youth smoking was attributed to Legacy's bold truth® campaign (Farrelly et al. 2005, 2009). Legacy's national efforts have been particularly important in states which failed to invest even the minimum expenditures recommended by CDC in 1999 for tobacco control and prevention programs.

United States v. Philip Morris, Inc. (Department of Justice Case)

On September 22, 1999, the U.S. Department of Justice (DOJ) filed a civil suit against the major U.S. tobacco companies in the U.S. District Court for the District of Columbia (Douglas et al. 2006; Guardino et al. 2007). The 11 defendants in this case were: Philip Morris, Inc., now Philip Morris USA, Inc. (“Philip Morris”); R.J. Reynolds Tobacco Co., now Reynolds American (“R.J. Reynolds” or “RJR”); Brown & Williamson Tobacco Co., now part of Reynolds American (“Brown & Williamson” or “B&W”); Lorillard Tobacco Company (“Lorillard”); the Liggett Group, Inc. (“Liggett”); American Tobacco Co., merged with Brown & Williamson, which is now part of Reynolds American (“American Tobacco”); Philip Morris Cos., now Altria (“Altria”); B.A.T. Industries p.l.c. (“BAT Ind.”), now part of BATCo, British American Tobacco (Investments) Ltd. (“BATCo”); The Council for Tobacco Research—U.S.A., Inc. (“CTR”); The Tobacco Institute, Inc. (“TI”). In the suit, DOJ alleged that the tobacco industry conspired to defraud the public by knowingly producing harmful and addictive products and by deliberately misrepresenting the risks of their products, in violation of the RICO Act (Douglas et al. 2006; Guardino et al. 2007). DOJ also originally sought to recover tobacco-related medical costs paid by the federal government; but in 2000 the district court dismissed the medical-recovery claims (U.S. v. Philip Morris Inc., 116 F. Supp. 2d 131 (D.D.C. 2000)). The relief the government sought under the RICO statute included a permanent injunction to restrain the tobacco industry from committing future fraud and misrepresentation; and an order compelling the cigarette manufacturers to disgorge the ill-gotten profits from their unlawful conduct. During the trial an appellate court ruled in 2005 that disgorgement of the defendants' proceeds was not permitted as a remedy under the civil provisions of the RICO Act (U.S. v. Philip Morris USA Inc., 396 F.3d 1190 (D.C. Cir. 2005)). The appellate court later ruled, based on the 2005 disgorgement decision, that other monetary remedies, such as smoker cessation programs and a counter-marketing campaign, were also not available under the civil provisions of the RICO statute (U.S. v. Philip Morris USA Inc., 566 F.3d 1095 (D.C. Cir. 2009) (per cieriam)).

The trial was split into a liability phase, which began on September 21, 2004, nearly 5 years after DOJ had filed the suit, and a remedies phase, which began on May 2, 2005 (Guardino et al. 2007). Presentation of evidence ended on June 2, 2005, and closing arguments ended on June 9, 2005 (Guardino et al. 2007). Not including subsequent appeals, the case involved “the exchange of millions of documents, the entry of more than 1,000 Orders, and a trial which lasted approximately 9 months with 84 witnesses testifying in open court” (Philip Morris 449 F. Supp. 2d at 1).

U.S. District Court Judge Gladys Kessler entered her final opinion and order on August 17, 2006, and found that the tobacco industry defendants violated the RICO Act by lying, misrepresenting, and deceiving the public “including smokers and the young people they avidly sought as ‘replacement smokers,’ about the devastating health effects of smoking and environmental tobacco smoke” (Philip Morris 449 F. Supp. 2d at 1). Based on the trial evidence Judge Kessler found that the tobacco industry established an enterprise “to accomplish the following goals: counter the growing scientific evidence that smoking causes cancer and other illnesses, avoid liability verdicts in the growing number of plaintiffs' personal injury lawsuits against Defendants, and ensure the future economic viability of the industry” (Philip Morris 449 F. Supp. 2d at 34).

Judge Kessler found the tobacco industry liable for perpetrating seven fraudulent schemes. The findings of this case have had a profound and continuing impact on public opinion and public policy. The Tobacco Control Act incorporates as congressional findings of fact Judge Kessler's determinations that “the major United States cigarette companies continue to target and market to youth,” that the companies sought to “encourage youth to start smoking subsequent to the signing of the Master Settlement Agreement in 1998,” and that they “have designed their cigarettes to precisely control nicotine delivery levels and provide doses of nicotine sufficient to create and sustain addiction while also concealing much of their nicotine-related research” (Tobacco Control Act 2009, §2(47) – (49)). The Sixth Circuit cited Judge Kessler's findings of facts extensively in its 2012 decision upholding the constitutionality of several key provisions (although striking down other provisions) of the statute (Discount Tobacco City & Lottery, Inc. v. United States, 674 F.3d 509 (6th Cir. 2012, cert. denied, 133 S. Ct. 1966 (2013)). A summary of Judge Kessler's monumental 1,700-page Opinion has been completed, primarily using a compilation of select quotes from the Opinion (Tobacco Control Legal Consortium 2006). Specifically, Judge Kessler found that the tobacco industry defendants had:

• The tobacco industry defendants have “Publicly denied, distorted, and minimized the hazards of smoking for decades” (Philip Morris 449 F. Supp. 2d at 146). In this section of the Opinion, Judge Kessler explains that the evidence shows that the Defendants (see footnote^a) knew for fifty years or more that cigarette smoking caused disease, but repeatedly denied that smoking caused adverse health effects (“The Hazards of Smoking,” Tobacco Control Legal Consortium 2006).
• “Since the 1950s, Defendants have researched and recognized, decades before the scientific community did, that nicotine is an addictive drug, that cigarette manufacturers are in the drug business, and that cigarettes are drug delivery devices.” In this section of the Opinion, Judge Kessler discusses the evidence that for over 40 years, the Defendants' research had shown that the nicotine in tobacco causes cigarette smoking to be addictive. Judge Kessler addresses the evidence that the Defendants not only publicly denied that smoking is addictive but also withheld information about their research from the American public, the government, and the public health community, including the United States Surgeon General. Judge Kessler explains that the evidence shows the Defendants acted this way to maintain profits by keeping people smoking and attracting new consumers, to avoid liability, and to prevent regulation of the industry (“Addiction,” Tobacco Control Legal Consortium 2006) (Philip Morris 449 F. Supp. 2d at 208).
• “Defendants have designed their cigarettes to precisely control nicotine delivery levels and provide doses of nicotine sufficient to create and sustain addiction.” In this section of the Opinion, Judge Kessler discusses evidence showing that the Defendants control the nicotine levels in cigarettes to ensure that smokers become addicted and stay addicted. Judge Kessler explains that, although the Defendants deny publicly that they manipulate or control the nicotine levels, the facts prove otherwise (“Nicotine Levels,” Tobacco Control Legal Consortium 2006) (Philip Morris 449 F. Supp. 2d at 309).
• Defendants falsely marketed and promoted low tar/light cigarettes as less harmful than full flavor cigarettes in order to keep people smoking and sustain corporate revenues” (Philip Morris 449 F. Supp. 2d at 430). In this section of the Opinion, Judge Kessler explains that, since the 1970s, Defendants have misled consumers into believing that so-called “low tar” and “light” cigarettes are healthier than other cigarettes and are an acceptable alternative to quitting. The Defendants do this even though they have known for decades that light cigarettes offer no clear health benefit. Judge Kessler describes how the Defendants dramatically increased their sales by exploiting consumers' belief that light cigarettes are less harmful, while claiming falsely that their marketing is based only on smokers' preference for a lighter taste. Judge Kessler finds that the Defendants are continuing to make these false and misleading claims in order to reassure smokers and dissuade them from quitting (“Light Cigarettes,” Tobacco Control Legal Consortium 2006).
• “The evidence is clear and convincing – and beyond any reasonable doubt – that Defendants have marketed to young people twenty-one and under while consistently, publicly, and falsely, denying they do so” (Philip Morris 449 F. Supp. 2d at 391). In this section of the Opinion, Judge Kessler discusses the evidence showing that the Defendants tracked youth behavior and used the information to create highly sophisticated marketing campaigns to get young people to start smoking and continue smoking. Judge Kessler explains that the Defendants sought to remain profitable by bringing new, young smokers into the market to replace those who die or quit (“Marketing to Youth,” Tobacco Control Legal Consortium 2006).
• Defendants' statements about secondhand smoke sought “to deceive the public, distort the scientific record, avoid adverse findings by government agencies, and forestall indoor air restrictions” (Philip Morris 449 F. Supp. 2d at 693). In this section of the Opinion, Judge Kessler explains that the evidence shows that the Defendants have long known that secondhand smoke, or environmental tobacco smoke, is hazardous to nonsmokers and that Defendants have understood how this information could affect the tobacco industry's profitability. Judge Kessler describes the steps the Defendants took, after promising to support objective research on the issue, to undermine independent research efforts, to fund industry-friendly research, and to suppress and trivialize unfavorable research results. Judge Kessler emphasizes that the evidence shows that the Defendants continue to deny the extent to which secondhand smoke is hazardous to nonsmokers (“Secondhand Smoke,” Tobacco Control Legal Consortium 2006) (Philip Morris 449 F. Supp. 2d at 208).
• “Defendants attempted to and, at times, did prevent/stop ongoing research, hide existing research, and destroy sensitive documents in order to protect their public positions on smoking and health, avoid or limit liability for smoking and health related claims in litigation, and prevent regulatory limitations on the cigarette industry” (Philip Morris 449 F. Supp. 2d at 801). In this section of the Opinion, Judge Kessler discusses the evidence that for over 50 years, the Defendants tried to protect themselves from litigation and regulation by (1) suppressing and concealing scientific research, (2) destroying documents, and (3) shielding other documents from public view by asserting that they were “privileged” and protected by law. Judge Kessler explains that the Defendants' destruction of documents makes it impossible to know what materials once existed (“Suppression of Information,” Tobacco Control Legal Consortium 2006).

Based on these findings, Judge Kessler determined that they were reasonably likely to continue engaging in fraud and deceit, and accordingly ordered a number of remedies (Philip Morris 449 F. Supp. 2d at 908). The specific remedies included prohibiting them from using brand descriptors (such as light, low-tar, mild, ultra light, and natural), which portray a healthier cigarette; requiring them to issue public “corrective statements” on the health consequences of smoking, cigarette addiction, industry manipulation of cigarettes as nicotine delivery devices, and the hazards of light and low-tar cigarettes; extending the defendants' obligation to maintain the Minnesota depository and their online document web/sites for tobacco documents for 15 additional years; and permanently enjoining (i.e., prohibiting) the defendants from “making, or causing to be made in any way, any material, false, misleading, or deceptive statement or representation… that is disseminated to the United States public and that misrepresents or suppresses information concerning cigarettes” (Philip Morris 449 F. Spp. 2d at 938). On May 22, 2009, the D.C. Circuit upheld Judge Kessler's findings of fact, her determination of liability, and the majority of the remedies she ordered, and on June 28, 2010, the Supreme Court declined to accept review of the case, exhausting the cigarette companies' appeals (Philip Morris 566 F.3d, 2009, cert. denied, 130 S. Ct. 3501).

The Court of Appeals affirmed Judge Kessler's determinations that the cigarette manufacturers engaged in deliberate deception, with “specific intent” to defraud consumers (Philip Morris 566 F.3d, 2009, cert. denied, 130 S. Ct. 3501). In rejecting the companies' claims that their deliberately false and misleading statements were protected First Amendment “free speech,” the D.C. Circuit stressed that the companies “knew of their falsity at the time and made the statements with the intent to deceive,” and observed, “we are not dealing with accidental falsehoods, or sincere attempts to persuade; Defendants' liability rests on deceits perpetrated with knowledge of their falsity” (Philip Morris 566 F.3d, 2009, cert. denied, 130 S. Ct. 3501). Based on the cigarette companies' demonstrated “proclivity for unlawful conduct,” the D.C. Circuit substantially affirmed Judge Kessler's remedies (Philip Morris 566 F.3d, 2009, cert. denied, 130 S. Ct. 3501).

In 2011, the cigarette companies asked the district court to vacate its findings of fact and remedies (Philip Morris 449 F. Supp. 2d at 1), claiming that due to the Tobacco Control Act (2009), future fraud and deception was no longer possible. The lower court decisively rejected this motion, observing that “FDA rulemaking is not designed to prevent future racketeering activity covered by RICO” (U.S. v. Philip Morris USA, Inc., 787 F. Supp. 2d 68 (D.D.C.) aff'd, 686 F. 3d 832 (D.C. Cir. 2012)). The Court of Appeals affirmed, observing that because the possibility of RICO liability had not deterred the tobacco companies from engaging in fraud and conspiracy, “the district court reasonably found the defendants were not likely to be deterred by the Tobacco Control Act either” (U.S. v. Philip Morris USA, Inc., 686 F.3d 832, 837 (D.C. Cir. 2012) (“Vacatur Opinion”)). Thus in 2012, the D.C. Circuit affirmed Judge Kessler's 2011 determination that the cigarette companies remain reasonably likely to continue engaging in fraud and deception (Philip Morris 686 F.3d 832). The cigarette companies did not seek Supreme Court review.

Also in 2012, the district court ordered specific text for the tobacco companies to disseminate as “corrective statements” (U.S. v. Philip Morris USA, Inc., 907 F. Supp. 2d 1 (D.D.C. 2012) (“Corrective Statement Decision”), appeal docketed, No. 13-5028 (D.C. Cir. Jan. 30, 2013)). The statements address five specific subjects. As samples, the addiction and nicotine-manipulation statements read:

A Federal Court has ruled that the Defendant tobacco companies deliberately deceived the American public about the addictiveness of smoking and nicotine, and has ordered those companies to make this statement. Here is the truth:

• Smoking is highly addictive. Nicotine is the addictive drug in tobacco.
• Cigarette companies intentionally designed cigarettes with enough nicotine to create and sustain addiction.
• It's not easy to quit.
• When you smoke, the nicotine actually changes the brain—that's why quitting is so hard. (Philip Morris, 686 F.3d 832).

A Federal Court has ruled that the Defendant tobacco companies deliberately deceived the American public about designing cigarettes to enhance the delivery of nicotine, and has ordered those companies to make this statement. Here is the truth:

• Defendant tobacco companies intentionally designed cigarettes to make them more addictive.
• Cigarette companies control the impact and delivery of nicotine in many ways, including designing filters and selecting cigarette paper to maximize the ingestion of nicotine, adding ammonia to make the cigarette taste less harsh, and controlling the physical and chemical make-up of the tobacco blend.

When you smoke, the nicotine actually changes the brain—that's why quitting is so hard (U.S. v. Philip Morris USA, Inc., 787 F. Supp. 2d 68 (D.D.C. 2011), aff'd, 686 F.3d 832 (D.C. Cir. 2012)). The statements are to be disseminated via print and online newspaper advertisements; TV spots; package “onserts”; and the companies' websites (Philip Morris USA 449 F. Supp. 2d at 938). They may also be delivered through countertop and header point-of-sale displays, although this would be limited to “participating retailers” in the cigarette companies' retailer-incentive programs (Philip Morris, 566 F.3d 1095 (D.D. Cir. 2009) (per curiam)). The cigarette companies have filed an appeal from the corrective-statement decision, contending that it violates their First Amendment free-speech rights.

Clinical and Educational Approaches for Tobacco Cessation

This section reviews the current status of clinical and educational approaches for tobacco cessation. These interventions are reviewed in greater detail within Appendix 14.4 and the efficacy of various pharmaceutical treatments are reviewed in Appendix 14.5 (both available online at www.surgeongeneral.gov). Although the health benefits of smoking cessation have long been documented (USDHEW 1979; USDHHS 1990, 2004; Doll 2004; Doll et al. 2004; Jha et al. 2013), the 2006 NIH State-of-the-Science Conference on Tobacco Use singled out the need to build consumer demand for and more widespread use of proven cessation services as having untapped potential for increasing their reach, use, and impact (Backinger and O'Connell 2007). The 2007 IOM report (Bonnie et al. 2007) emphasized the need to expand treatment use by aligning cessation treatments and the policies that support their use and delivery across all levels of health care and public health systems, and calls for a coordinated, comprehensive strategy to dramatically increase the number of smokers who quit each year (Abrams 2007). The IOM report further stated “systems integration is arguably the single most critical missing ingredient needed to maximize the as yet unrealized potential to significantly increase population cessation rates” (Bonnie et al. 2007, p. 376). Appendix 14.4 of this report provides a review of the current status of efforts to implement these recommendations for a more coordinated and comprehensive strategy for population-based smoking cessation. As reviewed in Appendix 15.1, recent studies model the impact on population quit rates with an integrated implementation of the multiple recommended policies (Levy et al. 2010). Based on a set of assumptions and the implementation of all five policies in combination, this model projected an increase in the baseline population quit rate by 150% (e.g., from about 4.3% baseline up to about 10.9%) (Levy et al. 2010). Although this projected increase has been viewed as optimistic, the model results suggest that more complete implementation of evidence-based cessation interventions could have large population impacts.

Comprehensive Statewide Tobacco Control Programs

Educational and community-wide approaches have long been used in tobacco control to reduce and prevent the initiation of tobacco use (USDHHS 2000). Over time, these initiatives have evolved in their approach, moving toward more comprehensive programs. Comprehensive tobacco control programs are funded as ongoing public health efforts to implement and coordinate evidence-based population-level interventions, (1) prevent initiation of tobacco among youth and young adults, (2) promote quitting among adults and youth (3) eliminate exposure to secondhand smoke (4) identify and eliminate tobacco-related disparities among population groups (CDC 1999, 2007a). A comprehensive approach—one that optimizes synergies from applying a mix of educational, clinical, regulatory, economic, and social strategies—has been established as the guiding principle for controlling tobacco use. In the United States, comprehensive tobacco control programs are typically organized and funded at the state level, with capabilities such as administrative support, surveillance, and program monitoring and evaluation (CDC 1999, 2007a).

Concurrent with the implementation of multiple community-based intervention trials, a broad national movement to reduce tobacco use began to emerge in the 1980s (USDHHS 2000). However, unlike the community-based intervention trials, the movement and the large-scale interventions that developed from it were not structured around research hypotheses and preplanned evaluation designs. Instead, the movement was characterized by community mobilization at the national, state, and local levels. In addition, the idea that multiple educational (including paid media), taxation, legislative, and regulatory approaches are needed to address the social, economic, and environmental influences on tobacco use was underpinned by established theories and principles of health promotion (Kickbusch 1989; Allison and Rootman 1996; Downie et al. 1996; Nutbeam 1998).

Following the establishment of statewide tobacco control programs in Minnesota in 1985 and California in 1989, comprehensive tobacco control programs began to develop during the 1990s (USDHHS 1994). ASSIST was established in 17 states in 1991 (NCI 2005), and the SmokeLess States coalitions, funded by the Robert Wood Johnson Foundation, were established in 19 states during 1993–2004 (Gerlach and Larkin 2005; NCI 2005). In 1994, CDC funded 32 non-ASSIST states and the District of Columbia through its Initiatives to Mobilize for the Prevention and Control of Tobacco Use (IMPACT) program (USDHHS 2000). In 1999, CDC launched the National Tobacco Control Program, which provides financial support and technical assistance for tobacco control programs in all 50 states, the District of Columbia, 8 U.S. territories, 6 national networks, and 8 tribal support centers (CDC 2007). From 2000–2012, Legacy funded a range of competitive grant initiatives including Youth Empowerment (19 states), Priority Populations (over 84 funded programs in over 40 States), Legacy Evaluation Research Network grants, Small Innovative Grants, CDC Match Grants, and Cessation Quitline Grants totaling approximately $120 million. Many of these grants directly supported comprehensive state and local tobacco control programs.

All 50 states and the District of Columbia currently have state tobacco control programs that are funded through various revenue streams, including tobacco excise tax revenues, tobacco industry settlement payments, state general funds, the federal government, and nonprofit organizations (CDC 2012e). Increases in the excise tax on cigarettes from either voter initiatives or state legislation were the mechanism to fund early statewide tobacco control programs. California's program was funded by voter initiatives (1989), as were programs in Massachusetts (1993), Arizona (1994), and Oregon (1996). Many states have also used MSA and other settlement funds to finance statewide programs. In 1997, Florida began a comprehensive program paid for, in part, by funding from the state's settlement with the tobacco industry. Similarly, Mississippi, Texas, and Minnesota used some funds from their individual settlements with the tobacco industry for tobacco control programs. Many of the 46 other states that signed the 1998 MSA also used some settlement funds to finance state-level tobacco control programs; however, this was not specified in the agreement (Campaign for Tobacco-Free Kids 2012a).

States that have made larger investments in comprehensive tobacco control programs have seen larger declines in cigarettes sales than the nation as a whole, and the prevalence of smoking among adults and youth has declined faster, as spending for tobacco control programs has increased (CDC 2007). Figure 14.7 shows the total funding for state tobacco control programs and the prevalence of current smoking among U.S. high school students during 1986–2009. In Florida, a comprehensive program reduced the prevalence of smoking during 1998–2003 among middle and high school students by 50% and 35%, respectively (Bauer et al. 2000). Similarly, during 2001–2010, declines in the prevalence of both adult and youth smoking in New York state outpaced declines nationally, resulting in smoking-attributable personal health care expenditures in 2010 that were $4.1 billion less than they would have been had the prevalence remained unchanged (RTI International 2011). Experience also shows that the longer the states invest in comprehensive tobacco control programs, the greater and faster the impact. In California, which has the nation's first and longest-running comprehensive state tobacco control program, the prevalence of cigarette smoking among adults declined from 22.7% in 1988 to 11.9% in 2010 (California Department of Public Health 2011).

Figure 14.7

Total funding for state tobacco control programs, 1986–2009 (adjusted to fiscal year 2010 dollars). Source: Project ImpacTEEN; University of Illinois at Chicago; CDC, Youth Risk Behavior Survey, 1991–2009. Current smoking defined as high (more...)

Evidence reviews in prior reports (USDHHS 2000, 2006, 2012), the Community Preventive Services Task Force (Task Force on Community Preventive Services 2005), and IARC Handbooks on Cancer Prevention (IARC 2009; 2011) have documented the efficacy of many of the individual interventions which are combined within comprehensive state tobacco control programs. As noted above in the section on “Tobacco Control Policies,” taxation, smokefree indoor air policies, and other policies are among the most effective tobacco control strategies. However, in the evaluation of individual state tobacco control programs where multiple policies and program initiatives are combined, it is often difficult to assess the relative contribution of each one. Nonetheless, several studies have quantified the impact of the policies and programs implemented in these comprehensive tobacco control programs. Table 14.4 summarizes available outcome data for some notable statewide programs, including Arizona, California, Maine, Massachusetts, Minnesota, New York, and Oregon. Additionally, many state programs have experienced, and are facing, substantial cuts to tobacco control funding, resulting in the near elimination of tobacco control programs in those states. In 2010, states were appropriating only 2.4% of their state tobacco revenues for tobacco control, and reaching the CDC's Best Practices for Comprehensive Tobacco Control Programs (Best Practices 2007) funding goal would have required an additional 13% of tobacco revenues, or $3.1 billion of the $24 billion collected (CDC 2012e). Table 14.5 shows the level of tobacco-related revenues and appropriations, by state, during 1998–2010. In fiscal year 2013, Alaska was the only state to fund its tobacco control program at the CDC-recommended level (Campaign for Tobacco-Free Kids 2012a).

Table 14.4

Summary of selected state program components and outcomes.

Table 14.5

Total state tobacco-related revenues (in millions of dollars)—United States, 1998–2010.

Best Practices 2007 outlined the elements of an evidence-based comprehensive state tobacco control program (CDC 2007). The report recommended four goals for comprehensive statewide tobacco control programs: (1) preventing initiation among youth and young adults; (2) promoting quitting among adults and youth; (3) eliminating exposure to secondhand smoke; and (4) identifying and eliminating tobacco-related disparities among population groups. Best Practices 2007 also described an integrated programmatic structure for implementing interventions proven to be effective, which includes the following overarching intervention components—state and community interventions, health communication interventions, and cessation interventions. Although these individual intervention components are effective, evidence from the most effective statewide programs indicates that these interventions can have greater impact when they work in concert with additional components, such as surveillance and evaluation, as well as administration and management, to produce the synergistic effects of a comprehensive tobacco control program.

State and Community Interventions

The history of successful public health practice has demonstrated that the active and coordinated involvement of a wide range of societal and community resources is the foundation of sustained solutions to pervasive problems, like tobacco use (Green and Kreuter 2000; IOM 2002; NCI 2005; CDC 2007; USDHHS 2012). In an evidence-based review of population-based tobacco prevention and control efforts, the Task Force on Community Preventive Services confirmed the importance of coordinated and combined intervention efforts (Zaza et al. 2005). The strongest evidence, demonstrating the effectiveness of many of the population-based approaches that were most highly recommended by the Task Force, comes from studies in which specific strategies for smoking cessation, preventing tobacco use initiation, and eliminating exposure to secondhand smoke are combined with efforts to mobilize communities and integrate these strategies into synergistic and multicomponent efforts (Zaza et al. 2005). Additionally, research has shown the importance of community support, and involvement at the grassroots level, in implementing several of the most highly effective policy interventions, including increasing the unit price of tobacco products and creating smokefree environments (CDC 2007). This community-based intervention model to create a social and legal climate, which cultivates changes in social norms around tobacco use, has now become a core element of comprehensive statewide tobacco control programs (USDHHS 2000, 2012; Mueller et al. 2006; NCI 2006; CDC 2007). The CDC-recommended community-based model to produce durable changes in social norms is based on evidence that strategies with the greatest span will have the largest population impact (USDHHS 2000; Wisotzky et al. 2004; NCI 2005; Bonnie et al. 2007; CDC 2007). Recommendations from evidence-based reviews indicate that more individual focused educational and clinical approaches, with a smaller span of impact, should be combined with population-based efforts at the state and community levels (USDHHS 2000; NCI 2005; Bonnie et al. 2007; CDC 2007).

Statewide programs can provide the skills, resources, and information needed for the coordinated, strategic implementation of effective community programs. For example, educating local community coalitions about the legal and technical aspects of smokefree air ordinances and enforcement can be provided most efficiently through statewide partners, who have experience in providing these services (CDC 2007). Direct funding provided to statewide organizations can also be used to mobilize their organizational assets to strengthen community resources (CDC 2007). Each state's financial and social demographic characteristics have a significant role in their tobacco prevention and control efforts. Statewide efforts can include establishing a strategic plan for comprehensive tobacco control with appropriate partners at the state and local levels; implementing evidence-based policy interventions to decrease tobacco initiation, increase cessation, and protect people from exposure to secondhand smoke; collecting data; and developing and implementing culturally appropriate interventions (CDC 2007).

In addition to statewide programs, communities can also engage in strategies to address the way tobacco is promoted; the time, manner, and place in which it is sold; and how and where it is used, while also changing the knowledge, attitudes, and practices of tobacco users and nonusers (NCI 2005; CDC 2007). Effective community programs involve and influence people in their daily environment (Eriksen 2005; Minkler 2005; NCI 2005; CDC 2007). Therefore, community engagement and mobilization are essential to programs addressing tobacco control, and changing policies that can impact societal organizations, systems, and networks necessitates the involvement of community partners. For example, family and school-based programs when coordinated with community-wide efforts may be useful in the prevention of smoking initiation (USDHHS 2012). During the 1990s, three nationally funded programs—two by the federal government and one by a private foundation—and one federally funded research project helped communities mobilize to reduce tobacco use. The ASSIST, IMPACT, and SmokeLess States programs are examples of community-based interventions that have been successful in achieving tobacco control outcomes among adults and youth (USDHHS 2000, 2004, 2012).

Following the publication of the 2000 Surgeon General's report, Carson and colleagues (2011) published a Cochrane Review on community interventions in tobacco control. This review concluded that community interventions may be effective in preventing the initiation of smoking, and recommended five principles that should be implemented when conducting a community intervention, which are presented in Table 14.6. The 2012 Surgeon General's report also highlighted COMMIT as a community-wide intervention. The COMMIT intervention was a multiyear, randomized control trial, in 10-paired communities across the United States and 1-paired community in Ontario, to assess if community-wide comprehensive programs were effective in increasing, cessation among smokers (COMMIT Research Group, 1995a,b). The COMMIT program was effective in increasing quit rates in intervention communities for light and moderate smokers, but not for heavy smokers (COMMIT Research Group, 1995a,b). COMMIT demonstrated no differences in smoking behavior, over time, for youth in the intervention communities compared to youth in the control communities; however, the intervention focus was primarily on adults (USDHHS 2012).

Table 14.6

Five principles for community interventions.

In addition to strategies associated with statewide and community-based policies and programs, essential components of a comprehensive tobacco control program also include disparity elimination initiatives and interventions specifically aimed at influencing youth (CDC 2007). Because some populations experience a disproportionate health and economic burden from tobacco use, a focus on eliminating such tobacco-related disparities is necessary. To ultimately eliminate tobacco-related disparities, equity in tobacco prevention and control must be achieved by removing avoidable structural and social barriers and equally implementing tobacco control programs and policies. State capacity and infrastructure, including clear leadership and dedicated resources, are essential to the development and implementation of a strong strategic plan that encompasses the identification and elimination of tobacco-related disparities (CDC 2007). Similarly, because most people who start smoking are younger than 18 years of age, intervening during adolescence is critical (USDHHS 2012). Community programs and interventions should be part of a comprehensive effort, coordinated, and implemented in conjunction with efforts to create tobacco-free social norms, including increasing the unit price of tobacco products, sustaining antitobacco media campaigns, and making environments smokefree (USDHHS 1994, 2012; Bonnie et al. 2007; CDC 2007).

The conceptual framework for state and community interventions, outlined in Best Practices 2007, has been used to develop the current generation of statewide comprehensive tobacco control programs (CDC 2007). However, it is important to note that most comprehensive programs currently in place have not been able to fully implement all recommended components. Policy and regulation components are especially hampered, because many state and local actions are limited by federal mandates and preemptions. Moreover, only two states, California and Massachusetts, have implemented comprehensive tobacco control programs for sufficient time to provide evaluation data on the overall efficacy of the emerging comprehensive model (CDC 2007; USDHHS 2012).

Health Communication Interventions

Mass-reach health communication interventions can be powerful tools for preventing the initiation of tobacco use, promoting and facilitating cessation, and shaping social norms related to tobacco use and exposure to secondhand smoke (CDC 2007). Typically, effective health communication interventions and counter-marketing strategies employ a wide range of efforts: paid television, radio, out-of-home (e.g., billboard, transit), print, and digital advertising at the state and local levels; media advocacy through public relations/earned media efforts, such as press releases/conferences, social media, and local events; health promotion activities, such as working with health care professionals and other partners promoting quitlines, and funding permitting, offering free nicotine replacement therapy such as nicotine patches, gums, or lozenges; and efforts to reduce or replace tobacco industry sponsorship and promotion as well as to decrease movie smoking imagery (CDC 2007). Innovations in health communication interventions include the ability to target and engage specific audiences through multiple communication channels such as online video, mobile Web site, and smartphone and tablet applications. However, these platforms should be considered complements to, not substitutes for, traditional mass media (NCI 2008; USDHHS 2012). Evaluation of each digital media effort must be conducted to determine effectiveness and to help build an evidence base.

Effective messages that are targeted appropriately can stimulate public support for tobacco control interventions and create a supportive climate for policy and programmatic community efforts (USDHHS 2000). Young people are particularly vulnerable to social and environmental influences to use tobacco; messages and images that make tobacco use appealing to them are everywhere (USDHHS 2000; McAfee and Tynan 2012). For example, youth and young adults see smoking in their social circles, movies, video games, Web sites, and throughout the communities where they live. Nonsmoking adolescents exposed to tobacco advertising and promotional campaigns are significantly more likely to become young adult smokers (Lovato et al. 2003; Gilpin et al. 2007). Moreover, youth who are exposed to images of smoking in movies are more likely to smoke; those who get the most exposure to onscreen smoking are about twice as likely to begin smoking as those who get the least exposure (USDHHS 2012). Furthermore, evidence indicates adults are also influenced by tobacco promotion, particularly at the point of purchase (Clattenburg et al. 2012). Because youth and young adults continue to be heavily exposed to protobacco media—including images of smoking in movies, advertising, and promotion—public education campaigns are needed to prevent tobacco use initiation and to promote cessation (CDC 2007; USDHHS 2012).

In addition, because smoking in movies is such a major source of protobacco media exposure, if smoking in PG-13-rated movies was reduced to the fifth percentile of exposure, youth smoking rates could be reduced by 18% (Sargent et al. 2012). The magnitude of this effect would be similar to an increase in the price of cigarettes from about $6.00 per pack to over $7.50 average price. However, since onscreen smoking imagery continues in home media (e.g., broadcast, cable, satellite, and on-demand; on DVD and Blu-ray and on streaming media), there is a continuing need for public education campaigns to prevent tobacco use initiation.

Although the relative effectiveness of specific message concepts and strategies varies by target audience, research shows that countermarketing and other media approaches must have sufficient reach, frequency, and duration to be successful (Terry-McElrath et al. 2005; CDC 2006). Mass media campaigns have been a particularly successful component of prevention efforts in tobacco control for decades; able to reach large proportions of the population, mass media messages have the potential to influence not only individual behaviors but also social norms and institutional policies, which in turn can shape patterns of population-wide tobacco use (Hopkins et al. 2001; Hornick 2002). The first example of a successful campaign resulted from a legal challenge based on the Fairness Doctrine, which required countermarketing antitobacco ads to be aired to balance the protobacco advertising by the tobacco industry (USDHHS 2000). The Fairness Doctrine campaign of 1967–1970, which was the first sustained nationwide tobacco control media effort, documented that an intensive mass media campaign can produce significant declines in smoking rates among both adults and youth (Hamilton 1972).

As discussed above in the Tobacco Products Litigation section, one of the positive impacts of the MSA settlement between the states and the tobacco industry was the establishment of the Legacy Foundation. From this funding, Legacy implemented a national youth prevention media intervention—the truth^® campaign, which employs an industry manipulation messaging strategy to help youth and young adults reject tobacco. Findings from numerous studies demonstrate that exposure to truth^® campaign messages is associated with increases in anti-tobacco attitudes and beliefs, as well as a lower likelihood of initiating tobacco use (Farrelly 2002; Farrelly et al. 2005, 2009).

In 2008, Legacy, together with the National Alliance for Tobacco Cessation, launched EX, the first national adult cessation campaign since the Fairness Doctrine. This campaign was found to increase quit attempts, particularly among low-socioeconomic and minority smokers (Vallone et al. 2011a,b).

More recently, CDC aired “Tips from Former Smokers” (TIPS) during March–June 2012, the first federally funded, nationwide, paid-media tobacco education campaign in the United States (CDC 2012b; McAfee et al. 2013). The TIPS campaign featured former smokers talking about their experiences living with diseases caused by smoking, and included advertising on national and local cable television, local radio, online media, and billboards, and in movie theaters, transit venues, and print media. A subsequent evaluation of the campaign found that the number of weekly calls to the telephone quitline portal 1-800-QUIT-NOW from the 50 states, the District of Columbia, Guam, and Puerto Rico increased 132% (207,519 additional calls) during the TIPS campaign, and the number of unique visitors to the NCI smoking cessation Web site (NCI 2013) increased 428% (510,571 additional unique visitors) (CDC 2012b). Quit attempts among smokers increased from 31.1–34.8% (12% relative increase) (McAfee et al. 2013); 13.4% of these quit attempters reported not smoking at follow-up. Nationally, an estimated 1.6 million additional smokers made a quit attempt, and 220,000 remained abstinent at follow-up. Cessation recommendations made by nonsmokers increased from 2.6–5.1%, while talking with friends and family about dangers of smoking increased from 31.9–35.2%, resulting in an estimated 4.5 million additional nonsmokers recommending cessation services to family members or friends and an additional 6 million talking about the dangers of smoking. As a result of the success of the first TIPS campaign, a second series of TIPS ads were released by CDC in March 2013.

The experience of tobacco control campaigns in many states, including Arizona, California, Florida, Massachusetts, Minnesota, and Oregon, as well as the national TIPS campaign, suggests that message content is very important (CDC 2007). Influential and successful campaigns contain a number of essential elements, including optimized themes, appropriate emotional tone, appealing format, clear messages, intensity, and adequate repetition (Pechmann 2001; Siegel 2002; Farrelly et al. 2003; Wakefield et al. 2003; Schar et al. 2006; Richardson et al. 2007; Angus et al. 2008; NCI 2008). Mass media campaigns lacking these elements have been shown to be less effective. In addition, messages that elicit strong emotional response, such as personal testimonials and viscerally negative content, produce stronger and more consistent effects on audience recall (Terry-McElrath et al. 2005).

Prior reports and reviews have shown that mass media campaigns are an effective tool to reduce the prevalence of tobacco and prevent initiation of tobacco use. The 1994 Surgeon General's report concluded that mass media campaigns are cost-effective. NCI Monograph 19 concluded mass media campaigns designed to discourage tobacco use can change youth attitudes about tobacco use, curb smoking initiation, and encourage adult cessation, and their effects are greater when mass media campaigns are combined with other prevention efforts, such as school and/or community-based programs (NCI 2008). In 2012, the U.S. Surgeon General's report included a systematic review of mass media campaigns and youth to update the NCI Monograph 19 review. The 2012 report noted that mass media campaigns are often a part of larger tobacco control programs; therefore, it is difficult to assess individual effects. Nevertheless, the report concluded that the evidence is sufficient to infer a causal relationship between adequately funded antismoking media campaigns and a reduced prevalence of smoking among youth, and that the evidence suggests a dose-response relationship between exposure to antismoking media messages and reduced smoking behavior among youth (USDHHS 2012).

Since the review conducted in the 2012 Surgeon General's report, there have been a few studies that examined the effects of mass media campaigns on tobacco use, cessation, behavior, attitudes, knowledge, intentions, or cessation. Summaries of these studies are shown in Table 14.7. Overall, these studies demonstrate that mass-reach health communications interventions are effective in reducing the prevalence of smoking (Davis et al. 2012; Emery et al. 2012); increasing cessation, quit attempts, or intentions to quit (Vallone et al. 2011; Davis et al. 2012; Emery et al. 2012); and increasing appropriate knowledge, beliefs, and attitudes regarding tobacco use (Murphy-Hoefer et al. 2010; Richardson et al. 2010). Further, Richardson and colleagues (2010) and Delva and colleagues (2009) provide evidence that mass media campaigns should be targeted toward specific populations (Delva et al. 2009; Richardson et al. 2010). However, it is difficult to assess the outcomes of mass media campaigns, because many do not reach CDC's recommended levels of funding, or they are components of other statewide or national programs.

Table 14.7

Summary of studies examining effects of mass media campaigns on youth and adult smoking behavior, attitudes, knowledge, intentions, or cessation.

Cessation Interventions

Quitting smoking is beneficial to health at any age, and cigarette smokers who quit before 35 years of age have mortality rates similar to those who never smoked (Doll et al. 2004; CDC 2011a). From 1965–2011, the prevalence of cigarette smoking among adults in the United States decreased from 42.4% to 19.0%, in part, because of an increase in the number who quit smoking (CDC 2011b). In 2011, 68.9% of adult smokers wanted to stop smoking, and 42.7% had made a quit attempt in the past year (see Table 13.8).

To increase tobacco use cessation, CDC's Best Practices 2007 recommends that state action on tobacco use treatment should include both health care system-based interventions and population-based interventions, such as quitlines and reducing cost barriers for treatment. The report specifically recommends the following elements: (1) sustaining, expanding, and promoting the services available through population-based counseling and treatment programs, such as cessation quitlines; (2) covering treatment for tobacco use under both public and private insurance, including individual, group, and telephone counseling and all FDA-approved tobacco cessation medication; (3) eliminating cost and other barriers to treatment for underserved populations, particularly the uninsured and populations disproportionately affected by tobacco use; and (4) making the health care system changes recommended by the Public Health Service guidelines (Fiore et al. 2008), such as implementing a system of tobacco use screening and documentation and linking tobacco users to quitline services (CDC 2007). However, it is important to note that the cessation landscape has changed considerably since Best Practices 2007, with the enactment of Affordable Care Act, the implementation of the Meaningful Use initiative, the widespread adoption of EHRs, the creation of the Centers for Medicare and Medicaid Innovation, the introduction of new voluntary Joint Commission hospital performance measures, the increasing shift to managed care plans in state Medicaid programs, changes in the organization of private health care, and the emphasis on establishing linkages between public health interventions and clinical interventions. These changes have presented significant new opportunities to institutionalize tobacco use screening and intervention and to increase the availability of evidence-based cessation treatments within health care systems (Koh 2012).

Quitlines are telephone-based tobacco cessation services that help tobacco users quit. Services offered by quitlines include coaching and counseling, referrals, mailed materials, training to health care providers, web-based services, and in some instances, free medications such as nicotine replacement therapy (North American Quitline Consortium [NAQC] 2012). Services are usually provided by a contractor, which can be a public or private organization; the specific services provided typically vary by state and eligibility. There are multiple advantages to telephone counseling, when compared to other smoking cessation interventions (Zhu et al. 1996; Lichtenstein et al. 2010). First, quitlines are convenient; telephone counseling decreases logistical barriers to treatment and increases service utilization. Second, the semi-anonymous nature of phone counseling allows for candid discussion and faster progression of initial counseling sessions. Third, quitlines promote accountability and social support, while reducing the likelihood of attrition. Finally, quitlines allow for the use of a structured protocol, which can dictate minimum acceptable content per session. Moreover, a structured protocol ensures quality control: that every call is comprehensive, yet brief, thus increasing its utility for population-based application (Zhu et al. 1996; Lichtenstein et al. 2010).

The history and growth of quitlines have been summarized by Anderson and Zhu (2007) and Lichtenstein and colleagues (2010). In the early 1980s, NCI introduced the first telephone-based smoking cessation service as a component of the Cancer Information Service. The effectiveness of a reactive quitline that provided services through client-initiated calls was subsequently established, and the American Lung Association adopted the approach (Ossip-Kelin et al. 1991; Lichtentstein et al. 2010) for several years. In 1992, Group Health Cooperative of Puget Sound, a health maintenance organization, introduced the Free & Clear quitline service for its members, which utilized a proactive approach with counselor-initiated calls after clients first phoned the quitline. Concurrently, California established the first publicly funded statewide quitline using a similar proactive approach. Massachusetts (1994), Arizona (1996), and Oregon (1998) instituted proactive quitlines in the ensuing years, and by 2005, 44 U.S. states had sponsored some form of quitline (Lichtenstein et al. 2010). As of 2013, all 50 states and the District of Columbia had their own quitlines (NAQC N.D.). Callers to the national 1-800-QUIT-NOW portal are transferred to their state quitlines. The quitline network is supported by NCI, which manages the national portal, and by CDC, which provides supplemental funding to state quitlines as part of its support for comprehensive state tobacco control programs, as well as providing funding to the NAQC (CDC 2012b; NAQC N.D.). A critical factor in the rapid and widespread adoption of quitlines in the United States has been state public health programs, which saw the value of quitlines as an accessible and cost-effective clinical service, as well as an integral component of population-based approaches to smoking cessation (Anderson and Zhu 2007; Lichtenstein et al. 2010).

Quitlines have been shown to significantly increase rates of smoking cessation, when compared with minimal interventions, self-help, or no counseling; a meta-analysis of nine studies estimated the odds of quitting as 1.6 to 1 (95% CI, 1.4–1.8) (Fiore et al. 2008). However, state quitlines currently reach only 1–2% of smokers, largely because most state tobacco control programs lack sufficient funding to provide and promote quitline services to more callers (Anderson and Zhu 2007; Keller et al. 2010). CDC recommends that state quitlines reach 6–8% of the state's smokers (CDC 2007). In the United States, some consistently funded state quitlines have reached 4–5% of their smoking populations in 1 year (Woods and Haskins et al. 2007; Woods et al. 2007), and some large cities have reached 4% of their smokers in just 1 month by publicizing free nicotine patches available from the quitline (Cummings et al. 2006a,b).

In addition to quitlines, CDC's Best Practices 2007 also recommends that statewide comprehensive tobacco control programs include health care system-based interventions (CDC 2007). The report specifically recommends that system-based initiatives ensure that all tobacco users, who are seen in the health care system, are screened for tobacco use. Additionally, all tobacco users should receive advice to quit and should be offered brief, or more intensive, counseling service and FDA-approved cessation medication (CDC 2007). Counseling and behavioral support for the treatment of tobacco use and dependence are described in more detail elsewhere in this chapter. In summary, the Public Health Service's evidence-based clinical practice guidelines on cessation state that brief advice by medical providers to quit smoking is an effective intervention (Fiore et al. 2008). More intensive interventions (e.g., individual, group, or telephone) that provide social support and coaching on problem-solving skills are even more effective. Combining counseling with FDA-approved medication for smoking cessation is most effective. The Public Health Service guideline also stresses that health care system changes are needed, such as covering treatment for tobacco use under both public and private insurance and eliminating cost and other barriers to treatment for underserved populations (Fiore et al. 2008). Model programs in large managed care plans show that full implementation of health care system changes, quitline services, comprehensive insurance coverage, and promotion of the services increases the use of proven treatments and decreases the prevalence of smoking (CDC 2007; Fiore et al. 2008).

International Tobacco Control

Increasingly, innovations in tobacco control programs and policies are occurring outside of the United States. Therefore, the history of international tobacco control is reviewed in this chapter since it provides a context for considering progress in the United States, and examples of what types of future efforts could be undertaken here. Previous Surgeon General's reports have reviewed the history of international tobacco control efforts. Although this chapter focuses primarily on the United States, this section briefly describes key global tobacco policy changes over the past half-century. Before the 1964 Surgeon General's report, significant scientific work was being conducted in other countries linking smoking with major health effects. In 1962, Royal College of Physicians (RCP) published the report, Smoking and Health (RCP 1962). In 1967, the first World Conference on Smoking and Health was held in New York City to convene international scientists and advocates to consider the findings of the 1962 RCP report and the 1964 Surgeon General's report. Since 1967, periodic (every 2–4 years) world conferences have been held to mobilize and coordinate international tobacco control efforts (see Table 14.8 for a listing of the years and locations of these conferences). Following a 1970 resolution at the World Health Assembly calling on governments to take action in the field of smoking control, WHO (1970) has had a commitment to antismoking action. WHO Expert Committees were convened in 1974 and 1979 to advise WHO in the field of smoking control. Beginning with the Third World Conference on Smoking and Health in 1975, WHO has cosponsored the world conferences and, increasingly, has taken a leadership role in activities. The WHO Technical Report, No. 636, Controlling the Smoking Epidemic: Report of the WHO Expert Committee on Smoking Control (WHO 1979), provided a comprehensive blueprint of the types of economic, policy, and regulatory interventions, which are very consistent with the established evidence-based best practices now defined in the WHO FCTC treaty and the MPOWER components: Monitor tobacco use and prevention policies; Protect people from tobacco smoke; Offer help to quit tobacco use; Warn about the dangers of tobacco; Enforce bans on tobacco advertising, promotion and sponsorship; and Raise taxes on tobacco. This is discussed in greater detail later in this chapter.

Table 14.8

Years and locations for the World Conferences on Smoking and Health.

The activities at the World Conferences on Smoking and Health (and, since 1990, called the World Conference on Tobacco or Health) (Table 14.8) have been a forum to share and discuss scientific findings; however, since the early conferences, there has been a strong emphasis on mobilizing country efforts to promote social and legislative changes, engaging the leadership in health ministries and major voluntary health organizations into the tobacco control effort, and creating strong alliances among tobacco control leaders from across the world. Between the conferences, a network of tobacco control experts provided technical assistance to small regional groups or individual countries to maintain these same themes. This network was led by Nigel Gray of the Anti-Cancer Council of Victoria in Australia, who was head of the Union for International Cancer Control (UICC) Tobacco Program from 1974–1990, and included staff and volunteers from the American Cancer Society (ACS) and other UICC member organizations (e.g., Hong Kong Anti-Cancer Society), international leaders from other medical and professional groups (e.g., International Union Against Tuberculosis and Lung Disease, World Lung Foundation), and groups such as the United Kingdom's Action on Smoking and Health and Norway's National Council on Smoking and Health. Advocacy organizations in the United States, such as Doctors Ought to Care and ANR, drew upon the experience of similar groups such as the United Kingdom's Action on Smoking and Health, the Australian Council on Smoking and Health, and the Australian BUGA UP, in adopting stronger anti-industry campaigns and strategies (Chapman 1996, 2007).

By the 1990s, the tobacco epidemic was recognized as a rapidly growing international cause of premature death. In 1993, Ruth Roemer, lawyer and public health researcher, began to raise support for an international legal approach to address the global tobacco epidemic (Roemer et al. 2005; WHO 2009a). The process of creating an international instrument for tobacco control was formally initiated in May 1995 at the 48th World Health Assembly (WHO 1995), but the enterprise was not formally launched until 1999. In 1998, the newly elected WHO Director-General, Gro Harlem Brundtland, established the Tobacco Free Initiative as a special cabinet project and championed the concept of a framework convention on tobacco control (WHO 2009a).

The history of WHO FCTC has been documented (WHO 2009a). FCTC was the first international health treaty negotiated under the WHO treaty-making constitutional authority. In May 2000, the 53rd World Health Assembly accepted the provisional text, which had been prepared by an intergovernmental technical working group, and called for the treaty negotiations to begin (WHO 2000). Following six Intergovernmental Negotiating Body sessions between October 2000 and March 2003, the treaty was adopted by the 56th World Health Assembly in May 2003 (WHO 2003). It became one of the most rapidly and widely embraced treaties in the United Nations (UN) history. By June 29, 2004, 168 UN member states had signed the WHO FCTC expressing their willingness to become a Party to the Convention. Ninety days after the 40th state had acceded to, ratified, accepted, or approved the FCTC, the treaty entered into force on February 27, 2005. Together with UN Member States and regional economic integration organizations, there are now 176 Parties to the Convention. The United States signed the Convention on October 5, 2004, but the treaty has not been ratified by the U.S. Senate.

The articles of FCTC provide a scientific basis for coordinating world tobacco control efforts. Based on these FCTC treaty articles, and the scientific evidence on effective strategies to control the tobacco epidemic, WHO developed the six component MPOWER format to evaluate the implementation of tobacco control in all countries (WHO 2008b).

• Monitor tobacco use and prevention policies. Articles 20 and 21 of FCTC
• Protect people from tobacco smoke. Article 8 of FCTC
• Offer help to quit tobacco use. Article 14 of FCTC
• Warn about the dangers of tobacco. Articles 11 and 12 of FCTC
• Enforce bans on tobacco advertising, promotion and sponsorship. Article 13 of FCTC
• Raise taxes on tobacco. Articles 6 and 15 of FCTC

Using specific indicators based on each of these MPOWER components, global progress in tobacco control has been monitored (see the text box “MPOWER Success: Turkey” for one example). The key findings of the status of tobacco control in 2008 are shown in Table 14.9.

Table 14.9

Global tobacco control MPOWER key findings, 2008.

In 2009, an update report was released focusing on the implementation of smokefree environments (WHO 2009b). In 2011, the third global report provided data on the level of countries' achievement of the six MPOWER measures, updated through 2010, and additional data collected on warning the public about the dangers of tobacco (WHO 2011). The report examines in detail the two primary strategies to provide health warnings—labels on tobacco product packaging and antitobacco mass media campaigns. It provides a comprehensive overview of the evidence base for warning people about the harms of tobacco use as well as country-specific information on the status of these measures. The fourth and most recent global report, released in 2013, examines the enforcement of bans on tobacco advertising, promotion, and sponsorship, in addition to providing data updates on MPOWER achievements through 2012, at the country level (WHO 2013b). The updated status report on global tobacco control on key indicators is shown in Figure 14.8.

Figure 14.8

World Health Organization (WHO) selected key indicators for tobacco control policies, 2012. Source: WHO 2013.

MPOWER Success: Turkey

Turkey was the first country to implement all MPOWER measures within 6 years. Turkey's MPOWER successes included:

• Monitor: Surveillance and monitoring through Global Adult Tobacco Surveys and Global Youth Tobacco Surveys
• Protect: 100% smokefree laws with regulations to ensure compliance
• Offer Help: National quitline and free cessation services (including nicotine replacement therapy)
• Warn: Mass media campaigns and graphic health warnings that cover 65% of tobacco packaging
• Enforce: Total ban on tobacco advertising, promotion and sponsorship
• Raise taxes: Increase in tobacco taxes (80.3% of retail price)

The results of implementing all MPOWER measures in Turkey:

• A 13.7% decline in smoking prevalence after comprehensive tobacco control measures were put into place (2008–2012)

As tobacco control gained greater priority under WHO Director-General Dr. Gro Harlem Brundtland, several international collaborations were expanded. In 1998, CDC and WHO created the Global Youth Tobacco Survey to address the need for surveillance of tobacco use among adolescents across the world (Warren et al. 2006, 2008). Additional surveillance surveys have been added, including the Global School Personnel Survey, the Global Health Professions Student Survey, and the Global Adult Tobacco Survey (GATS) (Warren et al. 2009). Tobacco Questions for Surveys: a subset of key questions from GATS was introduced to promote standard use of tobacco questions in surveys. Results from the GATS component were recently published showing the tobacco use rates in 14 low- and middle-income countries (LMICs) compared with data from the United Kingdom and United States (Giovino et al 2012).

Leading up to the FCTC negotiations, the Framework Convention Alliance (FCA) was created in 1999 (WHO 2013). FCA was formally established in 2003, and now includes over 350 organizations from more than 100 countries. FCA has a mission to work on the development, ratifications, and implementation of the FCTC. FCA produces policy papers supporting the implementation of FCTC articles (e.g., on price and tax; product regulation; packaging and labeling; education and training; advertising, promotion, and sponsorship; cessation, illicit trade, alternative livelihoods, and environments; liability; reporting on treaty implementation; and technical and financial assistance). FCA also organizes public events, workshops, and media campaigns to support the development, ratification, and implementation of the FCTC treaty and related tobacco control activities.

The Global Smokefree Partnership ([GSP] 2013) was formed to promote the implementation of smokefree air policies worldwide. The GSP currently is hosted by the International Union against Tuberculosis and Lung Diseases and FCA. GSP works together with the civil society and nongovernmental organizations within countries to gain the support of universities, intergovernmental organizations, ministries of health, corporations, and civic and medical leaders to support smokefree air policies and legislation. The pace at which comprehensive smokefree policies—such as policies that ban smoking in all enclosed public places and workplaces (no designated smoking rooms allowed), including bars, restaurants, and public transportation—have spread across the world has been cited as one of the most visible products of policy changes following a country's joining FCTC (Hyland et al. 2012). Ireland passed comprehensive smokefree legislation even before ratifying FCTC. Similarly, shortly after signing FCTC, both New Zealand and Norway implemented comprehensive smokefree policies. As of 2012, 28 countries had national comprehensive smokefree laws, which required 100% coverage of bars, restaurants, and nonhospitality workplaces (Table 14.10) and an additional 27 countries had national smokefree laws, which were not as fully comprehensive (Hyland et al. 2012).

Table 14.10

Global tobacco control MPOWER key findings, countries 100% smokefree, 2009.

Funding for global tobacco control has dramatically increased in recent years, primarily due to foundation support. In 2007, the Bloomberg Initiative to Reduce Tobacco Use was started to address the lack of global resources to implement FCTC (Bloomberg Philanthropies 2013). In 2009, the Bloomberg Philanthropies joined forces with The Bill & Melinda Gates Foundation to broaden the global tobacco control movement, particularly in China, India, Southeast Asia, and Africa, with a commitment of $125 million. The initial Bloomberg Initiative to Reduce Tobacco Use commitment of $600 million was increased by an additional $220 million in 2012 (Bloomberg Philanthropies 2012). The Initiative continues to fund five institutions with global reach in tobacco control advocacy and public health: Campaign for Tobacco-Free Kids, National Foundation for the Centers for Disease Control and Prevention, the Johns Hopkins Bloomberg School of Public Health, WHO, and the World Lung Foundation/International Union Against Tuberculosis and Lung Disease. GATS, described above, is one major component of the Initiative (Giovino et al. 2012). A short list of the accomplishments, as of 2013, among LMICs that the Bloomberg Initiative (2013) has supported since 2007 are shown below:

• 32 countries successfully supported to implement national smokefree legislation, providing protection from exposure to second-hand smoke to over 1.3 billion people.
• 24 countries successfully supported to implement legislative bans on tobacco advertising, protecting nearly 1 billion people from tobacco advertising.
• 31 countries successfully supported to implement pictorial health warnings to warn about the dangers of tobacco use to over 2.7 billion people.
• 12 countries successfully supported increased tobacco taxes.
• In total, 46 countries representing over 4.5 billion people, have made critical legislative improvements supported by the grants program (Bloomberg Philantrophies 2013).

The majority of the accomplishments in tobacco control reviewed in this chapter have focused on the United States. However, as the brief summary above shows, the tobacco control activities occurring within the United States, since 1964, have happened within a dramatic global context. Following the first World Conference on Smoking and Health in 1967, there has been an active flow of tobacco control efforts between the United States and its global partners. For example, as an ACS volunteer, Dr. Joseph W. Cullen was an active member of the UICC Tobacco Program technical assistance teams before joining NCI in 1982, where he established NCI's Smoking Tobacco and Cancer Program (Greenwald and Cullen 1984). As described above, STCP was a major funder of tobacco control research and programs in the 1980s, including the ASSIST program that was the foundation of comprehensive statewide tobacco control efforts (Cullen 1989; USDHHS 2000). Several of the international tobacco control innovations, particularly those related to media and public health advocacy, were integrated into ASSIST intervention activities (NCI 2005). Another member of the UICC Tobacco Program technical assistance teams, Michael Pertschuk, was an important advisor to ASSIST and other U.S. tobacco control program efforts on media advocacy strategies, including ACS's Smoke Signals: The Smoking Control Media Handbook (ACS 1987). In addition to these several examples, there have been many international links and contributions across many of the tobacco control activities reviewed in this chapter.

Summary

The past 50 years has witnessed a dramatic shift in attitudes among Americans toward tobacco products and the use of tobacco. This shift, from tobacco products being a widely accepted element of daily life to an addiction viewed unfavorably, has been driven by public health interventions and policies that discourage tobacco use and by the steps taken to regulate tobacco products and protect the population. We now have multiple examples of successful interventions, policies, and regulatory approaches, and these should guide future efforts to reduce tobacco use among youth and adults. Although there has been significant progress, much remains to be done in applying what is known to control tobacco use and in adapting these approaches to the new challenges for tobacco control as the industry diversifies its product lines.

This chapter expands and updates prior reviews in this series of reports on intervention approaches to reduce tobacco use in the population. As documented in previous reviews of a diverse and substantial body of research and evaluation literature, the evidence base documents the efficacy and effectiveness of a suite of tobacco control interventions and policy measures. These approaches, along with the regulatory authority of FDA, will be the foundation for designing strategies for further speeding the decline of tobacco use in the United States.

Conclusions

1. The evidence is sufficient to conclude that there are diverse tobacco control measures of proven efficacy at the population and individual levels.
2. The evidence is sufficient to conclude that advertising and promotional activities by the tobacco companies cause the onset and continuation of smoking among adolescents and young adults.
3. Tobacco product regulation has the potential to contribute to public health through reductions in tobacco product addictiveness and harmfulness, and by preventing false or misleading claims by the tobacco industry of reduced risk.
4. The evidence is sufficient to conclude that litigation against tobacco companies has reduced tobacco use in the United States by leading to increased product prices, restrictions on marketing methods, and making available industry documents for scientific analysis and strategic awareness.
5. The evidence is sufficient to conclude that increases in the prices of tobacco products, including those resulting from excise tax increases, prevent initiation of tobacco use, promote cessation, and reduce the prevalence and intensity of tobacco use among youth and adults.
6. The evidence is sufficient to conclude that smokefree indoor air policies are effective in reducing exposure to secondhand smoke and lead to less smoking among covered individuals.
7. The evidence is sufficient to conclude that mass media campaigns, comprehensive community programs, and comprehensive statewide tobacco control programs prevent initiation of tobacco use and reduce the prevalence of tobacco use among youth and adults.
8. The evidence is sufficient to conclude that tobacco cessation treatments are effective across a wide population of smokers, including those with significant mental and physical comorbidity.

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Appendix 14.3. Tobacco Litigation Case Summaries

Individual Cases

Along with the state-brought suits and class actions, several individual plaintiffs have successfully brought claims against the tobacco industry in the third wave of tobacco litigation. Most of these plaintiffs raised claims similar to the product liability claims individual plaintiffs brought in the second wave. In addition to compensatory damages, juries have punished the tobacco industry's conduct by awarding punitive damages in many of these cases. Individuals injured from cigarettes and industry misconduct continue to bring claims against the tobacco industry.

In 1991, Grady Carter brought the first tobacco case to produce a verdict that the defendant actually paid. Carter, a lifetime smoker of Lucky Strike cigarettes, sued Brown & Williamson Tobacco Corporation under theories of negligence and strict liability after being diagnosed with lung cancer (Tobacco Products Litigation Reporter 1996, p. 1.114). In 1996, the jury found that the defendant's cigarettes were “unreasonably dangerous and defective” and awarded Carter $750,000. After exhausting all of its appeals, the defendant paid Carter in 2001 (Van Voris 2001).

In a more recent lawsuit, Mayola Williams sued Philip Morris on behalf of her deceased husband, who smoked about three packs of the defendant's cigarettes per day from the early 1950s until his death from lung cancer in 1997 (Williams v. Philip Morris, Inc., 92 P.3d 126 [Or. Ct. App. 2004]; Guardino and Daynard 2005). After trial, an Oregon jury awarded Williams $821,485.80 in compensatory damages and $79.5 million in punitive damages. The trial judge reduced the damages to $500,000 and $32 million, respectively (Miura et al. 2006). The Oregon Court of Appeals reinstated the $79.5 million award for punitive damages. On the third appeal to the U.S. Supreme Court, the Court dismissed the writ of certiorari (the decision by the Supreme Court to hear an appeal from a lower court) as “improvidently granted,” exhausting all of the defendant's appeals and finalizing the $79.5 million award (Philip Morris Inc., v. Williams, 556 U.S. 178, 129 S. Ct. 1436, 173 L. Ed. 2d 346, 2009 U.S. LEXIS 2493, 77 U.S.L.W. 3557, 21 Fla. L.Weekly Fed. S. 731 [2009]).

Four individuals have separately sued Philip Morris successfully in California for injuries they sustained from smoking cigarettes. The first California suit, Henley v. Philip Morris Inc., 113 Cal.Rptr.2d 494, 93 Cal. App.4th 824 (2001); 114 Cal. App. 4th 1429, 9 Cal.Rptr.3d 29 (2004), resulted in a jury verdict of $1.5 million in compensatory damages and $50 million (later reduced to $9 million) in punitive damages (Table 14.3.1) (Guardino and Daynard 2005). In Whiteley v. R.J. Reynolds Tobacco Co., WL 3299595 (Cal. App. 1 Dist. Oct. 14, 2009), the jury initially awarded the plaintiff $1.7 million in compensatory damages and $20 million in punitive damages for her products liability claim. After a retrial, the jury awarded the plaintiff $2.4 million in compensatory damages, but no punitive damages.

Table 14.3.1

Punitive damages in tobacco litigation.

The other two California cases involved extraordinarily large awards of punitive damages that the courts later reduced. In Boeken v. Philip Morris USA, Inc., 48 Cal. 4th 788, 230 P.3d 342, 108 Cal. Rptr. 3d 806 (2010), the jury awarded the plaintiff, who was diagnosed with lung cancer after 10 years of smoking, $5.54 million in compensatory damages and $3 billion in punitive damages (Miura et al. 2006). A California appellate court reduced the punitive damages to $50 million, and the U.S. Supreme Court declined review, cutting off the defendant's final avenue of appeal (Miura et al. 2006). The jury in Bullock v. Philip Morris, Inc., 159 Cal. App. 4th 655 (2008) also found in favor of the plaintiff and awarded compensatory damages of $850,000 and $28 billion in punitive damages. The trial court reduced the punitive damages amount to $28 million, and a California appellate court remanded the case for a new jury trial solely to recalculate punitive damages. On August 24, 2009, the second jury awarded the plaintiff $13.8 million in punitive damages, and on August 17, 2011, a California appellate court upheld the jury's award (Bullock v. Philip Morris, Inc., 198 Cal. App. 4th 543 [2011]). California's highest court denied review of the $13.8 million punitive damages award.

In another individual plaintiff case, Willie Evans sued Lorillard in 2004 on behalf of his deceased mother, Marie Evans, alleging that the defendant negligently marketed Newport cigarettes (a menthol-flavored cigarette targeted at new, young, and African-American smokers) and negligently failed to warn consumers of the dangers associated with smoking Newports (Evans v. Lorillard Tobacco Co., 465 Mass. 411 [2013]). Marie Evans began smoking when she was 13 years of age, several years after Lorillard began distributing free cigarettes to her and other residents of her housing project; she continued to smoke, despite many attempts to quit, until shortly before her death from lung cancer at 54 years of age. After trial, in December 2010, the jury found for the plaintiff and awarded a total of $71 million in compensatory damages (which the trial judge later reduced to $35 million) and $81 million in punitive damages (Valencia 2010). The $81 million punitive damages award, was reversed by the Supreme Judicial Court for technical reasons; the settlement of the case prevents this from being retried.

In addition to product liability suits, some individuals have brought consumer protection lawsuits against the tobacco industry, which also are referred to as private attorney general cases because the individual is acting in the interest of the public. In the early 1990s, a California individual sued R.J. Reynolds Tobacco Company (RJR) claiming that its Joe Camel advertising unfairly targeted minors (Mangini v. R.J. Reynolds Tobacco Co., 7 Cal. 4th 1057 [1994]). Although the California Supreme Court later found that the Federal Cigarette Labeling and Advertising Act preempted this claim in In re Tobacco Cases II, 41 Cal. 4th 1257 (2007), Mangini and RJR settled this claim in 1997 (Mangini Settlement Agreement). RJR agreed to discontinue the Joe Camel advertising and paid $10 million, some of which was earmarked for educational programs to discourage minors from smoking, as part of the settlement agreement (Mangini Settlement Agreement 1997).