Stealing a March in the 21st Century: Accelerating Progress in the 100-Year War against Tobacco Addiction in the United States

doi:10.2105/AJPH.2008.154559

Am J Public Health. Author manuscript; available in PMC 2010 July 1.

Published in final edited form as:

Am J Public Health. 2009 July; 99(7): 1170–1175.

Published online 2009 May 14. doi: 10.2105/AJPH.2008.154559

PMCID: PMC2696654

NIHMSID: NIHMS117249

Stealing a March in the 21^st Century: Accelerating Progress in the 100-Year War against Tobacco Addiction in the United States

Michael C. Fiore, MD, MPH and Timothy B. Baker, PhD

Center for Tobacco Research and Intervention, School of Medicine and Public Health, University of Wisconsin, Madison

Corresponding Author: Michael C. Fiore, MD, MPH, Professor of Medicine and Director, University of Wisconsin Center for Tobacco Research and Intervention, 1930 Monroe St, Suite 200, Madison, WI 53711 (e-mail: mcf/at/ctri.medicine.wisc.edu)

The publisher's final edited version of this article is available at Am J Public Health

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Abstract

Tobacco use in the United States has declined dramatically over the past 50 years, with the prevalence of cigarette smoking falling from about 42% of all adults to less than 20%by 2007. If this rate of decline continues, smoking could be eliminated in the United States by 2047. Framed in military parlance, we may be halfway through a 100-year war against the leading public health killer of our time. We describe factors that have contributed to progress over the last 50 years and identify policy and other initiatives that can contribute to the elimination of tobacco use in the United States.

Among the public health successes of the 20^th century, the decline in tobacco use since the early 1960s has been historic. As shown in Figure 1, adult smoking in the United States has fallen from a rate of about 42% a half century ago, to less than 20% today. Framed in military parlance, we may be at the halfway point in a “100 Years War” against tobacco addiction. This framing raises the question of what can be done to shorten this war. In essence, how can we steal a march in the 21^st century in the battle against tobacco use and the tobacco industry? In this paper, we review strategies that have worked thus far, and recommend additional steps to further reduce tobacco use and dependence.

Figure 1

Smoking Prevalence Among Adults 18 and Older, United States 1965-2007, with Projections to 2047 *

Numerous observers have claimed over time that tobacco use has plateaued; that progress against tobacco use has stalled ¹^-³. However, the remarkable decline in tobacco use rates since the 1960s (Figure 1) belies this claim and underscores the remarkable success of tobacco control efforts to date. A review of smoking prevalence data from the CDC shows that adult smoking between 1965 and 2007 declined by an average of about one-half of one percentage point per year (from 42% to 20%, Figure 1), although the actual annual declines have varied over these four decades. Extrapolation of these data reveals that, if this rate of decline continues, smoking will be essentially eliminated in the United States by about 2047.

Importantly, the average rate of decline of one half of one percentage point/year observed over the last 42 years reflects an increase in the proportion of smokers removed from the smoker population over time. That is, one half of one percentage point reflects an annual decline in the smoker population of about 1.2% in 1965 (.5% of 42%) versus 2.5% in 2007 (.5% of 20%). Fine grained analyses of the declines suggest that the overall pattern of decreases was caused by the progressive enactment of new and stronger policies and interventions. Continued innovation of tobacco control efforts and continued attention to tobacco industry tactics (e.g., price discounting, increased marketing of smokeless tobacco products) will be needed to maintain this accelerating rate of decline into the future.

What strategies have been most effective in spurring declines in prevalence? There is no doubt that release of information about the health hazards of tobacco drove down use. The Report of the Surgeon General on the health effects of smoking released in 1964 presaged a burst of prevention and cessation activities ⁴. Additionally, the late 1960s demonstrated the power of public health countermarketing ⁵^-⁷, and this was amplified by later public health campaigns ⁷^-¹¹. Moreover, evidence that second-hand smoke is a significant cause of mortality ¹² and that tobacco is addictive ¹³ fostered both the acceptance of clean indoor air policies and the development of evidence-based clinical treatments ¹⁴^-¹⁶. Finally, given the cost-sensitive nature of tobacco use, increasing the cost of cigarettes through tobacco excise taxes, reliably leads to drops in consumption and prevalence ¹⁷^-²⁰. Formal modeling analyses suggest that the reductions in prevalence observed over the last 40 years are due to such policy changes and interventions as tax increases, clean indoor air laws, advertising restrictions, product labeling laws, youth access laws, mass media campaigns, and increased availability of cessation programs ¹¹^,²⁰^-²⁹.

Policies and Interventions that Could Accelerate Progress during the Second Half of the 100 Years War

While these successful strategies of the past provide a blueprint for maintaining the current downward pressure on prevalence rates, we believe that additional innovation over the next decade is needed to further accelerate the rate of decline. The strategies that may prove most effective arise from research in a wide array of fields, including: public policy, health economics, public health, cessation interventions, prevention, and genetics research that link nicotine dependence severity with age of nicotine exposure.

The relation of age of nicotine exposure warrants special consideration because a large body of converging evidence shows that early nicotine exposure is associated with more severe nicotine dependence amongst adult smokers. Smokers reporting an early onset of smoking (e.g., daily smoking in adolescence) differ from other smokers in that they develop more severe nicotine dependence ³⁰^-³², smoke more cigarettes/day ³¹^,³³, and are less likely to quit smoking ³⁰^,³⁴^-³⁹. This human research is complemented by animal research showing that adolescent vs. adult initial nicotine exposure produces greater effects on the brain, ⁴⁰^-⁴³, has greater rewarding effects ⁴¹^,⁴⁴^-⁴⁷, and produces higher levels of self-administration ⁴⁸^,⁴⁹. Importantly, recent data show that a major genetic risk for severe nicotine dependence, variations in the nicotinic receptor CHRNA5/A3/B4 gene cluster ³²^,⁵⁰^,⁵¹, will not be expressed unless an individual begins daily smoking prior to age 17 ³². The implication is that policies and interventions that significantly reduce smoking and nicotine exposure amongst adolescents will eventually produce a generation of Americans with a reduced vulnerability to nicotine dependence. Reducing smoking by youth is an especially important goal since research shows that once an adolescent has progressed to regular, heavy smoking, he or she is unlikely to quit for 20 – 30 years or more ⁵²^,⁵³. As a result, every new adolescent smoker today increases smoking prevalence, on average, for several decades.

The considerations enumerated above led us to identify several policies and interventions especially worthy of implementation (Figure 2):

Figure 2

Policies to Accelerate Progress in the War Against Tobacco

Price, the single most effective policy currently available, has been underutilized as a driver of decreased tobacco use. From 1965 to 2007, the proportion of the price of an average pack of cigarettes that went to taxes (federal and state) has declined from 51.4% to 32.3%, despite significant tax increases by some states ⁵⁴. In 2003 the Subcommittee on Cessation of the Interagency Committee on Smoking and Health proposed a comprehensive tobacco cessation policy program for the United States that included a $2.00/pack increase in the cigarette excise tax (with tax parity for non-cigarette tobacco products to discourage product switching). The Subcommittee estimated that the program would result in 4.7 million new quitters and a 10% reduction in adult smoking prevalence. Moreover, such a price increase would generate an estimated $28 billion in new revenue, part of which could be earmarked to fund other aspects of an aggressive campaign to eliminate tobacco use in America (including countermarketing, prevention, cessation, and research components). Importantly, research shows that youth are particularly sensitive to price increases; such increases have been shown to both promote cessation and prevent initiation of tobacco use among adolescents ¹⁷^,⁵⁵.
An ongoing extensive national paid media campaign has the potential to further denormalize tobacco use, highlight the dangers of second-hand smoke, discourage youth from initiating tobacco use, and drive tobacco users to use evidence-based treatments ⁵⁶^-⁵⁸. While such a well funded, national paid media effort has not been undertaken, state campaigns and other efforts have documented their effectiveness. For example, California's comprehensive tobacco control effort initiated in 1988 resulted in a 39% decline in adult prevalence over the last 20 years, with prevalence falling from 22.8% in 1988 to 14% in 2007 ⁵⁹^,⁶⁰. In contrast, the national rate of tobacco use declined only 30% over that time, from 28.1% in 1988 to 19.8% in 2007 ⁶¹^,⁶². As part of this national campaign, it would be important to include media strategies that have been found to affect youth attitudes towards both smoking and the tobacco companies and that appear to reduce youth smoking rates ¹⁰^,¹¹^,⁶³^,⁶⁴.
Graphic warnings have led to significant decreases in tobacco consumption in countries all over the world ⁶⁵^-⁶⁷. Such graphic warnings (e.g., on cigarette packs) have been recommended by the WHO Framework Convention on Tobacco Control ⁶⁸^,⁶⁹. If implemented in the United States such warnings would provide a low-cost, eminently feasible strategy that has the potential to dramatically boost awareness of risk, and increase interest in cessation. In addition to these graphic warnings, cigarette packaging labels that include misleading terms such as “lights” or “mild”, should be prohibited ⁷⁰^,⁷¹.
The United States should enact a strong, comprehensive nationwide ban on indoor smoking, an approach that has been adopted in many countries throughout the world ⁷². While more than half of the U.S. population now lives in a state or locality with a comprehensive clean indoor air law ⁷², the absence of a national law (without preemptions that limit stronger state and local ordinances) has limited its effectiveness. This strategy is supported by a compelling body of evidence that such a step will not only significantly reduce tobacco prevalence ¹⁵^,⁷²^-⁷⁶, but will also dramatically reduce illness and deaths for both smokers and nonsmokers ⁷⁷^-⁸¹. In fact, smoking bans have been shown to increase quit attempts ⁸²^-⁸⁴, decrease levels of consumption ⁷²^,⁷⁵^,⁸³, decrease youth smoking ¹⁵^,⁷³^,⁸⁵^,⁸⁶, promote denormalization of smoking ⁸²^,⁸⁷, and decrease morbidity and mortality from heart attacks ⁷⁹^,⁸⁰^,⁸⁸^-⁹⁰. Finally, clear indoor air ordinances are popular ⁹¹^,⁹². The widespread adoption of state and local bans reflects the substantial public and political acceptance of such policies ⁸¹.
The gradual elimination of nicotine from commercially available cigarettes, a strategy first proposed by Benowitz and Henningfield in the early 1990s ³⁰, would reduce the risk of nicotine dependence amongst adolescents, by removing the underlying additive substrate for dependence development. At the same time, this policy could assist many adults in overcoming their dependence upon tobacco ³⁰^,⁹³^,⁹⁴, particularly if the potential risk of compensatory smoking was addressed. Such mandated reductions in nicotine content could be just one aspect of another essential element to eliminating tobacco use in the United States – comprehensive FDA regulation of tobacco products and the tobacco industry ⁹⁵.
A final strategy would involve a greater emphasis on ensuring that all smokers have access to effective treatment interventions. The recently released PHS Guideline Update, Treating Tobacco Use and Dependence ⁹⁶ highlighted vital new information on the clinical treatment of smokers. One important finding was that effective interventions now exist for an unprecedented proportion of smokers. For example, it now appears that there are interventions that increase quit attempts by smokers who were previously unwilling to quit ⁹⁷^,⁹⁸, providing a treatment option for the 60-65% of smokers who don't try to quit each year ⁹⁹^,¹⁰⁰. The Guideline also identified counseling and medication treatments that were especially effective for smokers willing to make a quit attempt, treatments that have been independently endorsed by the Cochrane Collaboration and others ¹⁰¹^-¹⁰⁴. Finally, the 2008 Guideline Update found that there was now sufficient evidence to recommend certain smoking cessation interventions as effective for adolescent smokers, meaning that this vulnerable population can now benefit from cessation intervention.

At present, most smokers do not enjoy the benefits of such treatment advances. Most smokers unwilling to make a quit attempt typically receive no intervention, and smokers willing to quit often do not receive the most efficacious interventions ⁹⁶^,¹⁰⁵^,¹⁰⁶. This situation is avoidable since research shows that most smokers visit a healthcare setting each year ¹⁰⁷^,¹⁰⁸. All this underscores the need for enhanced treatment delivery mechanisms, including a greater use of chronic care models, telephone quitlines to deliver optimal smoking interventions to every smoker, and health insurance mandates for the coverage of evidence-based counseling and medication.

It is especially vital that effective treatments reach the populations that comprise disproportionate numbers of smokers: individuals with low educational attainment, certain ethnic minorities, and the mentally ill. For instance, mental illnesses such as depression, psychoses, or substance use disorders show prevalence rates that are 2 – 4 times higher than the population as a whole ¹⁰⁹^-¹¹⁵. Persons with mental illness and/or substance abuse disorders constitute 22% of the population in the US but consume 44% of all cigarettes sold ¹¹⁶^,¹¹⁷. These populations also bear a disproportionate health and economic burden from tobacco use. Cessation interventions are effective with these populations ⁹⁶, but they too infrequently receive treatment ¹¹⁸. Therefore, it is important to fund high-reach intervention delivery systems such as an expanded National Tobacco Quitline network (1-800-QUIT NOW) that would provide enhanced treatment options including medication interventions to complement the quitline counseling. The reach of the quitline would be increased by the expanded media campaign that targets underserved populations ¹¹⁹^-¹²¹.

Finally, there is a need for continued research aimed at the development of additional effective interventions: medications including the nicotine vaccine ¹²²^,¹²³, strategies to increase consumer demand for treatment ¹²⁴^,¹²⁵, treatments for those not willing to make a quit attempt at this time, and even more effective counseling interventions.

Progress made over the last fifty years now makes the elimination of tobacco dependence in the United States an achievable goal. Reaching that goal will require innovative policy and clinical approaches that result in an accelerated rate of decline in prevalence. These efforts must enhance previously effective strategies as well as implement novel ones. Given recent research underscoring the relation between early tobacco use and severe lifelong nicotine dependence, it is important that the efforts include ones that significantly reduce tobacco initiation by youth. Especially promising strategies in this ongoing public health battle include: an increased national excise tax on tobacco, aggressive national media campaigns, use of graphic warning labels of cigarette packaging, an expanded array of effective cessation therapeutics with greater access to such treatments, a systematic reduction in the nicotine content of commercially available cigarettes, comprehensive FDA regulation of tobacco products and the tobacco industry, and a national ban on indoor smoking. If implemented, the proposed strategies will dramatically reduce adult smoking prevalence while protecting adolescents from becoming dependent upon tobacco, thereby stealing a march in the 21^st century war against tobacco use and the tobacco industry.

Acknowledgments

Supported by grant P50 DA019706 from the National Institute on Drug Abuse to the University of Wisconsin-Center for Tobacco Research and Intervention.

References

1. Hughes JR. The case for hardening of the target. In: Marcus S, editor. Those who continue to smoke. Smoking and Tobacco Control Monograph No. 15. Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health, National Cancer Institute; 2003. NIH Pub. No. 03-5370.

2. Centers for Disease Control and Prevention. Tobacco use among adults - United States, 2005. MMWR. 2005;55(42):1145–1148. [PubMed]

3. Centers for Disease Control and Prevention. Cigarette smoking among adults - United States, 2006. MMWR. 2007;56(44):1157–1161. [PubMed]

4. U.S Department of Health Education and Welfare. Smoking and Health: Report of the Advisory Committee to the Surgeon General of the Public Health Service, PHS publication No. 1103. Washington, DC: U.S. Department of Health, Education, and Welfare, Public Health Service; 1964.

5. Bailey CJ. From “informed choice” to “social hygiene”: Government control of cigarette smoking in the US. Journal of American Studies. 2004;38:41–65.

6. Lewit EM, Coate D, Grossman M. The effects of government regulation on teenage smoking. New York: National Bureau of Economic Research; Mar, 1982. 1982.

7. Selin H. Mass media and tobacco control. [August 6, 2008]. eNotes.com. Available at: http://www.enotes.com/public-health-encyclopedia/

8. Friend K, Levy DT. Reductions in smoking prevalence and cigarette consumption associated with mass-media campaigns. Health Education Research. 2002 Feb;17(1):85–98. [PubMed]

9. Emery S, Wakefield MA, Terry-McElrath Y, et al. Televised state-sponsored antitobacco advertising and youth smoking beliefs and behavior in the United States, 1999-2000. Arch Pediatr Adolesc Med. 2005 Jul;159(7):639–645. [PubMed]

10. Niederdeppe J, Farrelly MC, Haviland ML. Confirming “truth”: more evidence of a successful tobacco countermarketing campaign in Florida. Am J Public Health. 2004 Feb;94(2):255–257. [PubMed]

11. Farrelly MC, Davis KC, Duke J, Messeri P. Sustaining ‘truth’: changes in youth tobacco attitudes and smoking intentions after 3 years of a national antismoking campaign. Health Educ Res. 2008 Jan 17; [PubMed]

12. U.S. Department of Health and Human Services. The health consequences of involuntary exposure to tobacco smoke: A report of the Surgeon General. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2006.

13. U.S Department of Health and Human Services. The health consequences of smoking: A report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2004.

14. Campaign for Tobacco-Free Kids. Smoke-free laws encourage smokers to quit and discourage youth from starting. Campaign for Tobacco-Free Kids. [July 23, 2008]. Available at: http://www.tobaccofreekids.org/research/factsheets/pdf/0198.pdf.

15. McMullen KM, Brownson RC, Luke D, Chriqui J. Strength of clean indoor air laws and smoking related outcomes in the USA. Tob Control. 2005 Feb;14(1):43–48. [PMC free article] [PubMed]

16. Schroeder SA. Shattuck Lecture. We can do better--improving the health of the American people. N Engl J Med. 2007 Sep 20;357(12):1221–1228. [PubMed]

17. Chaloupka FJ, Cummings KM, Morley CP, Horan JK. Tax, price and cigarette smoking: evidence from the tobacco documents and implications for tobacco company marketing strategies. Tob Control. 2002 Mar;11 1:I62–72. [PMC free article] [PubMed]

18. Reed MB, Anderson CM, Vaughn JW, Burns DM. The effect of cigarette price increases on smoking cessation in California. Prev Sci. 2008 Mar;9(1):47–54. [PubMed]

19. Gallus S, Schiaffino A, La Vecchia C, Townsend J, Fernandez E. Price and cigarette consumption in Europe. Tob Control. 2006 Apr;15(2):114–119. [PMC free article] [PubMed]

20. Wakefield MA, Durkin S, Spittal MJ, et al. Impact of tobacco control policies and mass media campaigns on monthly adult smoking prevalence. Am J Public Health. 2008 Aug;98(8):1443–1450. [PubMed]

21. Levy DT, Romano E, Mumford EA. Recent trends in home and work smoking bans. Tob Control. 2004 Sep;13(3):258–263. [PMC free article] [PubMed]

22. Levy DT, Chaloupka F, Gitchell J. The effects of tobacco control policies on smoking rates: a tobacco control scorecard. J Public Health Manag Pract. 2004 Jul-Aug;10(4):338–353. [PubMed]

23. Mendez D, Warner KE. Adult cigarette smoking prevalence: declining as expected (not as desired) Am J Public Health. 2004 Feb;94(2):251–252. [PubMed]

24. Shields M. Smoking-prevalence, bans and exposure to second-hand smoke. Health Rep. 2007 Aug;18(3):67–85. [PubMed]

25. Farkas AJ, Gilpin EA, White MM, Pierce JP. Association between household and workplace smoking restrictions and adolescent smoking. Jama. 2000 Aug 9;284(6):717–722. [PubMed]

26. McAlister A, Morrison TC, Hu S, et al. Media and community campaign effects on adult tobacco use in Texas. J Health Commun. 2004 Mar-Apr;9(2):95–109. [PubMed]

27. Farrelly MC, Davis KC, Haviland ML, Messeri P, Healton CG. Evidence of a dose-response relationship between “truth” antismoking ads and youth smoking prevalence. Am J Public Health. 2005 Mar;95(3):425–431. [PubMed]

28. Blecher E. The impact of tobacco advertising bans on consumption in developing countries. J Health Econ. 2008 Jul;27(4):930–942. [PubMed]

29. Saffer H, Chaloupka F. The effect of tobacco advertising bans on tobacco consumption. J Health Econ. 2000 Nov;19(6):1117–1137. [PubMed]

30. Benowitz NL, Henningfield JE. Establishing a nicotine threshold for addiction. The implications for tobacco regulation. New England Journal of Medicine. 1994 Jul 14;331(2):123–125. [PubMed]

31. Breslau N, Peterson EL. Smoking cessation in young adults: age at initiation of cigarette smoking and other suspected influences. American Journal of Public Health. 1996 Feb;86(2):214–220. [PubMed]

32. Taioli E, Wynder EL. Effect of the age at which smoking begins on frequency of smoking in adulthood. N Engl J Med. 1991 Sep 26;325(13):968–969. [PubMed]

33. Weiss RB, Baker TB, Cannon DS, et al. A candidate gene approach identifies the CHRNA5-A3-B4 region as a risk factor for age-dependent nicotine addiction. PLoS Genet. 2008 Jul;4(7):e1000125. [PMC free article] [PubMed]

34. Lando HA, Thai DT, Murray DM, et al. Age of initiation, smoking patterns, and risk in a population of working adults. Preventive Medicine. 1999 Dec;29(6 Pt 1):590–598. [PubMed]

35. Baker TB, Moffit T, Caspi A, Conti D. The nicotine dependence phenotype: Translating theoretical perspectives and extant data into recommendations for genetic mapping. In: Swan GE, editor. The nicotine dependence phenotype, NCI Monograph No. 22. Washington, DC: U.S. Government Printing Office; in press.

36. Chassin L, Presson CC, Sherman SJ, Edwards DA. The natural history of cigarette smoking: predicting young-adult smoking outcomes from adolescent smoking patterns. Health Psychol. 1990;9(6):701–716. [PubMed]

37. Cui Y, Wen W, Moriarty CJ, Levine RS. Risk factors and their effects on the dynamic process of smoking relapse among veteran smokers. Behav Res Ther. 2006 Jul;44(7):967–981. [PubMed]

38. Pisinger C, Vestbo J, Borch-Johnsen K, Jorgensen T. Smoking cessation intervention in a large randomised population-based study. The Inter99 study. Prev Med. 2005 Mar;40(3):285–292. [PubMed]

39. Nides MA, Rakos RF, Gonzales D, Murray RP, Tashkin DP, Bjornson-Benson WM. Predictors of initial smoking cessation and relapse through the first 2 years of the Lung Health Study. Journal of Consulting & Clinical Psychology. 1995 Feb;63(1):60–69. [PubMed]

40. Adriani W, Macri S, Pacifici R, Laviola G. Peculiar vulnerability to nicotine oral self-administration in mice during early adolescence. Neuropsychopharmacology. 2002 Aug;27(2):212–224. [PubMed]

41. Adriani W, Spijker S, Deroche-Gamonet V, et al. Evidence for enhanced neurobehavioral vulnerability to nicotine during periadolescence in rats. Journal of Neuroscience. 2003 Jun 1;23(11):4712–4716. [PubMed]

42. Kota D, Martin BR, Damaj MI. Age-dependent differences in nicotine reward and withdrawal in female mice. Psychopharmacology (Berl) 2008 Jun;198(2):201–210. [PubMed]

43. Trauth JA, Seidler FJ, Slotkin TA. An animal model of adolescent nicotine exposure: effects on gene expression and macromolecular constituents in rat brain regions. Brain Res. 2000 Jun 9;867(12):29–39. [PubMed]

44. Trauth JA, Seidler FJ, McCook EC, Slotkin TA. Adolescent nicotine exposure causes persistent upregulation of nicotinic cholinergic receptors in rat brain regions. Brain Res. 1999 Dec 18;851(12):9–19. [PubMed]

45. Belluzzi JD, Lee AG, Oliff HS, Leslie FM. Age-dependent effects of nicotine on locomotor activity and conditioned place preference in rats. Psychopharmacology (Berl) 2004 Jul;174(3):389–395. [PubMed]

46. Belluzzi JD, Wang R, Leslie FM. Acetaldehyde enhances acquisition of nicotine self-administration in adolescent rats. Neuropsychopharmacology. 2005 Apr;30(4):705–712. [PubMed]

47. Leslie FM, Loughlin SE, Wang R, Perez L, Lotfipour S, Belluzzia JD. Adolescent development of forebrain stimulant responsiveness: insights from animal studies. Ann N Y Acad Sci. 2004 Jun;1021:148–159. [PubMed]

48. Vastola BJ, Douglas LA, Varlinskaya EI, Spear LP. Nicotine-induced conditioned place preference in adolescent and adult rats. Physiology & Behavior. 2002 Sep;77(1):107–114. [PubMed]

49. Levin ED, Lawrence SS, Petro A, et al. Adolescent vs. adult-onset nicotine self-administration in male rats: duration of effect and differential nicotinic receptor correlates. Neurotoxicol Teratol. 2007 Jul-Aug;29(4):458–465. [PMC free article] [PubMed]

50. Saccone SF, Hinrichs AL, Saccone NL, et al. Cholinergic nicotinic receptor genes implicated in a nicotine dependence association study targeting 348 candidate genes with 3713 SNPs. Human Molecular Genetics. 2007 Jan 1;16(1):36–49. [PMC free article] [PubMed]

51. Schlaepfer IR, Hoft NR, Collins AC, et al. The CHRNA5/A3/B4 gene cluster variability as an important determinant of early alcohol and tobacco initiation in young adults. Biol Psychiatry. 2008 Jun 1;63(11):1039–1046. [PMC free article] [PubMed]

52. Chassin L, Presson CC, Pitts SC, Sherman SJ. The natural history of cigarette smoking from adolescence to adulthood in a midwestern community sample: multiple trajectories and their psychosocial correlates. Health Psychol. 2000 May;19(3):223–231. [PubMed]

53. Pierce JP, Gilpin E. How long will today's new adolescent smoker be addicted to cigarettes? Am J Public Health. 1996 Feb;86(2):253–256. [PubMed]

54. Orzechowski W, Walker RD. The tax burden on tobacco: Historical compilation. Vol. 37. Arlington, VA: Orzechowski and Walker; 2003.

55. Pierce JP, Gilmer TP, Lee L, Gilpin EA, de Beyer J, Messer K. Tobacco industry price-subsidizing promotions may overcome the downward pressure of higher prices on initiation of regular smoking. Health Econ. 2005 Oct;14(10):1061–1071. [PubMed]

56. Fiore MC, Croyle RT, Curry SJ, et al. Preventing 3 million premature deaths and helping 5 million smokers quit: A national action plan for tobacco cessation. American Journal of Public Health. 2004;94(2):205–210. [PubMed]

57. Orleans CT, Arkin EB, Backinger CL, et al. Youth Tobacco Cessation Collaborative and National Blueprint for Action. Am J Health Behav. 2003;27 2:S103–119. [PubMed]

58. Orleans T, Melvin C, Marx J, Maibach E, Vose KK. National action plan to reduce smoking during pregnancy: the National Partnership to Help Pregnant Smokers Quit. Nicotine Tob Res. 2004 Apr;6 2:S269–277. [PubMed]

59. Mendez D, Warner KE. Setting a challenging yet realistic smoking prevalence target for Healthy People 2020: learning from the California experience. Am J Public Health. 2008 Mar;98(3):556–559. [PubMed]

60. State Health Facts. California: Percent of adults who smoke, 2007. [August 7, 2008]. Available at: http://www.statehealthfacts.org/profileind.jsp?ind=80&cat=2&rgn=6.

61. Centers for Disease Control and Prevention. Cigarette smoking among adults--United States, 1988. MMWR Morb Mortal Wkly Rep. 1991 Nov 8;40(44):757–759. 765. [PubMed]

62. Centers for Disease Control and Prevention. Cigarette smoking among adults - United States, 2007. Morbidity and Mortality Weekly Report. 2008;57(45):1221–1226. [PubMed]

63. Bauer UE, Johnson TM, Hopkins RS, Brooks RG. Changes in youth cigarette use and intentions following implementation of a tobacco control program: Findings from the Florida Youth Tobacco Survey, 1998-2000. JAMA. 2000 Aug 9;284(6):723–728. [PubMed]

64. Siegel M, Biener L. The impact of an antismoking media campaign on progression to established smoking: Results of a longitudinal youth study. American Journal of Public Health. 2000 Mar;90(3):380–386. [PubMed]

65. Hammond D, Fong GT, Borland R, Cummings KM, McNeill A, Driezen P. Text and graphic warnings on cigarette packages: findings from the international tobacco control four country study. Am J Prev Med. 2007 Mar;32(3):202–209. [PMC free article] [PubMed]

66. Thrasher JF, Hammond D, Fong GT, Arillo-Santillan E. Smokers' reactions to cigarette package warnings with graphic imagery and with only text: a comparison between Mexico and Canada. Salud Publica Mex. 2007;49 2:S233–240. [PubMed]

67. Hammond D, Fong GT, McNeill A, Borland R, Cummings KM. Effectiveness of cigarette warning labels in informing smokers about the risks of smoking: findings from the International Tobacco Control (ITC) Four Country Survey. Tob Control. 2006 Jun;15 3:iii19–25. [PMC free article] [PubMed]

68. Warner KE. The Framework Convention on Tobacco Control: opportunities and issues. Salud Publica Mex. 2008;50 3:S283–291. [PubMed]

69. World Health Organization. WHO Report on the Global Tobacco Epidemic, 2008: The MPOWER package. World Health Organization. Available at: http://www.who.int/tobacco/mpower/en/

70. Ashley MJ, Cohen J, Ferrence R. ‘Light’ and ‘mild’ cigarettes: who smokes them? Are they being misled? Can J Public Health. 2001 Nov-Dec;92(6):407–411. [PubMed]

71. Cummings KM, Hyland A, Bansal MA, Giovino GA. What do Marlboro Lights smokers know about low-tar cigarettes? Nicotine Tob Res. 2004 Dec;6 3:S323–332. [PubMed]

72. Eriksen MP, Cerak RL. The diffusion and impact of clean indoor air laws. Annu Rev Public Health. 2008;29:171–185. [PubMed]

73. Siegel M, Albers AB, Cheng DM, Hamilton WL, Biener L. Local restaurant smoking regulations and the adolescent smoking initiation process: results of a multilevel contextual analysis among Massachusetts youth. Arch Pediatr Adolesc Med. 2008 May;162(5):477–483. [PMC free article] [PubMed]

74. Chapman S, Borland R, Scollo M, Brownson RC, Dominello A, Woodward S. The impact of smoke-free workplaces on declining cigarette consumption in Australia and the United States. American Journal of Public Health. 1999 Jul;89(7):1018–1023. [PubMed]

75. Farrelly MC, Evans WN, Sfekas AE. The impact of workplace smoking bans: results from a national survey. Tob Control. 1999 Autumn;8(3):272–277. [PMC free article] [PubMed]

76. Fong GT, Hyland A, Borland R, et al. Reductions in tobacco smoke pollution and increases in support for smoke-free public places following the implementation of comprehensive smoke-free workplace legislation in the Republic of Ireland: findings from the ITC Ireland/UK Survey. Tob Control. 2006 Jun;15 3:iii51–58. [PMC free article] [PubMed]

77. Centers for Disease Control and Prevention. State smoking restrictions for private-sector worksites, restaurants, and bars -- United States, 2004 and 2007. MMWR. 2008;57(20):549–552. [PubMed]

78. Abrams SM, Mahoney MC, Hyland A, Cummings KM, Davis W, Song L. Early evidence on the effectiveness of clean indoor air legislation in New York State. Am J Public Health. 2006 Feb;96(2):296–298. [PubMed]

79. Sargent RP, Shepard RM, Glantz SA. Reduced incidence of admissions for myocardial infarction associated with public smoking ban: before and after study. Bmj. 2004 Apr 24;328(7446):977–980. [PMC free article] [PubMed]

80. Pell JP, Haw S, Cobbe S, et al. Smoke-free legislation and hospitalizations for acute coronary syndrome. N Engl J Med. 2008 Jul 31;359(5):482–491. [PubMed]

81. Schmidt CW. A change in the air: smoking bans gain momentum worldwide. Environ Health Perspect. 2007 Aug;115(8):A412–415. [PMC free article] [PubMed]

82. Albers AB, Siegel M, Cheng DM, Biener L, Rigotti NA. Effect of smoking regulations in local restaurants on smokers' anti-smoking attitudes and quitting behaviours. Tob Control. 2007 Apr;16(2):101–106. [PMC free article] [PubMed]

83. Fichtenberg CM, Glantz SA. Effect of smoke-free workplaces on smoking behaviour: Systematic review. British Medical Journal. 2002 Jul 27;325(7357):188–194. [PMC free article] [PubMed]

84. Shields M. Smoking bans: influence on smoking prevalence. Health Rep. 2007 Aug;18(3):9–24. [PubMed]

85. Wakefield M, Forster J. Growing evidence for new benefit of clean indoor air laws: reduced adolescent smoking. Tob Control. 2005 Oct;14(5):292–293. [PMC free article] [PubMed]

86. Rainio SU, Rimpela AH. Home smoking bans in Finland and the association with child smoking. Eur J Public Health. 2008 Jun;18(3):306–311. [PubMed]

87. Albers AB, Siegel M, Cheng DM, Biener L, Rigotti NA. Relation between local restaurant smoking regulations and attitudes towards the prevalence and social acceptability of smoking: a study of youths and adults who eat out predominantly at restaurants in their town. Tob Control. 2004 Dec;13(4):347–355. [PMC free article] [PubMed]

88. Bartecchi C, Alsever RN, Nevin-Woods C, et al. Reduction in the incidence of acute myocardial infarction associated with a citywide smoking ordinance. Circulation. 2006 Oct 3;114(14):1490–1496. [PubMed]

89. Cesaroni G, Forastiere F, Agabiti N, Valente P, Zuccaro P, Perucci CA. Effect of the Italian smoking ban on population rates of acute coronary events. Circulation. 2008 Mar 4;117(9):1183–1188. [PubMed]

90. Samet JM. Smoking bans prevent heart attacks. Circulation. 2006 Oct 3;114(14):1450–1451. [PubMed]

91. Eriksen M, Chaloupka F. The economic impact of clean indoor air laws. CA Cancer J Clin. 2007 Nov-Dec;57(6):367–378. [PubMed]

92. Wakefield M, Roberts L, Owen N. Trends in prevalence and acceptance of workplace smoking bans among indoor workers in South Australia. Tob Control. 1996 Autumn;5(3):205–208. [PMC free article] [PubMed]

93. Henningfield JE, Benowitz NL, Slade J, Houston TP, Davis RM, Deitchman SD. Reducing the addictiveness of cigarettes. Tobacco Control. 1998 Autumn;7(3):281–293. [PMC free article] [PubMed]

94. Becker KM, Rose JE, Albino AP. A randomized trial of nicotine replacement therapy in combination with reduced-nicotine cigarettes for smoking cessation. Nicotine Tob Res. 2008 Jul;10(7):1139–1148. [PubMed]

95. Brandt AM. FDA regulation of tobacco--pitfalls and possibilities. N Engl J Med. 2008 Jul 31;359(5):445–448. [PubMed]

96. Fiore MC, Jaen CR, Baker TB, et al. Treating tobacco use and dependence: 2008 update. Rockville, MD: U.S. Department of Health and Human Services, U.S. Public Health Service; 2008.

97. Williams GC, McGregor HA, Sharp D, et al. Testing a self-determination theory intervention for motivating tobacco cessation: supporting autonomy and competence in a clinical trial. Health Psychol. 2006 Jan;25(1):91–101. [PubMed]

98. Carpenter MJ, Hughes JR, Solomon LJ, Callas PW. Both smoking reduction with nicotine replacement therapy and motivational advice increase future cessation among smokers unmotivated to quit. J Consult Clin Psychol. 2004 Jun;72(3):371–381. [PubMed]

99. American Cancer Society. Cigarette smoking. [Aug 14, 2008]. [Aug 14, 2008]. Available at: http://www.cancer.org/docroot/PED/content/PED_10_2X_Cigarette_Smoking.asp. Available at: http://www.cancer.org/docroot/PED/content/PED_10_2X_Cigarette_Smoking.asp.

100. U.S. Public Health Service. Treating tobacco use and dependence: Fact sheet. [Aug 14, 2008]. Available at: http://www.surgeongeneral.gov/tobacco/smokfact.htm.

101. Lancaster T, Stead LF. Individual behavioural counselling for smoking cessation. Cochrane Database Syst Rev. 2005;(2):CD001292. [PubMed]

102. Hughes, Stead L, Lancaster T. Antidepressants for smoking cessation. Cochrane Database Syst Rev. 2007;(1):CD000031. [PubMed]

103. Stead LF, Perera R, Bullen C, Mant D, Lancaster T. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev. 2008;(1):CD000146. [PubMed]

104. Zwar N, Richmond R, Borland R, Stillman S, Cunningham M, Litt J. Smoking cessation guidelines for Australian general practice. Canberra: Department of Health and Ageing, Commonwealth of Australia; 2004.

105. Browning KK, Ferketich AK, Salsberry PJ, Wewers ME. Socioeconomic disparity in provider-delivered assistance to quit smoking. Nicotine Tob Res. 2008 Jan;10(1):55–61. [PubMed]

106. Chase EC, McMenamin SB, Halpin HA. Medicaid provider delivery of the 5A's for smoking cessation counseling. Nicotine and Tobacco Research. 2007 Nov;9(11):1095–1101. [PubMed]

107. Centers for Disease Control and Prevention. Physician and other health-care professional counseling of smokers to quit – United States, 1991. Morbidity and Mortality Weekly Report. 1993;42(44):854–857. 11/12/1993. [PubMed]

108. Drilea SK, Reid BC, Li CH, Hyman JJ, Manski RJ. Dental visits among smoking and nonsmoking US adults in 2000. Am J Health Behav. 2005 Sep-Oct;29(5):462–471. [PubMed]

109. Kalman D, Morissette SB, George TP. Co-morbidity of smoking in patients with psychiatric and substance use disorders. Am J Addict. 2005 Mar-Apr;14(2):106–123. [PMC free article] [PubMed]

110. Lasser K, Boyd JW, Woolhandler S, Himmelstein DU, McCormick D, Bor DH. Smoking and mental illness: A population-based prevalence study. JAMA. 2000 Nov 22-29;284(20):2606–2610. [PubMed]

111. de Leon J, Diaz FJ. A meta-analysis of worldwide studies demonstrates an association between schizophrenia and tobacco smoking behaviors. Schizophr Res. 2005 Jul 15;76(23):135–157. [PubMed]

112. Vanable PA, Carey MP, Carey KB, Maisto SA. Smoking among psychiatric outpatients: relationship to substance use, diagnosis, and illness severity. Psychol Addict Behav. 2003 Dec;17(4):259–265. [PMC free article] [PubMed]

113. Morris CD, Alexis AA, Turnbull JJ, Dickinson M. Predictors of tobacco use among persons with mental illnesses in a statewide population. Psychiatric Services. 2006;57:1035–1038. [PubMed]

114. Kandel DB, Chen K. Extent of smoking and nicotine dependence in the United States: 1991-1993. Nicotine Tob Res. 2000 Aug;2(3):263–274. [PubMed]

115. Patton GC, Carlin JB, Coffey C, Wolfe R, Hibbert M, Bowes G. Depression, anxiety, and smoking initiation: a prospective study over 3 years. Am J Public Health. 1998 Oct;88(10):1518–1522. [PubMed]

116. Kandel DB, Huang FY, Davies M. Comorbidity between patterns of substance use dependence and psychiatric syndromes. Drug Alcohol Depend. 2001 Oct;Jan;64(2):233–241. [PubMed]

117. U.S Department of Health and Human Services. Mental health: A report of the Surgeon General - Executive summary. Rockville, MD: U S Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health; 1999.

118. Thorndike AN, Stafford RS, Rigotti NA. US physicians' treatment of smoking in outpatients with psychiatric diagnoses. Nicotine & Tobacco Research. 2001;3:85–91. 2001. [PubMed]

119. Anderson CM, Zhu SH. Tobacco quitlines: looking back and looking ahead. Tob Control. 2007 Dec;16 1:i81–86. [PMC free article] [PubMed]

120. Borland R, Segan CJ. The potential of quitlines to increase smoking cessation. Drug and Alcohol Review. 2006 Jan;25(1):73–78. [PubMed]

121. Lichtenstein E, Glasgow RE, Lando HA, Ossip-Klein DJ, Boles SM. Telephone counseling for smoking cessation: Rationales and meta-analytic review of evidence. Health Education Research. 1996 Jun;11(2):243–257. [PubMed]

122. Cornuz J, Zwahlen S, Jungi WF, et al. A vaccine against nicotine for smoking cessation: a randomized controlled trial. PLoS ONE. 2008;3(6):e2547. [PMC free article] [PubMed]

123. Wagena EJ, de Vos A, Horwith G, van Schayck CP. The immunogenicity and safety of a nicotine vaccine in smokers and nonsmokers: results of a randomized, placebo-controlled phase 1/2 trial. Nicotine Tob Res. 2008 Jan;10(1):213–218. [PubMed]

124. Domenighetti G, Grilli R, Liberati A. Promoting consumers' demand for evidence-based medicine. Int J Technol Assess Health Care. 1998 Winter;14(1):97–105. [PubMed]

125. Parente ST, Salkever DS, DaVanzo J. The role of consumer knowledge of insurance benefits in the demand for preventive health care among the elderly. Health Econ. 2005 Jan;14(1):25–38. [PubMed]