Declining cigarette consumption after 1964 corresponded to increased public awareness of the dangers of tobacco use, changing social norms about tobacco and increased governmental actions to regulate the use, sale, and advertising of tobacco products (12
). The most comprehensive change has been in attitudes and rules about smoking in enclosed public places. As late as 20 years ago, smoking was effectively ubiquitous in most places, with smoking allowed virtually everywhere (except where there was a danger or fires or damage to equipment). Over time the environment which had supported smoking indoors has transformed. Today, 23 states and 493 localities have adopted laws restricting indoor smoking (6
). Limiting where people can smoke has contributed to the social marginalization of smoking as an accepted behavior.
Communicating the health effects of smoking has been a primary goal of tobacco control efforts since the first Surgeon General’s report was issued nearly 50 years ago (15
). The provision of health warnings and/or product information on tobacco packages currently represents an important means of informing consumers about the health risks of smoking as a first step towards changing behavior. Virtually all countries throughout the world require package warning labels on cigarettes, although the content and size of the warnings vary widely (19
In 1966 the first caution label appeared on cigarette packs in the United States, telling smokers “Caution, smoking may be dangerous to your health.” This warning was strengthened in 1970 to read: “The Surgeon General Has Determined that Cigarette Smoking is Dangerous to Your Health.” In March 1972, Federal Trade Commission (FTC) rules went into effect requiring manufacturers to display the same health warning mandated on cigarette packages on all cigarette advertising. In 1984, Congress enacted the Comprehensive Smoking Education Act, which required four rotating health warnings on all cigarette packages and advertisements beginning in 1985 (21
- SURGEON GENERAL'S WARNING: Smoking Causes Lung Cancer, Heart Disease, Emphysema, and May Complicate Pregnancy.
- SURGEON GENERAL'S WARNING: Quitting Smoking Now Greatly Reduces Serious Risks to Your Health.
- SURGEON GENERAL'S WARNING: Smoking by Pregnant Women May Result in Fetal Injury, Premature Birth, and Low Birth Weight.
- SURGEON GENERAL'S WARNING: Cigarette Smoke Contains Carbon Monoxide.
Studies that have evaluated the US health warnings suggest that the warnings have been largely ineffective in changing behavior (22
). A 1967 FTC report concluded that “the warning label on cigarette packages has not succeeded in overcoming the prevalent attitude toward cigarette smoking created and maintained by the cigarette companies through their advertisements, particularly the barrage of commercials on television, which portray smoking as a harmless and enjoyable activity that is not habit forming and involves no hazards to health” (23
In a more recent study that used a sophisticated eye-tracking methodology to assess exposure to the health warnings in advertising, 44% of adolescents asked to view cigarette advertisements did not even look at the warning label displayed on the advertisement (24
). In 2009 the U.S. Food and Drug Administration (FDA) was given the authority by Congress to regulate tobacco products, including a mandate to update the current health warning labels on cigarettes (25
). The FDA recommended that a series of pictorial health warnings appear on cigarette packs beginning in 2012 (see –) (25
). Studies in countries that have adopted pictorial pack warnings have found that they are more likely to be noticed, result in improved awareness of the health risks of smoking, and motivate quit attempts in comparison to the text only warnings (26
Changes in smoking behavior have mirrored population trends in awareness about smoking as a cause of lung cancer and rates of smoking cessation (27
). The first large scale national counter-advertising campaign to educate the public about the health risks of tobacco use occurred between 1967 and 1970 when the Federal Communications Commission (FCC) required licensees who broadcast cigarette commercials to provide free media time for antismoking public service announcements (PSA) under the Fairness Doctrine (21
). The Fairness Doctrine obligated licensed broadcasters to encourage and implement the broadcast of all sides of controversial public issues over their facilities, over and beyond their obligation to make available on demand opportunities for the expression of opposing views (21
). In January 1967, an attorney by the name of John Banzhaf petitioned the FCC to apply the Fairness Doctrine to cigarette advertising (21
). In June of 1967, the FCC granted Banzhaf's petition and ruled that licensed broadcasters were required to air roughly one antismoking message for every three cigarette brand commercials. In July 1967, antismoking PSAs developed by the government and voluntary health agencies began to air. Unlike most public service advertising campaigns, many of the antismoking ads were aired during prime time. The time donated for the antismoking messages amounted to approximately nearly 300 million dollars per year. The Fairness Doctrine campaign ended in January 1971 as a result of a federal law that banned cigarette advertising on television and radio. After 1970, the number of antismoking PSAs declined markedly as antismoking messages were forced to compete for donated airtime. Between 1967 and 1970 cigarette consumption in the US dropped at a much faster rate than during the period immediately before or after the time when the Fairness Doctrine antismoking campaign was operational (21
). While it is impossible to rule out the effects of other influences that may have contributed to the decline in cigarette consumption between 1967 and 1970, several studies have concluded that the antismoking messages mandated by the Fairness Doctrine were responsible for much of the reduction in smoking during this period (13
The 1998 Master Settlement Agreement (MSA) between the tobacco industry and state governments provided resources to create a new foundation that had as one of its mandates sponsorship of a national counter-advertising campaign (31
). The American Legacy Foundation was created in 1999 and has spent approximately $100 million annually on a nationwide broadcast counter-advertising campaign (known as “the truth campaign”) targeting teens and young adults. The campaign has been successful in creating a high level of awareness of its messages among the intended target audience and smoking rates have declined among teenagers as a result.
In 1969, Congress passed the Public Health Cigarette Smoking Act that prohibited cigarette advertising in the broadcast media effective beginning in 1971 (21
). Congress extended the ban on broadcast advertising to little cigars in 1973, and to smokeless tobacco products in 1986 (21
). The federal law banning cigarette advertising on television and radio also included a clause preempting states and localities from regulating or prohibiting cigarette advertising or promotions for health reasons. The purpose of the preemption was to avoid chaos created by different, potentially conflicting regulations. However, the effect of the federal preemption was that few states and localities have attempted to regulate advertising of tobacco products (21
). In recent years, a number of cities and states have acted to restrict transit advertising, the free distribution of tobacco product samples, and point-of-sale advertising. In 1998, as part of the MSA, cigarette manufacturers agreed to discontinue billboard advertising, advertising in magazines with a high percentage of underage readers, and place limits on their sponsorship of sporting and cultural events (33
). In 2010, the FDA banned the use of misleading descriptor labels on cigarettes such as “light,” “low tar” and “mild” (25
). Unfortunately, cigarette manufacturers altered their packs using different color schemes to convey the same misleading perceptions about the strength of their cigarettes (light colors for previously labeled light cigarettes, blue and green for mint and menthol flavorings, etc) which means that many consumers continue to be misled about the fact that there is really no benefit to be gained by smoking a filtered or so-called low yield product as currently marketed.
It is well recognized in economic theory, as well as in everyday life, that purchasing decisions are influenced by the affordability of a product. The price of cigarettes is determined by the manufacturer's price, wholesale and retail markups and tobacco taxes. Perhaps the straightforward and reliable way to reduce cigarette consumption is to increase the price of cigarettes by raising the tax. In the US, tobacco taxes are levied at the federal, state, and local levels. During the first part of the century taxes of tobacco products were typically very low, were primarily used to generate revenue, and were raised infrequently. In 1951, the Federal tax was set at 8 cents per pack, the level at which it would remain for more than 30 years. Views about taxing cigarettes started to change after the release of the 1964 Surgeon General’s Report on smoking. Many states began increasing cigarette excise taxes in an apparent effort to reduce smoking and its consequences. Economists and others began producing studies documenting the impact of cigarette taxes and prices on smoking, particularly among youth and young adults. These findings led to growing pressure from public health groups for further increases in state and federal cigarette taxes. Eventually, the federal cigarette tax was doubled to 16 cents per pack on January 1, 1983. In the 1990s federal cigarette taxes were progressively raised and in 2008 were increased to its current rate of $1.01 per pack. Since 1980, most states have increased taxes on tobacco products, with some increases of 200% or more. Economists use estimates of the price elasticity of demand to quantify the impact of a change in price on consumption. Formally, the price elasticity of demand is defined as the percentage change in consumption resulting from a 1% increase in price. While a relatively wide range of estimates has been produced for the price elasticity of demand for cigarettes, most of the estimates from the US and other high-income countries tend to fall in the relatively narrow range from −0.30 to −0.50 (12
). Thus, estimates suggest that an increase of 10% in the price of cigarettes would decrease cigarette consumption by 3–5%, and, if implemented comprehensively, could prevent 5–16 million smoking-related deaths worldwide (34
). A number of studies have demonstrated that youth are relatively more sensitive to price than adults, implying that raising cigarette taxes would be a useful tobacco prevention intervention.
While cigarette taxes represent a fairly direct means of influencing consumption, other price policies can also alter smoking behavior. For example, some employers have started to charge higher health insurance premiums to employees who smoke; while others have chosen not to hire smokers at all (37
). Litigation and regulation of tobacco products has also had the effect of increasing the price of tobacco products, as these costs are merely passed onto consumers when they buy a pack of cigarettes.
Policies restricting where people can smoke correspond to changing attitudes about smoking and reductions in smoking behavior. Today, 23 states and 493 individual communities in the United States have adopted comprehensive smoke-free laws that prohibit smoking in non-hospitality workplaces, restaurants and bars (6
). Today the negative health effects (e.g., lung cancer, heart disease) of secondhand smoke are unequivocal. Studies have shown that smoke-free ordinances decrease secondhand smoke exposure and yield measurable improvements in public health. One meta-analysis documented a 19% reduction in hospital admissions for acute myocardial infarctions following passage of smoke-free laws (38
). Smoking restrictions have also been found to increase quit attempts among smokers as well as decrease total cigarette consumption (39
). Some estimates suggest that smoke-free worksites produce a 4% reduction in the overall prevalence of tobacco use, which roughly equals 3.1 fewer cigarettes consumed per day (43
Historically, the vast majority (>90%) of former smokers have reported that they stopped smoking without receiving formal assistance or help from anyone (44
). However, this statistic has changed with the introduction and wide availability of effective drug therapies to help smokers alleviate withdrawal symptoms commonly associated with cessation (45
). First line pharmacotherapy to support a quit attempt include nicotine replacement (gum, patch, lozenge, nasal spray or inhaler), bupropion, or varenicline, and use of these agents can increase quit rates by 1.5 to 3-fold (47
). Several studies have shown that combining the nicotine patch with either gum or nasal spray can increase quit rates over single modality therapy (48
The potential impact of treatments for tobacco dependence not only depends on their efficacy but also the extent to which these treatments reach those who might benefit from them. Today, there is not much evidence to support the idea that therapies for treating nicotine dependence have dramatically influenced rates of tobacco use on a population level (45
). The main reason for this failure is the generally low utilization of these therapies, which may be due in part to the failure of health-care workers to aggressively assist their tobacco-using patients in quitting (15
). Policies that can increase the reach, appeal and use of effective cessation treatments such as promotion of a national quit line number on cigarette packs, the development and marketing of more consumer appealing stop smoking treatments, and the creation of health care systems that require cessation treatment to be offered as routine care hold great untapped potential to reduce overall adult smoking prevalence and growing disparities in tobacco use in the future (15