Controlling
Tobacco Use

Fran Du Melle and Diane L. Maple

The American Lung Association (ALA), American Cancer Society (ACS), and American Heart Association (AHA) petitioned President John F. Kennedy in 1961 to appoint an official commission to study the effects of smoking on health. The request was followed by the 1964 release of the first report on smoking and health by the U.S. Surgeon General. That pivotal report identified smoking as a cause of lung cancer and heart disease.

Since the first Surgeon General's report appeared, tobacco use in the United States has changed. The intervening years have seen the United States move from a nation in which the dominant social norm was to smoke, to a nation in which smoking is becoming socially unacceptable.

In 1965 more than half of all US men aged 20 and older smoked, as did 35 percent of women in that age group. Today only 26.5 percent of the US adult population are smokers. This downward trend is the result of a far-reaching tobacco-control movement that has galvanized public opinion to seek changes in social and public policy. How did it happen?

Following release of the 1964 report, Congress enacted legislation to place on all cigarette packages a single warning label, reading: "Caution: cigarette smoking may be hazardous to your health." Quickly following this action the Federal Communications Commission ruled to allow equal, free radio and television time for health groups to counter the tobacco industry's well-heeled advertising campaigns. The net result of that counter-advertising was the steepest decline in smoking ever experienced in the United States.

Working with data supplied by the 1964 Surgeon General's report, the ALA, ACS, and AHA educated Americans about health hazards of smoking. Sentiment grew for changes in federal, state, and local policies to protect nonsmokers and to help keep more young people from beginning the habit.

The Federal Trade Commission proposed in 1969 to change the warning label on cigarette packages and banning all cigarette advertising from radio and television. Congress intervened with a less specific label: "Warning: the surgeon general has determined that cigarette smoking is dangerous to your health."

Congress banned cigarette advertising from radio and television on January 2, 1970, allowing a final cigarette
advertising blitz during the New Year's Day football bowl games.

In 1975 Minnesota became the first state to legislative restrictions on smoking in public places and at public meetings, except in designated smoking areas. A new trend was emerging: smoking would be prohibited in public unless specifically permitted.

The Surgeon General released a 1979 report linking smoking with other cancers involving the larynx, mouth, esophagus, bladder, pancreas, and, possibly, kidney.

The 1982 Surgeon General's report was a blockbuster, declaring that smoking is hazardous not only to the smoker but to others including nonsmokers who involuntarily breathe the smoker's sidestream or secondhand smoke. That same year Congress enacted the No-Net-Cost Tobacco Act that, for the first time in 40 years, began reducing the nation's financial commitment to the growing of tobacco. And the ALA, ACS, and AHA joined forces to form the Coalition on Smoking OR Health, combining their considerable individual resources into one strong cadre of tobacco-control advocates.

Today the coalition represents a combined force of 5 million citizen volunteers nationwide. Based in Washington, D.C., it focuses on the federal legislative and regulatory arenas.

At the state level, the three groups work together on another project, Tobacco-Free America (TFA). TFA operates a legislative clearinghouse to monitor tobacco-control progress at the state and local levels. This information-sharing has been invaluable in helping grassroots tobacco-control advocates plan and implement
their own strategies.

The 1980s saw an explosion of initiatives to protect nonsmokers in public places and at work. Today 42 states and 320 local communities have such laws.

 In September 1990 TFA released a comprehensive Blueprint for Action that defines public policy goals to meet a 1984 challenge from former Surgeon General C. Everett Koop to work toward a smoke-free society by the year 2000.

Congress replaced the single warning label in 1984 with a series of messages, to be rotated on cigarette packages and print advertisements and billboards. These new labels bore more specific health warnings. In 1986 congress made permanent a 16-cent increase in the cigarette excise tax and enacted the Comprehensive Smokeless Tobacco Health Education act, banning all advertising for smokeless tobacco products on radio and television and requiring rotating health warnings similar to those for cigarettes.

After intense prodding by the coalition, in 1987 congress banned all smoking aboard domestic airline flights lasting two hours or less. A 1990 law now bans all smoking on all flights lasting six hours or less. Thus, US skies are smoke free except for a few daily flights to Hawaii or Alaska.

Airports are another question. No federal law regulates smoking policy in US airports. Unless state or local law dictates differently, it is left to the discretion of the people who manage each particular airport to decide whether there will be separate smoking and nonsmoking sections, where those sections will be located and how many there will be. The result is a crazy-quilt of policies. Some airports, such as those in Denver, Colorado, and New Orleans, Louisiana, have gone completely smoke free. Others prohibit smoking in all public areas (Honolulu, Hawaii; Juneau, Alaska; and Albuquerque, New Mexico; for example). Still others prohibit smoking in the terminal except in designated areas (Tucson, Arizona, and San Diego, for example). Some merely provide separate, but adjacent, waiting areas for smokers and nonsmokers (Indianapolis, Indiana, for example).

Despite 26 years of warnings from the Surgeon General, smoking remains the chief preventable cause of death in the
United States. More than 1,200 Americans die each day 434,000 a year from diseases caused by smoking. More Americans die each year from smoking-related diseases than from all other major causes of death combined, including alcohol use, drug use, auto and other accidents, homicides, suicides, and AIDS. Approximately one of every five American deaths results from smoking.

True, the overall decline in smoking continues, but the decline is slower among women than among men. Smoking also continues to be higher among minorities, blue-collar workers, the less educated, and the young.

Alarmingly Americans are beginning to smoke earlier in life. Nearly all start smoking when they are teenagers. A 1986 survey of high-school seniors who had ever smoked found that 25 percent smoked their first cigarette by grade six, 50 percent by grade eight, and 75 percent by grade nine. A 1989 study found that nearly one-fifth of all high-school seniors admitted to daily cigarette use. Young smokers consume nearly one billion packs of cigarettes a year. Cigarette ads make smoking seem glamorous and make young people feel that smoking is not only OK, but is essential to be accepted.

The tobacco industry takes advantage of this vulnerability by pumping $3 billion each year into slick advertising and
promotional campaigns that appeal to young people. The industry must recruit 5,000 new smokers most of them children each day to replace those who quit or die from a tobacco-related disease.

Tobacco advertising cleverly targets women, youth, and minorities. The most offensive campaigns represent smoking as an adult, sophisticated behavior. This appeals to many youngsters. Cigarette advertising is rampant in publications such as Sports Illustrated with one-third of its readership being boys under the age of 18, and TV Guide with 8.8 million readers ages 12 to 17.

Advertising also is increasing in women's magazines, particularly those read by young women. Glamour magazine, for example, has increased its advertising of tobacco products. One-quarter of its readers are girls under the age of 18. One cigarette brand, Dakota, was specifically designed for young, less-educated women the group known to have the highest start-smoking rate in the nation.

Several studies have shown that women's magazines are highly influenced by cigarette advertising revenues to restrict their coverage of the health hazards of tobacco. Prominent women's magazines such as Cosmopolitan and Redbook that carry a high percentage of cigarette ads rarely, if ever, carry articles that seriously discuss quitting or the dangers of smoking. A May 1986 special issue of Ms. entitled "The Beauty of Health" included 15 articles, none of them dealing with smoking. The issue did, however, include four full-page cigarette ads, including the back cover. When they do touch on the subject of smoking in articles written for many women's magazines, writers may be told to
soften their references to smoking by, for example, using the word heavy when stating that smoking is a health risk (i.e., "heavy smoking is dangerous"). Publishers are afraid to offend cigarette advertisers.

The influence of tobacco has the potential for reaching even deeper now that the big tobacco companies have diversified and are owners of consumer products entities like Nabisco and General Foods. Publishers may fear the loss of non-tobacco advertising revenues from these tobacco-owned giants.

Minorities are another tobacco-marketing target. Advertisements for brands such as Kool, Salem, and Virginia Slims are splashed throughout the pages of magazines like Ebony and Jet. The industry craftily tried to market a new brand of cigarettes, called Uptown, to blacks. A community effort involving churches and civic and health groups and the personal participation of US Secretary of Health and Human services Louis W. Sul-livan put an end to that cigarette before its test-marketing had been completed. Sullivan, a black physician, called the Uptown advertising campaign "slick and sinister" and accused its manufacturer, the R.J. Reynolds Tobacco Company, of "promoting a culture of cancer."

Other tricks of the tobacco trade include sponsorship of sporting events, from bowling to boat racing something for
everybody. Winston sponsors a special toll-free telephone number to provide the latest game scores. Free samples and discount coupons are readily available through the mail, regardless of the recipient's age. Cigarette sponsorship of sporting events allows cigarette brands to be shown or mentioned on television, even though cigarette commercials are prohibited in the broadcast media.

Entering the final decade of this century, the coalition and supportive legislators will look at ways to keep the nation's
children from starting to smoke. If children learn early about the health hazards of smoking, future death tolls from smoking-related disease will diminish. Clearly no single public policy effort can untangle the complex web the tobacco industry uses to trap new, young smokers.

There are several ways that legislation at the federal, state and local levels can discourage youngsters from smoking. For example:

Cigarette ads should be banned or restricted. At a minimum advertisements should be limited to text-only material no
tantalizing photos or illustrations. This type of ad design is appropriately called "tombstone" advertising.

The accessibility of tobacco products to children also must be addressed. Although 45 states and the District of Columbia now ban the sale of cigarettes to minors, enforcement is virtually nonexistent. Not surprisingly, 86 percent of the students questioned during a 1987 National Adolescent Student Health Survey said it would be easy for them to obtain cigarettes. Children can easily purchase cigarettes at the nearest convenience store or from the 75,000 cigarette vending machines that are accessible to children. Only eight states now require that cigarette vending machines be located in adult-supervised areas. The Coalition on Smoking OR Health will work for consistent accessibility laws nationwide and stronger mechanisms for enforcing those laws.

Access also can be addressed by regulating the place of sale, which could be licensed as stores already are for the sale of alcohol, with stiff penalties levied for sales to minors.

The federal government, health organizations, and community groups can support counter-advertising campaigns to
educate young people better about the health hazards of smoking and to strengthen incentives not to begin smoking.

Another challenge for tobacco-control forces is the fact that US government policies are clearly inconsistent when it comes to tobacco. On one hand millions of tax dollars are allocated for scientific research and public education about the health hazards of smoking. On the other hand the government provides special financial assistance and tax dollars to support the growth of tobacco.

This schizophrenia might be expected when you understand that revenues from the sale of tobacco helped finance the
American Revolution. If you tour the impressive domed Capitol building in Washington, D.C., you will see a tobacco leaf motif decorating some of the huge indoor columns.

The current federal tobacco price support program guarantees that farmers can grow and sell their tobacco crops for a set price, whether or not the tobacco actually is sold on the open market.

Thanks to that support, tobacco is sixth among American crops as a source of farm income and fifth as an agricultural export. It is the leading source of farm income in two states North Carolina and Kentucky and a major contributor to farm income in five other states.

According to the US Department of Agriculture (USDA), 678,000 acres were planted in tobacco in 1989, producing 1.4 billion pounds of tobacco valued at $2,23 billion. USDA estimates for 1990 are 727,000 acres planted in tobacco and 1.6 billion pounds produced, valued at $2.7 billion.

The number of acres and pounds of tobacco produced are increasing largely because of the growing demand for US
cigarettes and leaf tobacco overseas. Interestingly, as more US-made cigarettes are exported, tobacco manufacturers in other parts of the world particularly among the Pacific Rim countries are buying more US-grown leaf tobacco. They need to add the high-quality US leaf tobacco to their own cigarettes to make them competitive with US-made brands.

The tobacco industry is even more aggressive and less scrupulous on the international scene. Fewer than 4 percent of
Asian women smoke, yet cigarette advertising campaigns in countries like Japan, Taiwan, and the Philippines are targeted primarily at women. Tobacco companies see a major, untapped market in this area of the world. In some Asian cities, children are given school tablets decorated with the Marlboro cigarette logo, and they can buy cigarettes on the street for pennies.

According to the World Health Organization, the 1990s will witness about 3 million deaths each year worldwide as a result of tobacco use. If current trends continue, more than 10 million people will die by the year 2020 from tobacco-related illnesses. Only 3 million of those deaths will be in developed countries; the bulk of the toll will strike the world's developing nations.

Each day brings new horror stories. US tobacco companies are pressing its trade officials to force US tobacco products into Thailand, despite the fact the Thailand has banned the import of foreign cigarettes. And Philip Morris is sending billions of cigarettes to the Soviet Union, a nation where the average citizen is having difficulty buying bread and meat.

Tobacco was the focus of another international story in 1990, when two tobacco companies began shipping free cigarettes to US troops stationed in and around Saudi Arabia during what was then the Operation Desert Shield. Those shipments violated a 1986 Department of Defense (DOD) directive issued to discourage tobacco use among US troops and at DOD facilities. Then-Secretary of Defense Casper Weinberger said he was concerned that smoking adds millions in direct military health-care costs, military smokers score lower on physical fitness tests than military nonsmokers, and high smoking rates create a combat readiness problem.

The DOD directive was used to thwart further shipments of free cigarettes to troops stationed in Saudi Arabia. An initial shipment slipped overseas before Pentagon officials discovered the policy violation and halted future shipments of donated cigarettes.

Though its own house must be put in order, the United States cannot ignore what is happening elsewhere, especially among those less able to defend themselves against the shrewd tactics of the tobacco industry.

As former US Surgeon General C. Everett Koop recently declared at a Tobacco-Free America conference in Washington, D.C., "It is the height of hypocrisy for the United States, in our war against drugs, to demand that foreign nations take steps to stop the import of cocaine to our country while at the same time we export nicotine, a drug just as addictive as cocaine, to the rest of the world. Our export of tobacco products is a moral outrage."

Anti-smoking forces are winning the battles, one by one, but the war continues.

Fran Du Melle is deputy managing director for the Washington Office of the American Lung
Association and chairperson of the Coalition on Smoking OR Health. Diane L. Maple is director of
media relations for the ALA's Washington Office.

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