smoking should be banned in public places thesis statement

Should Smoking Be Banned in Public Places? Essay

Introduction, thesis statement, reasons for the ban of smoking in public places, the opposing views, economic point of view, social point of view, works cited.

Many governments across the globe have moved to ban smocking in public places. Whether the action is justified or not, is a matter of fierce debate. Often, the proponents of the proposition carry the day arguing that smoke from cigarette inhaled by non-smokers poses health risks.

Thus, the banning action is based on the premise that non-smokers should be protected from risks associated with proximity to cigarette smoke (Warner 71). The other premise is that effects of smoke whether directly inhaled or partially taken in proximity with smokers are the same. However, little attention has been given to the opposing views which have always been dismissed as baseless.

Most academic studies and researches have cited individual rights as the basis for smocking in public ignoring other factors such as economy, social as well as other individualistic reasons (Viscusi 31). Moreover, much attention has also been given to dangers posed by cigarette smoking specifically health problems while ignoring the opponent side of view.

Further, little research has also been conducted to ascertain some of the issues that support public smoking or smoking in general (Viscusi 31). This does not necessarily mean that smoking should be allowed. However, other factors should be considered. Besides, various options should be explored before imposing a ban on smoking cigarette in public.

Smoking in public places poses health risks to non smokers and should be banned. This paper will be discussing whether cigarette smoking should not be allowed in public places. First the paper will explore dangers associated with smoking in public and not on those who smoke, but on non-smokers.

The paper will then examine these propositions and ascertain whether they hold and establish counter arguments against the propositions. It is concluded that even though smoking poses health risks among the individuals, economic, social and individual values must be taken into consideration before a blanket ban on the practice is imposed (Abedian et al. 71).

The proponents of this rule have several arguments majorly based on scientific studies and results from health institutions. These arguments cannot be disputed, but over reliance on them is what makes the arguments a bit absurd (Warner 71).

However, various researches have always pointed health risks associated with smoking. Besides, smoking is an environmental hazard as much of the content in the cigarette contains chemicals and hydrocarbons that are considered to be dangerous to both life and environment (Lott and Richard 102).

Biologists and epidemiologists point out passive smoking is harmful to health. In other words, those who come in contact with second-hand smoke risk their health statuses (Lott and Richard 102). Several risks are associated with second-hand smoke that majority come in contact with in public places.

In most cases, partial smokers suffer from cardiac arrests, lung cancers, central nervous system impairments as well as other diseases caused by carcinogenic chemicals from cigarette smoke (Viscusi 35).

Other health conditions caused by smoking include asthma and other respiratory infections resulting from hydrocarbons and ammonia present in the second-hand smoke. Partial smokers also suffer from eye irritations, headaches and flu as a result of smoke particles (Viscusi and Joseph 10).

Findings from other scientific studies indicate that smoking reduces individual lifespan by a minimum of ten percent. The discovery also indicates that women are likely to suffer eleven years off their life expectancy. Moreover, people who smoke are more susceptible to certain forms of cancer that would have been avoided without smoking (Viscusi and Joseph 10). Smoking is injurious to health.

Those who have opposed the view on smoking ban in public places have been accused of citing individual rights to support their actions. In as much as they might be true, the weak point in this argument is that the rule applies to both smokers and non-smokers (Abedian et al. 71). Every one has a right to smoke and also not to smoke. Therefore, the argument based on the legal rights of an individual remains ambiguous.

From the economic point of view, smoking is an individual choice. Like any other product these individuals may be willing to buy, cigarette is a commodity that its consumers would want and willing to purchase. Indeed, people make everyday choices founded on their preferences, and these choices are often associated with hazards and reservations (Warner 71).

All social interactions that individuals are involved in could be associated with risks which, in most cases are greater than risks related to smoke that smokers’ exhale. The reason is that the expected outcomes of the social interactions are greater than the risks as well as the costs involved (Viscusi 40).

Therefore, it would be ridiculous to make a conclusion that smoking in public should be prohibited simply because it presents a number of risks.

Based on this argument, the number of fatalities from other causes such as accidents, sexual relations, other diseases such as flu and pneumonia which are communicable and easily spread in public places are by far numerous than the fatalities caused by the second-hand smoke.

In other words, the risk of contracting other diseases, dying from AIDS as a result of sexual relations as well as dying from accidents are five times higher than the risk of dying from a second-hand smoke (Abedian et al. 71).

The other attribute of the economic proposition is that it examines the method through which individual choices can be reconciled based on their preferences (Viscusi and Joseph 44).

That is, individuals who smoke and those who tend to avoid second-hand smoke. According to the economic studies, primary institutes such as contractual freedom and property rights offer an effectual solution more than formal regulations in fulfilling personal preference (Viscusi and Joseph 44).

Another factor that should also be taken into consideration is the degree to which a place is considered public (Warner 71). It should be understood that most of the public places were previously private places. The difference is that owners allow the public to access them purely for commercial purposes.

As such, the role of property rights should be implemented to stop public smoking. In this regard, much of the places considered public are private such as the work places, restaurants, buses and bars. These places are opened for all manner of customers’ smokers as well as non smokers. The owner should specify the target customers who are purely non-smokers.

Therefore, any smoker who enters in these establishments is held liable for any risk of second hand smoking. On the other hand, an establishment may require that only smokers enter its establishment. In such a situation, any establishment will not be held responsible for any risks associated with second hand –smoke in a case non smoker enters the establishment.

In both scenarios, there is economic efficiency for all the parties concerned based on their preferences. However, in the circumstances that there is no specificity and the definition of the public, the whole process becomes chaotic (Warner 71).

Socially, smoking has been perceived as being fashionable and stylist. This perception has been carried over from generations to generations. Smoking is not something new rather it has been practiced for centuries. In a critical examination as to why people have been smoking for centuries, the reason is because they derived pleasure that was closely related to fashion and style.

That is why people still smoke and younger generations find themselves to be smoking despite health warnings or knowledge of health risks associated with the practice (Lott and Richard 102). This value should not be undermined as scientists could not explain why some smokers stay longer than those who smoke. Moreover, smoking is not the only cause of all health related diseases.

The best possible strategy to control tobacco consumption should be put in place. This will uphold individual’s self-esteem and appreciate society preferences. Scientists and other health proponents argue that people should not be guaranteed to smoke openly.

However, the economical approach stipulates that the management should not impose a ban on some individuals’ day to day choices. In fact, people’s preferences are highly regarded in the general public. Banning public smoking could favor certain communities while offend the treaty-liberty and material goods privileges.

Abedian, Iraj, Merwe Rowena, Nick Wilkins and Prabhat Jha. The Economics of Tobacco Control: Towards an Optimal Policy Mix . Cape Town: University of Cape Town, 1998. Print. p. 71.

Lott, John and Richard Manning. “Have Changing Liability Rules Compensated Workers Twice for Occupational Hazards? Earning Premiums and Cancer Risks.” Journal of Legal Studies , 29.1 (2000): 99-128. Print.

Viscusi, Kip and Joseph Aldy. “The Value of a Statistical Life: A Critical Review of Market Estimates throughout the World.” Journal of Risk and Uncertainty , 27.1 (2003): 5-76. Print.

Viscusi, Kip. “The Value of Life: Estimates with Risks by Occupation and Industry.” Economic Inquiry , 42.1 (2004): 29-48. Print.

Warner, Kenneth. The Economics of Tobacco and Health . Cape Town: University of Cape Town, 1998. Print. p. 71.

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• 17 April 2024
• Correction 18 April 2024

Smoking bans are coming: what does the evidence say?

• Carissa Wong

You can also search for this author in PubMed   Google Scholar

Smoking rates have declined globally over the past few decades. Credit: Debbie Bragg/Everynight Images via Alamy

Nations worldwide are aiming to introduce some of the tightest restrictions ever on smoking and vaping, especially among young people.

On 16 April, UK lawmakers backed one of the world’s most ambitious plans — to create by 2040 a ‘smoke-free’ generation of people who will never be able to legally buy tobacco. The proposal is now a step closer to becoming law. The UK, Australian and French governments are also clamping down on vaping with e-cigarettes. These countries’ bold policies are currently in the minority, say researchers, but such measures would almost certainly prevent diseases, as well as save lives and billions of dollars in health-care costs.

Smoking scars the immune system for years after quitting

The UK plan would probably “be the most impactful public-health policy ever introduced”, says health-policy researcher Duncan Gillespie at the University of Sheffield, UK. The Conservative government’s Prime Minister Rishi Sunak initiated the proposal. The government hopes that the smoking restrictions, alongside offering health benefits for individuals, will reduce toxic chemicals leaching from used vapes into the environment.

Smoke-free generations

The health harms of smoking tobacco have been established for decades — it substantially raises the risk of diseases including cancer, heart disease and diabetes. Increased awareness of these health risks has led to a global decline in the deadly habit in the past few decades (see ‘Smoke clearing’).

Source: WHO

Any drop in smoking rates saves money and reduces the burden on health-care systems, says Alison Commar, who studies tobacco policy at the World Health Organization (WHO) in Geneva, Switzerland. The WHO estimates that tobacco use costs the world US$1.4 trillion every year in health expenditures and lost productivity. “Every tobacco-related illness is adding to the burden on the health system unnecessarily,” says Commar.

The UK proposal, announced last October, would ban the sale of tobacco to any person born in or after 2009. That would prevent anyone who turns 15 or younger this year from ever buying cigarettes legally in the country. From 2027, the minimum legal age to purchase tobacco products would increase from 18 years old by one year each year — meaning that the threshold in 2028, for instance, would be 20. This strategy, the government hopes, will by 2040 create a smoke-free generation. The UK move follows similar legislation announced in 2021 by New Zealand. The nation reversed its intended ban because tobacco sales were needed to help pay for tax cuts, but the government said last month that it will seek to ban disposable vapes.

Modelling smokers

The UK government’s policies are backed by a modelling study published in December that predicts how the proposal would affect smoking rates and people over time. Its ‘pessimistic’ model predicts that the policy could reduce the smoking rate among people aged 14–30 from 13% in 2023 to around 8% in 2030. By 2040, just 5% of this age group would smoke. In the baseline scenario, 8% of 14- to 30-year-olds would smoke. In the ‘optimistic’ scenario, only 0.4% of that age group would start smoking by 2040 (see ‘Ban plan’). That model suggests that, by 2075, the policy would save tens of thousands of lives and £11 billion ($13.7 billion) in health-care costs by preventing smoking-related diseases.

These projections are based on solid evidence and are of high quality, says tobacco researcher Allen Gallagher at the University of Bath, UK.

Still, no country has ever introduced a policy that raises the minimum tobacco-purchasing age in this way — only time will tell what the effects will be, says Commar.

Vaping bans

Nations are also targeting vaping, a trend that began around 2010 and has surged among younger people. Many people have perceived it as a potentially healthier alternative to smoking — for which there is substantial evidence. But whether vaping itself harms health has long been controversial, and the evidence is uncertain.

“The results are not super clear, but certainly hint towards vaping causing damage to the lungs and other organs,” says Carolyn Baglole, who studies lung disease at the McGill University Health Centre in Montreal, Canada.

Source: UK government

Vapes are made of a box filled with liquid that usually contains nicotine, a heating element that turns the liquid into aerosols and a mouthpiece to inhale the aerosol ‘vape’ clouds, which are often fruity or dessert-flavoured. Although vapes lack tobacco and most of the toxic chemicals in cigarettes, the nicotine is still harmful. Nicotine can raise blood pressure, increase the risk of heart and lung disease and disrupt brain development in children and adolescents. In turn, this can lead to impairments in attention, memory and learning.

The UK plan includes banning disposable vapes, restricting vape flavours that appeal to young users and limiting how vapes are advertised. Most young people in Great Britain use disposable vapes rather than rechargeable ones than can be refilled with liquid, according to a survey by the public-health charity Action on Smoking and Health, based in London. Rechargeable vapes would remain legal.

Global policies

The French government also wants to ban disposable vapes this year, and in December its parliament unanimously backed the proposal. And in 2021, Australia restricted e-cigarette sales to smokers who have a prescription for using vapes to quit smoking. “There is a good consensus that vaping is likely to pose only a small fraction of risks of smoking over the long term,” says psychologist Peter Hajek at Queen Mary University of London, who led a study 1 that suggested vaping safely helped pregnant women to stop smoking.

But illegal vaping is still surging among people under the legal age of 18 in Australia, according to research by the Australian Institute of Health and Welfare. That’s led the government to tighten rules on vape products. “This policy push should see the upswing in youth vaping contained and reversed,” says epidemiologist Tony Blakely at the University of Melbourne in Australia.

The flavoured liquid in vapes also contains solvents such as propylene glycol and glycerin. Agencies including the US and European Union drug regulators have approved these chemicals for oral consumption. But animal studies suggest that inhaling them could cause damage and inflammation, raising the risk of lung and heart disease 2 . “The issue is we don’t know much about what happens when you heat these products and aerosolize them for inhalation,” says Baglole.

One thing researchers know is that the heating element in e-cigarettes can release heavy metals into the inhaled aerosols. These particles have been linked to a raised risk of heart and respiratory disease, she says.

Ultimately, scientists seem to be overwhelmingly in favour of tough restrictions on smoking and vaping. Research is needed to establish the long-term health impacts of such policies, says Baglole. “Hopefully, different types of studies, different models, in addition to human participants, will start to paint a more complete picture,” she says.

doi: https://doi.org/10.1038/d41586-024-00472-3

Updates & Corrections

Correction 18 April 2024 : The graphic ‘Smoking prevalence’ wrongly coloured the chart lines for the optimistic and pessimistic scenarios. This has been corrected.

Pesola, F. et al. Addiction 119 , 875–884 (2024).

Article   PubMed   Google Scholar  

Traboulsi, H. et al. Int. J. Mol. Sci. 21 , 3495 (2020).

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The case for a worldwide ban on smoking in public places

Affiliation.

• 1 University Hospital Llandough, Cardiff, Wales, UK. [email protected]
• PMID: 21365795
• DOI: 10.1097/mcp.0b013e328341ce98

Purpose of review: Second-hand smoke (SHS) is a major cause of morbidity and mortality on a global scale. Governments have increasingly sought to mitigate the effects of SHS by introducing legislation that restricts tobacco consumption in public places. There is emerging evidence that such legislation leads to direct and indirect health benefits.

Recent findings: Exposure to SHS is now shown to be associated with development of cardiovascular disease, and poorer health outcomes in patients with established chronic obstructive pulmonary disease. Childhood (including in-utero) exposure to SHS has recently been linked with increased risk of cleft palate, demonstrable signs of atherosclerosis, and the development of emphysema and lung cancer in adulthood. Comprehensive bans on smoking in public lead to a reduction in overall exposure to SHS for both adults and children and have also been shown to immediately attenuate the incidence of myocardial infarction and paediatric hospital attendances with acute asthma.

Summary: Banning smoking in public places is an effective tool for reducing tobacco-related morbidity across a multiplicity of diseases. Countries that have not already done so should introduce legislation to enforce effective legislation that prohibits smoking in public places.

Publication types

• Age Factors
• Cardiovascular Diseases / epidemiology
• Cardiovascular Diseases / etiology
• Cardiovascular Diseases / prevention & control
• Inhalation Exposure / adverse effects
• Inhalation Exposure / legislation & jurisprudence*
• Inhalation Exposure / prevention & control
• Inhalation Exposure / statistics & numerical data
• International Cooperation*
• Maternal Exposure / adverse effects
• Maternal Exposure / prevention & control
• Maternal Exposure / statistics & numerical data
• Respiratory Tract Diseases / epidemiology
• Respiratory Tract Diseases / etiology
• Respiratory Tract Diseases / prevention & control
• Smoking / adverse effects
• Smoking / epidemiology
• Smoking / legislation & jurisprudence*
• Tobacco Smoke Pollution / adverse effects
• Tobacco Smoke Pollution / legislation & jurisprudence*
• Tobacco Smoke Pollution / prevention & control
• Tobacco Smoke Pollution / statistics & numerical data
• Tobacco Smoke Pollution

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• Ban Smoking Essay

Ban Smoking in Public Places Essay

This is a  ban smoking in public places  essay. It is an example of an essay where you have to give your opinion as to whether you agree or disagree.

The sample answer shows you how you can present the opposing argument first, that is not your opinion, and then present your opinion in the following paragraph.

It is always a good idea to present a balanced essay which presents both sides of the argument, but you must always make it very clear what your opinion is and which side of the argument you support.

You should spend about 40 minutes on this task.

Write about the following topic:

Smoking not only harms the smoker, but also those who are nearby. Therefore, smoking should be banned in public places.

To what extent do you agree or disagree?

Give reasons for your answer and include any relevant examples from your own experience or knowledge.

Write at least 250 words.

Model Answer:

Medical studies have shown that smoking not only leads to health problems for the smoker, but also for people close by. As a result of this, many believe that smoking should not be allowed in public places. Although there are arguments on both sides, I strongly agree that a ban is the most appropriate course of action.

Opponents of such a ban argue against it for several reasons. Firstly, they say that passive smokers make the choice to breathe in other people’s smoke by going to places where it is allowed. If they would prefer not to smoke passively, then they do not need to visit places where smoking is permitted. In addition, they believe a ban would possibly drive many bars and pubs out of business as smokers would not go there anymore. They also argue it is a matter of freedom of choice. Smoking is not against the law, so individuals should have the freedom to smoke where they wish.

However, there are more convincing arguments in favour of a ban. First and foremost, it has been proven that tobacco consists of carcinogenic compounds which cause serious harm to a person’s health, not only the smoker. Anyone around them can develop cancers of the lungs, mouth and throat, and other sites in the body. It is simply not fair to impose this upon another person. It is also the case that people’s health is more important than businesses. In any case, pubs and restaurants could adapt to a ban by, for example, allowing smoking areas.

In conclusion, it is clear that it should be made illegal to smoke in public places. This would improve the health of thousands of people, and that is most definitely a positive development.

(290 words)

This essay is well organized and presented.

The introduction is clear - note how it follows the ban smoking in public places essay question - it paraphrases the information in order to introduce the topic and the argument.

The argument against a ban on smoking in public places is presented first. It is made clear that it is not the authors opinion by the topic sentence:

• "Opponents of such a ban argue against it for several reasons".

And also by the use of the word 'they' to refer to the opponents.

The writer then clearly shows they are moving on to the other argument which is their own (and it has clearly been stated in the thesis that this is their argument):

• "However, there are more convincing arguments in favour of a ban".

In this paragraph, 'they' is dropped because it is now the writers opinion.

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Preventing Exposure to Secondhand Smoke in the Community

• Eliminating smoking is the only way to fully protect people who do not smoke from secondhand smoke (SHS) exposure. 1
• Comprehensive smokefree policies * prohibit smoking in all areas of indoor spaces, at all times. These policies can fully protect people from secondhand smoke exposure. Comprehensive smokefree laws are smokefree policies that prohibit smoking in all areas of workplaces and public places, including restaurants and bars. 2,3,4
• Comprehensive smokefree laws and policies can also help people who smoke quit and can help keep young people from starting to smoke. 1,5

Many disparities in exposure, illnesses, deaths, and lost productivity could be prevented if comprehensive smokefree laws prohibiting smoking in all indoor areas of worksites, restaurants, and bars were implemented throughout the U.S. 2,30,33

Benefits of comprehensive smokefree policies

How smokefree policies vary across the u.s., why some population groups are more likely to be exposed to secondhand smoke.

* CDC defines a comprehensive smokefree law as one that prohibits smoking at all times, in all indoor areas of all workplaces, restaurants, and bars. If a law allows exemptions for designated or ventilated smoking areas in workplaces, restaurants, or bars, the state or community is not considered to have a comprehensive smokefree law. 

• Studies have found substantial declines in cotinine, a marker of secondhand smoke, among both hospitality workers and the public following the implementation of smokefree laws. 6,7,8,9,10,11,12,13,14 Cotinine is a byproduct the body creates when it breaks down nicotine, a major ingredient of tobacco smoke.
• Research has found that smokefree policies lead to substantial declines in secondhand smoke exposure, with air quality improvements of up to 90% in high-risk settings, such as bars. 15
• Smokefree laws lead to reductions in coronary events (especially heart attacks), making comprehensive smokefree laws one of the most effective and cost-effective approaches for reducing heart disease—the leading cause of death—in the U.S. 2
• Comprehensive smokefree laws are associated with rapid reductions in hospitalizations related to heart attacks and strokes after the laws take effect. 16,17
• Smokefree laws in hospitality venues—such as restaurants, bars, and casinos—protect both employees and customers from the harmful health effects of secondhand smoke exposure. These policies are associated with improved indoor air quality and with reduced secondhand smoke exposure, reduced sensory and respiratory symptoms, and improved lung function in employees who do not smoke. 2,18,19
• Smokefree laws also can make it easier for people who smoke to quit, reducing their risk of disease.
• Smokefree laws in workplaces and communities reduce tobacco use and increase smoking cessation. 2,20,21
• In 2010, a systematic review by the Task Force on Community Preventive Services reported that eleven studies found that smokefree laws and policies in workplaces were associated with a median 6.4% increase in tobacco use cessation, and twenty-one studies found that these laws and policies were associated with a median 3.4% decrease in tobacco use prevalence. 5
• Smokefree workplaces and communities make youth and young adults less likely to start smoking due to several factors, including seeing fewer role models smoke, fewer opportunities to smoke alone or with others, and reduced social acceptability for smoking. 2
• The implementation of smokefree laws increases the adoption of voluntary smokefree rules in homes. 22 In turn, smokefree rules in homes may increase the adoption of smokefree rules for private vehicles. 23 These rules can further protect people who do not smoke—especially those who are disproportionately affected by secondhand smoke exposure in homes and in vehicles, such as children. 2,24
• Only 62.5% of the US population is covered by 100% smokefree laws that apply to bars, restaurants, and worksites. 25
• Twenty-eight states, Puerto Rico, the U.S. Virgin Islands, and the District of Columbia have comprehensive smokefree laws in effect that prohibit smoking tobacco in private worksites, restaurants, and bars. Twenty-two states, Puerto Rico, and the U.S. Virgin Islands prohibit smoking in state-regulated gambling venues. 25
• Twenty-five states, Puerto Rico, and the District of Columbia prohibit the use of e-cigarettes in private worksites, restaurants, and bars, and 13 of those jurisdictions also prohibit the use of e-cigarettes in gambling venues. 26
• Over 1,100 U.S. cities and counties have comprehensive smokefree laws in effect that prohibit smoking tobacco products in private worksites, restaurants, and bars. 25 There are also 1,006 local US communities that prohibit the use of e-cigarettes in 100% smokefree venues. 26
• Smokefree laws and policies have a high level of public support and compliance, and studies have shown they do not negatively affect sales of food and beverage items, or employment in the hospitality industry. 27,28 Although the number of comprehensive smokefree laws has increased among states over time, variation and unequal protection remains. The tobacco industry has opposed these policies. 29
• Most comprehensive smokefree laws and policies also prohibit the use of e-cigarettes. The e-cigarette aerosol that people who use e-cigarettes breathe from the device and exhale can contain harmful and potentially harmful substances. Including e-cigarettes in smokefree or tobacco-free policies can protect people who do not use e-cigarettes from exposure to e-cigarette emissions, and can help change social norms about tobacco use. More information about e-cigarettes can be found on the Electronic Cigarettes page.
• Groups of people who are more likely than other groups to be exposed to secondhand smoke include: non-Hispanic, Black people; people who live below the federal poverty level; people with less than a college degree; people who live with someone who smokes inside the home; people who work in traditionally “blue collar” industries, service occupations, or construction; people who live in rental properties; and children 3-11 years of age. 30
• Almost two of every five children 3-11 years of age, including over half of non-Hispanic Black children, were exposed to secondhand smoke during 2017- 2018. 30,31
• During 2017-2018, secondhand smoke exposure among non-Hispanic Black individuals and those living below the poverty level continued to be approximately twice as high compared with non-Hispanic White individuals and those living above the poverty level, respectively. 31,32

Smokefree policies in commercial and residential settings can minimize the effects of secondhand smoke

• US Department of Health and Human Services. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General . Atlanta, GA: US 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.
• US Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General.  Atlanta, GA: US 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; 2014.
• US Department of Health and Human Services. A Report of the Surgeon General: How Tobacco Smoke Causes Disease: What It Means to You  . Atlanta, GA: US 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; 2010.
• National Toxicology Program. Report on Carcinogens, Fourteenth Edition.  Research Triangle Park (NC): US Department of Health and Human Services, Public Health Service; 2016.
• Hopkins DP, Razi S, Leeks KD, Priva Kalra G, Chattopadhyay SK, Soler RE, et al. Task Force on Community Preventive Services. Smoke-Free Policies to Reduce Tobacco Use: A Systematic Review . American Journal of Preventive Medicine 2010;38(2 Suppl):S275–89.
• CDC. Reduced Secondhand Smoke Exposure After Implementation of a Comprehensive Statewide Smoking Ban–New York, June 26, 2003–June 30, 2004 . MMWR 2007;56(28):705–8.
• Farrelly MC, Nonnemaker JM, Chou R, Hyland A, Peterson KK, Bauer UE. Changes in Hospitality Workers’ Exposure to Secondhand Smoke Following the Implementation of New York’s Smoke-Free Law . Tobacco Control 2005;14(4):236–41.
• Jensen JA, Schillo BA, Moilanen MM, Lindgren BR, Murphy S, Carmella S, et al. Tobacco Smoke Exposure in Nonsmoking Hospitality Workers Before and After a State Smoking Ban.  Cancer Epidemiology, Biomarkers & Prevention 2010;19(4):1016–21.
• Wilson T, Shamo F, Boynton K, Kiley J. The Impact of Michigan’s Dr. Ron Davis Smoke-Free Air Law on Levels of Cotinine, Tobacco-Specific Lung Carcinogen and Severity of Self-Reported Respiratory Symptoms Among Non-Smoking Bar Employees.  Tobacco Control 2012;21:593–5.
• Allwright S, Paul G, Greiner B, Mullally BJ, Pursell L, Kelly A, et al. Legislation for Smoke-Free Workplaces and Health of Bar Workers in Ireland: Before and After Study.  British Medical Journal 2005;331(7525):1117.
• Mulcahy M, Evans DS, Hammond SK, Repace JL, Byrne M. Secondhand Smoke Exposure and Risk Following the Irish Smoking Ban: An Assessment of Salivary Cotinine Concentrations in Hotel Workers and Air Nicotine Levels in Bars.  Tobacco Control 2005;14:384–8.
• Haw SJ, Gruer L. Changes in Exposure of Adult Non-Smokers to Secondhand Smoke After Implementation of Smoke-Free Legislation in Scotland: National Cross Sectional Survey.  British Medical Journal 2007;335(7619):549–53.
• Akhtar PC, Currie DB, Currie CE, Haw SJ. Changes in Child Exposure to Environmental Tobacco Smoke (CHETS) Study After Implementation of Smoke-Free Legislation in Scotland: National Cross-Sectional Survey . British Medical Journal 2007;335(7619):545–9.
• Sims M, Mindell JS, Jarvis MJ, Feyerabend C, Wardle H, Gilmore A. Did Smokefree Legislation in England Reduce Exposure to Secondhand Smoke among Nonsmoking Adults? Cotinine Analysis from the Health Survey for England.  Environmental Health Perspectives 2012;120(3):425–30.
• International Agency for Research on Cancer. Evaluating the Effectiveness of Smoke-free Policies . IARC Handbooks of Cancer Prevention. Vol. 13; 2009.
• Tan CE, Glantz SA. Association between smoke-free legislation and hospitalizations for cardiac, cerebrovascular, and respiratory diseases: a meta-analysis . Circulation; 2012;126(18):2177-83.
• Centers for Disease Control and Prevention. Smokefree Policies Improve Health .  [accessed 2022 Feb 10].
• Semple S, Creely KS, Naji A, Miller BG, Ayres JG. Secondhand smoke levels in Scottish pubs: the effect of smoke-free legislation . Tobacco Control 2007;16(2):127-132.
• CDC. Indoor air quality in hospitality venues before and after implementation of a clean indoor air law–Western New York, 2003 . MMWR 2004;53(44):1038-41.
• US Department of Health and Human Services. Smoking Cessation: A Report of the Surgeon General.  Atlanta, GA: US 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; 2020.
• Guide to Community Preventive Services. Tobacco Use: Smoke-Free Policies.  Task Force Finding and Rationale Statement [accessed 2022 Jul 15].
• Cheng KW, Glantz SA, Lightwood JM. Association between smokefree laws and voluntary smokefreehome rules.  Am J Prev Med. 2011;41(6):566-72.
• Bundy ŁT, Haardörfer R, Kegler MC, Owolabi S, Berg CJ, Escoffery C, et al. Disseminating a Smoke-free Homes Program to Low Socioeconomic Status Households in the United States Through 2-1-1: Results of a National Impact Evaluation . Nicotine Tob Res. 2020;22(4):498-505.
• Walton K, Gentzke AS, Murphy-Hoefer R, Kenemer B, Neff LJ. Exposure to Secondhand Smoke in Homes and Vehicles Among US Youths, United States, 2011-2019. Prev Chronic Dis. 2020; 17: E103.
• American Nonsmokers’ Rights Foundation. Overview List – Number of Smokefree and Other Tobacco Related Laws [PDF – 624 KB]  [accessed 2022 Jul 15].
• American Nonsmokers’ Rights Foundation. States and Municipalities with Laws Regulating Use of Electronic Cigarettes. [PDF – 2 MB]  [accessed 2022 Jul 15].
• Fong GT, Hyland A, Borland R, Hammond D, Hastings G, McNeill A, et al. Reductions in tobacco smoke pollution and increases in support for smokefree public places following the implementation of comprehensive smokefree workplace legislation in the Republic of Ireland: Findings from the ITC Ireland/UK Survey.  Tob Control 2006;15:iii51–iii58.
• Eriksen M, Chaloupka F. The economic impact of clean indoor air laws . CA Cancer J Clin. 2007;57:367–378.
• US National Cancer Institute and World Health Organization. The Economics of Tobacco and Tobacco Control . National Cancer Institute Tobacco Control Monograph 21. NIH Publication No. 16-CA-8029A. Bethesda, MD: US Department of Health and Human Services, National Institutes of Health, National Cancer Institute; and Geneva, CH: World Health Organization; 2016.
• Tsai J, Homa D, Gentzke A, Mahoney M, Sharapova SR, Sosnoff CS, et al. Exposure to Secondhand Smoke Among Nonsmokers — United States, 1988–2014.  MMWR 2018;67:1342-1346.
• Tsai J, Homa DM, Neff LJ, Sosnoff CS, Wang L, Blount BC, et al. Trends in Secondhand Smoke Exposure, 2011-2018: Impact and Implications of Expanding Serum Cotinine Range . Am J Prev Med. 2021;61(3):e109-e117.
• Shastri SS, Talluri R, Shete S. Disparities in Secondhand Smoke Exposure in the United States: National Health and Nutrition Examination Survey 2011-2018.  JAMA Internal Medicine 2021;181(1):134-137.
• Institute of Medicine. Ending the Tobacco Problem: A Blueprint for the Nation.  Washington, DC: The National Academies Press; 2007.
• Loomis BR, Shafer PR, van Hasselt M. The Economic Impact of Smoke-Free Laws on Restaurants and Bars in 9 States.  Preventing Chronic Disease 2013;10:E128.
• Babb S, McNeil C, Kruger J, Tynan MA. Secondhand smoke and smoking restrictions in casinos: a review of the evidence . Tob Control 2015;24(1):11-7.
• Harris JK, Carothers BJ, Luke DA, Silmere H, McBride TD, Pion M. Exempting casinos from the Smokefree Illinois Act will not bring patrons back: they never left.  Tob Control 2012;21(3):373-6.
• Tynan MA, Wang TW, Marynak KL, Lemos P, Babb SD. Attitudes Toward Smoke-Free Casino Policies Among US Adults, 2017 . Public Health Rep. 2019;134(3):234-240.
• Cowling DW, Bond P. Smoke-free laws and bar revenues in California–the last call.  Health Econ.  2005;14(12):1273-81.
• New York City Department of Finance, New York City Department of Health & Mental Hygiene, New York City Department of Small Business Services, New York City Economic Development Corporation. The State of Smoke-Free New York City: A One-Year Review [PDF – 47 KB] . 2004 [accessed 2022 Jul 15].
• Bonnie R, Stratton K, Wallace RB. Ending the Tobacco Problem: A Blueprint for the Nation.  Washington, DC: National Academy Press; 2007.
• Hennrikus D, Pentel PR, Sandell SD. Preferences and practices among renters regarding smoking restrictions in apartment buildings.  Tob Control 2003;12(2):189–194.
• CDC. Vital signs: Nonsmokers’ exposure to secondhand smoke-United States, 1999–2008 . MMWR 2010;59(35):1141–1146.
• CDC. Vital signs: disparities in nonsmokers’ exposure to secondhand smoke — United States, 1999–2012 . MMWR 2015;64(04):103–108.
• King BA, Babb SD, Tynan MA, Gerzoff RB. National and state estimates of secondhand smoke infiltration among U.S. multiunit housing residents.  Nicotine Tob Res. 2013;15(7):1316–1321.
• American Society of Heating, Refrigerating, and Air Conditioning Engineers, Inc (ASHRAE). Position Paper: Environmental Tobacco Smoke.  Atlanta, GA: ASHRAE; 2005 [accessed 2022 Jul 15].
• King BA, Peck RM, Babb SD. National and state cost savings associated with prohibiting smoking in subsidized and public housing in the United States . Prev Chronic Dis. 2014;11:140222.
• American Nonsmokers’ Rights Foundation. U.S. Laws for 100% Smokefree Multi-Unit Housing. [PDF – 306 KB]  [accessed 2022 Jul 15].
• Snyder K, Vick JH, King BA. Smokefree multiunit housing: a review of the scientific literature.  Tob Control 2015; 0:1–12.

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Why Smoking Should Be Banned in Public

Smoking should be banned in all public places to protect people from second-hand smoke and stop promoting the visual to minors. The cigarette is a small but deadly habit enjoyed by 45. 3 million Americans. Smoking is illegal inside most public restaurants and buildings as well as on school property. But, why should cigarette smoking be banned in all public spaces, including outside public establishments? The most obvious reason is second-hand smoke and the damage it causes to others who don't want to be exposed to cigarette smoke.

A ban on all public smoking would improve the air quality in each town, spare people from smoke exposure, decrease the overall amount of smoking, and make it less visible to children and teens as an accepted norm. The negative effects of second-hand smoke are scientifically documented and provide a valid reason for banning all public smoking. This proposal would likely upset many people since it may seem a bit constraining and overly invasive at first. Why are people not allowed to drink alcohol on the streets, walking throughout a town or city?

If someone were to do this they would get a ticket or arrested for public intoxication. It is unhealthy for the person drinking and dangerous for everyone else around the person drinking. The same principle applies for smoking cigarettes. It is unhealthy for the person smoking and for everyone around them that happens to be outside. The people who aren’t smoking deserve the right to clean air and the right to not be exposed to harmful chemicals found in nicotine. This individual right outweighs the individual right to smoke in an outdoor, public place. The smoking addiction is undoubtedly just that, an addiction.

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If people truly grasped what they were doing to their bodies, then everyone would quit smoking unless they wanted to die young. This addiction, like any other addiction, needs outside action taken to prevent the person in addiction from further harm. In this case, each state and/or city should enact a ban on smoking in outdoor public places. This ban should exclude peoples homes or personal property but it should includes all buildings, establishments, streets, parks, and anywhere else that people gather. The only exception to banning someone from smoking in their own house should be if they have children.

It may seem like an invasion of privacy and too much government control but the more important issue here is the safety of children. If there are children under the age of 18 living at home then it should be illegal to smoke in the house or car or within a certain distance of them, even at home. The second-hand smoke that these children are inhaling is not their choice and they are being subject to life-threatening disease and illness. In addition to being exposed to harmful chemicals, children who are around smoking will become more likely to smoke themselves.

The deadly cycle will continue and more people will become addicted to smoking cigarettes. Without government intervention, this is an issue that will not change and lives will continue to be lost due to the negative effects of cigarette smoking. Portland, Oregon is taking this issue seriously. Public smoking is banned within 25 feet of a playground or picnic table. This city understands the health concerns for people who choose not to smoke. The beauty of living in a free country is that any individual may choose whether to smoke cigarettes or not.

An individuals choice is taken away from them when people are allowed to smoke on streets and in outdoor public spaces. A law that prevents people from smoking in any public space, whether indoor or outdoor, would truly give non-smokers the choice not to inhale cigarette smoke. At a professional sporting event, even an outdoor one, smoking is banned almost everywhere. It is accepted as the social norm not to smoke while sitting in your seat and watching the game because it might bother another person sitting nearby. This same concept should be used to ban smoking while walking on a sidewalk or standing outside a building.

One of the biggest and most important reasons to ban all public smoking is the safety of children. Our government and states have made extensive laws, and rightly so, to protect children from abuse and neglect. This includes entering some ones private home if there is reason to believe the child is in danger. Children have no say whether or not to be abused and no child wants to or should be. No child wants to be addicted to cigarettes or chooses to have the lasting, harmful effects that cigarettes bring on a person. Our government seems to be taking small steps in the right direction but is still focused on only one part of the issue.

According to the FDA, “Every day nearly 4,000 kids under 18 try their first cigarette and 1,000 kids under 18 become daily smokers. Many of these kids will become addicted before they are old enough to understand the risks and will ultimately die too young of tobacco-related diseases. FDA is working to protect the health of America’s children and ultimately reduce the burden of illness and death caused by tobacco use. ” (“Save”) The stats are alarming as to how many children are smoking. A public ban on smoking would reduce the amount of cigarettes smoked and the amount of people who begin smoking due to lack of public exposure.

Every time someone smokes a cigarette they are giving free advertising to the tobacco industry. If you watch an old movie you will notice that smoking was socially accepted and even a part of being sophisticated. We have come a long way since the 1930’s and 1940’s but still have a large room for improvement. The visual aspect is the greatest one to overcome. If we can eliminate public smoking, it will decrease the amount of people who being smoking while also creating a healthier environment for everyone to enjoy.

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National Research Council (US) Committee on Population; Bobadilla JL, Costello CA, Mitchell F, editors. Premature Death in the New Independent States. Washington (DC): National Academies Press (US); 1997.

Premature Death in the New Independent States.

• Hardcopy Version at National Academies Press

11 Tobacco Control Policy Strategies: Lessons from Western Developed Countries

John P. Pierce

• Introduction

Tobacco usage, particularly daily consumption of multiple cigarettes, has been identified as the most preventable cause of disease in the developed world (U.S. Department of Health and Human Services, 1989). Tobacco is one of the few products on the legal market which, when used explicitly as the manufacturer intended, leads to untimely death and disability. Worse still, this negative health impact is not restricted to the consumer, but extends to others who are exposed to environmental tobacco smoke (U.S. Environmental Protection Agency, 1992). In the United States alone, it is estimated that consumption of tobacco is associated with over 400,000 deaths each year. The estimated direct health care costs per smoker per year in California in 1993 were $793, using the prevalence method of cost accounting (Rice and Max, 1993).

The very size of this health impact has forced many developed nations to formulate public policies related to tobacco usage. If the product were new on the market today, it could never meet the regulatory requirements for legal production and marketing for sale. However, tobacco was introduced into Europe five centuries ago, and it now plays an important role in many national and provincial economies. No country has sought to delegalize all tobacco products. The preferred public policy has been to use public monies to convince citizens not to smoke. This policy is broadly referred to as tobacco control.

Tobacco control aims to influence citizens' behavior related to smoking. The goals of tobacco control programs are very clear:

• To protect nonsmokers in society.
• - by encouraging smokers to quit and
• - by discouraging nonsmokers from starting to smoke.

The objective of this chapter is to identify generalizable elements from existing tobacco control programs in Western developed countries that might usefully be employed in the NIS.

The next section of the chapter reviews the current situation and trends in tobacco use in the NIS. This is followed by a look at the context for a tobacco control program, including the natural history of smoking behavior and the role of advertising in increasing tobacco consumption. The chapter then examines the various components of a tobacco control program. The final section addresses the application of these components to the NIS.

• Current Situation and Trends in Tobacco Use in the New Independent States

Tobacco Use in the New Independent States

The history of tobacco in Eastern Europe throughout the major part of this century has been marked by government-controlled production and sale of tobacco products. Throughout the 1980s, cigarette production in the region grew by around 1 percent per year. However, per capita consumption was relatively stable at around 1,600 smoking pieces per person per year between 1982 and 1988. This is approximately half the per capita consumption level of the United States.

In the 1980s, approximately half the adult men in the Soviet Union smoked, compared with less than 15 percent of the women (Zaridze et al., 1986); however, there were marked differences by age, as shown in Figure 11-1 . The highest prevalence was among men aged 20 to 39, over 60 percent of whom were smokers. Prevalence among men between ages 40 and 70 was around 40 percent. There appeared to be an educational gradient, with the better-educated men smoking less than the less educated (30 vs. 60 percent). The highest prevalence among women also occurred in the age group 20 to 39 years, at 20 percent. By comparison, in the United States in 1987, around 31 percent of men and 26 percent of women smoked. There was also a marked difference in prevalence for the better and less educated (16 vs. 35 percent). 1

Figure 11-1

Prevalence of smoking by gender and age: Soviet Union, 1981. SOURCE: Zaridze et al. (1986).

Tobacco Products in the New Independent States

The tobacco industry in Central and Eastern Europe has changed markedly in recent years in both structure and ownership (see also Prokhorov, in this volume).

Privatization has occurred very quickly, with purchasers being the major transnational tobacco companies. The impetus for this change in the tobacco industry started in 1990, when the rapidly developing economic crisis led to the temporary closing of 50 percent of tobacco factories in the Soviet Union. During this time, the worsening currency problem made large-scale importation of cigarettes very expensive. There was civil unrest resulting from the shortage of cigarettes. The transnational tobacco companies agreed to provide the region with a total of 38 billion cigarettes at enormously discounted rates. Since then, these tobacco companies have acquired major interests in 34 former state monopolies in Central and Eastern Europe, with 12 being owned outright. Table 11-1 shows recent investment by transnational tobacco companies in Central and Eastern Europe.

Recent Transnational Tobacco Company Investments in Central and Eastern Europe.

The entry of the transnational tobacco industry giants into the economy and politics of the region has changed expectations for consumption over the next decade. In 1988, per capita consumption projections for the Soviet Union foresaw a negligible increase through 1998, with some projected brand switching toward filtered cigarettes (60 percent of market in 1988 to 80 percent in 1998) and a move toward milder cigarettes preferred by younger consumers and women. These projections were made with the knowledge that tobacco advertising had been banned in 1980 and that government regulation was likely to remain in force. The entrance of the transnational tobacco companies significantly changed that scenario.

In purchasing tobacco plants in Central and Eastern Europe, the transnational tobacco companies have significantly increased their manufacturing capabilities. 2 It is expected that the long-term goals of the companies are to expand cigarette production within the region, to expand per capita consumption levels toward those seen in the United States, and to increase the level of profitability for each cigarette sold. 3

To promote higher consumption levels, the industry might be expected to follow the prescription that has been so successful in other countries: large marketing expenditures and the use of their economic might to create pressure. Indeed, the new tobacco industry in the region has moved quickly to begin stimulating demand for major brands of cigarettes produced by the transnational tobacco companies. The industry has started by completely ignoring the advertising ban. Connolly (1994) reports that of the 6,723 billboards in Moscow, 70 percent advertise tobacco products—almost exclusively key multinational brands. Indirect advertising of Marlboro and Rothman's is widespread on Moscow television. During one feature film, three commercial breaks advertised Lucky Strikes. In July of 1993, the Moscow City Council took its own action to ban tobacco advertising, and a similar ban passed in the Russian Parliament. However, the Press Ministry has refused to enforce the ban, citing the importance of the advertising revenue. Prokhorov and Alexandrov (1994) report that the Moscow Department of Public Transportation has noted an enormous expansion of protected bus stops featuring tobacco advertising. Further, the Moscow Trade Department has indicated that there will be a significant increase in ''brand-name" tobacco kiosks in Moscow, thus increasing the ease of access to Western-brand cigarettes.

Recent evidence suggests, moreover, that there has been a rapid increase in smoking prevalence among young adult women in the NIS, with prevalence already much closer to the high rates observed among men of the same age. There is also evidence suggesting a rapid recent rise in smoking among adolescents, with one study reporting 20 percent smoking rates among 12 year olds (Alexandrov et al., unpublished data, no date).

Thus, the situation in the NIS suggests that without effective tobacco control programs, there will be a major increase in tobacco use over the next few years, with the smoking-related disease epidemic worsening significantly over the next generation (see also Prokhorov, in this volume).

• Context for Tobacco Control

The majority of tobacco control programs that have been undertaken have focused on influencing individual behavior and reducing smoking prevalence. Accordingly, this discussion of the context for tobacco control starts with a review of the natural history of smoking behavior.

One of the peculiarities of tobacco control is the existence of a major industrial group that seeks to influence behavior in a way that is directly contradictory to the goals of tobacco control programs. A significant goal for tobacco control is thus to reduce the effectiveness of tobacco industry efforts to stimulate demand for tobacco. Therefore, this section also reviews the evidence for the effectiveness of tobacco marketing in increasing smoking among different population groups.

The Natural History of Smoking Behavior

Most societies measure the level of smoking behavior by assessing its prevalence in the community at a particular point in time and comparing this with per capita consumption (U.S. Department of Health and Human Services, 1989). Changes in the prevalence of smoking are effected either by a reduction in the proportion of nonsmokers who start to smoke, or an increase in the proportion of smokers who quit smoking, or a change in the in-out migration ratio of smokers to nonsmokers. Tobacco control focuses on the first two of these: it aims to reduce the uptake of smoking among nonsmokers and to increase successful quitting among smokers.

The uptake of smoking has been studied extensively over the past 20 years (U.S. Department of Health and Human Services, 1989, 1994a). From these studies, there is consensus that it is a time-dependent process that starts with the development of a susceptibility to smoking (U.S. Department of Health, Education and Welfare, 1964). A nonsmoker is considered susceptible once he or she has formed attitudes and beliefs about the utility of smoking. It is this susceptibility to smoking, which occurs prior to any experimentation with cigarettes, that is the focus of many tobacco control approaches. Recent evidence from California in the United States (Evans et al., 1992) supports earlier studies in Great Britain (Russell, 1978) indicating that 70 percent of those who experiment with cigarettes develop an addictive habit, as shown in Figure 11-2 .

Figure 11-2

Different measures of smoking behavior for Californian females, 1992. SOURCE: Pierce et al. (1994a).

Cigarette smoking fits all the criteria for an addictive behavior (U.S. Department of Health and Human Services, 1988). Nicotine has a psychoactive effect that is generally regarded as pleasant. Most individuals who smoke have built up tolerance, and their smoking behavior is highly controlled and compulsive. They have become physically dependent on the drug so that cessation of its use is associated with unpleasant physical withdrawal symptoms. The majority of attempts to quit smoking end in relapse (Gilpin and Pierce, 1994). In the United States, from one-third to one-half of smokers try to quit in any given year; however, over 90 percent of these attempts end in failure, with over half of these quitters relapsing in the first 4 days.

Quitting is not an all-or-nothing event, but a time-dependent process. Studies of successful quitting demonstrate that there are two variables that predict the probability of success: the level of addiction of the smoker and the individual's recent experience or practice in overcoming withdrawal symptoms. Thus, successful quitting of smoking can be likened to successfully completing a long-distance run. It depends on the level of fitness of the runner (read the level of addiction) and the recent practice the runner has had in overcoming the hurdles or difficulties involved in the race. Just as in the race, the smoker with the least chance of success is the one who goes into a quit attempt with a high level of addiction and no recent practice at overcoming withdrawal. The smoker who is better prepared on both of these counts has a sixfold better chance at long-term success in quitting (Farkas et al., 1996a, 1996b).

The Role of Advertising in Increasing Tobacco Consumption

Advertising is used both to attract new consumers to tobacco products (U.S. Department of Health and Human Services, 1994a) and to convince users of alternative or competing products to switch brands (Ray, 1982). Most of the interest in tobacco advertising has focused on whether it attracts new consumers who are adolescents or minors (Albright et al., 1988; Altman et al., 1987; King et al., 1991; Mazis et al., 1992; Schooler and Basil, 1990; Schooler et al., 1991). There is little public support for the encouragement of adolescents and children to start an addictive habit, before they are old enough to appreciate its consequences. The tobacco industry strongly argues that it does not use advertising to promote smoking among minors, although it has produced little evidence to support this argument.

A recent historical analysis of cigarette advertising and the uptake of smoking in the United States examines four periods in history associated with major, different advertising campaigns. 4 Cigarettes were advertised to males in two of these periods and to females in the other two. Strong evidence of the effectiveness of tobacco advertising is shown by the association of the timing of each campaign with a major increase in the uptake of smoking among the targeted gender-specific group (Pierce and Gilpin, 1995).

In recent research, we investigated the association between adolescent responsiveness to tobacco marketing and susceptibility to smoking among those who have never tried a cigarette (Pierce and Gilpin, 1995). We defined an index of receptivity that includes having a favorite cigarette advertisement and being prepared to use an item of clothing that displays a cigarette advertising logo. With this index, we demonstrated that receptivity to advertising is considerably more powerful than exposure to smokers in predicting which never-smokers will be susceptible to initiating smoking.

• Components of a Tobacco Control Program

A viable tobacco control movement requires widespread acceptance of and concern about the health consequences of smoking (U.S. Department of Agriculture, 1985, 1989). Dissemination of information about the health effects of smoking and environmental tobacco smoke is a key element in building a constituency for tobacco control. Health professionals and schools have important roles in this dissemination process.

Societal-level interventions, such as the use of mass media, can also be an important influence. Many tobacco control programs aim to reconstruct societal norms and rules to reduce the likelihood that smoking behavior will be associated with positive social benefits. Tobacco control seeks to influence the price of cigarettes, limit the access of the young, and encourage places where nonsmokers will be protected from the harmful effects of environmental tobacco smoke. In most successful programs, the use of the mass media has been crucial to these efforts (Pierce et al., 1990, 1994a; Flynn et al., 1992; Farquhar et al., 1977). One strategy has been to use paid counteradvertising and other forms of social marketing.

This section examines the various components of a tobacco control program, including the implementation of policies to restrict advertising, efforts to influence beliefs about the health consequences of smoking and environmental tobacco smoke, the role of health professionals, school-based smoking prevention programs, the use of cigarette pricing for tobacco control, efforts to control access by minors, use of mass media for counteradvertising, and the role of restrictions on smoking behavior.

The Implementation of Policies to Restrict Advertising

Advertising bans and their impact on tobacco consumption and smoking uptake.

A number of approaches to restricting tobacco marketing have been tried. The first approach undertaken in the United States was to ban tobacco advertising from the broadcast media (U.S. Department of Health and Human Services, 1989). A number of other countries have further restricted the rights of the tobacco companies to advertise, extending the ban to all print media as well.

In the United States, the ban on tobacco advertising in the broadcast media took effect in early 1971 (Whiteside, 1971). The impact of this ban on per capita cigarette consumption is shown in Figure 11-3 . From 1900 through the release of the first Surgeon General's report on smoking and health in 1964, per capita consumption of cigarettes in the United States increased almost every year, from a level of 54 cigarettes per capita in 1900 to 4,345 in 1963. Declines occurred in 1964 and again in each year from 1967 through 1970, the years of television counteradvertising. The consistent annual decline in per capita consumption started in 1973 (U.S. Department of Health and Human Services, 1989).

Figure 11-3

Adult per capita cigarette consumption and major smoking and health events: United States, 1900-1986. SOURCES: U.S. Department of Agriculture(1987); U.S. Department of Health and Human Services (1989).

For boys and girls aged 10 through 20, the first consistent decline in smoking initiation started in 1973, also approximately 2 years after the broadcast advertising ban. Before 1973, the incidence of smoking initiation among girls had sharply increased, a rise associated with the strong tobacco advertising campaign targeting women noted above. Between 1973 and 1978, the incidence rate among boys declined by approximately 25 percent and among girls by approximately 10 percent (Gilpin et al., 1994).

Can we claim that the broadcast advertising ban rather than some other contextual change was responsible for these declines in smoking uptake among minors? A plausible answer is that the broadcast advertising ban had a delayed effect on both incidence and consumption. 5 This answer relies on the assumption that advertising works by building a susceptibility to smoking among nonsmokers and by reducing the susceptibility to quitting among smokers. An end to this stimulation of demand could thus be expected to have a delayed effect on consumption, just as demand that has already been stimulated will be reflected only in consumption over time.

Reaction of the Tobacco Industry to Restrictions on Advertising

To investigate the reaction of the industry to the 1971 broadcast media advertising ban, we look at trends in marketing expenditures before and after the introduction of the ban. During the 1960s, tobacco marketing expenditures were relatively stable, exhibiting a 26 percent increase over the decade. The introduction of the advertising ban in the 1970s was not associated with a decline in industry marketing expenditures. Indeed, quite the opposite effect was observed. With rapid annual increases, the marketing budget doubled in a 7-year period. It doubled again over the next 4 years, so that in 1981, a total of $1.5 billion was being spent on tobacco marketing. By 1988 that total had doubled again. In the next 3 years, expenditures increased further by 42 percent, and there is no indication of a slackening of this almost exponential increase in annual marketing expenditures.

The change in the pattern of marketing expenditures that has occurred since the broadcast media advertising ban is of particular importance. During the 1960s, when there were relatively stable marketing expenditures, the industry allocated around 90 percent of its marketing budget to advertising. By 1991, 45 percent of the total marketing budget was being spent on promotional items labeled as coupons, retail value-added, or specialty item distribution. This represented over $2 billion and was equivalent to the total marketing expenditure in 1984.

In other countries, as in the United States, the introduction of restrictions on advertising has been accompanied by major budgetary increases in marketing and the introduction of new ways to promote tobacco products. In each country, the industry has developed creative ways to circumvent the ban on advertising. For example, there is considerable evidence that sponsorship of sporting events has been an excellent medium by which the industry has been able to promote its brands on television, even with the existence of the advertising ban (Blum, 1991).

The Importance of Beliefs About Health Consequences of Smoking and Environmental Tobacco Smoke

Shifts in beliefs about the health consequences of smoking.

In the 1920s, the health consequences of smoking were not well known. An example of this is given by a dean of medicine at a university who recounted the story of being awakened in the middle of the night so that he could see "a case that you will never see again in your career." It turned out to be a patient with lung cancer. Nor were attitudes about smoking and health much different in the 1930s, when the U.S. population was told, through tobacco advertisements, that "more doctors smoke Camels."

The major studies that were to prove the strong association of smoking with disease were initiated in the 1940s, with the first results being published in 1950. The famous Readers Digest article entitled "Cancer by the Carton" was published in 1953, and the health consequences of smoking appeared on the front covers of major news magazines in that year. Shortly thereafter, a population survey indicated that 41 percent of the U.S. population believed that smoking causes lung cancer, a figure that had increased to 50 percent by 1957. A tobacco industry counteroffensive appeared to lower the proportion to 44 percent in 1958. The release of the first Surgeon General's report on smoking and health (U.S. Department of Health and Human Services, 1964) increased the proportion of believers to two-thirds of the population, including over half the current smokers in 1964. The Surgeon General's report marked the start of the official public health campaign against smoking in the United States. In the years since then, the proportion of smokers who believe that smoking causes lung cancer has increased to around 90 percent (U.S. Department of Health and Human Services, 1989).

The late 1960s saw the publication of the first data suggesting that nonsmokers who were exposed to environmental tobacco smoke might also have an increased rate of lung cancer. By 1974, some 30 percent of U.S. adult smokers believed in this association. This level increased gradually over the next 4 years. The release of the Surgeon General's report on the issue in 1986 appeared to effect an increase in the proportion of believers to over 80 percent.

Trends in Initiation and Cessation

Prior to the official start of the public health campaign against smoking in 1964, the dissemination of information about the health consequences of smoking was the only anti-smoking intervention. Accordingly, we are able to assess its importance for smoking behavior by studying trends in initiation and cessation of smoking over the period.

Prior to the 1940s, cessation of smoking was rare among those who had become addicted. The incidence of cessation, defined as the number of smokers who quit successfully in a given year, started to increase among all birth cohorts of both men and women in the mid-1940s (U.S. Department of Health and Human Services, 1994b). For both genders, the incidence pattern can be described as a positively accelerating trend through the 1950s to 1970, so that between 1950 and 1964, the annual rate of successful cessation increased at least threefold among all older birth cohorts.

Changes in beliefs about the health consequences of smoking also appear to have had an effect on the incidence of the uptake of smoking, but in the 1950s and 1960s only among men over the age of 20 (U.S. Department of Health and Human Services, 1992). After the mid-1960s, there was a dramatic decline in uptake among all adults, so that by the mid-1980s very few nonsmoking adults in the United States were starting to smoke. This suggests that the message about the long-term health consequences of smoking is not very salient for children and adolescents, although it is for adults (Gilpin et al., 1994).

The Role of Health Professionals in Tobacco Control

The strong justification for spending public monies to undertake tobacco control comes from the enormous health consequences that result from regular use of tobacco. The central role of health professionals in conveying those consequences to the public has been well documented (U.S. Department of Health and Human Services, 1994b). Thus it is essential that health professions be the cornerstone of a tobacco control movement (although see the discussion of this issue by Prokhorov in this volume). The tobacco industry recognized the importance of physicians in the 1930s when it advertised that more doctors smoked Camels, and later advertised that dentists advised the public to smoke Viceroys.

In every country that has seen a decline in smoking prevalence, the first group that has reduced its prevalence is the medical profession. It would appear that physicians are very important role models for health behavior in society. If physicians smoke, the population is less likely to be concerned about the health hazards of smoking. In the United States, some 60 percent of physicians smoked in 1949. By 1964, some 30 percent of doctors smoked. Today, it is estimated that less than 6 percent of physicians in the United States smoke. Physicians' rate of quitting appears similar to that of other highly educated groups in society. This rapid decline in smoking prevalence among the medical profession has been brought about by the virtual elimination of smoking among medical students (U.S. Department of Health and Human Services, 1994b). Indeed, the trends in smoking among physicians, and particularly among medical students, can be used as a barometer for the level of tobacco control activity in a country.

In addition to being role models, health professionals can play an important part in convincing smokers to quit and nonsmokers not to start smoking, as shown in Table 11-2 . Over two-thirds of smokers visit a physician each year in the United States. While they may seek care for a specific problem not be related to smoking, the physician has an opportunity, and many would say a duty, to counsel them about preventing future disease. 6 The physician's role is to help reinforce the smoker's motivation to quit and to provide support on each subsequent visit. Unfortunately, physicians are much more likely to counsel a patient on smoking if the patient presents them with a problem that could be smoking related. Efforts to increase this kind of activity have not yet been able to generate widespread physician involvement in assisting patients to quit.

Other Progress Toward Successful Cessation of Smoking.

School-Based Smoking Prevention Programs

Since the 1964 Surgeon General's report started the official public health campaign against smoking, prevention of the uptake of smoking has been recognized as crucial to major long-term reductions in prevalence among the population (U.S. Department of Health and Human Services, 1964). To this end, the 1964 Surgeon General's report advocated the conduct of programs directed at educating high school and college students about the health hazards of smoking. Early programs assumed that young people who started to smoke had somehow either not been exposed to or not paid attention to information on the health effects of smoking. Efforts were concentrated on presenting the information as vividly as possible; educational aids included films, posters, and pamphlets, which focused on arousing fear of the long-term effects of smoking. However, by the late 1970s there was general agreement that these smoking prevention programs had little impact on the probability that an adolescent would become a smoker (Goodstadt, 1978; Thompson, 1978). An alternative approach was based on the observation that those adolescents who did start smoking were those who were not performing as well at school. Programs implementing this approach aimed to change student attitudes toward school, family, or community. However, long-term evaluations failed to demonstrate any impact on reducing adolescent smoking.

Both of the above approaches have given way to a focus on the social environment as a major determinant of behavior. Programs with this focus emphasize developing community norms, as well as individual skills, to identify and resist social influences to smoke. While there has been considerable variation on this theme, usual components of these programs have included training in identifying and interpreting tobacco marketing messages; practice in saying ''no" to peer pressures to smoke: and training that fosters general assertiveness, decision-making, and communication skills. In addition, these programs have sought to present the negative short-term consequences of smoking and the socially salient advantages of being a nonsmoker. 7

These school-based approaches have been extensively researched through a series of randomized controlled trials, which appear to have been successful in the short term. However, these lower initiation rates had completely disappeared by the time the intervention groups had reached adulthood. The conclusion from these studies is that school-based programs can be very effective in the short term, but we should not expect to be able to inoculate students against ubiquitous social influences toward smoking by providing a few classes at an important point in their development. In order for these school interventions to have long-term impact on the uptake of smoking, they need to be supported by other tobacco control efforts that reduce the environmental influences promoting smoking.

Use of Cigarette Pricing for Tobacco Control

The price of a commodity is known to affect its consumption in the marketplace. Price has not been used as a tool of competition among the cigarette manufacturers, but there have been price or tax changes on a number of occasions, offering the opportunity to assess the impact of price in tobacco control efforts.

During the years before the United States entered World War I, pictures of the war tended to show soldiers relaxing after a difficult time at the front, frequently smoking cigarettes. Cigarettes became viewed as an aide to help soldiers endure the strain, "to soothe the nerves and to deaden the loneliness," in the words of a reporter of the time. In addition, General Pershing became an ardent advocate for the provision of free cigarettes to the troops. The tobacco industry was fond of quoting him: "I'll tell you what we need to win the war: we need cigarettes just as much as bullets." As a result, the Red Cross became one of many associations raising money to dispatch free cigarettes to allied soldiers. Across the United States, soldiers received free chewing gum, toothpaste, and cigarettes.

There was a marked increase in the incidence of initiation of smoking among males aged 16 through 20 in 1917 and 1918 (Pierce and Gilpin, 1995). This increased uptake rate among nonsmokers disappeared when the free cigarettes were discontinued with demobilization. The war years were also associated with a major increase in per capita consumption of cigarettes. However, unlike initiation rates, the level of consumption did not decrease to previous levels after the end of the war. The most likely interpretation is that the young men who started to smoke because of the availability of free cigarettes during the war were unable or unwilling to quit when they returned to civilian life.

This war phenomenon was repeated during World War II. Free cigarettes were again available to the troops. There was a marked increase in the incidence of initiation among young men (Kennett, 1987). With demobilization, the incidence level declined to what it had been previously; again, however, there was no similar return to prewar levels in per capita consumption.

Numerous studies indicate that the demand for cigarettes generally decreases with increasing price; an example is shown in Figure 11-4 . Economists use the price elasticity of demand for cigarettes to estimate the impact of an increased excise tax on consumption. 8 These models suggest that a price elasticity of between -0.2 and -1.3 has existed in the United States and member countries of the Organization for Economic Cooperation and Development over the past 20 years (U.S. Department of Health and Human Services, 1989). Thus, a 10 percent increase in price could be expected to produce a reduction in consumption of between 2 and 13 percent. Variation in the level of response to a price increase may be associated with the amount of public agenda setting that accompanies the price increase. For example, in California in 1988, a 25-cent increase in the excise tax led to a 9-cent increase in price, which was associated with a 13 percent decrease in consumption. This tax increase was the subject of a major advertising campaign and an initiative voted on in a general election. In contrast, in 1991 a 4-cent increase in tax was subsumed into a major price increase by the cigarette industry. There was no public discussion of the tax or price increase and no identifiable effect on consumption.

Figure 11-4

Cigarette consumption and real price: United Kingdom, 1971-1992. SOURCE: Townsend (1988).

From the mid-1980s through 1993 in the United States, the tobacco industry introduced generic "no-name" cigarettes at a lower price while it systematically increased the price of its premium brand products. Thus, the smokers who converted to generic cigarettes could be assumed to be price sensitive. Heavier smokers, older women, and those with lower disposable incomes were much more likely to switch to generic brands. Importantly, many young people preferred to smoke the more expensive premium brands, even though the price differential was as high as 30 percent. This suggests that the price of cigarettes in the United States does not represent a recognizable drain on disposable income for many new smokers during the early years of the uptake process. Presumably, the daily consumption level is low during these years, and the smokers are less addicted and better able to adjust their consumption level to their budget. Teenagers are price sensitive, though, as was demonstrated with the reduction in adolescent smoking following the very large tax increases in the late 1980s (Ferrence et al., 1991).

Efforts to Control Access By Minors

The first major efforts to control access to cigarettes by minors occurred in the United States in the late 1890s with the formation of the anti-cigarette league. 9 By 1910, the league had been successful in introducing legislation banning the sale of cigarettes to minors in many states.

Today, all states have laws prohibiting the sale of cigarettes to persons under the age of 18 (U.S. Department of Health and Human Services, 1994a). Many surveys have demonstrated that these laws have overwhelming public support among adults (both smokers and nonsmokers). However, one survey indicated that 80 percent of adults thought it was either very easy or somewhat easy for teenagers to buy cigarettes near where they live. In 1993, 40 percent of Californian 12 to 13 year olds reported that it would be easy for them to get cigarettes if they wanted to (Pierce et al., 1994a). By age 16, 85 percent of adolescents said it was easy to get cigarettes.

Of those who have bought cigarettes, 35 percent have bought from a vending machine, 55 percent from a supermarket, and 94 percent from a small convenience store such as a 7-Eleven. Worse still, Californian small store owners break open packs and sell single cigarettes to adolescents. This action breaks four different laws (Klonoff et al., 1994; Pierce et al., 1994a). However, it is being done with impunity, since chances of being prosecuted are almost nonexistent. While all states have legislation banning cigarette sales to minors, small business owners have significant financial incentives to ignore the law, and police do not see enforcement of this law as a priority issue. Thus, we have no experience with providing major barriers to access to cigarettes by minors.

Use of Mass Media for Counteradvertising

The major tobacco control success stories involving the mass media have been in encouraging people to stop smoking. The first use of the mass media to counter the tobacco industry's marketing messages occurred between 1967 and 1970, when a young attorney successfully argued that the Fairness Doctrine applied to cigarette advertising (U.S. Department of Health and Human Services, 1989). Over this period, television stations were required to show anti-smoking commercials as public service announcements if they allowed paid cigarette advertisements. Although there was a plan for a 1 to 3 ratio, the effective ratio of anti-smoking messages to cigarette ads was 1 to 12. Nevertheless, this period was the first during which there was a sustained decline in per capita consumption (see Figure 11-5 ). The requirement for anti-smoking messages is widely believed to have provided the disincentive for the tobacco industry to conduct a vigorous fight against the broadcast media advertising ban. Following on this success, large-scale paid media campaigns have been undertaken in Australia and in California, with published evaluations demonstrating a major impact on smoking prevalence (Pierce et al., 1990, 1994a).

Figure 11-5

Adult per capita cigarette consumption: United States, 1950-1979. SOURCE: U.S. Department of Agriculture (1985, 1989).

Not all mass media campaigns have been effective. The media are, after all, merely channels through which people receive information and entertainment. It has been estimated that there are up to 1,500 persuasive messages each day aimed at any given individual in the United States. Advertisers have closely studied behavior and know where to put a message to maximize our chances of being exposed to it. We are not passive as an audience, however. We actively seek some messages, avoid others, and let the majority flow by us, paying attention to one here and there that catches our attention and interest.

The amount of money that needs to be spent to ensure that a target audience is exposed to and pays attention to a given message depends on how the message is packaged. To minimize the money needed for mass media campaigns, tobacco control programs have sought to produce television advertisements that viewers will remember forever after seeing them once. However, what is recalled is a version of the original message. One cannot predict how the media message will be processed to fit the individual's experience or how it will relate to other salient messages the person has received. Powerful messages focusing on the health consequences of smoking appear to have been very important in promoting a community atmosphere that encourages smokers to quit. In addition, many smokers think about quitting when they see such advertisements and will take an immediate action, such as picking up the telephone and asking for help in quitting. This window of willingness to change can be quite brief, and the emotional impact that demands an action response to the message is generally gone in a few days. Linking such messages with telephone counseling help lines is an effective way of extending the life of a message (Pierce et al., 1992; Zhu et al., 1996). If assistance in quitting is quickly available to these responding smokers, it becomes possible to double the rate of successful quitting.

Another mass media approach that has been used is to challenge the credibility of the tobacco industry. This approach, which has been used extensively in California, argues that the industry needs to present itself in a very positive light to sustain its influence on legislators and others in thwarting tobacco control efforts. Negative advertising on the image of the industry is seen as one means of reinforcing community norms against smoking. These norms appear to play an important role in influencing smokers' willingness to attempt to quit and in influencing nonsmokers' willingness to experiment with smoking (Pierce et al., 1993, 1994a).

The third area in which the mass media have been extensively used is in advertising to prevent the uptake of smoking. Typically, tobacco control programs have emphasized images that are salient to confirmed nonsmokers. Unfortunately, there are very few success stories in this area. The tobacco industry typically outspends these campaigns by orders of magnitude as high as 25 to 30 times. Furthermore, the industry, in conjunction with advertisers, has carefully honed its messages and their presentation so that it is virtually impossible for tobacco control programs to win the image war with adolescents. Recall that adolescents did not respond well to messages about long-term health effects of smoking (U.S. Department of Health and Human Services 1989, 1994a). They appear to qualify their willingness to experiment with the notion that they will quit before they suffer health problems. The inability of tobacco control programs to influence significantly the proportion of adolescents who start smoking is the major failing of the field to the present time. In recent years, adolescent smoking appears to have been increasing in the United States (Gilpin and Pierce, 1996).

Thus tobacco control efforts urgently need to develop a new approach for adolescents. The advertising message that is most successful is the one that ties the product to the values of the target group. The "cool," "fun," and ''relaxing" image has been staked out extremely well by the industry. However, this industry message may be vulnerable in the area of "lack of control." Many adolescent smokers report considerable difficulty in trying to quit, and for this age group in particular, such a loss of control could serve as an effective disincentive to start smoking.

The Role of Restrictions on Smoking Behavior

One of the major goals of tobacco control is to protect nonsmokers from the harmful effects of environmental tobacco smoke. As discussed earlier, the majority of the population in the United States believes that environmental tobacco smoke is harmful to nonsmokers. When the U.S. Environmental Protection Agency (1992) released its report concluding that environmental tobacco smoke is a carcinogen in the same category as asbestos, a significant additional impetus was added to the drive for clean indoor air legislation. We have a great deal of experience in developing public health legislation to protect the innocent, and rapid changes in this regard are being observed across the United States. In California, for example, in 1993, two-thirds of workers reported having a completely smoke-free workplace, and over 90 percent reported having a smoke-free work area. Since 1994, California has had statewide legislation that mandates smoke-free workplaces for all workers in the state.

There is considerable evidence that smoke-free workplaces lead to a reduction in the smoking level of heavy smokers (Borland et al., 1992). The evidence suggests that California's worksite policies assist heavy smokers in reducing their level of addiction, which in turn makes it easier for them to quit successfully in the future (Farkas et al., 1996a, 1996b; Gottlieb et al., 1990; Petersen et al., 1988; Pierce et al., 1994a; Stillman et al., 1990; Woodruff et al., 1993).

• Application of these Lessons to the New Independent States

How should the tobacco control movement in the NIS react to the significant new threat posed by the introduction of the transnational tobacco companies into their economic system? Recommendations on how to react depend on an assessment of the strength of support for tobacco control in the region. An analysis of smoking prevalence suggests that Eastern Europe may be in a position similar to that of the United States in the mid-1950s. The 1955 national survey in the United States reported a 50 percent prevalence rate for men and a 23 percent prevalence rate for women (Haenszel et al., 1955). As in the United States of that time, it would appear that the more highly educated in the NIS may have started to quit smoking. If the pattern of diffusion of cigarette smoking through society is the same as in Western countries, the more highly educated will have been the first to start smoking and the first to start to quit. The data indicate that in the United States during the mid-1980s, more highly educated men smoked at half the rate of the less well educated (Pierce et al., 1989).

However, in the NIS these promising indicators need to be balanced with other data, such as research suggesting that over half the male medical students in Eastern Europe smoke. As noted earlier, medical students in the United States were the most responsive to the start of the official campaign against smoking in 1964. In the 15 years from 1964 to 1980, smoking prevalence among medical students decreased to less than 2 percent (U.S. Department of Health and Human Services, 1994b). This decline is unprecedented in the smoking literature. It also suggests that the willingness of future physicians to start smoking is a strong statement about the medical community's tolerance of smoking behavior. A high level of tolerance can only be interpreted as a lack of strong beliefs about the health consequences of smoking among the profession.

The tobacco control movement clearly has had some legitimacy within some communities in the NIS. Recently, both the Moscow City Council and the Russian Parliament were prepared to ban cigarette advertising, which would have extended an earlier ban implemented by the Soviets in 1980. However, the willingness of legislators to promote tobacco control goals must be expected to change with the entry of the transnational tobacco companies into the economy. There is considerable evidence in the United States that the distribution of tobacco industry largesse is sufficient to weaken the enthusiasm and resolve of most legislators (Moore et al., 1994; Glantz and Begay, 1994). The tobacco industry often represents its expansion-related activities as very important to the local economy. The power of this argument, possibly supported by industry contributions to key members, has already been attested to by the unwillingness of the Russian Press Ministry to enforce legislation banning tobacco advertising.

Therefore, tobacco control would appear to have at best a tenuous grip within Eastern European communities. The initial goal of developing a tobacco control movement must be to build support among health professionals, as well as the public, for tobacco control.

In the United States, the building of a strong tobacco control coalition took over 15 years. The health effects of tobacco were plenary topics at meetings of cancer specialists in the late 1940s. While these efforts continued to be widespread through the 1950s, it was not until the first Surgeon General's report (U.S. Department of Health and Human Services, 1964) that there was a clear indication of the acceptance of the gravity of the issue by the profession. The length of this process was determined by the continual need to bolster the evidence linking smoking with disease. In most countries, there is a need to document the link between smoking and disease, both locally and internationally, in order to build broad-based support for tobacco control.

There is some evidence from Australia that the government health department's early use of strong television commercials on the health consequences of smoking had the effect of galvanizing the medical community toward tobacco control. Given that Eastern European government authorities have shown a willingness to try to ban cigarette advertising (although not to enforce such a ban), they may be willing to allow public service announcements presenting the health side of the issue. The most effective counteradvertising focusing on health impacts includes testimonials from famous actors dying of lung cancer (from the United States) and a commercial that has proved extremely successful in crossing cultural boundaries (the "Sponge" commercial, developed in Australia in 1977) (Pierce et al., 1986).

Another mass media theme that might be effective would be to challenge the apparent perception among Eastern European youth that most young Americans smoke. One way to do this might be to use current anti-smoking advertising from the United States, with voice-overs addressing the misperception.

A key approach, given the current state of the economies in the region, would be to focus on the price of cigarettes. There does appear to be a price inflation level that is acceptable to consumers. The pricing strategy that has worked best for the industry has been to increase the price of cigarettes by small increments at regular intervals. Whenever there is an excise tax, the industry appears to reduce the amount of its own price increase. However, as discussed earlier, pricing can be an effective component of a tobacco control strategy. At the same time, it is important to note that if the increase is too large, it runs the risk of fostering a black market in the area, as it has appeared to do in Canada in recent years.

The advantages of a taxation policy can be maximized if, say, 10 percent of the revenues can be earmarked for use in tobacco control, with the rest being used to assist in other needy areas of the health system or even placed in the general revenues. Both Victoria, Australia, and California are examples of how a creative tax policy has supported the development of an aggressive tobacco control movement (The Catalonia Declaration, 1995).

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1. In the United States among younger adults, the trend has been for an elimination of the gender difference in smoking, and adolescent smoking levels appear to have leveled off after a period of decline in the 1980s. The most recent national survey, in 1993, indicated that smoking prevalence increased from less than 1 percent among 12-year-olds, to 7 percent among 13- to 14-year-olds, to 18 percent among 15- to 17-year-olds, and to 29 percent among 18- to 22-year-olds.

2. The companies have increased capacity, although they will need to invest heavily in modernizing and repairing equipment, as well as rebuilding supply lines for the necessary raw materials (e.g., filters, papers).

3. On this last issue of profitability per product output, tobacco analyst Manuel Goldman reports that Phillip Morris earned $15.82 per 1,000 cigarettes sold in the United States in 1993, compared with $6.03 per 1,000 in the European Economic Community and a low $2.29 per 1,000 in the former Soviet Bloc countries.

4. The analysis focuses on four periods. During the decade of the 1880s, competing advertising and marketing strategies were focused on men, and there was a rapid sixfold increase in the consumption of cigarettes from a very low base, with no increase among women (Haenszel et al.. 1955). The second advertising period related to the launch of Camel cigarettes by RJ Reynolds in 1912, again targeting men and with the same result. The third unique period of cigarette advertising began in 1926, with advertising targeted to women (Tennant, 1950; Whelan, 1984); this campaign resulted in a threefold increase in the incidence of smoking initiation among females aged 10 to 25. The fourth unique period in tobacco advertising started with the launch of women's brands of cigarettes in 1967 (Albright, 1988; Ernster, 1985); this campaign occurred at the same time as a major counteradvertising campaign on the health consequences of smoking (U.S. Department of Health. Education, and Welfare, 1964), but also appeared very successful among the young and less educated. These data suggest that tobacco marketing plays an important role in developing attitudes and beliefs among nonsmokers that make them more likely to start smoking. Further details of the analysis are available from the author.

5. The major alternative explanation attributes the decline to the beginning of the nonsmokers' rights movement, which was reflected in the passage of state and local laws restricting smoking in public places and worksites. However, in 1974, one year into the decline, only three states had enacted even minimal laws restricting smoking. There is no published evidence to suggest that such minimal restrictions have any impact on cigarette consumption. The evidence that smoking restrictions change smoking behavior relates to the implementation of smoke-free work areas. However, worksite smoking restrictions did not appear in any state until 1975. Thus such legislation cannot explain the marked decline in overall cigarette consumption and smoking uptake that began in 1973.

6. Research shows that to facilitate this counseling, the medical chart should indicate smoking status as a vital sign. The reasons for quitting should be reviewed with the smoker at each visit. If the smoker is ready to quit, the physician should consider whether a nicotine substitute would be useful and refer to the smoker for behavioral counseling on how to quit successfully. Such total involvement in promoting quitting is necessary if physicians are to be effective agents of tobacco control.

7. In addition to program content, the following elements can be identified as essential to effective school-based smoking prevention: (1) the frequency of the program should be at least five sessions per year, incorporated into the regular curricula of at least 2 years from grades 6 through 8: (2) students should participate in the presentation and delivery of the program; (3) parental involvement should be encouraged; (4) teachers should be given specific training; and (5) the program content should be socially and culturally acceptable to the community.

8. Elasticity is defined as the percentage change in the quantity of cigarettes demanded, divided by the percentage change in price. Data on both consumption and average price of cigarettes are available on an annual basis in the United States at the state level, and many different econometric methods have been used to identify the price elasticity. Similar analyses have been completed on data available from member countries of the Organization for Economic Cooperation and Development.

9. While some have interpreted this movement as a precursor of the temperance movement, an alternative explanation is that it grew in popularity because of the type of advertising the tobacco industry undertook in the early years. Through the 1870s and 1880s, a picture of a scantily clad woman was included with each pack of cigarettes. This use of "soft pornography" was reported to have young boys scrambling after cigarette packs. There was widespread consternation over what was perceived to be a powerful corrupting influence of the cigarette industry on boys. The first editorial on the subject appeared in the New York Times in 1879, and as concern grew, strong public statements were issued by eminent educational leaders of the day.

• Cite this Page National Research Council (US) Committee on Population; Bobadilla JL, Costello CA, Mitchell F, editors. Premature Death in the New Independent States. Washington (DC): National Academies Press (US); 1997. 11, Tobacco Control Policy Strategies: Lessons from Western Developed Countries.
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