The Cigarette Century

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In 1900, the total consumption of cigarettes in the United States was 2.5 billion (U.S. Department of Health and Human Services, 1989b). Major advances in agriculture, manufacturing, and marketing, the Great Depression, two world wars, and changing cultural norms led to a marked increase in consumption. Total consumption increased from 2.5 billion in 1900 to 631.5 billion in 1980 (U.S. Department of Health and Human Services, 1989b). Cigarette consumption peaked in 1981 (640 billion) but declined in 1987 to an estimated 574 billion, the equivalent of more than 6 trillion doses of nicotine (Jones, 1987). An estimated 430 billion cigarettes were consumed in 2000 (U.S. Department of Agriculture, 2001).

Early Warning Signs

The decline in per capita cigarette consumption during the latter part of the 20th century was due in large part to growing concerns about the adverse health consequences of cigarette smoking and the growth of the anti-smoking movement. Early case reports and case studies called attention to the likely role of smoking and chewing tobacco as a cause of cancer (Samet, 2001). Key initial observations were made in epidemiological studies carried out to examine changing patterns of disease in the 20th century, particularly the dramatic rise in lung cancer, coronary heart disease, and chronic obstructive lung disease (Samet, 2001). Dr. Luther Terry, who served as Surgeon General of the U.S. Public Health Service from 1961 to 1965, noted that the landmark 1964 Sur-

geon General's Advisory Committee Report, Smoking and Health, was the culmination of growing scientific concern over a period of more than 25 years (Terry, 1983). The report also recognized the "habitual" nature of tobacco use but stopped short of recognizing tobacco use as an addiction.

The Leading Preventable Cause of Death

According to the Centers for Disease Control and Prevention (2002), tobacco causes approximately 440,000 deaths in the United States each year, making it the leading preventable cause of death. Cigarette smoking accounts for about 30% of all cancer deaths (87% of lung cancers) and is a major cause of heart disease, cerebrovascular disease, chronic bronchitis, and emphysema (American Cancer Society [ACS], 2003). Tobacco use costs the U.S. economy nearly $150 billion in health costs and lost productivity each year (American Lung Association [ALA], 2003). Smoking-related diseases cost the Medicare system $20.5 billion and Medicaid, the federal insurance program for the poor, $17 billion in 1997 (American Lung Association, 2003).

Nicotine Addiction

It was not until 1988 that the addictive nature of cigarette smoking was formally recognized. Major conclusions from the 1988 Surgeon General's report (U.S. Department of Health and Human Services, 1988) were as follows: (1) Cigarettes and other forms of tobacco are addicting; (2) nicotine is the drug in tobacco that causes addiction; and (3) the pharmacological and behavioral processes that determine tobacco addiction are similar to those that determine addiction to drugs such as heroin and cocaine.

The Anti-Smoking Movement

Key events that contributed to the decline in the per capita consumption of cigarettes in the United States were the banning of cigarette advertisements on the air waves, increases in the excise tax on cigarettes, and evidence that secondhand smoke harms nonsmokers. Mounting evidence of the dangers of environmental tobacco smoke (ETS; Environmental Protection Agency [EPA], 1992) served as a stimulus to advocate for smoke-free environments, and to support policies and legislation to protect young people and adults from secondhand smoke.

The EPA report officially categorized ETS as a known human carcinogen, placing ETS in the Class A (most dangerous) category reserved for only a few toxic substances, including radon, benzene, and asbestos (Carlson, 1997). The report also identified ETS as a cause of serious respiratory illness in children, including bronchitis, asthmatic episodes, new cases of asthma, and sudden infant death syndrome (SIDS). Nonsmokers exposed to ETS at work were 39% more likely to get lung cancer than nonexposed, nonsmoking workers (Carlson, 1997).

A Worldwide Problem

While tobacco consumption declined in the United States, global tobacco consumption increased, particularly in developing countries. According to the World Health Organization (WHO; 1999), cigarette smoking in developing countries increased at a rate of about 3.4% per year. Worldwide tobacco-related deaths are expected to increase from about 4 million per year in 1999 to about 10 million per year by the 2030s, with 70% of those deaths occurring in developing nations. This is a higher death toll than is expected from malaria, maternal and major childhood conditions, and tuberculosis combined (American Cancer Society, 2003).

Big Tobacco

In response to mounting health concerns and declining demand, Big Tobacco spared little expense to fend off criticism and to assuage public concern. Cigarette advertising expenditures in the United States were estimated at more than $2 billion for 1985—twice the annual expenditures of the National Cancer Institute (American Cancer Society, 1986). In 1999, the five largest cigarette manufacturers in the United States spent $8.24 billion on advertising and promotional expenditures (Federal Trade Commission, 2001), with additional expenditures for promoting and marketing cigarettes abroad.

Safe Cigarettes

Big Tobacco used its vast resources to keep alive debates about whether cigarette smoking is harmful or addictive, and whether secondhand smoke poses a danger to nonsmokers. Tobacco companies also responded to mounting health concerns by designing and marketing safer cigarettes. They introduced cigarette filters, menthol flavoring, light and ultralight brands, and, most recently, high technology cigarettes, such as Omni, Advance, Eclipse, Accord, Quest, and, soon to be released, the Phillip Morris product, SCOR. Innovations in manufacturing and design were heralded by expensive marketing campaigns, fostering the impression that new and improved cigarettes offered satisfaction, flavor, and peace of mind (Burns & Benowitz, 2001). Today, more than 80% of the cigarettes sold in the United States are of the low-tar and low-nicotine variety (Myers, 2002), and most smokers believe light and ultralight cigarettes are less harmful than regular cigarettes (Giovino et al., 1996).

Smokers are wrong about the safety of low-tar and low-nicotine cigarettes (Burns & Benowitz, 2001), and the new high-technology cigarettes similarly are likely to fall far short of the mark (Slade, Connolly, & Lymperis, 2002). A 20-year study by the American Cancer Society showed that smokers who smoked light and ultralight cigarettes experienced the same rates of lung cancer and heart disease as smokers who smoked regular cigarettes (Burns & Benowitz, 2001). This was due in part to compensatory smoking patterns by smokers seeking to regulate nicotine intake, the elastic nature of newly designed cigarettes that facilitate compensation, differences in machine-measured and biologically measured yields of tar and nicotine, and deceptive marketing and labeling practices (Kozlowski, O'Connor, & Sweeney, 2001).

The tactic of heralding new cigarette designs by sophisticated marketing campaigns proved equally effective with youthful smokers. R. J. Reynolds carried out a highly successful campaign in the 1980s and 1990s to promote the Camel brand among young people. The combination of a less harsh cigarette, sweetened to appeal to youthful tastes, and the Smooth Moves Joe Camel advertising campaign led to demonstrated share growth, moving progressively from 2.5% of the market in 1987, to 4.0% in 1988, to 4.4% in 1989, and to 6.1% in 1990 (Wayne & Connolly, 2002). Ultimately, Camel became one of the three leading brands, along with Marlboro and Newport, which today account for more than 80% of adolescent smoking.

The Challenge Ahead

By the end of the 20th century, the stage was set for a life or death struggle between Big Tobacco and the public health community over the fate of the next generation of smokers. Both parties are aware that most adults begin smoking as youth, and if people do not start smoking by their late teens, they are unlikely to smoke as adults (Lynch & Bonnie, 1994). Big Tobacco must recruit another generation of young people to stay in business, and the public health community must thwart its efforts.

While smoking rates in the United States have declined since the mid-1960s, much work remains. The United States failed to meet the Healthy People 2000 goals for tobacco prevention and control, and smoking initiation rates among middle and high school students increased dramatically in the 1990s (Bonnie, 2001). In 1996, more than 1.8 million people became daily smokers in the United States, two-thirds of them (1.2 million) under age 18 (Bonnie, 2001). Rates of cigarette smoking and use of other forms of tobacco also increased among college students (18-21 years old), the youngest legal target for tobacco advertising dollars (Rigotti, Lee, & Wechsler, 2000). According to a recent survey, 46% of college students reported using tobacco products in the past year, and more than 25% of them started smoking for the first time while in college (Wechsler, Kelley, Seibring, Kuo, & Rigotti, 2001).

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