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Worldwide, 1.1 billion people use tobacco products, primarily cigarettes. An estimated four million die annually as a consequence. By the year 2030, an estimated 1.6 billion will consume tobacco and tobacco’s death toll will have skyrocketed to 10 million per year, making tobacco the leading behavioral cause of preventable premature death throughout the world. Tobacco already claims that dubious distinction in the world’s developed countries (World Health Organization 1997).
The causes of this pandemic of avoidable disease and death are a complex web of physiological, psychological, social, marketing, and policy factors. Social and behavioral scientists of all disciplinary stripes have contributed to identifying and disentangling these factors, although no single model has yet adequately characterized the interactions of these determinants. Social and behavioral scientists have also elucidated important mechanisms by which both private sector and governmental intervention can discourage the initiation of smoking and encourage quitting.
After a brief description of the burden of smoking and how epidemiological science unearthed the principal tobacco-related disease connections, the causes of tobacco consumption are summarized. The eﬀorts of social and behavioral scientists to improve the ability of smokers to quit smoking are then described, including better theoretical characterization of the determinants of quitting success and the development of more eﬀective cessation interventions. Next examined is how social and behavioral scientists have analyzed the eﬀects of selected important tobacco control measures, and thereby contributed to the formulation and implementation of tobacco control programs and policies. Finally, the future contribution of the social and behavioral sciences to dealing with a potentially even more cataclysmic crisis in world health during the twenty-ﬁrst century is considered.
Traditional methods of youth smoking prevention, such as school health education and enforcement of minimum age-of-purchase laws, are only touched on due in part to limited scientiﬁc understanding of how initiation can be eﬀectively discouraged, and due to its coverage elsewhere (Lantz et al. 2000; see Substance Abuse in Adolescents, Prevention of; Smoking Prevention and Smoking Cessation; Health Promotion in Schools).
2. Cigarette Smoking And Disease: Making The Connection
In the major industrialized nations, smoking causes from a sixth to a ﬁfth of all mortality. The two major smoking-related causes of death are lung cancer and coronary heart disease (CHD). In the United States, epidemiologists estimate that smoking accounts for approximately 90 percent of all lung cancer deaths, with lung cancer the leading cancer cause of death in both men and women. Smoking is credited with better than a ﬁfth of CHD deaths. In addition, smoking causes four-ﬁfths of all chronic obstructive pulmonary disease mortality and just under a ﬁfth of all stroke deaths (US Department of Health and Human Services 1989). The exposure of nonsmokers to environmental tobacco smoke is also a cause of disease and death (American Council on Science and Health 1999).
The toll of smoking is proportionately smaller in developing countries, reﬂecting the more recent rise and lesser intensity of smoking to this point. However, projections indicate a future chronic disease epidemic quite comparable to that now experienced in the world’s more aﬄuent nations (World Health Organization 1997).
Although the health hazards of tobacco smoking have been suspected for centuries, serious interest is a twentieth-century phenomenon, coincident with the advent of cigarette smoking. Prior to the twentieth century, tobacco was smoked primarily in pipes and cigars, chewed, or used nasally as snuﬀ. Harsh tobaccos made deep inhalation of tobacco smoke diﬃcult. Tobacco likely exacted a modest toll through the nineteenth century.
In the US, four factors combined in the early twentieth century to make cigarette smoking the most popular, and lethal, form of tobacco consumption. Perfection of the Bonsack cigarette rolling machine in 1884 introduced relatively inexpensive and neater cigarettes to the market. Discovery of the American blend of tobaccos (combining more ﬂavorful tobaccos from Turkey and Egypt with milder American tobaccos) made deep inhalation of cigarette smoke feasible. The development and marketing of Camel cigarettes in 1913, the ﬁrst American blend cigarette, introduced this new-generation product to the American public with an advertising campaign often credited as inaugurating modern advertising. Finally, cigarettes were included in soldiers’ rations during World War I, permitting soldiers a quick and convenient battleﬁeld tobacco break. Considered eﬀeminate and unattractive prior to the war, cigarette smoking came home a ‘manly’ behavior. Since then, cigarette smoking has dominated all other forms of tobacco use by far in the US and in most countries of the world.
Lung cancer was virtually unknown at the beginning of the twentieth century. By 1930, it had become the sixth leading cause of cancer death in men in the United States. Less than a quarter of a century later, lung cancer surpassed colorectal cancer to become the leading cause of male cancer death. It achieved the same status among American women in the mid- 1980s, surpassing breast cancer (US Department of Health and Human Services 1989).
The rapidly growing rate of lung cancer in the early decades of the century spurred a number of epidemiologists and laboratory scientists to begin investigating the relationship between smoking and cancer. In 1950, Wynder and Graham published a now classic retrospective epidemiologic analysis that strongly linked the behavior to the disease. Throughout the decade, a series of articles documented similar ﬁndings from major prospective (cohort) mortality studies in the US and the UK. Scientiﬁc groups in both countries soon thereafter published seminal public health documents indicating smoking as the major cause of lung cancer and a cause of multiple other diseases (Royal College of Physicians of London 1962, US Public Health Service 1964, US Department of Health and Human Services 1989).
By the end of the twentieth century, approximately 70,000 studies in English alone associated cigarette smoking with a wide variety of malignant neoplasms and cardiovascular and pulmonary diseases, as well as numerous other disorders. The modern plague of tobacco-produced disease is now rapidly metastasizing—both ﬁguratively and literally—to the world’s poorer nations, where increasing aﬄuence and western image-making have combined to place cigarettes in the mouths of a sizable majority of men and a growing minority of women.
3. The Causes Of Smoking
Smoking aﬀords users a very mild ‘high’ and addresses a number of often seemingly competing physical and psychological needs, for relaxation or stimulation, distraction or concentration, for example. The crucial ingredient in the sustained use of cigarettes is the addictiveness of the nicotine in tobacco smoke. Once addicted, as most regular smokers are, smoking serves the physiological purpose of avoiding nicotine withdrawal. Nicotine aﬀects brain receptors in much the same manner as other addictive substances, and withdrawal shares many of the same unpleasant characteristics (US Department of Health and Human Services 1988).
In many countries, smoking is initiated during the teen and even pre-teen years. At the time of initiation, new smokers typically do not appreciate the nature of addiction, much less the addictiveness of nicotine. Further, they tend to be short sighted, unconcerned about potential distant adverse health consequences (US Department of Health and Human Services 1994). The combination translates into a large pool of new smokers who have adopted the behavior, and become addicted, without considering either the danger or addictiveness of smoking, a situation that most will come to regret.
The physical eﬀects of nicotine notwithstanding, history teaches that virtually all drug use is socially conditioned; tobacco smoking is no exception. The use of tobacco in the Americas prior to the arrival of Europeans demonstrates this vividly. Although tobacco played a prominent role in most native societies, in some tobacco smoking was restricted exclusively to the shaman, who used it for medicinal and relig-ious purposes. In other societies, tobacco smoking anointed oﬃcial nonsectarian functions of tribal leaders (such as the famous ‘peace pipe’). In still others, nearly all males smoked tobacco frequently, for personal and social reasons (Goodman 1993).
In contemporary society, the initiation of cigarette smoking is often viewed as a rite of passage to adulthood. In many poorer societies, smoking is seen as a symbol of aﬄuence. In virtually all cases, smoking results from role modeling, of parents, prominent celebrities, or youthful peers.
Many tobacco control advocates attribute much of smoking’s holding power to sophisticated tobacco industry marketing campaigns. In the United States alone, the industry spends over $5 billion per year on advertising and other forms of marketing. The industry insists that the purpose of its advertising is solely to vie for shares of the existing market of adult smokers, a claim greeted with derision by the public health community. With US smokers exhibiting strong brand loyalty and two companies controlling three-quarters of the US market, marketing directed at brand switching (or its defensive analog, maintaining brand loyalty) would appear to be a relatively fruitless investment. Tobacco control advocates thus believe that much of the industry’s marketing eﬀort is directed toward attracting new smokers, primarily children but also groups of ﬁrst-and second-generation American adults not yet fully acculturated into American society (e.g., Hispanic females, who have a very low smoking prevalence).
Similarly, the introduction of aggressive Western cigarette marketing into Asian societies and Eastern European and African countries has been attacked by the public health community as spurring the growth of smoking among children and other traditionally nonsmoking segments of society (e.g., Asian females). In many of these countries, cigarette advertising was nonexistent or restricted to modest use of print media prior to the introduction of advertising by the major multinational tobacco companies. Before dissolution of the Soviet Union, there was virtually no advertising of the state-produced cigarettes in the Eastern European countries. That ended with a ﬂourish when multinational tobacco companies entered the newly liberated economies and, in some instances, took over cigarette production from the ineﬃcient state-run enterprises. In Japan, the state tobacco monopoly had never bothered to advertise on television prior to the entry of the multinationals. In short order, competition from the advertising of Western cigarette brands led to cigarettes becoming the second most advertised product on Japanese television. In Africa, the advertising media portray smoking as the indulgence of the much admired aﬄuent set, with billboards in desperately poor villages depicting highsociety Africans smoking and smiling in convivial social settings (McGinn 1997).
Although many tobacco control advocates ﬁnd advertising a convenient villain to attack, widespread smoking has often preceded formal marketing. Tobacco smoking spread like wildﬁre through much of Europe in the sixteenth and seventeenth centuries. Similarly, male smoking rates in Russia and the Eastern European countries were very high prior to the fall of Communism and the advent of modern cigarette marketing. The eﬀects of advertising are further examined below in Sect. 5.
4. The Art And Science Of Smoking Cessation
In countries in which the hazards of smoking have been well publicized, surveys ﬁnd that most smokers would like to quit and most have made at least one serious quit attempt, yet relatively few of those who try to quit succeed on any given attempt. In the US, for example, approximately three-quarters of smokers report they want to stop and as many as a third try each year. Yet only 2.5–3 percent succeed in quitting each year. Combined with persistent cessation eﬀorts by many smokers, this modest quit rate has created a population in the US in which there are as many former smokers as current smokers (US Department of Health and Human Services 1989, 1990). In the aggregate, thus, quitting has signiﬁcantly reduced the toll of smoking, but the toll remains stubbornly high due to the diﬃculty of quitting.
Although most former smokers quit without the aid of formal programs or products, the widespread desire to quit, paired with its diﬃculty, has created a small but thriving market for smoking cessation. Formal cessation interventions range from the distribution of how-to-quit booklets, to mass media cessation campaigns, to individual and group counseling programs, to self-administered nicotine replacement therapy (NRT) products, to use of cessation pharmaceuticals combined with clinical counseling. The eﬃcacy of interventions ranges from sustained quit rates of about 5–7 percent for the most general and least resource-intensive interventions (e.g., generic cessation booklets) to 30 percent or more for the most resource-intensive programs that combine sophisticated counseling with the use of pharmaceuticals (Agency for Health Care Policy and Research 1996).
Over the years, behavioral scientists have helped reﬁne smoking cessation techniques by evaluating interventions and developing theory applied to smoking cessation. Pre-eminent in the domain of theory have been models that characterize how smokers progress, through a series of ‘stages,’ to contemplate, attempt, and eventually succeed or fail in quitting, with cessation maintenance also examined (Prochaska and DiClemente 1983). Relating cessation advice to smokers’ stages of readiness to change constitutes one way of ‘tailoring’ cessation messages. Another involves tying cessation advice to the speciﬁc motivations of individual smokers to quit and their speciﬁc concerns. For example, consider a smoker motivated to quit primarily by the high cost of smoking but also concerned about gaining weight. Armed with this knowledge, a cessation counselor can develop speciﬁc information on the ﬁnancial savings the smoker can expect once he or she quits, while suggesting speciﬁc strategies to avoid weight gain (or to deal with it if it occurs).
Tailored cessation messages have the obvious virtue of meeting the idiosyncratic needs of individual smokers. In the absence of computer technology, however, they would entail the substantial cost of collecting information on individuals’ needs and concerns and then developing individualized (tailored) cessation advice for them. Computers, however, permit simple and inexpensive collection and translation of information into tailored cessation materials, such as individualized advice booklets and calendars with speciﬁc daily advice and reminders (Strecher 1999). Health informatn kiosks placed in malls and other public locations can provide instant tailored suggestions to help people quit smoking. The concept of tailoring holds great potential to enhance quit rates both in individual counseling situations and in low-cost nontreatment settings, such as these kiosks.
Social and behavioral scientists have also played a central role in deﬁning appropriate medical treatment of smokers. The US Agency for Health Care Policy and Research (1996) clinical guideline for smoking cessation was produced by an expert committee including social and behavioral scientists who had worked on smoking cessation as service providers or developers or evaluators of interventions. The guideline urges physicians to regularly counsel their smoking patients about the implications of the behavior and to encourage them to quit. It concludes that a highly eﬀective cessation approach involves physician counseling to quit, supplemented with use of cessation pharmaceuticals and maintenance advice through follow-up contacts. A cost-eﬀectiveness analysis of the guideline added economics to the social sciences contributing to understanding optimal smoking cessation therapy (Cromwell et al. 1997).
Despite substantial improvements in the eﬃcacy of cessation treatments, in any given year only a small fraction of the smokers who say they want to quit succeed in doing so, and only a small fraction of these have employed professional or programmatic assistance. As such, in any short-run period of time, the contribution of smoking cessation interventions to reducing the health toll of smoking is modest at best. This source of frustration has led a subset of smoking cessation professionals to explore methods of achieving ‘harm reduction’ that do not depend on smokers completely overcoming their addictions to nicotine. Harm reduction techniques range from helping smokers to reduce their daily consumption of cigarettes to encouraging consideration of the long-term use of low-risk nicotine-delivery devices, such as nicotine ‘gum’ or the patch. Though fraught with problems, harm reduction may be an idea whose time has come (Warner 2001).
5. Analysis Of The Eﬀects Of Tobacco Control Policies
Another way to grapple with the toll created by smoking is to develop policies that discourage the initiation or continuation of smoking, or that restrict it to areas in which it will not impose risk on nonsmokers. Social and behavioral scientists have devoted substantial eﬀort to studying the impacts of policies, as well as the processes by which such policies come to be adopted. This section examines the former. (For the latter, see, e.g., Fritschler and Hoeﬂer 1996, Kagan and Vogel 1993.)
The World Health Organization and the World Bank have described and evaluated a wide array of tobacco control policies in countries around the globe (Roemer 1993, Prabhat and Chaloupka 1999). Three that have commanded the greatest amount of research attention are taxation, restricting or banning advertising and promotion, and limiting smoking in public places.
Research performed primarily by economists has established that taxing cigarettes is among the most eﬀective measures to decrease smoking (Chaloupka and Warner 2000, Prabhat and Chaloupka 1999). Because the quantity of cigarettes consumed declines by an amount proportionately smaller than the associated tax rise, taxation increases government revenues at the same time that it decreases smoking. In developed countries, economists ﬁnd that a 10 percent increase in cigarette price induces approximately a 4 percent decrease in quantity demanded. In developing countries, the demand impact may be twice as large. Eﬀective dissemination of research ﬁndings has made taxation one of the central tenets of a comprehensive tobacco control program.
Although the ‘bottom line’ about taxation is well established, research by economists and others points to concerns that remain unanswered. For example, does taxation discourage the initiation of smoking? Although evidence preponderantly suggests that it does, recent studies challenge the conventional view (Chaloupka and Warner 2000, Chaloupka 1999). ‘Side eﬀects,’ or subtle unanticipated impacts of taxation, warrant additional attention as well. Notably, cigarette tax increases in the US cause some smokers to switch to higher nicotine cigarettes to get their customary dose of nicotine from fewer cigarettes, particularly among younger smokers (Evans and Farrelly 1998).
In the emerging ﬁeld of ‘behavioral economics,’ a small cadre of psychologists is studying experimentally how smoking responds to incentives. For example, investigators give subjects a daily ‘budget’ (e.g., play money) with which to buy cigarettes, food, and other commodities, at prices established by the investigators, and evaluate the eﬀects of ‘taxation’ by raising the price of cigarettes. Findings generally have been quite consistent with those in the mainstream economics literature (Chaloupka et al. 1999).
Behavioral economics can investigate questions not addressable using existing real world data, but also has decided limitations in predicting how people will respond to price changes in that real world. By learning from each other, the two ﬁelds can enrich the evidentiary base for future tobacco tax policy.
A diverse group of sociologists, psychologists, economists, marketing specialists, and public health scholars has studied the eﬀects of marketing on smoking. Research by several scholars concludes that modern Western-style advertizing creates an imagery that many people, including large proportions of children, ﬁnd easily recognizable and attractive. There is a strong correlation between children’s interest in cigarette marketing campaigns and their subsequent smoking behavior. Temporally, advertising campaigns directed at speciﬁc segments of a population have often been followed by signiﬁcant growth in smoking in the targeted groups, including women in the US in the 1960s, young women in Asia in the 1990s, and children in many countries (Warner 2000 McGinn 1997).
Whether any of these associations constitutes a causal relationship is the essential question. The same unidentiﬁed factor that makes cigarette advertising attractive to certain children could account for their subsequent smoking, independent of the advertising per se. Similarly, cigarette marketers might foresee an (independently occurring) expansion of a market segment and dive into the advertising void to compete for shares of that new market.
In the absence of the ability to run randomized controlled trials, empirical analysis of the relationship between cigarette advertising and consumption has been unable to prove a causal connection or to estimate its likely extent (US Department of Health and Human Services 1989, Warner 2000). How- ever, strong new evidence supporting causality comes from a study re-examining data on the relationship between countries’ policies with regard to cigarette advertising (ranging from no restrictions to complete bans) and levels of smoking within those societies (Saﬀer and Chaloupka 1999). Blending marketing theory with empirical analysis, this study concluded that a complete ban on cigarette advertising would decrease smoking by about 6 percent, while partial bans (e.g., banning cigarette ads on the broadcast media) would be unlikely to have an impact on cigarette consumption.
Combined with the previously existing evidence, the new research leads to the most plausible interpretation of the relationship between advertising and cigarette consumption. It is a conclusion that likely will satisfy neither tobacco industry defenders of the ‘brand-share only’ argument, nor tobacco control advocates who condemn marketing eﬀorts as a principal cause of smoking. Cigarette advertising and other forms of marketing likely do increase the amount of smoking in a statistically signiﬁcant manner, possibly accounting for as much as 10 percent of cigarette consumption. (This ﬁgure is likely to vary among societies, depending on the maturity of the smoking market and on familiarity with large-scale marketing campaigns.) The converse, of course, is that advertising and marketing almost certainly do not account for the majority of cigarettes consumed. For these, one must turn to other inﬂuences, all less policy tractable than advertising, including role modeling, peer behavior, and the addictiveness of nicotine and smoking.
5.3 Restrictions On Smoking In Public Places
‘Clean indoor air laws,’ which restrict or prohibit smoking in public places and workplaces, grew out of concerns that the exposure of nonsmokers to environmental tobacco smoke (ETS) could create a risk of disease, leading in the US to rapid diﬀusion of state laws, beginning in 1973. A decade later, similar laws emerged at the local level of government, where most of the legislative action in the US has remained since then (Brownson et al. 1997).
The scientiﬁc knowledge base actually followed early diﬀusion of legislation, with a number of studies of the relationship between ETS exposure and the risk of lung cancer published in the 1980s (Brownson et al. 1997). By the 1990s, the research base had become suﬃciently strong that the US Environmental Protection Agency (EPA) declared ETS a ‘Class A Carcinogen,’ a proved environmental cause of cancer in nonsmoking humans. The EPA estimated that ETS caused approximately 3,000 lung cancer cases annually in the US, and also detailed nonfatal respiratory disease eﬀects of ETS, particularly in children (US Environmental Protection Agency 1992). More recently, research has implicated ETS in heart disease deaths in adult nonsmokers, possibly an order of magnitude greater than the lung cancer impact (American Council on Science and Health 1999).
Social and behavioral scientists have informed the debate by studying the process of the emergence and diﬀusion of clean indoor air laws and, subsequently, the eﬀects of such laws on nonsmokers’ exposure to ETS and on smokers’ smoking behavior. Studies have found generally high levels of compliance with the laws, even in bars (where low compliance was anticipated by many) (Warner 2000), and reductions in employees’ exposure to ETS, as measured both by self-reports, air sampling, and examination of employees’ body burdens of cotinine, a nicotine derivative.
Less obvious is whether clean indoor air laws discourage smoking or merely ‘reallocate’ it to times and places in which smoking is permitted. According to several studies, the laws do discourage smoking among workers in regulated workplaces, producing increased quit rates and lower daily consumption among continuing smokers (Brownson et al. 1997).
5.4 Interaction Of Policies
As policy research becomes more sophisticated, the relationships among policies and their impacts will come to be better understood. Illustrative is research examining the joint eﬀects of tax increases and the adoption of clean indoor air laws. For example, some of the smoking decline credited to tax increases might be associated with a citizenry more interested in reducing smoking. In turn, the latter could be reﬂected in the adoption of clean indoor air laws. Examining the joint eﬀects of the two policies conﬁrmed researchers’ suspicions, thereby suggesting a reduced (but still quite substantial) impact of taxation on smoking. Similarly, disentangling the impacts of state-level tobacco control programs that mix tax increases with media antismoking campaigns is important but analytically challenging. Recent research paves the way toward better evaluation of multiple-component policies (Chaloupka 1999, Chaloupka and Warner 2000).
6. The Future Of Social And Behavioral Science Contributions To Tobacco Control
Social and behavioral science have contributed greatly toward understanding how and why the epidemic of smoking has evolved throughout the twentieth century. They have also elucidated a set of tools that can help society to extricate itself from the tenacious grip of this public health disaster.
With innovations in information and pharmacological technology combining with better insights into human behavior, further improvements in assisting smokers to quit appear to be virtually certain. Although the long-range goal must focus on preventing future generations of children from starting to smoke, helping current adult smokers to quit remains critical to reducing the tobacco-attributable burden of disease and mortality over the next three decades. As such, the role of social and behavioral scientists in smoking cessation will likely be increasingly productive.
The eﬀectiveness of eﬀorts to encourage smokers to quit depends to a signiﬁcant degree on the environment in which smoking occurs. If smoking is increasingly viewed as antisocial, quitting smoking will become easier, and more urgent, for current smokers. Policy making is society’s best means of intentionally altering the environment; and better understanding of the eﬀects of policy interventions, and of how they come to be adopted, will be crucial to shaping the environment with regard to smoking in the coming years.
The multidimensional problems associated with tobacco use vividly illustrate the need for scientists of all disciplinary persuasions to work together. The next great challenge confronting the diverse ﬁelds of social and behavioral science in tobacco control is how to combine the methods and insights of the various disciplines into an integrated whole (Chaloupka 1999).
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