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CHAPTER 8

       CHANGES IN THE
SMOKING-AND-HEALTH ENVIRONMENT:
       BEHAVIORAL AND
    HEALTH CONSEQUENCES

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CONTENTS

Introduction ..................................................... ..64 9

The Antismoking Campaign  .......................................... 649

Behavioral Effects of the Campaign  .................................... 650
SmokingPrevalence...............................................65 0
Per Capita Cigarette Consumption ................................... .657
   Effects in Years of Major Smoking-and-Health Events .............. 658
   Aggregate Effects  ........................................... 662
Filter-Tipped and Low-Tar and -Nicotine Cigarettes  ..................... 664

Health Consequences of the Campaign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 665
Mortality Postponed by Campaign-Related Decreases in
SmokingPrevalence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...666

Conclusions ..................................................... ..66 9

Appendix ....................................................... ..67 1

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...681

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Introduction

As the preceding chapters have documented, concern about the hazards of smoking
during the past 25 years has been associated with development and dissemination of
scientific knowledge and with a wide variety of private and public sector activities in-
tended to reduce the disease burden of smoking. Collectively, these efforts have been
labeled "the antismoking campaign" (Warner 1977, 1989). This Chapter reports on
research concerning the effects of the campaign and accompanying knowledge and at-
titudinal changes on cigarette consumption and its mortality toll. Whereas previous
chapters have examined trends in smoking behavior and its health consequences, the
research reviewed in this Chapter analyzes how these trends compare with those that
would have been expected in the absence of changes in the smoking-and-health en-
vironment.

Prior to reviewing the evidence, the next section presents a brief discussion of what
the term "antismoking campaign" is intended to connote throughout the Chapter.

The Antismoking Campaign

Activities directed at discouraging the use of tobacco products were reviewed in
Chapters 6 and 7. While some of these activities have been developed explicitly as
campaigns against smoking, such as efforts of the major voluntary societies, there has
been no single, longstanding, organized, national campaign to reduce smoking and its
associated disease burden. The widespread perception of the existence of a national
"campaign" reflects the large number of antismoking activities, their shared goals of
smoking prevention and cessation, and their persistence throughout the past 25 years.
Smoking cessation and prevention activities predated the first Surgeon General's
Report, but 1964 marked the beginning of the first period of sustained, substantial, and
expanding antismoking activity. Hence "the antismoking campaign" is typically dated
from publication of the first Report. Important developments related to smoking and
health from 1964 through 1988 are presented in the Appendix to this Chapter.

Throughout this Chapter, the term "antismoking campaign" is used in a broader con-
text as a convenient designation for the collectivity of these activities and for the chang-
ing social norms that have accompanied them (see Chapter 4). In essence, it serves as
a shorthand expression covering smoking-and-health knowledge, concern, and reac-
tion, the entirety of changes in the social environment spawned by scientific and social
interest in the hazards of smoking. This includes the conduct of the tobacco industry
in response to concerns about those hazards. Thus, for example, manufacturers' promo-
tion of low-tar and -nicotine cigarettes in the 1970s is both a response to public con-
cerns about smoking and a contributor to smoking behavior and its health consequen-
ces. Research on the behavioral and health implications of the campaign therefore
examines the net effects of "pro" and "anti'`-smoking information and activities.

Scholars have addressed the effects of both specific seminal events of the antismok-
ing campaign and the consequences of the campaign in its entirety. Among the semi-
nal events analyzed by researchers are publication and media coverage of the first Sur-
geon General's Report, the Fairness Doctrine broadcast media antismoking public


service announcements of 1967-70, the ensuing ban on broadcast advertising of ciga-
rettes, and the spread of nonsmokers' rights legislation in the 1970s and 198Os, all dis-
cussed in the preceding chapter. The pattern of one significant influence on cigarette
consumption-excise taxation-has also been considered part of the antismoking cam-
paign: a steady pattern of increases in State taxes in the 8 years following release of the
first Surgeon General's Report might be construed as a campaign response, at least in
part (Warner 198 1 b). Analysis of the role of excise taxation in the antismoking cam-
paign, reviewed below, has treated taxation as both a component of the campaign and
an independent phenomenon (Warner 1977,1981a, 1989).

Research reviewed in this Chapter focuses on campaign effects since 1964, with one
important exception: the shift from unfiltered to filtered cigarettes in the 1950s follow-
ing the first widespread public concern about a link between smoking and lung cancer,
and cigarette manufacturers' development and marketing of new filter-tipped products.

Behavioral Effects of the Campaign

In terms of health implications, the most significant behavior changes associated
with the antismoking campaign likely relate to the most basic measures of smoking:
prevalence and per capita cigarette consumption. Following examination of the
evidence pertaining to impact of the campaign on these variables, this Section briefly
reviews two other behavioral measures relating to smokers' choice of cigarette type:
shifts toward filtered cigarettes and low-tar and -nicotine brands.

Smoking Prevalence

The most common index of changes in smoking behavior is smoking prevalence.
Trends in prevalence by a variety of socioeconomic and demographic characteristics
were reviewed in Chapter 5. Analytical studies relating prevalence trends to antismok-
ing activities are relatively few in number, although the literature on cigarette excise
taxation and the broadcast media advertising ban includes studies that have relied on
survey-based prevalence data; these were reviewed in Chapter 7 (e.g., Lewit, Coate,
Grossman 1981; Lewit and Coate 1982).

Evidence pertaining to the effects of the antismoking campaign on smoking in various
age-sex cohorts was examined in a previous Surgeon General's Report (US DHEW
1979). Since publication of that Report, two studies have analyzed the cohort
prevalence effects of the antismoking campaign in its entirety (Warner and Murt 1982;
Warner 1989). Findings from these studies are reviewed in this Section. Discussions
of the strengths and limitations of cohort analyses have been presented previously by
the Surgeon General (US DHHS 1980) and by other scientists (Harris 1983; Brown and
Kessler 1988).

Among changes in the prevalence of smoking since 1964, some logically suggest sig-
nificant response to the smoking-and-health message. The decreasing prevalence of
smoking among both men and boys serves as the most obvious example. Other pat-
terns often have been interpreted as reflecting little response to the message. The most
notable example is the relatively steady trend in adult female smoking prevalence from

650