Fifty Years in the Fight Against Tobacco

“You’ve come a long way, baby.” Virginia Slims' once ubiquitous slogan could serve an apt summary of progress in the half-century since the landmark Surgeon General’s Report on Smoking and Health.

Since 1964, the portion of Americans who smoke has been cut in two. And thanks to restrictions on advertising many today are unfamiliar with the Marlboro Man and Joe Camel, let alone Virginia Slims, noted Wafaa El-Sadr, MD, MPH, director of the Global Health Initiative and ICAP and the moderator of an April 8 symposium reflecting on the anniversary of the report.

Organized by the Global Health Initiative at the Mailman School and the Columbia Global Policy Initiative, the symposium took a wide-angle look at issues in the tobacco fight, from industry response to women smokers and the controversy surrounding e-cigarettes.

The 1964 report opened America’s eyes to the dangers of tobacco as never before, with the sobering finding that smokers were nearly 10 times more likely to develop lung cancer and 70% more likely to die than non-smokers. The findings were top news across the country. Some regulations followed, although they were blunted by fierce industry pushback. Even days after the report landed, newspaper editorials warned that restrictions on tobacco would threaten liberty.

Keynote speaker Derek Yach, MBCHB, MPH

Industry pushback wasn’t limited to the United States. Keynote speaker Derek Yach, MBCHB, MPH, executive director of the Vitality Institute and a key figure in the World Health Organization Framework Convention on Tobacco Control, said millions of industry documents brought to light through litigation with the tobacco companies made their intentions clear. Industry had been working to subvert WHO tobacco control efforts, a conclusion later substantiated by a United Nations committee. “It was the first time there had been a clear, explicit attack on a multinational set of interests,” said Yach.

But the documents proved useful by allowing public health advocates “to walk through the minds of tobacco industry executives like never before,” said Yach. Companies and governments were put on notice that “we now knew the way they were going to operate. And whatever they said in defense of tobacco, we could find the development of the argument [against tobacco control that] over decades they paid for.” (Today anyone can search the documents online at the Legacy Tobacco Documents Library at the University of California, San Francisco.)

Anti-tobacco advertisement

Next Yach and his tobacco control allies turned one tobacco tactic on its head by creating an ad campaign in the magazine COLORS pairing a classic Marlboro cowboy with the text, “Bob, I've got emphysema.” Simultaneously, they were able to get the Olympics, FIFA and other major sports organizations to reject tobacco sponsorship.

Despite the progress, much work remains. The smoking rate in the United States is still at 20% and twice that for those with only a high school education. Globally, tobacco use is on the rise. While 100 million people died from tobacco in the last century, the estimate for the 21st century is a staggering one billion if no further steps are taken. “Other parts of the world are now in the throes of that epidemic in ways that mimic where the U.S. was 50 years ago,” noted Dean Linda P. Fried, MD, MPH.

Women and Smoking

Another troubling trend is the rising share of smoking by women. Within a generation, it is predicted that there will be more women smokers than men smokers in several countries, including the United States and Russia. These rates will accompany rises in chronic disease and low birth weights. One possible explanation for the trend may be that women get more addicted to nicotine than men, as some data has suggested.

Sadly, the issue of female tobacco use has historically been neglected. The first Surgeon General’s Report to examine the topic came out in 1986. “Why is it that there was a 22-year lapse during which scientists were thinking that women were immune to the consequences of smoking?” asked Dean Fried.

The issue of women smokers is worth examining, but it is also important to remember that men still make up the vast majority of the world’s smokers, observed panelist Ronald Bayer, PhD, professor of Sociomedical Sciences. “Globally the issue is male smokers.” Rates of female smoking may be a function of social equity, he added.

E-Cigarettes

The hot topic in tobacco control circles today is e-cigarettes, whose sales are projected to eclipse traditional cigarettes within a decade. Most agree that the new technology is less harmful than burning tobacco, but a number of questions remain.

Left to right: Panelists Ronald Bayer, Derek Yach, Michael Jones, and Donna Shelley

Some are skeptical of giving industry free reign over the way the devices are marketed. Much e-cigarette advertising is reminiscent of cigarette campaigns of previous generations with flavoring and packaging some suggest exist only to lure in adolescents. “If we really think of e-cigarettes as smoking cessation devices, I don’t see why we don’t just have doctors prescribe them for people over the age of 30,” said David Rosner, PhD, professor of Sociomedical Sciences.

New York City took a measured approach to e-cigarette regulation, said panelist Kevin Schroth, JD, senior legal counsel for tobacco control policy at the New York City Department of Health and Mental Hygiene, by making them off-limits to anyone younger than 21 and banning their use anywhere regular cigarettes are banned. There is no single way e-cigarettes are used, Schroth observed. “Some people use them as cessation devices, others use them as a bridge so they can smoke e-cigarettes indoors and cigarettes outdoors.”

But are bans on e-cigarettes the equivalent of throwing the baby out with the bathwater—a remnant of absolutist thinking on tobacco cessation? This question is raised by Dr. Bayer and Mailman School colleagues Amy Fairchild, PhD, and James Colgrove, PhD, who argue that the technology has the potential to lower smoking rates. (Read their article in the New England Journal of Medicine.)  

E-cigarettes are also helping the tobacco control community think beyond the patch. Their lesson, said panelist Donna Shelley MD, MPH, associate professor of Population Health and Medicine at New York University: “create a product that smokers actually want to use, that comes as close as possible to the experience of using a cigarette.”

What does the future hold? Panelist Michael Jones, PhD at the New York City Department of Health of Mental Hygiene, predicts that e-cigarette technology “won’t be as deadly as tobacco, but it’s not going to be the savior of public health either.”

While talk of e-cigarettes dominated the conversation, there was broad agreement that the most effective way to curb cigarettes is taxation. States with the highest taxes on cigarettes have the lowest smoking rates, a trend that extends to the city level.

Another key ingredient: a new generation of public health leaders. “It’s really critical for us to have a young, vibrant leadership group” to take up the tobacco fight, said Yach. “That’s why it’s so important that we can [make this happen] through your work here at the School.”