Tobacco Documents Online

$~cki~a in Contemnorarv Society The medical llterature on the consequences of cigarette smoking is one of the most complete collections of scientific data ever accumulated. Since the release of the first Surgeon General's Report in 1964, thousands of studies have indicted smoking ss a leading cause of lung and other ca~ce~s, cardiovascular disease, emphysema, chronic bronchitis and other llfe threatening and disabling diseases. In the two decades following that Report, remarkable changes took place in the smoking patterns of Americans. Nilllons of smokers qult, and millions of peDDle never started -- there are 33 million former smokers In the United States today and the percentage of adult current smokers has dropped from 42 percent to ~3 percent. Attitudes and awareness about smoking changed as dramatically as smoking rates. Over 80 percent of current smokers now say they ~ould like to quit and 40 percent report at least three unsuccessful quit attempts each year. Smoking among adolescents also underwent dramatic changes. After surging In the early 1970,s, teenage smoking rates have shown a steady decline• The vast majority of teenagers are aware of the risks posed by cigarettes. Despite these dramatic changes and encouraging statistics there is another side to the picture. In 1982, 54 million CD Americans smoked 620 billion cigarettes. An estimated 340,000 of ~ those smokers wlll die prematurely this year. In addition, the ~ most recent survey of smoking by high school seniors raises ~4~:ii~i

questions about whether adolescent smoklng rates will continue downward. Other countries have experienced similar successes and problems. In Western Europe large numbers of smokers have Quit end teenage rates have declined. However, the number of current smokers and the rates of related disease in these countries remain high. Smoking rates and cigarette consumption are on the rise in developing nations, thanks in part to intensive marketing efforts. These countries can ill afford smoking related diseases while still struggling to eliminate the ravages of communicable disease. The i982 Surgeon General's Report puts the smoking problem in an appropriately broad and serious perspective: ~Cigarette smoking• is the chlef, single avoidable cause of death in our society and the most important public health issue of our time." ~oki~9 is s fa~ more complex and Inaldi~ua public health problem then many Americans realize. Many, especially smokers, ere unaware that in addition to lung cancer and emphysema, smokin9 m~uaes heart disease ~nd e ~sriety of other c~ncers. Also, Surveys show an alarming perception of the risks of lower tar and nicotine cigarettes -- }6 percent of smokers believe these cigarettes pose no risk at all. And although over 80 percent of Americans are aware that smoking is dangerous, they consistently rank it far below other health risks whose contributions to death and disability pale by Comparison.

"r Smoking is having a particularly insidious impact on developing countries where tobacco is grown° Worldwide as well es domestic demand has greatly i~reaaed tobacco acreage, ks a ~eault, more land has been cleared and more wood cut to oure the tobacco, creating serious problems of deforestation, soil erosion, air pollution and the diversion of agricultural ~esourcea f~om food production. 5moktno ~mouno Youno Peoole The most serious problems posed by smoking are among children and adolescents. Early ~esearch findings on the hazards of smoking focused on adulta and the long-latency ~iseases such as cancer. Nowever, since 1964, an increasing body of knowledge has aocumuIated on the effects of smoking on young people. Perhaps most important is the finding that teenage smoking habits are the major determinants of lifelong smoking dependence~ Very few smokers begin their habit after the age of twenty. In addition, there is overwhelming evidence that smoking during pregnancy has a serious impact on the welibeing of the fetus and the health of the newborn. Other effects on the y~ung include: o Maternal smoking retards fetal growth and increases the risk of spontaneous abortion, fetal death and neonatal death; o Children of smoking mothers may have deficiencies in physical growth, intellectual and emotional development;

$ + o Young cigarette smokers have evidence of irreversible small airway dysfunction; o Teenage and young adult smokers have a higher prevalence of respiratory symptoms than nonamokers~ o There is a significant relation between children's respiratory illness and parental smoking; c Children ~hose parents smoke ere twice as likely to become smokers than children from nonsmoking families. These disquieting facts about the effects of smoking or children Illustrate the significant interrelationship of adult and childhood smoking at all stages of development: maternal smoking oan affect fetal and neonatal health and overall development; parental smoking can affect childhood health end can determine teenage smoking habits; teenage smoking can determine , lifelong smoking habits with both short and long term health effects, It is clear from these interrelationships that programs aimed at preventing children from smoking or encouraging them to ~ • quit must consider the full spectrum of smoking behavior. They ~, '~ii~:~ adolescent behavior, in must focus on pregnant women, young children, young adult role models and peers, parents and other adult exemplars. And they must be based on a thorough understanding of smoking behavior and the broader context of adolescent

or "4 rlsk-taklng and experimentation with alcohol and other drugs. However, the strong llnk between childhood smoking and adult dependence argues that regardless of the specific policy or point of intervention, the elimination of smoking in our aoclety will ultimately depend on the elimination of smoking among young people. Understandlno Smokino Behavior The reasons for the dramatic changes in American smoking ~attarne are not nearly es apparent as the changes themselvesp nor are the reaso~a ~hy so aany young Amerlca~e continue to take up smoking and why so many adults smoke, despite widespread knowledge of the risks. The public health efforts launched In the sixties must have played a major role. The information, education and regulatory programs implemented by the federal govelnmant~ voluntary ~@encies an~ state and local governments have somehow had a measurable impact on smoking behavior, public knowledge end awareness and even on the social status of smoking. What Is not known is how these efforts worked and why they succeeded with some smokers an~ not with others. It is also not understood what other verlables have played independent or dependent roles in changing smoking behavior. While the health consequences of smoking are well documented, the bahavioriel aspects are not -- what makes young people start smoking, why it is so hard to quit, who sueceeos ano how, why relapse is so frequent, even after long periods of abstinence. C~ W~ 7

7he accumulated knowledge about the psychological, social, pharmacological and demographic aspects of the smoking problem is a small fraction of the thlrty-thsee thousand studies on smoking In the world literature. The sciences concerned with behavior have lagged far behind biomedical science in developing the techniques necessary to better understand smoking and in applying those techniques to fill the gaps in knowledge. These gaps are si9nlflcant. ?or example, while the ma~orlty of the ~ million former smokers quit on their own, little is known about their methods, metlvatlonst consumption patterns, relapse rates, basic demographics and other determinants of successful quitting. Little is also known about what effect parental quitting may have on teenage smoking. Without more knowledge about such key factors, policies and programs to prevent smoking and encourage quitting depend on anecdotal and incomplete data, thus limiting their effectiveness. There are also major gaps in our understsndlng of adolescent smoking and the determinants of decisions to take up smoking. The most recent data on teenage smoking patterns and attitudes were collected in 1979 and although there are indications that major changes may have occurred, no comparable new data are available. The problem is further complicated by the fact that much of the available data were collected by telephone surveys of small samples. These data not only lack statistical power, but ere also deficient in identifying racial end ethnlc origins. Questions have also been raised about the validity of telephone

d responses to sensitive questions asked wlth parents present. Wlthout better and more accurate knowledge, programs aimed at preventing teenagers from starting to smoke may be out of step wlth teenage attitudes and behavior. There are several basic reasons for this critical shortfall in understanding smoking behavior. Smoking is a complex set of behaviors involving psychological anP physiological dependence on tobacco, complicated by social relnfsrcements including efforts on the part of the tobacco industry to depict smoking as safe, attractive and socially acceptable. In addition, the natural evolutlonmry gap between biomedical and behavioral science has been widened by decisions allocating far greater resources to biomedical research than to behsviorml research on smoking. Structural problems within the research and public health communities have also contributed to the knowledge shortfall. While many groups and organlzatlons have placed greater emphasis on smoking related behavioral rssearch in recent years, coordlnatlon and follow through have been slow in coming. Because of a lack of leadership, coordlnetlon or awareness, researchers have missed opportunities to make significant strides through the analysis of emerging trends or the impact of new policies. Because of the political sensitivity of the smoking Issue, government agencies have been slow to exert leadership In these areas or have suffered cuts in resources, ~aking it difficult for them to respond. There is no place that fundinc agencies can turn to find out, es research priorities, w~at It is -t¸ CJ Gq

t we do not know about smoking that could be known that would contribute to effective public and private policies. The impact of this shortfall in knowledge has been to limit the capacity of lasesrehars and pollcy makers to design new and • ora effective ~pproaches to smoking prevention and control. While smoking has declined dramatically, greater momentum and new direction must be generated if greater success is to be achieved in preventing young people from taking up smoking and helping the 54 million Americans who still smoke. Without better snd more targeted research on smoking behavior, better coordination and olose~ ties between research and policy development, public health officials will have to apply m limited, outdated knowledge base to solve the smoking problems of the 1980's and 1990's. A New Resource for Smokino Researnh In response to the need for better direction, coordination and continuity in research on smoking behavior and policy, the John F. Kennedy School of Government is establishing a permanent center for the study of smoklng. This center, to be named the Instltute for the Study of Smoking Behavior and Policy, will have as its primary goal the development of new knowledge about smoking behavior and the translation of that knowledge into program designs and policy options. TO achieve this goal, the :~ Institute will draw on the resources of the Harvard co~,munity and ~b will reach out to those individuals and Institutions in the ~ United States and abroad who are addressing many of the same problem s. i ~:!!: '~ : ..... lO ....

The Institute will undertake a variety of functions designed to fill research gaps, examine policy options and stlmulate the behevleral and p@llcy research efforts of others. Primary ~mpha~Is in all of the Instltute's undertakings will be on broadening the knowledge base by increasing the participation of researchers from a wide range of disciplines. A second and equally important emphasis will be on serving the smoking research community, provldlng information and coordination for resesrch end policy d~velopment efforts. Broadly stated, the Instltute's mission will be to: • o Serve as e focal point @n~ 8n info~matlon resource for smoking behavior and policy research nationslly and internationally; o Create a mechanism for continuous assessment of the state of the art in smoking research; o L~artaks ~esearc~ p~ojects ~ith potential for program er policy sppllcations and, monitor events and change~ in pol~cles to identify research opportunities; o Gather and analyze detailed personal data on smoking behavior in order to develop a comprehensive natural history of smokimg as a research and poiicy resource.

t o Examine the relatlonshlps between smoking research and key policy Issues on a csntinuous basle and target research to support and enhance policy devmlopment; o Explore new epploeohes to tr~sl~ti~ research findings into programs and broad strategies for smoking prevention and control in settings ranging from schools to health care deilvery to natlonal leglslat~on; and o Provlde eoordlnatlon and oontlnulty ~n smoRing research and pollcy issues, especially with respect to the many research reoommendatlons developed Over the past several years, In short, the Instltute will endeavor to create a framework of information and expe~t judgment that can provlde dlreotlon to smoking ~esesrch in years to come. ~hls framewor~ will be eharacterlzed by a continous process involving the examlnatlon of research progress, needs and opportunitles and the stimulatl@n of new Ideas. CO "rip ~ The uitlmate goal of the Institute wlll be preventlon: preventing chi1~en from taking up smoking an~ preventlng the ~ damage caused by smoking° Given the wl~e range of concerns about the effects of smoking -- children, pregnant women, high rlsk