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I Please do not cite cr quote withcut -:er-ussicn I I I I I i ~ I t I I I S`IOKING AND HFIILTH LN MIGt iIGAIN Discussion paper prepared for the Governor's Citizens' Panel on Smoking and Health Kenneth E. Warner, Ph.D. Associate Professor Departn:ent of Health Plar.r.ing and Administration Sc.}:ool of Public Health Ltnive rs i ty o f Mi rhi g an Ann Arbor, Mich. 48109 June 1980 - Draft I Research for this paper was supported in part by Grant Number HS 036-74 :rom the National Center for Hea].th Services Research, CASH.

I Introducticn Cigarette smoking has been identified as Public 'r'.ealth Ene^tv M,.ber One, the most significant source of preventable .morbidit-r and mortality in the L'nited States today.* Each year, cigarette smoking is responsible for 350,000 prerature deaths and in excess of 80 million morbidity-days lost frem work (Surgeon General, 1979). The armual economic toll of smoking amcunts to $40 millicn, including $28 billion in avoidable productivity losses and roughly 8 percent of the Nation's direct health-care costs.** If Michigan's share of these burdens is proportienal to population, our State loses over 15,000 men and women eac, year to the ravages of smoking. Furtheznore, through taYes, insurance premiums, and direct pay^nents, Michigan citizens contribute over $500 million--or more than $50 per iran, woman, and child--to provide medical care for those made ill by smoking. Of course, these are only quantifiable costs of smoking. They ignore the inmeasurable suffering of the dying and disabled and their loved ones. In recognition of the severity of the smoking problem in Niichigan, Governor William Iiilliken has appointed a Citizens' Panel on Smoking and Health to study the problem and make recomtnendations for strategies to combat the initiation and continuation of smoking by Michigan residents. The purposes of this discussion paper are two: to provide Panel members with bac'.<grcund information and per- spective on the magnitude and nature of the smoking problem; and to suggest a wide variety of policy options to stimulate productive deliberations on desirable courses of action. The first section of the paper examines trends in smoking, including changes in the size and composition of the smoking population and changes in smokers' con- sumDtion habits (e.g., per capita consumption and tar and nicotine ingestion). The second section discusses the current health consequences of smoking and con- te=lates near-future shifts in the mix of health problems suggested by changing smoking patterns. The third section briefly examines the economics of smoking. The fourth section explores a variety of policy options to reduce the initiation of smoking habits and encourage cessation among existing smokers. This section opens with some historical backgTound on state and federal smoking policies and then focuses on areas of policy options in Michigan for the Panel's consideration. * This paper will focus exclusively on cigarette srrokizg. G't::er forms of tobacco use--cigars, pipes, snuff, and chewing tobacco--are less prevalent and, assumizg the absence of ccmplete ingestion (inhalation or swallowing), presum- ably less hazardous to health. About 20 percent of adult males smoke cigars and 12 percent pipes; 5 percent chew tobacco and 2.5 percent use snuff. Among women, all four alternative uses show very low prevalence. These habits are discsssed in the 1979 Surgeon General's Report. Should the Panel wish written materials on these habits, t.hese can be fort.'zccming. ** These economic estimates are derived from Luce and Schweitzer (1978), with direct and indirect costs inflated to 1980 dollars. I I I I I I I I I I ~ L -67-

i I ( I I I I ~ ~ I I I I i I. Trends in Smoking Use of tobacco dates back at least to the mid-1500s. Substantial cigarette ccnsumption, however, is a phenomenon of the present century, with cigarette smoking having grokn from an infrequently indulged lu:rury at the turn of the century to a habit of a majority of adult males by the end of World War II. Consistent with the slogan of a cigarette marketed to females, women have "come a long way." As recently as the mid-1950s, surveys found cnly a quarter of adult women identifying themselves as smokers, a rate less than half that of men. A decade later, the female self-reported participation rate had risen to a third. By the mid-1970s, the gap between male and female participation rates had dropped to roughly 10 percentage points. (See Table 1.) Twn important phenomena are discernible in such data: (1) the rate of self- reported smoking has been declining significantly and (2) the predominance of males in the smoking population has been receding. Indeed, among the youngest age groups, females now report higher participation rates than males. A recent survey of teenage smoking behavior found girls smoking more than boys in two age classes, 12-14 years and 17-18 years. A decade ago, boys' smoking rates significantly dom.inated girls' rates in all age classes. (See Table 2.)* * Survey data must be interpreted with considerable care. Comparison of differ- ent national surveys shows aggregate participation rates often varying by 5 or more percentage points in a given year (Surgeon General, 1979; Appendix Table 1). Niore dramatically, an analysis corrparing survey results with objective production-and sales-based consumption data found underreporting on surveys of more than a third of actual total consumption in 1975, up from a quarter in 1964 ('Varner, 1978). Data on teenage smoking are particularly suspect. In an experi- mental setting, researchers at the University of Minnesota found that teens told that their smoking behavior would be assessed by means of a che:nical analysis reported 50 percent more smoking than those who were not subjected to the "threat" of objective confirmation. In some circunstances, teens who view smoking as "adult" may overreport their consumption. -68-

i Table 1: Percentages of Acult Males s.nd Fe:.ales ReForting I Themselves to be Smokers, U.S., by Year Year ~Males % Fe:nales ~ Total I Ratio Male to Fema1e Rates 1955 52.6 24.5 37.6 I 2.15 1964 1966 52.9 51.9 31.5 33.7 40.3 42.2 1.68 i 1.54 1970 42.3 30.5 36.2 1.39 I 1975 39.3 28.9 33.8 1.36 1 Source: Surgeon General, 1979, appendix Table 1. Table 2: Percentages of Teenagers Reporting Themselves to be Regular Smokers, U.S., by Age, Sex. and Year % Males - % Fernales 1 I I Year: 1968 1970 1972 1974 1979 1968 1970 1972 1974 1979 Age ~ 12-14 2.9 5.7 4.6 4.2 3.2 0.6 3.0 2.3 4.9 4.3 ~ 15-16 17.0 19.5 17.8 18.1 13.5 9.6 14.4 16.3 20.2 11.3 17-18 30.2 37.3 30.2 31.0 19.3 13.6 22.3 25.3 25.9 26.2 ( Source: National Institute of Education 1979 Exhibit 1 , , . C11 L .D ~1! CD h+ -69-

I I I I I I I I t I I I I- *,Nhile Tables 1 and : clearly indicate the decreasing rate of smoking since the mid-1960s, they fail to convey the raoid grcwth in smoking in the decades preced- ing the :r,iddle of the century. This reflects the unavailability of use:ul surrey data prior to the 1950s. Fortunately, objective data on aggregate cigarette con- su7mtiont :nirror the recent survey trends and add historical perspective. Figure 1 shows the growth in adult per capita cigarette censumptiont* since 1930 (the solid line). ihe data indicate steady and rapid growth in smoking to the early 19S0s, with renewed growth for a decade following a two-year decline in 1953 and 1954. Since 1964, the trend has been generally downward, with the excep- tion of upward "bi=ps" in uhe mid-1960s and early 1970s. Deviations from the predominant trend are not random. I will disc-,iss these in greater detail in Section IV of the paper; here, note the following: - the sharp increase in per capita consti°nption in the mid-1940s likely represents an artifact of cheap cigarettes being available to Arnerican soldiers and valued by them as a form of currency - the decreases in 1953 and 1954 occurred during the first discussion in the popular press of the health hazards of cigarette smoking (Norr, 1952; Lieb, 1953; Stiller and Mbnahan, 1954) - the decline in 1964 followed the highly publicized release in January of the first Surgeon General's Report on smoking and health (Surgeon General, 1964) - the consecutive decreases in 1968, 1969, and 1970 accompanied the broad- cast media anti-smoking campaign required by the Federal Cemmumication Commissior.'s Fairness Doctrine (Warner, 1979a) - the increases in the early 1970s followed the banning of pro-smoking advertising on the broadcast media on January 2, 1971 and the consequent elimination of the Fairness Doctrine requirement of donated air time for anti-smoking messages; a considerable body of analytical opinion holds that the anti-smoking messages deterred smoking more than pro-smoking ads encouraged it Cilarner, 1979a). * These data are frem the Economics, Statistics, and Cooperatives Service of the U.S. Department of Agriculture. They are derived from data on production and sales, excise taxes, i^rcorts and exports, and loose tobacco production (for hand- rolled cigarettes). They appear to be valid, reliable indicators of aggregate cigarette consumptien. Adult per capita cigarette consumption is defined as total annual cigarette consumption divided by .he population over 17 years of age. A corrar.on indicator OD of aggregate smoh.ing behavior, this measure masks c.'langes in the composition and ~ individual behavior of t_he smoking population. It offers no insight into varia- ~ tions in the sex, age, income, or education distribution of smokers; it fails to Cn distinguish a change in the number of snckers from a'change in the ntzr,ber of CD cigarettes the average smoker consumes; and it ignores several other potentially 6"~ important reported c'rzanges in smoking behavior, such as reductions in the amount CA of each cigarette smoked and shifts from one brand to a lower "tar" and nicotine brand. Nevertheless, subject to these caveats, this measure serves as a reascn- able index of the aggregate level of srrboking activi ty CYarn.er, 1977). -70-

:,y,U r cz~ uu S u ~j i U 6000 5500 5000 4500 tti 4000 ~ 3500 .~ u' a u b 00 ~ 3000 2500 2 000- , 30 Actual and Predicted in Absence of Anti-Smoking Campaign 35 T 40 `,;Vurcc: Nirner, 1900 a. --- Actua l -------- Predicted, assuming actual price pattern •------------- Predicted, assuming steady prlce pat tern 4 5 .50 55 Ycar (19 ) 9T6S~9St~ 60 T 65 70 75 1 80

I I I I ( I I I I t I I I "he annual decreases in per capita smoking since 1973, averaging over 1 percent per year ( and growing), cannot be associated with similar specific "events". Cne can hypothesize that this unprecedented downward trend si..~;oly reflects a delayed behavioral response to c.`ianged attitudes and ;.-zowledge. Uterzatively, it is possible that cohort effects account for the trend, e.g., lower smoking participaticn rates among the "baby boom" population which has ncw reached the prime s^oking age. Conveivably, smoking behavior is "riding the coattails" of a general sccial concern with physical fit-iess. SVhatever the exalanaticn, the six year-old decline in per capita consumption represents an ecnouraging development. The data on adult per capita ccnsurotion show a decline from 4443 cigarettes in 1963, the year prior to the original Surgeon General's Report (1964) and the peak year for per capita consumption, to 3989 cigarettes in 1978, a drop of 10 percent. :as the pre-1964 trend suggests, however, per capita ccnsumption might have been expected to have increased considerably had there been no adverse publicity on the effects of smoking. In particular, diffusion of the habit among women was lagging that of men by 20 or more years. Rapid growth in the percentage of female smokers in the 1950s and 1960s augured more of the same in the 1970s. Thus the decline in per capita constnmption in the antismoking era is more impressive than that indicated by the simple calculaticn of 10 percent. I have estimated that, in the absence of all anti-smoking activities and publicity, by 1978 adult per capita consumption wnuld have been roughly 40 percent greater than it actually was (warner, 1980a). Thus, relative to the expected trend, smoking has declined significantly. Decreasing per capita consurrption is particularly impressive in light of the continuing declines in average tar and nicotine per cigarette. Table 3 presents the average tar and nicotine per cigarette sold in the U.S. since 1954. According to the data, today's average cigarette contains less than half the tar of the typical mid-1950s cigarette, while nicotine has dropped by over 60 percent. One obvious implication-is that smokers today would have to be smoking more than twice as many cigarettes as they did in the 1950s to ingest a comparable amount of tar and nicotine (hereafter, t/n). Clearly, they are not doing this. Figure 2 shows the pattern of adult per capita ingestion of tar per year. The drop since the mid-1950s indicates the profindity of the change in smoking behavior.* The trend in recent years toward low t/n smoking shows no signs of abating. The tobacco industry invests over 50 percent of its cigarette advertising and virtually all of its new-product research and development in this highly competitive * Figure 2 should be interpreted with several caveats in mind: (1) Full "ingestion" asstunes inhalation, which does not characterize all smoking. Indeed, if low tar and nicotine (t/n) content makes inhalation easier, it is possible that more smokers are inhaling more of the time, and hence that Figure 2 overstates the magnitude of the ingestion reduction. (2) The 1954 levels of t/n have been assuned for earlier years, for which I have no data. Stronger tobaccos in earlier ~ years might mean that this understates the true t/n ingestion of those years. ~ However, more reliance in earlier years on hand-rolled cigarettes, often packed M more loosely than manufactured cigarettes, could have produced lower t/n per 4 cigarette. (3) The per capita consumption base does not allow assessment of per ~ smoker consumption. Thus, if relatively light smokers have been the ones quitting 6,A or reducing smoking, continuing smokers iray be ingesting t/n quantities not too ~ dissimilar to those of the 1950s. That is, a smaller proportion of adults may be smoking, implying more cigarettes per smoker relative to the per capita measure. -72-

Table 3: Average Tar and ;licotine Per Cigarette 3old, by Y ear Year Tar (=Q) Nicotine (=Q) 1954 36.5 2.61 55 ' 37.0 2.69 56 35.4 2.56 57 37.0 2.55 58 33.5 2.20 59 28.9 1.84 60 27.0 1.60 61 26.6 1.57 62 26.3 1.52 63 25.1 1.44 64 23.0 1.30 65 22.8 1.39 66 23.5 1.47 67 22.4 1.43 68 21.6 1.40 69 21.0 1.39 70 19.9 1.40 71 19.6 1.38 72 19.3 1.35 73 18.5 1.26 74 18.3 1.26 75 18.0 1.1£ 76 17.3 1.15 7 / 16.7 1.14 Source: thipublished data from Phil:p L-ic. -73- I I t i ~ I L L

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I component of the smoking market.* ;Vhile the smcking-illness message clearly accounts for the current growth in low t/n smoking, credit must 'Ce acccrded the cigarette filter for producing the most dra.^utic decreases in average tar and nicotine. By 1964, the year of the Surgeon General's Report, tao-thi:-ds of the post-1954 tar reduction and over four-firths of the nicotine reduction had already been realized. Filter-tipped cigarettes constituted enlv 1.3 percent of all cigarettes smoked in 1952, but following two years of health scares, in 1955 fully 13.7 percent of cigarettes sold were filtered. Filters became the majority type of cigarette in 1960, captured four-fifths of the market by 1970, and currently account for over 90 percent of all cigarettes sold in the U.S. Other changes in smoking behavior have been explored in surreys (U.S. CE-ZV, 1969, 1973, 1976). These include proportion of cigarette smoked, freouency and depth of inhalation, and so on. While the surveys report many desirable changes, it is difficult to disentangle true behavioral changes from "guilt-induced" reporting errors. Suffice it to note that substantial behavioral changes in these areas do not seem probable to this observer. While the proportions of Americans smoking have dropped, population growth has kept the number of smokers from decreasing. On the debit side of the ledger, some 54 million American men and women are consuning over_600 billion cigarettes each year. In Michigan, 2.5 million smokers consumed close to 28 billion cigarettes in 1979. On the credit side of the ledger, nationally more than 30 million Americans have joined the ranks of the ex-smokers, well over a million of them citizens of our State. Furthermore, survey data suggest that fewer teenagers are initiating smoking habits (National Institute of Education, 1979). Continuation and intensification of this trend would assure decreases in the future smoking population, by a combination of attrition of current smokers and nonreplacement by the younger generation. The prevalence of smoking varies significantly within several socioeconomic, demographic categories, as sumtnarized in Table 4. The prime smoking age for both males and females--the years in which the highest percent of individuals are smokers--is from the mid-20s to the mid-40s. The participation rate drops precipitously following the mid-50s, in part due to the fact that cigarette- related deaths are concentrated in the older population. Mbre blacks smoke than whites, again for both men and women. Smoking rates differ dramatically by level of educational attainment, with close to half of males with some high school classified as smokers and fewer than 30 percent of college graduates. The comparable figures for women are a third and a fifth. The income distribution of smokers is surprisingly flat; while fewer high-inccme males smoke than do less affluent males, the highest smoking participation rate among women is in the highest income class. Among working groups, excepting the unemployed whose smoking rates exceed all others, blue collar workers are the heaviest smoking group in our society. Professional and technical workers are the lowest. Thus, though smoking is not confined to any single group in our population, it seems fair to observe that problems of smoking-induced illness have a class-based * The low-tar share of the market, defined as 15 or fewer mg tar per cigarette, exceeds 30 percent. As recently as 1974, it was under 10 percent; and in 1967, it totaled only 2 percent (Surgeon General, 1979). -75- I I I I I ~ °L