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I Please do not cite cr quote withcut -:er-ussicn I I I I I i ~ I t I I I S`IOKING AND HFIILTH LN MIGt iIGAIN Discussion paper prepared for the Governor's Citizens' Panel on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

I I I I I I I . I I I :able 4: Percentage of Begular Adult Smokers, by Sex and Socioeconoaic- Demographic Characteristics, 1975-76 2 Males " Females Age: 21-24 - 41.3 34.0 25-34 43.9 35.4 35-44 47.1 36,4 45-54 41.1 32.8 55-64 33.7 25.9 65+ 24.2 10.2 Race: White 41.2 31.8 Black 50.5 35.1 Education: Grade school or less 37.4 18.2 Some high school 47.8 33.2 High school graduate 45.6 31.9 Some callege 36.1 32.2 College graduate 28.1 21.1 Income: $0 - 4,999 42.5 28.3 $5,000 - 9,999 45.5 33.5 $10,000 - 14,999 45.5 32.5 515,000 - 24,999 40.4 33.0 $25,000 or more 34.7 35.1 Occupation: `Jhite collar 36.6 34.3 (Professional and technical) (30.0) (29.1) Blue collar 50.4 39.0 Farm 36.9 31.3 Unemployed 56.8 40.0 Vot in labor force 32.9 28.2 Source: Surgeon General, 1979, Appendix Tables 2, 5, 6, 7. I %-- -76-

I distribution, with the greatest concentration of siokers fc=d in t~:e blue collar and une:rplo,ved low-education blac:< populaticn. * Finally, in light of recent evidence (jv'hite and Froeb, 1980) on the deletericus ~ "involuntary" or "passive" or "seccnd- ~~ smoking--non..~.~..oxers~ ef~ects of hd inhalation of smoke from others' cigarettes--it is interesting to contemplate trends in this form of smoke ingestion. hhile there is little concrete evidence on the extent of this phenomenon, recent changes in social mores, regarding smoking as the exception rather than the rule, suggest that nonsmokers are less likely to be exposed involuntarily to second-hand smoke. The non-smokers' rights movement (discussed in section N) is both a contributor to and a reflection of newly prevailing attitudes. In some instances, including Michigan's public smoking-restriction law, nonsmoking environments have been legislated into existence. As the above paragraphs suggest, the status of cigarette smoking in Atichigan and throughout the country represents a classic exarr,ple of the proverbial glass being half empty or half full. Over the past quarter of a century, and particularly within the last decade, significant progress has been made toward weaning Americans off of cigarettes. Nevertheless, millions of Americans persist in smoking, despite the widespread awareness of the health effects of sr.;ok.ing (discussed in the next section) and the fact that a majority of s:nokers desire to quit (U.S. DHEIV, 1976). z '~ The class differentials in future illness patterns will be exacerbated if, as C'T I suspect, the higher-participation groups smoke higher t/n cigarettes (and/or ~ more cigarettes per smoker). ~, These class distinctions are not new. Most of the high-participation groups N have held that status over at least the past couple of decades. For example, N while Table 4 shows almost a 20-percentage point difference between participation rates for males with some high school and college graduates, the same difference was evident in 1964 in higher participation rates for both groups (62.0 and 42.5 percent, respectively). Among women, however, the education-based difference is new. In 1964, the difference was only 1.5 percentage points (36.5 and 35.0 percent, respectively). -77- i I I I I I I E I L L L l

L I I f I I I I I J I I I I- I ~ 1 L II. Health Effects of S;..ckinq* Maj or health effects of cigarette smoking are familiar to almost all kr:ericans : smoking is the principal cause of lung cancer, responsible for roughly 90 percent of all lung cancers and accounting for 80,000 lung cancer deaths per year; smoking annually claims over 200,000 victims-frcm cardiovascular disease; smoking is the major cause of chronic bronchitis and emphesema, debilitating chronic diseases whose toll includes close to 20,000 deaths per year. Michigan's share of this burden includes almost 10,000 cardiovascular deaths and over 3,500 lung cancer deaths. As the above data indicate, cardiovascular disease is by far the number one snroking=related killer. Nevertheless, the public's major smoking fear is lung cancer. The explanation for this likely reflects a combination of the general fear of cancer deaths and the heavy publicity emphasis on the link between cigarette smoking and lung cancer. The latter resulted in part from the clear attribution of causality, derived from overwhelming evidence, in the original Surgeon General's Report (Surgeon General, 1964). And while smoking-related cardiovascular disease may kill over two and a half times as many smokers as does lung cancer, the psychological linking of smoking with a disease which also kills hundreds of thousands of nonsmokers is i:uiderstandably somewhat tenuous. Comnon knowledge on smoking-related mortality can be supplemented with additional specific data. Overall, male smokers have a;nortality ratio of 1.7 compared to nonsmokers (i.e., a 70 percent excess for the former). The ratio rises to 2.0., or 100 percent excess, for two pack-a-day smokers. Another way to observe the mortality impact of smoking is to note that a 30- to 35-year old two pack-a-day smoker has a life expectancy 8 to 9 years shorter than that of a comparably aged nonsmoker. The mortality ratios of female smokers are less dramatic than those for males. Recent evidence suggests that this is explained by differences in exposure (e.g., later age of initiation of smoking, fewer cigarettes per day, lcwer average t/n per cigarette). Indeed, when analysts control for exposure character- istics, they find female mortality ratios comparable to those of males (Surgeon General, 1980). Smoking's contribution to cardiovascular disease is multifaceted, affecting numerous diseases in a variety of ways. In many instances, smoking appears to act synergistically with other risk factors, including hypertensicn and use of oral contraceptives. In addition to its role in lung cancer, smoking is implicated in over 20,000 deaths per year from other cancers, including oral cancer and cancers of the larynx, esophagus, bladder, kidney, and pancreas. Perhaps the most striking recent smoking-cancer news is identification of an epidemic of lung cancer among women, whom rrnich of the public thought to be "inamune" to this impact of smoking. The lung cancer mortality rate for women is three ti.-aes as high as it was in 1964, the year of the first Surgeon General's Report. Lfost dramatically, the nianber of deaths from lung cancer in wcmen will soon exceed the ntanber from * Unless otherwise indicated, the principal source of information for this section is the 1979 Surgeon General's Report. -78-

I breast cancer, for years the leading cancer cause of death in women (Surgeen General, 1980). As grim as the smoking mortality picture is, epidemiological data provide encour- quitting. For non-ill quit*_ers,* agement for the current smoker contemplating mortality ratios decline monotonically over time. Fifteen years follewing cessa- tion, former smokers' mortality risks approach those of individuals who have never smoked. The decline in risk is a function of length of smoking history, age of initiation, extent of habit (cigarettes per day), average t/n, and similar vari- ables. It is also noteworthy that the nature of mortality risks changes follow- ing cessation, as some smoking-related diseases reflect cumulative consuznption (e.g., lung cancer), while others are more sensitive to the irrmediacy of smoking. For e:car,ple, some sudden cardiovascular deaths may be caused by the greatly heightened carbon monoxide concentration during and immediately following the smoking of a cigarette. CO concentrations recede fairly quickly after a cigarette is entinquished. The mortality toll of smoking is obviously its most dramatic impact, but the morbidity and disability consequences impose an inIInense burden on smokers, their families, and society in general. Relatively few smokers contract lt.mg cancer, but the vast majority of long-term heavy smokers eventually experience scme degree of chronic bronchitis and/or emphesema.** For those who are fortunate, their disease may simply restrict their "wind", their ability to exercise, climb stairs and the like. For the less fortunate, chronic bronchitis and emphesema are severe- ly debilitating illnesses, seriously restricting activity and often chaining the victim to mechanical breathing apparatus. Many victims of smoking-related heart disease also-find their activity levels restricted. The qualify-of-life implica- tions are profound. Disabling chronic diseases obviously remove many individuals from the labor force. Less corrmonly known are the short-term morbidity consequences of smoking. Male smokers lose 33 percent more work days than nonsmokers; female smokers lose 45 percent more work days than nonsmoking women. All told, this adds to more than 80 million excess person-days of work lost in the U.S. in a single year. In our own State, the figure is close to 4 million person-days of work lost. (See the ne.xt section.) Both male and female smokers experience roughly 15 percent more days of bed disability than non-smokers, or close to 150 million excess days of bed disability throughout the country. This is not far from one excess day each year per man, woman, and child in the State of Michigan. The morbidity and even mortality consequences of smoking are not restricted to smokers. A tenet of the nonsmokers' rights movement (discussed in Section N) long has been that a smoke-polluted environment is hazardous to the health of nonsmokers. For years, the evidence on this question has been limited and mixed, with consensus only that certain high-risk populations (e.g., those wi th heart or lung disease) exposed to concentrated smoke could suffer significant adverse consequences. Recently, however, a study published in the New England Journal of Medicine demonstrated that nonsmokers regularly working in settings have gn * The highest mortality ratios are for individuals who have quit within one year. Analysis suggests that many such individuals have quit because they were suffering smoking-related illnesses. When the motivation to quit is other than present illness, mortality ratios fall. ** :Iknong male smokers of two or more packs a day, the prevalence of these diseases is 4 times that of nonsmokers. arnong high-use female smokers, pre- valence is 10 times that of nonsmoking women. -79- I I I i I I I I I p I ~ L

I F I I I I I I I I I concentrations of smoke experience health ir.macts si::ilar to those of light smokers te and Froeb, 1930) . T7,.us, the evidence on second-hand smoking is that it can be hazardous to health, though one must take care not to exaggerate the probable effects. The most recent Surgeon General's Report (1980), fccusing on smoking and health in women, has drawn considerable attention to another nonsmoking victi.^l of smoking: the fetus. Abundant evidence demonstrates that smoking during pregnancy is a cause of low birth weight. As smoking does not reduce the dura- tion of gestation, the lower birth weight of smokers' babies is attributable to retardation of fetal growth. Svhile the evidence is not conclusive, studies suggest that smoking during pregnancy may affect children's physical growth, mental development, and behavioral characteristics at least up to 11 years of- age. Finally, controlling for all other known factors, studies have found a highly significant risk of perinatal mortality attributable to smoking. The babies of women who smoke during pregnancy have increased risk of sudden infant death syndrome. Children's health can also be harmed by living with parents who smoke. One of the few definitive findings of the studies on second-hand smoking is that children of parents who smoke experience more bronchitis and pneunonia during the first year of life than do children of nonsmoking parents. Smoking and health in women and their children represents one of a few specific areas which are receiving focused attention within the smoking and health con¢mmity. Another area of considerable concern is the interaction of smoking with certain occupational hazards. It has been demonstrated, for exarple, that asbestos workers who smoke have a nich higher rate of lung cancer than would be suggested by the contributions to cancer of smoking and asbestos acting alone. That is, the effects appear to be synergistic rather than additive. Similar relationships between smoking and several chemicals have been suggested, but the epidemiological research needed to establish effects has not yet received adequate attention. While the list of health consequences of smoking is well defined, reflection on the implications of changing smoking behaviors gives pause in assessing the future health consequences of today's and tomorrow's smoking patterns. The illness patterns witnessed in 1980 reflect smoking behaviors initiated as long ago as the 1920s and 1930s. Today's lung cancers clearly represent the result in part of consumption of 1950s' cigarettes, a very different product from that consuned today. Intellectually, the shift toward lower t/n smoking suggests a decrease in at least some of the hazards associated with smoking, asstuning that smokers do not fully compensate for the lower unit dosage of t/n by smoking more cigarettes.* Recently, scientific evidence has emerged to support this logic. In general, low t/n smokers experience mortality ratios about 50 percent higher than those of nonsmokers, but 15 to 20 percent lower than those for all smokers. * The amotmt of nicotine compensation smokers do when shifting to a lower t/n cigarette has been the subject of much speculation and study. An articulate scientific proponent of the nicotine regulation hypothesis--that smokers do comnensate for the lower unit dose by smoking more cigarettes-- is Stanley Schicter (1978). Recent evidence, however, suggests that compensation is minimal, clearly less than that which would fully replace t/n ingestion before the switch (Garfinkel, 1979). -80-

In an interesting new study, Auerback et al. (1979) reported that histologic changes in the bronchial eDithelium of .ecent heavy smokers (two-plus packs a day) showed a frequency similar to that of light smokers (under one pack a day) who died 20 to 25 years ago. They attributed the drar,iatic decrease in frequency in the heavy-use class (from 22.5 percent in the earlier grcup to 2.2 percent in the recent group) to the reduction in t/n per cigarette. They labeled their findings consistent with evidence from epide:niologic studies and interpreted the findings as "presag(ing) a decline in the death rates of cigarette smokers from lung cancer"at some future date." Other researchers have interpreted modern low t/n smoking habits in terms of their equivalency with smoking patterns in the 1950s, where numbers of low t/n cigarettes cr.ultiplied by t/n content were translated into the equivalent number of high (1950s) t/n cigarettes. Possible health outcomes of low t/n smokers were interpreted_in light of the health experience of the earlier generation of "equivalent'smokers. The bottom line of the study was that many of today's low t/n smokers may not be subjecting themselves to statistically significantly higher risks than nonsmokers (Gori and Lynch, 1978). The study can be faulted on numerous technical groiumds (Warner, 1979b), but it adds qualitative evidence to the hypothesis that modern smoking habits may be less deleterious to health. Final determination of the health effects of current smoking patterns must await the passage of a generation. Nevertheless, e:cisting evidence does permit some speculation on future trends. The declining percentages of smokers should reduce the illness toll of smoking, hopefully across the board. Decreased ingestion of tar may lead to a reversal of the lung cancer epidemic; indeed, I expect to see signs of this within a decade or so. However, an apparent increase in the daily number of cigarettes consumed by confirmed smokers* increases their exposure to carbon monoxide which, in turn, might increase their risk of cardiovascular pro- blems. Finally, trace amounts of 4000 additives in modern cigarettes could conceivably exacerbate existing health problems or introduce new ones. All such considerations suggest, at miniimun, a change in the mix of smoking-induced health outcomes (Wynder and HofLnann, 1979). The narrowed gap between male and female participation rates suggests a relative redistribution of the illness burden toward women. * Surveys indicate that average daily consumption has not changed much over the past decade and a half (U.S. DHEW, 1969, 1973, 1976). However, as aggregate underreporting appears to have increased (ZVarner, 1978), it seems plausible that smokers are i,mderreporting their daily consurrmtion by greater amounts. Simply looking at aggregate objective data, it is impossible to disentangle increases in daily consumntion by heavy smokers from decreased participation by light smokers. M, conjecture that regular smokers constnne more cigarettes on a daily basis rests on the assumption of some, though not complete, nicotine compensatien. I I I I I I J I I p L L L

I I I I I I I I I 11! 11 I I- I ~ L L III. cconcmics of Smoking ;ebacco is big business. In 1973, Arericar.s eroended some S13 billion cn tobacco products, over 90 percent (516.6 billion) for cigarettes (Tobacco Institute, 1979). In Kic.iligan, smokers spent $780 million for their cigarettes.* To put these figures-into perspective in the autcmcbile State, national tobacco expenditures are-close to 40 percent of the amount Americans spend on new cars. annual expenditures on tobacco are comparable to the total spent on television sets, radios, records, and r,nisical instr^nents combined. Tobacco expenditures constitute roughly 1.3 percent of all retail expenditures (INli ller, 19"'8). Tobacco is big business, but it is also concentrated business. Despite the existence of dozens of brands of dcmestically-produced cigarettes, there are only six major U.S. tobacco firms. Rivalry among these companies is character- istic of that found in oligopolies (high.ly ccncentrated industries): cempeti- tion focuses on atterrIDts to differentiate and promote brands, as evidenced by close to a billion dollars in promotional spending; there is little price competi- tion. At the manufacturing level, in 1978, 147 establishments produced tobacco products in 20 states; but cigarette manufacturing, accounting for over 90 percent of tobacco retail sales, occurred in only 12 highly mechanized plants, 11 of which are located in three states (North Carolina, Virginia and Kentucky) (Tobacco Institute, 1979; Miller, 1978).** The cigarette business is least concentrated at both ends of the production- distribution spectrum. Final distribution to consumers occurs through some 1.4 million retail outlets, supulied by over 1500 primary tobacco wholesalers and another 1000 miscellaneous kholesalers which also distribute tobacco products (Tobacco Institute, 1979). At the other end of the spectrum, over a quarter of a million farms produced tobacco in 1977. Including farm operators, allottnent holders, and hired hands, an estimated one million people derive income from tobacco farming. However, most of the hired labor, over half of this total, is employed for less than 25 days a year (INtiller, 1978). Svhile tobacco is grown in 23 states, only half a dozen count tobacco as a major cash crop. Table 5 identifies these states and their estimated cash receipts for 1978. The total receipts for these six states is 93 percent of the value of the Nation's entire tobacco crop. That value--$2.55 billion--ranks tobacco as the country's sixth largest cash crop, accounting for 2.3 percent of the total for all cash crops and farm cornmodities (Tobacco Institute, 1979). * This is based on State tax-paid sales (Tobacco Tax Council, 1979). A study of cigarette bcotlegging (discussed below) estimated that 4 percent of Mli chigan cigarette censimmticn was non-State-tax-paid, i.e., bootlegged cigarettes (advisory Commission on Intergovernmental Relations, 1977). This suggests that actual Michigan expenditures were in excess of $800 million. ** The total number of tobacco products factories has dropped considerably in the past half dozen years. In 1972, there were 131 such establishments located in 29 states ClAiller, 1978). -a-

I Table 5: State Cash Receipts :rcn Tobacco, 1978 I I I State Cash Receiots (millions) I North Carolina Kentucky South Carolina Virginia Georg ia Tennessee $ 1106 542 205 I All other states Source: Tobacco Institute, 1979. 174 174 165 184 TOTAL $ 2550 I I I IL L

I I I I u ~ i ~ Tt•.e significance of the size and geographical concentration of the industry is substantial. Fere, suffice it to note that the imortance of the crop and derived consumer products in the six tcbacco states has created a powerful tobacco interest in Congress. By contrast, outside of the tobacco states, for example in Michigan, the economic contribution-of tobacco growing and manufactur- ing is negligible. Indeed, aside from generating tax revenues (discussed i.-runediately below)., tobacco use produces significant econcmic costs in nontobacco states (discussed later in this section). - - The one direct benefit of smoking shared by all states and the federal govern- ment is the generation of revenue. Since 1968, when North Carolina adopted a 2 cents per pack excise tax, all states have taxed cigarettes. As of 1979, state excise tax rates range from a low of North Carolina's 2 cents to a high of 21 cents per pack in each of Connecticut, Florida, and Massachusetts. The federal government taxes cigarettes at 8 cents per pack, a rate unchanged since 1952.* The federal tax grossed $2.4 billion in fiscal 1979, while the states, collectively, grossed 33.7 billicn. In the 365 cities and counties imposing their own local taxes, revenues totaled $130 million.** Net state tax collections ranged from a low of $4.4 million in Alaska to a high of $326.6 million in New York. Michigan netted $141 million from its tax of 11 cents per pack, the tenth highest net revenue in the country (Tobacco Tax Council, 1979). The gap between high- and low-tax states' excise taxation rates explains almost all the roughly 20-cent differential between the average price of a pack of cigarettes in North Carolina (47.3 cents in 1979) and in several high-tax states. (Each of Connecticut, the District of Columbia, Florida, Massachusetts, New Jersey, and New York has average 1979 prices in excess of 65 cents). This price differential has created a lucrative market in cigarette bootlegging in which a single truckload of contraband cigarettes purportedly can yield $20,000 or more in smuggling profits ('Bootleg Cigarettes," 1978). Cverall, high-tax states are estimated to lose from $400 to $500 million in tax revenues each year due to bootlegging ("Cigarette Contraband," 1978; Advisory Ccmmission on Inter- governmental Relations, 1977). The one ter.hnical analysis of bootlegging which attempted to estimate individual states' net gains or losses found that Michigan loses about 4 percent of its excise tax revenue potential (Advisory CortQnission on Intergovermental Relations, 1977). Compared with other states, this does not represent much bootlegging. The incentives for smuggling cigarettes into Michigan are relatively small, since Michigan's 11-cent excise tax is close to the states' average (12 cents) and consequently the average retail price in the State (60.3 cents is close to the national average (60.0 cents). In addition, Michigan's location places it far enough away from the major cigarette "exporting" states (Kentuc'.<y, New Hampshire, and North Carolina) that transportation costs * Since the nominal federal tax rate has not changed during three decades in which virtnsally all other prices have risen, the federal tax has fallen from 35 percent of retail price in the mid-19S0s to 13 percent today. ** Close to half of this total was accounted for by New York City's municipal tax on cigarettes, which yielded $63 million in 1979. -34-

would discourage major smuggling operaticns.* !bst of the states victiru_ed by bootlegging are situated on the Atlantic coast.** Cigarette excise taxes constitute a significant source of state revenue. In Michigan, the excise tax produces close to 3 percent- of t:^.e State's General Fur.ds revenue. One "pragmatic" argument against anti-smoking activities rests on the State's perceived dependence of excise tax revenues: successful anti-smoking efforts,night inflict damage on the State treasury. This argument suffers frcm two major flaws. The first is that even a highly successful anti-smoking effort would not reduce smoking sufficiently to drastically reduce cigarette tax revenues, and any revenue loss could be compensated for by raising the tax rate a modest amount.*** The second flaw in the argument is by far the more i:r~ortant; it is also a central feature of the economics of smoking: by causing illness, smoking imposes signifi- cant costs on the State and the Nation as a whole. Seme of these costs are direct-- the medical expenditures necessitated by smoking-induced illness--but the more substantial costs are indirect--namely, the productivity losses attributable to smokers' missing work due to smoking-related illness. As noted at the outset of this paper, estimates place the national costs of smoking in the vicinity of $40 billion per year. This includes some $12 billion in medical care costs and $28 billion in productivity losses. Together, the direct and indirect costs of smoking equal roughly 10 percent of the total social costs of illness in the U.S. (Cooper and-Rice, 1976, updated to 1980 prices); the direct costs alone account for approximately 8 percent of the Nation's medical care expenses. Michigan's share of these burdens exceeds $S00 million in medical care costs and over a billion dollars a year in productivity losses. This means that, thrcugh insurance premiums, taxes, and direct payments, a typical family of four pays some $200 per year in medical bills attributable to smoking. And the productivity losses due to smoking-related morbidity and disability total more than twice that sum. Both in terms of the public's general economic welfare and the State's budgetary expenditure requirements (e.g., Medicaid and welfare payments), smoking * While there is no published evidence to date, I would expect rising gasoline prices to have deterred stnugglers in general. This would reinforce the decreas- ing real value of the cigarette price differential among states which has been brought about by general inflation and the absence of any significant new state excise activity over the past several years. That is, the differential between high- and low-tax states has not changed, but its real value is dropping as the general price level rises. ** Exceptions are Arkansas, 4tinnesota, Texa.s, and Washingtcn. *** Virtually all studies of the price responsiveness of cigarette consumptien find that cigarette demand is price inelastic. This means that a given percent- age increase in price will produce a smaller percentage decrease in quantity demand. Consequently, a price rise increases total expenditures on cigarettes. This translates into increased tax revenue. 0 -a5- i I I I I I I L

I I I i I I I i I I I 1 exacts a high price. Note again that few of the benefits of cigarette production are captured within Michigan to offset these costs.* * According to a recent study at the University of Pennsylvania, ffiumded by the Tobacco Institute, the core sectors of the tobacco industry (farming, auction warehouses, manufacturing, wholesaling, and vending), combined with support industries, contribute 3,800 jobs within Michigan and a payroll_of $52.3 million. The study estimates the total national economic contribution of tobacco to be close to $50 billion, but 60 percent of this total is the indirect contribution generated by the spending of tobacco-prcduced income Rlharton ARC, 1979). -86-

i IV. Policy Gb tions Efforts to disccurage smoking are numerous and re^iarkably diverse, including such odd bedfellows as smoking cessation clinics and televised anti-smoking cartoons. Many efforts emanate from the public sector, the focus of the following discussion, but credit must be accorded private voluntary agencies for their long-standing active involvement (e.g., the American Cancer Society, American Heart Association, and American Lung Association). Even the for-profit private sector plays a significant role, marketing smoking cessation programs and paraphernalia (e.g., special filters and pills). One reason for the wide variety of anti-smoking activities is the multi- dilc:ensionality of the smoking problem. Helping people to quit smoking repre- sents something quite different than discouraging initiation of the habit. Cciram.micating about smoking effectively with teenagers, many of whom view themselves as imnortal, implies a different message than that which one might transmit to a more illness-conscious adult population. There are significant differences in smoking behaviors, even including specific brand preferer.ces, across age, sex, race, and socioeconomic groups. Though I will not always refer to the relevant sub-problem in the following discussion, these distinc- tions are highly germane to consideration of smoking and health policies. In particular, the two crucial distinctions are those of preventing initiation of smoking vs. assisting cessation and working with adults vs. dealing with children and teenagers. - This section of the paper opens with a brief historical examination of smoking and health policies in the federal government and in state and local govern- ments, with separate attention to Michigan. Following that presentation, I suggest a variety of possible policy initiatives within Michigan. My objective is not to provide a menu from which policies can be selected, but rather to offer a sampling of diverse alternatives to illustrate the range of options and to serve as food for thought. History of Smoking and Health Policies Federal Government Policies* Federal policy irn the area of smoking and health has concentrated on two not-unrelated principal tactics: (1) developing knowledge and providing infor- mation in order to educate and persuade the public not to smoke and (2) estab- lishing marketing rules of the game. The knowledge and information strategy dates from publication in January, 1964 of the first Surgeon General's Report, the Report of the Advisory Corrmittee to the Surgeon General of the Public Health Service on Smoking and Health (Surgeon General, 1964). Reflecting over a year's worth of-work by the 10- member Comnittee, the Report received widespread attention with its doctanenta- tion of the serious illness consequences of cigarette smoking. Perhaps most noted by the public was the Report's clearly defining the link between smoking * This discussion will focus exclusively on policies explicitly intended to discourage smoking. Thus, for example, federal tobacco price supports--an agricultural policy-will not be ccnsidered. C1~1 I I I i I I I I I L L L

I I i it I I I I I i q I I I and ltmg cancer in men as casual. In•response to the Report, adult per capita cigarette consurption dropped for only the second time since the smoking-health scares of 1955-54.* Following the Surgeon General's Report-, the "pure" knowledge and infor:nation strategy entered a lengthy "quiet" period.** The Federal Cigarette Labeling and Advertising Act of 1965 (P.L. 89-92) required the Secretary of the Depart- ment of Health, Education, and Welfare to prepare regular reports monitoring the scientific literature on smoking and health and offering legislative recom- mendations. Beginning in 1967, reports were published every year except 1970 and 1977. The reports, none of which received much public attention, were pre- pared by the National"Clearinghouse for Smoking and Health, the predecessor to the current Office on Smoking and Health. A small operation, NCSH labored with a budget of only $900,00 in its final year. As its name suggests, NCSH was an information clearinghouse primarily serving scientists and educators. NCSH attempted to keep on top of the burgeoning research in the area, much of it funded by the National Institute of Health, and to assist ccmn,mities in developing anti-smoking programs. The "quiet" information strategy ceased rather abruptly, if temporarily, in 1978 when HE.Y Secretary Joseph Califano labeled cigarette smoking "Public Health Enemy Number One" and announced a reinvigorated federal anti-smoking effort (Califano, 1978). Califano replaced the NCHS with the new Office on Smoking and Health and proposed a near-trebling of the government's smoking and health budget. While the publicity surrounding the initiative was spectac- lar, the guts of the federal comnitment looked suspiciously like those of earlier years, only more plentiful: most of the dollars were devoted to research and education, the least objectionable uses 'from the perspective of * Attribution of causality to the Report and associated publicity reflects my interpretation of the data (Warner, 1977). All that one can say scientifically is that per capita conswmption dropped that year following eight consecutive years of growth interrupted only by a slight decline in 1962. Note, however, that the single pre-1964 decline occurred the year of publication of England's "equivalent" of the Surgeon General's Report (Royal College of Physicians, 1962). Throughout this discussion I will discuss "events" (e.g., the Surgeon General's Report) as "causing" decreases in smoking rates. The reader is urged to keep the above caveat in mind. In addition, I am interpreting an "event" as includ- ing all of the publicity related to it, as well as derivative less-well-known activities which occurred the same year. ** By "pure", I mean activities intended solely to influence censimier behavior through development of knowledge and provision of information, but with no intervention into the marketing of cigarettes. As we shall see irmediately below, much of the gover.vnent's policy has used marketing interven- tions in order to persuade consumers. Such "impure" .rnowledge and information provision was hardly "quiet". -88-

the pcwerful tobacco lobby-in Congress.* Follcwing months of heated exchanges in the press between Califano, the tobacco industry, and southern politicians, the "pure" information strategy regained its "quiet" status. The federal government's other strategy has involved several interventions into the marketing of cigarettes. The first, accomplished through the afore- mentioned Cigarette Labeling and Advertising Act of 1965, was to require inclu- sion of a health warning label on all cigarette packs. The warning was " strengthened in the Public Health Cigarette Smoking Act of 1969 (P.L. 91-299), which also required manufacturers to print per-cigarette tar and nicotine content on all cigarette packs and advertisements.** In addition to its labeling requirements, the 1969 Act wrote part of the text for one of the most interesting chapters in the smoking and health policy story: the Act banned broadcast advertising of cigarettes after January 1, 1971. While this might appear to have been a significant victory for the anti-smoking forces, considerable evidence suggests quite the opposite (Warner, 1979a). This is because, beginning in 1968, broadcasters were required to donate air time for anti-smoking messages to "counter" pro-smoking advertising. The Federal CocrIImmication Commission's Fairness Doctrine required broadcasters to balance time devoted to both sides of a controversial issue; and smoking, the Comnission declared, was a controversial issue. While donated time never approached pro- smoking ad time, the ruling amounted to a $75 million subsidy (in 1970 dollars) to anti-smoking groups. Several analyses have concluded that the anti-smoking messages were considerably more effective in deterring smoking than pro-smoking ads were in encouraging it (Hamilton, 1972; Warner, 1977). Thus the net effect of prohibiting broadcast advertising of cigarettes, and hence ending the obliga- tion of donated time, would be favorable to the tobacco interests. And it is an empirical fact that following consecutive declines in 1968, 1969, and 1970, per capita consumption rose in 1971. It should be noted that prior to passage of the Act, the tobacco industry had made efforts of its own to voluntarily withdraw from broadcast advertising (Friedman, 1975). * For fiscal year 1979 Califano proposed a total of roughly $30 million for all federal smoking and health activities. Of this, some $6 million was earmarked for the new Office on Smoking and Health. Immediately preceding the new initiative, federal smoking and health dollars summed to $10 to 12 million. Though the increase was substantial, the new total was not large by federal enterprise standards. A commonly-noted coccparison was the three-quarters of a billion dollars being spent by the tobacco industry on cigarette promotion. It should be noted, though, that the industry itself devotes funds to _cnoking and health research. As of June 1, 1979, the combined commitment of the indus- try equalled $82 million (Tobacco Institute, 1979). ** Many knowledgeable observers consider the Acts to have been tobacco indus- try victories. The Congressional-compromise process resulted in the 1965 Act's prohibiting for three years any governmental unit's requiring health warnings on cigarette advertisements. The industry also won its battle to prevent non- uniform state and local regulation, which would.have been costly. Even the health warning on cigarette packs could be viewed as a victory of sorts: some considered it to provide a legal defense for the industry in instances of personal injury suits (Friedman, 1975). I I I I I I I I ; I I L L L -89-- L

I I I I I I I I I- I L L Ironically, an obvious potential federal policy lever has remained umtouched. .-Ls noted in section III, the federal cigarette excise tax has not been changed since 1952. The failure of this component of cigarette price to keep pace with inflation means that the federal government has been contributing to decreasing the real price of cigarettes, an influence which, other things being equal, translates into increased cigarette consumpticn.* While raising taxes is not in general, a popular governmental activity these days, the federal-goverrur,ent did_give consideration to taxation strategies in defining the new anti-smoking initiative. Of particular interest was the proposal for an excise tax graduated according to t/n content. At the same time that Administration analysts were examining the issue, Senator Edward Kennedy developed a bill which would have imposed taxes ranging from 5 cents per pack for the lowest t/n cigarettes to 50 cents for the highest. The logic behind the graduated tax is that it would induce high t/n smokers to switch to low t/n cigarettes. While there is some merit to the argument, ironically the tax could have the opposite impact for some individuals (Harris, forthcoming). The question is necessarily theoretical, since there is very limited experience with graduated taxes and no experience at the federal level, where presumably the system could work best.** State Policies While federal policies have focused on the marketing of cigarettes, state policies have concentrated on direct consurnption influences. In part, of course, this could reflect the prohibition of nonfederal advertising regulation included in the Federal Cigarette Labeling and Advertising Act of 1965. But both earlier and recent history suggest that the consumption orientation of state policies might have prevailed even in the absence of the Act's language. 'IWo types of policies have dominated states' activity in the smoking and health arena: excise taxation and restriction of smoking in public places. While three-quarters of the states have both in effect, the histories, motivations, and effects of the two policies have been radically different. Indeed, excise taxation cannot in fairness be labeled an "anti-smoking policy" at least as regards its origins. By contrast, the smoking restrictions laws are a direct development of the nonsmokers' rights movement, the 1970s' anti-smoking theme. *'Ihe consensus estimate of cigarette price elasticity of demand--a measure of the responsiveness of demand to price changes--is from -0.4 to -O.S. This means that a 10 percent price decrease (increase) would increase (decrease) demand by a 4 to 5 percent. While the federal government's excise tax did not keep pace with inflation, state excise taxes have, though not uniformly over time. As is discussed below, state excise taxes rose dramatically from 1964 to 1972, causing cigarette prices, to rise faster than general inflation, but since then there have been few excise tax increases; consequently, real cigarette prices (i.e., adjusted for infla- tion) have been dropping rapidly. ** New York has tried such a tax, but the potential for interstate bootlegging, the ease of state border crossing, makes it impossible for a state to administer successfully a significantly graduated tax. That could only occur at the federal level where the difficulties and costs of smuggling operations would be considerable. -90-

I That excise taxation was not originally intended to discourage s~noking--rather it was viewed as a revenue-raising device--is illustrated by the early entry into taxation of the tobacco states. The average year of_first enac u;ent of a cigarette excise tax for those states was 1939, compared with an average of 1940 for the other states. If North Carolina, the last state to adopt an excise tax (1969), is dropped from the calculation, the five remaining tobacco states' aver- age entry occurred in 1933, considerably earlier than the non-tobacco states. Initiation of excise taxation cannot be considered an anti-smoking policy-- indeed, only three states did not tax cigarettes by 1964, the year of the first Surgeon General's Report--but evidence presented in Table 6 suggests that excise taxation gained an anti-smoking "flavor" in the early years of the anti-smoking campaign. Prior to the first widespread publicity linking snoking to illness in the early 1950s, both the tobacco and other states imposed or increased taxes . with an identical frequency; resultant tax rates were quite close. However, from the time of the first publicity to the year prior to the Surgeon General's Report, the non-tobacco states increased taxes 60 percent more often than the tobacco states; at the end of the period,per-pack tax rates in the former ex- ceeded rates in the latter by 40 percent. From 1964 through 19i9--the "modern era" of the anti-smoking campaign--non-tobacco states increased their taxes twice as often as did the tobacco states, and average tax rates at the close of the 1970s were twice as large.* The growth in excise taxation has not been uniform throughout the years of the anti-smoking era. The nine years following issuance of the Surgeon General's Report saw an unprecedented flurry of excise tax activity, with states averaging close to a dozen tax increases per year. Beginning in 1973, however, new tax legislation slowed to a virtual standstill. From that year through the end of the decade, states averaged under 3 increases per year. (See Table 7.) A gen- eral opposition to new taxation may account for some of the slowdown. The principal explanation, however, seems to be recognition that years of rapidly- growing tax rates in the non-tobacco states had produced cigarette price differentials large enough to encourage interstate bootlegging. In addition to the social undesirability of such crime, bootlegging was draining potential tax revenue from the high-price states. According to one study, New York State, the most significant victim of bootlegging, lost $72.3 million in excise tax revenue in 1975. Michigan--an average tax, average price state--lost about $6.9 million (Advisory Comnission on Intergovernmental Relations, 1977). The general taxation climate combined with the bootlegging concern suggests that state tax increases may remain infrequent in the next few years. If this proves to be true, and assuming that the federal gover-iment does not increase its rate, the real price of cigarettes (i.e., cigarette price relative to the general price level) will continue to fall. An index of real relative cigarette price (set at 100 in 1967) has already fallen from 107.98 in 1972 to 92.02 in 1978. Such decreases in the real price of cigarettes contribute to increased consumption. Perhaps of greatest concern, the most price-sensitive (Z consurr.ers--teenagers--are finding it continually easier to afford cigarettes. U1 * Due to the relatively small number of cases involved, these differences are to not statistically significant. Nevertheless, they are strcngly suggestive. w 0! i I I I I I- p L -91-

I i I I Table 6: Excise Taxation by the States r i Average Number of Tax Average Rate of Per-?ack Increases Per State a Taxation (end of period) i 6 Tobacco States Other Statesb 6 Tobacco States Other Statesb ~ i 1921-1952 1.0 1.0 2.50C 2.88c I I 1953-1963 1.0 1.6 1964-1979 1.3 2.6 3.75 6.75 5.28 13.58 I I I Notes: a Includes first enactments b Includes District of Columbia - I Sources: Tobacco Tax Council, 1979, and Warner, 1980b. L L L -92-

Table 5z: Number of States with Tax Increases (Decreases), By Year No. of States with No. of States with Year Increases (Decreases) Year increases (Decreases) 1 1951 4 1966 18 1952. 4 (2) 1967 4 (1) 1953 0 1968 14 1954 3 1969 8 1955 5 1970 17 1956 12 1971 13 1957 3 (1) 1972 13 1958 8 1973 2 1959 8 1974 2 1960 13 1975 5 1961 6 1976 2 1962 12 (1) 1977 2 1963 9 1978 6 1964 11 1979 1 (1) 1965 8 ~ Source: Tobacco Tax Council, 1979, Table 7. -93- I I u I I I I I I ~ L L L

I I I I I I i i I I I I In contrast to excise taxaticn, state laws restricti.^.g srr.oking in public places are a pnencmencn of the 1970s, clearly a product of :.h:e anti-smoking csrmaigng nhile the :irst such law went on the books in 1392 (Ver;^ont prohibited smoking in any place in wnich the cwner or occupant posted no-smoking signs) , by the beginning of the 1970s only five states had relevant laws on the books. As Figure 3 shows, however, the growth rate from 1972 on aas explosive. By the end 1978, 36 states had relevant laws in effect. "Non-smokers' rights" has been -translated from a slogan into a reality. In addition to the simple diffusion of legislation a,^:ong the states, the re- strictiveness of laws has grown over time.* All of the five pre-1970s laws were only minimally restrictive. Of 13 laws passed frcm 1972 through 1974, eight were minimally restrictive, five moderately restrictive, and none highly restrictive. By contrast, of 37 new laws dating frcm 1975 through 1978, 10 were minimally restrictive, 17 moderately restrictive, and 10 highly restrictive. Table 8 presents data on the diffusion of new laws over time and the average restrictiveness weight per law per year.** Further evidence of the direct link between the nonsmokers' rights movement and smoking restricticn laws is fotmd in the distribution of laws among the states. By the end of 1978 only two of the six tobacco states (33 percent) had passed any smoking-restriction legislation, while 34 of the 45 other states (75 percent) '* Determination of the restrictiveness of a law required subjective judgments. In general, I rated laws as minimally restrictive if they refer to only a limited number of sites in which people spend relatively little time (e.g., elevators or public transportation). By contrast, a highly restrictive law is one with broad coverage and/or inclusion of sites populated by large rnmioers of people for significant periods of time (e.g., work places, public buildings, stores). While the classification of individual laws is subjective, I attempted a classification by myself and then compared my results with those prepared by the Tobacco Nferchants Association (Bloom, 1979). In the few instances in which discrepancies existed, I discussed them with an analyst at the Associa- tion and, when appropriate, adjusted my classification. Despite the subject- ivity of the process, our classifications were remarkably consistent. It should be eamhasized that "restrictiveness" is assessed independent of enforcement. Few of the laws are vigorously enforced. Most states rely on voluntary compliance resulting from social pressure and general "good citizen- ship." ** The restrictiveness weights were set arbitrarily as follows: minimally restrictive = 0.33, moderately restrictive = 0.67, and highly restrictive = 1.00. -94- 1

Figure 3: Diffusion Among the States of Legislated Restricticns on Smoking in Public P(cces 40, 35 -~ ~ 4 49 5 67 68 69 70 71 72 73 74 75 76 77 78 Year (!9_) Source: Unpublished data supplied by the Tobaccc Merchants Association and the Tobacco Institute. -95- I I I I ~ I I I p L L L

I I I I I Table 8: New Annual State Smoking-Restriction Legislation- Number and Average Restrictiveness I Year(s) -No. of new laws Average Restrictiveness* 7 5 1892-19 1 i 1972 3 .33 .33 1973 3 44 I 1974 7 . .52 1975 17 .65 1976 5 .60 1977 11 .76 1978 4 67 I . - 'See text footnotes for meaning of "restrictiveness" and restrictiveness weights. I Sources: Same as Figure 3, plus Warner, 1980b. L L -96-

I had such legislation on the books. If one separates cut t:e six other states which account for almost all tobacco production not attributable to the "big six" states, the percentage rises to 32 percent. Indiana and Wisccnsil, t:,;o of the "little six" (the others being Florida, Maryland, Chio, and Connecticut), had no relevant laws on the books as of the end of 19;5. ,Ainnesota is commonly acknowledged as having the Nation's most comprehensive smoking-restriction law. Passed in 1975, H 79 (the nli,-wer of the bill) restricts smoking in work places, restaurants, food stores, retail stores, public build- ings and meetings, health facilities, cultural facilities, public transporta- tion, and elevators. A recent survey found the public generally quite supportive of the law, including the smoking population.* It should be emphasized that the motivation underlying smoking-restriction laws is not to reduce the amount of smoking pe~r se, but rather to protect nonsmokers from the irritation and potential hazar E7o7involuntary exposure to smoke. Nevertheless, one might expect that smoking-restriction laws, particularly the highly restrictive ones, would force a reduction in total cigarette consumption, simply because smokers would be prohibited from smoking in unavoidable designat- ed places. Unfortunately, analysis of this phenomenon has been extremely limited to date. One study comparing states' consumption rates did not identify an impact (Bloom, 1979) and my own aggregate time series study proved inadequate to the analytical task ('nlarner, 1980a). The question may never be resolved, though other state cross-sectional analyses or disaggregated microeconomic constmiption survey studies might identify such an effect. Growth of the laws correlates highly with the recent decline in per capita consumption, but this does not appear to reflect causation. Rather, it seems probable that the former serves simply as a good gauge of a growing public nonsmoking sentiment, while the consiumption declines reflect a delayed behavioral response to the entirety of the anti-smoking campaign. Taxes and smoking-restriction laws are not the only smoking-health activities engaged in by the states. Many states require education on smoking and health as part of-their schools' health education curricula.** Revie,s of school smoking education programs emphasize the nonscientific development of most such programs and the lack of evaluation mechanisms to assess the programs' effective- ness (Surgeon General, 1979; Thompson, 1978; Wynder and Hoffman, 1979). The * Personal cocrmamication with Steven Coombs, Director of the Minnesota Poll. ** It is virtually impossible to determine from readily available data how many states require such education. The most authoritative source, a survey by the American School Health Association, found 35 states mandating health educa- tion including material on alcohol, drugs, and tobacco. (Tobacco was not treated separately.) Another 12 states had legislation encouraging such educa- tion. However, many of the pieces of legislation are extremely ambiguous as to specific content, amount, and timing of the education. It appears that few if any states have specific requirements enbodied in legislation focusing exclusively on smoking. (Person cortmamication with ASHA.) -97- i I I I I ! I I I I ~ L

I I I r I I u I i ~ I ! I L reviewers' frustration at the inability to evaluate progrars is palpable. nere are a couple of prominent exceptions to the non-evaluation rule, including t.':e School Health Curriculum Project and the University of Illinois .antisnoking Education study. Smoking education techniques have been categori:ed, with cne approach (with many variations) receiving a great deal of attention and experi- mentation: the youth-to-youth approach, use of respected peers in counseling and educational efforts. Unfortunately, the limited evidence on youth-to-youth programs and more traditional approaches is not enceuraging. In general, health education programs have not evidenced much ability to reduce the initiation or continuation of smoking among children. The children's knowledge level rises-- over 90 percent of surveyed students demonstrate an intellectual appreciation of the basic health consequences of smoking--but the link between their lciowledge and behavior is tenuous at best. This supports the notion that the conventional education message, effective with many adults, may not be an effective strategy in dealing with pre-adult smoking. . Other state-legislated activities, such as restrictions on vending, seem to be of minor importance. Local Government Policies Local government smoking and health policies are a microcosm of state policies, though at a much lower level of activity and with differences in emphasis. ttany, perhaps most local units have either no smoking-and-health policies or relatively insignificant rules, such as those relating to vending. Several towns, cities, and counties restrict smoking in public meetings and elsewhere. btany local school systems require smoking education components in their curricula, either in satisfaction of or in addition to those mandated by state policy. Relatively few local governments levy their own cigarette excise taxes, in part due to the ease of border crossing when the jurisdictional botmdaries are only a matter of a few miles at most. Furthermore, when local taxes are levied they tend to be small. A notable exception is New York City's tax which in 1979 generated $63 million, or close to 60 percent of the total revenue produced by - the 343 cities tadng cigarettes. Table 9 indicates the number of local tmits taxing cigarettes per year since 1963. Note that all such taxation is currently concentrated in seven states and only three of these have more than two local units taxing cigarettes (Alabama, biissouri, and Virginia). Michigan Policies In many respects, Michigan appears to be an average state in terms of its smoking and health policies. Its excise taxation pattern and amount are fairly typical; its smoking-restriction legislation, though progressive in certain dimensions, is rated moderately restrictive, the most corranon classification for those states which have laws in effect; the State has a broad school health education requirement which includes smoking along wi th numerous other health topics. -98-

I I Table 9: Cigarette Excise Taxation by Local Units of Government iscal No. of_states with local units of government imposing own tax No. of cities with own tax* No. of counties with own tax Total local units with own tax Year (1) (2) (3) (4)-(2)+(3) 1963 10 219 6 225 1964 10 220 6 226 1965 11 254 7 261 . 1966 11 269 10 279 1967 11 303 10 313 1968 11 308 10 318 1969 10 251 11 262 1970 10 263 12 275 1971 10 272 14 286 1972 10 363 15 378 1973 10 355 15 370 1974 8 285 15 300 1975 7 . 349 16 365 1976 7 348 17 365 1977 7 347 17 364 1978 7 348 17 365 1979 7 348 17 365 *For 1963-1971, excludes Florida cities, since muni.cipal taxes were in effect in lieu of the state-imposed tax. Source: Tobacco Tax Couacil, 1979, Table 16. ~ C1T I I i I I L 6 L L -99- L

i I I f I i'. I I I I i I t L Michigan enacted its first excise tax on cigarettas in 1947, beccraing the .i2r.d state to adcpt an excise tax.* The original 3-cent per pack tax was increased four times (legislation in 1957, 1960, 1962, and 1970) and decreased once (1961). The current tax of 11 cents per pack is close to the states' average (12 cents) and produces a retail price (60.3 cents) virtually identical to the national average (60 cents). The tax generated some S141 million in 19"9 on sales of close to 1.3 billion packs of cigarettes. There are no local umits of government within Michigan imposing their own cigarette excise tax. At one level, Michigan can be classified as an innovator in the area of smoking- restriction laws: in 1967 Michigan became only the ;ourth state, and the first outside of New England, to enact a public smoking restriction. The law, Act 227, prohibited smoking on elevators. In 1976 and 1977, the State legislature passed a series of smoking-restriction laws pertaining to health facilities, food stores, and restaurants. While health facilities are covered by most states' laws, only about 10 states restrict smoking in either food stores or restaurants. I have no concrete evidence on compliance, but my impression is that compliance is good, and based primarily on social pressure, the principal "enforcer" of virtually all smok- ing-restriction laws. In 1969 the State legislature passed the Critical Health Problems Act which re- quired health education on a wide variety of topics, including smoking, in both elementary and secondary schools. The Act is clear in its intent but (perhaps desirably) vague concerning implementation. Individual school districts throughout the State define their own health education curricula, and one suspects that those districts which provide significant smoking-and-health education do so out of their own conviction as to its importance; compliance with State law does not demand a significant effort.** Policy Options in Michigan In the remainder of this section, I describe a range of policy options for our State. As noted above, my purpose is simply to indicate the breadt.'i or diver- sity of options to stimulate productive deliberations by the Panel. Options missing here reflect the limits of my lanowledge and imagination, not intentional exclusions. Before listing policy options, I will identify seme guidelines which I personally believe important in approaching the smoking problem in Michigan: - A wide range of options should be examined with consideration given to recoeQnending many,if many appear likely to be cost- effective. *.actually, 31 states taxed cigarettes in 1947. In 1948, when Mic,'Ligan' s tax went into effect, seven states joined the rolls of cigarette-taxing states. ** Smoking education efforts probably vary widely across school districts. I have little knowledge of the variations and feel t.',.at this is a subject worthy of exploration. -1a0- L

Policy recorrQnendations should concentrate separately cn each of preventing initiation and assisting cessaticn of smoking. The problem of smoking by teenagers should be viewed and treated separately from that of smoking by adults. Given the State's near-term economic climate, reccrsnended policies should not require substantial expenditures; revenue-raising proposals should not envision significant new taxation. No policy recornnended should be prohibitory, except for smoking prohibitions designed to protect the health or rights of others (e.g., nonsmokers) and prohibitions relating to the behavior of minors. RecorQnended policies should be flexible, i.e., readily capable of being modified or ceased; thus, for example, intractable bureaucratic approaches should be discouraged. Evaluation mechanisms should be built into any policy recommendations; the evaluation function should be taken seriously in designing, implementing, and running.recom- mended activities. - Innovative approaches to the smoking problem should be sought and should receive serious consideration. The snoking-and-health field suffers from a notable lack of imaginative approaches. There is no obvious categorization of "types" of policies in the area of smoking and health, but for convenience I have structured this presentation by grouping policy options under the following headings: economic approaches; media campaigns; other publicity; legal strategies; education; other. Please note that these are not mutually exclusive categories and that several policy options properly belong -in more than one category. Economic Anaroaches As section III and muc'a of the section have emphasized, excise taxation lies at the heart of economic policy regarding smoking. The most obvious economic policy option would be to significantly raise the State's excise tax. Given the inelasticity of demand for cigarettes--the relatively small response of quantity demanded to a change in price--an excise tax increase would be expected to reduce conszmmtion by a relatively small amount and increase tax revenues. Of course, the latter depends on the absence of significant new bootlegging. The threat of bootlegging serves as a constraint on the size of a tax increase. A significant increase in the excise tax does not seem to be a desirable policy for a number of reasons, including the threat of bootlegging, the current general antipathy toward additional taxation, and the sense that a new large cigarette tax might be viewed as punitive. However, variations on, or using, _101- ( I I l I i L L

I u I I I I I ~ I I i I I I L L conventional excise taxation can be considered. Here I will discuss two, a graduated t/n tax and a small additional excise tax ea:marked for smoking-and- health program pureoses. The idea behind a graduated t/n tax is that while demand for cigarettes in general :ray be price inelastic, demand for different types of cigarettes may be quite price sensitive. That is, a general cigarette tax increase rr,a,v not discourage much smoking, but a tax rising significantly with t/n content r.tignt induce a lot of high t/n smokers to switch to low t/n cigarettes. For the con- firmed smoker, a long-term shift toward low t/n might substantially reduce health risk (Auerback et al., 1979; Gori and Lynch, 1978; 'Hymder and Hoffran, 1979). As noted above, the federal government investigated imposition of a federal graduated t/n excise tax, but neither HEW's investigation nor Senator Kennedy's bill resulted in adoption. Successful implementation of a significant State t/n would be exceedingly difficult due to the bootlegging incentives it would create. Adoption of a small differential tax would reduce the bootlegging danger, make the point such a tax is intended to convey, and establish Michigan as a"laboratory"-testing consumer response to a graduated t/n tax. We should keep in mind, however, that such a tax is not costless. In addition to the political response it would engender, it would add to distribution and collec- tion costs. Perhaps a more appealing tax strategy is a small "health tax." Revenues frcm the tax could be earmarked for one or more State smoking-and-health activities. For example, beginning in 1963 the government of Iceland imposed a tax on cigarettes which was devoted to supporting the entire program of the Icelandic Cancer Society. In 1971, the Australian Cancer Society proposed addition of a one-cent per pack educational tax. (The proposal was not accepted.) 1%7iile the idea of earmarking a cigarette tax might seem "radical", we should keep in mind that the U.S. national highway system has been financed by an earmarked gasoline excise tax (Green, 1977). As an example of a biichigan "health" tax, consider an increase in the current excise tax from 11 to 12 cents, or one cent per pack. Such a tax would be minimally burdensome--even a two-pack-a-day smoker would incur an additional annual tax liability of only $7.30 ($3.65 for the pack-a-day smoker)--yet it would generate revenues of roughly $13 million, a dramatic sum for State smoking- and-health spending. The tax has the additional attractive feature that it "self- destructs" as need for it recedes. That is, if the anti-snoking activities it funds are successful, revenues from the tax would drop as cigarette consimtption decreased. The excise tax is intended as a negative influence on smoking, a deterrent. Taxes can also be used as positive incentives. In particular, the State's individual income tax can be used to encourage individuals to quit smoking, while corporate taxes provide a vehicle for inducing business involvement in the anti-smoking effort. In both cases, some portion of expenditures on efforts to reduce or cease smoking can be allowed as tax credits. Thus, the individual who spends $150 on a c^mQnercial smoking cessation program might•be entitled to a $75 credit on his or her income tax, similar to treatment of contributions to Nlichigan -102-

I universities and libraries. Corporate tax credits could reward businesses for developing smoking cessation programs for their employees.* The major problem with this proposal, other than the loss of tax revenues and potential for abuse, is that it would be difficult, and possibly inappropriate, to provide such tax assistance for efforts to combat only one deleterious habit. Adoption of such tax credits would lead rapidly to demands for credits for e:cpenditures related to combatting alcoholism; excess weight, lack of exercise, etc. This would not necessarily be undesirable, but anyone consider- ing this strategy must recognize the substantial short-r,ui impact it would have on State revenues.** Nledia Camnaigns The saga of federal policy on broadcast advertising of smoking--and anti- smoking--serves as a potent reminder of the power of the media, as well as of the subtle, often counterintuitive outcomes of policy. When federal law re- moved pro-smoking advertising from the airwaves in 1971, anti-smoking forces hailed the move as a victory. So did the tobacco industry, albeit much more quietly. The industry recognized that the "equal-time" anti-smoking rr.essages, required to balance their ads, were deterring more smoking than their ads induced. Removal of both sets of ads, they reasoned (apparently correctly), would produce a net addition to cigarette consumpticn (Warner, 1979a). Elimination of the need for broadcasters to donate air time to the anti-smoking cause forced anti-smoking_messages to compete with munerous other worthy causes for scarce public-service air time. Consequently, the anti-smoking presence virtually disappeared from television and radio; it has been minimal for almost a decade. In foranil.ating the new anti-smoking campaign in 1977, HEW's Task Force examined strategies to regain some of the broadcast prominence of the anti-smoking message, but to date little has been accomplished in this area. Broadcast anti-smoking messages will never constitute a cure for smoking, but analysis suggests that the 1968-1970 messages decreased cigarette cons~tion 3 to 4 percent each year (~/arner, 1977). Long-run influences, particularly in keeping media-susceptible children off of cigarettes, are unknown. Nevertheless, use of media campaigns, particularly in the broadcast media, is a strategy which warrants serious attention. 17ie benefits of even small reductions in * Business involvement in promoting the health of employees is growing. RQughly 15 percent of businesses have smoking educaticn programs and another third have indicated interest in developing programs. Smoking ranks third behind hypertension and weight-control as the subject of business health education programs (National Interagency Council on Smoking and Health, 1979). ** I refer to the short-run impact because after a few years, it is possible that savings in Medicaid expenditures, worhan's compensation, etc., would outweigh the revenue loss, translating into a net suYplus. -103- II i I i IL 1 I L I- L

i i I I I I I I I I I I L L I L smoking well may outweigh the costs of producing the campaigns.* `dchi:an cculd devote e:t-ort to getting anti-smoking messages on TV and radio within the State. The conventional "moral suasion" approach could be employed, but success in getting broadcasters to donate public service time to smoking would translate into reduced time for other worthy causes. Alternatively, the State could apply some or all of the one-cent health tax to purchasing cer.ercial air tir,:e. The $13 million generated by a one-cent health tax could buy a lot of local air time. Use of the media to sell health messages is in its infancy. Five years ago at the Third World Conference on Smoking and Health, an advertising executive urged policy makers to contract with professional advertising agencies to develop a complete broadcast media anti-smoking campaign. The executive noted the apparent success of the 1968-70 "equal-time" messages and wondered how much more effective they might have been had they benefited from professicnal manage- ment (Green, 1977). Her question remains; the State could begin to provide an answer. Indeed, the State might be able to take advantage of professionally- developed broadcast messages recently produced under contract with the federal Office on Smoking and Health. A variety of other media strategies seem open to exploration. Imitating the Anerican Cancer Society's "IQ" (for "I Quit")-campaign of several years ago, the State could use prominent local personalities--sports figures, news conmentators, etc.--to plug the anti-smoking message. The nonbroadcast media could be used too. Other Publicity At various times over the past sixteen years, the federal government has "bought" air time for its anti-smoking message by making smoking a newsworthy event, semething the TV and radio news networks felt compelled to cover. The principal occasions have been release of major docuznents, such as the first and two most recent Surgeon General's Reports (1964, 1979, 1980), and delivery of strongly-worded speeches by prominent individuals (Califano, 1978). The final outcomes of the deliberations of this Panel and Governor Milliken's aruiouncement of new State smoking-and-health initiatives could provide grist for this mill. Other opportunities to acquire publicity for the anti-smoking cause should be sought out and exploited. Possibly the State could sponsor a nonsmoking day or week or cooperate with the American Cancer Society in its annual "Great American Smoke-Out." Legal Strategies There are a variety of legal strategies with which to attack the State's smoking problems. With smoking-restrictiorn laws ever more conmonplace, and with social mores moving clearly in the direction of the rights of nonsmokers, new, more comprehensive public smoking-restriction legislation might receive a favorable * To date, no one has estimated the economic benefits attributable to reductions in smoking; they are not simply a proportionate decrease in the costs of smok- ing (Luce and Schweitzer, 1978). I am currently working on methods to estimate such benefits; but the benefit-cost balance will remain a mystery for at least several ;nonths. -104- L

I t hearing. As noted before, Minnesota's law is generally regarded as the \aticn's most restrictive. Particularly given the acparently favorable assessmezt of the law, * it might serve as a model for new Nlichigan legislaticn. Areas covered by the liinnesota law not covered in Michigan include work places, retail stores, public buildings and meetings, cultural facilities, and public transportation. The last three of these are dealt with in the laws of a:najority of the states having smoking-restriction laws. For understandable reasons, the least-covered area across the states is the work place, with only five states i,rposing any relevant restrictions. However, the recent scientific evidence on the adverse effects of concentrated second-hand smoke in work settings (Stihite and Froeb, 1980) should increase interest in, as well as the logic of, work place restricucns. Needless to say, such restrictions must apply corrJnon sense, avoiding significant disturbance of production processes. Smoking restriction laws rely heavily on social pressure and voluntary compliance; police enforcement is a rarity. Legal enforcement of compliance represents an option open to the State. Compliance with existing law can be monitored, and appropriate penalties assessed, on a sporadic basis in most locations covered by law. Attention most likely should be focused on retailers' and managers' compli- ance, rather than on their customers'. Are vendors dispensing cigarettes to underage children? Do restaurants provide adequate nonsmoking areas? Do managers of grocery stores request smoking patrons to extinquish their cigarettes? While legal enforcement will remain an option, its drawbacks may be overwhelming ccmpared with its advantages. The dollar cost of a serious enforcement effort could be substantial; it is a labor-intensive activity, implying a high labor cost. Greater still could be the opportunity cost of using police officers, an increasingly scarce public resource, for such a relatively minor police problem. In addition, police monitoring smoking behavior has a distinctive Orwellian flavor. And in general voluntary compliance seems to work reasonably well. Direct legal-action strategies have attracted several organizations concerned with smoking and health. An often-mentioned tactic is to encourage suits by, for example, lung cancer victims against the tobacco companies for criminal negligence, wrongful death, etc. One lawyer-run national organization, Action an Smoking and Health (ASH), has focused much of its attention on such legal actions. Other organizations, including the American Cancer Society, have urged states to facilitate successful prosecution of the tobacco companies (National Commission on Smoking and Public Policy, 1978). 1 have no idea of the possibilities open to our State, but it seems obvious that successful multi- figure suits would severely, perhaps fatally, damage the industry.** *:as mentioned above, a recent poll found both smokers and nensmokers re- gistering approval- of the law (personal comlm.micatien with Steven Coombs, Director of the Minnesota Poll). ** Well-:rnown attorney Melvin Belli recently filed suit in U.S. District Court in California in behalf of a client who lost a lung to lung cancer a year ago (National Interagency Council on Smoking and Health, 1980). A ccmnon de- fense against such suits, I understand, is "contributory negligence" on the part of the smoker. In addition, of course, the plaintiff must establish a connection between smoking and lung cancer. _105- I I I I I I L ~ ,

i I I I I i I I II I u L Health Education Traditional health education, in schools or other ccmrrunitv organizations, is the cornerstone of most efforts to inform people of hazards to their health and encourage them to avoid those hazards. -Unfortunately, the evidence on the effectiveness of traditional health education in the smoking area is relatively negative, particularly for school children (Surgeon General, 1979; Thompson, 1978; 1"der and Hoffrnann, 1979). Children seem to absorb the basic informa- tion on the disease consequences of smoking, but they do not personalize it.; it does not significantly alter smoking behavior. This has resulted in a variety of experiments with innovative educational approaches, including the afore- mentioned youth-to-youth programs. Further innovative experimentation seems desirable. For example, a current popular theme--teaching teenagers how to deal with peer pressure--will be applied next year to junior high school students in Ann Arbor as the vehicle for providing education on substance abuse (including tobacco). Conceivably, this could be mixed iAth the more traditional health information being pro- vided in the elementary and/or senior high grades. Teenagers may prove quite responsive to certain smoking-related themes. Perhaps classes could develop survey instrtanents to query their schoolmates on attitudes toward the attractiveness of smoking. In high school, for example, if it turned out that the vast majority of the members of one sex did not like kissing smokers, the other sex might be far more responsive to this input than to learning that their risk of lung cancer would increase ten-fold if they smoked two packs of cigarettes a day for 30 years. Similarly, clear evidence that smoking reduces one's present athletic potential could affPct the thinking of many teens. - The review literature on school smoking education programs is ccnsistent on one theme: few programs are structured in accordance with scientific principles of behavior and few are monitored through formal evaluation mechanisms. Our State could make a contribution to the Nation, as well as its own citizenry, if we could deviate from the norm in this regard. We need to search for innovative prograaIInatic approaches to smoking-and-health education, but we must be able to assess the worth of the new approaches. This is easier said than done. Probably few teachers are interested in formal evaluation; still fewer come equipped with knowledge of formal evaluation tech- niques. More basic is the problem that only a handful of teachers possess significant substantive knowledge on smoking and health, much less understanding of how to convey it effectively to children. To alleviate these problems, formal instruction on the substance and commtuiication of health material, and possibly on evaluation methods, could be required as a condition of teacher certification or employment within Hichigan. Alternatively, health education specialists could receive additional relevant training, possibly commumicating some of it to other teachers through in-service training. Again, of course, the principal burden of adding such responsibilities is the opportunity cost of what they displace.* * I am not familiar with either State certification requirements in this area or the relevant content in the programs of schools of education. rlssuming that Nlichigan is fairly typical, however, one can guess that teachers acquire only the most rudimentary knowledge and skills in this area. -106- i L

Educational efforts can be carried on i.z zw ercus se*.tings outsiCe of schools. Niichigan's Public Health Code required local health departments to engage in ' health education activities in order to receive State funds; already, many departments have responded with ongoing or planned activities. Clearly this is a ready-made vehicle for experimentation and evaluation. In particular, local health departments might be encouraged to concentrate their efforts on high- motivaticn groups. For example, pregnant women have an importar.t and immediate reason to forswear smoking and hence may be auite susceptible to behavior-change education. Convincing the same group of the risks to infants and children of living in a smoked-filled environment may induce many women to maintain their cigarette abstinence beyong pregnancy (Surgeon General, 1980). In developing smoking education efforts, it is imperative to remember that the health information base has been transmitted reasonably successfully to most Americans (U.S. DHEW, 1976).* The factors which cause many people to continue to smoke and others to begin (apparently a declining fraction) are far more subtle and incidious than a "lack of information." It is possible that our knowledge of these factors - what they are, how they work, how they can be combated - is the major deficiency in smoking-and-health education. Other Policy Options Despite the wealth of knowledge of smoking and health, our knowledge is far from complete as -the preceding point illustrates. An obvious policy option is to'seek to fill gaps in knowledge through research. While I am not aware of any states which fund significant smoking-and-health research, thds has been a principal strategy adopted by the federal government. Indeed, a majority of the federal smoking-and-health dollars are devoted to research.** Basic research has classic characteristics of a "pure public good." That is, the results of such research enter the public domain and beceme useful to and usable by anyone, generally free of charge. For this reason, nationally- relevant research is commonly viewed as a federal government responsibility.*** With the exception of certain applied State-relevant research, such as evalua- tion of health education programs or estimation of the bootlegging effects of a State excise tax increase, the State's embarking on a serious research program * We know that the vast majority of Americans are aware that smoking causes lung cancer and emphesema, is a major contributing factor in heart disease, etc. fowever, the level of such lmowledge may be quite shallow. I have heard of (but cannot reference) one survey which found that 95 percent of the respondents kmow that smoking causes lung cancer, but a significant percentage did not know that lung cancer causes death. ** The motivation for this concentration is not wholly scientific. Research is viewed by the tobacco lobby as one of the more innocuous threats to the industry's economic health. -Indeed, same such research, such as work on "less hazardous" cigarettes, ultimately might contribute to the industry's survival and vitality. Recently, research published by a National Cancer Institute official created quite a furor within the anti-smoking establishment because lay interpretation of the research translated it into the conclusion that some very low t/n cigarettes were "safe" (Gori and Lynch, 1978). *** Put somewhat ,more prosaically, why should Michigan citizens pay the full cost of something which will be of benefit to the entire Nation? -10-1- i I J I I I ~ L

I I I F I I i I i I I i ~ ~ ~ , ` L seems neither likely nor appropriate. Fowever, the State could use its presence in Washingtcn to lobby for more research or for specific types of research. The lobbying strategy--one the tobacco industry has used so.effectively for years-- lends itself to several smoking-and-health initiatives. For example, if a graduated t/n tax were deemed desirable by the Panel but infeasible for implemen- tation within a single State (due to border-crossing problems), the Michigan congressional delegation could be urged to work toward a national t/n tax. An indirect method of increasing our State's lobbying pressure would be to work with the local chapters of the prominent national voluntary organizations, encouraging them to urge their national offices to support the State's lobbying objective. The voluntary agencies--the American Cancer Society, American Heart Association, and :american Li.mg Association--represent a major source of interest, effort, and influence in the area of smoking and health. jyh.ile their fiscal resources have never matched those of government, their energy and visibility on the smoking issue make them desirable allies in any State smoking-and-health initiatives. I am not certain of the propriety, legality, or desirability of encouraging ccopera- tion among the voluntaries and between them and the State, but simple efficiency argunents favor exploration of the possibilities. The same thinking applies to the State's interactions with labor, industry, and in particular the health pro- fessions. Each of these influential groups should be included in State policy making. It is highly plausible that cooperation with these groups would pro- vide a lever to impact smoking in Michigan far more effective than anything the State could do relying solely on its own resources. In addition to the major national voluntary organizations, our State might explore establishing relationships with other national groups interested in smoking and health. A prominent organization is the National Interagency Coimcil on Smoking and Health which includes in its roster the Michigan Health Council.* The National Council is willing to assist states and regional groups in establishing their own interagency councils. Several states have developed such counci ls . * P.O. Box 1010, East Lansing 48823, C. Allen Payne, M.D. -108-

I V. C:,nc'_usion The problem of smoking-induced illness -..=1; be with us for ;.any years to ccre. The start of the 1930s, however, represents a propitious time for the State of Michigan to launch smoking-controi ef;orts of our own. Cne can bemcan the horrendous magnitude of the problem--tz:o and one half million Michigan smcicers, ' over 15,000 deaths per year, half a billion dollars in unnecessary medical bills-- but one can also point with optimism to the recent trends in s-moking: six years of continuous decline in per capita consuir.ption; decreases in the per- centages of men, women, and teenagers who smoke; continuing decreases in the tar and nicotine content of cigarettes smoked. Both surveys and political develop- ments indicate popular acceptance of a ncnsnoking social ethic. The ccncept of nonsmokers' rights has become embodied in law in the vast „ajority of L~e states. Two decades ago,_ the problem of smoking-induced illness derived in large part from ignorance. Many millions of continuing smokers, a majority of whcm have indicated they w+ould quit if there were "an easy way," are victims of that ignorance. Today, however, the public is well-informed and Imcwledgeable about the hazards of smoking. Thus the challenge is not to inform but rather to transform, to convert knowledge into consistent behavior. Clearly this challenge is intellectually vastly more taxing than that of disseminating inforrration. The problem of smoking must be attacked frcro several different directions. We must assist smokers who wish to quit; we must help children decide not to start. A comprehensive approach to smoking in our State must recognize, and address, the widely divergent influences on smoking across age, sex, and socioeconomic groups. The successes of a decade and a half of anti-smoking efforts leave a residual, perhaps more intractable smoking population. This fact alone recommnds a search for innovative approaches to smoking control. The difficulty of the task is multiplied by the severe resource constraints which will define and limit Michigan smoking-and-health initiatives at least through 1931. Thus, as the Citizens' Panel contemplates policy reccr,r:endations, it nust blend realism with creativity. The task is iirmense, but so are the problem and the potential reward. i I I I i i t r I- -109-

i I I I I I I I I I L References advisory Ccrmissicn on Intergovernmental Relations (1977). CiQarette Bootleggina: A State and Federal Resoonsi'cilitv. LVashingtcn: ACIR. .auerbach, 0., E. Haranond, and L. Gartinkel (1979). "Changes in Brcn&.ial Epithelitzn in Relaticn to Cigarette Smoking, 1955-1960 vs. 19,0-197'." New Engl. J. Med. 300 (February 22) : ;81-356. Bloom, M. '(1979). "Restrictions on Srr.oking : Observations on Their I:rVact." Presented at the 28th Tobacco Workers' Conference, Orlando, Fla., Januar,v 18. "Bootleg Cigarettes" (1978). The lVashinQtcn Post, October 17 Califano, J. (1978). Address delivered to the National Interagency Council on Smoking and Health, January 11. "Cigarette Contraband" (1978). The Economist, March 11. Cooper, N., and D. Rice (1978). "Me Economic Cost of Illness Revisited." Soc. Secur. Bull., February, pp 21-36. Fried:nan, K. (1975). Public Policy and the Smoking-Health Controversy. - - Lexington, Mass.: re x ington o s. Garkinkel, L. (1979). "Changes in the Cigarette Consumption of Smokers in Relation to Changes in Tar-Nicotine Content of Cigarettes Smoked." Am. J. Pub. Health 69 (December): 1274-1278. Gori, G., and C. Lynch (1978). "Toward Less Hazardous Cigarettes - Current advances." J. Am. Med. Assoc. 240 (September 15 ): 1255-1259. Green, P. (1977). "The IMass Media Anti-Smoking Campaign Around the ti'r'orld." In J. Steinfeld et al., Proceedin s of the Third World Conference on Smoking and Healt, Vol. 11. Z..o. (: i,- 3, pp. 245-253. Hamilton, J. (1972). "The Demand for Cigarettes: Advertising, the f?ealth Scare, and the Cigarette Advertising Ban." Rev. Econ. Stat. 54 (.Wvember) : 401-411. - Harris. J. (forthcoming). "Taxing Tar and Nicotine." Am. Econ. Rev. Lieb, C. (1953). "Can the Poisons in Cigarettes Be Avoided?" Reader's Digest 63 (December): 45-47. Luce, B., and S. Schweitzer (1978). "Smoking and Alcohol Abuse: A Comparison of Their Economic Consequences." New Engl. J. 'Aed. 298 (,\farch 9) : 569-571. * - Miller, L., and J. Monahan (1954). "The Facts Behind the Cigarette Controversy." Reader's Digest 65 (July): 1-6. -110-

I Miller, R. (1973). "The Economic Importance of the U. S. Tobacco Ir.d;.:s:^,." U.S. Departnn:ent of Agriculture, Fconcmics, Statistics, and Coeperatives Service (Z1ay) . ,N'ational Commis-sion on Smoking and Public Po?icy (1978). A Naticnal Di1e=a: Cigarette Smoking or the Health of Americans. Report to the k,.ericsn Cancer Seciety (January 31). National Institute of Education (1979). TeenaQe Smoking: I,=r.ediate and Long-Term Patterns. Washington: U.S. Government rinting oL_ice. National Interagency Council on Smoking and Health (1979). Smoking and the Workplace, Business Survey. New York. (1980. "^yelvinBelli vs. Tobacco Companies." Smoking and .ea :ewsletter 15:1, P. 7. Norr, R. (1952). "Cancer by the Carton." Reader's Digest 61 (Dece:r.ber): 7-8 Royal College of Physicians (1962). SmokinQ and Health. Sutrrnary ar.d Report of the Royal College of Physicians or naon on „mo ing in Relation to Cancer of the Lung and Other Diseases. New York: PitTan Publishing Co. Schacter, S. (1978). "Pharmacological and Psychological Determinants of Smoking." Annals of Internal Med. 88 (January-) : 104-114. Surgeon General of the United States (1964). Smoking and Health. Report of the Advisory Corrmittee to the Surgeon Genera oz the ic Health Service, U. S. DHESV. PHS Pub. 1Vo. 1103. (1979). Smoking and Health. DHFiV Pub. No. (PHS) 79-50066. (1980). The Health Consequences of Smoking for 'N'onen. Thompson, E. (1978). "Smoking Education Programs 1960-1976." Am. J. Pub. Health 68 (March): 250:257. Tobacco Institute (1979). Tobacco Industry Profile 1979. Washington. Tobacco Tax Council (1979). The Tax Burden on Tobacco. Richinond. U. S. Deparrinent of Health, Education, and Welfare (1969). Use of Tobacco: Practices,Attitudes, Knowledge, and Beliefs, United States - Fall 1964 and Spring 1966. Washington: U.S. Governmnt Printing Office. (1973). Adult Use of Tobacco - 1970. Atlanta: isease ontrol (June). (1976). Adult Use of Tobacco - 1975. Atlanta: Disease ontrol (June). Center for Center for Warner, K. (1977). "The Effects of the Anti-Smoking Campaion on Cigarette Constmmtion. Am J. Pub. Health 67 (July): 645-650. I I I I I I I L -1:1- `-

i I i I I I u i I I L I (1978). "Possible Increases in the Ltnderreporting of Cigarette 7cnsL.^;mtion." J. Am. Stat. Assoc. 73 (Jtu:e) : 3;13-315. (1979a). "Clearing the Aintiaves : T'-:e Cigarette Ad Ban Revisited." Pc1. Analvsis 5 (Fall) : 435-450. (1979b). "Toward Less Hazardous Cigarettes." J. Am. Med. -soc. :-i1 L~1ay 18) : 2143. (1980a). "Cigarette Smoking in the 'Seventies: Consumption act o= t..e Anti-Smoking Campaign." Revision of paper presented at the Fourth World Conference on Smoking and Health, Stockholm, June 18-21, 1979.. (1980b). "State Legislative Responses to the Anti-Smoking t.anqpaign: A Diffusion Study." Presented at the annual meeting of the Western Political Science Assoc., San Francisco, March 28. Wharton Applied Research Center (1979). A Study of the Tobacco Industry's Economic Contribution to the Nation, Its Fifty States, and the District of Columbia. Philadelphia, Univ. of Pennsylvania (April). White, J., and H. Froeb (1980). "Small-Airways D,vsfunction in Nonsmokers Chronically Exposed to Tobacco Smoke." New Engl. J. Med. 302 (March 27): 720-723. - Wynder, E., and D. Hoffman (1979). "Tobacco and Health - A Societal Challenge." New Engl. J. Med. 300 (April 19) : 894-903. -112-