Here are some excerpts from tobacco ads in the United States from the thirties up to 1964: Lucky Strikes were “gentle on my throat.” Phillip Morris advised: “Play safe with your throat.” Old Golds were “fresh as mountain air.” And, in the type of claim that must be illegal today, “smoking Camels stimulates the natural flow of digestive fluids … increases alkalinity.”
Addressing the Problem through Public Health
The prevalence of smoking in the US peaked in 1964 at 42% among adults. In 2019, the number was 14% (males 15.3%. Females 12.7%).* What happened in 1964? The publication of the first Surgeon General’s report that explicitly warned of the dangers of tobacco use.
Over the years, a steady march of public health interventions amplified the messaging. In 1966, individual packs of cigarettes were required to bear the message that smoking “may be hazardous to your health.” Cigarette ads were banned from radio and television in 1971. In 1988, that year’s Surgeon General’s report stated that smoking was addictive, just like heroin. Attorneys generals and the largest tobacco companies agreed to prohibit advertising targeting youth. Legal restrictions on smoking in public spaces became commonplace, and media counter-marketing campaigns became prominent.
A factor that was (and is) just as important as the public health interventions in decreasing smoking, if not more so, was taxation. The price of cigarettes varies from state to state (the cost of smoking in tobacco growing states is generally less than the national average), but still high compared to the sixties. The average smoker smokes 15 cigarettes per day, spending $3.90 per day in the states where cigarettes are least expensive (Missouri and Virginia). In New York City, a similar consumption costs $9.60 per day, amounting to an expenditure of $3504 per year for tobacco.
For arcane technical reasons, the federal tax on cigarettes varies from state to state, but ranges from about $1.00 per pack to $4.00. The impact of taxation is remarkable: in Chicago (where taxes on cigarettes are the highest in the nation), city taxes per pack are $1.18, county taxes $3.00, and state taxes $2.98. And this does not include the federal tax.
What is the effect of all of the anti-smoking interventions? The incidence (new cases per year) of lung cancer in males has decreased by 47% since 1984 (the decrease in females, though real, is not as striking due to a lower prevalence of smoking). This success is largely due to smoking cessation, though improved treatment and earlier detection are also factors. And note this analysis does not even address mortality from other cancers and heart disease for which smoking is implicated.
We still have a ways to go. In 2018, 234,000 new cases of lung cancer were diagnosed in the US. In 2015, the national expenditure for treatment of lung cancer was $13.4 B. In 2019, 13.3% of cancer survivors were cigarette smokers.
The Power Intervention: Prevention
The moral of this story is that low tech intervention can have a major impact on health. Few public health campaigns have had the impact on well-being that the anti-smoking campaign in the US has had.
But, another condition that cries out for urgent public health intervention is America’s weight problem. According to the National Institutes of Health, obesity and overweight together are the second leading cause of preventable death in the United States, close behind tobacco use. An estimated 300,000 deaths per year are due to the obesity epidemic.
President Biden has recently revived the concept of the “moonshot,” a federal initiative to decrease cancer deaths by 50%. He is no doubt thinking about high tech interventions in the detection and treatment of conditions with high mortality. For the biggest and most cost effective interventions, however, he would do well to look at the power of prevention.
*These stats are from a trove of facts available to all at www.ncbi.nim.nih.gov, Among the most interesting: those who hold a college degree have a 6.9% rate of smoking, while the percentage for non-college grads is 21.6%. Households with incomes per year of more than $100,000 have a prevalence of smoking of about 7.1%; households with less than $35,000? 21.4%.