Snuffing Out Smoking Coletta Cook

Abstract

Increased public awareness of the adverse health effects of smoking has, in the past, resulted in
tobacco control interventions that positively impacted public health. Even though smoking rates
across America are significantly lower than at the height of the tobacco industries power, new
disabilities and diseases are constantly being linked to smoking. Since each state independently
creates laws regarding tobacco products, statewide action to reduce the current percentage of the
population that smokes is in the best interest of the public. The proposal of statewide legislation
to reduce secondhand smoking, lower current smoking rates, and improve public health in
Pennsylvania has the potential to protect Americans from preventable diseases and death. Proven
strategies that protect children and workers from secondhand smoking as well as decrease
smoking rates statewide provide comprehensive methods for Pennsylvania legislators to consider
and implement. Awareness of existing, successful tobacco control can develop into concrete
legislation that will positively impact public health.
Snuffing Out Smoking 1

Awareness of Adverse Health Effects

It may appear as though most people are aware that smoking is bad for them; however smoking
has adverse affects far beyond the scope of smokers alone. As the leading cause of preventable
disease and deaths per year, the availability of cigarettes kills both smokers as well as people
who have never touched a cigarette at deeply disturbing rates. Smoking accounts for over
480,000 deaths annually in the United States, or approximately 1 in 5 deaths.​i​ 41,000 of those
deaths are caused by secondhand smoke. The death and illness caused by smoking clearly does
not discourage young people from taking up the habit. In Pennsylvania, as of 2018, smoking
rates are above the national average, particularly for the population that is of college age.
Additionally, Pennsylvania has almost no statewide legislation restricting smoking or access to
cigarettes besides federal mandates, such as the tobacco tax. In the absence of regulations
regarding access to tobacco products and areas in which is it legal to smoke, buying and selling
cigarettes is made easy and smokers can cause harm not only to themselves but also to others in
public spaces.
While Pennsylvania’s statewide cigarette tax is ranked 12th highest in the US,​ii​ the state is
ranked 34th lowest in smoking rates.​iii​ With such a high cigarette tax one would expect the
smoking rates to be inversely low. Since data reveals that smoking rates across the state remain
among the highest in the nation, the apparent dissonance between the cigarette tax and its lack of
effectiveness in lowering smoking rates reveals a deficiency in legislation and public awareness.
Conversely, California’s smoking rates are ranked 2nd lowest in the US and has some of the
firmest laws against smoking and the sale of cigarettes, including statewide smoke free air laws,
demonstrating that additional legislation as well as the federally required laws do have a positive
affect.​iv​ Due to the alarming rates of disease and death caused by smoking, Pennsylvania should
declare smoking a public health crisis, join the other 28 states in the US in passing
comprehensive smoke free air laws, and enact firmer restrictions on the sale of tobacco products
statewide.

Official Reports and Public Action

Prior to 1964, public awareness of the adverse health effects of smoking were slim to none. It
was only in 1954 that Richard Doll and A. Bradford Hill published an article in the British
Medical Journal that linked smoking to lung cancer.​v​ Meanwhile, in America, smoking was
reaching the height of its popularity. Uninformed about the dangers of smoking, 43% of
Americans used tobacco products, unwittingly damaging their health and the health of
nonsmokers. After the British Medical Journal publication proving that smoking lead to lung
cancer, the American Lung Association campaigned for acknowledgement of the report at the
federal level. Several letters written to the United States Surgeon General and President Kennedy
between 1954 and 1964 urged officials to establish a commission to address the hazard. Despite
Snuffing Out Smoking 2

the lack of action from the general public, the American Lung Association and health partners
succeeded in focusing the attentions of the Surgeon General on smoking.
A long time smoker himself, Surgeon General Luther Terry released a statement in a press
conference that smoking definitely lead to lung cancer and probably caused heart disease as well
as other serious respiratory illnesses. The official report titled ​Smoking and Health: Report of the
Advisory Committee to the Surgeon General of the Public Health Service​ contained evidence
from examining the lungs of smokers and nonsmokers, revealing the lungs of those who smoked
to be stained black.​vi​ Evaluations of tobacco control established practice-based evidence that
secondhand smoke damaged the health of nonsmokers as well. Several subsequent Surgeon
General reports on the effects of tobacco usage have been published, and in a 60 year period
smoking rates have dropped to 17% nationwide as of 2018.​vii
While this drastic change may compel some to consider tobacco control to be a success of public
health brought about through education, inconsistent legislation allows for some states, such as
Pennsylvania, to remain above the national average in smoking rates. Even with the progress
made in tobacco control, smoking remains the leading cause of preventable deaths. Director
Thomas R. Frieden of the Centers for Disease Control and Prevention (CDC) states, “Tobacco is,
quite simply, in a league of its own in terms of the sheer numbers and varieties of ways it kills
and maims people”.​viii​ Frieden defends his statement twofold: new diseases and disabilities are
continuously being linked to tobacco products and strategies proven to prevent consequences of
smoking have not been fully implemented. Myocardial infarctions, strokes, and several types of
cancers being proven to be caused by smoking are not nearly as disturbing as the lack of
comprehensive protections for children and workers from the effects of secondhand smoking.
Nearly a third of all nonsmokers are exposed to secondhand smoke and only half of Americans
are protected from secondhand smoke in workplaces.​ix​ So, while public awareness of the adverse
health effects of smoking has continued to increase in the years since the 1964 Surgeon General
report, legislation has not been implemented effectively in response to the apparent urgency of
the situation. The call for federal acknowledgement issued by the American Lung Association
over 60 years ago shows that public action has been imperative in regulations regarding smoking
and other tobacco products, and suggests that pressure at a state level may be necessary to pass
statewide smoke free air laws to fully implement proven tobacco control policies.

Legislation Restricting Big Tobacco

Major Restrictions and Milestones

Over a seventy year period of reports, legislations, and campaigns have made the public aware of
how smoking affects one’s health. In 1954, Richard Doll and A. Bradford Hill proved that the
development of lung cancer had a direct connection to smoking, prompting health partners to
write to the President of the United States and urge him to address the issue. Ten years after Doll
and Hill’s study was published in the British Medical Journal, the US Surgeon General’s report
Snuffing Out Smoking 3

officially recognized the connection between smoking and lung cancer. This sparked public
debate and amendment anti-smoking advocates to push for government action regarding the sale
of cigarettes. However, big tobacco companies pushed back through advertisements, legal action,
and minimization of consumer health lawsuits. Below, a worryingly small list presents milestone
dates in the national struggle to regulate big tobacco:
1949: Public Law 363 establishes a federal tax on cigarettes.
1966: Federal Cigarette Labeling and Advertising Act requires all domestic and imported
cigarette packs to have a standard health warning label.​x
1975: Minnesota Clean Indoor Air Act requires separate areas for smoking in public places.
1987: Aspen, Colorado is the first city to require smoke-free restaurants.
1988: Proposition 99 raises the state tax on cigarettes in California.
1989: Congressional Transportation Bill bans smoking on airplanes during domestic flights.
1993: HR 881 bans smoking in federally owned buildings.
1998: Labor laws in California are redefined to ban smoking in bars.​xi
1999: United States v. Philip Morris. The Department of Justice sues several major tobacco
companies under Racketeer Influenced and Corrupt Organizations Act (RICO).
2002: Clean Indoor Air Act marks Delaware as the first state to pass a statewide smoke-free air
law.
2006: United States v. Philip Morris decision reached by Judge Kessler, holding tobacco
companies liable for violating RICO.
2009: HR 1256 — PL 111-31 grants the FDA regulatory authority over tobacco products.​xii
2015: State-wide bill HB 1509 makes Hawaii the first state to raise the minimum age of legal
tobacco sales to 21.
2018: Lawsuit against the FDA requires graphic health warnings on cigarettes and e-cigarettes.

The Tobacco Industry’s Role in Congress and Constitutionality

While the devastating health effects of smoking and public campaigns to restrict access to
cigarettes and other tobacco products have resulted in federal and state action, tobacco industry
advocates can prevent legislation from being quickly passed with support from big tobacco
companies. Only a few tobacco companies, the top two being Altria and R. J. Reynolds Tobacco,
control nearly the entirety of US tobacco market, and brands such as Camel have a condemning
history of purposely marketing cigarettes to children. These conglomerates, although they have
lost much of their power since the 1950s, exert influence over industry advocates to avoid legal
implication in public health.
1997 set itself up to be an important year in congressional hearings and task forces
regarding big tobacco, and several pending court cases were expected to reach a decision by
1998 so that the congressional settlements beginning the previous year could move forward.​xiii
However, the hearings and settlements did not proceed as anti-smoking activists hoped. Tax
reform bill HR 2014—PL 105-34, aimed towards tobacco industries for the purpose of collecting
Snuffing Out Smoking 4

payment on liabilities, suffered from provisions added by industry allies. While the provisions
were realized and opponents condemned cigarette companies for attempting to avoid nearly $50
million in liabilities, the bill lost momentum and the version that did pass proved to be much less
harsh. This particular bill regarding industry liability came through Congress at the same time a
deal between tobacco companies and several states over advertising bans and financial
compensation for smoking related costs on state Medicaid programs. The deal, much like the
provisions in the tax reform bill, contained references to lawsuits that mitigated the industry’s
responsibility for consumer health citing that “smokers knew the risks when they took up the
habit”.​xiv​ Due to the leniency built into the settlements for the deal, Congress, failure of the tax
reform bill still fresh in their minds, refused to approve any legislation until it was strict enough.
Additionally in 1997, big tobacco demonstrated their ability to dodge liability lawsuits by
protecting the industry from class action lawsuits. Four major tobacco companies were sued by
60,000 flight attendants who were non-smokers citing illnesses caused by passengers smoking in
the cabin. Despite a federal law from 1989 that banned smoking on planes, the attendants
demanded compensation for lung cancer, emphysema, and chronic bronchitis caused by
secondhand smoke. The companies involved agreed to pay $300 million to establish a foundation
for research on diseases caused by cigarette smoke, as well as $49 million for the attendants’
attorneys, but none of the money went to the attendants themselves.​xv​ Though this settlement
anti-smoking groups were appeased by the amount that that industry had agreed to pay. As a
result, individual lawsuits against the tobacco industry could no longer seek punitive damages,
further protecting big tobacco from responsibility for adverse health effects.
Moreover, industry allies in Congress questioned the constitutionality of federal
legislation in order to halt the process of passing anti-smoking actions. This tactic had not been
particular to the events of 1997, however, and was an effective way to keep bills from reaching
the Senate floor in the past. The argument is as follows: federal cigarette taxes infringe on states
right to tax, and that the Food and Drug Administration (FDA) should not have regulation over
tobacco because it is not a food or a drug. While federal regulations encroaching upon states
rights to self governing did cause more of an issue in 1949 before the first official report by the
Surgeon General linking smoking to lung cancer, a tax that federally mandated states to set their
own cigarette tax rate seemed to pacify the debate. However, because of the leniency over tax
laws, states such as Tennessee can require only a $0.62 tax on cigarettes and rank 47th for the
lowest smoking rates in the US.​xvi​ Tennessee’s rankings, like Pennsylvania's, indicate a need for
statewide legislation that must go through the local House rather than on a federal level. As for
the second issue regarding constitutionality, nicotine in cigarettes and the addictive, harmful
properties of tobacco were able to be classified as drug-like and Obama passed the bill 1256 —
PL 111-31 that gave the FDA regulatory authority over tobacco products.​xvii​ However, the FDA
is not able to require big tobacco to be considered responsible for health costs though this bill,
and have to instead go through provisions on the Affordable Care Act. Due to questions of
constitutionality, in addition to existing federal legislation, anti-smoking actions increasingly
Snuffing Out Smoking 5

must be pushed on a local level to compound state and federal laws to protect public health, as
well as benefit individuals by operating at a faster, cheaper, more desirable level for tobacco
companies to work with rather than engaging in high stakes lawsuits that the industry can retreat
from by appealing to allies in Congress.

Statistics and Demographics

Snuffing Out Smoking 6

Significance of Findings
According to the CDC and the Department of Health and Human Services (HHS), in 2017
around 14% of Americans were current smokers and over 17% of adults reported smoking at
least 100 cigarettes in their lifetime.​xviii​ The above map reveals that smoking rates in
Pennsylvania are at 18.7%, a seemingly small percentage above the national average. However,
taking into account the rest of the map, only a few states have a more severe smoking rate, and
when the data is broken down into different demographics a disturbing trend emerges.
Younger people, aged 18-44, have the highest smoking percentage of any other age demographic
in the state. This shows that college age people and the majority of the workforce are smoking at
a higher rate than the national average, and with no statewide clean air laws the implication is
that nonsmokers in this age group are also being exposed to the dangers of secondhand smoke.
The rate of smokers in rural settings is even higher, being nearly 5% above the national average.
Interestingly, urban settings have a much lower percentage of adults who smoke. This is likely
due to local legislation restricting the sale of tobacco in large cities. For example, Philadelphia
has one of the harshest local laws regarding the sale of tobacco products, and though still lenient
compared to states with a lower overall smoking rate, contributes to the the low percentage of
people who smoke in urban settings.

Pennsylvania Legislature

Potential Solutions to Statistical Findings

To address the apparent issue of younger people smoking at a higher rate than other age
demographics, raising the legal age of tobacco purchase to 21 would reduce the percentage of
18-44 year olds who smoke. Currently, 8.8% of high schoolers smoke and raising the legal age
of tobacco purchase would cause those numbers to plunge.​xix​ Additionally, to reduce the number
of high school and college age students who smoke, implementing laws restricting the use of
cigarettes on school grounds would discourage younger people from smoking as well as protect
nonsmokers from secondhand exposure. A local law in Philadelphia prohibiting tobacco retailers
within 500 feet of a school could be contributing to the low percentage of urban smokers, and
should therefore be applied in other local areas.​xx​ Outlawing tobacco retailers near schools would
make cigarettes less accessible to students which may contribute to lowering the rate of 18-44
year olds who smoke.
Furthermore, local and statewide campaigns for clean outdoor air laws have been proven to
reduce tobacco use. If Pennsylvania was to implement policies to improve public health and
reduce smoking, the MPOWER framework, proposed by the World Health Organization (WHO)
in 2003, has been proven to be effective in several countries globally.​xxi​ The most successful
applications of MPOWER have been in Turkey, which saw a 14% decline in smoking over a
four year period, and Uruguay, which experienced a 25% drop in smoking in just 3 years.​xxii
MPOWER measures monitor tobacco use though periodic data collection, ensures that all public
Snuffing Out Smoking 7

places are completely smoke free, offers help to people seeking to quit smoking, requires large
health warning labels and graphics on all tobacco products, restricts pro-tobacco mass media
campaigns, enforces bans on tobacco advertising, and raises taxes on tobacco. Currently,
independent public health partners, such as the American Lung Association, as well as the CDC
collect annual data on smoking statistics, there are federally required health warning labels for all
tobacco products, tobacco companies face severe legal repercussions for false advertising at the
national level, and Pennsylvania already has a fairly high cigarette tax. Despite the already
existing legislation that enforces MPOWER, the CDC urges for total implementation of the
MPOWER measures in order to protect at least 90% of the population from secondhand smoke.
In order to fully follow MPOWER tobacco control interventions, Pennsylvania implementing
statewide smoke free air laws, such as those in California, would undoubtedly be beneficial to
public health statewide.​xxiii​ It would be feasible to model legislature off of the 28 states already
benefiting from smoke free air laws. Additionally, revenue from Pennsylvania’s high cigarette
tax could be channeled into cost covered services to help people quit smoking, which, if
successful, would encourage an even higher cigarette tax. Restricting pro-tobacco media content
may also positively impact the number of youth who smoke. The tobacco industry’s history of
smoking advertisements targeting young audiences, addressed in the case of United States v.
Philip Morris, demonstrates that legislation restricting content produced by tobacco companies
and their partners may improve teen smoking rates.​xxiv

Conclusion

Finally, the adverse health effects of smoking should be addressed in Pennsylvania as a public
health issue by completely implementing MPOWER strategies statewide through comprehensive
smoke free air laws, restricting the sale of tobacco products, and enforcing federal legislation
regarding tobacco products. The current laws in Pennsylvania clearly could be more rigorous and
widespread to increase effectiveness in reducing smoking rates. Furthermore, the lack of
protections for nonsmokers continues to expose children and workers to secondhand smoke
which causes preventable disabilities, diseases, and death. Public action urging Pennsylvania
legislators to address smoking and create additional tobacco control laws could be successful in
positively impacting the percentage of the state population that smokes. If the state government
is willing to act in the best interests of American citizens, consideration of practice-based
evidence is imperative as it definitively reveals that tobacco control legislation positively impacts
public health.

“Current Cigarette Smoking Among Adults in the United States.” ​Centers for Disease Control
i​

and Prevention​, U.S. Department of Health & Human Services, 4 Feb. 2019. Web.
https://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm​.
Snuffing Out Smoking 8

ii​
Boonn, Ann. “State Cigarette Excise Tax Rates & Rankings.” Campaign for Tobacco-Free
Kids, 21 Dec. 2018. Web. ​https://www.tobaccofreekids.org/assets/factsheets/0097.pdf​.
iii​
“Annual Report: Smoking in 2018.” ​America's Health Rankings​, United Health Foundation,
2019. Web. ​https://www.americashealthrankings.org/explore/annual/measure/Smoking/state/PA​.
iv ​
Ibid. Annual Report.
v​
“Tobacco Control Milestones.” ​State of Tobacco Control​, American Lung Association, 2019.
Web. ​https://www.lung.org/our-initiatives/tobacco/reports-resources/sotc/tobacco-timeline.html​.
vi​
Komaroff, Anthony. “Surgeon General's 1964 Report: Making Smoking History.” ​Harvard
Health Publishing​, Harvard Medical School, 10 Jan. 2014. Web.
https://www.health.harvard.edu/blog/surgeon-generals-1964-report-making-smoking-history-201
401106970​.
vii​
Ibid. Annual Report.
viii​
Frieden, Thomas R. “Tobacco Control Progress and Potential.” ​JAMA,​ American Medical
Association, 8 Jan. 2014. Web.​ ​https://jamanetwork.com/journals/jama/fullarticle/1812970​.
ix​
Ibid. Frieden.
x​
"Health Warning Required on Cigarette Packs." In ​CQ Almanac 1965,​ 21st ed., 344-51.
Washington, DC: Congressional Quarterly, 1966. Web.
https://library.cqpress.com/cqalmanac/document.php?id=cqal65-1259268​.
xi ​
Terry, Don. “California's Ban to Clear Smoke Inside Most Bars.” ​The New York Times,​ The
New York Times, 31 Dec. 1997. Web.
https://www.nytimes.com/1997/12/31/us/california-s-ban-to-clear-smoke-inside-most-bars.html​.
xii ​
"FDA Authorized to Regulate Tobacco." In CQ Almanac 2009, 65th ed., edited by Jan Austin,
17-4-17-6. Washington, DC: CQ-Roll Call Group, 2010. Web.
https://library.cqpress.com/cqalmanac/document.php?id=cqal09-1183-59547-2251476​.
xiii​
“Smokefree Air Laws.” ​American Lung Association​, American Lung Association, 8 Mar.
2019. Web.
https://www.lung.org/our-initiatives/tobacco/smokefree-environments/smokefree-air-laws.html​.
xiv​
Ibid. Smokefree Air Laws.
xv​
Ibid. Smokefree Air Laws.
xvi​
Ibid. Annual Report.
xvii​
Ibid. FDA Authorized.
xviii​
Ibid. Current Cigarette Smoking.
xix​
“Tobacco Use in Pennsylvania.” ​Truth Initiative,​ 29 June 2018. Web.
https://truthinitiative.org/tobacco-use-pennsylvania​.
xx​
Ibid. Tobacco Use.
xxi​
Ibid. Frieden.
xxii​
Ibid. Frieden.
xxiii​
“Appendix C: Raise Your Grade.” ​SOTC 2018 California Local Grades,​ American Lung
Association, 2018. Web.
Snuffing Out Smoking 9

https://www.lung.org/local-content/california/documents/state-of-tobacco-control/2018/2018-sot
c-raise-your.pdf​.
xxiv​
"Passions Run High as Congress Wades Into Tobacco Issue." In ​CQ Almanac 1997,​ 53rd ed.,
3-3-3-7. Washington, DC: Congressional Quarterly, 1998. Web.
https://library.cqpress.com/cqalmanac/document.php?id=cqal97-0000181076​.