SMOKING AND HEALTH

A National Status Report
2nd Edition

A Report to Congress

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service
Centers for Disease Control
Center for Chronic Disease Prevention and Health Promotion
Office on Smoking and Health
Rockville, Maryland 20857
DHHS Publication No. (CDC) 87-8396 (Revised 02/90)
FOREWORD

Cigarette smoking is the chief preventable cause of death in our society. It is directly responsible for
some 390,000 deaths each year in the United States, or more than one of every six deaths in our
country. The number of Americans who die each year from diseases caused by smoking exceeds the
number of Americans who died in all of World War Il, and this toll is repeated year after year.

Public health officials know these figures well. But it is important that all Americans realize the heatth
consequences, and the cost consequences, of tobacco use. For that reason, | am pleased to present
to the Congress and to the American people this National Status Report on Smoking and Heaith.

The information presented in this report is both startling and distressing, especially the new compilation
of health and cost effects in each of our 50 States. For example:

- In 1985, the average number of smoking-attributable deaths per State was 6,096, ranging
from 271 in Alaska to 28,533 in California.

- The average smoking-attributabie economic costs per State were $1.0 billion, ranging from
$82 million in Alaska to $5.8 billion in California.

— With the sum of State economic costs exceeding $52 billion, the economic impact of
smoking can be put at some $221 per person each year. Thus cigarette smoking has an
economic impact on every American, whether or not he or she smokes.

This report also shows that smoking is a particularly important problem for young Americans -- nearly
all smokers now start smoking regularly in their teenage years. in addition, cigarette smoking is
increasingly becoming concentrated among Americans with lower incomes and less education. lam
especially concerned that we make more progress in reaching young people, women, minorities, and
blue-collar workers with accurate and compelling information about smoking and health.

There is encouraging news in this report, as well. But we still have far to go in giving all Americans
the information they need to make good health choices about smoking. it is my hope that the
information in this report will be of help in that important cause.

Louis W. Sullivan, M.D.
Secretary
PREFACE

During the past several years, Our progress toward a smoke-free society has continued. Per capita
cigarette consumption (18 years of age and older) decreased from 3,370 in 1985 to a preliminary
estimate of 2,850 in 1989. Total cigarette consumption fell from 594.0 billion cigarettes in 1985 to 524.6
billion in 1989, despite growth in the size of the population. Data from the 1986 Adult Use of Tobacco
Survey (reported here in detail) and the 1987 National Health Interview Survey (reported in other
publications of the Public Health Service) show that the prevalence of cigarette smoking among adults
is now under 30 percent, an important milestone.

Nevertheless, smoking remains the chief preventable cause of death in our society. More than 1,000
Americans die each day from diseases caused by smoking. The decline in smoking has been
substantially slower among women than among men. Smoking rates are higher among minorities, blue-
collar workers, and less educated persons than in the overall population.

This report provides valuable State-specific information on the health and economic impact of smoking,
legislative measures to contro! smoking, and smoking cessation and prevention programs. It is readily
apparent that many States have made much more progress than others in reducing smoking and
smoking-related disease.

| am pleased that Utah, my home State, has the lowest adult smoking prevalence among all 50 States
-- 15 percent. However, an estimated 742 smoking-attributable deaths still occurred in Utah in 1985,
and other States experienced smoking-attributable mortality rates three to four times as high as the rate
in Utah. Clearly more needs to be done in all 50 States to prevent the needless death and disability,
and pain and suffering, caused by the use of tobacco.

Later this year, the Public Health Service will publish National health promotion and disease prevention
objectives for the year 2000. These objectives have been developed in collaboration with State and
focal government agencies and the private sector. Tobacco is one of the 21 priority areas for which
specific objectives will be defined. The information in this report will serve as a benchmark against
which States can measure their progress toward achieving ambitious goals related to smoking and
smoking control.

James ©. Mason, M.D., Dr.P.H.
Assistant Secretary for Health
TABLE OF CONTENTS

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Introduction

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Special Sections

1986 Adult Use of Tobacco Survey ....0.. 0.0... eee e cece eee eee ene eee eee e er eene re ees

Smoking-Attributable Mortality,
Years of Potential Life Lost,
and Economic Costs

State-Specific Estimates, 1985 ...... 2.0.0.2... cece eee eee eee neers

Activities of the Interagency Committee

on Smoking and Health ... 2.2.2.0... cece een eee tenet ener tenn neerees

Legislation

Federal ...... oo. ccc ccc cc cnccccccceececceceeseteeeneteesecee ren ccssesseeeeceeenrereenenneess

National, State and Local Programs

National Programs ......... 20... 0c. cece eee ence eee tee ece tena eee eneeeneeeneeererenesss
State and Local Programs ..............0 222.2 eee ceeeeee eet en eee e cen e nena eeeeeerees
Smoking and Health Advocacy Groups ...........-....---2s-ece essere creer ener eee eter es

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INTRODUCTION

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——_—_ ss...
EXECUTIVE SUMMARY

Introduction

Since the 1964 publication of the first Surgeon General's
report linking cigarette smoking to illness and disease, efforts
on the part of government and private organizations to reduce
the prevalence of tobacco use and to educate the population
onthe harmiul effects of tobacco, have increased dramatical-
ly. Programs to educate the population on the harmful effects
of tobacco and to help current smokers quit are evident at
every level of government and in virtually every geographic
area of the United States.

Smoking cessation and prevention programs are offeredona
Nationwide basis by the major voluntary health organizations.
Private hospitals and organizations conduct cessation and
education programs in a wide variety of locations. State and
local governments have adopted legislation to control the sale
of tobacco products and to limit their use to certain specific
locations. The Federal Government has banned smoking on
all domestic flights scheduled for two hours or less. Smoking
and health advocacy groups have been formed to address the
need for clean indoor air. Hotels and motels frequently offer
nonsmoking rooms for their patrons, and one airline has
implemented a total smoking ban on all its flights in the
continental United States.

The numbers and types of programs have grown with the
publication of each new Surgeon General's report. Most of
the early programs focused on the individual smoker. Follow-
ing the release of the 1985 Surgeon General's Report on
Cancer and Chronic Lung Disease in the Workplace and the
1986 Surgeon General’s Report on the Health Consequences
of Involuntary (Passive) Smoking, many new programs were
established emphasizing nonsmokers’ rights; the obligation of
employers and operators of public places to provide smoke-
free working and public assembly areas was also em-
phasized. With the issuance in mid-1988 of the Surgeon
General's report on tobacco use as an addiction, it is expected
that many additional programs will come into existence, orthe
focus of existing programs will change to meet new areas of
concern.

in recognition of the magnitude of the health impact of tobacco
use and the ever increasing number of related programs, the
Congress passed Public Law (P.L.) 98-474, the Comprehen-
sive Smoking Education Act of 1984. Section 3(c) of this law
requires that the Secretary of Health and Human Services
report to the Congress biennially on the status of smoking
programs in the Nation. This is the second report in a series.
It covers the calendar years 1986 and 1987. These reports are
intended to be used as directories by Members of Congress
as well as by individuals at all levels.

The contents of this report reflect the growth of smoking-re-
lated programs and legislation. In the first report, ap-
proximately 800 State and local programs were listed. This
report identifies over 1,500 programs. At the time the 1986
Report was issued, 60 bills related to smoking and health had

been introduced at the Federal level. This report contains
information on nearly 100 Federal bills that have been intro-
duced or adopted. At the State level, approximately 400 laws
that influence smoking or tobacco sale and use were in effect
in 1986. As of December 1987, the number of State laws had
grown to nearly 600.

This report also contains a summary of the activities of the
Interagency Committee on Smoking and Health, listings of
smoking and health advocacy groups, a section on focal
ordinances in the twenty largest cities in the United States, a
summary of the results of the 1986 Adult Use of Tobacco
Survey, and a summary of a study conducted by the Centers
for Disease Control on smoking-attrioutable mortality, years
of potential life lost and economic costs in the 50 States.

Report Highlights

Results of the 1986 Survey of Adult Use of Tobacco.

The fifth Adult Use of Tobacco Survey was conducted by the
Office on Smoking and Health in 1986, 11 years after the
previous one, which was conducted in 1975. Adult Use of
Tobacco Surveys are unique in seeking information on
knowledge, attitudes and behaviors of representative samples
of the population relating to tobacco. Some key findings from
this survey include the following:

+ 26.5 percent of the U.S. adult population are cigarette
- smokers.

* Thirty percent of the population use some form of tobac-
co. Use of tobacco other than cigarettes is a male
phenomenon and 9 percent of men currently smoke a
cigar or pipe and 5 percent currently use smokeless
tobacco.

There has been a downward trend in the age at which
smokers start to smoke regularly. Nearly all smokers now
start smoking regularly in their teenage years.

Cigarette smoking and use of tobacco vary with education
and income. Those with higher education and who report
higher incomes are less likely to smoke or use tobacco.
There is no difference between these groups in the
proportion of people who have ever been smokers,
People of higher socioeconomic status are more likely to
have quit smoking.

There are different patterns of smoking among the dif-
ferent subgroups of the population. Blacks tend to smoke
fewer cigarettes a day than do whites, but use brands that
are higher in tar content and are mentholated.
Successtul quitters in 1986 were much more likely to
report success on the first or second quit attempt than
successful quitters in 1975. Even with the decrease in
the proportion of smokers in the population, there has
been little change in the proportion of smokers who have
tried to quit between 1975 and 1986. Both of these
figures suggest that the downward trend in smoking
prevalence will continue for at least the short term.

These findings suggest that the antismoking efforts in the
private and public sectors are meeting with some success and
that, if such efforts are continued, there will be a further
reduction in smoking prevalence in the community. Dissemi-
nation of these findings and other in-depth analyses of the
1986 survey are expected to lead to a more effective targeting
of antismoking campaigns. These, in turn, should lead to a
more rapid reduction in the prevalence of smoking in the
community.

Smoking-Attributable Mortality, Years of Potential Life Lost,
and Economic Costs

The adverse health impact of smoking and associated
economic costs have long been accepted as enormous. This
study attempted to quantify, on a State-by-State basis, the
number of deaths, years of potential life lost, and the costs
attributable to smoking for 1985. This study is not a cost-
benefit analysis, but rather an attempt to quantify both the
disease and economic impact of smoking for each State.

Costs associated with smoking-related death and illness may
be immediate or deferred. There are costs to the individual
and to society in general. Indirect costs of smoking are the
value of lost productivity, output, or manpower resources that
cannot be used because of illness.

In 1985, the average number of smoking-attributable deaths
per State was 6,099 (ranging from 271 in Alaska to 28,533 in
California). The rate of smoking-attributable deaths per
400,000 persons ranged from 45.3 in Utah to 175.9 in Ken-
tucky (the average State rate was 129.1).

The average number of smoking-attributable years of potential
life lost (YPLL) to life expectancy per State was 70,621 (rang-
ing from 4,335 in North Dakota to 335,319 in New York). The
rate of smoking-attributable YPLL per 100,000 persons
ranged from 643 in North Dakota to 2,167 in Kentucky (the
average State rate was 1,489 ).

The average smoking-attributable economic costs per State
were $1.0 billion (ranging from $82 million in Alaska to $5.8
billion in California). On a per capita basis, these costs ranged
from $54 per person in Puerto Rico to $284 in Rhode Island
(the average State per capita cost was $205).

Based on these State-specific estimates, the National totals
are as follows. In 1985, more than 316,000 deaths* and an
additional 3.7 million years of potential life lost (YPLL) to life

ean

expectancy were attributable to tobacco use. The total
economic impact for all 50 States was over $52 billion: $23.7
billion in direct morbidity costs, $10.2 billion in indirect mor-
bidity costs, and $18.4 billion in indirect mortality costs. On
a per capita basis, the economic impact was $221 per person
for the United States as a whole. A more recent national
estimate of smoking-attributable mortality, based on updated
relative risk estimates from the American Cancer Society's
Cancer Prevention Study H, is 390,000 deaths in 1985. The
derivation of this new estimate is explained in detailin the 1989
Surgeon General’s Report.

Smoking causes more premature deaths than cocaine,
heroine, alcohol, fire, automobile accidents, homicide, and
suicide combined. The vast health and economic impact of
smoking and tobacco use reinforces the need to sustain
smoking cessation and prevention of smoking as a high-
priority public health effort at the National level as well as within
each State.

Interagency Committee

The Interagency Committee on Smoking and Health was
established as part of the Comprehensive Smoking Education
Act of 1984 (P.L. 98-474). The Committee, chaired by the
Surgeon General of the U.S. Public Health Service, Dr. C.
Everett Koop, is comprised of 25 members; 20 Federal mem-
bers and 5 non-Federal scientists and physicians representing
private entities. Since the inaugural meeting on October 1,
1985, the Committee has met five times. Topics of the meet-
ings include: the impact of advertising and promotion of
tobacco products; free cigarette sampling and other related
marketing techniques; smoking and its impact on minority
populations; implementation of the new smoking regulations
promulgated by the General Services Administration; and the
international aspects of tobacco and health.

Legislation

in an effort to simplify and standardize existing information on
Federal and State legislation pertaining to smoking and health,
this report examines the Federal laws and the laws of all 50
States and the District of Columbia through calendar year
1987. Nearly 600 State laws pertaining to smoking and health
have been identified. This total does not include all laws
pertaining to the taxation of cigarettes or tobacco products,
but includes those laws that mandate that tax revenues be
earmarked for special health-related programs or research.

The smoking-related laws vary widely in their scope and
intent, but for purposes of evaluation and comparability, they
have been categorized as follows: limitations on smoking in
public places; regulation on sale and use of tobacco products
by minors; schools and school health education; regulations
of advertising practices; commerce, taxation; and health and
safety regulations.

Each of the 50 States and the District of Columbia regulate
the sale and/or use of tobacco in some fashion. In addition,

* The State estimates that provide the basis for this National total were derived using relative risk estimates for smoking-related diseases from

studies conducted in the 1950's and 1960's. Since those State calcula

tions were made, more current relative risk estimates have become

available. These estimates were used in the 1989 Surgeon General's Report on Reducing the Health Consequences of Smoking: 25 Years
of Progress to yield an estimate of 390,000 smoking-attributable deaths in the United States in 1985.
information was compiled from the largest 20 cities in the
United States to provide a sampling of local regulations on
smoking and tobacco sale and use. The local ordinances are
grouped into five categories: smoking in public places; smok-
ing regulations in the workplace; public safety regulations;
municipal tobacco taxation; and regulation of cigarette sales
to minors. All 20 cities have local ordinances pertaining to
smoking in public places; nine in the workplace; 14 regarding
public safety; tive enforcing local taxation; and eight regulating
the sale to minors.

Findings of State legislation include:

+ 43 States and the District of Columbia have lagislation
restricting smoking in public places.

* 20 States and the District of Columbia, a total of 21
jurisdictions, restrict smoking in Government and/or
private workplace settings.

+ All States tax cigarettes. State taxes range from a low of
2¢ (North Carolina) to a high of 38¢ (Minnesota) per pack
of cigarettes.

» Five states prohibit the sale or use of clove cigarettes.

* 19 States require elementary and secondary schools to
include instruction on the hazards of tobacco use. -

+ 44 States and the District of Columbia restrict sales or
distribution of tobacco products to minors. The age at
which an individual can purchase tobacco products range
from a high of 19 years of age toa low of 16 years of age;
14 States allow minors under age 18 to purchase tobacco
products. Six States have no law pertaining to the sale
or distribution of tobacco to a minor.

National, State and Local Programs.

The smoking and health movement in this country has been
acollaborative effort involving virtually every facet of the health
community. The National voluntary health organizations, their
State and local affiliates, State and local health departments,
the Federal Government, and numerous other agencies have
played a crucial role in this effort. This section attempts to give
the reader an overview of the activities of these various
organizations with a special review of more than 1,500 com-
munity level programs.

The programs described include cessation clinics, prevention
efforts aimed at children and adolescents, school programs,
community and patient education programs, mass media
campaigns, and individual self-help and counseling programs.
Also included are summaries of smoking education and infor-
mation programs of various agencies of the Federal
Government, particularly those within the U.S. Public Health
Service.
ACKNOWLEDGMENTS

This report was prepared by the U.S. Department of Health and Human Services under the general editorship of the Office on
Smoking and Health, Center for Health Promotion and Education, Centers for Disease Control. Research and production support
was provided by HCR, a management consulting firm in Washington, D.C. Managing Editor of the Report was John L. Bagrosky,
Associate Director of the Office on Smoking and Health. Managing Director was Ronald M. Davis, M.D., Director of the Office

on Smoking and Health.

The editors acknowledge with gratitude all the Federal agencies, State, county and loca} health departments, National voluntary
organizations and their State ‘and local affiliates, smoking and health advocacy groups, and the numerous individuals who
cooperated in the production of this Report.

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