The Tobacco Epidemic Isn’t Over Yet
Use of tobacco products has been a long-running epidemic, too often set aside in the face of more acute public health crises. Cigarette smoking has declined since the 1960s when the fact that smoking kills people became incontrovertible and widely known. But, the epidemic of tobacco use continues to reemerge, driven by the ever-changing marketplace of tobacco products, which repeatedly challenges efforts to curb tobacco use. The new products are analogous to the mutation of a virus, causing repeated surges of infection. When a new tobacco product comes on the market it may cause an uptake in tobacco use, and the latest in the string of mutations of tobacco products puts Colorado in the spotlight.
The Cigarette Century
Harvard historian Allen Brandt dubbed the 20th century as “the cigarette century.” It began with the introduction of Camel cigarettes in 1913, the first mass-marketed brand. Consumption peaked at its mid-point, and smoking declined greatly by its end (Figure). At its peak, consumption reached 200 packs (4000 cigarettes per year or 11 cigarettes per day) for each person 18 years of age and older in the United States. Smoking was ubiquitous and accepted within the prevalent social norms of the time. During the last decades of the 20th century, the hospitals where I trained and worked were smoky and some physicians even smoked while making ward rounds to see patients. And, remarkably from a 21st-century perspective, smoking was allowed on airplane flights originating in the U.S. until the year 2000.
Figure. Adult per capita cigarette consumption and major smoking and health events, United States, 1900–2012
The rise of cigarette smoking was driven by nicotine’s addictive power, effective marketing, and social norms that imbued cigarettes with seemingly desirable characteristics: glamorous and sexy, relaxing, and weight-controlling. Menthol cigarettes were promoted, particularly in African-American neighborhoods, with advertisements emphasizing “cool” and Kool was a leading brand. “Cool” was a proper message since menthol’s cooling and anesthetic properties blunted the irritation of nicotine, leading some to proclaim that “menthol helps the poison go down easier.”
The tobacco industry modified its products as the evidence on the risks of smoking rapidly increased from the 1950s on. One of the earliest modifications was the addition of filters. Later, perforation of the filters with small holes was added to increase ventilation with the purported purpose of producing a milder and possibly safer cigarette. The industry promoted these lower-yield cigarettes with labels like “mild” and “light”, implying lesser health risks. In the 2006 opinion by Judge Gladys Kessler in the Department of Justice litigation against the tobacco industry, this deception by the tobacco industry was one of the findings leading to the industry’s conviction under the Racketeer Influenced and Corrupt Organization (RICO) Act. From 1953 forward, we know from industry documents that an organized campaign was sustained to create doubt around the scientific evidence on smoking and health, a strategy now widely used and referred to as the “tobacco industry playbook.” Other industries have turned to that playbook to counter scientific evidence that their products pose risks to human health and the environment.
Health Impacts of Smoking and Secondhand Smoke
The fall in cigarette smoking paralleled the ever more abundant and convincing evidence that smoking caused lung cancer and other diseases, and led to premature death. While the 1964 report of the Advisory Committee to the Surgeon General is a landmark moment in tobacco control, a Johns Hopkins study in the 1930s showed a much greater risk of dying in heavy smokers. Starting in 1950, epidemiological research linked smoking to an ever longer list of diseases and other health problems, starting with lung cancer and chronic bronchitis in the 1964 report, which also noted the 70% greater risk of dying in male smokers compared with nonsmokers. When the 50th-anniversary report was released in 2014, that list lengthened, adding diabetes mellitus, rheumatoid arthritis, colorectal cancer, and also an adverse impact on the prognosis of cancer.
From the 1970s, research began showing the harm to nonsmokers from breathing secondhand smoke – the combination of exhaled mainstream smoke and sidestream smoke from the smoldering cigarette. This helped accelerate implementation of policies to restrict smoking in public places and workplaces (Figure). For example, studies showed how parents’ smoking impacted the health of their children, and smoking by a mother during pregnancy was found to reduce birth weight and increase the risk for complications. In 1981, Dr. Hirayama, a Japanese epidemiologist, reported increased lung cancer in nonsmoking women married to smokers compared with nonsmoking women married to nonsmokers. This landmark report, heavily criticized by the tobacco industry and its surrogates, was followed by further research with similar findings, leading to the powerful conclusion in Surgeon General Everett Koop’s 1986 report that: “Involuntary smoking is a cause of disease, including lung cancer, in healthy nonsmokers.”
21st Century Regulation
A new era in the tobacco epidemic began in the 21st century. The first two decades have seen the passage of a global tobacco control treaty, the World Health Organization’s Framework Convention on Tobacco Control (FCTC), the enactment of the Family Smoking Prevention and Tobacco Control Act (Tobacco Control Act) in the United States, and the advent of myriad new electronic products following the 2003 patent for the current generation of electronic cigarettes.
The FCTC, ratified and in force for most nations (the United States has signed but not ratified), provides a global platform for contending with the highly consolidated multinational tobacco industry. Over its two decades, the FCTC has strengthened the global policy infrastructure for contending with the industry and, with funding from Bloomberg Philanthropies and the Gates Foundation, tobacco control capacity has been expanded in low- and middle-income countries. The World Health Organization has implemented its MPOWER (Monitor, Protect, Offer, Warn, Raise) tobacco control package and regularly reports on its implementation progress for each nation.
In the U.S., the Tobacco Control Act, passed in 2009, gave the Food and Drug Administration (FDA) regulatory authority over combustible cigarettes, an authority that was expanded in 2016 to include electronic cigarettes and several other products not included in the original version of the Act. The FDA created the Center for Tobacco Products, funded by required industry contributions, to carry out its regulatory and public health missions. The Act called for the creation of the Tobacco Products Scientific Advisory Committee (known as TPSAC) and required TPSAC to produce a report on menthol cigarettes within the first year of its formation. I chaired the TPSAC for its first year, leading the development of a report that concluded: “Menthol cigarettes have an adverse impact on public health in the United States,” and “There are no public health benefits of menthol compared to non-menthol cigarettes.” While the TPSAC did not call for a ban on menthol, it gave the FDA a public health rationale for taking action. Unfortunately, the report’s impact was diminished by legal actions taken by the tobacco industry. Now, because menthol brands are predominantly used by African Americans, policies to address menthol cigarettes have become tangled in politics and race.
Electronic Cigarettes and Vaping
In the 15 years since the passage of the Tobacco Control Act, the FDA has moved slowly on some of the most critical issues related to tobacco products in the United States. Its “deeming process” to gain regulatory authority over electronic cigarettes was ponderous, and it has acted indecisively on flavored tobacco products, which entice youth. The FDA and the tobacco control community generally were caught off-guard by the 2017-2019 surge in vaping by youth that was driven by JUUL with its less irritating nicotine salts, flavors, and appealing format. Students used JUUL surreptitiously in school and disposal of confiscated e-cigarettes became a problem for school administrators. Fortunately, 2024 data from the National Youth Tobacco Survey show that current (past 30-day) electronic cigarette use has dropped greatly and was reported by only 3.5% and 7.8% of middle school and high school students, respectively. These figures are notable drops from the 2019 peaks of 10.5% and 27.5%, respectively.
The most contentious issue around electronic cigarettes and also the recently arrived heat-not-burn products, such as the IQOS brand of heated tobacco products, is their potential role in harm reduction; that is replacing high-risk cigarettes with less risky alternatives. Without argument, these electronic products are qualitatively less risky than combustible cigarettes, but their benefits to smokers need to be weighed against the consequences of their availability for youth for whom these products may be the entry point for nicotine addiction. We don’t yet know the course of nicotine addiction in youth who become hooked on nicotine by electronic cigarettes.
The Future of Tobacco
The rapid changes in the tobacco marketplace are a major challenge to tobacco control. During the “cigarette century,” cigarettes were the dominant product, relatively homogeneous across brands, and changing slowly. Electronic cigarettes have been disruptive, moving through multiple generations and becoming more effective in delivering nicotine. Other products have emerged as well, including ZYN, an oral pouch with nicotine delivered from a silica gel.
Here is the Colorado connection. Philip Morris International has broken ground in Aurora for a factory to make ZYN. At a ground-breaking ceremony, Governor Polis and Mayor Coffman welcomed the new plant and the employment it will bring without comment on the product that it will make. Both Cathy Bradley, dean of the Colorado School of Public Health, and I offered our concerns in op-eds in the Colorado Sun and the Denver Post.
At the start of the 21st century, I thought that we might soon see the end of the tobacco epidemic in higher-income countries. Meetings were held on the “endgame” and strategies were discussed to finally end the epidemic. Some countries, such as Australia, New Zealand, and Sweden, have taken steps towards eliminating smoking. In Panama, the prevalence of smoking among adults is less than 5%. However, the tobacco industry will not give up its markets and it will continue to seek new ones.
Personal Comment
For me, the last half-century of the tobacco epidemic has been a lived experience, covering 20 years of my clinical practice as a pulmonary physician and 50 years as a public health researcher. My research on the lung and the environment and health inevitably intersected with the risks of active and passive smoking, and engagement in tobacco control—doing something about the epidemic. I started by writing and editing the Surgeon General’s reports on smoking and health from 1984 to now. Some of these reports had powerful consequences. With funding initially from the National Institutes of Health and later from the Bloomberg Philanthropies, I worked internationally: in China with its very high rate of smoking in men and a national monopoly that makes and sells cigarettes; in Mexico as it struggled against Marlboro Mexico to control passive smoking; and in Brazil, also with a powerful industry but with progressive policies.
I became involved with tobacco litigation when states began lawsuits against the tobacco industry to recover costs of the health care utilization caused by tobacco smoking. For Minnesota, the only state case that went to trial, I testified on the harms of active and passive smoking and the resulting costs. The four-year experience of preparing for the trial and testifying taught me how litigation can benefit public health. One of the most significant consequences of the trial was gaining access to the industry’s documents. I played a similar role in the Department of Justice litigation, important because of the industry’s being found guilty under the RICO Act. Above, I mentioned my role in chairing TPSAC, a group that responded admirably and effectively to the charge of developing a report on menthol cigarettes on a very short timeframe.
I can’t stop following the story of the tobacco epidemic. I just wish that it had ended.
Resources
There are many resources on the history of the tobacco epidemic. I mentioned Allan Brandt’s book, The Cigarette Century: The Rise, Fall, and Deadly Persistence of the Product That Defined America. I also recommend The Golden Holocaust. Origins of the Cigarette Catastrophe and the Case for Abolition by Stanford historian Robert Proctor. He uses the industry’s documents to chronicle the epidemic and the industry’s actions in maintaining it. His anger about the epidemic is apparent and leads to his call for the abolition of the industry.
This article is part of a monthly column, The Jon Samet Report, on the biggest issues facing us today in public health, written by the former dean of the Colorado School of Public Health, Jon Samet, a pulmonary physician and epidemiologist, and Professor of Epidemiology and Occupational and Environmental Health. Dr. Samet is a global health leader, shaping the science and conversation on issues ranging from tobacco control to air pollution to chronic disease prevention and more. Each month he shares expert insights on public health issues from local to global.
Former dean of the Colorado School of Public Health and Professor of Epidemiology and Occupational and Environmental Health
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