Confronting America’s Smoking Pandemic, Part 3: 1986–1999

Also in this year, the National Cancer Institute begins funding of COMMIT (Community Intervention Trial for Smoking Cessation), a 6-year multicenter project, which has an impact on quit rates among light-to-moderate smokers in the study, but not among heavy smokers.[3-5]

Over the next 2 years, under the leadership of Ronald Davis, MD, the director of the Office on Smoking and Health of the Centers for Disease Control, the Surgeon General’s Interagency Committee on Smoking and Health convenes several conferences to address growing areas of concern, including the impact of smoking on minority communities and tobacco industry sponsorship of sports. In 1991, Secretary of Health and Human Services Louis W. Sullivan, MD, asks sports fans and promoters to boycott sports events sponsored by tobacco companies. He says Americans should send a message to those “who would encourage our children to use addictive substances which will ruin their health and send them to an early grave.”[6]

By 1989, Congress extends the airline smoking ban to all domestic flights, as reported in the September 14, 1989 issue of USA Today shown in the slide. Also during that year, Aspen, Colorado becomes the first city in the US to require smoke-free restaurants.

“Some ended up with lung cancer and died [even though they had never smoked]. When I repeatedly asked the medical professionals how a non-smoker could have smokers’ lungs and the diseases of smokers, they had no answers. We know now…people who are forced to breathe second hand tobacco smoke suffer and die from the same diseases as smokers. The flight attendants are the canaries in the coal mines and are the major power in the world who forced the no smoking issue into a global movement.”-Patty Young, on the Flight Attendants for Medical Research Institute (FAMRI) website.

Modified and reintroduced as Eclipse, the cigarette again fails to catch on. In 2000, Philip Morris introduces Accord, a cigarette that is inserted into an electronic lighter to heat the tobacco (and “virtually eliminate lingering odor”). Again, the product fails to sell. In 2014, Reynolds American announces it will launch Revo in 2015, a rebranded version of Premier.[7,8] Revo is to be positioned as “a modern classic in the consumer space between a combustible cigarette and a vapor product,” according to Brice O’Brien, Reynolds’s executive vice president of consumer marketing, as quoted in a November 2014 article in The Wall Street Journal.[8]

Under the directorship of Dileep Bal, MD, MS, MPH, Chief of the Cancer Control Branch of the California Health Department, the program-the first comprehensive statewide tobacco control effort in the nation-is estimated to have reduced health care costs in the state by $86 billion during its first 15 years, as well as reducing the incidences of lung cancer and heart disease.

Written by Robert Robinson, DrPH, Charyn Sutton, Denise James, and Carole Tracy Orleans, PhD, the guide was the first tobacco cessation program developed by and for African Americans. It is endorsed and disseminated by the National Medical Association, among other organizations. The CDC publishes an expanded second edition of Pathways to Freedom in 2002,[10] but neither the CDC nor the national smoking quit lines widely disseminate the program.

Also in this year, in Dade County, Florida, attorneys Stanley and Susan Rosenblatt file a class action lawsuit against the major cigarette manufacturers, on behalf of Patty Young and six other nonsmoking flight attendants, seeking $5 billion in punitive damages for lung cancer and other respiratory ailments allegedly caused by long-standing exposure to secondhand tobacco smoke.[13] The lawsuit is settled in 1997 with the tobacco companies agreeing to pay $300 million to establish the Flight Attendant Medical Research Institute (FAMRI),[14] for the purpose of conducting research on secondhand tobacco smoke.

Other states initiate quitlines during the 1990s, including Massachusetts (1994), Arizona (1996), Oregon (1998), and Mississippi (1999). The state of Alaska established its quitline in 2002, and the Missouri quitline was initiated in 2005. The North American Quitline Consortium (www.naquitline.org) highlights quitline start dates and specific program details for each of the 50 states, plus Puerto Rico and Guam.[15] By 2014, all 50 states and the District of Columbia offer a quitline, available through the same number, 1-800-QUIT NOW. The California Smokers’ Helpline, directed by Shu-Hong Zhu, PhD, is the most comprehensive in the US, offering counseling in six languages and for the hard of hearing.[16]

The website most widely used by the public for smoking cessation is WhyQuit.com, a free resource created by John Polito that provides proven behavioral and other nonpharmacologic approaches to stopping smoking, which were developed by educator Joel Spitzer.

With funds generated by the cigarette tax, the Massachusetts Tobacco Control Program (MTCP) is established in 1993 under the directorship of Gregory Connolly, DMD, MPH, to improve public health by reducing death and disability from tobacco use. With an average budget of $39 million from 1994 through 2002, MTCP implements smoking cessation counseling, school-based education programs, paid mass media campaigns, and tobacco product regulations. The annual number of cigarette packs sold in Massachusetts declines by 45%, from 510 million packs in 1993 to 282 million packs in 2006. Smoking prevalence among high school students in Massachusetts decreases from 35.7% in 1995 to 20.5% in 2005, representing a 43% decline. MTCP funding in 2006 is reduced to $8.25 million.[18]

In 2011, officials of Major League Baseball sought to ban players from using smokeless tobacco, but the Major League Players’ Association rejected the idea. A study by the Professional Baseball Athletic Trainers Society in 2014 finds that as many as one-third of major league players use oral tobacco. In 2014, baseball Hall of Famer Tony Gwynn, who played for the San Diego Padres and is considered one of the greatest hitters of all time, dies at age 54 from salivary gland cancer, which he attributed to his use of smokeless tobacco. In 2016, the use of smokeless tobacco is banned in baseball stadiums in San Francisco, Los Angeles, Boston, New York, and Chicago[22] as the result of laws passed by the city councils of these cities in an effort led by the Campaign for Tobacco-Free Kids.[23]

The EPA report on secondhand smoke made front-page news in Long Island New York’s Newsday, on January 8, 1993. The report classifies secondhand smoke as a Group A carcinogen, a designation which means that there is sufficient evidence that the substance causes cancer in humans, and which has been used by EPA for only 15 other pollutants, including asbestos, radon, and benzene.

Also in this year, Mississippi Attorney General Mike Moore files the first state lawsuit against cigarette manufacturers seeking to recoup the Medicaid costs of caring for persons made ill by smoking. In 1997, Mississippi settles with the tobacco industry for $3.6 billion. Florida settles its lawsuit for $11.3 billion. In 1998, Texas reaches a $15.3 billion settlement, and Minnesota (joined by Blue Cross and Blue Shield of Minnesota) settles for $6.6 billion.

“I believe they [the tobacco industry] are the most corrupt and evil corporate animal that has ever been created in this country’s history. They sell a drug, they make a drug, and they sell it knowing that it’s addictive. They market it to our children, who they know will become addicts and they know that they will die from causes attributable to tobacco related disease.”­- Mike Moore, Mississippi Attorney General from 1998–2004, in an interview airing on the PBS program “Frontline.”

In 2006, Reynolds American introduces Camel Snus, a moist powdered tobacco product claimed by harm reduction scientists to reduce the risk of cancers associated with the use of other tobacco products such as chewing tobacco and cigarettes. The widespread use of snus by Swedish men, displacing tobacco smoking and other varieties of snuff, is thought to be responsible for the lower incidence of tobacco-related mortality in Sweden than any other European country. Opponents of the use of snus, which does not require expectoration, decry it as a way for youth to use tobacco without detection.

Dr. Kessler’s 1995 assertion that nicotine is a drug followed a unanimous conclusion by an FDA panel in mid 1994 that nicotine is addictive.[25] Also in 1995, the nonprofit advocacy group Lung Cancer Alliance is formed.[26] It is dedicated solely to patient support and advocacy for people living with lung cancer or more at risk for the disease. Its goal is to reduce lung cancer mortality by at least 50% by 2020. In addition, Massachusetts is the first state to divest state pension funds of stock in tobacco companies.[27]

Also in this year, in response to the globalization of the tobacco pandemic, the World Health Organization (WHO) 49th World Health Assembly adopts a resolution requesting that the WHO Director-General initiate development of a WHO Framework Convention on Tobacco Control (WHO FCTC). Adopted by the Assembly in 2003 and entering into force in 2005, the WHO FCTC is the first global public health treaty, with the aim of fostering cooperative international actions against tobacco advertising, promotion, and sponsorship beyond national borders, as well as against the smuggling of tobacco products. The preamble of the Convention cites the “concern of the international community about the devastating worldwide health, social, economic and environmental consequences of tobacco consumption and exposure to tobacco smoke.”[29,30] In addition, the discount chain Target stops selling cigarettes in its 770 stores, citing high costs of keeping cigarettes out of the hands of minors.[31]

Also in this year, California eliminates smoking in bars. Together with the law eliminating smoking in restaurants and most other public places, this law makes California the first state to pass a comprehensive statewide smoke-free air law.

Alan Blum, MD, and Eric Solberg, director of Doctors Ought to Care (DOC), establish the University of Alabama Center for the Study of Tobacco and Society, the largest historical resource of original material on the tobacco industry, cigarette marketing, and the anti-smoking movement. Over the next 15 years the Center produces 10 museum exhibitions, including “Cartoonists Take Up Smoking” at the National Museum of Health and Medicine and “The Surgeon General vs. The Marlboro Man: Who Really Won?” at the Gorgas Library of the University of Alabama and the Lyndon Baines Johnson Presidential Library.

Also in this year, the American Legacy Foundation is established as part of the Tobacco Master Settlement Agreement.[33] The foundation is dedicated to research and providing public education about the impact of tobacco use in order to reduce morbidity and mortality. Renamed the Truth Initiative in 2015, the foundation also funds anti-smoking media campaigns and the online repository of tobacco industry documents (https://industrydocuments.library.ucsf.edu/tobacco/), released by the industry during the process of discovery in the attorneys-general lawsuits against the tobacco industry in the mid-1990s (http://www.tobaccoarchives.com/info.html).[34]

In 1975, a Times spokesman had replied to Dr. Gitlitz that “until Congress decides, if ever, that a total ban is both necessary and enforceable, adults who have been thoroughly informed on the dangers of cigarette smoking will have to decide for themselves whether they want to accept the risks involved.” In the 1980s the newspaper solicited cigarette advertisers in a trade publication, The U.S. Tobacco and Candy Journal, with full-page ads that claimed “Lifestyles are made, not born.”

The Seattle Times stopped accepting cigarette advertising in 1994, joining The Christian Science Monitor and The Deseret News (owned by the Church of Latter Day Saints) and The Salt Lake City Tribune, all of which had long banned the acceptance of cigarette advertising because of their publishers’ religious beliefs.