What are the laws regulating tobacco?

The laws vary from county to state to nation and are not easily codified. The major areas of legislation primarily focused on attempts to regulate the distribution of tobacco. These laws included sales tax, advertising limits, age limits, and smoking bans in public places. Additionally, legislations focused on warning the public about the health risks of smoking by including warning labels and content descriptions. Finally, many laws have occurred as a result of lawsuits against the tobacco companies and not through legislation. Most laws are state laws, particularly those regarding sales tax. The general trend over the years has been to raise the sales tax on cigarettes both to make the product less desirable but also to support state healthcare funding. The taxes vary from state to state just as all sales taxes. Regionally, taxes tend to be lower in the South, the Midwest, and in parts of the Western interior.

In 1967, the Federal Communication Commission (FCC) required that all tobacco advertising on television be counterbalanced with ads warning of the health risks associated with smoking. In 1970 Congress passed The Public Health Cigarette Smoking Act, which banned all cigarette advertising on television and radio beginning on January 2, 1971. Smokeless forms of tobacco continued to be advertised on television and radio until 1986 when they were banned as well. In 2003, tobacco companies and magazine publications voluntarily agreed to eliminate tobacco advertisements from school editions of four prominent news magazines: Time, Newsweek, People, and Sports Illustrated. This came on the heels of huge class-action lawsuits against tobacco companies and was not the result of legislative acts.

On the international level, The World Health Organization (WHO) Framework Convention on Tobacco Control was adopted in 2003 and enacted in 2005. Table 3 lists the significant provisions of the treaty that must be implemented. To date, the United States Congress has not signed the treaty.

What are the Surgeon General's Reports?

By the 1960s, there was growing pressure for the U.S. Public Health Service to take some kind of action against smoking. Several anti-smoking advocacy groups, for example, The American Lung Association and the American Heart Association, proposed to President Kennedy that he appoint a commission to study the implications of tobacco use in the United States. Luther Terry, then Surgeon General, appointed a committee to fully investigate the ongoing questions about smoking and health.

Persistent denials of a causal link between smoking and lung cancer by the tobacco industry stimulated the need to develop a consensus report. At that time, the consensus method was unprecedented in medicine. It became the model for evidence-based medicine (EBM) to help guide medical practice based on the consensus of researchers.

Table 3 The WHO Framework convention on Tobacco control

WHo Framework convention on Tobacco control

Committee members came from a variety of disciplines. Members included a pharmacist, a statistician, a pulmonary medicine specialist, an internist, a surgeon, a pathologist, a biologist who was a cancer specialist, a toxicologist, a chemist, a bacteriologist, an epidemiologist, and a tobacco industry spokesperson. Each member was a renowned expert in his or her field. Any individual who had already published on the issue or had publicly taken a stand was not eligible to be on the investigative committee, in order to ensure that the findings would be unbiased. The committee included smokers and nonsmokers.

After conducting a lengthy study, the committee members concluded that there is a strong link between smoking and cancer. This conclusion was based on a wide range of evidence and included both statistical and epidemiological findings. (Statistics is the study of numerical data. Epidemiology is the study of the incidence, distribution, and control of a disease found in a population.) The committee found that the death rate from cancer among male smokers was 1,000 times higher than among nonsmokers. The tobacco industry refuted the findings, calling the causal link between smoking and lung cancer a "mathematical aberration."

The Surgeon General's Report was released in January 1964. This was a pivotal document in the history of public health. The report provided legitimacy to the allegations that smoking is harmful. The consensus report became a model for other reports on health concerns because of the independence and the integrity of the committee members and their findings.

The next Surgeon General's Report focused on secondhand smoke or environmental smoke. Two major reports were issued in 1986, one from Surgeon General Koop and the other from an independent research institution, The National Academy of Sciences (NAS). Both addressed the effects of environmental smoke on nonsmokers. The two reports each confirmed the other's findings. First, mainstream smoke exhaled into the air by smokers mixed with smoke released directly from the burning end of a cigarette, and constituted approximately 85% of the nonsmoker's intake of tar and nicotine. Second, secondhand smoke also posed risks not only to vulnerable individuals, such as those with respiratory problems, but also to healthy adults and children. What had been considered an environmental nuisance became a recognized and validated risk to the health of anyone exposed to the polluted air. The conclusion was that the simplest expansive and most effective way to prevent diseases from secondhand smoke was to establish smoke-free environments, including work-sites.

How have the Surgeon General's Reports affected the smoking habits of Americans?

Since the publication of the Surgeon General's Reports, along with the mounting evidence that cigarettes were both dangerous to one's health and addictive, there has been a steady decline in smoking among Americans, including teenagers. Particularly as the dangers of environmental smoke came to the public's attention, organizations enacted rules to develop more smoke-free public facilities. Bans on smoking in public places are almost universal in the United States.

The second Surgeon General's Report about secondhand smoke, published in 1986, set off a cataclysmic shift away from public smoking because it adversely affected both smokers and nonsmokers.

Immediately after the first year that the Report was made public (1964), the number of smokers declined. However, the next year the industry rebounded, reporting record sales and an increase in the per capita consumption of tobacco products. During the 1980s, cigarette consumption reached a critical point, after which the rates of smoking in the United States began a slow and progressive decline. In 1982, one- third (33%) of all adults were smokers; three years later the number had fallen to 30%. The second Surgeon General's Report about secondhand smoke, published in 1986, set off a cataclysmic shift away from public smoking because it adversely affected both smokers and nonsmokers. Workplace initiatives banning cigarette smoking proliferated. By the twenty-first century, smoking has declined more dramatically, and now smoking has become more of a private rather than public activity.

What was the effect of the lobbying efforts of the flight attendants union on the rules about smoking on airlines?

The lobbying efforts of the flight attendants had a major impact on the relationship between the airline industry and the tobacco industry. Airlines changed the rules for smoking to nonsmoking on flights and in airports except in designated places.

Airplanes can be thought of as the epitome of an enclosed space, and they became the focus of debate during the late sixties. In 1971, the flight attendants complained about their working conditions because they were exposed to secondhand smoke while on their jobs. They lobbied the airline industry to ban smoking on airplanes. Both the airline industry and the tobacco industry resisted changing their policies because they feared that they would lose customers. Initially, the Civil Aeronautics Board made nonsmoking sections a requirement on all commercial flights in response to the flight attendant's demands. In 1986, the National Academy of Sciences reported that the air quality on planes was in violation of the environmental requirements for building codes and other indoor environments. Following that study, the airline industry banned all smoking on commercial flights.

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