The Tobacco Epidemic

As a leading cause of preventable disease, disability, and death, the tobacco epidemic has long been one of the largest threats to public health in the world—and reducing or preventing tobacco use is a focus of public health strategies in dozens of countries.¹ To more deeply explore the strategies embedded in public health, I extend the models that I discuss in the main article that illustrate the multi-level determinants of health and the 10 essential services of public health to the health risks posed by tobacco products.

Multi-Level Determinants of Risk from Tobacco

As shown in the figure below, at the individual (or “underwater”) level, addiction occurs because nicotine attaches to the nicotinic cholinergic receptors, which release dopamine, and upregulates them (i.e., increases their numbers).² Genes play a role in the likelihood of becoming addicted. Moving up the axis, smoking by family members and peers increases the risk of an individual becoming a smoker, as do neighborhood characteristics like the density of stores selling cigarettes. Smoking bans (at the local and state levels³) and changing norms contributed to the continuing decline of smoking that began in the later decades of the 20th century. At the state level, more comprehensive laws in the first decade of the 21st century⁴ and increasing taxation drove smoking downward, particularly among youth.⁵ Nationally, tobacco products have been regulated by the US Food and Drug Administration (FDA) since 2009 under the Family Smoking Prevention and Tobacco Control Act.⁶ Globally, the tobacco industry is consolidated into a small number of enormous companies, such as Philip Morris International and British American Tobacco. The Framework Convention on Tobacco Control, a global treaty advanced through the World Health Organization, provides a counter to the industry.⁷

Figure 1: Multi-Level Determinants of Risks from Tobacco Products. 

Adapted from T. Glass and M. McAtee, “Behavioral Science at the Crossroads in Public Health: Extending Horizons, Envisioning the Future,” Social Science & Medicine 62, no. 7 (2006): 1650–71.

10 Essential Services Model Applied to Tobacco Control

Applying the public health essential services model to the tobacco epidemic, now more than a century in duration, its components fit with what has happened over the decades (as shown in the table below). The two essential services under assessment, reflected in the complementary tasks of surveillance and research, functioned well in the first half of the 20th century. The first indications of an emerging lung cancer epidemic came from reports in the 1920s and 1930s by clinicians who saw spiraling numbers of cases of a once rare cancer. The epidemic was confirmed by the count of lung cancer deaths in routine vital statistics that moved progressively upward. Research had convincingly identified cigarette smoking as the main cause of the epidemic by the 1950s.

The four essential services underlying policy development have been in play since the mid-1900s, supporting an ever-changing set of policies as the tobacco epidemic’s face changed and scientific evidence and surveillance data identified new needs for policy development. Multiple channels have been used to educate the public, beginning with the surgeon general’s warnings printed on tobacco products and now involving social media and other contemporary messaging modalities. Community mobilization and engagement of nongovernmental organizations (e.g., the American Lung Association) were pivotal to changing social norms to establish smokefree indoor spaces. Legal and regulatory actions became critical in the more recent decades, including litigation by the states that resulted in the largest civil litigation settlement in US history. The Master Settlement Agreement reached in November 1998 between 52 state and territory attorneys general and the tobacco industry included restrictions on the industry’s activities and financial payments to the states and territories, compensating for the costs of providing care for people with diseases caused by tobacco products.⁸ Now well documented, the tobacco industry tried to stymie policy development for decades with strategies that led to its being found guilty in 2006 under the Racketeer Influenced and Corrupt Organizations Act in litigation brought by the US Department of Justice.⁹ And, as noted above, regulatory authority over tobacco products was given to the FDA in 2009.

The four essential services of assurance can also be mapped in tobacco control. Tobacco control has emerged as a specialty within public health that is represented in state health departments and in many county health departments. In larger entities, there may be focused expertise around cessation services, secondhand smoke, and prevention of youth smoking. This infrastructure is supported by funds received from the Master Settlement Agreement, the CDC, tobacco taxes, and other sources. At the national level, the Office on Smoking and Health was established in 1978 (though it didn’t join the CDC, its current home, until 1986); it carries out activities at the national level and supports states’ efforts to reduce death and disability from smoking.¹⁰ Tobacco control activities have been continuously evaluated and refined, shifting in focus as the epidemic has shape-shifted, for example with the emergence of vaping.

Equity is central in the essential services model (see the first figure in the main article here) and became an overarching consideration as the tobacco epidemic fragmented into multiple sub-epidemics, driven by the tobacco industry’s targeting of different groups with particular products and marketing. (One of the most infamous examples of this was the pushing of menthol cigarettes to African Americans.¹¹) Public health has responded, designing tobacco control measures that address those populations at greatest risk from tobacco products with guidance from surveillance findings.

The graph below provides a long-term perspective on how tobacco control affected the epidemic use of tobacco products, progressively reducing cigarette smoking from its peak in the 1960s. (For a detailed description of each event noted in the figure, see go.aft.org/q4q). The graph shows when various steps were taken, corresponding to the 10 essential services. This success was achieved, albeit slowly, in the face of sustained opposition from the tobacco industry. The 10 services do not directly incorporate the push-pull between public health actions and those who oppose them, particularly the tobacco industry, but tobacco control has been dynamic as the nature of the epidemic changed.

Figure 2: Cigarette consumption in the United States per capita. 

Adapted from US Department of Health and Human Services, The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General (Atlanta: 2014).¹²

–J. S.

Endnotes

1. World Health Organization, “Tobacco,” July 31, 2023, who.int/news-room/fact-sheets/detail/tobacco.

2. N. Benowitz, “Pharmacology of Nicotine: Addiction, Smoking-Induced Disease, and Therapeutics,” Annual Review of Pharmacology and Toxicology 49 (2009): 57–71.

3. Institute of Medicine, Committee on Secondhand Smoke Exposure and Acute Coronary Events, “The Background of Smoking Bans,” in Secondhand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence (Washington, DC: National Academies Press, 2010), ncbi.nlm.nih.gov/books/NBK219563.

4. Centers for Disease Control and Prevention, “State Smoke-Free Laws for Worksites, Restaurants, and Bars—United States, 2000–2010,” Morbidity and Mortality Weekly Report 60, no. 15 (April 22, 2011): 472–75, cdc.gov/mmwr/preview/mmwrhtml/mm6015a2.htm.

5. P. Bader, D. Boisclair, and R. Ferrence, “Effects of Tobacco Taxation and Pricing on Smoking Behavior in High Risk Populations: A Knowledge Synthesis,” International Journal of Environmental Research and Public Health 8, no. 11 (October 26, 2011): 4118–39.

6. US Food and Drug Administration, “Family Smoking Prevention and Tobacco Control Act—an Overview,” August 29, 2024, fda.gov/tobacco-products/rules-regulations-and-guidance-related-tobacco-products/family-smoking-prevention-and-tobacco-control-act-overview.

7. WHO Framework Convention on Tobacco Control, WHO Framework Convention on Tobacco Control (Geneva, Switzerland: World Health Organization, May 25, 2003), fctc.who.int/resources/publications/i/item/9241591013.

8. National Association of Attorneys General, “The Master Settlement Agreement,” naag.org/our-work/naag-center-for-tobacco-and-public-health/the-master-settlement-agreement.

9. United States of America, Plaintiff, and Tobacco-Free Kids Action Fund, American Cancer Society, American Heart Association, American Lung Association, Americans for Nonsmokers’ Rights, and National African American Tobacco Prevention Network, Intervenors, v. Philip Morris USA Inc., 449 F. Supp. 2d 1 (D.D.C. 2006).

10. L. Marshall et al., “The National and State Tobacco Control Program: Overview of the Centers for Disease Control and Prevention’s Efforts to Address Commercial Tobacco Use,” Preventing Chronic Disease 21 (May 30, 2024): E38.

11. Centers for Disease Control and Prevention, “Unfair and Unjust Practices and Conditions Harm African American People and Drive Health Disparities,” May 15, 2024, cdc.gov/tobacco-health-equity/collection/african-american-unfair-and-unjust.html.

12. US Department of Health and Human Services, The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General (Atlanta: 2014), ncbi.nlm.nih.gov/books/NBK179276/pdf/Bookshelf_NBK179276.pdf.

[Illustration by Mike Austin]