Surgeon General's Report Tobacco Education Oversight Committee. Toward a Tobacco-Free California: Strategies for the 21st Century, 2001-2003. Sacramento (CA): Tobacco Education Over- sight Committee, 2000. Traynor MP, Begay ME, Glantz SA. New tobacco industry strategy to prevent local tobacco control. Journal of the American Medical Association 1993;270 (4):479-86. University of Miami. Youth Tobacco Prevention in Florida: An Independent Evaluation of the Florida Tobacco Pilot Program. Miami: University of Miami, 1999. University of Michigan. Smoking among American teens declines some [press release]. Ann Arbor (MD): University of Michigan, Dec 18, 1998. US Department of Health and Human Services. The Health Consequences of Smoking: Cardiovascular Disease. A Report of the Surgeon General. Rockville (MD): US Department of Health and Human Services, Public Health Service, Office on Smoking and Health, 1983. DHHS Publication No. (PHS) 84-50204. US Department of Health and Human Services. 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World Health Organization. Guidelines for Controlling and Monitoring the Tobacco Epidemic. Geneva: World Health Organization, 1998. Comprehensive Prograits 429 Chapter 8 A Vision for the Future—Reducing Tobacco Use in the New Millennium Introduction 433 Continuing to Build the Scientific Base 433 The Changing Tobacco Industry 434 The Need fora Comprehensive Approach 435 Identifying and Eliminating Disparities 436 Improving the Dissemination of State-of-the-Art Interventions 436 Tobacco Use in Developing Nations 437 Tobacco Control in the New Millennium 438 References 439 Introduction Reducing Tobacco Use Tobacco use, particularly cigarette smoking, re- mains the leading cause of preventable illness and death in the United States (McGinnis and Foege 1993). A ma- jor challenge to our nation’s public health leaders in the new millennium is to make this disturbing obser- vation a thing of the past. Such a goal is no millennial dream. This Surgeon General's report provides evi- dence that tobacco use in this nation can be reduced through existing modalities of interventions. The substantial body of literature reviewed in this report indicates that each of the modalities—educational, clinical, regulatory, economic, and social—provides evidence of effectiveness. The six major conclusions of this report provide the framework for the development of a coherent, long-term tobacco policy for this nation. Thus, although our knowledge about tobacco control re- mains imperfect, we know more than enough to act now. Widespread dissemination of the approaches and meth- ods shown to be effective in each modality and especially in combination would substantially * Reduce the number of young people who will become addicted to tobacco. e Increase the success rate of young people and adults trying to quit using tobacco. e Decrease the level of exposure of nonsmokers to environmental tobacco smoke (ETS). Continuing to Build the Scientific Base * Reduce the disparities related to tobacco use and its health effects among different population groups. e Decrease the future health burden of tobacco- related disease and death in this country. These achievable improvements parallel the health objectives set forth in Healthy People 2010, the national action plan for improving the health of all people living in the United States for the first decade of the 21st century (U.S. Department of Health and Human Services [USDHHS] 2000). Twenty-one specific national health objectives related to tobacco use are listed in Healthy People 2010, including reducing the rates among young people and adults to less than half of the current rate of use. Attaining all of these tobacco-related objectives will almost certainly require significant national commitment to the vari- ous successful approaches described in this report. The report’s major conclusions are not formal policy recommendations. Rather, they offer a sum- mary of the scientific literature about what works. In short, this report is intended to offer policymakers, public health professionals, professional and advocacy organizations, researchers, and, most important, the American people guidance on how to ensure that ef- forts to prevent and control tobacco use are commen- surate with the harm it causes. Beginning with the 1964 Surgeon General's re- port, Smoking and Health (U.S. Department of Health, Education, and Welfare 1964), tobacco control policy in this nation has been built on a foundation of scien- tific knowledge. Each of the subsequent 24 reports of the Surgeon General on tobacco use has documented a vast and growing body of scientific literature. The substantial research reviewed in this report focuses on a key segment of the literature—what has been tried in the decades-old effort to reduce tobacco use. In turn, this focus clarifies which efforts work best. Certainly more research is needed so that these efforts can be more efficient and effective; the key conclusion from this report, however, is that we know more than enough to take actions now to decrease the future health burden of tobacco-related disease and death in this country. In the process of applying our current state of knowledge about preventing and controlling tobacco use, accountability and evaluation of the public health effort will be critical. However, because of the wide array of educational, clinical, regulatory, economic, and social influences that have been and will need to be brought to bear on the tobacco use problem, the direct A Vision for the Future 433 Surgeon General's Report impact of a specific maneuver on a specific outcome becomes less meaningful as the combined effects be- come more substantial. Investigators tend to work on small, manageable aspects of the tobacco use problem, but the synergistic influence of multiple factors over time will likely extend far beyond the outcomes pre- dicted from these smaller research undertakings. For example, as this report demonstrates, the most effica- cious educational programs are those that take place ina larger community context, one that engenders and supports an environment of nonsmoking. Similarly, although clinical interventions to manage tobacco ad- diction clearly have some specific power to help smok- ers quit, primarily through pharmacological means, the social environment remains a major determinant of whether these new former smokers maintain their ab- stinence from nicotine addiction. Regulatory efforts, on the other hand, raise a host of social and economic issues and can produce broad societal changes—issues and changes, however, that are difficult to isolate, docu- ment, and evaluate. Economic strategies also have a great potential, but being fundamentally political in The Changing Tobacco Industry nature, they require public consensus and changes in social norms before they can be attempted. Finally, the public health advocacy involved in social program modalities is virtually impossible to assess in a pro- spective or controlled research design. The research and evaluation tools of public health must expand to meet these complex issues. Compre- hensive, multifactorial approaches to tobacco control appear to offer the most promise. However, the pen- alty for comprehensive approaches is a loss of statisti- cal power to attribute outcomes to specific activities. Within each of the modalities, appropriate evaluation methodologies are being used (see Table 1.1). However, many of these methodologies involve retrospective case study, time trend, econometric, and surveillance ap- proaches to evaluate the “natural experiment” as it evolves in the changing social environment. Thus, the traditional biomedical and epidemiologic research methods that have worked so well in defining the health consequences of tobacco use are not well suited to evalu- ating the potentially most efficacious methods to reduce tobacco use. This report documents that this country’s efforts to prevent the onset or continuance of tobacco use have faced the pervasive, countervailing influences of tobacco promotion by the tobacco industry. De- spite the overwhelming and continually growing body of evidence of adverse health consequences of tobacco use, the norm of social acceptance of tobacco use in this nation has receded more slowly than might be ex- pected, in part because of such continued promotion. Litigation and legal settlements have produced notable changes in the tobacco industry’s public posi- tions on health risks, nicotine addiction, and advertis- ing and promotion limits. Additionally, individual manufacturing companies have become more directly involved in efforts to limit the access of underage per- sons to tobacco products and to prevent young people from initiating tobacco use. In this rapidly changing social and legal environment, it is difficult to project the nature and scope of future changes by the industry or their impact on the national effort to reduce tobacco use. Nevertheless, any analysis of changes in patterns of 434 Chapter 8 tobacco use must consider the influence of these indus- try changes. One of the major arenas of potential change will be in the tobacco product itself. The manufactured cigarette that is widely marketed in the developed world was noted to be changing dramatically when this issue was first considered by the Surgeon General in 1981, in The Changing Cigarette (USDHHS 1981). Recent public statements by the tobacco industry sug- gest that the pace of changes in the manufactured ciga- rette could be accelerating in the future. The public health implications of changes in manufactured ciga- rettes and other tobacco-containing products will re- quire careful and significant attention from both public health researchers and policymakers. The litigation environment has demonstrated the importance of tobacco industry documents in analyzing the industry’s influence. Legal and public health analyses are just beginning to sift through the millions of pages of documents made public as part of the various legal actions undertaken over the last decade. As this process continues, public health researchers may develop better methods to define and evaluate the industry’s past activities that may have Reducing Tobacco Use contributed to the character, pace, or direction of changes in tobacco use patterns in this country or around the world. The Need for a Comprehensive Approach The evidence of effectiveness summarized in this report emphasizes that public health success in reduc- ing tobacco use requires activity using multiple mo- dalities. A comprehensive approach—one that optimizes synergy from applying a mix of educational, clinical, regulatory, economic, and social strategies— has emerged as the guiding principle for future efforts to reduce tobacco use. The public health goals of such comprehensive programs are to reduce disease, dis- ability, and death related to tobacco use through pre- vention and cessation, as well as through protection of the nonsmoker from ETS. The emerging body of data on statewide tobacco control efforts is coming from programs broadly fo- cused on prevention, cessation, and protection of the nonsmoker from ETS (Chapter 7). Preventing initia- tion among young people is a primary goal of any to- bacco control effort. However, young people will perceive contradictory or inconsistent messages in our prevention efforts if programs do not also address the smoking behavior of millions of parents and other adult role models and the public health risks of ETS. The Centers for Disease Control and Prevention (CDC) recently released Best Practices for Compr- ehensive Tobacco Control Programs (CDC 1999), which recommends that states establish tobacco control programs that are comprehensive, sustainable, and accountable. This document draws upon “best prac- tices” determined by evidence-based conclusions from research and evaluation of such comprehensive pro- grams at the state level. In the review of evidence from these states, it was evident that reducing the broad cultural acceptability of tobacco use necessitates changing many facets of the social environment. Nine specific elements of a comprehensive program are de- fined in the guidance document. Although the im- portance of each of the elements is highlighted, the document stresses that these individual components must work together to produce the synergistic effects of a comprehensive program. A medical analogy might be helpful to under- stand the practical implications of the current state of knowledge about these best practices of tobacco con- trol. If we found a combination of nine therapy ele- ments that effectively treated an almost incurable disease (e.g., advanced lung cancer), we would study the combined therapy in many ways to learn more about how it worked and which aspects of this combi- nation therapy were most effective. However, while we were doing this research, we would give every patient with the disease the full combination of the nine therapy elements. In the same way, with the nine components of Best Practices, we need to continue evaluating ongo- ing comprehensive programs to gain more knowledge about how the components work individually and in combination. But while this research continues, states should be applying all nine components. Best Practices thus provides effective guidance for state-level efforts; a comprehensive national tobacco control effort, however, requires strategies that go be- yond this guidance to states. As documented in ear- lier chapters of this report, a comprehensive national effort should involve the application of a mix of edu- cational, clinical, regulatory, economic, and social strat- egies. In each of these modalities, some of the program and policy changes that are needed can be addressed most effectively at the national level. A Vision for the Future 435 Surgeon General's Report Identifying and Eliminating Disparities The elimination of health disparities related to tobacco use poses a great national challenge. Although this issue was not a main aspect of the current report, two other recent USDHHS publications have taken this focus. The 1998 Surgeon General’s report Tobacco Use Among U.S. Racial/Ethnic Minority Groups was the first to address the diverse tobacco control needs of the four major U.S. racial/ethnic minority groups— African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Islanders, and Hispanics (USDHHS 1998). Similarly, Healthy People 2010, released in January 2000, has two overarching goals: increase quality and years of healthy life and eliminate health disparities among different segments of the U.S. population (USDHHS 2000). Both publica- tions not only highlight the significant disparities in health that exist in the United States but also stress the critical need for a greater focus on this issue, both in research and in public health action. Cultural, ethnic, religious, and social differences are clearly important in understanding patterns of to- bacco use, but little research has been completed on the relative effectiveness of interventions for prevention and treatment in some of the population groups or com- munities. Reaching the national goal of eliminating health disparities related to tobacco use will necessi- tate improved collection and use of standardized data to correctly identify disparities in both health outcomes and efficacy of prevention programs among various population groups. Broader historical, societal, and community characteristics can have a significant in- fluence on the manner in which prevention and con- trol strategies that work overall for the population as a whole may impact diverse groups. Many of these broader variables do not lend themselves to traditional measurement methods, nor are they easily assessed at the individual level through the use of traditional epi- demiologic methods. Improving the Dissemination of State-of-the-Art Interventions One of the greatest challenges in tobacco control and public health in general continues to be overcom- ing the difficulty in getting advances in prevention and treatment strategies effectively disseminated, adopted, and implemented in their appropriate delivery systems. Simply stated, our recent lack of progress in tobacco control is attributable more to the failure to implement proven strategies than it is to a lack of knowledge about what to do. The result is that each year in this nation, more than 1 million young people continue to smoke, and more than 400,000 adults continue to die prema- turely from tobacco-related diseases. 436 Chapter 8 Within each of the modalities reviewed in this report, some specific research advances in tobacco pre- vention and control strategies have not been fully implemented. Studies are urgently needed to identify the social, institutional, and political barriers to the more rapid dissemination of these research advances. Understanding these barriers and determining how they could be overcome would benefit not only tobacco control but also public health efforts more broadly. Tobacco Use in Developing Nations Reducing Tobacco Use Analyses by the World Health Organization (WHO) have concluded that by 2030, current smok- ing patterns will produce about 500 million premature deaths from tobacco-related disease among people alive today (World Health Organization 1999). WHO further estimates that by 2030, tobacco is expected to be the single greatest cause of death worldwide, ac- counting for an estimated 10 million deaths per year. Although the impact of tobacco-related disease and death has been until recently a problem primarily for the developed countries of this world, WHO now es- timates that by 2020, 7 of every 10 tobacco-related deaths will be in the developing world. This report addresses research on strategies to re- duce tobacco use within our nation’s social, legal, and cultural environment. Nevertheless, findings from this report may have broad utility in the planning of tobacco control efforts around the world. As Chapter 2 documents, the public health response in this country to the scientific findings about the health consequences of tobacco products has taken more than four decades to emerge. In many parts of the developing world, the problems of tobacco use are similar to those in this country in the 1950s and 1960s. Hence, a key public health question for this millennium may be the fol- lowing: can the time interval be significantly short- ened between when the health risks of tobacco for a developing country are recognized and when a com- prehensive national response is begun? WHO, the World Bank, and the United Nations Foundation, with technical assistance from the CDC, have undertaken major new initiatives to address this problem. The WHO Tobacco Free Initiative is develop- ing an international tobacco control infrastructure, which includes a global tobacco surveillance system, intervention tool kits, and regional technical assistance workshops. The World Bank has published Curbing the Epidemic: Governments and the Economics of Tobacco Control Jha and Chaloupka 1999). This document provides an economic analysis that supports a multipronged approach to tobacco control, involving raising excise taxes, promoting policy changes related to the sales and promotion of tobacco products as well as to restrictions on smoking in public places, and wid- ening access to smoking cessation therapies. The sci- entific findings in this report are consistent with the programmatic recommendations of both the WHO Tobacco Free Initiative and the World Bank document. A momentous undertaking of WHO and mem- ber states, including the United States, is the develop- ment and negotiation of the Framework Convention on Tobacco Control. If brought to its intended ratifi- cation in the next few years, this agreement would provide a framework within which countries could develop more specific bilateral and multilateral pro- tocols for cooperation on containing the spread of the tobacco epidemic. The framework would enable coun- tries to start from a common understanding of the is- sues, priorities, and strategies necessary to harmonize tobacco control efforts between themselves so that some countries do not benefit at the expense of others. This is the spirit of the other activities of U.S, govern- mental and nongovernmental agencies in their effort to collaborate with WHO and with other countries in their development of surveillance, cessation, preven- tion, mass media, regulatory, economic, and social approaches to global tobacco control. In the near future, emphasis must be placed on the development of surveillance systems so that coun- tries can know the extent, distribution, and trends of the tobacco consumption problems in their popula- tions. These systems will also track—for international comparison and monitoring of progress—-the emer- gence of new forms of tobacco promotion, as well as new legislation, regulations, and programs for coun- tering tobacco use. In the longer term, the gaps must be filled in each country’s defenses against the incur- sions of tobacco use on their young people and other vulnerable populations. In particular, there will be a continuing need to ensure that the rapidly expanding knowledge about the efficacy of various tobacco con- trol modalities be made available to the developing world. The challenge to the world is to prevent tobacco use, particularly smoking, from ever becoming the lead- ing cause of preventable illness and death in the world. Dr. Gro Harlem Brundtland, the current director- general of WHO, clearly defined this challenge when she stated, “If we do not act decisively, a hundred years from now our grandchildren and their children will look back and seriously question how people claim- ing to be committed to public health and social justice allowed the tobacco epidemic to unfold unchecked” (Asma et al., in press). A Vision for the Future 437 Surgeon General’s Report Tobacco Control in the New Millennium Tobacco use will remain the leading cause of clinical, regulatory, economic, and social—that can preventable illness and death in this nation and a grow- guide the development of this expanded national ef- ing number of other countries until tobacco preven- fort. This report is, therefore, a prologue to the devel- tion and control efforts are commensurate with the opment of a coherent, long-term tobacco policy for this harm caused by tobacco use. This report provides the nation. composite review of the major methods—educational, 438 Chapter 8 References Reducing Tobacco Use Asma 5, Yang G, Samet J, Giovino G, Bettcher DW, Lopez A, Yach D. Tobacco. In: Oxford Textbook of Public Healtl, in press. Centers for Disease Control and Prevention. Best Prac- fices for Comprehensive Tobacco Control Programs— August 1999. Atlanta: Centers for Disease Control and Prevention, National Center for Chronic Disease Pre- vention and Health Promotion, Office on Smoking and Health, 1999. Cromwell J, Bartosch WJ, Fiore MC, Hasselblad V, Baker T. Cost-effectiveness of the clinical practice rec- ommendations in the AHCPR guideline for smoking cessation. fournal of the American Medical Association 1997 ;278(21):17359-66. Crossett LS, Everett SA, Brener ND, Fishman JA, Pechacek TF. Adherence to the CDC Guidelines for School Health Programs to Prevent Tobacco Use and Addiction. Journal of Health Education 1999;30(5 Supp): S4-S11. Cummings 5R, Rubin SM, Oster G. The cost-effectiveness of counseling smokers to quit. Journal of the Anierican Medical Association 1989;261(1):75-9. Environmental Protection Agency. Respiratory Health Effects of Passive Smoking: Lung Cancer and Other Diser- ders. Washington: Environmental Protection Agency, Office of Research and Development, Office of Air and Radiation, 1992. Publication No. EPA/600/5-90/006F. Jha P, Chaloupka FJ. Curbing the Epidemic: Governments and the Economics of Tobacco Control. Washington: World Bank, 1999. Kann L, Warren CW, Harris WA, Collins JL, Douglas KA, Collins ME, Williams BI, Ross JG, Kolbe LJ. Youth risk behavior surveillance—United States, 1993. Mor- bidity and Mortality Weekly Report 1995;44(SS-1):1-56. McGinnis JM, Foege WH. Actual causes of death in the United States. fourial of the American Medical Asso- ciation 1993;270(18):2207-12. Pirkle JL, Flegal KM, Bernert JT, Brody DJ, Etzel RA, Maurer KR. Exposure of the U.S. population to envi- ronmental tobacco smoke: the third National Health and Nutrition Examination Survey, 1988 to 1991. Jour- nal of the American Medical Association 1996;275(16): 1233-40. Tsevat J. Impact and cost-effectiveness of smoking in- terventions. American Journal of Medicine 1992;93(Suppl 1A):435-475. US Department of Health and Human Services. The Health Consequences of Smoking: The Changing Cigarette. A Report of the Surgeon General. Rockville (MD): US Department of Health and Human Services, Public Health Service, Office on Smoking and Health, 1981. US Department of Health and Human Services. Tobacco Use Among U.S. Racial/Ethnic Minority Groups— African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Islanders, and Hispanics: A Report of the Surgeon General. Atlanta: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1998. US Department of Health and Human Services. Healthy Peaple 2010 (Conference edition, in two volumes). Washington: US Department of Health and Human Services, 2000. US Department of Health, Education, and Welfare. Smoking and Health: Report of the Advisory Committee to the Surgeon General of the Public Health Service. Wash- ington: US Department of Health, Education, and Welfare, Public Health Service, 1964. PHS Publication No. 1103. World Health Organization. The World Health Report 1999: Making A Difference. Geneva: World Health Or- ganization, 1999, A Vision for the Future 439 Reducing Tobacco Use Abbreviations ABC American Broadcasting Company ACIR Advisory Commission on Intergovernmental Relations ACS American Cancer Society ADA Americans with Disabilities Act ADAMHA Alcohol, Drug Abuse, and Mental Health Administration AEG American Economic Group, Inc. AHA American Heart Association AHRQ Agency for Healthcare Research and Quality AIDS acquired immunodeficiency syndrome ALA American Lung Association ALERT Adolescent Learning Experiences in Resistance Training AMA American Medical Association ANR Americans for Nonsmokers’ Rights ASSIST American Stop Smoking Intervention Study AzTEPP Arizona Tobacco Education and Prevention Program BRFSS Behavioral Risk Factor Surveillance System BUGA-UP Billboard Utilising Graffitists Against Unhealthy Promotions CAUC Coalition Against Uptozwn Cigarettes CBO Congressional Budget Office cDC Centers for Disease Contro] and Prevention CHAD Community Syndrome of Hypertension, Atherosclerosis and Diabetes COMMIT Community Intervention Trial for Smoking Cessation CRS Congressional Research Service CSAP Center for Substance Abuse and Prevention CSH Coalition on Smoking OR Health D.A.R.E. Drug Abuse Resistance Education DOC Doctors Ought to Care EPA Environmental Protection Agency ETS environmental tobacco smoke FCC Federal Communications Commission FDA Food and Drug Administration FDCA Food, Drug, and Cosmetic Act FTC Federal Trade Commission GAO General Accounting Office GASP GATT GCP Icc IMPACT INWAT IOM IRS KYB LST MFN MHHP MPP NAAAPI NAFTA NCI NELS NHLBI NSA NSTEP NTCP OIG OR PSA RICO SAMHSA SCARC SHOUT SHPPS STAT TNT TPLR Group Against Smokers’ Pollution, Inc., Group Against Smoking Pollution, Group to Alleviate Smoking in Public Places, Georgians Against Smokers’ Pollution General Agreement on Tariffs and Trade German Cardiovascular Prevention Study Interstate Commerce Commission Initiatives to Mobilize for the Prevention and Control of Tobacco Use International Network of Women Against Tobacco Institute of Medicine Internal Revenue Service Know Your Body Life Skills Training most favored nation Minnesota Heart Health Program Midwestern Prevention Project National Association of African Americans for Positive Imagery North American Free Trade Agreement National Cancer Institute National Education Longitudinal Study National Heart, Lung, and Blood Institute National Smokers Alliance National Spit Tobacco Education Program National Tobacco Control Program Office of Inspector General odds ratio public service announcement Racketeer Influenced and Corrupt Organizations Act Substance Abuse and Mental Health Services Administration Smoking Control Advocacy Resource Center Students Helping Others Understand Tobacco School Health Policies and Programs Study Stop Teenage Addiction to Tobacco Towards No Tobacco Use Tobacco Products Litigation Reporter 441 Surgeon General's Report TVSFP U.S.C. USDA USDHEW USDHHS Television, School, and Family Smoking Prevention and Cessation Project United States Code U.S. Department of Agriculture US. Department of Health, Education, and Welfare U.S. Department of Health and Human Services VSMM WwcTU WHO WSP YRBS University of Vermont School and Mass Media Project National Woman’s Christian Temperance Union World Health Organization Waterloo Smoking Projects Youth Risk Behavior Survey List of Tables and Figures Chapter 1 Issues in Reducing Tobacco Use, Summary, and Conclusions Table 1.1. Characteristics of interventions 9 Table 1.2. Examples of a qualitative assessment of intervention impact 17 Figure 1.1. Influences on the decision to use tobacco 7 Figure 1.2. Overview of relationships among interventions & Chapter 2 A Historical Review of Efforts to Reduce Smoking in the United States Figure 2.1. Adult per capita cigarette consumption and major smoking and health events, Lnited States, 1900-1999 33 Chapter 3 Effective Educational Strategies to Prevent Tobacco Use Among Young People Table 3.1. School-based and multifaceted educational strategies 66 Chapter 4 Management of Nicotine Addiction Table 4.1. Percentage of adults aged 218 years who were current cigarette smokers, by sex, race/ ethnicity, education, age, and poverty status—United States, National Health Interview Survey, 1997 98 Table 4.2. Percentage of adults who abstained from smoking cigarettes in the previous year, by sex, race/ethnicity, age, education, and poverty status—Lnited States, National Health Interview Survey, 1991 99 Table 4.3. Meta-analyses of efficacy (estimated odds ratio and abstinence rates) for seven pharmacotherapies used in tobacco dependence treatment 114 Reducing Tobacco Use Chapter 5 Regulatory Efforts Table 5.1. Summary of landmark events in the development of U.S. policies for clean indoor air 198 Table 5.2. Summary of studies on the effects of a smoke- free workplace on smoking behavior 204 Table 5.3. Provisions of state laws relating to minors’ access to tobacco as of December 31, 1999 = 212 Table 5.4. Agencies responsible for enforcing state laws on minimum age for tobacco sales as of fiscal year 1998 218 Figure 5.1. Sales-weighted nicotine and tar levels in smoke as percentage of 1982 levels 180 Figure 5.2. Cumulative number of state laws and amendments enacted for clean indoor air, 1963-1998 200 Cumulative number of local laws and amendments enacted for clean indoor air, 1979-1998 202 Figure 5.3. Chapter 6 Economic Approaches Table 6.1. Burley tobacco production and value, 1975-1998 297 Table 6.2. Flue-cured tobacco production and value, 1975-1998 298 Table 6.3. Selected production and trade statistics for U.S.-grown, unmanufactured tobacco and for U.S.-produced cigarettes, 1975-1999 299 Table 6.4... Characteristics of the tobacco support program: flue-cured tobacco, 1975-2000 303 Table 6.5. Characteristics of the tobacco support program: burley tobacco, 1975-2000 304 Table 6.6. Domestic market shares of U.S. cigarette firms, selected years 307 Table 6.7. Recent estimates of the price elasticity of cigarette demand from aggregate data 324 443 Surgeon General's Report Table 6.8. Table 6.9. Table 6.10. Table 6.11. Table 6.12. Table 6.13. Table 6.14. 444 Estimates of the price elasticity of cigarette demand for adults from individual-level data 328 Estimates of the price elasticity of cigarette demand for youth and young adults from individual-level data 330 Federal cigarette excise taxes, selected dates, 1864-2002 339 Federal excise tax rates (cents/pound) on chewing tobacco, snuff, and pipe tobacco, selected years, 1986-2002 339 State cigarette excise taxes and sales taxes (cents/pack) applied to cigarettes 340 State tax rates on tobacco products other than cigarettes as of January 1, 2000 342 Number of increases and decreases in state excise taxes on cigarettes, July 1, 1950— May 1, 2000 345 Table 6.15. Cigarette taxes and cigarette prices, 1955-2000 (cents/pack) 346 Table 6.16. Average retail cigarette price and total taxes per pack (U.S. dollars / pack), selected countries, December 31,1996 348 Chapter 7 Comprehensive Programs No tables or figures. Chapter 8 A Vision for the Future—Reducing Tobacco Use in the New Millennium No tables or figures.