The Fund supports networks of state health policy decision makers to help identify, inspire, and inform policy leaders.
The Milbank Memorial Fund supports two state leadership programs for legislative and executive branch state government officials committed to improving population health.
The Fund identifies and shares policy ideas and analysis to advance state health leadership, strong primary care, and sustainable health care costs.
Keep up with news and updates from the Milbank Memorial Fund. And read the latest blogs from our thought leaders, including Fund President Christopher F. Koller.
The Fund publishes The Milbank Quarterly, as well as reports, issues briefs, and case studies on topics important to health policy leaders.
The Milbank Memorial Fund is is a foundation that works to improve population health and health equity.
December 2016 (Volume 94)
Quarterly Article
Jonathan Cohn
Nov 5, 2024
Oct 30, 2024
Oct 23, 2024
Back to The Milbank Quarterly
One of my favorite scenes from “All The President’s Men,” the 1976 dramatization of Watergate and The Washington Post, comes early in the film—when the Post’s Bob Woodward (played by Robert Redford) confronts his colleague Carl Bernstein (played by Dustin Hoffman) for surreptitiously rewriting an article. When I saw that clip recently, I saw something I’d never really noticed before. Bernstein is sitting at his desk and taking drags from a cigarette.
You wouldn’t see anything like that today—not in the real-life Washington Post newsroom and not in almost any other public indoor environment around the country. That’s because local, state, and federal governments have eradicated indoor smoking from just about everywhere except bars and restaurants. It’s only a matter of time before smoking is gone from those places, too. Roughly two-thirds of US states have already banned smoking in eating and drinking establishments, and within the outliers, which are mostly in the deep South, big cities are taking action on their own.
The spread of indoor smoking bans is just one visible byproduct of America’s war on tobacco, a war that has been going on for more than 50 years. By any reasonable account, the forces fighting tobacco have been winning. As of 2014, just 16.8% of American adults smoked, down from 42.4% in 1965.1 All signs point to that number going down more in the future.
Of course this war is far from over. Smoking is still more prevalent among the poor. In many developing countries, where US companies are increasingly focusing their efforts, smoking is actually on the rise. Big Tobacco has to look abroad precisely because selling cigarettes here has become harder and harder.
It’s an excellent case study in the efficacy of public health campaigns, and maybe in the efficacy of government itself. And yet it gets surprisingly little attention as either thing, except among the tiny community of advocates and experts who made it happen.
Historians generally trace the war on tobacco back to 1964, when Luther Terry, the surgeon general, formally endorsed the idea that smoking was “causally” related to lung cancer in the first report of the Advisory Committee on Smoking and Health. By that time, tobacco companies had successfully made smoking a part of American culture, and smoking rates had been rising for decades. As Helene Cole and Michael Fiore recounted in a recent retrospective that appeared in JAMA, the prelude to the release of the surgeon general’s report was shrouded in drama.2 In fact, the government released it on a Saturday just so it wouldn’t rattle the financial markets.
The report prompted Congress to act and within a year it had passed the Federal Cigarette Labeling and Advertising Act of 1965. That law required the imposition of mandatory warning labels on cigarettes, which finally happened 6 years later. But more important than the labels was the change in public attitudes and ultimately political will that the surgeon general’s 1964 report, along with its many successors, generated. That shift is what made possible the really effective tools against smoking, of which two come immediately to mind.
One is the economist’s favorite—the tax on cigarettes. Today the federal government puts a levy of $1.01 on each pack; most states add their own taxes, with New York’s $4.35 the highest. The money from these taxes finance all sorts of programs; the most recent federal increase, in 2009, helped finance government-sponsored insurance for low-income children. The greatest virtue of the cigarette tax, though, is that it deters smoking. Cigarette smokers are addicted to nicotine found in tobacco, but as research has shown conclusively, users are still subject to the laws of supply and demand. When the price of cigarettes go up, it makes people want to quit—or, at the very least, to smoke less.3
The other powerful tool against smoking has been the spread of indoor smoking bans, the ones that make those 1970s movies seem so anachronistic today. The primary goal of these prohibitions is to thwart the hazardous effects of secondhand smoke on nonsmokers. But these bans have a powerful cultural effect as well, as Stanton Glantz, a professor at the University of California–San Francisco, reminded me recently in an interview. Glantz, who has been called the “Ralph Nader of tobacco,” says that “the way that tobacco companies sell the product, recruit people for the product, and keep the product going is by making it a social norm. What smoke-free policies do, in addition to protecting people from secondhand smoke, is really change the underlying social dynamic.” The precise effect of these bans may be difficult to determine, but Glantz points to studies suggesting that bans ultimately have the same effect as hiking the per-pack cost of cigarettes by $4.
Anti-tobacco forces have deployed many other weapons in their fight—from public education campaigns in the media to the regulation of marketing, particularly when it targets children. Lawsuits against tobacco discredited the industry and generated extra money in the process. All of these efforts have reinforced one another. And, in general, the states that have fought tobacco most aggressively, such as California, are the ones where smoking rates are the lowest.4 This is not mere coincidence. (An exception is Utah, which actually has the lowest rate of any state, but that likely reflects the rejection of tobacco use by Mormonism, the dominant religion there.)
Anti-tobacco efforts come with their trade-offs. Cigarette taxes punish the poor disproportionately. Bans on smoking infringe upon the liberty of smokers, although the physical threat of secondhand smoke arguably infringes upon the liberty of nonsmokers even more. Reducing the demand for tobacco can hurt the farmers and workers responsible for producing it. But no public policy is totally free. And in this case the downside of fighting tobacco would seem minuscule when compared to the upside, which can be measured not only in dollars but also in lives saved.
There’s a powerful lesson here, one that goes well beyond tobacco or even public health. Faith in government is at a record low, as polls have shown.5 And a big reason is a lack of government success that people can perceive. But it’s hard to think of anything more concrete or more meaningful than the decline of smoking in the United States. All it took was the right combination of smarts, money, and political will—and a little patience.
References
Author(s): Jonathan Cohn
Read on Wiley Online Library
Volume 94, Issue 4 (pages 704–707) DOI: 10.1111/1468-0009.12221 Published in 2016
Jonathan Cohn is senior national correspondent for The Huffington Post and the author of Sick: The Untold Story of America’s Health Care Crisis—and the People Who Pay the Price (HarperCollins Publishing, 2007). He has been a media fellow with the Kaiser Family Foundation and a senior fellow at Demos, and is currently a member of the National Academy of Social Insurance. He has also written for the The New Republic, the Atlantic, The New York Times, and Self, among other publications.
