Smoking in America is now at its lowest point in more than 50 years.That’s according to newly released data from the Centers for Disease Control and Prevention showing that the percentage of adults who smoke cigarettes has continued to decline. As you can see in the chart below, 21 percent of Americans smoked regularly in 2005 (about 45 million people), and in 2014 that number was down to 17 percent (about 40 million people):
Smoking is still most prevalent among poorer Americans
It’s a remarkable shift. In 1964, when the surgeon general first began a public health campaign on cigarettes, nearly half of the adult population smoked.
But thanks to tobacco taxes, smoking bans, and public awareness campaigns, cigarette use has been on a downward trajectory for decades.
This major public health success story hasn’t been a total victory, either. Cigarette smoking remains the leading cause of preventable disease and death in the US, contributing to some 480,000 early deaths and more than $300 billion in health care expenditures and productivity losses every year. The push to eradicate smoking has been especially slow going among poorer Americans.
Percentage of American adults who were current cigarette smokers, by health insurance status and age group, in 2014.
Generally speaking, poorer Americans smoke at higher rates than wealthier Americans. The CDC shows this by looking at the relationship between insurance coverage and cigarette use.
People insured by Medicaid or those who are uninsured tend to be poorer, on average. In 2014, 29.1 percent of Medicaid recipients and 27.9 percent of the uninsured smoked. By contrast, only 12.9 percent of those with private insurance smoked.
Relatedly, education also makes a difference: Of adults with a graduate degree, only about 5 percent smoke. Meanwhile, about 25 percent of those who haven’t graduated high school smoke.
In an effort to address some of these gaps, the US Department of Housing and Urban Development just announced that it will ban smoking in public housing across the country.
How Smoking Became a Global Pandemic
Despite concerted public health campaigns, cigarette smoking remains a global pandemic that kills thousands around the world, Allan Brandt told listeners Wednesday night at the 2015 Boyarsky Lecture in Law, Medicine, and Ethics.
The lecture at the Nasher Museum of Art focused on the rise of tobacco consumption and the role of advertising in fueling that growth. Brandt explored the ways advertising campaigns transformed a deadly product into a commodity associated with pleasure.
“How could something that was very bad for you, and was even understood very clearly at the time, be so in fact exciting and interesting and advertised in such bold ways?” Brandt said.
Brandt is the Amalie Moses Kass Professor of the History of Medicine at Harvard University and author of “The Cigarette Century: The Rise, Fall, and Deadly Persistence of the Product that Defined America.”
In his talk, “The Global Tobacco Pandemic: Historical and Ethical Reflections on the Persistence of Smoking in the 21st Century,” Brandt described how 20th century cigarette ad campaigns found creative ways to undercut scientific findings about the harm caused by smoking. Adds for Camel cigarettes, for instance, suggested that doctors smoke that brand.
Smoking was initially more popular among men, he added, until Chesterfield and other cigarette companies began targeting women, leading to large increases among that group.
In the 20th century, approximately a hundred million people died because of tobacco-related diseases, Brandt said. But the threat is not behind us, he said. Citing World Health Organization estimates, Brandt said that if smoking rates do not change, roughly a billion people will have died from tobacco-related causes by the year 2100.
Brandt said cigarette companies exploited and manipulated doubt, uncertainty and ignorance to promote smoking. Rather than explicitly release data, for instance, cigarette companies would emphasize the process of research.
Nevertheless, by 2004, there was a substantial decline in smoking in the U.S. In response, the tobacco industry targeted foreign markets, upping their exports to countries such as China and Thailand, leading to a large increase in sales, Brandt said. World Health Organization recommendations for overseas advertising bans and warning labels on cigarettes sold overseas have been rejected by the tobacco industry, he added.
New, unregulated technologies such as electronic cigarettes may also contribute to the persistence of smoking, Brandt said. In the past month, 18 percent of 12th graders in the United States have used an e-cigarette, he noted.
Brandt concluded by challenging the audience to continue to think creatively about how to reduce smoking worldwide.
Ban Smoking in Public House
Smokers in public housing better take a few last drags. The federal government is proposing to ban smoking in public housing — not just in public areas like lobbies, but also in the apartments themselves. Fabulous cost savings are promised. But when you drill into the much-cited paper offered in support, the methods look too fuzzy to rely upon. So it’s hard to tell how much money we’ll save.
The most obvious question is whether and how this ban will be enforced. Fabulous cost savings are not going to materialize if you just ban smoking and the smokers merrily keep puffing away in their apartments.
There doesn’t seem to be a lot of good evidence on the results of these bans, some of which have already been implemented at the local level. The best I could come up with was a short-term study from Portland, which found that five months after the implementation of a ban, almost two- thirds of the residents were simply not complying.
Another study shows better results for indoor smoking, but fewer than half of the smokers even reported reducing their cigarette consumption, and non-smokers still reported significant weekly exposure to second-hand smoke.
The footnotes to the CDC study show a heavy reliance on data from multi-unit housing — which is to say, any sort of apartment building, not just public housing. But of course, public housing is a little different from your average apartment tower. The tenants don’t have a lot of extra cash to, say, pay a fine. Or to negotiate an eviction, which is ultimately the only penalty the housing authority can levy for someone who persistently violates the rules.
And there’s the rub: Are we really going to evict people from public housing for smoking in their apartments? We’re talking about people who definitionally don’t have a lot of financial resources: single parents, the elderly, the disabled. Where, exactly, are they going to go on short notice?
I’m not even making a moral argument about whether we should do this. The question is whether we’re going to do this.
As law-and-order hawks frequently forget, the problem with imposing draconian punishment is that their deterrent effect ends up blunted by the natural reluctance of authorities to impose very harsh punishments on violators who are mostly harming themselves.
Housing authorities already show reluctance to evict people who consistently fail to pay their rent. How many are going to be willing to regularly toss families out on the street because Mom smokes in the bathroom?
And indeed, HUD Secretary Julian Castro, quoted in the Times, is reluctant to endorse evictions for tenants who smoke.
The prohibition would be included in tenant leases, and violations would be treated like other nuisance violations, which are usually reported by neighbors or employees and are not meant to result in evictions, Mr. Castro said.
“The purpose is to go smoke-free and to have healthier communities,” he said. “My hope is that housing authorities would work with residents to prepare them for this change so that any kind of punitive measures like evictions are avoided at all costs.”
This is a lovely sentiment, but surely he doesn’t think every public housing tenant — about a quarter of whom smoked in one survey by the New York public housing authority — is going to comply with the new rules.
If you don’t evict the violators, then over time, the initially compliant smokers will realize there’s no penalty and return to smoking in their apartments, so that the net effect of this ban will mostly be more paperwork for the managers of the housing projects.
If you do evict the defiant smokers, what happens next? I suspect a lot of the projected cost savings get eaten up when the families end up in the city’s shelter system, or the disabled folks end up in hospitals.
If public housing had a better array of tools to deal with noncompliant tenants, this might be less of a problem. But they ultimately have one crude tool: eviction. And it’s hard to evict people from a facility created to house people who don’t have anywhere else to go.