Cigarette popularity peaked in the United States in the 1950s and 60s with more than 45 percent of Americans smoking in 1954, and over 40% smoking throughout the 60s, with consumption peaking before 1963.
In 1970, President Richard Nixon signed the Public Health Cigarette Smoking Act, aimed at limiting the practice in the wake of a landmark report in 1964 by the U.S. Surgeon General on the negative effects of smoking. The law forced manufacturers to put health warnings on packages and banned tobacco companies from advertising on television and radio. Though manufacturers still found ways to advertise. For example, R.J. Reynolds Tobacco’s Winston brand was the title sponsor of NASCAR’s top series (the Winston Cup) until financial trouble forced the company to pull out in 2003.
Despite a continuous drop in use since the 60s, tobacco use is the leading cause of preventable disease and death in the U.S. In 2022, nearly 1 in 5 adults reported using some kind of tobacco product. Cigarettes remain the most popular product, especially among 45–64-year-olds. E-cigarette use rose significantly between 2019 and 2022, with the most prevalent users being 18–24-year-olds.
HPM Assistant Professor Natalie Smith studies tobacco use and prevention efforts.
“Focusing on tobacco is important to me because it's a health behavior that we know has really big and bad impacts on health across a wide range of different outcomes like cardiovascular disease, cancer, and even diabetes, but because the drivers of tobacco use are so complex, it's really hard to completely get rid of tobacco use,” she said, citing statistics that while smoking is down and e-cigarette and vaping is up among younger users, so is the use of oral nicotine pouches like Zyn, which could also be harmful to a user’s health.
Tobacco policy is reactive to what the tobacco industry is doing, said Smith. (See the famous “It’s toasted” scene from AMC’s Mad Men) While not specific to her research, she says it does frame how state and local policymakers operate in the tobacco control space.
“Typically, to get any sort of policy action approved or passed, you have to show why that policy action is needed, which typically means that you have to show that certain amounts of people or kids are using and being harmed by a given tobacco product,” she said. “So, to advocate for a policy around prevention and control, we often need a certain number of people to be using a tobacco product. This makes it really hard for public health and policy to really get ahead of what the tobacco industry and market might do next.”
Instead of focusing exclusively on new policy, which can be a monumental task, Smith is working on how to better implement and enforce existing policies – like the 2019 decision to raise the minimum purchase age from 18 to 21. “Despite this, we know from research evidence that we still see a lot of noncompliance among retailers and underage buyers are still able to access and use tobacco products. So, I think this is a really big missed opportunity that doesn't require new legislative action, just doing something better/stronger than we already are.”
Despite being a leading cause of preventable disease and death, tobacco prevention and control at the federal level is seemingly not a priority. The Office on Smoking and Health at the Centers for Disease Control and Prevention (CDC), which handled much of the big tobacco prevention and control activities across the U.S., like the effective “Tips from a Former Smoker” ad campaign, was effectively shuttered last April. This means that tobacco surveillance at the federal level is nearly gone, quit lines across the country are jeopardized, and state health and tobacco control departments have been on a 'roller coaster ride' since the office’s elimination.
Smith has researched how decisions are made in state tobacco control departments and which factors influence action or inaction across different areas. “I did a survey of people who work in state tobacco control programs across the United States, and overall, we found that research evidence, as well as the potential impact of policies on priority populations, were some of the biggest drivers of why certain policies were prioritized,” she said.
Results showed important differences depending on the type of policy environment the tobacco control staff were actually working in. Those working in “innovative” environments reported that they were able to elevate priority populations and incorporate evidence into their decision-making. In contrast, people who reported working in slower-moving or less innovative environments typically ranked the state legislature and a concept called preemption as important drivers, in addition to citing evidence they had to consider.
Uncertainty in funding and guidance from the CDC means that state and local governments may have fewer resources to conduct tobacco prevention and control work, including policy, while simultaneously having to fill gaps left by work previously done by the federal government. Smith is beginning to consider how the onus of prevention and enforcement falling more on state and local policymakers and agencies might shape how their decisions and priorities change moving forward.
“One thing that I've learned and seen through my research is that some places are really still trying to get policies passed and implemented that will bring them essentially up to recommended levels,” said Smith. “For example, there’s a big difference in how much tobacco costs in different states, so sometimes places are working on raising taxes on all or some kinds of tobacco products.
In Pennsylvania, there is no tax on cigars, something advocates and control groups are working to change. Advocates are also working in Pennsylvania and other states to tax or ban other products like flavored vaping products, which they say are targeted at children.
Smith, a decision scientist by training, says she is always thinking about the “why” behind decisions made and actions taken by people and organizations, and is looking for new ways to measure them.
“My training and experience in implementation science also make it so that I like to think about how decisions are made and how they impact how a certain policy is implemented or sustained over time. So, my research usually ends up incorporating those things by examining decisions that are made, what those decisions entail for implementation, and looking at how implementation impacts health outcomes.”