Chapter 2 Cigarette Smoking Behavior in the United States David M. Burns, Lora Lee, Larry Z. Shen, Elizabeth Gilpin, H. Dennis Tolley, Jerry Vaughn, and Thomas G. Shanks INTRODUCTION Native Americans were using tobacco products in the Americas prior to the arrival of Columbus. Tobacco was commonly used in the American colonies and subsequently in the United States as chewing tobacco and snuff and in pipes and cigars during the 18th and 19th centuries. However, widespread use of tobacco in cigarettes is more recent, occurring largely during the 20th century. Figure 1 presents the per capita use of tobacco used in the United States as different product types during the past 115 years. Figure 2 shows total and per capita consumption of cigarettes from 1900 to 1995. There have been substantial changes in the use of tobacco products over time, with a shift toward cigarettes and away from other forms of tobacco. A dramatic rise and fall in the per capita and total number of cigarettes smoked also has occurred in the past century. Cross-sectional surveys of the U.S. population reveal differences in smoking prevalence among various demographic categories (U.S. Department of Health and Human Services, 1989a). Males have a higher prevalence of Figure 1 Per capita consumption of different forms of tobacco in the United States, 1880-1995 14 12 10 Snuff 8 Chewing 6 Tobacco 4 Pipe/roll your own Cigarettes Pounds of Tobacco Per Capita 2 Cigars 0 1880 1890 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 Year Source: U.S. Department of Agriculture, 1996. 13 Smoking and Tobacco Control Monograph No. 8 Figure 2 Total and per capita cigarette consumption in the United States, 1900-1995 700 Total cigarette production 7,000 (billions) 6,000 600 Per capita consumption (age 18 and older) 500 5,000 400 4,000 300 3,000 200 2,000 100 Per Capita Consumption Total Cigarette Production 1,000 0 0 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 Year Source: U.S. Department of Agriculture, 1996. smoking than females (U.S. Department of Health and Human Services, 1980; Centers for Disease Control and Prevention, 1994); there are differences in smoking prevalence among different age and racial groups; and smoking prevalence and cessation vary with educational attainment (Pierce et al., 1989). Differences in smoking prevalence among racial, gender, and age groups have also changed over time. Men began smoking in large numbers earlier in this century than women (U.S. Department of Health and Human Services, 1980; Harris, 1983), and differences among racial groups also have varied over time (Tolley et al. 1991; U.S. Department of Health and Human Services, 1986; Harris, 1983). Patterns of smoking prevalence, initiation, and cessation vary across racial, gender, and age categories and are different for individuals born in different years. Differences in smoking behavior by year of birth make interpretation of age-specific estimates from multiple cross-sectional samples over time difficult and often confusing. A given age group in cross-sectional surveys done at different points in time will contain individuals who were born in different years. Changes in smoking behaviors within the specified age group over time may be produced by either temporal (calendar year) or cohort (year-of-birth) effects. Analyses in this chapter are presented by race- and gender-specific 5-year birth cohorts. A birth cohort comprises individuals born during specific calendar years (5-year groups in this presentation) and followed as they age. Birth cohort analyses presented in this chapter describe changes in smoking behavior among groups of individuals born during the same calendar years as they advance in age. This format presents a more accurate picture of the life history of smoking than can be derived from examination of differences in smoking behavior among different age groups in single or 14 Chapter 2 multiple independent, cross-sectional samples of the population. Cross- sectional surveys describe smoking behaviors for specific age groups. Because changes in smoking behavior across age groups in a single study may be produced by either calendar year or year-of-birth effects, it is not valid to assume that differences in age-specific rates in a single study are attributable to age alone. Multiple cross-sectional studies define changes in age-specific rates at different points in time, but the difference in age-specific rates may be due to temporal (calendar year) effects or to age-specific rates in surveys done in different years that represent different birth cohorts. These different cohorts may have had different rates of smoking initiation and cessation and therefore wind up with different rates of smoking prevalence independent of changes relating to calendar year, which makes interpreting changes in age-specific smoking prevalences across multiple survey years difficult. Presentation of smoking behavior in multiple birth cohorts over time allows separation of calendar year trends from changes associated with aging. Prevalence of smoking, duration of smoking, and number of cigarettes smoked per day are powerful predictors of the tobacco-related diseases described in other chapters of this monograph (U.S. Department of Health and Human Services, 1982, 1983, 1984, 1989a, and 1990). This chapter describes changes in smoking prevalence, initiation, and cessation for the U.S. population during approximately the past 115 years. The description is based on a pooling of data from the National Health Interview Surveys (NHIS) conducted between 1965 and 1991, which asked questions on smoking behavior. TIMING OF EVENTS Smoking behaviors for the birth cohorts presented in this LINKED TO SMOKING chapter have been profoundly influenced by events and BEHAVIOR trends in the larger social environment within which smoking occurs (Burns, 1991) as well as by the addictive properties of cigarettes acting within the psychologic and physiologic structure of the individual (U.S. Department of Health and Human Services, 1988). Interpretation of the data on smoking behavior presented in this chapter requires an understanding of the social and political contexts within which smoking developed and which have led smokers to quit. Some of the events that influenced smoking behavior are listed in Table 1. Cigarette smoking as a form of tobacco use was uncommon prior to 1900 (Figure 1). Per capita consumption of cigarettes in the United States was 54 in 1900 (U.S. Department of Health and Human Services, 1989a) compared with its peak of 4,345 in 1963 (Figure 2). Conversion of tobacco use from pipes, cigars, and chewing tobacco to cigarettes was enabled by the invention of machines that could mass produce cigarettes, eliminating the need for hand rolling, and by the development of safety matches that allowed a convenient, portable means of lighting cigarettes (Whelan, 1984). However, the real growth in cigarette sales occurred after advertising and mass marketing techniques were applied to cigarettes during the second decade of this century. The remarkable growth in sales of Camel cigarettes after a national promotional campaign in 1913 established the power of advertising 15 Smoking and Tobacco Control Monograph No. 8 Table 1 Temporal events influencing cigarette use Date Event Reference 1884 Invention of a machine to manufacture cigarettes Whelan, 1984 1889 Invention of safety matches Whelan, 1984 1913 Introduction and mass marketing of Camel brand Burrough and Helyar, cigarettes by R.J. Reynolds Tobacco Company 1990 1914-18 World War I 1928 Introduction of cigarette advertisements targeting Burns, 1994 women, including the "Reach for a Lucky Instead of a Health Advocacy Center, Sweet" campaign 1986 1929 Beginning of the Great Depression in the United States 1941-45 United States involvement in World War II 1950 Publication of retrospective studies linking tobacco and U.S. Department of Health disease and Human Services, 1989a 1954 Publication of prospective mortality studies linking U.S. Department of Health cigarettes and lung cancer and Human Services, 1989a 1955 Marketing of filtered cigarettes U.S. Department of Health and Human Services, 1981 1956 Founding of the Council for Tobacco Research Freedman and Cohen, 1993 1964 Release of the U.S. Surgeon General's report on U.S. Department of Health, smoking and health Education, and Welfare, 1964 1967-70 Counteradvertising on television Warner, 1977 1968 Introduction of Virginia Slims and other brands targeted Burns, 1994 at women 1970 Cigarette advertisements banned from television; end of U.S. Department of Health free time for counteradvertisements and Human Services, 1989a 1970 Nonsmokers' rights movement begins Steinfeld, 1972 1983 Increase in the Federal excise tax on cigarettes by 8 cents Burns, 1991 1986 Release of U.S. Surgeon General's report on involuntary U.S. Department of Health smoking and Human Services, 1986 1992 Release of the U.S. Environmental Protection Agency U.S. Environmental report on environmental tobacco smoke Protection Agency, 1992 16 Chapter 2 in promoting sales (Burrough and Helyar, 1990). It set the stage for mass marketing of other brands of cigarettes and for a dramatic jump in cigarette use during the next several decades (Burrough and Helyar, 1990). Initially, cigarette marketing targeted males, but in the 1930's, advertising campaigns directed toward women began to appear (Health Advocacy Center, 1986). The most notorious of these campaigns was the "Reach for a Lucky Instead of a Sweet" series of advertisements that began a marketing theme linking cigarette smoking to weight control, a campaign that continues with other brands of cigarettes to this day (Health Advocacy Center, 1986; Burns, 1994). Dramatic changes have occurred in per capita consumption of cigarettes during each of the World Wars, with mobilization of many men into the military during both wars and mobilization of women into the war industries during World War II. Gen. John J.