What Will It Take for the Remaining 19 Percent of Smokers to Quit?
People have a few ideas.
Chances are it's been a long time since you saw an ashtray next to the salt and pepper shakers on a restaurant table. Right now, 25 American states, plus Puerto Rico and the Virgin Islands, forbid smoking in bars, restaurants, and workplaces. In areas without statewide tobacco restrictions, a patchwork of cities and counties have passed their own bans on puffing in public venues.
Nationwide, 57 percent of Americans currently support these kinds of bans, according to the most recent Gallup surveys. This represents a significant shift from only 39 percent support in 2001. Yet when Gallup asked survey respondents if tobacco should be "totally illegal" in the United States, 83 percent said "no"—a number that has stayed fairly consistent since they began asking the question in 1990.
Even the American Lung Association, the leading anti-smoking organization in the United States, isn't advocating for a complete ban on tobacco sales—a "prohibition" like the ill-fated 18th Amendment that made alcohol illegal for 14 years. "People use tobacco products for the most part because the tobacco industry has had extraordinarily effective marketing, and because tobacco products are extremely addictive," says Erika Sward, assistant vice president for national advocacy at the American Lung Association. "So most in the public health community do not support prohibition on a small or a larger scale."
Tobacco use is on the decline. In 1975, 40 percent of Americans surveyed told Gallup that they had at least one cigarette in the past week. By 1996, that number had dropped to 26 percent, and in 2016, only 19 percent of respondents copped to smoking. As the decline in smoking has appeared to level off in recent years, however, tobacco activists have begun to debate whether the remaining 19 percent represents "hardcore" smokers who could never be convinced to quit, or whether they're willing to quit but simply haven't been successful or seen enough incentive. The answer to that question determines just what kind of new policy or regulation—if any—is the right step to eliminate smoking for good.
"The reason I'm skeptical of all this endgame talk, it's all presumed on the fact that the current policies haven't worked very well, and that's just not true," says Stanton Glantz, professor of tobacco control at the University of California San Francisco. "So people are coming up with all these wild-ass ideas that I think go against what we know does and doesn't work."
The policies that most activists agree are working include many of the tobacco regulations that we've come to take for granted: It's illegal to sell cigarettes to someone under the age of 18, packaging must include the ubiquitous surgeon general's warning, tobacco companies can't advertise on television, and they're not supposed to market to children at all (more on that one later). Generally speaking, the most widely adopted tobacco regulations are aimed at preventing young people from trying cigarettes and becoming addicted.
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Public tobacco bans—which say you can't smoke in workplaces, bars, restaurants, or all of the above—add another layer of regulation to protect the health of non-smokers. They also have the side benefit of inconveniencing current smokers enough that they light up less often. In states with public smoking bans, cigarette consumption has dropped between 5 and 20 percent, according to the World Health Organization.
To understand how those bans are justified to skeptical populaces, you can look at the case of New Orleans's successful bid to ban smoking in bars and restaurants. Considering that the Big Easy is famous for being the kind of place where you can order your beer at a bar "to go" and sip it while walking down the street, a ban on tobacco seemed, to outside observers at least, like an uphill battle.
New Orleans's vibrant restaurant scene protested on the grounds that diners wouldn't patronize those establishments if they couldn't puff indoors. But in fact, a study Glantz conducted found that restaurants in areas with smoking bans turn out to be more profitable and more valuable than areas without bans, even after controlling for varying costs and food prices in different regions.
New Orleans's permissive attitudes are also reflected in the idea, which often emerges when tobacco bans are proposed, that people should have the freedom to inhale all the cancer-causing smoke they want as long as they know the risks. But that logic never really holds up, says Yvette van der Eijk, a postdoctoral research fellow who studies the ethics of tobacco policies at the University of California, San Francisco.
"The argument came about from tobacco industry efforts to oppose clean indoor air laws," she says. The notion centers around the right to privacy, which is intended to protect our personal development, autonomy, moral integrity, and mental stability. But it's hard to make the case that any kind of tobacco use has a positive effect on those values. "In other words, smoking is a privilege but not a right, and can be justifiably restricted to protect the public's health," van der Eijk says.
Along that line of reasoning, New Orleans's smoke-free campaign won allies from the city's many jazz musicians, who have to spend long hours in smoky bars and were concerned about their long-term lung health (particularly singers and wind-instrument performers). They also lent celebrity credibility to the effort. "There's a lot of Grammy Award-winning musicians in New Orleans," says Jennifer Cofer, who lobbied New Orleans on behalf of the American Lung Association, and is currently the director of the EndTobacco program at the MD Anderson Cancer Center in Houston.
The city council also heard testimony from people like one man who worked in a casino for many years. He was never a smoker, but developed lung cancer—and he was fired after he missed three days of work because of his cancer treatments.
The New Orleans city council approved the ban on tobacco use in bars and restaurants just three months after it was proposed, in January 2015. While the measure and others like it have been broadly successful, it's still an open question whether public smoking bans alone are enough to winnow down the number of people who pick up the habit.
In 2014, legislators in Tasmania, Australia, proposed a more radical variation on a tobacco prohibition called the "tobacco free generation." If enacted, the law would prohibit the sale of tobacco products to anyone born after the year 2000—forever. At the same time, proponents of the law take care to point out that it still doesn't target smokers themselves, instead penalizing shops. "The legislation does not 'ban' members of the Tobacco Free Generation from smoking or seek to criminalize them," says Nick Towle, clinical medical education adviser at the University of Tasmania.
Tasmania, an island off the southeastern coast of Australia the size of West Virginia with a population of 519,000, makes a convenient spot to try out these kinds of laws. Teens can't simply drive across a state border to buy cigarettes (40 percent of Tasmanians have never left the island). Tasmania has also historically been ahead of the curve on tobacco restrictions—they banned the sale of cigarettes to anyone under 16 way back in 1934, and they were one of the first places to add graphic health warnings to cigarette packs. "Culturally, I don't see Tasmanians attaching the same significance to cigarettes as a symbol of freedom and liberty, as compared to a number of my American friends," says Kathryn Barnsley, a policy advisor to Smoke Free Tasmania and a researcher at the University of Tasmania.
The proposal polls at roughly 75 percent support in Tasmania, but the current center-right government is not likely to move it forward. "They are disinterested in the idea, and have close ties with the tobacco industry," Barnsley says. "It is possible that the political environment may change."
Proponents of the law can take some comfort in the notion that a smoke-free generation law may not even be necessary, Glantz says. A study he co-authored in 2016 found that for every 1 percent drop in smoking prevalence, the percentage of smokers trying to quit creeps up by about a half a percent and cigarette consumption slips by 1/3 cigarette per day. Those might sound like small numbers, but those subtle changes all work together to further push down the number of tobacco users in the United States. As it is, nearly three in four current smokers say they would like to quit.
As far as creating a generation that sees cigarettes as a relic of the past, Glantz believes that the most effective measures would be to increase the age to buy tobacco products to 21, a law that went into effect in California in June, and prohibiting menthol cigarettes, which the city of San Francisco approved a few weeks ago. Raising the age to buy tobacco is less about targeting smokers between the ages of 18 and 21, Glantz explains, and more about enforcing laws that are supposed to block tobacco companies from advertising to young teens.
"If 18 is the legal age, they can say, 'Oh, well, we're marketing to these 18-year-old high school seniors, and gee, it's not our fault if a bunch of freshmen are seeing it,'" Glantz says. For example, a recent Centers for Disease Control and Prevention study on tobacco use in movies, which Glantz participated in, found that after a few years of decline, the number of incidents increased by 43 percent in PG-13 movies from 2010 to 2016, and 72 percent in all top-grossing movies.
With fewer young people picking up the habit, the tobacco companies might be forced to raise prices, which economic models show help to convince more and more smokers that keeping up the habit simply isn't worth the cost. "When you get it down that low, at some point the whole behavior will collapse," Glantz says. Instead of forbidding people from buying tobacco, the laws may have actually done the far more difficult task: finally, and permanently, convincing people to never try smoking in the first place.
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