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Toxins in Everyday Life - Tobacco

smoking cigarette percent smokers

Tobacco use remains the leading preventable cause of death in the United States, causing more than 440,000 deaths each year and resulting in an annual cost of more than $75 billion in direct medical costs. Nationally, smoking results in more than 5.6 million years of potential life lost each year.

—Centers for Disease Control and Prevention, Atlanta, GA [Online] http://www.cdc.gov/tobacco/issue.htm [accessed May 7, 2004]

The federal government has been warning people about the dangers of smoking for decades. In 1964 the first Surgeon General's Report on Smoking and Health was issued. Tobacco use, which had skyrocketed since 1900, dropped dramatically.

The latest smoking statistics by the CDC were published in Health, United States, 2003. In 2001 approximately 46.2 million American adults smoked cigarettes, representing 22.7 percent of the adult population (18 years of age and older). (See Table 8.4.) This percentage has declined significantly since 1965 when 41.9 percent of the adult population smoked. In 2001 slightly more adult males (24.7 percent) than females (20.8 percent) were smokers. African-American males aged 45-64 years (34.3 percent) and white males aged 18–24 years (32.5 percent) were most likely to smoke. Approximately one-third of both groups were current smokers in 2001. Education level and smoking are inversely related in adults; people with limited education are much more likely to smoke than are those with advanced degrees.

Table 8.5 shows the prevalence of smoking among high school seniors and eighth- and tenth-graders for various years between 1980 and 2002. In 2002 more than one quarter of high school seniors were smokers, as were nearly 18 percent of tenth-graders and nearly 11 percent of eighth-graders. These values have all declined in recent years.

In April 2002 the CDC issued its latest report on mortality associated with cigarette smoking. Based on data for 1995–99, the report states that smoking kills more than 440,000 people annually. Smoking is blamed for the deaths of 264,087 men and 178,311 women each year from 1995 to 1999. Smoking resulted in the average loss of 13.2 years of life for men and 14.5 years of life for women. Smoking during pregnancy is blamed for 1,000 infant deaths annually. The CDC noted that each pack of cigarettes sold in the United States costs the country $7.18 in medical care costs.

The CDC summarized its findings on the link between cigarette smoking and disease in the 2003 publication of "Cigarette Smoking—Attributable Morbidity—United States, 2000." The report estimates that 8.6 million people in the United States suffered from serious illnesses in 2000 due to smoking. Chronic bronchitis and emphysema accounted for 59 percent of all smoking-attributable diseases. The data are presented in Table 8.6.

In addition to nicotine, which is very addictive, cigarette smoke contains hundreds of mutagens, carcinogens,

TABLE 8.4
Cigarette smoking among adults, 1965–2001
[Data are based on household interviews of a sample of the civilian noninstitutionalized population]

Sex, race, and age 1965 1974 1979 1983 1985 1990 1995 19971 19981 19991 20001 20011
18 years and over, age adjusted2 Percent of persons who are current cigarette smokers3
All persons 41.9 37.0 33.3 31.9 29.9 25.3 24.6 24.6 24.0 23.3 23.1 22.7
Male 51.2 42.8 37.0 34.8 32.2 28.0 26.5 27.1 25.9 25.2 25.2 24.7
Female 33.7 32.2 30.1 29.4 27.9 22.9 22.7 22.2 22.1 21.6 21.1 20.8
White male4 50.4 41.7 36.4 34.2 31.3 27.6 26.2 26.8 26.0 25.0 25.5 24.9
Black or African American male4 58.8 53.6 43.9 41.7 40.2 32.8 29.4 32.4 29.0 28.4 25.7 27.6
White female4 33.9 32.0 30.3 29.6 27.9 23.5 23.4 22.8 23.0 22.5 22.0 22.1
Black or African American female4 31.8 35.6 30.5 31.3 30.9 20.8 23.5 22.5 21.1 20.5 20.7 17.9
18 years and over, crude
All persons 42.4 37.1 33.5 32.1 30.1 25.5 24.7 24.7 24.1 23.5 23.3 22.8
Male 51.9 43.1 37.5 35.1 32.6 28.4 27.0 27.6 26.4 25.7 25.7 25.2
Female 33.9 32.1 29.9 29.5 27.9 22.8 22.6 22.1 22.0 21.5 21.0 20.7
White male4 51.1 41.9 36.8 34.5 31.7 28.0 26.6 27.2 26.3 25.3 25.8 25.1
Black or African American male4 60.4 54.3 44.1 40.6 39.9 32.5 28.5 32.2 29.0 28.6 26.1 27.6
White female4 34.0 31.7 30.1 29.4 27.7 23.4 23.1 22.5 22.6 22.1 21.6 21.7
Black or African American female4 33.7 36.4 31.1 32.2 31.0 21.2 23.5 22.5 21.1 20.6 20.8 18.0
All males
18–24 years 54.1 42.1 35.0 32.9 28.0 26.6 27.8 31.7 31.3 29.5 28.5 30.4
25–34 years 60.7 50.5 43.9 38.8 38.2 31.6 29.5 30.3 28.5 29.1 29.0 27.2
35–44 years 58.2 51.0 41.8 41.0 37.6 34.5 31.5 32.1 30.2 30.0 30.2 27.4
45–64 years 51.9 42.6 39.3 35.9 33.4 29.3 27.1 27.6 27.7 25.8 26.4 26.4
65 years and over 28.5 24.8 20.9 22.0 19.6 14.6 14.9 12.8 10.4 10.5 10.2 11.5
White male4
18–24 years 53.0 40.8 34.3 32.5 28.4 27.4 28.4 34.0 34.1 30.5 30.9 32.5
25–34 years 60.1 49.5 43.6 38.6 37.3 31.6 29.9 30.4 29.2 30.8 29.9 29.0
35–44 years 57.3 50.1 41.3 40.8 36.6 33.5 31.2 32.1 29.6 29.5 30.6 27.8
45–64 years 51.3 41.2 38.3 35.0 32.1 28.7 26.3 26.5 27.0 24.5 25.8 25.1
65 years and over 27.7 24.3 20.5 20.6 18.9 13.7 14.1 11.5 10.0 10.0 9.8 10.7
Black or African American male4
18–24 years 62.8 54.9 40.2 34.2 27.2 21.3 *14.6 23.5 19.7 23.6 20.8 21.6
25–34 years 68.4 58.5 47.5 39.9 45.6 33.8 25.1 31.6 25.2 22.7 23.3 23.8
35–44 years 67.3 61.5 48.6 45.5 45.0 42.0 36.3 33.9 36.1 34.8 30.8 29.9
45–64 years 57.9 57.8 50.0 44.8 46.1 36.7 33.9 39.4 37.3 35.7 32.2 34.3
65 years and over 36.4 29.7 26.2 38.9 27.7 21.5 28.5 26.0 16.3 17.3 14.2 21.1
All females
18–24 years 38.1 34.1 33.8 35.5 30.4 22.5 21.8 25.7 24.5 26.3 25.1 23.4
25–34 years 43.7 38.8 33.7 32.6 32.0 28.2 26.4 24.8 24.6 23.5 22.5 23.0
35–44 years 43.7 39.8 37.0 33.8 31.5 24.8 27.1 27.2 26.4 26.5 26.2 25.7
45–64 years 32.0 33.4 30.7 31.0 29.9 24.8 24.0 21.5 22.5 21.0 21.6 21.4
65 years and over 9.6 12.0 13.2 13.1 13.5 11.5 11.5 11.5 11.2 10.7 9.3 9.2
White female4
18–24 years 38.4 34.0 34.5 36.5 31.8 25.4 24.9 29.4 28.1 29.6 28.7 27.2
25–34 years 43.4 38.6 34.1 32.2 32.0 28.5 27.3 26.1 26.9 25.5 25.1 25.5
35–44 years 43.9 39.3 37.2 34.8 31.0 25.0 27.0 27.5 26.6 26.9 26.6 27.0
45–64 years 32.7 33.0 30.6 30.6 29.7 25.4 24.3 20.9 22.5 21.2 21.4 21.6
65 years and over 9.8 12.3 13.8 13.2 13.3 11.5 11.7 11.7 11.2 10.5 9.1 9.4
Black or African American female4
18–24 years 37.1 35.6 31.8 32.0 23.7 10.0 *8.8 11.5 *8.1 14.8 14.2 10.0
25–34 years 47.8 42.2 35.2 38.0 36.2 29.1 26.7 22.5 21.5 18.2 15.5 16.8
35–44 years 42.8 46.4 37.7 32.7 40.2 25.5 31.9 30.1 30.0 28.8 30.2 24.0
45–64 years 25.7 38.9 34.2 36.3 33.4 22.6 27.5 28.4 25.4 22.3 25.6 22.6
65 years and over 7.1 *8.9 *8.5 *13.1 14.5 111.1 13.3 10.7 11.5 13.5 10.2 9.3
*Estimates are considered unreliable.
1Data starting in 1997 are not strictly comparable with data for earlier years due to the 1997 questionnaire redesign. Cigarette smoking data were not collected in 1996.
2Estimates are age adjusted to the year 2000 standard population using five age groups: 18–24 years, 25–34 years, 35–44 years, 45–64 years, 65 years and over.
3Beginning in 1993 current cigarette smokers reported ever smoking 100 cigarettes in their lifetime and smoking now on every day or some days.
4The race groups, white and black, include persons of Hispanic and non-Hispanic origin.
SOURCE: "Table 59. Current Cigarette Smoking by Persons 18 Years of Age and Over According to Sex, Race, and Age: United States, Selected Years 1965–2001," in Health, United States, 2003, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, Hyattsville, MD, 2003

and some 4,000 other chemical compounds including carbon monoxide and radioactive polonium. These chemicals not only enter the lungs, but also the bloodstream where they circulate into internal organs. Smoking can be responsible for, or contribute to, asthma; heart disease; cancer of the lungs, esophagus, mouth, bladder, pancreas,

TABLE 8.5
Cigarette smoking among teens, 1980–2002
[Data are based on a survey of high school seniors and eighth-graders in the coterminous United States]

Substance, sex, race, and grade in school 1980 1990 1991 1995 1998 1999 2000 2001 2002
Cigarettes Percent using substance in the past month
All seniors 30.5 29.4 28.3 33.5 35.1 34.6 31.4 29.5 26.7
Male 26.8 29.1 29.0 34.5 36.3 35.4 32.8 29.7 27.4
Female 33.4 29.2 27.5 32.0 33.3 33.5 29.7 28.7 25.5
White 31.0 32.5 31.8 37.3 41.0 39.1 36.6 34.1 30.9
Black or African American 25.2 12.0 9.4 15.0 14.9 14.9 13.6 12.9 11.3
All tenth-graders - - - - - - 20.8 27.9 27.6 25.7 23.9 21.3 17.7
Male - - - - - - 20.8 27.7 26.2 25.2 23.8 20.9 16.7
Female - - - - - - 20.7 27.9 29.1 25.8 23.6 21.5 18.6
White - - - - - - 23.9 31.2 32.4 29.1 27.3 24.0 20.8
Black or African American - - - - - - 6.4 12.2 13.8 11.0 11.3 10.9 9.1
All eighth-graders - - - - - - 14.3 19.1 19.1 17.5 14.6 12.2 10.7
Male - - - - - - 15.5 18.8 18.0 16.7 14.3 12.2 11.0
Female - - - - - - 13.1 19.0 19.8 17.7 14.7 12.0 10.4
White - - - - - - 15.0 21.7 21.1 19.0 16.4 12.8 11.1
Black or African American - - - - - - 5.3 8.2 10.8 10.7 8.4 8.0 7.3
SOURCE: "Table 63. Use of Selected Substances by High School Seniors, Eighth-, and Tenth-Graders, According to Sex and Race: United States, Selected Years 1980–2002," in Health, United States, 2003, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, Hyattsville, MD, 2003

and pharynx; bronchitis; emphysema; and low birth weight babies. One ironic result of the attempt to reduce smoking has been the marked increase in the use of smokeless tobacco, which can cause oral cancers. Tobacco use is known to increase the risks for nine cancers. According to the U.S. National Cancer Institute, it is the leading cause of 30 percent of all cancer deaths and 87 percent of lung cancer deaths.

Environmental Tobacco Smoke

While the dangers of smoking to smokers have been known for quite some time, the risks to nonsmokers have only recently attracted attention. In May 2000 the NIH released its ninth Report on Carcinogens in which substances, such as metals, pesticides, and other chemicals, are identified as "known" or "reasonably anticipated" to cause cancer and to which a significant number of Americans are exposed. For the first time the report included environmental tobacco (secondhand) smoke (ETS) as a "known" human carcinogen.

ETS is classified by the EPA as a Group A carcinogen, because it is known to cause cancer in humans. According to the CDC, exposure to ETS causes 3,000 lung cancer deaths annually among nonsmokers and increases the risk for heart disease. As many as 62,000 deaths every year from coronary heart disease are estimated as attributable to ETS. Secondhand smoke is also blamed for aggravating respiratory problems and ear infections in children and increasing the risk of sudden infant death syndrome. Passive smokers (those who inhale the smoke from others' cigarettes) have a 30 percent greater risk of dying of lung cancer than those who are not passive smokers.

ETS contains cotinine, a chemical that results from the breakdown of nicotine in the body. Cotinine levels in urine, saliva, hair, and blood can be measured. Active smokers have cotinine levels in excess of 15 nanograms per milliliter (ng/mL). Nonsmokers with average exposure to ETS have cotinine levels less than 1 ng/mL. The CDC reports that nearly 90 percent of the U.S. population had measurable levels of serum cotinine in their blood in 1991. Among nonsmokers the median cotinine level was 0.20 ng/mL. By 1999 this value had dropped to less than 0.050 ng/mL, a 75 percent decrease. Figure 8.11 shows that the concentration of cotinine measured in children's blood declined by more than 50 percent between 1988 and 2000.

Until the late 1990s nonsmokers generally had no choice about breathing tobacco smoke in many public buildings, including hospitals. This is no longer the case and, in fact, smokers may find themselves ostracized or, at the very least, required to smoke in designated areas. Many American companies are banning smoking from the workplace; some even refuse to hire smokers. Also, some restaurants and social clubs—places where smoking has historically been common—have begun to ban, or severely curtail, smoking on their premises.

Tobacco and the Legal System

In June 2002 a 67-year-old man from Kansas was awarded $15 million in punitive damages from R. J.

TABLE 8.6
Relationship between cigarette smoking and serious medical conditions, 2000

Current smokers Former smokers Current smokers Overall
Condition No. (%) No. (%) No. (%)
Chronic bronchitis 2,633,000 (49) 1,872,000 (26) 4,505,000 (35)
Emphysema 1,273,000 (24) 1,743,000 (24) 3,016,000 (24)
Heart attack 719,000 (13) 1,755,000 (24) 2,474,000 (19)
All cancer except lung cancer 358,000 (7) 1,154,000 (16) 1,512,000 (12)
Stroke 384,000 (7) 637,000 (9) 1,021,000 (8)
Lung cancer 46,000 (1) 138,000 (2) 184,000 (1)
Total4 5,412,000 (100) 7,299,000 (100) 12,711,000 (100)
Notes: Cigarette smoking-attributable conditions considered are stroke, heart attack, emphysema, chronic bronchitis, and cancer of the lung, bladder, mouth/pharynx, esophagus, cervix, kidney, larynx, and pancreas. Current smokers were defined as persons who reported smoking 100 cigarettes during their lifetime and who now smoke some days or every day. Former smokers were defined as persons who reported having smoked 100 cigarettes during their lifetime but did not smoke at the time of interview. Results are adjusted for age, race, sex, and state/area of residence and rounded to the nearest 1,000. Numbers might not add to total because of rounding.
SOURCE: "Cigarette Smoking—Attributable Morbidity—United States, 2000," in Morbidity and Mortality Weekly Report, vol. 52, no. 35, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Atlanta, GA, September 5, 2003

Reynolds (RJR) tobacco company. The man, who smoked for more than 40 years, had lost both legs to a circulatory disease that he blamed on smoking. It was the first time that a federal judge awarded punitive damages against a tobacco company. The judge ruled that the company had concealed the addictiveness of cigarettes. In the same week a man who had lost his tongue to cancer was awarded $37.5 million from Philip Morris, Brown and Williamson, and the Liggett Group by a Miami jury.

When individuals sue tobacco companies, they claim that cigarette smoking contributed to their ill health in a variety of ways. Some of the issues raised in these suits include the following:

  • The cost to society for medical expenses related to tobacco use
  • Advertising and selling tobacco products to youth
  • The location and placement of tobacco products
  • Taxes on tobacco products
  • The harmful effects of secondhand smoke
  • The addictive nature of nicotine
  • The failure of tobacco companies to divulge information about the harmful and addictive nature of smoking, and their concealment of evidence to that fact
  • Smoking in public buildings

Tobacco companies argue that smokers choose to smoke and that they must assume the risk for doing so. In the landmark 1994 case Cipollone v. Liggett Group Inc. FIGURE 8.11
Concentrations of cotinine in children's blood, 1988-91 and 1999-2000
(60 LW 4703), the Supreme Court ruled that smokers may sue cigarette companies for concealing facts about smoking and that the Liggett Group was at least partially liable in the death of Rose Cipollone. However, the court also determined that Cipollone herself was partially responsible for her cigarette use and subsequent death.

In 1991 the AMA publicly charged RJR with targeting children through its Joe Camel advertising campaign. Later that year Janet Mangini, a California attorney, brought suit to end the Joe Camel campaign, becoming the first person to legally challenge the tobacco industry for targeting minors in its advertising. Six years of "discovery," that is, taking depositions and obtaining records, followed. As the trial date neared in May 1997, RJR offered to halt the ad campaign in order to stop the trial and also agreed to provide for public release of its documents about youth marketing and the Joe Camel campaign.

In the 1997 case Broin v. Philip Morris, a flight attendant sued claiming that secondhand smoke in airplanes had harmed her health. The suit was settled out of court with Philip Morris agreeing to pay some $300 million to establish a medical foundation.

Nevertheless most legal action against "Big Tobacco" prior to 1998 was unsuccessful because most of the suits were filed as class action suits, where large numbers of complainants unite to sue. The 1995 case Castono v. The American Tobacco Company Inc. (85 F 3rd 734, 5th Cir. 1996), filed in Louisiana, included people who had purchased and smoked cigarettes and had become nicotine dependent. The U.S. District Appeals Court in Louisiana "decertified" the suit, ruling that individual issues predominated over common issues, thus making the case not a proper candidate for a class action.

That ruling—that individual issues were greater than common issues in suits against the tobacco industry—has been handed down both by state and federal courts in at least 30 suits. In 1996, however, in Howard A. Engle, MD v. R. J. Reynolds Tobacco, Philip Morris, Brown and Williams, Lorillard Tobacco, the American Tobacco Company, et al., filed in Dade County, Florida, the state appellate court ruled that the suit could proceed to trial, although it was reduced to include only Florida residents. In 1999 the jury ruled for the plaintiffs and, in July 2000, assessed penalties of $145 billion in punitive damages against the country's five largest tobacco companies. The money was to be split among Florida residents who could prove they became ill from smoking. Philip Morris was ordered to pay $73.96 billion, RJR $36.28 billion, Brown and Williamson $17.59 billion, Lorillard Tobacco $16.25 billion, and the Liggett Group $790 million.

The trial, which lasted for two years, was the longest civil trial in the history of tobacco litigation, and the penalty was the largest ever levied in any case. Rather than building their case around the dangers of smoking, the plaintiffs focused on the negligent conduct of the tobacco companies that they claimed had covered up smoking risks for more than four decades. While some observers suggested that the jury's decision would encourage other class actions, tobacco industry executives contend that the ruling will be reversed on appeal. They claim that the case will be overturned because it should not have been allowed as a class action and that the fine is outrageous and will put the tobacco companies out of business. In any case, legal experts predicted the verdict was many years away from being final.

In the mid-1990s a number of state governments initiated suits against tobacco companies to recoup state Medicaid spending on tobacco-related illnesses. With the pressure of state and private lawsuits building up, the tobacco industry has begun to seek settlements with the states. In November 1998, in what was termed a "Master Settlement Agreement" between the major tobacco manufacturers and 46 state attorneys general (Texas, Florida, Minnesota, and Mississippi settled independently), the tobacco companies agreed to accept a number of limitations on how they marketed and sold their products. These included: ceasing youth-targeted advertising, marketing, and promotion by stopping the use of cartoon characters in advertising; limiting brand-name sponsorship of events with significant youth audiences; terminating outdoor advertising; banning youth access to free samples; and setting the minimum cigarette package size at 20. In addition to these limits on their business practices, the tobacco industry agreed to pay more than $200 billion to the states.

In the 1990s testimony before Congress claimed that the tobacco industry deliberately manipulated the amount of nicotine in its cigarettes, and that cigarettes were nothing more than a delivery system for nicotine, a drug now widely recognized as physiologically addictive. The industry feared that if cigarettes were perceived as a delivery system for nicotine, tobacco products might fall under the control of the FDA. In 1995 the FDA ruled that nicotine was indeed a drug and liable to its regulation—the first time the tobacco industry had been regulated. In March 2000, however, the Supreme Court ruled 5–4 that the FDA does not have jurisdiction to regulate tobacco products or cigarette-company marketing practices under existing law.

In his 1999 State of the Union address, President Bill Clinton announced his intent to sue the tobacco industry to recover money spent by the federal government to treat illnesses caused by smoking. Accordingly, the U.S. Department of Justice filed suit in September 1999 (United States of America v. Philip Morris Inc., et al.) in the U.S. District Court for the District of Columbia. The government accused the tobacco companies of misleading and defrauding the public about the dangers of smoking. In September 2000 a federal judge dismissed part of the lawsuit in which the government was seeking to recover billions of dollars spent in health care costs related to smoking. As of April 2004 the government is seeking $289 billion in its case against the tobacco companies. The case is expected to go to trial in late 2004. It will likely be the most complex and lengthy case ever tried in U.S. court. Government attorneys plan to submit more than one million pages of exhibits as evidence.

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