Population Health: Behavioral and Social Science Insights

Cigarettes: The Rise and Decline

Full title
Cigarettes: The Rise and Decline But Not Demise of the Greatest Behavioral Health Disaster of the 20th Century

By David B. Abrams, Allison M. Glasser, Andrea C. Villanti, and Raymond Niaura


Tobacco use is expected to prematurely kill 1 billion people globally during the 21st century. More must be done than the current status quo approaches to tobacco control to avert this preventable global disaster. In contrast to a longstanding (status quo) and very effective focus of the U.S. tobacco control community on eliminating all tobacco/nicotine use behavior, the 50th anniversary U.S. Surgeon General's Report, for the first time, articulated a potentially game-changing harm-minimization strategy. The evidence is incontrovertible that the behavior of inhaling lethal smoke from combusting tobacco, primarily from the mass-produced, widely appealing, and heavily marketed cigarette, is responsible for the majority of deaths. The possible change to a harm minimization strategy is in part due to the urgent imperative to further reduce the massive disease burden resulting from cigarette use. This chapter selectively explores, at a broad brush or macro level of granularity, some of the individual and population perspectives that influenced arguably the greatest human engineered, behavioral lifestyle, public health disaster of the 20th century. We will briefly review the equally dramatic public health success of limiting tobacco use to date and discuss the rapidly changing present landscape with an increasingly diverse range of emerging tobacco and tobacco-derived nicotine products. Products that, if responsibly made and marketed and prudently managed by regulators and policymakers, could provide—for the first time in over a century—a way out for those unable or unwilling to stop using cigarettes and thus make cigarettes obsolete. We will conclude with a key question for science, practice, and policy: Should the endgame be the elimination of use of all forms of tobacco/nicotine, or is public health better served by speeding the obsolescence or outright banning of the lethal combustible products by supporting safer forms of nicotine use for those smokers who do not want to or are unable to quit all use?

Epidemic of Tobacco Use and Its Effects on Health

Overview of the Epidemic of Tobacco Use

It has now been more than 50 years since the original 1964 U.S. Surgeon General's report1 on smoking and health. In 2014, tobacco use, primarily the combustible tobacco products dominated by cigarettes, is estimated by the Surgeon General to prematurely kill even more users than ever before: 480,000 adults annually; furthermore, it is estimated that 5.6 million children alive in 2014 will die prematurely of a tobacco-related disease unless more is done.2 The Surgeon General also reports that cigarettes have killed over 20 million users, more American deaths than in any of the wars since the founding of the Nation. Moreover, the effects of combustible tobacco have been underestimated because analysts combined disease-specific causes of death rather than considering all-cause mortality.3

Despite 50 years of significant progress that has cut U.S. cigarette use by more than 50 percent (demonstrating that one can change human behavior on a large, population-wide scale), further and more rapidly reducing smoking and its exorbitant cost of over $200 billion annually to society, remains a priority.2 While there are many other pressing challenges in U.S. health care (obesity, eliminating disparities, universal/affordable care, escalating costs), smoking remains the primary cause of preventable death. Although stopping use, or not initiating use, is the best advice, the reality is that some youngsters will start, and many current smokers don't want to or cannot easily quit. Thus, for those already using tobacco and having difficulty stopping despite all that has been done to further change smoking behavior (prevention, treatment, and policy efforts), the use of alternatives and avoiding or desisting use of any combustible tobacco product (cigarettes, cigars, hookah, or pipe) at the earliest age possible may dramatically minimize the cumulative morbidity, mortality, and damage from combustible products.4,5

The disease burden, premature deaths, and high costs to the Nation that can be attributed to smoking will continue well into the next century unless we pick up the pace to reduce smoking prevalence more rapidly than the current trajectory. The results of several modeling studies projecting population smoking prevalence document the need for more aggressive action than the prevention and cessation interventions and tobacco control policies currently in place.6,7 Projections indicate that the prevalence of adult smoking could likely remain above the Healthy People 2020 objective of 12 percent, even by mid-century, if there is little change to current strategies.7,8

More aggressive action is needed because over 44 million Americans still smoke lethal cigarettes, despite the mountain of evidence showing adverse consequences.2 Cigarettes have become more appealing and addictive than ever before, presumably as a result of the tobacco industry's relentless product enhancements.2 Further, a widening chasm in prevalence by socioeconomic gradient means smoking is a primary driver of overall health disparities.9-11 The unprecedented resilience, persistence, and survival of the lethal cigarette is astounding and is instructive across biological, behavioral, and social science domains, in terms of understanding the complex systems forces at work. This is especially true, given that the basic product has largely been unaltered and has dominated the retail market for over 100 years, a period aptly termed the "Cigarette Century" and the "Golden Holocaust."12,13 "The cigarette is also a defective product, meaning not just dangerous but unreasonably dangerous, killing half its long-term users. And addictive by design" (p. i27)."14

Tobacco use behavior is embedded and embodied within sociocultural and neurobiological reciprocal interactions. This includes the behavior of individuals and the "behavior" of human- created and dynamically changing multi-level contexts (i.e., the collective behavior of various group aggregations, such as family and friendship networks, neighborhoods and culture, and organizations, corporations, governments, advocates, and policymakers). This goes along with the biological and neuro-behavioral underpinnings of the psychoactive effects of nicotine and other ingredients inhaled in combusting tobacco smoke that result in the sensorimotor satisfaction and appeal of smoking, its addiction liability, and the unavoidable toxic exposure from combustion by-products. The complexity of these pathways of influence on patterns of individual and collective behavior yields an important perspective on the need for an integrative strategy to understand and perhaps better intervene in the space of the bio-behavioral, sociocultural, economic, and population-level pathways and across scientific disciplines to improve the health of whole populations.15-17

At a deeper level of analysis, given what we have known about the lethality of cigarettes since at least the publication of the first 1964 Surgeon General's report,1 the question that needs to be answered is why and how what might be termed "a mass produced weapon of global mass destruction" has been permitted to continue to flourish and expand throughout the world from developed to developing nations? What story does this tell us about understanding human behavior change, the conceptual models and tools we use, and where the gaps are (what is missing or unexplained)? Perhaps one answer, although unsatisfying, is that it is complicated: the explanation lies not in one factor or element (each element is quite well understood), but in the interaction of various components in a complex dynamic interplay at multiple levels, from cells to society. Some of the interactions and trajectories over time are still poorly specified or appreciated, especially the influences on behavior of so-called long- and short-term feedback loops (of vicious and virtuous cycles), as well as the influences of systems within systems (later in this chapter).18,19 Lack of true systems integration has been proposed as the single most important missing ingredient in understanding the transformative and resilient cigarette epidemic and the failure of societies and governments worldwide to eliminate mass cigarette production and marketing from the consumer product marketplace, despite evidence that it's a defective product.20,21

The myriad factors influencing smoking behavior have led first to an increase, then a decline, and now a stubborn persistence of cigarette use over the last century (Figure 1). On the one hand, this story plays out within individuals over time, from the marketing of products that appeal to youth— like mentholated cigarettes—to the mere seconds it takes a teenager to "decide" to engage in a risky behavior, to the minutes it takes to ingest the smoke and the seconds after inhalation of the first puff when the complex chemosensory and neuro-active (e.g., cool menthol flavoring, other additives, nicotine, monoamine oxidase) chemicals hit the brain's reward/satisfaction pathways, to the months of experimental use and years of progression to established daily use, to the years and decades of sustained use, to the multiple cessation attempts or actual cessation.22 This goes on within and across generations.23 If nothing more, tobacco use provides a messy, sophisticated primer about biology and behavior in a societal and global context.16

Figure 1. Adult per capita cigarette consumption and major health events, United States 1900- 2012

Figure depicts the relationship between adult per capita cigarette use and major health events in the United States from 1900 to 2012. The chart shows a sharp rise in cigarette consumption beginning about 1930 to coincide with the Great Depression. Cigarette use peaked between 1960 and 1970 and then started a slow but steady decline after publication of the first Surgeon General’s report on smoking and health in 1964 and a doubling of the tax on cigarettes in 1980.

Source: The health consequences of smoking—50 years of progress. Atlanta, GA: Centers for Disease Control and Prevention; January 2014.

For any number of reasons, society continues to tolerate the sale of cigarettes. There is a product for every taste, social class, pocketbook, and group/tribal identity. Lifespan developmental psychology has also contributed to our understanding of bio-behavioral and now epigenetic factors associated with initiation and persistence of smoking in some young people but not in others. Many risky behaviors are experimented with during youth, but thankfully most people grow out of extreme risk- taking behaviors.24-27 But, the targeted marketing, appeal satisfaction, self-identity formation, and addiction to the nicotine in cigarettes lead to a journey and a lifelong struggle ending in disability and premature death. Given the premature deaths, industry spokesmen for tobacco use have said that youth are their "replacement customers."28

Contextual factors also play out over time and interact with individual factors. Human ingenuity, along with other events, have transformed patterns and norms of behavior both rapidly (e.g., world wars) and slowly (e.g., identifying cigarettes as the cause of lung cancer). Leaders and regulators worldwide have in effect also favored a concentration of powerful corporations with huge economic might; profits have overruled the priority for people's quality of life. Creation and maintenance of consumer demand also follows human nature's propensity (and vulnerability) to consume and to seek out satisfying immediate and relatively inexpensive "pleasant" experiences orchestrated by marketing and creating consumer demand.29

While this description is oversimplified, the cigarette as a device for combusting of tobacco yields a unique chain of stimuli and responses culminating in that nicotine and chemosensory satisfaction engineered together with marketing, packaging, placement, and cost. The cigarette has, perhaps more than any other product ever developed by humans, managed to slip through every layer of the multiple levels of the cells to interlaced societal systems that interact and result in specific patterns of individual and collective behavior. The cigarette has proven to be an ideal vehicle that conspires with micro and macro socio-behavioral and economic forces that capitalize on the vulnerability inherent in the human "limbic brain."

The limbic brain embodies a core of powerful drive and control systems that interact with the prefrontal, sensorimotor, and visual cortex for the ultimate goal of survival (e.g., the drive to seek food and water and belong to a tribe). The same areas of the brain involve the seeking of pleasure and the avoidance of discomfort or pain (in adolescents especially via emotional "hot cognition/impulsivity"). Other factors that include the pleasure of social bonding and feeling of belonging to a group influence behavior. The way cigarettes influence biological and behavioral pathways of seeking and craving to repeat a highly rewarding experience, in some respects, overrides rationality in critical decisionmaking contexts.30 There are also vast individual differences driven by genetic and epigenetic factors that determine why some individuals rapidly develop an addiction while others can take or leave the cigarette at will, and why still others can use cigarettes for a period of time and then stop (e.g., during adolescence and early adulthood), and still others find the product to be aversive and cannot use it at all.

The influences on behavior have become more immediate and direct and can now rapidly spread through society by the emergence of the ubiquitous digital and social media environments. Thus, the brain maintains and adapts to change via multi-level proximal and distal "contextual factors" tied to social networks of family, peers, and members of communities to sustain cigarette use.31 No one dimension adequately and rationally explains the dominance of the cigarette for over 100 years, but each piece accumulates and interacts with other components to produce the present status quo.

The Rise of Cigarettes and the Start of the Disease Epidemic

In this section, we will examine macro trends in tobacco use behavior and associated mortality from the perspective of human ingenuity, disruptive technology, mass production, marketing, and unintended consequences (Figures 1 and 2).

In the 1880s, the cigarette was an expensive, hand-made luxury item used by few. The vast majority of tobacco was consumed in non-combusted forms (e.g., snuff or chewing tobacco), and lung cancer was an extremely rare disease. An automated cigarette rolling machine, invented by 18-year-old James Bonsack, revolutionized production and proved to be a truly disruptive and ultimately lethal technological innovation.32 The machine produced 70,000 cigarettes over 10 hours in its trial run and rolled what 48 employees could roll by hand in a day. Ironically, another technological innovation, the refrigerator, was adopted by almost all households between 1930 and 1980 and, without much other intervention, reversed the then devastating toll of stomach cancer on the U.S. population.

Figure 2. Trends in age-adjusted cancer death rates by site, males, U.S., 1930-2011

Chart depicts age-adjusted death rates in U.S. males by cancer body site for 1930-2011. It shows It shows a sharp and steady increase in cancers of the lung and bronchus beginning in 1930 and peaking about 1990, at which point a downward trend is shown. Stomach cancer peaked about 1930 and then began a steady decline that continued through 2011. The other cancers depicted are leukemia, colon and rectum, pancreas, and prostate; these are shown to maintain a fairly steady rate across the time period with occasional small ups and downs.

Source: US Mortality Volumes 1930 to 1959, US Mortality Data 1960 to 2011, National Center for Health Statistics, Centers for Disease Control and Prevention. ©2015, American Cancer Society, Inc., Surveillance Research. Used with permission.
Notes: Cancer deaths are adjusted to the 2000 U.S. standard population. Mortality rates for pancreatic and liver cancers are increasing. Due to changes in International Classification of Diseases (ICD) coding, numerator information has changed over time. Rates for cancer of the liver, lung, and bronchus and colon and rectum are affected by these coding changes.

Among men, for example, the two prevalence curves of lung cancer and stomach cancer crossed over in the 1950s. Lung cancer went from a rare cancer in 1930 to the most prevalent cancer by 1990, and at its peak, the death rate for lung cancer (per 100,000) was about twice as high compared to stomach cancer at its peak (Figure 2). Stomach cancer was as rare in 1990 as lung cancer was in 1930, both changes resulting from population-level adoption of disruptive technology within 60 years. Most of the increase in overall cancer death rates for men prior to 1990 was attributable to the rapid increase in lung cancer deaths due to the tobacco epidemic. However, since 1990, the lung cancer death rate in men has been decreasing. This decline has accounted for nearly 40 percent of the overall decrease in cancer death rates in men.33 Even our most conservative estimate indicates that reductions in lung cancer resulting from reductions in tobacco smoking over the last half century account for about 40 percent of the decrease in overall male cancer death rates and have prevented at least 146,000 lung cancer deaths in men during the period 1991-2003. The death rate for stomach cancer, which was the leading cause of cancer death among men early in the 20th century, has decreased by 90 percent since 1930.

At first, adoption of cigarette smoking by the population was slow; companies were reluctant to invest in the cigarette rolling machine, believing consumers preferred hand-rolled cigarettes, cigars, snuff, and chewing tobacco (Figure 3). It is important to note that while they are not harmless, of course, these non-combustible forms of tobacco (snuff and chewing tobacco) dominated total tobacco sales in the late 1800s, and their use clearly did not cause the devastating diseases associated with pulmonary inhalation of toxic smoke (cardiovascular disease, lung cancer, and chronic obstructive pulmonary disease) that account for the vast majority of preventable deaths just 100 years later.34,35

This issue of using less harmful forms of tobacco—like new versions of the smokeless products that dominated in the 1880s—to obtain the nicotine without the lethal tars of combustion has taken center stage again in the early 21st century (discussed in more detail later in this chapter). Early proponents of harm minimization first suggested going back to the use of smokeless products to accelerate stalled reductions in cigarette use prevalence in the 1990s. Harm minimization has, with the introduction of e-cigarettes as a potential disruptive technology, now become perhaps the most hotly debated issue seen since the cigarette rolling machine produced the epidemic in the first place.36-38 The invention and rise of the e-cigarette and the use of low nitrosamine Swedish snus to reduce the harms from inhaled cigarette smoke in Sweden35,39 suggest a "back to the future" scenario where cigarettes are made obsolete by new non-combusting technology yielding use of safer tobacco-derived nicotine delivery not seen since the 1890s (Figure 3).

Figure 3. Trends in type of tobacco use

Figure shows trends in type of tobacco use from 1880 to 2010. Data are shown for snuff, chewing tobacco, pipe/roll your own, cigars, and cigarettes. According to this chart, use of all types of tobacco peaked between 1950 and 1960 and then began a steady decline.

Source: U.S. Department of Treasury, 2012.

Within two decades of the invention of the rolling machine, however, the volume of sales catapulted to 10 billion by 1910, and the retail price was halved. American Tobacco took advantage of the new technology so successfully that it was broken up in 1911 because of U.S. antitrust law. The uptake in patterns of adoption was driven over 50 years, first by predominantly male smoking, the two World Wars, and a decline during the great depression (macro trends and key events in Figures 1-3), and then by increasing marketing and adoption by women beginning with the infamous Torches of Freedom public relations (now termed marketing) campaign, still cited as a classic in marketing textbooks.40,41 Smoking prevalence by 1964, when the first Surgeon General's warnings were issued, exceeded 50 percent of the male population, but by the 1980s, smoking rates were almost identical for men and women.42-44

Consequences of Tobacco Use

By the early 20th century, articles addressing the health effects of smoking began to appear in medical journals. In 1930, researchers in Cologne, Germany, discovered a statistical correlation between cancer and smoking. In 1938, Dr. Raymond Pearl of Johns Hopkins University reported that smokers did not live as long as non-smokers. By the 1950s, the evidence mounted that smoking (i.e., inhaled smoke from the burning or combusting of tobacco) had caused the epidemic in lung cancer; this rarest cancer in 1900 exploded to overtake all other cancer death rates by 1955 and progressed to double any other cancer in death rate, responsible for over 30 percent of all cancer deaths by 1990 (Figure 2). These findings led to the landmark 1964 U.S. Surgeon General's report1 and a dramatic tipping point in the reversal in cigarette sales and smoking prevalence from over 50 percent in men to less than 20 percent in 2012.2

It is at this point that the story becomes quite complicated, pushed along by a range of forces working to promote cigarette use while others pushed against it. During the past 100 years, the basic structure and function of the cigarette have remained relatively unchanged in many respects, except for the optimization of the ingredients to enhance chemosensory appeal, satisfaction, and the rapid pulmonary absorption of smoke and nicotine to reach the brain's reward pathways within 7 seconds, thus ensuring the highest degree of addiction and enhanced performance.45 Over the decades, tobacco companies have masterfully re-engineered, optimized, innovated, adapted, and brilliantly packaged, priced, and marketed cigarettes. In the process, they have created brand loyalty and consumer demand for a defective product that nobody really "needed."

In the last 50 years in particular, the cigarette industry and marketing have withstood massive challenges from numerous sectors of society. These include public education campaigns about the harms of cigarettes, U.S. Surgeon General's Reports (1964-2014), bans on television advertising, restrictions on sales and marketing to children, State and Federal taxes and clean air laws, a U.S. Master Settlement Agreement of over $250 billion, being adjudicated by U.S. Federal court to have engaged in fraudulent behavior, and now being regulated under the 2009 U.S. Tobacco Control Act.2 However, everything done so far by tobacco control, although resoundingly successful from the 1960s to the 1990s, has reached diminishing returns. The resilience and sustained market share of cigarettes continues globally. If nothing disrupts the reign of the ubiquitous cigarette over the previous century, by 2100, this mass-produced retail product will prematurely kill 1 billion people worldwide. The cigarette has survived and thrived despite being clearly labeled for decades as lethal: "...a defective product—unreasonably dangerous, killing half its users and addictive by design."12,14

What Makes Cigarette Smoking Dangerous: Nicotine vs. Tars

Tobacco has been used for millennia without wreaking the harm that it now does on population health. Nicotine is neither necessarily very harmful nor very addictive; it depends on the mode of delivery (e.g., rapid pulmonary absorption from combustion or slow infusion via a transdermal nicotine patch) and the dose. Nicotine, per se, is therefore not the enemy, although not harmless, especially to some vulnerable populations such as the unborn fetus, young developing brains, and when delivered in modalities that increase its addiction liability.45 The enemy is the combustion or burning of tobacco that produces the gas phase tars, toxins, and carbon monoxide that kill, while also delivering nicotine in its most addictive form. As Russell succinctly stated almost 40 years ago, "people smoke for the nicotine but die from the tar."46 Not surprising, then, it was not until the early 1900s that the harms from mass production and marketing of cigarettes exponentially escalated to epidemic proportions and became the leading cause of over 480,000 preventable premature deaths annually.2,35 Cigarettes have approximately 600 ingredients; when burned, they create carbon monoxide, particulate matter, and more than 7,000 chemicals, commonly referred to as tars. At least 69 of these chemicals are known to cause cancer, and many are poisonous. This toxic mix and exposure to it for years cause the overwhelming majority of preventable morbidity and mortality from inhaled smoke.35,47

It is puzzling that a product known for over 50 years to be so lethal has escaped either being taken off the market by State or Federal governments empowered to protect public health or being limited by the companies themselves in line with how other industries recall defective products (e.g., Ford Explorers and Firestone Tires) or risk severe consequences and loss of reputation if they do not— as in the recent debacle of the decade-long use of a defective ignition switch in General Motors automobiles that appears to be responsible for at least 13 deaths.48-50 These contrasting scenarios make for an interesting lesson for the social and behavioral sciences by asking: How do these contradictory yet obvious injustices become accepted in a civil society and come to live side by side?

New breakthrough ideas and strategies are urgently needed to disrupt this human created and "systems within systems" epidemic. An epidemic that itself was begun with a "disruptive technology"—the invention and patenting of the cigarette rolling machine—can perhaps be halted through the introduction of another disruptive technology that will alter the way in which nicotine is delivered to the brain. Simulations of plausible futures indicate that even if policies are aggressively implemented, reductions in the prevalence of cigarette smoking will be frustratingly slow and reductions in smoking-related deaths even slower.6,7 We cannot accept a second cigarette century. As articulated in the 2014 Surgeon General's 50th anniversary Report: "Death... is overwhelmingly caused by cigarettes and other combustibles... promotion of e-cigarettes and other innovative products is... likely to be beneficial where the appeal, accessibility, and use of cigarettes are rapidly reduced" (pp. 15-17).2 The ultimate goal should be to use safer forms of nicotine delivery to speed the obsolescence of lethal combustibles for those who cannot stop using some form of nicotine, while ensuring that new products are kept out of the reach of youth as much as possible.

Harm Minimization and the Rise of the E-Cigarette

Is There a Safe Enough Replacement for the Lethal Cigarette?

Harm minimization, as a tobacco control strategy, includes achieving a society that rejects all tobacco use as the first priority. However, harm minimization recognizes that, pragmatically, some youth and adults will become addicted to combustible products/cigarettes that cause the greatest harm by far. Thus, a second priority is to focus on eliminating cigarette/combusted product use immediately. Obtaining nicotine without burning tobacco is safer and can be made less addictive. For anyone who cannot stop all use of combustibles/cigarettes, a harm minimization approach is a viable option. Harm minimization adopts a continuum of risk, which places cigarettes (or any burning of tobacco) at one extreme (most harm) and FDA-approved nicotine replacement therapy (NRT) at the other extreme (least harm).51

Electronic cigarettes ("e-cigarettes")—or electronic nicotine delivery systems (ENDS)—lie along this continuum. In 1963, Herbert A. Gilbert was granted a patent to produce a prototype of an e-cigarette that delivered nicotine through heated steam.52 E-cigarettes were not commercially viable until Hon Lik, a Chinese pharmacist, developed a more advanced product in 2003 and received an international patent in 2007.52 Since then, the products have evolved from disposable, "cigalike" products to larger rechargeable products, also known as "personal vaporizers." These devices deliver an aerosol mist from liquid containing tobacco-derived nicotine, flavorings, and other ingredients.53,54

Evidence from user surveys and interviews indicate that new e-cigarette users begin with "cigalike" products, but experienced and long-term e-cigarette users (i.e., "vapers") appear to transition to larger models (tank-like or open systems) and prefer to order nicotine liquid online/purchase from "vaping stores" or mix their own concentrations.55-59 There is wide variability in nicotine content vaporization efficacy by brand and potential delivery to the user,60,61 but exposure to toxicants is significantly lower for e-cigarettes than for conventional cigarettes.62-71 E-cigarettes are generally perceived to be less harmful than regular cigarettes56,72-74 and are commonly used as a smoking reduction/cessation aid.55,72-77

National cross-sectional data in the United States indicate that trial of e-cigarettes has increased in both youth and adult populations, from 4.7 percent in 2011 to 11.9 percent in 2013 among high school students,78-80 from 6.9 percent in 2011 to 7.8 percent in 2013 among young adults ages 18-24,81 and from 6.2 percent in 2011 to 8.5 percent in 2013 among adults 18 and older.81,82 Current use has also increased, but most recent available data show that overall prevalence remains low: 4.5 percent (2013) among high school students, 2.4 percent (2013) among young adults, and 1.9 percent (2013) among adults overall.76,83 The majority of ever and current e-cigarette users are current cigarette smokers. Among youth in the United States in 2012, 76.3 percent of current e-cigarette users were also current cigarette smokers.79,80 A national survey of U.S. adults found only a 1.2 percent trial of e-cigarettes among never smokers in 2013, compared to a 36.5 percent trial among current smokers.81 However, trends could be evolving, with the Monitoring the Future Study finding in 2014 that 17 percent of youth were trying e-cigarettes, also with 75 percent of them already using cigarettes.84

Despite considerable promise, concerns about e-cigarette use largely focus on the potential that they will serve as a new entry point into other tobacco products, particularly among youth, and that they will delay or halt cessation altogether via prolonged dual use of e-cigarettes and cigarettes without reduced harm exposure. While studies of youth have advanced the notion that use of e-cigarettes may encourage cigarette use,85 exploration of alternate hypotheses must also be considered.37,86,87

As noted by Niaura and colleagues, "It is equally plausible that use of combustible cigarettes leads to use of e-cigarettes because they are perceived as a less harmful alternative for smokers who are addicted to nicotine. The cross-sectional survey data do not prove that this is the process that explains the association, but they are just as consistent with it..."87 Additionally, there is very limited evidence from the longitudinal observational studies to determine how e-cigarette use influences other patterns of tobacco use,77,88 and this is further complicated by the low population prevalence of e-cigarette use and limitations of the selected nature of the populations included in observational studies. Evaluating the potential impact of e-cigarette use on youth cigarette uptake, for example, would require identification of youth who would start with e-cigarettes and move to combustible products over and above those youth who would smoke combustible products anyway. In short, the data required to document potential harms (or benefits) of a specific product at the population level will be difficult to acquire. However, the increased prevalence of e-cigarette use in U.S. youth is occurring at the same time when overall smoking by teens showed a decrease, from 10.6 percent in 2012 to record lows of 8.0 percent in 2014.89 Thus, it appears that e-cigarettes may not be promoting more cigarette use or delaying the cessation of cigarette use.90,91 Thus, it does not appear to be the case that increased e-cigarette use is leading to more conventional cigarette use.

A key question regarding e-cigarettes is their potential role in effectively facilitating cessation of combustible cigarettes in current smokers or significant harm reduction, both in individual users and in terms of overall population impact. There have been several studies on the use of e-cigarettes to quit smoking combustible cigarettes. Two randomized controlled trials have been conducted, indicating that e-cigarettes are effective in helping some adult smokers to quit or to reduce their cigarette consumption.92,93 Other prospective observational studies with comparison groups in population samples report any use of e-cigarettes (it is not clear in some studies that e-cigarette use was expressly for the purpose of trying to quit) may be associated with no change in smoking status or a reduced likelihood of cessation.74,94,95 Thus, these negative associations are impossible to interpret and may be due to other factors, especially selection bias (e.g., smokers who are less able to quit but more motivated to try are more likely to experiment with e-cigarettes out of curiosity or to have more difficulty with cessation).96 A longitudinal study that established use of e-cigarettes as part of a serious quit attempt found that in two U.S. metropolitan areas, after 2-3 years, intensive e-cigarette users (used daily for at least a month) had the highest rate of smoking cessation (20.4 percent), compared to intermittent users (more than once or twice but not daily for a month or more; 8.5 percent) and triers (used at most once or twice)/non-users (12.4 percent).97 Smokers who used e-cigarettes for at least a month were six times as likely to be abstinent at 2-year followup as triers/ non-users. Another large cross-sectional survey in the United Kingdom found that among adults who had smoked within the previous year and made at least one quit attempt during that period, e-cigarette users were more likely to report abstinence than either those who used NRT or no aid.98 It has also been noted by these authors that in the United Kingdom, e-cigarette use for cessation has surpassed use of NRTs, thus making their potential for larger scale population impact quite promising. More research—especially independent, high quality randomized controlled trials with appropriate control groups—is needed to further determine whether and how e-cigarettes can be an effective cigarette cessation or harm reduction aid; nevertheless, results to date are promising for some adult smokers.

Whether e-cigarettes can help people quit combustible cigarettes may also depend in part on their effectiveness at delivering nicotine at or near the level of cigarettes, as well as their overall satisfaction for users, based on the complex chemosensory experience that cigarettes now provide.

Acute examinations demonstrate that nicotine delivery is dependent on the e-cigarette device and liquid concentration, as well as the rate at which the nicotine is delivered and the user's experience with e-cigarette use (i.e., naïve or not naïve).99-105 As mentioned previously, more experienced users prefer larger personal vaporizers over the "cigalike" disposable devices. This is likely because, as studies have demonstrated, there are higher plasma nicotine levels after use of these new generation products, approaching the levels achieved after combustible cigarette use, although the levels peak after a longer duration of use.59,101 E-cigarettes have also been shown to reliably decrease adverse symptoms related to tobacco abstinence (e.g., cravings and urges to smoke, irritability).99,100,102,103,106,107

More research is needed to determine whether the levels of nicotine delivered support the potential for e-cigarettes to be sufficiently satisfying to displace combustible tobacco products and to determine what level of nicotine dependence may be acceptable at the population level. It is also unclear whether a cleaner form of nicotine, while not harmless and still potentially addictive, warrants as much public health concern if the nicotine delivery is de-coupled from the toxicity in combusted products (i.e., a delivery system that is as satisfying as a cigarette and may have addiction liability but confers significantly less harm than cigarettes). The net public health benefits versus harms would need to be determined by the degree to which the nicotine delivery system can successfully compete with combusted tobacco. That is, the benefits of a product with high addiction liability and with low harm (associated with cleaner nicotine devices) would outweigh harms of the high addiction liability provided that product strongly encouraged complete switching away from combustible cigarettes (a public health benefit if the nicotine addiction liability is compared to lethal cigarettes and not to a placebo or nothing). This would contrast with a lower addiction liability product that resulted not in complete switching but rather prolonged dual use.

Clearly, the emergence of new products like e-cigarettes raises a critical issue regarding whether society is now willing to tolerate a safer form of what might be termed "recreational" nicotine use, even if it has some or even quite a large addiction liability for some users, in order to speed the obsolescence of cigarettes. If so, then for the first time in over 100 years, it may be possible that the e-cigarette, a disruptive technology, could dethrone the cigarette rolling machine that has dominated since the 1880s and fueled the global multinational tobacco industry. Could this be a David and Goliath moment?37,108

Interpreting the Science to Improve Public Health While Minimizing Harms

Whether e-cigarettes are a disruptive technology with the potential to completely replace conventional cigarettes depends on consumers, how they perceive and use new and emerging products, how the products are regulated, and how they are made and marketed, both by tobacco companies (who have a vested interest in dual or poly use of all their products, including lethal cigarettes) and by independent manufacturers who do not sell other tobacco products and thus have less conflict and are able to focus on making cigarettes obsolete.37,52,86 This complex set of dynamics in a rapidly changing landscape calls for a systems science view of the challenges involved (more on this later in the chapter). The U.S. Food and Drug Administration (FDA) Center for Tobacco Products (CTP) regulates tobacco products using a variety of perspectives to inform a "public health standard" that requires the regulatory agency to weigh the harms versus benefits of products to both individuals and the population as a whole.109,110 The "public health standard" also must consider several "likelihoods" of (1) beginning use of a product; (2) preventing, delaying, or accelerating cessation of the use of combustible tobacco; and (3) in the case of e-cigarettes, promoting or discouraging product switching or dual use with no reduction in combustible cigarette use.109

Simulation modeling provides an opportunity to understand the multitude of influences of e-cigarettes on population health. The proof-of-concept study by Cobb et al.109 used a Markov model to make explicit the dynamic states and transitions of use over time, using data from a longitudinal cohort of U.S. young adults. The authors found that the largest changes over 10 years occurred in non-current use, cigarette use, and former use states, with dual use and e-cigarette use states remaining at low prevalence over the years; these findings demonstrate a projected minimal impact of e-cigarettes on patterns of cigarette use. This type of information could be used to guide regulatory policy through informing the "likelihoods" in considering whether e-cigarettes, or other potentially reduced-harm products, uphold the "public health standard."

In terms of economics, an argument can be made that companies may still want to market and addict generation after generation of youth; an outcome that should be avoided even if the products are much safer than cigarettes. This may be true of tobacco companies, since only the withdrawal of their lethal combusted products from the marketplace would eliminate the risk of future use among youth. Sweanor52 and other harm minimization proponents argue that in the case of cigarettes alone, smokers worldwide currently pay the equivalent of roughly $800 billion a year (in U.S. dollars) on a product many are aware is defective and likely to kill them. A non-combustible product line, for which there is already consumer demand among current smokers, could capture an increasing fraction of the enormous cigarette market, thus presenting a huge business opportunity while saving millions of lives and without needing to recruit another generation of adolescents or naïve users of any age. This incentive would be more appealing to independent e-cigarette makers, who if they acted in a responsible fashion, could drive a wedge between combustible and non–combustible product use and accelerate the demise of the lethal cigarette. Responsible behavior (i.e., not targeting youth or marketing in a way that appeals to youth) could be supported by tobacco control, FDA CTP, regulators and other policymakers. E-cigarettes could deliver enormous gains for public health if the tobacco companies would also take the initiative to withdraw combustible products and act in a trustworthy manner as stewards of public health rather than just for shareholder profits. Then, governments could work with rather than against entrepreneurs and collaborate on a pragmatic harm minimization approach.

The introduction of new products, along with changes in marketing and regulation, traditional tobacco control policies, and individual and group behavior represent a dynamic and complex interaction that could have a number of potential unintended effects. For example, this interaction could undermine efforts to end the tobacco problem or it could hasten efforts to eliminate cigarettes. It is possible that new tobacco products may reduce consumption and population harms by displacing combustible tobacco products. On the other hand, the new products may increase harms by promoting the use of multiple products or delaying cessation.111

At present, the tobacco landscape continues to evolve. The global and U.S. tobacco industry has stated in various ways that it plans to undergo a major paradigm shift towards making and marketing a wider range of tobacco-derived nicotine products with a purported mission of reduced harm. Innovations in the new products pipeline and the creative marketing that will be emerging during the next decades of the 21st century focus on non-combustible, next-generation products, especially more efficient pulmonary delivery of aerosolized nicotine, which is claimed to be more satisfying and more efficient at delivering "clean(er)" nicotine than the current e-cigarette. These game-changing moves will likely blur historic boundary lines drawn over the last 50 years between the tobacco control community, the tobacco industry, and the pharmaceutical industry.

Changes to product lines set forward in the tobacco industry playbook, if they come about, almost certainly will alter the tobacco control landscape, as well as individual and population patterns of uptake, regular use, and even the existence of tobacco-derived nicotine. The implications for tobacco control, in general, and FDA regulation, in particular, are largely unknown and potentially profound. These trends and marketing practices must be carefully tracked, and their impact on the knowledge, attitudes, risk perceptions, and behavior of consumers must be rapidly ascertained to inform regulation and education using the public health standard mandated in the Family Smoking Prevention and Tobacco Control Act.112-114

Another consequence of these game changing moves will likely blur the previously clear boundary lines drawn over the last 50 years between: (a) tobacco control as total abstinence from all tobacco and nicotine products; (b) a new set of potentially appealing harm-reduction options for consumers that also can carry risks of harm escalation or of slowing the progress made towards eliminating the epidemic; and (c) the traditional and previously clear-cut use of medicinal nicotine replacement therapies (NRT), either for short term use to achieve complete desistence of all combustible tobacco products and nicotine or as a long-term alternative to continued use of the most harmful combustible tobacco products.

In the next 50 years, we may well be in an era of paradigm-shifting perspectives and a shortened timeframe. The viral spread and dramatic penetration of e-cigarettes in just 5 years, from 2007-2012, is a clear example.115-117 As we look to the future through the lens of a new world of rapid digital communications and innovation of products to deliver nicotine in non-combustible form, whether for recreational use or as a therapeutic smoking cessation treatment, some informed speculation is inevitable as we conclude this chapter. The lessons of the last 50 years may no longer be the best predictor of the next 50 years, but lessons learned, better conceptual and analytic lenses, real-time data gathering capacity, and the FDA's regulatory authority all provide an evidence-based context to provide a sharper vision of what may be possible in the future.

In examining possible future directions for tobacco control, there are new uncertainties. In the future, we may not be able to rely on the past as a guide in developing recommendations due to the rapidly changing marketplace, the emphasis on digital and social media, tobacco product regulation by the FDA, and the industry's movement towards championing reduced-harm products and messages. We are entering a new era that, ironically, is fueled by similar dynamics that started the current epidemic a hundred years ago: new technology (spawning new modified risk/non-combustible alternative nicotine delivery products), digital communication (Internet, social media, smart phone) with new forms of rapid and targeted marketing and the viral spread of messages and products, and the new leverage of an FDA regulatory authority that could also change the dynamics in the future tobacco control context. Future strategies and projections of impact must now consider a more complex and dynamic model that addresses short and long-term feedback loops at multiple levels of influence. New vectors and pathways may have unpredictable intended and unintended consequences.118,119 Messages about new and existing tobacco products continue to spread virally and be maintained in the social networks of users in both developed and developing nations. Moving stealthily, just as a natural disaster might do, the vector continues to spread the message, damaging and "infecting" more and more humans with projections of over a billion lives lost in the 21st century. All of this new damage can be prevented or attenuated, while the already existing devastation can and should be cleaned up.

Implications for Research and Policy

Implications for Research

While much has been accomplished to date, there continues to be room for additional improvement in the current status of the field. As we have discussed in this chapter, there are significant if not groundbreaking changes occurring in the landscape of tobacco control at the present time. Evidence-based tobacco control interventions are unlikely to provide the same dramatic reductions in tobacco use over the next 50 years compared to the past 50 years. Novel endgame strategies that have a strong empirical basis may be needed to reduce the use of cigarettes and other forms of tobacco. While these new strategies may be able to minimize the harms of tobacco use over a shorter timeframe, there are likely to be political and social challenges to implementation. As proposed in a special supplement of the journal Tobacco Control in 2013, potential endgame strategies include reducing the nicotine content in cigarettes, creating a tobacco-free generation, creating limits on the amount of tobacco available for commercial sale ("sinking lid"), banning sales of cigarettes, and a range of other strategies.14,120-138

In addition to evaluating the outcomes and barriers to such endgame strategies, we also need to consider what constitutes a final endgame: is it a reduction in smoking prevalence or smoking-related deaths to a low rate, or is it the end of all smoking?136 This approach needs to be compared to (or combined with) the two other main solutions, sticking to traditional evidence-based tobacco control measures and harm minimization.140 Of all these strategies, perhaps the ones with the most potential for population benefit are those that reduce the appeal, addictiveness, and toxicity of cigarettes and increase their cost to consumers via taxation, while simultaneously providing reasonably satisfying but much less harmful forms of nicotine delivery such as prudently regulated and FDA-approved nicotine delivery products like e-cigarette or future innovative variants.

The convergence of three major trends challenges the status quo and what we know to date about effective and efficient tobacco-control interventions for prevention, treatment, and policy, which will need to be adjusted in light of new industry and regulatory developments. The two major trends in the morphing of the tobacco industry towards manufacturing a panoply of diverse products with claims for possible reduced harm and the digital media revolution are overshadowed by the regulatory authority given to the FDA Center for Tobacco Products in 2009. It is too early to say how and to what extent the regulation of tobacco products by the Government will impact the landscape in the United States.140 What is clear is that we need a new regulatory science that incorporates these emergent trends, embraces a transdisciplinary "systems thinking" and multi- level Social Ecological Model as one useful guiding framework,110 and from the very outset of designing the science, considers how the science can inform policymaking.

System sciences likely will play an increasingly important role as a tool to inform research, practice, and policymaking in tobacco control. Behavioral and social sciences researchers will continue to play a critical role, but they must adopt systems thinking and modeling tools to add to their ability to rapidly collect data that can keep pace with the changing landscape and consumer behaviors. In systems thinking, a coherent system comprises relationships that unveil "emergent properties" that are only visible at the system level and not by examining them in isolation.15 At work within the system are dynamic, non-linear feedback loops, stocks and flows, and time delays, including biological, organizational, social, and political forces.15,18,19 Stakeholder engagement and transdisciplinary thinking are necessary to understand and manage these complex challenges, and various methodologies can be employed, such as system dynamics simulation, agent-based modeling, network analysis, or Markov modeling to address the heterogeneity of the system, especially when real-world experiments are not possible or ethical.15,18,19

The Institute of Medicine's report, A Blueprint for the Nation, and the U.S. Department of Health and Human Services' Strategic Action Plan recommend simulation modeling to project the impact of integrating tobacco control interventions and policies, given the dynamic nature of the tobacco epidemic and its drivers.2,141,142 Figure 4 depicts a systems view of some of the major competing influences on patterns of tobacco use at a coarse level of granularity. In most cases, the tobacco industry strategies increase harmful patterns of tobacco use and have a health-damaging impact (red feedback loops) and the counter-tobacco strategies reduce tobacco use prevalence and have a health protective influence (blue feedback loops). The mechanisms of influence include tobacco industry anti-tobacco control strategies such as marketing, innovation of new products, litigation, and challenging of restrictive policies and higher taxes, whereas pro-tobacco control mechanisms include tobacco product regulation, restrictive tobacco control policies, mass media public education, State and local ordinances, tobacco control litigation, and prevention and cessation interventions. The systems diagram also provides a roadmap to examine the success of current tobacco control efforts and identify the policy and program levers that could dramatically reduce tobacco use and thus, tobacco-related morbidity and mortality and economic costs.

The problem then emerges from the reciprocal influences of multiple "systems within systems" that interact dynamically within and across many levels, ranging from molecular, neurobiological, and bio-behavioral systems within the individual to individual behavior and group-level reciprocal interactions that play out at cluster or aggregate levels, such as family, peer, neighborhood, community, and societal and global levels of influence.

Figure 4. Simplified dynamic model of protobacco and antitobacco forces on patterns of tobacco use

Figure illustrates the dynamic nature of the overlapping health-damaging and health-protecting effects of protobacco and antitobacco forces on use of tobacco products. Protobacco (health-damaging) effects include tobacco industry marketing, innovation, and litigation. Antitobacco (health-protecting) effects include intervention to prevent and stop tobacco use, public education, scientific evidence, tobacco control policies, regulation of tobacco products, and counter-tobacco litigation.

While still a work in progress, advances in engineering such as control systems and simulation models have advanced in the last decade. This type of science calls for integrated and transdisciplinary synthesis by scientists, advocates, and legal, political, government, and non- government stakeholders.110 This must be done within the context of a dramatically changing environment that includes the tobacco industry, marketing, and other stakeholders who are anticipating and reacting to the FDA's new authority. Now more than ever, science is needed to evaluate how industry efforts impact youth and adult tobacco use patterns, but it must be rapid, rigorous, and flexible to keep pace with the changing market. Research will be critical to help integrate new prevention and cessation interventions, and there is a pressing need to review and evaluate on an ongoing basis FDA CTP's performance to optimize its impact on reducing population harms from tobacco products. New methods of surveillance, including methods involving new technologies and shorter intervals between data collection, will be an essential complement to annual population-level surveys.

Given declining funding for tobacco prevention efforts, there is also a great need to optimize program effectiveness; this includes demonstrating the utility of new evaluation tools, potential products, and new channels and platforms of intervention delivery. Tobacco control interventions and policies must cover the rapidly growing digital environment and remain in-step with evolutions in social media.

The simultaneous opportunity and challenge for tobacco control researchers will be to conduct rigorous science that reduces the harms of tobacco use in the context of what we have referred to throughout this chapter as a series of "perfect storms," including the proliferation and ubiquity of digital and social media, a rapidly morphing tobacco industry with a panoply of new products and marketing tactics, and the dawning of the era of FDA-CTP regulatory authority over tobacco products. This perfect storm requires a strategic approach to science to determine the optimal leverage points for targeted intervention and policy changes.

Implications for Policy

Today's changing landscape includes vectors that can influence the status quo and where we go. For example, FDA can regulate existing and new products, and they can educate the public to reduce the death, disease, and economic burden associated with use of tobacco products. Thus, defining the goals of ending the tobacco problem at the outset is central to identifying the surveillance and intervention tools needed to reduce the death, disease, dollars, and disparities associated with tobacco use.

To date, Federal, State, and local policies shown to be effective in reducing tobacco use exhibit uneven implementation. In 2012, tobacco prevention spending was less than 2 percent of tobacco revenues across all States, State excise taxes on non-cigarette products remained markedly lower than cigarette excise taxes, and approximately two-thirds of Americans were not protected by State or local clean indoor air laws. It is our hope that health care policies like the Health Information Technology Economic and Clinical Health Act and the Affordable Care Act will be more effective than past policies, and that instead, they may help us to meet the Healthy People 2020 objectives of increasing tobacco use screening and cessation counseling in health care settings.

Development in 2010 of the Department of Health and Human Services Strategic Action Plan for Tobacco Control142 provided a blueprint for coordinating a comprehensive tobacco control program in the United States across Federal, State, and local partners, including supporting FDA regulation of tobacco. Increased funding for these efforts is essential if we are to implement a coordinated tobacco control response at these multiple levels. Further guidance and action at the Federal and State levels are needed to ensure that tobacco-related benefits are consistently implemented across insurers.

There is an increasing interaction between industry, public health advocates, and the FDA that could blur the distinctions and the typical ways the public understands the intended and unintended consequences of the changing vectors, and especially the implications for how changes at individual levels may influence group-level and population-level impacts. Thus, it is unclear how the FDA standard of determining the population level benefits or harms will be operationalized and used, especially in the new marketplace of tobacco products and claims.

The FDA's bottom line is to employ science-based rule making by determining the impact of any regulation or educational program at the population level, taking into account both users and non- users. Its mission is to reduce the deaths and harms that result from use of tobacco products. The FDA's recent regulatory tools provide additional opportunities and strategies that are consistent with the goal to end the tobacco problem or to change it into a less damaging problem without eliminating all tobacco product use per se. New strategies described as "endgame strategies" may offer a tremendous opportunity to transform the tobacco epidemic, though that will require strong scientific support and political will.


This chapter oversimplifies the achievements and challenges in tobacco control. The fact remains that to date, despite the wealth of evidence accumulated and the progress made in the 50 years now covered by the Surgeon General's reports, we as a society have not yet chosen to prohibit the manufacture, sale, and distribution of lethal tobacco products to adults, and we also have not been fully successful at keeping these products away from our children. The tobacco industry itself has not volunteered to take its lethal products off the market the way that the Firestone tire company and Ford Motor Company reacted when it became known that several hundred excess deaths were associated with the defective combination of Firestone tires on Ford Explorers.48-50 We see in our ongoing story a variety of political, cultural, economic, and ideological reasons not to take defective tobacco products off the market. Even for the sake of both adult users and our vulnerable children who will make up our future generations, and despite the tremendous harms caused primarily by using combustible tobacco products (the lethal combination of burning tobacco producing an addictive pleasure within toxic inhaled smoke), it is unlikely or impossible to envision that America will take these dangerous combusting products off the market any time soon. Some might argue that this century-old American story of creating an unprecedented disease epidemic, followed by partially ameliorating it with a 54 percent reduction in prevalence, is among the most notable human engineered mass disasters and massive ongoing cleanups in America's recorded history. There is more work to be done as we review current status and future directions.

A renewed call to action through the lens of social justice is needed now more than ever.143 This is not only for the sake of the current generation of adult tobacco users and for the current generation of vulnerable children, adolescents, and young adults who are potential users, but also especially for priority populations in whom cigarette use is highest (i.e., economically disadvantaged people and ethnic and racial minorities),9,144 those with comorbid mental and substance abuse disorders,145,146 and finally, for the generations to come.

There is great excitement at the prospect of the global eradication of smallpox, polio, and measles, and dramatic inroads and investments have been made into reducing the impact of malaria and HIV/ AIDS, as well as increasing concerns about global warming and carbon footprints. Why not place the wholly preventable deaths and disease burdens of tobacco use behavior on the same priority list of scourges to be eradicated? We can plausibly imagine a world where our families and generations to come will all grow up free of the known preventable harms of using tobacco products, especially the lethal and addictive combustibles like cigarettes, cigars, and hookah.

Perhaps the world of the 75th Surgeon General's report in 2039 will look more like the world before 1900, when the lethal and most addictive cigarette was not widely available, was not mass produced, was not inexpensive, and was not mass marketed to create a consumer demand for an addictive product that kills nearly half its users prematurely. A "back to the future" world where, as we saw prior to 1920, lung cancer was an extremely rare disease, and the other known major diseases caused by cigarette use, including cardiovascular and pulmonary diseases, were also much less prevalent because individuals were not as likely to inhale lethal smoke. A healthier world is possible, for the sake of our children and our children's children.


This work was supported by Legacy and the National Cancer Institute (P30CA051008). Parts of this chapter include material adapted from the authors' contributions to the 2014 publication, The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General, and commentaries and publications on e-cigarettes. The opinions expressed herein are those of the authors and may not necessarily reflect the position of the Agency for Healthcare Research and Quality, the National Institutes of Health, or the U.S. Department of Health and Human Services.

Authors' Affiliations

David B. Abrams, PhD, is Executive Director, the Schroeder Institute for Tobacco Research and Policy Studies, Legacy; Professor, Department of Health, Behavior and Society, The Johns Hopkins Bloomberg School of Public Health; and Professor of Oncology (adjunct), Georgetown University Medical Center, Lombardi Comprehensive Cancer Center. Allison Glasser, MPH, is Project Manager, the Schroeder Institute for Tobacco Research and Policy Studies, Legacy. Andrea C. Villanti, PhD, MPH, is Director for Regulatory Science and Policy at the Schroeder Institute for Tobacco Research and Policy Studies, Legacy. Raymond Niaura, PhD, is Director of Science and Director of Training, Schroeder Institute for Tobacco Research and Policy Studies, Legacy; and Professor (adjunct), Department of Health Behavior and Society, The Johns Hopkins Bloomberg School of Public Health.

Address correspondence to: David B. Abrams, Schroeder Institute for Tobacco Research and Policy Studies, Legacy, 1724 Massachusetts Avenue, NW, Washington, DC 20036; email DAbrams@legacyforhealth.org.


  1. Smoking and health. Report of the Advisory Committee to the Surgeon General of the Public Health Service. Washington, DC: U.S. Department of Health, Education, and Welfare; 1964.
  2. The health consequences of smoking—50 years of progress. A Report of the Surgeon General. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2014.
  3. Carter BD, Abnet CC, Feskanich D, et al. Smoking and mortality—beyond established causes. N Engl J Med 2015;372:631-40.
  4. Doll R, Peto R, Boreham J, et al. Mortality in relation to smoking: 50 years' observations on male British doctors. Br Med J 2004;328:1519.
  5. Jha P, Ramasundarahettige C, Landsman V, et al. 21st-century hazards of smoking and benefits of cessation in the United States. N Engl J Med 2013;368:341-50.
  6. Levy DT, Mabry PL, Graham AL, et al. Exploring scenarios to dramatically reduce smoking prevalence: a simulation model of the three-part cessation process. Am J Public Health 2010;100:1253-9.
  7. Mendez D, Alshanqeety O, Warner KE. The potential impact of smoking control policies on future global smoking trends. Tob Control 2013;22:46-51.
  8. Warner KE, Mendez D. Tobacco control policy in developed countries: yesterday, today, and tomorrow. Nicotine Tob Res 2010;12:876-87.
  9. Fagan P, Moolchan ET, Lawrence D, et al. Identifying health disparities across the tobacco continuum. Addiction 2007;102(Suppl 2):5-29.
  10. Schroeder SA, Warner KE. Don't forget tobacco. N Engl J Med 2010;363:201-4.
  11. Abrams DB. Applying transdisciplinary research strategies to understanding and eliminating health disparities. Health Educ Behav 2006;33:515-31.
  12. Proctor RN. Golden holocaust: origins of the cigarette catastrophe and the case for abolition. Oakland, CA: University of California Press; 2011.
  13. Brandt AM. The cigarette century: the rise, fall, and deadly persistence of the product that defined America. New York: Basic Books; 2007.
  14. Proctor RN. Why ban the sale of cigarettes? The case for abolition. Tob Control 2013;22(Suppl 1):i27-30.
  15. Mabry PL, Olster DH, Morgan GD, et al. interdisciplinarity and systems science to improve population health: a view from the NIH Office of Behavioral and Social Sciences Research. Am J Prev Med 2008;35:S211-24.
  16. Abrams DB, Leslie F, Mermelstein R, et al. Transdisciplinary tobacco use research. Nicotine Tob Res 2003;5(Suppl 1):S5-10.
  17. Rose G. Rose's strategy of preventive medicine. New York: Oxford University Press; 1992.
  18. Leischow SJ, Milstein B. Systems thinking and modeling for public health practice. Am J Public Health 2006;96:403-5.
  19. Sterman JD. Learning from evidence in a complex world. Am J Public Health 2006;96:505-14.
  20. Abrams DB. Comprehensive smoking cessation policy for all smokers: systems integration to save lives and money. In Bonnie RJ, Stratton K, Wallace RB (Eds), Ending the tobacco problem: a blueprint for the nation. Washington, DC: National Academies Press; 2007.
  21. Abrams DB. Nicotine addiction: paradigms for research in the 21st century. Nicotine Tob Res 1999;1(Suppl 2):S211-5.
  22. Colby SM, Clark MA, Rogers ML, et al. Development and reliability of the lifetime interview on smoking trajectories. Nicotine Tob Res 2012;14:290-8.
  23. Gilman SE, Rende R, Boergers J, et al. Parental smoking and adolescent smoking initiation: an intergenerational perspective on tobacco control. Pediatrics 2009;123:e274-81.
  24. Vanyukov MM, Tarter RE, Kirillova GP, et al. Common liability to addiction and "gateway hypothesis": theoretical, empirical and evolutionary perspective. Drug Alcohol Depend 2012;123(Suppl 1):S3-17.
  25. Chassin L, Presson CC, Sherman SJ, et al. Predicting the onset of cigarette smoking in adolescents: a longitudinal study 1. J Appl Soc Psychol 1984;14:224-43.
  26. Chassin L, Presson C, Seo DC, et al. Multiple trajectories of cigarette smoking and the intergenerational transmission of smoking: a multigenerational, longitudinal study of a Midwestern community sample. Health Psychol 2008;27:819-28.
  27. Chassin L, Presson CC, Pitts SC, et al. The natural history of cigarette smoking from adolescence to adulthood in a midwestern community sample: multiple trajectories and their psychosocial correlates. Health Psychol 2000;19:223-31.
  28. U.S. v. Philip Morris USA, Inc., et al.: U.S. Dist. Ct., D.C.; Final Opinion, August 17, 2006.
  29. Orleans CT, Mabry PL, Abrams DB. Increasing tobacco cessation in America: a consumer demand perspective. Am J Prev Med 2010;38:S303-6.
  30. Abrams DB. Transdisciplinary concepts and measures of craving: commentary and future directions. Addiction 2000;95(Suppl 2):S237-46.
  31. Cobb NK, Graham AL, Byron MJ, et al. Online social networks and smoking cessation: a scientific research agenda. J Med Internet Res 2011;13:e119.
  32. Bonsack JA, inventor patent U.S. Patent No. 238,640; 1881.
  33. Thun MJ, Jamal A. How much of the decrease in cancer death rates in the United States is attributable to reductions in tobacco smoking? Tob Control 2006;15:345-7.
  34. Lee PN. Epidemiological evidence relating snus to health—an updated review based on recent publications. Harm Reduct J 2013;10:36.
  35. Harris JE, Thun MJ, Mondul AM, et al. Cigarette tar yields in relation to mortality from lung cancer in the cancer prevention study II prospective cohort, 1982-8. Br Med J 2004;328:72.
  36. Kozlowski LT, Edwards BQ. "Not safe" is not enough: smokers have a right to know more than there is no safe tobacco product. Tob Control 2005;14(Suppl 2):ii3-7.
  37. Abrams DB. Promise and peril of e-cigarettes: can disruptive technology make cigarettes obsolete? JAMA 2014;311:135-6.
  38. Cobb NK, Abrams DB. The FDA, e-cigarettes, and the demise of combusted tobacco. N Engl J Med 2014;371:1469-71.
  39. Henley SJ, Thun MJ, Connell C, et al. Two large prospective studies of mortality among men who use snuff or chewing tobacco (United States). Cancer Causes Control 2005;16:347-58.
  40. Torches of Freedom: How the world's first PR campaign came to be. your story, 2014. Available at http://yourstory.com/2014/08/torches-of-freedom/. Accessed April 23, 2015.
  41. Torches of Freedom: Women and smoking propaganda. The Society Pages; February 27, 2012. Available at http://thesocietypages.org/socimages/2012/02/27/torches-of-freedom-women-and-smoking-propaganda/. Accessed April 23, 3015.
  42. Warner KE. Selling smoke: cigarette advertising and public health. Washington, DC: American Public Health Association; 1986.
  43. Donohue JM, Cevasco M, Rosenthal MB. A decade of direct-to-consumer advertising of prescription drugs. N Engl J Med 2007;357:673-81.
  44. Chapman S. Cigarette advertising and smoking: a review of the evidence. In Smoking out the barons: the campaign against the tobacco industry. Chichester, England: John Wiley and Sons; 1986.
  45. Niaura R. Nicotine. In: McCrady BS, Epstein EE (Eds), Addictions: a comprehensive guidebook (p. 269-84). New York, NY: Oxford University Press; 2013.
  46. Russell MA. Low-tar medium-nicotine cigarettes: a new approach to safer smoking. Br Med J 1976;1:1430-3.
  47. How tobacco smoke causes disease: the biology and behavioral basis for smoking-attributable disease. A report of the Surgeon General. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2010.
  48. Firestone Tire Recall. 2001. Washington, DC: National Highway Traffic Safety Administration; 2001. Available at http://www.nhtsa.gov/PR/FirestoneRecall. Accessed April 23, 2015.
  49. Consumer Advisory: Owners of recalled GM vehicles with faulty ignition switches urged to bring cars in for free remedy. Washington, DC: National Highway Traffic Safety Administration; 2014. Available at http://www.nhtsa.gov/About+NHTSA/Press+Releases/2014/owners-of-recalled-gm-cars-with-faulty-switches-urged-to-seek-free-remedy. Accessed April 23, 2015.
  50. Timeline: A history of GM's ignition switch defect. NPR, 2014. Available at http://www.npr.org/2014/03/31/297158876/timeline-a-history-of-gms-ignition-switch-defect. Accessed April 23, 2015.
  51. Zeller M, Hatsukami D. The strategic dialogue on tobacco harm reduction: a vision and blueprint for action in the US. Tob Control 2009;18:324-32.
  52. Sweanor D. Disruptive technology: a blessing and a curse. Rulebreaker Research 2014:54-7.
  53. Trtchounian A, Williams M, Talbot P. Conventional and electronic cigarettes (e-cigarettes) have different smoking characteristics. Nicotine Tob Res 2010;12:905-12.
  54. Williams M, Talbot P. Variability among electronic cigarettes in the pressure drop, airflow rate, and aerosol production. Nicotine Tob Res 2011;13:1276- 83.
  55. Dawkins L, Turner J, Roberts A, et al. 'Vaping' profiles and preferences: an online survey of electronic cigarette users. Addiction 2013;108:1115-25.
  56. Etter JF, Bullen C. Electronic cigarette: users profile, utilization, satisfaction and perceived efficacy. Addiction 2011;106:2017-28.
  57. Foulds J, Veldheer S, Berg A. Electronic cigarettes (e-cigs): views of aficionados and clinical/public health perspectives. Int J Clin Pract 2011;65:1037-42.
  58. McQueen A, Tower S, Sumner W. Interviews with "vapers": implications for future research with electronic cigarettes. Nicotine Tob Res 2011;13:860-7.
  59. Vansickel AR, Eissenberg T. Electronic cigarettes: effective nicotine delivery after acute administration. Nicotine Tob Res 2013;15:267-70.
  60. Cobb NK, Byron MJ, Abrams DB, et al. Novel nicotine delivery systems and public health: the rise of the "e-cigarette." Am J Public Health 2010;100:2340- 2.
  61. Goniewicz ML, Kuma T, Gawron M, et al. Nicotine levels in electronic cigarettes. Nicotine Tob Res 2013;15:158-66.
  62. Czogala J, Goniewicz ML, Fidelus B, et al. Secondhand exposure to vapors from electronic cigarettes. Nicotine Tob Res 2014;16:655-62.
  63. Goniewicz ML, Knysak J, Gawron M, et al. Levels of selected carcinogens and toxicants in vapour from electronic cigarettes. Tob Control 2014;23:133-9.
  64. Hutzler C, Paschke M, Kruschinski S, et al. Chemical hazards present in liquids and vapors of electronic cigarettes. Arch Toxicol 2014;88:1295-308.
  65. Kim HJ, Shin HS. Determination of tobacco-specific nitrosamines in replacement liquids of electronic cigarettes by liquid chromatography-tandem mass spectrometry. J Chromatogr A 2013;1291:48-55.
  66. McAuley TR, Hopke PK, Zhao J, et al. Comparison of the effects of e-cigarette vapor and cigarette smoke on indoor air quality. Inhal Toxicol 2012;24:850-7.
  67. Pellegrino RM, Tinghino B, Mangiaracina G, et al. Electronic cigarettes: an evaluation of exposure to chemicals and fine particulate matter (PM). Annali di igiene : medicina preventiva e di comunita 2012;24:279-88.
  68. Schripp T, Markewitz D, Uhde E, et al. Does e-cigarette consumption cause passive vaping? Indoor Air 2013;23:25-31.
  69. Williams M, Villarreal A, Bozhilov K, et al. Metal and silicate particles including nanoparticles are present in electronic cigarette cartomizer fluid and aerosol. PLoS One 2013;8:e57987.
  70. Kosmider L, Sobczak A, Fik M, et al. Carbonyl compounds in electronic cigarette vapors: effects of nicotine solvent and battery output voltage. Nicotine Tob Res 2014;16:1319-26.
  71. Hecht SS, Carmella SG, Kotandeniya D, et al. aluation of toxicant and carcinogen metabolites in the urine of e-cigarette users versus cigarette smokers. Nicotine Tob Res 2014:e-pub.
  72. Goniewicz ML, Lingas EO, Hajek P. Patterns of electronic cigarette use and user beliefs about their safety and benefits: an internet survey. Drug Alcohol Rev 2013;32:133-40.
  73. Zhu SH, Gamst A, Lee M, et al. The use and perception of electronic cigarettes and snus among the U.S. population. PLoS One 2013;8:e79332.
  74. Adkison SE, O'Connor RJ, Bansal-Travers M, et al. Electronic nicotine delivery systems: international tobacco control four-country survey. Am J Prev Med 2013;44:207-15.
  75. Farsalinos KE, Romagna G, Tsiapras D, et al. Characteristics, perceived side effects and benefits of electronic cigarette use: a worldwide survey of more than 19,000 consumers. Int J Environ Res Public Health 2014;11:4356-73.
  76. Kralikova E, Novak J, West O, et al. Do e-cigarettes have the potential to compete with conventional cigarettes? A survey of conventional cigarette smokers' experiences with e-cigarettes. Chest 2013;144:1609-14.
  77. Richardson A, Pearson J, Xiao H, et al. Prevalence, harm perceptions, and reasons for using noncombustible tobacco products among current and former smokers. Am J Public Health 2014;104:1437-44.
  78. Arrazola RA, Neff LJ, Kennedy SM, et al. Tobacco use among middle and high school students—United States, 2013. MMWR 2014;63:1021-6.
  79. Tobacco product use among middle and high school students—United States, 2011 and 2012. MMWR 2013;62:893-7.
  80. Corey CG, Wang B, Johnson SE, et al. Notes from the field: electronic cigarette use among middle and high school students - United States, 2011-2012. MMWR 2013;62:729-30.
  81. King BA, Patel R, Nguyen KH, et al. Trends in awareness and use of electronic cigarettes among US adults, 2010-2013. Nicotine Tob Res 2015;17:219-27.
  82. King BA, Alam S, Promoff G, et al. Awareness and ever-use of electronic cigarettes among U.S. adults, 2010-2011. Nicotine Tob Res 2013;15:1623-7.
  83. Agaku IT, King BA, Husten CG, et al. Tobacco product use among adults—United States, 2012-2013. MMWR 2014;63:542-7.
  84. Table 29. Use of cigarettes by e-cigarettes in the last 30 days. Ann Arbor, MI: University of Michigan, Monitoring the Future; 2014. Available at http://www.monitoringthefuture.org/data/14data/14tobtbl29.pdf. Accessed April 23, 2015.
  85. Dutra LM, Glantz SA. Electronic cigarettes and conventional cigarette use among U.S. adolescents: a cross-sectional study. JAMA Pediatr 2014;168(7):610-7.
  86. Abrams DB. Potential and pitfalls of e-cigarettes—reply. JAMA 2014;311:1922-3.
  87. Niaura RS, Glynn TJ, Abrams DB. Youth experimentation with e-cigarettes: another interpretation of the data. JAMA 2014;312:641-2.
  88. Richardson A, Williams V, Rath J, et al. The next generation of users: prevalence and longitudinal patterns of tobacco use among U.S. young adults. Am J Public Health 2014;104:1429-36.
  89. Table 3. Trends in 30-day prevalence of use of various drugs in grades 8, 10, and 12. Ann Arbor, MI: University of Michigan, Michigan News; 2015. Available at http://www.monitoringthefuture.org//pressreleases/14drugpr_complete.pdf. Accessed April 23, 2015.
  90. Teen smoking continues to decline in 2013. Ann Arbor, MI: University of Michigan, Institute for Social Research; 2013. Available at http://home.isr.umich.edu/releases/teen-smoking-continues-to-decline-in-2013/. Accessed April 23, 2015.
  91. Walton KM, Abrams DB, Bailey WC, et al. NIH electronic cigarette workshop: developing a research agenda. Nicotine Tob Res 2015;17:259-69.
  92. Bullen C, Howe C, Laugesen M, et al. Electronic cigarettes for smoking cessation: a randomised controlled trial. Lancet 2013;382:1629-37.
  93. Caponnetto P, Campagna D, Cibella F, et al. Efficiency and safety of an eLectronic cigAreTte (ECLAT) as tobacco cigarettes substitute: a prospective 12-month randomized control design study. PLoS One 2013;8:e66317.
  94. Vickerman KA, Carpenter KM, Altman T, et al. Use of electronic cigarettes among state tobacco cessation quitline callers. Nicotine Tob Res 2013;15:1787-91.
  95. Grana RA, Popova L, Ling PM. A longitudinal analysis of electronic cigarette use and smoking cessation. JAMA Intern Med 2014;174(5):812-3.
  96. Pearson JL, Stanton CA, Cha S, et al. E-cigarettes and smoking cessation: insights and cautions from a secondary analysis of data from a study of online treatment-seeking smokers. Nicotine Tob Res 2014:e-pub.
  97. Biener L, Hargraves JL. A longitudinal study of electronic cigarette use among a population-based sample of adult smokers: association with smoking cessation and motivation to quit. Nicotine Tob Res 2015;17:127-33.
  98. Brown J, Beard E, Kotz D, et al. Real-world effectiveness of e-cigarettes when used to aid smoking cessation: a cross-sectional population study. Addiction 2014;109(9):1531-40.
  99. Bullen C, McRobbie H, Thornley S, et al. Effect of an electronic nicotine delivery device (e cigarette) on desire to smoke and withdrawal, user preferences and nicotine delivery: randomised cross-over trial. Tob Control 2010;19:98-103.
  100. Dawkins L, Corcoran O. Acute electronic cigarette use: nicotine delivery and subjective effects in regular users. Psychopharmacology (Berl) 2014;231:401-7.
  101. Farsalinos KE, Spyrou A, Tsimopoulou K, et al. Nicotine absorption from electronic cigarette use: comparison between first and new-generation devices. Sci Rep 2014;4:4133.
  102. Vansickel AR, Weaver MF, Eissenberg T. Clinical laboratory assessment of the abuse liability of an electronic cigarette. Addiction 2012;107:1493-500.
  103. Vansickel AR, Cobb CO, Weaver MF, et al. A clinical laboratory model for evaluating the acute effects of electronic "cigarettes": nicotine delivery profile and cardiovascular and subjective effects. Cancer Epidemiol Biomarkers Prev 2010;19:1945-.
  104. Talih S, Balhas Z, Eissenberg T, et al. Effects of user puff topography, device voltage, and liquid nicotine concentration on electronic cigarette nicotine yield: measurements and model predictions. Nicotine Tob Res 2015;17:150-7.
  105. Spindle TR, Breland AB, Karaoghlanian NV, et al. Preliminary results of an examination of electronic cigarette user puff topography: the effect of a mouthpiece-based topography measurement device on plasma nicotine and subjective effects. Nicotine Tob Res 2015;17:142-9.
  106. Dawkins L, Turner J, Crowe E. Nicotine derived from the electronic cigarette improves time- based prospective memory in abstinent smokers. Psychopharmacology (Berl) 2013;227:377-84.
  107. Dawkins L, Turner J, Hasna S, et al. The electronic- cigarette: effects on desire to smoke, withdrawal symptoms and cognition. Addict Behav 2012;37:970- 3.
  108. Gladwell M. David and Goliath: Underdogs, misfits, and the art of battling giants. New York, NY: Little, Brown and Company; 2013.
  109. Cobb CO, Villanti AC, Graham AL, et al. Markov modeling to estimate the population impact of emerging tobacco products: a proof-of-concept study. Tob Regul Sci 2015;1(2):121-41.
  110. Villanti AC, Vargyas EJ, Niaura RS, et al. Food and Drug Administration regulation of tobacco: integrating science, law, policy, and advocacy. Am J Public Health 2011;101:1160-2.
  111. McNeill A, Munafo MR. Reducing harm from tobacco use. J Psychopharmacol 2012:e-pub.
  112. Southwell BG, Kim AE, Tessman GK, et al. The marketing of dissolvable tobacco: social science and public policy research needs. Am J Health Promot 2012;26:331-2.
  113. McNeill A, Munafo MR. Reducing harm from tobacco use. J Psychopharmacol 2013;27:13-8.
  114. Family Smoking Prevention and Tobacco Control Act, Public Law 111-31, U.S. Statutes at Large (2009):123.
  115. Ayers JW, Ribisl KM, Brownstein JS. Tracking the rise in popularity of electronic nicotine delivery systems (electronic cigarettes) using search query surveillance. Am J Prev Med 2011;40:448-53.
  116. Pearson JL, Richardson A, Niaura RS, et al. e-Cigarette awareness, use, and harm perceptions in U.S. adults. Am J Public Health 2012;102:1758-66.
  117. Hersey JC, Niederdeppe J, Evans WD, et al. The effects of state counterindustry media campaigns on beliefs, attitudes, and smoking status among teens and young adults. Prev Med 2003;37:544- 52.
  118. About one in five U.S. adult cigarette smokers have tried an electronic cigarette (press release). Atlanta, GA: Centers for Disease Control and Prevention; 2013. Available at http://www.cdc.gov/media/releases/2013/p0228_electronic_cigarettes.html. Accessed April 23, 2015.
  119. Evans WD, Abroms LC, Poropatich R, et al. Mobile health evaluation methods: the Text4baby case study. J Health Commun 2012;17(Suppl 1):22-9.
  120. Arnott D. There's no single endgame. Tob Control 2013;22(Suppl 1):i38-9.
  121. Benowitz NL, Henningfield JE. Reducing the nicotine content to make cigarettes less addictive. Tob Control 2013;22(Suppl 1):i14-7.
  122. Berrick AJ. The tobacco-free generation proposal. Tob Control 2013;22(Suppl 1):i22-6.
  123. Borland R. Minimising the harm from nicotine use: finding the right regulatory framework. Tob Control 2013;22(Suppl 1):i6-9.
  124. Callard CD, Collishaw NE. Supply-side options for an endgame for the tobacco industry. Tob Control 2013;22(Suppl 1):i10-3.
  125. Chapman S, Wakefield MA. Large-scale unassisted smoking cessation over 50 years: lessons from history for endgame planning in tobacco control. Tob Control 2013;22(Suppl 1):i33-5.
  126. Hatsukami DK. Ending tobacco-caused mortality and morbidity: the case for performance standards for tobacco products. Tob Control 2013;22(Suppl 1):i36- 7.
  127. Isett KR. In and across bureaucracy: structural and administrative issues for the tobacco endgame. Tob Control 2013;22( Suppl 1):i58-60.
  128. Kozlowski LT. Ending versus controlling versus employing addiction in the tobacco-caused disease endgame: moral psychological perspectives. Tob Control 2013;22(Suppl 1):i31-2.
  129. Malone RE. Tobacco endgames: what they are and are not, issues for tobacco control strategic planning and a possible US scenario. Tob Control 2013;22(Suppl 1):i42-4.
  130. Myers ML. The FCTC's evidence-based policies remain a key to ending the tobacco epidemic. Tob Control 2013;22(Suppl 1):i45-6.
  131. Rabe BG. Political impediments to a tobacco endgame. Tob Control 2013;22(Suppl 1):i52-4.
  132. Reuter P. Can tobacco control endgame analysis learn anything from the U.S. experience with illegal drugs? Tob Control 2013;22(Suppl 1):i49-51.
  133. Smith EA. Questions for a tobacco-free future. Tob Control 2013;22(Suppl 1):i1-2.
  134. Tam J. Cultivating the next generation of tobacco endgame advocates. Tob Control 2013;22(Suppl 1):i47-8.
  135. Thomas BP, Gostin LO. Tobacco endgame strategies: challenges in ethics and law. Tob Control 2013;22(Suppl 1):i55-7.
  136. Warner KE. An endgame for tobacco? Tob Control 2013;22(Suppl 1):i3-5.
  137. Wilson N, Thomson GW, Edwards R, et al. Potential advantages and disadvantages of an endgame strategy: a 'sinking lid' on tobacco supply. Tob Control 2013;22(Suppl 1):i18-21.
  138. Zeller M. Reflections on the 'endgame' for tobacco control. Tob Control 2013;22(Suppl 1):i40-1.
  139. Warner KE, Pollack HA. The nicotine fix. The Atlantic; 2014.
  140. Zeller M. Three years later: an assessment of the implementation of the Family Smoking Prevention and Tobacco Control Act. Tob Control 2012;21:453-4.
  141. Bonnie RJ, Stratton KR, Wallace RB (Eds). Ending the tobacco problem: a blueprint for the nation. Washington, DC: National Academies Press; 2007.
  142. Ending the tobacco epidemic: a tobacco control strategic action plan for the U.S. Department of Health and Human Services. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistant Secretary for Health; 2010.
  143. Cheyne A, Dorfman L, Daynard RA, et al. The debate on regulating menthol cigarettes: closing a dangerous loophole vs freedom of choice. Am J Public Health 2014;104:e54-61.
  144. Tobacco use among U.S. racial/ethnic minority groups—African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Islanders, and Hispanics: a report of the Surgeon General. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 1998.
  145. Schroeder SA, Morris CD. Confronting a neglected epidemic: tobacco cessation for persons with mental illnesses and substance abuse problems. Annu Rev Public Health 2010;31:297-314 1 p following.
  146. Hershey JC, Niederdeppe J, Evans WD, et al. The theory of "truth": how counterindustry campaigns affect smoking behavior among teens. Health Psychol 2005;24:22-31.
David B. Abrams David B. Abrams, PhD, is Professor, Johns Hopkins Bloomberg School of Public Health; Professor of Oncology, Georgetown University Lombardi Cancer and Executive Director, the Schroeder Institute for Tobacco Research and Policy Studies, Legacy. Previously, he was Director of the Office of Behavioral and Social Sciences Research, National Institutes of Health. He has served as President of the Society for Behavioral Medicine and was a recipient of their Distinguished Scientist and Research Mentorship awards. Dr. Abrams received the Joseph Cullen Memorial Award of the American Society for Preventive Oncology for lifetime contributions to tobacco control. He is a clinical psychologist specializing in health psychology, addictions, and tobacco use behavior.
Allison M. Glasser Allison M. Glasser, MPH, is a Project Manager with the Schroeder Institute for Tobacco Research and Policy Studies at Legacy. She manages various projects related to Food and Drug Administration regulatory science, including conducting evidence reviews, preparing knowledge synthesis papers, and facilitating communication among scientists, advocates, and other stakeholders through regular meetings and strategic consensus conferences. Her previous work has involved advancing evidence-based practices and policies through promoting cancer screening, worksite wellness programs, harm reduction policy advocacy, and managing systematic evidence reviews.
Andrea C. Villanti Andrea C. Villanti, PhD, MPH, is Director for Regulatory Science and Policy at the Schroeder Institute for Tobacco Research and Policy Studies, Legacy, where she also serves as Principal Investigator on Legacy's Young Adult Cohort Study. Dr. Villanti holds an adjunct faculty appointment in the Department of Health, Behavior and Society at the Johns Hopkins Bloomberg School of Public Health. Her interests include translational research to improve tobacco control policy and program decisionmaking, particularly the Food and Drug Administration's regulation of tobacco. Her interests also include tracking tobacco use patterns, trajectories, and the impact of tobacco interventions in young adults.
Raymond Niaura Raymond Niaura, PhD, is Director of Science and Director of Training at the Schroeder Institute for Tobacco Research and Policy Studies, Legacy; Professor (adjunct) in the Department of Health Behavior and Society, Johns Hopkins Bloomberg School of Public Health; and Professor (adjunct) in the Department of Oncology, Lombardi Comprehensive Cancer Center, at the Georgetown University Medical Center. While at Brown University, he was Director of Transdisciplinary Research and Director of Postdoctoral Training in Behavioral Medicine in the Department of Psychiatry and Human Behavior. Dr. Niaura is the former President of the Society of Nicotine and Tobacco Research.


Page last reviewed July 2015
Page originally created September 2015
Internet Citation: Cigarettes: The Rise and Decline But Not Demise of the Greatest Behavioral Health Disaster of the 20th Century. Content last reviewed July 2015. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/education/curriculum-tools/population-health/abrams.html