Led by public health crusader Mayor Michael Bloomberg (I), New York City has taken some serious steps to crack down on smoking rates. After instituting the highest cigarette tax in the nation and banning smoking in public places, the city’s smoking rates plummeted. But Bloomberg didn’t stop there. Within the past month, he has also pushed to hike cigarette prices even further and ban public cigarette displays in stores — and now, yet another anti-smoking initiative may prevent New Yorkers under the age of 21 from purchasing cigarettes.

The policy is being spearheaded by both the city’s health commissioner and the City Council speaker, Christine Quinn (D), as yet another method of keeping tobacco products out of the hands of New York City’s youth. Although Quinn opposed Bloomberg’s recent initiative to limit the sale of large sugary drinks, she emphasized at a press conference on Monday that she admires the mayor’s other public health policies. “The mayor probably has the most effective public health agenda of any mayor in history in the United States,” Quinn said. “This is another example of moving that aggressive public health agenda forward.”

If approved, New York City would be the biggest city to enact the nation’s highest smoking age. The Boston suburb of Needham, MA has also raised its smoking age to 21 years old. The smoking age is 19 in four states — Alabama, Alaska, New Jersey and Utah — and a handful of counties, and 18 throughout the vast majority of the country.

Advocates of the proposed measure point to some studies that project raising the smoking age to 21 could cut smoking rates among 18-to-20-year-old Americans by more than half. It could particularly help deter the rates in New York City, since 80 percent of the current smokers in the city say they picked up the habit before they turned 21. “If we can prevent our youth from starting smoking before they’re 21, we may just be able to protect an entire generation from a lifetime of being addicted to the world’s most dangerous drug. We think this is going to work,” Dr. Thomas Farley, New York’s health commissioner, said.

Tobacco kills an estimated 7,000 New Yorkers each year. On a national scale, tobacco-related illnesses kill an estimated 450,000 Americans each year, contributing to about $96 billion in total annual public and private health care expenditures caused by smoking. Despite the undisputed negative health effects of smoking, the tobacco industry continues to target its products to American youth.

England’s ban on smoking in indoor public places has been linked to a 5 percent annual drop in adult hospital admissions for asthma, according to new research.

The study, published in the journal Thorax, looked at the number of asthma-related emergency hospital admissions in England from 1997 to 2010, taking into account seasonal temperatures, changes in population size and long term trends in the prevalence of asthma. It found that since the smoking ban was implemented in July 2007, there have been 1,900 fewer asthma-related hospital admissions per year.

The study echoes other findings on the health benefits of England’s ban, which was implemented as part of a U.K.-wide effort to prohibit smoking in indoor public spaces:

• The ban led to the largest decrease in smoking ever seen in England, with an estimated 400,000 people quitting smoking in the year after the ban was implemented, according to survey findings.
• Asthma-related hospital admissions of children fell by 12.3 percent in the first year after the ban, and in each of the following two years fell again by more than 3 percent. Another study on a smoking ban in Scotland yielded similar results.
• Hospital admissions for heart attacks dropped by 2.4 percent, or 1,200 patients, in the first year after the ban.

The study’s results aren’t surprising — secondhand smoke is a known trigger of asthma, and previous studies done outside of the U.K. have also linked smoking bans to a range of health benefits. One 2012 study, which examined the effects of smoking bans in a Minnesota county, found the bans contributed to a 33 percent drop in heart attacks and a 17 percent drop in the incidence of sudden cardiac death. Another, which examined reports on smoking bans in multiple countries and U.S. cities, found the bans were linked to a 15 percent decrease in hospitalizations caused by heart attacks and a 16 percent decrease in stroke-related hospitalizations. In addition, the second study found the more comprehensive the smoking ban, the greater the health benefits.

And in contrast to critics’ claims that they stifle business, smoking bans have been found to have economic benefits as well. A report from the Robert Woods Johnson Foundation last year found states that invested in anti-tobacco programs and legislation saved significantly on health care expenditures, and last month New York City Mayor Michael Bloomberg lauded the city’s 2003 Smoke-Free Air Act, which prohibited smoking in restaurants and bars, as part of the reason for the 47 percent increase in the number of bars and restaurants across the city in the last 10 years.

Earlier this week, the body charged with implementing Washington D.C.’s Obamacare exchange joined Vermont, Rhode Island, and Massachusetts in prohibiting participating insurers from charging tobacco users higher premiums than what they charge other Americans. Under Obamacare, insurance plans can make smokers pay up to 50 percent more on their premiums than non-smokers. That provision was included for two reasons: First, to help cover the high costs associated with smoking-related illnesses, and, second, to give smokers a financial incentive to quit. But while this approach might appear logical — and just plain fair — there is cause to be skeptical about how effective it will be in discouraging smoking and cutting down on the habit’s resulting health care costs.

Charging smokers more money for insurance isn’t a new concept in American health care. Employers have been doing it for years, as federal regulations before Obamacare’s passage allowed them to charge tobacco users up to 20 percent more on their contributions to employer-sponsored plans. But those fees are supposed to be just one part of the picture, as employers can only assess the tobacco surcharges “if they are tied to a broader wellness program.” Unfortunately, past evidence shows that some employers have used the surcharges as an excuse to shift costs onto their workers, while offering the weakest cessation programs possible.

In a particularly blatant example of cost-shifting, Wal-Mart — the largest employer in America — decided to charge smokers a full $2,000 more than other employees for their coverage. In an effort to discourage premium-gouging, Obamacare stipulates that smokers who are enrolled in a cessation program cannot be levied the full 50 percent surcharge — but the potential impossibility of enforcing that rule and a lack of clear guidance under the reform law regarding wellness and smoking-cessation programs has some public health advocates worried that the it could actually end up encouraging insurers to act in bad faith.

What makes that possibility even more unpalatable — and has, against all odds, united both the tobacco industry and cancer groups — is the disproportionate effect that it would have on low-income Americans. U.S. smoking rates have plummeted from a high of about 42 percent of all Americans in the 1960s to around 21 percent today — but the vast majority of that 21 percent is poor and people of color. So added costs on smoking have a disproportionate effect: In New York, for example, a $4.35 tax on cigarettes has led to low-income smokers spending up to a quarter of their income on tobacco products.

Proponents of the smokers’ surcharge — including the vast majority of non-smoking Americans — might respond that people who use tobacco have made a costly choice that is bad for their bodies and raises the entire country’s health care costs, so they should be held financially liable for their decisions. An increasing number of employers are buying into that argument on an even broader level, as companies like CVS and Whole Foods have instituted various penalties and rewards for employees who weigh more as health care costs rise and employers remain America’s biggest sponsors of health insurance.

But unlike obesity, which employers can visibly observe and easily measure, it’s more difficult to identify whether or not someone smokes. Smokers are supposed to self-report their behavior to their employers and insurers, so it’s easy to imagine that Americans would lie about tobacco use, knowing that they will have to pay an added premium if they don’t. That could lead to an inaccurate public perception of how many Americans smoke. In a similar example, just Thursday, a new report showed that widely-accepted obesity metrics in the U.S. may be substantially skewed by people lying about their weight.

Putting a cost on smoking could also have the unintended consequence of discouraging people who lie about their tobacco use from joining cessation programs, since doing so would reveal their dishonesty.

A truly accurate measure of how effective anti-smoking efforts would not take into account how many people are paying a fine for self-reported behavior, but the actual rate of spending on and consumption of smoking-related medical care. That data doesn’t exist yet, and won’t for the foreseeable future. But the historical evidence shows that using carrots — such as robust cessation programs — rather than sticks in these efforts yields a 3:1 return on investment, suggesting that Obamacare would do well to bolster its incentives for wellness programs.

President Obama unveiled his budget proposal on Tuesday morning, confirming early reports that his initiatives include an expansion of universal preschool programs by raising revenue from additional tobacco taxes. Obama’s preschool plan is winning praise from both anti-smoking advocates and early childhood education proponents, but it isn’t popular with everyone. Even before the specific details were made available on Tuesday, the proposed tax increase garnered criticism from the powerful companies that comprise Big Tobacco.

The current federal tax on cigarettes is about $1 a pack, and President Obama’s proposal would increase that by an additional 94 cents. That hike would raise $75 billion to help subsidize preschool for children whose families who earn up to 200 percent of the federal poverty line, in a national effort to encourage more four-year-olds to enroll in pre-K programs. The tax increase would also raise $1.6 billion for the Early Head Start program and $15 billion for other programs.

The Campaign for Tobacco Free Kids has praised the policy, noting that higher tobacco taxes are a proven method of reducing smoking rates as well as a reliable revenue source. The advocacy group also points out that the majority of Americans support increasing taxes on tobacco products. In a statement released last week in regards to Obama’s forthcoming budget, the Campaign described the proposed tax as “a health win that will reduce tobacco use and save lives, a financial win that will raise revenue to fund an important initiative and reduce tobacco-related health care costs, and a political win that is popular with voters.” Total annual public and private health care expenditures caused by smoking are estimated at $96 billion.

But Big Tobacco’s powerful lobbying arm disagrees. “We oppose another federal tax increase on tobacco products,” a spokesperson for the Altria Group, the biggest lobbying organization representing the tobacco industry, told the Huffington Post on Friday. “[I]t is important to remember that the largest federal tobacco tax increase in U.S. history was enacted less than four years ago. We think it is unfair to single out adult tobacco consumers with another federal tobacco tax increase to pay for a broad, new government spending program.”
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For the bulk of the 20th century, Big Tobacco reigned supreme in the advertising world. Through aggressive marketing on billboards, magazine covers, television, radio, and corporate and celebrity sponsorship, cigarette manufacturers successfully hooked half of all American males and a quarter of American females in the 1950s and ’60s on cigarettes — a corporate coup whose adverse health effects are being felt to this day.

But just because the tobacco lobby’s stranglehold on Washington has somewhat subsided over the last several decades doesn’t mean that its marketing strategies have been left to the dustbin of history. To the contrary, manufacturers of some of America’s most medically harmful commodities — including processed foods and indoor tanning beds — take their advertising campaigns straight from Big Tobacco’s playbook. Unfortunately for Americans, the combination of these successful marketing strategies and the products’ addictive qualities make it extraordinarily difficult for consumers to change their lifestyles — even when the commodity in question makes them sick. For instance, somewhere between 14 and 20 percent of smokers who develop lung cancer continue to smoke even after being diagnosed with the disease.

Here are three Big Tobacco marketing strategies that food makers and tanning salons mimic in an effort to achieve that level of brand loyalty:

1. Gaining users’ trust through the use of authority figures.

This is perhaps the tobacco industry’s most infamous marketing tactic from the mid-20th century. In numerous television advertisements from the era, cigarette ads prominently featured doctors and nurses winding down from a long day of work with a smoke. Camel even had an ad claiming that “more doctors smoke Camels than any other brand.” The appeal to authority inherent in this tactic is extremely successful, as consumers react by assuming that the product use is medically safe.

Doctors have long ditched the likes of Philip Morris — but food makers and tanning salons use this same appeal to authority in this day and age. According to a landmark 2010 study in the Journal of the American Academy of Dermatology, researchers compared tanning marketing techniques to those used by tobacco distributors in the 1950s and found striking similarities — specifically, the use of physicians and faulty medical research downplaying health risks in their ads. “The thinking behind these ads is that if physicians do something, then somehow it must be okay,” said study author Dr. David Jones. “However, these ads omit the results of a recent survey indicating that 100 percent of dermatologists and 84 percent of non-dermatologist physicians would discourage UV tanning for non-medical purposes, even in healthy patients.”

While the food industry is a bit more hard-pressed to find doctors willing to peddle products high in salt, sugar, and fat, they compensate through corporate sponsorship with athletes and sports organizations. For instance, McDonald’s alone is affiliated with the National Hockey League, the Olympics, the FIFA World Cup, and has had a line of athletes ranging from Kobe Bryant to Venus Williams as its spokespeople.

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The Centers for Disease Control (CDC) has just rolled out a new anti-smoking campaign highlighting the negative effects of tobacco-related illnesses. The agency wants to emphasize all of the ways that smoking can indirectly impact a wider circle of people, like smokers’ loved ones or people breathing in secondhand smoke in public places. CDC officials also hope to influence a demographic they are particularly concerned about reaching: the LGBT community.

Dr. Tim McAfee, the director of the CDC’s Office on Smoke and Health, told San Diego Gay & Lesbian News that curbing smoking rates among LGBT individuals is a major priority for the agency. Since the smoking rate is 70 percent higher in the LGBT community than it is for heterosexual Americans, McAfee pointed out that it represents a “big, big health burden” in the nation — and effectively addressing it is a matter of “health justice and equity”:

“We need to pull back the curtain on this issue,” McAfee said, stressing that HIV-positive people can expect a long lifetime if they take their medicine, exercise and avoid smoking. “Smoking itself is bad,” he added. “But when you mix in HIV, it’s … like adding kerosene to a fire.”

He blasted the tobacco industry for targeting LGBT people, particularly the youth, and contributing to the rise in smoking in the gay community.

“This is a health justice and equity issue,” McAfee said. “We at the CDC are committed to this cause.”

McAfee is referring to the fact that recent studies have suggested that smoking now poses a bigger threat to HIV-positive Americans than the virus itself does. More than 60 percent of deaths among HIV patients are associated with tobacco-related illnesses, compared with about 25 percent that are associated with complications from HIV.

Unfortunately, however, the smoking rates among the LGBT community are still disproportionately high. That’s partly because Big Tobacco has specifically worked to target LGBT individuals, who already tend to be particularly susceptible to smoking due to minority stress. And there hasn’t been enough work on the other side focusing on LGBT-specific smoking cessation programs. LGBT leaders often don’t cite smoking as a big public health concern for members of their community, despite the fact that tobacco contributes to at least 30,000 gay and lesbian deaths each year. Campaigns like the CDC’s may help start to change that public perception.

Last week, the U.S. Food and Drug Administration (FDA) and the Justice Department bowed to tobacco industry-led legal challenges against their graphic anti-smoking ad campaign depicting the visceral consequences of tobacco-fueled chronic illness. That was a major blow to the public health initiatives included in the Family Smoking Prevention and Tobacco Control Act of 2009 — landmark tobacco regulation legislation signed by President Obama at the beginning of his first term.

But the federal government is not giving up on its efforts to discourage smoking. This week, the Centers for Disease Control (CDC) released a series of new videos and graphics that highlight the negative effects of tobacco use on both smokers and their loved ones:

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During his tenure as New York City mayor, Michael Bloomberg (I) has had no qualms about cracking down on products that pose a public health risk, tackling everything from sugary sodas, to salt in snack foods, to illegal guns. Now, the three-term executive has his sights set on the tobacco industry, pushing legislation that would raise cigarette pack prices in the city to at least $10.50 and end tobacco companies’ ability to offer coupons or special discounts on their products.

The recently-announced initiative comes at the heels of another Bloomberg-endorsed plan to limit cigarette makers’ ability to publicly advertise their products in city store fronts. Combined, the two proposals would constitute something of a public health coup for Bloomberg, targeting smokers’ bad habit where it hurts the most: their wallets. And as the New York Times reports, the effort is targeted at teens and low-income Americans:

“This is kind of a landmark set of proposals here,” said Kurt Ribisl, a professor of public health at the University of North Carolina, Chapel Hill, whose research on tobacco control influenced Mr. Bloomberg’s proposal. “For someone like me, who’s spent 18 years studying point-of-sale issues, this is kind of big.”

Dr. Ribisl studies what happens at the retail counter, where a customer at a typical convenience store sees a colorful array of signs, packaging and “shelf talkers” — the small tags that flutter from shelves — promoting two-for-one, dollar-off and other types of deals. According to a Federal Trade Commission report issued last year, the tobacco industry spent $6.5 billion on discounts in 2010, and Dr. Ribisl said they are one of the major ways cigarette makers encourage price-conscious customers like teenagers and low-income smokers to buy.

New York’s price-regulation bill would, in effect, close off the remaining means of access to cheap cigarettes and little cigars, which make it easier for teenagers to experiment with smoking, and progress to smoking regularly, said Brett Loomis, a researcher at RTI International, a nonprofit institute that offers research and technical services to governments and businesses.

Poor Americans are more likely to smoke, but less likely to be able to afford the habit and its associated health care costs. In fact, one study showed that low-income New York City smokers spend as much as a quarter of their income purchasing cigarettes — Bloomberg’s initiatives have the potential to price them out of the deadly habit altogether. While encouraging poor people to stop smoking is undoubtedly good from a public health standpoint, doing so through a commodity-based financial regulation has the potential to further drain their disposable incomes.

And Bloomberg’s legislative push won’t address all aspects of the problem. As cigarette prices rise nationwide and smoking rates plummet in the aggregate, studies have shown that low-income Americans — particularly, low-income women — are still smoking at higher rates than average, and turning to less costly alternatives such as loose leaf tobacco to get their fix on the cheap. Raising cigarette prices even further could propagate even more of that kind of behavior.

In a victory for the tobacco industry, the U.S. Food and Drug Administration (FDA) and the Justice Department have decided to bow out of an ongoing legal battle with several of America’s biggest cigarette manufacturers over proposed regulations requiring all of their products to be conspicuously branded with graphic imagery and warnings about their adverse health consequences.

Mandating the labels — which include visceral depictions of tobacco’s carcinogenic effect on the lungs, throat, and mouth — was made possible under the auspices of the Family Smoking Prevention and Tobacco Control Act of 2009. That landmark legislation put tobacco regulation under the FDA’s purview for the first time in American history and instructed the body to develop new cigarette labels with color graphics, prompting the FDA to propose the nine graphic warnings that have drawn tobacco distributors’ ire.

But a federal appellate court affirmed a lower court’s decision to strike down the proposed rule in March, claiming that its “graphic-image requirements are not the type of purely factual and uncontroversial disclosures that are reviewable under this less stringent standard” of 1st Amendment protections against compelled commercial speech — an argument heartily endorsed by the tobacco lobby:

Some of the nation’s largest tobacco companies, including R.J. Reynolds Tobacco Co., sued to block the mandate to include warnings on cigarette packs as part of the 2009 Family Smoking Prevention and Tobacco Control Act that, for the first time, gave the federal government authority to regulate tobacco. The nine labels originally set to appear on store shelves last year would’ve represented the biggest change in cigarette packs in the U.S. in 25 years.

Tobacco companies increasingly rely on their packaging to build brand loyalty and grab consumers — one of the few advertising levers left to them after the government curbed their presence in magazines, billboards and TV. They had argued that the proposed warnings went beyond factual information into anti-smoking advocacy.

The government, however, argued the images were factual in conveying the dangers of tobacco, which is responsible for about 443,000 deaths in the U.S. a year.

The legal argument against the labeling requirements is certainly not implausible — in fact, that’s likely the reason that the federal government chose not to appeal to the Supreme Court. But it’s a standard of free speech that federal judges apply asymmetrically, as they don’t give doctors who provide abortions the same protections against government-compelled speech as they grant to the multibillion dollar tobacco industry.

Brand labeling has become Big Tobacco’s signature avenue for advertising to its consumer base, since federal law has prohibited television advertisements for tobacco since the 1970s, and additional restrictions were included in the more recent legislation signed by President Obama. Consequently, the FDA’s new labels could have been an effective method of giving consumers information about tobacco’s negative health effects — especially considering that studies have shown that pictures speak louder than words in anti-smoking campaigns.

While American smoking rates have plunged in the last several decades, low-income Americans — particularly women — who are particularly unable to afford the massive health care costs of smoking-related illness still use tobacco in high numbers. Until the FDA comes up with a labeling rule that can withstand judicial scrutiny, public health and anti-smoking advocates may have to rely on more parochial efforts, such as New York City Mayor Michael Bloomberg’s (I) new initiative to crack down on public cigarette displays.

On the heels of his failed effort to combat rising rates of obesity by banning the sale of large sugary drinks, New York Mayor Michael Bloomberg is tackling a new public health initiative: dissuading Americans, and especially youth, from purchasing tobacco products.

Bloomberg is pushing a proposal that would ban stores from displaying cigarettes, which would make New York the first city in the nation to attempt to curb smoking by keeping tobacco products out of sight. The initiative wouldn’t prevent stores from advertising cigarettes or displaying the prices of their products — but it could significantly change the atmosphere in the city’s small corner stores. As the New York Times puts it, “In many of these stores, cigarettes are like wallpaper, the backdrop that every customer sees when going to the register to pay.”

But, considering the fact that tobacco kills an estimated 7,000 New Yorkers each year, Bloomberg doesn’t want customers to be exposed to that backdrop any longer. “Young people are targets of marketing, and the availability of cigarettes and this legislation will help prevent another generation from the ill health and shorter life expectancy that comes with smoking,” the mayor explained at a press briefing to unveil his new proposal.

Bloomberg has been a big proponent of anti-smoking initiatives, including public awareness campaigns and increased cigarette taxes, during his time in office. Those efforts have paid off. Smoking rates in the city have plummeted from 21.5 percent in 2002 to 14.8 percent in 2011. Despite the model that New York City provides for the rest of the nation, however, other states haven’t followed suit — austerity policies have led states across the country to slash funding for their smoking cessation programs over the past decade, even when those programs have proved to be effective.