The Impact of Policy,Environmental,and Educational Interventions

Surveillance, Research, and Evidence-Based Practice at Multiple Levels of Influence

The most commonly cited environmental determinants of success have been modifications to roadways and vehicles. Increased use of seat belts and child safety seats and decreased rates of drunk driving are the most frequently identified behavioral contributors to the sharp decline in motor vehicle fatality rates (Bonnie, Fulco, & Liverman, 1999; CDC, 1999b; Dellinger & Sleet, 2013; Nichols, 1994; Rivara & MacKenzie, 1999; Waller, 2001; Ye & Pickrell, 2008; Zwerling & Jones, 1999). Much of the success can be understood with William Haddon’s analysis of motor vehicle injuries as a function of the classic epidemiological triad of host (the driver and occupants), agent (the energy that abruptly transfers to vehicle occupants during a crash), and environment (the roadway design, traffic signs, traffic laws, etc.). His now famous “Haddon Matrix” combined this epidemiological framework with a time sequence from pre-event (factors present before the crash), to event (during the crash), and postevent (after the crash; Bonnie et al., 1999; Freire & Runyan, 2006). This framework describes both the determinants and time sequence influencing the likelihood and severity of injury, and specifying numerous intervention opportunities to prevent the crash, or the injury. This type of comprehensive analysis sets the stage for policy and environmental approaches to preventing MVCs, injuries, and fatalities.

Varied surveillance systems and research initiatives provided new knowledge about risk factors and effective interventions. For example, the National Vital Statistics System compiles death data, and the Fatality Analysis Reporting System provides detailed information on the incidence of fatal MVCs (Bonnie et al., 1999; National Highway Traffic Safety Administration [NHTSA], 2000). These have been invaluable in understanding where, when, why, and how crashes and their deaths occur, the prevalence of these risk factors, and pointing to ways to prevent them. For instance, Chen and colleagues (L.-H. Chen, Baker, Braver, & Li, 2000) analyzed Fatality Analysis Reporting System data to determine that teen drivers were at greater risk of dying in a crash when other teens occupied the car, an analysis that spurred several states to add passenger restrictions to the graduated driver-licensing policies. Surveillance, together with monitoring policy and enforcement practices across jurisdictions, provides a form of practice-based or evaluation evidence that has been influential in identifying and matching variations in events with variations in policies, disseminating effective policies and practices, and repealing or amending ineffective ones.

Evaluations of policy implementation and impact have identified effective interventions at multiple levels in specific jurisdictions for addressing motor vehicle injuries (Rivara & MacKenzie, 1999; U.S. Preventive Services Task Force, 1996; Zaza, Thompson, & Harris, 2001). Substantial reductions in rates of crashes, arrests, injuries, and deaths have been achieved, producing an emulation of the policies in other jurisdictions. The behavioral contributors to those reductions are most notable in occupant protection behaviors and alcohol-impaired driving. Evidence-based practices addressing these include in varied combinations: community information campaigns, education programs, incentives, child-seat safety laws, seat belt laws, enforcement programs, minimum legal drinking age laws, blood-alcohol-level laws, sobriety checkpoints, and others. Thanks to the data collection systems for surveillance and monitoring, it has been possible to trace the effects of education programs (delivered via clinicians, media, social marketing, etc.), policies, and enforcement efforts in various jurisdictions on health status and behavioral outcomes. These population changes in safety behaviors (e.g., use of seat belts, not drinking and driving) constitute changes in “social norms,” which are thought of as the habitual or statistically prevalent patterns of behavior that have become customary and perceived widely as normal or preferred behavior in specific populations (Gottlieb, Eriksen, Lovato, Weinstein, & Green, 1990; Green, 1970, 2001). Besides the visibility, acceptability, preferability, and increased public expectation of specific behaviors that constitute changed culture or social norms (Kroeber, 1957), the information campaigns have also built an informed electorate in support of the environmental and policy initiatives and their implementation or enforcement (Wallack, Dorfman, Jernigan, & Themba, 1993).

Individual-Level Intervention, Training, and Mass Media

Educating communities and individuals has been essential to generating support for policy interventions as well as promoting safer behaviors in both the presence and absence of legislated and police- or organizationally enforced behavior. For instance, the passage of car seat legislation was facilitated by community education delivered by pediatricians and others to convince parents to use child safety seats (Eriksen & Gielen, 1983). Now mandatory throughout the United States, the complexity of car seat installations has created an entirely new set of training needs for parents and others. Now a National Child Passenger Safety Certification Training Program (http://cert.safekids.org) prepares car seat technicians who provide personalized education to families, ensuring that child safety seats are used correctly to maximize protection.

Beverage service training programs illustrate the role for education in reducing alcohol’s contribution to MVC deaths. These programs give those who serve alcohol the knowledge and skills to serve it responsibly and to fulfill their legal requirements (e.g., checking driver’s licenses for patrons’ ages), thereby helping to reduce alcohol consumption and the harms associated with excessive consumption (Holder & Green, in press). Holder et al. (2000) found significant reductions in single-vehicle nighttime crashes and violence-related injuries when such measures were used as part of a comprehensive, environmentally oriented alcohol control program. Importantly, the Community Preventive Services Task Force concluded that beverage service training can be effective when it uses face-to-face training and is supported by management (www.thecommunityguide.org/alcohol/beverage_service.html). ¹ This assessment further illustrates the need for multilevel approaches that incorporate policy changes and enforcement of policies, to complement education and training. Sobriety checkpoint programs also have proved themselves most powerful in reducing drunk driving when combined with strong publicity that increases awareness of the checkpoints and engagement of significant others in discouraging driving under the influence. A systematic review of 10 evaluations of publicized sobriety checkpoints found a median reduction of 8.9% in alcohol-involved crash fatalities (Bergen et al., 2014).

Governmental Policies

The first federal agency specifically charged with coordinating a national highway safety program (the National Highway Safety Bureau) was established in 1966. But the federal government’s leadership was apparent as early as 1935 when President Franklin D. Roosevelt called for uniform state legislation, organization of agencies for administration and enforcement, and public safety education (Sleet, 2001). The Institute of Medicine (Bonnie et al., 1999) pointed out that as a result of the federal regulatory program, U.S. automakers developed a vehicle fleet that was substantially more “crashworthy” at the end of the century than 30 years earlier.

State and local policies emerge with considerable variation across jurisdictions, such as requirements for using safety equipment, driver licensing requirements, drunk driving standards, and speed limits. Such variation can contribute to disparities in protection across the population. For instance, despite the successes in reducing motor vehicle deaths in the United States as a whole, disparities persist, with population subgroups (e.g., American Indians and Alaska Natives) experiencing significantly higher crash and death rates (Pollack, Frattaroli, Young, Dana-Sacco, & Gielen, 2011).

The federal government can provide leadership in reducing some of the disparities in preventive policies through the use of incentives and disincentives. For example, the federal government has successfully incentivized states to pass certain laws (e.g., making it illegal to drive without wearing a seat belt or with a blood alcohol level of 0.08% or less) by threatening to reduce or withhold federal highway funding. Although this approach has worked in terms of passage of state laws, the success of such policies in reducing health outcome disparities depends in large part on the effectiveness of implementation of the policies.

Moreover, government policy solutions are often controversial, as in the case of driver’s education and motorcycle helmet–use laws. Driver’s education was found to be associated with increased rates of early licensure and crashes (Robertson & Zador, 1978), which led to a debate on whether driver’s education should be excluded from schools or not allowed to lead to earlier qualification for driver’s licenses (Green, 1980; Green & Lewis, 1986, pp. 245-248; Robertson, 1980). Subsequent innovations in some states gradually paced new drivers’ exposure to driving and their opportunity to learn the necessary skills in lower risk situations and with supervision. Evaluations consistently showed substantial crash reductions associated with Graduated Driver Licensing (GDL) programs (L.-H. Chen, Baker, & Li, 2006; Shope, Molnar, Elliott, & Waller, 2001). Today, all 50 states and DC have some form of a three-stage Graduated Driver Licensing system, and in some states, completing a driver’s education program meets the supervised-driving requirement (Insurance Institute for Highway Safety, 2012).

An example of an effective policy that continues to be challenged by public reactions is the passage by virtually all states’ legislatures of motorcyclist helmet laws in the late 1960s and early 1970s, which was supported by evidence that the use of helmets had resulted in substantial reductions in motorcyclists’ head injuries. Strong advocacy by motorcyclists (NHTSA, 2005) between 1976 and 1980 resulted in 28 state legislatures repealing or weakening their motorcycle helmet–use laws, with a consequent reversal in the reduced head injuries, costing states an additional $180 million (Hartunian, Smart, Willemain, & Zador, 1983). Today, 47 states have some type of motorcycle helmet–use laws, some voluntary, but the laws are continually under discussion and challenges, evidencing the need for constituency engagement, education, and advocacy.

Reframing and Social Marketing

The Haddon matrix had the early effect in the 1960s of reframing the “accident” perception of uncontrollable events by substituting the term injury or crash to describe the specific host, agent, and environmental causes that could be controlled or changed. By the 1980s, NHTSA and many states were conducting various large-scale public education programs that helped change public opinion and safety behavior among some individuals and, in turn, garner support for policy changes. This combination of interventional levels—education via social marketing with legislation—has succeeded dramatically. Today’s public is supportive of seat belt legislation and enforcement and recognizes the effectiveness of seat belts (Girasek & Gielen, 2003). Seat belt use rates increased from 11% in 1981 to 15% in 1984, using educational and mass media approaches to obtain voluntary seat belt use (Nichols, 1994). Use rates of 86% in 2012 are testament to the benefit of combining education with legislation and enforcement (Y. Y. Chen, 2014). NHTSA continues to keep media attention on motor vehicle safety through public education campaigns, such as “Buckle Up America” week and “Click It or Ticket.”

Public Advocacy and Changing Social Norms

Isaacs and Schroeder (2001) chronicled the adversarial and political roots of the “auto-safety crusade.” Ralph Nader’s (1965) public hero status they attributed to his landmark book Unsafe at Any Speed and his testimony at congressional hearings. Evolving motor vehicle product liability law and public outrage during the late 1960s also influenced automobile manufacturers to improve the crashworthiness of cars (Christoffel & Teret, 1993). Acrimonious debates among industry, government, scientists, and advocates dealt with issues such as whether active (manual seat belts) versus passive (air bags and other automatic restraints) protection should be available. Whether seat belt use should be voluntary or mandatory led Graham (1993) to conclude that such rancor slowed progress in reducing MVCs. Others have argued that the public debates and media advocacy were precisely what gave the injury control movement newsworthiness and, consequently, impetus, public interest, public understanding, and public support for policy initiatives and industry reforms (Finnegan & Viswanath, 2002) ² just as have the more recent media and political crossfire around Ebola outbreaks in the United States and Europe fueled public concern, policy initiatives, and environmental interventions. Ultimately the seatbelt controversy process and outcome transformed the social norms related to motor vehicle occupant safety. Gone were the days of children riding freely in the front seat of the car, of drivers and their passengers completely unrestrained, and of intoxication being an acceptable state for a driver. Such denormalization of previously accepted behavior and acceptance of an industry’s practices will appear again as a central element of the change in smoking behavior.

The high rate of child safety seat use—99% in the first year of life and 92% in children ages 1 to 3 (Pickrell, 2009) gives testimony to the fact that old norms have morphed to a new social norm concerning the safe transport of young children. A visible champion, a pediatrician in Tennessee, gave the initial stimulus to this public health success of increased use of child restraint devices. In 1978, Dr. Robert Sanders succeeded in getting the first law passed requiring the use of child safety seats (Graham, 1993). Spurred by his advocacy and the research evidence of infants being at significantly elevated risk of death as motor vehicle occupants (Baker, 1979), state and local government representatives from health, transportation, and law enforcement, along with community advocates (e.g., pediatricians, childbirth educators, women’s clubs), rallied to support not just legislation but also a variety of educational activities and low-cost car seat rental programs (Eriksen & Gielen, 1983). NHTSA facilitated the process by training potential local advocates in states throughout the country. Illustrating the efficacy of a multilevel approach that combines education and support at the individual level with legislation at the government level and support or advocacy at the community and regional levels, by 1985 all 50 states and DC had laws requiring the use of child safety seats (Nichols, 1994).

Playing an even larger role in the issue of drunk driving, denormalization and changed social norms again had champions and a strong grassroots movement. Doris Aiken started Remove Intoxicated Drivers in 1978 and Candy Lightner started MADD in 1980, after drunk driving crashes killed a daughter of each woman (Isaacs & Schroeder, 2001). Stories about victims of drunk drivers and their families were widely reported in all major media, and new chapters of the organizations sprang up all over the country. By elevating the visibility of the families of victims and influencing the public agenda, these groups brought pressure to bear on policy makers (Bonnie et al., 1999). Isaacs and Schroeder (2001) called the effect of this movement on public policy “stunning,” noting that between 1981 and 1985 state legislatures passed 478 laws to deter drunk driving. In 1984, Congress required states to pass a law increasing the minimum drinking age to 21 years or risk losing a portion of their federal highway funds. Most recently, Congress used the same approach to encourage states to lower their blood alcohol levels for drunk driving from 0.10 to 0.08. As Graham (1993) described it,

changes in social norms, in part spurred by such citizen activist groups as MADD, have apparently achieved what many traffic safety professionals believed was virtually impossible: a meaningful change in driver attitudes and behaviors resulting in a reduction of traffic fatalities. (p. 524)

The shift came when multifaceted efforts and advocacy to change public opinion reframed the individual-level behavior of drinking and driving from a matter of personal risk to one of imposing risks on others. This was accompanied by society providing support for the policy-level interventions that reduce risky individual behavior and that protect entire communities. This theme recurs with the history of secondhand smoke in the tobacco story, today with obesity, and will play out in the years ahead as each country or community faces a suspected Ebola contact.

Surveillance, Research, and Practice-Based Evidence at Multiple Levels of Influence

The emergence of the antitobacco movement as the 20th century approached the apex of tobacco consumption can be traced to the publication of three key research studies in 1950 that strongly linked tobacco smoking and lung cancer (Doll & Hill, 1950; Levin, 1950; Wynder & Graham, 1950). Though suspicion had long abounded that tobacco adversely affected health, this research and its combination with other evidence reviewed for the first Surgeon General’s Report on Smoking and Health (USDHEW, 1964) provided substantial and authoritatively reviewed scientific evidence that spurred the antitobacco movement and helped it gain traction in policy and environmental changes. Scientific research linking environmental tobacco smoke (“passive” or “secondhand” smoke) to cancer played a key role in the second antitobacco push during the last decades of the century, shifting the social norm from tolerance of smoking anywhere to social and then legal policy pressure not to smoke in public places. Although suspected for several decades, research on the negative health effects of tobacco smoke on nonsmokers led the U.S. Environmental Protection Agency (1992) to declare secondhand smoke a carcinogen. This, evidence-based justification for the shifting behavioral norm, in turn, produced the same policy and social–behavioral effect noted in the drunk-driving history above, denormalizing a behavior that had been seen as a personal risk factor to one seen increasingly as a social behavior affecting the health of others.

Education and Cessation Interventions as Drivers of Policy and Environmental Changes

A steep, though temporary, reduction in tobacco consumption followed a 1954 Reader’s Digest article summarizing the three scientific articles from 1950. Another more permanent one followed the first Surgeon General’s Report on Smoking and Health (USDHEW, 1964). Surgeon General Luther Terry led the committee of experts that examined the evidence for the 1964 report, which clearly implicated cigarette smoking as a cause of lung cancer and other health problems, and called for public health action. The evidence was compelling for some, although the tobacco industry rebounded repeatedly with marketing strategies that recruited new smokers and reassured continuing smokers by “debunking” the “junk science” of tobacco and health. They offered “filtered” cigarettes with their implicit promise of protection against carcinogens. With each new tobacco marketing strategy and design of the nicotine delivery device (e.g., filters, menthol), smoking prevention and cessation research stimulated public concern, then policy and program responses. These produced, in turn, evaluations of policies and programs that inspired other jurisdictions to try similar policies, programs and environmental reforms.

Programs contributing to the decreased rate of tobacco use and mitigation of tobacco-related health problems also included medical and health service interventions with screening to detect risk factors or early signs of tobacco-related disease, prescribing pharmaceutical agents to treat tobacco-related diseases (e.g., chemotherapies and bronchitis medications) or to assist in tobacco quitting attempts (e.g., Chantix, Zyban, and the nicotine patch), and counseling by physicians and health professionals. The efficacy of individually tailored programs of behavior change and pharmacotherapy to reduce nicotine dependence, however, was only marginal until the nicotine replacement therapies became available without prescription (a policy change), and telephone hotlines became more widely available (Shiffman, Mason, & Henningfield, 1998), an educational–environmental change.

One can see through such Western public health rearview mirrors how changes cumulatively depended on a growing public awareness, then concern, then collective activation in relation to environmental and policy deficiencies (Glantz & Balbach, 2000; Green, 1999). But one can see them today more clearly in real time as developing countries come to grips with their tobacco control problems. In India, for example, a northern regionwide adult sample survey where the smoking rate was still at 25% showed that

. . . 96% were aware . . . that smoking is harmful to health, 45% viewed second-hand smoke to be [as] harmful as active smoking, 84.2% knew that smoking is prohibited in public places and 88.3% wanted the government to take strict actions to control the menace of public smoking (Goel & Singh, 2014, p. 330)

Evidence accumulated that education and counseling increasingly empowered individuals, organizations, and communities to self-manage health-related behavior change outside the health care system (Daynard, 2003; Eriksen, 2005; Green, Mercer, Rosenthal, Dietz, & Husten, 2003; Green, Nathan, & Mercer, 2001; Mercer et al., 2003). The public had to come to an understanding through education that medical intervention alone would not save them from the harms of tobacco, that commercial terms such as “slim,” “low tar,” and “light” were not as healthful as industry advertising implied (Gallup Organization, Inc., 1993), and that they would need multiple attempts and multifaceted approaches to quit smoking in the face of other levels of influence at work—an environment of powerful and pervasive media and other commercial forces enticing them to consume products that were addictive and harmful to their health and that of their families.

Policies and Environmental Interventions

Numerous policy-level influences contributed to the progressive reduction in tobacco use. In particular, the tobacco control story highlights the role of restraints on broadcast advertising and of worksites, states, and localities as agents of and laboratories for effective policy change (Office on Smoking and Health, 2007) and as settings for local management of change. For example, reductions in nonsmokers’ exposure to secondhand smoke followed the widespread passage and implementation of statewide and corporate comprehensive tobacco control programs and policies in several states and local clean-air ordinances (Eriksen et al., 2007). California made significant efforts in tobacco control following the Master Settlement Agreement (MSA) in advance of other states, and the evidence demonstrated that the prevalence of smoking declined for most age groups and all race/ethnicity groups in California (TEROC, 2009, 2012). Although ultimately most of the MSA windfall was siphoned off to meet other state budget needs in many jurisdictions, there are examples of using dedicated MSA funds for effective comprehensive tobacco control initiatives (Lieberman, Diffley, et al., 2013; Lieberman, Golden, & Earp, 2013). Aggregate cigarette sales have declined significantly and independently in proportion to tobacco control program expenditures in states that followed California’s lead (Farrelly, Pechacek, & Chaloupka, 2003; Farrelly, Pechacek, Thomas, & Nelson, 2008; Tauras et al., 2005; TEROC, 2012). Heart attack and stroke death rates improved swiftly after smoke-free policies were enacted (Lightwood & Glantz, 1997); children’s hospital admissions for asthma, and premature births all declined significantly barely a year after smoking bans were enacted in the United States, Canada, and Europe (Been et al., 2014). After California’s smoking prevalence declined, it then rebounded when the state program support was cut back in line with reductions in cigarette tax revenues (Fichtenberg & Glantz, 2000). Declines in rates of chronic lung disease and bronchial cancer responded as well, although with greater lag times following the smoking rate declines. Lung cancer rate declines were four times greater in California than in the rest of the United States (California Department of Health Services, 2006).

A particularly powerful government policy and environmental change affecting smoking rates was increasing the cost of smoking via taxation of tobacco products (Dorfman, Wilbur, Lingas, Woodruff, & Wallack, 2005). Some states dedicated a portion of tobacco taxes to support comprehensive, statewide tobacco control programs. Evidence from systematic evaluations showed that each of the program components contributed synergistically to the overall effectiveness of the state programs, but none except the increased price of cigarettes could be shown by itself to reduce smoking rates (Green, 1997). The synergistic effects of combining interventions, and the selective effects of some interventions reaching and affecting some populations, some of the time, accounted for the growing recognition of the importance of multicomponent, multilevel, subpopulation-tailored, culturally textured interventions to surround the population with change opportunities (Huff, Kline, & Peterson, 2015).

Those policies restraining and countering the marketing of tobacco also proved essential. Laws were passed that increased the penalty for the sale of cigarettes to minors, removed cigarette vending machines from public places where minors could have access to them, and restricted advertising in media that reached youth (including bans on broadcast media advertising of tobacco). None of these policy-level interventions would have been as effective as they were without the support and advocacy of individuals, influential organizations, and ad hoc antitobacco groups (Glantz & Balbach, 2000).

E-cigarettes offer an illustration of the commercial counterforces normalizing a new tobacco product after tobacco control efforts have succeeded in denormalizing the former product. The nimble tobacco industry continues to morph itself and its products, now with the tobacco companies buying or spinning off smokeless tobacco subsidiaries and their acquisition of electronic cigarette brands, as shown in Table 1. These developments present new regulatory challenges to the Food and Drug Administration, and to state policy makers in their tax policies and whether public understanding and attitudes will force, encourage, discourage, or prevent them applying the same clean-air restrictions on e-cigarette vapors (Martínez-Sánchez et al., 2014).

OPEN IN VIEWER

Table 1.

Parent Company Ownership of Tobacco, Smokeless Tobacco, and Electronic Cigarette Companies.

Parent company	Altria	Reynolds American Inc	Lorillard	British American Tobacco
Tobacco company	Philip Morris	RJ Reynolds Sante Fe Natural Tobacco Co.	Lorillard	British American Tobacco
Smokeless tobacco subsidiary	USST	Conwood		Fiedler & Lundgren
E-cigarette subsidiary or acquisition (major brands)	Nu-Mark (Mark Ten, Green Smoke)	RJ Reynolds Vapor Company (Vuse)	(Blu, Skycig)	Nicoventures, CN Creative (Vype, Intellicig)

Public Support and Advocacy

As with motor vehicle injury control, tobacco control has depended on public support, if not demand, for most of the governmental initiatives, legislative acts, and regulatory controls on tobacco marketing and consumption. The clean air initiatives for smoke-free worksites, then schools, airlines, restaurants, public buildings, then even bars, and now some open spaces such as parks, beaches and outdoor areas near entry ways or air ducts, were progressively prompted by growing and shifting public concern and advocacy. These were directed initially at protecting children from secondhand smoke exposure and modeling of smoking behavior (e.g., by teachers at schools and role models in films). Public concern then shifted to include protecting adults and asserting clean air as a right, especially as evidence emerged that implicated secondhand smoke as a first-class carcinogen (U.S. Environmental Protection Agency, 1992). Key to the effectiveness of these advocacy efforts was a drumbeat of mass media messages that denormalized smoking and the tobacco industry’s glamorization of smoking. The same strategies of the industry in normalizing and glamorizing “vaping” e-cigarettes in public places can be expected to play out in the years to come with science and public resistance pushing back if the vapors are shown to be, and perceived to be, harmful to others in the environment. Thus will be the interplay of commercialization, science, public attitudes and concerns, and ultimately new policies directed at specific environments.

Mass Media and Social Marketing

In the years following the first Surgeon General’s Report on Smoking and Health, health warnings were required to go on cigarette packages. In 1969, the Federal Communications Commission applied their “Fairness Doctrine,” which required broadcast media to provide equal time for counteradvertising (public service advertisements). Antitobacco organizations suddenly gained a minute of no-cost broadcast time for every minute of tobacco advertising on radio or television. Their counteradvertising messages were so successful, and sufficiently threatening to tobacco industry interests, that the industry supported legislation passed in 1971 prohibiting tobacco advertising in the broadcast media because it also removed the antitobacco counteradvertising. They where then able to use the savings in their advertising budgets to diversify to more targeted and arguably more effective advertising in priority population-specific magazines and other print and billboard outlets reaching teens, young adults, and inner-city neighborhoods. Examining these new practices over the following decade, a Federal Trade Commission report found that the nonbroadcast cigarette advertising strategies associated smoking with “youthful vigor, good health, good looks and personal, social and professional acceptance and success” (Myers et al., 1981, pp. 2-13). These are the stuff of building a prosmoking social norm, which the antitobacco forces had to counter in subsequent years with the denormalization strategies.

Counteradvertising strategies by public health organizations became synergistic with other mass media efforts, especially news that contributed to the growing discomfort with secondhand smoke and to outrage at the marketing practices of the tobacco industry. As with the motor vehicle safety experience, this growing public concern and outrage fueled litigation and the threat of litigation against the industry and a sense among the public that they had been deceived by the industry. The states’ attorneys general sued the industry for the state medical costs incurred as a result of tobacco, and the master settlement agreement (MSA) funds from this landmark legal action fueled and subsidized the state comprehensive programs and local efforts for a time. A review by Golden, Ribisl, and Perreira (2014) of cigarette excise taxes for all U.S. states and the District of Columbia before and after the MSA showed that such taxes increased more than six times the rate of inflation between 1981 and 2011, and correlated with citizen attitudes toward tobacco. They concluded that future excise tax growth would depend in large part on such attitudes of the constituent populations of the state legislators.

An antitobacco policy push led by Mayor Michael Bloomberg and health commissioner Thomas Frieden in New York City provides an example of the effectiveness of media campaigns as part of a larger ecological approach in which increased access to cessation services were coordinated with the media. In January 2006, New York City launched public education messages in print and online, targeted ad campaigns and commercials showing testimonials by sick and dying smokers. Evaluation studies at the state level showed that these were effective in increasing calls to the telephone quit lines (Farrelly, Davis, & Nonnemaker, 2011). Calls to dedicated telephone assistance lines quadrupled in the first 6 months after the start of the media campaign (January-June 2006), compared with the same period the year before (January-June 2005).

Despite the successes of New York City in passing policies to control secondhand smoke exposures and overall smoking rates within smoke-free buildings, the serum cotinine levels of New Yorkers is higher than the national average, indicating that still wider environmental controls on smoking in public might be necessary in densely populated cities (Ellis et al., 2009).

Changing Social Norms

Changing the media environment of advertising cigarettes and using the media to engage smokers in quitting, when combined with policy changes such as smoke-free environments, have created a new landscape, one in which society’s norms about the acceptability of smoking and promoting tobacco clearly evolved from accommodation of smoking in public places to intolerance of smoking in those places. With these messages came the gradual shift in social norms: what the public perceived as acceptable public behavior, just as they had changed their perception of the unacceptability of young children riding in cars without restraint devices, or drinking while driving. The changing social norms, in turn, fueled public support for increased restrictions on tobacco advertising and higher taxes on tobacco, which in turn helped finance counteradvertising campaigns and tobacco education programs. This is a clear illustration of the synergy of the educational, environmental, and policy components of comprehensive programs.

Disparities in smoking have persisted, but progress in reducing them has gained some traction. The public health approach generally produced successful behavior change across boundaries of age, sex, race, and ethnicity (although the industry continues to target some advertising and product appeals to specific groups, as with menthol to the African American and youth populations). Conscious efforts were made in the statewide and community campaigns to use methods, messages, and channels appropriate to different socioeconomic, age, sex, and ethnic groups (TEROC, 2012, pp. 19-22). Major components of these efforts have been (a) the tilting of program budgets toward disproportionate funding in special populations, (b) engagement of leadership from these communities at state and local levels to assure relevance and culture appropriateness of the messages and methods, and (c) oversampling in these populations in the surveillance and evaluation of programs. The breadth of public support was particularly notable in the passage of the smokefree ordinances at local levels, where the tobacco industry could not keep pace with the multitude of simultaneous grassroots initiatives as effectively as it could with its lobbying in the U.S. Congress and in state legislatures.