In the early 1990s, the Robert Wood Johnson Foundation (RWJF) funded tobacco control tactics to get kids to “just say no,” pregnant smokers to stop puffing and the sons of good ol’ boys to stop chewing. We asked ourselves, how could this not work? For 30 years, the American people had been hammered with evidence telling them that smoking kills. Certainly they knew enough to quit. Instead, they blew their smoke right back in the face of the best medical evidence.
Determined to bring about change, the Foundation invested nearly $700 million between 1991 and 2009 in seven groundbreaking programs: SmokeLess States®: National Tobacco Policy Initiative; the Campaign for Tobacco-Free Kids; Addressing Tobacco in Managed Care (now called Addressing Tobacco in Health Care); Smoke-Free Families: Innovations to Stop Smoking During and Beyond Pregnancy; Substance Abuse Policy Research; The Tobacco Etiology Research Network and Partners with Tobacco Use Research Center. Through the “magnificent seven” initiatives, RWJF focused its efforts on building policy and public health infrastructures designed to prevent smoking, helping those who smoked to quit, and transforming the national culture and social acceptability of smoking.
The Foundation, along with other leading tobacco-control advocates, supported an expansion of comprehensive, statewide tobacco-control programs that used mass media and community-based organizations to discourage smoking. It promoted increases in federal and state excise taxes, a powerful disincentive to smoking, especially among youth. It also helped bring about smoking prohibitions in youth-targeted advertising and marketing, enactment of smoking bans, access to proven smoking cessation treatments, insurance coverage of such treatments and authority for the Food and Drug Administration (FDA) to regulate tobacco products.
Results: Becoming a National Leader
The activities of RWJF and its partners, over a period of approximately 17 years, put tobacco on the public health agenda and saved millions of lives. Adult rates of cigarette smoking had been dropping steadily, from 42.4 percent in 1965 to 25.5 percent in 1990.
Between 1997 and 2009, with the work of RWJF and key collaborators in full swing, the setbacks of the early 1990s were halted. The adult smoking rate began dropping again, reaching a low of 19.7 percent in 2007. The rate among high school students dropped even more dramatically,to 20 percent, putting their rates on par with those of adults for the first time since these data were collected.
The impact of these changes was momentous, in terms of smoking-related mortality and illness. As a result of the excise taxes, price increases linked to the Master Settlement Agreement (MSA) of November 1998 (the MSA limited the promotion and marketing activities of the five largest tobacco companies in America), indoor smoking bans and other tobacco-control policies put into place between 1993 and mid-2009, at least 5.3 million fewer people were smoking in 2010 and more than 60,000 smoking-attributable deaths had been averted.
By 2063, some 70 years after the first data became available and since RWJF started its tobacco-control work, 12 million fewer people will smoke and 2.1 million smoking-attributable deaths will have been averted, assuming the new policies continue.
How far did RWJF and its partners move the bar? In 1990, virtually no one was covered by smoking bans. By July 2010, state and local government smoking bans covered people in 61 percent of workplaces, 73.8 percent of restaurants, 62.8 percent of bars.
A recently published Institute of Medicine report found a causal relationship between smoke-free laws and decreases in heart attacks. Social norms related to the general acceptance of tobacco are both indicators and causes of tobacco use. One positive shift in social norms, during the period of RWJF’s tobacco campaigns, is the percentage of adults who favor smoke-free restaurants, which increased from 45 percent in 1992 to 64 percent in 2006–2007. Similarly, approval rates increased for smoke-free bars (24 percent to 43 percent) and indoor sports arenas (67 percent to 79 percent).
Despite these significant gains, complacency about the future of tobacco use and addiction is unwarranted. Smoking prevalence flattened out again from 2004 through 2009 although it is now 5 percent lower than when RWJF entered the fray in 1991.
But it is safe to say these efforts dramatically changed how the American public views tobacco. Where Hollywood once used movie stars to let us know that “L&M filters are just what the doctor ordered,” smoking today is widely viewed as reckless, dangerous, out of the mainstream, even aberrant. We now know for certain that there is no risk-free exposure to secondhand smoke. Nor do smoke-free policies hurt the bar and restaurant businesses.
RWJF helped change the country and world for the better. Along the way, the Foundation wrote the book on how to practice philanthropy as a transformative force in society. The successful challenge to Big Tobacco resulted from four key strategies. The Foundation took real risks and challenged the powerful, formed successful partnerships, produced precise research and evidence that helped to change the game, and withstood controversy and confrontation over many years.