August 10, 2017

Tobacco Control

The long-term anti-smoking effort, started in the 1950s, eventually reduced smoking rates by more than 60 percent among US teens and adults.
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In 1964, 42 percent of American adults smoked, with per capita consumption averaging over four packs per week. While more than 450,000 Americans still die preventable deaths each year as a result of smoking-related illnesses, 50 years of tobacco control efforts have helped to reduce the smoking rate of both adults and teens by more than 60 percent from that peak, down to 15.1 percent of the population who smoke today, and in the process saved the lives of more than eight million Americans.

This case study is part of a series that accompanies The Bridgespan Group article "Audacious Philanthropy: Lessons from 15 World-Changing Initiatives" (Harvard Business Review, Sept/Oct 2017). See below for 15 stories of social movements that defied the odds and learn how philanthropy played a role in achieving their life-changing results.

Smoking took off in America after World War I, in part as a result of tobacco companies’ aggressive advertising and photos of GIs lighting up. As war veterans and others began dying of lung cancer, robust scientific research on the health risks of smoking mounted, starting with a 1939 paper by medical researchers Alton Ochsner and Michael DeBakey, which presented evidence that smoking caused cancer. In 1952, Reader’s Digest published a journalistic account of smoking’s dangers, “Cancer by the Carton,” and philanthropically supported nonprofits like the American Cancer Society (ACS) and American Heart Association (AHA) began advocating against the practice.

While tobacco companies spent millions fighting this research and promoting “healthier” cigarettes, the pressure of these advocates finally created a breakthrough moment. In 1964, US Surgeon General Luther Terry, a smoker himself, issued a damning report linking smoking to cancer, which finally started to cut through the false advertising. The percentage of Americans who believed that smoking caused cancer jumped from 44 percent to 78 percent between 1958 and 1968, and Congress mandated a “Surgeon General’s warning” on cigarettes. Adult smoking rates began to slowly decline as many tried to stop on their own.

The second wave of tobacco research in the 1970s, which shifted the public’s awareness to the risks of secondhand smoke, represented a breakthrough for tobacco control advocates. On the basis of this research, nonsmoker rights groups (funded largely by concerned citizens) grew quickly, coordinating with major public health players like the ACS and AHA to provide models and templates and advocate for state and local smoking bans and taxes. By 1992, more than 500 municipalities had passed local ordinances to protect nonsmokers. From 1994 to 2010, the Robert Wood Johnson Foundation (RWJF) granted the equivalent of $135 million in 2017 dollars to build formal statewide and national coalitions to coordinate anti-tobacco efforts. In 1995, RWJF collaborated with ACS, AHA, and others, including the Annie E. Casey Foundation and California Wellness Foundation, to fund the creation of the Campaign for Tobacco-Free Kids, which advanced the cause for the next generation and became a hub for the movement.

Even as RWJF and other grantmakers underwrote advocacy and public awareness, tobacco CEOs actively fought back. In 1994, the CEOs of the seven leading tobacco companies testified before Congress (and a rapt television audience) that they did not believe nicotine was addictive. This blatant falsehood infuriated the public. Internal documents released the next year from a major tobacco producer, called the “cigarette papers,” showed that the company’s claims were knowingly false and sparked further outrage. By 1997, 46 states had lawsuits pending against tobacco companies seeking reimbursement for tobacco-related Medicaid costs. In the Master Settlement Agreement (MSA) of 1998, tobacco companies agreed to pay those states $206 billion over 25 years, including funds to create an anti-tobacco charitable organization, the American Legacy Foundation (ALF). Furthermore, over this same period of time, scientists, doctors, and drug companies gradually developed a suite of products and supports to help individual smokers break their nicotine addiction via patches, gum, counseling, or other tools.

During the 1990s, as adult smoking rates continued to fall, teen smoking rates surged due to clever marketing and cigarette price cuts. Beginning in 2000, the newly formed ALF spent more than $2 billion to establish its Truth Initiative, an anti-smoking campaign targeted at teens. Truth’s marketing is credited as a major factor in teen smoking rates falling from 36.4 percent in 1997 to 15.7 percent in 2013. Today foundations like Bloomberg Philanthropies continue to fund the battle to drive for total smoking cessation, both domestically and abroad.

Philanthropy’s Role in Large Scale Change

Our research shows that breakthrough social initiatives share a set of five practical approaches to large-scale change. In the case of tobacco smoking cessation, philanthropy played a pivotal role across the following four:
  • Build a shared understanding of the problem: Hundreds of research studies funded by government institutions like the National Institutes of Health, and philanthropically supported nonprofits like the American Cancer Society, American Lung Association, and American Heart Association established the harmful effects of smoking. Surgeon General reports about smoking and secondhand smoke built on their research and strengthened advocacy.
  • Design for massive scale at the outset: Advocates have used a wide variety of approaches to gradually drive down smoking rates—warnings, taxes, regulations, litigation, targeted marketing, and more. In the 1990s, as the movement matured and new opportunities for local action slowed, RWJF gave the equivalent of $132 million in 2016 dollars to coordinate state-level and national campaigns, helping to advocate for proven solutions, such as statewide taxes and selling restrictions. To combat smoking and exposure to smoke across generations, RWJF spent the equivalent of $127 million, with additional support from the Annie E. Casey Foundation and California Wellness Foundation to fund the Campaign for Tobacco-Free Kids, which became the hub of the cessation movement.
  • Drive demand, don’t assume it: This decades-long movement has seen countless approaches to generating demand. Early on, organizations like Americans for Nonsmokers’ Rights went city by city, coaching local leaders and using the media to raise public awareness and pass regulations. Decades later, the Truth Initiative, funded by the newly formed American Legacy Foundation (ALF), implemented a sophisticated viral marketing campaign to reduce the teen smoking rate.
  • Embrace course correction: Throughout the anti-tobacco movement, surveys on tobacco usage have identified which populations are smoking and helped to validate smoking cessation approaches. In establishing the Truth Initiative, the ALF made an important adjustment to focus on stemming rising teen rates of smoking.

Researched and written by Consultant Phil Dearing of The Bridgespan Group.


Selected Sources

Americans for Nonsmokers’ Rights. “History & Goals.” “Tobacco Facts and Figures.”
Blum, Alan. “Blowing Smoke: The Lost Legacy of the 1964 Surgeon General’s Report on Smoking and Health.” Oncology 28 (2014): 418-422.
CNN. “A Brief History of Tobacco.”
Columbia Law Review. “Fairness, Freedom and Cigarette Advertising: A Defense of the Federal Communications Commission.” Columbia Law Review 67 (1967): 1470-1489.
Gruber, Jonathan, and Jonathan Zinman. “Youth Smoking in the U.S.: Evidence and Implications.” NBER Working Paper No. 7780, 2000.
Komaroff, Anthony. “Surgeon General’s 1964 Report: Making Smoking History.” Harvard Health Blog, January 10, 2014.
Moon, Youngme. “American Legacy: Beyond the Truth Campaign.” Harvard Business School Teaching Note 506-056, March 2006.
Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion. “Fast Facts.”
Ibid., The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Atlanta, GA: Centers for Disease Control and Prevention, 2006.
Ibid., “History of the Surgeon General’s Reports on Smoking and Health.”
Public Health Law Center. “Master Settlement Agreement.”
Robert Wood Johnson Foundation. “Tobacco Control.”
Ibid., “The Tobacco Campaigns of the Robert Wood Johnson Foundation and Collaborators, 1991–2010.”
Schroeder, Steven A., and Howard K. Koh. “Tobacco Control 50 Years After the 1964 Surgeon General’s Report.” JAMA 311 (2014): 141-143
Szabo, Liz. “U.S. Smoking Warning Made History, Saved Lives.” USA Today, January 7, 2014.
Wiener, Jon. “The Cigarette Papers.” The Nation, January 1, 1996.

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