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sessments of the effectiveness of these efforts-which, collectively, for convenience we shall refer to as the antismoking campaign-have also varied widely. Analysts have employed a large number of different measures to assess the effectiveness of the campaign in altering smoking-and-health knowledge, attitudes, and behavior, and different measures have led to different interpretations and conclusions. For example, regarding smoking-and-health knowledge, a series of surveys (2-4) demonstrates that the public has learned the basic message that smoking is hazardous to health, and more specific understanding of smoking-and-health relationships has grown considerably over time. Nevertheless, recent evidence (5) suggests that the public's understanding is remarkably unsophisticated. For example, a significant minority is unaware that smoking causes cancer; and many people who agree that smoking is hazardous do not understand that a smoker reduces his or her life expectancy. In the area of behavioral change, selected measures indicate that both current and potential smokers have responded to adverse publicity on the disease consequences of smoking. Prior to the antismoking campaign, the majority of adult males were smokers; currently, well under 40% of that population smokes. An upward trend in smoking by women, which persisted through the 196os, was halted and reversed slightly in the past decade (6). And recent data on teenage smoking suggest that the seemingly

N late I985 and early I986, the American Medical Association, American Cancer Society, and American Heart Association added their voices to the call for a i: = 5 ban on the advertising and promotion of tobacco products, a call previously issued by many of the world's > s Za leadimg voluntary and professional health organizations. Widely publicized, the ban proposal has forced consideration of a number of issues, ranging from the constitutionality of prohibiting the advertising of a legal product to the behavioral consequences of advertising (i). Examination of the historical evidence pertaining to the latter has renewed interest in tobacco counteradvertising, a strategy that relies on the techniques and imagery of conventional product advertising to sell a health message. Counteradvertising is seen today in posters parodying cigarette ad themes, produced by such organizations as DOC (Doctors Ought to Care), and the major voluntary health agencies-the American Cancer Society, American Heart Association, and American Lung Association. Using the cigarette ads' underlying themes of attractiveness, physical fitness, success, and confidence, the counterads often portray models as happy and healthy because they avoid tobacco. To drive home the absurdity of cigarette ads' imagery, some of the counterads refer to such cigarette brands as DOC's "Emphysema Slims." But the problem with counteradvertising at present is simply that it is not very visible, because the resources to produce, distribute, andmost importantlypurchase magazine space or television time are miniscule, when measured against the $2 billion per year the tobacco industry devotes to promoting smoking (2). It has been estimated that total expenditures on tobacco

The World Conference on Smoking and Health meeting during July 1983 to discuss the scientific social and political aspects of smoking and its control around the world focused on 3 main themes: the problems of smoking and women smoking and children and smoking in developing countries. To examine the various aspects of these and other themes sessions were organized under 5 categories: the health consequences of smoking smoking cessation public information and public education the economic consequences of tobacco and legislation and political action. Overviews of the main themes and the 5 topic categories were presented in plenary sessions. The popularity of smoking has grown enormously among women worldwide. In the US the percentage of adult males who smoke exceeds that of adult females by fewer than 10 percentage points. 3 decades ago the gap was close to 30 percentage points. In the 1980s in the US lung cancer has overtaken breast cancer as the leading cancer cause of mortality in women. This results not from improvements in the treatment of breast cancers but rather from the epidemic of lung cancer in women. The average age of initiating smoking in the US is now about 16 years. There is general agreement that an individual is highly unlikely to start smoking after age 21. The concept of "immunizing" youngsters against smoking lies at the heart of this most primary of smoking disease. Several alternative approaches to preventing the onset of smoking by children were discussed at the Conference with greatest interest centering around the use of youths to influence their peers not to smoke. Smoking rates have leveled off or are falling in the developed world but they are increasing rapidly in developing countries. Cigarette companies have directed much of their marketing effort at this potentially substantial growth market and the profitability of tobacco farming in many developing countries is causing tobacco to compete successfully with staple food crops. Several Conference delegates reported that people in developing countries have little awareness of the health consequences of smoking. Other concerns discussed at the conference include passive smoking i.e. the nonsmokers inhalation of tobacco smoke in the air nonsmokers rights movement and civil disobedience. 20 recommendations were adopted by the Conference delegates. An additional 15 action oriented and somewhat bolder recommendations were also made and endorsed by the International Liaison Committee on Smoking and Health.

Many prevention-oriented community health services have relied on support from private sector organizations, particularly hospitals. As cost containment pressures and price competition increasingly push hospitals into the economic mainstream, the viability of hospital support of non-revenue-producing community health services is called into question. Poison control centers (PCCs) constitute an example of one such service that appears to produce social benefits well in excess of its social costs. Ignoring important indirect social benefits, and measuring only savings from avoided emergency room visits and hospitalizations, we estimate an annual net savings per center of $ 121,000, or a net benefit nationwide of $14.5 million through a system of regionalized PCCs. As the costs of the PCCs are borne predominantly by hospitals, however, without receipt of commensurate financial benefits, the private support base of PCCs is jeopardized. Using PCCs as an example of hospital-funded community health services, we examine the implications of the divergence between social and private net benefit for the future of these valued social health programs.

This paper considers whether there is a causal relationship between advertising and promotion and the consumption of cigarettes. If advertising and promotion increase cigarette consumption, then less than two million new or retained smokers–5.5 percent of smokers who start each year or try to quit (most failing)–alone would justify the annual promotional expenditure of $2 billion. A preponderance of quantitative studies of cigarette advertising suggest a causal relationship with consumption. Other studies show that children are influenced by cigarette advertising. Additionally, there are many individual examples of targeted marketing campaigns being followed by increased consumption within the target market. The evidence supports the hypothesis that cigarette advertising and promotion increase and sustain cigarette consumption. If brand share were the only function of advertising and promotion, as the cigarette manufacturers insist, the industry would lobby vigorously for an ad ban.

N the age of Reaganomics, the dream of all public health professionals is to identify public health measures that 9 I save both lives and dollars. With the emphasis placed on the latter in government circles, program effectiveness is not sufficient to justify policy development: even costQee Z effectiveness may not be sufficient, if it does not also translate into cost savings (1). One measure that delivers in both the health and economic dimensions is a cigarette excise tax. For adults, the price elasticity of demand for cigarettes-a measure of the responsiveness of cigarette demand to a change in price-has been estimated to be -0.42. This means that a lo percent increase in the price of cigarettes should produce a decrease in the quantity consumed of about 4.2 percent. Furthermore, a large majority of this response represents individuals' decisions not to smoke (i.e., to quit or not to start); the remainder is a decrease in the quantity of cigarettes consumed by continuing smokers (2). For teenagers, the price elasticity of demand is -1.4-a 10 percent price increase will produce a 14 percent consumption decrease-and the vast majority represents decisions not to smoke (the elasticity of demand for smoking participation is -1.2) (3). How do these numbers translate simultaneously into public health and government revenue benefits? To see this, we can work through the implications of the federal government's recent doubling of its cigarette excise tax, from 8 to 16 cents per pack (effective January 1, 1983). In 1982, the average price of a pack of cigarettes was 82 cents (4). In percentage terms, an 8-cent addition to the price translates into a 9.3 percent increase. Thus total adult cigarette consumption should have fallen almost 4 percent, including a decrease in the number of smokers of 2.3 percent and a decrease