TUSCALOOSA, Ala. -- Alan Blum compares it to wandering in the desert.
Forty years after the surgeon general condemned smoking, the health community is still searching for its promised land: The day when Americans stub out their cigarettes for good.
"The inability to curb cigarette use represents the worst public health failure in history," said Blum, who directs the University of Alabama's Center for the Study of Tobacco and Society.
Keeping in mind that the U.S. population has grown since 1964, Blum said the number of people who smoke has stayed virtually the same over the last four decades.
Even the recent decline in tobacco use among middle- and high-schoolers has not been enough to make up for years of dramatic increases among the age group, he said.
"There is no leadership," Blum said of such groups as the Coalition for Tobacco-Free Kids and the American Cancer Society, which he blames for creating mirages of progress in the war on tobacco.
"They're all fighting over what's passe. No one is stepping up and saying what's important. And in my opinion, clean indoor air legislation is what's important." All 50 states and the District of Columbia now have clean indoor air provisions restricting smoking in certain places. The laws range from simple, limited restrictions, such as designated areas in schools, to laws that limit or ban smoking in virtually all public places.
States like California and New York have gone the furthest, eliminating smoking in all enclosed public and private workplaces, including restaurants, bars and taverns.
"I definitely think in the next decade, it's something we'll all see," Amy Duckworth, Tuscaloosa health initiatives representative for the American Cancer Society, said of government bans on smoking.
"We've got to protect those babies who don't have a choice but still have to breathe that air." At the heart of the laws is limiting non-smokers' exposure to secondhand smoke, which the cancer society claims kills about 3,000 nonsmoking adults every year as a result of lung cancer.
Secondhand smoke also causes 150,000 to 300,000 lower respiratory tract infections, such as pneumonia and bronchitis, in U.S. infants, according to the society.
And it increases the number and severity of asthma attacks in about 200,000 to 1 million children, reports the U.S. Environmental Protection Agency.
Despite these statistics, secondhand smoke continues to be a controversial subject, with critics charging that the studies labeling it a health risk are inconclusive and focus on prolonged exposure, not the passing wisps encountered in public.
Fanning the flame was a study published in the May 2003 issue of British Medical Journal that claimed secondhand smoke may not be as harmful as previously thought.
Even some in the health community, like Tuscaloosa cancer specialist Dr. David Hinton, admit that the dangers of secondhand smoke may be driven more by politics than medicine.
"I don't think the government should interfere. People should have the right to do stupid things," said Hinton, an oncologist with DCH Cancer Treatment Center.
Smoke-free cities won't solve the cancer problem, Hinton said. The sole argument for banning smoking in restaurants and other businesses, he said, is to protect the health of the employees who are exposed to more smoke for longer periods of time.
Employee health, including lower insurance costs and reduced absenteeism, is one of the strongest arguments the Coalition for a Tobacco-Free Tuscaloosa County uses in trying to convince business owners to go smoke-free, said Faye Royal, tobacco prevention and control coordinator for West Alabama.
The coalition seeks to educate people on the dangers of secondhand smoke while lobbying for legislation that restricts tobacco use.
"We think if we can get stronger ordinances in place that will restrict smoking in restaurants, we can reduce the exposure to secondhand smoke," Royal said.
Bans on smoking, while aimed at protecting nonsmokers, also has a desired effect on those who choose to light up, Blum said.
"When their environment is changed where they can't smoke, they gradually don't need to," he said.
The Alabama Clean Indoor Air Act that took effect last September bans smoking in government buildings, hospitals, schools, most businesses, elevators, buses and taxicabs, except for designated areas.
The law, which gives discretion to owners of bars, restaurants and most workplaces, carries fines of $50 for proprietors of places where smoking is illegally allowed and $25 for the smokers themselves.
But because of confusion over the law's reach, many municipalities have passed their own smoke-free ordinances in the last year. Among those in Alabama is the city of Northport, which in November banned smoking in all city-owned facilities.
Dothan, Eufaula and Montgomery have gone further, outlawing smoking in any privately owned business with employees younger than age 18.
Prattville recently passed what is called a choice ordinance, eliminating smoking sections and forcing businesses to declare themselves either smoking or smoke-free.
And Auburn is scheduled in 2007 to become the first city in the state to go smoke-free, banning smoking in all public places except bars.
However, Selma is considering a similar ordinance that would go into effect before then.
Despite signs of progress, the American Lung Association gave Alabama an "F" in all areas in its 2003 State of Tobacco Control: smoke-free air, youth access, tobacco prevention and control spending, and cigarette taxes.
Alabama has one of the lowest tobacco taxes -- 42.5 cents per pack -- and only six states spend less on tobacco-control programs, said Diane Beeson, director of tobacco prevention and control at the Alabama Department of Public Health.
Alabama receives $110 million a year from its share of the 1998 Master Settlement Agreement that restricted tobacco manufacturers' marketing practices, particularly to youth.
Yet of that sum, the state spends only about $300,000 on tobacco-control programs, about one-tenth of what the Centers for Disease Control and Prevention says is necessary to have a viable program, Beeson said.
The bulk of the settlement money funds everything from road repairs to school security cameras to incentive packages luring new businesses to Alabama, she said.
Helping make up the difference is $1.3 million the state receives annually from the CDC, money that Beeson said the health department uses to advocate for stronger tobacco-control policies in schools and workplaces.
Meanwhile, smoking costs Alabama taxpayers $797.7 million each year in state and federal tax burden, an average of $459 per year per household, according to the Campaign for Tobacco-Free Kids.
Earlier this month, the Alabama Legislature passed a law mandating that state employees who smoke will pay higher insurance premiums. The law, only the second of its kind in the country, is aimed at reducing the cost of public employees' health insurance, which has risen $633 million since 1998.
Beeson said health officials are encouraged by a 26-cent per pack tobacco tax hike that took effect in July. Until then, Alabama had the fourth-lowest tobacco taxes in the country, behind South Carolina, North Carolina and Kentucky -- the last of which taxes 3 cents per pack. New Jersey has the highest tax, at $2.05 a pack.
With the new tax, Alabama becomes 36th.
Higher taxes are an important tool in reducing tobacco use, Beeson said, especially among youth who she said are particularly sensitive to price changes.
"We know that the higher we price tobacco products, the less kids will use it," she said. "So the fewer people buying tobacco, the fewer people dying later." (April Wortham writes for The Tuscaloosa (Ala.) News.) Editor Notes: NONE
c.2004 NYT Regional Newspapers