Monthly Archives: June 2011

2011-06-30 SJ-R Our Opinion: “Smoking ban is not what ails casinos”

This editorial appeared today in the State Journal-Register, Springfield, IL. It is a strong endorsement of continuing the present comprehensive smoke-free state law and not exempting casinos. It notes how the methodology used in the recently released study, “Exempting casinos from the Smoke-free Illinois Act will not bring patrons back: they never left” contrasts with that used by smoking proponents, namely: “Gambling revenue dropped in Illinois when indoor smoking was banned, therefore smoking is the cause.”

I sneezed and simultaneously my stock portfolio went down, so it’s my fault for sneezing! Well, not quite.

But the very first reader’sa comment is already dismissing the study as akin to “climate ‘experts’ using computer models to decide what the weather/climate will be instead of actually using historical data. They had to adjust the data to get to their predetermined conclusion.”

Naysayers abound aplenty these days, obviating the need for the tobacco industry to leap to its own defense anymore.

Our Opinion: Smoking ban is not what ails casinos

The State Journal-Register, Springfield, IL
The Associated Press – Posted Jun 30, 2011 @ 12:05 AM

The end of the spring legislative session marked one more milestone of survival for the Smoke-free Illinois Act, which withstood yet another challenge from the state’s gambling industry and its unwavering desire to live in the smoky past.

As strong proponents of the act, we feel obligated to remain vigilant about attempts to weaken it. This is especially true when big-money interests like the gambling lobby use spurious data to back their efforts.

So in the interest of getting ahead of the inevitable next round of attacks on the state’s indoor smoking ban from the Illinois casino crowd, we call to your attention a study published online this month in the journal Tobacco Control.

Appearing under the self-explanatory title “Exempting casinos from the Smoke-free Illinois Act will not bring patrons back: they never left,” the study compares state unemployment and home construction data with casino admission figures in Illinois, Iowa, Indiana and Missouri.

It’s conclusion?

“When economic conditions were accounted for, casino admissions in Illinois did not decline significantly relative to neighbouring (sic) states, nor did admissions increase in neighbouring (sic) states,” the study says.

The study’s methodology is a far cry from the evidence we’ve heard from the pro-smoking side since the Illinois smoking ban went into effect in January 2008. That evidence generally goes something like this: Gambling revenue dropped in Illinois when indoor smoking was banned, therefore smoking is the cause. By contrast, this study takes into account different admission reporting procedures among the states, focuses strictly on border casinos and compares unemployment and housing construction data — two important economic indicators for gauging a recession — among the states.

“Illinois experienced a steeper recession than neighbouring (sic) states…,” the authors note.
We’re certain that this study will be greeted with eye-rolling by the pro-smoking side. It’s the work of researchers at Washington University in St. Louis and Roberts Wesleyan College in Rochester, N.Y., but it’s also funded in part by the St. Louis-based Missouri Group Against Smoking Pollution.

But the authors go to great lengths to define their data and justify their conclusion that the recession, which arrived a month ahead of the Illinois smoking ban in December 2007, is to blame for the state’s gambling downturn.

Being an academic study, it does not make a couple points we believe will be relevant as long as this debate survives.

First, that the Illinois casinos in the St. Louis metropolitan area are simply outclassed by the giant, new Lumiere Place complex in St. Louis.

Second, that when an Illinois casino builds something like Lumiere Place, as happened in December 2008 with Jumer’s Casino & Hotel in Rock Island, it will crush its across-the-river, smoke-friendly competition.

Third, and most important, that Illinois’ indoor smoking law is designed to protect the health of all employees and business patrons in the state. That includes nonsmoking casino employees and nonsmoking gamblers.

2011-06-28 P-D Guest commentary: “Smokers need not apply”

A rather provocative title.

As I believe I’ve noted before, it was John Britton, former Jefferson City lobbyist for the now-defunct Tobacco Institute who inserted language into the Missouri Clean Air Act, passed in 1992, that made it illegal to discriminate against smokers in hiring decisions. There were a few exemptions, employers like SSM Healthcare mentioned below being one.

Guest commentary: Smokers need not apply

By Tyler S. Gibb | Posted: Tuesday, June 28, 2011 12:00 am

It has been a difficult time recently for smokers. Reports that the FDA issued new, more graphic warning labels and images for tobacco packaging followed on the heels of a report that SSM Health Care, a large health care provider in the St. Louis area, will not consider job applications from smokers.

SSM’s hiring policy is not discriminatory. Federal and state anti-discriminatory laws are intended to protect individuals in narrowly defined groups. These groups are identifiable by one or more immutable characteristics, such as ethnicity or having a disability. The theory behind these anti-discrimination laws is simple: Our society should not tolerate prejudice based upon characteristics that are outside the volition of the individual — one did not choose to be disabled anymore than one chose to be Hispanic. Traditionally, these groups lacked sufficient political or social power to protect themselves, thus, protective laws were created. Stiff penalties exist to punish employers who hire or fire workers based upon these group characteristics.

Being a smoker is not a recognized group in need of protection for two key reasons.

First, regardless of a smoker’s addiction to nicotine, at some point, beginning to use tobacco, regardless of peer-pressure, social norms or enticing advertising, was a personal choice. Second, smokers are not a socially or politically disadvantaged group that laws need to protect. Smoking cuts across all segments of society and includes people from all walks of life and all demographics.

Missouri anti-discrimination laws support this position. Unlike other states in which policies against hiring smokers have been successfully challenged in courts, Missouri law permits SSM’s policy.

But is SSM’s policy ethical? Assuming that by ethical we mean supportive of individuals and society’s endeavor to seek out the human flourishing, or the “good life,” as described by Aristotle and his ilk, the policy is ethical. SSM has a duty as a provider of health care to provide quality health care and, as an organization, to embody the ideals (or virtues, according to Aristotle) they espouse. A policy against hiring individuals with blue hair has no rational bearing on SSM’s organizational mission or on promoting the good life, and would thus be unethical. Encouraging employees to develop healthful habits, and enforcing those habits, is a necessary and ethically justifiable position by SSM.

As a private organization, SSM has more latitude in policing the personal lives of its employees than a public employer, such as state government. This assumes that the activities the employer chooses to police have a direct and identifiable relationship to the mission of the organization and do not run afoul of other existing laws.

If we can agree that smoking is bad for individuals, we may also agree that it is bad for society. SSM defended its hiring policy by providing statistics showing it is more expensive to employ a smoker versus a non-smoker. By implementing this policy, SSM, like other leading health care providers such as Cleveland Clinic, are increasing the pressure on individuals who consume a higher percentage of finite health care resources.

Public health campaigns long have sought to end smoking. First they tried to inform, then educate, then scare and, most recent, shame people into not using tobacco. SSM, within its limited sphere as one employer in the Midwest, is taking this campaign one step further by placing real, tangible, economic consequences on personal choices that negatively impact society at large.

There is little public support for outlawing tobacco use, although recent legislation has severely restricted where smoking can occur and governments at all levels levy ever-increasing taxes on tobacco. Americans love their freedoms too much, and rightly so. I should be able to smoke an exquisite hand-rolled cigar if I so choose. However, SSM is taking a rational, justifiable step in deciding what type of workforce it will employ by filtering job applications on the basis of an individual’s exercise of their rights. Some fear this will lead down a slippery slope of intrusion by employers into the personal lives of employees, but SSM’s policy is narrowly tailored, directly relevant to its role as a health care provider and fiscally prudent.

Perhaps in addition to disturbing photos of the ills of tobacco use, the U.S. Food and Drug Administration should warn the public that smoking could make you unemployable. Perhaps then individual choices will begin to support our society’s fiscal and health goals.

Tyler S. Gibb studied health care law at St. Louis University, where he is a doctoral student in health care ethics.

2011-06-28 P-D: “Smoking ban didn’t hurt Illinois casinos, study says”

I conceived the idea of comparing smoke-free casinos in Illinois with nearby smoking-permitted casinos in Missouri in April, 2007, when it started to look like Illinois would pass a comprehensive statewide Smoke Free Air law which would include casinos. That possibility became closer to reality when the Smoke-Free Illinois Air Act was signed into law on July 23, 2007.

A group of researchers in the Center for Tobacco Policy Research, led by Douglas A. Luke, PhD, expressed interest and wrote grant proposals for a major study but the effort was stymied by a lack of funding.

Fortunately, MoGASP managed to obtain a small grant from a private foundation to pay for one researcher, Jenine K. Harris, PhD, to work on the project part-time. It has been a long and arduous undertaking for Dr. Harris. In reality, she devoted far more time to this project than was covered by MoGASP’s grant, and the other coauthors provided assistance without charge. All have PhDs except for me. They are Bobbi J. Carothers, Douglas Luke, Hiie Silmere, Timothy D. McBride, and Martin Pion, BSc., MoGASP president and author of this blog. Some background on the coauthors:

Jenine K. Harris has a PhD in Public Health Studies/Biostatistics. Her main job is teaching Biostatistics courses in the Public Health graduate program within the Brown School of Public Health, Washington University in St. Louis. She has an affiliation with the Center for Tobacco Policy Research, which is where she does most of her research, but her primary affiliation is the Brown School.

Bobbi J. Carothers works for the Center for Tobacco Policy Research full time as a data manager/analyst

Professor Douglas A. Luke is a leading researcher in the areas of health behavior, organizations, policy, and tobacco control. A top biostatistician and social science methodologist, Professor Luke has made significant contributions to the evaluation of public health programs, tobacco control and prevention policy, and the application of new methods to community health interventions.

Hiie Silmere has a PhD in Social Work and helped with much of the early data collection and writing of the introductory/background text

Tim McBride is an economist who works with the Brown School of Social Work and typically studies healthcare reform; he helped identify the economic variables, including the housing variable, for this study.

Garrett and Pakko are mentioned among the critical comments of this study on stltoday. Dr. Harris responded that Garrett and Pakko are professional economists, yet they did not include a measure of the housing market in their models; the housing market is a well-known driver of the Great Recession, as generally agreed upon by economists.

Dr. Harris also notes that, contrary to the comments on stltoday, she is NOT a social worker, nor a social work student.

Finally, Dr. Harris wanted to emphasize this important point:

“This report is NOT about revenue, and makes no claims about revenue: It is about admissions. We were driven by the arguments that casinos in Illinois would lose patrons to neighboring states. This is a point that David Nicklaus’s Post-Dispatch article may not have made clear.”

Personally, embarking on this effort it wasn’t evident at all that we would get this result since accepted wisdom has often suggested the reverse to be true, i.e. that making a casino smoke-free leads to a net loss in revenue. And I should emphasize that MoGASP was not, and never has been interested in funding research to reach a foregone conclusion.

Although there are plenty of pro-smoking comments on stltoday, I did notice some that were positive, like the following two:

frp706 said on: June 28, 2011, 2:53 pm
the only casino i go to is the casino queen and i live in west county.i will not go to any casino that has smoking, and if illinois changes it’s ban, i won’t go there either

BRIAN W said on: June 28, 2011, 2:42 pm
All I know is that the only casino in the St. Louis area that has gotten my money has been the Casino Queen, DUE to the smoking ban…I will not set foot in the smoke infested Lumiere or Rivercity casinoes….

Related stories:
         Illinois, other states consider smoking exemptions for casinos
         Bill to allow smoking in Illinois casinos passes House
         Illinois looks to squeeze more revenue from gambling

Smoking ban didn’t hurt Illinois casinos, study says

BY DAVID NICKLAUS • > 314-340-8213 | Posted: Tuesday, June 28, 2011 7:58 am | Comments (55 as of June 28, 2011, 7:00 pm)

Ever since Illinois implemented a smoking ban in January 2008, the state’s casinos have been lobbying for an exemption. As Kevin McDermott reported in March, the industry blames the ban for as much as $800 million in lost revenue.
         Now an academic study, funded in part by Missouri Group Against Smoking Pollution, says the ban didn’t cost them a cent. The article in the journal Tobacco Control carries a provocative title:
         Exempting casinos from the Smoke-free Illinois Act will not bring patrons back: They never left
         The study’s authors, led by Jenine K. Harris of Washington University’s George Warren Brown School of Social Work, analyze casino admissions in Illinois and four neighboring states* in 2007 and 2008, before and after the ban took effect. They control for economic conditions by including each state’s unemployment rate and building-permit activity in their equation.

*mogasp correction: Illinois casinos were compared with those in the following three, not four, neighboring states: Missouri, Iowa and Indiana.

         The economic part was important, the authors note, because a nationwide recession began in December 2007, almost simultaneously with the smoking ban. In the end, they end up blaming all of the casinos’ lost business on the recession:

Illinois experienced a steeper reession than neighbouring states ….

When economic conditions were accounted for, casino admissions in Illinois did not decline significantly relative to neighbouring states, nor did admissions increase in neighbouring states. Reductions reported in Illinois casinos are therefore not due to patrons leaving Illinois casinos for neighbouring states where they could smoke.

         The study contradicts a 2009 assessment by the Illinois Commission on Government Forecasting and Accountability, which concluded:

It appears that the indoor smoking ban and Illinois’ lack of gaming expansion in recent years (especially as compared to other states) is likely why other states have not struggled like Illinois.

         The commission didn’t take economic conditions into account.
         Given that Illinois is considering a major expansion of gambling to raise revenue, we probably haven’t heard the last word on this issue. The study may also be influential in Missouri, where St. Louis and St. Louis County currently have smoking bans that exempt casinos. And when St. Charles County Executive Steve Ehlmann recently blocked a smoking-ban referendum, he criticized a provision that would exempt Ameristar Casino from the proposed ban.

2011-06-26 P-D Letters: “Political reality”

The following letter I submitted appeared on the St. Louis Post-Dispatch Letters to the Editor page on Sunday, June 26. It followed a brief conversation I had with St. Charles County Executive, Steve Ehlmann, after I sent him a letter recently on the subject of comprehensive smoke-free air laws in the metro area, including St. Charles. That related to his recent veto of a St. Charles smoke-free ballot initiative. While I point out the rationale behind legislation with exemptions, which I agree should not occur with a health and welfare issue, his insistence on legislation with no exemptions should motivate him to try and work with other area legislators, like St. Louis County Chairman Steve Stenger, to pass such legislation.

Political reality

St. Charles County Executive Steve Ehlmann picked two examples of exemptions for comment in his veto of a proposal to put a smoke-free air bill on the 2012 ballot. He wrote: “If the purpose of the smoking ban is to protect the health of employees, there is no rational reason to exclude casino floor workers. If tobacco smoke is harmful, there is no reason to exempt cigar bars, while regulating bars that allow cigarette smoking.”
         That sounds reasonable, except for political reality.
         For example, in 2009, former St. Louis County Councilwoman Barbara Fraser introduced a comprehensive smoking ban but couldn’t garner the necessary council support without exempting casinos and small bars. Missouri Group Against Smoking Pollution and others strongly opposed the exemptions and urged County Executive Charlie Dooley to veto the measure. However, after it passed and went on the November 2009 ballot as Proposition N, we supported it after getting overwhelming positive feedback to do so from our members.
         Proposition N’s overwhelming success resulted in both St. Louis and St. Louis County going largely smoke-free on Jan. 2.
         Since then, St. Louis County Council Chairman Steve Stenger, who originally had insisted on the Harrah’s Casino and small bar exemptions, has gone on record as seeking legislation to remove the existing loopholes.
         If only private homes were exempted when not being used for child care, that would bring our metropolitan area up to the current standard for 100 percent smoke-free air laws. Paraphrasing Mr. Ehlmann, why should we do otherwise?

Martin Pion • St. Louis County
President, MoGASP

Read more:

2011-06-21 P-D Editorial “Smokers: ‘Move ’em out of here.'” and Letters

I missed this Post-Dispatch editorial, published on June 21, 2011, when it first appeared but two letters from readers alerted me to it today and I went back and retrieved it on-line. The editorial ends with this observation and plea:

Smokers are merely people who struggle with a dangerous and expensive addiction. Some of them, like some non-smokers, are obnoxious. But they deserve better than “Move ’em out of here! They disgust me.”

Here’s the full editorial. Maybe the point is that as long as smokers don’t pollute the air nonsmokers breathe they shouldn’t be treated as pariahs. What do you think?

Doctor-approved Camels cigarette ad

Editorial: Smokers: ‘Move ’em out of here.’

By the Editorial Board | Posted: Tuesday, June 21, 2011 12:00 am Comments (12 as of June 22, 2011, 10:42 pm)

The last cigarette smokers in America were located in a box canyon south of Donner Pass in the High Sierra by two federal tobacco agents in a helicopter who spotted the little smoke puffs just before noon.

So begins “End of the Trail,” a well-known short story by the humorist Garrison Keillor published in 1984 in The New Yorker. The story imagines that the last five smokers “had been on the run since the adoption of the 28th Amendment.”
         Some 27 years later, things aren’t quite that bad for the one in five American adults who still smokes. There has been no 28th Amendment making smoking unconstitutional. But the attitude of the chief tobacco agent in Mr. Keillor’s story is pretty common: “Move ’em out of here! They disgust me.”
         Consider some of the 370 comments posted (at last count) at to a story in the Friday Post-Dispatch by reporter Blythe Bernhard. Seven SSM Health Care hospitals in the area will start a tobbaco-free hiring policy next month.
         “If you smoke at all you stink of it,” wrote one reader. “You reek. Your eyes are yellow. You have fatty deposits around your eyes. You look old and leathery before your time. Your fingers are dry and cracked, yellow and unattractive. You can’t quit because you are addicted.”
         The other side is heard from: “Our rights are being taken away little by little. First this, then it’ll be if you eat fast food, or Twinkies or if you are single [and] you have sex outside of marriage.”
         Live and let live (or not, as the actuaries suggest) is not an attitude that the Internet encourages.
         A spokesman for SSM said the company took the action to “encourage our employees to take better care of themselves and set good examples for our patients.” A side benefit, he said, is that having “healthier employees does mean lower health care costs.”
         It should be noted that SSM has the absolute right under Missouri law to set rules for its employees’ off-hour drinking and smoking habits. Most companies don’t have that right, but the law makes an exception for religious and church groups and not-for-profit health care organizations. SSM could have applied the rule retroactively to current employees, but it chose not to.
         Still, we wish SSM would rethink the policy. Low-income workers — about a third of whom smoke — will be disproportionately affected. For them, life is hard enough and jobs are scarce enough. And will it really reflect poorly on the hospital if a food-service worker is spotted smoking off-hours?
         Studies show only about one in every 20 physicians in America smokes and only one in every 12 nurses. They know the risks better than most people. Also, they’re more employable than most people.
         As to the fast-food-and-Twinkie argument, that day may come. But right now federal law suggests that obesity is a disability that deserves protection, not a life-choice that can be proscribed.
         Is there a “right” to smoke? No, courts have said smoking is “not fundamental to the concept of ordered liberty.” Further, courts have ruled, smokers do not qualify as a protected class under the 14th Amendment.
         Smokers are merely people who struggle with a dangerous and expensive addiction. Some of them, like some non-smokers, are obnoxious. But they deserve better than “Move ’em out of here! They disgust me.”

Following are the two published letters prompted by the above editorial:

Letters Page: June 24, 2011

Cost of smoking
The editorial “Nicotine stain” (June 21) brought together two separate thoughts. First, Garrison Keillor had the right idea. If smoking is as bad as it is being viewed, maybe it should be illegal, It’s certainly heading that way. Second, how does anyone who is at the poverty level afford to buy cigarettes? The price is about $5 a pack. A two-pack-a-day habit would cost more than over $3,600 per year.

Phillip Wells • Dellwood

Stop enabling
The editorial “Nicotine stain” (June 21) really pushed the limit of responsibility. I do not quarrel with the statistic that “about one-third” of low-income workers smoke. However, for the paper to suggest that this group would be “disproportionately affected” neglects the responsibility to care for one’s self.
         I am shocked by the price of cigarettes. Maybe if poor people would accept responsibility and quit smoking, life would be less hard — by maybe as much a $40 a week — and they might improve their chances of getting a job. Sounds like a “win-win” situation to me.
         When are we going to stop enabling people and relieving them of taking personal responsibility for their lives?

Don Hammond • Lake Saint Louis

2011-06-23 P-D Letters: “Anti-smoking policies improve employee productivity, health”

The following is the original text of a letter submitted to the St. Louis Post-Dispatch recently and published today. Please click Anti-smoking policies improve employee productivity, health to view the edited on-line version published in the newspaper.

Ernie Wolf, recent photo from Facebook page

Date: Sat, 18 Jun 2011 21:13:56 -0500
From: Ernest Wolf
Subject: Smokers unwanted at work

The Post-Dispatch, in its June 17 article, makes it sound as if SSM hospitals are starting a new trend in our area.  Far from it. 
         This policy was pioneered by Sky-Top Sunroofs Ltd. in St. Louis over 30 years ago.  At first the P-D refused to accept help wanted ads for Sky-Top staff members with the admonition “non-smokers only should apply”.  It required the firm’s attorney to convince the paper that this selectivity is not a federal EEOC issue.  A search in the P-D Help Wanted columns of the early ’80s will confirm this fact. 
         This information was adequately publicized at the time, having been cited in local publications, during television interviews, and through discussions at employer association meetings. 
         Unfortunately, it seems few employers learned from Sky-Top’s experience.   This experience was even the basis of free employer consulting provided by the federally funded ASSIST (American Stop Smoking Intervention Study) program in the early ’90s. 
         Sky-Top’s experience included hard data which showed that in the unionized assembly operation with about 45 employees, the non-smokers were far more productive than the smokers.  With that data, plus the fact that the company-paid health and life insurance for employees was more expensive for smokers, our Teamster local agreed to hiring only non-smokers for the assembly operation after 1986 or 1987.  The savings could be used to provide more benefits as well as in-house smoking secession classes for smokers who desired to quit.  Sky-Top’s experience was well before the Centers for Disease Control and Prevention came out with the fact that each smoker costs a company an additional $3,400 annually in health care costs and lost productivity.
         It is never too late for employers to recognize that smoking policies can be mutually beneficial for both employees and employers.  Missouri has one of our country’s highest smoking rates.  A likely cause is that our State legislature has chosen not to pass an effective Clean Air act, allows the head tobacco lobbyist to smoke anywhere in the otherwise smoke-free State Capitol building, and persists in maintaining the lowest cigarette tax in the country at just 17 cents per pack while the overall States average is $1.45 per pack. 
         Effective employer policies could reverse that smoking rate and lead to a healthier state population.

Ernest Wolf
Founder, Sky-Top Sunroofs
St. Louis County

2011-06-22 P-D “New FDA cigarette-pack labels are graphic, gruesome”

Today’s St. Louis Post-Dispatch reproduced on the front page most of a story by New York Times reporter Duff Wilson. The Post-Dispatch headline in the print version was “Labels pull no punches on cigarettes” but on-line it was “New FDA cigarette-pack labels are graphic, gruesome.”

The NYT story headline was “U.S. Releases Graphic Images to Deter Smokers” and kicked off by showing 8 of them. The ninth shows a smoker exhaling through a stoma, a hole in his throat resulting from laryngeal cancer surgery. That, of course, demonstrates the powerfully addictive nature of nicotine: when you still can’t quit after surviving that kind of life-threatening operation.

It’s really hard to predict with certainty this latest effort to reduce smoking rates.

Previously, the most effective programs were those like the first one started in California and funded by a statewide proposition which paid for hard-hitting TV ads. One of the best, with a memorable punch line, shows cigarette executives in a darkened conference room with tobacco smoke wafting towards the ceiling discussing the need to recruit more smokers. An executive at the head of the table says:

“Gentlemen, gentlemen. The tobacco industry has a very serious multi-billion-dollar problem.
We need more cigarette smokers. Pure and simple.
Every day, 2,000 Americans stop smoking and another 1,178 also quit. Actually, technically, they die.
That means that this business needs 3,000 fresh, new volunteers every day.
So, forget all that cancer, heart disease, stroke stuff.
Gentlemen, we’re not in this for our health.”
(He laughs, and the others join in.)

For those who are smoke-sensitive, the fewer smokers the less likelihood of scofflaws polluting the air with tobacco smoke, and the more likely that politicians will do their job and implement comprehensive smoke-free air ordinances instead of worrying about offending smokers.

Incidentally, the St. Louis Post-Dispatch version of the story added some quotes from Bill Hannegan, obtained by health reporter Blythe Bernhard, which I’ve highlighted below.

Eight of the nine new graphic warnings on cigarette packs

By DUFF WILSON • New York Times | Posted: Wednesday, June 22, 2011 12:00 am

Ninth cigarette pack image

Federal health officials released on Tuesday their final selection of nine graphic warning labels to cover the top half of cigarette packages beginning next year, over the opposition of tobacco manufacturers.
         In the first major change to warning labels in more than a quarter-century, the graphic images will include photographs of horribly damaged teeth and lungs and a man exhaling smoke through a tracheotomy opening in his neck. The Department of Health and Human Services selected nine color images among 36 proposed to accompany larger text warnings.
         Health advocacy groups praised the government plan in the hope that images would shock and deter new smokers and motivate current smokers to quit.
         The images are to cover the upper half of the front and back of cigarette packages produced after September 2012, as well as 20 percent of the space in cigarette advertisements.
         “These labels are frank, honest and powerful depictions of the health risks of smoking, and they will help encourage smokers to quit, and prevent children from smoking,” Kathleen Sebelius, the secretary of health and human services, said Tuesday in a statement.
         Bill Hannegan, a St. Louis opponent of smoking bans, said he agreed with some limits on tobacco advertising. But he called the new package labels a “hostile and offensive” action by the government.
         “This campaign crosses a line of what can be done in a civil society, even for the sake of someone’s health,” Hannegan said. “And I don’t think it will work.”

         The four leading tobacco companies were all threatening legal action, saying the images would unfairly hurt their property and free speech rights by obscuring their brand names in retail displays, demonizing the companies and stigmatizing smokers.
         The government won one case last year in a federal court in Kentucky on its overall ability to require larger warning labels with images; the specific images released Tuesday are likely to stir further legal action. The Kentucky case is before the 6th U.S. Circuit Court of Appeals.
         The new labels were required under landmark antismoking legislation giving the Food and Drug Administration power to regulate, but not ban, tobacco products. The Family Smoking Prevention and Tobacco Control Act required FDA action on the graphic warning labels by today, the second anniversary of President Barack Obama’s signing it into law.
         The United States was the first nation to require a health warning on cigarette packages more than 25 years ago; but since then, at least 39 other nations, including Canada and many in Europe, have imposed more eye-catching warnings, including graphic photographs.
         “This is a critical moment for the United States to move forward in this area,” the FDA commissioner, Dr. Margaret Hamburg, said in an interview. “The trends in smoking really support the need for more action now. For four decades, there was a steady decline in smoking, but five to seven years ago, we leveled off at about the 20 percent level of adult and youth smoking in this country.”
         Dr. Lawrence Deyton, director of the Center for Tobacco Products at the FDA, said the government estimated — based on other countries’ experience — that the new warning labels would prompt an additional 213,000 Americans to quit smoking next year.
         The nine images chosen in the United States include some that are among the most graphic of the 36 draft images. But they also include some of the less vivid.
         The images, which are to appear on cigarette packs on a rotating basis, also include one of a man proudly wearing a T-shirt that says: “I QUIT.”
         All of the packs will also display a toll-free telephone number for smoking cessation services.
         The government surveyed 18,000 Americans of all ages to determine which of the 36 proposed labels would be most effective to deter smoking.

Blythe Bernhard of the Post-Dispatch contributed to this report.