Tobacco use is the leading preventable cause of death in developed countries, and by the year 2030 is projected to be so for the entire world. The situation is particularly tragic given that the harm caused by tobacco use has been known by the medical and public health communities, as well as by the tobacco industry, for nearly half a century, and that the means to reduce tobacco use are well known and relatively inexpensive and cost-effective.
THE HARM CAUSED BY TOBACCO USE
In the United States, cigarette smoking is responsible for over one in five deaths (over 400,000 deaths a year), with an annual loss of over 5 million years of life. Globally, about 3 to 4 million people die every year as a result of tobacco use, primarily in the developed world. The World Health Organization (WHO) projects that if current trends in tobacco use continue through to 2030, approximately 10 million people around the world will die each year, the majority in developing countries, which can ill afford the health costs of tobacco related illness and the associated loss of productivity.
It is estimated that one out of two lifelong smokers will have their lives shortened as a result of their addiction to tobacco products. On average, a death caused by smoking robs about twelve years of life from the smoker, compared to the life expectancy of a person who has never smoked. While there is a substantial lag time from the beginning of tobacco use to the usual manifestation of symptoms, the death and disease caused by smoking is not limited to the older age groups. Cigarette smoking is a major killer of those in middle age (ages forty-five to sixty-four) and it is estimated that 80 percent of coronary heart disease deaths in this age group are caused by cigarette smoking.
Tobacco use causes a panoply of diseases, affecting nearly all vital organ systems. Diseases of the pulmonary and cardiovascular systems predominate, with heart, cancer, and respiratory diseases being most common. In the United States each year, smoking causes 155,000 cancer deaths, 122,000 cardiovascular deaths, and 72,000 chronic lung disease deaths, along with 81,000 deaths from other causes. Among all diseases, smokers are now most likely to die of lung cancer (123,000 deaths a year). This is true for both men and women, with lung cancer recently surpassing breast cancer as the leading cause of cancer death among U.S. women. The magnitude of the lung cancer burden is particularly tragic given that, in the beginning of the twentieth century, lung cancer was a relatively rare disease, and that nearly 90 percent of lung cancer today has been caused by cigarette smoking.
In addition to cigarette smoking, other forms of tobacco use also cause disease. Pipe and cigar smoking increases the risk of lip, oral, and lung cancer, and smokeless (spit) tobacco causes oral cancer, as well as other oral lesions. Other tobacco products, popular throughout the world, are also harmful and can cause death and disease. Most notably, kreteks, popular in Indonesia, and bidis, popular in India, have been shown to cause cancer, heart, and lung diseases. The use of these novel tobacco products is beginning to spread from their original location, and, unfortunately, are becoming popular among children, particularly in the United States.
Not only does smoking cause disease in the smoker, but nonsmokers also are adversely effected by exposure to secondhand smoke. In 1986, a report by the U.S. Surgeon General concluded that exposure to secondhand smoke causes disease, including cancer, in otherwise healthy adults. In 1992, the U.S. Environmental Protection Agency documented the effects of secondhand smoke on respiratory outcomes, especially among children, and concluded that secondhand smoke was a potent carcinogen.
THE MAGNITUDE OF THE USE OF TOBACCO PRODUCTS
In the United States, tobacco products have been used for hundreds of years. Early consumption of tobacco products was predominantly ceremonial use by Native Americans, followed by more widespread use of tobacco for pipes, hand-rolled cigarettes, cigars, and chewing. Cigarette smoking as we know it today—as a highly addicting and habituated behavior—is a function of the twentieth century. The introduction of blended tobacco that allowed for inhalation, the invention of the safety match, the ability to mass produce cigarettes, coupled with sophisticated distribution systems and unprecedented marketing efforts led to the rapid adoption of cigarette smoking during the first half of the twentieth century, peaking in the mid-1960s. Annual per capita cigarette consumption increased from 54 cigarettes in 1900 to a high of 4,345 cigarettes in 1963. The release of a landmark report by the Surgeon General in 1964, which detailed the health effects of smoking, has led to a series of social and behavioral changes associated with a nearly 50 percent decline in annual per capita consumption, to a level of 2,136 cigarettes in 1999.
In addition to the reduction in per capita cigarette consumption, the United States has also experienced a reduction in adult smoking prevalence, decreasing from about 43 percent in 1965 to 24 percent in 1998, meaning there are tens of millions of fewer smokers than if earlier rates of smoking had continued. The reduction in the proportion of the adult population who smoke has not been as great as the reduction in per capita consumption, indicating that those who continue to smoke are also smoking fewer cigarettes.
While the U.S. reduction in adult smoking rates has been substantial when compared to the level of smoking in 1964, there has been relatively little progress in the 1990s, when adult smoking rates appeared to have plateaued at about 25 percent. In addition, the progress that has been achieved since 1964 has not been experienced equally by all U.S. population groups. Smoking rates appear to vary by race and ethnicity, level of education, age, poverty status, and region of the country. Contrary to other parts of the world, there is a relatively small difference in smoking rates based on gender. In 1998, there was a nearly threefold difference in the likelihood of smoking based on race and ethnicity, with the highest smoking rates occurring among American-Indian and Alaska Native populations (40.0%), and the lowest occurring among Asian and Pacific Islander groups (13.7%). A similar differential is seen in relation to level of education, with high school drop outs at least three times more likely to smoke than college graduates (36.8% vs. 11.3%, respectively), and the difference between the two groups appear to be increasing. Additionally, state of residence seems very important, with the lowest smoking rates in Utah (13.9%) and the highest in Nevada (31.5%). Lastly, smoking rates vary by age and poverty level, but not as greatly as for race and ethnicity, educational level, or state of residence. For example, those sixty-five years of age and older, and those whose income is at or above the poverty level, are less likely to smoke than those under sixty-five years of age and those living in poverty.
The 1994 Surgeon Generals Report Preventing Tobacco Use among Young People focused intense interest on smoking among young people. This report emphasized the fact that smoking onset, and nicotine addiction, almost always begin in the teen years, and it provided an early warning of an increase in the use of tobacco products among young people. In fact, after more than a decade of relatively stable youth smoking rates in the 1980s, cigarette smoking began increasing among high school students in the early 1990s, peaking in 1997.
One of the most interesting observations about youth-smoking rates is the difference in likelihood of smoking between black and white youth. In the late 1970s, there was virtually no difference between smoking rates based on race. However, over the subsequent two decades, white youth continued relatively high smoking rates, while smoking rates among black youth plummeted. Unfortunately, this difference between black and white youth in high school is beginning to erode, and there is no difference in cigarette smoking rates between black and white middle school students.
While cigarette smoking rates among young people may have peaked, there is a disturbing increase in the use of alternative or novel tobacco products, notably in cigars, bidis, and kreteks. Because of the harm caused by all tobacco products, it is important to monitor total tobacco consumption. When this is done, tobacco use rates typically are in the 30 to 40 percent range for all demographic subgroups, and actually exceeds 50 percent for white, high school boys.
Broadly speaking, other developed countries are experiencing changes in smoking rates similar to that observed in the United States. These changes can be characterized by gradual declines in adult smoking, contrasted with increases in the early and mid-1990s among young people. The situation in the developing world, however, is quite different and somewhat difficult to characterize due to less systematic attention to monitoring patterns of tobacco use over time in a manner that allows for inter-country comparisons. However, it can be said that global tobacco consumption is increasing, with over one billion smokers, but with large differences in tobacco use by gender, type of product consumed, and intensity of tobacco use. For example, in many countries in the Far East, the majority of men smoke, but relatively few women do. In India, relatively few women smoke, but smokeless tobacco use is common. In many countries, smoking intensity (the number of cigarettes smoked per day) is much lower than in developed countries. However, all of these parameters are likely to change as the multinational tobacco companies increase marketing and promotion efforts in developing countries.
In an effort to systemize and standardize the collection of tobacco data, the World Health Organization (WHO), in collaboration with the Centers for Disease Control and Prevention (CDC), have developed the Global Youth Tobacco Survey (GYTS), which is an effort to collect in-depth data on tobacco use patterns and attitudes from adolescents throughout the world. By the end of 2001, over seventy countries are expected to have collected standardized data on tobacco use among young people as part of the GYTS project. Clearly, more is needed to standardize the global collection of tobacco data, not just tobacco-use rates, but country-specific data on the effect of tobacco use on public health, the presence of tobacco-control legislation, and the cost of cigarettes. Accordingly, the American Cancer Society, in collaboration with WHO and CDC, has recently published Tobacco Control Country Profiles, which is a summary of the existing tobacco-related data for each country of the world.
EFFORTS TO REDUCE TOBACCO USE
The reduction of cigarette smoking in the United States during the final third of the twentieth century has been counted as one of the ten greatest public health achievements of the century. Unfortunately, the achievement is only half completed, and the progress that has been achieved in reducing tobacco use has come too late for millions of smokers. The CDC estimates that since the time of the first Surgeon General's Report, in 1964, 10 million Americans have died as a result of smoking. Additional analysis suggests that, if current trends continue, another 25 million Americans alive today, including 5 million children, will be killed by cigarette smoking, Thus, while progress in the United States and other developed countries has been significant, the past and future public health burden caused by tobacco continues to be unacceptable.
To accelerate efforts to reduce tobacco use, the United States has proposed specific objectives for the year 2010, including the bold objective of reducing tobacco use by one-half, to no more than 12 percent for all population groups. While this is an extremely ambitious objective in the face of demographic trends, it is felt that it can be achieved if the nation, states, and communities simply implement what is known to work in preventing and reducing tobacco use.
To assist in this effort, the U.S. Department of Health and Human Services (USDHHS) has prepared a series of publications reviewing the evidence on the effectiveness of tobacco control interventions. In 1999, the CDC published Best Practices for Comprehensive Tobacco Control Programs to assist states in the development, implementation and evaluation of comprehensive tobacco-control programs. Best Practices provides the research and scientific evidence in support of nine programmatic elements that have been shown to be effective in reducing tobacco use. In 2000, Reducing Tobacco Use: A Report of the Surgeon General was released. This publication took a broader view of tobacco control, reviewing the evidence for programmatic work and assessing the effectiveness of economic and regulatory strategies to reduce tobacco use. Most recently, the Task Force on Community Preventive Services established rules of evidence to rigorously review the published literature on a variety of tobacco-control strategies, including efforts to reduce exposure to environmental tobacco smoke, increasing tobacco-use cessation, and preventing initiation. Additional reviews will be forthcoming on pricing, minors' access to tobacco products, and media campaigns.
While these several documents were developed for slightly different purposes, together they provide a complete picture of the evidence for tobacco control, and the Surgeon General has concluded that if the evidence-based interventions that already exist were applied, the Healthy People 2010 objective of reducing tobacco use in half could be achieved. If smoking rates are reduced in half, millions of lives will be saved, and the expenditure of billions of dollars on treating diseases caused by smoking can be averted. Preliminary evidence from California is already demonstrating that sustained implementation of effective tobacco-control interventions not only reduces smoking rates, but can save lives and dollars.
There are many important components in successfully reducing tobacco use. Most practitioners and scholars recommend comprehensive approaches, where the different program elements work in concert to reinforce a specific tobacco-control message. These program components should strive to reduce both the demand and the supply of tobacco products, although a recent review of the evidence strongly recommends that "demand" reduction strategies are more effective than those attempting to influence the "supply" of tobacco products. The most influential supply-side intervention is control of smuggling.
Many interventions have been found to influence reduction in tobacco use (e.g., increasing the price of tobacco products, treating nicotine addiction, restricting indoor smoking), while others have been shown to increase the use of tobacco products (e.g., tobacco advertising campaigns targeted to young people, decreases in the price of tobacco products), other actions have little evidence, simply because they have yet to be tried or adequately evaluated (e.g., product regulation, plain packaging, limits on tar and nicotine levels).
Of the strategies not yet tested, regulation of tobacco products may be one of the most important to consider. Tobacco products are currently subject to minimal regulation, and they are expressly exempted from regulation by a number of federal laws designed to protect consumers, such as the Consumer Product Safety Act.
Many people consider the Food and Drug Administration (FDA) the logical U.S. agency to regulate tobacco products. However, up until recently, the FDA had not considered such regulations. This perspective changed dramatically in February 1994, when FDA commissioner David Kessler announced his intent to investigate the role of nicotine in tobacco products and whether the regulations of these products should come under FDA authority. Following a thorough investigation, the FDA did determine that nicotine was a drug that causes addiction, and that cigarettes were medical devices, intended to deliver nicotine in a manner to affect the structure and function of the body—the critical threshold for FDA to assert jurisdiction. During the last half of the 1990s, the FDA went forward with its rule-making authority, asserted jurisdiction over tobacco products, with an initial focus on the sale and marketing of tobacco products to young people. The tobacco industry, along with advertising groups, challenged the FDA's authority to regulate tobacco, with the case going all the way to the Supreme Court. In March 2000, the Supreme Court ruled five to four against the FDA asserting its jurisdiction over tobacco, citing the fact that Congress had not provided such authority.
Part of meaningful product regulation includes restrictions on the promotion and marketing of tobacco products. The evidence is clear that money spent by the tobacco industry to market and promote tobacco products contributes to continued usage by improving the appeal, access, and affordability of tobacco products. In 1999, the U.S. cigarette companies reported spending $8.24 billion on marketing and promoting cigarettes, the most ever spent—and a 22 percent increase from expenditures in the preceding year. This amounts to an annual marketing expenditure of approximately $165 per smoker, or over forty cents for every pack sold. The magnitude of this expenditure is presumably in response to the rapid decline in per capita consumption, which decreased 10.3 percent between 1998 and 1999, following a 4.2 percent decline between 1997 and 1998.
Implementing comprehensive tobacco-control programs that fully integrate all available approaches to tobacco control, including educational, clinical, and regulatory approaches, will result in significant gains in longevity and quality if life.
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