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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.

MICHAEL ERIKSON