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Progress Review

Tobacco Use

U.S. Department of Health & Human Services—Public Health Service

May 14, 2003

Healthy People 2010 logo

Surgeon General and Acting Assistant Secretary for Health Richard Carmona chaired a focus area Progress Review on Tobacco Use, the ninth in a series of assessments of Healthy People 2010. Dr. Carmona noted that his predecessors as Surgeon General had been at the forefront of efforts to control smoking over the past several decades. In conducting the Progress Review, he was assisted by representatives of the Office on Smoking and Health of the Centers for Disease Control and Prevention (CDC), which has the agency lead for this focus area, as well as by spokespersons for the National Institutes of Health (NIH), the Agency for Healthcare Research and Quality (AHRQ), and the Environmental Protection Agency (EPA). For information about the focus area, see the chapter text at www.healthypeople.gov/ document/html/volume2/27tobacco.htm. The meeting agenda, summary data tables, and charts are available at www.cdc.gov/nchs/about/otheract/hpdata2010/fa27/tobacco.htm.

Data Trends

In reporting on the latest data for objectives in the Tobacco Use focus area and related areas, National Center for Health Statistics (NCHS) Director Edward Sondik noted that about 440,000 deaths per year in the United States can be attributed to smoking. Most of these deaths are due to cancer, cardiovascular disease, or respiratory disease. Annual per capita consumption of cigarettes peaked at over 4,000 in the early 1960s, then declined to about 2,000 cigarettes in 2000. After rising for more than 40 years, death rates from lung cancer in black and white men peaked around 1990 and declined during the succeeding decade. While lung cancer death rates for black and white women have remained well below the rates for men, they continued to rise between 1950 and 2000.

The prevalence of smoking among adults declined from 25 percent in 1990 to 23 percent in 2000. Preliminary data for 2002 indicate a further decline to 22.5 percent. Smoking during pregnancy declined from 12.2 percent of all births in 2000 to 12 percent in 2001. Smoking prevalence among high school students fell to 28 percent in 2001. A known human carcinogen, secondhand smoke is responsible for an estimated 3,000 lung cancer deaths annually in nonsmokers and an estimated 35,000 deaths annually from cardiovascular disease. In 2001, the tobacco industry spent about $9.6 billion marketing its products, according to the Federal Trade Commission (FTC). In contrast, total funding for tobacco control activities in that year was $883 million.

Key Challenges and Current Strategies

In the discussion that followed, U.S. Department of Health and Human Services (HHS) and EPA staff were joined by representatives of the FTC and the Bureau of Alcohol,Tobacco, Firearms and Explosives (ATF), who provided perspectives on tobacco use issues from the standpoint of their agencies' regulatory mission. Topics were addressed under four themes:

  • Cessation. In 1998, 20 percent of mothers aged 18-49 years who smoked quit smoking during their pregnancy. However, most women return to smoking after pregnancy: up to two-thirds are smoking again within 12 months of delivery.
  • The Public Health Service Guideline, Treating Tobacco Use and Dependence: A Clinical Practice Guideline, and the Community Preventive Services Task Force Guideline continue to provide the best evidence base for translating tobacco cessation research into effective interventions. The Guidelines also served as the framework for the development of the National Adult Cessation Blueprint, a model for public-private partnership in disseminating, implementing, and evaluating practical strategies for tobacco cessation.
  • In 2002, the HHS Centers for Medicare & Medicaid Services launched a pilot program in seven states to determine the best clinical service reimbursement strategies to support older Medicare beneficiaries who are trying to quit smoking.
  • Thirty-three states now have "quit lines," that is, telephone counseling to help tobacco users quit, and in some cases, these lines provide limited access to medication. NIH's National Cancer Institute (NCI) has a Web site at www.smokefree.gov that provides guidance to state and national resources for helping smokers quit.
  • Under a 5-year initiative called Prescription for Health, funded by The Robert Wood Johnson Foundation in collaboration with AHRQ, primary care practice-based research networks will develop practical strategies for promoting healthy behaviors among their patients, including tobacco use avoidance, that can be easily adopted by other primary care practices.
  • New Products. Scientific studies have shown little or no reduction in cancer risk from smoking low-tar cigarettes. Indeed, some smokers may increase their consumption on the mistaken assumption that these cigarettes are "safer."
  • The FTC is the law enforcement agency that determines whether claims of reduced risk in tobacco products are deceptive, that is, false, misleading, or not adequately supported by scientific evidence. In exercising this legal authority, the FTC relies on expert assistance from NCI and other HHS agencies in evaluating these claims. The FTC currently is awaiting HHS recommendations on test methods for measuring tar and nicotine yields.
  • Secondhand Smoke. Because their respiratory, immune, and nervous systems are immature and still developing, young children are at significant risk from secondhand smoke. Secondhand smoke inhalation is associated with asthma induction and exacerbation, sudden infant death syndrome, decreased lung function, chronic middle ear infections, and respiratory tract infections.
  • Research sponsored by AHRQ has shown that young children exposed to secondhand smoke have much higher rates of tooth decay than children who are not exposed.
  • Surveillance. The ATF reports that illegal trade in tobacco products is increasingly prevalent and is driven by growing differentials among state tobacco excise tax rates.
  • The World Bank estimates that billions of dollars in revenue worldwide are lost to the illicit tobacco market. For example, counterfeit cigarettes originating in China are now flooding the black market in Los Angeles.

Approaches for Consideration

The following suggestions were offered by discussion participants for steps that could be taken to bring about improvements in tobacco use control:

  • Cessation. Promote collaboration by public and private sector organizations, as outlined in the Interagency Committee on Smoking and Health Subcommittee on Cessation report and the National Adult Cessation Blueprint.
  • Customize antismoking messages to reach and influence occupational and ethnic groups that continue to show relatively high rates of cigarette use.
  • Aim for toll-free access to quit lines for all Americans.
  • New Products. In messages to the public about emerging tobacco products, stress that the only proven way to minimize tobacco-related health risk is to quit smoking or never start.
  • Expand the science base on new potential reduced-exposure tobacco products to include the addition of data on their physical and chemical characteristics, addictive potential, impact on tobacco use, and level of toxins and carcinogens delivered in actual usage.
  • Work in collaboration with the FTC to ensure that consumers receive truthful, scientifically substantiated information about new tobacco products.
  • Secondhand Smoke. Step up monitoring of and the provision of technical assistance to state and local governments and private companies in their efforts to protect people from exposure to secondhand smoke.
  • Establish and promote evidence-based best practices for reducing children's exposure to secondhand smoke.
  • Strengthen the interconnection between clean indoor air restrictions and cessation efforts; identify and create opportunities to link programs and messages.
  • Surveillance. To enhance current tobacco control surveillance systems, delineate a detailed natural history of smoking initiation, maintenance, cessation, and relapse.
  • Maintain rigorous standards for evaluation of the effectiveness of tobacco control activities and base resource allocation on an analysis of the results.
  • Other. Expand the science base from which evidence-based best practices in tobacco control interventions can be developed.
  • Cultivate an expanded range of partnerships with nongovernmental organizations that share an interest in controlling tobacco use.
  • Strive for a tobacco-free norm for all schools that could be extended seamlessly into the communities of which they are a part.
  • Work with the ATF to explore the possibility of adding an objective on smuggling of tobacco products in a future iteration of the Healthy People initiative.

Contacts for information about Healthy People 2010 focus area 27 – Tobacco Use:

  • Centers for Disease Control and Prevention-Victoria Wagman, vdw2@cdc.gov
  • Office of Disease Prevention and Health Promotion (coordinator of the Progress Reviews)-Emmeline Ochiai, eochiai@osophs.dhhs.gov (liaison to the focus area 27 workgroup)

Cristina V. Beato
Cristina V. Beato, M.D.
Acting Assistant Secretary for Health

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