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Tobacco use, particularly smoking, remains the number one cause of preventable disease and death in the United States. This report of the Surgeon General on smoking and health is the first to offer a composite review of the various methods used to reduce and prevent tobacco use. The topic is a new one in this series of reports, although previous reports have looked at aspects of such strategies. | This report evaluates each of five major approaches to reducing tobacco use: educational, clinical, regulatory, economic, and comprehensive. Further, the report attempts to place the approaches in the larger context of tobacco control, providing a vision for the future of tobacco use prevention and control based on these available tools. The report is clear in its overriding conclusion: Although our knowledge about tobacco control remains imperfect, we know more than enough to act now. |
"If the recommendations in this report were fully implemented, the Healthy People 2010 objectives related to tobacco use could be met, including cutting in half the rates of tobacco use among young people and adults. It is clear that the major barrier to more rapid reductions in tobacco use is the effort of the tobacco industry to promote the use of tobacco products. Our lack of greater progress in tobacco control is more the result of failure to implement proven strategies than it is the lack of knowledge about what to do. As a result, each year, more than 1 million young people continue to become regular smokers and more than 400,000 adults die from tobacco-related diseases. Tobacco use will remain the leading cause of preventable illness and death in this Nation and a growing number of other countries until tobacco prevention and control efforts are commensurate with the harm caused by tobacco use."
–David Satcher, MD, PhD, Surgeon General
Major Conclusions of the Surgeon General’s Report | |
sEfforts
to
prevent
the
onset
or
continuance
of
tobacco
use
face
the
pervasive,
countervailing
influence
of
tobacco
promotion
by
the
tobacco
industry,
a
promotion
that
takes
place
despite
over-whelming
evidence
of
adverse
health
effects
from
tobacco
use.
s The available approaches to reducing tobacco use–educational, clinical, regulatory, economic, and comprehensive–differ substantially in their techniques and in the metric by which success can be measured. A hierarchy of effectiveness is difficult to construct. s Approaches with the largest span of impact (economic, regulatory, and comprehensive) are likely to have the greatest long-term, population impact. Those with a smaller span of impact (educational and clinical) are of greater importance in helping individuals resist or abandon the use of tobacco.
s
Each
of
the
modalities
reviewed
provides
evidence
of
effectiveness. |
Even
less
intense
measures,
such
as
physicians
advising
their
patients
to
quit
smoking,
can
produce
cessation
proportions
of
5
to
10
percent.
• Regulation of advertising and promotion, particularly that directed at young people, is very likely to reduce both prevalence and uptake of tobacco use.• Clean air regulations and restriction of minors’ access to tobacco products contribute to a changing social norm with regard to smoking and may influence prevalence directly. • An optimal level of excise taxation on tobacco products will reduce the prevalence of smoking, the consumption of tobacco, and the long-term health consequences of tobacco use. s The impact of these various efforts, as measured with a variety of techniques, is likely to be underestimated because of the synergistic effect of these modalities. The potential for combined effects underscores the need for comprehensive approaches. s State tobacco control programs, funded by excise taxes on tobacco products and settlements with the tobacco industry, have produced early, encouraging evidence of the efficacy of the comprehensive approach to reducing tobacco use. |
Reducing Tobacco Use, A Report of the Surgeon General, appears at a time of considerable upheaval in efforts to control and prevent tobacco use. Legal and legislative efforts to protect children from tobacco initiation and to reduce smoking among adults are in a state of flux, with some important gains and some sobering setbacks. Major changes in the public stance of the tobacco industry have evoked a reevaluation of strategies for controlling and preventing tobacco uptake. Enormous monetary settlements have provided the resources to fuel major new comprehensive anti-tobacco efforts, but the ultimate cost and benefit of these resources are still to be determined. Into this changing landscape, this report introduces an assessment of information about the value and efficacy of the major approaches that have been used to reduce tobacco use: educational, clinical, regulatory, economic, and comprehensive. Widespread dissemination of the approaches and methods shown to be effective, especially in combination, would substantially reduce the number of young people who will become addicted to tobacco, increase the success rate of young people and adults trying to quit using tobacco, decrease the level of exposure of nonsmokers to environmental tobacco smoke, | reduce
the
disparities
related
to
tobacco
use
and
its
health
effects
among
different
population
groups,
and
decrease
the
future
health
burden
of
tobacco-related
disease
and
death
in
this
country.
What We Know This Surgeon General’s report provides evidence that tobacco use in this nation can be reduced through existing types of interventions, in line with health objectives detailed in Healthy People 2010. Attaining these objectives will almost certainly require significant national commitment to using the various successful approaches described in the report. Educational Strategies More consistent implementation of effective educational strategies to prevent tobacco use will require continuing efforts to build strong, multi-year prevention units into school health education curricula and expanded efforts to make use of the influence of parents, the mass media, and other community resources. School-based programs can have a significant impact on smoking behavior among young people and are |
most
effective
when
part
of
a
comprehensive,
community-based
effort.
Implementing
effective
school-based
programs–along
with
community
and
media-based
activities–can
prevent
or
postpone
smoking
onset
in
20
to
40
percent
of
U.S.
adolescents.
Unfortunately,
less
than
5
percent
of
schools
nation-wide
have
implemented
the
major
components
of
CDC’s
recommended
guidelines
for
school-based
programs
to
prevent
tobacco
use.
Management of Nicotine Addiction The
vast
majority
of
smokers
in
the
United
States
want
to
quit,
but
only
a
little
more
than
2
percent
successfully
quit
each
year.
Tobacco
dependence
is
in
fact
best
viewed
as
a
chronic
disease
with
remission
and
relapse.
Even
though
both
minimal
and
intensive
interventions
increase
smoking
cessation,
most
people
who
quit
smoking
with
the
aid
of
such
interventions
will
eventually
relapse.
Moreover,
there
is
little
under-standing
of
how
such
treatments
produce
their
therapeutic
effects. Regulatory Efforts Tobacco products are far less regulated in the United States than they are in many other developed countries. This level of regulation applies to the manufactured tobacco products; to the advertising, promotion, and sales of these products; and to the protection of nonsmokers from the involuntary exposure to ETS from the use of these products. Effective regulatory approaches can minimize the onset of smoking, particularly among young people, and may change tobacco use as an accepted social norm. |
Advertising
and
Promotion
The report concludes that regulation of the sale and promotion of tobacco products is needed to protect young people from smoking initiation. Current regulation of advertising and promotion of tobacco products in this country is considerably less restrictive than in several other countries, notably Canada and New Zealand. In 1998, tobacco companies spent $6.7 billion to market their products–more than $18 million each day. Attempts to regulate tobacco marketing continue to take place in a markedly adversarial and litigious atmosphere. Product Regulation Warning
labels
on
cigarette
packages
in
the
United
States
are
weaker
and
less
conspicuous
than
those
of
other
countries,
notably
Canada
and
Australia.
Federal
law
preempts,
in
part,
states
and
localities
from
imposing
other
labeling
regulations
on
cigarettes
and
smokeless
tobacco. Clean Indoor Air Regulation Although population-based data show declining environmental tobacco smoke (ETS) exposure in the workplace over time, ETS exposure remains a common public health hazard that is entirely preventable. Most state and local laws for clean indoor air reduce but do not eliminate nonsmokers’ exposure to ETS; smoking bans are the most effective method for reducing ETS exposure. Beyond eliminating ETS exposure among nonsmokers, smoking bans have additional benefits, including reduced smoking intensity and potential cost savings to employers. Optimal protection of nonsmokers and smokers requires a smoke-free environment. Minors’ Access to Tobacco Despite the widespread support among the general public, policymakers, and the tobacco industry for restricting the access of minors to tobacco products, a high proportion of underage youth smokers across this country continue to be able to purchase their own |
tobacco.
Measures
that
have
had
some
success
in
reducing
minors’
access
include
restricting
distribution,
regulating
the
mechanisms
of
sale,
enforcing
minimum
age
laws,
and
providing
merchant
education
and
training.
Requiring
licensure
of
tobacco
retailers
provides
both
a
funding
source
for
enforcement
and
an
incentive
to
obey
the
law
when
revocation
of
the
license
is
a
provision
of
the
law.
Litigation approaches Private law initiative is a diffuse, uncentralized activity, and the sum of such efforts is unlikely to produce optimal results for a larger policy to reduce tobacco use. On the other hand, the actions of individuals are likely to be a valuable component in some larger context of strategies to make tobacco use less prevalent.Economic Interventions Research clearly shows that raising tobacco prices is good public health policy. Further, raising tobacco excise taxes is widely regarded as one of the most effective tobacco prevention and control strategies. Increasing the price of tobacco products will decrease the prevalence of tobacco use, particularly among adolescents and young adults. Nevertheless, the average price and excise tax levels on cigarettes in the United States is well below that of most industrialized nations.Furthermore, the taxes on smokeless tobacco products are well below those on cigarettes in the U.S. Making optimal use of economic strategies in a comprehensive program poses special problems because of the complexity of government and private controls over tobacco economics and the need for a concerted, multilevel, political approach. Healthy People 2010 calls for state and federal taxes to average $2.00 for both cigarettes and smokeless tobacco products by 2010. Comprehensive Programs The most important advance in comprehensive programs has been the emergence of statewide tobacco control efforts. Evidence shows that multi-faceted, state-based tobacco control programs are effective in reducing tobacco use. Components of a multifaceted approach include: (1) community interventions, which include diverse entities such as schools, health agencies, city and |
county
governments,
and
civic,
social,
and
recreation
organizations
(2)
countermarketing,
which
includes
using
media
advocacy,
paid
media,
prohealth
promotions,
and
other
media
strategies
to
change
social
norms
regarding
tobacco
use
(3)program
policy
and
regulation,
which
addresses
such
issues
as
minors’
access,
tobacco
pricing,
advertising
and
promotion,
clean
indoor
air,
product
regulation,
and
tobacco
use
cessation
and
(4)
surveillance
and
evaluation,
which
includes
monitoring
tobacco
industry
promotional
campaigns,
evaluating
the
economic
impact
of
ETS
laws
and
policies,
conducting
surveys
of
public
opinion
on
program
interventions,
and
other
activities
to
make
ongoing
refinements
that
lead
to
more
effective
prevention
strategies.
The
synergy
created
by
the
interaction
of
various
program
components
in
a
comprehensive
approach
is
believed
to
be
responsible
for
increased
success
in
reducing
tobacco
use.
Global Efforts The report addresses research on strategies to reduce tobacco use within our nation’s social, legal, and cultural environment. Nevertheless, findings from this report may have broad utility in the planning of tobacco control efforts around the world. Globally, smoking-related deaths will rise to 10 million per year by 2030, and 7 million of these deaths will occur in developing countries. For the first time, the United States will collaborate with international organizations like the World Health Organization and with individual countries to help create a global partnership to stem the pandemic of tobacco-related death and disease. This report can serve as a blueprint with which the national and global public health communities can begin building capacity to combat the devestating health and economic effects of tobacco use. Elimination of Health Disparities The elimination of health disparities related to tobacco use poses a great national challenge. Cultural, ethnic, religious, and social differences are clearly important in understanding patterns of tobacco use. Reaching the national goal of eliminating health disparities related to tobacco use will require more research to develop effective interventions for various population groups. |
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more
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Department of Health and Human Services |