Highlights: At A Glance
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
- Efforts 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.
- 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.
- 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.
- Each of the modalities reviewed provides evidence of effectiveness.
- Educational strategies, conducted in conjunction with community- and media-based activities, can postpone or prevent smoking onset in 20 to 40% of adolescents.
- Pharmacologic treatment of nicotine addiction, combined with behavioral support, will enable 20 to 25% of users to remain abstinent at one year post treatment. Even less intense measures, such as physicians advising their patients to quit smoking, can produce cessation proportions of 5 to 10%.
- 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.
- 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.
- 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.
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% of U.S. adolescents. Unfortunately, less than 5% 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% 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.
Advancements in treating tobacco use and nicotine addiction have been summarized in an evidence-based guideline,Treating Tobacco Use and Dependence: A Clinical Practice Guideline, published by the U.S. Public Health Service. Less intensive interventions, such as brief physician advice to quit smoking, could produce cessation rates of 5 to 10% per year. More intensive interventions, combining behavioral counseling and pharmacological treatment of nicotine addiction, can produce cessation rates of 20 to 25% per year.
Treating tobacco dependence is particularly important economically in that it can prevent a variety of costly chronic diseases, including heart disease, cancer, and chronic lung disease. It has been estimated that smoking cessation is more cost-effective than other commonly provided clinical preventive services, including screening for cervical, breast, and colon cancer, treatment of mild to moderate high blood pressure, and treatment of high cholesterol. Not surprisingly, Healthy People 2010 calls for universal insurance coverage of evidence-based treatment for nicotine dependency.
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.
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.
Smokers receive very little information regarding chemical constituents when they purchase a tobacco product. Without information about toxic constituents in tobacco smoke, the use of terms such as "light" and "ultra light" on packaging and in advertising may be misleading to smokers. Because cigarettes with low tar and nicotine contents are not substantially less hazardous than higher-yield brands, consumers may be misled by the implied promise of reduced toxicity underlying the marketing of such brands. As with all other consumer products, adult users of tobacco should be fully informed of the products’ ingredients and additives and any known toxicity when used as intended. Additionally, the manufactured tobacco product should be no more harmful than necessary given available technology.
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.
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.
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.
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:
- community interventions, which include diverse entities such as schools, health agencies, city and county governments, and civic, social, and recreation organizations
- countermarketing, which includes using media advocacy, paid media, prohealth promotions, and other media strategies to change social norms regarding tobacco use
- 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
- 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.
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.
Disclaimer: Data and findings provided on this page reflect the content of this particular Surgeon General's Report. More recent information may exist elsewhere on the Smoking & Tobacco Use Web site (for example, in fact sheets, frequently asked questions, or other materials that are reviewed on a regular basis and updated accordingly).
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