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Tobacco use in the United States has declined dramatically over the past 50 years, with the prevalence of cigarette smoking falling from about 42% of all adults to less than 20%by 2007. If this rate of decline continues, smoking could be eliminated in the United States by 2047. Framed in military parlance, we may be halfway through a 100-year war against the leading public health killer of our time. We describe factors that have contributed to progress over the last 50 years and identify policy and other initiatives that can contribute to the elimination of tobacco use in the United States.
Among the public health successes of the 20th century, the decline in tobacco use since the early 1960s has been historic. As shown in Figure 1, adult smoking in the United States has fallen from a rate of about 42% a half century ago, to less than 20% today. Framed in military parlance, we may be at the halfway point in a “100 Years War” against tobacco addiction. This framing raises the question of what can be done to shorten this war. In essence, how can we steal a march in the 21st century in the battle against tobacco use and the tobacco industry? In this paper, we review strategies that have worked thus far, and recommend additional steps to further reduce tobacco use and dependence.
Numerous observers have claimed over time that tobacco use has plateaued; that progress against tobacco use has stalled 1-3. However, the remarkable decline in tobacco use rates since the 1960s (Figure 1) belies this claim and underscores the remarkable success of tobacco control efforts to date. A review of smoking prevalence data from the CDC shows that adult smoking between 1965 and 2007 declined by an average of about one-half of one percentage point per year (from 42% to 20%, Figure 1), although the actual annual declines have varied over these four decades. Extrapolation of these data reveals that, if this rate of decline continues, smoking will be essentially eliminated in the United States by about 2047.
Importantly, the average rate of decline of one half of one percentage point/year observed over the last 42 years reflects an increase in the proportion of smokers removed from the smoker population over time. That is, one half of one percentage point reflects an annual decline in the smoker population of about 1.2% in 1965 (.5% of 42%) versus 2.5% in 2007 (.5% of 20%). Fine grained analyses of the declines suggest that the overall pattern of decreases was caused by the progressive enactment of new and stronger policies and interventions. Continued innovation of tobacco control efforts and continued attention to tobacco industry tactics (e.g., price discounting, increased marketing of smokeless tobacco products) will be needed to maintain this accelerating rate of decline into the future.
What strategies have been most effective in spurring declines in prevalence? There is no doubt that release of information about the health hazards of tobacco drove down use. The Report of the Surgeon General on the health effects of smoking released in 1964 presaged a burst of prevention and cessation activities 4. Additionally, the late 1960s demonstrated the power of public health countermarketing 5-7, and this was amplified by later public health campaigns 7-11. Moreover, evidence that second-hand smoke is a significant cause of mortality 12 and that tobacco is addictive 13 fostered both the acceptance of clean indoor air policies and the development of evidence-based clinical treatments 14-16. Finally, given the cost-sensitive nature of tobacco use, increasing the cost of cigarettes through tobacco excise taxes, reliably leads to drops in consumption and prevalence 17-20. Formal modeling analyses suggest that the reductions in prevalence observed over the last 40 years are due to such policy changes and interventions as tax increases, clean indoor air laws, advertising restrictions, product labeling laws, youth access laws, mass media campaigns, and increased availability of cessation programs 11, 20-29.
While these successful strategies of the past provide a blueprint for maintaining the current downward pressure on prevalence rates, we believe that additional innovation over the next decade is needed to further accelerate the rate of decline. The strategies that may prove most effective arise from research in a wide array of fields, including: public policy, health economics, public health, cessation interventions, prevention, and genetics research that link nicotine dependence severity with age of nicotine exposure.
The relation of age of nicotine exposure warrants special consideration because a large body of converging evidence shows that early nicotine exposure is associated with more severe nicotine dependence amongst adult smokers. Smokers reporting an early onset of smoking (e.g., daily smoking in adolescence) differ from other smokers in that they develop more severe nicotine dependence 30-32, smoke more cigarettes/day 31, 33, and are less likely to quit smoking 30, 34-39. This human research is complemented by animal research showing that adolescent vs. adult initial nicotine exposure produces greater effects on the brain, 40-43, has greater rewarding effects 41, 44-47, and produces higher levels of self-administration 48, 49. Importantly, recent data show that a major genetic risk for severe nicotine dependence, variations in the nicotinic receptor CHRNA5/A3/B4 gene cluster 32, 50, 51, will not be expressed unless an individual begins daily smoking prior to age 17 32. The implication is that policies and interventions that significantly reduce smoking and nicotine exposure amongst adolescents will eventually produce a generation of Americans with a reduced vulnerability to nicotine dependence. Reducing smoking by youth is an especially important goal since research shows that once an adolescent has progressed to regular, heavy smoking, he or she is unlikely to quit for 20 – 30 years or more 52, 53. As a result, every new adolescent smoker today increases smoking prevalence, on average, for several decades.
The considerations enumerated above led us to identify several policies and interventions especially worthy of implementation (Figure 2):
At present, most smokers do not enjoy the benefits of such treatment advances. Most smokers unwilling to make a quit attempt typically receive no intervention, and smokers willing to quit often do not receive the most efficacious interventions 96, 105, 106. This situation is avoidable since research shows that most smokers visit a healthcare setting each year 107, 108. All this underscores the need for enhanced treatment delivery mechanisms, including a greater use of chronic care models, telephone quitlines to deliver optimal smoking interventions to every smoker, and health insurance mandates for the coverage of evidence-based counseling and medication.
It is especially vital that effective treatments reach the populations that comprise disproportionate numbers of smokers: individuals with low educational attainment, certain ethnic minorities, and the mentally ill. For instance, mental illnesses such as depression, psychoses, or substance use disorders show prevalence rates that are 2 – 4 times higher than the population as a whole 109-115. Persons with mental illness and/or substance abuse disorders constitute 22% of the population in the US but consume 44% of all cigarettes sold 116, 117. These populations also bear a disproportionate health and economic burden from tobacco use. Cessation interventions are effective with these populations 96, but they too infrequently receive treatment 118. Therefore, it is important to fund high-reach intervention delivery systems such as an expanded National Tobacco Quitline network (1-800-QUIT NOW) that would provide enhanced treatment options including medication interventions to complement the quitline counseling. The reach of the quitline would be increased by the expanded media campaign that targets underserved populations 119-121.
Finally, there is a need for continued research aimed at the development of additional effective interventions: medications including the nicotine vaccine 122, 123, strategies to increase consumer demand for treatment 124, 125, treatments for those not willing to make a quit attempt at this time, and even more effective counseling interventions.
Progress made over the last fifty years now makes the elimination of tobacco dependence in the United States an achievable goal. Reaching that goal will require innovative policy and clinical approaches that result in an accelerated rate of decline in prevalence. These efforts must enhance previously effective strategies as well as implement novel ones. Given recent research underscoring the relation between early tobacco use and severe lifelong nicotine dependence, it is important that the efforts include ones that significantly reduce tobacco initiation by youth. Especially promising strategies in this ongoing public health battle include: an increased national excise tax on tobacco, aggressive national media campaigns, use of graphic warning labels of cigarette packaging, an expanded array of effective cessation therapeutics with greater access to such treatments, a systematic reduction in the nicotine content of commercially available cigarettes, comprehensive FDA regulation of tobacco products and the tobacco industry, and a national ban on indoor smoking. If implemented, the proposed strategies will dramatically reduce adult smoking prevalence while protecting adolescents from becoming dependent upon tobacco, thereby stealing a march in the 21st century war against tobacco use and the tobacco industry.
Supported by grant P50 DA019706 from the National Institute on Drug Abuse to the University of Wisconsin-Center for Tobacco Research and Intervention.