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 ():
Policies to Accelerate Progress in the War Against Tobacco
- Price, the single most effective policy currently available, has been underutilized as a driver of decreased tobacco use. From 1965 to 2007, the proportion of the price of an average pack of cigarettes that went to taxes (federal and state) has declined from 51.4% to 32.3%, despite significant tax increases by some states 54. In 2003 the Subcommittee on Cessation of the Interagency Committee on Smoking and Health proposed a comprehensive tobacco cessation policy program for the United States that included a $2.00/pack increase in the cigarette excise tax (with tax parity for non-cigarette tobacco products to discourage product switching). The Subcommittee estimated that the program would result in 4.7 million new quitters and a 10% reduction in adult smoking prevalence. Moreover, such a price increase would generate an estimated $28 billion in new revenue, part of which could be earmarked to fund other aspects of an aggressive campaign to eliminate tobacco use in America (including countermarketing, prevention, cessation, and research components). Importantly, research shows that youth are particularly sensitive to price increases; such increases have been shown to both promote cessation and prevent initiation of tobacco use among adolescents 17, 55.
- An ongoing extensive national paid media campaign has the potential to further denormalize tobacco use, highlight the dangers of second-hand smoke, discourage youth from initiating tobacco use, and drive tobacco users to use evidence-based treatments 56-58. While such a well funded, national paid media effort has not been undertaken, state campaigns and other efforts have documented their effectiveness. For example, California's comprehensive tobacco control effort initiated in 1988 resulted in a 39% decline in adult prevalence over the last 20 years, with prevalence falling from 22.8% in 1988 to 14% in 2007 59, 60. In contrast, the national rate of tobacco use declined only 30% over that time, from 28.1% in 1988 to 19.8% in 2007 61, 62. As part of this national campaign, it would be important to include media strategies that have been found to affect youth attitudes towards both smoking and the tobacco companies and that appear to reduce youth smoking rates 10, 11, 63, 64.
- Graphic warnings have led to significant decreases in tobacco consumption in countries all over the world 65-67. Such graphic warnings (e.g., on cigarette packs) have been recommended by the WHO Framework Convention on Tobacco Control 68, 69. If implemented in the United States such warnings would provide a low-cost, eminently feasible strategy that has the potential to dramatically boost awareness of risk, and increase interest in cessation. In addition to these graphic warnings, cigarette packaging labels that include misleading terms such as “lights” or “mild”, should be prohibited 70, 71.
- The United States should enact a strong, comprehensive nationwide ban on indoor smoking, an approach that has been adopted in many countries throughout the world 72. While more than half of the U.S. population now lives in a state or locality with a comprehensive clean indoor air law 72, the absence of a national law (without preemptions that limit stronger state and local ordinances) has limited its effectiveness. This strategy is supported by a compelling body of evidence that such a step will not only significantly reduce tobacco prevalence 15, 72-76, but will also dramatically reduce illness and deaths for both smokers and nonsmokers 77-81. In fact, smoking bans have been shown to increase quit attempts 82-84, decrease levels of consumption 72, 75, 83, decrease youth smoking 15, 73, 85, 86, promote denormalization of smoking 82, 87, and decrease morbidity and mortality from heart attacks 79, 80, 88-90. Finally, clear indoor air ordinances are popular 91, 92. The widespread adoption of state and local bans reflects the substantial public and political acceptance of such policies 81.
- The gradual elimination of nicotine from commercially available cigarettes, a strategy first proposed by Benowitz and Henningfield in the early 1990s 30, would reduce the risk of nicotine dependence amongst adolescents, by removing the underlying additive substrate for dependence development. At the same time, this policy could assist many adults in overcoming their dependence upon tobacco 30, 93, 94, particularly if the potential risk of compensatory smoking was addressed. Such mandated reductions in nicotine content could be just one aspect of another essential element to eliminating tobacco use in the United States – comprehensive FDA regulation of tobacco products and the tobacco industry 95.
- A final strategy would involve a greater emphasis on ensuring that all smokers have access to effective treatment interventions. The recently released PHS Guideline Update, Treating Tobacco Use and Dependence 96 highlighted vital new information on the clinical treatment of smokers. One important finding was that effective interventions now exist for an unprecedented proportion of smokers. For example, it now appears that there are interventions that increase quit attempts by smokers who were previously unwilling to quit 97, 98, providing a treatment option for the 60-65% of smokers who don't try to quit each year 99, 100. The Guideline also identified counseling and medication treatments that were especially effective for smokers willing to make a quit attempt, treatments that have been independently endorsed by the Cochrane Collaboration and others 101-104. Finally, the 2008 Guideline Update found that there was now sufficient evidence to recommend certain smoking cessation interventions as effective for adolescent smokers, meaning that this vulnerable population can now benefit from cessation intervention.
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.