2000 Surgeon General’s Report – Highlights

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.

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% 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.

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.

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.

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
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.

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.

–David Satcher, MD, PhD, U.S. Surgeon General

Tobacco use, particularly cigarette smoking, is the leading cause of preventable illness and death in the United States. Each year, more than 400,000 Americans die too young because of smoking-related diseases. Today, nearly one in four U.S. adults and one in three teenagers smoke. Tragically, if current trends continue, an estimated 25 million people (including 5 million of today’s children) will die prematurely of a smoking-related disease. A major challenge to our nation’s public health leaders and policy makers in the new millennium is to provide the support and resources necessary to carry out tobacco control programs that work.

The Surgeon General’s report on Reducing Tobacco Use will give the nation a blueprint for preventing tobacco use and improving our citizens’ quality of life. Each type of activity described in this report—educational, clinical, regulatory, economic, and comprehensive—has proven to be effective. Although our knowledge about tobacco control remains imperfect, we already know more than enough to take action now. If we start today, we can greatly ease the future burden of tobacco-related disease and death in our country.

Educational Interventions

• Increase the number of schools that fully implement the CDC’s Guidelines for School Health Programs to Prevent Tobacco Use and Addiction. Less than 5% of schools nationwide currently use these guidelines, even though full implementation could help 20% to 40% of U.S. adolescents postpone or never start smoking.
• Establish a smoke-free and tobacco-free environment in schools, including all school facilities, property, vehicles, and school events, as called for in Healthy People 2010. In 1994 only 37% of middle, junior high, and senior high schools were free of smoke and tobacco. Fully implementing the Pro-Children’s Act of 1994, which prohibits smoking in facilities that receive any federal funding for children’s services, will bring us closer to the Healthy People 2010 target of 100% smoke-free schools.

Clinical Interventions

• Begin providing universal insurance coverage of evidence-based treatment for nicotine dependency as called for in Healthy People 2010. It is estimated that smoking cessation programs are 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.
• Encourage more physicians to advise their patients to quit smoking. This simple intervention could produce quit rates of 5% to 10% per year.
• Combine behavioral counseling with pharmacologic treatments such as nicotine gum or nicotine patches. A combination of counseling and treatment can produce 20% to 25% quit rates after one year.

Regulatory Interventions

• Increase smoking bans to reduce people’s exposure to environmental tobacco smoke (ETS). ETS contains more than 4,000 chemicals; of these, at least 43 are known carcinogens. ETS is still a common public health hazard that can be easily eliminated, and smoking bans are the most effective method for reducing ETS exposure. Healthy People 2010 calls for an increase in laws that prohibit smoking or limit it to separately ventilated areas in public places and worksites.
• Strengthen warning labels on tobacco products sold in the United States. Current U.S. labels are weaker and less conspicuous than those in other countries.
• Better regulate the advertising, promotion, and sale of tobacco products in the United States. Tobacco marketing here is considerably less restricted than in several other countries, notably Canada and New Zealand. U.S. youth have easy access to tobacco. A high proportion of underage smokers across the country continue to be able to purchase their own tobacco. Healthy People 2010 calls for more states to suspend or revoke retail licenses for violating laws that prohibit the sale of tobacco to minors. Stricter regulation of selling and promoting tobacco products is needed to keep young people from starting to smoke.
• To protect young people around the world, make exported tobacco products subject to the same laws as domestic tobacco products. Federal laws and regulations concerning the packaging and advertising of domestic cigarettes do not apply to tobacco products exported from the United States.

Economic Interventions

Raise tobacco prices to Healthy People 2010 target levels by increasing the average federal and state tax on tobacco products to $2.00 for both cigarettes and spit tobacco products. Research shows that increasing the price of tobacco products would decrease the prevalence of tobacco use, particularly among minors and young adults. However, both the average price of cigarettes and the average cigarette excise tax in this country are well below those in most other industrialized countries, and the taxes on smokeless tobacco products are well below those on cigarettes.

Comprehensive Interventions

• Allocate more Master Settlement Agreement funds to tobacco control. The National Conference of State Legislatures reported that less than 10% of tobacco settlement funds appropriated by state legislatures in fiscal year 2000 were allocated for tobacco prevention and control programs.
• Reduce the cultural acceptability of tobacco use. By carrying out a comprehensive program that includes educational, clinical, regulatory, and economic interventions, we can change the social environment that makes tobacco use acceptable.
• Finally, while putting all these activities into motion, we must focus on making the elimination of tobacco-related health disparities a priority. Cultural, ethnic, religious, and socioeconomic differences clearly are important in understanding patterns of tobacco use. For example, the average smoking rate among American adults is 24%, but among Native American adults is 34%. People with 16 or more years of education smoke much less than people with 9 to 11 years of education—11% and 36%, respectively. Achieving the goal of eliminating tobacco-related health disparities will require stronger research efforts to find new and more effective interventions for our nation’s diverse population groups.

Minimal Clinical Interventions

• As reported in 1992 by the U.S. Environmental Protection Agency (EPA), exposure to tobacco smoke in the environment can cause lung cancer in adult nonsmokers. Environmental tobacco smoke (ETS) also has been linked to an increased risk of heart disease among nonsmokers.
• ETS causes about 3,000 lung cancer deaths annually among adult nonsmokers.
• In 1997, the California EPA concluded that ETS causes coronary heart disease and death in nonsmokers. Scientific studies have estimated that ETS accounts for as many as 62,000 deaths from coronary heart disease annually in the United States.
• The 1992 EPA report also concluded that ETS causes serious respiratory problems in children, such as greater number and severity of asthma attacks and lower respiratory tract infections. ETS exposure increases children’s risk for sudden infant death syndrome (SIDS) and middle ear infections as well.
• Each year ETS causes 150,000–300,000 lower respiratory tract infections, such as pneumonia and bronchitis, in children.
• In a large U.S. study, maternal exposure during pregnancy and postnatal exposure of the newborn to ETS increased the risk for SIDS.
• Comparative risk studies performed by the EPA have consistently found ETS to be a risk to public health. ETS is classified as a group A carcinogen (known to cause cancer in humans) under the EPA’s carcinogen assessment guidelines.
• Several studies have documented the widespread exposure of ETS among nonsmoking adults and children in the United States. Testing nonsmokers’ blood for the presence of cotinine, a chemical produced when the body metabolizes nicotine, shows that nearly 9 out of 10 nonsmoking Americans (88%) are exposed to ETS.
• A 1988 National Health Interview Survey reported that an estimated 37% of the 79.2 million nonsmoking U.S. workers were employed in places that permitted smoking in designated areas, and that 59% of these workers experienced moderate or great discomfort from ETS exposure in the workplace.
• Under common law (laws based on court decisions rather than government laws and regulations), employers must provide a work environment that is reasonably free of recognized hazards. Courts have ruled that common–law duty requires employers to provide nonsmoking employees protection from the proven health hazards of ETS exposure.
• The Occupational Safety and Health Administration is considering regulations that would either prohibit smoking in all workplaces or limit it to separately ventilated areas.
• The federal government has instituted increasingly stringent regulations on smoking in its own facilities. On August 9, 1997, President Clinton signed an Executive Order declaring that Executive Branch federal worksites be smoke-free, thereby protecting nonsmoking federal employees and thousands of citizens who visit federal facilities from the dangers of ETS.
• The Pro-Children’s Act of 1994 (Public Law 103–227, secs. 1041–1044) prohibits smoking in facilities where federally funded children’s services are provided on a regular or routine basis.
• As of December 31, 1999, at least some degree of smoke-free indoor air laws were present in 45 states and the District of Columbia. These laws vary widely, from limited smoking restrictions on public transportation to comprehensive restrictions in worksites and public places.
• Twenty states and the District of Columbia limit smoking in private worksites. Of these states, only one (California) meets the nation’s Healthy People 2010 objective to eliminate exposure to ETS by either banning indoor smoking or limiting it to separately ventilated areas.
• Forty-one states and the District of Columbia have laws restricting smoking in state government worksites, but only 13 of these states meet the nation’s Healthy People 2010 objective.
• Thirty-one states have laws that regulate smoking in restaurants; of these, only Utah and Vermont completely prohibit smoking in restaurants. California requires either a no smoking area or separate ventilation for smoking areas.

Additional Benefits

• An additional benefit of clean indoor air regulations may contribute to a reduction in smoking prevalence among workers and the general public. Studies have found that moderate or extensive laws for clean indoor air are associated with a lower smoking prevalence and higher quit rates.
• The majority of smokers support smoke-free hospitals. Smokers and nonsmokers were in favor of smoke-free workplace six months after a smoke-free policy was implemented.
• Employers are likely to save money by implementing policies for smoke-free workplaces. Savings include costs associated with such things as fire risk, damage to property and furnishings, cleaning, workers’ compensation, disability, retirement, injuries, and life insurance. Cost savings were estimated at $1,000 per smoking employee based on 1988 dollars.
• The EPA estimates a nationwide, comprehensive policy on clean indoor air would save $4 billion to $8 billion per year in building operations and maintenance costs.

Establishing Public Policy

• Involuntary exposure to ETS remains a common public health hazard that is entirely preventable by adopting appropriate regulatory policies.
• To fight the establishment of such policies, the tobacco industry tries to shift the focus from the science-based evidence on the health hazards of ETS to the controversial social issue of personal freedom. The industry has lobbied extensively against legislation to restrict smoking, and has supported the passage of state laws that preempt stronger local ordinances. (Preemptive legislation is defined as legislation that prevents a local jurisdiction from enacting laws more stringent than, or at a variance with, the state law.)
• A case study conducted in six states found that the existence of an organized smoking prevention coalition among local citizens was a key determinant in successfully enacting clean indoor air legislation.
• Smokefree environments are the most effective method for reducing ETS exposure. Healthy People 2010 objectives address this issue and seek optimal protection of nonsmokers through policies, regulations, and laws requiring smoke-free environments in all schools, work sites, and public places.

Rationale for Comprehensive Intervention

• Statewide programs have emerged as the new laboratory for developing and evaluating comprehensive plans to reduce tobacco use.
• Initial results from statewide tobacco control programs are encouraging, particularly in per capita declines of tobacco consumption.
• State findings also suggest that youth behaviors regarding tobacco use are more difficult to change than adult ones.
• People do not make behavior choices in isolation, but rather in a larger, complex context that includes the family, community, and culture; the economy and physical environment; formal and informal government policy; and the prevailing legal atmosphere. Programs to reduce tobacco use will be most effective if they address all the components that may influence the individual’s behavior choices.
• There are several advantages to shifting from an approach that targets the individual to a population approach that uses social, policy, and environmental strategies.
• First, by recognizing that many environmental determinants of health behavior are not under the direct control of the individual, the population approach avoids blaming persons who fail to change their behavior.
• Second, many individual efforts may fail to reach those in greatest need. Because many of these strategies are most effective with better-educated, wealthier persons, the disparities in health between population groups may widen.
• Third, making regulatory and policy changes can be more cost-effective than conducting numerous interventions to modify individual behavior.

CDC’s National Tobacco Control Program

• In May 1999, CDC launched the National Tobacco Control Program (NTCP), bringing the various federal initiative activities into one national program. In fiscal year 2000, the NTCP distributed $59 million for comprehensive tobacco control efforts in all states, the District of Columbia, seven U.S. territories, and Native American tribal organizations.
• CDC recommends four program goals in its comprehensive framework for statewide programs
  1. Prevent initiation of tobacco use among young people.
  2. Promote quitting among adults and young people.
  3. Eliminate exposure to environmental tobacco smoke (ETS).
  4. Identify and eliminate health disparities among population groups.
• Each program goal would be fully addressed by implementing four program components:
  1. Community interventions, which include diverse entities such as schools, health agencies, city and county governments, and civic, social, and recreational organizations
  2. Countermarketing, which includes using media advocacy, paid media, pro–health promotions, and other media strategies to change social norms related to 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 treatment
  4. Surveillance and evaluation, which includes monitoring the tobacco industry’s promotional campaigns, evaluating the economic impact of ETS laws and policies, conducting surveys of public opinion on program interventions, and making ongoing refinements that lead to more effective prevention strategies
• The elimination of health disparities among population groups remains a challenge due to the lack of culturally appropriate programs of proven efficacy. However, in recent years, a number of people and organizations with more diverse backgrounds have assumed a greater role in efforts to reduce tobacco use. Particularly in view of the tobacco industry’s targeted marketing to women, young people, and racial/ethnic populations, such heightened activity is critically important for ensuring that nonsmoking becomes the norm within diverse communities.
• To be effective, comprehensive programs should include campaigns that include the following:
  1. Target young people and adults with complementary messages
  2. Highlight nonsmoking as the majority behavior
  3. Communicate the dangers of tobacco while providing constructive alternatives
  4. Use multiple nonpreachy voices in a complementary, reinforcing mix of media and outdoor advertising
  5. Include grassroots promotions, local media advocacy, event sponsorships, and other community tie-ins
  6. Encourage youth empowerment and involvement

Minimal Clinical Interventions

• According to three study findings, nearly 70% of American smokers (36 million) make at least one outpatient visit each year, but health care providers gave smoking cessation advice to only 40% to 52% of the smokers.
• One recent study reported that only 15% of smokers who saw a physician in the past year were offered assistance with quitting, and only 3% were given a follow-up appointment to address the problem.
• In 1992, about half of all adult U.S. smokers visited a dentist, but only 25% were advised to quit by their dentist.
• Effective strategies for treating tobacco use include brief advice by medical providers, counseling, and pharmacotherapy.
• Less intensive interventions, as simple as physicians advising their patients to quit smoking, can produce cessation rates of 5% to 10% per year. More intensive interventions, combining behavioral counseling and pharmacologic treatment, can produce 20% to 25% quit rates in one year.

Pharmacotherapy

• Nicotine nasal spray was approved for prescription use in March 1996. The spray consists of a pocket-sized bottle and pump assembly, with a nozzle that is inserted into the nose. Each metered spray delivers 0.5 mg of nicotine to the nasal mucosa.
• In May 1997 the nicotine inhaler was approved as a prescription medication to treat tobacco dependence. The inhaler consists of a plastic tube about the size of a cigarette and contains a plug filled with nicotine. Menthol is added to the plug to reduce throat irritation. Smokers puff on the inhaler as they would a cigarette. Each inhaler contains enough nicotine for 300 puffs.

Economic Benefits

• Cost-effectiveness analyses have shown that smoking cessation treatment compares favorably with hypertension treatment and other preventive interventions such as annual mammography, pap tests, colon cancer screening, and treatment of high levels of serum cholesterol.
• Treating tobacco dependence is particularly important economically because smoking cessation can help prevent a variety of costly chronic diseases, including heart disease, cancer, and lung disease. In fact, smoking cessation treatment has been referred to as the “gold standard” of preventive interventions.
• Progress has been made in recent years in disseminating clinical practice guidelines on smoking cessation. Healthy People 2010 calls for universal insurance coverage, both public and private, of evidence-based treatment for nicotine dependency for all patients who smoke.

• It is illegal in all states to sell cigarettes to persons under age 18. Progress has been made in the past several years in reducing the percentage of retailers willing to sell tobacco to minors.
• In 1991 an estimated 225 million packs of cigarettes were sold illegally to minors, and in 1997 daily smokers aged 12 to 17 years smoked approximately 924 million packs of cigarettes.
• An estimated 20% to 70% of teenagers who smoke report purchasing their own tobacco; the proportion varies by age, social class, amount smoked, and factors related to availability.
• More than two-thirds of states restrict cigarette vending machines, but many of these restrictions are weak. Only two states (Idaho and Vermont) have total bans on vending machines.
• Results from nine published studies found illegal vending machine sales to minors ranged from 82% to 100% between 1989 and 1992.
• More than 290 local jurisdictions, including New York City, successfully adopted and enforced outright bans on cigarette vending machines or restricted them to locations such as taverns and adult clubs where minors often are denied entry.
• Almost two-thirds of the states and many local jurisdictions require retailers to display signs that state the minimum age for purchase of tobacco products. Some regulations specify the size, wording, and location of these signs.
• All states have a specific restriction on the distribution of free tobacco samples to minors, and a few states or local jurisdictions prohibit free distribution altogether because of the difficulty of controlling who receives free samples.
• Several studies have found that single or loose cigarettes are sold in some locations. Such sales often are prohibited by state or local law, given single cigarettes do not display the required state tax stamp or federal health warning.
• Other regulations specify a minimum age for salespersons. These regulations recognize the difficulty young salespersons may have in refusing to sell cigarettes to their peers.
• Many state or local laws specify penalties only for the sales-person. However, applying penalties to business owners, who generally set hiring, training, supervising, and selling policies, is considered essential to preventing the sale of tobacco to minors.
• License suspensions or revocations imposed as penalties for repeated violation of youth access laws would communicate a clear message that illegal tobacco sales to minors should never be accepted or tolerated. Revenues from fines could be used for enforcement and retailer education programs.
• Numerous studies have shown that comprehensive merchant education and training programs help reduce illegal sales to minors.
• Growing number of states and local jurisdictions are imposing sanctions against minors who purchase, attempt to purchase, or possess tobacco products. Although these laws are a potential deterrent, some tobacco control advocates believe such laws deflect responsibility from retailers to underage youth.
• In 1992 the Synar Amendment (Public Law 102–321), was passed to curb the illegal sale of tobacco products to minors. An amended Synar Regulation, was issued by the Substance Abuse and Mental Health Services Administration in January 1996, and requires each state receiving federal grant money to conduct annual random, unannounced inspections of retail tobacco outlets to assess the extent of sales to minors. In 1999, seven states and the District of Columbia failed to attain their Synar Amendment targets. Failure to comply with the law puts states at risk of forfeiting federal block grant funds for substance abuse prevention and treatment services.
• On March 21, 2000, the United States Supreme Court ruled that the FDA lacked jurisdiction to regulate tobacco products and to enforce rules to reduce the access and appeal of tobacco products for children and adolescents. The loss of the FDA’s education and enforcement program eliminates vital federal support for state tobacco control programs.

• Many factors interact to encourage tobacco use among youth, including tobacco advertising and promotion, tobacco use by peers and family members, and easy access to tobacco products.
• Early adolescence (age 11–15 years, or sixth through tenth grade) is the period when young people are most likely to try smoking for the first time.
• Tobacco-free policies involving the school’s faculty, staff, and students have a critical role in reducing tobacco use among young people, especially when these policies apply to all school facilities, property, vehicles, and school-sponsored events. While two-thirds of schools (62.8%) had smoke-free building policies in 1994, significantly fewer (36.5%) reported having policies that included the entire school environment.
• Implementing effective educational programs for preventing tobacco use could postpone or prevent smoking onset in 20% to 40% of U.S. adolescents.
• Programs with the most educational contacts during the critical years for smoking adoption (ages 11–15 years) are more likely to be effective, as are programs that address a broad range of educational needs.
• Educational strategies to prevent tobacco use must become more consistent and effective. This will require continuing efforts to build strong, multiyear prevention units into school health education curricula. It will also require expanded efforts to make use of the influence of parents, the mass media, and community resources.
• Existing data suggest that evidence-based curricula and national guidelines have not been widely adopted. Less than 5% of schools nationwide are implementing the major components of CDC’s Guidelines for School Health Programs to Prevent Tobacco Use and Addiction, which recommends schools should—
  • Develop and enforce a school policy on tobacco use.
  • Provide instruction about the short- and long-term effects of tobacco use, social influences on tobacco use, peer norms regarding tobacco use, and refusal skills.
  • Provide tobacco-use prevention education in kindergarten through 12th grade, with especially intensive instruction in junior high or middle school.
  • Provide program-specific training for teachers.
  • Involve parents and families in support of school-based programs to prevent tobacco use.
  • Support cessation efforts among students and school staff who use tobacco.
  • Assess the tobacco-use prevention program at regular intervals.
• Educational curricula that address social influences (of friends, family, and media) that encourage tobacco use among youth, have shown consistently more effectiveness than programs based on other models.
• Two middle school programs that have demonstrated effectiveness in reducing tobacco use behaviors in youth have been identified by the Centers for Disease Control and Prevention as programs that work, and they are Life Skills Training Program, and Project Toward No Tobacco (TNT).
• Schools cannot bear the sole responsibility for preventing tobacco use. School-based programs are more effective when combined with mass media programs and with community-based efforts involving parents and other community resources.

• Despite the overwhelming evidence of the adverse health effects from tobacco use, efforts to prevent the onset or continuance of tobacco use face the pervasive challenge of promotion activity by the tobacco industry.
• Regulating advertising and promotion, particularly that directed at young people, is very likely to reduce both the prevalence and initiation of smoking.
• The tobacco industry uses a variety of marketing tools and strategies to influence consumer preference, thereby increasing market share and attracting new consumers.
• Among all U.S. manufacturers, the tobacco industry is one of the most intense in marketing its products. Only the automobile industry markets its products more heavily.

Youth and Tobacco Advertising and Promotion

• Children and teenagers constitute the majority of all new smokers, and the industry’s advertising and promotion campaigns often have special appeal to these young people.
• One tobacco company, the Liggett Group, Inc., has admitted that the entire tobacco industry conspired to market cigarettes to children.
• Tobacco documents recently obtained in litigation indicate that tobacco companies have purposefully marketed to children as young as 14 years of age.
• The effect of tobacco advertising on young people is best epitomized by R.J. Reynolds Company’s introduction of the Joe Camel campaign. From the introduction of the “Old Joe” cartoon character in 1988, Camel’s share of the adolescent cigarette market increased dramatically—from less than 1% before 1988, to 8% in 1989, to more than 13% in 1993.
• In 1997 the Federal Trade Commission (FTC) filed a complaint against R.J. Reynolds alleging that “the purpose of the Joe Camel campaign was to reposition the Camel brand to make it attractive to young smokers…” The FTC ultimately dismissed its complaint after the November 23, 1998, Master Settlement Agreement (MSA), which calls for the ban of all cartoon characters, including Joe Camel, in the advertising, promotion, packaging, and labeling of any tobacco product.

Ethnic Groups and Tobacco Advertising and Promotion

• Many public health and smoking prevention groups are concerned about the tobacco industry’s practice of targeting cultural and ethnic minorities through product development, packaging, pricing, advertising, and promotional activities.

Overview of Tobacco Products

• More than 4,000 chemical compounds have been identified in tobacco smoke. Of these, at least 43 are known to cause cancer.
• Current tobacco product regulation requires cigarette manufacturers to disclose levels of magnify tar and nicotine. Smokers receive very little information regarding chemical constituents in tobacco smoke, however, and the use of terms such as “light” and “ultra light” on packaging and in advertising may be misleading.
• 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.
• Early data showed a lower cancer risk from low-tar cigarettes; however, more recent data suggest otherwise. Lower-yield cigarettes may be somewhat better than very high-yield cigarettes; but, when comparing full-flavor cigarettes and current light cigarettes, there is no evidence to suggest a lower cancer risk from the low-tar cigarettes.

Cigarette Additives

• Federal law (the Comprehensive Smoking Education Act of 1984 and the Comprehensive Smokeless Tobacco Health Education Act of 1986) requires cigarette and smokeless tobacco manufacturers to submit a list of ingredients added to tobacco to the Secretary of Health and Human Services.
• Hundreds of ingredients are used in the manufacture of tobacco products. Additives make cigarettes more acceptable to the consumer—they make cigarettes milder and easier to inhale, improve taste, and prolong burning and shelf life.
• In 1994, six major cigarette manufacturers reported 599 ingredients that were added to the tobacco of manufacture cigarettes. Although, these ingredients are regarded as safe when ingested in foods, some may form carcinogens when heated or burned.
• Knowledge about the impact of additives in tobacco products is negligible and will remain so as long as brand-specific information on the identity and quantity of additives is unavailable.

Smokeless Additives

• In 1994, 10 manufacturers of smokeless tobacco products released a list of additives used in their products. The additives list contained 562 ingredients approved for foods by the FDA.
• Moist snuff products with low nicotine content and pH levels have a smaller proportion of free nicotine. In contrast, moist snuff products with high nicotine content and pH levels have a higher proportion of free nicotine.
• The epidemiology of moist snuff use among teenagers and young adults indicates that most novices start with brands having low levels of free nicotine and then “graduate” to brands with higher levels.
• Sweeteners and flavorings, such as cherry juice concentrate, apple juice, chocolate liqueur, or honey are used in various smokeless tobacco products. As with manufactured cigarettes, these additives increase palatability and may increase the use of smokeless tobacco, at least among novices.

• Cigarettes were first introduced in the United States in the early 19th century. Before this, tobacco was used primarily in pipes and cigars, by chewing, and in snuff.
• By the time of the Civil War, cigarette use had become more popular. Federal tax was first imposed on cigarettes in 1864. Shortly afterwards, the development of the cigarette manufacturing industry led to their quickly becoming a major U.S. tobacco product.
• At the same time, the populist health reform movement led to early anti-smoking activity. From 1880–1920, this activity was largely motivated by moral and hygienic concerns rather than health issues.
• The milder flue-cured tobacco blends used in cigarettes during the early 20th century made the smoke easier to inhale and increased nicotine absorption into the bloodstream.
• During World War I, Army surgeons praised cigarettes for helping the wounded relax and easing their pain.
• Smoking was first linked to lung cancer and other diseases in the late 1940s and early 1950s.
• In 1956, a Surgeon General’s scientific study group determined that there was a causal relationship between excessive cigarette smoking and lung cancer.
• In England, the 1962 Royal College of Physicians report emphasized smoking’s causative role in lung cancer.
• Anti-smoking messages had a significant impact on cigarette sales; however, when cigarette advertising on television and radio was banned in 1969, anti-smoking messages were discontinued.
• The 1972 Surgeon General’s report became the first of a series of science-based reports to identify environmental tobacco smoke (ETS) as a health risk to nonsmokers.
• In 1973, Arizona became the first state to restrict smoking in a number of public places explicitly because ETS exposure is a public hazard.
• By the mid-1970s, the federal government began administratively regulating smoking within government domains. In 1975, the Army and Navy stopped including cigarettes in rations for service members. Smoking was restricted in all federal government facilities in 1979 and was banned in the White House in 1993.
• In 1988, Congress prohibited smoking on domestic commercial airline flights scheduled for 2 hours or less. By 1990, the ban was extended to all commercial U.S. flights.
• In 1992, the Environmental Protection Agency (EPA) classified ETS as a “Group A” carcinogen, the most dangerous class of carcinogen.
• In 1994, Mississippi became the first state to sue the tobacco industry to recover Medicaid costs for tobacco-related illnesses, settling its suit in 1997. A total of 46 states eventually filed similar suits. Three other states settled individually with the tobacco industry—Florida (1997), Texas (1998), and Minnesota (1998).
• On November 23, 1998, the tobacco industry approved to a 46-state Master Settlement Agreement, the largest settlement in history, totaling nearly $206 billion to be paid through the year 2025. The settlement agreement contained a number of important public health provisions.
• In April 1999, as part of the Master Settlement Agreement, the major U.S. tobacco companies agreed to remove all advertising from outdoor and transit billboards across the nation. The remaining time on at least 3,000 billboard leases, valued at $100 million, was turned over to the states for posting anti-tobacco messages.
• On March 21, 2000, the U.S. Supreme Court narrowly affirmed a 1998 decision of the U.S. Court of Appeals for the 4th Circuit and ruled that the FDA lacks jurisdiction under the Federal Food, Drug, and Cosmetic Act to regulate tobacco products. As a result, the FDA’s proposed rule to reduce access and appeal of tobacco products for young people became invalid.

• The Federal Cigarette Labeling and Advertising Act of 1965 (Public Law 89–92) required that the warning “Caution: Cigarette Smoking May Be Hazardous to Your Health” be placed in small print on one of the side panels of each cigarette package. The act prohibited additional labeling requirements at the federal, state, or local levels.
• In June 1967 the Federal Trade Commission (FTC) issued its first report to Congress recommending that the warning label be changed to “Warning: Cigarette Smoking Is Dangerous to Health and May Cause Death from Cancer and Other Diseases.”
• In 1969 Congress passed the Public Health Cigarette Smoking Act (Public Law 91–222), which prohibited cigarette advertising on television and radio and required that each cigarette package contain the label “Warning: The Surgeon General Has Determined That Cigarette Smoking Is Dangerous to Your Health.”
• In 1981 the FTC issued a report to Congress that concluded health warning labels had little effect on public knowledge and attitudes about smoking. As a result of this report, Congress enacted the Comprehensive Smoking Education Act of 1984 (Public Law 98–474), which required four specific health warnings on all cigarette packages and advertisements:
  • SURGEON GENERAL’S WARNING: Smoking Causes Lung Cancer, Heart Disease, Emphysema, and May Complicate Pregnancy.
  • SURGEON GENERAL’S WARNING: Quitting Smoking Now Greatly Reduces Serious Risks to Your Health.
  • SURGEON GENERAL’S WARNING: Smoking by Pregnant Women May Result in Fetal Injury, Premature Birth, and Low Birth Weight.
  • SURGEON GENERAL’S WARNING: Cigarette Smoke Contains Carbon Monoxide.
• By the mid-1980s scientific evidence revealed that smokeless tobacco use causes oral cancer, nicotine addiction, and other health problems. The Comprehensive Smokeless Tobacco Health Education Act of 1986 (Public Law 99–252) required three rotating warning labels on smokeless tobacco packaging and advertisements:
  • WARNING: This product may cause mouth cancer.
  • WARNING: This product may cause gum disease and tooth loss.
  • WARNING: This product is not a safe alternative to cigarettes.
• Warning labels on cigarette packages in the United States are weaker and less prominent than those of many other countries.
• The Australian warning method uses six rotating messages covering 25% of the front of the cigarette package. One side panel is entirely given to the labeling of dangerous constituents. The government also requires that 33% of the back panel include the same message and an elaboration of that message.