Ending Tobacco Use in the United States – Our Past, Present and Future

CDC Congressional Testimony

Witness: Tim McAfree, MD, MPH

Testimony – Testimony before the Senate Health, Education, Labor and Pensions Committee

Chairman Harkin, Ranking Member Alexander, and members of the Committee, it is an honor to provide this statement for today’s hearing on progress in tobacco prevention and control. Fifty years ago, half of the men and a third of the women in this country smoked cigarettes. Tobacco companies advertised everywhere, and school children carried lunch boxes and wore baseball caps branded with cigarette logos. Except for churches and grade school classrooms, smoking was common in almost all public places, including hospitals.

Today the landscape is different. Tobacco prevention and control measures have saved an estimated eight million lives over the last half-century.1 In fact, the success of the tobacco-control movement constitutes one of the greatest public health achievements of the 20th century. Adult smoking rates have fallen from about 43 percent in 1965 to about 18 percent today.2 The latest surveys show that cigarette smoking rates among high school students are at the lowest in our history of measuring them. Most indoor workplaces are smoke-free and over half of states prohibit smoking in other indoor areas of public places such as restaurants, bars, and airports.2 Colleges and universities have embraced these policies, and many have adopted smoke-free and tobacco-free campuses, indoors and out. Instead of images of glamorous people enjoying a cigarette, today we see the real health consequences of smoking through Tips from Former Smokers, the first Federally-funded anti-smoking national media campaign in the United States, which was initially established through the Prevention and Public Health Fund. These hard-hitting ads pull back the curtain to reveal real people fighting serious diseases and disabilities because they smoked, and in their first year led 1.6 million Americans to make a quit attempt and 100,000 quit for good.3

However, we are far from the finish line. Despite enormous progress, the tobacco epidemic still rages on—in every community and in every corner of our country. Every day, more than 3,200 children under age 18 smoke their first cigarette, and another 2,100 youth and young adults who are occasional smokers become daily smokers.2 Smoking-related deaths now approach half a million a year in the United States, and another 16 million Americans have at least one serious smoking-related disease.2 One-third of all cancer deaths are caused by smoking, including the vast majority of lung cancers—the leading cause of cancer death in our nation for both men and women.2

Progress in reducing the disease and death caused by the tobacco epidemic has not been consistent across all populations. The burden of smoking now falls disproportionately on some of our most vulnerable populations– the poor, some racial and ethnic minorities, some members of the gay and lesbian community, and those living with mental illness and substance use disorders.2

This entirely preventable public health tragedy did not occur by accident. The Surgeon General concluded that “the tobacco epidemic was initiated and has been sustained by the aggressive strategies of the tobacco industry, which deliberately misled the public on the risks of smoking cigarettes.”2 Today’s cigarettes contain over 7,000 chemicals and chemical compounds – over 70 of which are known to cause cancer.4 They are designed to addict their users quickly and heavily, speeding a jolt of nicotine to receptors in the brain in as little as ten seconds after the smoke is inhaled.5 The adolescent brain is especially sensitive to nicotine and teens become dependent on nicotine more quickly than adults.6 In fact, nicotine will cause three out of four teen smokers to become adult smokers – even though most say they plan to quit in a few years.2 Prevention and intervention in the teen and youth years is important because nearly 90 percent of adult smokers say they started before they were 18 years old.2

In addition to making their products powerfully addictive, the tobacco industry spends eight billion dollars annually-nearly a million dollars an hour-to advertise and market cigarettes and smokeless tobacco. 2 They outspend current state tobacco-control programs by a factor of 18-to-one.7 In the United States, the tobacco industry recruits customers to consume over 14 billion packs of cigarettes a year.8 Marketing and glamorization of tobacco products remains widespread. Despite causal evidence that depictions of smoking in the movies lead to smoking initiation among young people, movies remain one of the largest unrestricted traditional media channels promoting smoking and tobacco use to youth. In fact, tobacco incidents in PG-13 rated top-grossing U.S. movies surged 98 percent from 2010 to 2012.2

The Surgeon General concluded that combusted – or burned – tobacco products, such as cigarettes, cigars, and pipes, are overwhelmingly responsible for the burden of death and disease from tobacco use in the United States.2 Cigarettes carry the highest risk of addiction fol­lowing initiation. 2 This is due to cigarette designs that facilitate efficient and tolerable inhalation of nicotine-laden toxic smoke deep into the lung. 2 In addition to cigarettes, there is an increasing array of combustible and noncombustible tobacco products on the market. New, novel tobacco products pose challenges to research, surveillance, health policy, and regulation because they vary so widely in form, mode of use, contents, designs and emissions, potential health effects, and marketing claims.2 Combustible product lines include fruit and candy-flavored little cigars and cigarillos, which are about the same size and shape as cigarettes. These are of particular concern because their flavors and low pricing relative to cigarettes (largely attributable to differential tax treatment) are appealing to young people. In fact, research surveys have found that high school boys are smoking cigars at the same rate as cigarettes.2

Noncombustible product lines include smokeless tobacco, dissolvable tobacco products, and the increasingly prevalent electronic nicotine delivery systems (ENDS). ENDS, including e-cigarettes, e-hookahs, hookah pens, vape pens, e-cigars, and others, are battery-powered devices that provide doses of nicotine and other constituents to the user in an aerosol. ENDS contain nicotine, which is addictive, toxic to developing fetuses, and may have lasting consequences for adolescent brain development.2 Potentially-harmful constituents also have been documented in some ENDS, including: irritants, toxicants that can change genes, and other ingredients that have been shown to cause cancer in animals.9 ENDS are not “safe,” and because of the known risks associated with nicotine, the Surgeon General specifically cautions against their use by young people and pregnant women.2 ENDS could be less dangerous for the smoker to use than conventional cigarettes or other combusted tobacco products if and when used by established adult smokers as a complete substitution for cigarettes.2 However, the consequences of long-term use of ENDS are unknown.

In 1971, the tobacco companies stopped advertising cigarette and smokeless tobacco products on television and radio. This had a lasting impact on deglamorizing smoking.10 But now, electronic nicotine delivery systems are being heavily marketed on television and radio. The 2014 Surgeon General’s Report observed that ENDS marketing “has included claims of safety, use for smoking ces­sation, and statements that they are exempt from clean air policies that restrict smoking.” Moreover, some ENDS marketing uses tactics which the Surgeon General has found lead to youth smoking:5 candy-flavored products; youth-resonant themes such as rebellion, glamour, and sex; and celebrity endorsements and sports and music sponsorships. This is of concern because the Surgeon General has found that “many changes in tobacco product form and marketing have been documented as efforts by the tobacco industry to contribute to tobacco use and addiction by fostering initiation among young people; making products easier and more acceptable to use; making and marketing products so as to address health concerns; and making and marketing products to perpetuate addiction through the use of alternate products, when smoking is not allowed or is socially unacceptable.”2

These actions appear to be successfully recruiting adult and youth ENDS users. Results from the HealthStyles survey suggest that adult e-cigarette experimentation nearly doubled from 2010 (3.3 percent) to 2011 (6.2 percent).2 In 2012, approximately 1.8 million students in grades 6-12 reported ever trying an e-cigarette.11 We do not yet know the long-term health effects that may result from use of ENDS, or the consequences of exposure to secondhand aerosol for bystanders. The recent Surgeon General’s Report on smoking and health says that ENDS will cause harm if they:

  • Encourage nonsmoking youth or adult non-smokers to start using them and become addicted to nicotine,
  • Entice former smokers to relapse,
  • Delay current smokers from trying to break their nicotine addiction altogether, or
  • Encourage dual use of combustible tobacco products and electronic devices.2

Additional risks include:

  • The potential for ENDS to expose bystanders involuntarily to aerosolized nicotine, and
  • Accidental poisonings resulting from ingestion or absorption through the skin of liquids containing high concentrations of nicotine.

While we respond to the new challenges and opportunities presented by ENDS, we must remember that cigarettes and other combusted tobacco products are overwhelmingly responsible for the burden of tobacco-related death and disease in the United States. Cigarettes remain cheap; ubiquitous; heavily marketed; appealing to children; “unreasonably dangerous, killing half of long-term users; and addictive by design.”2 Every adult who dies prematurely from smoking in this country is replaced by two younger smokers who have been recruited to sustain the epidemic.2 In fact, if current rates of smoking by youth and young adults continue, 5.6 million American children under age 18 will ultimately die early because of smoking.2

How do we accelerate the decline in the use of these deadly products? The good news is that we know a great deal about what works. The 2014 Surgeon General’s Report emphasizes the effectiveness of comprehensive approaches to tobacco control that apply a mix of educational, clinical, regulatory, economic, and social strategies to:

  • prevent ini­tiation of tobacco among youth and young adults,
  • promote quitting among adults and youth
  • eliminate exposure to secondhand smoke, and
  • identify and elimi­nate tobacco-related disparities among population groups.

Unfortunately, the Surgeon General concluded that these evidence-based strategies are currently underutilized, but we are taking steps to change that dynamic:

  • We know that a 10 percent increase in cigarette prices cuts consumption by four percent in adults, and by even more for youth.6 Yet many states have excise taxes of less than a dollar on a pack of cigarettes – and as a result, have higher smoking rates and higher medical costs to treat smoking-related disease relative to states with lower excise taxes. The Fiscal Year (FY) 2014 and FY 2015 President’s Budgets propose a 94-cent per-pack increase in the Federal excise tax on cigarettes, which has the potential to prevent at least 450,000 premature deaths of children alive today.
  • We know that over half of current cigarette smokers want to quit and at least half will try to quit this year—the Affordable Care Act expanded access to smoking-cessation services and requires most insurance companies to cover cessation interventions. Integrating cessation help into behavioral health treatment will improve cessation rates, treatment retention, and outcomes for individuals with mental illness—a group disproportionately affected by tobacco use.
  • We know that hard-hitting media campaigns such as CDC’s Tips from Former Smokers have the potential to motivate even more smokers to quit successfully if they are sustained, as the Surgeon General recommends, at a high frequency for 10 years or more. The Affordable Care Act’s Prevention and Public Health Fund supported the creation of this innovative campaign, which already has helped tens of thousands to quit smoking.
  • We know that smoke-free policies protect nonsmokers from the dangers of secondhand smoke without harming businesses. Through the Office of the Assistant Secretary for Health’s Tobacco-Free College Campus Initiative, the number of smoke-free campuses increased 73 percent from 772 in 2012 to 1,343 in 2014. More work remains, as close to 90 million non-smokers, including over half of children between ages three and 11—continue to be exposed to this known carcinogen. This year, 41,000 Americans will die from a disease caused by this exposure.2
  • We know that adequately-funded, comprehensive, statewide tobacco control programs help inform tobacco-free social norms throughout communities and lower smoking rates and health care costs. CDC continues to invest in these state-based efforts through the National Tobacco Control Program. Yet states will spend less than two percent of the more than $25 billion they receive in tobacco revenues this fiscal year on tobacco control.5

At the Federal level, the work at the Food and Drug Administration to implement the landmark Family Smoking Prevention and Tobacco Control Act of 2009 is critical to further progress, and we are pleased to work in close partnership with FDA on the work described in its testimony today. CDC, FDA, and the National Institutes of Health are also partnering to fill critical research gaps.

We also know that states and cities are taking action– implementing smoke-free indoor air policies, raising minimum age requirements for tobacco purchases, and putting policies into place to minimize potential harms of e-cigarettes. For example:

  • Over half of states already prohibit e-cigarette sales to minors, as FDA is proposing in it deeming rule. Some are enforcing those policies through licensing requirements and penalties for violations.
  • Three states prohibiting e-cigarette use in places where smoking is prohibited such as restaurants, bars, and worksites.

As part of the National Prevention Council, agencies across the Federal Government are undertaking important commitments to promote tobacco-free living. For example, the Department of Housing and Urban Development is increasing access to smoke-free multi-unit housing for residents.12 Within the Department of Defense, efforts are underway to prevent and reduce tobacco use on DOD installations to promote health and mission readiness, help tobacco users quit, and lead by example for all workplaces. In addition, the U.S. Department of Veterans Affairs health care system provides evidence-based tobacco cessation counseling and FDA-approved medications for Veterans enrolled in care, including a national smoking cessation quitline and a mobile texting program, in collaboration with the National Cancer Institute. These and other initiatives have extended the reach of tobacco use treatment to Veterans nationally.

CDC and the Department of Health and Human Services are committed to providing agencies with technical assistance and support as they implement these critical, but often challenging commitments. As resources permit, CDC is also committed to increasing the frequency of its high-impact Tips from Former Smokers campaign; conducting cutting-edge research and surveillance to monitor the rapidly changing landscape of tobacco control; powering comprehensive tobacco control programs in states, tribes, and territories with resources and technical assistance, and expanding access to barrier-free tobacco-cessation treatment, including through 1-800-QUIT-NOW.

Real progress in tobacco control will require commitment and effort across all sectors of our society – not just local, state, and Federal agencies. One important partner will be the business community, and we are seeing some important movement in this sector. A striking example is the decision by CVS pharmacies to stop selling tobacco products in all their stores. Employee well-being and productivity also serve as motivators for business engagement. In addition to providing insurance coverage for smoking cessation, many large companies offer their employees free help to quit on the job, with cessation classes and support groups available throughout the work day. And smoking cessation as an important part of corporate wellness programs is spreading to smaller companies as well. Public health and tobacco-control stakeholders are working together with business leaders around the country to identify other opportunities for progress.

If we end the tobacco-use epidemic, we can prevent one out of three cancer deaths in this country.13 We can prevent 480,000 premature deaths a year from smoking-related illnesses.13We can prevent a third of heart disease cases, 80 percent of chronic obstructive pulmonary disease cases, and over 90 percent of lung cancer cases. 13 We can keep 400,000 babies every year from being exposed to the chemicals in cigarette smoke before they are even born.13 We can save our economy nearly $300 billion a year in medical costs and economic losses.13 And we can help individual men and women live longer, healthier lives and avoid the pain and suffering that are a part of preventable diseases caused by smoking.

Thank you.

1Holford TR, Meza R, Warner KE, Meernik C, Jeon J, Mool­gavkar SH, Levy DT. Tobacco control and the reduction in smoking-related premature deaths in the United States, 1964–2012. JAMA: the Journal of the American Medical Association 2014.

2 U.S. Department of Health and Human Services (2014). Reports of the Surgeon General. The Health Consequences of Smoking-50 Years of Progress: A Report of the Surgeon General. Atlanta (GA), Centers for Disease Control and Prevention (US).

3 McAfee, Tim et al (2013). Effect of the first federally funded US anti-smoking national media campaign. The Lancet. Published Online September 9, 2013. Available at: http://dx.doi.org/10.1016/S0140-6736(13)61686-4. Accessed May 9, 2014.

4 U.S. Department of Health and Human Services. How Tobacco Smoke Causes Disease—The Biology and Behavioral Basis for Smoking-Attributable Disease: A Report of the Surgeon General. Atlanta (GA): U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2010.

5 U.S. Department of Health and Human Services. The Health Consequences of Smoking: Nicotine Addic­tion. A Report of the Surgeon General. Atlanta (GA): U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Center for Chronic Disease Prevention and Health Pro­motion, Office on Smoking and Health, 1988. DHHS Publication No. (CDC) 88-8406.

6 U.S. Department of Health and Human Services. Pre­venting Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General. Atlanta (GA): U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2012.

7 Campaign for Tobacco-Free Kids. Broken Promises to Our Children: The 1998 State Tobacco Settlement 15 Years Later. Washington: Campaign for Tobacco Free Kids, American Heart Association, American Cancer Society, Cancer Action Network, American Lung Asso­ciation, and Robert Wood Johnson Foundation, 2013.

8 Maxwell JC. The Maxwell Report: Year End & Fourth Quarter 2011 Sales Estimates for the Cigarette Industry. Richmond (VA): John C. Maxwell, Jr., 2012

9 Cobb, N. K., M. J. Byron, D. B. Abrams and P. G. Shields (2010). “Novel nicotine delivery systems and public health: the rise of the “e-cigarette”.” Am J Public Health 100(12): 2340-2342.

10 Department of Health and Human Services (2000). Reducing Tobacco Use: A Report of the Surgeon General. Atlanta (GA): U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2000.

11 CDC (2013). “Notes from the field: electronic cigarette use among middle and high school students – United States, 2011-2012.” MMWR Morb Mortal Wkly Rep62(35): 729-730.

12 Department of Health and Human Services (2010). National prevention Council Action Plan. Available at: http://www.surgeongeneral.gov/initiatives/prevention/2012-npc-action-plan.pdf . Accessed May 5, 2014.

13 U.S. Department of Health and Human Services (2014). Let’s Make the Next Generation Tobacco-Free: Your Guide to the 50th Anniversary Surgeon General’s Report on Smoking and Health. Available at: http://www.surgeongeneral.gov/library/reports/50-years-of-progress/. Accessed May 5, 2014.

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