Reducing Tobacco Use: A Report of the Surgeon General-2000

ABSTRACT: "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."

Tobacco use, particularly smoking, remainsthe number 1 cause of preventable disease and death in the United States. Thisreport of the Surgeon General on smoking and health is the first to offer acomposite 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 havelooked at aspects of such strategies.

This report evaluates each of five major approaches to reducingtobacco use: educational, clinical, regulatory, economic, and comprehensive.Further, the report attempts to place the approaches in the larger context oftobacco control, providing a vision for the future of tobacco use prevention andcontrol based on these available tools. The report is clear in its overridingconclusion: Although our knowledge about tobacco control remains imperfect, weknow more than enough to act now.

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 overwhelming 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 1 year posttreatment. 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 theuse of tobacco. Legal and legislative efforts to protect children frominitiating tobacco use and to reduce smoking among adults are in a state offlux, with some important gains and some sobering setbacks. Major changes in thepublic stance of the tobacco industry have evoked a reevaluation of strategiesfor controlling and preventing tobacco uptake. Enormous monetary settlementshave provided the resources to fuel major new comprehensive antitobacco efforts,but the ultimate cost and benefit of these resources are still to be determined.

Into this changing landscape, this report introduces anassessment of information about the value and efficacy of the major approachesthat have been used to reduce tobacco use: educational, clinical, regulatory,economic, and comprehensive. Widespread dissemination of the approaches andmethods shown to be effective, especially in combination, would substantiallyreduce the number of young people who will become addicted to tobacco, increasethe 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 amongdifferent population groups, and decrease the future health burden oftobacco-related disease and death in this country.

What We Know

This Surgeon General’s report provides evidence that tobaccouse in this nation can be reduced through existing types of interventions, inline with health objectives detailed in Healthy People 2010. Attainingthese objectives will almost certainly require significant national commitmentto using the various successful approaches described in the report.

Educational Strategies

More consistent implementation of effective educationalstrategies to prevent tobacco use will require continuing efforts to buildstrong, multiyear prevention units into school health education curricula andexpanded efforts to make use of the influence of parents, the mass media, andother community resources.

School-based programs can have a significant impact on smokingbehavior among young people and are most effective when part of a comprehensive,community-based effort. Implementing effective school-based programs—alongwith community and media-based activities—can prevent or postpone smokingonset in 20% to 40% of US adolescents. Unfortunately, less than 5% of schoolsnationwide have implemented the major components of the Centers for DiseaseControl’s (CDC) recommended guidelines for school-based programs to preventtobacco 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 dependenceis in fact best viewed as a chronic disease with remission and relapse. Eventhough both minimal and intensive interventions increase smoking cessation, mostpeople who quit smoking with the aid of such interventions will eventuallyrelapse. Moreover, there is little understanding of how such treatments producetheir therapeutic effects.

Advancements in treating tobacco use and nicotine addiction havebeen summarized in an evidence-based guideline, Treating Tobacco Use andDependence. A Clinical Practice Guideline, published by the US Public HealthService. Less intensive interventions, such as brief physician advice to quitsmoking, could produce cessation rates of 5% to 10% per year. More intensiveinterventions, combining behavioral counseling and pharmacologic treatment ofnicotine addiction, can produce cessation rates of 20% to 25% per year.

Treating tobacco dependence is particularly importanteconomically in that it can prevent a variety of costly chronic diseases,including heart disease, cancer, and chronic lung disease. It has been estimatedthat smoking cessation is more cost-effective than other commonly providedclinical preventive services, including screening for cervical, breast, andcolon cancer, treatment of mild to moderate high blood pressure, and treatmentof high cholesterol. Not surprisingly, Healthy People 2010 calls foruniversal insurance coverage of evidence-based treatment for nicotinedependency.

Regulatory Efforts

Tobacco products are far less regulated in the United Statesthan they are in many other developed countries. This level of regulationapplies to the manufactured tobacco products; to the advertising, promotion, andsales of these products; and to the protection of nonsmokers from involuntaryexposure to environmental tobacco smoke (ETS) from the use of these products.Effective regulatory approaches can minimize the onset of smoking, particularlyamong young people, and may change tobacco use as an accepted social norm.

Advertising and Promotion

The report concludes that regulation of the sale and promotionof tobacco products is needed to protect young people from smoking initiation.Current regulation of advertising and promotion of tobacco products in thiscountry is considerably less restrictive than in several other countries,notably Canada and New Zealand. In 1998, tobacco companies spent $6.7 billion tomarket their products—more than $18 million each day. Attempts to regulatetobacco marketing continue to take place in a markedly adversarial and litigiousatmosphere.

Product Regulation

Warning labels on cigarette packages in the United States areweaker and less conspicuous than those of other countries, notably Canada andAustralia. Federal law preempts, in part, states and localities from imposingother labeling regulations on cigarettes and smokeless tobacco.

Smokers receive very little information regarding chemicalconstituents when they purchase a tobacco product. Without information abouttoxic constituents in tobacco smoke, the use of terms such as "light"and "ultra light" on packaging and in advertising may be misleading tosmokers. Because cigarettes with low tar and nicotine contents are notsubstantially less hazardous than higher-yield brands, consumers may be misledby the implied promise of reduced toxicity underlying the marketing of suchbrands. As with all other consumer products, adult users of tobacco should befully informed of the products’ ingredients and additives and any knowntoxicity when used as intended. Additionally, the manufactured tobacco productshould be no more harmful than necessary given available technology.

Clean Indoor Air Regulation

Although population-based data show declining ETS exposure inthe workplace over time, ETS exposure remains a common public health hazard thatis entirely preventable. Most state and local laws for clean indoor air reducebut do not eliminate nonsmokers’ exposure to ETS; smoking bans are the mosteffective method for reducing ETS exposure. Beyond eliminating ETS exposureamong nonsmokers, smoking bans have additional benefits, including reducedsmoking intensity and potential cost savings to employers. Optimal protection ofnonsmokers 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 totobacco products, a high proportion of underage youth smokers across thiscountry continue to be able to purchase their own tobacco. Measures that havehad some success in reducing minors’ access include restricting distribution,regulating the mechanisms of sale, enforcing minimum age laws, and providingmerchant education and training. Requiring licensure of tobacco retailersprovides both a funding source for enforcement and an incentive to obey the lawwhen revocation of the license is a provision of the law.

Litigation Approaches

Private law initiative is a diffuse, uncentralized activity, andthe sum of such efforts is unlikely to produce optimal results for a largerpolicy to reduce tobacco use. On the other hand, the actions of individuals arelikely to be a valuable component in some larger context of strategies to maketobacco use less prevalent.

Economic Interventions

Research clearly shows that raising tobacco prices is goodpublic health policy. Further, raising tobacco excise taxes is widely regardedas one of the most effective tobacco prevention and control strategies.Increasing the price of tobacco products will decrease the prevalence of tobaccouse, particularly among adolescents and young adults. Nevertheless, the averageprice and excise tax levels on cigarettes in the United States is well belowthat of most industrialized nations.

Furthermore, the taxes on smokeless tobacco products are wellbelow those on cigarettes in the United States. Making optimal use of economicstrategies in a comprehensive program poses special problems because of thecomplexity of government and private controls over tobacco economics and theneed for a concerted, multilevel, political approach. Healthy People 2010 callsfor state and federal taxes to average $2.00 for both cigarettes and smokelesstobacco products by 2010.

Comprehensive Programs

The most important advance in comprehensive programs has beenthe emergence of statewide tobacco control efforts. Evidence shows thatmulti-faceted, state-based tobacco control programs are effective in reducingtobacco use. Components of a multifaceted approach include:

(1) Community interventions, which include diverse entities suchas schools, health agencies, city and county governments, and civic, social, andrecreation organizations;

(2) Countermarketing, which includes using media advocacy, paidmedia, pro-health promotions, and other media strategies to change social normsregarding tobacco use;

(3) Program policy and regulation, which addresses such issuesas minors access, tobacco pricing, advertising and promotion, clean indoor air,product regulation, and tobacco use cessation; and

(4) Surveillance and evaluation, which includes monitoringtobacco industry promotional campaigns, evaluating the economic impact of ETSlaws and policies, conducting surveys of public opinion on programinterventions, and other activities to make ongoing refinements that lead tomore effective prevention strategies. The synergy created by the interaction ofvarious program components in a comprehensive approach is believed to beresponsible for increased success in reducing tobacco use.

Global Efforts

The report addresses research on strategies to reduce tobaccouse within our nation’s social, legal, and cultural environment. Nevertheless,findings from this report may have broad utility in the planning of tobaccocontrol efforts around the world. Globally, smoking-related deaths will rise to10 million per year by 2030, and 7 million of these deaths will occur indeveloping countries. For the first time, the United States will collaboratewith international organizations like the World Health Organization and withindividual countries to help create a global partnership to stem the pandemic oftobacco-related death and disease. This report can serve as a blueprint withwhich the national and global public health communities can begin buildingcapacity to combat the devastating health and economic effects of tobacco use.

Elimination of Health Disparities

The elimination of health disparities related to tobacco useposes a great national challenge. Cultural, ethnic, religious, and socialdifferences are clearly important in understanding patterns of tobacco use.Reaching the national goal of eliminating health disparities related to tobaccouse will require more research to develop effective interventions for variouspopulation groups.