Highlights: A Call for Action

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.