While people have smoked tobacco for many centuries, the epidemic of tobacco-related morbidity and mortality did not begin until the early 20th century. Three technological breakthroughs around 1900 created this phenomenon: cigarette rolling machines that reduced costs; safety matches; and mass-marketing programs. Later, the tobacco industry systematically increased the addictive potential of cigarettes.1 Thanks to these innovations, yearly cigarette use by adults in the United States grew from 54 in 1900 to 4148 in 1973, when use peaked.2 In 1999, 22.7% of US adults smoked, with a range between 29.7% in Kentucky and 13.9% in Utah.3 Because tobacco is the leading cause of preventable death in the United States, killing 430 000 US smokers and 53 000 nonsmokers annually,4 reducing smoking is the single most important action that can be taken to improve overall US health status.
The goal of the US Public Health Service's "Healthy People 2010" is to reduce adult smoking prevalence to 15% by 2010. This goal seems daunting given that adult US smoking prevalence reached a plateau between 1990 and 1999 and has since fluctuated between 23% and 26%.5 Some have argued that this goal is a policy mistake because it is unattainable through decreases in smoking initiation alone, and would require an unrealistic increase in the rate of smoking cessation.6 However, the success of aggressive state tobacco control programs indicates that this goal could be achieved if there were sufficient political will to overcome the tobacco industry's opposition to these programs.
Several states have found that such programs can dramatically decrease the rates of decline in both smoking prevalence and per capita consumption.7 Prior work has established that the changes in smoking rates are directly due to these programs and not to other coincidental factors.7- 9
Using data from state and federal sources, we estimated the average rate of decline in consumption and prevalence for the first 4 states to create large tobacco control programs— California (started in 1989), Massachusetts (1992), Arizona (1994), and Oregon (1996). Florida started a program in 1998 to reduce youth tobacco use. To determine these rates of decline we used prevalence or consumption as the dependent variable and time (over the life of the program) as the independent variable and used the slope of the resulting regression as an estimate of the average rate of change over this period. All these programs substantially accelerated the decline in smoking prevalence and per capita consumption above the rates observed in the rest of the country (Table 1). On average, the 4 adult programs yielded an average rate of decline in adult prevalence of 1% a year over the duration of the programs, compared to a 0.3% decline in the rest of the nation.
California's tobacco control program is an illustration of the possibilities and problems associated with running a successful program.7,8,10 After rapid declines in smoking between 1989 and 1993, when the program was large and aggressive, the progress in reducing smoking prevalence in California stopped in the mid-1990s due to the tobacco industry's success working with allies such as the California Medical Association to reduce funding for the program.11 Even so, adult smoking prevalence in California in 1999 was about 18%, well below the national average.3
The reductions in prevalence, however, do not tell the whole story. Despite the fact that prevalence in California has not changed significantly between 1994 and 1998, per capita consumption continued to decline during this period.8 The overall decline in cigarette consumption in the 7 years between 1989 and 1997 has translated into 59 000 fewer coronary heart disease deaths in California than would have been expected in the absence of the program.9,11
The situation in California demonstrates that the Healthy People 2010 goal of 15% prevalence by 2010 is not only achievable in California, but surpassable. Indeed, it is possible to reduce smoking prevalence in California to 10% in five years. While prevalence has not been dropping, the percentage of light smokers (those who smoke less than 15 cigarettes/day) increased by 9% between 1996 and 1999, to 60% of all smokers.12 The fact that most smokers are light smokers will make it easier to reduce overall smoking rates as light smokers are more likely to quit than heavy smokers. The National Cancer Institute COMMIT trial, an experiment involving a cohort of 13 415 smokers from 20 US and 2 Canadian communities, showed that 40% of those who smoked fewer than 15 cigarettes per day had stopped smoking after 5 years compared to 21% who smoked 15 cigarettes or more.13 Applying these quit rates to California (where 60% are light smokers) corresponds to 24% of the light smokers quitting within 5 years. Therefore, approximately 30% of all smokers would be expected to quit within 5 years. If smoking initiation does not increase substantially, this effect would correspond to a decline in prevalence of 1.2% per year. Reaching a goal of 10% prevalence in California in 5 years only requires accelerating this rate to 1.4% per year.
A reinvigorated, well-funded tobacco control program in California could achieve a reduction to 10% smoking prevalence if it includes a few proven elements.7 These include a large, aggressive antitobacco media campaign similar to the early successful campaign that focused on exposing the tobacco industry's lies, the dangers of secondhand smoke, and nicotine addiction; strong community-based programs concentrating on clean indoor air laws and countering pro-tobacco influences in the community; a smokers' quitline. Achieving this degree of reduction in smoking prevalence would require restoring not only the level of aggressiveness, but also the level of funding that was present in the early years of the effective California program (Table 1).
The public health and medical communities have historically set their sights too low and instituted tobacco control programs that have focused either on individual smoking cessation or on smoking prevention in children. Medically mediated smoking cessation programs, while an important element of treatment, are too expensive to achieve major results on a mass basis. In addition, most smokers quit without using such programs.14 Primary prevention programs for youth do not result in significant population health benefits for at least 30 years.15
Smoking is inherently a social and cultural phenomenon with an addictive individual aspect. The experience in California and other states suggests that an effective, aggressive tobacco control program employing political, legal, and social action can reduce smoking prevalence by 1% per year. Putting money from the 1998 master settlement agreement into these types of programs across the country would achieve the 10% goal by 2010.
Overall smoking prevalence need not hover at 23%-26% nationwide if public health advocates are willing to force politicians to create and fund effective tobacco control programs. Doing so will require overcoming formidable opposition from the tobacco industry, which is highly motivated and experienced at protecting its profits. Rather than reaching a floor in prevalence below which it cannot be lowered, if prevalence is reduced below 10%, the public acceptability and social support networks for smoking might collapse. Should this situation develop, smoking in the early 21st century could return to the low levels of a hundred years earlier.
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