Setting the National Tobacco Control Agenda

President Obama's recent comment that the White House will be smoke-free even if he continues to smoke¹ and the report that cancer will surpass heart disease in 2010 as the leading cause of death in the world largely due to tobacco use² are reminders that smoking—the leading preventable cause of death in the United States—remains a massive public health problem for this and future generations. The prevalence of tobacco use has declined to just less than 20% of the US population,³ but with more than 43 million smokers³ in the United States, an estimated 400 000 individuals die prematurely each year due to tobacco use.⁴

Tobacco control efforts in the United States are similar to any battle, for which strategic goals exist but success is defined as gradually taking more territory until a tipping point has occurred, which allows for more rapid and expansive successes. The United States has arguably achieved a critical tipping point now that there are more former smokers than active smokers and more than half the population lives where smoking is prohibited in workplaces.⁵ But tobacco control successes are tempered by major challenges. For example, there are now smoking cessation quit lines in every state, but because there are few resources, they can help only 1% to 2% of smokers quit.⁶ Moreover, businesses have begun to recognize the health and cost benefits of supporting smoking cessation programs within insurance programs, but a large percentage of those with the lowest income—who also happen to have the highest smoking prevalence—have no insurance at all and thus cannot afford the most effective smoking cessation treatments. Furthermore, much of the world ratified the first global health treaty—the Framework Convention on Tobacco Control (FCTC)—but the United States has still not ratified this treaty that is fundamental to reducing tobacco use in the United States and around the world.

To maximize tobacco control and to ensure capitalization on existing successes, it is essential to target the system of tobacco use by coordinating efforts to make tobacco use less likely. The public health model of addressing agent, host, vector, and environment reflects a systems approach that, based on lessons from the communicable disease community, can be highly effective. Thus, by simultaneously reducing the health risks of tobacco or reducing its availability (agent), by decreasing demand for tobacco by helping more smokers to quit and reducing the desire to smoke by youth (host), by reducing the ability of tobacco companies to create new tobacco addicts (vector), and by fostering social norms whereby tobacco simply does not fit (environment), it should be possible to most rapidly decrease tobacco use.

The current administration along with Congress has the unique opportunity to return the United States to a position of public health leadership by actively supporting a series of tobacco control efforts that address agent, host, vector, and environment, and thus has the potential to protect hundreds of thousands of lives in the short term and hundreds of millions in the long term. Several evidence-based and actionable initiatives, if enacted soon, together will have system-wide influence. Some have minimal cost and others are based on an investment that would provide a substantial long-term return through reduced health care costs, improved productivity, and increased quality and quantity of life. But together these suggested initiatives emphasize both the broadest implementation of evidence-based practices and the conduct of new research to ensure even greater advances in tobacco control.

The FCTC should be sent to the Senate with the strongest recommendation that this essential global public health treaty be ratified. Ratification of the FCTC would establish requirements for the United States to implement a broad array of tobacco control measures, including placing restrictions on tobacco company advertising, ensuring that all smokers have access to affordable treatment, increasing the cost of tobacco, and establishing a broad array of other evidence-based tobacco policies.⁷ Ratification of the FCTC would also legally bind the United States to implement the evidence-based tobacco control practices that would reduce tobacco use, including essential efforts including policy initiatives and community programs to denormalize tobacco use. Moreover, once the FCTC is ratified, the United States will finally have a formal seat at the global table of FCTC partner nations, now numbering 160, to help ensure that the FCTC has maximum capability to improve public health.

Congress should approve and the president should sign legislation that would give the US Food and Drug Administration (FDA) authority over tobacco. At present, the FDA is prohibited from regulating tobacco products, but this legislation would create important new opportunities to reduce the substances in tobacco that cause disease and to even restrict substances in tobacco (eg, nicotine) that cause tobacco addiction. Even though this legislation has not received universal support from the public health community, it is a major step that most likely will cause tobacco companies to begin moving more rapidly out of the tobacco business and into more socially acceptable product lines.

Congress should pass and the president should sign legislation to implement the National Action Plan for Tobacco Cessation.⁸ This initiative would increase the tax on cigarettes in order to fund an array of tobacco control efforts ($14 billion), with the rest ($14 billion) going into the US Treasury. The new funding would support a large increase in funding for state smoking cessation quit lines, create media campaigns to encourage more smokers to quit, and support new research designed to improve tobacco treatment. The value of prioritizing smoking cessation was made clear by Peto and Lopez,⁹ whose analyses show that cessation more than prevention will have the greatest effect on reducing tobacco-caused mortality between now and 2050.

As provisions of the FCTC make clear, the tax alone would also lead to a significant decrease in tobacco use because more individuals would quit smoking because of the higher cost of cigarettes. Smokers pay the tobacco tax, so the tax they pay should fund tobacco prevention and treatment programs, as well as provide some partial payment back to the federal government for tobacco-caused health care. The net projected benefit from this initiative alone is that 5 million individuals will quit smoking and 3 million premature deaths will be averted.⁸

The president should identify a tobacco control leader with high-level access to senior officials in the administration to serve as the government's point person on tobacco. This leader would have the mandate to press for action within specific agencies, along with the mandate to coordinate tobacco control efforts government-wide to ensure maximum progress. For example, the tobacco control leader could press for very specific agency actions, such as using the FDA's critical-path process to foster public and private partnerships that could speed the development of more effective medications to help smokers quit. At the same time, the tobacco control leader would be responsible for more macro-level activities, such as fostering greater coordination among the operational divisions (eg, National Institutes of Health, Centers for Disease Control and Prevention, FDA) of the Department of Health and Human Services (DHHS) to ensure that the government is working in a coordinated way to speed new science discoveries into clinical and community practice.

In 2004-2005, I temporarily served as senior advisor for tobacco policy within the Office of the Secretary in the DHHS. After moving into that role, it was clear that coordination across the government on tobacco control matters is critically needed but is often lacking. Tobacco control is complex and requires action from virtually every branch of government, so it needs a visible and effective leader who has a mandate from senior DHHS and White House policy makers to ensure coordination and action.

Given that an estimated 50% of smokers will die of tobacco-caused diseases,¹⁰ it is essential that a coherent funding and implementation plan be developed across DHHS to ensure that the requisite research is supported and that policies and practices that evidence shows have a high likelihood of reducing tobacco use are promoted. For example, current medications and behavioral programs are only modestly effective and typically help fewer than 30% of smokers quit over the long term.¹¹ Thus, it is essential to increase the National Institutes of Health budget for cessation research, with the goal of ensuring that treatments exist so that every tobacco user, even the most highly addicted, who wishes to stop can do so. Just as efforts to reduce the morbidity and mortality associated with HIV/AIDS has resulted in 30 antiretroviral drugs that have dramatically decreased AIDS-related mortality,¹² rapid expansion of medication development for smoking cessation is needed. Currently, only 7 medications are approved by the FDA for smoking cessation, and 5 of them are the same medication delivered in different ways.

But even this investment could ultimately be for naught if smokers do not have access to those new treatments. For example, too many smokers, particularly the underserved or uninsured, cannot access effective smoking cessation medications. A national infrastructure for assessing and treating tobacco use and addiction in both youth and adults must be part of a comprehensive and cohesive tobacco control funding plan—along with the other practice and policy recommendations identified in the National Action Plan for Tobacco Cessation, FCTC, and FDA tobacco control plans.

Taking action to dramatically reduce tobacco use will have cascading positive benefits on society, most importantly via decreases in health care costs now paid by businesses and taxpayers. Major reductions in tobacco use will create a healthier and more productive workforce that may help ensure the success of US businesses. Members of the CEO Roundtable on Cancer recognized this fact when it identified tobacco treatment as a fundamental priority for the business community.¹³

This short list of tobacco control initiatives is based on solid science and merits rapid consideration and implementation. The evidence is clear that these initiatives will likely have the desired effect of speeding the United States toward a time when tobacco addiction and tobacco-caused disease are remembered as a footnote in public health history.