In the 24th session of the second series of assessments of
Healthy People 2010, Principal Deputy Assistant Secretary for Health
Donald Wright chaired a Progress Review on Tobacco Use. He was assisted by
staff of the lead agency for this Healthy People 2010 focus area, the
Centers for Disease Control and Prevention (CDC). Also participating in the
review were representatives from other agencies and offices within the U.S.
Department of Health and Human Services (HHS). Dr. Wright framed the public
health challenge that tobacco use poses to the United States in the following
terms: the cause of an estimated 12 million deaths over the past four decades,
including 4.1 million deaths from respiratory disease and 94,000 infant deaths
relating to mothers smoking during pregnancy. Despite these risks,
approximately 45.3 million U.S. adults smoke cigarettes. Coupled with this
health toll is a tremendous economic burdenmore than $96 billion per year
in medical expenditures and another $97 billion per year resulting from lost
productivity. Dr. Wright praised CDC's Office on Smoking and Health, the
National Cancer Institute (NCI), and the Agency for Healthcare Research and
Quality (AHRQ) for being in the forefront of collaborative efforts nationwide
to advance a comprehensive, broad-based approach to reducing tobacco use.
The complete November 2000 text for the Tobacco Use focus
area of Healthy People 2010 is available online at
www.healthypeople.gov/document/html/volume2/27tobacco.htm.
Revisions to the focus area chapter that were made after the January 2005
Midcourse Review are available at
www.healthypeople.gov/data/midcourse/html/focusareas/fa27toc.htm.
For comparison with the current state of the focus area, the report on the
first-round Progress Review (held on May 14, 2003) is archived
http://www.healthypeople.gov/data/2010prog/focus27/2003fa27.htm.
The meeting agenda, tabulated data for all focus area objectives, charts, and
other materials used in the Progress Review can be found at a companion site
maintained by the CDC National Center for Health Statistics (NCHS): www.cdc.gov/nchs/about/otheract/hpdata2010/focusareas/fa27-tobacco2.htm.
That site has a link to wonder.cdc.gov/data2010,
which provides access to detailed definitions for the objectives in all 28
Healthy People 2010 focus areas and periodic updates to their
data.
Data Trends
In providing an overview of data that relate to Tobacco Use
objectives, NCHS Director Edward Sondik stated that smoking is the leading
cause of preventable death in the United States, exacting a toll of 438,000
deaths and 8.6 million serious illnesses each year. He noted that one of the
singular and constraining characteristics of the focus area is the rapid
turnover of the cohort most susceptible to taking up the smoking
habitadolescents. Most objectives in the focus area are improving or
remaining much the same. Of the objectives and subobjectives that were retained
after the 2005 Healthy People 2010 Midcourse Review, 3 have met or
exceeded their targets, 24 are moving toward their targets, 11 are showing
little or no change, and 2 are moving away from their targets. Seven are
without supporting data at all or none beyond the baseline. Dr. Sondik provided
a more detailed examination of objectives selected by the focus area workgroup
for highlighting at the Progress Review:
(Obj. 27-1a): The age-adjusted proportion
of adults aged 18 and older who smoked cigarettes decreased from 24 percent in
1998 to 21 percent in 2006. A decrease over this period in the age-adjusted
proportion of adults who smoked cigarettes held true for all racial and ethnic
groups for whom data were available: among American Indians/Alaska Natives,
from 35 percent to 27 percent; among non-Hispanic blacks, from 25 percent to 22
percent; among non-Hispanic whites, from 25 percent to 23 percent; among
Hispanics, from 19 percent to 15 percent; and among Asians, from 13 percent to
11 percent. The 2010 target is 12 percent for all population groups. In 1965,
51 percent of adult males smoked cigarettes, compared with 34 percent of adult
females. Even though the proportion of adult males who smoke remains higher
than the proportion of adult females who smoke, the proportion declined more
sharply for males than for females between 1965 and about 1985. From a
geographic perspective, higher proportions of adult smokers are, in general, to
be found in the Appalachian and south central States and in certain western
States and Alaska. A similar geographic pattern is seen for lung cancer death
rates.
(Objs. 27-2a-e): The proportion of
adolescents in high school (grades 9 through 12) who had used any tobacco
product during the previous month decreased from 40 percent in 1999 to 26
percent in 2007. The target is 21 percent. With respect to specific tobacco
products, the pattern of use by adolescents in high school was as follows:
cigarettesused by 35 percent in 1999, compared with 20 percent in 2007
(target: 16 percent); spit tobaccoused by 8 percent in 1999, the same as
in 2007 (target: 1 percent); cigarsused by 18 percent in 1999, compared
with 14 percent in 2007 (target: 8 percent); and bidisused by 4 percent
in 2000, compared with 3 percent in 2006 (target: 2 percent). In general, the
proportion of high school students who smoked cigarettes increased each year
during the early 1990s, plateaued during the late 1990s, and began to decline
in about 1999. The downward trend ended in about 2003 and the proportion of
students who smoke cigarettes has remained much the same in the years
since.
(Objs. 27-14a, 27-15): In 2007, 4 States
had a rate of illegal tobacco sales to minors of 5 percent or less, compared
with no States in 1998. The target is 51 (50 States and the District of
Columbia). The number of States that suspend or revoke State retail licenses
for violations of laws prohibiting the sale of tobacco to minors increased from
22 in 1998 to 24 in 2007. The target is 51 (50 States and the District of
Columbia).
(Objs. 27-16a, b): In 2000, 28 percent of
adolescents in grades 6 to 12 recalled being exposed to tobacco advertising and
promotions on the Internet, a proportion that increased to 38 percent in 2006.
The target is 25 percent. The proportion of that age group that recalled being
exposed to tobacco advertising and promotions in magazines and newspapers was
74 percent in 2000, a proportion that decreased to 58 percent in 2006,
surpassing the target of 67 percent.
(Objs. 27-17a-c): The proportion of
adolescents who disapprove of smoking increased from 1998 to 2007 as follows:
among 8th-graders, from 80 percent to 87 percent; among 10th-graders, from 75
percent to 85 percent; and among 12th-graders, from 69 percent to 81 percent.
The target is 95 percent for all three grades.
(Obj. 27-5): The age-adjusted proportion of
adults aged 18 years and older who had made attempts to quit smoking increased
from 45 percent in 1998 to 47 percent in 2006. The target is 80 percent. In
2006, only 4 percent of the age-adjusted total of adults in the age group were
abstinent at the time of the survey, that is, could be judged successful in
their attempts. This proportion had varied little since 1998.
(Obj. 27-9): In 1998, 20 percent of
children aged 6 years and younger lived in a household where someone smoked
inside the home at least 4 days per week, compared with 8 percent in 2005.
Reductions over this time period in exposure of young children to indoor
smoking were reported for racial and ethnic groups and family income groups as
follows: among non-Hispanic blacks, from 27 percent to 12 percent; among
non-Hispanic whites, from 22 percent to 9 percent; among Hispanics, from 11
percent to 4 percent; among the poor, from 32 percent to 15 percent; among the
near poor, from 26 percent to 12 percent; and among those in a middle- or
high-income household, from 13 percent to 5 percent. The target for all groups
is 6 percent.
(Obj. 27-10): Measured exposure to
environmental tobacco smoke of nonsmokers aged 4 years and older (age-adjusted)
decreased from 84 percent in the period 19881994 to 44 percent in
20032006. Among three racial and ethnic groups for whom data were
available, measured reductions in such exposure occurred as follows: among
non-Hispanic blacks, from 93 percent to 62 percent; among non-Hispanic whites,
from 84 percent to 43 percent; and among Mexican Americans, from 74 percent to
34 percent. The target is 56 percent.
(Obj. 27-11): The proportion of middle,
junior high, and senior high schools that was smoke-free and tobacco-free
increased from 37 percent in 1994 to 64 percent in 2006. The target is 100
percent.
(Objs. 27-13a-f, i): In 2007, the number of
States that had established laws mandating smoke-free air for specific
worksites and public places were as follows: private workplaces, 22 (compared
with 0 in 1998); public workplaces, 27 (compared with 10 in 1998); restaurants,
21 (compared with 1 in 1998); public transportation, 31 (compared with 16 in
1998); daycare centers, 34 (compared with 20 in 1998); retail stores, 23
(compared with 6 in 1998); and bars, 13 (compared with 0 in 1998). The target
for each of these locations is 51 (50 States and the District of Columbia)
Key Challenges and Current Strategies
Representatives from CDC, AHRQ, and NCI made presentations
on the principal themes of the Progress Review. They included Janet Collins,
Director of the CDC National Center for Chronic Disease Prevention and Health
Promotion; CAPT Matthew McKenna, Director of the CDC Office on Smoking and
Health; Christine Williams, AHRQ's Director for Strategic Partnerships; Erik
Augustson of the NCI Tobacco Control Research Branch; and Cathy Backinger,
Chief of the Tobacco Control Research Branch. Their statements, the discussion
that ensued, and Progress Review briefing materials prepared by an interagency
workgroup identified a number of barriers to achieving the objectives, as well
as activities under way to meet these challenges, including the following:
Barriers
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Each day in the United States, approximately 4,000 young
people aged 12 to 17 years start smoking, of whom about 1,140 become daily
cigarette smokers. Most people who smoke begin before age 18 and almost 87
percent of all adult smokers started smoking when they were teenagers.
-
If current trends continue, more than 6 million people
who are now smoking as adolescents will die more than 10 years prematurely due
to their smoking addiction. Three out of four teenage smokers have tried to
quit at least once, but have failed.
-
Tobacco dependence is a chronic condition that often
requires repeated intervention. Quitting tobacco use is difficult and may
require multiple attempts, as users often relapse because of withdrawal
symptoms.
-
Smokeless tobacco companies are marketing their products
to smokers to use when they cannot smoke.
-
The 2006 report The Health Consequences of
Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General
stated that, on average, children are exposed to more secondhand smoke than
nonsmoking adults and are especially vulnerable to the more than 250 toxic or
carcinogenic chemicals it contains. Both babies whose mothers smoke while
pregnant and babies exposed to secondhand smoke after birth are more likely to
die from sudden infant death syndrome (SIDS) than babies who are not exposed.
On the basis of scientific evidence, the Surgeon General concluded that there
is no risk-free level of exposure to secondhand smoke. Even brief exposures can
be harmful.
-
Children exposed to secondhand smoke are at an increased
risk for SIDS, acute respiratory infections, ear problems, severe asthma, other
respiratory symptoms, and slowed lung growth.
-
According to the National Health and Nutrition
Examination Survey conducted during the first half of the current decade, more
than 60 percent of children aged 4 to 11 years had detectable levels of
cotinine, a biomarker of secondhand smoke exposure, in their blood, compared
with 42 percent of nonsmoking adults aged 20 years and older.
-
In 2003, the most recent year of record, the amount of
money spent on tobacco industry marketing was more than 22 times the amount
spent on tobacco use prevention ($15.15 billion vs. $0.67 billion).
-
Exposure to tobacco imagery in movies is causally
related to smoking by youth, who are also influenced to start smoking by
tobacco advertising and promotions.
-
Anti-tobacco campaigns directed at youth that are
sponsored by the tobacco industry are generally not effective and may actually
increase youth smoking.
Activities and Outcomes
-
People who stop smoking greatly reduce their risk of
dying prematurely. In 2006, an estimated 45.7 million adults were former
smokers.
-
Smoking rates increased rapidly throughout the 1930s,
'40s, '50s and '60s, and then started to decrease with the release of the first
Surgeon General's report on tobacco in 1964. Per capita cigarette consumption
is now at the lowest rate since the Great Depression.
-
State tobacco control programs that are comprehensive,
sustained, and accountable and that employ evidence-based interventions reduce
tobacco use rates and tobacco-related disease and death. If States invested in
comprehensive tobacco control and prevention at CDC-recommended levels, there
would be an estimated 5 million fewer smokers and hundreds of thousands of
premature tobacco-related deaths would be prevented.
-
A 2007 Institute of Medicine Report presented a
blueprint for action to "reduce smoking so substantially that it is no longer a
public health problem for our Nation." The executive summary of the report is
available at
www.cdc.gov/tobacco/tobacco_control_programs/stateandcommunity/best_practices/00_pdfs/2007/ BestPractices_ExecutiveSummary.pdf
[PDF - 152 kb].
-
The number of States in which the Medicaid program
provides coverage for treatment of nicotine dependency rose from 24 in 1998 to
36 in 2002, then to 39 in 2006.
-
Significant progress in expanding secondhand smoke
protections has continued to occur at the local level. Most of the largest U.S.
cities are covered by a local or State law that makes at least some settings
smoke-free.
-
In contributing to the public health campaign to reduce
the proportion of young children who are exposed to secondhand smoke in their
homes, the Environmental Protection Agency is carrying out a sustained public
education initiative to encourage parents to make their homes
smoke-free.
-
The U.S. Public Health Service Clinical Practice
Guideline Treating Tobacco Use and Dependence: 2008 Update, produced
by AHRQ, offers clinicians a greater number of effective medications to help
achieve smoking cessation. The guideline provides evidence of the effectiveness
of each medication relative to the others. The HHS Food and Drug Administration
has now approved seven effective first-line smoking cessation medications.
-
Treating Tobacco Use and Dependence: 2008
Update also provides stronger evidence that counseling is an effective
treatment strategy for adults, both clinically and in terms of cost. In
addition, combining counseling with medication increases the likelihood of
quitting more than either alone. For the first time, counseling for adolescent
smokers has been shown to be effective. Counseling by telephone through
"quitlines" can significantly expand the reach of effective treatment.
-
Launched in November 2004, the HHS initiative
"1-800-Quit-Now" provides a single nationwide access number for smoking
cessation counseling by telephone, a service that is now available in all
States and the District of Columbia. NCI provides access to and maintenance of
the call number and CDC has supported the States in expanding their quitline
services, which collectively serve about 400,000 smokers per year. The number
of calls to 1-800-Quit-Now passed 1 million by the end of 2007.
-
The cost of tobacco has a significant impact on use of
tobacco by youth, who are much more susceptible than adults to altering their
smoking behavior when prices increase. A 10 percent increase in the price of
cigarettes leads to a 5 percent reduction in smoking prevalence among youth, a
much greater percentage reduction than among adults.
-
In media campaigns to prevent initiation of tobacco use
and encourage tobacco cessation, ads that show industry manipulation, the
effects of secondhand smoke, and those that elicit negative emotions are the
most effective strategies for denormalizing smoking and reducing cigarette
consumption.
Approaches for Consideration
Participants in the Progress Review made the following
suggestions for public health professionals and policymakers to consider as
steps to enable further progress toward achieving the objectives for Tobacco
Use:
-
Increase efforts to bring about resumption of the
decline in smoking among youth that stalled in the middle of this
decade.
-
Support research and evidence-based programs to address
disparities in secondhand smoke exposure among ethnically and socioeconomically
diverse populations, as well as among children.
-
To further reduce secondhand smoke exposure, seek to
more fully extend policy protections to include blue collar, service,
hospitality, and gaming workers.
-
Strengthen the alignment between cessation and
secondhand smoke interventions and between chronic disease prevention and
secondhand smoke reduction initiatives.
-
Expand research to find ways to increase demand for and
use of existing smoking cessation services and treatments.
-
Target additional research on smoking cessation toward
pregnant women, adolescents, people with low socioeconomic status, and those
with psychiatric co-morbidities.
-
Urge insurers and purchasers to ensure that insurance
plans include as covered benefits the kinds of counseling and medication that
have been identified as effective in tobacco dependence treatment aimed toward
achievement of smoking cessation.
-
Encourage clinicians and health care delivery systems to
ensure patient access to quitlines and promote quitline use on a broader
scale.
-
Step up national advocacy of quitlines and seek ways to
expand their capacity.
-
Direct additional research efforts to the effects on
youth of tobacco use policies, such as those regarding taxes, smoke-free laws,
and media.
-
Devote increased attention to the impact of tobacco
industry advertising and marketing.
Contacts for information about Healthy
People 2010 Focus Area 27Tobacco Use:
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[Signed October 27, 2008] Donald Wright, M.D.,
M.P.H. Principal Deputy Assistant Secretary for Health
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