More than 50 years after the first U.S. surgeon general's report on its dangers, smoking remains the leading cause of preventable disease and death in the United States.
And almost three out of four of those in this country who still smoke say they want to quit, so they know the consequences.
The good news is that because so many did quit, smoking, at least in the United States, has been in decline. Robert Proctor, professor of the history of science at Stanford University, said cigarette smoking continued to grow throughout the 1960s and 1970s, reaching a peak of about 630 billion cigarettes, or more than 31 billion packs, smoked annually in the United States before the start of its decline in 1982.
The 1964 surgeon general's report set off one of the most powerful public health efforts ever, dramatically cutting the number of smokers. But tobacco products still pose significant risks to the health of Americans, and while the number of smokers in the U.S. has significantly declined, for every American smoker who has quit, the global rate of smoking has increased, said Allan Brandt, a professor at Harvard Medical School.
Within months of the 1964 report, the Federal Trade Commission ordered cigarette companies to put warning labels on packaging, and in 1969, cigarette advertising was banned from television and radio. Since then, according to the surgeon general's office, adult smoking rates have been cut in half.
Those who continue to smoke may subject themselves to at least 11 kinds of cancer, numerous other diseases and a lower quality of life. Since 1964, more than 20 million Americans have died as a result of smoking. Most have been active smokers, but 2.5 million were nonsmokers who died from diseases caused by secondhand smoke, according to federal statistics.
Although a smaller percentage of Americans smokes now, those who do have a greater risk of developing lung cancer than did smokers 50 years ago. That's because, according to the surgeon general's office, changes in the composition of cigarettes have increased the risk of adenocarcinoma, the most common kind of lung cancer. Ventilated filters also have allowed for more vigorous inhalation that draws toxins more deeply into the lung tissue.
Even with smoking rates far below what they were in 1964, the American Lung Association says that more than 43 million Americans, or one in five people in the U.S., still smoke. Compared with those who have never smoked, smokers have more disabilities and health problems and lose an average of more than 10 years of life. The surgeon general's office adds that the costs associated with smoking and exposure to tobacco is approaching $300 billion a year. Of that, $130 billion is direct medical costs, and $150 billion is lost productivity.
Even though the costs are high, smokers today are more hidden due to laws that prohibit smoking in public places, Brandt said, and because of the stigma attached to smoking. Smokers no longer are the social puffers who used to be seen at bars, restaurants and parties.
Erika Sward, of the American Lung Association, said that those who are most likely to smoke today generally are the less educated of a lower socioeconomic status. Targets of aggressive tobacco company marketing campaigns are the poor, the needy, the impaired, the vulnerable, those who are unable to quit, and children, she added.
"People who still smoke," Proctor said, "are those who have lost the freedom not to." He added that Hollywood still depicts smoking as glamorous, accounting for about one third of new smokers.
The tobacco industry, according to Proctor, clearly knew by the mid-1950s that cigarettes were dangerous, and the surgeon general's office charged that it deliberately misled the public about the risks.
The evolving tobacco market offers little comfort. A spokesman for the MD Anderson Cancer Center in Houston confirmed that all tobacco products, including e-cigarettes and hookahs, contain highly addictive levels of the chemical nicotine. Thus the tobacco habit hangs on.
If smoking continues at the current level, 5.6 million Americans who are younger than 16 today will die prematurely from smoking-related causes. Clearly there still is a lot of work to do.
Public health and medical organizations know what needs to be done to reduce the number of smokers and prevent kids from starting to smoke, Sward said. Policy changes are needed, she added, but politicians are afraid to challenge the tobacco industry's strong political influence. She listed these steps: Increased taxation would price buyers out of the market, smoke-free laws that prohibit smoking in certain areas need to be enacted in all states, and Medicaid must do more to help smokers quit. More prevention programs and pressure on the federal government to enhance tobacco regulation by the Food and Drug Administration would hasten the process, she added.
A little known provision of The Affordable Care Act of 2010 mandates that health insurers cover the total cost of tobacco-cessation programs. It allows for payment of the cost of prescription or over-the-counter tobacco-cessation medications and two quit attempts a year. A quit attempt includes four 10-minute counseling sessions either in a group, privately or on the phone. Thus far, Sward said, many insurance companies have yet to comply with this part of the law, which many experts agree doesn't offer enough.
Robin Koval, president of Legacy, a nonprofit organization that focuses on youth tobacco prevention, said that on average, smokers make up to 11 attempts to quit before they stop for good. Seventy percent of U.S. smokers say they want to quit, and half make an attempt each year, but only 6 percent of smokers succeed.
Help with that lonely effort to quit
Quitting cigarettes will be one of the hardest things a smoker will ever do. Ask anyone who has quit. And it can be a lonely battle as the quitter deals with inevitable cravings and ever-present temptations. But there is help.
Smoking-cessation programs are numerous, but three of the most current are the Quitter in You (quitterinyou.org), Freedom From Smoking (ffsonline.org) and the EX program (becomeanex.org).
Quitter in You, sponsored by the American Lung Association and funded by the insurance company WellPoint, recognizes that past attempts at quitting smoking are not failures and encourages more attempts. Participants can join online or attend in-person programs.
Freedom From Smoking, also an American Lung Association initiative for adults, guides smokers through an eight-session, step-by-step plan designed to help them control behavior. A Legacy initiative, the EX program helps young smokers learn to cope with smoking triggers and addiction.
The FDA public service campaign The Real Cost (therealcost.betobaccofree.hhs.gov targets youth in ads on TV, radio, print and online. Tips From Former Smokers (cdc.gov/tobacco/campaign/tips), the Centers for Disease Control and Prevention's first ever media campaign, launched in 2012, profiles ex-smokers living with serious long-term health effects from smoking.
In the last 50 years, said Stanton Glantz, director of the Center for Tobacco Control Research and Education at University of California San Francisco School of Medicine, a solid base of evidence has been accumulated to completely eliminate tobacco as a public health issue, but the political will to do that simply is lacking.
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