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© 2004 American Public Health Association
EDITORIAL |
C. Everett Koop, Julius Richmond, and Jesse Steinfeld are former surgeons general of the United States. C. Everett Koop is now with Dartmouth Medical School, Hanover, NH. Julius Richmond is with Harvard Medical School, Boston, Mass. Jesse Steinfeld is a former President of the Medical College of Georgia, Augusta, Ga.
Correspondence: Requests for reprints should be sent to C. Everett Koop Institute Dartmouth Medical School 7025 Strasenburgh, Hanover, NH 03755.
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INTRODUCTION |
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 TOP INTRODUCTION WE HAVE A CHOICEHELPING SMOKERS QUIT IS...WE KNOW HOW TO...WE NEED TO ACT...References |
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America has a choice—a choice born of science and advances in policy, a choice we never had during our tenures as surgeons general. That choice, offered by the Subcommittee on Cessation of the Interagency Committee on Smoking and Health (ICSH), is described in this issue of the Journal.1 The ICSH plan provides specific, evidence-based steps to dramatically reduce tobacco use in the United States and prevent 3 million premature deaths. It is now up to policymakers and private sector leaders to abandon cautious half-measures and instead boldly enact the laws and policies outlined in the ICSH plan. When those laws and policies are implemented, millions of American smokers will successfully quit. It is, indeed, time for action.
More than 10 million Americans prematurely lost their lives to tobacco-caused diseases during the 20th century.2 At the current pace of approximately 450 000 deaths attributable to tobacco per year, we will suffer another 10 million deaths in little more than the first 2 decades of the 21st century. Nearly half of today’s approximately 50 million cigarette smokers will die prematurely because of their addiction.3
Tobacco use is a unique cause of death. We are so used to recording the annual toll of nearly half a million deaths that we have become complacent. We write off the victims of tobacco dependence, unlike the victims of any other treatable disease, as if their deaths were acceptable, deserved, or unavoidable. When a new disease, AIDS, hit America like a bombshell in the early 1980s, there were some who wanted to focus exclusively on prevention and avoid the difficult and expensive challenge of finding and administering treatments. Though much is yet to be done to treat those afflicted with HIV/AIDS, America has made enormous progress toward meeting that challenge. Will America rise to meet the current challenge posed by tobacco addiction?
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WE HAVE A CHOICE |
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TOPINTRODUCTIONWE HAVE A CHOICEHELPING SMOKERS QUIT IS...WE KNOW HOW TO...WE NEED TO ACT...References |
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Let us underscore the good news: our nation has a choice. But the choice is not prevention versus treatment. In fact, we can probably achieve both ends more effectively if we tackle both prevention and cessation goals together. We have a path open to us, a path that may at first glance seem radical to those who have not spent their professional lives trying to reduce tobacco-caused disease. This path, although innovative, rests on a strong foundation of science. It is the path recommended by the prestigious panel that constituted the Subcommittee on Cessation of the ICSH, the path described in this issue of the Journal.1 We have reviewed these recommendations and we strongly endorse them.
As past surgeons general we understand, perhaps better than most, that politics and misunderstandings about tobacco addiction and disease could hinder efforts to implement the recommendations of the subcommittee. We understand the power of the tobacco industry and its interest in keeping its customers, not losing them to cessation and good health. We also understand that many people, people who should know better, believe the tobacco industry’s rhetoric claiming that smoking is an adult choice, not realizing that the vast majority of tobacco users lost their free choice when they became addicted as children. Most tobacco users started to smoke during adolescence and were hooked before the age of 18 years. 4,5
Unless one understands the tenacious hold of tobacco addiction on the user, one cannot understand the need for treatment. In fact, when we were appointed to our terms as surgeons general, the official position was that smoking was a habit and not an addiction. That did not change until the 1988 surgeon general’s report on the health consequences of smoking. That report concluded that cigarette smoking, because of the nicotine in tobacco, was a form of drug addiction similar in its strength and biological action to other forms of drug addiction,6 which were thought by the public to be much more perilous. That conclusion paved the way for the first US Public Health Service clinical practice guideline on smoking cessation7 and many other publications that have contributed to more effective prevention efforts, enhanced cessation activity, and increased treatment availability. But there is so much more to do.
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HELPING SMOKERS QUIT IS ESSENTIAL |
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TOPINTRODUCTIONWE HAVE A CHOICEHELPING SMOKERS QUIT IS...WE KNOW HOW TO...WE NEED TO ACT...References |
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Despite the successes of recent years, only a small percentage of cigarette smokers achieve lasting tobacco abstinence each year, and they are largely replaced by new smokers. As a result, the prevalence of smoking has dropped little over the last decade, from about 25% in the mid-1990s to approximately 23% in 2001.8 Compelling evidence indicates that we need comprehensive tobacco control. We need more accessible treatment. We need policies that encourage smokers to quit. We need to make it as easy to get treatment as it is to get tobacco. The ICSH plan provides a path to those ends. We must seize the opportunity. As surgeons general from the 1970s and 1980s we fervently believe that America must not squander this unique opportunity to improve public health. Victory is within our grasp, but it can be achieved only through the bold and visionary application of new scientific knowledge.
America has a choice. The choice is to put health and life over the profits and political concerns of the tobacco industry. The ICSH subcommittee plan would give millions of Americans a better chance at health. It has been estimated that implementation of this plan would enable 5 million American smokers to achieve freedom from tobacco within the first year and prevent the premature tobacco-caused deaths of 3 million individuals. We believe in this plan and therefore support it. We urge that all health professionals and policymakers review it carefully. This plan offers an opportunity unlike any offered before.
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WE KNOW HOW TO REDUCE TOBACCO’S TOLL |
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TOPINTRODUCTIONWE HAVE A CHOICEHELPING SMOKERS QUIT IS...WE KNOW HOW TO...WE NEED TO ACT...References |
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The plan builds upon a strong foundation of converging science. Research findings from the Centers for Disease Control and Prevention, the National Institutes of Health, the American Cancer Society, and many other organizations provide a powerfully persuasive body of evidence on how to reduce tobacco use and dependence.9,10 We know, on the basis of previous studies, that increasing the cost of tobacco products not only keeps youngsters from starting to smoke but will actually save lives.9,11 We also know, with a fair degree of precision, how many lives. We know through repeated studies that particular treatments will double or triple the odds of quitting tobacco use permanently. These treatments are far more cost-effective than many accepted treatments for other life-threatening disorders. We know that tobacco addiction is not an equal opportunity killer; rather, it disproportionately claims the least advantaged members of our society. We also now know that addiction is not something that must be accepted with resignation but is instead a disorder that can be treated, and treated effectively.
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WE NEED TO ACT NOW |
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TOPINTRODUCTIONWE HAVE A CHOICEHELPING SMOKERS QUIT IS...WE KNOW HOW TO...WE NEED TO ACT...References |
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The subcommittee’s recommendations are particularly timely because our nation is entering an era in which the tobacco industry has learned from its recent losses and is trying to offer smokers a substitute for cessation. Tobacco companies, big and small, have been launching wave after wave of new products with promises that appeal to the health concerns of cigarette smokers—promises of reduced risk of disease, reduced environmental tobacco smoke, even reduced carcinogens.5 However, none of these promises has been proven true; these products may alleviate smokers’ anxiety but not necessarily their health risks.12 This is a time to redouble our efforts to help people stop tobacco use—the only proven, powerful and effective way to reduce the risk of tobacco-related disease.
We live in a tax-phobic time. Yet "sin taxes" should not be considered in the same category as general tax levies. Sin taxes affect the sinner only, and can be structured in a way to provide benefit. Smokers already pay $7 billion each year in federal excise taxes, but none of this money is earmarked to help them stop smoking. The increase in tobacco taxes proposed in the ICSH plan would, for the first time, be used to help tobacco users overcome their powerful addiction and thereby both improve health and save lives. The American people should know that if the White House or Congress opposes the legislation called for by this plan, these agents of the people are putting their stamp of approval on tobacco-caused disease, the disability of millions, and the premature deaths of nearly half a million Americans each year.
In sum, the plan recommended by the subcommittee of the ICSH lays out specifically what can be accomplished for the health of Americans and how to pay for it. Its scientific basis is sound, its steps feasible, and its potential benefits profound. Only a wholehearted adoption of the plan will create maximum savings of human life and prevention of suffering. The promise to prevent 3 million premature deaths among current tobacco users is powerful and credible. We urge full and expeditious implementation of the plan.
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Acknowledgments |
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The authors wish to thank Jack Henningfield, Timothy Baker, and Michael Fiore, as well as the Robert Wood Johnson Foundation Innovators Award Program for their kind assistance in the preparation of this editorial.
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Footnotes |
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Contributors
C. E. Koop led the writing of the editorial. All authors helped review drafts of the editorial.
Accepted for publication November 2, 2003.
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References |
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TOPINTRODUCTIONWE HAVE A CHOICEHELPING SMOKERS QUIT IS...WE KNOW HOW TO...WE NEED TO ACT...References |
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1. Fiore MC, Croyle RT, Curry SJ, et al. Preventing 3 million premature deaths and helping 5 million smokers quit: a national action plan for smoking cessation. Am J Public Health. 2004;94:205–229.
2. Centers for Disease Control and Prevention. Perspectives in disease prevention and health promotion: smoking-attributable mortality and years of potential life lost—United States, 1984. MMWR Morb Mortal Wkly Rep. 1997;46:444–451.[Medline]
3. Tobacco or Health: Global Status Report. Geneva, Switzerland: World Health Organization; 1999.
4. Colby SM, Tiffany ST, Shiffman S, Niaura RS. Are adolescent smokers dependent on nicotine? A review of the evidence. Drug Alcohol Depend. 2000;59(suppl 1): S83–S95.
5. Henningfield JE, Moolchan ET, Zeller M. Regulatory strategies to reduce tobacco addiction in youth. Tob Control. 2003;12(suppl 1): I14–I24.[Medline]
6. The Health Consequences of Smoking: Nicotine Addiction: A Report of the Surgeon General. Rockville, Md: Center for Health Promotion and Education, Office on Smoking and Health; 1988.
7. Fiore MC, Bailey WC, Cohen SJ, et al. Smoking Cessation. Clinical Practice Guideline No. 18. Rockville, Md: Agency for Health Care Policy and Research; 1996.
8. Centers for Disease Control and Prevention. Cigarette smoking among adults—United States, 2001. MMWR Morb Mortal Wkly Rep. 2003;52:953–956.[Medline]
9. Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, Md: US Public Health Service; 2000.
10. Hopkins DP, Fielding JE, and the Task Force on Community Preventive Services. The guide to community preventive services: tobacco use prevention and control. Am J Prev Med. 2001;20(suppl):1–88.
11. Reducing Tobacco Use: A Report of the Surgeon General. Atlanta, Ga: National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2000.
12. Stratton K, Shetty P, Wallace R, Bondurant S, eds. Clearing the Smoke: Assessing the Science Base for Tobacco Harm Reduction. Washington, DC: National Academy Press; 2001.
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