Tobacco Control: How Are We Doing?

Follow-up on: Warner K, Sexton D, Gillespie B, Levy D, Chaloupka F. Impact of tobacco control on adult per capita cigarette consumption in the United States. Am J Public Health. 2014;104(1):83–89.

The tobacco epidemic still looms large as one of the greatest human-created threats of all time.¹ In the last century alone, a staggering 100 million people lost their lives to it¹, and in this century—unless something changes drastically—a billion people could die needlessly or be plagued by disability. To avoid this calamity, a broad range of policy, public health, and health service interventions must be employed in an orchestrated manner. In this journal, on the 50th anniversary of the first surgeon general’s report on smoking and health, Warner et al. analyzed the impact of tobacco control efforts on US per capita cigarette consumption, concluding that these efforts represent a major public health victory.² The war on tobacco-related death and disease is of course a global one, and the success of high-income nations must be replicated.

Given the steady reduction in smoking rates in most countries, there is much to be optimistic about. However, in many middle- and low-income nations where usage rates were previously all on the rise, we must anticipate that the tobacco industry will endeavor to maximize its market reach and thwart the new policy efforts of civil society. Although smoking rates worldwide may be falling, the sheer number of smokers globally is still on the rise, driven by overall population growth and a handful of populous nations where rates are still rising, most notably China.¹

Thanks to the passage of the Framework Convention for Tobacco Control, now ratified by 180 nations³—although sadly not the United States—progressive work worldwide is changing policies and truncating the growth in smoking rates. This is the only path that can avert the loss of a billion lives this century short of an end game that makes tobacco illegal for sale and use.

The efforts of Bloomberg Philanthropies and the Gates Foundation in partnership with the Campaign for Tobacco-Free Kids, as well as those of governments and nongovernmental organizations around the world, represent a true public–private model that may turn the tide on the global tobacco epidemic. In just one decade, we have moved from a world in which smoking rates were increasing to one in which they are falling in most countries. Levy et al. estimated that, from 2007 to 2010 alone, 7.5 million lives were saved by initiatives related to the framework convention,⁴ paralleling the US tobacco control progress described by Warner et al.

ENHANCING CESSATION AND REDUCING INITIATION

The strongest tools for promoting cessation are increasing the price of cigarettes, passing comprehensive clean air laws, and facilitating access to cessation through promotion and quit services. Access to cessation services is slowly rising, but, for a variety of reasons (e.g., competing health priorities), few low-income countries support cessation with evidence-based approaches.¹

As with cessation, price, clean indoor air initiatives, marketing restrictions, and media campaigns are also key in reducing the chances that adolescents and young adults will initiate smoking. Although rates of youth smoking are at their lowest levels in developed nations, new forms of combustible and noncombustible tobacco products are joining the mix of products used. We have made considerable progress in reducing the prevalence of tobacco advertising in traditional venues such as television and billboards, but promotion of smoking still persists in blockbuster Hollywood movies seen here in the United States and exported globally. Although smoking imagery has been cut in half in youth-rated films, the United States remains a principal exporter of smoking imagery in film and television, reaching and adversely affecting millions of young people worldwide.

E-CIGARETTES: THE NEWEST BATTLEGROUND

The introduction of electronic nicotine delivery systems has spawned a heated debate among tobacco control advocates, scientists, and public health leaders around the world. The debate is hampered by a pair of critical problems: we have no crystal ball to predict over time how this new technology will evolve, particularly given the role of the tobacco industry in its growth, and—at least for now—we have no high-quality, large-scale clinical trials demonstrating the relative efficacy of these products in helping smokers quit. The latter data are sorely needed, and the fact that these trials have not occurred may one day be blamed for a considerable loss of life.

Public Health England has concluded that many UK smokers have quit and are quitting with e-cigarettes, and one underpowered but otherwise well-designed trial and a number of observational trials have shown e-cigarettes to be as effective as nicotine replacement therapy. Notably, in one study e-cigarettes were far more likely to be recommended by users to others as a quit aid than nicotine replacement therapy.⁵

Understandably, initiation of e-cigarette use among young people is sounding alarms; however, what this pattern implies remains complicated by the steep downward trend among youths in combustible cigarette use.⁶ It is feasible that e-cigarettes are in part replacing combustibles as starter products among youths who would largely have tried combustibles in any event. Young people who describe themselves as “not planning to smoke” are trying e-cigarettes. This finding may not be as problematic as it appears given that many youths transition to being open to smoking in middle school. The FDA's recently proposed legislations will rightly restrict youth access to e-cigarettes, though the full impact of this policy will take time to evaluate once implemented.

E-cigarettes likely represent a substantial order of risk below that of combustible products and appeal to many consumers, and thus have a high potential to displace combustible tobacco, particularly if tax policies are established to encourage their use in lieu of combustible products.⁷ The existence of a noncombustible, nonmedicinal alternative to combustible cigarettes could well be the game changer that accelerates the demise of deadly combustible cigarettes, especially if nations have the fortitude to ban combustible tobacco.

THE LOOMING TSUNAMI OF DEATH

Deaths from lung cancer have now eclipsed AIDS deaths globally and will continue to grow until the smoking epidemic long subsides.⁸ In many developed nations, lung cancer deaths are still rising among women and have already peaked among men. Thankfully, we now have a cost-effective, diagnostic intervention—computerized tomography scanning—to both save lives from lung cancer through early diagnosis and offer routine annual opportunities to persistently promote cessation among those who still smoke. The US Preventive Services Task Force has given a B rating to computerized tomography screening for early lung cancer diagnosis, and millions of current and former US smokers are eligible under the narrow guidelines.

Computerized tomography annual screening of current and former smokers will identify more people with stage 1 cancers over time as greater numbers are routinely screened under the guideline. This is true because if people are screened annually as recommended by the guideline, few of the cancers will progress to stage 2 and beyond, and instead they will be diagnosed while in stage 1 where the chances of being cured are greatest. The price of screening will decline as use rises, and if we approach screening correctly, many more people will survive through early diagnosis and quitting smoking.

Sadly, uptake has been slow owing to a variety of factors such as misunderstanding concerning the radiation dose, which is low and falling with new generation scanners and concerns regarding false alarms (those findings that turn out not to be cancer but require additional testing) have now greatly decreased as a result of improving technology and improvements in the way protocols recommend how these findings are managed. Similarly as a result of these efficiencies fewer cancers are being missed. This trend should continue to improve over time as screening becomes more accepted and more knowledge is accumulated. Finally, a bias against “smokers” may indeed be a malady of some health professionals themselves, who daily offer costly diagnostic tests and treatment to people for whom a “behavioral” component contributed to an illness yet fail to make referrals for live-saving lung cancer screening. Current and former smokers—the latter accounting for the majority of new lung cancer diagnoses—deserve the same access and life-saving care as everyone else, including support in quitting an addiction considered by experts as uniquely recalcitrant.

The world has the opportunity to swiftly truncate the epidemic of tobacco-related death and disease by applying the successful efforts of the United States and other nations on a global scale. Hopefully it will.