50 Years of Progress Threatened
Cover Story — October 2014
Tex Med. 2014;110(10):18-25.
By Kara Nuzback
Fifty years of health warnings, smoking restrictions, and deaths from cancer paved the way for the arrival of Acting Surgeon General Boris Lushniak, MD, at the White House in January, where he affirmed the burning need to put an end to tobacco use in the United States.
"Since the first surgeon general's report in 1964, over 20 million premature deaths can be attributed to cigarette smoking. Today, the annual death toll from smoking is approaching 500,000 per year," he said. "Enough is enough."
Dr. Lushniak unveiled a 1,500-page report titled The Health Consequences of Smoking — 50 Years of Progress on the 50th anniversary of the first surgeon general's report to link smoking to cancer.
To coincide with the semicentennial, state and federal health organizations, including MD Anderson Cancer Center, the Centers for Disease Control and Prevention (CDC), and the Food and Drug Administration (FDA), are ramping up efforts to make smoking a thing of the past.
But the tobacco industry, which rakes in more than $135 billion in sales every year, isn't going down without a fight and is marketing a new wave of products, such as electronic cigarettes, to a new generation of consumers.
At the Texas Tobacco Summit in June, hosted by MD Anderson Cancer Center, the center's Vice President for Health Policy Lewis Foxhall, MD, said despite widespread knowledge of the dangers of smoking, millions of people in the United States continue to use tobacco.
"Tobacco is still the single most preventable cause of illness and death in this country," he said.
If smoking persists at its current rate among youth, an estimated 5.6 million of today's children will die prematurely as adults from a tobacco-related illness, according to The Health Consequences of Smoking.
Texas Department of State Health Services (DSHS) Commissioner David Lakey, MD, told summit attendees tobacco kills about 24,500 Texans every year — more than alcohol, car accidents, fires, AIDS, heroin, cocaine, and murder combined. And, he says, for every person who dies from smoking, 20 more people suffer from a smoking-related illness.
Past vs. Present
Jonathan Samet, MD, director of the University of Southern California Institute for Global Health, began working on surgeon general's reports in the 1980s. He earned the Surgeon General's Medallion in 1990 and again in 2006. The medallion honors those who attain exceptional achievements in public health and medicine.
In the early 1960s, smoking peaked, Dr. Samet says, with the average user smoking 200 packs of cigarettes annually.
That was the cultural backdrop when the Surgeon General's Committee, mostly smokers themselves, released the surgeon general's report linking cigarette smoking to chronic bronchitis, coronary artery disease, and lung cancer in men, he says.
The 1964 report declared, "Cigarette smoking is a health hazard of sufficient importance in the United States to warrant appropriate action."
The committee did not specify, however, what action smoking warranted.
More than 30 surgeon general's reports followed, all casting further light on the dangers of tobacco use. (See "Highlights of the Surgeon General's Reports.")
The Health Consequences of Smoking reveals newly identified health consequences of smoking, such as diabetes, rheumatoid arthritis, erectile dysfunction, and increased risk for tuberculosis.
CDC estimates 18 percent of the U.S. population smokes. In the report, the surgeon general's goal is to achieve a smoking rate of 12 percent by 2020, 10 percent 10 years from now, and a smoke-free generation in a generation.
Dr. Samet says the new challenge of addressing electronic cigarettes, or e-cigarettes, further complicates reaching the public health community's goal.
An e-cigarette is a battery-powered vaporizer that simulates tobacco smoking and almost always includes nicotine. By law, FDA can regulate cigarettes, smokeless tobacco, and roll-your-own tobacco. E-cigarettes are currently unregulated in Texas and at the federal level.
But in April, FDA issued a proposed rule that would subject e-cigarettes to federal regulation and ban the sale of e-cigarettes to those younger than 18. The FDA's proposal would also target other unrestricted tobacco products, such as cigars, hookahs, and water pipes.
The FDA's proposal would not, however, restrict flavored e-cigarettes or television advertising of the products, which health experts say attracts children to them. On its website, FDA says it does not know the potential risks of e-cigarettes or whether there are any benefits.
E-cigarette companies such as Veppo claim their products are a safer alternative to traditional cigarettes because they contain no tar or carbon monoxide and do not emit secondhand smoke. Visit the Veppo website to read more about Veppo's e-cigarette benefit claims.
Jack Henningfield, PhD, vice president of research and health policy for consulting firm Pinney Associates and adjunct professor at Johns Hopkins Medical School, says e-cigarettes carry both promise and peril, depending on how effectively FDA regulates them and whether smokers use them to quit or simply as alternatives to traditional cigarettes. In January, Pinney Associates signed an agreement to provide e-cigarette company NJOY with scientific, regulatory, and policy support to encourage adult cigarette (referred to as "combustible tobacco") smokers to switch to e-cigarettes.
"Use by cigarette smokers as an escape from combustible tobacco could help put an end to the tobacco epidemic, whereas use by youth might undermine tobacco prevention efforts," he said.
Dr. Henningfield urged tobacco summit participants to send comments to FDA, expressing their concerns and ideas, such as making conventional cigarettes less addictive and less attractive to youth and adult smokers.
Matthew Myers, president of the Campaign for Tobacco-Free Kids, visited Texas for the tobacco summit, where he told physicians to pressure FDA to enforce product standards for e-cigarettes. He says FDA could propose a rule to regulate the ingredients it allows in e-cigarettes, including the amount of nicotine.
Mr. Myers says FDA should set one broad nicotine policy that applies to all tobacco products, rather than regulating each product separately.
The Texas Medical Association House of Delegates adopted a new policy in May opposing the sale of e-cigarettes to minors. According to the policy, TMA also supports "regulation of e-cigarettes in Texas in a similar manner as tobacco products, increased clinical research on the effects of e-cigarettes, and education in schools for children and adolescents about the effects of e-cigarettes, nicotine, tobacco, and other addictive substances."
TMA plans to work with the 2015 Texas Legislature to pass a law restricting the sale of e-cigarettes to anyone younger than 18. (See "TMA's Vision for Tobacco Control.")
Prevention, Control Spending Lacking
Lack of funding for prevention efforts makes it difficult to curb tobacco use in the state. Texas scored an "F" in tobacco prevention and control spending in the American Lung Association's (ALA's) 2012-14 State of Tobacco Control reports. In the 2014 report, ALA says Texas spends about $11 million a year in state funding and $4 million a year in federal funding on tobacco control programs.
CDC recommends Texas spend more than $266 million annually on comprehensive tobacco control programs, based on the state's population and rate of inflation. Texas currently invests only 5.8 percent of the CDC-recommended amount on comprehensive tobacco control programs.
The state allocates most of its cigarette tax revenue to the General Revenue Fund, and varying amounts go to special funds, such as the Foundation School Fund, the Property Tax Relief Fund, and the Physician Education Loan Repayment Program.
Texas filed a federal lawsuit against the tobacco industry in 1996, in which it sought to recover billions of tax dollars the state had spent treating tobacco-related illnesses.
In a settlement, the tobacco industry agreed to pay the state $15 billion over 25 years, plus $2.3 billion a year until 2003 to Texas counties and hospital districts.
However, an informal survey published in the Oct. 13, 1999, issue of The Wall Street Journal shows several Texas counties used their tobacco dollars for construction and renovation projects. According to the survey, Fort Bend County used nearly $2 million to renovate a former Walmart into office space; Falls County used $100,000 to upgrade county roads; and Limestone County spent part of its share to renovate a 1924 courthouse.
In 1999 and 2001, the state legislature allocated $1.5 billion from the settlement to create permanent endowments for health and human services and higher education. Lawmakers also use settlement funds to support the Children's Health Insurance Program, which helps uninsured children get medical coverage.
But the government allocates only a fraction of the funds — $11 million out of $2 billion, according to the Campaign for Tobacco-free Kids — for tobacco prevention. According to Christine Mann, spokeswoman for DSHS, the fiscal year 2014 budget also includes $978,000 from the Cancer Prevention & Research Institute of Texas for Quitline services and another $4 million from the federal government for tobacco control.
Meanwhile, the tobacco industry spends more than $586 million marketing its products in Texas each year, according to the Campaign for Tobacco-Free Kids.
Tim McAfee, MD, director of the CDC Office on Smoking and Health, said, "A lot of it just boils down to political will." Dr. McAfee says the money to increase cessation and prevention efforts exists, but the state is choosing to spend it elsewhere.
"It isn't that we [Texas] can't do it. It isn't that we don't have the money," he said. (See "Smoking and Mental Health.")
Meanwhile, Dr. McAfee says, smoking costs the country about $300 billion annually in health care expenses, including the direct cost of patient care and the indirect cost of lost productivity.
"Being Poor Is Bad for Your Health"
At the summit, Dr. Lakey noted the education and income disparities associated with smoking. According to CDC, 9 percent of adults with college degrees are smokers, whereas 23 percent of adults with just a high school diploma and 42 percent of adults with a GED smoke.
Lower socioeconomic status, or social position based on education, income, and employment, leads to higher smoking levels and lower cessation rates, says MD Anderson Health Disparities Research Chair David Wetter, MD.
"Being poor is bad for your health," he said.
Dr. Wetter told physicians at the Texas Tobacco Summit individuals with lower socioeconomic status are subject to more stress, discrimination, and violence, leading to higher smoking rates. This population is also at a "neighborhood disadvantage," he said.
"Simply where you live makes a huge difference," he said.
Those in areas with a high unemployment rate are more likely to smoke and less likely to quit, Dr. Wetter says.
"We know that poor neighborhoods have a higher incidence of tobacco outlets," he said, increasing the likelihood someone will smoke.
"Simply how close you live to a tobacco outlet affects your ability to quit," he said. Houston alone has more than 6,000 tobacco retailers, Dr. Wetter says. But the solution is not easy.
"If we really want to eliminate health disparities, we have to eliminate income inequality," he said.
Because tobacco companies can't advertise traditional cigarettes on radio, on television, or in print magazines with an audience younger than 21, an entire generation of people were never exposed to cigarette ads, until now, Mr. Myers laments.
Mr. Myers says e-cigarette manufacturers such as blu eCigs have created glamorous marketing campaigns in print and on television that use celebrities and sex appeal to attract adolescents.
Mr. Myers says physicians should put pressure on their legislators at the city and state levels to protect children from e-cigarette advertising, also currently allowed at music venues.
"Our political figures have a lot of other things on their hands," he said. But with health officials predicting 5.6 million of today's children will die prematurely in their adulthood from tobacco, he says, "this is the time to act."
MD Anderson President Ronald DePinho, MD, says 88 percent of adult smokers started puffing as children.
"The most vulnerable segment of our population is children, and they continue to be targeted for addiction," he said at the tobacco summit.
End Tobacco is an MD Anderson initiative that brings together disease experts, prevention scholars, and the media with a goal to eliminate tobacco use, Dr. DePinho says.
"Cancer's greatest vulnerability is knowledge," he said.
End Tobacco includes three goals:
- Reduce the prevalence of cigarette use among children, adolescents, and adults;
- Reduce the number of nonsmokers exposed to secondhand smoke; and
- Increase cessation attempts in adults and adolescents and increase cessation counseling in ambulatory care settings.
To achieve its goals, the campaign intends to implement a tobacco-free hiring policy at MD Anderson and offer continuing medical education on tobacco cessation counseling, among other strategies.
CDC is launching a new wave of advertisements encouraging smokers to quit. The Tips From Former Smokers campaign, launched in 2012, targeted adult smokers, and it put the spotlight on real smokers who suffer from the long-term health effects of smoking. "Terrie," featured in the Tips series, found out she had oral and throat cancer at age 40. Doctors removed her larynx, and she spoke through an artificial voice box inserted in her throat until she died in 2013 at age 53.
A new wave of explicit Tips ads attempts to reach a broader audience, Dr. McAfee says. New subject "Amanda" smoked while she was pregnant, and her premature baby spent the first weeks of her life in a hospital incubator. "Brian," an HIV patient, suffered a stroke because he was a smoker.
Dr. McAfee says in developing the Tips campaign, CDC talked to thousands of smokers who said the fact that cigarettes could kill them did not motivate them to quit smoking; instead, seeing how they were going to die motivated them to quit. He says CDC found people struggling to live normal lives while dealing with the consequences of tobacco use.
"We developed this campaign based on the idea we were going to tell real stories about real people," he said.
FDA also launched a new campaign in 2014 called The Real Cost, which targets adolescents. In one television ad, a young man uses a pair of pliers to remove his own tooth in exchange for a pack of cigarettes.
Travis County Health and Human Services Medical Director Phil Huang, MD, says on a local level, many city facilities, schools, and worksites in Austin have instituted smoke-free or tobacco-free policies, including The University of Texas at Austin, Austin Community College, Dell, and Seton and St. David's medical centers.
"Our libraries [in Austin] are now smoke-free; our parks are smoke-free," he said.
On a state level, ALA Plains-Gulf Region Interim Chief Executive Officer Jennifer Cofer says Texas has 37 smoke-free cities, including Austin, Dallas, and Plano. She says ALA is currently working to make Lubbock, Irving, Wichita Falls, Fort Worth, and Waco smoke-free.
Ms. Cofer says Texas could decrease its youth smoking rate by 12 percent by increasing tobacco taxes by $1. The state's tax on cigarettes is currently $1.41 – the 25th highest tax in the nation.
"This is one of the strategies we know works," she said.
Physicians should reach out to House and Senate members in support of higher tobacco taxes and more funding for tobacco prevention and cessation programs, Ms. Cofer says.
"This is not a [political] party issue; it's a public health issue," she said. "You are part of the solution."
Kara Nuzback can be reached by telephone at (800) 880-1300, ext. 1393, or (512) 370-1393; by fax at (512) 370-1629; or by email.
TMA's Vision for Tobacco Control
Healthy Vision 2020 is TMA's strategic roadmap for state and federal advocacy initiatives for the remainder of the decade. TMA has several tobacco-related recommendations and initiatives in the updated second edition, including:
- Enact regulation of electronic cigarettes and associated products by:
- Restricting their sale to minors;
- Including these in smoking prohibition legislation and local policies;
- Providing school-based education for children on the hazards of electronic cigarettes;
- Assessing the feasibility of taxing electronic cigarettes and associated products to affect the use of these products; and
- Requiring the Food and Drug Administration to assess the marketing of electronic cigarettes to minors.
- Maintain funding for the Quitline and the state's smoking cessation program and require monitoring on the use of electronic cigarettes.
- Make Texas smoke-free and encourage cities throughout the state to adopt uniform policies for smoke-free public places, workplaces, restaurants, and bars.
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Smoking and Mental Health
At the Texas Tobacco Summit in Houston, MD Anderson Cancer Center Associate Professor Jan Blalock, PhD, told physicians about the high, often overlooked rate of smoking among those with mental illness.
Dr. Blalock says in studies of all mental disorders, from serious psychotic disorders to more easily treatable conditions, she has found substantially higher smoking rates when compared with the average population.
"We've got twice the smoking rate in this population," she said. "It actually represents 31 percent of all smokers."
Those with mental illness also smoke more heavily, Dr. Blalock says, and they die on average 20 years younger than the general population, many times due to smoking-related diseases. And though Texas spends a meager $11 million a year on cessation and prevention programs for adolescents and adults, it uses even less to fund cessation programs for those with mental illness, she says.
On top of that, she says, the common practice is to encourage smoking in mental health facilities, including using a smoke break as a treat or reward for patients.
"Smoking has been used as a reinforcer in mental health facilities," she said.
Like many workplaces and college campuses, treatment facilities for patients with mental illness should adopt smoke-free policies, and staff should promote cessation efforts, Dr. Blalock says. And she recommends health professionals use standard smoking cessation interventions among those with mental illness.
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Highlights of Surgeon General's Reports
- 1964: Surgeon General Luther Terry, MD, issues the first report confirming several health risks associated with smoking.
- 1972: Surgeon General Jesse L. Steinfeld, MD, issues the first report noting the indoor pollution caused by smoking.
- 1979: Surgeon General Julius Richmond, MD, releases a report addressing adult and youth education to prevent smoking.
- 1986: Surgeon General C. Everett Koop, MD, releases a report on the dangers of secondhand smoke, including a health risk to children from parental smoking.
- 1988: Dr. Koop releases a report establishing nicotine as a highly addictive substance.
- 1990: Surgeon General Antonia Novello, MD, releases a report on decreasing risk of disease after an individual quits smoking.
- 2001: Surgeon General David Satcher, MD, releases a report calling tobacco use a serious women's health issue.
- 2004: Surgeon General Richard Carmona, MD, releases a report declaring smoking harms nearly every organ in the body.
- 2012: Surgeon General Regina Benjamin, MD, releases a report on tobacco use among youth and young adults and proven intervention methods.
- 2014: Acting Surgeon General Boris Lushniak, MD, releases the 50th anniversary report, which establishes new health risks associated with smoking.
Sources: SurgeonGeneral.gov and Jonathan Samet, MD
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