After a Decade of Decline in Smoking Rates, Progress Has Stalled

IOM National Cancer Policy Forum convenes workshop to discuss the future of tobacco use

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Approximately 20% of all Americans smoke, and 443,000 of them will die each year as a result. Tobacco use is the leading cause of preventable death in the United States and the greatest behavioral determinant of morbidity and mortality (6%–10% of U.S. health-care costs). Nearly 30% of all cancer deaths (87% of lung cancer deaths) are due to smoking, and tobacco use increases the incidence of almost all types of the disease and adversely affects treatment.

Smoking had been on the wane in this country, but now the cessation rate has flattened. About 70% of smokers say they want to quit, and every year 50% try. Fewer than 2.5% succeed.

Roy S. Herbst, MD, PhD, Professor of Medicine and Pharmacology, Yale Comprehensive Cancer Center, New Haven, Connecticut, made these grim observations as he opened the Institute of Medicine (IOM) National Cancer Policy Forum’s workshop, “Reducing Tobacco-related Cancer Incidence and Mortality,” held recently in Washington, DC.

The purpose of the workshop was to explore the effects of state and federal policies on reducing tobacco use, as well as ways to encourage cessation.

Largest Contributor to Cancer Risk

“Most people don’t realize that continued tobacco use by cancer patients decreases the effectiveness of cancer treatment,” said Graham Warren MD, PhD, a radiation oncologist and Director of the Tobacco Assessment and Cessation Program at Roswell Park Cancer Institute in Buffalo, NY. “The 7,000 compounds in cigarette smoke include known carcinogens that increase cancer growth, angiogenesis, metastasis, and decrease the effectiveness of chemotherapy and radiotherapy.”

He cited several studies showing that smoking increases cancer treatment toxicity, decreases cancer treatment compliance, decreases quality of life, and decreases survival in cancer patients. He also presented new data demonstrating that tobacco assessments and cessation are not well incorporated into federally funded research. “This significantly limits our ability to understand the true effects of smoking on cancer treatment and prevents cancer patients on clinical trials from gaining the health benefits of smoking cessation.”

Terry F. Pechacek, PhD, Associate Director for Science, CDC Office on Smoking and Health, Atlanta, added that the duration of exposure to cigarette smoke is a more important risk factor than the number of cigarettes smoked. Moreover, dual tobacco use (for instance, smoking accompanied by snuff or chewing tobacco) increases risk significantly.

Society and Public Policy

“There has been a 180-degree change in social attitudes and norms about smoking,” said Kenneth E. Warner, PhD, Avedis Donabedian Distinguished University Professor of Public Health, University of Michigan School of Public Health, Ann Arbor. “Since 1964, approximately 5 million premature deaths have been averted because people have quit smoking or decided not to start. This is the greatest public health success story of the last 50 years. Nevertheless, smoking remains the greatest remaining burden of preventable illness and death.”

According to Dr. Warner, there are three categories of public policy interventions:

Information and education, such as Surgeon General reports, warning labels, school health information, and media antismoking campaigns

Financial incentives such as tax increases: A critical factor in cigarette consumption is price; the more expensive a pack is, the less likely people are to purchase it. Low-income smokers are more responsive to price hikes than are high-income smokers, and children are two to three times more responsive than adults.

Laws and regulations, such as bans on advertising, smoke-free workplaces, and sales to minors

Some of these factors work better than others. For example, school health education doesn’t work well, nor do warning labels, although the proposed graphic warning labels might do better. Cessation treatment works for some people, and professional instruction and/or counseling is generally more effective than going cold turkey alone.

Dr. Warner noted that the big problem with smoking now—and a major reason why the cessation rate is flat—is the possibility that a growing proportion of people who still smoke are addicted, and many do not want to quit. Up to half of current smokers have another substance abuse problem or a mental illness comorbidity (eg, 60% of schizophrenics smoke), he pointed out.

FDA Regulatory Authority­

Lawrence Deyton, MD, Director of the FDA Center for Tobacco Products, said that under the Family Smoking Prevention and Tobacco Control Act, FDA now has the authority to regulate tobacco product manufacturing, distribution, and marketing,  including conducting research, issuing health warnings, and reporting harmful levels of tobacco product constituents.

There was discussion about a number of actions that the federal and state governments could potentially take to further reduce tobacco-related illness, some of which are more practical than others (see sidebar). ■

Disclosure: Drs. Herbst, Pechacek, Warren, Warner, and Deyton reported no potential conflicts of interest.