Saturday marks the 50-year anniversary of perhaps the most important document in U.S. public-health history.
The 1964 report “Smoking and Health, Report of the Advisory Committee to the Surgeon General of the Public Health Service” had a profound impact that led to interventions that likely saved more lives than any other public-health effort in the second half of the last century, and the anti-tobacco fight continues unabated to this day.
The report called cigarette smoking the primary cause of lung and laryngeal cancer in men and chronic bronchitis in both sexes, and associated the behavior with coronary heart disease and emphysema.
“What probably seemed like a ground-breaking announcement a half-century ago is now accepted as common knowledge among most people, which is a big step in the right direction,” said Methodist Dallas Medical Center pulmonologist Arturo Aviles.
Prior to the report, per-capita U.S. adult cigarette smoking had increased annually for six decades. With the report’s release, smoking prevalence promptly did an about-face and has declined steadily since then. The adult smoking rate has been cut by more than half—from more than 42 percent to about 18 percent in 2012. Researchers have estimated that per-capita tobacco consumption would have been five times higher than it was in 2011 without tobacco-control efforts.
It is hard to believe a government report could have that kind of impact today. Americans’ trust in the federal government has plummeted from 68 percent during the Kennedy and Johnson administrations to 22 percent during President Obama’s first term.
Texas and Tarrant County match the 18 percent U.S. smoking rate. Only 12 percent of adults smoke in Collin and Denton counties, and 16 percent do so in Dallas County.
The 50-year effort added nearly 20 years of life to eight million Americans. U.S. death rates from all cancers combined decreased by 1.8 percent a year for men and 1.4 percent annually for women from 2001 to 2010, and researchers credited anti-smoking efforts for the progress.
Despite the success of anti-tobacco interventions, smoking persists especially among those with the least education. In 1966, more than 45 percent of high school dropouts smoked, compared with about 33 percent of college graduates. By 2011, less than 8 percent of college graduates smoked, compared with more than 36 percent of those without a high school diploma. Unfortunately, those smokers also generally occupy the lowest rung of the economic ladder and can least afford to support their habit.
Four proven strategies, if pursued aggressively, could nearly wipe out cigarette smoking. The policies with documented success are: increasing tobacco taxes; expansion of public smoking bans; anti-smoking advertising campaigns; and banning methods of cigarette marketing. The only barrier is the political will to stand up to strong tobacco lobbying efforts.
For example, New England Journal of Medicine researchers estimated tripling tobacco taxes worldwide would reduce the number of smokers by one-third and prevent 200 million premature deaths this century. Although smoking prevalence has decreased worldwide, the number of cigarette smokers has increased in the past 30 years because of population growth.
Smoking merely is considered a “bad habit,” said Tricia Nguyen, MD, Texas Health Resources executive vice president for population health, leading to limited coverage by insurance companies and making physicians less inclined to treat patients. She said tobacco “addiction,” which has a high relapse rate, should be treated as a life-long chronic disease, much like diabetes or hypertension.
David Balis, MD, director of the smoking cessation program at Parkland Health & Hospital System, added: “We know that smoking is the No. 1 preventable cause of death and illness, yet we don’t put the amount of resources and emphasis on smoking cessation or prevention that we should. The medical community needs to put even more effort into getting people to quit smoking. Tobacco is widely available, and even though most people know it’s bad for them, it’s a very, very strong addiction and it’s not simple to quit even when people want to do so.”
The nation’s bars, restaurants, and workplaces could be smoke-free by 2020, according to a Centers for Disease Control and Prevention official. About half of the 50 states have banned smoking in those venues since 2000, when none of the states had such bans.
“It is by no means a foregone conclusion that we’ll get there by 2020,” Dr. Tim McAfee, director of the CDC’s Office on Smoking and Health, said. “I’m relatively bullish we’ll at least get close to that number.”
Arlington and Fort Worth are among 20 of the 50 largest U.S. cities that do not have comprehensive smoking bans. Smoking is banned in Arlington’s restaurants, Cowboys Stadium, the University of Texas at Arlington, and many businesses. However, there are no comprehensive prohibitions for the city’s workplaces and bars. Smoking is prohibited in Fort Worth’s workplaces and restaurants, but not in bars. Dallas has a comprehensive smoke-free prohibition.
Texas has resisted a statewide smoking ban. State Rep. Myra Crownover (R-Denton) and state Sen. Rodney Ellis (D-Houston) have introduced smoke-free legislation for the past four legislative sessions. The House passed the legislation in 2007 and 2011 but the measures never gained traction in the Senate.
November also marked another important milestone: the 1998 tobacco settlement between the four largest tobacco manufacturers and the attorneys general of 46 states. The companies agreed to halt some tobacco marketing activities and pay the states at least $206 billion over 25 years to offset Medicaid healthcare costs in exchange for private tort liability.
Texas was among the first states to file suit against Big Tobacco. The state’s cut of the agreement was $15 billion over 25 years and $2.3 billion through 2003 to Texas counties and hospital districts.
The states collectively are expected to receive $25 billion in fiscal year 2014. According to Campaign for Tobacco-Free Kids, states are spending less than two cents of every dollar in tobacco revenue to fight tobacco use.
“I remember thinking early in my career that if people would just stop smoking, then most of the diseases I treat would be cured,” said Michael Mack, MD, chief of cardiovascular services at Baylor Health Care System. “To a large degree that has come true due in large part to the public health campaign against cigarette smoking. Unfortunately, this public health hazard has largely been supplanted by another one: morbid obesity with the high blood pressure, diabetes and sleep apnea that is caused by it. It is long past time for a new campaign against obesity to match the success of the one against cigarette smoking 50 years ago.”
Steve Jacob is editor-at-large of D Healthcare Daily and author of the book Health Care in 2020: Where Uncertain Reform, Bad Habits, Too Few Doctors and Skyrocketing Costs Are Taking Us. He can be reached at [email protected]