Reducing Tobacco Use: A Report of the Surgeon General—2000

Reducing Tobacco Use: A Report of the Surgeon General—2000

ABSTRACT: "If the recommendations in this report were fully implemented, the Healthy People 2010 objectives related to tobacco use could be met, including cutting in half the rates of tobacco use among young people and adults. It is clear that the major barrier to more rapid reductions in tobacco use is the effort of the tobacco industry to promote the use of tobacco products. Our lack of greater progress in tobacco control is more the result of failure to implement proven strategies than it is the lack of knowledge about what to do. As a result, each year, more than 1 million young people continue to become regular smokers and more than 400,000 adults die from tobacco-related diseases. Tobacco use will remain the leading cause of preventable illness and death in this nation and a growing number of other countries until tobacco prevention and control efforts are commensurate with the harm caused by tobacco use."

Tobacco use, particularly smoking, remains
the number 1 cause of preventable disease and death in the United States. This
report of the Surgeon General on smoking and health is the first to offer a
composite review of the various methods used to reduce and prevent tobacco use.
The topic is a new one in this series of reports, although previous reports have
looked at aspects of such strategies.

This report evaluates each of five major approaches to reducing
tobacco use: educational, clinical, regulatory, economic, and comprehensive.
Further, the report attempts to place the approaches in the larger context of
tobacco control, providing a vision for the future of tobacco use prevention and
control based on these available tools. The report is clear in its overriding
conclusion: Although our knowledge about tobacco control remains imperfect, we
know more than enough to act now.

Major Conclusions of the Surgeon General’s Report

  • Efforts to prevent the onset or continuance of tobacco use
    face the pervasive, countervailing influence of tobacco promotion by the
    tobacco industry, a promotion that takes place despite overwhelming evidence
    of adverse health effects from tobacco use.

  • The available approaches to reducing tobacco use—educational,
    clinical, regulatory, economic, and comprehensive—differ substantially in
    their techniques and in the metric by which success can be measured. A
    hierarchy of effectiveness is difficult to construct.

  • Approaches with the largest span of impact (economic,
    regulatory, and comprehensive) are likely to have the greatest long-term,
    population impact. Those with a smaller span of impact (educational and
    clinical) are of greater importance in helping individuals resist or abandon
    the use of tobacco.

  • Each of the modalities reviewed provides evidence of

  • Educational strategies, conducted in conjunction with
    community- and media-based activities, can postpone or prevent smoking onset
    in 20% to 40% of adolescents.

  • Pharmacologic treatment of nicotine addiction, combined with
    behavioral support, will enable 20% to 25% of users to remain abstinent at 1
    year posttreatment. Even less intense measures, such as physicians advising
    their patients to quit smoking, can produce cessation proportions of 5% to

  • Regulation of advertising and promotion, particularly that
    directed at young people, is very likely to reduce both prevalence and
    uptake of tobacco use.

  • Clean air regulations and restriction of minors’ access to
    tobacco products contribute to a changing social norm with regard to smoking
    and may influence prevalence directly.

  • An optimal level of excise taxation on tobacco products will
    reduce the prevalence of smoking, the consumption of tobacco, and the
    long-term health consequences of tobacco use.

  • The impact of these various efforts, as measured with a
    variety of techniques, is likely to be underestimated because of the
    synergistic effect of these modalities. The potential for combined effects
    underscores the need for comprehensive approaches.

  • State tobacco control programs, funded by excise taxes on
    tobacco products and settlements with the tobacco industry, have produced
    early, encouraging evidence of the efficacy of the comprehensive approach to
    reducing tobacco use.

Reducing Tobacco Use, A Report of the Surgeon General,
appears at a time of considerable upheaval in efforts to control and prevent the
use of tobacco. Legal and legislative efforts to protect children from
initiating tobacco use and to reduce smoking among adults are in a state of
flux, with some important gains and some sobering setbacks. Major changes in the
public stance of the tobacco industry have evoked a reevaluation of strategies
for controlling and preventing tobacco uptake. Enormous monetary settlements
have provided the resources to fuel major new comprehensive antitobacco efforts,
but the ultimate cost and benefit of these resources are still to be determined.

Into this changing landscape, this report introduces an
assessment of information about the value and efficacy of the major approaches
that have been used to reduce tobacco use: educational, clinical, regulatory,
economic, and comprehensive. Widespread dissemination of the approaches and
methods shown to be effective, especially in combination, would substantially
reduce the number of young people who will become addicted to tobacco, increase
the success rate of young people and adults trying to quit using tobacco,
decrease the level of exposure of nonsmokers to environmental tobacco smoke,
reduce the disparities related to tobacco use and its health effects among
different population groups, and decrease the future health burden of
tobacco-related disease and death in this country.

What We Know

This Surgeon General’s report provides evidence that tobacco
use in this nation can be reduced through existing types of interventions, in
line with health objectives detailed in Healthy People 2010. Attaining
these objectives will almost certainly require significant national commitment
to using the various successful approaches described in the report.

Educational Strategies

More consistent implementation of effective educational
strategies to prevent tobacco use will require continuing efforts to build
strong, multiyear prevention units into school health education curricula and
expanded efforts to make use of the influence of parents, the mass media, and
other community resources.

School-based programs can have a significant impact on smoking
behavior among young people and are most effective when part of a comprehensive,
community-based effort. Implementing effective school-based programs—along
with community and media-based activities—can prevent or postpone smoking
onset in 20% to 40% of US adolescents. Unfortunately, less than 5% of schools
nationwide have implemented the major components of the Centers for Disease
Control’s (CDC) recommended guidelines for school-based programs to prevent
tobacco use.

Management of Nicotine Addiction

The vast majority of smokers in the United States want to quit,
but only a little more than 2% successfully quit each year. Tobacco dependence
is in fact best viewed as a chronic disease with remission and relapse. Even
though both minimal and intensive interventions increase smoking cessation, most
people who quit smoking with the aid of such interventions will eventually
relapse. Moreover, there is little understanding of how such treatments produce
their therapeutic effects.

Advancements in treating tobacco use and nicotine addiction have
been summarized in an evidence-based guideline, Treating Tobacco Use and
Dependence. A Clinical Practice Guideline,
published by the US Public Health
Service. Less intensive interventions, such as brief physician advice to quit
smoking, could produce cessation rates of 5% to 10% per year. More intensive
interventions, combining behavioral counseling and pharmacologic treatment of
nicotine addiction, can produce cessation rates of 20% to 25% per year.

Treating tobacco dependence is particularly important
economically in that it can prevent a variety of costly chronic diseases,
including heart disease, cancer, and chronic lung disease. It has been estimated
that smoking cessation is more cost-effective than other commonly provided
clinical preventive services, including screening for cervical, breast, and
colon cancer, treatment of mild to moderate high blood pressure, and treatment
of high cholesterol. Not surprisingly, Healthy People 2010 calls for
universal insurance coverage of evidence-based treatment for nicotine

Regulatory Efforts

Tobacco products are far less regulated in the United States
than they are in many other developed countries. This level of regulation
applies to the manufactured tobacco products; to the advertising, promotion, and
sales of these products; and to the protection of nonsmokers from involuntary
exposure to environmental tobacco smoke (ETS) from the use of these products.
Effective regulatory approaches can minimize the onset of smoking, particularly
among young people, and may change tobacco use as an accepted social norm.


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