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

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 effectiveness.

• 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(Drug information on 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 10%.

• 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 dependency.

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.