Background and overview
The Tobacco Epidemic in the United States

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Abstract

Tobacco use, primarily in the form of cigarettes and exposure to tobacco smoke pollution, has caused the premature deaths of more than 14 million Americans since 1964. The major diseases caused by tobacco and tobacco smoke include lung cancer, other cancers, coronary heart disease, other cardiovascular diseases, chronic respiratory diseases, pregnancy complications, and respiratory diseases in children. Per capita consumption of various tobacco products has declined substantially since 1950, with current consumption at approximately 3.7 pounds per capita. Whereas approximately two in five adults smoked cigarettes in 1965, approximately one in five did so in 2005.

Several factors can influence initiation and cessation, including product factors (e.g., ventilation holes, additives, and flavorings); host factors (intention to use, level of dependence); tobacco company activities (e.g., marketing strategies, efforts to undermine public health activities); and environmental factors (e.g., peer and parental smoking, smoke-free air laws and policies). Efforts to prevent initiation, promote quitting, and protect nonsmokers should reduce exposure to pro-tobacco marketing and increase (1) the price of tobacco products, (2) protection from tobacco smoke pollution, (3) effective mass media strategies, (4) provision of effective cessation support, (5) effective regulation, and (6) litigation that holds the industry responsible for its misdeeds. Adequate implementation of effective tobacco-control strategies and useful scientific advances will help to ensure that per capita consumption decreases to the lowest level possible. The economic benefits of tobacco in our society are replaceable and they pale in comparison to the extent of human life lost.

Introduction

Tobacco use, primarily in the form of cigarettes, has caused more than 14 million premature deaths in the United States since 1964.1, 2 It remains the single leading preventable cause of death in this country, with 400,000 current and former smokers dying annually from smoking-attributable diseases, and 38,000 nonsmokers dying annually because of exposure to tobacco smoke pollution.2, 3 Approximately 8.6 million Americans live with serious disease(s) caused by their smoking.4 Peto and his colleagues5 estimate that one half of all smokers, especially those who began as teens, can expect to die of tobacco use. Of these, approximately one half will die in middle age, losing an average of 20–25 years of life expectancy.

This article provides an overview of the consequences and patterns of tobacco use, factors that can influence use, and efforts to control use. It documents the tremendous progress that has been made in reducing use and discusses factors that either can promote or reduce use. A final section will describe possible future scenarios of tobacco consumption and discuss some economic considerations that would arise if U.S. consumption is reduced substantially.

Section snippets

Active Cigarette Smoking

Using criteria that were described in the initial report of the Advisory Committee to the U.S. Surgeon General and later elaborated upon by A.B. Hill, scientists have documented a list of diseases for which sufficient evidence exists to conclude that they are caused by cigarette smoking (Table 1).1, 6, 7, 8 Tobacco use remains the single leading preventable cause of death in the U.S.3 Nearly one of every five deaths in the U.S. is caused by cigarette smoking.2

Cigarette smoke contains 4800

Patterns of Use

In the early 1880s the tobacco in manufactured cigarettes accounted for only 1% of all tobacco consumed in the U.S. (Figure 1). By 1950, this figure was 80%; and by 2006, 79% of tobacco consumed in the U.S. was in cigarettes.39, 40, 41 Overall tobacco consumption peaked in the early 1950s, at about 13 pounds per person; by 2006, per capita consumption was down to 3.7 pounds per capita, the lowest estimate since recordkeeping began in 1880. Some of this decline is due to greater efficiencies

Factors Influencing Use

This section incorporates the traditional epidemiologic model of agent, host, vector, and environment as a framework for understanding factors influencing the development of nicotine addiction and strategies to prevent initiation, promote quitting, and protect nonsmokers.44, 56 This model recognizes that factors operating at multiple levels contribute to use, addiction, disease, and death. Specifically, tobacco products are the agents of addiction and disease; smokers and users of other tobacco

Tobacco Control

Warner104, 112 estimates that the antismoking campaign in the U.S., initiated following the release of the first Surgeon General’s report in 1964, has averted the premature deaths of more than 3 million Americans, each of whom has gained on average 15 years of life. This campaign is likely the most successful public health effort of the past 50 years. Numerous reports document the evidence base in support of tobacco control.77, 103, 104, 113 One dynamic of the tobacco-control movement in the

The Future

The data on pounds of various tobacco products consumed per capita in the U.S. through 2004 shown in Figure 1 have been projected to depict three hypothetical scenarios in Figure 5, Figure 6, Figure 7, which are presented for heuristic purposes. The simple linear projection of Figure 5 suggests that work on this public health problem will be completed in about 30 years. Of course, the probability that no tobacco will be consumed in the U.S. by 2035 is infinitesimally small, for three main

Conclusion

This article has incorporated a holistic approach to understanding and controlling the tobacco epidemic. Continuation of the progress that has been achieved will require application of the what is already known, for as former U.S. Surgeon General David Satcher stated, “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.”77 In addition to the political will to make health-promoting policy

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