Opinion
VIEWPOINT
Thomas R. Frieden, MD, MPH Centers for Disease Control and Prevention, Atlanta, Georgia.
Corresponding Author: Thomas R. Frieden, MD, MPH, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, MS D-14, Atlanta, GA 30333 ([email protected]).
Tobacco Control Progress and Potential The 1964 surgeon general’s report on the health harms of smoking “hit the country like a bombshell.”1 More than 40%ofUSadultssmoked,andsmokingwasacceptedand considered normal behavior. Today, the US adult smoking rate is around 18%2 and about half of Americans are protected from secondhand smoke in workplaces.3 Researchers documented the harms of tobacco through rigorous, often innovative studies; activists implemented tobacco control interventions and then evaluated them rigorously to establish practice-based evidence. Tobaccousedeclinedsteadilyastheevidencebaseofsuccessful tactics increased, and social mores changed gradually asaresultofeducation,advocacy,andpolicyinterventions. Tobacco control has been described, accurately, as one of the great public health successes of the 20th century. However, there are 2 important and concerning surprises in tobacco control. First, even 50 years later, studies are continuing to elucidate new ways tobacco causes death and disability among both smokers and people exposed to secondhand smoke—new diseases it causes or complicates. Tobacco is, quite simply, in a league of its own in terms of the sheer numbers and varieties of ways it kills and maims people. Second, despite progress both in the United States and globally, proven strategies have not been fully implemented to protect children, support smokers who want to quit, and prevent myocardial infarctions, strokes, cancers, and other tragic and expensive health consequences of smoking. In 2003, the World Health Organization (WHO) adopted the Framework Convention on Tobacco Control (FCTC) and, in 2008, introduced MPOWER, a technical package of evidence-based tobacco control interventions proven to reduce tobacco use and that help countries meet their obligations under the FCTC (Table).4 In the United States, despite reducing smoking prevalence by more than half since 1964, nearly a third of nonsmokers are still exposed to secondhand smoke; most smokers who want to quit do not receive proven treatment that would double their odds of success; graphic pack warnings have not been implemented, and, until recently, sustained national antitobacco advertising has not run; tobacco images continue to be omnipresent in retail environments; images of smoking in movies, television, and on the Internet remain common; and cigarettes continue to be far too affordable in nearly all parts of the country, with both low taxes and increasing tax evasion. MPOWER works and is expanding throughout the world. In the past 5 years, the population covered by at least 1 tobacco control MPOWER measure more than doubled, from 1 billion people in 44 countries to 2.3 billion people in 92 countries.5 Largely due to the work of the Bloomberg Initiative to Reduce Tobacco Use, half the people in the world have now seen antitobacco ads—a proportion that doubled in just 2 years. Turkey, the only country to fully implement all MPOWER measures, expe-
rienced a 13% relative decline in smoking prevalence between 2008 and 2012.6 Uruguay, which implemented most MPOWER policies sooner than any other country, reduced smoking prevalence by a quarter in just 3 years, perhaps the most rapid decline recorded.7 Further progress will require continuous implementation, enforcement, monitoring, and evaluation of MPOWER strategies. Many countries have made little or no progress and are not much further along in implementing effective tobacco control policies than the United States was in 1964. Implementation of measures already proven to work could protect millions of Americans and tens of millions of people around the world from tobacco-related harms. In the United States, if the national smoking rate were as low as the rate in states that have implemented effective policies,therecouldbeasmanyas15millionfewersmokersand potentially millions of fewer deaths from tobacco-related disease. Globally, if MPOWER policies had been implemented at their highest level in 2010, along with tax increases doubling the retail price of cigarettes, an estimate suggeststhatsmokingprevalencecouldhavebeenreduced fromthecurrent24%to15%in2020andto13%in2030.8 Even modest declines would have remarkable health benefits. If global adult smoking prevalence were to decline to 20% by 2020, a target in line with recent progress in the UnitedStates,aprojectionsuggeststhatmorethan100millionprematuretobacco-relateddeathscouldbeprevented during this century among both current adult smokers and potential future smokers who are alive today.9 Inadditiontoimplementingprovenstrategiesthatare not yet in place, new approaches to end the epidemic of tobacco-caused disease must be developed. The United States’ target of reducing cigarette smoking among adults to 12% or less by 2020 will be attainable nationally only by implementing proven strategies aggressively and by developing new prevention and cessation tools that keep pace with tobacco company product innovation and accelerate progress. Newer products such as e-cigarettes could potentially help smokers quit, but will increase harms from tobacco if they increase the number of children who become addicted to nicotine, reduce the likelihood smokers will quit completely, entice former smokers back to smoking, or reglamorize the act of smoking. Although there is much more to do to implement currently proven strategies, innovation in tobacco control in the coming years will also be essential. Future strategies for tobacco control may be considered as radical as the strategies now in widespread use were when they were first introduced. Protecting the next generation is essential; it’s much easier not to start using tobacco than it is to quit. In addition to implementing MPOWER strategies, which are effective in reducing youth smoking, other potential approaches to be considered and evaluated rigorously include reducing exposure of children to smoking imagery in movies, television, and social media; re-
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133
Opinion Viewpoint
Table. Status of Implementation of MPOWER Measures According to the 2013 WHO Report on the Global Tobacco Epidemic Achievement Needed for Highest Implementation Level
Status in United States
Global Status
Monitor tobacco use and prevention policies
Recent, representative, and periodic data for both adults and youth
Highest level; United States has long been a global leader in health monitoring and surveillance
54 countries with 2.8 billion people have achieved highest level; 45 additional countries with 1.2 billion people conducted recent adult and youth surveys but have not done so periodically
Protect people from secondhand smoke
All public places completely smoke-free (or at least 90% of the population covered by complete subnational smokefree legislation)
Lowest level; no comprehensive national smoke-free legislation; about half of Americans are covered by state and local smoke-free laws3; national smoking ban currently in place only on commercial airline flights
43 countries with 1.1 billion people have achieved highest level; 16 additional countries with 280 million people would achieve highest level by further strengthening existing smoke-free laws
Offer help to quit tobacco use
National quit line, and both NRT and some cessation services cost-covered
Highest level; national toll-free quit line (1-800-QUIT-NOW) since 2006; cessation medications and services covered by Medicare /Medicaid and some private insurance plans
21 countries with 1 billion people have achieved highest level; 43 additional countries with 3 billion people would achieve highest level by establishing a national toll-free quit line or at least partially covering costs of NRT
Measure
Warn about the dangers of tobacco Health warning labels
Large health warnings on cigarette packaging that include all appropriate characteristics, including pictures and/or graphics
Lowest levela; warnings would need to increase in size to cover half of tobacco packaging and incorporate graphic images to achieve highest level; regulations to mandate this were challenged in court and are being revised
30 countries with 1 billion people have achieved highest level; 35 additional countries with 1.3 billion people would achieve highest level by further strengthening existing warning label requirements
Mass media campaigns
National campaign conducted with at least 7 appropriate characteristics, including airing on television and/or radio for a duration of a least 3 weeks
Highest level; Tips From Former Smokers ad campaigns aired nationally in 2012 and 2013 moving the United States into highest category
37 countries with 3.8 billion people have achieved highest level; 18 additional countries with 480 million people conducted campaign with most characteristics, or one that did not air on broadcast media
Enforce bans on tobacco advertising, promotion, and sponsorship (TAPS)
Ban on all forms of direct and indirect advertising
Lowest level; current ban (implemented in 1970) only covers TV and radio broadcast advertising
24 countries with 700 million people have achieved highest level; 103 additional countries with 4.5 billion people ban most but not all forms of TAPS
Raise taxes on tobacco
More than 75% of retail price is tax
Second-lowest level; even with recent tax bxincreases, federal taxes make up 43% of retail price—proportion is higher in some states and municipalities that levy additional taxes
32 countries with 530 million people have achieved highest level; the global average is 58% of retail price is tax
Abbreviations: NRT, nicotine replacement therapy; WHO, World Health Organization.
a
ducing youth access to tobacco (eg, through changes in minimum age of purchase); decreasing the addictiveness of cigarettes; and addressing the production, distribution, and marketing of tobacco. These and other measures provide a starting point for debate and action. Just as different communities in the United States implemented policies such as smoke-free laws and demonstrated their feasibility and effectiveness, communities and countries around the world are implementing programs that will lead to the practicebased evidence needed to accelerate progress.
Smallpox eradication required innovation, audacity, and aggressive, persistent application of science and technology. Eliminating the harms caused by tobacco is both easier and more difficult than eradicating smallpox because the tobacco epidemic is entirely a result of human activity. Effective action can ensure that the surgeon general’s report on tobacco a generation from now will simply reflect on the lessons of having successfully ended the epidemic of disease and death caused by tobacco.
ARTICLE INFORMATION Conflict of Interest Disclosures: Dr Frieden has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. Additional Contributions: I thank Ursula Bauer, PhD, and Tim McAfee, MD, MPH (Centers for Disease Control and Prevention), for helpful suggestions and Drew Blakeman, MS, for assistance with manuscript preparation. No one received compensation in addition to their regular pay. REFERENCES 1. US National Library of Medicine. Profiles in science: the reports of the surgeon general. http://profiles.nlm.nih.gov/ps/retrieve/Narrative /NN/p-nid/60. Accessed November 26, 2013.
134
Most recent categorization by WHO (second-highest level) was based on challenged regulations being in place.
2. Centers for Disease Control and Prevention. Early release of selected estimates based on data from the January-September 2012 National Health Interview Survey. http://www.cdc.gov/nchs/data /nhis/earlyrelease/earlyrelease201303.pdf. Accessed November 26, 2013. 3. Centers for Disease Control and Prevention. Vital signs. MMWR Morb Mortal Wkly Rep. 2010;59(35):1141-1146. 4. World Health Organization. MPOWER. http://www.who.int/tobacco/mpower/mpower _english.pdf. Accessed November 26, 2013. 5. World Health Organization. WHO report on the global tobacco epidemic, 2013. http://who.int /tobacco/global_report/2013/en/index.html. Accessed November 26, 2013.
/tobacco/surveillance/survey/gats/gats_turkey _2008v2012_comparison_fact_sheet.pdf. Accessed November 26, 2013. 7. International Tobacco Control Policy Evaluation Project. ITC Uruguay National Report: Findings From the Wave 1 to 3 Surveys (2006-2011). Waterloo, Canada: University of Waterloo; 2012. 8. Méndez D, Alshanqeety O, Warner KE. The potential impact of smoking control policies on future global smoking trends. Tob Control. 2013;22(1):46-51. 9. Frieden TR, Bloomberg MR. How to prevent 100 million deaths from tobacco. Lancet. 2007;369(9574):1758-1761.
6. World Health Organization. Global Adult Tobacco Survey (GATS). http://www.who.int
JAMA January 8, 2014 Volume 311, Number 2
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of Birmingham User on 06/03/2015
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VIEWPOINT
Thomas R. Frieden, MD, MPH Centers for Disease Control and Prevention, Atlanta, Georgia.
Corresponding Author: Thomas R. Frieden, MD, MPH, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, MS D-14, Atlanta, GA 30333 ([email protected]).
Tobacco Control Progress and Potential The 1964 surgeon general’s report on the health harms of smoking “hit the country like a bombshell.”1 More than 40%ofUSadultssmoked,andsmokingwasacceptedand considered normal behavior. Today, the US adult smoking rate is around 18%2 and about half of Americans are protected from secondhand smoke in workplaces.3 Researchers documented the harms of tobacco through rigorous, often innovative studies; activists implemented tobacco control interventions and then evaluated them rigorously to establish practice-based evidence. Tobaccousedeclinedsteadilyastheevidencebaseofsuccessful tactics increased, and social mores changed gradually asaresultofeducation,advocacy,andpolicyinterventions. Tobacco control has been described, accurately, as one of the great public health successes of the 20th century. However, there are 2 important and concerning surprises in tobacco control. First, even 50 years later, studies are continuing to elucidate new ways tobacco causes death and disability among both smokers and people exposed to secondhand smoke—new diseases it causes or complicates. Tobacco is, quite simply, in a league of its own in terms of the sheer numbers and varieties of ways it kills and maims people. Second, despite progress both in the United States and globally, proven strategies have not been fully implemented to protect children, support smokers who want to quit, and prevent myocardial infarctions, strokes, cancers, and other tragic and expensive health consequences of smoking. In 2003, the World Health Organization (WHO) adopted the Framework Convention on Tobacco Control (FCTC) and, in 2008, introduced MPOWER, a technical package of evidence-based tobacco control interventions proven to reduce tobacco use and that help countries meet their obligations under the FCTC (Table).4 In the United States, despite reducing smoking prevalence by more than half since 1964, nearly a third of nonsmokers are still exposed to secondhand smoke; most smokers who want to quit do not receive proven treatment that would double their odds of success; graphic pack warnings have not been implemented, and, until recently, sustained national antitobacco advertising has not run; tobacco images continue to be omnipresent in retail environments; images of smoking in movies, television, and on the Internet remain common; and cigarettes continue to be far too affordable in nearly all parts of the country, with both low taxes and increasing tax evasion. MPOWER works and is expanding throughout the world. In the past 5 years, the population covered by at least 1 tobacco control MPOWER measure more than doubled, from 1 billion people in 44 countries to 2.3 billion people in 92 countries.5 Largely due to the work of the Bloomberg Initiative to Reduce Tobacco Use, half the people in the world have now seen antitobacco ads—a proportion that doubled in just 2 years. Turkey, the only country to fully implement all MPOWER measures, expe-
rienced a 13% relative decline in smoking prevalence between 2008 and 2012.6 Uruguay, which implemented most MPOWER policies sooner than any other country, reduced smoking prevalence by a quarter in just 3 years, perhaps the most rapid decline recorded.7 Further progress will require continuous implementation, enforcement, monitoring, and evaluation of MPOWER strategies. Many countries have made little or no progress and are not much further along in implementing effective tobacco control policies than the United States was in 1964. Implementation of measures already proven to work could protect millions of Americans and tens of millions of people around the world from tobacco-related harms. In the United States, if the national smoking rate were as low as the rate in states that have implemented effective policies,therecouldbeasmanyas15millionfewersmokersand potentially millions of fewer deaths from tobacco-related disease. Globally, if MPOWER policies had been implemented at their highest level in 2010, along with tax increases doubling the retail price of cigarettes, an estimate suggeststhatsmokingprevalencecouldhavebeenreduced fromthecurrent24%to15%in2020andto13%in2030.8 Even modest declines would have remarkable health benefits. If global adult smoking prevalence were to decline to 20% by 2020, a target in line with recent progress in the UnitedStates,aprojectionsuggeststhatmorethan100millionprematuretobacco-relateddeathscouldbeprevented during this century among both current adult smokers and potential future smokers who are alive today.9 Inadditiontoimplementingprovenstrategiesthatare not yet in place, new approaches to end the epidemic of tobacco-caused disease must be developed. The United States’ target of reducing cigarette smoking among adults to 12% or less by 2020 will be attainable nationally only by implementing proven strategies aggressively and by developing new prevention and cessation tools that keep pace with tobacco company product innovation and accelerate progress. Newer products such as e-cigarettes could potentially help smokers quit, but will increase harms from tobacco if they increase the number of children who become addicted to nicotine, reduce the likelihood smokers will quit completely, entice former smokers back to smoking, or reglamorize the act of smoking. Although there is much more to do to implement currently proven strategies, innovation in tobacco control in the coming years will also be essential. Future strategies for tobacco control may be considered as radical as the strategies now in widespread use were when they were first introduced. Protecting the next generation is essential; it’s much easier not to start using tobacco than it is to quit. In addition to implementing MPOWER strategies, which are effective in reducing youth smoking, other potential approaches to be considered and evaluated rigorously include reducing exposure of children to smoking imagery in movies, television, and social media; re-
jama.com
JAMA January 8, 2014 Volume 311, Number 2
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of Birmingham User on 06/03/2015
133
Opinion Viewpoint
Table. Status of Implementation of MPOWER Measures According to the 2013 WHO Report on the Global Tobacco Epidemic Achievement Needed for Highest Implementation Level
Status in United States
Global Status
Monitor tobacco use and prevention policies
Recent, representative, and periodic data for both adults and youth
Highest level; United States has long been a global leader in health monitoring and surveillance
54 countries with 2.8 billion people have achieved highest level; 45 additional countries with 1.2 billion people conducted recent adult and youth surveys but have not done so periodically
Protect people from secondhand smoke
All public places completely smoke-free (or at least 90% of the population covered by complete subnational smokefree legislation)
Lowest level; no comprehensive national smoke-free legislation; about half of Americans are covered by state and local smoke-free laws3; national smoking ban currently in place only on commercial airline flights
43 countries with 1.1 billion people have achieved highest level; 16 additional countries with 280 million people would achieve highest level by further strengthening existing smoke-free laws
Offer help to quit tobacco use
National quit line, and both NRT and some cessation services cost-covered
Highest level; national toll-free quit line (1-800-QUIT-NOW) since 2006; cessation medications and services covered by Medicare /Medicaid and some private insurance plans
21 countries with 1 billion people have achieved highest level; 43 additional countries with 3 billion people would achieve highest level by establishing a national toll-free quit line or at least partially covering costs of NRT
Measure
Warn about the dangers of tobacco Health warning labels
Large health warnings on cigarette packaging that include all appropriate characteristics, including pictures and/or graphics
Lowest levela; warnings would need to increase in size to cover half of tobacco packaging and incorporate graphic images to achieve highest level; regulations to mandate this were challenged in court and are being revised
30 countries with 1 billion people have achieved highest level; 35 additional countries with 1.3 billion people would achieve highest level by further strengthening existing warning label requirements
Mass media campaigns
National campaign conducted with at least 7 appropriate characteristics, including airing on television and/or radio for a duration of a least 3 weeks
Highest level; Tips From Former Smokers ad campaigns aired nationally in 2012 and 2013 moving the United States into highest category
37 countries with 3.8 billion people have achieved highest level; 18 additional countries with 480 million people conducted campaign with most characteristics, or one that did not air on broadcast media
Enforce bans on tobacco advertising, promotion, and sponsorship (TAPS)
Ban on all forms of direct and indirect advertising
Lowest level; current ban (implemented in 1970) only covers TV and radio broadcast advertising
24 countries with 700 million people have achieved highest level; 103 additional countries with 4.5 billion people ban most but not all forms of TAPS
Raise taxes on tobacco
More than 75% of retail price is tax
Second-lowest level; even with recent tax bxincreases, federal taxes make up 43% of retail price—proportion is higher in some states and municipalities that levy additional taxes
32 countries with 530 million people have achieved highest level; the global average is 58% of retail price is tax
Abbreviations: NRT, nicotine replacement therapy; WHO, World Health Organization.
a
ducing youth access to tobacco (eg, through changes in minimum age of purchase); decreasing the addictiveness of cigarettes; and addressing the production, distribution, and marketing of tobacco. These and other measures provide a starting point for debate and action. Just as different communities in the United States implemented policies such as smoke-free laws and demonstrated their feasibility and effectiveness, communities and countries around the world are implementing programs that will lead to the practicebased evidence needed to accelerate progress.
Smallpox eradication required innovation, audacity, and aggressive, persistent application of science and technology. Eliminating the harms caused by tobacco is both easier and more difficult than eradicating smallpox because the tobacco epidemic is entirely a result of human activity. Effective action can ensure that the surgeon general’s report on tobacco a generation from now will simply reflect on the lessons of having successfully ended the epidemic of disease and death caused by tobacco.
ARTICLE INFORMATION Conflict of Interest Disclosures: Dr Frieden has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. Additional Contributions: I thank Ursula Bauer, PhD, and Tim McAfee, MD, MPH (Centers for Disease Control and Prevention), for helpful suggestions and Drew Blakeman, MS, for assistance with manuscript preparation. No one received compensation in addition to their regular pay. REFERENCES 1. US National Library of Medicine. Profiles in science: the reports of the surgeon general. http://profiles.nlm.nih.gov/ps/retrieve/Narrative /NN/p-nid/60. Accessed November 26, 2013.
134
Most recent categorization by WHO (second-highest level) was based on challenged regulations being in place.
2. Centers for Disease Control and Prevention. Early release of selected estimates based on data from the January-September 2012 National Health Interview Survey. http://www.cdc.gov/nchs/data /nhis/earlyrelease/earlyrelease201303.pdf. Accessed November 26, 2013. 3. Centers for Disease Control and Prevention. Vital signs. MMWR Morb Mortal Wkly Rep. 2010;59(35):1141-1146. 4. World Health Organization. MPOWER. http://www.who.int/tobacco/mpower/mpower _english.pdf. Accessed November 26, 2013. 5. World Health Organization. WHO report on the global tobacco epidemic, 2013. http://who.int /tobacco/global_report/2013/en/index.html. Accessed November 26, 2013.
/tobacco/surveillance/survey/gats/gats_turkey _2008v2012_comparison_fact_sheet.pdf. Accessed November 26, 2013. 7. International Tobacco Control Policy Evaluation Project. ITC Uruguay National Report: Findings From the Wave 1 to 3 Surveys (2006-2011). Waterloo, Canada: University of Waterloo; 2012. 8. Méndez D, Alshanqeety O, Warner KE. The potential impact of smoking control policies on future global smoking trends. Tob Control. 2013;22(1):46-51. 9. Frieden TR, Bloomberg MR. How to prevent 100 million deaths from tobacco. Lancet. 2007;369(9574):1758-1761.
6. World Health Organization. Global Adult Tobacco Survey (GATS). http://www.who.int
JAMA January 8, 2014 Volume 311, Number 2
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of Birmingham User on 06/03/2015
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