January 2014 marked the fifty-year anniversary of the first Surgeon General (SG) Report on Smoking and Health. It was a landmark event that changed the course of the tobacco epidemic. The report set the stage for the growth of a robust evidence base for tobacco control policy and programs that led to the dramatic decline in tobacco use from 42% in 1964 (the peak year for smoking) to 18% today. The story is one of public health advocacy, informed by strong science, triumphing over multi-billion dollar international corporations whose strategies aimed to mislead the public and subvert implementation of evidence-based policies.
It is important to remember that much of the scientific advances and innovative research were made possible through the critical financial support of the federal government and foundations. In 1990, Dr. Steve Schroeder, the president of the Robert Wood Johnson Foundation (RWJF) committed, over the next decade, more than $400 million to tobacco control. The U.S. Centers for Disease Control and Prevention and National Institutes of Health also provided core support for research and statewide coalitions to spread “best practices” in tobacco control.
But it was another landmark event in 1998 that again accelerated progress made in the decades since the 1964 Report. That is the year that the major U.S. tobacco companies settled (the Master Settlement Agreement [MSA]) with the U.S. Attorneys General agreeing to pay about $200 billion to states and curtail marketing of cigarettes to youth. The MSA also led to the creation of the American Legacy Foundation which has subsequently played a central role, through groundbreaking counter advertising campaigns, in the dramatic drop in smoking rates among youth.
Since 1996, teen smoking rates have declined by nearly 80 percent among 8th graders, 70 percent among 10th graders, and 50 percent among 12th graders. As important, the MSA led to the release of hundreds of thousands of documents now available through the University of California, San Francisco Library. These documents provided the tobacco control community with evidence of years of the industry’s deceitful practices and specific strategies they used to sustain youth smoking rates, increase smoking among specific target groups, and increase their market share globally.
As the U.S. was making progress implementing evidence-based tobacco control programs including raising cigarette taxes and passing comprehensive smoke-free air laws, there was growing concern about the global impact of tobacco use. Worldwide, more than 1 billion people use tobacco, resulting in about 6 million deaths per year.
On April 8th,to mark the 50th anniversary of the SG Report, Columbia University hosted a seminar on the Global Tobacco Epidemic. Dr. Derek Yach, Executive Director of the Vitality Institute, provided a wonderful history of the early global tobacco control movement that culminated in the adoption of the Framework Convention on Tobacco Control (FCTC). As the first Director of the Tobacco-Free Initiative in 1998, he steered development of the FCTC from its inception to adoption in March 2003. It became the first World Health Organization (WHO) treaty adopted under article 19 of the WHO constitution and is legally binding in 178 ratifying countries.
To assist countries in implementing the FCTC, in 2008, the WHO introduced MPOWER, a package of six evidence-based measures that are core components of the WHO FCTC. Dr. Yach and panel participants reflected on past successes and current and future challenges to maintaining gains and making a deeper impact globally. Dr. Yach ended his talk by noting several challenges that we face moving into the next 50 years of tobacco control including fully implementing the FCTC, focusing on women and girls, and embracing potential disruptive technologies like electronic cigarettes, a product that is forcing us to rethink our strategies for how to end the scourge of combustible tobacco products.
When Acting Surgeon General Borish Lushniak declared, “enough is enough”, at a White House ceremony unveiling the Report, he was echoing frustration with the over 400,000 deaths per year related to tobacco use and growing calls to implement an “end game” strategy. The end game conversation has focused on asking the FDA to slowly reduce nicotine levels in cigarettes to a point where they are no longer addictive. But the entry of electronic cigarettes (e-cigarettes) has changed the conversation to include a larger role for harm reduction and the sale of safe, effective nicotine replacement therapies delivered in vehicles that meet smokers’ demands for a cigarette-like experience. With $2 billion in sales, smokers are voting with their feet.
There are certainly valid concerns about the growth of e-cigarette use among teens, but we have 50 years of experience countering tobacco industry tactics and can begin to put similar policies in place to prevent a new generation from becoming addicted to nicotine. In New York City, we have banned using e-cigarettes in public spaces and regulated the age of purchase to 21. This is just the beginning. We need to catch up in terms of regulation, but as Dr. Michael Johns, an epidemiologist in the NYC Department of Health and Mental Hygiene, asked during the panel discussion, “Does it make sense to ban e-cigarettes when at the same time traditional cigarettes remain on the market?” It is time for the tobacco control community to embrace harm reduction and address the concerns about safety and adolescent use with rational policy approaches.
So what will the next 50 years in tobacco control look like? In many ways, New York City has led the way in demonstrating the next phase of tobacco control. Innovative policies like fire-safe cigarettes, banning flavored cigarettes, and, more recently, raising the purchase age to 21 and regulating a minimum price for tobacco products to stop the industry’s attempts to undercut tax increases, are just a few. The industry continues to evolve their strategies to respond to tobacco control policies. That means we have to remain vigilant and counter with new and more creative approaches. It would be hubristic to think we can predict the future. Who would have imagined the e-cigarette 20 years ago?
What we can imagine is a world in which proven strategies are fully implemented in the U.S. and globally; the U.S. Food and Drug Administration (FDA) uses their regulatory authority to increase the availability of safer nicotine delivery systems and eliminate the addictive potential of combustible tobacco products; and we reach our national goal of less than 10% smoking rates across all income levels, race/ethnicities and among those with comorbidities that place them at highest risk for in tobacco related deaths.
We must also continue to generate the science to support innovation in tobacco control and inform evidence-based policies and programs around the world. Working together, the tobacco control community of scientists, policy makers, employers, clinicians, and advocates can ensure that the next 50 year anniversary report will tell the story of how we ended the epidemic of death and disease related to tobacco use.