November 15th marks the thirty-first annual "Great American Smokeout," a campaign initially undertaken by the American Cancer Society, whose goal was to encourage smokers to quit -- even if only for one day -- hoping this would lead to prolonged abstinence from cigarettes. Through educating smokers about the wide spectrum of smoking-related illnesses, promoting cessation medications and other quitting techniques, restricting areas where smokers can light up, and raising the price of ciggies, the hope is to get the over 40 million Americans still addicted to quit. Most of them know that quitting smoking is the single most important thing they can do to improve their health, both now and in the future, yet the 20%-plus of adult Americans who still smoke nonetheless can't or won't quit. Smoking is a strongly addictive behavior (it took me several years to quit two decades ago), though half of all who ever smoked have quit.
More bad news about smoking, just arrived from the CDC: their most recent survey of smoking patterns, "Cigarette Smoking Among Adults," shows that the decline in the rate of smoking which was noted from 1997 through 2004 -- when rates went down from almost 25% to just over 20% -- has not changed much from 2004 through 2006, the most recent year measured. The federal officials term this a "stall" in smoking's decline, as though it will clear up when the obstruction is removed. The only problem: no one seems to know exactly what the problem is, what the obstacle is to continued reduction in smokers puffing rates.
Two obvious possibilities are reduced funding across the board for cigarette-control activities by the states and a doubling of tobacco-industry marketing expenditures.
When the Master Settlement Agreement was signed in 1998, the states promised to devote over 10% of the billions of dollars they were to receive to anti-smoking programs. The facts are quite different, and they constitute a sad strikeout for public health:
•Few states devote any significant portion of these funds to these programs.
•Insurance coverage for cessation programs is also a patchwork from state to state and HMO to HMO, which is very short-sighted, since getting a smoker to quit is the most cost-effective therapy known to medical science.
•Public health authorities, in consort with the fervent anti-tobacco advocates who won't consider anything tobacco-related beneficial, continue to ignore or condemn the use of smokeless tobacco as a harm-reduction tool to help addicted smokers quit. This product has been shown to be effective in Sweden, where the rate of smoking and smoking-related diseases has dropped significantly, commensurate with increased use of smokeless tobacco.
Another simple, underutilized tactic would be to strongly encourage primary care doctors to advise their smoking patients to quit, and follow-up with specific quitting assistance. As I wrote a few years ago, only an unacceptably low fraction of doctors take the few minutes this requires.
Maybe it's time for the CDC to switch from railing against the dangers of overweight -- which have been downgraded significantly by recent studies in the Journal of the American Medical Association showing that being mildly overweight poses no major health hazard -- to warning more vigorously against cigarette smoking, the country's most potent, preventable killer.
Gilbert Ross, M.D., is Executive and Medical Director of the American Council on Science and Health (ACSH.org, HealthFactsAndFears.com).
