The 32nd Great American Smokeout: A Perspective

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As we approach yet another Great American Smokeout -- tomorrow, November 20th -- both good and bad news on smoking abounds.

•The good news is that adult smoking rates in 2007 have dropped below 20% for the first time since this statistic has been recorded with any accuracy. There are now more former smokers than current smokers, and women's smoking rates have declined for the fifth year in a row.

•The bad news is still shocking: there remain over 43 million adult smokers in the U.S., and the decline in teen smoking has leveled off of late. Cigarettes still kill well over 400,000 Americans each year, mainly from heart disease and lung cancer, but also from other cancers and chronic obstructive pulmonary disease (which is on the increase). Also, the number of smokers who have been trying to quit declined in 2007 -- possibly because of the well-known difficulty of quitting.

Worse, the ineffectiveness of currently-approved cessation aids is partly responsible for the abysmal success rate: at one year, the abstinence rate with all the approved modalities hovers in the 20% range. But are there are ways of quitting cigarettes even while continuing to receive nicotine.

One such is substituting smokeless tobacco products for cigarettes. Unfortunately, federal health authorities at every level continue to deny the possibility that smokeless tobacco might be an effective means to help addicted adult smokers quit.

The new published guidelines continue to toe the party line that "there is no safe tobacco product," so no thought is given to the dramatically lower risk of smokeless as compared to cigarettes. "Treating Tobacco Use and Dependence" -- the latest federal publication -- asserts that "the use of smokeless tobacco is not a safe alternative to smoking, nor is there evidence to suggest that it is effective in helping smokers quit."

To which I respond, "there are none so blind as those who will not see." In fact, there is a plethora of evidence that smokeless can help people quit cigarettes -- but no one in the federal health system will consider it, choosing the "quit or die" policy instead. They seem willing to accept the abject failure of the currently approved cessation products, as long as tobacco is not involved -- even though smokeless tobacco has less than one-tenth the health risks of smoking cigarettes.

The fraction of smokers advised by their doctors to quit rose slightly last year to just over 70% -- still entirely unacceptable, given the fact that getting a doctor's advice to quit costs nothing and is a powerful inducement to give it a try. The problem is, advising people to quit is of little benefit if the advice doesn't come with practical ideas on how to do it. Successful quitters -- and there are over 50 million of them -- are those who keep trying, often needing five, seven, or ten attempts before succeeding. Among Medicaid patients -- who tend to be younger and poorer -- and among teens, only one-quarter receive quitting advice, an unbelievable failure of primary medical care.


This month also marks the tenth anniversary of the Master Settlement Agreement, in which forty-six states made a deal with Big Tobacco to be compensated for the health costs of smoking -- to the tune of $246 billion payable over twenty-five years. That money was supposed to be used to educate the public about smoking's dangers, thus reducing the rate of smoking. Well, the large majority of that money was hijacked by state governments and diverted to general revenues, leaving little -- sometimes none -- for the stated health goals.

A new report states that only 3% of the MSA billions has been spent on smoking-related issues, and the number of states currently funding smoking prevention at the CDC-recommended levels In essence, the MSA enabled the tobacco companies to keep doing business as usual. The citizens of those states continue to suffer the consequences of cigarette addiction -- premature disease, disability, and death.

A recent attempt to put the tobacco industry under the oversight of the FDA thankfully came to naught during this Congress -- that bill would have done nothing to reduce smoking rates, but would have given cigarettes the imprimatur "FDA Approved." A renewed effort in the next session may well lead to passage of an FDA tobacco bill -- but hopefully the new measure will be re-crafted to contain real safeguards for public health, not merely lip service about "toxic constituents."

Meanwhile, we should take a look at the wider world. While smoking rates have declined in the U.S. and the EU as tighter controls are instituted, in the rest of the world cigarette companies are making dramatic inroads. Millions of Chinese, Indians, Indonesians, and Africans will die of smoking-related diseases over the next several decades. Their environments and markets are largely unregulated, leaving them exposed to marketing by Big Tobacco. Now that Philip Morris has gone international, outside of U.S. regulatory reach, there is almost nothing we can do about this -- which is exactly what they planned.

Back in the U.S., further restrictions on workplace and public-area smoking and cigarette advertising, efforts to make teens more aware of the dangers of smoking, and more effective cessation therapies -- including forthright communications about harm reduction and smokeless tobacco -- will likely lead to continuing reductions in smoking rate and save thousands of lives over the next decade.

Gilbert Ross, M.D., is Medical Director of the American Council on Science and Health (,