Tobacco was America’s great public health scourge of the past century, but the tobacco control movement was one of its great public health success stories. It is estimated that 8 million lives have been saved since the first Surgeon General’s report on tobacco in 1964. In large measure, this is because American culture shifted away from the social norms that everybody smokes and anybody can smoke anywhere. The public health game plan changed, expanding from simple measures like small warnings on cigarette packs to comprehensive tobacco control programs, which include smoking bans, advertising restrictions, media campaigns, and tax increases. As a result, there is less tobacco use today, and consequently, there are lower mortality rates for heart disease, cancer, and other maladies.
But all is not well. Lest we rest on our laurels, it would be wise to consider that tobacco use in 2016 is still the leading cause of preventable disease and mortality. Worldwide, tobacco is projected to cause 1 billion deaths in the 21st century, dwarfing the 100 million lives that it took in the last century. There are tried and true strategic interventions with a strong evidence base behind them, but are they moving the needle fast enough?
To this end, Altarum Institute surveyed the ActionToQuit Network, a nationwide group of tobacco control leaders and practitioners, to learn what course it might recommend for the future of tobacco control. What gaps and opportunities exist? What should be prioritized?
The following is a summary of the responses offered by ActionToQuit members:
Question 1: In the past decade, what do you consider to have been the most successful strategies for reducing tobacco use and tobacco-related deaths in the U.S.?
- The most common responses were smoke-free laws, tobacco tax increases, media campaigns, and expansion of tobacco cessation services, in that order.
“The Truth Campaign really changed the way we look at tobacco control. Engaging youth to reach out to their peers about being manipulated into using a product that is almost guaranteed to kill them really changed the game.”
Question 2: What challenges remain in the effort to reduce tobacco use and tobacco-related deaths?
- The top response was the challenge of e-cigarettes and other emerging products and their widespread marketing.
- Next was protecting disparate populations, including behavioral and mental health patients, poor people, and the LGBT community.
“The tobacco industry’s focus on low-SES populations and the lack of regulations around tobacco marketing to these specific target groups is a social justice issue; we need to do more about the pervasive and permissive nature of tobacco advertising to at-risk communities.”
Question 3: What are the gaps in U.S. tobacco control strategies, policies, and activities? What issues are not being addressed fully?
- The top response, by far, was that all tobacco products are not currently included in tobacco control laws, policies, and regulations. Food and Drug Administration regulation must extend to all products, including vape devices and liquids, cigars, flavors like menthol, hookahs, and other emerging products.
“Hookahs are hooking kids into tobacco use. At the door of hookah bars, they tell people it is good for their lungs. There is no regulation at all.”
Question 4: What future tobacco control strategies do you believe have potential?
- Several responses received an equal number of votes, including an increase in the nationwide legal age to purchase tobacco to 21, smoke-free multiunit housing, support for behavioral health facilities in tobacco cessation and smoke-free policies, and point-of-sale policies such as displaying bans or penalties for violators and sales in adult-only venues.
“I believe that every store that sells tobacco products should be made to scan a driver’s license. This way, you can verify the person is over 18 to buy. Perhaps there should be greater penalties assessed to stores selling tobacco to youth.”
Question 5: What should future tobacco control strategies incorporate or consider?
- The top response was to increase tobacco cessation services, including a greater role for health care providers, reimbursement for tobacco treatment, cessation training for all health care specialties, use of electronic health records, and insurance coverage.
“Recognize nicotine as an addiction that should be treated like alcohol and other addictive drugs. No one would suggest that heroin addicts quit on their own.”
In addition, the following comments were insightful:
- Tobacco control isn’t a priority any more. There is a common misconception that tobacco use is no longer a problem.
- Oppose the strong and wealthy tobacco industry that has political/legal influence, marketing budgets, and misinformation campaigns.
- More thorough acceptance of tobacco use as a chronic disease, a primary substance use disorder in itself and not just a risk behavior for other medical problems. Take that into consideration when designing cessation/recovery services.
- Oppose anti-tobacco control philosophies, such as the notion that tobacco policies infringe on constitutional rights or represent government playing “big brother.”
- Fund tobacco control research and its knowledge dissemination.
- A stronger focus on protecting infants, children, and pets from second- and third-hand smoke. Placing the significance on those we love will often play on the empathy of others and provide the incentive needed to quit tobacco use.
As Altarum searches for the contribution that it will make to tobacco control in the coming decade, these observations and recommendations will be given careful consideration.