Many thought it could never happen. In an action once considered inconceivable, the major pharmacy chain CVS Caremark recently announced that it will stop selling all tobacco products throughout its 7,600 outlets nationwide (1). Declaring that the sale of tobacco represented an unacceptable paradox for a business trying to promote health, CVS Caremark leaders began phasing out tobacco sales in February 2014 and will end all such sales by October 2014. And thus a new social norm has come to pass.
As extraordinary as it was, this private sector action represents only one of three major milestones that have already made 2014 a standout year for tobacco control. A second milestone was the release of The Health Consequences of Smoking—50 Years of Progress (2). On one hand, the 50th Anniversary Report noted striking advances over the past half century. Since 1964, the country has witnessed declining adult per capita cigarette consumption by more than 70%, and the prevalence of adult smoking has decreased by over half [from 42.7% (1964) to 18.1% (2012)]. Tobacco control has helped to avert at least eight million early deaths over that period. Furthermore, the incidence of lung cancer, an uncommon disease in the early 20th century, which then increased markedly to become the leading cause of cancer death, has begun a decline, first among men and more recently among women. And of note, the report states that quitting smoking improves the prognosis of cancer patients.
But the new report also summarizes major challenges for the future. More than 42 million smokers still struggle with tobacco dependence, and 16 million current and former smokers live with smoking-related illnesses (2). New estimates now indicate annual tobacco-related deaths approach half a million in the United States, with more than five million a year worldwide. Fifty years after the first Surgeon General's Report, evidence now links tobacco as a new causal factor for malignancies, such as colorectal cancer and liver cancer, as well as nonmalignant conditions, such as diabetes mellitus and rheumatoid arthritis. And in a startling conclusion, the report states that 5.6 million youth alive today will die prematurely because of tobacco dependence if we continue at current smoking rates.
The 50th Anniversary Report urges enhanced attention to both new and proven strategies for tobacco control to make the next generation tobacco free. Such strategies are sorely needed as the tobacco industry spends $8 billion a year—nearly a million dollars an hour—to advertise and market cigarettes and smokeless tobacco, thereby outspending current state tobacco control programs by a factor of 18 to 1. Last year, customers consumed over 14 billion packs of cigarettes, and over time these cigarettes have become more complex and more addictive, and the risks from smoking have become more deadly. Furthermore, each year the tobacco industry adds to an ever-growing array of novel products, such as flavored small cigars and e-cigarettes, that may have special appeal to young people. In particular, significant questions remain about the net public health benefits of e-cigarettes.
In short, the 50th Anniversary Report underscores again that tobacco dependence represents a pediatric disease. Of note, most smokers start before age 18, with the median age for initiation being only 13 years of age. And for each adult who succumbs to tobacco, two younger replacement smokers stand ready to take their place, thereby perpetuating a cycle of dependence. Too many kids still routinely see tobacco use everywhere and assume it is part of the social norm. Half of the U.S. states still lack comprehensive smoke-free laws for public places. Images glamorizing tobacco use still reach kids through the Internet, at retail stores, and in movies (3). And because tobacco causes damage that may be unseen until many years later, youth can easily dismiss the risks involved. To capture their attention, vulnerable kids need to see, and feel, what the true risks of tobacco actually are.
That's why the third major 2014 tobacco control milestone, the February launch of a $115-million mass media youth prevention campaign by the U.S. Food and Drug Administration (FDA), represents yet another major opportunity to reduce tobacco use. Entitled “The Real Cost,” this media campaign has been constructed based on critical scientific and marketing research on how best to reach at-risk youth. The campaign, which will extend over a period of a year, vividly and viscerally conveys graphic messages about tobacco use, building on lessons learned from previous successful national and statewide mass media campaigns. The FDA campaign will have a rigorous evaluation, involving thousands of youth. Other notable related events include the unveiling by the Centers for Disease Control (CDC) of the latest version of its “Tips from Former Smokers” campaign designed to encourage smokers to quit, along with the Legacy Foundation's planned mass media efforts to take place later this year (3). Through all of these efforts, more public attention to tobacco use may well be generated in 2014 than at any time in recent memory.
These new 2014 milestones accelerate momentum stemming from the release from the U.S. Department of Health and Human Services (HHS) of the first ever Strategic Action Plan for Tobacco Control Ending the Tobacco Epidemic, released in 2010 (4). The Strategic Action Plan urges reinvigorated tobacco control efforts, emphasizing pillars of improving the public's health, engaging the public and changing social norms, leading by example, and advancing research. Major accomplishments emerging from the Strategic Action Plan already include expanded coverage of tobacco cessation counseling to approximately five million Medicare tobacco users (not just those with tobacco-related diseases), new Medicaid guidelines that mandate full cessation coverage for pregnant women, and 50% reimbursement to states providing telephone “quit line” support to beneficiaries who smoke. The Strategic Action Plan has also served as a framework for enhanced access to robust evidence-based cessation treatments for all federal employees (as well as retirees and dependents as ensured by the federal Office of Personnel Management); ongoing FDA contracts to states to enforce tobacco marketing, sale, and distribution laws and regulations at retail locations; CDC grants to communities for tobacco prevention; and a requirement for no cost sharing for tobacco counseling and cessation services for millions in new private health plans made available through the Affordable Care Act.
In addition to these accomplishments, we need further action to realize the full impact of proven strategies such as fully funded comprehensive statewide tobacco control programs at CDC-recommended levels, higher prices on cigarettes and other tobacco products that will drive down consumption, and complete protection of our entire country—not just half the population as is seen currently—through smoke-free indoor air policies.
But accelerating progress for the future will also require more innovative actions like the decision made by CVS Caremark. An area of great need is to bring more attention to reduction of tobacco-related disparities and to the disproportionate burden tobacco places on those with mental illness and substance use disorders. Individuals with mental illness smoke at rates approximately double those of adults without mental illness and comprise more than half of nicotine-dependent smokers (2, 4). Moreover, tobacco use drives much of the excess mortality among people with serious mental illness. We need greater attention to cessation and prevention policies for this key population.
Another issue relates to the current and future extent of FDA regulatory authority over tobacco products. The 2009 Family Smoking Prevention and Tobacco Control Act gave the FDA explicit regulatory authority over cigarettes, smokeless tobacco, and “roll-your-own” but was silent on other tobacco products. However, the 2009 act also provided FDA the option to extend its authority and thereby “deem” other tobacco products to be subject to regulation. Ultimately, such extended authority through the issuance of proposed regulations could include products that are not currently regulated.
A promising future direction revolves around possible “end game” strategies. The 50th Anniversary Report summarizes such strategies, which could include requiring the reduction of nicotine content to nonaddicting levels (2). Through notice and comment rule making, the FDA can issue product standards, supported by science and as “appropriate for the protection of public health.” Such product standards, as part of a comprehensive nicotine regulatory strategy, have the potential to fundamentally change the market for the spectrum of nicotine products in the future.
In short, 2014 has already delivered historic actions for tobacco control that accelerate public health momentum. The ultimate goal for the nation should be to relegate the morbidity and mortality associated with tobacco to the history books as a conquered epidemic (4). And it shouldn't take another 50 years. Achieving that goal will require even more committed leadership through every sector of society that rejects the status quo and envisions a healthier future. In 2014, we honor new milestones but also must explore the promise of a true end game for tobacco. It is time to reclaim the social norm as one that is tobacco free and to bring better health to future generations.