A half century after linking smoking to lung cancer, the U.S. is confronting stalled progress in kicking the habit of 42 million Americans with new evidence that many common ailments such as diabetes, arthritis and impotence can be tied to tobacco use.
Acting Surgeon General Boris Lushniak in a report today criticized the "fraudulent campaigns" by cigarette companies, weaknesses in regulation and a rebound in smoking depicted in Hollywood films. He said he's considering greater restrictions on sales to achieve "a society free of tobacco-related death and disease."
While a landmark 1964 report on smoking and lung cancer helped cut cigarette use by more than half to 18 percent of U.S. adults, the decline has slowed. Smoking remains the leading preventable cause of death, killing 480,000 people each year, and the U.S. may miss a 2020 goal of limiting to 12 percent the share of smoking adults, today's report shows.
"Enough is enough," Lushniak said repeatedly at a news conference in Washington where he presented the more than 900-page report. "It's astonishing that so many years later we're still making these findings."
The report shows the U.S. must be more aggressive in promoting tobacco control than regulators have been, he said.
"What we really need to do is say 'Now is the time,'" Len Lichtenfeld, deputy chief medical officer at the Atlanta-based American Cancer Society, said in a telephone interview.
Maintaining the status quo on tobacco control will lead to further stalling in the declining rate of smoking, said Lushniak, whose job serves as the nation's main public-health advocate. He placed part of the blame on tobacco companies.
"The tobacco epidemic was initiated and has been sustained by the aggressive strategies of the tobacco industry, which has deliberately misled the public on the risk of smoking cigarettes," he said in the report.
Earlier this week, Altria Group Inc., Reynolds American Inc. and other tobacco companies agreed with the U.S. on how they will publicize admissions that they deceived the American public on the dangers of smoking. Altria is the largest tobacco company in the U.S. and its Philip Morris unit makes the popular Marlboro brand of smokes.
"Philip Morris USA agrees with the overwhelming medical and scientific consensus that cigarette smoking causes lung cancer, heart disease, emphysema and other serious diseases in smokers," David Sutton, a spokesman for parent company Altria Group Inc., said in an e-mail." Smokers are far more likely to develop serious diseases, like lung cancer, than non-smokers. There is no safe cigarette."
The report lists smoking as a cause of liver cancer and colorectal cancer, which is responsible for the second-largest number of cancer deaths each year. Cigarette use may cause breast cancer and women smokers' chances of dying from lung cancer have caught up to men, the surgeon general said. Even secondhand smoke can now be linked to a higher risk of stroke, Lushniak said.
The first surgeon general report on tobacco's ill effects was made in January 1964, when at least half of all men in the U.S. and almost 40 percent of women smoked. Congress later adopted an act that required warning labels about the health consequences of smoking and in 1970 it prohibited cigarette advertising on television and radio.
Measures, such as city and state bans on smoking in workplaces, restaurants and bars, also have helped to prevent 8 million early deaths and extended lifespans by two decades. About 5.3 million men and 2.7 million women live longer thanks to tobacco control, according to one of six studies on the topic published last week in the Journal of the American Medical Association.
Advertising and promotional activities entice younger smokers and nicotine addiction keeps people smoking as they grow older. Portrayals of tobacco use in U.S. films rebounded in the past two years and the use of multiple tobacco products may increase initiation rates among teens and young adults, according to the report.
While the share of teens and young adults who smoke is down, the number of them who start to smoke has increased since 2002. In addition, the prevalence of U.S. students in middle and high school who used electronic cigarettes doubled in 2012, the Centers for Disease Control and Prevention said in a September report.
"There are a substantial number of diseases, not just cancer, but certain cardiovascular disease, stroke, respiratory disease, whether it's chronic lung disease or asthma, the list goes on and on about how tobacco impacts this country," Lichtenfeld said.
Smokers also have as much as a 40 percent higher risk of developing Type 2 diabetes and the habit is attributable to erectile dysfunction and deadly ectopic pregnancies where the embryo implants in the Fallopian tube or elsewhere outside the uterus, according to the report. People exposed to second-hand smoke are as much as 30 percent more likely to have a stroke.
Women smokers were 2.7 times more likely to develop lung cancer in 1959, a number that jumped to 25.7 percent by 2010. Male smokers were 12.2 times more likely to get lung cancer in 1959 and now smokers of both genders carry almost an equal chance of being diagnosed with the disease.
In the last 50 years almost 25 trillion cigarettes have been consumed in the U.S. costing at least $130 billion a year for direct medical care and $150 billion annually in lost productivity from premature death, according to the surgeon general.
Kicking the habit
The surgeon general recommended helping people kick the habit with more national media campaigns like the federally funded graphic advertisements that featured former smokers with missing limbs and holes in their throats. He also advocated consideration of additional cigarette taxes and legislation to extend smoke-free indoor protections.
Banning smoking "is a bigger societal issue," Lushniak said at the press conference. "We need to have that discussion."
The tobacco companies and the Justice Department resolved this week that "corrective statements" will appear in the print and online editions of newspapers and on television as well as on the companies' websites. Expanded information on the adverse health effects of smoking will appear on cigarette packages, according to the agreement filed Jan. 10 in federal court in Washington.
"Moving forward, we believe FDA regulation, particularly as it applies to product innovation, has the potential to substantially reduce the harm caused by smoking," Altria's Sutton said. "We support extending its regulatory authority over all tobacco products, including those containing tobacco- derived nicotine such as e-cigarettes."
The FDA regulates cigarettes and is poised to extend its oversight to their electronic counterparts.
While smoking substitutes such as e-cigarettes may help reduce tobacco use, more needs to be known about their health effects and how much they may help, the report said.
"However, the promotion of electronic cigarettes and other innovative tobacco products is much more likely to be beneficial in an environment where the appeal, accessibility, promotion, and use of cigarettes are being rapidly reduced," Lushniak said.