Smoking quit rates stall as anti-tobacco funding declines
■ People with tobacco-related chronic diseases are more likely to smoke than are those who are not sick.
By Stephanie Stapleton — Posted Dec. 3, 2007
The number of Americans giving up cigarettes may have hit a plateau.
A Centers for Disease Control and Prevention analysis of 2006 data found that approximately 20.8% of U.S. adults -- about 45 million -- are cigarette smokers. This prevalence, which has held steady since 2004, suggests a stall in the previous seven-year decline. During that period, the proportion of smokers shrank from 24.7% to 20.9%.
Public health and tobacco control advocates point to recent developments in which state tobacco control funds have been reallocated and policy initiatives have faced roadblocks as possible explanations for the slowing quit rates. They also view the report as a wake-up call.
"It's not as disheartening as it is a call to work harder at what we know [is effective]," said Thomas J. Glynn, PhD, the American Cancer Society's director of cancer science and trends.
Smoking rates have been on a downturn since a 1964 surgeon general's report linked lung cancer and cigarette use. At that time, an estimated 42% of the American population were smokers. But more than 400,000 people still die each year from smoking-related illnesses and, for every death, 20 more people are living with such conditions.
Inside the numbers
The CDC analysis was based on information collected from the National Health Interview Survey's nationally representative sample of 24,275 people 18 or older. The study, published in the Nov. 9 Morbidity and Mortality Weekly Report, was done to measure progress toward the national health objective of reducing adult cigarette smoking prevalence to less than 12% by 2010.
Cigarette use varied widely among different population subgroups. For instance, adults 18 to 24 and 25 to 44 had the highest smoking rates by age, 23.9% and 23.5% respectively. However, people diagnosed with smoking-related illnesses continued to be a difficult-to-reach population when it comes to cessation messages.
One possible reason, explained American Medical Association President Ron Davis, MD, is that they may feel the damage from smoking is already done, that it is too late. "That's a misinformed opinion," he said. "[Stopping] is beneficial at any age -- whether sick or not."
The CDC found that people with smoking-related chronic diseases had a higher prevalence (36.9%) of being current smokers than people without chronic diseases (19.3%). Nearly half of U.S. adults with emphysema and 41.1% of those with chronic bronchitis were current smokers. Similarly, rates were higher among those with smoking-related cancers other than lung cancer (38.8%), coronary heart disease (29.3%) and stroke (30.1%).
People who do quit have a lower risk for death as well as a slower decline in lung function and a lower incidence of bronchitis, emphysema and other respiratory conditions than people who continue to smoke, according to the CDC report. Those with cancer who smoke while receiving treatment decrease that treatment's potential effectiveness. They also risk undermining survival prognosis and quality of life, and increasing chances of another malignancy.
"We as physicians need to communicate more effectively with our patients the myriad risks of smoking and the myriad benefits of quitting," said Dr. Davis.
Experts agree this message has an important place in clinical practice. Physicians should be aware of which patients smokes and use every opportunity to urge them to stop.
"It's not rocket science," said Tom Houston, MD, a member of the American Academy of Family Physician's Tobacco Cessation Advisory Committee. "The issue is not to beat patients over the head, but to point out the benefits," added Dr. Houston, who also directs the OhioHealth Nicotine Dependence Program at McConnell Heart Health Center in Columbus. "It's never too late."
Funding issues a possible culprit
The CDC researchers wrote that decreasing support for tobacco control activities is a likely factor behind the recent stall in overall quit rates.
"They are dead on target," said Dr. Houston, also a clinical professor in family medicine and public health at The Ohio State University. Not only are the majority of states falling well below the CDC's recommended level of anti-tobacco expenditures, he said, but funding streams from the 1998 master settlement agreement between the tobacco industry and many state attorneys general also are dwindling.
Specifically, investments in comprehensive state programs for tobacco control and prevention decreased by 20.3% from 2002 to 2006.
By contrast, tobacco industry marketing budgets have nearly doubled since 1998, from $6.7 billion to $13.1 billion.
Public health and anti-tobacco advocates say a range of steps is necessary to offset tobacco's draw. These include increasing state program funding, implementing state and local clean-indoor-air laws, enacting higher cigarette taxes, and granting the Food and Drug Administration the authority to regulate tobacco products -- measures supported by AMA policy.
"Good science shows that when we put funding behind efforts for comprehensive tobacco control, we do get results," said Dr. Glynn, also the ACS director of international cancer control.
The AMA has long advanced a range of anti-smoking initiatives. "We need constant pressure on smokers to stimulate continued efforts at quitting," said Dr. Davis. New cessation medications can help. So can smoking bans in workplaces or public places. "And cigarette taxes can be the straw that breaks the camel's back," he said, noting that the AMA supports the use of a federal cigarette tax to help pay for an expansion of the State Children's Health Insurance Program.
"The bottom line," he added, "is we need to maintain an aggressive campaign against tobacco that includes education and public policies."