Tobacco control efforts: The case for persistence

Even with notable gains in the fight against tobacco-related disease, much work lies ahead.

Posted Sept. 22, 2008.

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The tobacco wars have been fought for many years on numerous fronts.

Skirmishes have occurred in Congress, state capitols and city halls, where anti-tobacco advocates have tirelessly advanced measures to protect the health of Americans by the millions. Meanwhile, physicians in their exam rooms can engage on an entirely different level. They reach out to individual patients they identify as smokers and try, sometimes with frustration, to help them break cigarettes' grip.

Regardless of the setting, the watchword is persistence.

A recent victory in the House of Representatives is an example of the struggle. On July 30, that chamber passed by a 326-to-102 vote the Family Smoking Prevention and Tobacco Control Act. It is a noteworthy step forward because the bill would grant the Food and Drug Administration oversight of tobacco products. The American Medical Association and other public health organizations applauded the House action, terming it long overdue. After all, these anti-tobacco advocates have for years argued FDA authority is critical because tobacco products are among the least regulated in our society.

Consider current law. Big tobacco does not have to disclose the levels of nicotine or any of its products' ingredients. Moreover, no government agency regulates the toxic ingredients included in cigarettes or can challenge misleading advertising claims such as "light," "low tar" or "mild."

The House-passed measure addresses these issues. It also allows the FDA to restrict further tobacco marketing, especially to kids, and requires more informative health warnings on packages. It would not give the agency power to ban tobacco.

Even though an estimated 20.8% of U.S. adults are smokers and cigarette smoking is the country's leading preventable cause of death, history shows this measure will still face obstacles in its path to enactment.

In 1996, for instance, the FDA took steps to regulate tobacco products, citing the Food, Drug and Cosmetic Act. In response, the tobacco industry pursued a lawsuit to stop it. The U.S. Supreme Court ruled in 2000 that Congress had not given the agency this legal authority. And, as recently as 2004, related legislation was considered, and even passed in the Senate, only to die in the House.

It's remembering such experiences that underscores the watchword's value -- especially when so much is at stake. According to the Centers for Disease Control and Prevention, for every person who dies of smoking-related disease, 20 more people have at least one smoking-related illness. Annually, cigarette smoking costs more than $193 billion, based on lost productivity and health care expenditures. And health care costs associated with exposure to secondhand smoke average $10 billion a year. These are among the reasons the AMA and other public health and anti-tobacco advocates are urging the Senate to follow the House's lead and pass this measure.

As important as the efforts are on the legislative front, persistence is critical in other areas, too -- particularly the exam room.

Bottom line: Forty-five million American adults continue to smoke. Given that more than 70% of them visit a physician or health care setting each year, doctors are well positioned to help them quit. But studies show clinicians often fail to provide patients with effective smoking cessation information and treatment.

"Treating Tobacco Use and Dependence: 2008 Update," a set of updated clinical practice guidelines, was released this spring at the AMA headquarters in Chicago. These guidelines are empowering because never before have physicians had so many tools to help smokers. One central message is that doctors should be persistent and take every clinical opportunity to discuss smoking cessation with patients. After all, the CDC notes that even brief clinical interventions can increase the chance of success.

Recent chapters in the tobacco control saga involve stories of significant progress, but also offer no room for complacency. Just think about the status quo, the lack of tobacco industry oversight and need for protections against tempting children to pick up this deadly habit. The legislation passed by the House would make a difference in these matters. As it awaits Senate consideration, though, its critics maintain such a law would put an enormous burden on the FDA that could detract from other public health responsibilities. They also argue that requiring the FDA to oversee tobacco products could be perceived as a sign the products are safe, resulting in more smoking. How this particular battle plays out remains to be seen.

Still, reason for optimism also exists. In 1965, according to information included in the guidelines, current smokers outnumbered former ones by 3 to 1. Now, national quit rates have so outpaced the picking-up-the-habit rate that there are more reformed smokers than current ones.

Numbers like those are testimonials to the power of persistence on the part of physicians and other public health advocates. But they also underscore the continuing dark reality that calls for determination: Half of all U.S. smokers alive today will die prematurely from a disease directly caused by their tobacco use if they are unable to quit.

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