The Nation’s Leading Cause of Death

Since the release in 1964 of the first Surgeon General’s report on smoking and health, the scientific knowledge about the health consequences of tobacco use has greatly increased. It is now well documented that smoking can cause chronic lung disease, coronary heart disease, and stroke, as well as cancer of the lung, larynx, esophagus, mouth, and bladder. In addition, smoking is known to contribute to cancer of the cervix, pancreas, and kidney. Researchers have identified more than 40 chemicals in tobacco smoke that cause cancer in humans and animals. Smokeless tobacco and cigars also have deadly consequences, including lung, larynx, esophageal, and oral cancer.

The harmful effects of smoking do not end with the smoker. Women who use tobacco during pregnancy are more likely to have adverse birth outcomes, including babies with low birth weight, a leading cause of death among infants. The health of nonsmokers is adversely affected by environmental tobacco smoke (ETS). Each year, exposure to ETS causes an estimated 3,000 nonsmoking Americans to die of lung cancer and causes up to 300,000 children to suffer from lower respiratory tract infections. Evidence also indicates that exposure to ETS increases the risk of coronary heart disease.

430,000 U.S. Deaths Attributable Each Year to Cigarette Smoking * *Average annual number of deaths, 1990-1994.  Source: CDC, MMWR 1997;46:448-51

Actual Causes of Death, United States, 1990 * *The percentages used in this figure are composite approximations derived from published scientific studies that attributed deaths to these causes.  Source: McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 1993;270:2207-12.

A Comprehensive, Broad-Based Approach to Tobacco Control

In the past, helping people quit smoking was the primary focus of efforts to reduce tobacco use. This strategy has been a critical one, since smoking cessation at all ages reduces the risk of premature death. In recent years, the focus of tobacco control has expanded to include strategies to prevent individuals from ever starting to smoke—particularly young people, since the decision to use tobacco is nearly always made in the teenage years, and about one-half of young people who take up smoking continue to use tobacco products as adults. This preventive strategy also includes efforts to protect people from exposure to ETS.

A broad-based spectrum of federal, state, and local government agencies, professional and voluntary organizations, and academic institutions have joined together to advance the elements of a comprehensive approach to tobacco use, including:
 

Tobacco use causes about one of every five deaths in the United States and is the single most preventable cause of death and disease in our nation.

 

• Eliminating exposure to ETS.
• Preventing initiation among youth.
• Promoting quitting among adults and youth.
• Eliminating disparities among population groups.

• State and community interventions.
• Countermarketing.
• Policy/Regulation.
• Surveillance/Evaluation.

 

With estimated fiscal year 1999 appropriations of approximately $74 million, the Centers for Disease Control and Prevention (CDC) provides national leadership for a comprehensive, broad-based approach to preventing and controlling tobacco use. Through collaboration with the states, with national, professional, and voluntary organizations, with academic institutions, and with other federal agencies, CDC leads and coordinates strategic efforts to prevent tobacco use among young people, promote smoking cessation, and reduce exposure to ETS. Designed to reach multiple populations, these activities target high-risk groups, such as young people, racial and ethnic minority groups, blue-collar workers, persons with low income, and women.

Building State Capacity

Beginning in fiscal year 1999, CDC is supporting comprehensive programs for preventing and controlling tobacco use in all 50 states, the District of Columbia, and 8 territories (American Samoa, the Commonwealth of Puerto Rico, the Virgin Islands, the Federated States of Micronesia, Guam, the Northern Mariana Islands, the Republic of the Marshall Islands,

and the Republic of Palau). CDC provides extensive technical assistance and training through site visits, workshops, and teleconferences on planning, developing, implementing, and evaluating tobacco control programs. Although CDC supports all 50 states with fiscal year 1999 funding, available resources enable only limited support to 33 states and more comprehensive support to 17 states. States funded at the higher level are able to more comprehensively address youth and adult tobacco use, as well as ETS issues, and to fully extend these programs to reach diverse and local communities in all states. To define and implement the best practices in prevention and control, CDC is working with all states receiving substantial additional resources from excise taxes or settlements with the tobacco industry.

CDC supports and actively collaborates with a variety of national organizations (for example, the National Medical Association and the National Association for African-Americans for Positive Imagery) to ensure the participation of diverse community groups, coalitions, and community leaders in tobacco control efforts.

Reaching Young People Through Schools

The key to reducing adult tobacco use is to prevent children from using tobacco. CDC’s state-based tobacco control programs are closely linked to its state-based coordinated health education programs in schools.

• CDC has established a national framework to support coordinated school health programs. In addition to fiscal year 1999 tobacco control resources of $74 million, CDC dedicates more than $9.6 million to directly support 15 states to provide coordinated health programs in schools. Such programs are targeting high-risk health behaviors among young people, with a heavy focus on tobacco use. Planned, sequential health education has been found to result in a 37% reduction in the onset of smoking among 7th-grade students. CDC also collaborates with more than 30 professional and voluntary organizations to assist schools and agencies serving youth in developing model policies and guidelines. States are using these to implement effective school health programs.

• Through the Research to Classroom project, CDC works with health and education experts to identify curricula that have credible evidence of reducing health risk behaviors, including tobacco use, among young people. CDC then ensures that curricula found to be effective, together with training, are available to schools nationwide.

CDC strengthens and expands the scientific foundation for tobacco-use prevention and control by examining trends, patterns, health effects, and the economic costs associated with tobacco use. For example,

• Since 1964, the Surgeon General’s reports on the health consequences of tobacco use have documented comprehensive, scientific findings on cigarette smoking and smokeless tobacco use. Recent reports have addressed tobacco use among adolescents and special populations.

• CDC’s Morbidity and Mortality Weekly Report (MMWR) serves as a major outlet for surveillance data and research findings on tobacco use. Topics include the enactment and status of state laws on tobacco use and trends in smoking initiation and prevalence among young people.

• CDC’s Smoking-Attributable Mortality, Morbidity, and Economic Cost (SAMMEC) software, a computer program designed to estimate deaths, disease impact, and costs related to smoking, provides essential information to state tobacco control programs and for Surgeon General’s reports, MMWR articles, and responses to public inquiries.

• CDC’s State Tobacco Activities Tracking and Evaluation (STATE) System is a state-based comprehensive surveillance system that tracks legislative, programmatic, and epidemiologic data that will be used for reporting on current status and trends of tobacco use. The system will answer state-specific queries and generate reports on topic areas of particular interest to individual states. In 1999, information from the STATE System will be available to states via the Internet. CDC is collaborating with the World Health Organization to create a similar system to support international efforts to reduce tobacco use.

• CDC’s air toxicants laboratory is developing and applying laboratory technology to further public health efforts to prevent death and disease resulting from tobacco use and ETS exposure. Specific areas of interest are tobacco additives, toxic chemicals in cigarette smoke, and biological monitoring to assess exposure to harmful substances in tobacco products.

CDC serves as a primary resource for tobacco and health information. In this role, CDC develops and distributes important information to the public and other interested groups nationwide. For example,

• CDC responds to a diverse audience, including 50,000 personal inquiries and 30,000 automatic voice-operated facsimile requests, through a variety of channels, including brochures, fact sheets, articles, and video products—many available through a toll-free dissemination service. In addition, CDC provides the public with ready access to tobacco use prevention information through a Web site on the Internet. This Web site documented approximately 200,000 visits during 1998.

• Responding to a call from the Secretary of Health and Human Services, CDC developed the Secretarial Initiative: Reduce Tobacco Use Among Teens and Preteens. Through partnerships with

other federal, state, and local agencies, key tobacco control messages are being communicated through a variety of avenues, including the media, schools, and communities. The following themes are being highlighted:

Promote positive alternatives to tobacco use—through national- and local-level sports activities as well as dance, theater, and art.

Empower young people—through educational programs such as Research to Class-rooms, MediaSharp, and MTV Talks Tobacco, and by providing resources to mentors.

Deglamorize tobacco use through the entertainment industry—by providing technical assistance to movie and television productions, coordinating with producers, directors, and writers, and establishing partnerships with spokespeople, such as the popular music group Boyz II Men.

Involve parents and families—through scientifically grounded interventions while offering support and
enhancing skills to reduce
tobacco use.

Implement paid counteradvertising campaigns—for example, through the Media Campaign Resource Center.

 
• Through the Media Campaign Resource Center, CDC develops, obtains, and distributes high-quality materials to help states and local programs conduct counteradvertising media campaigns to prevent tobacco use. Materials available include television, radio, magazine, newspaper, and billboard advertisements. The resource center also provides direct technical assistance in conducting counteradvertising campaigns.

Facilitating Action Through Partners

CDC works with state health departments, national organizations, other federal agencies, and professional, voluntary, academic, medical, and international organizations to reduce tobacco use. For example:

• CDC supports the Interagency Committee on Smoking and Health and cosponsors the annual Tobacco Use Prevention Summer Institute.

• CDC is the lead agency for the Healthy People 2000/2010 national objectives on tobacco use. This role includes monitoring the nation’s progress toward reaching the year 2000 and 2010 goals for reducing tobacco use. The objectives include topics such as youth and adult smoking prevalence, reduction of tobacco-related diseases, cessation treatment, ETS exposure, and state legislation for clean indoor air.

• CDC collaborates with the National Association of County and City Health Officials, the National Association of Local Boards of Health, the National Conference of State Legislators, and the Association of State and Territorial Health Officials in the coordination and promotion of tobacco prevention and control activities.

• Through an agreement with the World Health Organization, CDC serves as the only WHO Collaborating Center for Smoking and Health in the United States and as the catalyst for communication between all nine international WHO Collaborating Centers and the six WHO Regional Offices. CDC prepares and implements international and regional studies, as well as epidemiologic research, and provides health education and other assistance to help international organizations and other countries reduce tobacco use.