PREVENTING DISEASE AND DEATH FROM TOBACCO USE

Overview: Preventing tobacco use, especially among America's youth, is one of our nation's most important health challenges. According to the Department of Health and Human Services' Substance Abuse and Mental Health Administration (SAMHSA), more than 57 million individuals currently smoke, putting themselves at risk for serious health consequences such as cancer, heart disease and high blood pressure. In addition, data from HHS' Centers for Disease Control and Prevention (CDC) indicates that more than 430,000 deaths in the United States are attributable to tobacco use, making tobacco the leading preventable cause of death and disease in the country. Adolescents and young teens are particularly at high risk for smoking. Every day, 3,000 young people become regular tobacco users, and one third of them will die from smoking-related diseases. The CDC estimates that smoking related deaths worldwide will reach 10 million per year by 2030, with 70 percent of deaths in developing countries.

The first Surgeon General report on tobacco and health was issued in 1964, and since then a total of 26 Surgeon General reports on tobacco have been issued. On Aug. 9, 2000, the Surgeon General released "Reducing Tobacco Use," the first-ever report to provide an in-depth analysis of the effectiveness of various methods for decreasing tobacco use. Aiming to halve U.S. smoking rates by the year 2010, the report calls for the widespread use of approaches that have proven effective in substantially reducing the number of people who are addicted to nicotine. Goals include decreasing nonsmokers' exposure to environmental tobacco smoke, increasing the success rate of individuals attempting to quit smoking, reducing health disparities related to tobacco use, and reducing the health burden of tobacco related disease and death.

CDC provides national leadership to prevent tobacco use, with fiscal year 2001 appropriations of approximately $104 million, to promote smoking cessation and reduce exposure to environmental tobacco smoke. Other HHS agencies are also at work combating one of the most preventable health risks: SAMHSA implements the Synar Amendment, which requires states to adopt and enforce laws prohibiting the sale of tobacco products to anyone under the age of 18.

The National Institutes of Health (NIH) conducts extensive research into tobacco use and dependence and the Medicare program plans a demonstration project to pay for smoking cessation programs. Total spending by HHS to prevent tobacco use and dependence is more than $1 billion in fiscal year 2001.

PREVENTION

The CDC estimates that more than 3,000 children and adolescents become regular tobacco users each day, and 1,000 of them will die from smoking-related illnesses. To combat growing use, HHS is implementing special programs that target adolescents and teens, specifically because the majority of adult smokers - roughly 80 percent - started using tobacco as teenagers.

• Reducing Tobacco Use -- A Report of the Surgeon General: Released in August 2000, the Surgeon General's report outlines several strategies aiming to halve U.S. smoking rates by the year 2010. Those tools include implementing effective school-based programs which can prevent or postpone smoking onset in 20 to 40 percent of adolescents; changing physician behaviors, medical system procedures and insurance coverage to encourage state-of-the-art nicotine addiction treatment; enforcing stringent clean indoor air regulations; improving tobacco warning labels; increasing tobacco prices and excise taxes; and changing the social environment to reduce the broad cultural acceptance of tobacco use. The report can be found at http://www.surgeongeneral.gov/library/tobacco_use.
  
  
• Healthy People 2010: In January 2000, HHS Secretary Donna E. Shalala and Surgeon General Dr. David Satcher unveiled Healthy People 2010, a set of broad-based national health goals for the next decade. Comprised within the initiative are 10 health indicators targeting several health risks, including the goal of reducing tobacco use by 50 percent by 2010. Information about Healthy People 2010 can be found at http://www.health.gov/healthypeople/.
  
  
• CDC's Best Practices for Comprehensive Tobacco Control Programs: CDC's best practices provides recommended strategies and tobacco control funding levels for states to implement or enhance tobacco control programs to prevent and reduce tobacco use. The guidelines identify and describe key elements for effective state tobacco control programs, including initiatives designed for communities, schools, and statewide programs. These best practices also address the significance of surveillance and evaluation, enforcement, counter-marketing, smoking cessation programs, and chronic disease programs to reduce the burden of tobacco-related disease. More details are available at http://www.cdc.gov/tobacco/bestprac.htm.
  
  
• Girl Power!: In 1996, HHS Secretary Donna E. Shalala launched Girl Power!, a multi-phase national public education campaign designed to help encourage 9- to 14-year-old girls to make the most of their lives. The Girl Power! Campaign combines strong "no use" messages about tobacco, alcohol, and illicit drugs with emphasis on providing opportunities to build skills and self-confidence through many endeavors, including physical fitness and sports. Since 1996, the campaign has partnered with nearly 300 organizations and 60 national endorsers to promote the Girl Power! message. More information on Girl Power! is available at http://www.health.org/gpower.
  
  
• SmokeFree Soccer: SmokeFree Soccer is a collaboration among HHS - including the CDC and the National Cancer Institute. It is a tobacco control prevention strategy that was originally introduced by the department in 1996. The program is designed to promote participation in youth soccer and help children learn about the adverse health effects of tobacco on athletic performance. The program promotes physical activity, while helping kids resist the pressures to use tobacco. Currently, ten states are receiving funds to implement SmokeFree Soccer activities at the local level. In 2000, the program was also expanded globally in collaboration with the World Health Organization (WHO) and Federation Internationale de Football Association (FIFA), the international governing body for soccer. The SmokeFree Soccer program provides a powerful, unifying theme that will further the tobacco prevention objective globally. More information on the SmokeFree Soccer program can be found at http://www.smokefree.gov.
  
  
• CDC's Initiative to Reduce Tobacco Use Among Teens and Preteens: CDC has developed partnerships among federal, state and local agencies to promote tobacco control messages through the media, schools and communities. Targeting teens and preteens, several themes are being highlighted, including promoting positive alternatives to tobacco use, deglamorizing tobacco use and implementing counteradvertising campaigns and reaching parents and family members. More information on this initiative is available on the Internet at http://www.cdc.gov/tobacco/tips4youth.htm.
  
  
• SAMHSA's Substance Abuse Prevention and Treatment (SAPT) Block Grant: This block grant provides more than $1.6 billion annually to states to support substance abuse prevention and treatment activities. States are required to spend a minimum of 20 percent of their block grant on primary prevention initiatives for alcohol, tobacco and other drugs. More information on SAMHSA's Substance Abuse Prevention and Treatment (SAPT) Block Grant is available at http://www.samhsa.gov.
  
  
• World Health Organization (WHO) Framework Convention on Tobacco Control: In October 2000, 150 of the 191 member nations of the WHO gathered to negotiate the Framework Convention on Tobacco Control, the first international health treaty ever sought by the WHO. This Framework Convention will serve as a multilateral treaty allowing member states to jointly craft international tobacco agreements through various protocols. The protocols could include specific obligations to address prices, tobacco smuggling, tax-free tobacco products, advertising and sponsorship, Internet trade, testing methods, package design and labeling, information sharing, as well as agricultural diversification. Additional information is on the Internet at http://tobacco.who.int/en/fctc/index.html
  
  
• Synar Amendment: The Synar Amendment was enacted into law in July 1992 to reduce youth access to tobacco by requiring states to have and enforce laws prohibiting the sale of tobacco products to anyone under age 18. In 1996, SAMHSA issued the Synar regulation requiring states to conduct random, unannounced inspections of state tobacco vendors. Furthermore, states are expected to meet the Synar regulation goal - an inspection failure rate of less than 20 percent for a state's vendor sites by the year 2003. The regulation requires states to establish annual target rates moving towards the ultimate goal of 20 percent. States that fail to achieve their annual targets may lose a percentage of their federal SAPT Block Grant, a major source of funding allowing states to develop, implement and monitor comprehensive substance abuse treatment and prevention programs. More details on the Synar Amendment is available at http://prevention.samhsa.gov/tobacco/.
  
  
• Cigar Labeling: On June 26, 2000, the Surgeon General and the Federal Trade Commission (FTC) announced that the seven largest U.S. cigar companies agreed to include warnings about significant adverse health risks associated with cigar use in advertising and packaging. Details on Cigar Labeling can be found at http://www.ftc.gov/opa/2000/06/cigars.htm.

TREATMENT

According to the CDC, costs attributed to smoking are more than $50 billion each year. Lost earnings and productivity cost an additional $47 billion annually. HHS agencies are working to help millions of smokers quit the habit.

• Clinical Practice Guideline: The Surgeon General's "Treating Tobacco Use and Dependence: A Clinical Practice Guideline" offers clinicians, insurance plans, purchasers and medical school officials evidence-based information on adult cessation therapies such as nicotine gum, patches, inhalers, nasal sprays, bupropion, as well as telephone counseling. The guideline was a public-private initiative developed by U.S. Public Health Service (PHS), in collaboration the Robert Wood Johnson Foundation, the University of Wisconsin Medical School. A full-fledged dissemination and implementation strategy is being coordinated by the PHS, the Agency for Healthcare Research and Quality, other federal agencies, state health departments and professional health care organizations. More information is available on the Internet at http://www.surgeongeneral.gov/tobacco.
  
  
• Medicare Demonstration: HCFA is beginning a new demonstration project to help Medicare beneficiaries stop smoking. As part of Medicare's Healthy Aging Project, the demonstration will last three years and test specific cessation strategies and usual care in various states. According to independent research, Medicare will spend $800 billion treating smoking-related illnesses between 1995 and 2015. Details on this new demonstration project can be found at http://cms.hhs.gov/healthyaging/Background.asp.

SURVEILLANCE

HHS agencies monitor smoking trends, especially among youth, and their use of other tobacco products. Through a variety of both home and school-based surveys-the National Household Survey, the Monitoring the Future survey, and the Youth Risk Behavior Survey-as well as test interventions, HHS is gaining a wider understanding of the young smoker's demographic and the psychological influences that spur many adolescents to start smoking.

Because the three surveys differ in the populations covered, time periods of data collection, questionnaire wording, effects of non-response bias, and interview setting (school vs. home), combined, they provide a more comprehensive perspective on trends in youth tobacco use. The national trends seen in all three surveys are generally consistent, showing a leveling or declining trend in cigarette use among adolescents since 1997, after a period of significant increases in the early 1990s.

• National Household Survey: Each year, SAMHSA conducts a home-based survey that is the primary source of prevalence data on the incidence of illicit drug, alcohol and tobacco use. The National Household Survey provides annual estimates of the prevalence of illicit drug, alcohol and tobacco use in the U. S. and monitors the trends in use over time. The most recent NHS data released in August 2000 showed a decline, from 19.9 percent in 1997 to 15.9 percent in 1999, in past month use of cigarettes among youth age 12-17. The Survey can be found at >http://www.samhsa.gov/oas/household99.htm.
  
  
• Monitoring the Future: NIH's National Institute on Drug Abuse and the University of Michigan's Institute for Social Research fund Monitoring the Future, a school-based yearly survey on the behaviors and values of American secondary school students, college students and young adults. MTF data released in December 2000 showed that cigarette use among teens dropped significantly, with past month use of cigarettes down from 17.5 percent to 14.6 percent among 8th graders and from 34.6 percent to 31.4 percent among 12th graders in the last year. Reductions in other categories of smoking also occurred among 8th, 10th, and 12th graders. MTF data can be found on the Internet at http://www.nida.nih.gov/DrugPages/MTF.html.
  
  
• Youth Risk Behavior Survey: CDC's Youth Risk Behavior Survey is the only surveillance system to monitor a wide range of priority health risk behaviors among youth at the national, state and local levels. The YRBS covers injury-related behaviors, such as weapon carrying and attempted suicide, tobacco use, alcohol and other drug use, sexual and dietary behaviors, and physical activity. Biennial data from the YRBS released in August 2000 showed that current smoking rates among U.S. high school students may have leveled or begun to decline during the late 1990s (34.8 percent in 1995, 36.4 percent in 1997, and 34.8 percent in 1999) following years of increased rates. Information about CDC's Youth Risk Behavior Survey is available at http://www.cdc.gov/nccdphp/dash/yrbs/index.htm.

RESEARCH

The National Institutes of Health has conducted clinical research focusing on reducing children's exposure to environmental tobacco smoke (ETS), the psychological and physiological effects of nicotine dependence, as well as nicotine replacement therapies. With the President's budget of $558 million, an increase of $29 million over the fiscal year 2000 budget, scientists will be further able to investigate behavior therapies and genetic factors for nicotine dependence, and provide funding for innovative research initiatives at national, state and local levels.

• National Cancer Institute (NCI): In October 2000, NCI awarded over $13 million in first-year funding for its new antismoking initiative, the Research in State and Community Tobacco Control Interventions. These 12 grants will support research on innovative tobacco prevention and control interventions at the community, state, or multistate level, and emphasize collaboration between tobacco control researchers and state-based tobacco control programs. The funds will be used for the first year of the four-year projects. More information on NCI's new antismoking initiative can be found at http://rex.nci.nih.gov/massmedia/pressreleases/tobaccocontrol.html.
  
  
• NCI Tobacco Prevention and Cessation Initiative: The "Prevention and Cessation of Tobacco Use by Children and Youth in the U.S." initiative to funded innovative research for reduction of tobacco use by children and youth in the U.S. Funding was a collaborative effort from a number of institutes at NIH. A total of 29 grants were funded from 1997 to 1999, at about $9 million per year. These research projects include prevention, experimentation and onset of regular tobacco use, dependence and withdrawal, and cessation and treatment of tobacco use by adolescents. More information about this initiative is available on the Internet at http://dccps.nci.nih.gov/tcrb/youth.html.
  
  
• Transdisciplinary Tobacco Use Research Centers: NCI and the National Institute on Drug Abuse recently awarded $14.5 million to seven academic institutions to create the Transdiciplinary Tobacco Use Research Centers. These facilities tackle a wide range of studies, including tobacco susceptibility factors, new cessation treatments and behaviors that lead to smoking relapse. Additionally, The Robert Wood Johnson Foundation has committed an additional $14 million over five years to help support the effort. Additional information is available at http://rex.nci.nih.gov/massmedia/pressreleases/tobcetwo.html.
  
  
• Environmental Tobacco Smoke: As part of NCI's Smoking and Tobacco Control Program, the institute supported a comprehensive report on the health risks associated with secondhand smoke in November 1999. Developed by the California Environmental Protection Agency, the report states that the thousands of chemicals found in lighted cigarettes, pipes and cigars comprise known carcinogens - cancer-causing substances. The report can be found at http://rex.nci.nih.gov/NCI_MONOGRAPHS/INDEX.HTM.
  
  
• Teen Tobacco Addiction Treatment Research Clinic (TTATRC): NIDA recently announced the opening of its TTATRC at the new Adolescent Clinic in NIDA's Intramural Research Program's laboratories. The center will assess which smoking cessation methods -- including the use of nicotine patches and gum, with supportive counseling - are effective with teenagers. While ample research has shown that nicotine patches and gum can help adults, the center's study is one of the first to focus on whether they can help teens who want to quit smoking. In addition to testing the effectiveness of nicotine replacement therapies, the studies will assess the usefulness of different counseling and behavioral support approaches. More information on TTATRC is available on the Internet at http://165.112.78.61/NIDA_Notes/NNVol14N4/Teens.html.

Additional resources related to HHS programs and initiatives on tobacco are available at http://www.hhs.gov/pharmacy/phpharm/smoking.html.

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