In 1964, the United States was a place where over 50% of adult males smoked tobacco. Smoking was accepted in any indoor environment, on airplanes, and in elevators. Even Saturday morning cartoon shows had cigarette sponsors. But, on January 11, 1964, Surgeon General Luther Terry released the first Surgeon General’s Report called Smoking and Health and concluded that smoking caused cancer.
Over the next 45 years, 28 additional reports on tobacco smoking followed from various Surgeons General. On December 9, 2010, the current U.S. Surgeon General, Dr. Regina Benjamin, issued the 30th Surgeon General’s Report on the dangers of smoking tobacco. The 30th Report is entitled How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-Attributable Disease.
[Read more on tobacco smoke in the workplace]
It’s fair to ask “why issue another report?” Despite 29 previous reports, tobacco use remains the leading cause of preventable death in the United States, and is responsible for 443,000 deaths each year. Thirty percent of all cancer deaths are due to tobacco. Each day 1,200 lives of current and former smokers are lost prematurely due to tobacco-related diseases. As HHS Secretary Kathleen Sebelius noted, “Every day, almost 4,000 youth try a cigarette for the first time and 1,000 youth become regular, daily smokers.”
The new Report is a weighty one. Spanning over 700 pages, it presents a detailed, scientific look at the toxicology and biology behind nicotine addiction and tobacco smoking, including carcinogenic effects and the adverse effects on cardiopulmonary and reproductive health. Many additional scientific and other international publications for the general public and healthcare providers are available at http://www.smokefree.gov and http://www.ahrq.gov/path/tobacco.htm
Brief Summary of Findings from the 2010 Surgeon General’s Report
- There is no safe level of exposure to tobacco smoke. The evidence on the mechanisms by which smoking causes disease indicates that there is no risk-free level of exposure to tobacco smoke.
- Damage from tobacco smoke is immediate. Evidence in the new Report indicates that the risk does not increase in a linear fashion with increasing exposure, and even low levels of exposure to tobacco—such as a few cigarettes a day, occasional smoking, or exposure to secondhand tobacco smoke—are sufficient to substantially increase the risk of adverse cardiac events.
- Smoking longer means more damage. Through multiple defined mechanisms, the risk and severity of many adverse health outcomes caused by smoking are directly related to the duration and level of exposure to tobacco smoke.
- Cigarettes are designed for addiction. Sustained use and long-term exposures to tobacco smoke are due to the powerfully addicting effects of tobacco products, which are mediated by diverse actions of nicotine and perhaps other compounds, at multiple types of nicotine receptors in the brain.
- Even low levels of exposure, including exposure to secondhand tobacco smoke, are dangerous. In 2006, the Surgeon General reported that the scientific evidence was sufficient to conclude that there is no risk-free level of exposure to secondhand smoke. The 2010 Report provides a more detailed review of the mechanisms that validate that conclusion. Low levels of exposure, including exposures to secondhand smoke, lead to a rapid and sharp increase in endothelial dysfunction and inflammation, which are implicated in acute cardiovascular events and thrombosis.
- There is no safe cigarette. There is insufficient evidence that product modification strategies—including new cigarette products—to lower emissions of specific toxicants in tobacco smoke reduce the risk for major adverse health outcomes.
HHS Comprehensive Strategy to End the Tobacco Epidemic
In November of 2010, the U.S. Department of Health and Human Services announced a new comprehensive control strategy for tobacco smoking reduction.
A major impetus for the new HHS tobacco control strategy is that the proportion of tobacco smokers in the U.S. has remained stuck at the 20% level since 2003. For seven years, there has been no progress in reducing tobacco smoking in the U.S. And, even though 25 states have enacted comprehensive tobacco smoking control laws, 25 states have none. Among the states with the highest 2009 smoking prevalence were Kentucky (25.6 percent), West Virginia (25.6 %) and Oklahoma (25.5 %). Prevalence was lowest in Utah (9.8 %) California (12.9 %), and Washington State (14.9 %).
California was the first state to enact tobacco control laws in 1994 and California has seen a four-fold faster reduction in lung cancer incidence than states without smoking bans. The new goal for Health People 2020 will be to reduce tobacco smoking prevalence from 20% to 12%.
The Family Smoking Prevention and Tobacco Control Act (FSPTCA) gives the U.S. Food and Drug Administration (FDA) explicit regulatory authority over tobacco products. FDA now has the authority to require companies to reveal all of the ingredients in tobacco products—including the amount of nicotine—and to prohibit the sale of tobacco products labeled as “light,” “mild,” or “low.”
In November, FDA announced a proposed rule titled Required Warnings for Cigarette Packages and Advertisements. The proposed rule would require nine new larger and more noticeable textual warning statements, and color graphic images depicting the negative health consequences of smoking to appear on cigarette packages and in cigarette advertisements. The public has an opportunity to comment on 36 proposed images through January 9, 2011. By June 22, 2011, FDA will select the final nine graphic and textual warning statements after a comprehensive review of the relevant scientific literature, the public comments, and results from an 18,000 person study. Implementation of the final rule on September 22, 2012 will ultimately prohibit companies from manufacturing cigarettes without new graphic health warnings on their packages for sale or distribution in the United States. In addition, manufacturers, importers, distributors and retailers will no longer be allowed to advertise cigarettes without the new graphic health warnings in the United States. By October 22, 2012, manufacturers can no longer distribute cigarettes for sale in the United States that do not display the new graphic health warnings.
HHS’ new comprehensive tobacco control strategy also includes the following elements:
- The Affordable Care Act gives Americans in private and public health plans access to recommended preventive care, like tobacco use cessation, at no additional cost.
- The American Recovery and Reinvestment Act (ARRA) invested $225 million to support local, state, and national efforts to promote comprehensive tobacco control and expand tobacco quitlines like 1.800.QUIT.NOW
- The Children’s Health Insurance Program Reauthorization Act (CHIPRA) raised the federal cigarette tax by 62 cents per pack. Raising the price of tobacco products is a proven way to reduce tobacco use, especially among price-sensitive populations such as youth.
Tobacco and Occupation
Tobacco smoking remains common in many occupational groups, with prevalence often exceeding 30%. Smoking is an especially important risk for blue-collar workers who are also exposed to occupational carcinogens. For example, risks from tobacco smoking and asbestos exposure are multiplicative. Integrating health protection programs for workers with health promotion or wellness programs that can provide modern smoking cessation services is a critical need. NIOSH believes that integrating protection and promotion best supports the goal of total worker health. Tobacco-free workplaces, on-site tobacco cessation services, and comprehensive, employer-sponsored healthcare benefits that provide multiple quit attempts, have all been shown to increase tobacco treatment success.
Even non-smoking workers are at risk from tobacco smoke. Secondhand exposures are an important problem for workers in environments such as gaming, food service, and other occupations where they are often around smokers. Even though they do not smoke themselves, these workers may have measurable levels of chemical contaminants from cigarette smoke in their blood or urine. As the Surgeon General’s Report points out, even intermittent exposure to secondhand smoke can be harmful. For example, workplace exposure to tobacco significantly increases the risk for adult-onset asthma. Because secondhand smoke is an avoidable risk to all who are exposed, the U.S. Department of Health and Human Services has set a Healthy People 2020 goal that 100% of workplaces should be covered by indoor worksite policies that prohibit smoking.
Dr. Howard is the director of the National Institute for Occupational Safety and Health.
Dr. Weissman is the director of NIOSH’s Division of Respiratory Disease Studies.
Dr. Chosewood is the director of NIOSH’s Total Worker Health Program (WorkLife).
- Achutan C, West C, Mueller C, Boudreau Y, Mead K. Environmental and biological assessment of environmental tobacco smoke among casino dealers. NIOSH; Health Hazard Evaluation Report #2005-0076; 2005-0201-3080 (May, 2009). Available at http://www.cdc.gov/niosh/hhe/reports/pdfs/2005-0201-3080.pdf
- Bang KM, Kim JH. Prevalence of cigarette smoking by occupational and industry in the United States. Am J Ind Med 2001;40:233-239. Available at http://onlinelibrary.wiley.com/doi/10.1002/ajim.1094/pdf
- Centers for Medicare and Medicaid Services. Childrens Health Insurance Program Reauthorization Act (CHIPRA) of 2009. Available at https://www.cms.gov/chipra/
- Centers for Disease Control and Prevention. Community Guide for Preventive Services. Available at http://www.thecommunityguide.org/index.html
- Food and Drug Administration. Required Warnings for Cigarette Packages and Advertisements. 75 Fed. Reg. 69524 (November 12, 2010). Available at http://www.federalregister.gov/articles/2010/11/12/2010-28538/required-warnings-for-cigarette-packages-and-advertisements
- Howard J. Smoking is an occupational hazard. Am J Ind Med 2004;46:161-169. Available at http://onlinelibrary.wiley.com/doi/10.1002/ajim.10364/pdf
- U.S. Department of Health and Human Services . How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-Attributable Disease. A Report of the Surgeon General. Available at http://www.cdc.gov/tobacco/data_statistics/sgr/2010/index.htm
- U.S. Department of Health and Human Services. Ending the Tobacco Epidemic: A Tobacco Strategic Action Plan for the U.S. Department of Health and Human Services. November 2010. Available at http://www.hhs.gov/ash/initiatives/tobacco/tobaccostrategicplan2010.pdf