2020 Director's Corner: Top 20 Successes and Challenges for Smoking Cessation

As an inveterate list maker, I can’t resist the opportunity to usher in the year 2020 with a list about smoking cessation. Below I enumerate my nominees for the top 20 successes that have helped promote smoking cessation, as well as the top 20 challenges facing smoking cessation today. I hope that you will find these provocative, and suspect that many would have variants on these lists. What matters is that we celebrate progress made while focusing on what is still needs doing.

Top 20 Successes

  1. Decline in adult smoking prevalence. Probably the most important public health accomplishment over the past half century has been the impressive decline in adult smoking prevalence, which has fallen from a high of 42.7% in 1964 to the most recent level of 13.7% in 2018. This translates into about ten million premature deaths prevented. In addition, it means that previous estimates of future cases of such vascular-related conditions as Alzheimer’s disease were overly pessimistic. Still, there are over 34 million adults who currently smoke cigarettes, and half will die prematurely unless they stop smoking.
  2. Decline in youth smoking prevalence. Even more impressive has been the decline in youth smoking, defined as high school students who have smoked a cigarette in the past 30 days. That figure fell from 35% in 1997 to a modern low of 5.8% in 2019, meaning that there will be far fewer adult smokers in the future. Of course, a counter-vailing trend is the increase in youth vaping of e-cigarettes, to be discussed in the challenges section below.
  3. Decline in smoking intensity among people who continue to smoke. It was initially estimated that stopping smoking would occur disproportionately among persons who were light rather than heavy smokers, and as a result, there would be an increased number of daily cigarettes consumed by those who continued to smoke. But that was not the case, and in fact since 1970 there has been a steady decline in cigarettes consumed per day by persons who smoke, dropping from 22 per day in 1970 to 14 in 2016. Furthermore, about a quarter of all persons who smoke cigarettes are non-daily smokers. It is likely that these declines among persons who have not quit reflect the influence of tobacco control policies as well as the increasing stigma with which smoking is viewed. But we should remember that cutting back conveys many fewer health benefits than quitting.
  4. The 1964 Surgeon General’s Report on Smoking and Health that catalyzed the decline in smoking and the creation of tobacco control policies. The January 8, 2014 issue of the Journal of the American Medical Association celebrated the Report’s 50th anniversary with a special issue on 50 years of tobacco control. It is worth reading or re-reading that JAMA issue to see both how far we have come and what more we need to do.
  5. Science linking second-hand smoke and illness. Beginning over 50 years ago, research began to show links between exposure to secondhand smoke and the development of cancer and diseases of the heart and lungs. This information was critical in transforming public attitudes about smoking from benign acceptance to active resistance, and provided political support for the set of tobacco control policies that emerged despite severe opposition from the tobacco industry.
  6. Taxing tobacco products to create fiscal disincentives for purchase. One of the most important tobacco control policies is to make the product more expensive. Research has shown that demand is sensitive to price, and taxes can be imposed at the federal, state, and municipal levels. Since 2009 the federal tax rate has been $1.01 per pack of cigarettes. Beginning in 1921 in Iowa, states have also imposed taxes, which currently range from a low of 17 cents in Missouri to a high of $4.50 in Washington DC. Additionally, some localities, such as New York City, also tax tobacco products.
  7. Clean indoor air laws. As with tobacco taxation, laws restricting smoking in public places can be enacted at the federal, state, and community levels. Currently there are no federal restrictions on smoking except for airplane travel (1973) and federal housing projects (2018), but there are over 5,000 different laws restricting smoking that encompass states and local communities, with that number continuing to expand. Of note is that the push to pass such legislation derives directly from success #5, the science that links second-hand smoke and illness.
  8. Counter-marketing. Yet another effective tobacco control policy is counter-marketing using messages on television and other media outlets that encourage smokers to quit and youth to forego initiation of smoking. The messages include stressing the harmful health effects of smoking, its social undesirability, and the untrustworthy nature of the tobacco industry. Many states have featured counter-marketing as a part of their tobacco control programs, the federal FDA and CDC agencies have featured memorable campaigns, and the truth® campaign of the American Legacy Foundation (now Truth Initiative) has won awards for its messaging.
  9. Smoking cessation medications. Until 1984, there were no pharmacologic aids to help smokers quit, and the only available help was counseling, aversive conditioning, and hypnosis. Now there are 7 FDA-approved medications, including 5 forms of nicotine replacement therapies (gum, patch, lozenge, nasal spray, and inhaler), plus the more recent additions of the oral therapies bupropion and varenicline. It is likely that another drug, cytisine, which has long been used in Europe, will also soon come on the market. The good news is that use of these medications, in combination with counseling, can increase quit rates from about 4% unassisted to up to 20%. But the bad news is that even with this assistance, most quit attempts are unsuccessful.
  10. Telephone quitlines. First introduced in the late 1980’s, telephone quitlines are now available without charge in all 50 states and Washington, DC, accessible via a single toll-free number (1-800-QUIT-NOW). Callers receive advice on how to quit and in many states can get vouchers for free nicotine replacement therapy. Evidence shows that quitline callers have a much higher rate of quitting. But only a small proportion of people who smoke avail themselves of this option.
  11. The 1998 Master Settlement Agreement. Negotiated between the four major tobacco companies and the Attorneys General of 46 states, the MSA granted the companies immunity from state lawsuits aimed at recovering smoking-induced Medicaid expenditures. In exchange, the tobacco companies awarded $206 billion to the settling states (separate payments were made to four other states), created the American Legacy Foundation, dissolved the industry-sponsored Tobacco Institute, prohibited youth-targeted cigarette advertising, and permitted wide dissemination of previously secret tobacco-industry documents. However, the settlement did not stipulate how the funds would be spent by the states, and as a result very little was spent on tobacco control efforts. An indirect benefit was that the prices of cigarettes set by the industry were increased in order to recoup these payments, resulting in economic incentives to dissuade smoking.
  12. The creation of new tobacco control advocacy organizations. At least three major such entities were created in the past two decades: The Campaign for Tobacco-Free Kids (supported by founding grants from the Robert Wood Johnson Foundation and the American Cancer Society); The American Legacy Foundation (funded by the MSA); and the Tobacco Documents Library of the UCSF Center for Tobacco Control Research and Education (supported by a founding grant from the American Legacy Foundation). In association, existing organizations such as the American Cancer Society, American Lung Association, American Heart Association, and the Robert Wood Johnson Foundation--plus many federal and state agencies—provided energy and muscle to promote tobacco control.
  13. The identification of the tobacco industry as a perpetrator of great public health harm. As a result of revelations of decades of deception and other nefarious practices—including the 1994 disclosure that tobacco companies manipulate nicotine in cigarettes to cause and sustain addiction, the industry is now consistently viewed with great suspicion and ranked at the bottom of trusted institutions. These public attitudes were enhanced when the CEOs of the seven largest tobacco companies tested falsely under oath in April 1994 that nicotine was not addictive. Consequently, the industry is less effective than previously at halting tobacco control actions, although its lobbying efforts remain robust.
  14. The de-normalization of tobacco. Spurred by the above factors, the public’s view of smoking has undergone a profound shift. Where it was once associated with glamor (think Humphrey Bogart and Lauren Bacall) it is now stigmatized. The only down side to that stigma is that persons who smoke, most of whom would like to quit, risk being socially marginalized.
  15. The FDA is empowered by the 2009 Family Smoking Prevention and Tobacco Control Act to regulate the tobacco industry. The act banned flavored cigarettes except for menthol, and also forbade the use of modifier descriptors such as “mild”, “light” or “low”. Potential actions yet to be realized, are the incorporation of new warning labels on tobacco packaging, the reduction of nicotine in combustible tobacco products to non-addictive levels, and the potential to ban menthol flavoring if the evidence so warrants.
  16. Government agencies going smoke-free. Beginning in 2018, HUD public housing facilities banned indoor smoking, and in 2019 Veterans’ Administration facilities banned all smoking on their premises, thus closing the pre-existing smoking shelters outside VA hospitals.
  17. Beginning of culture change regarding smoking and behavioral health conditions. For many years, smoking was tolerated and even encouraged among persons with mental illnesses and/or substance use disorders. Smoking, it was felt, was a relatively trivial concern, might help treat the underlying behavioral health condition, and could be used to reward good behavior. As smoking became increasing concentrated, among this population, and its devastating health consequences were appreciated, enthusiasm grew for helping these persons quit. Behavioral health clinicians are increasingly emphasizing smoking cessation, treatment facilities are going smoke-free, and the federal Substance Abuse and Mental Health Services Administration has designated the Smoking Cessation Leadership Center at UCSF as the National Center of Excellence for Tobacco-Free Recovery.
  18. Tobacco 21 legislation. In order to restrict youth access to tobacco, a recent surge of legislation raised the age of purchase of tobacco products from age 18 to 21. At last count, 19 states plus the District of Columbia have passed such laws, and an additional 510 localities did so as well. It is also possible that federal legislation will authorize this policy.
  19. The states lead the way. In the United States, policy leadership often emerges at the state level. An example is how many pioneering tobacco control policies were first introduced in California, which currently has the nation’s second-lowest adult smoking rate (11%), surpassed only by Utah (9%), where half the population is (presumably non-smoking) Mormon.
  20. Expanding the ranks of smoking cessation clinicians. Once thought of as a role restricted to primary care physicians, smoking cessation advocates are now found among many medical specialties as well as nurses, psychiatric nurses, dental hygienists, pharmacists, physical therapists, respiratory therapists, psychologists, and other health clinicians. This expansion creates many more opportunities for clinicians to help smokers make quit attempts and to have those attempts succeed.

Top 20 Remaining Challenges for Smoking Cessation

  1. Keeping smoking on the radar screen. Despite the good news about declines in smoking prevalence, there are still some 34 million Americans who smoke, half of whom will die prematurely from their use of tobacco. Because most of these people are in marginalized populations (mental illness, substance use disorders, homelessness, low education level, low socioeconomic status, incarcerated), it is difficult to mobilize public support for programs to help them quit smoking. A telling contrast is how quickly the public rallied around concerns about vaping, which differentially affected middle class students. The challenge for the tobacco control community is to be relentless about the human cost of smoking among the millions who are still at risk for tobacco-induced illness.
  2. Sorting out the risk/benefit calculations about vaping. Tobacco control in 2019 could be characterized as the year of vaping. Not only did youth use of e-cigarettes continue to spike, but there was a scary epidemic of vaping-induced pulmonary disease, which now seems to be primarily related to inhaling THC mixed with vitamin E acetate oil. It also seems clear that vaping offers some adult smokers a pathway to quitting the use of combustible tobacco products. The optimal outcome would be to keep vaping out of the hands of youth but to provide it as yet another way to help smokers quit. Achieving those goals will not be easy. It will require dispassionate science about the short and longer-term health consequences of vaping, deciding about what restrictions to put on flavored vaping products, and understanding the effectiveness and consequences of such policies as restricting youth purchase, regulating advertising, eliminating or restricting flavors, and public education.
  3. Maintaining and increasing clinician interest in smoking cessation. Because it can be so hard to quit smoking, and because clinicians face major time pressures, there are many missed opportunities to help people who smoke try to quit and to do so successfully. We have been struck by the paradox that some of the specialties most affected by smoking, such as physicians treating patients with cancer, heart disease, or lung disease, seem to be less interested in the “upstream” work of smoking cessation. But upping the ante for all clinicians will be essential to make further progress.
  4. Develop and nurture smoking cessation advocates and leaders among groups with high smoking rates. It is impressive how important advocates for specific diseases have been in generating support for private and public research funding, as well as medical treatment. The special populations most affected by smoking, including the LGBTQ+ community, would similarly benefit from more robust advocacy efforts.
  5. More progress on taxes. As mentioned under the successes list (#6), the demand for tobacco products is price-sensitive. The best opportunities to increase price lie in many of the states that currently have the highest smoking rates as well as the lowest state taxes.
  6. More progress on clean indoor air laws. By contrast with taxation, the U.S. is further along with guaranteeing non-smokers protection from secondhand smoke. Nevertheless, there are still pockets where progress can be made, especially the Tobacco Nation states of the southeast and central parts of the country.
  7. Maintaining federal and state tobacco control budgets. As a consequence of smoking being increasingly concentrated in populations with little political influence, federal and state policymakers are tempted to trim tobacco control programs in order to fund other priorities such as health care or education. Fighting to maintain those funds will require continuing effort and strong advocacy voices. By contrast with conditions such as breast cancer or autism, there are no strong citizen groups pushing for tobacco control, and that role will thus fall to the public health community.
  8. Developing better smoking cessation medications. Although the seven FDA-approved medications to help stop smoking greatly enhance the odds of quitting, most attempts still fail. Having a medication that increased those odds would add a powerful cessation weapon.
  9. Expanding the reach of quitlines. Telephone quitlines provide an effective way to help smokers quit, and serve as an efficient handoff for busy clinicians. Unfortunately, only about 1% of smokers avail themselves of this service. Experience with the states has shown that it is possible to increase that reach to as much as 8% by effective marketing and incentives.
  10. Better health insurance coverage for smoking cessation treatment. State Medicaid programs vary both in the extent that they cover cessation counseling and medications, and the degree to which they comply with their policies. Similar differences exist among private health insurance plans. Providing incentives for clinicians and removing fiscal barriers for patients who smoke would help to drive more quit attempts.
  11. Better incentives for hospitals and health care systems to help smokers quit. The federal Center for Medicare and Medicaid Services, as well as private insurers, has the potential to provide financial rewards to health care systems for identifying patients who smoke and engaging them in quit attempts. To date this potential has yet to be realized.
  12. Arriving at the right nicotine strategy. The FDA has just approved the sale of low nicotine cigarettes, and has the authority to mandate a reduction—either quickly or gradually—in the nicotine content of combustible tobacco products. Clearly these actions could reduce the addictiveness of tobacco products. Would they also lead to decreased consumption of these products, which are harmful not because of the nicotine but because of the other thousands of toxic compounds in inhaled tobacco smoke? What would be the potential for black market sales, as is happening so frequently with cannabis products?
  13. Understand better the epidemiology and health consequences of cannabis use in its various forms. The U.S. is currently undergoing a major social experiment involving the decriminalization and partial legalization (depending on the state) of marijuana. This is occurring in a relative vacuum of knowledge about the short and long-term consequences of cannabis use for youth and adults. By contrast with the huge public concern about e-cigarettes and vaping, cannabis use is almost a stealth phenomenon. It is also likely that many youth and adults are dual users of cannabis and tobacco products. We need to understand much more in order to create sensible policies.
  14. Understand more about the new heat not burn tobacco products. Altria is now test marketing its IQOS product (“I quit ordinary smoking”) in the Atlanta area, following a very successful product introduction in Japan. What are the consequences of using this product? Will it help smokers switch from the more harmful combustible cigarettes? Will it lure youth into use as has occurred with vaping? We need to track these issues.
  15. How to react to potential new roles of the tobacco industry? As mentioned in my Success (#13), the tobacco industry has been widely exposed as the perpetrator of great public health harm. As its market power shrinks in the developing world, driven by steady and impressive declines in consumption of combustible tobacco products, it has diversified. One example of diversification is the large share Altria holds in the leading e-cigarette manufacturer, Juul. Another is the IQOS product mentioned in Challenge #14. Perhaps the most attractive example of the tobacco industry developing a harm reduction product is Swedish Snus, an oral tobacco substitute that is much less harmful than cigarettes and has essentially driven the rate of adult cigarette smoking in Sweden to 3%, with major reductions in the incidence of tobacco-caused illnesses. It is likely that the negative publicity here about vaping and the restrictions imposed by new regulations will drive out small independent manufacturers, with the result that the vaping industry may come to be dominated by big tobacco. This will pose challenges for public health advocates who are rightfully suspicious of the industry but are also focused on reducing the harm from smoking.
  16. How can the US help countries with high smoking rates? Not all countries have followed the role of developed nations in reducing tobacco use. In particular, Asian countries and former USSR states have very high smoking rates, especially for men. The Bloomberg and Gates Foundations have supported US agencies to assist selected low and middle-income countries in adopting tobacco control policies, and the Framework Convention on Tobacco Control provides a sound set of strategies as well. Compared with other health relief, however, such as US help to combat HIV infection, our assistance has been disproportionately small in comparison to the health consequences of smoking.
  17. Continue the move to make all behavioral health treatment facilities smoke-free, both indoors and on the campuses. As mentioned in Success (#17), a culture change is under way regarding smoking and behavioral health conditions, the largest population now imperiled by tobacco use. A legacy of old attitudes is the condoning and even encouraging of smoking as a part of the treatment plan. As smoking cessation becomes more central to behavioral health treatment, it will be crucial to ban smoking from places where such treatment occurs, and to provide smoking cessation assistance for those clients and staff who need it.
  18. Develop better data tracking systems to capture and monitor smoking status among the various behavioral health conditions. During our work with 20 different states we frequently identify gaps in knowledge about the smoking status for various behavioral health conditions. In order to target treatment approaches and monitor their effectiveness, it would help to have better data.
  19. Create and disseminate graphic package warning materials for cigarettes. The FDA now has the authority to do this, and initially created vivid materials illustrating the hazards of smoking. However, the courts ordered FDA to reconsider these warnings. Now FDA has the green light to reintroduce a new set of materials. Other nations, such as Canada and Brazil, have such warnings, and Australia even enforced plain packaging of cigarettes. This is one policy where the US is a laggard.
  20. Better dissemination of Carbon Monoxide (CO) monitors for clinician offices. Exhaled CO is an accurate and sensitive measure of smoking, and its use can help persons who smoke to track their exposure and encourage them to quit. Barriers to their use include cost (about $500 for one-time purchase) and ignorance of their availability and utility. Making these devices more widely available would help clinicians to improve their smoking cessation performance

If you have made it this far, you have digested my list of 20 smoking cessation successes and 20 challenges. If there are others that you think merit inclusion, please send them to me and we will publish them in a future note.