Looking back at 2017
The end of a year provides an opportunity to take stock as well as to look forward. Obviously, the most dramatic events in 2017 revolved around the change of administration in our federal government. Although tobacco was not a major feature in those stories, nevertheless, there was still much activity.
The numbers. According to a recent CDC MMWR article citing results from the 2015 National Health Interview Survey, adult cigarette smoking hit a modern low of 15.1%. The elation we felt at learning this news was tempered by the slight increase, provisional 2016 figure of 15.6%, which would still count as the second lowest smoking prevalence rate in the modern era. The CDC data also reaffirmed that smoking is now concentrated among vulnerable populations, most notably those with behavioral health conditions, low educational status, the homeless, those who have been incarcerated, the LGBTQ community, and certain geographic areas (see below). Of note is the fact that similar declines in smoking prevalence and concentrations of smoking among the most vulnerable are occurring now in most developed nations.
These remarkable changes were illustrated by a recent experience at a medical school reunion I attended, which typically attracts five-year graduating classes, with a weighting toward older cohorts. I was asked to lead a panel on tobacco, and began with a survey. “How many of you had parents who smoked?” Almost every hand went up. “How many of you smoked in college?” This time only about half raised a hand. Finally, I enquired, “How many of you have children who smoke?” And in this highly educated and prosperous group, not a single person raised a hand. These responses, I explained, are why--despite the enormous toll still exerted by tobacco—it risks becoming an invisible issue.
Tobacco policy progress. Although the SCLC focuses on smoking cessation, we are very aware of the policy environment that can help shape decisions about smoking, especially tobacco taxes and clean indoor air laws. Notably, in 2017, new state taxes went into effect in five places: California ($2); Delaware ($.50); Minnesota ($.04); Puerto Rico ($1.70); and Rhode Island ($.50). Passages of tax increases require great energy and skill, but once passed the taxes are rarely rolled back. The same is true of clean indoor air ordinances.
A recent policy increased the minimum age of tobacco purchase to 21, providing the potential of discouraging youth initiation of tobacco use. The 5 states that have enacted this policy include Hawaii, California, New Jersey, Maine, and Oregon (http://tobacco21.org/ along with at least 270 municipalities, including New York City, Chicago, Boston, Cleveland and both Kansas Cities.
In addition, the United States Department of Housing and Urban Development (HUD) issued a rule requiring each public housing agency (PHA) to implement a smoke-free policy, no later than 18 months from the effective date of February 3, 2017. Each PHA must implement a “smoke-free” policy banning the use of prohibited tobacco products in all public housing living units, indoor common areas in public housing, and in PHA administrative office buildings. The smoke-free policy must also extend to all outdoor areas up to 25 feet from the public housing and administrative office buildings. This rule improves indoor air quality in the housing; benefits the health of public housing residents, visitors, and PHA staff; reduces the risk of catastrophic fires; and lowers overall maintenance costs. (https://www.federalregister.gov/documents/2016/12/05/2016-28986/instituting-smoke-free-public-housing).
Another great example of organizational policy changes was the July 31, 2017, announcement by NASMHPD (the National Association of State Mental Health Program Directors) that all behavioral health clinical settings—not just hospitals—should be smoke-free. Finally, 2017 was remarkable for one threatened policy change that did not occur—the repeal of the Affordable Care Act, including its several public health and tobacco coverage provisions. Nevertheless, it is safe to say that the ACA remains politically vulnerable. And as yet, the administration has not produced a tobacco control champion in the spirit of C Everett Koop, David Satcher, or Howard Koh.
Controversies. Electronic nicotine delivery devices remained a major source of news coverage as well as debate within those in public health. An unexpected finding was that E-cig use among highschool students declined from 16% in 2015 to 11.3% in 2016 (https://www.cdc.gov/mmwr/volumes/66/wr/mm6623a1.htm). For adults, an overall 3.5% used an e-cig product.
This year also marked a major shift in the posture of the FDA toward nicotine in two major ways. First, it proposed to examine the potential benefits and harms of mandating reduced cigarette nicotine yields to levels that would not create or sustain addiction. Second, the agency extended its deadline for tobacco product review of new products, such as e-cigarettes. Ken Warner and I were asked to comment on these actions in a Viewpoint published in JAMA. In our commentary, we dwelled on the concepts of continuum of risk and harm reduction, as well as lamenting the reality that so many people erroneously believe that it is the nicotine in cigarettes that causes death and disease, rather than the 7,000 products in combustible tobacco smoke. The issue of the risks and benefits of alternative forms of nicotine delivery continues to roil the public health community. Opponents fear that these products will re-glamorize smoking, provide a gateway to regular cigarettes for young people, discourage cessation by smokers, expose users and bystanders to toxic emissions, and provide a new market for the tobacco industry. Proponents point to the decreases in youth smoking concurrent with the spike in e-cigarette use as refuting the gateway theory, cite several new papers suggesting that for some smokers the use of e-cigarettes improves the odds of quitting smoking, and assert that the harm from using these devices is much less than from smoking cigarettes. Both sides understand that it may be several decades or more before the relative toxicity of e-cigarettes is fully understood. A silver lining to this controversy is that it serves to reaffirm the deadly health effects of smoking at a time when other public health issues such as opioid overdose and obesity seem more newsworthy.
Another controversy surfaced in 2017 with the announcement that Philip Morris International (PMI) had pledged $1billion over 12 years to fund a Foundation for a Smoke Free World, the effort to be led by former WHO official Derek Yach. Not surprisingly, most tobacco control experts view this as tainted money and are suspicious of the intent of PMI as well as whether the new foundation can demonstrate independence from its funder. Some, however, have adopted a wait and see posture pending disclosure of the Foundation’s governance and operating procedures.
Tobacco Nation. Among its many recent campaigns, the Truth Initiative (formerly the American Legacy Foundation and a long-time supporter of ours), in 2017 launched a campaign drawing attention to the 12 states with the highest adult smoking prevalence: Alabama, Arkansas, Indiana, Kentucky, Louisiana, Michigan, Mississippi, Missouri, Ohio, Oklahoma, Tennessee and West Virginia. With more than 66 million residents, these states include roughly 20 percent of the U.S. population. Not only do they have high smoking rates, they also suffer from poorer health and poverty, with higher rates of heart disease, stroke, cancer, and opioid overdose. We at the SCLC have also called attention to this region, and have held summits on behavioral health and smoking in five of them. They clearly deserve special emphasis.
Looking Forward. This January marks the 15th birthday of the Smoking Cessation Leadership Center. We can look back with gratitude on the support we have had from multiple funders, on the privilege of working with dedicated champions in many organizations, and in the very real progress that has been made during this period. But our gratitude for this progress is matched by the urgency of needing to do more to stop the preventable deaths and disability that will surely occur among the almost 40 million smokers today, plus those who will be joining their ranks. Thanks to all of you for working toward that goal.