Is Smoking Yesterday’s News?

When I tell people what I do, they often ask, “isn’t smoking on its way out”? That attitude may be reinforced by the September, 2015 report from the CDC showing that for the first quarter of 2015 age-adjusted smoking rates for adults hit a modern low of 15.3%, down from 20.6% in 2009. This follows a recent pattern of declining prevalence rates (see my previous post, Smoking Rates Continue to Decline) that contradicts earlier conventional wisdom that we are in a plateau regarding smoking and that “nothing seems to work.”

Although the trend data are both clear and welcome, they also raise many questions. Here are four I will address:

  1. What accounts for the declining smoking rates?
  2. Who are those who continue to smoke and how can they be reached?
  3. What are the obstacles to continued progress?
  4. Why should we care about smoking if the trends are favorable?

What accounts for declining smoking rates?

John F Kennedy famously remarked that victory has a thousand fathers and defeat is an orphan. In the case of decreased smoking rates, the list of potential contributors is less than a thousand, but does include many possible claimants. Certainly continued pressure from evidence-based public health measures such as tobacco taxes, clean indoor air legislation, and tobacco control programs helped to combat smoking. Yet, there have not been dramatic changes to these familiar programs in the past several years, and in fact most states have taken big bites out of their tobacco control programs in the face of budget deficits. Recent counter-marketing campaigns by the CDC, Legacy (now renamed as Truth Initiative) and the FDA seem to have stimulated new interest in quitting smoking, as judged from increased calls to telephone quitlines following airing of the CDC Tips From Former Smokers campaign. Another new stimulus is increased insurance coverage provided by the Affordable Care Act (ACA), including its Medicaid expansion option, which not only makes it easier for low-income smokers to see a physician, but also provides coverage for smoking cessation treatment, including counseling and cessation medications. Declines in smoking rates among the Massachusetts Medicaid population were documented after the state dramatically expanded health insurance coverage in 2006. But, the opportunity for all states to expand coverage was blunted as a result of the 2012 Supreme Court decision that made Medicaid expansion a state option. Nearly four million people living in Southern states—which have the highest smoking rates—remain in a coverage gap, too wealthy to qualify for Medicaid in their state and too poor to buy insurance on the new ACA exchanges. So, if health insurance coverage expansion is important, many more opportunities still exist.

There are other possible contributors. One that has garnered the most media attention and has embroiled the tobacco community in controversy, is the rapid spread of alternative forms of nicotine, including electronic nicotine delivery systems (ENDS) such as the e-cigarette, as well as other combustible products such as hookahs and marijuana. Are young potential smokers choosing these products as alternatives to cigarettes? Given that youth rates of ENDS are rapidly climbing while cigarette use is falling, the answer seems to be yes. The many critics of ENDS have worried, with reason, that ENDS may serve as a gateway to smoking for youth and might counter the successful de-normalization of smoking that has been so important for tobacco control. As yet, however, there is no overall population-wide evidence that such a gateway phenomenon is occurring. Are current smokers using ENDS to quit or to sustain their smoking habit? Here the evidence is mixed and anecdotal. It is likely that both phenomena are occurring. Finally, what are the health consequences if some smokers shift from using combustible cigarettes to other products? As yet we do not know the full health consequences of END use, and the fact that the product itself is in evolution and that there may be a long interval between exposure and adverse health outcomes makes that ascertainment a challenge. Nevertheless, as we await definitive evidence, I am persuaded both that if all smokers of combustible cigarettes changed to ENDS we would be a healthier nation, but also that inhaling pure air is preferable to vaping. If that switch were coupled with renewed initiation of cigarette smoking by youth, however, those gains might be compromised. The data on the safety of chronic marijuana use are also sparse. Clearly safety is an urgent research priority regarding these increasingly popular substances.

Other potential contributors to the decline include: the economic recovery, which may contribute to lower stress-induced smoking; lower rates of smoking in the movies; the decision by CVS in September of 2014 to stop selling tobacco products, with a resultant modest but important dip in cigarette sales in states where CVS has a major presence; increasing ability to make direct e-referrals of hospitalized smokers to state quitlines; progress with the behavioral health population, as seems to be occurring with several of the states involved in SAMHSA-endorsed leadership academy efforts; and state-based efforts in states with high smoking states. As one example, Oklahoma’s adult prevalence fell from 28.7% in 2001 to 23.2% in 2012, thereby dropping from the 49th highest rate in the nation to 39th

Most likely, the progress results from a combination of all these factors. But before we become overly satisfied, we should reflect that trends can be capricious and data imperfect, and that the surveys ignore high smoking populations such as the institutionalized and incarcerated, so that the real population rate is likely higher than 15.3%.

How to reach existing smokers?

Increasingly smoking is confined to “marginalized populations,” including persons with behavioral health issues, those involved with the criminal justice system, the homeless, and persons with low socioeconomic status. In addition, the LGBT community (many of whom are not economically deprived), many young people, and manual workers also have high rates of smoking. Striking regional concentrations of smoking exist, with the highest rates occurring in the South and certain Midwestern states such as Indiana. These concentrations suggest a limit to the reach of national strategies and a need for targeted ones. States that involve relevant state agencies, voluntary associations such as state chapters of the National Alliance on Mental Illness (NAMI), the American Cancer Society, American Heart Association, American Lung Association and key clinical organizations can generate local strategies and stay clear of the political baggage that can surround more national efforts. We at the SCLC have been gratified to work on state strategies with dedicated tobacco control advocates in 18 states, 9 of which are located in regions with high smoking rates: Arkansas, Indiana, Kentucky, Louisiana, Mississippi, North Carolina, Oklahoma, Texas, and West Virginia. Local advocates are better situated to devise policies and practices that are germane to their own regions.

In addition, the United States is undergoing a culture change in behavioral health treatment settings and congregate living sites, where tobacco use, once formerly intrinsic to the culture, is now being exorcised. This is important work, and it is just beginning.

Obstacles to continued progress

As with all social movements, change does not come easily. In many of the states in which we work, budget crises, personnel changes, territorial disputes, and shifts in political leadership have stalled good efforts. The lack of visible advocacy groups on behalf of this stigmatized population hampers the ability to garner resources from potential donors as well as politicians. The fact that so few “influentials” have family and friends who are smokers limits the appeal, urgency, and perceived salience of tobacco control. The controversy over the potential harm and benefits of ENDS has captured the media and divided the tobacco control community, at the risk of taking our eyes off the prize of reducing the harm from combustible tobacco products. And, of course, the tobacco industry continues the relentless promotion of its deadly product.

Why should people care about smoking if it is in decline?

The best answer to that question is the staggering toll from tobacco use. Even in the face of gradually decreasing numbers, the estimates of tobacco-induced disease have increased, as we have learned more about its many adverse health consequences. In the past decade, estimates of annual tobacco-caused deaths rose from 440,000 to 480,000, and most recently to 540,000 annual deaths. And the number of Americans with severe tobacco-induced morbidities has increased to 14 million. This seemingly paradoxical situation—declining rates and increasing damage—results from the long period between exposure and disease as well as new knowledge about pathology. Soon we can expect the numbers damaged by tobacco use to peak and then decline, but absent accelerated smoking reduction, the numbers of tobacco-induced deaths will stay in the hundreds of thousands for years to come. The immensity of the harm caused by tobacco use, including the collateral harm from exposure to second hand smoke, is the most powerful potential weapon to mobilize support. In addition, the personal and economic costs of those illnesses are needless expenses, as are the suffering and losses by involved family and friends.

Yes, let’s celebrate these recent gains. But let’s not forget all the deaths and diseases that will continue year after year unless we can accelerate our current progress. Now is the time. Inaction means needless deaths and disability, especially for our most vulnerable populations.