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Tobacco Control: Where Are We Now and Where Are We Going?

Nelson, Roxanne

AJN The American Journal of Nursing: March 2014 - Volume 114 - Issue 3 - p 18–19
doi: 10.1097/01.NAJ.0000444484.18597.40
AJN Reports

Limits on availability and access still needed.

Roxanne Nelson



Strange as it may seem, there was a time when nurses smoked at nursing stations in hospitals, when tobacco companies hawked their products on television, and lighting up one's first cigarette was considered a rite of passage. But on January 11, 1964, U.S. Surgeon General Luther Terry issued the landmark report, Smoking and Health: Report of the Advisory Committee to the Surgeon General, which implicated smoking in a host of illnesses, including lung cancer.

According to a National Institutes of Health narrative describing the event, Terry said that the report “hit the country like a bombshell. It was front page news and a lead story on every radio and television station in the United States and many abroad.”

The following year Congress ruled that cigarette packages in the United States had to carry a health warning, and in 1969 all cigarette advertising on television and radio was banned. The trend continued over the next few decades, with increasing restrictions placed on where smoking was permitted. Warnings on cigarette packaging grew steadily more ominous. Higher taxes were levied on cigarettes, smoking was banned or severely restricted in almost all indoor public places, and smokers are finding it increasingly difficult to light up even outdoors; according to the PBS NewsHour Web site (, over the past 20 years, smoking has been banned in 843 parks and more than 150 beaches. Even James Bond has kicked the habit.

These efforts have paid off. Cigarette smoking has declined among American adults to less than half of what it was in 1965. But questions arise: Has enough been done to control tobacco use? Is progress still being made, or have we reached a plateau?

Ruth Malone, PhD, RN, a professor at the University of California, San Francisco, School of Nursing, is known internationally for her research on the tobacco industry. She believes that much more needs to be done. She said that most of the public is in favor of further restrictions on smoking, including about a third of smokers. “About 70% of smokers want to quit,” she said. “Many pharmacies and grocery stores no longer sell cigarettes. They've stopped voluntarily, and this helps limit the availability of tobacco.” She believes such voluntary actions could be a stepping-stone to policies that place further limitations on where and how tobacco can be purchased.

A paper by Holford and colleagues in the January 8 issue of JAMA estimates that tobacco control efforts from 1964 to 2012 prevented 8 million premature deaths. “Tobacco control has been a great public health success story but requires continued efforts to eliminate tobacco-related morbidity and mortality,” write the authors.

A significant number of Americans continue to smoke, despite restrictions and warnings of health risks. Statistics from the American Cancer Society suggest that about 44 million Americans continue to light up, even though the proportion of the population who smoke has dropped from 42% in 1965 to about 19% in 2011.

The American Lung Association (ALA) has also expressed a degree of frustration. In its most recent report on U.S. tobacco use, State of Tobacco Control 2013, the organization describes 2012 as “missed opportunities to save lives.” It notes that although the Obama administration deserves credit for implementing policies that will reduce tobacco use across the nation, almost all meaningful action to reduce “the leading cause of preventable death in the U.S. ground to a halt” in 2012. In addition, the ALA writes, the “complete lack of action by the U.S. Food and Drug Administration [FDA] was particularly noteworthy.”

But Linda Sarna, PhD, RN, FAAN, who holds the Lulu Wolf Hassenplug Endowed Chair in Nursing at the University of California, Los Angeles, School of Nursing, thinks the numbers of smokers will still decline as more states implement measures. “If prices and taxes increase, we'll also see further declines, so there are still some policy measures that can be taken at the state level to continue this downward trend,” she said.

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In 2009, the FDA was given the authority to regulate tobacco products, which includes the individual components of those products. That same year the agency banned tobacco flavorings, such as vanilla, strawberry, and coffee, primarily to make tobacco products less enticing to teens; 17-year-old smokers are about three times as likely to use flavored cigarettes as those older than 25, and many young smokers mistakenly believe that the flavored products are safer than nonflavored ones.

The FDA hasn't yet banned menthol, however. Although flavored cigarettes account for only about 0.2% of the market, about a quarter of cigarettes sold are menthol, according to a report in the August 28, 2013, issue of JAMA; there are also racial and ethnic differences in use: about 81% of black teenagers opt for menthol cigarettes, compared with 32% of white and 45% of Hispanic teens. In October 2013, the European Parliament voted to ban menthol and other flavors, as of 2022, and the FDA may be following suit. Last July the agency issued a preliminary report on menthol, an “advance notice of proposed rulemaking,” and called for public comment to aid in making informed decisions about menthol in cigarettes.

“Banning menthol will have a tremendous impact, particularly in reducing initiation rates,” said Sarna. “Nurses should support the measure. There are additional harms caused by using tobacco products that are flavored with menthol.”

As part of its review process, the FDA is funding three menthol-related studies: one will examine genetic differences in taste perceptions in tobacco use; the second study will look at the health effects of menthol in cigarettes, assessing exposure to smoke-related toxins and carcinogens (menthol-containing cigarettes will be compared with nonmenthol products having otherwise identical components); the third study will evaluate the effects of menthol and nonmenthol compounds in various tobacco products on both tobacco addiction and toxicants of tobacco smoke.

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Tobacco use was associated with 100 million deaths in the 20th century. This moment in time, then, according to Stella Bialous, DrPH, RN, president of Tobacco Policy International, is historic, an opportunity to celebrate 50 years of progress and success in reducing tobacco use in the United States. “It's also an opportunity to outline strategies that will continue to lead us toward a tobacco-free future,” she said. Tobacco-free college campuses, tobacco-related content in the core curricula of schools for health professionals, further increases in prices and restrictions on advertising, and regulation of electronic cigarettes are all part of that future, according to Bialous, and are all “policy steps that should be supported by nurses.”

To commemorate the 50th anniversary of that first report on tobacco, the surgeon general's office released its 32nd report on the topic, The Health Consequences of Smoking—50 Years of Progress, on January 17. Among its many findings are recently discovered links between tobacco use and diabetes, rheumatoid arthritis, and orofacial clefts (from maternal smoking), as well as a link between secondhand smoke and stroke. The complete report can be found at—Roxanne Nelson

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